Cutaneous Squamous Cell Carcinoma Mimickers: Beware the Pruritic Papule on the Leg of an Older Female.

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.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

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.

The Navicular Graft for Reconstructing Deep Alar Defects.

The reconstruction of deep nasal ala defects can be challenging. The often thick, sebaceous skin of the nose provides structural support helping maintain the ala shape and nasal patency; loss of this support may result in ala deformity and nasal vestibule collapse. Traditional full-thickness skin grafts of deep alar defects may result in depressed scars. We present a variation of the full-thickness skin graft to repair deeper alar defects, sculpting the graft into a boat-shaped or "navicular" form. This allows for sufficient volume restoration and good cosmesis while avoiding more extensive surgical repairs of the nasal ala. The navicular graft offers several advantages: the avoidance of more extensive procedures involving cartilage grafts and/or flaps, appropriate color/texture match, and volume restoration without pitting, notching, or retraction of nasal structures. In addition, no struts or bolsters are needed.

The role of radiation therapy in the management of cutaneous malignancies. Part I: Diagnostic modalities and applications.

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.

The role of radiation therapy in the management of cutaneous malignancies. Part II: When is radiation therapy indicated?

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.

Melatonin-Associated Facial Swelling in an Oncology Patient: Case Report and Review of Swelling of the Face in Individuals With Head and Neck Cancer.

Facial swelling has several etiologies. In patients with head and neck malignancies, this can include primary disease progression or iatrogenic causes. A 66-year-old man presented with increased facial swelling and erythema for 18 months. He had a history of baseline postoperative facial lymphedema following head and neck surgery and radiotherapy for desmoplastic melanoma approximately 20 years ago. However, his facial edema acutely worsened 18 months prior to presentation. A medication review revealed that he was regularly taking melatonin for the past two years. Approximately two weeks after cessation of melatonin therapy, the patient's facial appearance returned to baseline. In conclusion, it is important for clinicians to perform a thorough medication review for patients with facial swelling and erythema.

Dermatofibrosarcoma Protuberans Found Within Procedural Scars: A Retrospective Review at a Tertiary Referral Cancer Center.

BACKGROUND: Surgical scars are not a well-known risk factor for the development of dermatofibrosarcoma protuberans (DFSP). However, DFSP can arise within a surgical scar. OBJECTIVE: This study determined the number of DFSP found within scars from prior surgical procedures at a tertiary academic cancer center. METHODS: A retrospective data analysis was performed of all patients with biopsy-proven DFSP from January 2000 to April 2018 at MD Anderson Cancer Center (MDACC), a tertiary referral cancer center. Chart review was performed, and data were recorded for gender, race, and age of patients. We also recorded the site, location, and size of the DFSP and whether the patients had a history of prior surgery at the DFSP site. All patients had a pathologic diagnosis of DFSP at MDACC. Patients were selected from the pathology database at MDACC using the keywords "DFSP" or "dermatofibrosarcoma protuberans". A total of 458 patients were identified; however, 94 patients were excluded from the study because they were only referred to MDACC with a confirmed diagnosis of DFSP and were not seen as patients by a MDACC physician. RESULTS: Of the remaining 364 patients, 37 patients (10.1%) had either a history of a benign neoplasm or an inflammatory disease that had been evaluated or treated by either punch biopsy, shave biopsy, or minor excision at the site of DFSP (8.5%, 31 patients) or a DFSP arising within a major surgical procedural scar (1.6%, six patients). The surgical sites identified were the abdomen (four patients) and the groin (two patients). Three of the patients with a major surgical scar DFSP had prior laparoscopic surgery at the site. CONCLUSIONS: DFSPs occur at surgical scars. The development of surgical scar DFSP in 10% of our patients prompts us to postulate that the neoplasm may be associated with the malignant transformation of these scars.

Superficial Basal Cell Cancers Demonstrate Higher Rates of Mixed Histology on High-Risk Anatomical Sites.

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.

A Survey of Mohs Tissue Tracking Practices.

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.

Tinea Capitis Masquerading as Basal Cell Carcinoma.

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.

Giant Pigmented Squamous Cell Carcinoma in Situ: A Diagnostic and Therapeutic Challenge.

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.

A conceptual framework for navigating the superficial territories of the face: Relevant anatomic points for the dermatologic surgeon.

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.

Patient safety in dermatologic surgery: Part I. Safety related to surgical procedures.

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.

Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures.

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.