Mohs Micrographic Excision of Melanoma Using Immunostains

BACKGROUND: Mohs excision of melanoma remains controversial, in part because of concerns regarding evaluation of frozen section margins. Several immunohistochemical stains are available for melanoma that can be used on frozen sections. OBJECTIVE: To review our experience with Mohs micrographic excision of melanoma using immunostains. METHODS: Sixty-eight patients were treated, including 46 with melanoma in situ and 22 with invasive melanoma, 62 of which were on the head or neck. HMB-45, MEL-5, Melan-A (A-103), and S-100 stains were employed. RESULTS: Sixty-seven of 68 tumors were excised to clear margins, requiring an average of 2.0 layers. Immunostains greatly enhanced detection of melanoma on frozen sections. The average margin required for clearance of in situ melanoma was 8.3 mm and of invasive melanoma was 11.1 mm. Only 23 of 46 (50%) in situ melanomas were clear with < or =6 mm margins; 15 mm margins were required to clear 96% of the tumors. Eleven of 22 (50%) invasive melanomas were clear with < or =6 mm margins; 26 mm margins were required to clear 95% of the tumors. Melan-A (A-103) was the most consistently crisp and easily interpreted immunostain. CONCLUSIONS: Mohs excision of melanoma using immunostains can be useful, especially for tumors on the head and neck. For routine excision, margins wider than those currently recommended may be required to ensure tumor clearance. We recommend that (1) biopsies be stained preoperatively for Melan-A and/or HMB-45, (2) a debulking layer be obtained for permanent sections prior to Mohs layers, and positive and negative control specimens from the tumor and distant skin should be employed for comparison of staining patterns. Large-scale prospective studies of in situ and invasive melanoma on the head and neck are necessary.     

Superficial Leiomyosarcoma Treated With Mohs Micrographic Surgery

BACKGROUND: Leiomyosarcoma (LMS) is a rare cutaneous malignancy with an infiltrative growth pattern and high risk of local recurrence (30-45%) with conventional wide excision. Mohs micrographic surgery (MMS) may offer an improved cure. OBJECTIVE: To illustrate by case reports the spectrum of clinical presentation of this rare neoplasm and management with MMS. METHODS: The outcomes of three cases of LMS treated by Mohs micrographic are described and compared with other cases in the medical literature. RESULTS: Three cases of LMS were excised using MMS. Two cutaneous tumors located on the trunk and arm were easily removed and have not recurred. The third tumor on the leg of an immunosuppressed patient demonstrated deep soft-tissue invasion that developed subsequent cutaneous metastases but no recurrence adjacent to the primary site. The patient remains disease free at 36 months after amputation below the knee. A total of 15 cases of LMS treated by MMS are reported in the literature, including these cases, with an aggregate recurrence rate of 13%. CONCLUSIONS: The overall cure rate of leiomyosarcoma treated by MMS is 87%, which compares favorably to wide excision and offers the advantage of tissue sparing. Immunosuppression may promote aggressive tumor behavior. Deeply invasive tumors may result in cutaneous or distant metastases regardless of the method of excision.     

Infantile Digital Fibroma Treated With Mohs Micrographic Surgery

BACKGROUND: Infantile digital fibroma (IDF) is a rare benign fibrous tumor of childhood that frequently recurs despite local excision. Conservative, nonsurgical management may result in regression and/or joint deformity. OBJECTIVE: To describe the histologic features of IDF and discuss a case excised using Mohs micrographic surgery (MMS). METHODS: Case report and review of the clinical, histologic, and ultrastructural features. RESULTS: Characteristic inclusion bodies of actin were identified with hematoxylin and eosin, Masson's trichrome, and rapid actin immunostain. The tumor was debulked and the majority was removed after one stage of MMS, except where the deep margin approached the joint space. The defect healed by secondary intention. At 2 years the patient had no recurrence or functional joint deformity. CONCLUSION: MMS is a surgical treatment option for IDF.     

Mohs Micrographic Surgery for Fungal Soft Tissue Infections

BACKGROUND: Invasive fungal infections of the integument are relatively rare. In the immunocompromised patient, however, they may show an extremely aggressive biological behavior despite high dosed topical or systemic antifungal therapy. As the fungal tissue invasion usually reaches well beyond the area of clinical necrosis or other visible changes, standard surgical excision often proves to be inadequate, resulting in the need for repeated relatively wide excisions with the resulting substantial loss of initially healthy tissues. OBJECTIVE: To present the use of Mohs surgery as a safe and effective treatment modality for invasive fungal infections in a patient with a zygomycetes infection of his scalp. RESULTS: The micrographic excision of the highly aggressive fungal infection, the acute postoperative course, and the delayed reconstruction with a split-thickness skin graft were all well tolerated without complications. CONCLUSION: Mohs micrographic excision deserves serious consideration in the treatment of aggressive localized fungal infections.     

Digital Photography for Mapping Mohs Micrographic Surgery Sections

BACKGROUND: Instant photographic print images have been used to diagram tissue sections excised for Mohs micrographic surgery (MMS). This approach is limited by the size of the print image, the potential difficulty of writing on a glossy photo print, and the cost of film. OBJECTIVE: We describe the use of digital photographic images as templates for making maps of tissue excised for MMS. METHODS: Digital photographic images of patients undergoing MMS are downloaded to a computer and printed onto plain paper. A map of the tissue excised for MMS is drawn directly onto the digital print. RESULTS: Several methods of creating MMS maps using digital photographic print images are described. CONCLUSION: Advantages of using digital photographs in MMS include speed of producing images, low cost of materials, greater accuracy of depicting the MMS excision defect, and ease of correlating the MMS map to the patient for subsequent stages of excision.     

Atypical Cellular Neurothekeoma Treated with Mohs Micrographic Surgery

BACKGROUND: Atypical cellular neurothekeoma is a rare neoplasm generally regarded as a benign tumor with locally aggressive behavior. Recurrence is common with inadequate excision, but metastatic disease has yet to be reported. OBJECTIVE: The objective was to report a case of atypical cellular neurothekeoma of the nasal ala in a young woman treated by Mohs micrographic surgery. The biologic behavior and histopathology will be reviewed. METHODS: Case report and review of the literature. RESULTS: The neoplasm was extirpated in a three-stage, five section Mohs surgery procedure. The resulting defect was repaired by a two-stage, pedicled nasolabial transposition flap with a cartilage graft taken from the ipsilateral ear. No clinical recurrence was noted after 6-months of follow-up. CONCLUSION: Mohs micrographic surgery is unsurpassed in its efficacy in treating a wide variety of nonmelanoma skin cancers. Although most commonly used to address basal and squamous cell carcinoma, it has also been reported as a successful treatment for melanoma and a wide variety of cutaneous malignancies. We discuss a case of atypical cellular neurothekeoma removed with the Mohs technique. Debate in the literature is ongoing regarding the true histogenesis of this rare tumor. Because of this tumor's local destructive behavior and propensity to recur with inadequate resection, we recommend Moths micrographic surgery for the treatment of cellular neurothekeomas.     

Mohs Micrographic Surgery for Squamoid Eccrine Ductal Carcinoma

Background. Squamoid eccrine ductal carcinoma is a rare cutaneous malignancy. There are no accepted standards for surgical margins in eccrine carcinomas.
Objective. We report a case of squamoid eccrine ductal carcinoma resembling squamous cell carcinoma and discuss Mohs micrographic surgery as a surgical modality for eccrine carcinomas.
Method. The patient was a 30-year-old Korean woman with a 4-year history of a nodule on her neck. Following primary diagnosis of squamous cell carcinoma by punch biopsy, the tumor was completely removed by Mohs micrographic surgery with a 2 mm cancer-free margin.
Result. A one-stage Mohs micrographic surgical procedure was performed, and the size of the tumor mass was 2.3 × 2.5 cm in width and 1.5 cm in depth. On histopathologic examination, the tumor was characterized by both eccrine and squamous differentiation. The squamous cells expressed epithelial membrane antigen and cytokeratin 5 and 6, and the cells forming ductal structures expressed anti–carcinoembryonic antigen. Although eccrine carcinomas show a generally aggressive clinical course, the patient was disease free at 14 months after surgery.
Discussion. Squamoid eccrine ductal carcinoma should be considered in the differential diagnosis of squamous cell carcinoma and other cutaneous adnexal neoplasms showing squamoid and ductal features of differentiation. In addition, Mohs micrographic surgery can be an option sufficient for complete surgical removal of eccrine carcinomas such as squamoid eccrine ductal carcinoma.
YONG JU KIM, MD, AE REE KIM, MD, PHD, AND DONG SOO YU, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Telepathology as an Aid in Mohs Micrographic Surgery

BACKGROUND: Mohs surgeons are occasionally confronted by challenging pathology ideally requiring the advice of a dermatopathologist. The Internet transmission of digital images of the pathology (telepathology) allows for such opinions to be easily and rapidly obtained. OBJECTIVE: The objective was to obtain images utilizing a digital camera focused directly through one microscope eyepiece with subsequent e-mail to a pathologist for an immediate opinion. METHODS: The particular area of interest on the slide is selected. The lens of the digital camera is placed directly on one eyepiece of the microscope and using the zoom and autofocus options of the camera a sharp image is obtained. The camera flash must be disabled. The images are immediately downloaded to computer and e-mailed to the pathologist for an opinion. RESULTS: Three case reports illustrate that the pathologist is able to offer suggestions on a diagnosis with a high degree of confidence using the e-mailed images. CONCLUSION: Digital camera technology now allows for images to be taken directly through an eyepiece of the microscope. These images can be almost instantaneously e-mailed to a pathologist anywhere in the world for an immediate opinion. The technique provides for greater surety where doubt exists about the pathology during Mohs surgery.     

Mohs Micrographic Surgery of a Plexiform Fibrohistiocytic Tumor

BACKGROUND: Plexiform fibrohistiocytic tumor (PFT) is a rare mesenchymal neoplasm first described by Enzinger and Zhang in 1988. Clinically it is characterized by slow growth, frequent local recurrences, and rare systemic metastasis. These tumors occur chiefly in children and young adults and are most commonly located on the shoulders and forearms. OBJECTIVE: To present a case report of an incompletely excised PFT, its complete resection using simple excision and Mohs micrographic surgery, and review of the literature. METHODS: An 11-year-old Hispanic girl was evaluated for the treatment of an incompletely excised plexiform fibrohistiocytic neoplasm located in the right axilla. Mohs micrographic surgery (MMS) was chosen because of the ill-defined borders and the need for tissue conservation. The patient underwent a two-stage, six section, micrographically controlled excision. Upon completion of the MMS a 2 mm final stage, taken as a peripheral and deep section around and underneath the cleared area, was submitted for paraffin embedding. Residual plexiform histiocytic tumor was found at the margin of resection in one location. Reevaluation of the Mohs slides demonstrated the possible presence of tumor at one deep focus. The tumor was reexcised with a 5 mm margin and repeat hematoxylin and eosin staining showed no residual tumor. There has been no evidence of recurrence in 4 years. RESULTS: Complete resection of the PFT and absence of tumor recurrence 4 years later. CONCLUSION: Over the past few years the list of neoplasms for which MMS is the treatment of choice has steadily grown. PFT is a recently described locally aggressive mesenchymal neoplasm with potential for distant metastasis. To our knowledge this is the first time MMS has been used to resect this tumor. To ensure the chance of complete extirpation we recommend the harvest of an additional stage for hematoxylin and eosin staining, as is done in some aggressive squamous cell carcinomas.     

Current Histologic Preparation Methods for Mohs Micrographic Surgery

BACKGROUND: Recently Mohs micrographic surgery, which is widely used for the removal of nonmelanoma skin cancers, has been used to remove lentigo maligna with both rush permanent sections and frozen sections. Several investigators have incorporated the use of immunohistochemical techniques to aid in the interpretation of the specimens. OBJECTIVE: To determine the current practices of Mohs surgery laboratories, including the use of immunostains and automation of laboratory processes. METHODS: A total of 108 laboratories responded to a written questionnaire with 13 items about the types of tumors resected, routine stains performed, average number of slides processed per day, and use of automation and immunostains. RESULTS: Forty-nine percent of the laboratories are completely manual and 51% are automated. The Linistainer automated system, which is the predominant one used, decreased processing time by about 30% and provided an estimated 21-30% improved quality. Automation was associated with the number of slides processed. Immunostaining is performed by a limited number of laboratories which use the technique for basal and squamous cell carcinoma, lentigo maligna, and dermatofibrosarcoma protuberans. CONCLUSION: Automation of routine slide preparation with a Linistainer decreased staining variability by providing a consistent environment, and decreased processing time. Most laboratories do not perform immunostaining. The relatively high cost of reagents, lack of a reliable automated process, the additional time to process specimens, and the additional technician and physician time makes the procedure impractical for many laboratories.     

Mohs Micrographic Surgery of a Papillary Eccrine Adenoma

BACKGROUND: Papillary eccrine adenoma (PEA) is a rare benign sweat gland neoplasm first described by Rulon and Helwig in 1977. Although these lesions typically behave in a benign fashion, PEA's on the volar surfaces may demonstrate more aggressive biologic behavior. Additionally, aggressive digital papillary adenomas (ADPA) may histologically simulate PEAs and behave in a more malignant fashion. OBJECTIVE: To present a case report of a patient with an incompletely excised PEA that was successfully extirpated using Mohs micrographic surgery (MMS). METHODS: A 51-year-old black woman was evaluated for the treatment of an incompletely excised PEA located on the dorsum of her left hand at the base of the thumb. Mohs micrographic surgery was felt to be the ideal treatment choice because of incomplete prior resections, ill-defined clinical borders, the need for conservative surgical excision to preserve sensory and motor function of the left hand, and the previously reported more aggressive nature of this tumor when located on volar surfaces. The patient underwent a two-stage, six section micrographically controlled excision using the fresh tissue technique. RESULTS: Complete resection of the PEA without significant damage to neurovascular structures. CONCLUSION: This case demonstrates the increasingly important role MMS is playing in the surgical management of a wide variety of cutaneous tumors. To our knowledge, this is the first time MMS has been used in the resection of a PEA.     

Mohs Micrographic Surgery for Angiolymphoid Hyperplasia with Eosinophilia

BACKGROUND: Angiolymphoid hyperplasia with eosinophilia is a benign vascular proliferation that typically presents on the head and neck. Multiple treatment modalities have been proposed for angiolymphoid hyperplasia with eosinophilia, each with limited success or undesirable side effects. At this time, standard surgical excision is considered the treatment of choice but carries recurrence rates of 33% to 50%. OBJECTIVE: The objective was to present a case of angiolymphoid hyperplasia with eosinophilia successfully extirpated using Mohs micrographic surgery. METHODS: A 52-year-old woman presented with an ill-defined solitary plaque of angiolymphoid hyperplasia with eosinophilia within her left conchal bowl that enlarged despite conservative therapy with intralesional and topical corticosteroids. Mohs micrographic surgery using the fresh tissue technique and standard hematoxylin and eosin staining was performed. The characteristic histologic features of angiolymphoid hyperplasia with eosinophilia were readily identifiable on frozen sections and complete extirpation required two stages of micrographically controlled resection. RESULTS: Resection of angiolymphoid hyperplasia with eosinophilia of the conchal bowl with complete resolution of symptoms and no evidence of clinical recurrence 8 months after surgery. CONCLUSION: Given the high recurrence rates reported for standard excision, Mohs micrographic surgery with complete margin examination should be considered as a treatment option for angiolymphoid hyperplasia with eosinophilia, particularly for lesions with ill-defined margins or in locations where tissue sparing is desirable.