Mohs frozen tissue sections in comparison to similar paraffin-embedded tissue sections in identifying perineural tumor invasion in cutaneous squamous cell carcinoma.

BACKGROUND: Perineural invasion (PNInv) in cutaneous squamous cell carcinoma (cSCC) increases the risk of recurrence, possibly because of suboptimal identification on frozen or paraffin-embedded tissue sections. Perineural inflammation (PNInf) may portend PNInv. OBJECTIVE: We sought to correlate identification of PNInv and PNInf in hematoxylin-eosin-stained Mohs frozen sections with PNInv and PNInf identified in similarly oriented paraffin-embedded sections obtained in cases of cSCC. METHODS: We reviewed same patient Mohs frozen and paraffin-embedded tissue sections for all patients presenting within a 2-year period to our Mohs micrographic surgical unit for removal of cSCC with PNInv or PNInf identified on either type of tissue section. RESULTS: Of 537 patients undergoing surgical resection of cSCC, 21 (3.9%) had either PNInv (n = 11) or PNInf (n = 10) on frozen sections. PNInv on Mohs frozen sections was identified in 11 cases and confirmed on paraffin-embedded sections in 9 cases (82%). Paraffin-embedded sections failed to identify PNInv present in Mohs frozen sections in two (2/11), or 18% of cases. PNInf on Mohs frozen sections was confirmed on paraffin-embedded sections in 3 cases (30%), but PNInv was identified in 5 cases (50%). LIMITATIONS: Our results are a retrospective case review from a specific time period by one institution. Furthermore, it is impossible to compare identical tissue specimens using two sequential tissue processing techniques. CONCLUSION: PNInv can be accurately identified with Mohs frozen sections. PNInf on Mohs frozen sections suggests the presence of PNInv and requires further histologic investigation.

Nonanatomic free cartilage batten grafting with second intention healing for defects on the distal nose.

BACKGROUND: Defects of the distal nose, particularly the nasal ala, pose a reconstructive challenge due to the lack of loose adjacent tissue and proximity to a free margin. OBJECTIVE: We report our experience using nonanatomic free cartilage batten grafts in combination with second intention healing for nasal ala defects. METHODS: A retrospective study of distal nose defects repaired using nonanatomic free cartilage batten grafting with second intention healing was performed. Detailed data on the quality of the scar, post-operative complications, free margin distortion, functional impairments, and patient satisfaction were recorded. Digital images were also shown to an experienced fellowship-trained Mohs surgeon to assess the overall aesthetic outcome using a 5-point score ranging from poor to excellent. RESULTS: Sixteen subjects were included in the study. Complications were common, but minor. Five (~31%) subjects had subtle contour depressions, three (~18%) subjects had excessive granulation tissue, two (~12%) subjects had post-operative ear pain at the donor site lasting up to 10 days, and one (~6%) subject had a hypertrophic scar at the recipient site. There were two occurrences (~12%) of mild alar notching but no occurrences of significant alar margin distortion or nasal valve dysfunction. In terms of aesthetic outcome, seven (~43%) were assessed by an independent fellowship-trained Mohs surgeon as having excellent aesthetic outcomes, six (~38%) were very good, and three (~19%) were good. All sixteen subjects reported satisfaction on follow-up evaluation. CONCLUSIONS: Nonanatomic free cartilage grafting with second intention healing allows for facile, single-step repair of nasal ala defects with high patient satisfaction and aesthetically pleasing results. This provides an attractive alternative to other flap techniques, skin grafting, and healing via secondary intention.

Metallic taste as a side effect of topical fluorouracil use.

Topical fluorouracil is widely used for the treatment of precancerous and cancerous lesions of the skin. The most common side effect of this medication is localized irritant dermatitis. The authors report a case of dysgeusia with metallic taste as a side effect of this medication. While not previously seen with topical use, this is not an uncommon side effect seen with systemic administration of 5-fluorouracil. The etiology of dysgeusia from chemotherapeutic agents and systemic absorption of fluorouracil is discussed.

Keloid formation occurring in the distribution of a congenital vascular malformation.

A 35-year-old African American man presented with complaints of malodorous drainage from hypertrophic lesions on his occipital scalp (Figure 1, inset). The patient had no family history of keloid formation and no other keloids on his body. The hypertrophic mass on his scalp had been present for 10 years and had not been a result of any type of mechanical, surgical, or laser treatment. It corresponded to the distribution of a large vascular malformation over the occiput (Figure 1). The vascular malformation extended from the occipital scalp to the right parietal scalp, the right side of the face, neck, upper chest, and right arm, with varicosities and hypertrophy of the right upper extremity (Figure 2). The vascular malformation over the right parietal scalp and ear was characterized by bleb formation and hypertrophy of the right ear. The patient reported that no manipulation, including laser treatment, of the vascular malformation had been previously performed. He did state that a previous dermatologist had attempted serial surgical excision of the cerebriform nodules but retired during the course of treatment. He stated that the appearance of his keloid formation and port-wine stain had not changed during the past 10 years. A previous biopsy of a hypertrophic lesion showed histologic findings consistent with folliculitis keloidalis nuchae. Cephalexin 500 mg 4 times daily for 14 days was prescribed for the purulent drainage. A Doppler ultrasound was ordered of the right upper extremity to evaluate for an arteriovenous malformation and showed no evidence of venous thrombosis or arteriovenous malformation. On a second visit 2 weeks later, the hypertrophic lesions continued to show drainage. Clindamycin gel to be applied twice daily to the scalp was added. The patient also had magnetic resonance imaging with and without gadolinium contrast (Figure 3) ordered, which showed a large hypertrophic giant scalp keloid overlying the occipital and suboccipital region measuring 12x 19 cm. There was soft tissue thickening involving the right external ear, extending inferior to the right ear, overlying an intact parotid gland. There was no evidence of muscular or skull invasion.

The importance of reviewing pathology specimens before Mohs surgery.

BACKGROUND: The review of outside biopsy slides before performing surgery is the standard of care in many surgical specialties. Previous studies have shown high discrepancy rates between the original and second-opinion diagnoses. The frequency with which this practice changes the diagnosis and management of patients undergoing Mohs surgery is undocumented in the literature. It is standard practice at our institution to review all outside biopsy slides before Mohs surgery. OBJECTIVE: To investigate how often review of outside biopsies by an internal dermatopathologist changes patients' initial referral diagnosis and subsequent management. METHODS & MATERIALS: This is a retrospective review of all patients referred to Mohs surgery from January 2003 through March 2007. The number of cases in which the diagnosis changed and how this change affected management were recorded. RESULTS: Seventy-four of 3,345 (2.2%) cases were identified in which the diagnosis changed after review of the biopsy slides. Management was affected in the majority (61%) of cases. Board-certified dermatopathologists originally read nearly half of the biopsies. CONCLUSION: Review of outside biopsy slides before surgery can change the diagnosis in a large proportion of patients, with a resulting change in management. This quality-assurance practice may improve patient care.

Elastosis perforans serpiginosa.

A 41-year-old white man with Down syndrome presented with a slightly pruritic, papular eruption on bilateral forearms of several years' duration. Physical examination revealed multiple 2- to 3-mm keratotic, umbilicated pink papules in an annular configuration distributed symmetrically on the flexural surfaces of the forearms (Figure 1). The skin surrounding these papules was noted to be hyperpigmented and somewhat atrophic. The remainder of his skin examination was unremarkable. A shave biopsy of 1 papule was performed and stained with hematoxylin-eosin. Hematoxylin-eosin-stained sections showed clumps of bright red fibers being extruded through an acanthotic epidermis with a central invagination (Figure 2). Verhoeff-van Gieson stain confirmed these fibers to be elastin (Figure 3). Elastosis perforans serpiginosa was diagnosed.

Nasal trumpet orthosis to maintain nares opening during a melolabial interpolation flap.

BACKGROUND: The nasal trumpet has been used in emergency resuscitation, anesthesia, and facial burns to maintain nares openings. The dermatologic surgery literature is not as familiar with this device to improve respiratory function during the postoperative period after reconstruction of large defects on the nose. OBJECTIVE: To present a novel way of using a modified nasal trumpet orthosis to maintain nasal valve patency and improve nasal valve respiratory function postoperatively following a melolabial interpolation flap. MATERIALS: A sterile nasal trumpet orthosis. CONCLUSION: We present a novel way of using a modified nasal trumpet orthosis after a melolabial interpolation flap procedure. For large defects involving the nares and/or nasal valve of the nose, the nasal trumpet is well tolerated by the patient and can lead to increased postoperative respiratory function while acting as a "bolster" for the closure.

Combined Merkel cell carcinoma and atypical fibroxanthoma.

BACKGROUND: Although there are reports of squamous cell carcinoma arising within and adjacent to Merkel cell carcinoma, and one report of an atypical fibroxanthoma-like tumor arising in an irradiated recurrent Merkel cell carcinoma, there have previously been no reports of an immunohistochemically verified atypical fibroxanthoma occurring in conjunction with a Merkel cell carcinoma. OBJECTIVE: We report on a neoplasm with distinct features of both Merkel cell carcinoma and atypical fibroxanthoma. METHODS: Histologic and immunohistochemical evaluations were performed. RESULTS: Our results verify the finding of a combined Merkel cell carcinoma and atypical fibroxanthoma. CONCLUSION: This case is an interesting and unusual combination of tumors. The origin of the Merkel cell carcinoma is revisited. Debated origins include neuroendocrine, epithelial, and pleuripotent stem cell.

Merkel cell carcinoma.

Merkel cell carcinoma is an aggressive tumor that should be treated early and aggressively. Although there are 5 published cases of spontaneous regression of Merkel cell carcinoma, a patient's best chance for survival is early detection with either wide local excision or Mohs' micrographically controlled margins with a final 5- to 10-mm layer. This should be followed by sentinel lymph node biopsy with lymph node dissection of the draining basin if metastases are discovered. Adjuvant radiation to the primary site and the draining basin should follow. Although this aggressive approach to treatment is not appropriate for every case, the literature, although scanty, supports this. Chemotherapy with or without additional radiation therapy should be offered to patients with advanced disease, mostly for palliation. The need for prospective trials and longer follow-up for larger series of patients is obvious.

White piedra: further evidence of a synergistic infection.

White piedra is a fungal infection of the hair shaft caused by Trichosporon beigelii. A synergistic coryneform bacterial infection is often present with T beigelii. White piedra, although not commonly reported to infect scalp hair in North America, is an important consideration in the differential diagnosis of scalp hair concretions. We report a case of white piedra of scalp hair with synergistic coryneform bacterial infection in two sisters, both US natives. Culture and light and electronmicroscopic evidence of the synergistic infection are presented.