Usefulness of High-Frequency Ultrasound in the Classification of Histologic Subtypes of Primary Basal Cell Carcinoma. / Utilidad de la ecografía cutánea en la clasificación de subtipos de los carcinomas basocelulares primarios.

INTRODUCTION: Incisional biopsy may not always provide a correct classification of histologic subtypes of basal cell carcinoma (BCC). High-frequency ultrasound (HFUS) imaging of the skin is useful for the diagnosis and management of this tumor. OBJECTIVES: The main aim of this study was to compare the diagnostic value of HFUS compared with punch biopsy for the correct classification of histologic subtypes of primary BCC. We also analyzed the influence of tumor size and histologic subtype (single subtype vs. mixed) on the diagnostic yield of HFUS and punch biopsy. METHODS: Retrospective observational study of primary BCCs treated by the Dermatology Department of Hospital Costa del Sol in Marbella, Spain, between october 2013 and may 2014. Surgical excision was preceded by HFUS imaging (Dermascan C©, 20-MHz linear probe) and a punch biopsy in all cases. We compared the overall diagnostic yield and accuracy (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of HFUS and punch biopsy against the gold standard (excisional biopsy with serial sections) for overall and subgroup results. RESULTS: We studied 156 cases. The overall diagnostic yield was 73.7% for HFUS (sensitivity, 74.5%; specificity, 73%) and 79.9% for punch biopsy (sensitivity, 76%; specificity, 82%). In the subgroup analyses, HFUS had a PPV of 93.3% for superficial BCC (vs. 92% for punch biopsy). In the analysis by tumor size, HFUS achieved an overall diagnostic yield of 70.4% for tumors measuring 40mm2 or less and 77.3% for larger tumors; the NPV was 82% in both size groups. Punch biopsy performed better in the diagnosis of small lesions (overall diagnostic yield of 86.4% for lesions ≤40mm2 vs. 72.6% for lesions >40mm2). CONCLUSIONS: HFUS imaging was particularly useful for ruling out infiltrating BCCs, diagnosing simple, superficial BCCs, and correctly classifying BCCs larger than 40mm2.

Clinical and pathological features of melanoma in europeans living on the Western costa del sol in southern Spain.

OBJECTIVE: To compare clinical and pathological features of melanoma in Spanish patients with those of patients from Central or Northern Europe living in the health district of Costa del Sol Occidental in southern Spain. METHODS: We conducted a descriptive cross-sectional study of all cases of primary cutaneous melanoma histologically confirmed between 2005 and 2011 in the health care district covered by Hospital Costa del Sol in Marbella. We analyzed clinical and pathological features and performed a descriptive analysis of the 2 populations, in addition to univariate analysis with place of birth (Spain vs Central or Northern Europe) as the independent variable. RESULTS: Compared with Spaniards, patients from Central or Northern Europe were 10 years older at the time of melanoma diagnosis (66.2 vs 56.2 years, P<.001), had lighter skin (types I or II) (90.3% vs 67.1%, P<.001), and greater recreational sun exposure (93.7% vs 66.2%, P<.001). In addition, multiple melanomas (17.6% vs 4.4%, P=.001), nonmelanoma skin cancer (47.2% vs 15.7%, P<.001), and a family history of melanoma (9.5% vs 2.3%, P=.01) were more common in these patients. Central and Northern Europeans also had a higher overall frequency of melanoma on the trunk (46.3% vs 38.7%) and melanoma in situ (54.7% vs 41.8%, P=.03). CONCLUSION: Differences in melanoma presentation between Spanish patients and patients from Central or Northern Europe appear to be linked to phenotypic and lifestyle factors. A better understanding of these differences will help to tailor melanoma prevention and follow-up programs for multicultural populations, such as those on Spain's Costa del Sol.

The usefulness of high-resolution ultrasound in detecting invasive disease in recurrent basal cell carcinoma after nonsurgical treatment.

INTRODUCTION AND OBJECTIVES: Accurate subtyping of basal cell carcinoma (BCC) is crucial for the effective management of this disease and it is particularly important to distinguish between aggressive and nonaggressive histologic variants. Histologic subtype is not always accurately identified by biopsy and this can have serious implications. High-resolution ultrasound (HRUS) is a recent technique that has proven to be of value in differentiating between variants of BCC. The aim of this study was to investigate the potential usefulness of HRUS for detecting invasive disease in recurrent BCC treated nonsurgically following an initial diagnosis of noninvasive BCC by biopsy. MATERIAL AND METHODS: This was a prospective observational study of consecutive cases of BCC with clinical suspicion of recurrence following nonsurgical treatment and a pretreatment diagnosis of superficial BCC by punch biopsy. Before surgical excision, the recurrent lesions were evaluated by HRUS followed by a punch biopsy of the site of suspected recurrence. The diagnostic agreement between HRUS, punch biopsy, and excisional biopsy was then evaluated. RESULTS: Eight lesions were studied. HRUS identified invasive disease in 3 of the 4 cases that were incorrectly classified as superficial subtypes by punch biopsy. CONCLUSION: HRUS could be useful for detecting persistent tumor after nonsurgical treatment and for choosing the site most likely to harbor invasive disease for punch biopsy.

Preoperative 15-MHz ultrasound assessment of tumor thickness in malignant melanoma.

BACKGROUND: Tumor thickness is of great importance in the management of cutaneous malignant melanoma (MM): this variable not only affects prognosis but is also a key factor in planning surgical margins and selecting candidates for sentinel node biopsy. Breslow depth is the standard histologic measure of thickness, but technological advances have provided imaging techniques such as cutaneous ultrasound that can potentially assess tumor thickness and enable prompt initiation of definitive treatment. OBJECTIVES: a) To evaluate the utility of ultrasound assessment of tumor thickness in MM, and b) to analyze histologic variables that affect ultrasound assessments of thickness. MATERIALS AND METHODS: Retrospective study of a consecutive series of 79 primary cutaneous MMs in which tumor thickness had been assessed by 15-MHz ultrasound before surgery. We gathered data from histology reports, studying Breslow depth and the presence of ulceration, regression, inflammatory infiltrate, and associated nevi. Correlation coefficients were calculated to evaluate the strength of association between Breslow depth and thickness assessed by ultrasound. We also calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound measurement in the diagnosis of MMs more than 1mm thick. Associations between histologic variables and the overestimation of thickness by ultrasound were also analyzed. RESULTS: The 79 primary MMs studied had a mean (SD) Breslow depth of 0.8 (1.4) mm. There was moderate correlation and agreement between Breslow depth and the ultrasound assessment of thickness (Pearson correlation coefficient, 0.678; intraclass correlation coefficient, 0.78). The tendency of ultrasound to overestimate thickness was nonsignificantly related to the presence of a moderate to intense infiltrate and associated nevi (P>.05). The sensitivity of ultrasound for the diagnosis of MM over 1mm thick was 82%; specificity was 80%, and positive and negative predictive values were 54% and 94%, respectively. CONCLUSIONS: Ultrasound imaging quite correctly identifies thin MMs and can be useful for planning adequate surgical margins; however, there are limitations on its usefulness in the diagnosis of thick MMs. Additional studies are required to confirm whether certain histologic characteristics, such as the presence of a moderate to intense inflammatory infiltrate or associated nevi can lead to overestimation of thickness by ultrasound, limiting the clinical utility of this imaging technique in MM management.

[Cost analysis of Mohs micrographic surgery in high-risk facial basal cell carcinoma]. / Análisis de costes de la cirugía micrográfica de Mohs en el carcinoma basocelular facial de alto riesgo.

INTRODUCTION: Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost. OBJECTIVES: To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS. MATERIAL AND METHODS: Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence. RESULTS: Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was e106,129.07 and e1325.80, respectively (compared to e97 700 and e1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=0.534). CONCLUSIONS: MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.

Cost Analysis of Mohs Micrographic Surgery in High-Risk Facial Basal Cell Carcinoma. / Análisis de costes de la cirugía micrográfica de Mohs en el carcinoma basocelular facial de alto riesgo.

INTRODUCTION: Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost. OBJECTIVES: To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS. MATERIAL AND METHODS: Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence. RESULTS: Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was e106,129.07 and e1325.80, respectively (compared to e97 700 and e1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=0.534). CONCLUSIONS: MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.

[Ileo-ileal and ileocecal invagination due to intestinal lipomatosis]. / Invaginación ileoileal e ileocecal por lipomatosis intestinal.

Intestinal lipomatosis is a rare entity and few cases have been reported in the literature. The condition is usually asymptomatic. Symptomatic cases usually present as obstruction or, less frequently, as bleeding. Intestinal barium studies, ultrasonography and computed tomography are useful diagnostic techniques. We present the case of a 47-year-old man with no relevant medical history who presented with intestinal obstruction of several months' duration. Complementary investigations yielded a diagnosis of intestinal obstruction due to ileocecal invagination secondary to endoluminal tumors of the ileum. Surgery and pathological analysis revealed the latter to be intestinal lipomatosis. This rare clinical entity has been associated with diverticulosis and intestinal volvulus.

[Dermoscopic study of cutaneous malignant melanoma: descriptive analysis of 45 cases]. / Estudio dermoscópico del melanoma maligno cutáneo: análisis descriptivo de 45 casos.

INTRODUCTION: Dermoscopy or epiluminescence microscopy is a novel in vivo technique that can be used for the diagnosis of pigmented cutaneous lesions. The aim of this study was to analyze the dermoscopic patterns observed in a consecutive series of primary cutaneous melanomas. MATERIAL AND METHODS: A cross-sectional study was carried out in which clinical, histological, and dermoscopic characteristics were analyzed in 45 primary melanomas. RESULTS: Two thirds of the series were thin melanomas and 50 % were in situ melanomas. According to the ABCD rule, there was clinical suspicion of melanoma in 72 % of the lesions. Specific dermoscopic patterns were observed in 93 %. A multicomponent pattern was the most commonly observed (71 %). A nonspecific pattern was observed in 7 % of lesions. The most noteworthy local findings were irregular pigmented patches (80 %), irregular dots and globules (68 % and 62 %), atypical pigmented network (57 %), blue-gray veil (42 %), and radial streaming and pseudopods (20 %). In addition, hypopigmented areas (86 %), regression structures (80 %), and vascular abnormalities (73 %) were also often seen. Acral lesions presented patterns characteristic of these sites. CONCLUSION: Analysis of dermoscopic patterns aids early definitive diagnosis of melanoma and is particularly useful in the case of clinically indolent lesions. Dermoscopic findings provide information complementary to that obtained by conventional histology.

[Unusual localization of granulosa cell tumor]. / Localización poco habitual de un tumor de células granulosas.

OBJECTIVE: To present a case of granular cell tumor with an uncommon localization. METHODS: A 38-year-old patient presented with a painless nodule 10 mm in diameter on the scrotum that he had noted two years earlier. RESULTS: The tumor was surgically excised. Pathological analysis demonstrated a granular cell tumor that was strongly positive for protein S-100 and negative for cytokeratin AE1-AE3 and CEA. CONCLUSIONS: Granular cell tumors are very frequent in the head and neck, but rare in the genitourinary region and are asymptomatic. Histological diagnosis is simple but should be confirmed by protein S-100 staining, which is positive in all cases. Treatment is by simple excision of the lesion. Tumor recurrence and metastasis have been reported, therefore follow-up is necessary.