Elizabeth M. Billingsley

Intraoperative and postoperative bleeding problems in patients taking warfarin, aspirin, and nonsteroidal antiinflammatory agents. A prospective study.

BACKGROUND Many patients, who undergo cutaneous surgery take medications that can affect bleeding. The role of these medications in postoperative bleeding complications is unclear. Dermatologists have no clear guidelines regarding the need to discontinue these medications preoperatively. OBJECTIVE We designed a prospective study to evaluate the incidence of postoperative bleeding complications in patients taking aspirin, warfarin, or nonsteroidal antiinflammatory agents. METHODS Data were collected from patients undergoing Mohs surgery regarding preoperative medication history, operative bleeding, and postoperative bleeding. Frequency of postoperative bleeding complications was then evaluated. RESULTS There was no statistically significant difference in postoperative bleeding complications between patients on aspirin, warfarin, or nonsteroidal antiinflammatory agents, when compared with controls. CONCLUSION It may not be necessary to discontinue aspirin, warfarin, or nonsteroidal antiinflammatory agents in patients undergoing many common dermatologic surgical procedures, such as Mohs surgery.

Increased incidence of melanoma in renal transplantation recipients.

It is well established that the incidence of nonmelanoma skin carcinoma is increased in renal transplantation recipients. However, existing studies are not in agreement over whether patients who undergo transplantation have an increased risk of melanoma. The objective of this study was to estimate the risk of melanoma among immunosuppressed renal transplantation recipients and to determine whether that risk is associated with patient and transplantation characteristics.

Awareness of skin cancer by kidney transplant patients

BACKGROUND Skin cancer is the most common malignancy occurring after kidney transplantation. OBJECTIVE Our purpose was to identify the skin problems of kidney transplant recipients, the extent of their awareness of skin cancer, and interest in skin cancer screenings. METHODS One hundred twenty-two patients were administered an oral questionnaire during regular follow-up at a renal transplant clinic. RESULTS The average time from transplantation was 3.1 years. Thirty-nine percent of patients reported skin problems, including warts, fungal infection, and skin cancer. Forty-one percent of patients were unable to recall specific skin cancer education, and 52% expressed an interest in skin cancer screening. Twenty-seven percent of patients had seen a dermatologist since their transplant, but only 14% were followed up regularly by a dermatologist. CONCLUSION We believe the need for continuing skin cancer education and early detection and treatment of skin lesions establishes an important role for the dermatologist on the transplant recipients health care team.

Melanoma in solid organ transplant recipients.

This manuscript outlines estimated risk and clinical course of pretransplant MM, donor‐transmitted MM and de novo MM posttransplantation and includes an analysis of risk factors for metastasis, data from clinical studies and current and proposed management. MM in situ and thin melanoma (<1 mm) in the transplant population has similar recurrence and survival estimates to those in the general population. A minimum wait time of 2 years prior to transplantation is suggested for MM with a Breslow depth <1 mm and no clinical evidence of metastasis. More advanced MM may adopt a more aggressive course in transplant recipients. Sentinel lymph node biopsy may be of additional prognostic benefit. Revision of immunosuppression in the management of de novo melanoma in collaboration with the transplant team should be considered. Larger studies utilizing uniform staging criteria or at minimum Breslow depth, are required to assess true risk and outcome of MM in the immunosuppressed transplant population. Emphasis remains on patient education and regular screening to provide early detection of MM.

An unusually aggressive trichoblastoma

Trichogenic tumors are neoplasms of the hair germ cell that usually exhibit benign behavior. We describe a case of a large invasive trichoblastoma requiring Mohs micrographic surgery for its removal. Immunohistochemical studies performed demonstrate overlapping features of this trichogenic tumor with basal cell carcinoma.

Primary mucinous carcinoma in a 54-year-old man

Primary mucinous carcinoma is a rare malignant tumor that most frequently occurs in the periorbital area. This tumor originates from the deepest portion of the eccrine sweat duct. This normally asymptomatic and slow-growing tumor has demonstrated a local recurrence rate of 30% after excision with narrow surgical margins and can have local metastases. It is difficult to differentiate this tumor histologically from metastatic lesions. Immunohistochemical staining and cytokeratin profiles have been studied to aid in the differentiation between primary lesions and metastatic mucinous carcinomas. We present a case of a 54-year-old man with recurrent primary eccrine mucinous carcinoma and review the clinical, histologic, and immunohistochemical features of this tumor.

The Spectrum of Epidermal Nevi: A Case of Verrucous Epidermal Nevus Contiguous with Nevus Sebaceus

During the normal development of skin, pluripotential cells give rise to keratinocytes, sebaceous glands, hair follicles, apocrine glands, and eccrine glands. In epidermal nevi, these components emerge in an abnormal mixture within a circumscribed site. Many authors have categorized epidermal nevi based on their predominant component; however, there is often notable overlap that occurs within a single area or within contiguous areas. We report a verrucous epidermal nevus contiguous to a nevus sebaceus of Jadassohn. The categories of epidermal nevi are somewhat artificial. Our case supports the view that epidermal nevi have a spectrum of manifestations, including verrucous epidermal nevi and nevus sebaceus of Jadassohn.

“PTCH”-ing It Together: A Basal Cell Nevus Syndrome Review

BACKGROUND Basal cell nevus syndrome (BCNS) has existed at least since Dynastic Egyptian times. In 1960, Gorlin and Goltz first described the classic clinical triad: multiple basal cell carcinomas (BCCs), jaw keratocysts, and bifid ribs. As an autosomal‐dominant disorder, it is characterized by tumorigenesis and developmental defects. OBJECTIVE To review the current literature on BCNS, including reports on epidemiology, pathogenesis, clinical presentation, diagnostic criteria, management, treatment, and prognosis. METHODS A literature review of currently available articles related to BCNS. RESULTS Individuals with a mutation in the tumor suppressor gene PTCH1 are predisposed to tumorigenesis and developmental defects. Clinical features include BCCs, often with onset in adolescence, jaw keratocysts, bifid ribs, craniofacial defects, palmar‐plantar pits, and ectopic intracranial calcification. Despite high cure rates for individual lesions and various treatment modalities including excision, Mohs micrographic surgery, photodynamic therapy, and topical imiquimod, management of BCCs is challenging. The development of an oral hedgehog pathway inhibitor, vismodegib, has added a new dimension to current treatment algorithms. CONCLUSIONS Adolescents and young adults with BCC should be evaluated for BCNS. Early diagnosis of BCNS is critical for possible prevention of the devastating effects of BCCs and establishment of multidisciplinary care.

The heterogenous nature of in vivo basal cell carcinoma.

background. There have been nearly 70 different histologic subtypes of basal cell carcinoma (BCC) described. Some of the subtypes have been shown to have clinical relevance. The degree to which one type may merge to another, within the same tumor mass, has been poorly studied. objective. To determine if BCCs maintain biopsy histology throughout the entire architecture of the tumor. method. Tumors were evaluated with a prospective histologic analysis of all primary BCCs using the Mohs “removal in layers” technique. All BCCs that required more than a single Mohs stage to clear were included in analysis. results. One hundred forty‐nine tumors were examined. Fourteen of these were of mixed histologic subtype on biopsy and were not included in the analysis. Six biopsy specimens were inadequate to make a subtype diagnosis and were excluded from calculation. Of the remaining 129 tumors 59% maintained their biopsy diagnosis at first Mohs stage, and 49% at the second Mohs stage. Infiltrative tumors were the most likely to maintain their histologic subtype classification. Of the tumors that showed nodular BCC on biopsy, 13% were infiltrative or micronodular at first Mohs stage. conclusion. While many BCCs demonstrate a single histolog‐ical subtype, roughly 40% change in their microscopic appearance at the subclinical extension. This finding has the potential to alter therapy.

Rapidly growing squamous cell carcinoma.

Background: Squamous cell carcinoma (SCC) may present with a history of rapid growth. Although multiple subtypes have been described regarding histologic characteristics and etiology, the subset of rapidly growing squamous cell carcinomas (RGSCC) has not been described. Objective: To evaluate and describe the clinical and histologic characteristics of squamous cell carcinomas that grow rapidly. Methods: Recorded clinical data and biopsies of 26 lesions with a history of rapid growth and histologically diagnosed as SCC were reviewed. Results: Rapidly growing SCC occurred most commonly on the head and neck, followed by hands and extremities, and had an average duration of 7 weeks before diagnosis. The average size of the lesions was 1.29 cm and nearly 20% occurred in immunosuppressed patients. Conclusions: Some SCCs may grow rapidly. The reason for the rapid growth is not clear and several hypotheses are discussed including immunosuppression and viral etiology. These lesions should be treated aggressively as their behaviour and prognosis are not yet well described.