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.     

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.     

Utility of the quadrilobe flap for repairing defects of the nasal tip

The quadrilobe flap allows the mobilisation of the skin of the upper nose and nasofacial sulcus to the distal nose while avoiding unfavourable tension vectors that would distort the free margin of the ala. We report our experience over the past 3 years in the first case series of quadrilobe flaps for repair of surgical defects on the nose.     

Erythroplasia of Queyrat treated with topical methyl aminolevulinate photodynamic therapy

An 82-year-old man presented with invasive squamous cell carcinoma of the glans penis arising in erythroplasia of Queyrat. He underwent Mohs' micrographic surgery for the invasive carcinoma. Seven weeks later, the residual erythroplasia of Queyrat was treated using photodynamic therapy. Methyl aminolevulinate cream was applied to the glans of the penis under occlusion for 3 hours and then, after local anaesthesia, irradiated with a 630-nm red-light-emitting diode lamp at a dose of 37 J/cm(2) for 8 min. The patient experienced some mild swelling, redness and pain, which subsided over the following 5 days. Eighteen weeks after photodynamic therapy, there had been no recurrence of the lesion, when the patient died from an unrelated cause.     

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。     

Radiotherapy of carcinomas of the skin overlying the cartilage of the nose: our experience in 671 lesions

Background  The skin overlying the nose cartilage is a particularly frequent localization of skin carcinoma (about 25% of all carcinomas occurring on the head and neck). It is therefore of great practical interest to identify the best therapy, able to combine effectiveness with a good cosmetic and functional result.
Objective  To verify both the therapeutic effectiveness of dermatologic radiotherapy and its 'toxicity' in the treatment of a large number of skin carcinomas overlying the cartilage of the nose.
Methods  A retrospective study was done on 671 basal and squamous cell carcinomas treated by kilovoltage radiotherapy in the period 1972–2007.
Results  The mean follow-up time was 38.016 months (range, 1–351 months). The 5-year cure rate was 88.09%. Cosmetic results were evaluated as 'good' or 'acceptable' in 96.84% of the treated lesions in complete remission. So far, no complication or sequelae to the radiologic treatment have been observed.
Conclusion  Dermatologic radiotherapy showed to be a safe, effective and non-invasive method, superior, on the basis of the literature data, to any other available therapeutic modality in the management of basal and squamous cell skin carcinomas localized over the nasal cartilages.     

Characteristics of skin cancers among adult patients in an urban Malaysian population

There has been a rising incidence of skin cancers among Asians in recent years. We present a retrospective analysis of 106 skin cancers and analysed the demography, clinical subtypes of skin cancers and surgical techniques used for skin cancer treatment. In our population, skin cancers were most frequently basal cell carcinomas and diagnosed among ethnic Chinese patients.     

Cutaneous squamous cell carcinoma of the scalp extending to the skull: A case report and review of the literature

Squamous cell carcinoma (SCC) of the scalp has increased prevalence in older patients and often presents later in life. Mohs micrographic surgery remains the most effective treatment in most cases. Delayed presentation may result in localized bony invasion or distant metastases. We present a case of an elderly woman presenting with extension of SCC into the parietal bone of the skull.     

Keratoacanthoma with perineural invasion: a report of 40 cases

Keratoacanthoma is a unique clinicopathological entity, despite a recent trend to regard it as a variant of squamous cell carcinoma. The occurrence of perineural invasion is an uncommon phenomenon in keratoacanthomas, with a predilection for lesions on the face. We studied a series of 40 cases of keratoacanthoma in which perineural invasion occurred. Of the 40 cases, 27 were from the head or neck region. We found no metastasis or direct death attributable to the presence of perineural invasion in the 35 cases in our series for whom follow-up data were available. In only one case did local recurrence occur and this was not considered by the authors to be directly attributable to the presence of perineural invasion. These findings add further support to the notion that keratoacanthoma is biologically different from squamous cell carcinoma.     

Management of squamous cell and basal cell carcinomas of the head and neck with perineural invasion

Perineural invasion (PNI) occurring in non‐melanoma skin cancers (NMSC) is associated with an increased risk of locoregional recurrence and reduced disease‐free survival. This necessitates early and accurate diagnosis, appropriate risk‐stratification and a clear management strategy. The diagnosis of PNI is based on careful clinical assessment, imaging and histopathology. Surgery, preferably with margin control, and definitive or adjuvant radiotherapy (ART) are established treatment strategies for PNI. Clinical uncertainty remains over the role of ART in incidental PNI. This review synthesises current literature to ascertain which clinicopathological features impart a higher risk to individuals with PNI in NMSC, in order to provide treatment algorithms, including the identification of patient subsets that are most likely to benefit from ART. This includes those with extratumoural PNI, involvement of larger‐calibre nerves, tumour invasion beyond dermis, recurrent tumour or diffuse intratumoural spread. Patients with clinical PNI may be optimally managed by a multidisciplinary head and neck cancer service that is best placed to offer skull base surgery and intensity‐modulated radiation therapy (IMRT). The management options presented are stratified by histological subtype and a new classification of PNI into low‐risk, medium‐risk and high‐risk groups.     

Bowen's disease of the nail bed

A 77-year-old man presented with a 2-year history of left thumbnail dystrophy, purulent discharge and aching pain. There was no history of trauma. On examination there was a linear area of nail dystrophy and dyschromia of the nail bed. The nail plate was thinned proximally. No other digits were affected. There was no lymphadenopathy. X-ray of the digit was normal. Longitudinal nail biopsy revealed Bowen's disease along the length of the nail bed and nail matrix specimen. After avulsion of the nail plate, the nail matrix and tumour were fully excised. The defect was repaired with a split-skin graft. His symptoms were relieved.     

The role of radiotherapy in the management of non-melanoma skin cancer

The global incidence of non-melanoma skin cancer continues to increase as the global population ages with the highest incidence in the world occurring in Australian and New Zealand patients. There are numerous treatment options available for non-melanoma skin cancer patients of which radiotherapy is an efficacious and versatile tissue preserving non-surgical (or medical) option. In patients where excision may not be an option (medically/technically inoperable) or considered less ideal (e.g. cosmetic outcome), radiotherapy offers an excellent option. Following surgery, adjuvant radiotherapy in patients with unfavourable pathology can decrease the risk of recurrence and associated morbidity. Elderly and co-morbid patients with poor performance status can benefit from short-course hypofractionated radiotherapy in the setting where surgery is not an option. As with any modality, radiotherapy has advantages and disadvantages and it is therefore important for clinicians to appreciate these. We aim to present an update for clinicians that manage patients with non-melanoma skin cancer on the role of radiotherapy.     

Malignant transformation of leg ulcers: a retrospective study of 85 cases

Background  Malignant transformation remains a rare, under-recognized and ominous, complication of leg ulcers, although its exact prevalence is unknown.
Patients and methods  This retrospective French study included cases of chronic ulcers of vascular origin complicated by histologically proven carcinomas. For squamous cell carcinomas (SCC), the duration of the ulcer had to be longer than 3 years. For basal cell carcinomas (BCC), a negative previous biopsy of the ulcer was considered.
Results  Eighty patients, accounting for 85 tumours, were included, with a female : male ratio of 2.5 : 1 and a mean age of 75 years. Eighty-eight percent of the ulcers were of venous origin and their mean duration was 27.5 years. Five patients developed bilateral cancers. Clinical findings included abnormal granulation tissue in 76% of cases, absence of healing in 14% and unusual extension in 6%. Histologically, 83/85 (98%) of tumours were SCC, among which 82% were very well or well differentiated and 18% moderately or poorly differentiated. The two remaining cases were BCC. The overall death rate was 32%; it was higher when lymph-node (66%) or visceral metastases (83%) were present. Leg amputation was performed in 29/51 (57%) of patients, irrespective of the degree of histological differentiation. For well-differentiated (grade I) and localized (stage Ia) SCC, simple surgical excision was preferred to amputation.
Conclusion  Malignant transformation of chronic leg ulcers of vascular origin is mainly encountered in elderly patients and manifests as an abnormally vegetating lesion, which may be occasionally bilateral. Malignant transformation usually occurs towards well-differentiated SCC and only exceptionally towards BCC. The high death rate, especially in metastatic cases, is at least partly due to delay in diagnosis. Surgery remains the treatment of choice. Leg amputation should be considered in the most extensive cases.     

Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions

Summary Nonmelanoma skin cancer (NMSC) is the most common malignancy occurring in white populations. It is currently becoming an important challenge in terms of public health management as the increasing incidence rates will probably have a tremendous impact on healthcare costs. Possible factors driving this rise in NMSC numbers are increases in both acute and prolonged UV exposure together with increasing numbers of older people in the population. A better understanding of NMSC epidemiology in Europe is essential if an evidence-based European-wide public health policy is to be developed. It is obvious this can only be achieved by recording and analysing comparative epidemiological data. Finally, by improving the skin examination training for physicians, developing guidelines and exchanging best practices, a high level of healthcare could be provided for NMSC.     

Histopathologic features of multiple cutaneous squamous cell carcinomas of the lower extremity

Recent studies suggest cutaneous squamous cell carcinomas (SCCs) of the leg, particularly those occurring multiply in sun exposed skin of nonimmunosuppressed women, are a distinct clinical subtype. There are few reports of the histopathologic features of this subtype. A retrospective chart review of 4 patients with multiple SCCs on the leg was performed and a total of 35 biopsies from the legs examined. Histopathologically, the tumors lacked adjacent actinic keratosis (AK) and often had adjacent basaloid retiform proliferations. Most lesions (all but one) were well differentiated and about 40% could be classified histopathologically as keratoacanthoma. Perineural invasion was absent in all but one case. Using the American Joint Committee on Cancer (AJCC) staging criteria for SCC, 21 tumors were Stage I, and 9 Stage II. During 7–10 years of follow‐up, no recurrence or metastasis occurred. Patients with multiple SCCs on the lower extremities can have a range of histopathologic features, from keratoacanthoma‐like to well‐differentiated SCC.