Histological evaluation of residual basal cell carcinoma after shave biopsy prior to Mohs micrographic surgery.

BACKGROUND: Patients who are referred for Mohs surgery after pre-operative biopsy has been performed show in some cases no clinical or pathological evidence of tumour persistence. We have previously shown that 25% of these patients show no residual skin cancer either basal cell carcinoma or squamous cell carcinoma. The reasons for 'disappearance' of the tumour may be true non-persistence or false non-persistence because of wrong-site Mohs surgery. OBJECTIVE: To determine the incidence of residual basal cell carcinoma after shave biopsy of primary nodular basal cell carcinoma prior to Mohs micrographic surgery. METHODS: A prospective unblinded study was performed on patients undergoing Mohs surgery for primary nodular basal cell carcinoma. The tumour was removed as a shaved excision using a No. 15 blade at the clinical borders like a shave biopsy (Mohs shave). The bases of the tumors were excised and then sectioned vertically at the middle and cut to the periphery at 10-15 µm intervals till the edge. RESULTS: Fifty-one patients were evaluated. In 40 patients, residual basal cell carcinoma was found at the base of the shave excision site (78.4%). CONCLUSIONS: Pre-operative shave biopsy performed during Mohs surgery for primary nodular basal cell carcinoma is 'curative' in 22% of the patients.

Basal cell carcinoma arising over facial port wine stain: a single-centre experience.

BACKGROUND: A growing number of reports point to a possible connection between basal cell carcinoma (BCC) and port wine stain (PWS). Researchers suggest that either the elevated temperature induced by the increased dermal vasculature or an oncogenic factor produced by the ectatic vessels makes the overlying epidermis more susceptible to ultraviolet or ionizing radiation. OBJECTIVE: To check the prevalence of BCC in patients with PWS at a large national vascular amomalies centre. METHODS: The study group included 68 patients, 44 women and 24 men, with facial PWSs. Detailed data were collected on background features, past treatments and past exposure to radiation, and a comprehensive physical examination was performed. Biopsy samples were taken from suspect lesions for histological study. RESULTS: Four patients (5.9%) were found to have histologically proven BCC, 3 nodular and one multifocal. All had been exposed to radiation during childhood. Treatment consisted of excision; there was one recurrence. CONCLUSION: Although the co-occurrence of BCC and PWS is probably related to radiation treatment in childhood, these findings should alert physicians to regularly examine PWSs for cancerous changes, especially in patients at risk.

Blood pressure levels decrease during Mohs micrographic surgery.

BACKGROUND: A common practice is not to operate on patients with elevated blood pressure (BP) levels to avoid cardiovascular and cerebrovascular complications. We therefore designed a study to evaluate the effect of prolonged surgery under local anesthesia on BP levels, and to compare the outcome of patients with elevated BP to those with normal BP. METHODS: We studied 121 patients (65 males) with a mean age of 60 ++/-14 years (range 31-89) who were referred for Mohs micrographic surgery (MMS) during 2 consecutive months. Forty six patients had a history of hypertension. Blood pressure was measured in all subjects in the supine position with an automated device 5 times during surgery. RESULTS: Blood pressure decreased significantly during surgery from 152 +/- 2/85 +/- 1 mm Hg at baseline to 139 +/- 2/79 +/- 1 at the end of the surgery (p < .05). Forty two patients (34%) had elevated BP levels at baseline whereas only 18 patients had these levels at the end of the first stage. There was no difference in surgery outcomes between those with elevated and those with normal BP levels at baseline. CONCLUSIONS: Blood pressure levels decrease during MMS under local anesthesia and the outcome of patients with elevated BP is good. Thus, patients with elevated BP can safely undergo surgery under local anesthesia.

Epidermolytic hyperkeratosis type PS-1 caused by aberrant splicing of KRT1.

Mutations in the keratin 1 (KRT1) gene underlie epidermolytic hyperkeratosis (EHK). This autosomal dominant disorder is characterized by phenotypic heterogeneity. In the present study, we assessed a 33-year-old individual presenting with severe palmoplantar keratoderma and histopathological findings suggestive of EHK. We analysed genomic DNA extracted from the patient's blood lymphocytes for pathogenic mutations in KRT1. A heterozygous 4-bp deletion was identified in intron 1 of the gene (591+3_+6delGAGT), suggesting the possibility that it may interfere with the normal splicing of intron 1. We detected a 66-bp deletion in KRT1 mRNA extracted from the patient's skin, predicted to result in the translation of a mutant KRT1 lacking 22 amino acids, including the conserved helix initiation motif. The identification of this unusual and novel mutation underscores the diagnostic importance of sequence analysis of keratin gene noncoding regions.

Cutaneous surgery in patients receiving warfarin therapy.

BACKGROUND: Anticoagulant treatment with warfarin is an essential therapy in patients with prosthetic heart valves and atrial fibrillation to prevent thromboembolisms. The question whether to stop warfarin treatment in patients undergoing cutaneous surgery is debatable. OBJECTIVE: To evaluate the outcome of surgery in patients that were treated with warfarin and underwent excisional and Mohs surgeries. METHODS: Warfarin therapy was continued in all patients that underwent excisional and Mohs surgery in our practice from November 1999 to November 2000. Perioperative complications such as bleeding and cosmetic outcome are evaluated. RESULTS: A total of 560 patients underwent Mohs surgery and 530 patients underwent excisional surgery. Sixteen patients (1.5%) were treated with coumadin with international normalized ratio (INR) values within the therapeutic values. Seventy-seven patients that underwent surgery on the same days as the warfarin-treated patients served as the control group. Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients. All wounds healed without any complication, including full-thickness grafts. CONCLUSION: Coumadin treatment should be continued in patients undergoing cutaneous surgery. This will decrease the risk of thromboembolic events.

The versatility of the nasolabial flap enhanced by the delay procedure.

BACKGROUND: The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall following Mohs surgery. However, both extirpation of a tumor in the region of the base of the flap or previous use of the flap often destroy the proximal axial blood supply to the flap, excluding its immediate utilization. We describe a different use of the nasolabial flap and a technique for preserving its capacity in the case of reutilization OBJECTIVE: To describe the versatility of the nasolabial flap and a delay procedure that enables its exploitation despite prior disruption of the proximal blood supply. METHODS: Three different uses of the same nasolabial flap are demonstrated in one patient. The surgical techniques are discussed in detail. RESULTS: The reconstructive results were excellent. There were no postoperative complications. CONCLUSION: The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall. When the nasolabial flap has been used before, or its blood supply compromised, the delay procedure can reestablish its applicability.

Analysis of laboratory data in acne patients treated with isotretinoin: is there really a need to perform routine laboratory tests?

INTRODUCTION: Isotretinoin has been used to treat acne since 1982. Its current indications in the package insert are limited and many physicians still feel uncomfortable prescribing it because of its side effects. Serum levels of liver enzymes and lipids are carried out as a routine in most clinics both before and during treatment. AIMS: Our objective was to evaluate the effect of isotretinoin on serum lipids, liver function and other laboratory parameters in order to assess the necessity to perform routine laboratory tests. METHODS: Computerized medical files of 1292 patients in private practice that received isotretinoin for acne were analyzed. RESULTS: 907 patients completed a treatment course of 5 to 9 months. Serum levels of liver enzymes were not elevated to a degree necessitating discontinuation of treatment. Only 1.5% of the patients had serum triglyceride levels above 400 mg%. No laboratory abnormalities were a cause for discontinuation of treatment. During a 6-year follow up only 3.5% of patients received a second course of therapy with isotretinoin. CONCLUSIONS: Aside from its teratogenic effect, isotretinoin is a safe and excellent drug for acne therapy. It should be prescribed for any inflammatory acne and in our opinion there is no need for a routine laboratory follow-up in young, healthy patients aside from a pregnancy test in females. At present, isotretinoin should be considered as the drug of choice for moderate to severe acne.

Clinical significance of markedly elevated serum creatine kinase levels in patients with acne on isotretinoin.

Muscle-related complaints and high creatine kinase (CK) blood levels have been reported in 16-51% of patients with acne treated with isotretinoin. It has been suggested that this retinoid and exercise have a synergistic effect on muscle. The presence of marked hyperCKemia during the treatment raises concern about rhabdomyolysis. The objective of this report was to evaluate the incidence, course and clinical significance of severe hyperCKemia in isotretinoin therapy for acne. Out of 442 patients on isotretinoin, we reviewed 7 patients (1.58%) with CK values above 5,000 IU/l. Only two of them had myalgia. Physical activity or intramuscular injection prior to blood testing was reported in 6 patients. CK values returned to normal within 2 weeks and all subjects except 2, completed treatment. In conclusion, marked hyperCKemia with or without muscle-related complaints in isotretinoin-treated patients with acne is a benign phenomenon.

Lack of association between varicocele and angiokeratoma of the scrotum (Fordyce).

Angiokeratoma of the scrotum is thought to be associated with varicocele. Our study population consisted of young soldiers and adult reservists. The young population was screened during routine medical examination for the existence of varicocele or angiomas on the scrotum, while the adult reservists, who according to their medical records had varicocele, were randomly questioned for the existence of any kind of spots or lesions on their scrota. We found no association between varicocele and angiokeratoma of the scrotum. Since the prevalence of varicocele is high, it is possible that in the reported cases the association of varicocele and angiokeratoma of the scrotum was coincidental.

Basal cell carcinoma occurring at the site of a strawberry hemangioma.

A twenty-seven-year-old white woman presented with a basal cell carcinoma at the former site of a strawberry hemangioma. The strawberry hemangioma had been treated in infancy with dry ice. The lesion spontaneously regressed and left no visible scar. To our knowledge, this is the first reported association of basal cell carcinoma and strawberry hemangioma.

Intraoperative nasal ala stabilization using the Foley catheter.

The authors describe a technique of intraoperative nasal ala stabilization to aid excision of skin lesions on the nasal ala and the surrounding skin. The fixation is achieved by inserting a Foley catheter into the nasal antrum and inflating the balloon. The inflated balloon produces pressure against the surrounding walls, allows convenient excision of skin lesions with good hemostasis, and is comfortable for the patient.

Antigen-presenting activity of draining lymph node cells from mice painted with a contact allergen during ultraviolet carcinogenesis.

The induction of skin cancers in mice by chronic UV irradiation is accompanied by a decrease in the numbers of Ia+ and Thy-1+ dendritic cells in the epidermis early in the course of UV irradiation. Subsequently, the number of Ia+ cells, but not Thy-1+ cells, increases until the time of tumor development. To assess the functional significance of these changes in cutaneous immune cells, and to help define the role these cells may play in immune surveillance against skin cancers, we tested the afferent immunologic capability of the skin during the development of UV-B radiation-induced skin cancers. Afferent immune function was measured by testing the Ag-presenting capacity of draining lymph node (DLN) cells from mice sensitized epicutaneously with dinitrofluorobenzene. A reduced contact hypersensitivity response was induced in mice immunized with DLN cells from UV-irradiated mice that had been sensitized with hapten on UV-irradiated skin. This decreased reactivity was present during the entire latent period of tumor development. However, in tumor-bearing mice, the DLN cells from UV-irradiated, sensitized animals exhibited normal Ag-presenting activity. DLN cells from UV-irradiated mice sensitized on ventral, unirradiated skin exhibited normal Ag-presenting activity. The lowest amount of Ag-presenting activity in the draining lymph nodes of UV-irradiated mice correlated temporally with the lowest number of Ia+, adenosine triphosphatase+ dendritic epidermal cells in the UV-irradiated skin. At least during the early part of the tumor latent period, an increase in the number of these cells was paralleled by an increase in the Ag-presenting activity of the DLN cells. In contrast, the number of Thy-1+ dendritic epidermal cells in UV-irradiated skin did not correlate with the Ag-presenting activity. Thus, the decrease in the number of identifiable epidermal Langerhans cells early in the course of chronic UV irradiation correlated with a decrease in Ag-presenting activity after sensitization through the UV-irradiated skin. These studies demonstrate that the afferent arm of the cutaneous immune response is impaired in the site of tumor development throughout the latent period of UV carcinogenesis.

Excision repair of pyrimidine dimers induced by simulated solar radiation in the skin of patients with basal cell carcinoma.

One prominent lesion induced in DNA by ultraviolet (UV) radiation is the cyclobutyl pyrimidine dimer formed between adjacent pyrimidines on the same DNA strand. We investigated whether people who have developed basal cell carcinoma on sun-exposed skin have an altered ability to repair UV-induced pyrimidine dimers in DNA. Twenty-two patients with at least one basal cell carcinoma, aged 31-84 years, and 19 healthy volunteers, aged 25-61 years, took part in the study. Both groups were given one minimal erythema dose (MED) of simulated solar radiation on the lower back. DNA was extracted from the irradiated skin 0 to 6 h later, and the number of UV-induced pyrimidine dimers was determined using a dimer-specific endonuclease. At time 0, the average number of dimers per unit of DNA was similar in the two groups. After 6 h, an average of 22 +/- 4% of the dimers were removed in the group with basal cell carcinoma compared to 33 +/- 4% in the cancer-free group. In the basal cell carcinoma group, only 23% of the patients repaired more than 30% of the dimers after 6 h, compared with 53% of the cancer-free subjects (p less than 0.05). We conclude that patients who develop basal cell carcinoma on sun-exposed skin may have a decreased ability to repair pyrimidine dimers induced in skin exposed to simulated solar radiation.

Ultraviolet radiation-induced damage to human Langerhans cells in vivo is not reversed by ultraviolet A or visible light.

Exposure of human skin in vivo to UVB radiation induces pyrimidine dimers in DNA and alters the morphology and function of epidermal Langerhans cells. Cells in human skin have been reported to contain a photoreactivation repair mechanism that, following exposure to UVA or visible light, repairs UVB-induced pyrimidine dimers. The purpose of this study was to determine whether exposure to photoreactivating light would also reverse the UVB-induced morphologic alterations in human Langerhans cells. The skin of eight healthy volunteers was exposed to a low dose of UVB radiation (between 0.75 and 1.5 times the minimal erythema dose), and immediately thereafter exposed to photoreactivating light from either BLB fluorescent lamps (UVA radiation) or incandescent bulbs (visible light). After exposure to UVB radiation, the number of ATPase+ epidermal Langerhans cells was reduced in all subjects to between 21% and 65% of that in unirradiated skin, and the majority of the remaining cells exhibited morphologic alterations. Exposure of the UVB-irradiated skin to photoreactivating light did not reverse or reduce these effects. We conclude that UVB-induced morphologic alterations of human Langerhans cells are not subject to photoreactivation. These results imply either that pyrimidine dimers are not involved in these effects of UVB irradiation, or that photoreactivation does not occur in human Langerhans cells in situ.