Periocular Squamous Cell Carcinoma

BACKGROUND We present a case report of periocular squamous cell carcinoma and a review of the literature with emphasis on early diagnosis, proper follow-up and management, reconstructive options, and new immunomodulatory therapies.
OBJECTIVE The objective is to guide the dermatologist and the dermatologic surgeon in proper management and continued care of patients with periocular squamous cell carcinoma in light of its propensity for perineural involvement and regional lymphatic metastases.
MATERIALS AND METHODS A MEDLINE, Ovid, and PubMed search was conducted for recent relevant articles pertaining to "periocular,""periorbital,""squamous cell" carcinoma, and their "surgery""treatment" modalities.
CONCLUSIONS Periocular squamous cell carcinoma is an aggressive tumor, characterized by perineural involvement and an overall rate of regional lymph node metastases reported to range from 10% to as high as 20% to 25%. Increased vigilance must be undertaken when treating these high-risk tumors. Mohs micrographic surgery or excision with frozen section analysis is the standard of care for periocular squamous cell carcinoma. Multiple options exist for the reconstruction of the postoperative defect that allow for excellent function and cosmesis. Finally, research into new immunomodulators will hopefully lead to an increased understanding of the aggressive nature of periocular squamous cell carcinoma and potential aid in the treatment of the tumor.     

Periungual Basal Cell Carcinoma: Case Report and Literature Review

BACKGROUND Basal cell carcinoma, the most common malignancy in humans, rarely occurs on the nail unit and may be frequently misdiagnosed clinically.
OBJECTIVES To present a case of basal cell carcinoma of the nail unit successfully treated with the mohs technique and to review the literature regarding this unique presentation of this tumor.
MATERIALS AND METHODS: Case report and review of the English literature of nail unit basal cell carcinoma.
RESULTS In addition to the currently described patient, 17 other patients with nail unit basal cell carcinaoma have been reported. The tumor occurred approximately 3 times more often on the fingers then on the toes and had a slight predilection to occur in men. Ulceration, noted in more than one-half of patients, was the most common presentation of nail unit basal cell carcinoma. Mohs micrographic surgery. Often with second intention healing, was successfully employed in 39% of patients.
CONCLUSIONS Basal cell carcinaom infrequently involves the nail unit and often presents as ulceration. Adequate biopsy of the lesion is essential in making a timely diagnosis. Mohs micrographic surgery with second intension healing is an effective treatment that may offer excellent cosmetic and functional results.     

Pigmented Speckling as a Sign of Basal Cell Carcinoma

Background. Basal cell carcinoma may present as a discrete skin-colored papule, which may mimic other common skin tumors.
Objectives. We present pigmented speckling as a clinical sign for basal cell carcinoma.
Methods. Twenty cases of basal cell carcinoma with pigmented speckling were collected and their clinical and histologic features were reviewed.
Results. There were 12 men and 5 women. The patients' average age was 70.5 years (range 33–90 years). Fifteen of the 17 tumors were on the head and neck, and 2 tumors were on the shoulders and back. Clinical examination revealed a "speckled appearance" of brown-black pigmentation within and/or at the border of the tumors. Histopathology showed basal cell carcinoma with melanin pigment (positive for Fontana-Masson stain and negative for Perl's stain) within nests of tumor cells.
Conclusion. The speckled pigmentation of a basal cell carcinoma is a distinguishing feature, which may be useful in the differential diagnosis of this tumor from other discrete skin tumors.     

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.     

Metastatic Basal Cell Carcinoma

BACKGROUND: Basal cell carcinoma is the most common malignancy of humans. Although it is axiomatic that this tumor does not evolve into metastatic disease, such events rarely occur, and this possibility should not be overlooked. OBJECTIVES: The reader should better understand the sequence of events that resulted in metastatic disease and how these events are emblematic of the rare cases of basal cell carcinoma that systemically spread. METHODS: We present a case report of basal cell carcinoma that underwent distant metastasis. A short review of the literature is included. RESULTS: Although basal cell carcinoma is commonly considered a regional tumor with virtually no propensity for distant spread, this case reveals that metastatic disease does occur and with devastating results. CONCLUSION: Metastatic disease in basal cell carcinoma is a very rare but catastrophic consequence of this very common skin malignancy.     

Dietary Supplements: Altered Coagulation and Effects on Bruising

Background. Patient use of dietary supplements that alter coagulation or have an effect on bruising is becoming increasingly common.
Objective. To identify and describe dietary supplements that alter coagulation or are reported to alter bruising during and after surgical procedures.
Methods. The MEDLINE, Cochrane Collaboration, and International Bibliographic Information on Dietary Supplements databases were searched for articles using the search words "bruising,""bleeding,""coagulation,""hemostasis,""herbal medicine,""alternative medicine," and "dietary supplement." Additional sources were obtained from manual searches of recent journal articles.
Results. In vivo and in vitro evidence supports the notion that many dietary supplements alter coagulation. Limited evidence is available to support anecdotal claims of diminished postoperative bruising after the use of dietary supplements.
Conclusion. Surgeons should be aware that many of their patients are taking dietary supplements that may alter coagulation. Because most patients will not readily volunteer this information, specific steps should be taken to obtain it prior to more extensive surgical procedures.
SCOTT M. DINEHART, MD, AND LANCE HENRY, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Aggressive Basal Cell Carcinoma with Invasion of the Parotid Gland, Facial Nerve, and Temporal Bone

Aggressive variants of basal cell carcinoma (BCC), such as infiltrating, morpheaform, and basosquamous types, are associated with invasion of underlying tissues and are often difficult to treat.1 BCCs located in embryonic fusion planes, such as the periauricular region, are thought to exhibit deep extension and, subsequently, high recurrence rates, although this theory has been challenged and remains controversial.2-4 Despite the known features of aggressive BCC, parotid gland invasion and temporal bone and facial nerve involvement are rarely reported occurrences. We describe two patients with morpheaform BCC in the periauricular region demonstrating direct invasion of the parotid gland and concomitant facial nerve involvement. These patients require complex surgical management, as highlighted in this report.     

Basal Cell Carcinoma Metastatic to Parotid Gland

Metastasis from basal cell carcinoma of the skin is very rare with cases being documented in the lymph nodes, lung, bone and parotid gland. The main histopathological differential diagnosis is the locally arising basal cell adenocarcinoma from which it is difficult to distinguish by morphology and routine immunohistochemistry. Approximately 85 % of all reported metastatic basal cell carcinomas arise in the head and neck region. Here we present a case of basal cell carcinoma of the skin of the left lateral canthus of the eye which metastasized to the intraparotid lymph nodes with infiltration of the adjacent parotid parenchyma. More awareness and vigilance is required on the part of the reporting pathologist to consider metastasis in the presence of a parotid tumour. Features favouring metastasis include history of primary cutaneous basal cell carcinoma, histological similarity to the primary lesion and absence of any demonstrable direct extension from the skin lesion. We also review the literature on metastatic basal cell carcinoma and discuss the need for adequate follow up in high risk patients.     

Cutaneous basal cell carcinoma with endobronchial metastasis

Although basal cell carcinoma is a very common malignancy, metastasis from this tumour is extremely rare. For this reason, many plastic surgeons, dermatologists and physicians dealing with skin malignancies consider this as a locally invasive malignancy. We present a rare case of metastatic basal cell carcinoma manifested as a bronchial tumour. This case highlights the fact that despite basal cell carcinoma’s local invasive potential, the possibility of distant metastasis still exists and clinicians should therefore be cautious about interpreting extracutaneous symptoms. Chest physicians should always consider the possibility of this rare tumour in the lungs in patients with a history of large basal cell carcinomas in the head and neck region.     

Metastatic basal cell carcinoma: review of the literature and report of three cases

Basal cell carcinoma is the most common type of malignant cutaneous neoplasm found in man. Rarely, however, is it life-threatening or does it metastasize. A review of the literature revealed 138 cases of metastatic basal cell carcinoma. We describe 3 additional patients with metastatic basal cell carcinoma who were treated at the Mayo Clinic during the past ten years. Patients with metatypical carcinoma (basosquamous) were excluded. All metastatic lesions were to regional lymph nodes, and two patients died of their disease. It is important to recognize this rare but lethal condition.     

Treatment of Basal Cell Carcinoma with the Pulsed Carbon Dioxide Laser: A Retrospective Analysis

Background and Objective. Treatment options for basal cell carcinoma include surgical excision, cryotherapy, radiation, photodynamic therapy, Moh's micrographic surgery, and topical treatment with 5-fluorouracil and immunomodulators such as imiquimod. Resurfacing and ablation with a CO₂ laser (UltraPulse, Coherent Inc.) may present an attractive and effective treatment option in the management of these cutaneous cancers. We demonstrate the efficacy and safety of the UltraPulse CO₂ in the treatment of basal cell carcinomas of the skin.
Methods. We performed a retrospective chart review of 23 patients treated with the UltraPulse CO₂ laser. A total of 61 biopsy-proven superficial and nodular basal cell carcinomas without prior treatment were included in the study. The patients were followed postoperatively for a period of 15 to 85 months (mean 41.7 months) and assessed for clinical recurrence.
Results. Of the 61 tumors treated, clinical recurrence was observed in two cases (3.2%). Adverse effects included significant hypertrophic scarring in one patient and hypopigmentation in one patient.
Conclusions. Destruction of superficial and nodular basal cell carcinomas may be accomplished successfully and safely with the UltraPulse CO₂ laser with a cure rate of 97%.     

Basal Cell Carcinoma Arising in a Port-Wine Stain

BACKGROUND: The occurrence of basal cell carcinoma within a port-wine stain or nevus flammeus is rare. Sixteen cases of basal cell carcinoma which developed in a port-wine stain or nevus flammeus have been reported. OBJECTIVE: The objective was to demonstrate a rare case of basal cell carcinoma occurring in a port-wine stain successfully treated with Mohs micrographic surgery. METHODS: This is a case report and literature review. RESULTS: An 87-year-old man presented with a basal cell carcinoma on the margin of a previously untreated port-wine stain on the left cheek. Histologic examination showed a nodular basal cell carcinoma. The basal cell carcinoma was completely excised with Mohs micrographic surgery and complex linear closure was used to repair the wound in layers. The postoperative course was complicated by a hematoma, which developed 24 hr postoperatively. The hematoma was drained and there was no further bleeding or evidence of recurrence of the tumor after 12 months. CONCLUSION: Basal cell carcinoma should be included in the differential diagnosis of a skin lesion occurring in a port-wine stain.     

Carcinoma of scrotum

Twelve patients with carcinoma of the scrotum were evaluated: 9 with squamous carcinoma and 3 with basal cell carcinoma. The presenting complaint was a visible skin lesion; the interval between awareness of this lesion and diagnosis averaged 3.3 years. Three of the 12 patients were black, although this disease previously has been considered rare in blacks. No occupation predominated among the patients in this series, and scrotal carcinoma today may occur as a result of nonspecific factors such as poor hygiene and chronic irritation, rather than industrial exposure. Only 5 of 12 patients were disease free after treatment; 5 of the others died of squamous carcinoma, 1 died of a postoperative complication, and 1 was lost to follow-up. The most significant correlative with survival was stage at initial diagnosis, indicating the need for a high index of suspicion regarding lesions of the scrotum.     

A Correlation of Alpha-Smooth Muscle Actin and Invasion in Micronodular Basal Cell Carcinoma

BACKGROUND: Actin is largely responsible for cell motility and is only sparsely found in normal epithelial cells. An altered expression of actin in some malignancies may facilitate aggressive invasion. Micronodular basal cell carcinoma (BCC) has been shown to require more surgical stages, wider tissue margins, and deeper defects for extirpation during Mohs micrographic surgery relative to nodular BCC. OBJECTIVE: To provide preliminary data regarding a possible correlation between alpha-smooth muscle actin (alpha-SMA) expression within the cells or stroma of micronodular BCC and aggressive invasion. In addition, the incidence of alpha-SMA expression in micronodular, morpheaform, and nodular BCC is evaluated. METHODS: Nine micronodular basal cell carcinomas (7 primary, 2 recurrent) were evaluated for neural invasion, depth of tissue invasion, and alpha smooth muscle actin antibodies. The presence of alpha-smooth muscle actin antibodies was assessed using immunoperoxidase staining and compared with 13 morpheaform (13 primary, 0 recurrent) and 12 nodular (12 primary, 0 recurrent). RESULTS: Six of the nine micronodular (67%), eight of the 13 morpheaform (62%), and 0 of the 12 nodular (0%) BCCs stained positive for alpha-SMA. Of the six micronodular BCCs that stained positive for alpha-SMA, three invaded the fascia or muscle and three displayed neural invasion. In contrast, of the three micronodular BCCs that stained negative for alpha-SMA, none invaded the fascia or muscle and only one exhibited neural invasion. CONCLUSION: Actin was present in 66% of micronodular, 62% of morpheaform, and 0% of nodular BCC. The presence of actin in micronodular BCC may be a marker for aggressive invasion.     

Late Inguinal Metastasis of a Well-Differentiated Subungual Squamous Cell Carcinoma after Radical Toe Amputation

Background Although squamous cell carcinoma (SCC) is commonly found on sun-exposed skin, this malignancy in nail beds is rare. There is a very low rate of metastases, especially for well-differentiated lesions without bony involvement.
Objective To present a case of late inguinal metastasis after radical toe amputation 3 years previously for subungual SCC.
Materials and Methods Case report.
Results The patient received modified inguinal lymphadenectomy and adjuvant radiation therapy. No recurrence or metastases were observed for 12 months.
Conclusion For patients with subungual SCC postsurgery, it is important to regularly evaluate for a minimum of 3 years, despite the very low rate of metastases.     

Malignant transformation in congenital sebaceous naevi in childhood.

Sebaceous naevi are uncommon congenital skin lesions with a well-recognised potential for neoplastic change. They should be considered premalignant lesions as malignant degeneration, most commonly basal cell carcinoma and squamous cell carcinoma, occurs with a lifetime risk of between 5% and 22%. This incidence is equal to that of actinic keratosis and exceeds that of oral leukoplakia. Such change, however, is rare before puberty. Basal cell carcinoma may develop in children with naevoid basal cell carcinoma syndrome, xeroderma pigmentosum and rarely de novo but sebaceous naevus is the only solitary lesion in childhood associated with the development of basal cell carcinoma. We present two cases of malignant transformation in a congenital sebaceous naevus occurring in childhood and review the literature and discuss the evidence upon which to base management guidelines.     

5% Imiquimod Cream and Reflectance-Mode Confocal Microscopy as Adjunct Modalities to Mohs Micrographic Surgery for Treatment of Basal Cell Carcinoma

Background. Imiquimod is an immune response modifier that up-regulates cytokines and has been shown in clinical studies to reduce or clear basal cell carcinoma tumors when applied topically.
Objective. The objectives were to evaluate the efficacy of 5% imiquimod cream in treating basal cell carcinoma preceding excision by Mohs micrographic surgery and to determine if reflectance-mode confocal microscopy is useful to establish the need for surgical intervention after imiquimod treatment.
Methods. Subjects applied study cream to one biopsy-confirmed basal cell carcinoma tumor 5 ×/week for 2, 4, or 6 weeks in this vehicle-controlled, double-blind study. Confocal microscopy was used for the 6-week treatment group to examine the target tumor area at each interval visit and immediately before Mohs micrographic surgery. After the Mohs micrographic surgery excision, the tissue was evaluated histologically, and the excision area was measured. Confocal microscopy readings were correlated to the histologic diagnosis.
Results. Tumors cleared or the target tumor area was reduced in subjects in the 4- and 6-week dosing regimens. Confocal microscopy assessments correlated well with the histologic diagnosis.
conclusion. Imiquimod improved excision results relative to vehicle when used for treating basal cell carcinoma before Mohs micrographic surgery. Confocal microscopy assessments correlated well with tumor response to therapy, suggesting that confocal microscopy may help determine the need for surgery.     

Desmoplastic infantile and non-infantile ganglioglioma. Review of the literature

Desmoplastic gangliogliomas (DIG) are rare primary neoplasms that comprise 0.5–1.0% of all intracranial tumors. Clinically, there are two forms of DIG, the infantile and the non-infantile. These tumors invariably arise in the supratentorial region and commonly involve more than one lobe, preferentially the temporal and frontal. On neuroimaging are seen as large hypodense cystic masses with a solid isodense or slightly hyperdense superficial portion. The histologic diagnosis is characterized by the presence of three different cell lines: astrocytic, neuronal, and primitive neuroectodermal marker sites, which were demonstrable. The treatment of choice is radical surgical excision, and if this is done, achieved complete healing of the patient does not require additional treatment. A literature review of DIG was compiled through Medline/Ovid using the keywords “desmoplastic infantile ganglioglioma”, “desmoplastic non-infantile ganglioglioma” covering the years 1984–2009. We present a review of a total of 113 cases of infantile (94) and non-infantile gangliogliomas (19) published to date, examining the clinical, radiologic, surgical, and pathological aspects, as well as the outcome. Desmoplastic gangliogliomas represent a rare tumor group with two well-defined age groups, the children and non-children. Desmoplastic infantile gangliogliomas are the most common and occur in children below 5 years of age, and the large majority of them present within the first year of life. Surgery is the treatment of choice and no complementary treatment is needed in cases of complete tumor resection.     

Clinical management of emerging sinonasal malignancies

Several emerging sinonasal malignancies have recently been described in the pathology literature. Although not all distinctly classified by the World Health Organization, these rare tumors present a management challenge to surgeons and oncologists. While prior studies have summarized histologic details, a clinically focused review is currently lacking in the literature. This review describes the presentation, histopathology, imaging, treatment, and prognosis of newly described or recently evolving sinonasal malignancies while highlighting the distinguishing features of these entities. It includes teratocarcinosarcoma, human papillomavirus‐related multiphenotypic carcinoma, biphenotypic sinonasal sarcoma, sinonasal renal cell‐like adenocarcinoma, NUT‐midline carcinoma, squamous cell carcinoma associated with inverted papilloma, sinonasal undifferentiated carcinoma, and INI‐1‐deficient sinonasal carcinoma. By describing the diagnosis, treatment, and prognosis of these recently defined entities, this clinical review aims to help guide oncologists in the clinical management of these patients.     

A review of liver masses in pregnancy and a proposed algorithm for their diagnosis and management

BACKGROUND: Liver masses in pregnancy are rare; some behave aggressively while others remain indolent. The paucity of case series has hindered the development of a defined approach to their diagnosis and management. This paper presents an algorithm for the diagnosis and management of hepatic hemangiomas, focal nodular hyperplasia, liver cell adenomas and hepatocellular carcinoma associated with pregnancy based on our own experience and literature review. DATA SOURCES: A Medline search from 1966 to present was performed. Seven additional illustrative cases from our institution are included. Twenty pregnancies with hepatic hemangiomas, 37 with focal nodular hyperplasias, 26 with liver cell adenomas and 33 with hepatocellular carcinomas were identified. CONCLUSIONS: Gestational hepatic hemangiomas and focal nodular hyperplasia behave indolently and can be observed. Liver cell adenomas often require surgery, but small, asymptomatic lesions may be carefully observed. Meticulous observation postpartum is mandatory. As pregnancy impacts survival in hepatocellular carcinoma, resection maybe indicated.