Perineural invasion of cutaneous malignancies.

BACKGROUND: Perineural invasion is an important mode of tumor spread and is associated with increased aggressiveness and a propensity for recurrence among cutaneous malignancies. OBJECTIVE: To review the pathogenesis, diagnosis, and treatment of cutaneous tumors exhibiting perineural invasion. METHODS: This article is based on a review of the medical literature concerning tumors with perineural involvement. RESULTS: This article describes the clinical signs and histologic features of cutaneous malignancies exhibiting perineural involvement. CONCLUSION: Appropriate patient care mandates consideration of perineural invasion in the evaluation of cutaneous tumors. As the majority of patients present without symptoms of neural involvement, physicians must be vigilant in the search for this type of tumor spread.

Malignant melanoma: a clinical review.

The incidence of cutaneous malignant melanoma is increasing at an alarming rate. It is projected that Americans born in the year 2000 will have a 1 in 75 lifetime risk of developing melanoma. Long-term survival for patients with metastatic disease is only 5% and approximately 15% of patients diagnosed with melanoma eventually die from their disease. Conversely, the prognosis for early disease is excellent and often simple surgical excision is curative. It is therefore crucial that the practicing physician becomes familiar with all of the clinical and histologic presentations in order to ensure an accurate and prompt diagnosis. This, in turn, should lead to earlier detection and a more favorable prognosis.

Ocular melanoma.

The eye is the second most common site for primary melanoma after the skin. An ophthalmologic evaluation should be an integral aspect of melanoma screening that is often not even considered by nonophthalmologists. Delays or failures to make an accurate and early diagnosis can have grave consequences. Early recognition and diagnosis, before the tumor has progressed into an advanced process with a poor prognosis, can often result in complete cures through early interventional treatments. It is imperative that physicians adequately understand and appropriately examine or refer patients for appropriate screening for ocular melanoma as a routine practice in screening for melanoma. This article is intended to raise the clinical awareness of the practicing physician regarding this disease.

Current therapy of cutaneous melanoma.

We review the current therapy for cutaneous malignant melanoma. Early surgical resection offers the best likelihood of cure. The initial staging of melanoma patients determines subsequent therapeutic decisions and follow-up care. The prognosis and appropriate therapy for each stage of melanoma are discussed. We review the controversy over lymph node dissection, and recent recommendations for the use of lymphoscintigraphy. Interferon-alpha continues to be the only Food and Drug Administration-approved adjuvant therapy for high-risk patients. In addition, the follow-up care of melanoma patients will be discussed.

Mohs' micrographic surgery for nonmelanoma skin cancers.

The incidence of NMSC is increasing at a phenomenal rate, with a current estimated annual incidence in the United States of more than 600,000 cases. It is vitally important for all surgeons to become familiar with all modalities, surgical as well as nonsurgical, that are used to treat these skin cancers. This article was designed to inform the reader about the surgical technique called MMS (Figs. 9 and 10), and to present the facts regarding its historical evolution, actual technique, indications, and limitations. MMS has been modified and refined over a period spanning 60 years. During this time, tens of thousands of tumors have been treated, and the literature supports the fact that MMS provides the highest possible cure rates for the treatment of NMSCs.

Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor of the skin; its microscopic extent of invasion beyond the grossly visible tumor is frequently difficult to appreciate. Although wide local excision has been the standard treatment of DFSP, recurrence rates range from 11% to 53%. Because Mohs micrographic surgery allows the extent of excision to be tailored to the microscopic extent of tumor, we evaluated this technique for the treatment of primary and recurrent DFSP. OBJECTIVE: Our purpose was to determine the local recurrence rate and microscopic extent of spread of primary and recurrent DFSP after treatment with Mohs micrographic surgery. METHODS: The records of 58 patients with primary and recurrent DFSP treated with Mohs micrographic surgery at three institutions were reviewed and the macroscopic and microscopic extents of tumor were recorded. RESULTS: One patient with a twice-recurrent DFSP had another recurrence after Mohs micrographic surgery, for an overall local recurrence rate of 2% (zero for primary tumors and 4.8% for recurrent tumors). There were no cases of regional or distant metastases. Macroscopic tumor size ranged from 0.3 x 0.6 cm to 30 x 20 cm, whereas microscopic (postoperative) size ranged from 1.8 x 1.0 cm to 35 x 40 cm. We calculated the likelihood that a given width of excision around the macroscopic tumor would clear the entire microscopic extent of tumor. Standard wide excision with a width of 1 cm around the primary tumor would have left microscopic residual tumor in 70.7%; a width of 2 cm, 39.7%; 3 cm, 15.5%; and 5 cm, 5.2%. Even an excision width of 10 cm would not have cleared the microscopic extent of some tumors, despite taking a huge excess of normal tissue. CONCLUSION: Treatment of primary and recurrent DFSP by Mohs micrographic surgery results in a low recurrence rate because of the ability of the technique to permit the detection and excision of microscopic tumor elements in even the most asymmetric tumors. Whatever type of surgery is chosen to treat DFSP, it is necessary to assess the entire perimeter of the tumor for microscopic extension and to achieve tumor-free margins in all directions.

The efficacy of dermabrasion in the treatment of nodular amyloidosis.

Nodular amyloidosis is a rare entity that predominantly affects females in the sixth and seventh decades. Frequent cutaneous sites of involvement are the extremities, trunk, and genitalia. Numerous cosmetic procedures have been employed to treat the lesions of nodular amyloidosis. Dermabrasion, which was performed on the lesions of nodular amyloidosis on the chin after surgical debulking, proved successful in the treatment of localized nodular amyloidosis. Follow-up at 26 months showed no clinical evidence of recurrence. Dermabrasion offers another acceptable modality for cosmetic treatment of nodular amyloidosis.

A comparison of wire brush and diamond fraise superficial dermabrasion for photoaged skin. A clinical, immunohistologic, and biochemical study.

BACKGROUND: Superficial dermabrasion has a proven beneficial effect on photoaged skin, but little is known about the differences between the two major modalities used in dermabrasion, the diamond fraise (DF) and the wire brush (WB). OBJECTIVE: We compared the clinical, immunohistologic, and biochemical changes after superficial dermabrasion with DF and WB. METHODS: Eight photoaged patients (mean age, 68 years; range, 49 to 80 years) underwent facial dermabrasion to the level of the papillary dermis. Clinical assessments were performed at baseline and at 3 and 12 weeks after dermabrasion. Biopsy specimens were taken from both dermabraded halves at the same time points and assessed by routine histologic and immunohistologic examinations, western blot analysis, and radioimmunoassay. Scoring of intracellular and extracellular transforming growth factor-beta 1 was based on a semiquantitative ordinal scale (0 = no staining to 4 = maximum staining) in half-unit increments. The score for each specimen represents the average of values obtained from four high-power fields. RESULTS: Both methods of dermabrasion resulted in significant resolution of actinic keratoses, lentigines, and wrinkling. No statistical significance was noted between the two methods in regard to clinical efficacy. Significantly fewer milia occurred after DF than after WB. Solar elastosis decreased with both the WB and DF. Immunohistologic examination demonstrated a highly significant increase in papillary dermal fibroblast staining for amino terminal procollagen I (type I pN-collagen) at 3 weeks for both DF and WB compared to baseline. Staining at 12 weeks had decreased from the peak noted at week 3, but was still significantly increased from baseline. Western blotting of type I pN-collagen demonstrated a 5.4-fold (p = 0.01) increase from baseline at 3 weeks and a 4.9-fold (p = 0.002) increase at 12 weeks after dermabrasion with the WB. Similarly, the DF produced a 4.9-fold (p = 0.006) increase at 3 weeks and a 5.1-fold (p = 0.008) increase at 12 weeks after dermabrasion. Western blotting of amino terminal procollagen III (type III pN-collagen) showed a 6.1-fold (p = 0.07) increase from baseline at 3 weeks and a 3.9-fold (p = 0.04) increase at 12 weeks after dermabrasion with the DF. The WB showed a 3.8-fold (p = 0.07) increase from baseline at 3 weeks and a 5.1-fold (p = 0.05) increase at 12 weeks. Transforming growth factor-beta 1 demonstrated a significant increase in extracellular staining with DF (3.3 +/- 0.2) and WB (3.7 +/- 0.2) from baseline (1.2 +/- 0.2, p < 0.001) at 3 weeks. CONCLUSION: Superficial dermabrasion with DF and WP appears to be similarly efficacious in the treatment of photoaged skin. Significant increases in type I pN-collagen, type III pN-collagen, and TGF-beta 1 occurred in the papillary dermis after both types of dermabrasion. These results suggest that increased fibroblast activity and consequent collagen I and III synthesis underlie the clinical improvement.

Sebaceous carcinoma.

Sebaceous carcinoma is a rare, aggressive, malignant tumor derived from the adnexal epithelium of sebaceous glands. It may arise in ocular or extraocular sites and exhibits such a variety of histologic growth patterns and diverse clinical presentations that the diagnosis is often delayed for months to years. We discuss incidence as well as clinical, histologic, diagnostic, prognostic, and management issues of this aggressive neoplasm.

The importance of maintaining the alar-facial sulcus in nasal reconstruction.

The alar-facial sulcus is an important topographical region because it represents a junctional zone of three cosmetic units: the nasal base, the medial aspect of the cheek, and the upper lip. Too often, the sulcus is violated by transposition flaps that have been harvested from the cheek to reconstruct defects of the nasal-alar lobule. When the sulcus is violated by surgery, it is difficult to restore a completely natural appearance. For this reason, we suggest an alternative method of reconstructing the alar lobule through the use of an interpolated flap. When defects extend into the alar-facial sulcus, reconstruction of the sulcus is necessary and should be accomplished with a separate skin flap from that used to repair the nasal component of the defect. When a single flap is used to reconstruct both lobule and sulcus, restoration of a completely natural-appearing sulcus is rarely achieved and usually involves multiple surgical procedures often facilitated by aggressive flap contouring, secondary intention healing, and Z-plasty. We describe our methodology in restoring the alar-facial sulcus after nasal reconstruction.

The Rieger flap for nasal reconstruction.

OBJECTIVE: To repair surgical defects of the middle and distal third of the nose. DESIGN: The anatomic and technical design of the Rieger (dorsonasal) flap is described. CONCLUSION: When performed on properly selected patients, the Rieger flap is an aesthetically predictable, one-stage procedure.

Current therapy for cutaneous melanoma.

We review the current therapy for melanoma. The diagnosis, prognostic variables, staging, treatment, and follow-up guidelines for cutaneous melanoma are reviewed from the earliest to the most advanced stages. New guidelines for margins are discussed. A new, evolving, innovative radiographic technique, positron emission tomography using 2-fluorine-18-fluoro-2-deoxy-D-glucose, may be useful to identify subclinical nodal and visceral disease. Recent advances with respect to tumor vaccines, gene therapy, immunotherapy, and interleukin 2 as well as current concepts regarding lymph node dissection are discussed.

The role of dermabrasion and chemical peels in the treatment of patients with xeroderma pigmentosum.

We describe our experience with two patients with xeroderma pigmentosum who underwent periodic trichloroacetic acid chemical peels. One also received a full-face dermabrasion. The effect of chemical peeling was more transient than dermabrasion but was associated with less morbidity. Both chemical peeling and dermabrasion provided a prophylactic effect against the development of skin malignancies; the latter had a more pronounced effect.

Pilot histologic and ultrastructural study of the effects of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin.

BACKGROUND: Chemical peels are employed for a variety of benign and premalignant skin disorders. OBJECTIVE: We compared clinical and histologic features with ultrastructural changes that occur after medium-depth chemical facial peel. METHODS: Three men with actinically damaged facial skin underwent a single 35% trichloroacetic acid peel. Biopsy specimens were taken before the peel, and 2 weeks and 3 months after the peel, for histologic examination, electron microscopy, and gel electrophoresis to assess total collagen type I content. RESULTS: Clinical resolution of actinic damage corresponded with restoration of epidermal polarity. Collagen type I was markedly increased after the peel. Characteristic ultrastructural features of skin after peeling include markedly decreased epidermal intracytoplasmic vacuoles, decreased elastic fibers, and increased activated fibroblasts. CONCLUSION: Electron microscopic studies after a medium-depth chemical peel of photodamaged skin reveal more profound changes than those seen histologically.

Clinical improvement following dermabrasion of photoaged skin correlates with synthesis of collagen I.

BACKGROUND AND DESIGN: The ability of superficial dermabrasion to improve clinical features of photoaged skin is well known, but the specific biological mechanisms involved are poorly understood. The so-called repair zone, as visualized by routine histologic examination, has been attributed to new collagen formation within the papillary dermis and may be responsible for clinical improvement following dermabrasion. We investigated molecular and histologic events occurring in dermabraded skin and correlated them with clinical improvement. Ten photoaged patients (mean age, 59 years) underwent facial dermabrasion to the level of the papillary dermis. Clinical severity of photoaging was graded in a blinded manner at baseline and 12 weeks after dermabrasion. Biopsy specimens obtained at baseline and 3 and 12 weeks after dermabrasion were analyzed histologically and by in situ hybridization for fibroblast procollagen I mRNA, immunohistologically and by Western blotting with a monoclonal antibody specific for the aminoterminal cleavage site of procollagen I. RESULTS: Masson's trichrome staining demonstrated an increase in collagen from baseline (as an upper dermal band in the dermabrasion "repair zone") at 3 and 12 weeks' postdermabrasion. Immunohistologic examination demonstrated papillary dermal fibroblast staining for procollagen I at baseline that increased by threefold at 3 weeks' postdermabrasion and by 1.5-fold at 12 weeks' postdermabrasion. Western blotting demonstrated an average-fold increase in pN collagen I of 4.2 +/- 1.5 at 3 weeks and of 2.7 +/- 0.7 at 12 weeks. By in situ hybridization, baseline levels of procollagen I mRNA in papillary dermal fibroblasts increased sixfold at weeks 3 and 12 postdermabrasion. Increase in procollagen I mRNA correlated with clinical improvement, ie, reduction in wrinkling. CONCLUSION: Superficial dermabrasion clinically improves photoaged skin, and this improvement correlates strongly with increased collagen I gene expression.

Increased expression of matrix metalloproteinase-3 (stromelysin-1) in cultured fibroblasts and basal cell carcinomas of nevoid basal cell carcinoma syndrome.

Nevoid basal cell carcinoma syndrome (NBCCS), an autosomal dominant disorder, is characterized by the development of numerous cutaneous basal cell carcinomas (BCCs). To better characterize this disorder, we examined the expression of matrix metalloproteinase-3 (MMP-3; also known as stromelysin-1) in BCC tumor specimens, adjacent normal skin, and fibroblasts isolated from the normal-appearing skin of NBCCS patients. Three of three BCC tumors obtained from NBCCS patients overexpressed MMP-3 mRNA. In contrast, only 25% of BCC specimens in patients without NBCCS demonstrated overexpression of MMP-3 mRNA. Moreover, fibroblasts isolated and cultured from all nine uninvolved skin specimens of NBCCS patients overexpressed MMP-3 mRNA. MMP-3 mRNA was not detected or was detected at very low levels in normal skin and fibroblast cultures isolated from normal skin in nonsyndrome patients.

Unusual basal cell carcinomas.

The typical features of basal cell carcinoma are well recognized. However, manifestations of uncommon and unusual basal cell carcinomas are less well known. In this review, unusual basal cell carcinomas are described based on their clinical characteristics, histologic appearance, behavior, and treatment.