Incidence of Nonmelanoma Skin Cancers in Alberta, Canada, From 2007 to 2018.

BACKGROUND: Nonmelanoma skin cancer (NMSC) is the most common malignancy affecting Caucasian populations and has been seeing steady increases in incidence globally for decades. Our previous study (from Alberta, Canada) had shown a plateau in the incidence rates for NMSC. This contrasts with data from other regions within Canada and throughout the world that indicated a continued increase in incidence rates of NMSCs. OBJECTIVES: The objective of this study was to provide an update on the trends in incidence of NMSC in Alberta, Canada, from 2007 to 2018. METHODS: A retrospective analysis of patients from Alberta diagnosed with NMSC from 2007 to 2018 inclusive was conducted with data retrieved from Alberta Cancer Registry. Sex-, age-, anatomical location-, NMSC subtype-, stage-specific incidence rates and trends were examined. RESULTS: From 2007 to 2018, overall incidence rates of NMSC increased by 36%. Invasive squamous cell carcinoma (SCC) and in situ SCC demonstrated the most significant increase, invasive SCC [annual percentage change (APC) 3.48, P = .014] and in situ SCC (APC 5.61, P = .0001). In addition, we were able to determine that females had the most significant increases in NMSC incidence rates from 2007 to 2018 particularly invasive SCC (APC 3.03, P = <.0001) and in situ SCC (APC 5.08, P = <.0001). CONCLUSIONS: After initial levelling of NMSC incidence in Alberta in the early part of 21st century, the incidence of NMSC continues to increase over the past decade. The reasons for this change are not clear and likely multifactorial.

Histopathology for Mohs micrographic surgery with photoacoustic remote sensing microscopy.

Mohs micrographic surgery (MMS) is a precise oncological technique where layers of tissue are resected and examined with intraoperative histopathology to minimize the removal of normal tissue while completely excising the cancer. To achieve intraoperative pathology, the tissue is frozen, sectioned and stained over a 20- to 60-minute period, then analyzed by the MMS surgeon. Surgery is continued one layer at a time until no cancerous cells remain, meaning MMS can take several hours to complete. Ideally, it would be desirable to circumvent or augment frozen sectioning methods and directly visualize subcellular morphology on the unprocessed excised tissues. Employing photoacoustic remote sensing (PARS) microscopy, we present a non-contact label-free reflection-mode method of performing such visualizations in frozen sections of human skin. PARS leverages endogenous optical absorption contrast within cell nuclei to provide visualizations reminiscent of histochemical staining techniques. Presented here, is the first true one to one comparison between PARS microscopy and standard histopathological imaging in human tissues. We demonstrate the ability of PARS microscopy to provide large grossing scans (>1 cm2, sufficient to visualize entire MMS sections) and regional scans with subcellular lateral resolution (300 nm).

Reflection-mode virtual histology using photoacoustic remote sensing microscopy.

Histological visualizations are critical to clinical disease management and are fundamental to biological understanding. However, current approaches that rely on bright-field microscopy require extensive tissue preparation prior to imaging. These processes are both labor intensive and contribute to creating significant delays in clinical feedback for treatment decisions that can extend to 2-3 weeks for standard paraffin-embedded tissue preparation and interpretation, especially if ancillary testing is needed. Here, we present the first comprehensive study on the broad application of a novel label-free reflection-mode imaging modality known as photoacoustic remote sensing (PARS) for visualizing salient subcellular structures from various common histopathological tissue preparations and for use in unprocessed freshly resected tissues. The PARS modality permits non-contact visualizations of intrinsic endogenous optical absorption contrast to be extracted from thick and opaque biological targets with optical resolution. The technique was examined both as a rapid assessment tool that is capable of managing large samples (> 1 cm2) in under 10 min, and as a high contrast imaging modality capable of extracting specific biological contrast to simulate conventional histological stains such as hematoxylin and eosin (H&E). The capabilities of the proposed method are demonstrated in a variety of human tissue preparations including formalin-fixed paraffin-embedded tissue blocks and unstained slides sectioned from these blocks, including normal and neoplastic human brain, and breast epithelium involved with breast cancer. Similarly, PARS images of human skin prepared by frozen section clearly demonstrated basal cell carcinoma and normal human skin tissue. Finally, we imaged unprocessed murine kidney and achieved histologically relevant subcellular morphology in fresh tissue. This represents a vital step towards an effective real-time clinical microscope that overcomes the limitations of standard histopathologic tissue preparations and enables real-time pathology assessment.

Staged margin-controlled excision (SMEX) for lentigo maligna melanoma in situ.

BACKGROUND: No consensus exists regarding the best surgical strategy to achieve clear surgical margins while minimizing tissue excision when definitely excising lentigo maligna melanoma in situ (LM). The staged margin controlled excision (SMEX) technique is a modification of the spaghetti technique that allows surgeons to minimize margins and ensure complete excision of LM. OBJECTIVES: Our objectives were twofold: a) to evaluate the effectiveness of SMEX for treatment of LM and b) detail the SMEX technique. METHODS: A retrospective chart review of adult patients who underwent the SMEX technique for treatment of LM from 2011 to 2016 was conducted. RESULTS: Twenty-four patients were identified with predominantly facial lesions. The mean defect size was 12.1 cm2 . A mean number of two SMEX procedures, with an average margin of 9 mm, were required to obtain complete excision of the LM. Using SMEX, we achieved 100% clearance of LM over a median follow up period of 18 months, with a range of 1-63 months. CONCLUSIONS: SMEX offers a reliable surgical excision method that ensures complete excision of LM in a cosmetically sensitive manner. The recurrence outcomes of SMEX are comparable, if not better, than those of alternative excision techniques in the literature.

Sun-Smart Practices Amongst School Students (Grades 5, 7, and 9) in Alberta, Canada.

OBJECTIVES: The aim of this study was to assess the current knowledge children possess on melanoma and sun-protective behaviour. METHODS: A one-page survey was administered to students in grades 5, 7, and 9. RESULTS: Three hundred ninety-two students from 11 schools in Edmonton were surveyed. Seventy-one percent of students knew that sun exposure can cause skin cancers. Sixty-nine percent were taught by their parents about sun protection, but only 44% of students received similar instructions from teachers. Twenty percent of students indicated that they never or rarely wore sunscreen. Twenty-five percent of students had experienced painful sunburns, and only 46% were willing to use sunscreen if it were available at school. More Caucasian students reported painful or peeling sunburns in each grade level than their non-Caucasian peers (for grade 5, P = .003; for grade 7, P < .0001; for grade 9, P = .001). For all grade levels, the percentage of Caucasian students who indicated that they would not wear sunscreen when going out in the sun was greater than among their non-Caucasian peers (for grade 5, P < .001; for grade 7, P = .003; for grade 9, P = .015). CONCLUSIONS: A comprehensive and focused approach to sun-smart education is recommended for students.

Acrokeratosis paraneoplastica (Bazex syndrome) presenting in a patient with metastatic breast carcinoma: possible etiologic role of zinc.

BACKGROUND: Bazex syndrome (acrokeratosis paraneoplastica) is a rare paraneoplastic syndrome that usually occurs in males over 40 years old and is particularly associated with squamous cell carcinoma of the upper aerodigestive tract and adenopathy above the diaphragm. OBJECTIVE: The objectives of our article are (1) to describe a unique case of acrokeratosis paraneoplastica and (2) to review the current literature regarding skin findings, commonly associated neoplasms, and treatment options relative to this condition. PATIENT: We describe a 68-year-old female with lobular breast carcinoma, complicated by local and distant recurrences, who presented with a 1-year history of prominent acral skin and nail changes. RESULTS: Our patient's clinical skin findings improved significantly following treatment and partial remission of her underlying malignancy. CONCLUSIONS: Our patient represents one of few females described with this syndrome, which is especially rare in association with lobular breast carcinoma. Further, the patient's presentation is unique as she was discovered to demonstrate laboratory findings consistent with coexistent porphyria cutanea tarda and relative zinc deficiency.

Intraoral extraction of cheek skin cyst.

BACKGROUND: When a physician encounters a benign subcutaneous cyst in the cheek, his or her decision whether to excise and how to excise the cyst takes into account the potential risk of postsurgical scarring. OBJECTIVE: To describe and show an intraoral buccal mucosal approach to excising a cyst in the inferior-anterior cheek so that skin scarring is avoided. METHOD: An incision was made intraorally in the buccal mucosa, and dissection was carried through the buccinator muscle until the cyst wall was seen. Careful separation of tissue around the cyst was done by blunt dissection, and the unruptured cyst was removed through the buccal mucosal incision. RESULT: The entire intact cyst was removed without creating any excision marks in the cheek skin. No complications were encountered, and buccal mucosal healing was excellent. CONCLUSION: A buccal mucosal intraoral approach is an alternative to a percutaneous excision to remove a cyst in the lower cheek region. The intraoral approach avoids a visible scar on the cheek skin.

Restylane persistent for 23 months found during Mohs micrographic surgery: a source of confusion with hyaluronic acid surrounding basal cell carcinoma.

BACKGROUND: Restylane (Q-Med, Uppsala, Sweden), a hyaluronic acid (HA) that is microbiologically produced and then cross-linked, is becoming popular as a dermal filler for improvement of facial lines and wrinkles. However, it is currently believed that the clinical and histologic persistence of this filler is from 6 to 9 months. We recently encountered Restylane in tissue where it had been implanted 23 months prior to removal of a basal cell carcinoma (BCC) on the lip, and its presence caused some confusion with HA that surrounds BCC nests. OBJECTIVE: To show and to contrast the histologic dermal appearance of Restylane and its metachromatic staining characteristics with toluidine blue from those of HA that surrounds BCC nests. METHOD: Toluidine blue staining at pH 7.07 was performed on excised tissue containing Restylane and BCC on the upper lip. RESULTS: Restylane appeared as reddish-purple amorphous masses, whereas the HA that frames BCC nests appeared redder and more well defined. CONCLUSION: The amorphous metachromatic reddish-purple color staining of Restylane with toluidine blue is due to its HA content. This staining pattern should be differentiated from the well-defined red color of HA that normally borders BCC nests. Restylane may persist in the dermis as long as 23 months after implantation.

Acneiform facial eruptions: a problem for young women.

OBJECTIVE: To summarize clinical recognition and current management strategies for four types of acneiform facial eruptions common in young women: acne vulgaris, rosacea, folliculitis, and perioral dermatitis. QUALITY OF EVIDENCE: Many randomized controlled trials (level I evidence) have studied treatments for acne vulgaris over the years. Treatment recommendations for rosacea, folliculitis, and perioral dermatitis are based predominantly on comparison and open-label studies (level II evidence) as well as expert opinion and consensus statements (level III evidence). MAIN MESSAGE: Young women with acneiform facial eruptions often present in primary care. Differentiating between morphologically similar conditions is often difficult. Accurate diagnosis is important because treatment approaches are different for each disease. CONCLUSION: Careful visual assessment with an appreciation for subtle morphologic differences and associated clinical factors will help with diagnosis of these common acneiform facial eruptions and lead to appropriate management.

Combination oral prednisone and intravenous immunoglobulin in the treatment of scleromyxedema.

BACKGROUND: Scleromyxedema is a clinical variant of the rare disease papular mucinosis that has both cutaneous and systemic manifestations. Treatment options are numerous and tend to be associated with serious potential side effects and frequent relapse. OBJECTIVE: We report a case of scleromyxedema treated with low-dose oral prednisone and intravenous immunoglobulin (IVIg). This is followed by a review of the literature. CONCLUSION: IVIg is being used for a growing number of inflammatory and immune disorders. It is being increasingly reported as a successful treatment for scleromyxedema. Although our patient succumbed to the disease, combination therapy with prednisone and IVIg provided temporary symptomatic, laboratory, and clinical improvement of the condition. Optimization of this therapeutic strategy is thus indicated for the management of scleromyxedema.

Successful hair transplant of eyebrow alopecia areata.

BACKGROUND: Alopecia areata of the eyebrows can be difficult to treat. Intralesional triamcinolone or potent topical steroids are considered the mainstay of medical therapy. This case illustrates the results of an experimental hair transplant to the eyebrows following years of modest response to intralesional triamcinolone. OBJECTIVE: The aim of this study was to ascertain the benefits of a hair transplant for chronic eyebrow alopecia areata not responding to appropriate medical therapy. METHODS: A hair transplant was performed with tumescent anesthesia and a total of 85 mini and micrografts placed in the right eyebrow. Followup after the hair transplant occurs every 8 weeks. RESULTS: The patient was free of eyebrow alopecia areata for 8 months following the initial hair transplant. Although the disease relapsed, hair growth is now manageable with intralesional cortisone injection performed six times per year. CONCLUSIONS: For the first time in years, this patient was given 8 months of reprieve from his eyebrow alopecia areata and is currently well-maintained on monthly intralesional cortisone which originally was of only modest benefit. The patient is pleased with the outcome.