Mohs Micrographic Surgery: Development, Technique, and Applications in Cutaneous Malignancies

Postoperative permanent section evaluation of Mohs micrographic surgery debulk specimens does not result in upstaging of cutaneous squamous cell carcinoma compared to stage at the completion of surgery: A retrospective case series

Background

Mohs micrographic surgery (MMS) is used for the treatment of high-risk cutaneous squamous cell carcinoma (cSCC). MMS examines the surgical margins in real time and does not commonly examine the central component of the tumor.

Objective

To determine if debulk specimens provide additional details relevant to tumor staging not gained from routine MMS.

Methods

A retrospective chart review of debulk specimens taken during MMS for cSCC was performed. Dermatopathology reports were analyzed and tumors were staged using Brigham and Women's Hospital and American Joint Committee on Cancer's 8th edition staging systems.

Results

Permanent section evaluation of debulk specimens did not result in clinically meaningful information for staging that could not be gained from MMS layers or initial biopsy analysis.

Limitations

A single institution, and a small sample size of 39 tumors.

Conclusions

Evaluation of debulk specimens during MMS may not always be an effective use of time or health care resources.

Removal of Incidental Skin Cancer During Mohs Micrographic Surgery Indicated for a Different Primary Tumor

BACKGROUND

Mohs surgery is a tissue-sparing, microscopically controlled procedure used to treat biopsy-proven skin cancers. Because Mohs surgery allows for examination of the complete margin of each tissue layer removed, separate cancers can be treated concomitantly when identified. As early detection of skin cancer is beneficial for reducing morbidity, incidental tumors discovered during Mohs surgery are of significant interest.

OBJECTIVE

Our objective was to determine the prevalence and characteristics of incidental skin cancers found during Mohs surgery.

METHODS

A retrospective chart review of cases seen at University of California, San Diego, from 2014 to 2021 was performed.

RESULTS

Of 13,464 Mohs surgery cases, 4.53% ( n = 610) had incidental skin cancers found during removal of the initially identified tumor. Of the 610 cases, 88.4% ( n = 539) had basal cell carcinoma as the primary tumor and either squamous cell carcinoma (SCC) or SCC in situ as the incidental tumor. About 7.87% ( n = 48) had SCC as the primary tumor and basal cell carcinoma as the incidental tumor. All tumors were removed with clear margins and without significant complications.

CONCLUSION

Diagnosis of incidental tumors during Mohs surgery enables early detection of skin cancer and circumvents the need for additional surgery, likely resulting in decreased morbidity and improved cost-effectiveness.

Squamous cell carcinoma of the eyelid

Eyelid squamous cell carcinoma is a major type of rare eyelid cancer, together with basal cell carcinoma and sebaceous gland carcinoma. It is a painless disease that progresses slowly and is often detected by the appearance of nodules or plaques. Risk factors include exposure to ultraviolet light, fair skin, radiation and human papillomavirus infection. The standard treatment is surgical removal, and in cases of orbital invasion, orbital content removal is required. If sentinel node biopsy reveals a high risk of lymph node metastasis, adjuvant radiotherapy may be considered. Local chemotherapy, such as imiquimod and 5-fluorouracil, may be used for eyelid squamous cell carcinoma in situ. When surgery or radiotherapy is not recommended for distant metastases or locally advanced disease, drug therapy is often according to head and neck squamous cell carcinoma in Japan. The treatment often requires a multidisciplinary team to ensure the preservation of function and cosmetic appearance.

More than Just Skin-Deep: A Review of Imaging's Role in Guiding CAR T-Cell Therapy for Advanced Melanoma

Advanced melanoma is one of the deadliest cancers, owing to its invasiveness and its propensity to develop resistance to therapy. Surgery remains the first-line treatment for early-stage tumors but is often not an option for advanced-stage melanoma. Chemotherapy carries a poor prognosis, and despite advances in targeted therapy, the cancer can develop resistance. CAR T-cell therapy has demonstrated great success against hematological cancers, and clinical trials are deploying it against advanced melanoma. Though melanoma remains a challenging disease to treat, radiology will play an increasing role in monitoring both the CAR T-cells and response to therapy. We review the current imaging techniques for advanced melanoma, as well as novel PET tracers and radiomics, in order to guide CAR T-cell therapy and manage potential adverse events.

Mohs micrographic surgery revisited: A multidisciplinary, collaborative approach for the treatment of aggressive and recurrent basal cell carcinoma on the head and neck

Mohs micrographic surgery is the preferred surgical option for high-risk basal cell carcinomas. In our institution, the method is exclusively used for the treatment of aggressive and recurrent facial tumours selected via multidisciplinary team meetings and consistently managed using a multidisciplinary approach. The aim of this retrospective patient-record study was to examine the outcomes for basal cell carcinomas managed with Mohs micrographic surgery and to present our experience from multidisciplinary team meetings and interdisciplinary collaborations. All patients treated between September 2009 and March 2019 at Karolinska University hospital were included. In a total of 143 facial basal cell carcinomas in 138 patients, 86 primary and 57 recurrent, the recurrence rate was 4.9% after a median follow-up of 24 months. In regions, where highly specialised Mohs surgeons performing all the steps of the procedure are limited, interdisciplinary collaboration can be an effective strategy for appropriate patient selection and for performing all steps of Mohs surgery with dermatosurgeons eradicating the tumour, pathologists evaluating the histopathology, followed by reconstructive surgery by plastic surgeons. The approach we present here provides a robust and functioning Mohs surgical service during the build-up of the organisation, while providing the opportunity to train new surgeons. Once the clinic has been set up, the multidisciplinary approach should always be considered and applied when dealing with complex cases.

Risk Factors for Complicated Mohs Surgery in the South Sweden Mohs Cohort

BACKGROUND

Mohs micrographic surgery (MMS) is a precise, tissue-sparing surgical technique that offers superior cure rates compared to traditional surgical excision. However, the degree of difficulty of MMS depends on many variables and, consequently, the number of surgical stages required for each case is quite unpredictable.

OBJECTIVES

To identify risk factors for complicated MMS, defined as MMS requiring ≥3 stages.

METHODS

In a cohort study design, data was prospectively collected from 612 patients that underwent MMS for basal cell carcinoma (BCC) at the Department of Dermatology, Skåne University Hospital, Lund, between 2009 and 2020. Univariate and multivariate logistic regression were used to estimate risk of MMS requiring ≥3 stages. Due to risk of multicollinearity between recurrent or incompletely excised BCC and previous treatments, a partially and a fully adjusted multivariate logistic regression model were constructed.

RESULTS

In fully adjusted multivariate analyses, age (odds ratio (OR) 1.02; confidence interval (CI) 95% 1.00-1.04), previous cryotherapy (OR 2.3; CI 95% 1.1-4.8) and >1 previous surgery (OR 3.4; CI 95% 1.5-7.7) were significantly associated with risk of complicated MMS. Recurrent BCC was associated with risk of complicated MMS in partially adjusted multivariate analyses, but not in the fully adjusted analyses. In this highly selected cohort, histopathological subtype and tumour localisation were not associated with risk of complicated MMS.

CONCLUSIONS

Older age and tumours previously treated with cryotherapy or multiple prior surgeries increased risk of MMS requiring ≥3 stages. Whether recurrent BCC is an independent risk factor for complicated MMS needs further evaluation. Knowledge of these risk factors may ameliorate planning of Mohs surgeries.

Site-Specific Vesicular Drug Delivery System for Skin Cancer: A Novel Approach for Targeting

Skin cancer, one of the most prevalent cancers worldwide, has demonstrated an alarming increase in prevalence and mortality. Hence, it is a public health issue and a high burden of disease, contributing to the economic burden in its treatment. There are multiple treatment options available for skin cancer, ranging from chemotherapy to surgery. However, these conventional treatment modalities possess several limitations, urging the need for the development of an effective and safe treatment for skin cancer that could provide targeted drug delivery and site-specific tumor penetration and minimize unwanted systemic toxicity. Therefore, it is vital to understand the critical biological barriers involved in skin cancer therapeutics for the optimal development of the formulations. Various nanocarriers for targeted delivery of chemotherapeutic drugs have been developed and extensively studied to overcome the limitations faced by topical conventional dosage forms. A site-specific vesicular drug delivery system appears to be an attractive strategy in topical drug delivery for the treatment of skin malignancies. In this review, vesicular drug delivery systems, including liposomes, niosomes, ethosomes, and transfersomes in developing novel drug delivery for skin cancer therapeutics, are discussed. Firstly, the prevalence statistics, current treatments, and limitations of convention dosage form for skin cancer treatment are discussed. Then, the common type of nanocarriers involved in the research for skin cancer treatment are summarized. Lastly, the utilization of vesicular drug delivery systems in delivering chemotherapeutics is reviewed and discussed, along with their beneficial aspects over other nanocarriers, safety concerns, and clinical aspects against skin cancer treatment.

Japanese Dermatological Association Guidelines: Outlines of Guidelines for Cutaneous Squamous Cell Carcinoma 2020

In consideration of the development of treatment options for squamous cell carcinoma (SCC), the Japanese Skin Cancer Society issued the first guidelines of SCC in 2007 and revised them in 2015. Here, we report the English version of the 2020 edition of the Japanese SCC guidelines. The first half of this article is an overview of SCC including actinic keratosis and Bowen's disease, and the second half discusses three clinical questions: (i) treatment of actinic keratosis; (ii) determination of the resection margin of the primary lesion; and (iii) treatment of radically incurable cases, as contemporary problems encountered in treating SCC. In these evaluations, all processes were implemented according to the Grading of Recommendations, Assessment, Development, Evaluation system. Also, items of recommendation concerning each clinical question were determined by a multidisciplinary expert panel consisting of dermatologists, plastic/reconstructive surgeons, radiologists, and oncologists through a comprehensive literature search and systematic reviews.

Sebaceous carcinoma of the vulva treated with sentinel lymph node biopsy: a case report and literature review

Sebaceous carcinoma (SC) is a rare and aggressive cutaneous malignancy. It often occurs on the eyelid, where it is called periocular SC, while extraocular SC mainly occurs on the head and heck. Extraocular vulvar SC is extremely rare; only nine cases have been described in the literature, and the optimal treatment strategy is unknown. We herein report a case of vulvar SC that was successfully treated with local excision in combination with sentinel lymph node biopsy (SNB). A 66-year-old female presented with vulvar discomfort. An 8 mm ulcerated mass was palpable in her left labia minora. Skin biopsy suggested SC. Imaging showed no swelling of the pelvic and inguinal lymph nodes and no metastasis. Sentinel lymph node scintigraphy using technetium-99 m showed three sentinel lymph nodes. The patient underwent local excision with SNB; intraoperative frozen-section examination revealed no nodal metastasis, and no further inguinal lymphadenectomy was performed. The final diagnosis was SC of the vulva, FIGO stage IB (pT1bN0M0). At the 14-month follow-up, she remained asymptomatic and had no signs of recurrence. The scientific rationale for SNB in extraocular SC has not yet been established, although SNB can be considered for periocular SC. However, considering the insufficient data on the management of vulvar SC and the aggressive nature of both periocular and extraocular SCs, SNB can be a reasonable and useful method for avoiding inadequate treatment and reducing the complications caused by unnecessary inguinal lymphadenectomy.

Amelanotic melanoma of the head and neck: analysis of tumor characteristics from the National Cancer Database

BACKGROUND

Amelanotic melanoma is an extremely rare subtype of cutaneous melanoma. The tumor characteristics are still not well understood, especially for those located in the head and neck.

METHODS

Tumor characteristics of patients diagnosed with amelanotic melanoma of the head and neck (AMHN) from January 1, 2004, to December 31, 2015, were analyzed by querying the National Cancer Database. Characteristics of AMHN were subsequently compared with common malignant melanoma of the head and neck (CMMHN).

RESULTS

Three hundred and sixty-eight patients were diagnosed with AMHN, and 69,267 were diagnosed with CMMHN. Of those with AMHN, 128 (34.8%) had melanoma located on the scalp and neck, and 172 (46.7%) were diagnosed with an early disease stage (i.e., 0, I, or II). When compared with CMMHN, patients with AMHN were more likely to be diagnosed after 80 years of age (25.3% vs. 18.2%; odds ratio [OR], 3.28; 95% CI, 1.09-9.84; P = 0.03), when Breslow depth was between 2.01 and 4.00 mm (28.5% vs. 6.5%; OR, 1.92; 95% CI, 1.15-3.19; P = 0.01), when ulceration was present (36.7% vs. 9.0%; OR, 1.99; 95% CI, 1.34-2.97; P = 0.001), and when mitotic count was 1 or more/mm² (40.5% vs. 12.8%; OR; 2.53; 95% CI, 1.09-5.89; P = 0.03). No statistical difference was found for sex, specific location, stage, or lymph node involvement.

CONCLUSION

Our study determined that AMHN is associated with older age, increased Breslow depth, presence of ulceration, and greater mitotic count when compared with CMMHN.