Mohs surgical treatment of a granular cell tumor on the toe of a child

Systematic review of Mohs micrographic surgery in children: Identifying challenges and practical considerations for successful application

BACKGROUND

Few data exist to guide the application of Mohs micrographic surgery (MMS) in the pediatric population.

OBJECTIVE

We sought to summarize the clinical characteristics of children undergoing MMS, identify challenges that limit the use of MMS in this population, and examine how these challenges can be overcome.

METHODS

A systematic review of PubMed and EMBASE, from inception of databases to November 2, 2019, identified all cases of pediatric skin lesions treated with MMS.

RESULTS

A total of 111 patients were included. The median patient age was 11 years (range 6 weeks to 17 years). The most commonly treated tumor was dermatofibrosarcoma protuberans (n = 62), followed by basal cell carcinoma (n = 30). The most common location was the head and neck (n = 34), followed by the trunk (n = 28) and the extremities (n = 23). The most commonly cited challenges in the application of MMS in children included patient cooperation, concerns for the safety of prolonged general anesthesia, availability of a MMS service in the pediatric setting, and access to a histopathology laboratory experienced in MMS sectioning.

LIMITATIONS

Many articles did not report specific patient characteristics.

CONCLUSION

Multiple obstacles limit the application of MMS in pediatric patients. This review describes practical methods to circumvent these obstacles to facilitate the appropriate use of MMS in children.

Pediatric Granular Cell Tumor of the Breast: An uncommon neoplasm in an uncommon site and age group

Granular cell tumor (GCT) is a rare soft tissue neoplasm of Schwann cell origin. Most cases occur in adults; however, the precise incidence is unknown in children. GCT is usually a slow-growing, painless tumor involving the skin and soft tissues that is mostly located in the head and neck region, especially the tongue. The breast is one of the least common sites involved by GCT. This paper presents a 3-year-old girl who presented with a soft to firm, ill-defined swelling on the right breast with painful ulceration of the overlying skin. Fine needle aspiration rendered an initial diagnosis of fibrocystic change accompanied by apocrine metaplasia. Histologic evaluation of the excised breast mass revealed a benign granular cell tumor. Although rare, GCT of the breast should be included in the differential diagnosis for breast masses in pediatric patients. Proper diagnosis and timely management of this tumor are essential because of its malignant potential (<2% of cases) and high rate of local recurrence if not properly excised.

Mohs micrographic surgery for cutaneous malignancies: A focus review of its indications in pediatric age groups

Mohs micrographic surgery (MMS) is a highly specialized technique that has been successful in the treatment of a variety of skin tumors. The technique can be performed as an outpatient procedure and encompasses surgical excision and intraoperative assessment of tumor margins in one setting by the same physician. The process ensures precise margin control with maximal preservation of healthy tissues. Mohs micrographic surgery has been practiced worldwide, including in the United States, Europe (United Kingdom, Germany, Spain, Netherlands, Switzerland), and Australia. Although it is commonly performed in adults with greater success, it has been discussed less frequently in children. In this article, we describe several cutaneous tumors in children and the role of Mohs micrographic surgery in their management. A PubMed search was conducted to review the most common cutaneous tumors in children treated using Mohs micrographic surgery. In this review, we discuss indications for Mohs micrographic surgery and pertinent studies examining success rates in children. Mohs micrographic surgery has been used to treat several tumors in children and offers the advantage of high cure rates and tissue conservation. This report emphasizes the benefits of Mohs micrographic surgery in children and highlights several cutaneous tumors for which it has been used to treat successfully.

Cutaneous Granular Cell Tumors in Children: Case Series and Review of the Literature

Granular cell tumors (GCTs) are uncommon benign neoplasms thought to originate from Schwann cells. They most commonly present in adults as papules or nodules on mucosal sites. The clinical spectrum of GCT in children is not well delineated, although mucosal and cutaneous presentations have been reported. We present three children with cutaneous GCTs and review the literature in an attempt to further characterize this rare pediatric neoplasm.

Malignant granular cell tumor of the back: a case report and review of the literature

Malignant granular cell tumors are rare, intensely aggressive entities. This paper presents a case of a large rapidly recurrent malignant granular cell tumor with regional and distal metastases on the back of a 54-year-old Cuban man. The primary tumor recurred within six months of the original wide local excision and with satellite lesions apparent at twelve months, and the mass was diagnosed using the histological criteria established by Fanburg-Smith et al. for malignant granular cell tumors. By fifteen months, right axillary lymphadenopathy, multiple satellite lesions, pulmonary nodules, and distant metastasis in the right thigh were present. At sixteen months, wide local excision of recurrent mass and local satellite masses along with right axillary dissection and placement of Integra with subsequent split-thickness skin graft were performed by surgical oncology and plastic surgery teams. The surgical specimen measured 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses with the largest mass 22.0 × 9.0 × 4.6 cm. Following surgery, patient was started on Pazopanib 800 mg/day based on phase III randomized trial data in the treatment of soft tissue sarcomas showing this as a potential novel therapy for malignant granular cell tumors.

A malignant granular cell tumor excised with mohs micrographic surgery

Malignant granular cell tumors are extremely rare, aggressive neoplasms displaying rapid growth and frequent associated metastatic disease. Excision and evaluation for metastatic disease are mandatory. We present a 54-year-old patient with a malignant granular cell tumor, treated with Mohs micrographic surgery. Cutaneous granular cell tumors are uncommon neoplasms, likely of perineural origin. Most follow a benign and uneventful course, with wide local excision being the treatment of choice (Enzinger, 1988). The malignant granular cell tumor is an extremely rare, aggressive variant, which provides a diagnostic challenge and management dilemma, especially with early presentation when it may be mistaken for other entities. There is also controversy regarding surgical management and follow-up of both benign and malignant granular cell tumors.

Granular cell tumor on the sole of a child: a case report

Granular cell tumor, also known as Abrikossoff tumor, is a rare infrequent neoplasm of unclear etiology which has been rarely described in children. Involvement of the feet is extremely rare. We report a 7-year-old boy presenting a granular cell tumor on the sole.

[Mohs micrographic surgery in two children with dermatofibrosarcoma protuberans]

Dermatofibrosarcoma protuberans is a rare low-grade malignant tumor. The pseudopodia structure of the tumor requires 3-5 cm surgical margins. Mohs micrographic surgery (MMC) can reduce these margins to 1.3 cm while controlling all the histological excision margins. Children seem to be a good indication for this technique because it reduces the amount of skin removed. We report 2 cases of pediatric DFS treated with CMM to illustrate the usefulness of this technique in pediatrics. Two girls, aged 12 and 13 years, had a dermatofibrosarcoma located on the breast and sternum, respectively. CMM was proposed. One operative session was needed with direct closure in a second phase. MMS is a useful surgical technique for childhood tumors. If dermatofibrosarcoma is a very good indication in children, other skin tumors could benefit from this approach.

[Childhood cutaneous Abrikossoff tumor]

INTRODUCTION

Granular cell tumor (GCT), also known as Abrikossoff tumor, is a rare and benign neoplasm that more commonly affects the oral cavity in adults. We report here 2 childhood cases of a cutaneous granular cell tumor.

CASE REPORTS

An 8- and a 12-year-old girl, with no past medical history, presented with pigmented nodular lesions located, respectively, in the left scapular region and the left iliac crest. Histological examination showed sheets and clusters of infiltrating tumor cells with morphologic and immunohistochemical features consistent with granular cell tumor. In both cases, the lesions were excised with 2-cm margins. The patients are presently being reviewed at 6-month and 2-month intervals to evaluate for recurrence and any malignant transformation. They were in good health with no signs of further tumor development.

DISCUSSION

GCT is a relatively uncommon benign neoplasm probably of neural origin derived from Schwann cells. The tongue and buccal mucosa are commonly affected. It develops between the second and sixth decades of life, more frequently among women and blacks. It can also occur in childhood, but this is rare. The cutaneous forms, as in the present observations, are exceptional. Benign granular cell tumours are generally seen as a solitary asymptomatic nodule less than 3 cm in size involving the subcutaneous or submucosal tissues. Histologically, the tumor is not encapsulated but is well circumscribed. The tumor cells may show a degree of infiltration of the surrounding connective tissue. The cells are polygonal, have abundant cytoplasm, are granular and weakly eosinophilic. The nuclei are small, vesicular, and highly chromatic. Mitotic figures are rare. A key element for the histological diagnosis is the expression of S100 protein, neuron specific enolase (NSE), and vimentin on immunohistochemistry. The treatment of choice is a conservative surgical excision of the lesion. However, as the GCT has a poorly defined margin, it is suggested that the tumor should be excised along with portions of adjacent tissue. A low rate of recurrence of the lesion has been reported.

CONCLUSION

The specific value of these rare cases is the occurrence in 2 children and the cutaneous location.

Granular cell tumor on the palm of an 8-year-old girl

Granular cell tumors are rare benign peripheral nerve neoplasms that are most commonly reported on the tongue and oral mucosa. Rarely, they can present as masses on the extremities. They are often treated surgically, however, guidelines for the optimal surgical management of these lesions have yet to be defined. We report a child with a granular cell tumor of the palm that required removal by an orthopedic hand surgeon.

Granular cell tumor of the toe: a case report

Granular cell tumor is a rare tumor of unknown etiology that more commonly affects the oral cavity but can also occur at other sites. The majorities of granular cell tumors are benign and present as a singular dermal nodule. We discuss a case of granular cell tumor of the fourth toe in a 54-year-old patient that was treated with conservative surgery, instead of amputation, and reconstruction with a dermal regeneration template.