Daniel S. Winchester

Leiomyosarcoma of the skin: Clinical, histopathologic, and prognostic factors that influence outcomes

BACKGROUND Superficial leiomyosarcoma (LMS) is a rare tumor with important clinical, pathologic, and treatment features. Previous LMS studies have included few patients, included minimal follow-up, and typically combined the superficial and subfascial (deep) forms. OBJECTIVE We sought to characterize clinical features, effectiveness of treatment approaches, and long-term outcomes for LMS stratified by depth of invasion. METHODS In all, 71 cases of primary superficial LMS, 48 dermal and 23 subcutaneous (mean follow-up of 8 years), were examined and clinical, histopathologic, and treatment factors reported. RESULTS Tumor size and subcutaneous classification correlated with greater likelihood of metastasis and death at 5 years. When superficial LMS metastasizes, other skin sites are the most common distant location. Treatment with wide local excision with minimum 1-cm margins showed statistically lower rates of recurrences and metastasis compared with excision with narrow surgical margins. Fourteen cases of Mohs micrographic surgery had no recurrences or metastases. Five cases of dermal LMS metastasized, 2 of which resulted in death. LIMITATIONS This study is a retrospective review of a relatively small number of patients. CONCLUSION LMS can metastasize and warrants surgical intervention and long-term follow-up. Wide local excision, and Mohs micrographic surgery in particular, appear to provide the best management approach for definitive treatment.

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist

&NA; The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high‐risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost‐effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost‐effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

Early clinical presentations and progression of calciphylaxis

Untreated calciphylaxis is a fatal disease of intra‐ and extravascular calcification, most commonly presenting in end‐stage renal disease (ESRD) patients. While early identification is critical for timely treatment, early‐stage clinical and histopathological descriptions have not, to our knowledge, been elucidated. As early clinical recognition is essential to prompt definitive histopathological diagnosis, this study describes a range of clinical and histopathological manifestations of early‐stage calciphylaxis.

Demographics and Outcomes of Microcystic Adnexal Carcinoma

To the Editor: Microcystic adnexal carcinoma (MAC) is an uncommon eccrine adnexal tumor. Mohs micrographic surgery (MMS) is reported in the literature to be among the most effective surgical options. We aimed to describe the demographics of a large series of patients with MAC, with long-term follow-up outcome data. This retrospective chart review of biopsy-proven MAC was performed with institutional review board approval. Statistical analysis was performed with SAS version 9.3 (SAS Institute Inc, Cary, NC). Follow-up was reviewed until date of death or last documented patient contact. The Kaplan-Meier method and Cox proportional hazards regression models were used. We identified 67 patients with MAC during 1986-2016. Demographics and tumor characteristics (Table I) and sites of involvement for each tumor (Fig 1) were evaluated. Median (range) tumor size

Undifferentiated Pleomorphic Sarcoma: Factors Predictive of Adverse Outcomes

Background Undifferentiated pleomorphic sarcoma (UPS) encompasses rare neoplasms that can arise either in the dermis or in the subfascial soft tissue. The behavior of UPS ranges from indolent to aggressive, but data predicting outcomes are limited. Objective Identify predictors of poor outcomes by analyzing a large collection of UPS cases. Methods We evaluated all available cases of UPS (including those termed atypical fibroxanthoma, malignant fibrous histiocytoma, pleomorphic dermal sarcoma, and subfascial UPS) across 3 tertiary care centers. Results Among the 319 patients, 45 experienced recurrence, 33 experienced metastasis, and 96 died of any cause. Risk factors for recurrence were clinical tumor size larger than 5 cm and invasion beyond subcutaneous fat. Risk factors for distant metastases were tumor site, tumor size larger than 2 cm, invasion beyond subcutaneous fat, and lymphovascular invasion. Risk factors for overall mortality were age, immunosuppression, tumor size larger than 2 cm, and lymphovascular invasion. History of skin cancer was associated with a lower risk of recurrence and metastasis. Limitations This was a retrospective study. Conclusions Using the unbiased approach of pooling all UPS cases regardless of terminology, we identified clinical and histologic factors predicting poor outcomes. We propose subcategorization of UPS (into superficial versus deep UPS), which is consistent with the American Joint Committee on Cancer staging of soft‐tissue sarcoma.