The life of a skin cancer.

The mechanisms of carcinogenesis and metastasis are becoming better elucidated. The recent literature pertaining to the current understanding of the mechanisms of carcinogenesis and metastasis was reviewed, and some of the basic information that is known about these processes and how they relate to the development of cutaneous cancers is presented in this article. The development of a skin cancer consists of a three-step process of carcinogenesis-initiation, promotion, and progression. When metastasis occurs, a six-step process of complex cellular adaptations enables the tumor cell to metastasize and proliferate successfully. The mechanisms of carcinogenesis and metastasis are pertinent not only to dermatologists and physicians who treat skin cancer but also to any physician who must manage human malignant tumors. Therefore, a general background of information on this subject is an important aspect of medical knowledge for most physicians.

Trichloroacetic acid chemexfoliation (chemical peel) for extensive premalignant actinic damage of the face and scalp.

Trichloroacetic acid chemexfoliation is an effective, versatile, and safe therapeutic option for patients with extensive actinic keratoses of the face and scalp. With an experienced and skilled operator, the associated complications are rare and tend to be mild. Cosmetically, the patient not only benefits from removal of the erythematous, scaly actinic keratoses but also obtains cosmetically pleasing rejuvenation of facial skin and diminution of fine facial wrinkles. Two representative cases are presented. In comparison with other available treatment modalities, trichloroacetic acid chemexfoliation involves a shorter treatment period and wound healing time and is not dependent on patient compliance.

Kayser-Fleischer rings in a patient with basal cell carcinoma: fortuitous diagnosis of presymptomatic Wilson's disease.

Kayser-Fleischer rings were detected during a routine ophthalmologic workup in a 25-year-old man with basal cell carcinoma of the eyelid. Although the importance of this association is uncertain, the routine preoperative evaluation of basal cell carcinoma led to the presymptomatic diagnosis of Wilson's disease. These disorders are discussed, as are the benefits of a multidisciplinary approach for the diagnosis and management of medical problems.

Overview of skin cancer detection and prevention for the primary care physician.

The incidence of both melanoma and nonmelanoma skin cancer is increasing, and an accurate and timely diagnosis is important to reduce the morbidity and mortality associated with these malignancies. Clinical features and examination techniques are discussed, and the need to recognize important secondary tumor characteristics, which supplement the primary diagnosis, is reviewed. Recent evidence on etiologic factors and their importance are addressed to highlight the role of primary prevention. Pediatricians, family physicians, and all primary care physicians are encouraged to promote skin cancer awareness among children and their parents.

Carbon dioxide laser surgery for skin disease.

Since it was developed in the 1960s, the carbon dioxide (CO2) laser has had an important role in the practice of dermatology. The CO2 laser has some advantages over conventional techniques used in dermatologic surgical treatment. It routinely provides a bloodless surgical field as well as unusual surgical precision. Although the CO2 laser is specifically indicated for certain conditions, in other situations, only marginal benefit may be noted in comparison with standard techniques such as scalpel surgical procedures, dermabrasion, cryosurgery, and electrosurgery. In this article, we briefly review the history and physics of the CO2 laser, its operation, and safety principles and discuss dermatologic conditions that are treated with the CO2 laser. We also describe 8 representative cases from our experience with more than 800 cases of CO2 laser treatment in the practice of dermatology at the Mayo Clinic since 1986.

Skin cancers associated with acquired immunodeficiency syndrome.

OBJECTIVE: To describe the types of skin cancer associated with the acquired immunodeficiency syndrome (AIDS). DESIGN: A literature review of AIDS-related mucocutaneous neoplasms, including basal cell carcinoma, squamous cell carcinoma, bowenoid papulosis and Bowen's disease, squamous cell carcinoma, cloacogenic carcinoma, and malignant melanoma, is presented, and the incidence, etiopathogenesis, clinicopathologic features, treatment, and prognosis are discussed. RESULTS: The association between cutaneous neoplasms and AIDS is well known. Neoplasms seem to grow more rapidly and be more invasive in patients with AIDS than in other groups of patients. Several oncogenic factors--for example, sunlight exposure or human papillomavirus infection--have been associated with the development of skin cancer in these patients. The morbidity and mortality rates of skin cancer are higher in patients infected with the human immunodeficiency virus (HIV) than in the general population. Early and complete excision of the neoplasm is especially important. CONCLUSION: A link exists between AIDS and the development of skin cancer. HIV-infected patients should be followed up vigilantly for early diagnosis of skin cancer. Because these patients are less able to suppress common cutaneous malignant disease due to their immunocompromised status, biopsy specimens should be obtained from all suspicious lesions, and histopathologic assessment should be done.

Cutaneous micrographic surgery: Mohs procedure.

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.

Factitial leg ulcers associated with an unusual sleep disorder.

A 19-year-old woman presented with a 14-month history of multiple, factitially induced, full-thickness leg ulcers. Nocturnal polysomnography with video monitoring revealed a short sleep latency and frequent sleep stage changes. Rapid eye movement sleep was absent. All stages of non-rapid eye movement sleep were associated with leg rubbing. After treatment that included avoidance of daytime naps and administration of chlorpromazine at bedtime, affect, daytime behavior, nocturnal sleep, and the ulcers improved markedly. To our knowledge, there are no reports of factitial dermatosis associated with disordered sleep. Our findings suggest that abnormal sleep may play a role in initiating or perpetuating factitial dermatoses. This case illustrates that polysomnography and video monitoring may be indicated in the evaluation of patients with factitial dermatoses.

Reinnervation of flaps and grafts of the face.

BACKGROUND: The degree to which disruption of sensory innervation is affected by flaps and grafts on the face has not been explored. The decision to choose a flap or a graft for reconstruction may affect future sensation at the surgical site. OBJECTIVES: To characterize the clinical recovery of sensory innervation after facial reconstructive surgery with flaps and grafts and to offer clinical guidelines on the recovery of sensation in reconstructed sites involving flaps and grafts of the face. METHODS: Seventy patients who underwent Mohs surgery and subsequent repair by either a flap or a graft were evaluated at different postoperative intervals. Fifty patients underwent flap reconstruction and 20 patients underwent graft reconstruction. Three principal modes of sensation were objectively assessed: light touch, temperature, and pinprick. RESULTS: Median time of evaluation after surgery was 11 months. The most common locations tested were the nose (36 patients) and the forehead (9 patients). Postoperative evaluation showed that flap sensation recovery to light touch was present in 10% of patients before 3 months, 41% of patients from 3 to 12 months, 27% of patients from 1 to 2 years, and 75% of patients after 2 years. Graft sensation recovery to light touch was present in no patients evaluated less than 2 years after surgery and in 29% of patients evaluated more than 2 years after surgery. After adjustments for postoperative size and interval, patients with flaps were more likely than those with grafts to have touch sensation at the time of testing (adjusted odds ratio, 8.91; 95% confidence interval, 1.06-74.62; P = .04), to be able to distinguish between warm and cold (adjusted odds ratio, 3.99; 95% confidence interval, 1.05-15.16; P = .04), and to be able to distinguish between sharp and dull (adjusted odds ratio, 27.31; 95% confidence interval, 2.20-339.71; P = .01). CONCLUSIONS: Predictable factors are associated with sensation recovery in patients with flaps and grafts. The recovery of sensory innervation after surgery is earlier with flaps than with grafts. Our data provide clinicians with guidelines for recovery of sensation that ultimately will reassure the patient.

A primer of facial chemical peel.

Facial chemical peel encompasses a plethora of procedures or techniques and so may be confusing. This should not blunt one's enthusiasm for what chemexfoliation can achieve. With the use of TCA, chemical peel is a safe, effective, elegant, and simple method for treating some common problems of photoaged, fair skin (Table 7). When a standardized technique is used, it is possible to quantify the therapeutic effects and to predict the outcome reliably. Variations of chemical peel will be used as clinicians try to achieve better results. If possible, variations from standard techniques should be scientifically studied and quantified to establish their safety and efficacy. The goal of chemical face peeling is not simply to achieve a deep or longer-lasting peel. The highest concentrations of TCA and phenol may cause full-thickness facial chemical burns and leave long-lasting scars. Therefore, variations on standard techniques provide only subjective, difficult-to-measure benefits. Conversely, standardized testing on the facial skin of patients is difficult and thus we chose an animal model. Clinicians, especially dermatologists, who want to perform chemical peel should know the indications. Using the procedures described here and in other articles, one can safely and reliably undertake facial chemical peel.

Fundamentals of flap and graft wound closure in cutaneous surgery.

Optimal closure of cutaneous defects with flaps and grafts requires an understanding of the dynamics of tissue movement. The best cosmetic outcome is attained when all closure options are considered and the one most suitable for a given defect is chosen. The mnemonic "STARS" provides a convenient way to recall and consider all closure options. The basic principles and some practical considerations of these closure options are reviewed to assist in the understanding of the fundamentals of flap and graft wound closure in cutaneous surgery.

Androgenetic alopecia (common baldness).

Alopecia is a common problem affecting the scalp in both men and women. The vast majority of all cases of alopecia are of the androgenetic variety. The clinical and endocrinologic features of this disorder are reviewed. Potential therapies, including surgical and medical modalities, are mentioned.

Metastasis. A primer for dermatologists.

BACKGROUND: Dermatologists often diagnose, treat, and manage patients who have cutaneous tumors that are potentially metastatic. While the fund of knowledge regarding metastasis is still quite incomplete, more and more is becoming understood about the mechanisms of carcinogenesis and metastasis. OBJECTIVE: To present in understandable terms what is known about carcinogenesis and metastasis and how this information can and should affect the clinician's approach to diagnosis, management, and follow-up of potentially metastatic cutaneous disease. METHODS: The recent literature pertaining to the current understanding of the mechanisms of carcinogenesis and metastasis are assimilated and reviewed. RESULTS: Carcinogenesis is fundamentally a three-step process comprised of initiation, promotion, and progression. One of the most dramatic results of progression is metastasis. Metastasis is the result of a complex set of cellular adaptations that enable the tumor cell to be able to separate from the primary tumor, invade, intravasate, circulate, implant at a distant site, extravasate, and lastly proliferate. CONCLUSION: A fundamental understanding of the mechanism of carcinogenesis and metastasis is important to the clinical dermatologist. Understanding these principles can affect the way in which the practitioner teaches and institutes preventative measures. It may also influence diagnostic and therapeutic approaches as well as subsequent management and follow-up of potentially metastatic or metastatic disease. There is little doubt that the best care for a patient with skin cancer can be given by the physician who knows the most about the integument. This behooves dermatologists to remain well informed about the present understanding of the development and progression of cancer.

A regional approach to reconstruction of the upper lip.

Treatment of upper lip wounds by second intention, full-thickness skin grafts, and local flaps is discussed. The location, size, depth, and type of closure for each defect in 200 cases involving defects of the upper lip are reviewed. The percentages of wounds treated by each modality were 20, 6, 74% for second intention, grafts, and local flaps, respectively. Of wound treatment by local flaps, 80% used advancement flaps, 10% used transposition flaps, and 10% used island-pedicle flaps. Advancement flaps, island-pedicle flaps, possible complications, and post-operative care are reviewed.

Transcranial eosinophilic granuloma manifested by a subcutaneous scalp mass. Differential diagnosis in children.

BACKGROUND: The differential diagnosis of nodular scalp lesions in a child is surprisingly extensive. OBJECTIVE: To present a case of eosinophilic granuloma that was manifested by a scalp mass in a pediatric patient. METHODS: The case is presented and the relevant literature is reviewed. CONCLUSIONS: The seriousness of some of these lesions requires a thorough evaluation, including noninvasive imaging, and carefully planned surgical intervention so that effective diagnosis and treatment are ensured. Surgical exposure of unsuspected central nervous system connections may lead to infection, hemorrhage, seizures, or other significant morbidity and mortality.

Surgical margins for excision of primary cutaneous squamous cell carcinoma.

BACKGROUND: No guidelines for the margin of resection of cutaneous squamous cell carcinoma have been based on data measuring subclinical tumor extension, as have been formulated for basal cell carcinoma. OBJECTIVE AND METHODS: Guidelines for appropriate margins of excision of primary cutaneous squamous cell carcinoma were formulated on the basis of a prospective study of subclinical microscopic tumor extension. RESULTS: Four millimeter margins were adequate for most squamous cell carcinomas. However, certain tumor characteristics were associated with a greater risk of subclinical tumor extension and included size of 2 cm or larger, histologic grade 2 or higher, invasion of the subcutaneous tissue, and location in high-risk areas. CONCLUSION: Minimal margins of excision of 4 mm around the clinical borders of the squamous cell carcinoma are proposed for all but the high-risk tumors, in which at least a 6 mm margin is recommended.

Mechanisms of metastasis.

The role of dermatologists in the diagnosis and treatment of skin cancer continues to increase. Consequently, they will more frequently be involved in the diagnosis, treatment, and management of patients with metastatic or potentially metastatic tumors. Squamous cell carcinomas and malignant melanomas are frequently seen in dermatologic practices and have the capability to metastasize. Metastases are the result of a complex process that is characterized by a sequence of steps, each of which requires acquisition by the malignant cell of key biologic properties. The metastatic sequence can be conceptualized as detachment from the primary tumor followed by invasion, intravasation into a vessel, circulation, stasis within a vessel, extravasation, invasion of the recipient tissue bed, and ultimately proliferation. The basic steps of the metastatic sequence are described as well as how these steps and other tumor cell adaptations can affect the clinical patterns of metastasis. Finally, practical applications of the understanding of these principles of metastasis are discussed.