The incidence of skin cancer in dermatology.

BACKGROUND: It is known that the incidence of skin cancer is rising rapidly worldwide, but no reliable figures on multiple nonmelanoma skin cancer (NMSC) are available. AIM: To determine the actual incidence of skin cancer in dermatology practice and to estimate how this relates to the first primary tumours (registered at the Eindhoven Cancer Registry). METHODS: We examined 1001 randomly selected patient records at Catharina Hospital Eindhoven for mention of skin cancer. For each patient, skin cancers were recorded in a database, starting from 1 January 2004 until 1 March 2010. The time interval between tumours and any history of skin cancer were also recorded. RESULTS: Of this group, 876 patients were treated for skin cancer during the study period. We recorded a total of 2106 tumours with a mean of 2.4 skin cancers per patient. Nearly half (46%) of patients developed multiple tumours, and the second tumour developed within a median period of 5 months. Over a quarter (28%) of patients were known to have had skin cancer before 2004, the start of the study period. CONCLUSIONS: The number of NMSCs in practice differs substantially from the number of first primary histologically confirmed NMSCs, as usually reported by the Eindhoven Cancer Registry. To obtain the optimum benefit from registration of NMSC, it is recommended to register all NMSCs, because only this complete number will give an insight into the incidence of the rising skin-cancer numbers. Because subsequent tumours occur frequently, NMSC should be regarded as a chronic disease, and innovations in disease management are required for cost-effective control.

Admission and capacity planning for the implementation of one-stop-shop in skin cancer treatment using simulation-based optimization.

Hospitals and health care institutions are facing the challenge of improving the quality of their services while reducing their costs. The current study presents the application of operations management practices in a dermatology oncology outpatient clinic specialized in skin cancer treatment. An interesting alternative considered by the clinic is the implementation of a one-stop-shop concept for the treatment of new patients diagnosed with basal cell carcinoma. This alternative proposes a significant improvement in the average waiting time that a patient spends between the diagnosis and treatment. This study is focused on the identification of factors that influence the average throughput time of patients treated in the clinic from the logistic perspective. A two-phase approach was followed to achieve the goals stated in this study. The first phase included an integrated approach for the deterministic analysis of the capacity using a demand-supply model for the hospital processes, while the second phase involved the development of a simulation model to include variability to the activities involved in the process and to evaluate different scenarios. Results showed that by managing three factors: the admission rule, resources allocation and capacity planning in the dermato-oncology unit throughput times for treatments of new patients can be decreased with more than 90 %, even with the same resource level. Finally, a pilot study with 16 patients was also conducted to evaluate the impact of implementing the one stop shop concept from a clinical perspective. Patients turned out to be satisfied with the fast diagnosis and treatment.

Imiquimod 5% cream as pretreatment of Mohs micrographic surgery for nodular basal cell carcinoma in the face: a prospective randomized controlled study.

BACKGROUND: Imiquimod 5% cream can reduce or clear superficial and small nodular basal cell carcinoma (BCC). It could be used as a pretreatment of Mohs micrographic surgery (MMS) to decrease defect size. OBJECTIVES: To study if a pretreatment with imiquimod 5% cream decreases defect size after MMS. In addition, to study the effect on the number of Mohs stages and reconstruction time. METHODS: Seventy patients aged >18 years with a primary nodular BCC in the face were included. The imiquimod group used imiquimod 5% cream for 4 weeks, before MMS. The control group was treated with MMS only. Tumour and defect sizes were measured. We noted the number of Mohs stages, reconstruction time and side-effects. RESULTS: The median percentage increase in area from tumour size at baseline to the post-MMS defect for the imiquimod group was significantly less compared with the control group, 50% vs. 147% (P < 0·001). A tendency towards fewer Mohs stages in the imiquimod group was observed and the reconstruction time was significantly shorter in this group (P = 0·01). CONCLUSIONS: Imiquimod 5% cream as pretreatment of MMS significantly reduced the tumour size in primary nodular BCC and reduced the surgical defect size. Further research is necessary to investigate cost-effectiveness.

One-stop-shop treatment for basal cell carcinoma, part of a new disease management strategy.

BACKGROUND: The number of skin cancer patients, especially patients with basal cell carcinoma (BCC), is rapidly increasing. Resources available at dermato-oncology units have not increased proportionally, which affects the throughput time of patients. OBJECTIVE: To assess the feasibility and safety of implementation of the one-stop-shop concept for the treatment of patients with BCC at a dermato-oncology unit. METHODS: A pilot study on a one-stop-shop concept for BCC was performed to investigate procedure safety and patient satisfaction. Fresh frozen sections were used to diagnose the tumours, and subsequently treatment with photodynamic therapy or excision was performed on the same day. Time spent in the hospital was measured and questionnaires were used to evaluate patient satisfaction. RESULTS: Sixteen patients, who together had 19 tumours, were included. Diagnoses were made within a mean time of 100 min (range 27-160 min). The mean throughput time was 4 hours and 7 min (range 60-420 min). No complications were observed, and patient satisfaction was high. CONCLUSION: The one-stop-shop concept for the treatment of skin cancer patients is feasible and efficient for both patients and dermato-oncology units. Further research is necessary to investigate cost-effectiveness when larger patient groups are involved.

Treatment of basal cell carcinomas in patients with nevoid basal cell carcinoma syndrome.

BACKGROUND: Nevoid basal cell carcinoma syndrome (NBCCS) is characterized by the development of multiple basal cell carcinomas (BCCs). A major problem for these patients is the enormous amount of BCCs which can invade in the deep underlying structures, especially in the face. Different treatment modalities are used in these patients; surgical excision, Mohs micrographic surgery, cryotherapy, photodynamic therapy, ablative laser therapy and topical 5% imiquimod. There is no evidence based advice how to treat a NBCCS patient. OBJECTIVE: To give a review of the literature about the possible treatment modalities for the multiple BCCs in NBCCS patients. RESULTS: Literature consists mainly of case reports; no evidence based advice how to treat a NBCCS patient exists. Multiple treatments are available (surgical and non-surgical), and a lot of them can be combined. Treatment in a megasession is an option to diminish the medical and social inconvenience for the patient.

[A pseudo-outbreak of pharyngeal gonorrhoea related to a false-positive PCR-result]. / Een pseudo-uitbraak van keelgonorroe samenhangend met een fout-positieve PCR-uitslag.

Nucleic acid amplification tests, including the polymerase chain reaction (PCR), are sensitive and specific tests that are often used for diagnosing sexually transmitted diseases (STDs). A pseudo-outbreak of pharyngeal gonorrhoea in a group of prostitutes turned out to have been caused by false-positive test results due to commensal oropharyngeal Neisseria species. Specific molecular tests may yield erroneous results. When the results of an STD study have major consequences at a legal or social level, it is advisable, in consultation with a medical microbiologist, to take a sample for culture or to carry out a second molecular test aimed at a different part of the bacterial genome.

Do systemic antibiotics increase the survival of a full thickness graft on the nose?

BACKGROUND: Full thickness grafts on the nose do not always heal without problems. Partial or entire necrosis of the graft is likely to lead to less favourable cosmetic results and prolonged wound care. No consensus exists as to the use of systemic antibiotics to increase the success rate of survival of a full thickness skin graft on the nose after non-melanoma skin cancer surgery. OBJECTIVE: The objective of the study was to evaluate the effect of systemic antibiotics on the survival of full thickness grafts on the nose. METHODS: We performed a randomized, controlled trial in which we compared azithromycin with standard treatment in 30 patients, who underwent a full thickness graft reconstruction of a surgical defect on the nose after surgery for non-melanoma skin cancer. Percentage survival of the graft was the main outcome measure. RESULTS: A statistically significant difference in favour of the grafts treated with azithromycin was seen (P=0.002). Of all the variables analysed, only smoking had a significant negative effect on the survival of the graft. CONCLUSIONS: Systemic antibiotics with an accurate bacterial spectrum should be advised in full thickness skin graft reconstruction after surgery for non-melanoma skin cancer of the nose. Smoking should be strongly discouraged.

Histopathological characteristics of metastasizing squamous cell carcinoma of the skin and lips.

AIMS: The reported incidence of metastasis from squamous cell carcinoma (SCC) of the skin and lip varies between 0.5% and 16%. Clinical and histopathological criteria have been proposed to identify tumours that may have an increased risk of metastasis. The aim of this study was to define such high-risk tumours, especially since the incidence of SCC of the skin is increasing. METHODS AND RESULTS: Histopathological features of metastasized skin and lip tumours and a matched group of non-metastasizing tumours were reassessed. Characteristics studied were: tumour width, excision margins, histological subtype, Clark level, Breslow depth, tumour differentiation, inflammation, perineural and angio-invasive growth, ulceration and desmoplasia. Data were statistically analysed separately for skin and labial lesions. Desmoplasia, Clark level, Breslow depth, maximum diameter, angio-invasion, grading, perineural invasion, plasma cells and eosinophilic inflammatory response proved to be statistically significantly related to metastasis of skin tumours. Breslow depth, plasma cells and grading appeared to be statistically significantly related to metastasis of SCC of the lips. CONCLUSIONS: A typical metastatic SCC showed: a tumour width of at least 15 mm, a vertical tumour thickness (=Breslow) of at least 2 mm, less differentiation, presence of desmoplasia and an inflammatory response with eosinophils and plasma cells.

Actinic keratosis: how to differentiate the good from the bad ones?

Our objective was to obtain practical clinical parameters to indicate those actinic keratoses (AK) that are at risk of becoming invasive. A systematic review of the literature, with focus on randomized trials, retrospective studies and reviews was undertaken. The main outcome measure was the rates and clinical features of AK that transformed into SCC. This study reviewed randomized and retrospective studies and reviews of AK and their risk of becoming SCC. We reviewed a total of 875 studies and identified 62 useful prospective, retrospective studies and reviews. Finally 15 studies covering percentage and/or clinical parameters of malignant transformation were found to be useful: a total of 9 reviews, 4 randomized controlled trials and 2 retrospective studies. Only 1 study (meta-analysis) examined the percentage of malignant transformation and found a rate between 0.025% and 20% per year/per lesion. Clinical parameters found were: induration (3 studies), bleeding (3 studies), enlargement in diameter (3 studies), erythema (2 studies) and ulceration (2 studies). Other minor clinical criteria were pain, palpability, hyperkeratoses, pruritic lesions and pigmentation. The amount of quality research on the most common premalignant lesion in humans is disappointing. The only longitudinal study looking at the incidence of malignant transformation of AK to SCC dates from 1988. Besides the known risk factors (skin type, photodamage, immunosuppression etc), based on this review we found clinical features that provide a practical guide to practitioners in the treatment of AK. Although not prospectively studied, clinical parameters indicating those AK with an increased risk of malignancy are IDRBEU. I (Induration /Inflammation), D (Diameter > 1 cm), R (Rapid Enlargement), B (Bleeding), E (Erythema) and U (Ulceration). In future prospective studies, these parameters should be included.

Local immune modulator (imiquimod 5% cream) as adjuvant treatment after incomplete Mohs micrographic surgery for large, mixed type basal cell carcinoma: a report of 3 cases.

BACKGROUND: Surgical excision, including Mohs micrographic surgery, is the treatment of first choice for basal cell carcinoma (BCC). Occasionally, the Mohs procedure has to be ceased prematurely for unforeseen reasons. OBJECTIVE: We sought for possibilities to adjuvantly treat patients in which superficial basal cell carcinoma remained after incomplete Mohs surgery. METHODS: We report 3 cases of patients in which Mohs micrographic surgery for their large basal cell carcinomas was ceased for different unforeseen reasons, with remaining superficial fields of BCC after the aggressive and deeply localized part had been removed. Three weeks after closure of the defect, adjuvant therapy for the superficial remnants of the tumor with imiquimod 5% cream was given for 6 weeks, covering at least 1 centimeter around the surgically treated area. RESULTS: The treatment was well accepted with no serious side effects and a good cosmetic result. No recurrences were seen after a follow-up period of 20 to 34 months. CONCLUSION: A combination of surgical intervention for the central deeper part of the BCC and topical imiquimod 5% cream for the superficial part at the border might be a therapeutic option for those patients with multiple facial BCCs, severe sun damage, and extensive surgery in the past, in whom completion of the Mohs surgical procedure for the entire tumor is not possible for different reasons.

Congenital naevi treated with erbium:YAG laser (Derma K) resurfacing in neonates: clinical results and review of the literature.

BACKGROUND: Giant congenital melanocytic naevi (CMN) are often disfiguring, potentially malignant pigmented lesions present at birth. Their management is based on two main considerations: attempt to minimize the risk of malignancy and to obtain an acceptable cosmetic result. In the past various approaches have been used to treat these naevi. OBJECTIVES: To describe clinical and histopathological results after treatment of CMN in neonates with erbium:YAG (Er:YAG) laser resurfacing. METHODS: Ten children with CMN were treated with Er:YAG laser resurfacing in the first weeks of life. RESULTS: Laser ablation was well tolerated by all children and immediate results were good. At a total follow-up ranging from 3 to 36 months we saw good results, with no or minimal repigmentation, in eight of 10 patients. Patients experienced minimal side-effects such as postoperative pain, bleeding and scar formation. Postoperative histopathology showed disappearance of heavily pigmented cells in the upper part of the dermis. CONCLUSIONS: Er:YAG laser resurfacing is an effective method of ablating CMN, with minimal scarring and postoperative complications.

Molecular aetiology and pathogenesis of basal cell carcinoma.

Recent insights into the cell biology of the epidermis and its appendages are transforming our understanding of the pathogenesis of basal cell carcinoma (BCC). The significant progress that has been made warrants a comprehensive review of the molecular and cellular pathology of BCC. The items addressed include environmental and genetic risk factors, the biology of the putative precursor cell(s), and the contribution of aberrations in processes such as apoptosis, cell proliferation, differentiation and signalling to carcinogenesis. Furthermore, established and novel treatment modalities are discussed with particular attention to future biological approaches.

Mohs' micrographic surgery for treatment of basal cell carcinoma of the face--results of a retrospective study and review of the literature.

BACKGROUND: The incidence of skin cancer and especially basal cell carcinoma (BCC) has increased in the last decade and is still increasing. Many treatment modalities can be used to treat BCC; surgical excision is the most frequently used. Mohs' micrographic surgery (MMS) is an advanced excision technique which is often used to treat BCC in the U.S.A. In Europe it is practised less frequently. OBJECTIVE: The aim of this article was to evaluate the efficiency of MMS for the treatment of facial BCC. METHODS: In a retrospective study recurrence rates after the treatment of facial BCC by MMS were estimated by reviewing the records of all patients with BCCs (620 patients with 720 BCCs) treated by MMS in our department from April 1992 until December 1999. RESULTS: The 5-year recurrence rates estimated from this study were 3.2% for primary BCC and 6.7% for recurrent BCC. Prognostic factors for recurrence are: an aggressive histopathological subtype, more than four Mohs' stages, a large defect size and a recurrent BCC. CONCLUSION: Based on the fact that MMS provides the lowest recurrence rates, it is the treatment of first choice for primary facial BCCs with an aggressive histopathological subtype and for recurrent BCCs in the face.

The garlic-derived organosulfur component ajoene decreases basal cell carcinoma tumor size by inducing apoptosis.

Although the therapeutic role of ajoene, an organosulfur compound of garlic, in cardiovascular diseases and mycology has been established, its usefulness in cancer treatment has only recently been suggested. We applied ajoene topically to the tumors of 21 patients with either nodular or superficial basal cell carcinoma (BCC). A reduction in tumor size was seen in 17 patients. Immunohistochemical assays for Bcl-2 expression in a selection of these tumors before and after treatment showed a significant decrease in this apoptosis-suppressing protein. On average, the percentage of tumor cells expressing the proliferation marker Ki-67 was not decreased, which suggests that the action of ajoene is not explained by a cytostatic effect. To obtain further insight into the mode of action of ajoene, the BCC cell line TE354T and a short-term primary culture of BCC were analyzed for apoptosis induction after treatment with the drug. Apoptosis was detected by morphology of the cells and by flow cytometry. Ajoene induced apoptosis in a dose- and time-dependent manner in these cultures. Taking together the results of the in vivo and in vitro studies, we conclude that ajoene can reduce BCC tumor size, mainly by inducing the mitochondria-dependent route of apoptosis.

[Diagnostic image (13). Erythropoietic protoporphyria]. / Diagnose in beeld (13). Erytropoëtische protoporfyrie.

In a five-year-old girl with photosensitivity (burning skin sensation after a sun bath) and purpura on the nose and the sides of the fingers erythropoietic protoporphyria was diagnosed, an autosomal dominant disease.

[Mohs' method of micrographic surgery as treatment for recurrent basal cell carcinoma]. / Micrografische chirurgie volgens Mohs als behandeling voor recidief van basalecelcarcinoom.

OBJECTIVE: Evaluation of Mohs' micrographic surgery as treatment for recurrent basal cell carcinoma of the skin. DESIGN: Retrospective. SETTING: University Hospital Maastricht, the Netherlands. METHOD: In the period April 1992 to December 1995, 91 recurrent basal cell carcinomas (88 patients) were treated by Mohs' micrographic surgery. Medical records were analysed retrospectively with respect to different aspects. RESULTS: The mean age of the patients was 69 years. The recurrent basal cell carcinomas, with an mean diameter of 19.7 mm, were mainly localized on the nose and forehead. There were equal numbers of solid and morphea-like types of basal cell carcinomas. Most of these tumours had been treated by means of surgical excision in the past. The last treatment had taken place 3 years previously on average. Reconstruction was performed by means of primary closure, a graft or a flap. The mean follow-up period after Mohs' micrographic surgery was 12 months, in which one tumour recurred. CONCLUSION: Mohs' micrographic surgery is a surgical technique which provides the best prospect of total tumour removal together with maximal functional and cosmetic preservation. Mohs' micrographic surgery is of particular value for the treatment of recurrent basal cell carcinomas.