Mohs micrographic excision of melanoma using immunostains.

BACKGROUND: Mohs excision of melanoma remains controversial, in part because of concerns regarding evaluation of frozen section margins. Several immunohistochemical stains are available for melanoma that can be used on frozen sections. OBJECTIVE: To review our experience with Mohs micrographic excision of melanoma using immunostains. METHODS: Sixty-eight patients were treated, including 46 with melanoma in situ and 22 with invasive melanoma, 62 of which were on the head or neck. HMB-45, MEL-5, Melan-A (A-103), and S-100 stains were employed. RESULTS: Sixty-seven of 68 tumors were excised to clear margins, requiring an average of 2.0 layers. Immunostains greatly enhanced detection of melanoma on frozen sections. The average margin required for clearance of in situ melanoma was 8.3 mm and of invasive melanoma was 11.1 mm. Only 23 of 46 (50%) in situ melanomas were clear with < or =6 mm margins; 15 mm margins were required to clear 96% of the tumors. Eleven of 22 (50%) invasive melanomas were clear with < or =6 mm margins; 26 mm margins were required to clear 95% of the tumors. Melan-A (A-103) was the most consistently crisp and easily interpreted immunostain. CONCLUSIONS: Mohs excision of melanoma using immunostains can be useful, especially for tumors on the head and neck. For routine excision, margins wider than those currently recommended may be required to ensure tumor clearance. We recommend that (1) biopsies be stained preoperatively for Melan-A and/or HMB-45, (2) a debulking layer be obtained for permanent sections prior to Mohs layers, and positive and negative control specimens from the tumor and distant skin should be employed for comparison of staining patterns. Large-scale prospective studies of in situ and invasive melanoma on the head and neck are necessary.

A comparison of Mohs micrographic surgery and wide excision for the treatment of atypical fibroxanthoma.

BACKGROUND: Atypical fibroxanthoma (AFX) is an uncommon spindle cell neoplasm occurring most often in actinically damaged skin of elderly patients. This tumor has invasive potential, may recur locally after excision, and rarely metastasizes. To conserve tissue and improve the likelihood of cure, Mohs micrographic surgery (MMS) has been used for treatment. OBJECTIVE: We review and discuss the Mayo Clinic experience treating AFX with MMS and retrospectively compare the clinical outcome with that in a similar cohort of patients treated with wide local excision (WE). METHODS: The medical records of 45 patients were reviewed at three Mayo Clinic practices. Follow-up data were available for 44 patients: 19 treated with MMS and 25 with WE. RESULTS: In patients treated with MMS, there were no recurrences after a mean follow-up of 29.6 months. There were three first recurrences in 25 patients (12%) treated with WE after a mean follow-up of 73.6 months. One patient had a single local recurrence, and two patients each had two local recurrences. Parotid node metastasis eventually developed in one of the patients with two local recurrences, so that the regional metastatic rate in this series was 4% (1 in 25 patients). CONCLUSION: Microscopic control of the surgical margins with MMS in the treatment of AFX results in a lower recurrence rate than that with WE and conserves normal tissue.

Localized involutional lipoatrophy: a clinicopathologic study of 16 patients.

BACKGROUND: Localized loss of adipose tissue without antecedent clinical or histologic inflammation is termed idiopathic lipoatrophy. OBJECTIVE: Our purpose was to study the clinical and pathologic features in 16 patients with clinically focal lipoatrophy and a distinct pathologic pattern of fat lobule involution. METHODS: A retrospective study of 16 patients was performed. RESULTS: The buttocks and proximal extremities were involved most frequently. Lesions were solitary in 10 patients and multiple in six. Nine patients had received intramuscular or intraarticular corticosteroid or antibiotic injections in the affected areas before the development of lipoatrophy. Histologic examination showed that individual fat cells were decreased in size and separated by hyaline material. Progressive reduction in the size and number of adipocytes resulted in diminutive fat lobules with prominent vessels resembling embryonic fat lobules. Some adipocyte masses were acidophilic. Scattered macrophages, confirmed by immunoperoxidase staining for CD68 (KP-1), were identified within the fat lobules and surrounding connective tissue. Yellow-gray granules were recognized within the cytoplasm of macrophages in nine cases. Macrophages becoming lipophages were observed by electron microscopy in one case. Other inflammatory cells were not prominent. CONCLUSION: This is a common pattern of postinjury response to fat tissue characterized by macrophage infiltration of the fat lobules in variable numbers. The term involutional lipoatrophy is justified by the resemblance of the distinctive pathologic changes to embryonic fat lobules.

Kaposi's sarcoma. An Update.

BACKGROUND: Kaposi's sarcoma (KS) had been an uncommon entity prior to the outbreak of the AIDS epidemic but is now the most common neoplasm occurring in patient's with AIDS. KS occurs in four distinct subsets, each of which the dermatologist is well suited to diagnose and manage. Significant advances have been made recently related to the etiology of KS and new options for treatment. OBJECTIVE: The purpose of this paper is to update clinicians on the diagnosis, etiology, and treatment of KS. METHODS: Articles from the recent dermatologic and nondermatologic literature have been reviewed and summarized. RESULTS: The clinical features of the four subsets of KS are presented. Recent evidence reveals a close association between KS and a new human herpesvirus, termed Kaposi's sarcoma-associated herpesvirus (KSHV), in all subsets of KS. KSHV may play an etiologic role in the development of some cases of KS. Treatment options include local destructive measures and systemic regimens, the choice of which is based on extent of disease, symptomatology, degree of immunosuppression, and concurrent medical problems. New treatments aimed at factors involved in the pathogenesis of KS may provide additional options for the future. CONCLUSION: KS is a disease well suited to diagnosis and management by dermatologists. As more is learned of its etiology and pathogenesis, new therapeutic approaches will continue to be developed.

The coexistence of psoriasis with lupus erythematosus and other photosensitive disorders.

The coexistence of psoriasis with LE or other photosensitive disorders is rare in our patient population, occurring in 0.69% of patients with psoriasis and 1.1% of those with LE. PMLE was the most common cause of photosensitivity in psoriatic patients without LE, occurring in 32%. Less common causes included drug-related photosensitivity (thiazides and thiazide derivatives in four of the five cases), PUVA reactions, and photocontact reactions. The Goeckerman regimen or UVB applied in a cautious, well-controlled atmosphere was generally well tolerated in this group, including patients with PMLE. Photosensitivity occurred in 50% of our patients with psoriasis and LE, and it was secondary to LE in 70% of cases. Most patients were female and had SLE. Psoriasis developed first in 55% of the cases. Studies that were useful for distinguishing photosensitive from nonphotosensitive patients with SLE included determination of antibodies to extractable nuclear antigens (67% versus 14%), double-stranded DNA (64% versus 9%), and skin biopsy for direct immunofluorescence (58% versus 27%). Occasional patients have features suggestive of photosensitivity with or without signs or symptoms of LE. These patients may have atypical psoriatic plaques occasionally yielding routine histology diagnostic of psoriasis with direct immuno-fluorescence results suggestive of lupus. Frequently, connective tissue serology findings are positive, and affected patients require close follow-up for the development of LE. In patients with psoriasis and suspected photosensitivity, we recommend a careful history and examination, skin biopsy for routine histology and direct immunofluorescence, blood tests including determination of antibodies to antinuclear antibodies (Hep-2 substrate if negative on routine substrate), extractable nuclear antigens, and double-stranded DNA, and phototesting when indicated. Large-scale prospective studies are required before the most appropriate therapy for patients with psoriasis and LE can be recommended.

Involutional lipoatrophy: macrophage-related involution of fat lobules.

Involutional lipoatrophy is an apparent idiopathic lipoatrophy with characteristic histopathologic features. We report a patient with a distant history of intramuscular injections and subsequent typical involutional lipoatrophy in whom macrophage invasion of the fat was prominent. Light microscopy revealed small, thin lobules of fat with focally prominent blood vessels and a variably hyaline background. Macrophages containing granular acid mucopolysaccharide material were present in direct apposition to lipocytes, around involuting lobules and between collagen fibers in the neighboring dermis. Focal deposits of iron were observed. Electron-microscopic examination revealed macrophages abutting lipocytes and containing lipid droplets, clear vacuoles and lysosomes in varying proportions. Lipocytes varied in size. The lipid appeared normal in most, but scattered cells contained electron-dense granules or needle-shaped clefts within the lipid. We speculate that previous injections in our patient stimulated a macrophage response, with subsequent regression of lipocytes of the neighboring fat lobules.

Basic cutaneous surgery.

Basic surgical procedures are an integral part of the practice of dermatology. Instruction in basic cutaneous surgery is required of dermatology residency programs, and surgical procedures occupy a significant portion of the practicing dermatologist's time. This paper reviews the basic surgical techniques of fusiform excision, electrosurgery, cryosurgery, and curettage and briefly mentions the use of chemical destruction as it relates to these modalities. These techniques provide the basis for treatment of a multitude of benign and malignant lesions. Familiarity with the use, indications, and contraindications of each technique allows the appropriate choice of treatment for a given lesion, to ensure optimal outcome and minimize the chance of complications.

Subcutaneous T-cell lymphoma. Report of two additional cases and further observations.

BACKGROUND: Peripheral T-cell lymphomas involving subcutaneous tissue are rare. With modern immunohistochemical stains, subcutaneous T-cell lymphomas may be demonstrated in patients previously thought to have fatal Weber-Christian disease, malignant histiocytosis, and histiocytic cytophagic panniculitis. OBSERVATIONS: We describe two young women with subcutaneous lymphomas. They presented with erythematous nodular lesions, which suggested benign panniculitis. Skin biopsy specimens in both patients demonstrated large atypical lymphocytes in the subcutaneous tissue, karyorrhexis, and cytophagia. Immunohistochemical studies confirmed a T-cell phenotype. Molecular genetics studies performed in one patient showed a major T-cell clonal population. CONCLUSIONS: Subcutaneous T-cell lymphoma is a rare, distinct subtype of postthymic peripheral T-cell lymphoma. Cytophagic "histiocytic" panniculitis is frequently a prominent histologic feature. Early systemic chemotherapy may offer therapeutic advantages in patients with this disease.

The nasolabial fold donor site for full-thickness skin grafts of nasal tip defects.

BACKGROUND: The nasal tip has unique skin texture, geographic, and topographic qualities that frequently make repair of defects in this area difficult from the standpoint of function and cosmesis. OBJECTIVE: To assess seven outcome variables of function and cosmesis in 41 patients who underwent nasolabial graft repair for nasal tip defects. METHODS: A retrospective review of photographic and written records as well as person to person and phone interviews with 41 patients who underwent nasolabial graft repair of nasal tip defects after Mohs micrographic surgery was performed. Seven outcome variables were assessed. Follow-up periods ranged from 3 to 28 months. RESULTS: Patient and doctor evaluators rated overall outcome as good or excellent in 95% and 89% of cases respectively. CONCLUSION: We consider the nasolabial graft to be an important reconstructive option for nasal tip defects when the underlying cartilage is not involved.

Dermatologic manifestations of human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) have become major health problems in the United States, and patients with manifestations of these diseases are seen by physicians in all areas of medicine. Cutaneous manifestations develop in as many as 92% of HIV-positive persons. Familiarity with these manifestations facilitates early diagnosis and enhances the care of HIV-infected patients. The spectrum of mucocutaneous disorders in these patients includes an acute exanthem, multiple infections, neoplastic processes, and miscellaneous disorders. Herein we review the most common and the most specific dermatologic manifestations associated with HIV infection, which often are atypical, more severe, or less responsive to treatment than the corresponding diseases encountered in non-HIV-infected persons.