Follow-up of basal cell carcinomas: an audit of current practice

BACKGROUND: Follow-up of patients after treatment of basal cell carcinoma (BCC) allows for monitoring of recurrence and detection of new tumours, but adds a significant burden to outpatient clinics. At the skin tumour clinic in the dermatology department, the Royal Hospitals, Belfast, all patients are reviewed for 2 years after surgical excision of a low-risk primary BCC. OBJECTIVES: An audit was undertaken to determine the quality of data set recorded relating to prognostic factors for BCCs to determine the rate of recurrence and number of new primary tumours detected and to determine the completeness of follow-up by patients. METHOD: Patients who had primary BCCs treated by excision were identified from a database held at the clinic. Medical charts were reviewed to determine data recorded about lesions, the number of recurrent BCCs and new tumours detected, and the number of patients completing follow-up. RESULTS: Between January 1999 and December 2000, 114 patients had 121 primary BCCs excised. BCC location and size were recorded in 100% and 35% of cases, respectively. Histological type was stated for morphoeic or multifocal lesions. Two years of follow-up was completed by 53% of patients and 1 year by 78% of patients. The rate of recurrence was low, with 2 BCC recurring within 2 years of excision. The risk of developing a new BCC was 11.6% in the first year and 6.3% in the second year. CONCLUSIONS: Follow-up of patients after excision of a low-risk BCC at the clinic has been reduced to 1 year. A proforma has been developed to encourage documentation of prognostic factors.     

Basal cell carcinoma in young adults: not more aggressive than in older patients

BACKGROUND: An increased incidence of sporadic basal cell carcinoma (BCC) has been observed in young adults within the last years. It has been hypothesized that these BCC in younger subjects might be more aggressive compared to BCC in the elderly. OBJECTIVE: To compare BCC recurrence rates between young and older patients. METHODS: Retrospective study of patients under the age of 35 years (group 1) with previously untreated BCC and comparison with BCC in patients older than 35 years (group 2). Each patient in group 1 was matched with 2 patients in group 2. RESULTS: 70 patients in group 1 and 140 patients in group 2 were included. The median follow-up was 76 months. In group 1, 13% of the BCC were of the morphea-like type and 9% in group 2 (p = 0.30), respectively. The 5-year recurrence rate was 4.6% in group 1 and 9.8% in group 2. They did not significantly differ between the two groups (log rank test p = 0.48). CONCLUSION: BCC in young patients are not more aggressive than in older patients.     

Second malignancies in melanoma patients in Thuringia

OBJECTIVE: The incidence of melanoma is increasing. Melanoma patients are at risk for the development of second neoplasias. Data for the new German Bundesl?nder are not available, but would be suitable to define frequency, site and type of secondary malignancies and conclusions for follow-up of melanoma patients. DESIGN: Retrospective study at the Melanoma Outpatient Clinic of the Department of Dermatology and Allergology at the University of Jena (Germany) for patients seen between June 1966 and June 1999. To investigate the impact of second malignancies on survival a case-comparison study of mortality was performed. The log-rank test and chi2-test were used to investigate statistical significance. There were 554 patients with malignant melanoma, 237 male and 317 female, with an age at time of diagnosis between 17.0 and 90.1 years (mean 53.7 years). The mean follow-up was 5.6 years. RESULTS: Sixty-one patients (11.0%) developed a second tumour. The total number of tumours was 83. Forty-five patients developed one, 16 developed > or = 2 second tumours. Basal cell carcinoma (BBC) was the most frequent neoplasia (17 patients, 22 tumours; mean age 64.9 years). A second melanoma was found in 15 patients, while two developed a third melanoma. The mean tumour thickness was 0.81 mm (in second or third melanomas) compared with 1.92 mm of primary melanomas. Seven female patients developed breast cancer (eight cancers; mean age 57.3 years). The other second tumours included skin cancer (eight), gastrointestinal tract tumours (four), genital cancers (19), brain tumours (two), lung cancer (two) and other tumours (six). The difference in survival of patients with second tumours was not statistically significant from age-, sex- and melanoma thickness-matched controls. CONCLUSIONS: Second malignancies were seen in 11.0% of melanoma patients. Most important are second skin tumours such as second melanomas and BCC, recommending follow-up by the dermatologist. In a group of patients with regular follow-up examinations, no negative impact of second tumours (BCC, melanoma, breast cancer) on overall survival could be detected.     

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.     

Multiple HPV-positive basal cell carcinomas on the abdomen in a young pregnant woman

Basal cell carcinoma (BCC) is the most common malignant skin tumour. In the last few years, the incidence of multiple BCC has also increased in young patients. We describe the clinical case of a young 29-year-old woman who developed 7 BCC on her abdomen during her first pregnancy and 4 other similar tumours 2 years later during her second pregnancy, all located on the abdomen. Polymerase chain reaction revealed the presence of numerous human papillomavirus DNA sequences. To our knowledge, such a clinical presentation has not been previously reported. Different physiopathological considerations are discussed.     

Multiple primary malignancies in patients with Merkel cell carcinoma1

Background Merkel cell carcinoma (MCC) is a rare malignant cutaneous tumour, the incidence of which is increasing. Second malignancies have been reported to occur with high incidence in these patients. Objectives We report the rate and nature of multiple malignancies in patients with MCC treated over a 10 year period in Addenbrooke’s Hospital in Cambridge, United Kingdom, as well as the temporal relationship of these additional malignancies to the diagnosis of MCC. Results The 27 patients had an approximately equal sex incidence with a median age at diagnosis of 79 years. Seventy percent (n=19) of patients had a second primary malignant tumour; and 7 of these patients had two or more tumours in addition to the MCC. Eighteen patients had additional cutaneous malignancies: melanoma, squamous cell carcinoma and basal cell carcinoma, and 8 patients presented non‐cutaneous malignancy including colorectal, haematological and breast tumours. Of the 28 additional tumours in our patients, half were diagnosed prior to presentation of MCC, 32% within 6 months of diagnosis, and 18% between 6 months and 3 years after diagnosis. Possible reasons for the high rate of additional tumours in this population are discussed. Conclusions Our figures reflect a higher incidence of multiple malignancies in those with Merkel cell tumour than has previously been reported. This has important implications for the care and surveillance of these patients.     

"High single-dose'' European PUVA regimen also causes an excess of non-melanoma skin cancer

We report the results of a long-term (12.8 years) follow-up study of the detection of malignant and benign skin tumours in patients with psoriasis, who were treated with PUVA according to the European, 'high single-dose' regimen. A total of 13 squamous cell carcinomas (SCC) and 24 basal cell carcinomas (BCC) were diagnosed in 11 of 260 patients. The incidence of both SCC and BCC was increased in comparison with the general Dutch population. The ratio of SCC to BCC in the general population was 1:8 but was 1:2.5 in our study group. A positive correlation was observed between the development of SCC and the total UVA dosage, the age of the patient at the start of the PUVA treatment and a history of arsenic use. This dose-related increase in the incidence of SCC, reported in studies from the U.S.A., has not been found in earlier European studies. The average time period between the start of PUVA therapy and the diagnosis of the first malignant skin tumour was 6.0 years for SCC and 4.7 years for BCC. Among the 49 benign skin tumours were actinic keratoses, a keratoacanthoma and 'PUVA keratoses', a newly described hyperkeratotic lesion, especially found in PUVA-treated patients.     

Photodynamic therapy with 5-aminolaevulinic acid, dimethylsulfoxide and curettage in basal cell carcinoma: a 6-year clinical and histological follow-up

Background   Long-term follow-up data are needed to evaluate treatment effect after photodynamic therapy (PDT).
Objective   To investigate long-term clinical, histological and cosmetic follow-up results in basal cell carcinoma (BCC) after PDT, including treatment response related to patients and lesion characteristics.
Materials and methods   A longitudinal study of 44 patients with 60 histologically verified BCC tumours, treated with one or two sessions of dimethylsulfoxide (DMSO)-supported 5-aminolaevulinic acid – PDT following curettage, was performed. Lesions in complete remission after 3 months were followed with clinical inspection, histological investigation and evaluation of cosmetic outcome at regular intervals; long-term efficacy assessed as verified recurrence within 72 months after PDT.
Results   Complete remission at 3 months was achieved in 55 lesions from 39 patients. Two patients with one lesion each died. At 72 months, 43 of 53 lesions remained disease-free (81%); 68% remained after one treatment session, and 91% remained after two treatment sessions. Recurrence of tumour occurred at 6, 12, 24 and 36 months in 2, 4, 2 and 2 lesions, respectively; clinical investigation identified 97% of them. Male sex and H-mid-face zone were significantly associated with recurrence.
The cosmetic outcome at 72 months was rated as good or excellent by patients and investigators in more than 90% of evaluated cases.
Conclusion   DMSO-PDT following curettage is an effective treatment for BCC, with favourable long-term clinical, histopathological and cosmetic results. Clinical examination of treated lesions appears to be sufficient for long term follow up.     

Basal cell carcinoma follow-up practices by dermatologists: a national survey

BACKGROUND: After treatment of a basal cell carcinoma (BCC) patients are at risk of recurrence of that BCC; also, patients who have had a primary BCC are those who have an increased risk of developing a subsequent primary BCC. However, long-term hospital-based follow-up of all patients would put large strains on the U.K. health service. OBJECTIVES: To investigate the follow-up intentions of U.K. dermatologists for well-defined facial BCC and to investigate the effect that variations in site and clinical indicators might have on those intentions. METHODS: A self-completion questionnaire relating to BCC follow-up sent to 388 dermatology consultants and associate specialists in the U.K. had a response rate of 68%. The effects of treatment modality, tumour site, histology, multiple lesions and various patient variables that might alter the likelihood of follow-up were examined. General views on the subject of BCC follow-up were sought. RESULTS: Twenty-seven per cent of respondents reported that they would not review further after excision of a 'well-defined' BCC from inside a central 'T' area on the face; 37% reported that they would review on one occasion; and 36% reported that they review more than once. CONCLUSIONS: While it is currently not feasible to follow-up all treated BCCs, a strategy to identify and monitor high-risk patients and a system to gather long-term outcome data prospectively are necessary aspects of a national health service. This study illustrates that the first issue is being addressed to some extent, but at the currently reported level of BCC follow-up in the U.K. there is little scope for collecting comprehensive long-term data on outcomes.     

Powerful neodymium laser radiation for the treatment of facial carcinoma: 5 year follow-up data

A retrospective non-comparative follow-up study was performed to evaluate the curative efficacy of powerful neodymium laser radiation (λ = 1,060 nm) for the treatment of 2,837 patients with 3,001 histologically confirmed facial skin carcinoma lesions of stages T1-2N0M0: 2,743 primary basal cell carcinomas (BCC), 172 recurrent limited basal cell carcinomas (RLBCC), and 86 primary squamous cells carcinomas (SCC). All patients were followed-up from 5 to 11 years (mean: 8.2 years; median: 7.0 years) after treatment. The overall recurrence rate (RR) after treatment with laser radiation of facial carcinomas was 2.5% of all irradiated tumours (mean: 13.4 months; median: 11.0 months). Patients with BCC treated by radiation with the pulsed Neodymium (Nd) laser developed RR in 2.2% of cases and patients treated with the Nd:YAG laser had RR of 3.1%. Recurrences following treatment for RLBCC, and those of SCC, after irradiation with the Nd laser appeared in 4.1% and 4.6% of patients, respectively. Neodymium laser radiation is a safe and effective means of treating facial carcinomas of stages T1-2N0M0 with good cosmetic results.     

Photodetection of basal cell carcinoma using methyl 5-aminolaevulinate-induced protoporphyrin IX based on fluorescence image analysis

BACKGROUND: The preferential accumulation of 5-aminolaevulinic acid (ALA)-induced protoporphyrin IX (PpIX) in neoplastic cells supports its potential use in the photodetection of porphyrin fluorescence in tumour cells. Hence, epithelial tumours, including basal cell carcinoma (BCC), might be visualized using the fluorescence of selectively accumulated ALA-induced PpIX. AIM: In this study, we evaluated the clinical efficacy of PpIX fluorescence images using fluorescence image analysis (FIA) to define the lateral border between the tumour and tumour-free areas of facial BCC. METHODS: FIA was used to define the lateral border between the tumour and tumour-free areas on red fluorescence images induced by the topical application of methyl 5-aminolaevulinate (MAL) ointment. According to the FIA results, 50 tissue samples, obtained from 10 patients with BCC, were divided into three categories: tumour area (n = 10), suspected tumour area (n = 20) and suspected tumour-free area (n = 20). These tissue samples were evaluated by histopathological examination. The FIA tool marked out the PpIX fluorescence image for defining the lateral border between the BCC tumour and tumour-free areas. RESULTS: The rate of tumour detection from BCC lesions using PpIX fluorescence with the FIA tool showed a sensitivity of 94.1% and specificity of 82.6%. CONCLUSION: These results suggest that MAL-induced PpIX fluorescence imaging using FIA is quite sensitive and specific for detecting tumour and occult tumour in facial BCC lesions. This method of presurgical in vivo imaging is therefore proposed as a useful tool for defining the lateral border between BCC tumour and tumour-free areas.     

Increase in basal cell carcinoma incidence steepest in individuals with high socioeconomic status: results of a cancer registry study in the Netherlands

Background  Development of both basal cell carcinoma (BCC) and cutaneous malignant melanoma (MM) is associated with acute and intermittent sun exposure. In contrast to MM, the association between socioeconomic status (SES) and BCC is not well documented.
Objectives  To investigate the incidence of BCC according to SES, stratifying by age and tumour localization in a large population-based cohort. To assess changes over time in the distribution of the patients with BCC across the SES categories.
Methods  All patients with a histologically confirmed first primary BCC ( n  = 27 027) diagnosed between 1988 and 2005 in the Southeast of the Netherlands were stratified by sex, age (25–44, 45–64 and ≥ 65 years), period of diagnosis, SES category (based on income and value of housing) and localization of the BCC. Age-standardized BCC incidence rates were calculated for the year 2004 by SES category and localization. Ordinal regression was used to assess changes over time in the proportion of patients with BCC by sex, age and SES.
Results  For men in all age groups higher BCC incidence in the highest SES category was observed, which remained significant after stratification for tumour localization. For women a consistent relationship was found only in younger women (< 65 years) for truncal BCCs, which occurred more frequently in high SES groups. Between 1990 and 2004, the proportion of BCC patients with high SES increased (+6%) and the proportion with low SES decreased (−7%).
Conclusions  High SES is associated with increased incidence of BCC among men. Our data suggest that BCC is changing from a disease of the poor to a disease of the rich.     

Dermatofibrosarcoma protuberans: a population-based cancer registry descriptive study of 66 consecutive cases diagnosed between 1982 and 2002

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare malignant tumour of the skin, with an estimated incidence of 0.8 to five cases per 1 million people per year. OBJECTIVE: To study epidemiological, immunohistochemical and clinical features, delay in diagnosis, type of treatment and outcome of DFSP from 1982 to 2002. METHODS: Using data from the population-based cancer registry, 66 patients with pathologically proved DFSP were included (fibrosarcomatous DFSP were excluded). Each patient lived in one of the four departments of Franche-Comté (overall population of 1 million people) at the time of diagnosis. The main data sources came from public and private pathology laboratories and medical records. The rules of the International Agency for Research on Cancer were applied. RESULTS: The estimated incidence of DFSP in Franche-Comté was about three new cases per 1 million people per year. Male patients were affected 1.2 times as often as female patients were. The trunk (45%) followed by the proximal extremities (38%) were the most frequent locations. DFSP occurred mainly in young adults between 20 and 39 years of age. Mean age at diagnosis was 43 years, and the mean delay in diagnosis was 10.08 years. Our 66 patients initially underwent a radical local excision. Among them, 27% experienced one or more local recurrences during 9.6 years of follow-up. There was one regional lymph node recurrence without visceral metastases. These recurrences were significantly related to the initial peripheral resection margins. We observed a local recurrence rate of 47% for margins less than 3 cm, vs. only 7% for margins ranging from 3 to 5 cm [P=0.004; OR=0.229 (95%, CI=0.103-0.510)]. The mean time to a first local recurrence was 2.65 years. Nevertheless, there was no death due to the DFSP course at the end of the follow-up, and the final outcome was favourable. CONCLUSION: Our study emphasizes the importance of wide local excision with margins of at least 3 cm in order to prevent local recurrence. However, the recent development of inhibitors of signal transduction by the PDGFB pathway should soon modify the surgical strategy, which is often too mutilating.     

Perianal and genital basal cell carcinoma: A clinicopathologic review of 51 cases.

BACKGROUND: Basal cell carcinoma (BCC) occurring on non-sun-exposed sites, especially the perianal and genital regions, is very rare. OBJECTIVE: We analyzed the incidence, clinical and pathologic features, and etiologic and prognostic factors of all non-nevoid perianal and genital BCCs diagnosed at our institution within a defined period (January 1985-September 1996). METHODS: A retrospective review was performed with the use of patient clinical records and dermatopathologic slides. Cutaneous biopsy samples were tested for the presence of human papillomavirus (HPV) by in situ hybridization using biotinylated pan-HPV and serotype-specific (6, 11, 16, 18, 31, 33, 51) probes. RESULTS: Of all non-nevoid BCC syndrome cases, 51 BCCs (0.27%) were located within the perianal and genital regions. The average age of the patients was 73 years. Nine perianal BCCs occurred in men, 6 in women. Ten BCCs occurred in the pubic area, 18 on the vulva, 6 on the scrotum, and 2 on the penis. Three patients had 2 tumor sites. The average size of BCC was 1.95 cm; 29.4% were ulcerated. Seventeen patients (36%) had a history of skin cancer on sun-exposed sites and 10 (21%) had a possibly relevant associated condition. HPV was not detected in the specimens tested. Treatments included wide excision (n = 32), electrodesiccation and curettage (n = 10), Mohs micrographic surgery (n = 8), and carbon dioxide laser (n = 1). Of 30 patients with 5 years' follow-up or longer, 1 recurrence was noted 7 years after wide excision. There were no metastases. CONCLUSION: BCC of the perianal and genital skin is rare and exhibits clinical and histologic heterogeneity. Advancing age and local trauma may contribute to the pathogenesis of BCC at these sites.     

Intradermal and subcutaneous leiomyosarcoma: a clinicopathological and immunohistochemical study of 41 cases

Superficial leiomyosarcomas are rare tumours. The lesions confined to the dermis, contrary to those involving the subcutis, have been reported to carry a favourable prognosis.
A retrospective study of 41 consecutive cases of surgically treated intradermal and subcutaneous leiomyosarcomas was undertaken in order to determine the prognostic factors that may influence the survival of these patients. Seven tumours were predominantly intradermal and 34 involved the subcutaneous tissue. Fifty-four percent of the tumours were located in the lower extremities. All cases stained positively for smooth muscle antigen and 66% for desmin. The tumours were classified with regard to tumour grade I (low grade, 3%), II (intermediate, 12%), IIIA (high grade, 46%) and IIIB (high grade, 39%). In all patients, follow-up information was available. Mean follow-up time was 5 years. The patients with intradermal tumours were all alive without signs of recurrence, whereas 14 of those with leiomyosarcomas involving the subcutis have died with pulmonary metastases.
Our study confirms that "pure" intradermal leiomyosarcomas independent of tumour grade behave in a benign fashion, probably due to small tumour size. Tumour size ≥ 5 cm, deep localization with fascia involvement, and high malignancy grade (IIIB) were found to deteriorate survival based on a univariate analysis. However, in a multivariate analysis only tumour size was found to be an independent prognostic factor.     

Management of basal cell carcinoma by surveyed dermatologists in Scotland

Background. The British Association of Dermatologists (BAD) has produced guidelines for management of basal cell carcinoma (BCC) in the UK. Objectives. Our primary objectives were to assess the management of BCCs in Scotland and to compare it with BAD guidelines. Our secondary objectives were to audit waiting times and referral patterns. Methods. In phase I of the audit, dermatologists in 14 centres across Scotland prospectively registered demographic and clinical data of all lesions suspected to be BCCs over a 6‐week period between October and December 2000. In phase II, details of management of these lesions were evaluated by case note review. Results. Of the 48 consultant dermatologists contacted, 42 took part in the survey. There were 524 clinically suspected BCCs seen in 470 patients; 164 lesions in 146 patients showed pathology other than BCC and were excluded from analysis, thus leaving 360 lesions available for analysis. There was wide variation in waiting times among Scottish dermatology centres. BCCs were equally distributed between the sexes, and lesions most commonly presented in those aged 71–80 years. A diagnostic biopsy was taken in 22% of lesions, and the rest were treated definitively after a clinical diagnosis of BCC, of which 90% were confirmed on histology. Nodulocystic lesions were the most common type of tumour, comprising 48% of lesions, and most BCCs were located on the head and neck region. Correlation of the histological type of BCC and treatment received showed that nodulocystic and morpheic BCCs were managed as recommended. There were more superficial BCCs treated with surgical excision than expected (22 of 34 lesions). Four of 21 recurrent tumours and 9 of 81 tumours on high‐risk areas of the face were managed with curettage and cautery or cryotherapy, rather than surgical excision. Of the 297 excised tumours, 25 (9%) were incompletely excised. All the high‐risk tumours and incompletely excised tumours were offered follow‐up in the dermatology clinics. Conclusions. In general, BCCs are managed according to BAD guidelines in Scotland, but waiting times vary considerably.     

Mast cells in melanocytic tumours

The importance of mast cells in local homeostasis, inflammation and tumour surveillance is supported by many studies, and the association of mast cells with various neoplasms has been known for a long time. The functional significance of mast cells surrounding tumours is currently unclear. In the present histopathological study, 16 naevi and 44 primary malignant melanomas were analysed. The follow-up time after primary surgery of malignant melanoma patients was almost 10 years, during which time half of the tumours had metastasized. The numbers of mast cells surrounding pigmented lesions were determined. The mast cells were visualized using a modified toluidine blue staining (pH 0.5; 24 h). Significantly different numbers of mast cells were found in naevi compared to melanomas (P=0.0013), but no significant correlation could be identified regarding prognostic parameters including tumour thickness and clinical outcome.     

Disease progression in patients with thin cutaneous melanomas (tumour thickness < or = 0.75 mm): clinical and epidemiological data from the Tumour Center Munich 1977-98

BACKGROUND: Although survival in patients with thin melanomas (tumour thickness < or = 0.75 mm) is usually excellent, thin melanomas have the potential to metastasize. OBJECTIVES: To determine risk factors for the development of disease progression in patients with thin cutaneous melanomas. METHODS: A retrospective study was performed between 1977 and 1998 to identify risk factors for the development of disease progression in 2302 patients with cutaneous melanoma with tumour thickness < or = 0.75 mm, diagnosed and treated at the Department of Dermatology and Allergology, Ludwig-Maximilians University, Munich, Germany. The Kaplan-Meier method was used to estimate the influence of different clinical characteristics for the occurrence of first progression during 10 years of follow-up. RESULTS: An analysis of the data from 6298 patients with cutaneous melanoma identified 2302 patients (37%) who presented with cutaneous melanoma with a tumour thickness < or = 0.75 mm, without clinical signs of metastasis at initial diagnosis (clinical stage Ia). A small subgroup of our patients (77 of 2302) developed metastatic disease during the follow-up period. The estimated rate of occurrence of metastasis after 10 years of follow-up was 4.7%. The mean follow-up time was 62 months (median 46). Of these 77 patients, 16 experienced progression at the primary tumour site and 32 presented with regional lymph node metastases. Twenty-eight patients primarily developed systemic metastases (seven patients with and 20 without regional lymph node metastases, one patient with regional lymph node metastases and local recurrence). In one patient the primary site of metastatic disease was not reported. Clinical characteristics included age, sex of the patient and different subtypes of cutaneous melanoma: superficial spreading melanoma, nodular melanoma, acrolentiginous melanoma (ALM) and lentigo maligna melanoma (LMM). Male patients and patients with LMM or ALM were significantly over-represented (P = 0.02 and P = 0.002). In the group of 77 patients with thin melanomas (< or = 0.75 mm), local recurrence was over-represented as compared with those with melanomas > 0.75 mm. No difference in group was found for overall survival after the occurrence of lymph node metastasis as the first manifestation of disease progression. CONCLUSIONS: Thorough follow-up and skin examination is recommended for a subgroup of patients with thin tumours, which consists of male patients with LMM or ALM located in the head and neck region.     

Dermatofibrosarcoma protuberans: a clinicopathological analysis of 10 cases in Asians

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive cutaneous neoplasm that exhibits a marked tendency for recurrence after local excision. This case series aims to study the clinical, histological and immunohistochemical features of DFSP in Asians. Ten patients with DFSP diagnosed between 1992 and 2001 were reviewed. There were more women than men in a ratio of 4:1. There were six Chinese, two Malays, one Indian and one Eurasian. The mean age was 38 years. The duration of each lesion before excision varied from 6 months to 27 years. Fifty per cent of tumours occurred on the trunk. On histology, all the lesions were dermal-centred spindle cell tumours, extending to the subcutis, and exhibited the characteristic storiform pattern. One tumour also demonstrated fibrosarcomatous changes. Two tumours were of the rare pigmented variant (Bednar tumour). Immunohistochemistry with CD34 was positive in all cases, except the fibrosarcomatous area of one tumour, which was negative for CD34. For comparison, six cases of deep-penetrating dermatofibroma were stained for CD34 and all showed an absence of CD34 expression. Wide excision of the tumour was performed in all cases of DFSP. There was no recurrence after mean follow up of 6 years (range 2.25-9.5 years).     

Immunocryosurgery for basal cell carcinoma: results of a pilot, prospective, open-label study of cryosurgery during continued imiquimod application

Background/aim  Theoretical considerations support the combination of cryosurgery and topical imiquimod to treat basal cell carcinomas (BCC). The aim of the present study was to test the feasibility and efficacy of 'cryosurgery during continued imiquimod application' ('immunocryosurgery') to treat 'high-risk-for-recurrence' BCCs.
Methods  Thirteen patients with 21 biopsy-proven tumours (4 of 21 relapses after prior surgery) were included. After 2–5 weeks (median, 3) of daily 5% imiquimod cream application, the tumours were treated by liquid N₂ cryosurgery (spray, two cycles, 10–20 s) and imiquimod was continued for additional 2–12 weeks (median, 4). The outcome after at least 18 months of follow-up (18–24 months) is currently reported.
Results  Nineteen of 21 tumours responded promptly to immunocryosurgery; two tumours required additional treatment cycles to clear. Thus, the clinical clearance rate was 100%. Only 1 of 21(5%) tumour relapsed after at least 18 months of follow-up (cumulative efficacy: 95%).
Conclusions  'Immunocryosurgery' is a promising non-surgical combination modality to treat 'high-risk-for-recurrence BCCs'. Initial evidence is suggestive of an at least additive effect of the two combined modalities. Further studies comparing immunocryosurgery directly with cryosurgery and imiquimod monotherapies will confirm the reported results.