2005 ASDS-ACMMSCO Combined Annual Meeting:
Mohs Accepted Abstracts
Bilateral Vermilion Flap for Lip Reconstruction
Authors: Andrew J. Kaufman, MD
Purpose: Because of the central facial location and primary functional and aesthetic importance of the lips, successful repair is critical in this location. Numerous procedures to reconstruct the lip have been reported; however, many result in a significant decrease in the oral aperture as well as dysesthesias, limitation of mobility, and significant scarring.. The purpose was to describe a novel reconstructive option that repairs with skin of similar characteristics and avoids crossing into adjacent cosmetic subunits or sacrifice of normal skin or muscle. The proposed procedure is able to repair large surgical defects in one-stage and minimize risk of nerve damage, scarring or functional impairment.
Design: The bilateral vermilion rotation flap permits repair within cosmetic subunits, repairs with skin of identical surface characteristics, and avoids surgery to the adjacent cutaneous or muscular portions of the lip. Risk of injury to neurovascular structures is minimized through flap design.
Summary: The procedure provides an excellent repair for selected defects of the vermilion lip by following guidelines for optimum aesthetic and functional repair (i.e. repair within cosmetic subunits using skin of identical characteristics while avoiding trauma to the uninvolved cutaneous lip or orbicularis oris). It avoids a cross-lip, staged or wedge repair of the lip and can reconstruct large defects of the vermilion.
Conclusions: The bilateral vermilion rotation flap is a useful technique for repair of surgical defects on the vermilion lip. It avoids unnecessary sacrifice of cutaneous or muscular lip tissue and provides an excellent cosmetic and functional result.
The Use of a Microscope Grid to Precisely Localize Tumor and Holes on Mohs Sections
Authors: Hugh M. Gloster, Jr. MD
Purpose: During the microscopic evaluation of Mohs sections, tumor in deeper sections may appear to clear but holes in the section may make it difficult to determine whether the tumor cleared or simply "fell out" in the hole. This dilemma may be solved by using the pointer arrow in the microscope and a removable microscope reticle with a grid in the lens to localize residual tumor. At 2X magnification, one of the reticles is removed and replaced by a reticle containing a 9mm x 9mm grid consisting of 3x3 (9) squares. An intersecting line of the grid is placed on a point of reference on the Mohs section and the surgeon notes which of the 9 square(s) contains tumor. The pointer arrow is then placed on the residual tumor . The grid is placed on the exact same point of reference as the surgeon scans each section deeper in the tissue block. Consequently, on each section the square(s) will roughly localize residual tumor and the pointer arrow will precisely localize residual tumor, allowing the surgeon to determine if the tumor clears or "falls out". Thus, the surgeon can confidently determine if tumor has been eradicated or another layer is necessary.
The Accuracy of Bread-Loafing in Detecting Residual Basal Cell Carcinoma at the Surgical Margins of an Elliptical Excision Specimen
Authors: Arash Kimyai-Asadi, MD, Leonard H. Goldberg, M.D., Ming H. Jih, M.D., Ph.D.
Purpose: There has been no published study estimating the proportion of positive surgical margins that is missed when bread-loafing is used to histologically evaluate surgical margins.
Design: 42 small, well-defined, primary, non-morpheic facial basal cell carcinomas that had positive surgical margins utilizing en-face Mohs sections after elliptical excision with 2 mm margins were included. Transparencies with parallel lines spaced at 4 mm intervals were superimposed on the histologic slides. Areas in which the lines intersected tumor at the surgical margin were noted.
Summary: The 42 tumors had a total of 50 positive surgical margins. Overall, the cross-sectional lines intersected tumor 44% of the time (95% confidence interval 37-51%). Only 5 (10%) of the residual tumors at the surgical margins exceeded 4 mm in their longitudinal dimension. In the 9 sections containing tumor in the deep margin, tumor intersected the lines 39% of the time.
Conclusions: Bread-loafing at 4 mm intervals of elliptical excision specimens from facial basal cell carcinomas excised with 2 mm surgical margins is 44% sensitive in detecting residual tumor at the margins. We recommend en-face tissue orientation (Mohs surgery) to identify residual tumor and reduce the risk of tumor recurrence after elliptical excision of facial basal cell carcinomas.
Efficacy of Narrow-Margin Excision of Well-Demarcated Primary Facial Basal Cell Carcinomas
Authors: Arash Kimyai-Asadi, MD, Murad Alam, M.D., Leonard H Goldberg, M.D., S. Ray Peterson, M.D., Sirunya Silapunt, M.D., Ming H Jih, M.D., Ph.D.
Purpose: As 4 mm surgical margins are often not feasible on the face due to cosmetic and functional concerns, an appropriate margin is often determined by the surgeon based on clinical features of the tumor. We performed a study of the efficacy of narrow-margin elliptical excision for small, well-demarcated facial basal cell carcinomas.
Design: 134 primary, small (
Summary: On average, the tumors measured 0.6 x 0.5 cm. Twenty-seven (20.1%) had positive margins, requiring additional excisions. Excisions with 1, 2, and 3 mm margins were associated with positive margins in 16%, 24%, and 20% of tumors, respectively. There was no statistically significant difference in the occurrence of positive margins based on tumor size, anatomic location, or the measured margin used.
Conclusions: Narrow margins are inadequate for the excision of facial basal cell carcinomas. These tumors should be treated with standard margins or Mohs micrographic surgery.
Diffuse Epidermal and Periadnexal Squamous Cell Carcinoma in Situ
Authors: Arash Kimyai-Asadi, MD, Leonard H. Goldberg, M.D.
Purpose: Diffuse epidermal and periadnexal squamous cell carcinoma in situ (DEPS) is a condition in which large areas of skin are affected by atypical keratinocytes that grow beneath the epidermis and encase adnexal epithelia. Normal differentiation of the overlying epidermis and adnexal epithelium is seen. Our aim is to describe the clinical features of DEPS.
Design: We describe a series of 13 patients with DEPS.
Summary: All 13 patients were fair-skinned men over age 50 with significant sun exposure. Lesions were present on the scalp, face, and neck. Histologically, there is a growth of atypical keratinocytes in the lower epidermis with encasement of adnexal structures. In the 52 cumulative patient-years of follow-up, we treated 80 invasive squamous cell and 48 basal cell carcinomas in these patients. Despite improvement of DEPS with aggressive topical and destructive therapy, multifocal recurrence would develop within a few months.
Conclusions: DEPS is characterized by diffuse involvement of chronically sun-exposed skin with atypical keratinocytes grow along the inferior portion of the basal layer of the epidermis and around adnexal structures. The treatment of DEPS is challenging due to its widespread nature and deeper periadnexal involvement. DEPS is also associated with the development of invasive squamous and basal cell carcinomas.
Repair of Partial-thickness Mohs Defects of the Vermilion Lip with Combination Graft and Mucosal Advancement
Authors: Maralyn B. Seavolt, MD, Michael McCall, M.D. Univ. of Louisville, Div. of Dermatologic Surgery
Purpose: Following Mohs micrographic removal of skin cancers on the lips, repair of defects can be problematic. Lip wedge repair, mucosal advancement and secondary intention healing are all repair options but carry the risk of possible side effects. We would like to present an alternative repair technique for this defect.
Design: This repair of partial-thickness lip defects involves harvesting a small periauricular full-thickness graft and suturing into place near the vermilion border or anterior wound. The posterior half of the wound is closed with mucosal advancement. A small bolster dressing is sutured into place over the graft and removed in one week.
Summary: We have performed this repair on a few patients and have achieved good cosmesis without loss of lip function.
Conclusions: The combination of mucosal advancement and graft repair of partial-thickness lip defects gives the Mohs surgeon another viable option for lip repair with decreased risk of lip dysesthesia or decreased lip function.
Microstaging Accuracy Following Subtotal Incisional Biopsy of Cutaneous Melanoma
Authors: Darius James Karimipour, MD, Jennifer Schwartz, Timothy Wang, Timothy Johnson, Jeffrey Orringer, Chris Bichakjian, Anya King, University of Michigan, Conway C. Huang : University of Alabama
Purpose: Background: A significant portion of cutaneous melanoma may remain following subtotal incisional biopsy. The accuracy of microstaging and impact on clinical practice in this scenario is unknown. Objectives: Examine microstaging accuracy of an initial incisional biopsy with significant clinical lesion remaining (=50%).
Design: Methods: Patients with cutaneous melanoma, diagnosed by incisional biopsy with =50% remaining lesion were prospectively evaluated for microstaging accuracy, comparing initial Breslow depth (BD1) to final depth (BD2) following excision of the residual lesion. Impact on prognosis and treatment was also evaluated.
Summary: Results: Two hundred fifty (14%) of 1783 patients presented with =50% residual clinical lesion following incisional biopsy. Mean BD1 was 0.66 mm, mean BD2 1.07 mm (p=.001). After complete excision of the residual lesion, upstaging occurred in 21% and 10% became candidates for sentinel node biopsy.
Conclusions: Conclusion: An incisional biopsy with = 50% clinical lesion remaining may be inadequate for accurate microstaging of melanoma. This scenario is relatively uncommon but clinically significant.
A Mathmatical Model for MOHS Error
Authors: Tony Wong, MD, Daniel M Siegel; SUNY Downstate Department of Dermatology, Tatiana Khrom; SUNY Downstate Department of Dermatology, Jeffrey Ellis; SUNY Downstate Department of Dermatology
Purpose: Over the past sixty years, Mohs micrographic surgery has become the standard of care in the management and treatment of skin cancer. Unlike standard vertical sectioning, the horizontal sectioning utilized by the Mohs technique allows a full view of surgical margins and has a reported cure rate of over 99%. Differences in operator technique, however, introduce variability into our ability to fully view the surgical margins. In this manuscript, we present a mathematical model of potential error during the processing of Mohs specimens.
Summary: Via this model, it becomes clear that the false positive and false negative error rate directly increases with multiple sectioning of Mohs specimens.
Conclusions: Therefore, we advocate minimal division of Mohs specimen to keep the inherent error rate to a minimum.
An international survey on the current use of oral retinoids in transplant recipients: indications, monitoring, and management of adverse effects
Authors: Bradley Kovach, MD, Clark C. Otley, MD; Mayo Clinic, Rochester, MN, Thomas Stasko, MD; Vanderbilt University, Nashville, TN
Purpose: Solid organ transplant recipients are a growing population at high risk for developing skin cancers, causing significant morbidity and mortality. Management of skin cancers in this population is challenging, making prevention an important goal. Several small randomized-controlled trials and multiple small, uncontrolled series have supported the use of oral retinoids for chemoprevention of skin cancers in solid organ transplant recipients.
Design: To further clarify the manner in which systemic retinoids are currently used in transplant recipients, we surveyed members of the International-Skin Cancer Collaborative (ITSCC) and Skin Care in Organ Transplant Patients Europe (SCOPE), two groups of practitioners who frequently treat transplant patients, attending a scientific meeting in August 2004 with a questionnaire. The survey was designed to elucidate the indications for initiating retinoids, dosages used, methods for monitoring patients, and management of adverse effects.
Summary: The results indicate that a majority of the respondents, approximately 80%, use oral retinoids in transplant recipients. The decision to initiate retinoids is influenced by the number and severity of squamous cell skin cancers appearing yearly and the extent of concomitant actinic keratoses. Initial doses of 10 milligrams or 25 milligrams of acitretin daily are most often used, with a majority of respondents using a maintenance dose of 25 milligrams daily. Screening labs are often checked monthly while an optimal maintenance dose is being determined, and every 3 months during maintenance therapy. Most clinical adverse effects are managed symptomatically or with dosage reduction, whereas most laboratory abnormalities result in dosage reduction. Elevations of serum creatinine or skeletal effects are more likely to prompt discontinuation of retinoids or referral to a specialist.
Conclusions: Immunosuppressed solid organ transplant recipients are a population at high risk for developing aggressive cutaneous neoplasms, and thus are candidates for prophylactic and suppressive strategies such as the use of oral retinoids. We propose that those situations in which at least 66% of our respondents sometimes or usually use oral retinoids to be strong indications for their use, and those situations in which 33 to 65% of respondents consider their use to be lesser indications. We also propose a schedule for laboratory monitoring of solid organ transplant recipients receiving oral retinoids based on the responses of the survey. In the absence of large randomized-controlled trials, the practices of physicians experienced in managing transplant recipients, such as provided by this survey, provide a useful guide for the use of retinoids in these patients.
Acellular Dermal Matrix (AlloDerm) Grafting For Large Wounds After Mohs Micrographic Surgery
Authors: Ashraf Hassanein, MD, PhD, Steven A. Proper,M.D. Center for Dermatology & Skin Surgery, Tampa-Florida, Nadia S. Urato, M.D. Boston, MA
Purpose: Background : Acellular dermal matrix (AlloDerm) is an allograft processed from human cadavers. It provides bioactive components and the extracellular matrix that serves as a foundation for tissue remodelling. It is available in variable thickness, and has primarily been used for reconstruction after cutaneous burns. Objectives : Our aim was to assess the effectiveness, ease and cosmetic acceptance of AlloDerm as a graft for reconstruction of large Mohs Micrographic Surgery (MMS) defects. These defects were suboptimal for conventional autologous grafting, particularly in selected patients with other comorbidities.
Design: Methods : Delayed wound closure with AlloDerm was planned in three patients with large defects on the face, great toe and scalp after MMS for morpheaform basal cell carcinoma, malignant melanoma in-situ and squamous cell carcinoma in-situ, respectively. The patients were evaluated at weeks 1,2,3,4,6,8 and 12 and an assessment of wound coverage, patient satisfaction and presence of infection was done.
Summary: Results : Wound coverage during all the follow-up visits for all patients ranged from 80-100%. On a scale of 1-10 with ten being complete satisfaction, patient satisfaction ranged from 8-10. there were no signs of infection during any of the follow-up visits.
Conclusions: Conclusion : AlloDerm is effective in revascularizing and repopulating dermal and epidermal tissues in large defects after MMS. the results are cosmetically acceptable to both the patients and the surgeons. There is no evidence of increased incidence of infection.
Basal cell carcinoma with mixed histology: a possible pathogenesis for recurrent skin cancer
Authors: Philip R. Cohen, MD, Keith E. Schulze, M.D.; Dermatologic Surgery Center of Houston, Houston, TX, Bruce R. Nelson, M.D.; Dermatologic Surgery Center of Houston, Houston, TX
Purpose: Skin cancer recurrence results from the persistence of the previously treated tumor. Basal cell carcinoma (BCC) with mixed histology is a cutaneous neoplasm which demonstrates two or more pathologic patterns of tumor within the same neoplasm, such as superficial BCC in the papillary dermis and sclerosing BCC in the deeper dermis. Inadequate treatment of BCC with mixed histology may represent an unsuspected etiology for recurrent skin cancer. For example, a patient presents for evaluation of a cutaneous lesion for which the diagnosis of skin cancer is clinically entertained and a superficial shave biopsy is performed. The deep margin of the specimen only extends into the papillary dermis, the pathology report diagnosis is superficial BCC, and the patient is treated with imiquimod 5% cream. However, if sclerosing strands of BCC are present in the reticular dermis of this tumor, they remain undetected by the physician and undiagnosed by the pathologist; hence the patient's BCC is being inadequately-albiet unintentionally-treated. Subsequently, the skin cancer may persist following therapy that was only directed towards its superficial component. Eventually, the residual deep component of the cancer may manifest clinically as recurrent tumor.
Design: We prospectively evaluated the incidence and characteristics of BCC with mixed histology in patients with BCC who were referred to us for tumor removal using the Mohs micrographic surgical technique during a period of three months from November 6, 2004 to February 18, 2005. Microscopic sections from specimens obtained at surgery were evaluated. Sections that were positive for cancer after the first stage of excision were examined for one or more pathologic patterns of tumor: (1) nonaggressive growth patterns (superficial, nodular, and follicular) or (2) aggressive growth patterns (keratinizing and sclerosing or infiltrative) or (3) both.
Summary: Tumor was present on the tissue sections from 114 of 243 BCC after the first stage of Mohs excision. More than one pathologic pattern of BCC was observed in 49 (43%) of the cancers: superficial (20 tumors), nodular (41 tumors), follicular (16 tumors), keratinizing (5 tumors) and sclerosing (39 tumors). Two different growth patterns were detected in 28 tumors (57% of patients), three patterns in 19 tumors (39% of patients), and four patterns in 2 tumors (4% of patients). Thirty nine of the 49 (80%)BCC with mixed histology-which represents more than one-third of the BCCs that had residual tumor after the first Mohs stage-had a nonaggressive pattern of tumor growth associated with an aggressive pathologic pattern of the cancer.
Conclusions: BCC with mixed histology are not uncommon. Although none of the pathology reports from the initial cancer biopsies indicated that the tumors had mixed patterns of histologic growth, we observed BCC with more than one pathologic pattern of tumor growth in over 40% of the cancers referred to us for removal using Mohs micrographic surgery. Importantly, 80% of the BCC with mixed histology had an unsuspected aggressive pathologic pattern of growth in addition to the diagnosed nonaggressive tumor pattern. A possible mechanism for the recurrence of BCC may result from the inadequate initial treatment of unsuspected tumors with mixed histology: if a clinician receives a report diagnosing a superficial BCC after a superficial biopsy has been performed, the sclerosing component-in the deeper portion of the tumor-will not only remain undetected, but also unsuspected; eventually, clinical recurrence of the cancer may result if the patient is treated using a modality that is only appropriate for tumor subtypes with nonaggressive histologic features. Also, to ensure complete pathologic evaluation of all surgical margins for any residual cancer, we suggest that clinicians consider Mohs surgical excision of BCCs with mixed histology.
Increased Metastasis and Mortality From Cutaneous Squamous Cell Carcinoma in Patients With Chronic Lymphocytic Leukemia
Authors: Khosrow Mehrany, MD, Roger H. Weenig, MD; Mayo Clinic, Rochester MN, Ken K. Lee, MD; Oregon Health & Sciences University, Mark R. Pittlekow, MD; Mayo Clinic, Rochester MN, Clark C. Otley, MD; Mayo Clinic, Rochester MN
Purpose: In patients with chronic lymphocytic leukemia, squamous cell carcinoma behaves aggressively. Our purpose was to compare squamous cell carcinoma metastasis and mortality between patients with chronic lymphocytic leukemia and controls.
Design: Medical records were assessed retrospectively for 28 patients with chronic lymphocytic leukemia who underwent surgical excision of cutaneous squamous cell carcinoma and for 56 matched controls. The rate of metastasis and mortality from cutaneous squamous cell carcinoma were determined on a per-patient basis.
Summary: Three of 28 patients with chronic lymphocytic leukemia had metastasis and died of metastatic disease. No metastases or deaths occurred among the 56 controls. Compared with controls, chronic lymphocytic leukemia patients with cutaneous squamous cell carcinoma were more likely to have metastasis (P=.0031) and die of metastasis (P=.0033).
Conclusions: Among patients with chronic lymphocytic leukemia, surveillance for skin cancer and a decreased threshold for biopsy of suspicious lesions are warranted.
A Better technique for taking MOHS sections involving cartillage
Authors: Ravi Krishnan, MD, Heidi Donnelly, MD, Dayton Skin Surgery Center, Dayton, OH
Purpose: When a Mohs layer is taken to include cartilage, if it is removed using the standard 45 degree angle technique, then it is extremely difficult to flatten the edge of the specimen in such a way that the edge of the skin and the edge of the cartilage are in the same plane (which is required for the true margin to be visualized on histopathologic examination). The reason for this is because the skin edge has a tendency to severely retract around the cartilage. If the angle is changed to 15-25 degrees, and a few additional millimeters of skin are added to the section, this problem can be easily avoided.
Design: This is a pilot study involving a few patients in which sections have been taken using both the traditional 45 degree angle technique and our improved technique. Gross photographs of specimens resulting from the application of each technique will be contrasted as will photomicrographs of the resulting slides.
Summary: The flatter angle at which the incisions are made and additional skin which is taken allow for the edge of the skin and the edge of the cartilage to be in the same plane during tissue processing, despite the tendency for the skin to retract around the cartilage.
Conclusions: When taking Mohs sections involving the cartilage, this modified technique greatly facilitates the preparation of slides that demonstrate the true margin of the section. This technique is very easy to perform and has no significant drawbacks.
IS THERE A ROLE FOR ELECTIVE LYMPH NODE DISSECTION IN THE MANAGEMENT OF PATIENTS WITH HIGH RISK SQUAMOUS CELL CARCINOMA?
Authors: Juan-Carlos Martinez, MD, Jonathan L. Cook, MD Duke University Medical Center
Purpose: Elective lymph node dissection (ELND) is the prophylactic dissection of a nodal basin performed in the absence of known nodal disease. Its role in the management of cutaneous SCC (cSCC) is controversial. Some surgical specialists suggest that ELND may be beneficial for patients with clinically node-negative (N0) high-risk cSCC, but there are few data to support this claim. We sought to review critically the available literature regarding the use of ELND in the management of patients with N0 cSCC.
Design: The available medical literature pertaining to ELND and cSCC was reviewed. Head and neck surgeons and Mohs surgeons were consulted for expert multidisciplinary advice.
Summary: Unfortunately, there is a striking lack of uniform data regarding the proper management of regional nodal basins in patients with N0 cSCC. ELND is routinely performed in patients with node-negative SCC of the upper aerodigestive tract when the risk of occult metastases is estimated to exceed 20%. However, these patients have no proven survival benefit over those who undergo therapeutic lymph node dissection after the development of palpable adenopathy. Multiple retrospective studies of cSCC have identified primary tumor characteristics qualitatively associated with higher risk of nodal metastasis. In the absence of suitable, evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of clinically disease-free nodal basins in patients with cSCC.
Conclusions: Appropriate workup for occult nodal disease, including imaging studies and sentinel lymph node biopsy procedures, may occasionally be warranted in patients with high risk cSCCs. With the currently available information, elective lymph node dissection in the absence of palpable nodal disease may play only a very limited role in the management of patients with high-risk cSCC.
Electronic templates versus traditional dictation: Comparing cost, accuracy, time to completion, and time to reimbursement
Authors: David Andrew Cowan, MD, Nanette Liegeois, MD, PhD The Johns Hopkins University Department of Dermatology
Purpose: There are few studies comparing the ideal method for interfacing with electronic medical records (EMR) to record operative notes. An ideal system would be user- friendly, inexpensive, have a low error rate, assure that all pertinent clinical and billing related information is documented, and take little time to complete. The standard options are to create operative notes through dictation, manual data entry, the use of templates, or a combination of the above. While dictation has the advantage of speed, it is limited by cost, high dictation error rate, delay from dictation to availability of note, and the frequent absence of key procedural details. Alternatively, electronic templates are quickly completed and can be designed to prompt users to enter required information that would otherwise be forgotten and is critical from a medical-legal, patient care, or billing perspective. Currently there are no peer reviewed articles which directly compare dictation versus electronic templates. We believe that using an electronic mohs micrographic surgery template for operative notes is superior to dictation in terms of speed, accuracy, inclusion of critical medical and billing details, and cost.
Design: An internal service was contracted to establish an electronic template for the Johns Hopkins Electronic Medical Record (EMR). Patients undergoing Mohs micrographic surgery for the treatment of cutaneous malignancies were enrolled in this study to compare dictation versus the use of an electronic template to complete the operative note. Half of the operative notes for enrolled patients undergoing Mohs micrographic surgery were generated using dictation. The time to complete the dictation was recorded for each case. Once transcribed, the notes were reviewed, documenting the number of errors/omissions per note, as well the time required to proofread the note and insert the missing data. For the other half of patients, operative notes for enrolled Mohs micrographic surgery cases were generated using an electronic template (already being used in our department), and the time required to complete the note was recorded. At the completion of the study, each operative note was re-evaluated using the paper chart to assess for accuracy and inclusion/omission of important medical and billing information. The time from procedure date to submission for billing, and from procedure date to date of reimbursement were also recorded.
Summary: Electronic templates reduced physician time required to complete a Mohs micrographic surgery operative note and improved the accuracy of the data as well as the time to reimbursement. Once established, electronic templates proved to be a less expensive modality for generating operative notes.
Conclusions: Mohs micrographic surgery electronic templates compare favorably to traditionally dictated notes. They are more accurate and complete, are not prone to errors of omission seen in traditional dictation, and therefore do not require additional time spent proofreading. Additionally, support staff can more easily complete these notes in comparison to dictation systems. We believe that electronic templates (both for Mohs and likely other cutaneous and non-cutaneous surgeries) are an ideal tool for documenting operative notes within EMR systems.
Use of a Novel Thrombin-Based Hemostatic Agent to Control Bleeding During Mohs' Micrographic Surgery and Subsequent Reconstruction
Authors: William B. Henghold, MD, Thomas Stasko, M.D., Vanderbilt University, Brent R. Moody, M.D., Vanderbilt University
Purpose: Control of intraoperative bleeding during Mohs' micrographic surgery and subsequent reconstruction can be particularly challenging with tumor extirpation in highly vascular locations (e.g., periorbital area) and when executing more complex repairs, such as musculocutaneous flaps or large grafts over areas of exposed muscle. Maintaining patients on their prescribed anticoagulant or antiplatelet medications is evolving to be the standard practice in dermatologic surgery, and while this may not necessarily result in an overall increase in postoperative bleeding complications, operative time may be significantly prolonged when hemostasis cannot be readily achieved by conventional approaches such as manual pressure, electrocoagulation, and suture ligature. A number of topical hemostatic agents are available to help control troublesome intraoperative bleeding, all with variable efficacy, cost, and ease of use. We describe a novel hemostatic agent that combines a particulate carrier (glutaraldahyde crosslinked gelatin) with a pharmacologically active thrombin solution that we have found particularly useful in select situations.
Summary: We report a series of patients who underwent Mohs' micrographic surgery with subsequent reconstruction who for various reasons experienced intraoperative bleeding difficult to control by conventional means. In all cases this thrombin-based hemostatic agent proved easy to use and produced prompt and lasting hemostasis. In one instance the product was instrumental in managing a severe postoperative bleeding complication in a patient with an undiagnosed coagulopathy. It does not interfere with the processing or interpretation of subsequent Mohs' layers and does not limit choice of reconstructive procedure. In several patients it appeared to facilitate postoperative wound healing.
Conclusions: This novel thrombin-based hemostatic agent is highly effective, easy to use, relatively cost effective, and appears to reduce operating time significantly. It is a useful adjunct to conventional methods of hemostasis, especially in the setting of diffuse capillary oozing from muscle in the patient on blood thinners. To our knowledge its use has not been previously described in the dermatologic surgical literature.
Prolonged Survival of Angiosarcoma on the Nose: A Report of 3 Cases
Authors: C. William Hanke, MD, MPH, J. Barton Sterling, MD
Purpose: We report on the prolonged survival of three patients with angiosarcoma on the nose. Patients have survived 7, 7, and 4 years to date. Prolonged survival of patients with angiosarcoma on the nose has previously been described in the literature. We discuss possible reasons for prolonged survival and show photographs of our three patients, whose clinical lesions could have easily been overlooked.
Summary: Three cases will be described. Case 1 is a 57-year old female who presented with angiosarcoma on her right nasal bridge and ala. She was treated with total rhinectomy and radiation therapy. Seven years later the patient died of Hodgkins disease. Case 2 is a 67-year old man with angiosarcoma on the nasal bridge and medial cheeks. He was treated with rhinectomy and, after a recurrence, radical neck disection. He experienced no further recurrences and died seven years later from a stroke. Case 3 is a 73-year old man with angiosarcoma of the nasal ala. He was treated with partial rhinectomy and radiation therapy. He is currenly alive and tumor free four years after initial biopsy.
Conclusions: The improved survival of our three patients with angiosarcoma of the nose may be possible due to an number of factors. Each patient's lesion was detected early, tumour sizes were small at presentation, and early, aggressive therapy was instituted. Early recognition of angiosarcoma on the nose by the clinician may be important for patient survival.
Squamous Cell Carcinoma is Defined by Expression of Invasion, Proliferation, and Immune Response Genes Distinct from Benign Hyperplasia
Authors: John A. Carucci, MD, PhD, Peters, S.B., Department of Pathology, Weill Medical College of Cornell, New York, N, Ott, J., Laboratory of Investigative Dermatology, Rockefeller University, New York, NY, Krueger, J.G, Laboratory of Investigative Dermatology, Rockefeller University, New York, NY, Haider, A.S., Laboratory of Investigative Dermatology, Rockefeller University, New York, NY
Purpose: These studies were performed to define specific elements of malignant hyperproliferation in SCC and to better define the state of natural immunity to SCC.
Design: We studied differential expression of ~12,000 genes in SCC and defined malignant hyperproliferation by comparison with psoriasis. Gene expression profiles were categorized based on cancer associated biological functions including invasion, proliferation, differentiation and immune response. The inflammatory infiltrate associated with SCC was characterized by immunohistochemsitry.
Summary: SCC showed increases in: (1) invasion associated MMPs, 1, 10, and 13; (2) proliferation associated K-ras, R-ras, CDK7, CDC7, EREG, and E2F3; (3) immune response associated IL-18; and, decreases in (1) invasion associated TIMP3 and CXCR4; (2) proliferation associated NFKB2, NFKBIA, and VEGFC; (3) immune response associated CD69, CD83 and iNOS. Genes increased in both psoriasis and SCC and thus attributed to benign hyperplasia included: (1) proliferation associated NFKB1, STAT1, and TGFa; (3) differentiation associated SPR1A, S100A8, and IVL; and (4) immune response associated IL12R. Many T cells and few monocytes were associated with SCC. Mature dendritic cells were not observed within invading nests of SCC.
Conclusions: SCC is characterized by expression of a unique set of invasion, proliferation, and immune response related genes and a natural, sub-optimal state of immunity.
Histiologic and Clinical Characteristics of Non-melanoma Skin Cancer in Young Patients: A Retrospective Analysis
Authors: Margaret Mann, MD, Arianne E. Chavez-Frazier, M.D., University of California San Francisco, Ashley A. Smith, M.D., Washington University, Bradley Evanoff, M.D., Washington University, Roberta D. Sengelmann, M.D., Washington University
Purpose: Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) occur relatively infrequently in patients less than 40 years of age. Previous reports suggest that this subset of patients may have certain risk factors that predispose them to tumors at an earlier age. In addition, previous studies indicate that BCC and SCC arising in the young individuals tend to behave more aggressively, both clinically and histologically. The purpose of our study was to elucidate host and tumor variables associated with the occurrence of these tumors early in life.
Design: We retrospectively compared 55 consecutive patients under 40 years of age with 55 patients over 60 years of age who underwent Mohs micrographic surgery for a biopsy-proven BCC or SCC during a 24-month time period. Patients with known genetic syndromes were excluded. We reviewed patient demographics including history of tobacco use, immunosuppression, organ transplantation, radiation exposure, pertinent medications such as NSAIDs, and prior family or personal history of skin cancer. Surgery and tumor characteristics for the two groups of patients were analyzed including duration of lesion, pre-operative tumor size, post-operative defect size, number of Mohs stages, and histologic subtypes. A database was constructed and analyzed using SPSS 10.0. Dichotomous variables were analyzed using the paired McNemar test and continuous variables were compared using a paired t-test.
Summary: Consistent with previous studies, we found a female predominance in the younger patient group (73%) compared to the older group (36%, P = >0.005). Similar patient characteristics were noted between the two groups including history of organ transplant, immunosuppression, and radiation exposure. No statistical difference was observed in the use of tobacco even though more patients in the control group smoked presently or in the past (16% in the young compared to 25% in the control, P = 0.18). Regarding family history, 53% of the young patients had a first or second degree relative with a history of skin cancer compared to 38% in the control group; however, this did not prove to be statistically significant (P = 0.17). No difference was observed with regards to the duration of lesion, histologic subtype, postoperative defect size, and the number of Mohs stages. Preoperative lesion size were similar in the two groups (mean size 85.8mm2 in the young versus 79.3mm2 in the control group), though the range was much greater in the younger population (9-1024mm2) compared to the control group (8-286mm2).
Conclusions: Our findings indicate that similar patient characteristics and risk factors exist between the younger and older patients who develop BCC and SCC. Furthermore, tumors arising in young patients are histologically and clinically indistinguishable from those found in the older population. In contrast to the predominately male older group, the overwhelming female predominance in the young patient group is consistent with previous studies. Factors such sun exposure, tanning bed use, and heightened awareness of their skin may prompt female patients to seek treatment at an earlier age than their male counterpart. At the same time, lower levels of suspicion for skin cancer in younger patients and cosmetic considerations may result in delayed biopsy and diagnosis. This may account for the larger range in preoperative lesion size observed in the younger group. While our findings did not show any significant difference in tumors and patient characteristics among younger and older patients, further studies with a larger sample population may help to elucidate why certain patients are more likely to develop BCC and SCC early in life.
Reduction in incidence of squamous cell carcinomas in transplant recipients treated with cyclic topical photodynamic therapy with 20% 5-aminolevulinic acid
Authors: Andrea Willey, Peter K. Lee, M.D., Ph.D.
Purpose: Solid organ transplant recipients have an increased propensity to develop multiple actinic keratoses, which demonstrate an increased transformation rate into invasive squamous cell carcinomas (SCC). Photodynamic therapy (PDT) with 20% 5-aminolevulinic acid (ALA) has been shown to be effective in the primary treatment of actinic keratoses in both immuno-competent and immuno-suppressed transplant recipients. We report a prospective series of 12 patients who demonstrate a significant reduction in the incidence of SCC of the upper or lower extremitites following multiple treatments with PDT.
Design: The patients underwent repeated PDT treatments (range 6-14) every 4 to 8 weeks.
Summary: Therapy was well tolerated by all patients. Each patient showed a significant reduction in the number of SCCs after treatment. The incidence of new SCCs were counted at each treatment visit and compared to the number of SCCs developed during the previous 12 months.
Conclusions: Our experience shows that this method of ALA-PDT is well tolerated and effective in managing multiple actinic keratoses in immunosupressed patients and may significantly reduce the risk of developing aggressive, potentially fatal tumors.
Incidence of and risk factors for medical malpractice lawsuits among Mohs surgeons
Authors: Clifford Scott Perlis, R.M. Campbell; Brown Medical School, Dept of Dermatology, RI, R.H. Perlis; Harvard Medical School and Massachusetts General Hospital, Dept of Psychiatry, MA, M. Malik; Brown Medical School, Dept of Dermatology, RI, R.G. Dufresne; Brown Medical School, Dept of Dermatology, RI
Purpose: Despite rising medical malpractice costs, little is known about the factors associated with claims filed against Mohs surgeons. Dermatology's previous relative immunity from rising medical malpractice judgments and associated premiums is disappearing. The average indemnity paid by dermatologists in malpractice claims closed between 1992 and 2002 rose from $104,654 to $299,499. Furthermore, dermatologists' professional liability premiums have, on average, doubled over the past two to three years. Despite the significant costs associated with medical malpractice premiums in dermatology, existing data is sparse and mostly gleaned from data sets over 20 years old. We sought to define the scope of medical malpractice claims filed against Mohs surgeons and to identify salient factors associated with the filing and disposition of those claims.
Design: In 2004, we developed a survey instrument exploring malpractice experiences among Mohs micrographic surgeons. The project protocol was formulated and approved by the Rhode Island Hospital Institutional Review Board. The survey was mailed to all 599 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology with United States addresses listed in the 2003 directory. Each survey was accompanied by a self-addressed, stamped envelope and cover letter. Recipients were guaranteed that their responses would be kept anonymous.
Summary: Three hundred and three completed responses were returned from the initial mailing. Of the 599 mailed, however, 16 were returned due to "undeliverable address" or "no forwarding address." The response rate was 52% (303/583). Overall, twenty-nine of 303 (9.6%) respondents reported ever having been sued. Of these, 23/29 (79.3%) reported having been sued only once. Three of 29 (10.3%) have been sued twice, and 3 of 29 (10.3%) have been sued three or more times. The three most frequently cited reasons for lawsuits included: cosmetic outcome (9), wrong site (6), and functional outcome (6). Misdiagnosis (1) and delayed diagnosis (2) were the two least commonly cited reasons. .
Conclusions: This study provides the first data of its kind on the scope of medical malpractice cases among Mohs surgeons and associated risk factors. Many factors hypothesized to show a relationship to risk of being sued (ie. pre-operative consultation, lesion location documentation, practice setting, closure technique) did not reveal statistically significant associations. Future studies could benefit from examination of primary source data from insurers and legal court records. In a setting of rising medical malpractice premiums, such future studies are clearly indicated to minimize legal risk and improve patient care.
Results of a survey of 641 members of the ACMMSCO regarding preoperative and perioperative antiseptic techniques
Authors: Daniel B. Eisen, MD, Larry Warshawski University of British Columbia, David Zloty University of British Columbia
Purpose: Many traditional Operating Room(OR) techniques have not been proven to reduce infection rates. Since randomized, controlled, trials to prove the usefullness of these techniques would likely require tens of thousands of patients they are not likely to be performed. We were interested to see which techniques the members of the American College of Mohs Micrograhic Surgery and Cutaneous Oncology deemed important. Results of this survey should be of immediate interest to anyone who performs dermatologic surgery. Based upon the results of our survey many traditional operating room antiseptic practices are not routinely performed by ACMMSCO members. Reported infection rates were extraordinarily low supporting the notion that many of these old unproven techniques are probably not necessary for cutaneous surgical procedures.
Design: A survey containing 10 questions regarding pre and perioperative techniques was mailed to 641 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. Return addressed, pre-payed envelopes were included with the survey. Questions regarding the use of a surgical cap, mask, sterile gloves, sterile gown, pre-operative hand scrub, pre-operative skin preps, booties, number of procedures and associated infections were asked with regards to the performance biopsies, excision, Mohs surgery, Botox, Non-permanent soft tissue fillers, Non-ablative facial rejuvenation, Ablative facial rejuvenation, Blepharoplasty, Brow/face/neck lift, Hair transplantation, and Liposuction. Surveys were collected for the first 3 months following the mailing. The results were manually entered into a microsoft excel spreadsheet and the results were computed for number, mean, median, range and percent.
Summary: 265 responses, 41% of those surveyed, were received within the first 3 months of the mailing. Many traditional Operating Room(OR) antiseptic techniques, were not commonly practiced by the respondents. Only 22% of respondents wear caps for excisions. 6% of respondents wear sterile gowns or booties for excisions. Reported infection rates were very low; the highest rate reported for Mohs Surgery was 1 infection for 40 procedures(2.5% infection rate). Most were considerably lower than this. Few precautions were used for shave biopsies; 94% do not wear surgical caps, 77% do not wear surgical masks, 81% do not use sterile gloves, 97% don't wear surgical gowns, 96% don't wear booties, 61% do not perform a preoperative scrub. For more invasive procedures, respondents tended to be slightly more cautious. For Mohs surgery: 73% don't wear surgical caps, 25% don't wear masks, 31% don't use sterile gloves, 86% don't wear sterile gowns, 84% don't wear booties. 58% of respondents who perform ablative resurfacing do not wear surgical caps, 11% do not wear surgical masks, 43% don't wear sterile gloves, 83% don't wear sterile gowns, 85% don't wear booties. The rest of the data will be described in charts at the time of the talk.
Conclusions: Many traditional OR techniques are not practiced by respondents of this survey. Reported infection rates have been extremely low. Scientific evidence supporting the use of many of these traditional techniques is lacking and may not have any clinically significant effects on infection rates. The results of this survey will give the listeners an idea of what the survey respondents are doing and what they are not. In addition, information about infection rates regarding several procedures will be presented and allow practitioners to compare surgery site infection rates in their own practices with those reported by the survey respondents.
Preoperative Imatinib Mesylate to Improve Surgical Outcomes in Patients with Locally Advanced Dermatofibrosarcoma Protuberans
Authors: Elbert Chen, Desiree Ratner, MD, Columbia University
Purpose: Dermatofibrosarcoma protuberans (DFSP) is an uncommon fibrohistiocytic tumor associated with extensive subclinical involvement and a high rate of local recurrence but low metastatic potential. Standard treatment for DFSP traditionally consisted of wide local excision with 3 cm margins, despite relatively high recurrence rates following this treatment. More recently, Mohs micrographic surgery (MMS) has emerged as the treatment of choice for DFSP. Although MMS has a high local cure rate, excisional removal of DFSP may be associated with significant deformity or disability due to the locally infiltrative nature of the tumor and the substantial margins required for complete resection. Almost all DFSPs are characterized by chromosomal rearrangements which fuse the collagen type Ia1 (COLIA1) gene to the platelet-derived growth factor B-chain (PDGFB) gene. Fusion gene products are processed to mature PDGF-BB protein leading to autocrine stimulation via the PDGF receptor. Imatinib mesylate is a selective inhibitor of the PDGF receptor that has been shown to have activity in metastatic DFSP.
Design: Two patients with biopsy proven DFSPs were given imatinib mesylate 400 mg once or twice daily for at least 1 month prior to resection by MMS. The standard technique for MMS was performed. The lesion/scar site was outlined and a margin not > 2 cm was marked from the periphery of the lesion/scar. Local anesthesia was obtained using 1% lidocaine with a 1:100,000 dilution of epinephrine. A biopsy of the macroscopic tumor was obtained. The margins were incised as drawn above the level of underlying fascia. Tissue was divided into multiple sections and mapped and color coded by the Mohs histotechnician. Horizontal frozen sections of the complete peripheral margin, including adipose and fascia, were interpreted by a Mohs surgeon. If any slides revealed positive margins, the patient was returned to the surgical operatory and underwent further excision of the positive areas only, with 0.5 to 1.0 cm margins. Serial excision and processing and analysis of tissue continued until tumor free margins were obtained.
Summary: Both patients experienced partial clinical responses to imatinib mesylate, with significant decreases in the clinically evident dimensions of their tumors compared with matched controls. Complete tumor removal was achieved by MMS in both patients.
Conclusions: Preoperative imatinib may improve surgical outcomes in patients with locally advanced DFSP by decreasing the extent of the resection required for complete tumor removal.
Patient exposures and characteristics of first nonmelanoma skin cancer
Authors: R. Sonia Batra, MD, MSc, MPH, Thomas E. Rohrer, MD, SkinCare Physicians and Boston University Medical Center, Boston, MA, Larisa C. Kelley, MD, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
Purpose: This study investigates the relationship between patient exposures and medical history and the location and histology of their first nonmelanoma skin cancer (NMSC) in a population of Mohs micrographic sugery patients.
Design: One hundred forty-four patients with nonmelanoma skin cancer who presented for Mohs micrographic surgery completed a detailed survey regarding their prior exposures and medical history. Multinomial logistic regression analysis was performed to identify significant predictors of patient age at first NMSC and first tumor histology and location based on past social and medical history.
Summary: The mean age for development of a first nonmelanoma skin cancer was 60.5 years. 68% of patients had an outdoor hobby, 26.3% of patients were current or former smokers, 9.1% had undergone prior radiation therapy, 6.9% reported use of a tanning bed, and 3.5% were organ transplant recipients. 34.5% of patients reported a first-degree relative with any type of skin cancer. Patients under 50 years old were significantly more likely to present with a first tumor on the neck. Participants in water sports were at significantly higher risk for NMSC on the nose, neck, trunk, or extremity. Patients with higher phototype skin were less likely to develop tumors on the scalp. Smokers were at significantly higher risk for eyelid NMSC. Organ transplant recipients had a high likelihood of a first tumor on the eyelid, cheek, neck or extremity. A family history of skin cancer was significantly associated with a first tumor on the temple, trunk, or extremity.
Conclusions: Data on the association between exposures/medical history and likely characteristics of a first NMSC can help to tailor screening and management. These results are based on preliminary analysis of the first 144 patients in an ongoing study designed to enroll 500 patients. Complete data will be presented.
Cobblestone Basal Cell Carcinoma: Characterization of a novel histopathologic variant
Authors: David Berk, MD, Hayes B. Gladstone, MD, Div. of Dermatolgoic Surgery, Stanford University
Purpose: There are several histologic subtypes of basal cell carcinoma. Some are based on architecture while others are based on cellular characteristics. Some variants such as micronodular are associated with a more infiltrative pattern. It is useful to characterize specific subtypes associated with an aggressive clinical course since this will aid the surgeon in anticipating the size of the potential defect and complexity of repair. During Mohs micrographic surgery, we have observed a histopathologic variant of basal cell carcinoma with apparent cystic degeneration, which has tended to be clinically more aggressive. The purpose of this study is to characterize a novel histopathologic variant of BCC showing cystic degeneration that appeared to ahve a cobblestone patttern, and determine whether it is clinically more aggressive than other types of BCC's.
Design: A chart review was conducted of consecutive cases of Mohs surgery performed at Stanford University Medical Center for histologically confirmed basal cell carcinoma from June 2002 through March 2004. Cases had been prospectively categorized as having a cobblestoned appearance if there was a consistent distinct clear areas around the individual tumor cells of all the tumor islands. We retrospectively compared "cobblestone" and control cases in terms of patient age, gender, tumor anatomic location, number of Mohs stages to required, area of post Mohs defect and type of reconstruction.
Summary: A total of 489 cases of Mohs surgery for histologically confirmed BCC's were reviewed. Forty-four (9%) of the cases met criteria for classification of cooblestone BCC. Patients with cobblestone BCC did not differ statistically from the control group in terms of gender, but tended to be older. The distribution of cases on the head and neck differed significantly between the cobblestone and control groups (p=0.016), with more cobblestone cases located on the nose and ears. Cobblestone BCCs required more stages to clear histologic margins, and had a larger size (median 3.00 vs 1.68 cm2 p<0.001). Only 4.5% were able to heal by second intent while 20.4% required complex primary closure. Staged flaps were performed in 13.6% of the individuals who had this histologic subtype.
Conclusions: This study suggests that there is a histologic subtype of basal cell carcinoma that has a cobblestone appearance within the tumor islands. It is characterized by a more aggressive course in terms of number of stages for clear margins and the size of the post-Mohs defects. It may also require more complex repairs. Recognition of this aggressive variant of BCC may benefit future patients by facilitating prediction of the clinical extent of this tumor based on its histopathology.
A National Tumor Registry for Mohs Micrographic Surgery: A Practical Approach
Authors: Girish S. Munavalli, MD, Ashish C. Bhatia, MD - DuPage Medical Group, Naperville, IL; Northwestern University School of Medicine, Chicago, IL
Purpose: Compilation of nationwide data regarding Mohs Micrographic Surgery can provide a rich resource for our specialty. This can be used for the self analysis and benefit of the entire field. The challenges of collecting this data has hindered previous attempts at development such a system.
Design: With the guidance of a software development taskforce of the ACMMSCO, data points were selected for a software application designed to capture procedural data in a standardized and automated fashion from Mohs procedures and generate operative documentation. Several surgeons in various practice settings utilized the software for a period of 3 months. Procedural and demographic data was captured within the workflow of a busy office practice. The non-identifiable procedural information from each practice was integrated via the Internet into a centralized database for analysis.
Summary: The collective data was analyzed for tumor types, location, lesion size, and number of stages required for tumor extirpation. In addition to facilitating documentation of Mohs and reconstructive procedures, sites reported decreasing transcription cost and time spent completing procedure-related paperwork.
Conclusions: The software offers the beginnings of an analytic tool provides benefits to the individual surgeon, as well as to the entire field of Mohs surgeons through the compilation of a national repository of Mohs surgical data
A Novel Technique For Repairing Adjacent Surgical Defects With a Rotation Flap
Authors: Jamie L. McGinness, MD, Harry L. Parlette III, MD, Professor Emeritus, University of Virginia
Purpose: The incidence of cutaneous head and neck carcinomas continues to rise. Mohs surgery is a frequently used method for removing these carcinomas. It is not uncommon to have multiple skin carcinomas present at the same time or in close proximity to each other. Therefore, it is not unusual for the Mohs surgeon to be presented with the challenge of repairing adjacent surgical defects while avoiding unacceptable wound closure tension and distortion of neighboring structures.
Summary: We present a novel method for repairing adjacent surgical defects with a rotational flap.
Conclusions: Frequently Mohs surgeons are presented with adjacent surgical defects and challenged to find the repair option that will give the most optimal cosmetic result. Options for closing small adjacent surgical defects include making the twin defects a single large defect and proceeding with primary closure, full thickness skin grafting, primary closure of each defect separately, flap coverage, secondary intention healing, or any combination of these. The use of a single rotation flap to cover two adjacent surgical defects provides the surgeon with a convenient and very cosmetically acceptable option that also avoids unacceptable wound tension or distortion of neighboring structures. In conclusion, we describe a novel and convenient method for repairing adjacent surgical defects with a rotation flap.
Basal cell carcinoma responding to systemic 5-fluorouracil
Authors: Clancy Johnson Snipes, Patrick J. Sniezek MD, Hobart W. Walling MD
Purpose: We present a case of a large basal cell carcinoma which responded completely to systemic 5-fluorouracil. This has been reported only once in the world literature and represents a potential treatment option.
Summary: A 51 year old male was seen for a left medial canthal nodule present for 3 years and measured at 2.5 cm the previous year. He had been diagnosed with stage IV colon carcinoma in 2001 with metastases to the liver found in 3/2003. He had undergone 4 cycles of systemic chemotherapy with 5-Fluorouracil and Irinotecan at 2 week intervals prior to Dermatology consultation. The patient reported the lesion was diminishing in size during this therapy. On presentation, a 1.5 cm pearly, eroded nodule with rolled telangiectatic borders was present at the left medial canthus. Shave biopsy of a corner of the lesion was performed, with focal electrocoagulation. Histology revealed a micronodular basal cell carcinoma with involved margins. Given the subjective response of the BCC to his 5-FU containing chemotherapy, the decision was made to follow the lesion clinically with Mohs surgery if necessary. The patient completed eight cycles of 5FU chemotherapy. Abdominal CT showed response to his metastatic colon carcinoma. At 1 month follow-up, a flat 8 mm papule was present at the site of BCC. Six weeks later, a well-healed 7 mm macule remained, and a punch biopsy showed no evidence of residual BCC.
Conclusions: This case report shows complete response of a large facial BCC to systemic 5-FU. Though this patient was receiving chemotherapy for metastatic colon cancer, the exquisite response suggests that systemic 5FU may be a primary or adjunctive treatment option in exceptional cases of aggressive BCC or when other surgical options are contraindicated.
A nasal trumpet orthosis to maintain nares opening during a melolabial interpolation flap.
Authors: Evan Jones, MD, Summer Youker MD Saint Louis University, Scott Fosko MD Saint Louis University
Purpose: Background. The nasal trumpet has been used in emergency resuscitation, anesthesia, and in facial burns to maintain nares openings. The dermatologic surgery literature is not as familiar with this device to improve respiratory function during the post operative period after reconstruction of large defects on the nose. Objective. To present a novel way of using a modified nasal trumpet orthosis to maintain nasal valve patency and improve nasal valve respiratory function post operatively following a melolabial interpolation flap.
Design: Materials. A sterile nasal trumpet orthosis.
Conclusions: Conclusion. We present a novel way of using a modified nasal trumpet orthosis after a melolabial interpolation flap procedure. For large defects involving the nares and/or nasal valve of the nose the nasal trumpet is well tolerated by the patient and can lead to increased post operative respiratory function, while acting as a "bolster" for the closure.
Helical repair utilizing the subcutaneous island pedicle graft
Authors: Ross Campbell, MD, Raymond G. Dufresne, Jr., M.D.-Brown Medical School
Purpose: The subcutaneous island pedicle flap provides a method of repairing select cutaneous defects that closely matches the original tissue in texture, color, and sebaceous and follicular qualities, and minimizes regional anatomic distortion. We present a new technique of using the subcutaneous island pedicle flap to repair mid and inferior helical defects that preserves auricular shape and symmetry.
Design: We review flap planning and specific anatomic considerations for use of the island pedicle flap on the ear.
Summary: Patient photographs and illustrations demonstrate that the subcutaneous island pedicle flap may be used on the ear with success.
Conclusions: The subcutaneous island pedicle graft provides an effective method of repairing helical defects preserving anatomic shape and closely matching original tissue characteristics.
Cutaneous squamous cell carcinoma spontaneously cleared in a patient treated with capecitabine for pancreatic cancer
Authors: Andrea Willey, Valda Kaye, MD, Peter K. Lee, M.D.,Ph.D.
Purpose: Capecitabine (Xeloda®) is an oral tumor selective 5-fluorouracil prodrug used in the treatment of metastatic breast, colorectal, pancreatic and head and neck carcinomas. Inflammation of actinic keratoses has recently been reported in patients treated with capecitabine similar to that described with the use of 5-fluorouracil. We describe the spontaneous clearance of an invasive squamous cell carcinoma in a patient treated with capecitabine for pancreatic cancer which has not previously been reported.
Summary: A 73-year-old male presented for evaluation of a 1cm erythematous nodule on the dorsal hand. The nodule had been present for approximately one year; however, the patient noted that it had been decreasing in size during the past two months following initiation of oral capecitabine therapy for metastatic pancreatic cancer. Histopathologic evaluation showed transepidermal keratinocyte atypia with dermal invasion consistent with invasive squamous cell carcinoma. When the patient returned two months later for surgical excision, the tumor appeared to have resolved. A shave biopsy confirmed complete resolution of the tumor.
Conclusions: Given the favorable toxicity profile of oral capecitabine, this observation raises the possibility that capecitabine may be useful in the management of multiple recurrent squamous cell carcinomas seen in elderly and immunosuppressed patients.
Perioperative Management And Practice Standards In The Use Of Electrosurgery In Patients With Implantable CardioverterDefibrillators (ICDs) in Dermatologic Surgery
Authors: Katherine M. Brown, M.D., Raymond Dufresne, MD; Brown Medical School Department of Dermatology
Purpose: Electrosurgery is a technique frequently employed by dermatologic surgeons, who commonly treat elderly patients. The incidence of implantable cardioverter defibrillators (ICDs) is greater in this population. The potential for patient morbidity and mortality from electromagnetic interference (EMI) exists, but the magnitude of this risk in the setting of cutaneous surgery is not known. Though electrosurgery is commonly employed by dermatologic surgeons, no widely held practice guidelines exist for the use of electrosurgery in cutaneous surgery in patients with implantable cardioverter defibrillators (ICDs). There is little current data about practice management standards or experience among dermatologic surgeons.
Design: A two page survey was sent by fax to 71 directors of fellowships accredited by the American College of Mohs Micrographic Surgery and Cutaneous Oncology located in the United States asking about perioperative and intraoperative management practices of patients with ICDs, and about adverse outcomes, and actions taken.
Summary: Twenty-two surveys were returned out of 71 sent, a 31% response rate. The responding surgeons had a cumulative 379.5 years of surgical experience, with an average of 17.3 years. Of all respondents, only one noted an adverse event in a patient with an ICD, in which the ICD fired intraoperatively. Analysis of practice management techniques for patients with ICDs revealed significant variability among practicing physicians. The most commonly employed precautions included pre- and post-operative monitoring (82%), use of short bursts (
Conclusions: This preliminary study is encouraging in that we found no evidence of significant complications related to electromagnetic interference. Despite the significant variability in practice management and operative techniques, only one adverse event was reported, which did not result in serious morbidity. However, the potential for serious complications exists, suggesting it is imperative to characterize further the nature and scope of the risks of cutaneous surgery in patients with ICDs. The range of perioperative and intraoperative management practices employed by dermatologic surgeons speaks to the need for uniform guidelines, after thorough review of potential risks of electromagnetic interference. Our data are encouraging, but our study is limited by small sample size, response rate, and a potential bias in surveying only fellowship directors. Analysis of this data from academic Mohs surgeons comprises an important subset of cutaneous surgeons. This study represents an initial effort to examine perioperative management techniques in ICD patients, which we hope to study further in a larger sample size, comparing the experience of dermatologic surgeons with other surgical subspecialties. Additional data will help to provide evidence based guidelines for the management of patients with ICDs, as they represent a growing and important segment of the dermatologic surgery population.
Getting Complete and Accurate Mohs Layers: Painting the Deep Blue
Authors: Ruchik Desai, MD, Heidi Donnelly, Dayton Skin Surgery Center
Purpose: Mapping and subsequent tumor removal in Mohs micrographic surgery requires accurate estimation of tumor location. Once tumor is noted on a deep or peripheral margin during the first stage of tumor extirpation, the surgeon must determine where and how much tissue to remove on subsequent stages. Mapping the tumor location on paper with color-coded hashes corresponding to tissue orientation is the first step to efficient tumor removal and is standard practice in Mohs micrographic surgery. In addition, many Mohs surgeons may then use a skin marker in vivo to delineate positive peripheral margins. We propose another step whereby the deep tissue map is transferred to the actual patient, through tissue coloring, allowing for even more precise removal of tumor. This is achieved by using methylene blue (1%) to mark positive areas within the subcuateous fat, muscle, perichondrium, periosteum or cartilage that correspond to the deep margin where tumor is noted. Marking the tissue in this manner ensures a complete and accurate Mohs section.
The Tunneled Island Pedicle Flap for Upper Lip Reconstruction
Authors: Daniel Stewart, Basil Hantash, MD, PhD, Department of Dermatology, Stanford University, Hayes B. Gladstone, MD, Div. of Dermatologic Surgery, Stanford University
Purpose: Medium to large upper lip defects including the nasal floor can be challenging to repair. While there are several options, none of them are optimal. A full thickness skin graft will not fill the defect, and will not provide a good color match. An A-T advancement flap will cross the midline, and there may not be enough skin laxity to close the defect. An island pedicle will create a lengthy, visible scar. In contrast, a tunneled island pedicle from the proximal cheek will resurface this defect with a minimal scar without any functional loss.
Design: Reconstruction case report Based on the size of the defect, a skin paddle is designed from the proximal cheek abutting the melo-nasal crease. The pedicle is dissected inferiorly and down to muscle to ensure proper length. A subdermal tunnel is created. The skin paddle is mobilized through this tunnel, and then sewn into the defect in two layers. The donor site is closed along the melo-nasal crease.
Summary: The patient's upper lip healed without complication or loss of function. The skin color match was good and the aesthetic result was excellent. Scars were minimized.
Conclusions: The tunneled island pedicle provides a satisfactory method for repairing a complex medium to large sized upper lip defect. It has excellent reach. The key to this repair is the pedicle's inferior orientation, and debulking it which will increase mobility.
Extramammary Paget's Disease: Treatment with Mohs Micrographic Surgery and the Use of Cytokeratin 7 Immunohistochemical Stain
Authors: Karen J. Johnson, MD, John A. Zitelli, M.D., David G. Brodland, M.D.
Purpose: ABSTRACT: Background. Extramammary Paget's disease is a cutaneous malignancy that is notoriously difficult to treat successfully. Extramammary Paget's disease is known to have high recurrence rates with traditional surgery, and rarely the potential to be invasive and metastasize. Various treatment methods have been attempted but none with satisfactory recurrence rates. Even Mohs surgery, the most effective treatment, has a recurrence rate as high as 16% and 50% for primary and recurrent extramammary Paget's disease respectively. We wish to report an improvement on traditional Mohs surgery with the addition of cytokeratin 7 immunohistochemical staining to facilitate the reading of tissue specimen slides and allow for more definitive removal of the tumor. Methods. The report of two cases and the use of Mohs micrographic surgery in conjunction with cytokeratin 7 immunohistochemical staining in the excision of extramammary Paget's disease. Conclusion: Use of cytokeratin 7 staining facilitates the reading of hematoxalin and eosin tissue slides and allows for a more precise delineation of tissue with extramammary Paget's disease from tumor free skin. Therefore, the potential for complete removal of the tumor is increased with improved cure rates compared to traditional Mohs surgery.
Mohs Micrographic Surgery for Squamous Cell Carcinoma associated with Epidermolysis Bullosa
Authors: Aradhna Saxena, MD, Jason B. Lee, Tatyana R. Humphreys
Purpose: background. Squamous cell carcinoma (SCC) in the setting of scarring epidermolysis bullosa (EB) presents unique surgical challenges. objective. To illustrate, by case reports, the management of SCC in EB patients using Mohs micrographic surgery (MMS), and to address the potential pitfalls in frozen section evaluation and wound healing.
Design: methods. The outcomes of five cases of SCC treated by MMS in EB patients are described and compared with other cases in the medical literature.
Summary: results. MMS for SCC secondary to chronic EB presents both technical and reconstructive challenges. Technical challenges encountered during MMS include difficulty in obtaining complete peripheral epidermal margins in fragile tissue and the presence of chronic inflammation, scarring, and pseudoepitheliomatous hyperplasia that can complicate margin evaluation. Reconstructive challenges include tissue fragility and increased risk of infection secondary to bacterial colonization.
Conclusions: conclusions. Modification of standard MMS technique and reconstructive approaches may optimize treatment outcomes for SCC in EB patients.
Traumatic keratoacanthoma arising in a 15-year-old boy following a motor vehicle accident
Authors: Joseph Janik, MD, Ran H. Bang, MD =University of New Mexico Department of Dermatology, R. Steven Padilla, MD=University of New Mexico Department of Dermatology
Purpose: Keratoacanthomas (KA) appear most commonly in sun-damaged skin in middle-aged and elderly people. We present a 15-year-old boy who developed a rapidly growing nodule within a hypertrophic scar that was the result of trauma suffered in a rollover motor vehicle accident six months prior to presentation. Biopsy of the nodule confirmed the presence of squamous cell carcinoma, keratoacanthoma type. The development of KAs has been associated with sun exposure, chemical carcinogens, Marjolin's ulcers, radiation therapy, genetic factors, and various forms of preceding trauma including surgery or grafting, thermal burns, laser resurfacing, and vaccination. This report describes the youngest case of traumatically-induced KA, and the first report of an association between KA and friction burn.
Treatment Modalities for Lentigo Maligna: A Survey of the Mohs College
Authors: Jeffrey K. McKenna, MD, Glen M. Bowen, MD, Department of Dermatology, University of Utah
Purpose: There are numerous methods available to dermatologists for the treatment of lentigo maligna (LM). We surveyed all members of the Mohs College on what modalities they currently utilize. The purpose in presenting this data is to provide information on what our colleagues across the country are using.
Design: A one-page survey was sent to all members of the Mohs College. Recipients were given a list of treatment modalities that included: techniques with permanent sections, techniques without permanent sections, and non-surgical techniques. We asked them to clarify the use of any special staining, and/or adjuvant therapies.
Summary: A total of 650 surveys were mailed. The response rate was 50% (325/650). Analysis shows that 53% of respondants use Mohs surgery, 30% use wide local excision, and 17% use a staged square/polygonal excision. Sixty-four percent use only one surgical modality for treating LM. The remainder use a variety of techniques depending on the clinical scenario. When asked about the processing of tissue, 85% utilize permanent sections (or a combination) and 26% rely on frozen sections. The most commonly used surgical adjuvant was imiquimod (30%). Immunohistochemical stains are used by 18%.
Conclusions: Members of the Mohs College appear to use some form of Mohs surgery as their primary treatment modality for lentigo maligna. However, wide local excision remains a commonly used approach. The vast majority of respondants rely on permanent sections to verify their margins.
Patterns of Internet use and impact on patients with melanoma
Authors: Christopher K. Bichakjian, MD, Michael S. Sabel, MD, Vic Strecher, PhD MPH, Jennifer L. Schwartz, MD,, Timothy S. Wang, MD, Darius J. Karimipour, MD, Jeffrey S. Orringer, MD, Timothy M. Johnson, MD, (all co-authors from University of Michigan)
Purpose: Patients with cancer and their families frequently, and increasingly, turn to outside sources for information, particularly the World Wide Web. Our objective was to examine the use of the Internet and its impact among patients with melanoma.
Design: A prospective survey was obtained from 1613 consecutive patients with cutaneous melanoma seen at our institution between August 2001 and February 2003.
Summary: Of patients with melanoma, 39% indicated that they had used the Internet to research their disease. Nearly half of patients younger than 40 years researched melanoma on the Internet compared with only 12% of patients 60 years or older. Neither sex nor disease severity impacted Internet use. The vast majority of patients (94%) thought the Internet was useful and 67% believed it helped them better understand their condition. A third thought it decreased their anxiety, whereas a similar proportion believed the Internet made them more anxious. Increased anxiety correlated with decreasing age and increasing disease severity.
Conclusions: The use of the Internet is common among patients with melanoma. Anxiety attributed to online information about their disease suggests that clinicians caring for patients with melanoma should familiarize themselves with online melanoma information, and be proactive in assisting their patients in using this resource.
Epithelioid Sarcoma treated by Mohs Surgery
Authors: Frank Charles Saporito, MD, Stephen N. Snow, M.D.; Dermatology Dept., Univ of Wisconsin
Purpose: BACKGROUND: Epithelioid sarcoma is a rare malignancy that typically presents as an asymptomatic, slow growing nodule on the distal extremities of young adults. The benign clinical appearance belie this tumor's insidious nature. Epithelioid sarcoma has a predilection for spreading along fascial planes, tendons, and neurovascular bundles resulting in an 85% recurrence rate after local excision. Metastases via lymphatic or hematogenous routes occur in 45% of cases. The prognosis of metastatic disease is dismal with over 90% of patients succumbing to the disease. Historically, the treatment has been radical resection or amputation.
Design: METHOD: A case of an 85 year old white male with an epithelioid sarcoma of the right temple is presented. The tumor was extirpated via Mohs surgery. In addition to the specific details of this case, a pertinent review of epithelioid sarcoma and treatment options is discussed.
Summary: CONCLUSION: Epithelioid sarcoma is an aggressive malignancy that requires early recognition and adequate surgical resection. Our experience indicates that Mohs surgery may be an alternative to radical resection.
Conclusions: Please consider the above abstract for a poster presentation. We have no conflicts of interest. Thank you for your consideration. Frank Saporito, M.D. Stephen N. Snow, M.D Dermatology Department University of Wisconsin
Recurrence rate of nonmelanoma skin cancer after Mohs excision and margin analysis by permanent histopathological evaluation
Authors: Ross Campbell, MD, David Barral, M.D.-Brown Medical School, Caroline Wilkel, M.D.-Brown Medical School, Raymond G. Dufresne, Jr, M.D.-Brown Medical School
Purpose: This purpose of this study is to confirm the low rate of recurrence after Mohs excision of skin cancers on the face. This study is a follow-up to previously presented data demonstrating the effectiveness of the Mohs technique for tumor excision by evaluating Post-Mohs tissue by permanent histopathologic sections.
Design: A retrospective analysis of our university's surgical logbooks identified 296 Mohs cases which after excision, were sent to plastic surgery for reconstruction. A plastic surgeon at our university takes an additional layer and sends for histopathological analysis at the time of reconstruction by an independent dermatopathologist. One-hundred two patients were contacted and/or evaluated for signs of tumor recurrence.
Summary: There were no recurrences of skin cancer at the sites of Mohs excision in 102 patients after a mean of 71.4 postoperative months. Tumor types included 80 previously excised basal cell carcinomas, 21 squamous cell carcinomas, and one microcystic adnexal carcinoma.
Conclusions: This data supports the high reliability of Mohs surgery for margin control and low rate of recurrence. It also suggests that recurrence after Mohs maybe secondary to persistent tumor since no recurrences were observed in these patients who had an additional layer of tissue taken after Mohs examined by permanent histopathological evaluation and found to be free of tumor.
Ductal Eccrine Carcinoma with Extensive Subclinical Bony Involvement of the Skull in an Elderly Female
Authors: Megan M. Bogart, MD, Julia K. Padgett, MD, University of Virginia
Purpose: Ductal eccrine carcinoma (DEC) is a rare tumor that arises in the eccrine sweat glands. It occurs most commonly on the head and neck of elderly females. The tumor is characterized by an indolent growth pattern and a high tendency for local and distant spread. DEC frequently recurs after standard surgical excision. There have been few reports in the literature of excision of ductal eccrine carcinomas with Mohs micrographic surgery. We report a case of a DEC on the scalp of an elderly female with extensive subclinical spread involving the skull.
Summary: Two stages of Mohs micrographic surgery were required to clear the cutaneous margins of the 1.8cm tumor. Invasion of the underlying skull bone by tumor was noted grossly and histologically. Subsequent CT scan revealed an 8cm area of destruction of the outer table of the skull.
Conclusions: Ductal eccrine carcinomas are rare cutaneous neoplasms with the potential for aggressive clinical behavior and high recurrence rate after standard surgical excision. The presentation of DEC is highly variable and underlying subclinical involvement can often be extensive. Mohs micrographic surgery is a superior treatment option because most ductal eccrine carcinomas exhibit poorly circumscribed growth patterns with often clinically unapparent extent of the tumor.
Biphenotypic tumor with squamous and melanocytic differentiation demonstrating ultrastructural features of malignant melanoma
Authors: Andrea Willey, Kaye, Valda M.D.
Purpose: Cutaneous tumors with squamous and melanocytic differentiation have been rarely reported. Such tumors are of uncertain biologic behavior and must be distinguished from melanomas and pigmented squamous cell carcinomas. Of the six reported cases of such biphenotypic tumors ultrastructural studies were performed on one. This tumor showed melanocytes without definite evidence of malignancy. In the present study, we describe a biphenotypic tumor that demonstrates ultrastructural atypia within the melanocytic component, which has not previously been reported.
Summary: The dermal tumor with focal attachment to an abnormal epidermis was composed of atypical epithelial cells with focal keratinization admixed with smaller atypical cells containing intracytoplasmic melanin. Immunohistochemical staining shows areas of strong reactivity with cytokeratins admixed with cells staining positively with S-100, HMB45, Mart-1, and tyrosinase. Electron microscopy revealed numerous keratinocytes with desmosomes and tonofilaments containing melanosomes in all stages of development. Melanocytes were highly activated, containing numerous mitochondria, stage II melanosomes, and aberrant melanosomal forms.
Conclusions: These ultrastructural features are characteristic of malignant melanoma and raise the possibility that the melanocytic component of this tumor may exhibit biologic behavior characteristic of malignant melanoma.
Bilateral nasolabial flap (Butterfly flap) for repair of large nasal defects
Authors: zheng qian, Nathalie Zeitouni, MD. Dept of Dermatology, Roswell Park Cancer Institute, Buffalo, NY 14263., Paul Tomljanovich, MD. Dept of Head and Neck Surgery, Roswell Park Cancer Institute, Buffalo, NY 14263.
Purpose: Repair of large defects involving the lower 1/3 of the nose often presents a unique challenge. Frequently median or paramedian forehead flaps are used for these defects, necessitating multi-stage repairs and frequent need of revision. Full thickness skin graft is simple and straightforward, but often results in a poor match for skin texture and color. We present an alternative repair method for large defects of the lower 1/3 of the nose, involving the dorsum and ala.
Design: Bilateral nasolabial flaps were used to reconstruct the large and relatively symmetrical defects (4-5 cm in diameter) involving the lower 1/3 of the nasal dorsum and ala. Normal tissues on bilateral cheeks adjacent to nasolabial folds are transposed like two wings of a butterfly and used to cover the defects. The technique is illustrated, and post-op results are evaluated.
Summary: This flap is straightforward and can be performed in one stage. It contains rich dermal vasculature, provides a good match for skin color and texture, and maintains the symmetry. The scars can be camouflaged along the natural skin lines along the facial cosmetic units. Follow-ups at 17- and 42-months follow-up prove excellent results. For optimal outcome, it is important to undermine the defect widely, allow sufficient pedicle width and length, and thin the flap.
Conclusions: Butterfly flap is a simple and effective method to repair large symmetrical nasal defects involving the lower 1/3 of the nasal dorsum and ala. It provides superior cosmetic outcome than FTSG, and may prove to be especially useful when median or paramedian forehead flap, or melolabial flap are difficult or complicated for the patient.
Time-motion study of Mohs micrographic surgery
Authors: Erin J Allen, Summer R. Youker, MD, Jenine K. Harris, MA, Scott W. Fosko, MD
Purpose: Mohs surgery is the preferred treatment method for many cutaneous malignancies by offering high cure rates. Mohs surgery is a time and labor-intensive procedure for the physician, nursing and laboratory staff. This directly impacts patient care and patient wait times. To improve a process, its dynamics must first be clearly defined. By isolating the time requirements of the components of the Mohs surgical process, we hope to better define the procedure. Measuring the time required of all aspects of the Mohs procedure can identify possible process improvements and ultimately improve quality of care.
Design: Mohs surgery patients were tracked by recording the time throughout the registration, surgery, tissue processing, slide reading, defect repair and discharge process.
Summary: Patients had an average of 2.03 stages (range 1-6) and overall visit time of 226 minutes (range 96-614). Tissue processing averaged 32.6 minutes per stage and was statistically significantly shorter for stages 2 and 3 when compared to stage 1, as smaller tissue took less time to process. Of 171 stages, 18 (10%) required recuts of the tissue to view complete epidermis. 146 minutes were spent in the removal of the tumor and 40 minutes for the repair process. After completing preparation, patients waited an average of 6 minutes to start stage 1 and 10 minutes to start stage 2. Additionally, patients waited an average of 9 minutes to start the closure after completing repair preparation by the Mohs staff. The longest wait time came between stages. Patients waited 24 minutes after the slide was ready for physician review until the next stage, or repair if clear, was begun by the physician. Additional data will be reported as more cases are added to our series.
Conclusions: Better understanding of where time is spent during the Mohs process can benefit time management and hopefully shorten the patient's visit leading to enhanced utilization of resources.
Association of Number of Mohs Stages with Tumor Type and Anatomic Location: A Prospective Study of 10 Surgeons' Case Logs
Authors: Murad Alam, MD, Ross Levy, MD, Leonard H. Goldberg, MD
Purpose: There is variation regarding the number of stages or layers of Mohs surgery required to clear specific tumors. Moreover, there is variation across surgeons. The purpose of this study is to see whether, across surgeons and lesions, there are common patterns regarding the number of stages associated with removal of specific tumor types (basal cell carcinoma versus squamous cell carcinoma) and tumors at specific anatomic locations (ear/eyelid/nose/lip; other face; other head and neck; hands/feet/genitals; other trunk and extremity). This information may be useful to novice surgeons and to others who wish to compare their treatment patterns to median patterns among other surgeons.
Design: 30 surgeons were randomly selected from a national list of Mohs surgeons. From this list, 12 surgeons were selected to represent 4 geographic areas (West, Midwest, Northeast, South) and type of practice environment (urban/suburban/rural; and private practice/academic practice). 10 of these surgeons agreed to participate in this study. De-identified case records were prospectively collected for 200 consecutive Mohs cases from each surgeon. Fields required included histologic tumor type, anatomic location, and number of stages. Statistical analysis was performed to assess the correlation between number of stages and : (1) histologic tumor type; and (2) anatomic location of the tumor. Subgroup analysis was performed for geographic region and practice type.
Summary: On average, 1.8 Mohs stages were required to clear tumors. There was no statistically significant difference regarding number of stages associated with histologic tumor type. Anatomic location was associated with the number of stages, with the nose/lips/eye/ear associated with a statistically greater number of stages. Subgroup analysis was not statistically significant but indicated substantial variation across surgeons and geographic regions..
Conclusions: There is, reassuringly substantial agreement among surgeons regarding the optimal number of stages required to remove common cutaneous tumors by Mohs surgery. Anatomic area is the most notable determinant of this number. Variation across surgeons is likely due to differences in patient populations and the tumors seen.
The Novel Use of Superglue for Mohs Surgery
Authors: Priya Swamy Zeikus, Raymond G. Dufresne, Brown University School of Medicine
Purpose: Many Mohs procedures involve the handling and manipulating of thin, fragile skin tissue sections. Proper handling of the tissue becomes critical for tissue orientation and histological processing. We present a novel was to handle thin friable tissue with the use of superglue.
Design: One to two drops of superglue can be added to the epidermal surface of excised thin tissue sections before sectioning and processing. Sectioning and histological processing are performed per routine.
Summary: The superglue increases tissue rigidity of thin tissue and provides for easier handling while staining and orienting the tissue. Frozen sectioning and histological staining is unaltered. Tissue integrity is preserved and minimal artifact is seen upon histological examination.
Conclusions: This technique adds little time to the Mohs procedure. An example of superglue used during Mohs surgery for handling eyelid tissue is presented. In conclusion, the application of superglue to eyelid tissue and potentially other delicate tissue skin becomes a simple and novel approach for processing tissue during Mohs surgery.
Excision of a Peristomal Basal Cell Carcinoma Using Mohs Micrographic Surgery
Authors: Lindsay D. Sewell, M.D., Victor J. Marks, M.D., Both Drs. Marks and Sewell are with Geisinger Health System in Danville, PA
Purpose: Basal cell carcinoma is a common skin cancer of the head and neck that has also been reported in unusual sites such as the axilla, anus, and male nipple. We report the case of a 74-year-old male with a nodular basal cell carcinoma that developed adjacent to his abdominal colostomy, which was placed 33 years earlier. Because of its tissue sparing nature and high rate of cure, Mohs micrographic surgery was chosen for tumor removal. To our knowledge, this is the first reported case of a peristomal basal cell carcinoma treated with Mohs micrographic surgery.
Summary: After appropriate pre-operative preparations, the clinically apparent portion of the tumor was surgically removed. As Mohs layers were taken, the tumor was found to have invaded the superior and medial aspects of the terminal colostomy to the level of the muscularis mucosa. The patient was pronounced clear after a total of 3 stages and evaluation of 26 tissue sections. The medial abdominal skin of the wound was then undermined and closed by an advancement of the wound edges. The stoma was then tacked to an open edge of epidermis. The patient was able to use the colostomy immediately post-operatively. Sutures were removed after 15 days with no complications and a continuously functional colostomy.
Conclusions: A review of the literature showed one previously reported case of a peristomal basal cell carcinoma, which also developed about 30 years after colostomy placement. It was treated with wide, full-thickness abdominal wall excision and consequently required colostomy revision. Use of Mohs micrographic surgery in our patient spared him the risks and costs of general anesthesia and major surgery. It also preserved the original colostomy and prevented the need for revision. The patient's recovery time was more rapid than might have been expected from full-thickness excision and colostomy revision. Therefore, we suggest that Mohs micrographic surgery should be considered in basal cell carcinoma arising in unusual sites.
Predetermining the Surgical Margin of High Risk Basal Cell Carcinomas through the use of Clinical Predictors and Mohs Micrographic Surgery: A Validated, Model-Based Approach
Authors: David A. Lee, Dr. Desiree Ratner, M.D.; Columbia University, Department of Dermatology, Dr. Manisha Desai, Ph.D.; Columbia University, Department of Biostatistics
Purpose: BACKGROUND: While the goal of the surgical dermatologist is to maintain a balance between tissue conservation and surgical efficiency, a standard margin for removal of basal cell carcinoma (BCC) has never been firmly established. In many instances, BCCs demonstrate significant subclinical extension beyond the visually apparent tumor. Mohs micrographic surgery has been used to quantify these extensions. Previous studies of BCC have evaluated clinical predictors such as tumor size, location, and histologic subtype and recommend excisional margins ranging from 2 - 10 mm of normal skin around the visible lesion. OBJECTIVE: To develop a simplified model based on clinical predictors such as age, gender, race, tumor size, location, and primary versus recurrent status, that predicts the number of millimeters required for clearance of high risk BCC.
Design: METHODS: We prospectively evaluated 599 patients with biopsy-proven BCCs who underwent Mohs micrographic surgery. The age, gender, race, location, and primary versus recurrent status for each patient was recorded. We measured the preoperative dimensions of each tumor and the final defect dimensions after each surgical stage, and also calculated the amount of tissue stretch occurring after specimen removal. Our primary outcome was defined as the difference between the final defect size, after accounting for tissue stretch, and preoperative tumor size. In order to construct a model that could be impartially validated, we randomly partitioned our data set into a training set (399 patients) and a test set (200 patients). Logistic regression was applied to the training set to develop a model based on predictors significantly associated with our outcome. Our final model was validated using the test set.
Summary: RESULTS: On average, male gender, non-Caucasian race, recurrent tumors, older age, and tumor location were associated with larger excisions for tumor clearance after accounting for tissue stretch. However, only race, tumor size, and tumor site showed statistically significant associations with our outcome. Therefore, only these variables were incorporated into our final model as predictors of the number of millimeters required for tumor clearance after accounting for tissue stretch. Validation of this model using our test data set revealed a median prediction error of 1.5 mm with an interquartile range of 1.9 mm.
Conclusions: Using race, tumor size, and tumor location as clinical predictors, we have developed a model that predicts the number of millimeters required for clearance of high risk BCCs. This model represents a practical tool for estimating the margins required for extirpation of these tumors. However, its use should not circumvent the need for Mohs surgery, as BCCs may grow asymmetrically and therefore require careful examination of all margins to achieve maximal cure rates and tissue conservation.
The Economic Impact of Preoperative Curettage in Mohs Micrographic Surgery for Basal Cell Carcinoma
Authors: Dr. Desiree Ratner, David A. Lee; Columbia University, Department of Dermatology
Purpose: Mohs micrographic surgery requires a delicate balance between tissue conservation and surgical efficiency. This balance may be influenced by the use of preoperative tumor curettage. Curettage allows the surgeon to delineate the subclinical extensions of high risk basal cell carcinomas (BCCs) and thereby enables a more precise first stage excision around tumor-containing tissue. We have previously shown that preoperative curettage of high risk BCCs can significantly reduce the number of Mohs surgical stages required for tumor clearance; however, the impact of these findings on clinical practice has not been evaluated. OBJECTIVE: To systematically assess the economic impact of preoperative curettage on patients, insurers, and providers for Mohs micrographic surgery for high risk BCCs.
Design: To universally compare the duration of one stage of Mohs surgery versus two stages, we assumed that for a given BCC, the time required to complete a second stage was 75% of that required to complete the first stage. To estimate the costs borne by insurers and select patients for an additional Mohs stage, we used New York City Medicare and Standard reimbursement rates for each stage of Mohs surgery for high risk BCCs.
Summary: We calculated that a two-stage Mohs surgery is 1.75 times longer than a one-stage surgery and that the total duration of 4 Mohs surgeries with two stages equals that of 7 one-stage surgeries. Accordingly, preoperatively curetting BCCs can reduce the number of required Mohs stages from two to one, resulting in a total time savings equivalent to the duration of the 3 one-stage surgeries. The time saved for each patient is this value divided by 7.
Conclusions: With proper technique and experience, preoperative curettage may reduce the number of Mohs surgical stages required for tumor clearance. This may shorten encounters for patients and surgeons and allow surgeons to treat additional patients, while also decreasing costs for patients and insurers and improving the quality of the patient's surgical experience. Overall, curetting high risk BCCs prior to Mohs micrographic surgery can promote operative efficiency without comprising tissue conservation.
Multiple Primary Acral Melanomas in African-Americans.
Authors: Angela Hutcheson, MD, Joel Cook, MD, Associate Professor, Medical University of South Carolina, Department of Dermatology, Joseph McGown, Medical Student, University of South Carolina School of Medicine
Purpose: Melanoma is a very serious form of skin cancer. Although melanoma accounts for only 4-5% of all skin cancers in the United States, it causes most (approximately 71%) skin cancer-related deaths. As the incidence of melanoma continues to rise at a rate of ~3% per year, a unique subpopulation has emerged that includes patients with multicentric primary melanomas. Within the context of patients with multiple primary melanomas, those with multiple melanomas located solely in an acral distribution has not, to our knowledge, been reported thus far. The purpose of this presentation is to discuss the case histories and management of a cohort of patients in the MOHS practice of our dermatologic surgeon with multiple primary acral lentiginous melanomas.
Design: This study consists of a case series of patients with multiple acral lentiginous melanomas (ALM). A chart review was performed on all patients within this practice diagnosed with ALM from 2000-2005. 4 patients were identified, all African-American, with more than one ALM including evolving ALM. The clinical data including sex and concomitant diseases of these patients was noted. The histology, staging workup (where appropriate) and surgical intervention of each melanoma including reconstruction were reviewed. In addition, a thorough review of literature was performed and will be briefly discussed.
Summary: Of the patients diagnosed with ALM at our site, 4 patients were identified with more than one (from two to four) acral melanomas. One lesion was recurrent. None of these lesions appeared as "satellites" or metastases. None of the patients had any other types of skin cancers. While several had atypical nevi, none of the patients with single or multiple primary ALM had primary melanomas at non-acral sites. All 4 patients were African-American, three female and one male. Three of the four had type II diabetes. None were on immusuppression. The risk factors normally associated with melanoma (including fair skin, blue eyes and a history of sunburns) were not present in our patients with multiple ALM. Several were noted to have multiple melanotic macules on their palms and soles consistent with acral melanosis. Upon review of the literature, it was discovered that information of patients with multiple primary acral melanomas was not available. Therefore, the appropriate management of these patients, including staging workup and surgical intervention, will be extrapolated from available literature as well as our experience.
Conclusions: Here we discuss the presentation and management of a cohort of patients with multiple primary melanomas located solely in an acral distribution. We recommend the biopsy of all suspicious lesions as several of our patients had other, albeit benign, pigmented lesions. Because survival prognosis is markedly improved when these lesions are diagnosed early and in the superficial stage, the importance of close monitoring is emphasized.
Infection with Mycobacterium Abscessus after Mohs Micrographic Surgery
Authors: Emily Fisher, Hugh Gloster, MD; University of Cincinnati
Purpose: Background: Nontuberculous mycobacterial infections are increasing in incidence. They have been reported following multiple procedures including dialysis, liposuction, soft tissue augmentation, pedicures, public baths, acupuncture, placement of contaminated foreign devices such as Norplant, intravenous catheters, and during surgery from contamination of medical instruments.
Summary: Objective: We report a case of Mycobacterium abscessus infection presenting as erythematous papules occurring after Mohs micrographic surgery. We also review the literature on nontuberculous mycobacterial infection to discuss common presentations, diagnosis and treatment options.
Conclusions: Results/Conclusion: Infection with nontuberculous mycobacteria can present with varied nonspecific morphologies. A high degree of clinical suspicion is necessary to avoid delays in diagnosis and treatment.
Penile Cancer: Large Case Series from Combined Dermatologic and Urologic Experience in a University Setting
Authors: Eva A. Hurst, MD, Viraj Master, MD, PhD; University of California, San Francisco, Maria L. Wei, MD, PhD; University of California, Veterans Affairs Medical Center, San Francisco
Purpose: Penile cancers are uncommon and therefore information regarding presentation, risk factors, and treatment is limited. We report the results of an interdisciplinary retrospective study encompassing three medical centers in a major metropolitan city.
Design: Using systematic chart review, we analyzed consecutively presenting cases of penile cancer during the time period of January 1, 1999 through January 1, 2004. Data regarding presentation, diagnosis, risk factors, and treatment was collected. We also surveyed treatment modalities utilized by the departments of dermatology and urology at this medical center and compared them with reports in the literature.
Summary: Thirty-seven cases were squamous cell carcinoma (SCC). In addition to SCC, there were seven cases of other cancers including Kaposi's sarcoma, melanoma, Paget's disease, leiomyosarcoma, and metastatic prostate cancer. Seventy percent of our patients were Caucasian, 11% were African-American, and the remainder were divided among Hispanic and Asian ethnicities. Follow-up information was available for 25 patients, with an average follow-up time from diagnosis of 24 months. A preponderance of SCC cancers (53%) presented at the glans or tip of the penis. The majority (54%) of SCC's presented as in situ or Stage I disease, with the remainder being equally divided between Stages II-IV.
Conclusions: Most cancers occurring on the penis were squamous cell carcinomas, many of which presented distally as in situ or Stage I malignancies. Advanced disease at presentation, including distal metastases, was not uncommon in our patient population. In our patient sample, lack of circumcision did not appear to be a significant risk factor for the development of penile malignancy. Smoking was a risk factor. Immune status likely played a small role in our patients' penile cancers. Treatment modalities at our institution correlated with stage of presentation and were similar to those commonly reported in the dermatologic and urologic literature.
Primary Mucinous Eccrine Carcinoma Treated with Mohs Surgery
Authors: Bethanee J. Schlosser, MD, PhD, Akash Patel, MD, Emory University School of Medicine, Carl Washington, MD, Emory University School of Medicine
Purpose: We present a case of mucinous eccrine carcinoma in a 69-year old African American male to demonstrate the characteristic clinic and histopathologic features. The utility of Mohs micrographic surgery for definitive treatment of this rare but aggressive adnexal malignancy is discussed.
Summary: A healthy 69-year old African American male presented with an 18-month history of an asymptomatic, slowly enlarging mass at the left lateral infraorbital ridge. Initial examination revealed a firm, exophytic, skin-colored tumor with increased vascular markings. Histopathology revealed islands of small, uniform-appearing, epithelial cells floating in pools of mucin consistent with mucinous eccrine carcinoma. Mohs micrographic surgery was performed with complete excision of the lesion.
Conclusions: Mucinous eccrine carcinoma is a rare adnexal neoplasm. This malignancy most frequently occurs on the face and scalp. It is twice as common in men, and approximately 64% of affected patients are Caucasian. Histopathologic features are distinctive but must be distinguished from metastatic lesions of mucin-producing visceral carcinomas. Standard excision using narrow margins may result in local recurrence in up to 30% of cases and regional nodal metastases in up to 10% of cases. Wide local excision is recommended. Most tumors occur in cosmetically sensitive areas; therefore, Mohs micrographic surgery may be useful to ensure complete excision and to allow for optimal reconstruction.
Squamous Cell Carcinoma arising in a Nevus Sebaceous of Jadassohn in an 8-year old girl. Treatment by Mohs Micrographic Surgery.
Authors: Muba Taher, MD, Richard Bennett, MD Clinical Professor of Medicine (Dermatology) University of Southern California and University of California at Los Angeles
Purpose: Squamous cell carcinoma rarely occurs in a nevus sebaceous of Jadassohn (NSJ) and even more rarely in childhood. We present a case of an 8-year-old girl who developed a rapidly growing squamous cell carcinoma in her NSJ.
Design: A biopsy taken of a rapidly growing nodule on a previously stable congenital lesion on the temple of an 8-year-old girl showed a squamous cell carcinoma. The tumor was removed with Mohs micrographic surgery.
Summary: Histopathology of the rapidly growing nodule showed a spindle cell squamous cell carcinoma occurring in an NSJ. Immunohistochemistry stains revealed strong positive staining of tumor cells with antibodies to cytokeratin 5/6, pankeratin, and vimentin. Staining was negative with antibodies to S-100 and MART-1. EMA showed faint positive staining focally. Immunohistochemical staining for antibodies to the various subtypes of human papilloma virus was negative (HPV types 6/11/16/18/31/33/51). The squamous cell carcinoma was removed using Mohs micrographic surgery (two stages), and the resulting defect was closed with a complex repair.
Conclusions: Our case represents one of the very few reported cases of squamous cell carcinoma complicating a NSJ in childhood. Sudden growth in a child's NSJ should be carefully evaluated to rule out the possibility of a malignancy.
Mohs Micrographic Surgery for the Treatment of Chromoblastomycosis
Authors: Saadia Raza, MD, Fiona O'Reilly; Dept of Dermatology, Emory University, Atlanta, Georgia, Carl Washington; Department of Dermatology, Emory University, Atlanta, GA
Purpose: Chromoblastomycosis is an uncommon deep fungal infection often requiring surgical excision in addition to oral long-term antifungal therapy. We report a case of chromoblastomycosis of the left dorsal index finger in a solid organ transplant patient, successfully treated with Mohs micrographic surgery.
Design: Our patient is a 50 year old male on multiple immunosuppressant medications following renal transplantation who presented with two adjacent slowly growing nodules on the left index finger. Skin biopsies for culture and microscopic examination demonstrated chromoblastomycosis. Mohs micrographic surgery was performed in order to eradicate the lesion while sparing normal tissue in this critical location.
Summary: The lesion was cleared after two Mohs surgical stages. Pigmented fungal elements were easily identified on frozen tissue examination. The defect was repaired with a full thickness skin graft. The patient was placed on two months of adjuvant itraconazole.
Conclusions: In 1986 Frederic Mohs first reported the successful treatment of chromoblastomycosis using staged micrographic surgery. We present Mohs micrographic surgery with frozen section examination as an excellent choice for eradication of deep fungal infections in areas where tissue conservation is important, such as the hand and in immunocompromised patients who tend to have more extensive involvement and a higher incidence of recurrence.
A Prospective Study Comparing Curettage to Scalpel in Debulking of Basal Cell Carcinoma Before Mohs Surgery
Authors: William Posten, MD, Sarah Weitzul, MD UT Southwestern Medical Center, Maryam Asgari, MD UT Southwestern Medical Center, R. Stan Taylor III, MD UT Southwestern Medical Center
Purpose: The first step of Mohs surgery ("debulking") involves removing any clinically visible tumor. Several techniques are used for this step, including removing visible tumor with a scalpel excision as well as using a curette to scrape any visible tumor or tumor detected by tactile sensation. Several recent studies have attempted to compare these two methods of debulking. An article by Ratner, et al, demonstrated in a prospective study that using curette debulking can reduce the number of Mohs surgical stages required for basal cell carcinoma clearance, concluding that a mean curetted margin of 1.7mm decreased the need for another stage compared to 2mm surgical margins in 93% of cases studied. Another combined retrospective and prospective study by Jih, et al, found that curettage debulking did not decrease the number of stages required for basal cell carcinoma clearance. We performed an observer blinded prospective randomized study on 108 lesions in 93 patients where the patient's lesions were randomized to receive either curette debulking or scalpel debulking with 2mm margins to see if there was any difference in the number of stages required for clearance and whether there was any difference in deep vs lateral margin clearance between the two methods.
Design: Ninety three patients with at least one biopsy-proven basal cell carcinomas treated with Mohs micrographic surgery at University of Texas Southwestern Medical Center were enrolled into the study. Patients were enrolled in a randomized prospective fashion, with the surgeon being told which debulking technique to use on an enrolled patient. Data was collected at the end of the study from the Mohs maps used in surgery as well as from the computerized medical record and included age of patient, tumor site, tumor histology, preoperative tumor size, number of stages required to clear tumor and visual maps from the Mohs surgery procedure. Statistical comparisons were then performed using Microsoft Excel spreadsheet functions.
Summary: The mean number of stages using the curettage debulking method was 1.78 +/- 0.89, while the mean number of stages using the scalpel debulking method was 1.65 +/- 1.18. Although more stages were performed after curettage debulking, this was not statistically significant. We examined the effectiveness of debulking on surgery, by counting cases where the debulk specimen demonstrated histologic presence of tumor but no tumor was found on the first stage of Mohs surgery. This occured 16% of the time using the curettage method and 24% of the time using the scalpel method. Both methods resulted in debulk specimens which did not contain tumor, but tumor was found on the first stage of Mohs surgery. This occured 16% of the time using the curettage debulking technique and 9% of the time using the scalpel debulking technique. Analysis of the cases in which the first stage of Mohs surgery was positive we found that curretage debulking appeared to have more positive deep margins as compared to scalpel debulking (22% vs 7%), while scalpel debulking had slightly more positive lateral margins (26% vs 24%).
Conclusions: In examining our data, there is no significant difference between the use of scalpel debulking or curettage in delineating tumor margins. Both techniques resulted in a similar mean number of stages. We had initially hypothesized that scalpel debulking provides a more visually precise lateral margin and would thus clear lateral margins better than curettage debulking. Conversely, curettage debulking would clear deep margins better than scalpel debulking. We found that curretage debulking appeared to have more positive deep margins, while scalpel debulking had slightly more positive lateral margins. These results suggest that both visualization of tumor margins with the unaided eye in scalpel debulking and tactile sensation with curretage debulking are both imprecise methods. Furthermore, neither technique provides an advantage over the other with regards to decreasing the number of stages required to clear tumor.
Disseminated intravascular coagulation unmasked by Mohs micrographic surgery
Authors: Kjetil Kristoffer Guldbakke, Carl F Schanbacher, Department of Dermatology, Harvard Medical School,, Brigham and Women's Hospital, Dana-Farber Cancer Institute,, 44 Binney Street, Boston, MA, 02115
Purpose: To report a case of disseminated intravascular coagulation (DIC) manifesting after Mohs micrographic surgery of a basal cell carcinoma. May be presented either in oral or poster format.
Design: Case report with a concise review of the literature and discussion.
Summary: We report a case of an 83-year-old male with metastatic prostate adenocarcinoma, manifesting DIC after relatively minor Mohs micrographic surgery of a basal cell carcinoma. The patient presented with post-operative bleeding, wound edge necrosis and facial ecchymoses. Blood tests revealed findings consistent with DIC. His clinical course was prolonged and complicated, with therapy targeting the underlying malignancy as well as measures to stop bleeding.
Conclusions: To our knowledge, no previous case of DIC germane to dermatologic surgery has been reported. A surgical procedure, such as Mohs micrographic surgery in our patient, may serve to reveal underlying DIC or act as a triggering event by activating the fibrinolytic system, and push a patient into an acute decompensated state of DIC. The case emphasizes the importance of obtaining a full medical history before beginning treatment, thorough investigation of any patient who does not respond to routine hemostatic manoeuvres and the novel preventive and therapeutic approaches for patients with DIC.
Comparison of Sentinel Lymph Node Biopsy versus Breslow Thickness as a Prognostic Indicator for Cutaneous Melanoma
Authors: Justin J. Vujevich, MD, David G. Brodland, MD, Assistant Professor, Univerity of Pittsburgh Medical Center, John A. Zitelli, MD, Assistant Professor, Univeristy of Pittsburgh Medical Center
Purpose: For years Breslow thickness was the gold standard in predicting 5-year survival for patients with cutaneous melanoma. Over the last decade, however, several studies have suggested that sentinel lymph node biopsy (SLNBx) status is a better prognostic indicator than Breslow thickness in predicting survival for these patients. In fact, SLNBx has been incorporated into latest version of the American Joint Committee on Cancer staging system for melanoma. However, side-by-side comparison of these two prognostic indicators has never been undertaken. The aim of this presentation is to demonstrate the relative value of prognoses derived from SLNBx studies versus Breslow thickness prognosis alone. This comparison, and delineating how much more information a SLNBx would provide for prognostication, when compared with Breslow thickness alone should assist the physician in providing comprehensive informed consent to patients contemplating a SLNBx to further aid in determining their prognosis.
Design: Using a Medline search, we identified studies that included SLN status and overall 5-year survival of patients, stratified by Breslow thickness groups. The SLN status and overall 5-year survival was compared to historical overall 5-year survival data based solely on Breslow thickness. This information is presented utilizing case scenarios.
Summary: Several studies were found which presented SLN positivity data and associated 5-year survival analyses for various Breslow thickness groups. These survival percentages were compared to historical 5-year survival percentages based on Breslow thickness alone. For example, if a patient presents with a 1mm thick melanoma, what is the chance of having a positive SLN? What is the overall 5-year survival if that patient has a positive SLN? What is the overall 5-year survival of the same patient with a negative SLN? Finally, how do these survival percentages compare to overall 5-year survival percentages based solely on Breslow thickness?
Conclusions: Data from this presentation should assist the clinician when discussing the risks and benefits of undergoing a sentinel lymph node biopsy, given the Breslow thickness of the melanoma. Until results are reported from randomized, prospective studies verifying the therapeutic benefit of SLNBx and subsequent complete lymph node dissection, clinicians must remain familiar with SLNBx survival data. The results of this study will enable the clinician to have the ability to compare this to Breslow thickness survival data in order to provide a frame of reference for the use of SLNBx as a prognostic tool for melanoma patients.
The Use of Acellular Bovine Collagen Dermal Matrix Grafts in the Repair of Full Thickness Mohs' Surgery Defects: A Report of Six Cases
Authors: , Martiza Perez, MD, Department of Dermatology, St. Luke's-Roosevelt Hospital Center, Columbia University
Purpose: Since the initial reports by Burke et al. in 1981 describing the use of physiologically acceptable artificial skin for the treatment of extensive burn injuries, there have been a great number of advances in the areas of dermal substitution and wound healing. To date, however, there are no commercially available or experimental products that can be used as a direct substitute for living skin grafts. Although both artificial and natural polymers have been designed to reconstitute the dermis, there has been a recent emphasis placed on the use of bovine fetal collagen matrices. In vitro studies have confirmed that collagen is a natural substrate for fibroblast attachment, proliferation and differentiation. In burn patients with extensive injuries, there are numerous reports in which reconstruction of the dermis using collagen matrices is followed by transplantation of autologous split-thickness skin grafts to obtain wound closure. In the dental literature, however, acellular dermal matrix grafts have been successfully used to repair mucogingival defects, without the need for subsequent grafting. We report the novel use of an acellular bovine collagen dermal tissue matrix graft in the repair of full thickness Mohs' surgery defects without the need for additional surgical correction.
Design: Each patient underwent Mohs' micrographic surgery for removal of a cutaneous malignancy. All surgical margins were found to be free of tumor and hemostasis was obtained. An acellular bovine collagen dermal tissue matrix graft was sized to match the surgical defect, and sutured to the adjacent epidermis using a running monofilament nylon suture. The patients were instructed to perform twice daily dressing changes with mupirocin cream under a hydrocolloid gel dressing. Sutures were removed after two weeks, and wound dressings were continued daily under re-epithelialization was complete.
Summary: Six patients underwent Mohs' surgery for cutaneous malignancies followed by primary closure with an acellular bovine collagen dermal tissue matrix graft. The average age of the patients was 78 years. All patients had one of the following cutaneous malignancies: atypical fibroxanthoma (n=2), basal cell carcinoma (n=2), or squamous cell carcinoma (n=2). The locations of the tumors were either scalp (n=5) or lower extremity (n=1). The average defect size was 14.2 cm2, with a range of 7 cm2 to 25 cm2. Clinical photographs confirm satisfactory wound healing in the initial four cases and promising granulation tissue in the most recent two cases. The average length of wound healing was 25 weeks with a range of 16-36 weeks. No complications were observed in these five cases.
Conclusions: In conclusion, the use of acellular fetal bovine collagen dermal matrix grafts is a potential method for the correction of full-thickness Mohs' surgery defects when living cutaneous flaps and grafts are impractical or a less invasive approach to wound closure is desired by the patient or surgeon.