Effects of non‐amputative wide local excision on the local control and prognosis of in situ and invasive subungual melanoma

Subungual melanomas (SUM) are rare, and amputation is often required. Non‐amputative wide local excision (WLE) of the nail unit with the periosteum of the distal phalanx, followed by skin graft, has been accepted for in situ or SUM of 0.5 mm or less thickness. However, previous reports have included a limited number of cases, and not all more than 0.5‐mm thick SUM exhibit invasion or attachment to the distal phalanx. The aim of the present study was to investigate the local recurrence and prognosis for in situ, minimally invasive and invasive SUM that were treated using WLE. We retrospectively reviewed 50 patients with in situ (n = 48) or minimally invasive SUM (n = 2) (in situ or minimally invasive group) and 12 patients with more than 0.5‐mm thick invasive SUM (invasive group) who were treated using WLE. All patients survived the follow‐up period (24–207 months), although four patients with in situ SUM experienced local recurrence at the lateral margin and re‐excision was required. In the invasive group, no patients experienced local recurrence, although one patient (8.3%) developed nodal metastasis at 86 months and regional lymph node dissection was required. WLE may provide acceptable local control for in situ and intermediate thickness SUM, without compromising the vital prognosis. However, a larger randomized prospective study with long‐term follow up is required to evaluate adequately the risks associated with a non‐amputative WLE for in situ and invasive SUM.     

Cost-effectiveness of Mohs Micrographic Surgery vs Surgical Excision for Basal Cell Carcinoma of the Face

OBJECTIVE: To assess the cost-effectiveness of Mohs micrographic surgery (MMS) compared with the surgical excision for both primary and recurrent basal cell carcinoma (BCC). DESIGN: A cost-effectiveness study performed alongside a prospective randomized clinical trial in which MMS was compared with surgical excision. SETTING: The study was carried out from 1999 to 2002 at the dermatology outpatient clinic of the University Hospital Maastricht, Maastricht, The Netherlands. PARTICIPANTS: A total of 408 primary (374 patients) and 204 recurrent (191 patients) cases of facial BCC were included. MAIN OUTCOME MEASURES: The mean total treatment costs of MMS and surgical excision for both primary and recurrent BCC and the incremental cost-effectiveness ratio, calculated as the difference in costs between MMS and surgical excision divided by their difference in effectiveness. The resulting ratio is defined as the incremental costs of MMS compared with surgical excision to prevent 1 additional recurrence. RESULTS: Compared with surgical excision, the total treatment costs of MMS are significantly higher (cost difference: primary BCC, 254 euros; 95% confidence interval, 181-324 euros; recurrent BCC, 249 euros; 95% confidence interval, 175-323 euros). For primary BCC, the incremental cost-effectiveness ratio was 29,231 euros, while the ratio for recurrent BCC amounted to 8094 euros. The acceptability curves showed that for these ratios, the probability of MMS being more cost-effective than surgical excision never reached 50%. CONCLUSIONS: At present, it does not seem cost-effective to introduce MMS on a large scale for both primary and recurrent BCC. However, because a 5-year period is normally required to determine definite recurrence rates, it is possible that MMS may become a cost-effective treatment for recurrent BCC.     

It's time for Mohs: Micrographic surgery for the treatment of high‐risk basal cell carcinomas of the head and neck regions

Basal cell carcinoma (BCC) is the most common variety of non‐melanoma skin cancer and its incidence is increasing worldwide. The centrofacial sites (area H) are considered a high‐risk factor for BCC local recurrence. Mohs micrographic surgery (MMS) is a technique that allows intraoperative microscopic control of the surgical margins and is a good treatment option when tissue conservation is required for esthetic or functional reasons or for high‐risk lesions. The present study aimed to evaluate the recurrence rate of head and neck high‐risk BCCs comparing MMS vs conventional surgical excision. Clinical data of patients diagnosed from September 2014 to March 2017, referring to the Dermatology Unit of the Policlinico Sant'Orsola‐Malpighi, University of Bologna, were retrospectively evaluated (285 treated with MMS and 378 treated with traditional surgery). Of the 285 patients treated with MMS, 9 experienced a recurrence (3.1%). Of the 378 patients treated with traditional surgery, 53 relapsed (14%), 13 of whom presented residual tumor on the deep or lateral margins of the main surgical specimen. Our study confirms the trend reported in the literature that MMS represents the best treatment option for high‐risk BCCs arising in the head and neck region or presenting as a recurrence (P < .00001). Many more MMS centers and more trained dermatologists are needed worldwide in order to deal with the increasing number of BCC diagnosed every year.     

Dermatofibrosarcoma Protuberans in Childhood Treated with Slow Mohs Micrographic Surgery

Dermatofibrosarcoma protuberans (DFSP) in childhood is a rare tumor with high recurrence rates. Wide local excision can result in disfiguring mutilation, whereas Mohs micrographic surgery (MMS) reduces surgical margins. MMS in children is not performed routinely, as the required infrastructures such as a histopathology lab in close proximity to the operating room is often lacking. We retrospectively reviewed children diagnosed with DFSP treated at our hospital over 2 years. We recorded surgical treatment details, including margins, duration of inpatient stay, outcome, follow‐up, and molecular genetic tumor tissue analysis. Four children with a median age of 6.8 years (range 6.0–8.8 years) were identified who had a diagnostic delay of a median of 2.5 years (range 0.5–4.0 years); all underwent complete tumor excision using the slow MMS technique using vacuum‐assisted closure systems between repeated excisions and before wound closure. The median maximal safety margins were 1.5 cm (range 1.0–3.0 cm). By using vacuum‐assisted closure systems, no dressing changes were needed, pain was limited, and full mobility was maintained in all children. The median total time in the hospital was 11 days (range 10–14 days). No relapses occurred during a median follow‐up of 25.8 months (range 11.3–32.6 months). Collagen 1A1/platelet‐derived growth factor B (COL1A1/PDGFB) translocation on chromosomes 17 and 22 was detected in all three analyzable specimens. Lesions suspected of being DFSP warrant prompt histologic evaluation; interdisciplinary management is mandatory in particular for children. Micrographic surgery allows smaller surgical margins than wide excision and should be considered as the treatment of choice in children with DFSP. The interim usage of vacuum‐assisted closure systems increases patient comfort. Translocations in the COL1A1/PDGFB gene imply susceptibility to targeted treatment modalities for therapy‐resistant cases.     

Basal cell carcinoma of the head region: therapeutical results of 350 lesions treated with Mohs micrographic surgery

Background Basal cell carcinoma (BCC) is a non‐melanocytic skin tumour with a high risk of recurrence after incomplete treatment, especially the aggressive subtypes (basosquamous, micronodular and morphea BCC). The percentage of recurrence also depends on the anatomical site of the tumour. Nose–cheek fold, paranasal fold, retroauricular fold and internal canthus are considered to be critical sites. Objective The aim of this study was to report on recurrence rates for BCC treated with Mohs micrographic surgery (MMS). Material and Methods We retrospectively studied 350 BCCs of the head region treated with MMS. Results were analysed with chi‐squared test and Fisher test and were considered significant when P value was ≤0.05. Results In our study, the percentage of BCC recurrence rate after MMS was of 3.4% for primary BCC and 4.9% for recurrent BCC; these were similar to the recurrence rates reported in the literature. Conclusions Low recurrence rate can be achieved when treated with MMS; it is the treatment of choice for many BCC of the head. Aggressive histopathological subtypes, critical head sites and recurrence after incomplete excision are the most important indications for MMS.     

隆突性皮肤纤维肉瘤诊治进展

隆突性皮肤纤维肉瘤是一种发生于皮肤和皮下的间叶细胞恶性肿瘤,以局部复发率高和远处转移率低为特点.近年研究发现,除了组织病理和免疫组化可诊断隆突性皮肤纤维肉瘤外,细胞遗传学、分子生物学、影像学及皮肤镜和皮肤CT(反射式的激光共聚焦显微镜)均对隆突性皮肤纤维肉瘤的诊断、治疗及评估起到重要的辅助作用.目前,对于隆突性皮肤纤维肉瘤的手术治疗为扩大切除手术或Mohs显微外科手术,两种方法各有利弊,术后可辅助放疗、免疫综合治疗;冷冻治疗对复发患者有效;对不能手术或手术切缘阳性的患者需联合靶向药物伊马替尼的治疗.另外,抗雌激素(如他莫昔芬)或新型靶向药物乙酰肝素酶抑制剂roneparstat(SST0001)可能也有一定疗效.     

Mohs' micrographic surgery for treatment of basal cell carcinoma of the face--results of a retrospective study and review of the literature

BACKGROUND: The incidence of skin cancer and especially basal cell carcinoma (BCC) has increased in the last decade and is still increasing. Many treatment modalities can be used to treat BCC; surgical excision is the most frequently used. Mohs' micrographic surgery (MMS) is an advanced excision technique which is often used to treat BCC in the U.S.A. In Europe it is practised less frequently. OBJECTIVE: The aim of this article was to evaluate the efficiency of MMS for the treatment of facial BCC. METHODS: In a retrospective study recurrence rates after the treatment of facial BCC by MMS were estimated by reviewing the records of all patients with BCCs (620 patients with 720 BCCs) treated by MMS in our department from April 1992 until December 1999. RESULTS: The 5-year recurrence rates estimated from this study were 3.2% for primary BCC and 6.7% for recurrent BCC. Prognostic factors for recurrence are: an aggressive histopathological subtype, more than four Mohs' stages, a large defect size and a recurrent BCC. CONCLUSION: Based on the fact that MMS provides the lowest recurrence rates, it is the treatment of first choice for primary facial BCCs with an aggressive histopathological subtype and for recurrent BCCs in the face.     

Mohs’ micrographic surgery for dermatofibrosarcoma protuberans

Background. Dermatofibrosarcoma protuberans (DFSP) is a rare soft-tissue tumour with a high local recurrence rate. Recent reports indicate more favourable cure rates with Mohs’ micrographic surgery (MMS). Aim. To investigate the beneficial use of MMS for DFSP in a single institution in Korea. Methods. A retrospective review was performed of pertinent demographic data, tumour data, treatment characteristics and follow-up data of 11 patients between 1997 and 2007. A review of literature for treatment methods and recurrence rates of DFSP was also performed. Results. In total, 11 patients (7 female, 4 male; mean age 26.9 years, range 3–36) with DFSP were identified and analysed. A mean number of 1.8 MMS layers were required to clear the tumour. All tumours were excised and reconstructed by the surgeon. There were no identifiable recurrences in the follow-up period of an average of 26 months. Conclusions. Treatment of primary and recurrent DFSP by MMS results in a low recurrence rate with possible benefits of smaller defects compared with wide local excision. This study provides further support for MMS as the treatment of choice for DFSP.     

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.     

Management of dermatofibrosarcoma protuberans with fibrosarcomatous transformation: an evidence‐based review of the literature

Fibrosarcomatous transformation represents a rare event in dermatofibrosarcoma protuberans (DFSP) with unpredictable biological behaviour. No guidelines for the adequate treatment of patients with this rare neoplasm have been published. Herein, we present a comprehensive review of the literature comprising 157 patients with transformed DFSP focussing on surgical and adjuvant treatment modalities for this tumour. In the cohort examined, local recurrence occurred in 36% of cases and was significantly lower in patients treated by wide excision with margins ≥2 cm when compared with those treated with local excision without defined margins (P = 0.01). Consistently, negative margin status was associated with a lower recurrence rate when compared with positive or unknown margin status (P = 0.01). Distant metastases were detected in 13% of patients, which is significantly higher when compared with ordinary dermatofibrosarcoma protuberans. Systemic dissemination was preceded by local recurrence in 81% of cases, and is therefore strongly associated with tumour recurrence (P ≤ 0.001). The present data confirm that wide excision with margins ≥2 cm represent the gold standard in the treatment of transformed dermatofibrosarcoma protuberans, and prevents recurrence as well as metastasis. When R0‐resection is not feasible, adjuvant radiation should be considered for cases with incomplete resection or unknown surgical margins. Irresectable or metastatic transformed DFSP harbouring the COL1A1‐PDGFB fusion gene should be treated with imatinib in the palliative setting or as an adjunctive treatment before surgery, although responses may be short‐lasting.     

Basal cell carcinoma of the vulva: a case report and systematic review of the literature

The vulva is an unusual site for basal cell carcinoma (BCC). Vulvar BCC accounts for <1% of all BCCs and <5% of all vulvar malignancies. We report the case of an 83 year-old woman who presented with a 2-month history of a tender labial growth, with histopathology confirming nodular BCC. We conducted a systematic literature review of the characteristics of reported cases of vulvar BCCs. A comprehensive systematic review of articles indexed for MEDLINE and Embase yielded 96 reports describing 437 patients with 446 BCCs of the vulva. The mean age at presentation was 70 (range 20–100). Most women had no underlying vulvar disease. Approximately 60% of cases were of the nodular subtype. Treatment approach varied widely with over half of cases treated with wide local or local excision. Mohs micrographic surgery (MMS) for vulvar BCC was first reported in 1988 with seven total MMS cases reported. Twenty-three cases of recurrence have been reported; 21 of these cases after local excision but none following MMS. Vulvar BCC is a rarely reported cancer that affects older women predominantly. MMS represents a promising treatment for BCC in this anatomic location.     

Atypical fibroxanthoma management: Recurrence,metastasis and disease‐specific death

Atypical fibroxanthoma (AFX) is a rare spindle cell neoplasm predominantly found on the head and neck of elderly individuals with sun‐damaged skin, with no evidence‐based guidelines for their management. A systematic retrospective review of the literature focusing on treatment modality found a recurrence and metastasis rate of 8.0% (5.6% when adjusted for incomplete excisions) and 0.5% for local excision and 4.6% and 3.2% for Mohs micrographic surgery, respectively. Our results suggest that with clear surgical margins, AFX is unlikely to recur and metastases are rare, with significantly higher rates in the immunosuppressed population.     

A rare low-grade malignant scalp tumor. Atypical fibroxanthoma

A 79-year-old patient presented with an asymptomatic scalp tumor which had grown over the past 9 months. Based on clinical, histological and immunohistochemical staining, we made the diagnosis of an atypical fibroxanthoma (AFX). AFX is a rare tumor, but important in the differential diagnosis of other scalp tumors. The routine histological staining allows one to identify a malignant fibrous histiocytoma, while a spindle-cell malignant melanoma can be excluded with immunohistochemical staining. An anaplastic squamous cell carcinoma cannot always be separated with completed certainty from atypical fibroxanthoma. AFX is a low-grade malignant tumor and most cases behave in a benign fashion. After complete excision, we recommend follow-up for a number of years because of the possibility of local recurrence.     

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.     

Postoperative DAV‐IFN‐β therapy does not improve survival rates of stage II and stage III melanoma patients significantly

Background DAV‐interferon (IFN)‐β therapy is a combination chemotherapy of dacarbazine (D TIC), nimustine (A CNU) and vincristine (V CR) with local subcutaneous injection of IFN‐β that is widely employed as postoperative adjuvant chemotherapy to treat malignant melanoma in Japan. However, the efficacy of DAV‐IFN‐β therapy has not been confirmed by randomized controlled trials and the benefit of DAV‐IFN‐β therapy has not been established yet. This study evaluated the contribution of DAV‐IFN‐β therapy to improve survival of postoperative patients with cutaneous melanoma. Methods Patients with stage II or III cutaneous melanoma seen at Nagoya University Hospital from January 1998 to December 2009 were eligible for this study. Disease‐free survival rates and melanoma‐specific survival rates were evaluated. A propensity score was calculated to control for the effects of variables related to decisions regarding the application of DAV‐IFN‐β therapy. Results Eighty‐two stage II and 60 stage III melanoma patients were included. In the post‐matched stage II patients (17 matched pairs), the mean (±SE) disease‐free survival rates were 39.9±13.7% for DAV‐IFN‐β therapy and 73.1±11.7% for non‐use (hazard ratio for recurrence, 2.06; 95% CI, 0.63–6.69; P = 0.23), and the melanoma‐specific survival rates were 66.2±20.0% for DAV‐IFN‐β therapy and 86.2±9.1% for non‐use (hazard ratio for death, 1.09; 95% CI, 0.17–6.82; P = 0.93). In the post‐matched stage III patients (nine matched pairs), the disease‐free survival rates were 29.6±16.4% for DAV‐IFN‐β therapy and 33.3±15.7% for non‐use (0.69; 95% CI, 0.22–2.17; P = 0.53), and the melanoma‐specific survival rates were 55.6±16.6% for DAV‐IFN‐β therapy and 44.4±16.6% for non‐use (0.67; 95% CI, 0.18–2.50; P = 0.55). Conclusions DAV‐IFN‐β therapy brought no significant improvement in either disease‐free survival rates or melanoma‐specific survival rates of patients with stage II or III cutaneous melanoma. A randomized controlled trial would be required to further evaluate the efficacy of DAV‐IFN‐β therapy as an adjuvant chemotherapy.     

Photodynamic therapy using topical 5‐aminolaevulinic acid vs. surgery for basal cell carcinoma

Background Photodynamic therapy (PDT) is an attractive modality for the treatment of BCC, based on its generally favorable efficacy, adverse effect profile and its excellent cosmetic outcome. Objectives The purpose of the study is to compare the efficacy and cosmetic outcome of photodynamic therapy with topical 5‐aminolaevulinic acid (ALA‐PDT) vs. simple excision surgery for superficial and nodular basal cell carcinoma (BCC). Methods A total of 72 patients, 32 with 48 lesions, were treated with ALA‐ PDT, and 40 with 46 lesions treated by excision were included in this prospective, comparative, controlled, clinical study. The patients have been followed for 16–37 months (mean 25 months). The PDT was performed in combination with 5‐aminolaevulinic acid twice, one month apart. Surgical excision was performed under local anesthesia with a 3‐mm margin, followed by histological examination. The cosmetic outcome was evaluated by the physician according to a 4‐point scale. Results Overall 94 BCC were treated. Complete healing rates did not differ significantly between groups, P = 0.64 (46/48 [95.83%] lesions treated with PDT vs. 44/46 [95.65%] lesions with surgery). In the first 12 months of follow‐up, 4 lesions had recurred, 2 of which were in the PDT group while 2 lesions after surgery. The mean follow‐up was 25 months. The recurrence rate in the ALA‐PDT group was 4.16% vs. 4.34% in the surgery group, p = 0.64. The cosmetic outcome was superior for ALA‐PDT at all time points. At 12 months, 100% lesions treated with ALA‐PDT had an excellent or good cosmetic outcome, according to the investigator, compared with 88.86% with surgery, P = 0.01. Conclusion ALA‐PDT offers a similarly high efficacy, and a better cosmetic outcome than simple excision surgery in the treatment of BCC.     

Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura

Background and objectives

Amputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications.

Basal cell carcinoma of the vulva: treatment with Mohs micrographic surgery

Vulval basal cell carcinomas (BCCs) are rare, representing < 5% of vulval malignancies and 1% of all BCCs. They often present with nonspecific symptoms and features that lead to large, poorly circumscribed and late‐presenting lesions. Current and conventional treatments used to treat vulval BCC include cryotherapy, imiquimod and excision. However, recurrence rates as high as 20% have been reported with these treatments. Furthermore, there are no current clinical guidelines for their management. We present the first reported series of patients with vulval BCC treated with Mohs micrographic surgery (MMS). We report seven cases of vulval BCC treated with MMS at a tertiary referral centre over 3 years. Follow‐up was performed at 3 months and up to 3 years. Our series demonstrates that there were no postoperative complications, functional sequelae or recurrences up to the 3‐year follow‐up. We therefore recommend that MMS should be considered in the management of vulval BCCs.     

Microcystic adnexal carcinoma: report of four cases treated with Mohs' micrographic surgical technique

BACKGROUND: Microcystic adnexal carcinoma (MAC) is a rare and aggressive malignant tumor of the sweat glands. Clinically, it often presents as a firm subcutaneous nodule on the head and neck regions. On histology, MAC exhibits both pilar and sweat duct differentiation with a stroma of dense collagen. It often extends beyond the clinical margins with local spreading in the dermal, subcutaneous, and perineural tissue planes. It has a high local recurrence rate after standard excision. Recent preliminary reports have indicated more favorable cure rates with Mohs' micrographic surgery (MMS). OBJECTIVE: To present our data on four cases of MAC treated by MMS. We also compared our findings with more recently reported series in the English language literature. METHODS: We reviewed the medical records of four patients (two males and two females) with MAC treated by MMS over the last 3 years. We also obtained follow-up data. RESULTS: In all four patients with MAC treated by MMS, there were no recurrences, with a mean follow-up of 1 year. CONCLUSION: We report an additional four MAC cases treated by MMS. The accumulated data continue to confirm that, if the diagnosis of MAC is made early, and if the anatomic location is accessible to excision by MMS, a favorable outcome can be expected.     

Atypical fibroxanthoma with perineural or intraneural invasion: report of two cases

We report two cases of atypical fibroxanthoma (AFX) that both had the previously unreported feature of neural invasion (one perineural and the other intraneural). AFXs recur in approximately 10% of cases but only rarely metastasize. Features associated with recurrence are inadequate excision and invasion into fat. Features associated with metastasis include recurrence, vascular invasion, deep tissue invasion, and tumor necrosis. Both of these tumors invaded deeply into subcutaneous fat and reached the deep fascia. Some authors would regard such cases as malignant fibrous histiocytoma (MFH) because of such deep extension; however, the concept of AFX as a superficial variant of MFH is outmoded--AFX is a distinct clinicopathologic entity with established clinical, histological, and immunohistochemical features.