Mohs surgery

Reconstruction of nasal defects presents a particularly unique challenge for the surgeon. Complex aesthetic subunits and limited available adjacent mobile skin with varying color, texture, and thickness all contribute to this task. The ideal reconstruction of nasal defects recruits tissue of similar color, texture, and thickness to that of the defect. Two versatile local flaps for nasal reconstruction are the glabellar flap and an extension of the glabellar flap, the dorsal nasal flap. The authors describe the use of these two local flaps for reconstruction of nasal defects and modifications of these procedures for certain indications, as well as their use in medial canthal reconstruction.

Background Basal-cell carcinoma (BCC) is the most common form of skin cancer and its incidence is still rising worldwide. Surgery is the most frequently used treatment for BCC, but large randomised controlled trials with 5-year follow-up to compare treatment modalities are rare. We did a prospective randomised controlled trial to compare the eff ectiveness of surgical excision with Mohs' micrographic surgery (MMS) for the treatment of primary and recurrent facial BCC.

BACKGROUND Lentigo maligna (LM) is a subtype of melanoma in situ that typically develops on sun-damaged skin. Presentation may be quite subtle and delayed diagnosis is common. Clinical margins are often ill defined. Histologic evaluation can be difficult due to the widespread atypical melanocytes that are present in the background of longstanding sun damage. Recurrence following standard therapies is common.

BACKGROUND. For dermatologists the preparation of frozen sections means micrographic surgery. The preparation of frozen sections is meant to be rapid, but has multiple, discrete steps that demand attention to detail. OBJECTIVE. The objective was to summarize both the proven and the cutting-edge techniques of frozen section preparation.

Sebaceous carcinoma of the ocular region is a malignant neoplasm that is being recognized more frequently and managed by innovative techniques of local resection, cryotherapy, topical chemotherapy, and radiotherapy, resulting in improved visual and systemic prognosis. (Surv Ophthalmol 50:103-122, 2005. Ć 2005 Elsevier Inc. All rights reserved.)

background. Post surgical scars can be erythematous, raised, pruritic and painful. Numerous modalities are available to improve the appearance and symptomatology of these scars. A topical onion gel extract is the newest in the armamentarium of scar treatments. The active ingredient in this gel is allium cepa. Published studies evaluating the usefulness of this gel in the treatment of scars are not available. objective. To evaluate the effectiveness of topical onion gel extract in improving the appearance and symptomatology of postsurgical scars and to compare the results of its use to those of a topical emollient ointment. methods. Seventeen patients with surgical scars resulting from Mohs surgery were assigned to 1 of 2 groups on the day of su-

Dermatofibrosarcoma protuberans (DFSP) is a rare superficial tumor characterized by high rates of local recurrence and low risk of metastasis. DFSP occurs most commonly on the trunk and proximal extremities, affects all races, and often develops between the second and fifth decade of life. The tumor grows slowly, typically over years. Histologically, several variants of DFSP have been described and should be well characterized to avoid misdiagnosis with other tumors. These include pigmented (Bednar tumor), myxoid, myoid, granular cell, sclerotic, atrophic DFSP, giant cell fibroblastoma, and DFSP with fibrosarcomatous areas. Of all these variants, only the DFSP with fibrosarcomatous areas is high grade, with a higher rate of local recurrence and distant metastasis. DFSP is genetically characterized by the t(17;22)(q22;q13), resulting in the fusion of alpha chain type 1 of collagen gene and platelet-derived growth factor beta gene. This translocation is present in 90% of DFSP and represents a very useful tool in the differential diagnosis of DFSP with other tumors with similar histology. The standard treatment is wide local excision with at least a 2-cm margin. However, local recurrence after apparently adequate surgical excision is well recognized. Mohs micrographic surgery would be the treatment of choice with a better cure rate and maximal conservation of tissue. When surgery is insufficient, clinical evidence has suggested that imatinib mesylate is a safe and effective treatment in DFSP, especially in cases of local advanced or metastatic disease. This article presents an overview of the state of the art in the clinicopathological management of this disease.

BACKGROUND The success of Mohs micrographic surgery (MMS) is contingent on high-quality frozen tissue sections for histologic interpretation. Laboratory assistive personnel (LAP) are central to this process, but their training and tissue processing techniques are neither standardized nor certified for competence.

Background: Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin with high rates of local recurrence. It is debated whether Mohs micrographic surgery (MMS) involves lower recurrence rates than wide local excision (WLE). Recent preliminary reports indicate more consistently favorable cure rates with MMS. We report comparative observational data on 41 patients who underwent MMS and 38 who underwent WLE. Their data were then pooled with those available in the medical literature to obtain more precise estimates of recurrence rates with MMS and WLE. Methods: The records of 79 patients with DFSP who underwent WLE (n = 38) or MMS (n = 41) in 1990-2005 were reviewed retrospectively. The primary endpoint was tumor recurrence rate. The PubMed database was searched for DFSP case series treated with WLE or MMS, and the recurrence proportions reported for the two separate procedures were pooled. Results: Five of the 38 WLE patients (follow-up = 4.8 years) had recurrences (13.2%, 95% CI 4.4-28.1%) as opposed to none (95% CI 0-8.6%) of the 41 MMS patients (follow-up = 5.4 years). Pooling of these data with those from the literature yielded 6/463 recurrences for MMS (1.3%, 95% CI 0.5-2.8%) and 288/1394 recurrences for WLE (20.7%, 95% CI 18.6-22.9%). The relative risk of recurrence for WLE vs. MMS patients was 15.9 (95% CI 7.2-35.5). Conclusions: Significantly lower recurrence rates were recorded in our patients subjected to MMS compared with those treated with WLE. The pooled data also indicated a clear advantage 0305-7372/$ -see front matter c

BACKGROUND. Primary cutaneous mucinous carcinoma is a rare adnexal malignancy with a high recurrence rate following conventional excision and the potential for aggressive local invasion. OBJECTIVE. To enhance the microscopic detection of mucinous carcinoma in Mohs micrographic surgical sections by incorporating rapid immunohistochemical staining. METHODS. Standard Mohs micrographic surgical technique was used in conjunction with frozen section immunohistochemistry using an antibody to low-molecular-weight cytokeratin. RESULTS. Rapid immunoperoxidase staining using low-molecular-weight cytokeratin detected residual foci of mucinous r

Dermatofibrosarcoma protuberans (DFSP) is a rare superficial tumor characterized by high rates of local recurrence and low risk of metastasis. DFSP occurs most commonly on the trunk and proximal extremities, affects all races, and often develops between the second and fifth decade of life. The tumor grows slowly, typically over years. Histologically, several variants of DFSP have been described and should be well characterized to avoid misdiagnosis with other tumors. These include pigmented (Bednar tumor), myxoid, myoid, granular cell, sclerotic, atrophic DFSP, giant cell fibroblastoma, and DFSP with fibrosarcomatous areas. Of all these variants, only the DFSP with fibrosarcomatous areas is high grade, with a higher rate of local recurrence and distant metastasis. DFSP is genetically characterized by the t(17;22)(q22;q13), resulting in the fusion of alpha chain type 1 of collagen gene and platelet-derived growth factor beta gene. This translocation is present in 90% of DFSP and represents a very useful tool in the differential diagnosis of DFSP with other tumors with similar histology. The standard treatment is wide local excision with at least a 2-cm margin. However, local recurrence after apparently adequate surgical excision is well recognized. Mohs micrographic surgery would be the treatment of choice with a better cure rate and maximal conservation of tissue. When surgery is insufficient, clinical evidence has suggested that imatinib mesylate is a safe and effective treatment in DFSP, especially in cases of local advanced or metastatic disease. This article presents an overview of the state of the art in the clinicopathological management of this disease.

Aims: To analyse the presence of collagen type I alpha 1platelet-derived growth factor beta (COL1A1-PDGFB) transcripts in 20 cases of dermatofibrosarcoma protuberans (DFSP) and to assess the relationship between COL1A1 breakpoints and clinical and histopathological variables. Methods and results: Multiplex reverse transcriptasepolymerase chain reaction was carried out using frozen tissue. Our series contained 14 men and six women. Histologically, most cases were of conventional type (n = 9), followed by fibrosarcoma (n = 4), Bednar tumour (n = 2), sclerosing (n = 2), myoid (n = 1) and atrophic (n = 1) DFSP, and giant cell fibroblastoma (n = 1). Immunohistochemistry revealed CD34 expres-sion in 90% of cases. COL1A1-PDGFB fusion transcripts were present in 89% of cases (exons 18, 19, 20, 25, 26, 31, 33 ⁄ 34, 39, 40, 46, 47 and 48 of COL1A1 with exon 2 of PDGFB). There was no recurrence of DFSP in any of the 19 patients treated by Mohs surgery. A partial response was obtained in the two patients treated with imatinib. Conclusions: The COL1A1-PDGFB fusion was present in all histological subtypes of DFSP, but not all cases expressed the fusion transcript. No association was observed between different COL1A1 breakpoints and clinicopathological parameters. Imatinib mesylate can be useful in locally advanced tumours and metastases.

Sebaceous carcinoma of the ocular region is a malignant neoplasm that is being recognized more frequently and managed by innovative techniques of local resection, cryotherapy, topical chemotherapy, and radiotherapy, resulting in improved visual and systemic prognosis.

BACKGROUND. Processing multiple tissue sections in large Mohs cases is time consuming and labor intensive. OBJECTIVE. To present innovative laboratory techniques to facilitate processing of large Mohs cases. METHODS. A method for processing a large dermatofibrosarcoma protuberans Mohs case is outlined. RESULTS. Modifications in tissue processing and equipment employed in a large Mohs case are presented. CONCLUSION. Innovative modifications to the standard Mohs laboratory technique can facilitate processing of large Mohs cases, resulting in high-quality, rapid frozen sections while optimizing efficiency.

FRANZCO • PURPOSE: To analyze the outcome of management of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) in a tertiary referral eye center in Sydney, Australia. • DESIGN: Retrospective case series. • METHODS: Review of medical records of 485 consecutive cases (469 patients) with confirmed eyelid cancer. INTERVENTION PROCEDURES: Surgical excision with 3-to 5-mm clinically clear margins and histologic confirmation of the surgical margins. Frozen section histology or Mohs' micrographic surgery (MMS) was used for incompletely excised cases, and those located in the medial canthus or close to the lacrimal drainage system. Standard reconstruction techniques were employed. MAIN OUTCOME MEA-SURES: Survival period free of tumor, incomplete excision, recurrences, type of closure, and complications.

A 72-year-old woman presented with a basal cell carcinoma of the left lateral nasal ala measuring 1.0 Â 1.3 cm. The tumor was excised with Mohs micrographic surgery. Two stages were required to clear the tumor, resulting in the full-thickness defect pictured below, measuring 1.9 Â 1.5 cm ). How would you repair this defect?

Sebaceous carcinoma of the ocular region is a malignant neoplasm that is being recognized more frequently and managed by innovative techniques of local resection, cryotherapy, topical chemotherapy, and radiotherapy, resulting in improved visual and systemic prognosis. (Surv Ophthalmol 50:103-122, 2005. Ć 2005 Elsevier Inc. All rights reserved.)

Eleven patients (6%) had IFS positive for carcinoma, whereas another 25 (14%) had benign prostatic tissue in the IFS specimen. • IFS and non-IFS patients had similar pathological and nerve-sparing characteristics. • The IFS group had significantly lower rates of positive surgical margins, 7% vs 18% ( P = 0.001) but similar rates of biochemical recurrence (5%) at a median follow-up of 11 months.

BACKGROUND. Curettage prior to excision and Mohs' micrographic surgery for nonmelanoma skin cancer is performed based on the assumption that the curette will remove softer, more friable tumor-infiltrated dermis and leave structurally intact normal skin. This assumption, however, has not been objectively examined in the dermatologic surgery literature. OBJECTIVE. We performed a study to examine the ability of curettage to selectively remove and delineate nonmelanoma skin cancer prior to Mohs' micrographic surgery. METHODS. The study included 150 previously biopsied basal cell and squamous cell carcinomas less than 1.5 cm in size. We conducted (1) a retrospective study of 50 tumors curetted prior to Mohs' surgery by a surgeon who routinely curettes preoperatively;

Background Dermatofibrosarcoma protuberans (DFSP) is an uncommon intermediategrade 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 cm 2 , and mean defect size was 12.65 cm 2 , yielding a difference of 7.49 cm 2 and a ratio (defect size/lesion size) of 2.45. No tumors recurred after MMS.

Introduction: Basal cell carcinoma is the most common tumor of the eyelid. In this region, reconstruction is complex and damage to healthy tissue should be minimal. Objective: To define the relationship between margin clearance at excision and the recurrence rate of basal cell carcinoma of the eyelid. Methods: This prospective study was conducted with 111 patients submitted to surgery for basal cell carcinoma of the eyelid between 2001 and 2003 and followed up for a period of five years. The patients were evaluated according to age, tumor site, recurrence rate and margin clearance at excision. Results: No significant association was found between incomplete tumor excision and recurrence except in patients under 56 years of age, female patients and in the case of tumors of the medial canthus. Conclusion: A risk of recurrence in incompletely excised basal cell carcinomas of the eyelid was only confirmed in younger patients, females and for tumors of the medial canthus.

Sebaceous carcinoma of the ocular region is a malignant neoplasm that is being recognized more frequently and managed by innovative techniques of local resection, cryotherapy, topical chemotherapy, and radiotherapy, resulting in improved visual and systemic prognosis. (Surv Ophthalmol 50:103-122, 2005. Ć 2005 Elsevier Inc. All rights reserved.)

Background. Extramammary Paget's disease is a rare cutaneous adenocarcinoma that occurs in an apocrine gland distribution mainly in the anogenital region.Objective. To formulate treatment recommendations for this rare disease, we examined clinical and follow-up data of patients with it.Methods. A retrospective review is given about the treatment and outcome for 95 patients at Mayo Clinic, Rochester, Minnesota, and Scottsdale, Arizona, between 1976 and 2001. The literature regarding diagnosis and treatment of this disease is also reviewed.Results. Of the 95 patients, 86 had primary disease and 9 had recurrent disease. At mean follow-up (wide excision, 65 months; Mohs surgery, 24 months), disease had recurred in 18 of 83 (22%) who underwent standard wide excision, compared with recurrence in 1 of 12 (8%) who had the Mohs micrographic excision.Conclusion. Mohs micrographic surgery compares favorably with wide excision. Intraoperative immunostaining with cytokeratin 7 is helpful in delineating disease, as are preoperative scouting biopsies and photodynamic diagnosis.

As the width of surgical margins declines, histologic evaluation of the margins is needed to assess the completeness of excision of a malignant melanoma. We studied 221 specimens in 59 patients and compared the interpretations of frozen and paraffin sections from the same block. Frozen sections had a sensitivity of 100% in detecting melanoma when present and a specificity of 90%. (J AM ACAD DV.RMATOL 1991;24:102-6.)

BACKGROUND Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins.OBJECTIVE The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure.METHODS Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group.RESULTS Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P=0.029) and in transplant recipients (P=0.55).CONCLUSION Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.

FRANZCO • PURPOSE: To analyze the outcome of management of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) in a tertiary referral eye center in Sydney, Australia. • DESIGN: Retrospective case series. • METHODS: Review of medical records of 485 consecutive cases (469 patients) with confirmed eyelid cancer. INTERVENTION PROCEDURES: Surgical excision with 3-to 5-mm clinically clear margins and histologic confirmation of the surgical margins. Frozen section histology or Mohs' micrographic surgery (MMS) was used for incompletely excised cases, and those located in the medial canthus or close to the lacrimal drainage system. Standard reconstruction techniques were employed. MAIN OUTCOME MEA-SURES: Survival period free of tumor, incomplete excision, recurrences, type of closure, and complications.

BACKGROUND. Incomplete resection of nonmelanoma skin cancer is associated with a relatively high rate of recurrent tumors. Mohs micrographic surgery provides microscopic evaluation of tumor margins to ensure complete excision of nonmelanoma skin cancers at high risk of recurrence.