In search of prognostic indicators for lymphomatoid papulosis: a retrospective study of 123 patients.

BACKGROUND: Lymphomatoid papulosis (LyP) is a benign recurrent papulonodular skin eruption with histologically malignant features that sometimes (10%-20%) progresses to lymphoma. OBJECTIVE: We retrospectively evaluated the clinical course of patients with LyP and identify prognostic factors possibly indicating a malignant course. METHODS: Clinical, histopathologic, and immunologic features and molecular genetics were examined and correlated with clinical course and outcomes. Immunophenotyping and chemokine profiling were performed in select skin biopsy samples. A follow-up questionnaire was sent to patients. Clinical course and association with neoplastic disorders were correlated with LyP subtypes, molecular genetics, and immunophenotyping studies. RESULTS: Of 123 patients with LyP (1991-2008) followed up a mean of 4 years (range, 2 months to 14 years), 17 (14%) had an associated hematologic malignancy, 8 of which were mycosis fungoides. Histopathologic analyses demonstrated classic LyP type A (n = 69), B (n = 13), or C (n = 6), and a slight predominance of T-cell CD8 marker expression for type A. More than one type of lesion was present in 9 patients with a higher incidence of hematologic malignancies. T-cell receptor gene rearrangement positivity was about two times higher, with LyP associated with hematologic malignancy (82% vs 44%; odds ratio 5.7; P = .02). Chemokine studies in a subset of 25 patients showed chemokine receptor (CCR) CCR4(+) and thymus and activation-related chemokine (TARC(+)) in all LyP types and CCR3(+) and chemokine-related receptor (CXCR) CXCR3(+) in types B and C. LIMITATIONS: Retrospective study design is a limitation. CONCLUSIONS: Positive T-cell receptor gene rearrangement or diagnosis of mixed-type LyP may be a prognostic indicator of disease more prone to progress to lymphoma.

Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose.

BACKGROUND: A large proportion of facial skin cancers occur on the nose, and defects after Mohs surgery in this location often present a reconstructive challenge. For intermediate-sized defects, the choice of reconstruction is usually between skin flap and full-thickness skin graft. Ongoing debate exists, and limited data are available to determine which of these methods is more satisfactory. OBJECTIVE: To evaluate and compare the clinical appearance of wound healing after surgical repair with a skin graft versus a skin flap for Mohs defects on the nose. METHOD: In this study, 43 flaps and 24 grafts were evaluated using a modified Hollander Wound Evaluation Scale and a visual analogue scale. RESULTS: The mean visual analogue scale score was significantly better for flap repairs than for graft repairs. In addition, 100% of flaps had an acceptable overall cosmetic appearance on the basis of the Hollander Wound Evaluation Scale, compared with only 75% of skin grafts. CONCLUSIONS: For defects on the nose where flap and graft repair may both be technically possible, a flap may be more likely to result in superior cosmetic outcome.

Clinical, histopathologic, and immunophenotypic features of lymphomatoid papulosis with CD8 predominance in 14 pediatric patients.

BACKGROUND: Lymphomatoid papulosis (LyP) is a cyclic papulonodular eruption that is clinically benign and histologically malignant. Association with hematologic neoplasias has been reported in 5% to 20% of all cases. OBJECTIVE: We sought to review the clinical and histopathologic features of LyP in pediatric patients. METHODS: We searched for the records of all patients with a clinical and histopathologic diagnosis of LyP seen at our clinic from January 1991 through April 2008. The cases of pediatric patients (aged < 20 years) were reviewed in detail. RESULTS: Of 123 patients with LyP identified, 14 (11%) were in the pediatric age group. Most were male (64%); mean age of onset was 12 years. Type A LyP was identified in 12 patients, one patient had type B, and none had type C (type not determined in one case). Ten cases showed CD8 predominance by immunohistochemistry. T-cell intracytoplasmic antigen staining was positive in 3 cases of CD8(+) LyP type A and the one case of LyP type B. Lesional T-cell receptor gene rearrangement studies were negative in 9 of 10 patients with LyP type A. The average follow-up time was 5.5 years. Lesions improved with treatment in most cases, and none of the cases were associated with hematologic malignancies. LIMITATIONS: This was a retrospective review. CONCLUSIONS: Among our pediatric patients, we noted a predominance of CD8(+) LyP, which does not seem to have an aggressive course. Further longitudinal studies are necessary to evaluate prognostic differences between CD4(+) and CD8(+) LyP and their biological significance.

Role of multiple scouting biopsies before Mohs micrographic surgery for extramammary Paget's disease.

BACKGROUND: Extramammary Paget's disease (EMPD) frequently extends subclinically, resulting in high recurrence rates after surgical excision. Mohs micrographic surgery (MMS) improves cure rates but may require time-consuming reexcision of subclinical extension. A mechanism to estimate the location and extent of subclinical extension would be helpful. OBJECTIVE: To describe and evaluate a technique for multiple scouting biopsies before MMS for EMPD. METHOD: A retrospective review of patients at Mayo Clinic who had multiple scouting biopsies before MMS for EMPD without dermal invasion. TECHNIQUE: The clinical extent of EMPD is identified. The scouting biopsy sites are determined and documented with photographs. The scouting biopsy specimens are sent for permanent sections. The results of the scouting biopsies help guide the extent of the initial Mohs layer. The tumor is cleared with MMS. An additional 1 mm peripheral margin of tissue is usually submitted for permanent sections. RESULTS: Multiple scouting biopsies were done in five patients. Four of the five patients had at least one true-positive result. At least one true-negative result was obtained in all five patients. Two patients had at least one false-negative result. CONCLUSION: Multiple scouting biopsies before MMS for EMPD without dermal invasion can be a beneficial adjuvant technique.

Sebaceous carcinoma of the eyelid: a review of 14 cases.

BACKGROUND: Sebaceous carcinoma of the eyelid is a rare tumor. Treatment can be complicated by noncontiguous spread of the tumor. OBJECTIVE: Review a series of patients with sebaceous carcinoma to illustrate clinical presentations, treatments, and outcomes. METHODS: We retrospectively reviewed medical records of patients with sebaceous carcinoma treated at Mayo Clinic (Rochester, MN). RESULTS: Fourteen patients had sufficient follow-up data available for review. Mean follow-up was 57 months (range 18-134 months). Treatment included wide local excision with frozen and permanent section control (9 patients, 64%), Mohs micrographic surgery (2 patients, 14%), external beam radiation (2 patients, 14%), and exenteration and total parotidectomy with cervical lymph node dissection (1 patient, 7%). Two patients (14%) had local recurrence of the tumor after wide local excision, and 1 patient (7%) had tumor recurrence after Mohs micrographic surgery. CONCLUSION: Treatment should be chosen on the basis of the extent of the tumor and the specific needs of the patient. The mainstay of treatment of tumors without orbital involvement has been wide local excision, with the margins checked in both permanent and frozen sections, in combination with conjunctival map biopsies when warranted. Mohs micrographic surgery is an alternative that may provide tissue conservation and lower recurrence rates. Recurrence rates between treatments are difficult to assess because of the small number of cases reported in the literature. In cases with orbital involvement, exenteration may be warranted. Radiation may be useful when surgery cannot be tolerated.