Interdisciplinary Management of Extramammary Paget's Disease using Mohs Micrographic Surgery with Frozen Section Cytokeratin-7 Immunostains

OBJECTIVES

To describe local recurrence rates and patient reported outcomes when Mohs micrographic surgery with cytokeratin-7 immunostains (MMS-CK7) is included in the interdisciplinary management of extramammary Paget's Disease (EMPD).

METHODS

A retrospective study was conducted of EMPD treated with MMS-CK7 as part of an interdisciplinary team at an academic medical center between 2009 and 2016. Local recurrence rates and patient-reported outcomes were determined by record review and patient surveys.

RESULTS

Twenty tumors in 19 patients were treated using MMS-CK7. After MMS-CK7 defined clear microscopic margins, seventy-five percent (15/20) of tumors underwent excision or reconstruction by a surgical colleague. Internal malignancy screening was performed by multiple specialties in 17 patients, with one associated malignancy of prostate cancer detected. No local recurrence was detected with a mean follow-up of 75.2 months. Most patients were satisfied with appearance (18/19, 95%) and function (16/19, 84%) after surgery.

CONCLUSIONS

Interdisciplinary teams that include MMS-CK7 can treat EMPD with low local recurrence rates, high patient satisfaction, and thorough internal malignancy screening.

Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision

BACKGROUND

Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck.

OBJECTIVE

To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision.

METHODS

A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision.

RESULTS

Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%).

LIMITATIONS

Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity.

CONCLUSION

Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.

Severe phymatous rosacea of the nose, cheeks, and chin treated with hydrosurgery

Phymatous rosacea is a rare and severe form of rosacea that manifests as disfiguring soft-tissue hypertrophy and sebaceous gland hyperplasia and fibrosis. Most cases are surgically treated; surgical modalities vary, however, ranging from cryosurgery to conventional excision, and consensus guidelines for surgical management do not exist. The Versajet II Hydrosurgery System (Smith-Nephew) is a high-pressure, pulsatile lavage system. We present the case of a 75-year-old man with severe phymatous rosacea of the nose, cheeks, and chin who was successfully treated with the Versajet II Hydrosurgery System, yielding excellent contouring.

Persistent Agminated CD30+ Lymphoproliferative Disorder

Lymphomatoid papulosis (LyP) is a chronic skin condition, characterized by recurrent eruptions of papules and nodules with or without central necrosis that spontaneously resolve. This condition was originally described by Macaulay in 1968 as a self-healing rhythmical paradoxical eruption that was clinically benign yet histologically malignant.1 Clinically, it is defined by papules that wax and wane, are generally less than 1cm in diameter, and heal spontaneously after 6–8 weeks with subsequent scarring.2

Gardnerella vaginalis causing pulmonary infection in a young adult: A novel case

Gardnerella vaginalis is an anaerobic, gram-variable bacterium primarily found in vaginal microflora of women. Previous reports of G. vaginalis cultured in men are few and have primarily been limited to the gastrointestinal and genitourinary tract.^2-4 Few reports of G. vaginalis causing severe infections have been reported in the literature, including septicemia⁷ and two cases of perinephric abscess.^8,9 There has been one previously reported case of G. vaginalis causing pulmonary complications that occurred in a male alcohol abuser. In our case review, we aim to demonstrate an unusual source of a pulmonary infection and highlight the importance of proper microbial isolation to guide treatment. Our patient is a young male who presented following multiple gunshot wounds including one to his head causing an intracranial hemorrhage, hydrocephalus, and a dural sinus thrombosis. His hospital course was complicated by a decline in neurological status treated with a craniotomy and external drain placement and multiple pulmonary infections. During his fever work-ups, he found to have G. vaginalis on mini-bronchoalveolar lavage and was subsequently treated with metronidazole. After treating his G. vaginalis pneumonia and other infectious sources, namely Haemaphilus influenzae and coagulase-negative staphylococcus pneumonias, his fevers and leukocytosis resolved and he was successfully discharged to a rehabilitation facility for neurologic recovery. To our knowledge, this is the second reported case of G. vaginalis isolated from a pulmonary culture and the first in a previously healthy, immunocompetent young male outside of the urinary tract.

Systematic Review of Surgical Treatment and Outcomes After Local Surgery of Primary Cutaneous Melanomas of the Penis and Scrotum

BACKGROUND

Few data exist to guide surgical management and counseling about local recurrence after surgery of primary male genital melanoma.

OBJECTIVE

To compile all available data on local recurrence rates after surgery of primary cutaneous melanoma of the penis and scrotum.

MATERIALS AND METHODS

A systematic review of PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Excerpta Medica database (EMBASE), and Web of Science identified all surgically treated penile and scrotal melanomas that reported local recurrence status and follow-up time.

RESULTS

One hundred twenty-seven melanomas from 74 manuscripts were included. Eighty-six percent of melanomas were located on the penis, and 14% were located on the scrotum. Average follow-up time was 35.7 months. Scrotal melanomas were predominantly treated with organ-sparing surgeries (16/18, 88.9%), whereas penile melanomas were treated more often with amputation (61/109, 56.0%). Overall, local recurrence rate was 15.7% (20/127). Local recurrence rates for penile cases were 18.8% (9/48) after organ-sparing surgery versus 13.1% (8/61) for amputative surgery. Local recurrence rates were 66.7% (4/6) after positive surgical margins versus 10.2% (5/49) after negative surgical margins.

CONCLUSION

Local recurrence rates are high after both organ-sparing and amputative surgery of primary cutaneous melanoma of the penis and scrotum. There is a need to standardize reporting for this rare tumor, as more complete data are necessary to develop consensus guidelines for surgical management of male genital melanoma.