Cutaneous lip tumours treated with Mohs micrographic surgery: clinical features and surgical outcome

BACKGROUND: The Australian Mohs micrographic surgery (MMS) database was initiated in 1993 by the Skin and Cancer Foundation Australia (SCFA) with the aim of collecting prospective data, and involved all Mohs surgeons in the country. OBJECTIVES: To present a large series of patients with cutaneous lip tumours treated with MMS in Australia between 1993 and 2002. METHODS: This prospective multicentre case series included all patients with cutaneous lip tumours who were monitored by the SCFA. The main outcome measures were patient demographics, reason for referral, duration of tumour, site, preoperative tumour size and postoperative defect size, recurrences prior to MMS, histological subtypes, perineural invasion and 5-year recurrence after MMS. RESULTS: There were 581 patients (66.1% women and 33.9% men, P < 0.0001) with a mean +/- SD age of 58 +/- 15 years. The upper lip was the most common site involved (81.1%). Basal cell carcinoma (BCC) was diagnosed in 82.3%, squamous cell carcinoma (SCC) in 16.5%, Bowen's disease (BD) in 0.7% and microcystic adnexal carcinoma (MAC) in 0.5% of cases. BCC was more common on the upper lip and in women, whereas SCC was more common on the lower lip and in men (P < 0.0001). Most upper lip tumours occurred in women (75.4%), whereas most lower lip tumours occurred in men (73.6%). SCC was associated with a larger tumour and postoperative defect size compared with the other tumours. The 5-year recurrence for BCC was 3.0%, and there were no cases of recurrence for SCC, BD or MAC. CONCLUSIONS: BCC was the most common cutaneous lip tumour managed by MMS, and was significantly more common on the upper lip and in women. The low 5-year recurrence rate emphasizes the importance of margin-controlled excision.     

Cutaneous epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma is a rare vascular tumor of intermediate aggressiveness, which usually appears in adults. It generally affects soft tissues and, less frequently, the lungs and liver. Diagnosis is by histological evaluation, and the epithelioid appearance of the neoplastic endothelial cells is typical, as is the tendency to form vascular channels. Treatment is surgical excision, with broad margins. This tumor may in exceptional cases affect the skin, with few cases having been described in literature. We describe the case of a male patient with plantar epithelioid hemangioendothelioma, and we review the literature.     

Cutaneous epithelioid hemangioendothelioma

INTRODUCTION: Epithelioid hemangioendothelioma is a tumor of soft tissues arising from the vascular endothelium. It is considered as a low-grade malignant tumor. Cutaneous involvement is rare and often associated with multi-systemic localizations. CASE REPORT: We report the case of a 34 year-old woman with a 6-month history of a 1.5 cm erythematous-violaceous, soft, painful cutaneous nodule involving the right forearm. An abdominal sonography had been performed 1 month before the onset of the nodule, because of epigastric pain and was normal. Histological and immunohistological examinations led to diagnosis of an epithelioid hemangioendothelioma. Assessment of the extension with radiology, sonography, tomodensitometry and magnetic resonance imaging, revealed nodules of the liver. Treatment consisted in the wide and complete excision of the tumor. There was no evidence of local recurrence after one year follow-up, and the hepatic lesions were stable. DISCUSSION: Epithelioid hemangioendotheliomas belong to the epithelioid vascular tumor spectrum. They have in common the morphologic epithelioid aspect of endothelial tumor cells. Cutaneous localization is rare, and to the best of our knowledge, only 20 cases of epithelioid hemangioendothelioma with skin involvement have been reported in the literature. Epithelioid hemangioendothelioma can be isolated or associated with internal visceral involvement. The detection of skin lesions should lead to a complete assessment of the extension of the disease to detect any internal localization. Because of low-grade malignancy of the tumor, and the integrity of the liver observed one month before the onset of the disease in our patient, epithelioid hemangioendothelioma appears to be a multicentric disease rather than metastatic hepatic localizations of a primitive skin cancer.     

Cutaneous epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor of endothelial cell origin. We describe an EHE arising on the plantar surface of the foot that was treated as verruca vulgaris for several years before a biopsy showed EHE. We discuss the clinical and histopathologic differential diagnoses for these tumors and review additional cases in which EHE has been mistaken for benign entities clinically.     

Sebaceous carcinoma of the eyelid treated with Mohs micrographic surgery

BACKGROUND: Sebaceous carcinoma is an aggressive neoplasm that commonly arises from the meibomian glands of the eyelids and other sebaceous glands of the ocular adnexa. Historic data indicate a nearly 30% local recurrence rate with standard surgical excision. Excision by means of Mohs micrographic surgery may be more efficacious. However, reports documenting the effectiveness of this technique for the treatment of eyelid sebaceous carcinoma have been limited to a few cases. OBJECTIVE: We report our experience in the treatment of ocular sebaceous carcinoma with the Mohs fresh tissue technique. METHODS: Eighteen patients with a diagnosis of sebaceous carcinoma of the eyelid who underwent resection by means of the Mohs fresh tissue technique during the years 1988-1998 were reviewed. RESULTS: Sixteen of the 18 patients were free of disease after an average follow-up of 37 months (11.1% recurrence rate). One patient who experienced local recurrence also had metastatic disease of the parotid lymph nodes (5.6% metastatic rate). The recurrence and metastasis were noted 9 months after excision. The other patient experienced a local recurrence 19 months postoperatively. Both patients exhibited pagetoid spread and involvement of both the upper and lower eyelid at the time of Mohs excision. CONCLUSION: Mohs surgery offers excellent results when used as the primary treatment modality for sebaceous carcinoma of the eyelid. When compared with historic series of standard surgical excision, Mohs micrographic surgery has a significantly lower recurrence rate and metastatic rate.     

Mohs micrographic surgery technique

This article provides a protocol for the systematic approach to the technique of Mohs micrographic surgery. Each step, from tumor excision and tissue mapping, to specimen processing and histologic interpretation, through wound closure and postoperative management, is covered. The advantages of Mohs surgery over other treatment modalities are observed histologic margin control, superior cure rates, and maximal tissue-sparing potential. The increased preservation of normal tissue leads to smaller surgical defects, optimal reconstructive results, and diminished risk of poor surgical outcomes. Overall, the risks of the procedure are few, the benefits numerous, and the outcomes worth the time and effort spent in learning the technique.     

Mohs micrographic surgery pearls

Mohs micrographic surgery has evolved over the last 60 years from fixed-tissue chemosurgery with secondary intention healing to fresh-tissue surgical excision utilizing advanced histotechnology and reconstructive techniques. This evolution has occurred while preserving the fundamental characteristics of Mohs surgery: microscopically controlled tumor excision by one surgeon acting as pathologists to ensure complete tumor extirpation while maximally conserving tissue. Refinements, modifications, and clinical pearls will be outlined that uphold these tenets and enhance the quality of patient care.     

Mucoepidermoid carcinoma (adenosquamous carcinoma) treated with Mohs micrographic surgery

BACKGROUND: Mucoepidermoid carcinoma (MEC), sometimes referred to as adenosquamous carcinoma (ASC), is a common malignant tumor of the salivary glands that can also develop from the esophagus, lacrimal passages, lung, upper respiratory tract, pancreas, prostate and thyroid. Rarely, MEC will present primarily in the skin. CASE: We present a case of primary MEC of the lower eyelid treated successfully with Mohs micrographic surgery. RESULTS: Mohs micrographic surgery was performed because of the highly aggressive and unpredictable nature of this tumor. The tumor was completely excised using Mohs with negative margins achieved in three stages. The patient has been disease free for 3 years since the surgery. CONCLUSION: We offer Mohs as an option for treating MEC.     

Syringomatous carcinoma in a young patient treated with Mohs micrographic surgery

Syringomatous carcinoma (SC) has typically been observed in middle-aged and older patients. We report a case of SC mimicking an epidermoid cyst in a 23-year-old Asian man. Histopathologic examination results showed a dermal neoplasm consisting of nests of basaloid cells, focal areas of ductal differentiation, moderate dermal fibrosis, and moderate nuclear atypia consistent with a diagnosis of SC. No perineural involvement was noted. Results of 2005. immunohistochemical analysis revealed positivity for high- and low-molecular-weight cytokeratins, as well as for carcinoembryonic antigen (CEA). There was scattered immunoreactivity to S-100 protein. The tumor was completely excised Pennsylvania. using Mohs micrographic surgery (MS). This case demonstrates the importance of differentiating SC from other benign or malignant entities, the value of a prompt diagnosis of SC, and the effective treatment of SC with MMS.     

Outcomes in 11 patients with dermatofibrosarcoma protuberans treated with Mohs micrographic surgery

Background Dermatofibrosarcoma protuberans (DFSP) is an uncommon intermediate‐grade fibrohistiocytic sarcoma. It occurs most often in adults aged 20–50 years and is associated with local invasion and a high recurrence rate. Uncontrolled local disease or metastases may result in death. Treatment has involved wide excision, Mohs micrographic surgery (MMS) and other approaches. The purpose of the current study was to review our experience with MMS in the treatment of patients with DFSP over the past six years. Methods We carried out a retrospective chart review for all patients treated with MMS at the Hospital Italiano de Buenos Aires during a six‐year period to October 2009. Patient data included age and sex, site, and prior surgical treatment (if any) of the tumor and details of the Mohs procedure. Results Eleven patients were treated for DFSP. Four (36.4%) patients had been previously treated with a standard wide excision. Three (27.3%) of the 11 tumors were located on the back, four (36.4%) on the upper extremity, one (9.1%) on the lower extremity, and three (27.3%) on the trunk. Mean lesion size at presentation was 5.16 cm², and mean defect size was 12.65 cm², yielding a difference of 7.49 cm² and a ratio (defect size/lesion size) of 2.45. No tumors recurred after MMS. Conclusions The recurrence potential of DFSP is directly related to the extent of resection. Mohs micrographic surgery with continuous histological margin control allows for maximum tissue preservation and low recurrence rates and is rapidly emerging as a first‐line treatment modality for this condition.     

Pitfalls of Mohs micrographic surgery

This article discusses some of the pitfalls and disadvantages of Mohs micrographic surgery for the excision of skin cancer. These include (1) frozen section quality; (2) interpretation of frozen sections; (3) holes in fragmented tissue margins; (4) tissue orientation problems; (5) excessively narrow or wide margins; (6) transection of the tumor itself; (7) problems with multifocal tumor; and (8) the tedious, time-consuming nature of the procedure. Despite these problems, the importance of the procedure in the treatment of cutaneous neoplasms should not be underestimated.     

Mohs micrographic surgery for melanoma

The results of multiple investigators have confirmed the value of Mohs surgery in the treatment of melanoma. In addition, these studies have contributed to our understanding of the biologic behavior of melanoma. The success of Mohs surgery confirms that melanoma grows in a contiguous fashion before it spreads systemically. It is known that once tumor breaks away from the main mass, trying to improve survival by increasing the extent of conventional surgery is often fruitless. Therefore, the goal of surgery is to remove all of the tumor, including the silent contiguous foci. If melanoma did not grow in a contiguous fashion before metastasis, the results of Mohs surgery would be inferior to wide excision, and higher local recurrences would be expected. Instead, the excellent results support the concept of contiguous tumor growth. Satellites and in-transit metastases that appear later may be removed with the fixed-tissue technique. We have also learned that melanoma sends out silent contiguous extensions, necessitating excision of some normal-appearing skin. The width of those extensions is unrelated to the depth of the melanoma. The value of Mohs surgery is the ability to identify these extensions microscopically and to excise tumor-bearing tissue while sparing normal skin. In fact, Mohs surgery often spares a diameter of 1.8 cm or more when compared with standard surgery, a distinct advantage to patients whose melanomas are on the head, neck, hands, feet, or genitalia or in patients whose melanoma has indistinct clinical margins and would require an even wider margin of normal skin when using standard surgical techniques. We now have long-term results from large numbers of patients--confirmed by multiple investigators and data--to support the concept of Mohs surgery for melanoma. This information emphasizes the important role that Mohs micrographic surgery plays in the treatment of melanoma.