Multistep Approach for Improved Aesthetic and Functional Outcomes for Lower Extremity Wound Closure After Mohs Micrographic Surgery.

BACKGROUND: Lower extremity wounds present a major clinical challenge. OBJECTIVE: This paper introduces a new multistep approach for improved aesthetic and functional outcome for lower extremity wound closure after Mohs micrographic surgery. PATIENTS AND METHODS: In this prospective case series, 12 consecutive patients undergoing Mohs micrographic surgery for cutaneous malignancies of the lower extremities underwent closure assisted by elastic bandages, proper positioning with 45° flexion of the knee, buried vertical mattress sutures, and careful eversion, using a premium angled stapler. Assessment of cosmetic outcome was performed by 2 blinded observers, using the Hollander Wound Evaluation Scale. RESULTS: The mean age was 73 ± 9 years with most patients having at least one comorbidity. Six patients (50%) underwent resection of a basal cell carcinoma and 5 patients (42%) underwent resection of a squamous cell carcinoma and 1 patient (8%) underwent resection of a keratoacanthomatous carcinoma. There were no wound complications, and at the 3- to 6-month follow-up, 11 of the 12 wounds (92%) had an optimal Hollander Wound Evaluation Scale score of 6. CONCLUSION: This new approach to lower extremity wounds provides excellent cosmetic outcome with no reported complications.

Diagnosis and Management of Dermatofibrosarcoma Protuberans in a 3-Year-Old Patient.

In this case report, we present a 3-year-old boy with a diagnosis of dermatofibrosarcoma protuberans (DFSP) on the dorsum of his right hand. Although rarely metastatic, DFSP is highly locally invasive and can cause considerable local morbidity. In the hand, DFSP is uncommon in the young pediatric patient. In our patient, the tumor extended down to the second and third metacarpal heads and was treated with a multistaged excision of his tumor to achieve negative margins under slow Mohs micrographic surgery.

Basal cell carcinomas of the ear are more aggressive than on other head and neck locations.

BACKGROUND: On pathology review, basal cell carcinomas (BCCs) on the ear more commonly present as aggressive subtypes. It is unclear if this histologic observation translates into more clinically aggressive tumors. OBJECTIVE: We sought to determine the clinical aggressiveness of ear BCCs compared with BCCs elsewhere on the head and neck. METHODS: We conducted a retrospective chart review of all BCCs treated at an academic center from 2005 through 2012. Subjects were divided into ear and non-ear groups. Subtypes classified as "aggressive" included morpheaform, infiltrative, micronodular, adenoid, metatypical, and mixed histology. RESULTS: Of the 7732 head and neck BCCs, 758 (9.8%) were on the ear. Ear BCCs presented as larger lesions (1.28 vs 0.98 cm(2)), required more Mohs layers (16.5% vs 10.7%), and produced a larger final defect (4.29 vs 3.49 cm(2)) than non-ear lesions. When comparing only aggressive subtypes, ear BCCs also presented as larger lesions (1.42 vs 1.23 cm(2)), more frequently required 3 or more layers for clearance (22.3% vs 14.2%), and produced a larger final defect (4.92 vs 4.21 cm(2)) than non-ear lesions. LIMITATIONS: Limitations include single-center design and lack of long-term follow-up. CONCLUSION: Ear BCCs appear to exhibit greater subclinical extension compared with non-ear head and neck BCCs. Therefore, the ear should be considered a high-risk location for BCCs.

Gender differences in tumor and patient characteristics in those undergoing Mohs surgery.

BACKGROUND: Nonmelanoma skin cancer is the most common cancer in the United States, and when indicated, Mohs micrographic surgery (MMS) is an effective method for tumor removal. Few studies have focused on gender-specific characteristics among those undergoing MMS. OBJECTIVE: To elucidate patient- and tumor-specific characteristics in female MMS patients. MATERIALS AND METHODS: We performed a retrospective chart review of 12,344 consecutive patients undergoing MMS from 2005 to 2012. RESULTS: There was a 1.5:1 male predominance in the presentation of basal cell carcinoma (BCC) for MMS. However, BCC comprised 72% of tumors in women compared with 63% in men. Presenting tumor sizes of BCCs were smaller in women (0.9 vs 1.2 cm, p < .01). Superficial BCCs were more common in women (p < .001). Women had fewer squamous cell carcinoma (p < .01) and squamous cell carcinoma in situ (p < .01). They were more likely to present with tumors on their legs and central facial areas, whereas men had more tumors on their scalps and ears. Plastic surgery referral was over twice as common in the female population (p < .01). CONCLUSION: In our data set, significant gender-specific differences were found in women compared with men undergoing MMS. These findings may be the result of discrepancies in sun exposure, protective behavior, and cosmetic concern.

Hyperpigmented palmar plaque: an unexpected diagnosis of Bowen disease.

An unusual case of pigmented Bowen disease on the palm is presented.

Characteristics of basal cell carcinoma of the lip treated using Mohs micrographic surgery.

BACKGROUND: There is a lack of U.S-based studies on basal cell carcinoma (BCC) of the upper lip treated using Mohs micrographic surgery (MMS). OBJECTIVE: To explore characteristics of BCC of the upper lip treated using MMS. METHODS: We performed a chart review of BCC cases from 2005 to 2011. RESULTS: Two hundred eighty-one cases were identified. There was a slight female predominance (55%). Men had a larger initial (p < .01) and final (p = .03) defect size. Infiltrative tumors had larger initial (p < .01) and final areas (p < .01). Ten percent of tumors were designated recurrent after previous treatment. Recurrent lesions (p < .001) and older age (p = .03) were associated with larger initial size. Complex reconstruction was required: 44% by local flap or graft and 13% by plastic surgery. CONCLUSION: There was a 1.2:1 female to male ratio, in contrast to the previously reported female predominance of 3.5:1. This cohort showed a higher recurrence rate than reported in the literature. Men and elderly patients were also found to have significantly larger initial lesion size. Thirteen percent of patients required repair by plastic surgery, reflecting heightened levels of cosmetic concern. These findings suggest that MMS is important in delineating subclinical tumor spread and providing complex repairs.

Characteristics of squamous cell carcinoma in situ of the ear treated using Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is used to treat squamous cell carcinoma in situ (SCCIS) for tissue conservation. OBJECTIVE: To examine characteristics of patients with SCCIS of the external ear treated using MMS. METHODS: A retrospective review from 2005 to 2011. RESULTS: We identified 173 cases of SCCIS of the ear. The population was 94% male (p < .01), with a mean age of 71. Eight percent (n = 13) of tumors were recurrent after prior treatment. Recurrent tumors occurred exclusively in men and were associated with larger initial size (p = .05), more layers for clearance p = .059), and larger final defect size (p = .01). Tumors with larger initial area were independently associated with older age (p < .01). Complexity of repair was independently associated with more layers (p < .01), larger initial area (p = .01), and larger final area (p = .02). Sex did not affect repair type. CONCLUSION: SCCIS of the ear predominantly affects men in our referral base of 85% to 90% private patients and 10% to 15% veterans. Recurrent tumors were associated with larger initial size and subclinical spread of tumor. Primary tumors on average required 1.6 layers, validating the utility of MMS in this population in delineating the subclinical spread of SCCIS of the ear.

The appearance of pili annulati following alopecia areata.

Pili annulati is a rare autosomal-dominant hair shaft abnormality. It is characterized by alternating light and dark bands along the shaft due to air-filled cavities within the cortex of the hair shaft. Alopecia areata has been previously described as a common association with pili annulati, with improvement in alopecia areata coinciding with resolution of pili annulati. We report the case of a patient with a history of alopecia areata and alopecia universalis who developed the characteristic banded hair of pili annulati upon resolution of her alopecia areata. We provide direct microscopic examination of postregrowth hairs compared to normal and cross-polarized light microscopy.

Behavioral Effects of Systemic, Infralimbic and Prelimbic Injections of a Serotonin 5-HT2A Antagonist in Carioca High- and Low-Conditioned Freezing Rats.

The role of serotonin (5-hydroxytryptamine [5-HT]) and 5-HT2A receptors in anxiety has been extensively studied, mostly without considering individual differences in trait anxiety. Our laboratory developed two lines of animals that are bred for high and low freezing responses to contextual cues that are previously associated with footshock (Carioca High-conditioned Freezing [CHF] and Carioca Low-conditioned Freezing [CLF]). The present study investigated whether ketanserin, a preferential 5-HT2A receptor blocker, exerts distinct anxiety-like profiles in these two lines of animals. In the first experiment, the animals received a systemic injection of ketanserin and were exposed to the elevated plus maze (EPM). In the second experiment, these two lines of animals received microinjections of ketanserin in the infralimbic (IL) and prelimbic (PL) cortices and were exposed to either the EPM or a contextual fear conditioning paradigm. The two rat lines exhibited bidirectional effects on anxiety-like behavior in the EPM and opposite responses to ketanserin. Both systemic and intra-IL cortex injections of ketanserin exerted anxiolytic-like effects in CHF rats but anxiogenic-like effects in CLF rats. Microinjections of ketanserin in the PL cortex also exerted anxiolytic-like effects in CHF rats but had no effect in CLF rats. These results suggest that the behavioral effects of 5-HT2A receptor antagonism might depend on genetic variability associated with baseline reactions to threatening situations and 5-HT2A receptor expression in the IL and PL cortices. Highlights -CHF and CLF rats are two bidirectional lines that are based on contextual fear conditioning.-CHF rats have a more "anxious" phenotype than CLF rats in the EPM.-The 5-HT2A receptor antagonist ketanserin had opposite behavioral effects in CHF and CLF rats.-Systemic and IL injections either decreased (CHF) or increased (CLF) anxiety-like behavior.-PL injections either decreased (CHF) anxiety-like behavior or had no effect (CLF).

Apoptosis caused by chemotherapeutic inhibition of nuclear factor-kappaB activation.

Both the protein kinase C (alpha/beta) inhibitor Go6976 and expression of dominant-negative nuclear factor (NF)-kappaB inhibitor kinase mutants: (a) blocked the growth and caused regression of a mammary tumor insyngeneic mice; (b) inhibited epidermal growth factor (EGF)-induced activation, nuclear translocation, and DNA-binding activity of NF-kappaB; and (c) caused apoptosis of EGF-stimulated cultured mammary tumor cells. cDNA microarray analysis revealed that these treatments reversed the expression changes of a subset of genes altered by EGF treatment. These included: up-regulation of proapoptotic genes of the tumor necrosis factor (TNF) pathway, death-associated protein (DAP) kinase, p53, and p21/Waf1; and down-regulation of inhibitors of apoptosis: inhibitor of apoptosis(IAP)-1 and X-IAP, TNF receptor-associated factor (TRAF)-2, and factors OX40 and 4-1BB. These results and our previous studies suggest the practicality of a target-directed chemotherapy for EGF-responsive breast cancers, by blocking NF-kappaB activation and thereby reinstating apoptosis.