Gary S. Rogers

Prognostic index for malignant melanoma

This report verifies the ability of a Prognostic Index (PI) to accurately predict 5‐year survival rates for 879 Stage I cutaneous malignant melanoma (MM) patients seen at New York University Medical Center. The PI used in this study was first reported from Munich, West Germany, and is calculated from standard histologic sections by multiplying the MM thickness in millimeters (Breslow method) by the number of MM mitoses per square millimeter. A PI value of <19 versus ≥19 was found to be a significant and independent prognostic variable for Stage I MM when compared with seven other predictive variables (including Breslow thickness). These PI intervals identified a subgroup of patients with MM of intermediate thicknesses (1.50–3.49 mm) whose significantly worse survival would not have been anticipated if prognosis were determined by Breslow thickness alone. For example, patients with MM 1.50 to 2.49 mm thick have a 5‐year survival rate of 84.1% determined by Breslow thickness alone; however, among these patients exists a subgroup with PI ≥ 19 whose survival rate is only 57.6%. This study verifies the additive usefulness of the PI in predicting survival rates of patients with Stage I cutaneous MM. Cancer 59:1236‐1241, 1987.

Botulinum A toxin for glabellar wrinkles : Dose and response

background. Botulinum A exotoxin injection is a well‐established method for treatment of glabellar frown lines, crows feet, and horizontal furrows of the forehead. However, there is no consensus as to the optimal dosage per injection site or the concentration of injectate to be used. objective. The purpose of this study was to determine the minimal effective dose per injection site to be used as well as the effect of concentration in response to treatment. results. A total of 46 subjects were divided into ten groups and injected with escalating doses and concentrations of botulinum toxin. The response and longevity of treatment were then followed on a monthly basis. A dose between 2.5–4 U per injection site (12.5–20 U total) was determined to be an effective starting dose, with a duration of 2–5 months (median 14 weeks). conclusions. There was no statistically significant difference in safety or efficacy for concentrations ranging from 50 to 200 U/ml of botulinum toxin.

Regression in malignant melanoma

A multiple stepwise logistic regression analysis shows that histologic regression is more likely to be found in a malignant melanoma that is level III or less, more than 10 mm in diameter, associated with solar elastosis, located on an anatomic area other than the head or neck, and when there are areas of whiteness clinically. Although patients with malignant melanomas displaying signs of regression histologically have a slightly better 5-year disease-free survival, this may be attributed to a difference in tumor thickness.

Burn scar carcinoma. Diagnosis and management.

background. The term Marjolin ulcer is now synonymous with malignant transformation of chronic ulcers, sinus tracts, and burn scars. objective. To illustrate the importance of incisional or excisional biopsies in cases of suspected burn scar carcinoma. methods. Case report and review of the literature. results. Multiple punch biopsies were negative while a complete excision revealed the diagnosis of squamous cell carcinoma. conclusion. Because of the focal nature of malignant change in burn scars, incisional or excisional biopsy should be performed.

Relationship of nevocytic nevi to sun exposure in dysplastic nevus syndrome

In eighty consecutive patients who have the dysplastic nevus syndrome, the concentration of nevocytic nevi on the relatively sun-protected lateral thoracic area was compared to the concentration on the relatively sun-exposed areas of the anterior and posterior thorax. Nevocytic nevi in an area 7 X 20 cm were counted in each location. There was a total of 177 nevi on the lateral thorax (average, 2.2 nevi/person), 361 on the anterior thorax (average, 4.5 nevi/person), and 506 on the posterior thorax (average, 6.3 nevi/person). Men showed no significant difference in the number of nevi on the anterior and posterior thoracic areas, but women had fewer nevi on the anterior than on the posterior thoracic sites. These findings are consonant with the hypothesis that sunlight induces nevocytic nevi in patients who have the dysplastic nevus syndrome.

Perineural Invasion of Cutaneous Squamous Cell Carcinoma and Basal Cell Carcinoma: Raising Awareness and Optimizing Management

BACKGROUND Perineural invasion (PNI) by cutaneous squamous cell carcinoma (CSCC) and basal cell carcinoma (BCC) is an infrequent but not rare complication of traditionally low-morbidity skin cancers that can lead to catastrophic sequelae; 2.5% to 14% of CSCC and approximately 3% of BCC exhibit PNI. Tumors with PNI tend to be larger, have greater subclinical extension, have a higher rate of recurrence, and have a greater risk of metastases. Tumors with PNI may result in major neurologic deficits. OBJECTIVE To review current recommendations for the management of PNI and to evaluate a treatment strategy involving excision using Mohs micrographic surgery (MMS) followed by adjunctive radiotherapy. MATERIALS AND METHODS Cases of PNI treated with MMS and radiotherapy were reviewed for recurrence, disease-free follow-up, and adverse events. RESULTS Twelve patients with incidental PNI treated with MMS and adjunctive radiotherapy are presented. After 3 to 32 months of follow-up, there had been no recurrences. Adverse events from radiotherapy were minor and self-limited. CONCLUSIONS The use of adjunctive radiotherapy in these patients remains controversial. When managing superficial skin tumors with PNI, a multidisciplinary team including a cutaneous surgeon and a radiation oncologist familiar with PNI is recommended.

Incidence of residual basal cell carcinoma in patients who appear tumor free after biopsy

BACKGROUND Basal cell carcinoma (BCC) biopsy sites often heal with no clinical evidence of residual tumor. OBJECTIVE The purpose of our study is to determine whether such patients require further therapy. If biopsies can be curative, health care costs can be reduced by avoiding unnecessary surgery. METHODS We prospectively evaluated 41 consecutive subjects with 42 biopsy-confirmed BCCs who appeared disease free. Each biopsy site was excised and processed by the Mohs micrographic technique. The tissue block was sectioned horizontally at 30-micrometer intervals until exhausted. Sections were stained and examined microscopically for residual tumor. RESULTS Tumor was identified in 28 (66%) of 42 cases. No statistically significant relationship was found between the presence or absence of residual tumor and the following variables: age, sex, tumor location, biopsy technique, histopathologic subtype, scar size, time from biopsy to surgery, and extent of inflammation in histologic sections. CONCLUSION Our data suggest that patients with small (< 1 cm) primary BCCs that appear to be completely removed after a biopsy procedure are at risk for recurrence without further treatment.

Nonhealing leg ulcers: A manifestation of basal cell carcinoma

Seven patients with basal cell carcinomas presenting as nonhealing ulcers are reported. The importance of considering malignancy and taking biopsy specimens of leg ulcers that fail to respond to treatment is emphasized.

Atypical (Dysplastic) Nevi: Outcomes of Surgical Excision and Association With Melanoma

OBJECTIVE To evaluate the effect of surgical excision, performed after biopsy diagnosis of dysplastic nevus, on final diagnosis, melanoma prevention, and melanoma detection. DESIGN, SETTING, AND PARTICIPANTS Outcome study using retrospective review conducted in an academic dermatopathology practice (Boston Medical Center Skin Pathology Laboratory) that receives specimens from community and academic practices across the United States. Consecutive patient pathology samples of dysplastic nevi and cutaneous melanomas evaluated between September 1, 1999 and March 1, 2011, and identified using systematized nomenclature of medicine codes were included. MAIN OUTCOMES AND MEASURES In dysplastic nevi cases, the rate of clinically significant change in diagnosis and the rate of melanoma detection as a result of excision. In melanoma cases, the rate and characteristics of association with dysplastic nevus. RESULTS Of dysplastic nevi, 196 of 580 (34%) showed a positive biopsy margin, increasing with grade of atypia (P < .001); 127 of 196 with positive biopsy margin received excision (65%), performed more often as grade of atypia increased (P < .001). Two excisions (2 of 127, 1.6%) resulted in a clinically significant change in diagnosis, from biopsy-diagnosed moderately-to-severely dysplastic nevi before excision to melanoma in situ after excision. In melanomas (n = 216), in situ and superficial spreading subtypes were more often associated with dysplastic nevi (20% and 18%, respectively) (P = .002), most often of moderate-to-severe or severe grade. CONCLUSIONS AND RELEVANCE Excision of biopsy-diagnosed mildly or moderately dysplastic nevi is unlikely to result in a clinically significant change in diagnosis, and risk of transformation to melanoma appears very low. Moderately-to-severely and severely dysplastic nevi are more often associated with melanoma, and excision may be beneficial for melanoma detection or prevention.

Common complementary and alternative therapies with potential use in dermatologic surgery: Risks and benefits

BACKGROUND Ambulatory surgery patients often use complementary and alternative medicine (CAM) therapies. CAM therapies may create beneficial and detrimental perioperative conditions. OBJECTIVE We sought to improve knowledge of CAM effects in dermatologic surgery, allowing dermatologists to potentially capitalize on therapeutic actions and to mitigate complications. METHODS PubMed literature search of CAM therapies in dermatologic and surgical settings was performed. Common CAM therapies with possible effects on dermatologic surgery were selected. Beneficial and detri-mental effects were reviewed. RESULTS A myriad of products may be used perioperatively by the patient. Therapies appearing to have some evidence for potential benefit include bromelain, honey, propolis, arnica, vitamin C and bioflavonoids, chamomile, aloe vera gel, grape seed extract, zinc, turmeric, calendula, chlorella, lavender oil, and gotu kola. Potential complications vary according to product and include platelet inhibition, contact dermatitis and, in rare cases, systemic toxicity. LIMITATIONS This review focuses on CAM having significant published studies evaluating efficacy for wound healing, anti-inflammatory, antipurpuric, or perioperative-related use. Most published studies have been small and often have design flaws. The scope of CAM is large and not all therapies are discussed. CONCLUSION Selected CAM therapies have been reported to promote wound healing, reduce edema or purpura, and provide anti-inflammatory effects. Because of high rates of CAM use, surgeons should familiarize themselves with common uses, potential benefits, and complications. Further study of effects in the dermatologic surgery setting may improve the patient-doctor relationship and enhance outcomes.