RESUMO
Radiation therapy offers distinct advantages over other currently available treatments for cutaneous malignancies in certain circumstances. Dermatologists and dermatologic surgeons should be familiar with the available radiation therapy techniques as well as their value and potential limitations in a variety of clinical scenarios. The first article in this 2-part continuing medical education series highlights the mechanisms, modalities, and applications of the most commonly used radiotherapy treatments as they relate to cutaneous oncology. We review the current indications for the use of radiation in the treatment of various cutaneous malignancies, the techniques commonly employed in modern radiotherapy, and the associated complications.
Assuntos
Braquiterapia , Neoplasias Cutâneas , Humanos , Radioterapia/efeitos adversos , Neoplasias Cutâneas/radioterapiaRESUMO
Radiation therapy may be performed for a variety of cutaneous malignancies, depending on patient health status, tumor clinical and histologic features, patient preference, and resource availability. Dermatologists should be able to recognize the clinical scenarios in which radiation therapy is appropriate, as this may reduce morbidity, decrease risk of disease recurrence, and improve quality of life. The second article in this 2-part continuing medical education series focuses on the most common indications for radiation therapy in the treatment of basal cell carcinoma, cutaneous squamous cell carcinoma, dermatofibrosarcoma protuberans, Merkel cell carcinoma, Kaposi sarcoma, angiosarcoma, cutaneous lymphoma, melanoma, undifferentiated pleomorphic sarcoma, and sebaceous carcinoma.
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Carcinoma de Células Escamosas , Sarcoma , Neoplasias das Glândulas Sebáceas , Neoplasias Cutâneas , Carcinoma de Células Escamosas/radioterapia , Humanos , Recidiva Local de Neoplasia/radioterapia , Qualidade de Vida , Sarcoma/radioterapia , Neoplasias das Glândulas Sebáceas/radioterapia , Neoplasias Cutâneas/radioterapiaRESUMO
BACKGROUND: The Mohs Appropriate Use Criteria (MAUC) have come into question recently regarding the most appropriate treatment for superficial basal cell carcinoma (sBCC). At the heart of this debate is the limited body of evidence describing tumor behavior of sBCC based on clinical factors relevant to the MAUC. OBJECTIVE: To determine whether sBCC is more likely to harbor aggressive subtypes in high-risk anatomical locations and in immunocompromised patients. MATERIALS AND METHODS: A single institution retrospective review produced 133 evaluable Mohs cases performed on sBCC over a 10-year period. All slides from the respective cases were reviewed for the presence of histologic patterns other than known sBCC. Cases were then grouped by both MAUC anatomical zone (H, M, and L) and patient immune status for statistical analysis. RESULTS: A significantly higher rate of mixed histology (MH) was observed when comparing Zone H with Zone L across all patients, healthy patients, and immunocompromised patients. The same was true when comparing Zone M with Zone L for all patients and healthy patients (immunocompromised did not reach significance). CONCLUSION: The authors' data very clearly demonstrate a higher rate of MH in sBCC of the head and neck which provides strong support to the current MAUC scoring.
Assuntos
Carcinoma Basocelular/diagnóstico , Cirurgia de Mohs/normas , Neoplasias Cutâneas/diagnóstico , Pele/patologia , Adulto , Idoso , Biópsia , Carcinoma Basocelular/imunologia , Carcinoma Basocelular/patologia , Carcinoma Basocelular/cirurgia , Tomada de Decisão Clínica , Feminino , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Neoplasias Cutâneas/imunologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgiaAssuntos
Carcinoma Basocelular , Carcinoma de Células Escamosas , Neoplasias Cutâneas , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Carcinoma Basocelular/cirurgia , Carcinoma Basocelular/patologia , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Escamosas/patologia , Cirurgia de Mohs , Estudos Prospectivos , Neoplasias Cutâneas/cirurgia , Neoplasias Cutâneas/patologia , Pigmentação da Pele , Resultado do TratamentoRESUMO
BACKGROUND: There are little data regarding error within the multistep process of Mohs micrographic surgery (MMS). OBJECTIVE: A survey of Mohs surgeons was performed to evaluate variation in tissue handling and processing within the MMS process. METHODS AND MATERIALS: A 9-question electronic survey was distributed to members of the American College of Mohs Micrographic Surgery. A total of 97 responses were analyzed. RESULTS: Most surgeons personally transport the tissue (71.1%), most frequently in a specimen container (54.6%). Method of tissue identification during transportation varied significantly. Most surgeons personally hand-draw the map (77.1%). A diagram was most commonly used to convey tissue orientation to the histotechnician (65.4%). Only 31.3% of histotechnicians used labeling of blocks to identify tissue within the cryostat. Most respondents (72.2%) are the only surgeon processing tissue in the laboratory at one time; however, 28.9% reported performing 10 or more cases per day. CONCLUSION: Most respondents are responsible for tissue transport and mapping, which likely reduces potential error. However, the method of transport and labeling, as well as identification by the histotechnician, was more variable. Ultimately, having a consistent process and clear communication with personnel will help reduce potential error during Mohs surgery.
Assuntos
Cirurgia de Mohs/métodos , Neoplasias Cutâneas/cirurgia , Manejo de Espécimes/métodos , Pesquisas sobre Atenção à Saúde , Humanos , Erros Médicos , Cirurgia de Mohs/efeitos adversos , Manejo de Espécimes/efeitos adversosRESUMO
A 52-year-old white man with alcoholic cirrhosis presented to the Mohs surgery clinic with a 1-month history of tender "bumps" located diffusely on his scalp. Two biopsies performed at an outside institution were read as "basal cell carcinoma" and "actinic keratosis." The patient was scheduled for a large excision of the scalp for presumed multiple nodules of basal cell carcinoma and desired a second opinion from our Mohs surgery clinic.
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Carcinoma Basocelular/diagnóstico , Couro Cabeludo , Neoplasias Cutâneas/diagnóstico , Tinha do Couro Cabeludo/diagnóstico , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
While uncomplicated cases of nonmelanoma skin cancer can be treated with surgery, destruction, or topical therapy alone, advanced or neglected cases require more complex management decisions. Dermatologists and dermatologic surgeons should be familiar with the imaging techniques relevant to cutaneous oncology and their value in different clinical scenarios. Herein we review imaging modalities used in management of nonmelanoma skin cancer.
Assuntos
Carcinoma Basocelular/diagnóstico por imagem , Carcinoma de Células Escamosas/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Neoplasias Cutâneas/diagnóstico por imagem , Meios de Contraste/efeitos adversos , Gerenciamento Clínico , Humanos , Metástase Linfática , Imageamento por Ressonância Magnética/métodos , Imagem Multimodal/métodos , Especificidade de Órgãos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodosRESUMO
When treating aggressive skin cancers, pre- and postoperative imaging provides important information for treatment planning and multidisciplinary cooperation of care. It is important for dermatologists to recognize the clinical scenarios where imaging is indicated in the management of skin cancer. We here address the most common indications for imaging in cutaneous oncology and how to best utilize the modalities available.
Assuntos
Carcinoma Basocelular/diagnóstico por imagem , Carcinoma de Células Escamosas/diagnóstico por imagem , Neoplasias Cutâneas/diagnóstico por imagem , Nádegas , Carcinoma Basocelular/patologia , Carcinoma Basocelular/cirurgia , Carcinoma de Célula de Merkel/diagnóstico por imagem , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Dermatofibrossarcoma/diagnóstico por imagem , Dermatofibrossarcoma/cirurgia , Gerenciamento Clínico , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Metástase Linfática/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Cirurgia de Mohs , Invasividade Neoplásica , Recidiva Local de Neoplasia/diagnóstico por imagem , Nervos Periféricos/patologia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Procedimentos de Cirurgia Plástica , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Crânio/diagnóstico por imagem , Crânio/patologia , Crânio/cirurgia , Tomografia Computadorizada por Raios X/métodos , PunhoRESUMO
A 91-year-old Hispanic man with a diffuse large B-cell lymphoma of the stomach that was currently being treated with immunosuppressive therapy was referred for evaluation of a biopsy-proven squamous cell carcinoma in situ (SCCis) on the left mid-region of his back. The lesion had apparently been present at birth and had recently started to itch, become red, and progressively enlarge.
Assuntos
Carcinoma de Células Escamosas/diagnóstico , Neoplasias Cutâneas/diagnóstico , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Humanos , Hiperpigmentação/complicações , Masculino , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Carga TumoralRESUMO
Recent publications in the dermatologic surgery literature have sparked a re-emergence of interest in anatomy relevant for the Mohs surgeon necessitating a re-visit of under-appreciated concepts, regarding the topography of the face and its visceral contents from a surgically relevant perspective. This paper presents a pre-operative review and a conceptual framework for intra-operative planning for Mohs micrographic surgery and reconstruction. The key concepts presented are based on a series of (1) reviews regarding clinically significant points aimed at improving outcomes for reconstructive surgery, (2) anatomical dissections of fresh frozen cadavers, and (3) surgical experience of the authors. Basic anatomical concepts have been assimilated, surgically evaluated and re-directed toward the dermatologic surgeon in the hope that improved anatomic competence will reduce surgical hesitance.
Assuntos
Pontos de Referência Anatômicos , Face/anatomia & histologia , Procedimentos Cirúrgicos Dermatológicos , HumanosRESUMO
Surgical procedures involve unique elements related to patient safety. One must be aware of potential complications and safety issues within the practice of dermatologic surgery. Developing a high level of competence in skin surgery will address some safety issues, while implementing protocols and redundancies provides systems-based correction for other safety issues. We provide an in-depth review of patient safety in dermatologic surgery. In particular, we highlight the most common safety issues and methods for reducing error.
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Procedimentos Cirúrgicos Dermatológicos/normas , Segurança do Paciente , Biópsia/normas , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Humanos , Erros Médicos/prevenção & controleRESUMO
Cosmetic procedures are growing in popularity and are associated with unique risks. Considering potential complications and prioritizing patient safety will help practitioners improve outcomes of elective procedures. In part II of this continuing medical education article, we provide a comprehensive review of patient safety in cosmetic procedures, including medical and legal issues surrounding the supervision and training of physician extenders.
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Técnicas Cosméticas/normas , Procedimentos Cirúrgicos Dermatológicos/normas , Segurança do Paciente , Materiais Biocompatíveis/efeitos adversos , Técnicas Cosméticas/efeitos adversos , Procedimentos Cirúrgicos Dermatológicos/efeitos adversos , Humanos , Lasers/efeitos adversos , Neurotoxinas/efeitos adversosRESUMO
BACKGROUND: Quantitative data on soft tissue aging of the face are scarce, particularly in men. OBJECTIVE: Magnetic resonance imaging (MRI) was used to quantify and compare facial soft tissue loss in men. MATERIALS AND METHODS: Two thousand thirty-seven MRIs were screened and 30 male subjects were divided into young, middle, and old-aged groups. A blinded radiologist measured temporal, infraorbital, and medial and lateral cheek areas. RESULTS: The mean thickness of the subcutaneous tissue in the temporal area was 12.5, 10.9, and 9.6 mm in the young, middle, and older age groups, respectively (p < .001). A 40% reduction in the skin thickness was seen in the infraorbital areas. Finally, a decrease of 1.5 and 2.7 mm in medial cheeks (p < .001), and 0.9 and 1.6 mm (p = .03) in lateral cheeks were measured in middle and old age groups. CONCLUSION: A steady and significant decline in the soft tissue thickness was noted at all measured sites in men over time. These findings are in contrast to our recently study in women showing dramatic loss of soft tissue between the ages of 30 and 60 with no significant differences between the middle and old-aged groups. These results have implications for volume correction and maintenance of a youthful appearance in the aging male face.
Assuntos
Envelhecimento/patologia , Face/patologia , Imageamento por Ressonância Magnética , Pele/patologia , Tela Subcutânea/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Atrofia/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Envelhecimento da Pele/patologia , Adulto JovemRESUMO
Atypical vascular lesions are an uncommon adverse sequela to the radiotherapy of tumors. Many characteristics are shared between atypical vascular lesions caused by radiation port and well-differentiated radiation-induced angiosarcomas. The authors retrospectively reviewed the medical literature using PubMed, searching the terms acquired, atypical, benign, lymphangioma, lymphangioendothelioma, lymphangiomatous, lesion, papules, progressive, and vascular. Patient reports and previous reviews of the subject were critically assessed and the salient features are presented. Atypical vascular lesions associated with the radiation port present as clinically innocuous flesh-colored to erythematous papules or plaques. The condition presents within the radiation field, approximately 3 years after initial treatment. While the exact me chanism remains to be elucidated, growing evidence supports an association between radiation-associated atypical vascular lesions and radiation-induced angiosarcomas. Atypical vascular lesions within a radiation port are suggested to be in a state of morphologic continuum, which may progress into the more aggressive, malignant angiosarcoma. The authors recommend consideration for biopsy of new skin lesions within or adjacent to radiation. While it is clear that atypical vascular lesions caused by radiation are not equivalent to angiosarcoma, growing evidence supports that radiation-associated atypical vascular lesions may progress to angiosarcoma in some patients; therefore, the authors recommend excision of the lesion with margins depending on clinical judgment and the lesion encountered.
Assuntos
Neoplasias da Mama/radioterapia , Células Endoteliais/efeitos da radiação , Endotélio Vascular/efeitos da radiação , Lesões por Radiação/patologia , Biópsia , Células Endoteliais/patologia , Endotélio Vascular/citologia , Endotélio Vascular/patologia , Feminino , Hemangiossarcoma/diagnóstico , Hemangiossarcoma/etiologia , Hemangiossarcoma/patologia , Humanos , Pessoa de Meia-Idade , Neoplasias Induzidas por Radiação/diagnóstico , Neoplasias Induzidas por Radiação/patologia , Lesões por Radiação/diagnóstico , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/etiologia , Neoplasias Cutâneas/patologia , Fatores de TempoRESUMO
BACKGROUND: The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. OBJECTIVE: We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. METHODS: A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. RESULTS: Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. LIMITATIONS: Specific causes of death were not accessible. CONCLUSION: This growing section of the population may safely undergo MMS.
Assuntos
Expectativa de Vida , Cirurgia de Mohs/mortalidade , Neoplasias Cutâneas/cirurgia , Idoso de 80 Anos ou mais , Carcinoma Basocelular/cirurgia , Carcinoma de Células Escamosas/cirurgia , Comorbidade , Feminino , Humanos , Masculino , Estudos Retrospectivos , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/patologiaRESUMO
Background Correctly identifying cutaneous squamous cell carcinoma (cSCC) mimickers can be both clinically and histopathologically challenging. We present a series of patients with biopsy-proven cSCCs for whom multiple surgeries were avoided by assessing the clinical situation, recognizing an alternative diagnosis that pathologically mimics cSCC, and prescribing appropriate therapy for the underlying condition. Methodology Seven female patients presented for treatment of biopsy-proven cSCC affecting the lower leg. After further investigation, we observed that these women shared similar characteristics, including age ranging from the 5th to the 9th decade, often experiencing stress, exhibiting associated pruritus with diverse causes, having few or no previous skin cancers, and generally showing minimal photodamage. Results In all cases, surgery was deferred and patients demonstrated complete clinical response to therapies directed toward an alternative diagnosis. Repeat biopsies of treated lesions revealed no evidence of cSCC. Conclusions Not all histologically diagnosed cases of cSCC should be treated with surgery, and each patient should be worked up thoroughly to evaluate for an alternative diagnosis. Possible clinical and histologic cSCC mimickers include allergic contact dermatitis (ACD), stasis dermatitis, hypertrophic lichen planus (LP), and drug eruption, among others. In the described population, pruritic papules on the lower leg should prompt further investigation to prevent the morbidity associated with unnecessary surgery.
RESUMO
Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.
Assuntos
Carcinoma Basocelular , Neoplasias Cutâneas , Idoso , Carcinoma Basocelular/patologia , Carcinoma Basocelular/cirurgia , Feminino , Humanos , Masculino , Cirurgia de Mohs , Prática Privada , Estudos Prospectivos , Pele/patologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgiaRESUMO
A 41-year-old human immunodeficiency virus (HIV)-positive man was hospitalized with complaints of a 4-week history of nausea and vomiting, associated with decreased oral intake, and a 4-day history of frontal headache and fever. His medical history was significant for a gunshot wound to the head 3 years prior, with a residual seizure disorder. He also had two previous hospitalizations, both for culture-negative bacterial meningitis; the first episode occurred 12 months before admission and the second episode occurred 5 months later. At that time, he was found to be positive for serum antibodies against HIV and a CD4+ T-lymphocyte count of 126/mm3. He had no known drug allergies and was not receiving any medication. On admission, the patient was febrile (104.0 degrees F) and hypotensive (blood pressure, 92/40 mm Hg). Pertinent physical examination findings included cachexia with bitemporal wasting, dry mucus membranes, adherent white patches on the oral mucosa, and negative Kernig's and Brudzinski's signs. His laboratory results revealed macrocytic anemia, a decreased serum sodium of 125 mEq/L, and a normal total leukocyte count with a CD4+ T-lymphocyte count < 50/mm3. Lumbar puncture opening pressure was elevated at 160 mm Hg, and cerebrospinal fluid analysis showed an increased white cell count of 97/microL (84% lymphocytes), a decreased glucose level of 26 mg/dL, and a decreased protein level of 42 mg/dL. The patient was started on empiric therapy that included intravenous ampicillin and cefotaxime, oral Bactrim, and clotrimazole lozenges for thrush. Cerebrospinal fluid culture was positive for Escherichia coli, sensitive to cefotaxime. Two days later, the patient developed fine, erythematous, nonblanchable macules primarily on his abdomen, with minimal involvement of his thorax and back. His skin lesions remained unchanged for the next 2 weeks. Repeat lumbar puncture was performed after 14 days of cefotaxime. The cerebrospinal fluid analysis showed an elevated white cell count of 7/microL (100% lymphocytes), a decreased glucose level of 53 mg/dL, and a decreased protein level of 33 mg/dL. The cerebrospinal fluid culture was now positive for Pseudomonas aeruginosa resistant to cefotaxime. The patient was started on imipenem. On day 34 of his admission, the patient became tachypneic with complaints of dyspnea. A chest roentgenogram revealed bilateral patchy infiltrates. He was transferred to the intensive care unit and intubated for hypoxemic respiratory failure (arterial blood gas values on 6 L of oxygen: pH, 7.46; bicarbonate, 23; and oxygen saturation, 37). That evening, the patient was also noted to have diffuse petechiae and purpura in a reticulated pattern over his abdomen (Figure 1A and 1B), most heavily concentrated in the periumbilical region, extending to the axillae and upper thighs. A 3x3-mm punch biopsy from abdominal skin demonstrated Strongyloides stercoralis larvae in the dermis (Figure 2A and 2B). His sputum specimen was teeming with adult S stercoralis worms (Figure 3) and, subsequently, numerous S stercoralis larvae were observed not only from the bronchoalveolar lavage but also from the nasogastric fluid specimen. These findings confirmed the diagnosis of disseminated strongyloidiasis. On hospital day 35, the patient was doing poorly and was started on thiabendazole (1250 mg twice daily for 28 days). Nine days later, ivermectin (4.5 mg once daily for 3 days for 2 courses) was also added. He continued to clinically deteriorate. The patient died 31 days after systemic antihelminthic treatment was initiated.