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Aoki KC, Glick BP, Bartos S. Complex Management of Basal Cell Carcinoma in a Frail Patient. Cureus 2024; 16:e53518. [PMID: 38440025 PMCID: PMC10911882 DOI: 10.7759/cureus.53518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/31/2024] [Indexed: 03/06/2024] Open
Abstract
Basal cell carcinoma (BCC) is one of the most common cancers diagnosed in older patients and has low mortality. Surgical versus medical management is considered in patients with multiple comorbidities and limited life expectancy (LLE), where the risk-to-benefit ratio must be carefully assessed. Watchful waiting (WW) is a viable option for some patients with severe LLE when follow-up care can be provided vigilantly and frequently. Special consideration should be given to morbidity factors such as tumor growth, bleeding, pain, and social withdrawal that negatively affect the quality of life. We present the case of a 75-year-old male with a past medical history of multiple system atrophy, who presented with a BCC on the ear and face. We discuss the management of this patient and factors that may have led to the inappropriate use of WW.
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Affiliation(s)
- Kawaiola Cael Aoki
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Brad P Glick
- Dermatology, Larkin Community Hospital Palm Springs Campus, Margate, USA
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2
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Woodson J, Baha A, Verma N. Case Study of Atypical Fibroxanthoma: Presentation and Management. Cureus 2024; 16:e55094. [PMID: 38558602 PMCID: PMC10978462 DOI: 10.7759/cureus.55094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Atypical fibroxanthoma (AFX) is a rare spindle cell proliferation arising from significant sun exposure. AFX often appears as a red papule, typically found in the head and neck region of elderly patients. Since there is no specificity in immunohistology, various stains differentiate AFX from other skin cancers. The stains include cluster of differentiation 68 (CD68), cluster of differentiation 163 (CD163), vimentin, cytokeratin epithelial (CKAE), and melanin. While local recurrence is common, AFX rarely metastasizes. Thus, the treatment options are complete surgical excision or micrographically oriented histographic surgery.
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Affiliation(s)
| | - Alexander Baha
- Dermatology, Chaparral Medical Group, Rancho Cucamonga, USA
| | - Nikita Verma
- Dermatology, Chaparral Medical Group, Rancho Cucamonga, USA
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3
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Ezaldein HH. Rapidly Growing and Aggressive Squamous Cell Carcinoma of the Forearm: A Report of Successful Treatment With Mohs Surgery and Complex Reconstruction With Rhombic Triple Z-Plasty. Cureus 2024; 16:e55182. [PMID: 38558613 PMCID: PMC10980786 DOI: 10.7759/cureus.55182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 04/04/2024] Open
Abstract
Reconstruction of complex post-surgical wounds requires functional and aesthetic considerations. We present a case of a complex radial-dorsal forearm defect in a patient who underwent Mohs surgery for an aggressive and rapidly growing squamous cell carcinoma. Following complete tumor excision, we utilized a modified rhombic flap for complete wound coverage with long-term conservation of extensor function. The rhombic flap modification included three Z-plasties at the flap base to add rotational components to the flap transposition. Long-term follow-up showed acceptable cosmesis, preserved extensor tendon function, and no evidence of tumor recurrence.
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Affiliation(s)
- Harib H Ezaldein
- Mohs Micrographic Surgery, Bennett Surgery Center, Santa Monica, USA
- Dermatology, Miami Dermatology and Mohs Surgery, Miami, USA
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4
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Ezaldein HH. The Treatment of a Multisubunit Defect of the Earlobe Involving an Exposed Parotid Gland. Cureus 2023; 15:e50224. [PMID: 38192968 PMCID: PMC10773539 DOI: 10.7759/cureus.50224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/10/2024] Open
Abstract
Defects with multiple aesthetic subunits may need specific approaches for each subunit. We present a case of a post-surgical defect in a patient who underwent Mohs micrographic surgery for an invasive melanoma of the earlobe with an exposed parotid gland. We utilized a retroauricular-based rhomboid flap to provide full and immediate coverage for earlobe reconstruction in the setting of insufficient infra-auricular recruitable skin. The addition of Z-plasties at the base of an interpolation flap may reduce rotational restraint, thereby improving perfusion while enhancing flap extension for complete wound coverage where there is a lack of abundant donor tissue. The patient healed appropriately with no evidence of tumor recurrence.
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Affiliation(s)
- Harib H Ezaldein
- Mohs Micrographic Surgery, Bennett Surgery Center, Santa Monica, USA
- Dermatology, Miami Dermatology and Mohs Surgery, Miami, USA
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5
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Slater KN, Ryder E, Gomez-Meade C. 40-Gene Expression Profile Representative of Metastatic Risk of Squamous Cell Carcinoma in a Mohs Surgical Patient. Cureus 2023; 15:e46853. [PMID: 37954812 PMCID: PMC10636499 DOI: 10.7759/cureus.46853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
This case study examines using a 40-gene expression profile (40-GEP) as an independent predictor of metastatic risk in a 74-year-old male with cutaneous squamous cell carcinoma on the scalp. The patient's previous medical history included melanoma and non-melanoma skin cancers. While conventional staging methods, such as the American Joint Committee on Cancer 8th edition (AJCC8) and Brigham and Women's Hospital (BWH) staging, indicated a higher metastatic risk, the 40-GEP testing classified the patient as low risk (Class 1 result) for metastasis within three years. The patient underwent successful Mohs surgery with no evidence of perineural invasion. This case highlights the discrepancy between current staging techniques and gene expression profile testing, demonstrating the potential of the 40-GEP as a more accurate predictor of metastatic risk. The study contributes to the growing body of literature on the use of gene expression profile testing in cutaneous cancers, emphasizing the need for further research in this area to improve patient care outcomes using 40-GEP testing.
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Affiliation(s)
- Kristin N Slater
- Dermatology, Lincoln Memorial University DeBusk College of Osteopathic Medicine, Harrogate, USA
| | - Elizabeth Ryder
- Dermatology, Lincoln Memorial University DeBusk College of Osteopathic Medicine, Harrogate, USA
| | - Carlos Gomez-Meade
- Mohs Surgery, Oklahoma Cancer Specialists Skin Cancer Center, Broken Arrow, USA
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6
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Tariq S, Saeed A, Ismaeel H, Ullah S, Hamid MA. Rise in the Number of Complex Skin Cancers Necessitates Establishing Mohs Micrographic Surgery Fellowships in Pakistan. Cureus 2023; 15:e43183. [PMID: 37692578 PMCID: PMC10485791 DOI: 10.7759/cureus.43183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
As more and more patients seek treatment for increasingly complicated and cosmetically challenging skin cancers, Mohs Micrographic Surgery (MMS) is now exceedingly in demand. Training in MMS could help dermatologists improve patient outcomes allowing them to handle complex lesions safely and efficiently and hence, provide the best possible care. As a result, there is an urgent need to train additional dermatologists in Mohs Surgery in order to meet the huge demand for dermatologists with imperative expertise, specifically in this field.
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Affiliation(s)
- Shahan Tariq
- Dermatology, National University of Medical Sciences, Rawalpindi, PAK
| | - Afshan Saeed
- Dermatology, Pak-Emirates Military Hospital, Rawalpindi, PAK
- Dermatology, District Headquarters (DHQ) Hospital Haripur, Haripur, PAK
| | - Hamza Ismaeel
- Pediatrics, Rawalpindi Medical University, Rawalpindi, PAK
| | | | - Muhammad Ammar Hamid
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
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Muacevic A, Adler JR, Shimizu I, Ranario J. Squamous Cell Carcinoma With Unusual Benign-Appearing Cystic Features on Histology. Cureus 2023; 15:e33610. [PMID: 36788857 PMCID: PMC9910816 DOI: 10.7759/cureus.33610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 01/12/2023] Open
Abstract
Squamous cell carcinoma (SCC) is a malignancy that arises from keratinocytes of the epidermis. Cystic variants of several types of cutaneous neoplasms have been rarely described in the literature. We report a case of biopsy-proven, well-differentiated invasive SCC treated with Mohs surgery. On frozen sections, the pathology slides showed benign-appearing cystic structures in the margins that persisted after it had appeared that the original malignancy had been cleared. After taking another Mohs stage due to clinical suspicion, additional SCC was found and was subsequently cleared after two more Mohs stages. To the best of our knowledge, this is the first report to histologically demonstrate biopsy-proven invasive SCC with benign-appearing cystic structures on frozen sections.
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8
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Muacevic A, Adler JR, Herrera Ortiz AF, Dussan Tovar CA, Saldarriaga Santamaría S, Cifuentes Burbano J, García N, Rodríguez Díaz MC, Sierra Molina SM, Jiménez Calfat G. Incipient Melanonychia: Benign Finding or Occult Malignancy? A Case Report of Subungual Melanoma. Cureus 2023; 15:e34292. [PMID: 36721707 PMCID: PMC9883383 DOI: 10.7759/cureus.34292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
Subungual melanomas are rare neoplasms that tend to debut as longitudinal melanonychia. They are primarily found in patients over 60 years of age and are usually diagnosed late, representing a diagnostic challenge. We present a case report of a 59-year-old female Hispanic patient who initially presented with melanonychia and was eventually diagnosed with subungual melanoma in situ. She was surgically treated and, after three months, remained healthy. Relevant risk factors, clinical and onychoscopic findings, diagnostic criteria, and treatment options are also discussed. Since many benign entities present similarly, high clinical suspicion is critical for diagnosing this entity.
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9
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Manci R, Nazir ZH, Dusza SW, Chen CSJ. Topical timolol enhances surgical wound healing in the lower portion of the leg in older patients with comorbidities: A retrospective review. J Am Acad Dermatol 2022; 87:661-663. [PMID: 35183658 PMCID: PMC10510088 DOI: 10.1016/j.jaad.2022.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 01/25/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Rachel Manci
- Dermatology Service, Memorial Sloan Kettering Cancer Center, Hauppauge, New York; Cooper Medical School of Rowan University, Camden, New Jersey
| | - Zaeem H Nazir
- Dermatology Service, Memorial Sloan Kettering Cancer Center, Hauppauge, New York; Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Stephen W Dusza
- Dermatology Service, Memorial Sloan Kettering Cancer Center, Hauppauge, New York
| | - Chih-Shan Jason Chen
- Dermatology Service, Memorial Sloan Kettering Cancer Center, Hauppauge, New York.
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10
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Farshchian M, Goldberg LH. Rosacea exacerbation following Mohs surgery. J Cosmet Dermatol 2021; 21:2682-2683. [PMID: 34510704 DOI: 10.1111/jocd.14454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Mehdi Farshchian
- Department of Dermatology, Wayne State University, Detroit, MI, USA
| | - Leonard H Goldberg
- Division of Dermatology, Houston Methodist Hospital; DermSurgery Associates, Houston, TX, USA
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11
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Robinson C, Aboul-Fettouh N, Hansen T, Auh SL, MacFarlane DF. The Navicular Graft for Reconstructing Deep Alar Defects. Cureus 2021; 13:e16657. [PMID: 34462688 PMCID: PMC8388222 DOI: 10.7759/cureus.16657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/29/2022] Open
Abstract
The reconstruction of deep nasal ala defects can be challenging. The often thick, sebaceous skin of the nose provides structural support helping maintain the ala shape and nasal patency; loss of this support may result in ala deformity and nasal vestibule collapse. Traditional full-thickness skin grafts of deep alar defects may result in depressed scars. We present a variation of the full-thickness skin graft to repair deeper alar defects, sculpting the graft into a boat-shaped or “navicular” form. This allows for sufficient volume restoration and good cosmesis while avoiding more extensive surgical repairs of the nasal ala. The navicular graft offers several advantages: the avoidance of more extensive procedures involving cartilage grafts and/or flaps, appropriate color/texture match, and volume restoration without pitting, notching, or retraction of nasal structures. In addition, no struts or bolsters are needed.
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Affiliation(s)
- Caitlin Robinson
- Dermatology, Colorado Springs Dermatology Clinic, Colorado Springs, USA
| | - Nader Aboul-Fettouh
- Dermatology, University of Texas Health Science Center at Houston, Houston, USA
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12
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Bard JT, Kornmehl HA, Chang LK. Cryotherapy-Enhanced Chemowrap Treatment of Squamous Cell Carcinoma: A Case Series. Cureus 2021; 13:e15148. [PMID: 34178485 PMCID: PMC8216569 DOI: 10.7759/cureus.15148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
An estimated 20% of all malignant cutaneous neoplasms are diagnosed as squamous cell carcinoma (SCC). Chemotherapeutic wraps, or chemowraps, consist of application of topical 5-fluorouracil (5-FU) 5% cream along with occlusive zinc oxide and a compressive bandage (e.g., Unna boot). This treatment modality is often used as a less invasive option compared to surgery, especially in the presence of numerous SCCs. Cryotherapy, the use of liquid nitrogen gas, can be utilized to obliterate pre-malignant and malignant skin lesions. In this report, we present four cases in which females between the ages of 65 and 80 with multiple lower extremity SCCs were treated with cryotherapy prior to each chemowrap application, resulting in favorable clinical tumor improvement. Our observations indicate that cryotherapy may enhance the effectiveness of chemowrap treatment when used before each application. To our knowledge, the use of cryotherapy to synergistically enhance the efficacy of chemowraps has not yet been reported. We hypothesize that cryotherapy induces edema and first strips the outer, hyperkeratotic layers of skin, which facilitates deeper penetration of the 5-FU cream from chemowraps. Chemowraps may also relieve the pain associated with cryotherapy. Therefore, dual cryotherapy and chemowrap treatment may be considered to maximize skin penetration, thus minimizing the extent of surgical intervention in patients with a significant number of SCC lesions.
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Affiliation(s)
- Jason T Bard
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, USA
| | - Heather A Kornmehl
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, USA
| | - Lawrence K Chang
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, USA.,Mohs Surgery, Pariser Dermatology Specialists, Norfolk, USA
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13
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Abstract
BACKGROUND Verrucous carcinoma is a rare mucocutaneous malignancy characterized by slow, relentless growth and a low metastasis rate. OBJECTIVE Herein we summarize surgical success rates and review newer approaches to the treatment of verrucous carcinomas.Methods & Materials: PubMed electronic searches were performed by B.F. and C.V. using combinations of the following terms: ''verrucous carcinoma,'' ''Ackerman tumor,'' ''Buschke Lowenstein,'' ''epithelioma cuniculatum,'' ''carcinoma cuniculatum,'' ''papillomatosis cutis,'' ''treatment,'' ''therapeutics,'' ''management,'' ''mohs surgery,'' and ''excision.'' A systematic review was conducted on 49 articles in accordance with PRISMA guidelines. RESULTS Surgical management remains first-line therapy. Wide local excision is most commonly utilized, with highly variable margins (0.5-3.0 cm) and recurrence rates (4.6-75.0%). Mohs Micrographic Surgery has also been used, especially for recurrent tumors, with an overall recurrence rate of 12.9%. CONCLUSION Surgery is the treatment of choice, either by Mohs Micrographic Surgery or wide local excision. However, surgical recurrence rates are high, and tissue-sparing therapies are desirable given the sensitive locations involved. Ultimately, randomized control trials are needed to develop evidence-based guidelines for the management of VCs.
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Affiliation(s)
- Bilal Fawaz
- Cooper Center for Dermatologic Surgery, Evesham, NJ
| | - Carlos Vieira
- Cooper Medical School of Rowan University, Camden, NJ
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González A, Etchichury D, Rivero JM, Adamo L. Squamous cell carcinoma of the external ear: 170 cases treated with Mohs surgery. J Plast Reconstr Aesthet Surg 2021; 74:2999-3007. [PMID: 33967017 DOI: 10.1016/j.bjps.2021.03.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/11/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Squamous cell carcinoma of the ear (SCC-E) shows high rates of local recurrence (LR) and lymph node metastases (NM). SCC-E is the leading cause of death from nonmelanoma skin cancer. OBJECTIVE To determine the LR and NM rates and survival after Mohs micrographic surgery (MMS). PATIENTS AND METHODS We treated 170 invasive SCC-E with MMS with a mean follow up of 48 months. Mean age was 76 years, 93.2% were male patients, mean size: 1.5 cm, and 61.8% of the tumours were well differentiated. RESULTS We observed 5 LRs, 2 locoregional recurrences, and 16 NMs in 23 patients. LR and NM rates were 4.1% and 10.6%, respectively. Only 3/25 recurrences occurred after 2 years of follow up. We observed 1(0.6%) distant metastasis (DM) in a patient who also presented LR + NM. Six out of seven cases with LR and 8/18 with NM died of disease, regardless of aggressive surgical rescue with or without adjuvant radiotherapy. Five-year overall survival, disease-free survival, and disease-specific survival were 81%, 82.6%, and 89.7%, respectively. CONCLUSIONS Undeniably, the outcome in SCC-E is determined by locoregional control. DM are sporadic and rarely the cause of death. Systematic reviews and retrospective studies show a solid trend in favor of MMS vs surgical excision. The LR rate of this series (4.1%) is one of the lowest published to date with regard to SCC-E, and confirms this assertion. We observed 10.6% NMs according to other series that treated the whole spectrum of SCC-E. Almost 2/3 of patients with NMs die after therapeutic rescue. We believe that it is essential to identify prognostic factors to select patients for one of the following: close surveillance (ultrasonography) during the first 2 years after surgery, sentinel node biopsy, or elective treatment of the nodes (surgery or radiotherapy).
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Affiliation(s)
- Abel González
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina.
| | - Dardo Etchichury
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina
| | - Juan Mario Rivero
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina
| | - Lucia Adamo
- Angel H. Roffo Oncology Institute, Mohs Surgery Unit, Head and Neck Department, Alexander Fleming Institute, Skin Cancer Oncology, 1180 Cramer St., CABA (ZIP 1426), Buenos Aires, Argentina
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15
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Chalfant V, Schriber T, Sabri A, Gossen J, Groh D. Primary Cutaneous Leiomyosarcoma of the Lower Extremity: A Case Report and Literature Review. Cureus 2021; 13:e14282. [PMID: 33959460 PMCID: PMC8093099 DOI: 10.7759/cureus.14282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cutaneous leiomyosarcoma is a rare soft-tissue sarcoma that appears non-specific clinically and often is misdiagnosed as squamous cell carcinoma. We report the case of a 59-year-old Caucasian male with a grade I leiomyosarcoma tumor on his lower extremity with no previous history of local trauma. The tumor is composed of highly atypical spindle cells with pleomorphic nuclei and mitotic activity on hematoxylin and eosin stains. The diagnosis is confirmed with immunohistochemistry staining positive for smooth muscle actin, vimentin, and desmin. Due to high recurrence rates, the prognosis for leiomyosarcomas remains poor and requires close follow-up to prevent progression.
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Affiliation(s)
- Victor Chalfant
- Department of Pathology, Creighton University School of Medicine, Omaha, USA
| | - Tyler Schriber
- Department of Pathology, Creighton University School of Medicine, Omaha, USA
| | - Ahmed Sabri
- Department of Pathology, Creighton University School of Medicine, Omaha, USA
| | - John Gossen
- Department of Pathology, Creighton University School of Medicine, Omaha, USA
| | - Darren Groh
- Department of Pathology, Creighton University School of Medicine, Omaha, USA
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16
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Nieto-Benito LM, Ciudad-Blanco C, Sanmartin-Jimenez O, Garces JR, Rodríguez-Prieto MA, Vilarrasa E, de Eusebio-Murillo E, Miñano-Medrano R, Escutia-Muñoz B, Gonzalez-Sixto B, Artola-Igarza JL, Alfaro Rubio A, Redondo P, Delgado-Jiménez Y, Sánchez-Schmidt JM, Allende-Markixana I, Alonso-Pacheco ML, García-Bracamonte B, de la Cueva Dobao P, Navarro-Tejedor R, Suarez-Fernández R, Carnero-González L, Vázquez-Veiga H, Barchino-Ortiz L, Ruiz-Salas V, Sánchez-Sambucety P, López-Estebaranz JL, Botella-Estrada R, Feal-Cortizas C, Martorell Calatayud A, Gil P, Morales-Gordillo V, Toll-Abelló A, Ocerin-Guerra I, Mayor-Arenal M, Garcia-Donoso C, Cano-Martinez N, Sainz-Gaspar L, Descalzo MA, Garcia-Doval I. Mohs micrographic surgery in dermatofibrosarcoma protuberans: Rate and risk factors for recurrence in a prospective cohort study from the Spanish Registry of Mohs Surgery (REGESMOHS) and review of the literature. Exp Dermatol 2021; 30:717-722. [PMID: 33523531 DOI: 10.1111/exd.14291] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/07/2021] [Accepted: 01/17/2021] [Indexed: 12/14/2022]
Abstract
Characterization of patients, surgery procedures and the risk factors for dermatofibrosarcoma protuberans (DFSP) recurrences is poorly defined. In this study, we aimed to describe the demographics, tumor characteristics and interventions of DFSP treated with Mohs micrographic surgery (MSS) to determine the rate and risk factors for recurrence. Data were collected from REGESMOHS, a nationwide prospective cohort study of patients treated with MMS in Spain. From July 2013 to February 2020, 163 patients with DFSP who underwent MMS were included. DFSP was mostly located on trunk and extremities. Recurrent tumors had deeper tumor invasion and required higher number of MMS stages. Paraffin MMS was the most frequently used technique. Overall recurrence rate was 0.97 cases/100 person-years (95% IC = 0.36-2.57). No differences were found in epidemiological, tumor, surgery characteristics or surgical technique (frozen or paraffin MMS [p = 0.6641]) in terms of recurrence. Median follow-up time was 28.6 months with 414 patient-years of follow-up. In conclusion, we found an overall low recurrence rate of DFSP treated with MMS. None of the studied risk factors, including MMS techniques, was associated with higher risk for recurrence.
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Affiliation(s)
| | - Cristina Ciudad-Blanco
- Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Hospital La Zarzuela, Madrid, Spain
| | | | - Joan R Garces
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro Médico Teknon, Barcelona, Spain
| | | | - Eva Vilarrasa
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro Médico Teknon, Barcelona, Spain
| | | | | | | | | | | | | | | | - Yolanda Delgado-Jiménez
- Hospital Universitario Quirón Salud, Madrid, Spain.,Hospital Universitario de la Princesa, Madrid, Spain
| | | | | | | | | | | | | | | | | | - Hugo Vázquez-Veiga
- Complexo Hospitalario Universitario de Santiago, Santiago Compostela, Spain
| | | | | | | | | | | | | | | | - Pilar Gil
- Clínica Universidad de Navarra, Pamplona, Spain
| | | | | | | | | | | | | | - Laura Sainz-Gaspar
- Complexo Hospitalario Universitario de Santiago, Santiago Compostela, Spain
| | - Miguel A Descalzo
- Fundación Piel Sana Academia Española de Dermatología, Madrid, Spain
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17
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Abstract
Cutaneous squamous cell carcinoma (cSCC) typically arises from a malignant proliferation of keratinocytes. It is the second most common cancer in the United States and typically affects older white men. Risk factors for cSCC include ultraviolet radiation exposure, light skin tone, and immunosuppression. Although metastasis in cSCC is rare, primary tumor characteristics such as location, size, and depth of invasion, among others, can help risk-stratify lesions for local recurrence, metastatic events, and death. We present a case of primary cutaneous metastatic squamous cell carcinoma masquerading as a cyst on the left temple of a 73-year-old Caucasian man following numerous treatments of cryotherapy to an ipsilateral helical lesion.
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Affiliation(s)
- Colby Shreve
- Dermatology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - Chase Shropshire
- Dermatology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
| | - David G Cotter
- Dermatology, University of Nevada Las Vegas School of Medicine, Las Vegas, USA
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18
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Gironi LC, Boggio P, Giorgione R, Esposto E, Tarantino V, Damiani G, Savoia P. The impact of COVID-19 pandemics on dermatologic surgery: real-life data from the Italian Red-Zone. J DERMATOL TREAT 2020; 33:897-903. [PMID: 32600085 DOI: 10.1080/09546634.2020.1789044] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The COVID-19 pandemic is challenging healthcare systems worldwide. Dermatology had to re-prioritize visits, guarantee urgent care, and ensure continuity for chronic patients. OBJECTIVES To evaluate the COVID-19 impact on dermatologic surgery outpatient management. MATERIAL AND METHODS In this real-life retrospective observational study, we evaluated both major and minor outpatient surgeries (MaOS and MiOS) performance in 2020, before and during the first month of lockdown declaration, in a primary referral center in Northern Italy. During the lockdown, all lifesaving and cancer surgery, (approximately 80% of our usual activities), were continued. Data from 2020 were compared with the 2019 corresponding periods to assess the real-life impact of COVID-19 in dermatologic surgical activities. RESULTS From January 1st to April 3rd, 2020 we performed 769 interventions, compared to 908 over the corresponding 2019 period. After the lockdown, scheduled surgeries were reduced by 14.8%; overall performed ones displayed a reduction of 46.5% (51.6% MaOS, 44.2% MiOS). 52.9% and 12.5% procedures were canceled due to patients' renunciation and due to confirmed/suspected COVID-19, respectively. CONCLUSIONS While reduced in number, dermatologic surgeries, similarly to other surgical specialties, remained operative to provide oncological and/or life-saving procedures.
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Affiliation(s)
| | | | | | - Elia Esposto
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Vanessa Tarantino
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Giovanni Damiani
- Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Paola Savoia
- Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
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19
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Abstract
The incidence of skin cancer (e.g., squamous cell carcinoma, basal cell carcinoma, and melanoma) has been increasing over the past several years. It is expected that there will be a parallel demand for cutaneous tumor samples for biomedical research studies. Tissue availability, however, is limited due the cost of establishing a biorepository and the lack of protocols available for obtaining clinical samples that do not interfere with clinical operations. A protocol was established to collect and process cutaneous tumor and associated blood and saliva samples that has minimal impact on routine clinical procedures on the date of a Mohs surgery. Tumor samples are collected and processed from patients undergoing their first layer of Mohs surgery for biopsy-proven cutaneous malignancies by the Mohs histotechnologist. Adjacent normal tissue is collected at the time of surgical closure. Additional samples that may be collected are whole-blood and buccal swabs. By utilizing tissue samples that are normally discarded, a biorepository was generated that offers several key advantages by being based in the clinic versus the laboratory setting. These include a wide range of collected samples; access to de-identified patient records, including pathology reports; and, for the typical donor, access to additional samples during follow-up visits.
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Affiliation(s)
- Sarah E Belden
- Affiliated Dermatology & Affiliated Laboratories, Midwestern University Osteopathic Postdoctoral Training Institute, Midwestern University
| | - Chandana K Uppalapati
- Department of Microbiology & Immunology, Arizona College of Osteopathic Medicine, Midwestern University
| | - Agnes S Pascual
- Biomedical Sciences Program, College of Health Sciences, Midwestern University
| | - McKale R Montgomery
- Biomedical Sciences Program, College of Health Sciences, Midwestern University
| | - Kathryn J Leyva
- Department of Microbiology & Immunology, Arizona College of Osteopathic Medicine, Midwestern University
| | - Elizabeth E Hull
- Biomedical Sciences Program, College of Health Sciences, Midwestern University;
| | - Richard L Averitte
- Affiliated Dermatology & Affiliated Laboratories, Midwestern University Osteopathic Postdoctoral Training Institute, Midwestern University
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20
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Jain M, Rajadhyaksha M, Nehal K. Implementation of fluorescence confocal mosaicking microscopy by "early adopter" Mohs surgeons and dermatologists: recent progress. J Biomed Opt 2017; 22:24002. [PMID: 28199474 PMCID: PMC5310648 DOI: 10.1117/1.jbo.22.2.024002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/20/2017] [Indexed: 05/06/2023]
Abstract
Confocal mosaicking microscopy (CMM) enables rapid imaging of large areas of fresh tissue ex vivo without the processing that is necessary for conventional histology. When performed in fluorescence mode using acridine orange (nuclear specific dye), it enhances nuclei-to-dermis contrast that enables detection of all types of basal cell carcinomas (BCCs), including micronodular and thin strands of infiltrative types. So far, this technique has been mostly validated in research settings for the detection of residual BCC tumor margins with high sensitivity of 89% to 96% and specificity of 99% to 89%. Recently, CMM has advanced to implementation and testing in clinical settings by “early adopter” Mohs surgeons, as an adjunct to frozen section during Mohs surgery. We summarize the development of CMM guided imaging of ex vivo skin tissues from bench to bedside. We also present its current state of application in routine clinical workflow not only for the assessment of residual BCC margins in the Mohs surgical setting but also for some melanocytic lesions and other skin conditions in clinical dermatology settings. Last, we also discuss the potential limitations of this technology as well as future developments. As this technology advances further, it may serve as an adjunct to standard histology and enable rapid surgical pathology of skin cancers at the bedside.
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Affiliation(s)
- Manu Jain
- Memorial Sloan Kettering Cancer Center, Dermatology Service, Department of Medicine, New York, United States
- Address all correspondence to: Manu Jain, E-mail:
| | - Milind Rajadhyaksha
- Memorial Sloan Kettering Cancer Center, Dermatology Service, Department of Medicine, New York, United States
| | - Kishwer Nehal
- Memorial Sloan Kettering Cancer Center, Dermatology Service, Department of Medicine, New York, United States
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21
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Takata Pontes L, Fantelli Stelini R, Cintra ML, Magalhães RF, Velho PENF, Moraes AM. The importance of superficial basal cell carcinoma in a retrospective study of 139 patients who underwent Mohs micrographic surgery in a Brazilian university hospital. Clinics (Sao Paulo) 2015; 70:721-5. [PMID: 26602517 PMCID: PMC4642494 DOI: 10.6061/clinics/2015(11)01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/12/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Mohs micrographic surgery is a specialized surgical procedure used to treat skin cancer. The purpose of this study was to better understand the profile of the patients who underwent the procedure and to determine how histology might be related to complications and the number of stages required for complete removal. METHODS The records of patients who underwent Mohs micrographic surgery from October 2008 to November 2013 at the Dermatology Division of the Hospital of the Campinas University were assessed. The variables included were gender, age, anatomical location, histology, number of stages required and complications. RESULTS Contingency tables were used to compare the number of stages with the histological diagnosis. The analysis showed that patients with superficial basal cell carcinoma were 9.03 times more likely to require more than one stage. A comparison between complications and histological diagnosis showed that patients with superficial basal cell carcinoma were 6.5 times more likely to experience complications. CONCLUSION Although superficial basal cell carcinoma is typically thought to represent a less-aggressive variant of these tumors, its propensity for demonstrating "skip areas" and clinically indistinct borders make it a challenge to treat. Its particular nature may result in the higher number of surgery stages required, which may, as a consequence, result in more complications, including recurrence. Recurrence likely occurs due to the inadequate excision of the tumors despite their clear margins. Further research on this subtype of basal cell carcinoma is needed to optimize treatments and decrease morbidity.
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Affiliation(s)
- Luciana Takata Pontes
- Clínica Médica, Divisão Dermatologia, Hospital das Clínicas da Universidade Estadual de Campinas, São Paulo, Brazil
| | - Rafael Fantelli Stelini
- Patologia, Hospital das Clínicas da Universidade Estadual de Campinas, São Paulo, SP, Brazil
| | - Maria Leticia Cintra
- Patologia, Hospital das Clínicas da Universidade Estadual de Campinas, São Paulo, SP, Brazil
| | - Renata Ferreira Magalhães
- Clínica Médica, Divisão Dermatologia, Hospital das Clínicas da Universidade Estadual de Campinas, São Paulo, Brazil
| | - Paulo Eduardo N F Velho
- Clínica Médica, Divisão Dermatologia, Hospital das Clínicas da Universidade Estadual de Campinas, São Paulo, Brazil
| | - Aparecida Machado Moraes
- Clínica Médica, Divisão Dermatologia, Hospital das Clínicas da Universidade Estadual de Campinas, São Paulo, Brazil
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22
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Flores ES, Cordova M, Kose K, Phillips W, Rossi A, Nehal K, Rajadhyaksha M. Intraoperative imaging during Mohs surgery with reflectance confocal microscopy: initial clinical experience. J Biomed Opt 2015; 20:61103. [PMID: 25706821 PMCID: PMC4405085 DOI: 10.1117/1.jbo.20.6.061103] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/04/2014] [Indexed: 05/22/2023]
Abstract
Mohs surgery for the removal of nonmelanoma skin cancers (NMSCs) is performed in stages, while being guided by the examination for residual tumor with frozen pathology. However, preparation of frozen pathology at each stage is time consuming and labor intensive. Real-time intraoperative reflectance confocal microscopy(RCM), combined with video mosaicking, may enable rapid detection of residual tumor directly in the surgical wounds on patients. We report our initial experience on 25 patients, using aluminum chloride for nuclear contrast. Imaging was performed in quadrants in the wound to simulate the Mohs surgeon’s examination of pathology. Images and videos of the epidermal and dermal margins were found to be of clinically acceptable quality. Bright nuclear morphology was identified at the epidermal margin and detectable in residual NMSC tumors. The presence of residual tumor and normal skin features could be detected in the peripheral and deep dermal margins. Intraoperative RCM imaging may enable detection of residual tumor directly on patients during Mohs surgery, and may serve as an adjunct for frozen pathology. Ultimately, for routine clinical utility, a stronger tumor-to-dermis contrast may be necessary, and also a smaller microscope with an automated approach for imaging in the entire wound in a rapid and controlled manner.
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Affiliation(s)
- Eileen S. Flores
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
- *Address all correspondence to: Eileen S. Flores, E-mail:
| | - Miguel Cordova
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
| | - Kivanc Kose
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
| | - William Phillips
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
| | - Anthony Rossi
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
| | - Kishwer Nehal
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
| | - Milind Rajadhyaksha
- Memorial Sloan Kettering Cancer Center, Dermatology Service, New York, New York 10022, United States
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23
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Abeytunge S, Li Y, Larson B, Peterson G, Seltzer E, Toledo-Crow R, Rajadhyaksha M. Confocal microscopy with strip mosaicing for rapid imaging over large areas of excised tissue. J Biomed Opt 2013; 18:61227. [PMID: 23389736 PMCID: PMC3565124 DOI: 10.1117/1.jbo.18.6.061227] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 12/19/2012] [Accepted: 12/21/2012] [Indexed: 05/20/2023]
Abstract
Confocal mosaicing microscopy is a developing technology platform for imaging tumor margins directly in freshly excised tissue, without the processing required for conventional pathology. Previously, mosaicing on 12-×-12 mm² of excised skin tissue from Mohs surgery and detection of basal cell carcinoma margins was demonstrated in 9 min. Last year, we reported the feasibility of a faster approach called "strip mosaicing," which was demonstrated on a 10-×-10 mm² of tissue in 3 min. Here we describe further advances in instrumentation, software, and speed. A mechanism was also developed to flatten tissue in order to enable consistent and repeatable acquisition of images over large areas. We demonstrate mosaicing on 10-×-10 mm² of skin tissue with 1-μm lateral resolution in 90 s. A 2.5-×-3.5 cm² piece of breast tissue was scanned with 0.8-μm lateral resolution in 13 min. Rapid mosaicing of confocal images on large areas of fresh tissue potentially offers a means to perform pathology at the bedside. Imaging of tumor margins with strip mosaicing confocal microscopy may serve as an adjunct to conventional (frozen or fixed) pathology for guiding surgery.
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Affiliation(s)
- Sanjee Abeytunge
- Memorial Sloan-Kettering Cancer Center, Research Engineering Laboratory, New York, New York 10065, USA.
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24
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Gareau D, Bar A, Snaveley N, Lee K, Chen N, Swanson N, Simpson E, Jacques S. Tri-modal confocal mosaics detect residual invasive squamous cell carcinoma in Mohs surgical excisions. J Biomed Opt 2012; 17:066018. [PMID: 22734774 PMCID: PMC3381035 DOI: 10.1117/1.jbo.17.6.066018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/27/2012] [Accepted: 05/01/2012] [Indexed: 05/23/2023]
Abstract
For rapid, intra-operative pathological margin assessment to guide staged cancer excisions, multimodal confocal mosaic scan image wide surgical margins (approximately 1 cm) with sub-cellular resolution and mimic the appearance of conventional hematoxylin and eosin histopathology (H&E). The goal of this work is to combine three confocal imaging modes: acridine orange fluorescence (AO) for labeling nuclei, eosin fluorescence (Eo) for labeling cytoplasm, and endogenous reflectance (R) for marking collagen and keratin. Absorption contrast is achieved by alternating the excitation wavelength: 488 nm (AO fluorescence) and 532 nm (Eo fluorescence). Superposition and false-coloring of these modes mimics H&E, enabling detection of cutaneous squamous cell carcinomas (SCC). The sum of mosaic Eo+R is false-colored pink to mimic the appearance of eosin, while the AO mosaic is false-colored purple to mimic the appearance of hematoxylin in H&E. In this study, mosaics of 10 Mohs surgical excisions containing invasive SCC, and five containing only normal tissue were subdivided for digital presentation equivalent to 4 × histology. Of the total 50 SCC and 25 normal sub-mosaics presented, two reviewers made two and three type-2 errors (false positives), respectively. Limitations to precisely mimic H&E included occasional elastin staining by AO. These results suggest that confocal mosaics may effectively guide staged SCC excisions in skin and other tissues.
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Affiliation(s)
- Dan Gareau
- Oregon Health & Science University, Department of Dermatology, CH16D, 3303 SW Bond Avenue, Portland, Oregon 97239, USA.
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25
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Bini J, Spain J, Nehal K, Hazelwood V, DiMarzio C, Rajadhyaksha M. Confocal mosaicing microscopy of human skin ex vivo: spectral analysis for digital staining to simulate histology-like appearance. J Biomed Opt 2011; 16:076008. [PMID: 21806269 PMCID: PMC3154052 DOI: 10.1117/1.3596742] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Confocal mosaicing microscopy enables rapid imaging of large areas of fresh tissue, without the processing that is necessary for conventional histology. Mosaicing may offer a means to perform rapid histology at the bedside. A possible barrier toward clinical acceptance is that the mosaics are based on a single mode of grayscale contrast and appear black and white, whereas histology is based on two stains (hematoxylin for nuclei, eosin for cellular cytoplasm and dermis) and appears purple and pink. Toward addressing this barrier, we report advances in digital staining: fluorescence mosaics that show only nuclei, are digitally stained purple and overlaid on reflectance mosaics, which show only cellular cytoplasm and dermis, and are digitally stained pink. With digital staining, the appearance of confocal mosaics mimics the appearance of histology. Using multispectral analysis and color matching functions, red, green, and blue (RGB) components of hematoxylin and eosin stains in tissue were determined. The resulting RGB components were then applied in a linear algorithm to transform fluorescence and reflectance contrast in confocal mosaics to the absorbance contrast seen in pathology. Optimization of staining with acridine orange showed improved quality of digitally stained mosaics, with good correlation to the corresponding histology.
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Affiliation(s)
- Jason Bini
- Memorial Sloan-Kettering Cancer Center, Department of Dermatology, New York, New York 10022, USA.
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26
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Abeytunge S, Li Y, Larson B, Toledo-Crow R, Rajadhyaksha M. Rapid confocal imaging of large areas of excised tissue with strip mosaicing. J Biomed Opt 2011; 16:050504. [PMID: 21639560 PMCID: PMC3117897 DOI: 10.1117/1.3582335] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 04/04/2011] [Accepted: 04/04/2011] [Indexed: 05/22/2023]
Abstract
Imaging large areas of tissue rapidly and with high resolution may enable rapid pathology at the bedside. The limited field of view of high-resolution microscopes requires the merging of multiple images that are taken sequentially to cover a large area. This merging or mosaicing of images requires long acquisition and processing times, and produces artifacts. To reduce both time and artifacts, we developed a mosaicing method on a confocal microscope that images morphology in large areas of excised tissue with sub-cellular detail. By acquiring image strips with aspect ratios of 10:1 and higher (instead of the standard ~1:1) and "stitching" them in software, our method images 10 × 10 mm(2) area of tissue in about 3 min. This method, which we call "strip mosaicing," is currently three times as fast as our previous method.
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Affiliation(s)
- Sanjee Abeytunge
- Memorial Sloan-Kettering Cancer Center, Research Engineering Laboratory, 430 East 67th Street, RRL513, New York, New York 10065, USA
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27
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Abstract
Precise micro-surgical removal of tumour with minimal damage to the surrounding normal tissue requires a series of excisions, each guided by an examination of frozen histology of the previous. An example is Mohs surgery for the removal of basal cell carcinomas (BCCs) in skin. The preparation of frozen histology is labour-intensive and slow. Confocal microscopy may enable rapid detection of tumours directly in surgical excisions with minimal need for frozen histology. Mosaicing of images enables observation of nuclear and cellular morphology in large areas of surgically excised tissue. In skin, the use of 10-1% acetic acid as a reflectance contrast agent brightens nuclei in 0.5-5 min and enhances nuclear-to-dermis contrast and detectability of BCCs. A tissue fixture was engineered for precisely mounting surgical excisions to enable mosaicing of 36 x 36 images to create a field of view of 12 x 12 mm. This large field of view displays the excision at 2x magnification, similar to that routinely used by Mohs surgeons when examining frozen histology. Comparison of mosaics to histology demonstrates detectability of BCCs. Confocal mosaicing presently requires 9 min, instead of 20-45 min per excision for preparing frozen histology, and thus may provide a means for rapid pathology-at-the-bedside to expedite and guide surgery.
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Affiliation(s)
- D S Gareau
- Dermatology Service, Room 230, Memorial Sloan-Kettering Cancer Center, 160 East 53rd Street, New York, NY 10022, USA.
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28
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Gareau DS, Li Y, Huang B, Eastman Z, Nehal KS, Rajadhyaksha M. Confocal mosaicing microscopy in Mohs skin excisions: feasibility of rapid surgical pathology. J Biomed Opt 2008; 13:054001. [PMID: 19021381 PMCID: PMC2662759 DOI: 10.1117/1.2981828] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Mosaicing of confocal images enables observation of nuclear morphology in large areas of tissue. An application of interest is rapid detection of basal cell carcinomas (BCCs) in skin excisions during Mohs surgery. A mosaic is currently created in less than 9 min, whereas preparing frozen histology requires 20 to 45 min for an excision. In reflectance mosaics, using acetic acid as a contrast agent to brighten nuclei, large and densely nucleated BCC tumors were detectable in fields of view of 12 x 12 mm (which is equivalent to a 2x-magnified view as required by Mohs surgeons). However, small and sparsely nucleated tumors remained undetectable. Their diminutive size within the large field of view resulted in weak light backscatter and contrast relative to the bright surrounding normal dermis. In fluorescence, a nuclear-specific contrast agent may be used and light emission collected specifically from nuclei but almost none from the dermis. Acridine orange of concentration 1 mM stains nuclei in 20 s with high specificity and strongly enhances nuclear-to-dermis contrast of BCCs. Comparison of fluorescence mosaics to histology shows that both large and small tumors are detectable. The results demonstrate the feasibility of confocal mosaicing microscopy toward rapid surgical pathology to potentially expedite and guide surgery.
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Affiliation(s)
- Daniel S Gareau
- Memorial Sloan-Kettering Cancer Center, Dermatology Service, 160 East 53rd Street, New York, New York 10022, USA.
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29
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Abstract
Clinical features of facial skin cancer in Asian population including Korean are not readily available. In the present study, we analyzed the clinical characteristics and the surgical results of primary facial skin cancer in Chungbuk Province, Korea. Eighty-six cases of primary facial skin cancer collected during a 10-yr period (1994-2003) were retrospectively reviewed about the clinical characteristics including age, sex, annual diagnostic rate, types of tumor, specific sites of occurrence, and the surgical results. The average age at the diagnosis was 67 and male to female ratio was 1 to 1.05. The average annual diagnostic rate was 0.73% and the rate surged during the period 2001-2003 compared with the period 1994 to 2000. Basal cell carcinoma was the most common tumor and the nose was the most frequent site. Traditional surgical excision with immediate reconstruction was performed in 81 cases. During the 23 months of average follow-up, three patients had recurrences (3.7%) and three patients had secondary skin cancers. Facial skin cancer is increasing in the province and basal cell carcinoma is most frequent. Traditional surgical excision and immediate reconstruction with local flap are a good therapeutic modality with an acceptable recurrence rate.
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Affiliation(s)
- Hong-Ryul Jin
- Department of Otolaryngology, College of Medicine, Chungbuk National University, Cheongju, Korea.
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