Mohs micrographic surgery

Adjuvant cytokeratin staining in Mohs micrographic surgery for basal cell carcinoma

BACKGROUND

Mohs micrographic surgery (MMS) is a technique that offers excellent cure rates in the treatment of basal cell carcinoma (BCC). One of the reasons for its success is the 100% visualization of the resection margins. Still, recurrences do occur in 2% to 5% of the treated BCCs. It has been suggested that BCC cells in frozen sections stained with hematoxylin and eosin (H&E) may be missed.

OBJECTIVE

To determine whether an additional immunohistochemical staining with a cytokeratin marker (MNF 116) indicates BCC cells in sections in which the H&E-stained frozen sections were negative.

METHODS

The Mohs procedure was performed under standard conditions in which H&E-stained slides were judged by the Mohs surgeon and the pathologist. After the H&E slides where judged negative, an extra slide was stained using immunohistochemistry and a monoclonal antibody against cytokeratin (MNF 116).

RESULTS

A total of 143 complete slides were stained and judged by two Mohs surgeons and a pathologist. One of the 143 slides stained with MNF 116 showed positive staining where the H&E slides were negative, which is 0.7% of the slides. However, this single slide represents a failure of nearly 2% of the treated patients.

CONCLUSION

Frozen sections stained with H&E in MMS offer enough security in detecting BCC cells during surgery; however, adjuvant cytokeratin staining can be useful in very selected cases of aggressive growing BCC.

Basal cell and squamous cell carcinoma

OBJECTIVES

To describe the clinical and histologic subtypes, pathophysiology, recognition, and treatment options for basal cell and squamous cell carcinoma, and the molecular biology of sunlight-induced carcinogenesis.

DATA SOURCES

Journal and review articles, research studies, textbooks, and clinical practice.

CONCLUSIONS

Basal cell and squamous cell carcinoma will occur in more than one million cases annually in the United States, and are highly curable when detected and treated early. During the last decade, significant progress has been made in elucidating the molecular basis of skin carcinogenesis and in identifying newer approaches for the management and treatment of these keratinocyte cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play crucial roles in decreasing the morbidity and mortality from the skin cancer epidemic by identifying and referring patients with lesions suspicious for basal cell and squamous cell carcinomas.

Terahertz pulse imaging of ex vivo basal cell carcinoma

Terahertz pulse imaging has been used for the first time to study basal cell carcinoma ex vivo, the most common form of skin cancer. This noninvasive technique uses part of the electromagnetic spectrum in the frequency range 0.1-2.7 THz. A total of 21 samples were imaged; the study was performed blind and results were compared to histology. Each image consisted of possible diseased tissue and normal tissue from the same patient. The diseased tissue showed an increase in absorption compared to normal tissue, which is attributed to either an increase in the interstitial water within the diseased tissue or a change in the vibrational modes of water molecules with other functional groups. Seventeen of the images showed a significant difference between the normal and the diseased tissue. These were confirmed by histology to be basal cell carcinomas. Of the remaining four cases, three showed no contrast and were confirmed as blind controls of normal tissue; the fourth case was a suspected basal cell carcinoma but showed no contrast, and histology showed no tumor. Cross-sections of the terahertz images, showing the terahertz absorption, were compared to histology. Regions of increased terahertz absorption agreed well with the location of the tumor sites. Resolutions at 1 THz of 350 microm laterally and 40 microm axially in skin were attainable with our system. These results demonstrate the ability of terahertz pulse imaging to distinguish basal cell carcinoma from normal tissue, and this macroscopic technique may, in the future, help plan surgery.

Anchored flaps in post-Mohs reconstruction of the lower eyelid, cheek, and lateral canthus: avoiding eyelid distortion

PURPOSE

To describe a system of post-Mohs reconstruction that addresses lower eyelid susceptibility to unopposed tractional, cicatricial, and gravitational forces. Large flaps are anchored to fixed tissue to avoid transmitting flap tension to the eyelids.

METHODS

This is a retrospective, cohort study drawn from approximately 40 patients with post-Mohs defects of the nonmarginal lower eyelid, cheek, and lateral canthus. Surgical intervention involved horizontally oriented, relaxed skin tension line-designed advancement flaps, usually with eyelid margin stabilization. The use of anchoring sutures and any requirement for flap-graft combinations were based on defect size and the elasticity of adjacent tissues.

RESULTS

Anchoring eyelid and cheek flaps to underlying periosteum permitted broad flap dissection and advancement without distortion, as the semimobile eyelid and canthi were protected from the resulting flap tension. Anticipated defect size limits for flap reconstruction often were exceeded. Defects too broad for flap reconstruction alone could be downsized, leaving a relatively small area for graft resurfacing.

CONCLUSIONS

Anchored cheek flaps extend recognition of the continuity of the lower eyelid and midface to the primary reconstruction of tumor-free defects, and they address the relation by restoring deep attachments that minimize eyelid and canthal dystopia.

Micrographic surgery of basal cell carcinomas of the head

Basal cell carcinoma (BCC) is a locally invasive malignant cutaneous tumour with a rising incidence. This tumour can be treated successfully by a variety of techniques, including local excision, radiation, cryotherapy, curettage, electrodessication and laser obliteration. Micrographic surgery is a specialised type of minimal marginal surgery that offers higher cure rates than do other options in the treatment of contiguous skin cancers in selected settings. The horizontal frozen histological sections of the excised tumour permit complete microscopic examination of the surgical margin. Maximum sparing of tumour-free adjacent tissue is achieved with histological mapping of the tumour boundaries, and subsequent wound reconstruction is optimised. Data on topographical distribution, histopathological subtype, subclinical tumour extension, therapeutic procedures required for complete eradication, and recurrence rates were recorded in 3065 BCC of the head. Micrographic surgery is the treatment of choice for large or invasive primary BCC with uncertain clinical boundaries, especially in difficult anatomical regions, for recurrent or re-recurrent BCC, and for tumours with an aggressive histopathological pattern.

Terahertz pulse imaging in reflection geometry of human skin cancer and skin tissue

We demonstrate the application of terahertz pulse imaging (TPI) in reflection geometry for the study of skin tissue and related cancers both in vitro and in vivo. The sensitivity of terahertz radiation to polar molecules, such as water, makes TPI suitable for studying the hydration levels in the skin and the determination of the lateral spread of skin cancer pre-operatively. By studying the terahertz pulse shape in the time domain we have been able to differentiate between diseased and normal tissue for the study of basal cell carcinoma (BCC). Basal cell carcinoma has shown a positive terahertz contrast, and inflammation and scar tissue a negative terahertz contrast compared to normal tissue. In vivo measurements on the stratum corneum have enabled visualization of the stratum corneum-epidermis interface and the study of skin hydration levels. These results demonstrate the potential of terahertz pulse imaging for the study of skin tissue and its related disorders, both in vitro and in vivo.

Mohs' micrographic surgery for the treatment of melanoma

Surgical excision with clear margins remains the treatment of choice for melanoma. Under appropriate conditions MMS may offer a means of achieving clear margins while sparing normal tissue. This requires a Mohs' surgeon expert in interpretation of melanocytic lesions and excellent technical support. As the popularity of special histologic stains continues to grow these may offer and additional means to increase sensitivity and specificity in the detection of melanoma.

A risk scale for predicting extensive subclinical spread of nonmelanoma skin cancer

BACKGROUND

The clinical appearance of nonmelanoma skin cancer may represent only a portion of microscopic tumor invasion.

OBJECTIVE

To develop a scale based on high-risk characteristics for predicting the probability of extensive subclinical spread of nonmelanoma skin cancer.

METHODS

Retrospective analysis of 1095 Mohs micrographic surgical cases (MMS) yielded high-risk factors for extensive tumor spread, defined as requirement of greater-than-or-equal3 MMS layers. Predictive characteristics included: any BCC on the nose, morpheaform BCC on the cheek, neck tumors and recurrent BCC in men, location on the eyelid, temple, or ear helix, and size>10 mm. Multivariate logistic regression was applied to develop a risk index.

RESULTS

Tumor characteristics were assigned point values calculated from the respective odds of extension and categorized into six risk classes with probabilities of extensive subclinical spread ranging from 10% to 56%.

CONCLUSION

A risk scale simplifies and enhances prediction of extensive tumors. The associated probabilities can help to guide patient preparation and appropriate therapy.

Immunohistochemical staining of lentigo maligna during Mohs micrographic surgery using MART-1

BACKGROUND

Lentigo maligna (LM) often displays extensive subclinical spread. Mohs micrographic surgery (MMS) has been proposed to help delineate the true histologic margin; however, visualizing atypical melanocytes on frozen section is challenging and often requires confirmatory permanent paraffin sections.

OBJECTIVE

Our aim was to use a monoclonal antibody to rapidly stain frozen sections during MMS to facilitate better visualization of atypical melanocytes.

METHODS

Frozen sections of LM during MMS were stained with MART-1 (melanoma antigen recognized by T cells) and compared with paraffin-embedded sections.

RESULTS

We found 100% correlation between frozen sections stained with MART-1 and paraffin-embedded sections.

CONCLUSIONS

Atypical melanocytes can be better visualized on frozen sections of LM by using MART-1 rather than hematoxylin and eosin. This allows for easier identification during MMS and better chance of complete removal of LM lesions.

Granular cell tumor treated with Mohs micrographic surgery: report of a case and review of the literature

BACKGROUND

Granular cell tumors are uncommon soft tissue neoplasms of neural origin that most often arise in the oral cavity. Penile lesions are distinctly uncommon. Mohs micrographic surgery (MMS) is a highly effective treatment for several cutaneous neoplasms when tissue conservation is crucial.

OBJECTIVE

To examine the use of MMS for this soft tissue malignancy.

METHODS

We report only the eighth granular cell tumor of the penis. The literature was reviewed regarding the use of MMS for these neoplasms.

RESULTS

MMS was performed to minimize the destruction of normal tissue in treating this patient's granular cell tumor. Only one previous article documented the use of MMS for this soft tissue tumor.

CONCLUSION

Although utilized infrequently to treat granular cell tumors, MMS may prove beneficial when lesion location or size render tissue conservation or assuredness of cure paramount.

Mohs micrographic surgery for facial skin cancer

Although it is well established that conventional treatment modalities generally result in high cure rates for non-melanoma skin cancer, it has been demonstrated over recent decades that the highest overall cure rates are achieved using Mohs micrographic surgery. The key to Mohs surgery is the excision and control of complete peripheral and deep resection margins in one plane, allowing orientation, mapping and re-excision of microscopic tumour extension. These extensions can be followed without sacrificing inappropriate amounts of normal tissue, yielding high cure rates and maximum preservation of tissue. These qualities make Mohs surgery an important and reliable treatment for skin cancer of the face, in particular when it concerns large, aggressive or recurrent carcinoma in cosmetic and functionally important areas. In an 8-year study period, 369 basal cell carcinomas (BCCs) and 56 squamous cell carcinomas (SCCs) of the face were treated in our department using Mohs surgery. With a follow-up ranging from 3 months to 99 months (mean 33 months), none of the BCCs recurred and only one (2%) of the SCCs recurred a few months postoperatively. These favourable cure rates using the modality of Mohs surgery are the reason for highlighting this technique in the current review.

Perineural invasion of cutaneous malignancies

BACKGROUND

Perineural invasion is an important mode of tumor spread and is associated with increased aggressiveness and a propensity for recurrence among cutaneous malignancies.

OBJECTIVE

To review the pathogenesis, diagnosis, and treatment of cutaneous tumors exhibiting perineural invasion.

METHODS

This article is based on a review of the medical literature concerning tumors with perineural involvement.

RESULTS

This article describes the clinical signs and histologic features of cutaneous malignancies exhibiting perineural involvement.

CONCLUSION

Appropriate patient care mandates consideration of perineural invasion in the evaluation of cutaneous tumors. As the majority of patients present without symptoms of neural involvement, physicians must be vigilant in the search for this type of tumor spread.

Cutaneous malignancies and their management

Skin cancer is the most common malignancy occurring in humans, and the incidence of basal cell carcinoma, squamous cell carcinoma, and melanoma continues to rise. Advances in the diagnosis and treatment of skin cancer have led to more successful management of these tumors. A number of options for the treatment of skin cancer are available to the patient and physician, allowing for high cure rates and excellent functional and cosmetic outcomes.

Digital photography for mapping Mohs micrographic surgery sections

BACKGROUND

Instant photographic print images have been used to diagram tissue sections excised for Mohs micrographic surgery (MMS). This approach is limited by the size of the print image, the potential difficulty of writing on a glossy photo print, and the cost of film.

OBJECTIVE

We describe the use of digital photographic images as templates for making maps of tissue excised for MMS.

METHODS

Digital photographic images of patients undergoing MMS are downloaded to a computer and printed onto plain paper. A map of the tissue excised for MMS is drawn directly onto the digital print.

RESULTS

Several methods of creating MMS maps using digital photographic print images are described.

CONCLUSION

Advantages of using digital photographs in MMS include speed of producing images, low cost of materials, greater accuracy of depicting the MMS excision defect, and ease of correlating the MMS map to the patient for subsequent stages of excision.

Bilateral auricular squamous cell carcinomas with perineural invasion

BACKGROUND

Bilateral squamous cell carcinoma (SCC) of the external ears is a rare phenomenon, and we are unaware of instances of bilateral perineural involvement.

OBJECTIVE

To describe bilateral auricular SCCs, each with perineural invasion.

METHODS

Case report and literature review.

RESULTS

Histopathologic examination revealed perineural invasion in both tumors.

CONCLUSION

This appears to be an unusual presentation of bilateral auricular SCCs with perineural invasion in an elderly immunocompromised patient.

Early malignant melanoma manifested as longitudinal melanonychia: subungual melanoma may arise from suprabasal melanocytes

A 51-year-old woman developed longitudinal melanonychia of 3 months' duration on the right index fingernail. A biopsy specimen revealed that atypical melanocytes were distributed in the lower third of the matrix epithelium but were few in number at the basal layer. The involved nail matrix was resected because of continual growth of the lesion after the biopsy. It has been proven in normal nail matrices that melanocytes are distributed not only in the basal layer but also in the lower half of the epithelium. It is therefore understandable that malignant melanoma of the nail matrix can arise from melanocytes situated in the squamous epithelium above the basal layer. The present case is a good example in which malignant melanoma of the nail matrix may arise from the intraepithelial region where melanocytes normally reside.

Second intention healing after Mohs micrographic surgery

BACKGROUND

Although second intention healing has been used for many years in Mohs micrographic surgery, it has lost popularity. This is due to the long process and functional alteration of important anatomical units if certain wound healing factors are not carefully taken into consideration.

OBJECTIVE

To review indications, contraindications, complications, advantages, disadvantages, as well as basic concepts of the wound healing process, wound care and antibiotic prophylaxis in the management of open wounds after Mohs surgery.

METHODS

A short but comprehensive review of studies published in the literature dealing with second intention healing as a reconstruction alternative option in certain situations.

CONCLUSIONS

Second intention healing is a simple and cost-effective method for reconstruction after Mohs micrographic surgery in well-defined cases. It allows adequate tumoral control with good to excellent functional and cosmetic results.

Unplanned incomplete Mohs micrographic surgery

BACKGROUND

Incomplete Mohs micrographic surgery (MMS) is the cessation of MMS while the tumor margins are known to be still positive.

OBJECTIVE

Our purpose was to examine the factors behind unplanned incomplete MMS and to identify means of avoiding and managing this situation when it arises.

METHODS

We performed a retrospective case review examining clinical presentations, histologic features, and management of incomplete MMS.

RESULTS

Fifteen of 10,346 procedures (0.15%) were identified as incomplete MMS. Complete records were available in 14 cases. The age range was 30 to 90 years; the study comprised 10 men and 4 women. The tumors included 9 basal cell and 4 squamous cell carcinomas and 1 dermatofibrosarcoma protuberans. The sites involved were nose, medial canthus, ear, scalp, and lower eyelid. Twelve cases dealt with unresectable disease, whereas two patients were unable to tolerate further surgery. Of the unresectable cases, MMS was terminated because of ongoing multifocal positive skin margins, bony invasion, or extension of tumor to other locations. Surgical defects were repaired, whereas residual disease was managed with a variety of methods.

CONCLUSION

Incomplete MMS is a rare problem of either unresectable disease or inability of the patient to tolerate the procedure. Preoperative planning may help to identify both subgroups of patients. A multispecialty approach to managing these cases is often necessary.

Surgical treatment of nonmelanoma skin cancer

Nonmelanoma skin cancer is the most common human malignancy. An estimated 2.75 million patients worldwide are diagnosed with skin cancer each year, with more than one million in the United States alone. Treatment for skin cancer includes methods such as cryosurgery, curettage and electrodessication, local excision, and Mohs micrographic surgery. Regardless of the method used, the goal is to provide the patient with the safest, most cost-effective and curative treatment.

Mucoepidermoid carcinoma of an accessory lacrimal gland with orbital invasion

PURPOSE

To report a case of mucoepidermoid carcinoma of an accessory lacrimal gland with orbital invasion.

METHODS

The clinical history and pathologic findings of a patient with a left upper eyelid lesion were reviewed.

RESULTS

The patient was evaluated and found to have an epithelial tumor arising in an accessory lacrimal gland. Special stains showed mucin production by individual tumor cells. The tumor was classified as mucoepidermoid carcinoma.

CONCLUSIONS

Mucoepidermoid carcinoma may arise in accessory lacrimal glands and invade the orbit.

Eyebrow reconstruction with free skin and hair-bearing composite graft

We describe a surgical reconstruction after micrographic surgery of a recurrent basal cell carcinoma of the middle third of the left eyebrow. After micrographic surgery there was a 46- x 26-mm defect in the middle part of the eyebrow. To perform a cosmetically satisfactory repair a combined nude and hair-bearing full-thickness skin graft was harvested from the contralateral postauricular temporoparietal region and placed in the defect with hair growth direction of the graft and the recipient bed in the same direction. By using a combined nude and hair-bearing full-thickness skin graft, larger eyebrow defects can be repaired with an optimal functional and aesthetic result.