A retrospective study of outcome of Mohs' micrographic surgery for cutaneous squamous cell carcinoma using formalin fixed sections

The surgical management of recurrent or large squamous cell carcinoma (SCC) can be challenging as tumours often extend beyond visible margins. Micrographic surgery is a potentially effective method of ensuring complete clearance of tumour. A retrospective study of all cases of SCC treated by micrographic surgery in this department between 1986 and 1996 has been done. Sixty-one patients were treated using a formalin-fixed paraffin-embedded tissue technique with a median follow-up of 4 years. In two cases there was local recurrence and in three others metastasis to local lymph nodes. The overall cure rate was 92% (56 of 61), which compares favourably with published series using chemosurgery and frozen tissue techniques. The results show that this technique of micrographic surgery is a satisfactory and cost-effective alternative to conventional frozen section techniques in the treatment of SCC. The formalin-fixed tissue method has the advantage of providing high-quality permanent histological sections using existing conventional pathology services.     

An overview of Mohs micrographic surgery for the treatment of basal cell carcinoma

This article reviews Mohs micrographic surgery for basal cell carcinoma. Its evolution to the present day technique, indications, and limitations are discussed, along with future expectations for the procedure.     

Terahertz pulsed imaging of basal cell carcinoma ex vivo and in vivo

BACKGROUND: Terahertz radiation lies between the infrared and microwave regions of the electromagnetic spectrum and can be used to excite large amplitude vibrational modes of molecules and probe the weak interactions between them. Terahertz pulsed imaging (TPI) is a noninvasive imaging technique that utilises this radiation. OBJECTIVES: To determine whether TPI could differentiate between basal cell carcinoma (BCC) and normal tissue and to test whether it can help facilitate delineation of tumour margins prior to surgery. METHODS: A portable TPI system was used in the clinic to image 18 BCCs ex vivo and five in vivo. RESULTS: The diseased tissue showed a change in terahertz properties compared with normal tissue, manifested through a broadening of the reflected terahertz pulse. Regions of disease identified in the terahertz image correlated well with histology. CONCLUSIONS: This study has confirmed the potential of TPI to identify the extent of BCC in vivo and to delineate tumour margins. Further clinical study of TPI as a surgical tool is now required.     

Treatment of 208 extensive basal cell carcinomas with Mohs micrographic surgery

Aim With the rapidly increasing number of basal cell carcinomas in Europe, a close look at Mohs Micrographic Surgery (MMS) is timely. Subject We report the results of MMS in the Netherlands, as treatment for extensive basal cell carcinomas. Methods Patients (n= 198) with extensive basal cell carcinoma (n= 208) were treated with MMS. The mean follow up period was 6.4 years. Results Four of 208 BCCs recurred. Conclusions Considering a recurrence rate of only 2% for the treatment of extensive and mainly recurrent basal cell carcinomas, we suggest that MMS provides the best prospect for total tumour removal.     

Mohs' micrographic surgery for basal cell carcinoma

Mohs' surgery for basal cell carcinoma (BCC) is widely recommended by dermatologists as first line surgical therapy for recurrent or ill-defined skin tumours. The technique assumes that BCC spread by contiguous growth and that all tumour cells have to be removed. Advocates claim that Mohs' surgery provides a better chance of cure, and because less uninvolved tissue is excised the smaller defect can be readily closed resulting in a superior cosmetic result. This review examines the evidence for these claims.     

MOHS micrographic surgery for head and neck nonmelanoma skin cancer: An approach for ENT surgeons

Surgery is the main approach for skin cancer, with Mohs micrographic surgery (MMS) allowing the highest cure rates, best esthetics and superior functional outcomes. Ear, nose, and throat (ENT) surgeons are often challenged with patients presenting skin cancer, needing appropriate expertise to its adequate management. This paper highlights the most important aspects of MMS, enabling ENT surgeons to become familiar with its fundamental aspects. A review of the literature was performed, concomitantly presenting the author's outcomes as an ENT surgeon. A total of 51 MMSs were performed in 41 patients, and 78.4% of the tumors were cutaneous basal cell carcinomas (cBCCs), 19.6% were cutaneous squamous cell carcinomas (cSCCs), and one case was a microcystic adnexal carcinoma. Most tumors were located in high‐risk areas (88.2%), and 84.3% of them were ≥10 mm in diameter. Most tumors (90.2%) required no more than two MMS excision steps to be completely removed. All cases were managed by reconstruction either using flaps or grafts. Recurrence occurred in only 2% of the cases. This study addressed the main issues of MMS, which may be important in ENT surgeons' daily practice.     

Treatment of basal cell carcinoma

Basal cell carcinoma is the most common tumor in Central Europe, the U.S. and Australia. The increasing incidence of basal cell carcinoma presents the health care system, especially dermatology, with great challenges. In recent years new options for treating basal cell carcinoma have become available, enriching our therapeutic options. We review the current status of each of these treatment approaches.     

Histological evaluation of residual basal cell carcinoma after shave biopsy prior to Mohs micrographic surgery

Background Patients who are referred for Mohs surgery after pre‐operative biopsy has been performed show in some cases no clinical or pathological evidence of tumour persistence. We have previously shown that 25% of these patients show no residual skin cancer either basal cell carcinoma or squamous cell carcinoma. The reasons for ‘disappearance’ of the tumour may be true non‐persistence or false non‐persistence because of wrong‐site Mohs surgery. Objective To determine the incidence of residual basal cell carcinoma after shave biopsy of primary nodular basal cell carcinoma prior to Mohs micrographic surgery. Methods A prospective unblinded study was performed on patients undergoing Mohs surgery for primary nodular basal cell carcinoma. The tumour was removed as a shaved excision using a No. 15 blade at the clinical borders like a shave biopsy (Mohs shave). The bases of the tumors were excised and then sectioned vertically at the middle and cut to the periphery at 10–15 μm intervals till the edge. Results Fifty‐one patients were evaluated. In 40 patients, residual basal cell carcinoma was found at the base of the shave excision site (78.4%). Conclusions Pre‐operative shave biopsy performed during Mohs surgery for primary nodular basal cell carcinoma is ‘curative’ in 22% of the patients.     

Mohs' micrographic surgery using frozen sections alone may be unsuitable for detecting single atypical melanocytes at the margins of melanoma in situ

BACKGROUND: It remains questionable whether micrographic surgery with frozen sections is an appropriate technique for excision of melanoma in situ (MIS) of the lentigo maligna type. Advocates of the technique have interpreted MIS as being histologically defined by nests and contiguous atypical melanocytes on the basal layer. Others, however, have viewed the periphery of MIS as consisting of scattered single atypical melanocytes, a finding that may be difficult or impossible to establish on frozen sections. OBJECTIVES: To examine the reliability of micrographic surgery using frozen sections interpreted by an experienced Mohs' surgeon, in the excision of MIS. METHODS: From a total of 154 specimens, frozen sections from the 50 specimens with margins that were considered difficult to interpret were thawed, sent for routine processing and then examined 'blind' by a dermatopathologist. RESULTS: Using the dermatopathologist's report on paraffin-embedded sections as a reference point, the sensitivity and specificity of frozen sections were calculated to be 59% and 81%, respectively. CONCLUSIONS: Using these histological criteria, micrographic surgery with frozen sections alone is unreliable in the excision of MIS.     

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.     

Risk factors for recurrence in cutaneous squamous cell carcinoma after Mohs micrographic surgery: A retrospective review of 237 Asian patients

Even after complete removal with Mohs micrographic surgery (MMS), cutaneous squamous cell carcinoma (cSCC) may recur; however, information about risk factors for recurrence in Asian patients is limited. This retrospective study reviewed cSCC patients treated with MMS at a single tertiary referral center from 2000 to 2017. Two hundred and thirty-seven patients were included and 36 showed recurrence (20 with local recurrence, 16 with distant metastasis). History of organ transplantation, diabetes, other malignancies and poorly differentiated histology correlated with cSCC recurrence. History of organ transplantation and cryotherapy at the cSCC site were related to higher local recurrence rates, and poor differentiation related to higher distant metastasis in Asian cSCC patients treated with MMS.     

Use of 5% imiquimod cream in the treatment of facial basal cell carcinoma: a 3-year retrospective follow-up study

There has been considerable research into the safety and efficacy of topical 5% imiquimod cream for the treatment of skin cancers in recent years, in particular superficial and nodular basal cell carcinomas. However, there are limited long-term follow-up studies. This retrospective study aims to determine the efficacy of 5% imiquimod cream in the treatment of facial basal cell carcinomas over 3 years. Medical records of 12 patients treated with 5% imiquimod cream at a private dermatology practice during 2001 and 2002 were retrospectively reviewed. Target tumours included superficial and nodular basal cell carcinomas, giving a total lesion number of 19. Patients were commenced on a once daily treatment regimen for up to 9 weeks, and given rest periods as required according to the severity of application site reactions. We found that 5% imiquimod cream is an effective treatment option for superficial and nodular basal cell carcinomas, giving a clearance rate of 89.5% at an average of 39 months of follow up.     

Cutaneous basal cell carcinosarcoma: case report and literature review

Carcinosarcomas are malignant neoplasms with biphasic carcinomatous and sarcomatous or sarcoma‐like components. In general, the sarcomatous component is accepted to be the result of divergent mesenchymal differentiation of the epithelial component. Although well characterized in some anatomic locations (e.g. uterus, upper aerodigestive tract and lung), carcinosarcomas of the skin are rare. Reported epithelial components include squamous, adnexal, neuroendocrine and basaloid. Including this case, only 47 cases of primary cutaneous basal cell carcinosarcoma have been reported in the literature to date. We performed an extensive immunophenotypic evaluation in our case, which confirmed the previously reported coexpression of p53 in both components, and revealed a hitherto unreported coexpression of p16 and p63. Additionally, this report reviews the clinical, pathologic, immunophenotypic characteristics and outcomes of the basal cell carcinosarcomas reported in the literature, in order to emphasize the overall uniform characteristics and clinical behavior of this neoplasm.     

Photodynamic therapy for the treatment of a giant superficial basal cell carcinoma

A 74-year-old man was referred to our department for the treatment of a 15 × 15 cm superficial basal cell carcinoma (BCC) on his lumbar region. As surgical excision was considered too destructive, photodynamic therapy (PDT) was proposed. Methyl 5-aminolevulinate (MAL) cream was applied under occlusion for 3 h before illumination with a light-emitting diode lamp with an emission peak of 632 nm, a fluence rate of 83.3 mW/cm, and a light dose of 37 J/cm. A second MAL-PDT session was repeated 1 week later. The neoplastic area healed in 30 days. No recurrence has occurred after a 40-month follow-up period, but clinical observation continues. Although surgery still remains the treatment of choice for giant BCC, for which the local invasiveness and metastatic potential are well known, we offered our patient the option of PDT because we believed that classical surgery could hardly provide the same satisfactory outcome. As far as we know, this is the first case of giant BCC treated with PDT.     

Metastatic basal cell carcinoma: case series and review of the literature

Metastatic basal cell carcinoma is exceedingly uncommon, with a poorly defined natural history, and its incidence, risk factors, patterns of spread, prognosis and potential treatment options are not well understood. This retrospective single institution case series aims to shed light on these issues. Aggressive local management in patients with locoregional disease may result in long‐term survivors.     

改良Mohs显微描记手术26例分析

目的　观察改良Mohs显微描记手术治疗皮肤癌的临床疗效。方法　沿皮损外约2mm～4mm切除病灶,用数码相机拍下切除组织的位置及形状,并即时打印,将送检的组织在打印图纸上及病人身上相对应的位置作相同的记号。然后按Mohs显微描记手术其他步骤进行。结果　26例患者经改良Mohs显微描记手术治疗,所有切口均Ⅰ期愈合,皮片或皮瓣均成活,随访1个月～2年,除一例头皮复发性鳞状细胞癌术后一月复发外,余患者均治愈,肿瘤无复发。结论　改良Mohs显微描记手术可指导手术医生更精确地控制扩大切除的范围,在根治肿瘤的同时最大限度的保留正常组织,为下一步的成形修复创造最佳条件。     

Mohs外科手术治疗颜面皮肤恶性肿瘤31例疗效观察

目的：探讨颜面部皮肤恶性肿瘤的皮肤外科手术治疗方法。方法：应用Mohs外科手术切除25例颜面皮肤基底细胞癌和6例皮肤鳞状细胞癌。结果：31例患者切口均Ⅰ期愈合，其中采用局部转移皮瓣者16例，全厚皮片移植者10例，其余患者采用直接缝合。术后随访4—26个月，患者均对手术后的外形满意，美容效果好，眼、耳、鼻未见损害，肿瘤无复发。结论：Mohs外科手术治疗颜面部皮肤恶性肿瘤具有损伤小、美容效果好、复发率低和安全性好的优点。     

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.