Cost-effective device for locating and circumscribing superficial tumors with contrast enhancement and fluorescence quantification

BACKGROUND

Two Bispectral contrast enhancement approaches for the fluorescence diagnosis with chlorine-e6 and a wide field-of-view imaging system with fluorescence excitation at 405 nm and time-resolved background suppression were analyzed and compared.

METHODS

Two techniques for the contrast enhancement of a fluorescent video system (Red/Green (R/G) ratio and Red-Green (R-G)) with time-resolved background suppression for fluorescent diagnosis (FD) were tested in four patients with basal cell carcinoma (BCC).

RESULTS

The results of both contrast enhancement methods were compared for the diagnostic efficiency for FD of BCC. Both techniques successfully determined the boundaries of the lesions and the fluorescence intensity.

CONCLUSIONS

Both contrast enhancement modes have proven effective in identifying tumor borders in cases of low contrast in BCC FD with Ce6. While the Red/Green (R/G) mode provides sharper lesion borders, the Red minus Green (R-G) mode visualizes more fluorescent features and makes it easier to assess the lesion margins.

Interaction of Arsenic Exposure and Transcriptomic Profile in Basal Cell Carcinoma

Exposure to inorganic arsenic (As) is recognized as risk factor for basal cell carcinoma (BCC). We have followed-up 7000 adults for 6 years who were exposed to As and had manifest As skin toxicity. Of them, 1.7% developed BCC (males = 2.2%, females = 1.3%). In this study, we compared transcriptome-wide RNA sequencing data from the very first 26 BCC cases and healthy skin tissue from independent 16 individuals. Genes in “ cell carcinoma pathway”, “Hedgehog signaling pathway”, and “Notch signaling pathway” were overexpressed in BCC, confirming the findings from earlier studies in BCC in other populations known to be exposed to As. However, we found that the overexpression of these known pathways was less pronounced in patients with high As exposure (urinary As creatinine ratio (UACR) > 192 µg/gm creatinine) than patients with low UACR. We also found that high UACR was associated with impaired DNA replication pathway, cellular response to different DNA damage repair mechanisms, and immune response. Transcriptomic data were not strongly suggestive of great potential for immune checkpoint inhibitors; however, it suggested lower chance of platinum drug resistance in BCC patients with high UACR compared high platinum drug resistance potential in patients with lower UACR.

Combination curettage and modified ALA-PDT for multiple basal cell carcinomas of the face and head

Basal cell carcinoma (BCC) is a common non-melanoma skin malignancy arising in sun exposure area. Patients with multiple BCCs have a high-risk factor for recurrence and are very difficult to  treat with current methods. 5-aminolaevulinic acid-photodynamic therapy (ALA-PDT) treat superficial type of BCCs with superior efficacy and an excellent cosmetic result, but deep tumor success is limited. Herein, a case of numerous nodular BCCs scattered on the face and head, which was treated with the combination of topical curettage and modified ALA-PDT is reported. Curettage was to rapidly scalp away nodular tumors and contributed to ALA transdermal depth to the tumor base. Modified ALA-PDT as an advanced treatment was nearly painless and can cure multiple BCCs of face and head combing curettage.

The Management of Periocular Basal Cell Carcinoma: Mohs Micrographic Surgery Versus Wide Excision with Later Reconstruction. Predictors for Margin of Resection >4 mm in Mohs Micrographic Surgery

Purpose

To determine the margin of resection (MOR) for periocular basal cell carcinoma (BCC) and compare the outcomes of BCC treatment, namely Mohs micrographic surgery (MMS) and wide excision with later reconstruction (WELR).

Methods

This is a retrospective, comparative, interventional study of patients who underwent surgical treatment of periocular BCC. One hundred forty-two patients were included. One hundred patients were treated with MMS and 42 with WELR. Inclusion criteria were primary periocular BCC with postoperative follow-up of ≥6 months, age more than 18-year-old. Exclusion criteria were, orbital extension, BCC origin outside the periocular area, or those associated with Gorling or nevoid BCC. The main outcome measure was variables associates with MOR >4 mm.

Results

There was a positive correlation between the preoperative tumor horizontal and vertical diameter with the corresponding MOR, of 0.27 (p = 0.01) and 0.28 (p = 0.007), respectively. Receiver operating characteristics suggest that a tumor with a horizontal diameter ≥5 mm or a vertical diameter of ≥6 mm, might need MOR >4 mm. One patient in the MMS group had BCC recurrence compared to none in the WELR group, and one patient in the WELR had a positive surgical margin, which was cleared during the reconstruction.

Conclusions

BCC tumor margins may extend far beyond clinical margins and the MOR required is often more than 3–4 mm. MMS ensures clear tumor margins but is not practical for all patients. A stratification system could help divide patients between the treatment strategies.

Basal Cell Carcinoma Surgery in general practice: Is there a role for the local General Practitioner?

Basal cell carcinoma (BCC) is a common disease of the skin caused principally by prolonged solar radiation exposure. It is normally a malignancy with favorable prognostic features and is potentially curable by standard excision. In White populations with high disease incidence, general practitioners (GPs) play a vital role in diagnosing and managing BCC, including surgical excision. Dedicated care at the primary care level by adequately trained GPs is conceivably cost effective for the health system and more convenient for the patient. In Asia and other parts of the world with low incidence, this valuable role of GPs may appear to be inconsequential. In this regard, any justification for the involvement of local GPs in BCC surgery is debatable. This article aims to provide a clinical update on essential information relevant to BCC surgery and advance understanding of the intricate issues of making a treatment decision at the primary care level.

CASE REPORT

Madam Tan, a 71-year-old Malaysian Chinese lady, otherwise healthy, presented to her local GP with a complaint of a nodule over the left cheek that had been there for more than a decade. Her concern was that the lesion was growing and had become conspicuous. She had spent most of her life as a farmer working in her orchard.Upon examination, she had an obvious dome-shaped nodule over the left cheek measuring approximately 1.8 cm in diameter. The lesion was firm, pigmented, well-demarcated, and slightly ulcerated at the top. Clinically, she was diagnosed with a pigmented nodular basal cell carcinoma of the left cheek. Examination of the systems was unremarkable.She requested that the consulting GP remove the growth. The cost for specialist treatment and waiting time at the local hospital were her concerns.

CLINICAL QUESTIONS

Can the basal cell skin cancer be excised safely and effectively in the local primary care setting? What are the crucial preoperative concerns?

Evaluation of Immunohistochemical Findings and Clinical Features Associated with Local Aggressiveness in Basal Cell Carcinoma

Background & Objective:

Basal cell carcinoma (BCC) is classified into BCC1 or low risk (nodular, superficial type) and BCC2 or high risk (micronodular, morpheaform, infiltrative, and basosquamous types) based on clinical behavior. This study attempts to evaluate immunohistochemical (IHC) findings and clinical features associated with local aggressiveness and recurrence in BCC lesions.

Methods:

This is a cross-sectional descriptive study conducted on 42 paraffin blocks (22 BCC1, 20 in BCC2) at Pathology Department of Afzalipour Teaching Hospital. First, demographic features of the patients were recorded and pathology blocks were classified by two dermatopathologists based on histopathological types of BCC1 and BCC2. Then, primary monoclonal antibodies including CD10, CD1a, SMA, Ki67, CD34, and P53 were utilized for IHC study. We compared BCC1 and BCC2 according to IHC markers, demographic features of patients, and tumoral features.

Results:

The mean number of Langerhans cells (LCs) within epidermis above tumor mass was 14+1.92 and 4.7±1.23 in BCC1 and BCC2, respectively; these results show a significant difference between the two groups (P=0.001). P53 was positive in 41.13±6.39% and 74.5 ±6.26% of the tumor cells in BCC1 and BCC2 groups, which was statistically significant (P=0.001). Also, the mean number of blood vessels was 14.40±1.30 and 21.40±1.97 in BCC1 and BCC2, that was statistically significant (P=0.005).

Conclusion:

Higher numbers of angiogenesis (SMA positive) and positive P53 were observed in BCC2 than BCC1. Also, more active positive CD1a cells were observed in BCC1 compared to BCC2.

[Cytopenia under topical imiquimod in two patients treated with oral hydroxyurea]

BACKGROUND

Aldara^® is a topical immunomodulatory treatment. The risks of systemic passage are minimal. There have been rare reports of systemic adverse effects.

PATIENTS AND METHODS

Case 1. Five sachets weekly of imiquimod were prescribed for Bowen's disease on the forearm in a patient known to have essential thrombocytosis under Hydrea^®. His CBC was normal (6000 leukocytes/mm³, 2200 PMN/mm, 230,000 platelets/mm³). Imiquimod was given in 15 sachets weekly. Fifteen day later, the patient presented bicytopenia (3000 leukocytes/mm³, 1400 PMN/mm³, 119,000 platelets/mm³). Hydroxyurea and imiquimod were suspended until normalization of CBC. Hydroxyurea was resumed without recurrence of the bicytopenia. The patient's history included an identical episode following application of imiquimod. Case 2. Five sachets weekly of imiquimod were prescribed for actinic keratosis on the scalp in a patient known to have primary polycythemia under hydroxyurea. Her CBC was normal except for anemia (Hb 11.5g/L, 160,000 platelets/mm³, 1100 lymphocytes/mm³). Imiquimod was given in 12 sachets weekly. Ten days later, anemia increased (Hb 10g/dL) with lymphopenia (800/mm³) and thrombocytopenia (115,000/mm³). Suspension of imiquimod resulted in normalization of the previous CBC values.

DISCUSSION

. The literature review identified reports of dose-dependent lymphopenia under oral imiquimod but not under Aldara^®. The National Pharmacovigilance Database listed 10 cases of hematological disorders most likely caused by Aldara^®. Hydroxyurea may induce cytopenia, and while it was not considered the sole causative agent in this case, it is likely to have had a triggering role in these patients with blood dyscrasias. Our findings show that misuse of imiquimod carries a potential risk of hematologic abnormality in patients receiving concomitant hydroxyurea, a commonly combined drug.

Nodular Cystic Basal Cell Carcinoma of the Trunk: a Diagnostic Dilemma in an Unsuspecting Youth

Basal cell carcinoma (BCC) commonly affects the elderly and is mostly confined to the head and neck region. Only 10% of all cases occur on the trunk. We presented a case of bullous lesion on the abdomen in a young male, initially diagnosed by clinicians as a vascular nevus. Histopathological examination and immunohistochemistry (IHC) revealed it to be Nodular cystic variant of BCC. This rare variant of BCC morphologically resembles benign skin adnexal tumor of Eccrine syringofibroadenoma. Ber Ep4 positivity on IHC established the correct diagnosis. This case highlights that nodular cystic variant of BCC can be a diagnostic dilemma for clinicians and pathologists.

Myths in the Diagnosis and Management of Orbital Tumors

Orbital tumors constitute a group of diverse lesions with a low incidence in the population. Tumors affecting the eye and ocular adnexa may also secondarily invade the orbit. Lack of accumulation of a sufficient number of cases with a specific diagnosis at various orbital centers, the paucity of prospective randomized studies, animal model studies, tissue bank, and genetic studies led to the development of various myths regarding the diagnosis and treatment of orbital lesions in the past. These myths continue to influence the diagnosis and treatment of orbital lesions by orbital specialists. This manuscript discusses some of the more common myths through case summaries and a review of the literature. Detailed genotypic analysis and genetic classification will provide further insight into the pathogenesis of many orbital diseases in the future. This will enable targeted treatments even for diseases with the same histopathologic diagnosis. Phenotypic variability within the same disease will be addressed using targeted treatments.

Giant basal cell carcinoma of the face: surgical management and challenges for reconstruction

BACKGROUND

Giant basal cell carcinoma, in which the tumour measures 5 cm or greater in diameter, is a very rare skin malignancy that accounts for less than 1 per cent of all basal cell tumours. Very few studies have reported on the incidence, resection and reconstruction of this lesion worldwide.

METHODS

In total, 17 patients with giant basal cell carcinoma of the head and neck region underwent surgical excision and reconstruction at our hospital. Medical charts were retrospectively reviewed and analysed.

RESULTS

The lesion was usually in the forehead, eyelid, lips or nasal-cheek region. The greatest diameter ranged from 5 to 11 cm, with 5-6 cm being the most common size at the time of presentation. All patients had their tumour resected and reconstructed in a single-stage procedure, mostly with a local advancement flap, and with no post-operative flap failure.

CONCLUSION

Giant basal cell carcinoma of the head and neck can be successfully treated with a local flap in a single-stage approach.

Review of Ocular Manifestations of Nevoid Basal Cell Carcinoma Syndrome: What an Ophthalmologist Needs to Know

Nevoid basal cell carcinoma syndrome (NBCCS) is a rare, autosomal dominant disorder characterized by multiple basal cell carcinomas (BCCs), odontogenic keratocysts, palmar and/or plantar pits, and ectopic calcifications of the falx cerebri. Myriad ophthalmologic findings are associated with NBCCS, including periocular BCCs, hypertelorism, strabismus, myelinated nerve fibers, and disorders of the retina and retinal pigment epithelium. We performed a literature search in PubMed for articles on the ophthalmologic manifestations of Gorlin syndrome, published between 1984 and 2014. Of 33 papers, 31 were included. Although Gorlin syndrome is due to mutations in a single gene, it displays variable phenotypic expressivity. Therefore, familiarity with this disorder across clinical specialties is necessary to avoid misdiagnosis. The ophthalmologist should be included in the multidisciplinary team for the management of Gorlin syndrome in order to prevent visual loss and improve the quality of life of these patients.

Eyelid Tumors at the University Eye Clinic of Ioannina, Greece: A 30-year Retrospective Study

Aims:

The aim was to describe the epidemiology of primary eyelid tumors over a 30-year period at the Ioannina University Eye Clinic, Greece.

Materials and Methods:

This retrospective case series examined the histopathology of eyelid tumor specimens of patients treated between 1983 and 2012. Data were collected on patient age, gender, location of the lesion, extent of tumor excision and recurrence. Descriptive and inferential statistics were used to describe the study subgroups.

Results:

A total of 851 eyelid tumors comprised the study sample. There were 351 (41.2%) malignant cases and 500 (58.8%) benign cases. For malignant tumors, there were 86% basal cell carcinomas, 7% squamous cell carcinomas, and 7% basosquamous cell carcinomas. The benign eyelid lesions were comprised of 20% cysts, 18% seborrheic keratosis, 13% nevi, and 13% papillomas. Benign eyelid lesions occurred with equal frequency in the upper and lower lids. Malignant lesions were more frequently located in the lower lid. The mean age at diagnosis was 49 ± 1.45 years for patients with benign lesions and 67 ± 1.6 years for patients with malignant lesions.

Conclusions:

In this Greek cohort, benign eyelid lesions affected mostly young individuals, and malignant lesions occurred predominantly in elderly patients. Males and females were equally affected by malignant lesions, and recurrence after surgical excision was rare.

Topical calcitriol prior to photodynamic therapy enhances treatment efficacy in non-melanoma skin cancer mouse models

Non-melanoma skin cancers (NMSCs) such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common form of human cancer worldwide, and their incidence is increasing. Photodynamic therapy (PDT), mediated by topically applied aminolevulinic acid (ALA) and subsequent exposure to light (either a laser or a noncoherent source), is being increasingly used for the treatment of dermatological disorders, including BCC and SCC. However, therapeutic responses of NMSCs to ALA-PDT are currently not superior to standard therapies, although the latter have undesirable side effects including scarring. In this study, we report that preconditioning of skin tumors with calcitriol (active form of Vitamin D; Vit D) prior to ALA-PDT, significantly improves the treatment outcome. In BCC and UVB-induced SCC mouse models, we identified an increase in tumor-specific accumulation of ALA induced photosensitizer (protoporphyrin IX, PpIX) due to Vit D preconditioning, of up to 6-fold in vivo. In addition, increased expression of differentiation (145 fold, p < 0.02) and proliferation (42 fold, p < 0.005) markers were identified in BCC tumors, all leading to increased tumor destruction (18.3 fold, p < 0.03) with the combination approach, as compared to ALA-PDT alone. Histomorphological changes identified using hematoxylin and eosin staining, and results of TUNEL staining, together documented a beneficial effect of Vit D pretreatment upon tumor cell death. We conclude that this new combination approach with Vit D and ALA-PDT has great potential to achieve complete remission of NMSC tumors, with excellent cosmetic results and an overall beneficial impact upon patient care.

The Effects of Cyclin D1 and Bcl-2 Expressıon on Aggressive Behavior in Basal Cell and Basosquamous Carcinoma

BACKGROUND AND OBJECTIVE

Clinical behavior of basal cell carcinoma (BCC) is known to be different according to histological growth pattern and basosquamous cell carcinomas (BSC) are known with their aggressive behavior and metastatic capacity. In this study, we evaluated bcl-2 and cyclin D1 expressions in BCC and BSC cases comparatively, to explore their predictive value on the aggressive behavior of these tumors.

METHODS

One hundred tumors belong to 92 patients diagnosed as basal cell carcinoma and basosquamous carcinoma were studied. Basal cell carcinomas were classified as aggressive and non-aggressive types according to growth pattern. Number of Cyclin D1 and bcl-2 positive cells in immunohistochemically stained serial sections were scored as low (0-1 +) and high (2 and 3+) in all tumors.

RESULTS

A statistically significant difference was found between non-aggressive (nodular type) and aggressive types (micronodular, infiltrative types and BSC) for these markers ( P <0.005). Cyclin D1 was higher in the aggressive group, while bcl-2 was lower in the aggressive group compared to the non-aggressive group.

CONCLUSION

Higher Cyclin D1 and lower bcl-2 scores was correlated with aggressive tumor types and these results could be used as markers to predict aggressive behavior in BCC and BSCs.

Basal cell nevus syndrome or Gorlin syndrome

Basal cell nevus syndrome (BCNS) or Gorlin syndrome is a rare neurocutaneous syndrome sometimes known as the fifth phacomatosis, inherited in autosomal dominant fashion with complete penetrance and variable expressivity. Gorlin syndrome is characterized by development of multiple basal cell carcinomas (BCCs), jaw cysts, palmar or plantar pits, calcification of falx cerebri, various developmental skeletal abnormalities such as bifid rib, hemi- or bifid vertebra and predisposition to the development of various tumors. BCNS is caused by a mutation in the PTCH1 gene localized to 9q22.3. Its estimated prevalence varies between 1/55600 and 1/256000 with an equal male to female ratio. The medulloblastoma variant seen in Gorlin syndrome patients is of the desmoplastic type, characteristically presenting during the first 3 years of life. Therefore, children with desmoplastic medulloblastoma should be carefully screened for other features of BCNS. Radiation therapy for desmoplastic medulloblastoma should be avoided in BCNS patients as it may induce development of invasive BCCs and other tumors in the skin area exposed to radiation. This syndrome is a multisystem disorder so involvement of multiple specialists with a multimodal approach to detect and treat various manifestations at early stages will reduce the long-term sequelae and severity of the condition. Life expectancy is not significantly altered but morbidity from complications and cosmetic scarring can be substantial.

Syringocystadenoma papilliferum of the upper lip

Syringocystadenoma papilliferum (SCAP) is a rare skin tumour believed to arise from the apocrine or eccrine sweat glands. It appears predominantly in childhood, usually at birth. It is exceedingly rare for it to appear on the upper lip. We report a case of SCAP in a 10-year-old Omani girl who presented to the Sultan Qaboos University Hospital in Muscat, Oman, in February 2012 with a non-tender, non-pruritic, solitary verrucous papule of 4 × 5 mm on the left side of the upper lip. It had been present since birth and had slowly been increasing in size over the years. It was occasionally associated with recurrent ulceration and bleeding and had previously been misdiagnosed and mismanaged. An excisional biopsy was performed and the whole lesion was removed. The surgical site was then sutured and the patient was discharged on the same day.

Eyelid masses: a 10-year survey from a tertiary eye hospital in Tehran

Purpose:

The purpose of this study was to evaluate the demographics and clinical features of eyelid masses in a tertiary eye hospital over a 10-year period.

Materials and Methods:

A retrospective chart review was performed for patients admitted with eyelid tumors from 2000 to 2010. Data were collected and analyzed on the demographic features, location of the tumor, types of treatment, and pathologic findings.

Results:

A total number of 182 patients were evaluated of which, 82 cases were benign and 100 cases were malignant neoplasms. The most common benign tumors included melanocytic nevi (35%), papilloma (19.5%), and cysts (11%). The most frequent malignant tumors included basal cell carcinoma (BCC) (83%), squamous cell carcinoma (8%) and sebaceous gland carcinoma (6%). The most common site for malignancy was the lower lid followed by the upper lid. BCC recurred in 16 cases that were most frequent in the lower lid.

Conclusion:

Melanocytic nevus, papilloma and cysts are the most common benign lesions and BCC is the most common malignant lesion in the eyelids. Recurrence is a feature of BCC especially in the lower lid.

A young military pilot presents with a periocular Basal Cell Carcinoma: a case report

INTRODUCTION

Basal Cell Carcinoma (BCC) is the most common form of skin malignancy in the UK with 75, 000 new cases per year. It commonly presents as a non-healing lesion in the H zone of the face. The significant risk factors for this condition include UV radiation exposure and a history of sunburn. The gold standard treatment for BCC is Mohs Micrographic Surgery as well a variety of traditional surgical and non-surgical options.

CASE PRESENTATION

A 32 year old white male military helicopter pilot presented with a pea sized lesion which appeared highly vascularised with multiple telangiectasia on the surface. The main risk factors were regular foreign travel to regions of high UV radiation and previous episodes of sunburn.

CONCLUSION

BCC is the commonest form of eye lid malignancy and any form of non-healing lesion on the periocular area should be investigated as a possible neoplasm. The main risk factors are travel to areas of high UV radiation and exposure to UV radiation as a child. There is also a possible risk factor of occupational exposure to ionising radiation from cosmic sources although there is limited research to support this. This is an interesting case of an unusual first presentation of a BCC in a male under 40 years of age and demonstrates the important risk factors in a military population for developing a non-melanoma skin cancer.

Automatic annotation of histopathological images using a latent topic model based on non-negative matrix factorization

Histopathological images are an important resource for clinical diagnosis and biomedical research. From an image understanding point of view, the automatic annotation of these images is a challenging problem. This paper presents a new method for automatic histopathological image annotation based on three complementary strategies, first, a part-based image representation, called the bag of features, which takes advantage of the natural redundancy of histopathological images for capturing the fundamental patterns of biological structures, second, a latent topic model, based on non-negative matrix factorization, which captures the high-level visual patterns hidden in the image, and, third, a probabilistic annotation model that links visual appearance of morphological and architectural features associated to 10 histopathological image annotations. The method was evaluated using 1,604 annotated images of skin tissues, which included normal and pathological architectural and morphological features, obtaining a recall of 74% and a precision of 50%, which improved a baseline annotation method based on support vector machines in a 64% and 24%, respectively.

Basal cell carcinoma superimposed on a cutaneous leishmaniasis lesion in an immunocompromised patient

Leishmaniasis is a protozoan infection due to organisms of the genus Leishmania. The differential diagnosis of cutaneous leishmaniasis includes arthropod bites, basal cell carcinoma (BCC) and other malignancies. BCC is the most common form of skin cancer. We present a case of cutaneous leishmaniasis resistant to standard intralesional glucantime injection in an immunocompromised patient, which was proved to be BCC after surgical excision.

CD10 expression helps to differentiate basal cell carcinoma from trichoepithelioma

BACKGROUND

The distinction between basal cell carcinoma (BCC) and trichoepithelioma (TE) may be very difficult in some cases because of the close similarities of these two lesions clinically and histopathologically. The purpose of this study is to investigate the usefulness of CD10 in distinguishing BCC and TE.

METHODS

The immunohistochemical expression of CD10 was evaluated in an archived group of 30 BCCs and 12 TEs in a retrospective cross sectional study. The localization of anti-CD10 to the tumoral and/or stromal cells was determined in each case and was compared between these two tumors using Fisher's Exact Test.

RESULTS

In BCC cases, the expression of CD10 was noted in tumoral cells in 26 cases (83.2%). Of these, 3 cases showed positivity of the stromal and basaloid cells, two cases demonstrated stromal expression alone and two BCCs were not immunoreactive. On the other hand, 10 out of 12 (83.3%) TEs showed positive stromal immunoreactivity. Of these, one case also showed positivity of the basaloid cells. One TE demonstrated epithelial expression alone and one TE was not immunoreactive. The pattern of staining of basaloid cells and stromal cells in BCC and trichoepithelioma was statistically different (p < 0.001).

CONCLUSIONS

We conclude that CD10 is a useful marker in the differential diagnosis of BCC versus TE.