Excision margins for melanoma in situ on the head and neck-A single-center 10-year retrospective review of treatment with Mohs micrographic surgery.

BACKGROUND: Although current guidelines recommend a 5 mm surgical margin for the excision of melanoma in situ (MIS), increasing evidence has shown this may be suboptimal to achieve tumor clearance. OBJECTIVE: To evaluate margins required for optimal cure rates with excision of MIS on the head and neck and investigate tumor and/or patient factors in those requiring >5 mm margins to achieve tumor clearance. METHODS: A retrospective chart review was performed on 846 (807 primary and 39 recurrent) MIS cases on the head and neck treated in the authors' dermatologic surgery department over a 126-month (10.5 year) period. RESULTS: Sixty-two percent were cleared with 5 mm margins. A total of 15 mm margins were required to achieve a 97% clearance rate. Difference in clearance rate between margin thresholds was significant (P < .001). Tumor location on the cheek and larger preoperative size correlated with requiring >5 mm margins to achieve tumor clearance (P = .006 and P = .001, respectively). LIMITATIONS: This is a single-center retrospective study which relies on accurate documentation of clinical data. CONCLUSION: This study demonstrates that MIS on the head and neck often requires margins >5 mm margins to achieve tumor clearance. When Mohs micrographic surgery is not possible, excision margins of ≥10 mm are likely necessary for head and neck tumors.

Factors predicting outcomes of patients with high-risk squamous cell carcinoma treated with Mohs micrographic surgery.

BACKGROUND: There is limited literature on the long-term outcomes and prognostic factors of high-risk cutaneous squamous cell carcinomas (hrSCC) treated with Mohs micrographic surgery (MMS). OBJECTIVE: To determine the rates of local recurrence, metastatic disease, and disease-specific death in hrSCCs treated with MMS and patient or tumor factors associated with poor outcomes. METHODS: Single-institution, retrospective cohort analysis of hrSCC treated with MMS alone and MMS with adjuvant therapy. RESULTS: A total of 882 cases of hrSCC treated with MMS were identified, of which 842 were treated with MMS alone, with a median follow-up time of 2.4 years. The rate of local recurrence was 2.5%, of metastatic disease was 1.9%, and of disease-specific death was 0.57%. Perineural invasion, poor differentiation, and immunosuppression were significantly associated with poor outcomes. In propensity score-matched case patients treated with adjuvant therapy and control patients treated with Mohs alone, there was no significant difference in progression-free survival, but matching was imperfect. LIMITATIONS: Single-institution, retrospective review. CONCLUSIONS: MMS remains an effective treatment for hrSCC. Current SCC staging systems may be limited by inconsistent inclusion of poor differentiation. Immunosuppression, especially transplant, should be considered a high-risk clinical feature. Further study is needed on the effect of adjuvant treatment.

Nail Unit Melanoma In Situ Treated With Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is under used in the treatment of nail unit melanoma in situ (MIS), with limited studies in the literature. OBJECTIVE: Report clinical outcomes for nail unit MIS using MMS with melanoma antigen recognized by T cells-1 (MART-1) immunostaining. METHODS: A retrospective observational study at a single academic institution of patients with a diagnosis of nail unit MIS treated with MMS with MART-1 immunostaining from January 1, 2006, to December 30, 2016. The primary outcome measure was the recurrence rate after MMS. RESULTS: Fourteen patients were identified. With an average follow-up of 6.0 years (71.6 months; range = 5-139 months), 1 patient developed recurrence 6.6 years after undergoing initial MMS, requiring amputation with no further treatment or recurrence thereafter. CONCLUSION: Mohs micrographic surgery for nail unit MIS offers a high cure rate similar to other surgical modalities and can reduce the need for digital amputation. The evolution of the Mohs technique over time, namely, using MART-1 immunostaining, has led to improvement in treatment outcomes. Performing complete nail unit excision with nail plate remaining intact attached to the nail bed may also contribute to improved outcomes. Further refinement in technique and more data are necessary to continue to advance this treatment.

Factors Influencing Squamous Cell Carcinoma In Situ Recurrence and Implications for Treatment Choice.

BACKGROUND: Numerous treatment modalities have been reported for squamous cell carcinoma in situ (SCCIS). Risk factors for recurrence have not been systematically reviewed. OBJECTIVE: To systematically review and summarize the data on risk factors that contribute to recurrence of SCCIS. MATERIALS AND METHODS: A PubMed search was completed using the terms "SCCIS," "Bowen's disease," "Bowen's disease and recurrence," and "Bowen's disease and Mohs." These sources were cross-referenced for the terms "treatment," "management," "therapy," "recurrence," and "margins." Studies were selected on the basis of relevance and applicable treatments. RESULTS: Immunosuppression was the only variable with a statistically signficant association with progression or recurrence of SCCIS. Although there were no data directly correlating subclinical lateral extension or invasive squamous cell carcinoma within SCCIS with recurrence, evidence supports both of these as common features of SCCIS. Other potential recurrence risk factors for which there are limited supporting data included tumor size, depth of follicular extension, and location. CONCLUSION: Immunosuppression was the only risk factor associated with increased risk of tumor recurrence. Subclinical tumor extension and occult invasive squamous cell carcinoma are relatively common features that theoretically could increase recurrence risk. These factors should be considered when deciding upon treatment for SCCIS. Further study is required to quantify variables that influence recurrence and to identify optimal treatment options.

Brief Report: HPV-17 Infection in Darier Disease With Acrokeratosis Verrucosis of Hopf.

The co-existence of Darier disease (DD) and acrokeratosis verruciformis of Hopf (AKV) has been noted for decades and the relationship between the 2 entities remains controversial. Although, it has been shown that both diseases are associated with mutations in ATPA2 gene, it is yet to be determined if they are the same disease, or separate but allelic, or interlinked in some other fashion. Herein, the authors report the case of a 13-year-old girl presenting with shiny flat-topped verruca plana-like papules, on the dorsal hands and feet and red-brown crusted papules on her forehead and along the sides of her neck. Histological evaluation of a wart-like lesion shows features of AKV, a verruca plana-like histopathology and focal acantholytic dyskeratosis. Forehead biopsy also demonstrated focal acantholytic dyskeratosis supporting the diagnosis of DD. Polymerase chain reaction for human papillomavirus (HPV) DNA detected HPV-17, a human betapapillomavirus in the verruca plana-like papule. Cytoplasmic expression of the L1 capsid expression was seen in areas of hypergranulosis. The presence of productive betaPV infection in the setting of DD and AKV suggests a susceptibility to HPV infection.

Cutaneous polyarteritis nodosa localized to a region of lymphedema secondary to Streptococcus viridans cellulitis and multiple surgeries.

Cutaneous polyarteritis nodosa (CPAN) is a chronic, indolent, single organ arteritis that generally presents with lower extremity nodules and/or livedo racemosa, accompanied by malaise and arthralgias. CPAN is often triggered by infection, commonly Group A streptococcal species, and is considered an autoimmune reaction. Scarring from surgery and obliterative lymphangiitis from bacterial cellulitis are the causes of lymphedema. Lymphedematous skin is predisposed to autoimmune disorders. Herein we report a 53-year-old woman who developed CPAN restricted to a localized area of the right upper arm-shoulder that had undergone multiple surgeries, complicated by episodes of Streptococcus viridans cellulitis. Clinically, a 15 cm diameter plaque exhibited violaceous, reticulate margins, subtle papules and nodules and central livedo racemosa. Biopsy showed numerous foci of arteritis in active, subacute and reparative stages. In addition, a broad zone of fibrosis replaced the deep dermis-subcutis zone and harbored numerous dilated lymphatic vessels scar lymphedema. Treatment consisted of high potency topical corticosteroids under occlusion; remission after 3 months therapy and follow-up. CPAN primarily affects the lower legs, a region of frequently affected by phlebolymphedema. This report of CPAN localized to an area of scar lymphedema underscores the importance of lymphatic function in the pathogenesis of CPAN.

Comparison of Total Lung Capacity Determined by Plethysmography With Computed Tomographic Segmentation Using CALIPER.

PURPOSE: Traditionally, determination of total lung capacity (TLC) by plethysmography (TLCpleth) has been important in the diagnosis of lung diseases. Alternatively, data acquired from computerized tomography (CT) can be utilized to calculate a measure of TLC (TLCCT). The clinical utility of TLCCT is not certain. We sought to determine, in a clinical setting, whether TLCCT correlates with TLCpleth across a range of lung diseases and scanning techniques. In addition, we determined whether TLCCT affects the interpretation of pulmonary function tests. SUBJECTS AND METHODS: Records of 118 of 148 consecutive lung transplant recipients were reviewed and determined to have coinciding pulmonary function tests, including plethysmography as well as volumetric chest CT performed supine during full inspiration. CT images acquired with a wide range of scanning protocols were analyzed using CALIPER, a software program for lung and trachea extraction from a CT volume and volumetric tissue characterization of the lung. Segmentation of the lung was achieved by using completely automated dynamic thresholding and region-growing techniques developed to extract the relatively low-density lung and tracheal anatomy from the CT data set without user intervention. RESULTS: TLCpleth and TLCCT were strongly related with a correlation coefficient of 0.88 (P<0.001). The efficacy of the CT-derived measure was not influenced by specific lung diagnoses, age, height, body mass index, or spirometric parameters. TLCCT did not misidentify any diagnosis of restrictive lung disease, nor hyperinflation. CONCLUSIONS: In a clinical setting, CT segmentation analysis provides a favorable determination of TLC compared with traditional plethysmography. The technique has general applicability across varying CT data acquisition protocols, lung diseases, and patient characteristics. TLCCT may substitute for TLCpleth in pulmonary function interpretation and may be preferable for some patients in whom plethysmography is difficult to perform, such as transplant subjects with severe pulmonary fibrosis.