Mohs micrographic surgery for the treatment of spindle cell tumors of the skin

BACKGROUND

Because of the uncommon nature of dermal spindle cell tumors, the effectiveness of various treatment modalities is difficult to assess.

OBJECTIVE

Our purpose was to measure the effectiveness of treating dermatofibrosarcoma protuberans, atypical fibroxanthoma, malignant fibrous histiocytoma, and leiomyosarcoma by means of Mohs micrographic surgery (MMS). In addition, we attempted to determine whether MMS is useful in treating dermal spindle cell tumors when no definitive histopathologic diagnosis can be rendered.

METHODS

In a retrospective chart review, demographic data, tumor data, treatment characteristics, recurrence, and follow-up data were tabulated.

RESULTS

The recurrence rate for dermatofibrosarcoma protuberans treated by MMS was 3.0%, for atypical fibroxanthoma was 6.9%, for malignant fibrous histiocytoma was 43%, and for leiomyosarcoma was 14%. The recurrence rate for spindle cell tumors not otherwise specified was 0%.

CONCLUSION

These data establish the effectiveness of MMS in the treatment of dermal spindle cell tumors, including those for which no definitive histopathologic diagnosis can be rendered.

Undermining in cutaneous surgery

BACKGROUND

Benefits, risks, and technical aspects of undermining in cutaneous surgery are presented and reviewed in order to facilitate the execution of this fundamental task of cutaneous surgery.

METHODS

The authors' extensive experience with thousands of cutaneous reconstructions and literature consultation form the basis of this review.

RESULTS

Literature review and practical experience indicate that undermining reduces wound closing tension. Pertinent anatomic considerations, benefits, risks, as well as sharp and blunt undermining techniques and regional undermining recommendations are discussed.

CONCLUSIONS

It is concluded that judicious undermining, properly performed by surgeons knowledgeable of cutaneous anatomy facilitates the execution and enhances cosmesis in cutaneous reconstruction. It is the authors' opinion that sharp undermining technique is the optimal method for most cutaneous reconstructions.

Overview of skin cancer detection and prevention for the primary care physician

The incidence of both melanoma and nonmelanoma skin cancer is increasing, and an accurate and timely diagnosis is important to reduce the morbidity and mortality associated with these malignancies. Clinical features and examination techniques are discussed, and the need to recognize important secondary tumor characteristics, which supplement the primary diagnosis, is reviewed. Recent evidence on etiologic factors and their importance are addressed to highlight the role of primary prevention. Pediatricians, family physicians, and all primary care physicians are encouraged to promote skin cancer awareness among children and their parents.

A single postoperative application of nitroglycerin ointment does not increase survival of cutaneous flaps and grafts

BACKGROUND

Nitroglycerin is a vasodilator that has been reported to improve cutaneous flap and graft survival. It has not been tested in controlled studies.

OBJECTIVE

We designed our study to test the effectiveness of a single postoperative application of nitroglycerin on flap and graft survival.

METHODS

Eighty-eight surgical repairs received topical nitroglycerin and 85 received control ointment (polysporin). Treatment sites were evaluated on postoperative day 7 and assigned a percentage of surface area survival.

RESULTS

There was no significant difference in the complication rate of flaps and grafts treated with nitroglycerin (12.5%) compared with those treated with control ointment (8.4%) (P = .244). Subset analysis of flaps as a group and grafts as a group were not meaningful because the complication rates were so low.

CONCLUSION

There is no survival increase of flaps and grafts treated with a single application of nitroglycerin ointment.

Linear basal cell carcinoma: report of seventeen cases and review of the presentation and treatment

BACKGROUND

Linear basal cell carcinoma was first described as a distinct clinical morphologic variant in 1985. Subsequently, twelve cases were reported.

OBJECTIVE

To review and identify cases of linear basal cell carcinoma in our institutions and determine optimal treatment based on review of our cases and those in the literature.

METHODS

Primary basal cell carcinomas treated at the three campuses of Mayo Clinic and the University of Montreal were reviewed retrospectively, as were the twelve cases in the literature.

RESULTS

Seventeen cases of linear basal cell carcinoma were identified. The age and sex ratios were similar to those of patients with standard basal cell carcinomas. Based on the review of the few reported cases of linear basal cell carcinoma (29), the percentage of aggressive histologic subtypes (38%) was increased compared with that in a general population. The average number of Mohs layers required for treatment was higher than that reported for standard basal cell carcinoma, an indication of increased subclinical spread.

CONCLUSION

Linear basal cell carcinoma is an uncommonly recognized morphologic variant. Based on the small number of cases, these tumors have more aggressive histologic subtypes. Because of the possibility for increased subclinical spread, Mohs micrographic surgery can be considered for treatment. Further studies are needed to confirm these findings.

Reinnervation of flaps and grafts of the face

BACKGROUND

The degree to which disruption of sensory innervation is affected by flaps and grafts on the face has not been explored. The decision to choose a flap or a graft for reconstruction may affect future sensation at the surgical site.

OBJECTIVES

To characterize the clinical recovery of sensory innervation after facial reconstructive surgery with flaps and grafts and to offer clinical guidelines on the recovery of sensation in reconstructed sites involving flaps and grafts of the face.

METHODS

Seventy patients who underwent Mohs surgery and subsequent repair by either a flap or a graft were evaluated at different postoperative intervals. Fifty patients underwent flap reconstruction and 20 patients underwent graft reconstruction. Three principal modes of sensation were objectively assessed: light touch, temperature, and pinprick.

RESULTS

Median time of evaluation after surgery was 11 months. The most common locations tested were the nose (36 patients) and the forehead (9 patients). Postoperative evaluation showed that flap sensation recovery to light touch was present in 10% of patients before 3 months, 41% of patients from 3 to 12 months, 27% of patients from 1 to 2 years, and 75% of patients after 2 years. Graft sensation recovery to light touch was present in no patients evaluated less than 2 years after surgery and in 29% of patients evaluated more than 2 years after surgery. After adjustments for postoperative size and interval, patients with flaps were more likely than those with grafts to have touch sensation at the time of testing (adjusted odds ratio, 8.91; 95% confidence interval, 1.06-74.62; P = .04), to be able to distinguish between warm and cold (adjusted odds ratio, 3.99; 95% confidence interval, 1.05-15.16; P = .04), and to be able to distinguish between sharp and dull (adjusted odds ratio, 27.31; 95% confidence interval, 2.20-339.71; P = .01).

CONCLUSIONS

Predictable factors are associated with sensation recovery in patients with flaps and grafts. The recovery of sensory innervation after surgery is earlier with flaps than with grafts. Our data provide clinicians with guidelines for recovery of sensation that ultimately will reassure the patient.

Merkel cell carcinoma. Comparison of Mohs micrographic surgery and wide excision in eighty-six patients

BACKGROUND

Merkel cell carcinoma is an uncommon malignant tumor of the skin that, after standard surgical excision, tends to recur locally and develop regional nodal spread.

OBJECTIVE

This study evaluated the use of Mohs micrographic surgery for this aggressive neoplasm.

METHODS

A retrospective study of 86 patients with Merkel cell carcinoma established rates of local persistence and the development of regional metastasis after standard surgical excision. Detailed follow-up was available on a subgroup of 13 patients treated with Mohs surgery.

RESULTS

Standard surgical excision for local disease was associated with high rates of local persistence (13 of 41 [31.7%]) and regional metastasis (20 of 41 [48.8%]). Mean follow-up was 60 months. Mean follow-up for the group treated with Mohs was 36 months. Only one of 12 (8.3%) Mohs-treated patients with histologically confirmed clearance has had local persistence of disease. This patient underwent a second Mohs excision and has remained disease free for 84 months. Regional metastasis developed in four of 12 cases (33.3%). Regional metastasis developed in none of the four patients treated with radiotherapy after Mohs surgery and in four of eight patients treated with Mohs surgery without postoperative radiotherapy.

CONCLUSION

Mohs surgery compares favorably with standard surgical excision. Radiotherapy after Mohs surgery may further reduce persistent metastases in transit and nodal disease.

The life of a skin cancer

The mechanisms of carcinogenesis and metastasis are becoming better elucidated. The recent literature pertaining to the current understanding of the mechanisms of carcinogenesis and metastasis was reviewed, and some of the basic information that is known about these processes and how they relate to the development of cutaneous cancers is presented in this article. The development of a skin cancer consists of a three-step process of carcinogenesis-initiation, promotion, and progression. When metastasis occurs, a six-step process of complex cellular adaptations enables the tumor cell to metastasize and proliferate successfully. The mechanisms of carcinogenesis and metastasis are pertinent not only to dermatologists and physicians who treat skin cancer but also to any physician who must manage human malignant tumors. Therefore, a general background of information on this subject is an important aspect of medical knowledge for most physicians.

Thyroid carcinoma metastatic to the skin: a cutaneous manifestation of a widely disseminated malignancy

BACKGROUND

Cutaneous metastases develop in 2% to 9% of patients with an internal malignancy. Thyroid carcinoma metastatic to the skin is a rare clinical entity.

OBJECTIVE

Our purpose was to study the clinical and pathologic features and outcome in patients with cutaneous metastasis from thyroid carcinoma.

METHODS

The study included a retrospective analysis of six patients with skin metastases from thyroid carcinoma and a review of the English-language literature since 1964.

RESULTS

Including our six patients, 43 patients with skin metastases from thyroid carcinoma have been reported. Papillary carcinoma was the most common (41%), followed by follicular (28%), anaplastic (15%), and medullary carcinomas (15%). The scalp was the most common site of metastasis. For our patients, the average length of survival after diagnosis of cutaneous metastasis was 19 months.

CONCLUSION

Cutaneous metastasis from thyroid carcinoma is rare and occurs in the setting of disseminated neoplastic disease.

A comparison of Mohs micrographic surgery and wide excision for the treatment of atypical fibroxanthoma

BACKGROUND

Atypical fibroxanthoma (AFX) is an uncommon spindle cell neoplasm occurring most often in actinically damaged skin of elderly patients. This tumor has invasive potential, may recur locally after excision, and rarely metastasizes. To conserve tissue and improve the likelihood of cure, Mohs micrographic surgery (MMS) has been used for treatment.

OBJECTIVE

We review and discuss the Mayo Clinic experience treating AFX with MMS and retrospectively compare the clinical outcome with that in a similar cohort of patients treated with wide local excision (WE).

METHODS

The medical records of 45 patients were reviewed at three Mayo Clinic practices. Follow-up data were available for 44 patients: 19 treated with MMS and 25 with WE.

RESULTS

In patients treated with MMS, there were no recurrences after a mean follow-up of 29.6 months. There were three first recurrences in 25 patients (12%) treated with WE after a mean follow-up of 73.6 months. One patient had a single local recurrence, and two patients each had two local recurrences. Parotid node metastasis eventually developed in one of the patients with two local recurrences, so that the regional metastatic rate in this series was 4% (1 in 25 patients).

CONCLUSION

Microscopic control of the surgical margins with MMS in the treatment of AFX results in a lower recurrence rate than that with WE and conserves normal tissue.

The use of perichondrial cutaneous grafts to repair defects of the lower third of the nose

The reconstruction of surgical defects on the nasal tip and nasal ala which require both skin coverage and underlying support is often a complex surgical problem. The perichondrial cutaneous graft (PCCG) is a composite graft of skin and perichondrium harvested from the conchal bowl of the car. It is an excellent alternative to full-thickness skin grafts and local flaps for reconstructing defects of the lower third of the nose. This composite graft, which is composed of epidermis, dermis, a small amount of subcutaneous tissue, and the underlying perichondrium, yields excellent cosmetic and functional results in a simple, single-stage, out-patient procedure. This article describes and illustrates the repair of surgical defects on the nasal tip and nasal ala using the PCCG.

Metastasis. A primer for dermatologists

BACKGROUND

Dermatologists often diagnose, treat, and manage patients who have cutaneous tumors that are potentially metastatic. While the fund of knowledge regarding metastasis is still quite incomplete, more and more is becoming understood about the mechanisms of carcinogenesis and metastasis.

OBJECTIVE

To present in understandable terms what is known about carcinogenesis and metastasis and how this information can and should affect the clinician's approach to diagnosis, management, and follow-up of potentially metastatic cutaneous disease.

METHODS

The recent literature pertaining to the current understanding of the mechanisms of carcinogenesis and metastasis are assimilated and reviewed.

RESULTS

Carcinogenesis is fundamentally a three-step process comprised of initiation, promotion, and progression. One of the most dramatic results of progression is metastasis. Metastasis is the result of a complex set of cellular adaptations that enable the tumor cell to be able to separate from the primary tumor, invade, intravasate, circulate, implant at a distant site, extravasate, and lastly proliferate.

CONCLUSION

A fundamental understanding of the mechanism of carcinogenesis and metastasis is important to the clinical dermatologist. Understanding these principles can affect the way in which the practitioner teaches and institutes preventative measures. It may also influence diagnostic and therapeutic approaches as well as subsequent management and follow-up of potentially metastatic or metastatic disease. There is little doubt that the best care for a patient with skin cancer can be given by the physician who knows the most about the integument. This behooves dermatologists to remain well informed about the present understanding of the development and progression of cancer.

The many faces of squamous cell carcinoma

BACKGROUND

Cutaneous squamous cell carcinoma is a disease that has a multitude of clinical, histologic, and etiologic subtypes, all of which are of significance to the clinician.

OBJECTIVE

Ten of the most common and clinically significant subtypes of squamous cell carcinoma are presented to emphasize the clinical importance of each and to emphasize and contrast their differences.

METHODS

The literature of each subtype of squamous cell carcinoma is reviewed and capsulized.

RESULTS

Appropriate diagnosis, therapy, and postoperative management of all subtypes of squamous cell carcinomas are dependent upon the understanding of their unique characteristics.

CONCLUSION

The 10 common variants of squamous cell carcinoma presented in this paper: neurotrophic squamous cell carcinoma, Bowen's disease, squamous cell carcinoma in transplant patients, keratoacanthoma-like squamous cell carcinoma, squamous cell carcinoma of the lip, adenoid squamous cell carcinoma, spindle cell squamous cell carcinoma, radiation-induced squamous cell carcinoma, verrucous carcinoma, and Marjolin's ulcer, have unique etiologic, histologic, and clinical features that significantly influence their diagnosis, treatment, and subsequent management. It is imperative that physicians responsible for the care of these patients understand the implication of these unique characteristics.

The epidemiology of skin cancer

BACKGROUND

The incidence of skin cancer is increasing at an alarming rate.

OBJECTIVE

To discuss current epidemiologic data concerning the incidence, morbidity, environmental influences, predisposing, host conditions, precursor lesions, and prevention of melanoma and nonmelanoma (basal and squamous cell) skin cancer.

METHODS

The current literature was reviewed in order to provide current epidemiologic data for melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).

RESULTS

Skin cancer is exceedingly common and the incidence is rising rapidly. Although the mortality rate for nonmelanoma skin cancer (NMSC) is decreasing, that of melanoma is increasing. Both NMSC and melanoma are associated with significant morbidity. Whereas chronic sun exposure is the main cause of NMSC, the development of melanoma appears to be related to intense, intermittent sun exposure. Ozone depletion has contributed to rising incidence rates of both NMSC and melanoma. In contrast to NMSC, there is not a direct relationship between ultraviolet radiation and melanoma. Genetic susceptibility significantly increases the lifetime risk of acquiring melanoma. There is no precursor lesion for BCC. Precursor lesions for invasive SCC include actinic keratoses and SCC in situ. Melanoma may arise from benign nevi and dysplastic nevi. Prevention of melanoma and NMSC is extremely important since prognosis improves with early detection. Prevention may be achieved by educating patients and physicians how to detect skin cancers early and by decreasing or eliminating exposure to ultraviolet light.

CONCLUSION

The incidence of skin cancer has reached epidemic proportions. Only through heroic efforts by health care professionals and the general public to prevent the development or progression of skin cancer will this epidemic be abated.

Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma is an aggressive tumor with nonspecific clinical features. The prognosis in general is worse than malignant melanoma. Local recurrence rates are high with one-third of patients having recurrence within one year of excision. The tumor invades blood vessels and lymphatics. This frequent lymphatic dissemination leads later to satellite lesions and recurrence. Distant metastases occur in one-third of patients. One-,two- and three-year survival rates are poor, being estimated at 88%, 72%, and 55%, respectively.

OBJECTIVE

To increase awareness of the behavior of this uncommon tumor.

METHODS

A review of the current literature and recommendations regarding this tumor.

RESULTS

Wide local excision with 3-cm margin shows significant reduction in local recurrence compared with 2-cm margins. Two-thirds of patients with local recurrence ultimately die from their disease. Radiation therapy has a role to play in the local and regional clearance of the tumor.

CONCLUSION

Prompt diagnosis and surgical excision are necessary to improve survival. Mohs micrographic surgery offers potential advantages in evaluating both the lateral and the deep margins. Follow-up studies of patients treated with this modality will be beneficial.

Skin cancers associated with acquired immunodeficiency syndrome

OBJECTIVE

To describe the types of skin cancer associated with the acquired immunodeficiency syndrome (AIDS).

DESIGN

A literature review of AIDS-related mucocutaneous neoplasms, including basal cell carcinoma, squamous cell carcinoma, bowenoid papulosis and Bowen's disease, squamous cell carcinoma, cloacogenic carcinoma, and malignant melanoma, is presented, and the incidence, etiopathogenesis, clinicopathologic features, treatment, and prognosis are discussed.

RESULTS

The association between cutaneous neoplasms and AIDS is well known. Neoplasms seem to grow more rapidly and be more invasive in patients with AIDS than in other groups of patients. Several oncogenic factors--for example, sunlight exposure or human papillomavirus infection--have been associated with the development of skin cancer in these patients. The morbidity and mortality rates of skin cancer are higher in patients infected with the human immunodeficiency virus (HIV) than in the general population. Early and complete excision of the neoplasm is especially important.

CONCLUSION

A link exists between AIDS and the development of skin cancer. HIV-infected patients should be followed up vigilantly for early diagnosis of skin cancer. Because these patients are less able to suppress common cutaneous malignant disease due to their immunocompromised status, biopsy specimens should be obtained from all suspicious lesions, and histopathologic assessment should be done.

Dermabrasive scar revision. Immunohistochemical and ultrastructural evaluation

BACKGROUND

Dermabrasion of facial scars 4-8 weeks after injury frequently completely eliminates visible evidence of scar formation. However, efforts to define the cellular and structural mechanisms by which this phenomenon occurs have been limited in their success.

OBJECTIVE

We investigated wound healing after dermabrasive scar revision.

METHODS

The surgical scars of seven patients were abraded 6-8 weeks after injury. Comparative electron microscopic and immunohistochemical studies were performed on punch biopsy specimens taken before and after the dermabrasion. Ultrastructural changes in the basement membrane components and dermal structures were evaluated. Monoclonal antibody staining techniques were used to observe the presence, location, and temporal expression of tenascin, epiligrin, cadherins, and integrin subunits.

RESULTS

We observed: 1) an increase in collagen bundle density and size with a tendency toward unidirectional orientation of fibers parallel to the epidermal surface, 2) an upregulation of tenascin expression throughout the papillary dermis, and 3) expression of alpha-6/beta-4 integrin subunit on the keratinocytes throughout the stratum spinosum.

CONCLUSIONS

The mechanisms by which dermabrasive scar revision alters the events of primary cicatrix formation include modification of extracellular ligand expression, thereby influencing epithelial cell-cell interaction, and reorganization of connective tissue.

Fundamentals of flap and graft wound closure in cutaneous surgery

Optimal closure of cutaneous defects with flaps and grafts requires an understanding of the dynamics of tissue movement. The best cosmetic outcome is attained when all closure options are considered and the one most suitable for a given defect is chosen. The mnemonic "STARS" provides a convenient way to recall and consider all closure options. The basic principles and some practical considerations of these closure options are reviewed to assist in the understanding of the fundamentals of flap and graft wound closure in cutaneous surgery.

Giant basal cell carcinoma (T3). Who is at risk?

BACKGROUND

Giant basal cell carcinomas can cause extensive local invasion and disfigurement. This study determines in whom giant basal cell carcinomas develop.

METHODS

Fifty patients with giant basal cell carcinomas (over 5 cm, T3) were compared with other groups of patients with small (< 2 cm, T1) or intermediate-sized (2-5 cm, T2) basal cell carcinomas. The patients were treated at the Mayo Clinic between August 1986 and December 1990.

RESULTS

Characteristics that were more common in giant basal cell carcinomas than in smaller lesions were duration, patient neglect, recurrence after previous treatment, aggressive histologic pattern, and history of radiation exposure.

CONCLUSIONS

Patients who have a basal cell carcinoma with an aggressive histologic subtype, a recurrence after previous treatment, a history of radiation exposure, or a history of neglect are at risk for giant basal cell carcinoma.

Transcranial eosinophilic granuloma manifested by a subcutaneous scalp mass. Differential diagnosis in children

BACKGROUND

The differential diagnosis of nodular scalp lesions in a child is surprisingly extensive.

OBJECTIVE

To present a case of eosinophilic granuloma that was manifested by a scalp mass in a pediatric patient.

METHODS

The case is presented and the relevant literature is reviewed.

CONCLUSIONS

The seriousness of some of these lesions requires a thorough evaluation, including noninvasive imaging, and carefully planned surgical intervention so that effective diagnosis and treatment are ensured. Surgical exposure of unsuspected central nervous system connections may lead to infection, hemorrhage, seizures, or other significant morbidity and mortality.

Histologic preparation for Mohs micrographic surgery. The single section method

BACKGROUND

Tissue processed by Mohs micrographic surgery is usually cut into several sections before it is processed.

OBJECT AND METHODS

We describe a single section method, in which the tissue is not subdivided, for preparing a tissue specimen for histologic examination in Mohs micrographic surgery.

RESULTS

This technique saves time for both technicians, who prepare fewer specimens, and physicians, who have fewer histologic specimens to interpret. It may minimize false-positive margins and technical errors.

CONCLUSIONS

Small specimens are handled best by this technique; however, the size of the specimen is limited only by the size of the cryostat chuck and histologic slide. The single section method is technically more difficult for preparing specimens that contain cartilage or ones that are extremely concave or convex, such as specimens from the conch of the ear.

A primer of facial chemical peel

Facial chemical peel encompasses a plethora of procedures or techniques and so may be confusing. This should not blunt one's enthusiasm for what chemexfoliation can achieve. With the use of TCA, chemical peel is a safe, effective, elegant, and simple method for treating some common problems of photoaged, fair skin (Table 7). When a standardized technique is used, it is possible to quantify the therapeutic effects and to predict the outcome reliably. Variations of chemical peel will be used as clinicians try to achieve better results. If possible, variations from standard techniques should be scientifically studied and quantified to establish their safety and efficacy. The goal of chemical face peeling is not simply to achieve a deep or longer-lasting peel. The highest concentrations of TCA and phenol may cause full-thickness facial chemical burns and leave long-lasting scars. Therefore, variations on standard techniques provide only subjective, difficult-to-measure benefits. Conversely, standardized testing on the facial skin of patients is difficult and thus we chose an animal model. Clinicians, especially dermatologists, who want to perform chemical peel should know the indications. Using the procedures described here and in other articles, one can safely and reliably undertake facial chemical peel.

Cutaneous micrographic surgery: Mohs procedure

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.

Surgical margins for excision of primary cutaneous squamous cell carcinoma

BACKGROUND

No guidelines for the margin of resection of cutaneous squamous cell carcinoma have been based on data measuring subclinical tumor extension, as have been formulated for basal cell carcinoma.

OBJECTIVE AND METHODS

Guidelines for appropriate margins of excision of primary cutaneous squamous cell carcinoma were formulated on the basis of a prospective study of subclinical microscopic tumor extension.

RESULTS

Four millimeter margins were adequate for most squamous cell carcinomas. However, certain tumor characteristics were associated with a greater risk of subclinical tumor extension and included size of 2 cm or larger, histologic grade 2 or higher, invasion of the subcutaneous tissue, and location in high-risk areas.

CONCLUSION

Minimal margins of excision of 4 mm around the clinical borders of the squamous cell carcinoma are proposed for all but the high-risk tumors, in which at least a 6 mm margin is recommended.

Mechanisms of metastasis

The role of dermatologists in the diagnosis and treatment of skin cancer continues to increase. Consequently, they will more frequently be involved in the diagnosis, treatment, and management of patients with metastatic or potentially metastatic tumors. Squamous cell carcinomas and malignant melanomas are frequently seen in dermatologic practices and have the capability to metastasize. Metastases are the result of a complex process that is characterized by a sequence of steps, each of which requires acquisition by the malignant cell of key biologic properties. The metastatic sequence can be conceptualized as detachment from the primary tumor followed by invasion, intravasation into a vessel, circulation, stasis within a vessel, extravasation, invasion of the recipient tissue bed, and ultimately proliferation. The basic steps of the metastatic sequence are described as well as how these steps and other tumor cell adaptations can affect the clinical patterns of metastasis. Finally, practical applications of the understanding of these principles of metastasis are discussed.

Kayser-Fleischer rings in a patient with basal cell carcinoma: fortuitous diagnosis of presymptomatic Wilson's disease

Kayser-Fleischer rings were detected during a routine ophthalmologic workup in a 25-year-old man with basal cell carcinoma of the eyelid. Although the importance of this association is uncertain, the routine preoperative evaluation of basal cell carcinoma led to the presymptomatic diagnosis of Wilson's disease. These disorders are discussed, as are the benefits of a multidisciplinary approach for the diagnosis and management of medical problems.

Carbon dioxide laser surgery for skin disease

Since it was developed in the 1960s, the carbon dioxide (CO2) laser has had an important role in the practice of dermatology. The CO2 laser has some advantages over conventional techniques used in dermatologic surgical treatment. It routinely provides a bloodless surgical field as well as unusual surgical precision. Although the CO2 laser is specifically indicated for certain conditions, in other situations, only marginal benefit may be noted in comparison with standard techniques such as scalpel surgical procedures, dermabrasion, cryosurgery, and electrosurgery. In this article, we briefly review the history and physics of the CO2 laser, its operation, and safety principles and discuss dermatologic conditions that are treated with the CO2 laser. We also describe 8 representative cases from our experience with more than 800 cases of CO2 laser treatment in the practice of dermatology at the Mayo Clinic since 1986.

Androgenetic alopecia (common baldness)

Alopecia is a common problem affecting the scalp in both men and women. The vast majority of all cases of alopecia are of the androgenetic variety. The clinical and endocrinologic features of this disorder are reviewed. Potential therapies, including surgical and medical modalities, are mentioned.

A regional approach to reconstruction of the upper lip

Treatment of upper lip wounds by second intention, full-thickness skin grafts, and local flaps is discussed. The location, size, depth, and type of closure for each defect in 200 cases involving defects of the upper lip are reviewed. The percentages of wounds treated by each modality were 20, 6, 74% for second intention, grafts, and local flaps, respectively. Of wound treatment by local flaps, 80% used advancement flaps, 10% used transposition flaps, and 10% used island-pedicle flaps. Advancement flaps, island-pedicle flaps, possible complications, and post-operative care are reviewed.

Depths of chemexfoliation induced by various concentrations and application techniques of trichloroacetic acid in a porcine model

The depth of wounds created by various concentrations and application techniques of trichloroacetic acid (TCA) in a porcine model is evaluated. The depth of tissue necrosis increased with the concentration of TCA. Tape occlusion did not deepen the wound but rather decreased its depth. An inverse relationship of wound depth to epidermal thickness is described.

Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp

Trichloroacetic acid chemexfoliation is an effective, versatile, and safe therapeutic option for patients with extensive actinic keratoses of the face and scalp. With an experienced and skilled operator, the associated complications are rare and tend to be mild. Cosmetically, the patient not only benefits from removal of the erythematous, scaly actinic keratoses but also obtains cosmetically pleasing rejuvenation of facial skin and diminution of fine facial wrinkles. Two representative cases are presented. In comparison with other available treatment modalities, trichloroacetic acid chemexfoliation involves a shorter treatment period and wound healing time and is not dependent on patient compliance.