The Controversy and Value of Mohs Micrographic Surgery for Melanoma and Melanoma in Situ on the Trunk and Extremities.

BACKGROUND: The use of Mohs surgery for melanoma on the trunk and extremities is not supported in the guidelines of dermatology, but is widely used in the real world. OBJECTIVE: The purpose of this article is to expose the value of Mohs surgery for melanoma on the trunk and extremities for consideration of updating the guidelines. MATERIALS AND METHODS: This was a retrospective review of a prospectively maintained database 7 to identify patients whose melanomas would likely have recurred using standard surgical margins. A prediction model was used to evaluate the value of Mohs surgery. RESULTS: The model predicted that 2,847 (2%) patients with melanoma on the trunk and extremities would likely recur each year with standard surgical margins even after re-excision when positive margins were identified, compared with 0.1% after Mohs surgery. This likely would result in the upstaging of 27% of melanoma in situ patients and 13% of patients with invasive melanoma. The upstaging would also result in a decrease in melanoma-specific survival and the death of 1% of patients with true local recurrences of melanoma. CONCLUSION: Mohs surgery has value for melanoma on the trunk and extremities by minimizing local recurrence and death from disease progression.

Mohs Micrographic Surgery Pearls for the Nose and Lips.

BACKGROUND: Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips can lead to larger defects and tumor recurrence, which can have aesthetic and functional repercussions for patients. OBJECTIVE: To review pre-, intra-, and postoperative techniques and pearls for performing MMS on the nose and lips to optimize outcomes. MATERIALS AND METHODS: Technical nuances and pearls cultured from the authors' own practice, those acquired from mentors and colleagues, and information identified from the literature are discussed to provide a logical approach to performing effective MMS on the nose and lips. RESULTS: When performing MMS on the nose and lips, sound preoperative preparation, precise surgical technique, and particular attention to reducing false-positives and false-negatives while harvesting Mohs layers enhances the fidelity of the MMS procedure, minimizing defect sizes and reducing tumor recurrence. CONCLUSION: Refining Mohs technique on the nose and lips allows more effective performance of tumor extirpation, improved microscopic evaluation, and more conservative reconstruction, leading to better patient outcomes.

Prognostic value of sentinel lymph node biopsy according to Breslow thickness for cutaneous melanoma.

BACKGROUND: Sentinel lymph node (SLN) biopsy is widely performed for melanoma with certain histologic parameters and offers important prognostic and staging information. Breslow thickness (BT) by itself also provides meaningful prognostic information. OBJECTIVE: To evaluate whether SLN status provides prognostic information independent from that which is already provided by BT. METHODS: We conducted a retrospective cohort study of 896 patients who underwent SLN biopsy for primary cutaneous melanoma. Stratified analysis of the impact of SLN status within BT groups (0.01-1 mm, 1.01-2.00 mm, 2.01-4.00 mm, and >4.00 mm) was performed. In addition, a Cox proportional hazard model was fit to evaluate the interaction between BT unadjusted and then adjusted for SLN status to determine whether predictive ability is improved. RESULTS: Having a negative SLN did not confer a statistically significant survival advantage for any BT subgroup (P = .54, .075, .17, and .95 for subgroups 0.01-1 mm, 1.01-2.00 mm, 2.01-4.00 mm, and >4.00 mm, respectively). In multivariate analysis, SLN status did not demonstrate independent prognostic ability over that of BT alone (P = .067). LIMITATIONS: Retrospective study, single institution. CONCLUSION: Our data suggest that SLN status does not offer better prognostic information for patients than BT alone.

Correlation Between Original Biopsy Pathology and Mohs Intraoperative Pathology.

BACKGROUND: The pathology observed on initial biopsy specimens for nonmelanoma skin cancer (NMSC), specifically the tumor subtype, weighs heavily into the selection of the treatment modality. Recognizing aggressive features on intraoperative Mohs micrographic surgery (MMS) frozen sections that were not indicated on initial biopsy reports is not uncommon. To date, there is limited data describing this discrepancy. OBJECTIVE: To investigate the frequency and nature of incongruity between the pathology seen in initial biopsies and intraoperative Mohs sections, providing information that will potentially impact skin cancer treatment and biopsy recommendations. METHODS: Retrospective chart review of cases of NMSC referred for MMS at the authors' institution over a 1-year period, recording changes between tumor subtypes observed at biopsy and those observed during MMS. RESULTS: Cases (50.5%) (n = 163) changed aggressiveness. Of these, 33% (n = 108) were more aggressive, whereas 17% (n = 55) were less aggressive. CONCLUSION: A substantial discrepancy was observed between preoperative biopsy and intraoperative pathology, including a significant portion tumors that became more aggressive. These results suggest that treatment modalities without margin control may not provide adequate treatment for a considerable number of NMSC based on preoperative tumor type alone.

Simultaneous fzd4 and lrp5 mutation in autosomal dominant familial exudative vitreoretinopathy.

PURPOSE: The purpose of this study was to report simultaneous mutations of FZD4 and LRP5 genes associated with autosomal dominant familial exudative vitreoretinopathy in members of one family. METHODS: Case report. RESULTS: A 16-month-old white boy with a 6-month history of leukocoria was referred for possible retinoblastoma. On examination, the left eye displayed extensive white vitreoretinal fibrosis filling the entire vitreous cavity up to the lens and with additional dystrophic calcification and iris neovascularization. The right eye showed temporal peripheral fibrovascular ridge. Fluorescein angiography showed 360° of peripheral nonperfusion with leakage from the fibrovascular ridge of the right eye and diffuse leakage from the massive vitreoretinal fibrosis and iris neovascularization of the left eye, consistent with familial exudative vitreoretinopathy. Laser photocoagulation of the avascular areas of the right eye was performed with disease stabilization. Clinical examination and genetic testing of the family members demonstrated that the proband and a male sibling had similar clinical findings and simultaneous mutations in the FZD4 and LRP5 genes. Both affected patients had normal bone mineral dual-energy X-ray absorptiometry. CONCLUSION: Familial exudative vitreoretinopathy is a retinal vascular disorder usually caused by a single mutation. Rarely, multiple simultaneous mutations can occur and, in this case, result in classic ophthalmic phenotypic and known risk for bone disorders.