Preoperative expectations and values of patients undergoing Mohs micrographic surgery.

BACKGROUND: Dermatologists have championed Mohs micrographic surgery (MMS) for its unsurpassed treatment success for skin cancers, safety profile, cost-effectiveness, and tissue-sparing quality. It is unclear whether patients undergoing MMS also value these characteristics. OBJECTIVE: To evaluate patients' preoperative expectations of MMS and identify the factors that may influence such expectations METHODS: The study prospectively recruited participants who were newly diagnosed with skin cancer and referred for MMS. A questionnaire listing the characteristics of MMS was given to the participants asking them to score the importance of each characteristic on a 10-point scale. The participants were also asked to provide information regarding their gender, age, subjective health status, education level, family annual income, and their referral source RESULTS: On average, participants placed the highest value, in descending order, on a treatment that yielded the highest cure rate, reconstruction initiation only after complete tumor removal, and the surgeon being a skin cancer specialist. Overall, participants placed high values on characteristics of MMS that dermatologists have long esteemed. CONCLUSION: Our data corroborate that MMS is a valuable procedure that meets the expectations not just of physicians, but also of patients. The authors have indicated no significant interest with commercial supporters.

Sebaceous gland carcinoma of the right flank.

Extraocular sebaceous gland carcinoma is a rare cutaneous malignancy which sometimes can grow rapidly. There is no proven effective treatment for metastatic disease, but the tumor can be successfully treated by surgery if diagnosed early. We report an 83-year-old gentleman with a rapidly growing sebaceous gland carcinoma of the right flank which was initially misdiagnosed as a vascular malformation. By the time he was referred, he had widespread metastatic disease and was a candidate for palliative radiation only.

The role of observation in the management of atypical nevi.

OBJECTIVE: The definition and management of the atypical nevus remains a controversial issue. Some believe that atypical nevi are common variants of benign melanocytic nevi while others believe they are lesions intermediate between benign melanocytic nevi and melanoma. Therefore, the question of whether or not partially removed atypical nevi should be re-excised with clear margins in order to prevent their evolution into melanoma remains unanswered. Although studies have shown that most atypical nevi will never progress into melanoma, re-excision, when biopsy margins are positive, is commonly practiced. We argue that re-excision in such cases is not necessary. METHODS: Our cohort study includes 55 previously biopsied atypical nevi that were not re-excised and which were followed for at least 5 years with a mean follow up time of 6.12 years. RESULTS: The experimental group included 26 atypical nevi whose biopsy revealed at least one involved margin. The control group included 29 atypical nevi whose biopsy revealed clear margins. No melanomas were observed to arise in association with a pre-existing atypical nevus in either the experimental or control group during the follow-up period. CONCLUSIONS: The results of our study support observation as a safe alternative to re-excision for incompletely removed atypical nevi. A large prospective study with longer follow up would be necessary to better answer the question of how often atypical nevi evolve into melanoma and over what time period this occurs.

Sentinel lymph node biopsy for high-risk nonmelanoma skin cancers.

BACKGROUND: Although the utility of the sentinel lymph node biopsy (SLNB) in the staging of melanoma is well established, its usefulness in high-risk nonmelanoma skin cancer (NMSC) is yet to be determined. OBJECTIVE: The objective was to report our experience with patients who underwent SLNB for the staging of a high-risk NMSC. MATERIALS AND METHODS: We identified 13 patients with a high-risk NMSC who underwent SLNB between 1998 and 2006 and conducted a retrospective review of their medical records and tumor pathology. Their status as regards tumor recurrence and survival was obtained when possible. RESULTS: Of 13 patients, 9 had squamous cell carcinoma (SCC), 2 had sebaceous gland carcinoma, 1 had porocarcinoma, and 1 had atypical fibroxanthoma. All SLNB were negative for metastatic disease, but 1 appeared to be a false-negative finding. CONCLUSION: Compared to melanoma, SCC of the skin are much less predictable as regards their tendency to metastasize to the regional lymph nodes. Although the SLNB appears to be a reliable staging procedure for NMSC (especially SCC), the yield may be too low to justify its routine use in this patient population. More data are needed to determine when a SLNB is justified in the management of NMSC.

The density and distribution of melanocytes adjacent to melanoma and nonmelanoma skin cancers.

BACKGROUND: The determination of clear margins during Mohs surgery for melanoma in situ arising on sun-damaged skin is often made difficult by the presence of background atypical melanocytic hyperplasia. OBJECTIVE: To determine the density and distribution patterns of melanocytes adjacent to melanoma and nonmelanoma skin cancers. METHODS: 180 skin specimens obtained during the routine repair of defects resulting from the removal of melanoma and nonmelanoma skin cancers were analyzed using H and E-stained permanent sections to determine the quantity and distribution of epidermal melanocytes. RESULTS: The mean melanocyte density was 7.97 melanocytes per 1 mm of epidermis (SD,+/-6.7). Contiguous melanocytes were found in 30 (16.7%), atypical melanocytes were observed in 8 (4.4%), and follicular extension of melanocytes was observed in 11 (6.1%) of the specimens. These features were significantly associated with higher melanocyte densities (p< .001) and were more commonly observed in specimens from patients with melanoma. CONCLUSIONS: There is a high degree of variability in melanocyte densities seen adjacent to melanoma and nonmelanoma skin cancers. Contiguous melanocytes, atypical melanocytes, and follicular melanocytes can be seen in the sun-damaged skin surrounding both melanoma and nonmelanoma skin cancers, but especially with melanoma. Because some of the features of melanoma in situ can be seen in chronically sun-damaged skin, the Mohs surgeon should be cautious when assessing the margins for melanoma in this setting.

Aggressive squamous carcinomas of the scalp.

BACKGROUND: Squamous cell carcinomas of the scalp sometimes exhibit unusually aggressive behavior. OBJECTIVE: To describe a series of 11 cases of extraordinarily aggressive squamous cell carcinomas of the scalp. METHODS: These cases were selected based on a number of criteria including their tendency to recur after Mohs surgery, their propensity to develop satellite lesions, their tendency to invade bone, and their tendency to metastasize to regional nodes and systemically. A chart review was performed for each patient. RESULTS: Five of 11 patients have succumbed to their disease. Of note is that the patients all had significant long-standing alopecia or thinning of their hair with marked actinic damage. Initial biopsies of the tumors revealed them to be either moderate or well-differentiated. Four of 11 patients developed satellite lesions and experienced recurrences despite obtaining clear margins with Mohs micrographic surgery. CONCLUSION: Squamous cell carcinomas of the scalp may metastasize and cause death. Thus, early diagnosis and treatment of these neoplasms is mandatory. In the setting of satellitosis, it is believed that it is best to perform a wide excision with margin control followed by split-thickness grafting and postoperative irradiation. The employment of radiation therapy, however, should be done with appropriate caution owing to the significant risk of osteoradionecrosis.

Basal cell carcinomas with unusual histologic patterns.

Uncommon histologic variants of basal cell carcinoma (BCC) can present a diagnostic challenge. In this case series, we describe 3 patients with unusual BCCs encountered in a dermatologic surgical unit over a 1-year period from September 2003 to September 2004. The formalin-fixed, paraffin-embedded histologic specimens were initially examined microscopically after staining with hematoxylin and eosin. Additional stains, including diastase periodic acid-Schiff, colloidal iron, carcinoembryonic antigen, and cytokeratin-20, were subsequently performed as appropriate. Of the 3 lesions, one exhibited apocrine differentiation and two demonstrated a trabecular growth pattern. Although BCCs demonstrating apocrine differentiation have previously been described, a trabecular growth pattern, to our knowledge, has not been previously reported for BCC.

Occurrence of subclinical tumor in excised facial subunits.

OBJECTIVE: To determine the incidence of subclinical tumor in excised facial subunits in patients undergoing reconstruction after Mohs surgery. DESIGN: The study group comprised 45 patients who had their Mohs defects repaired by a facial plastic surgeon at a tertiary care center (university hospital). In the group, there were 74 biopsy-proved cutaneous neoplasms of the face. The median age of the group was 67 years. Nineteen patients (42%) had multiple tumors. There were 63 basal cell carcinomas (85%) and 11 squamous cell carcinomas (15%). Forty-seven tumors (64%) were primary and 27 (36%) were recurrent. Reconstruction of the defects was based on the principle of aesthetic subunits. Excised subunits were examined by the Mohs surgeon. Further excisions were performed, as necessary, if tumor was present in the subunit. RESULTS: Five patients (11%) had subclinical basal cell carcinomas in their excised facial subunits. Four patients underwent further resections. CONCLUSIONS: In patients with severe sun damage, recurrent tumors, and a history of skin cancer, clinically normal tissue excised during the reconstruction of their Mohs defects may contain subclinical tumor. Consequently, when these "high-risk" patients undergo reconstruction, excised facial subunits should be submitted for pathologic examination.

The role of Mohs' micrographic surgery in the management of skin cancer and a perspective on the management of the surgical defect.

In the past 30 years, MMS has become recognized as the treatment of choice for certain uncommon cutaneous neoplasms and for certain variants of BCC, squamous cell carcinoma, and melanoma. It offers an extremely high cure rate and maximally preserves healthy tissue, which often allows for preservation of function as well as an optimal cosmetic outcome. Because it is performed in an office setting under local anesthesia, MMS is a very cost-effective procedure and often extends operability to patients who are poor candidates for general anesthesia. In the past 30 years, MMS has evolved in a number of ways. The fixed tissue technique is uncommonly employed today. This makes the procedure less painful and faster and allows for immediate reconstruction. In addition, because statistics have demonstrated the reliability of MMS, it has become less necessary to delay definitive reconstruction or use temporizing measures. With experience and training, more Mohs' surgeons have become adept at repairing the surgical defects they create; nevertheless, at times, it is necessary for the Mohs' surgeon to call on his or her colleagues to reconstruct the Mohs' defect or to assist in ridding patients of their cancer. At times, a multidisciplinary approach may provide the best care for patients. It also encourages collegiality and this has led to increasing respect for MMS by other surgical disciplines in the past 30 years.

Extensive angiosarcoma on chronically sun-damaged skin.

Cutaneous angiosarcoma of the face and scalp is a rare malignant vascular tumor that most often occurs in the white elderly males. No clear etiologic factors have been associated with the development of this aggressive neoplasm. Due to delay in diagnosis, inability to adequately define clinical and surgical margins, and its high local recurrence and metastatic rates, angiosarcomas generally have a poor prognosis. Histologic evaluation of angiosarcoma can be somewhat difficult due to the varying patterns of differentiation. We present a case of angiosarcoma arising on chronically sun-damaged skin and review the histopathology and prognostic factors important in this malignancy.

Delayed full-thickness skin grafts revisited.

BACKGROUND: There are many options for the management of surgical defects after Mohs micrographic surgery (MMS). For patients with complex defects who are not candidates for immediate grafting or who lack appropriate donor skin for a flap or who do not desire to undergo a major flap procedure, delayed full-thickness skin grafting (FTSG) may be an option. OBJECTIVE: To determine the role and usefulness of delayed FTSG in the management of Mohs surgical defects. METHODS: The records of 70 patients, seen over a 5-year period, who had their Mohs surgical defects repaired with a FTSG or who were scheduled for a delayed FTSG, were reviewed, along with their accompanying photographs (when available). The outcome of immediate and delayed FTSG was compared in terms of (1) graft loss, (2) epidermal sloughing, (3) thickening and/or irregularity, (4) contour correction, (5) hypopigmentation/hyperpigmentation, (6) persistent erythema, and (7) need for surgical revision. RESULTS: Twenty-seven patients underwent immediate FTSG, and 20 patients underwent delayed FTSG on an average 3.6 weeks after Mohs surgery. Twenty patients, originally scheduled for a delayed FTSG, were allowed to heal by second intention, with a very satisfactory cosmetic result in most instances. When patients undergoing immediate FTSG were compared with those undergoing delayed FTSG, there was essentially no difference in the two groups, as judged by the parameters cited previously here. CONCLUSION: Delayed skin grafting is often a viable option for patients undergoing Mohs surgery who are not candidates for immediate FTSG or who lack appropriate donor skin for a flap or who do not desire a major flap repair. It also has the added advantage in that as these patients are monitored in preparation for delayed grafting, it quite often becomes obvious that a significant proportion (more than 50%) can be allowed to heal by second intention with a satisfactory cosmetic result.

Management of actinic keratoses.

Actinic keratoses are quite common. Since they represent the initial stage in the evolution of squamous cell carcinoma, recognition and treatment are important. Recently, new treatment modalities have become available including immune modulators, photodynamic therapy, and topical nonsteroidal anti-inflammatory agents.

Current concepts in the management of patients with melanoma.

Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.

Prognostic factors for metastasis in squamous cell carcinoma of the skin.

BACKGROUND: Squamous cell carcinoma (SCC) of the skin exhibits a significant propensity to metastasize. A number of variables have been reported to influence the tendency of SCC to metastasize. Because of the increasing incidence of skin cancer, it is becoming increasingly important to identify those neoplasms which are biologically more aggressive. We report 25 cases of metastatic SCC and compare them to 175 cases of nonmetastasizing SCC treated during the same period. OBJECTIVE: To characterize tumors with the greatest tendency to metastasize. METHODS: A tumor registry from the Dermatologic Surgery Unit at the Medical University of South Carolina was accessed to obtain records on 200 patients diagnosed with invasive SCC managed by Mohs surgery from 1988 to 1998. A retrospective analysis was conducted. The characteristics of patients with metastatic SCC and those with nonmetastatic SCC were compared using the chi-squared test and Fisher's exact test. RESULTS: Of 200 tumors, 25 (12.5%) metastasized. Size, Clark's level, degree of differentiation, the presence of small tumor nests, infiltrative tumor strands, single-cell infiltration, perineural invasion, acantholysis, and recurrence all correlated strongly with metastasis. Location, ulceration, inflammation, and Breslow depth did not correlate with the development of metastasis. CONCLUSION: Patients with tumors that exhibit certain clinical and histologic features are more likely to metastasize and need close follow-up to detect recurrence and metastasis early, allowing for appropriate life-saving intervention. Sentinel lymph node biopsy should be considered in patients with high-risk SCC.