H. William Higgins

Melanoma in situ : Part I. Epidemiology, screening, and clinical features

The incidence of melanoma has steadily increased over the past 3 decades, with melanoma in situ comprising a disproportionately high percentage of the rising incidence. Our understanding of melanoma in situ has been shaped by epidemiologic and clinical studies. Central to a review of melanoma in situ is a focus on its epidemiology, pathology, biologic behavior, treatment, and clinical outcome, which may differ significantly from that of malignant melanoma. Part I of this continuing medical education article reviews the epidemiology, risk factors, and clinical features of melanoma in situ; part II covers the histopathology, treatment options, and clinical management.

Melanoma in situ: Part II. Histopathology, treatment, and clinical management

Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Similarly, the approach to treatment should take into account the potential for MIS to transform into invasive melanoma, which has a significant impact on morbidity and mortality. Part II of this continuing medical education article reviews the histologic features, treatment, and management of MIS.

Tumor recurrence after Mohs micrographic surgery

To the Editor: An otherwise superb account of the cutaneous manifestations of Crohn’s disease is unfortunately incomplete because Thrash et al have omitted genital presentations, particularly penile edema/lymphedema/granulomatous lymphangitis. Genital involvement is rare in Crohn’s disease but can be encountered as genital (‘‘knife-cut’’) ulcers, fistulae, fissures, abscesses, and genital edema. In 20 years of specialized male genital clinical activity, I (C.B.B.) have diagnosed and managed the last situation about a dozen times. In some patients (over a third in my experience) it can be the first and only intimation of Crohn’s disease, thus is an important pointer to gastrointestinal investigations and the confirmation or exclusion of Crohn’s disease.

Safety of Cosmetic Dermatologic Procedures During Pregnancy

BACKGROUND Safety of cosmetic procedures in pregnant women has not been extensively studied. Maternal and fetal health risks are important to consider in any procedure performed. With the increasing popularity of cosmetic procedures, dermatologic surgeons will be faced with scenarios necessitating knowledge regarding the safety of such procedures during pregnancy. Furthermore, dermatologic surgeons may inadvertently perform cosmetic procedures during the first trimester, before the patient is aware of the pregnancy. OBJECTIVE To investigate the safety of cosmetic procedures during pregnancy and the postpartum period. METHODS AND MATERIALS A literature search of PubMed and Google Scholar was conducted of all English‐language articles published from 1960 through 2012. RESULTS Definitive recommendations on the safety of procedures such as chemical peels, injectables, fillers, and most laser therapies during pregnancy cannot be made. The safety of onabotulinum toxin usage is well documented in the neurology literature, although isolated events of miscarriage have been reported with high doses of toxin in women with a previous history of miscarriage. Carbon dioxide laser therapy for genital condylomas has considerable evidence supporting its safety during pregnancy. CONCLUSION There is a lack of controlled trials addressing the safety of cosmetic procedures during pregnancy and postpartum periods. It is advisable to delay elective cosmetic procedures until after the baby is born.

Characteristics of basal cell carcinoma of the lip treated using Mohs micrographic surgery.

BACKGROUND There is a lack of U.S‐based studies on basal cell carcinoma (BCC) of the upper lip treated using Mohs micrographic surgery (MMS). OBJECTIVE To explore characteristics of BCC of the upper lip treated using MMS. METHODS We performed a chart review of BCC cases from 2005 to 2011. RESULTS Two hundred eighty‐one cases were identified. There was a slight female predominance (55%). Men had a larger initial (p < .01) and final (p = .03) defect size. Infiltrative tumors had larger initial (p < .01) and final areas (p < .01). Ten percent of tumors were designated recurrent after previous treatment. Recurrent lesions (p < .001) and older age (p = .03) were associated with larger initial size. Complex reconstruction was required: 44% by local flap or graft and 13% by plastic surgery. CONCLUSION There was a 1.2:1 female to male ratio, in contrast to the previously reported female predominance of 3.5:1. This cohort showed a higher recurrence rate than reported in the literature. Men and elderly patients were also found to have significantly larger initial lesion size. Thirteen percent of patients required repair by plastic surgery, reflecting heightened levels of cosmetic concern. These findings suggest that MMS is important in delineating subclinical tumor spread and providing complex repairs.

Characteristics of Squamous Cell Carcinoma In Situ of the Ear Treated Using Mohs Micrographic Surgery

BACKGROUND Mohs micrographic surgery (MMS) is used to treat squamous cell carcinoma in situ (SCCIS) for tissue conservation. OBJECTIVE To examine characteristics of patients with SCCIS of the external ear treated using MMS. METHODS A retrospective review from 2005 to 2011. RESULTS We identified 173 cases of SCCIS of the ear. The population was 94% male (p < .01), with a mean age of 71. Eight percent (n = 13) of tumors were recurrent after prior treatment. Recurrent tumors occurred exclusively in men and were associated with larger initial size (p = .05), more layers for clearance p = .059), and larger final defect size (p = .01). Tumors with larger initial area were independently associated with older age (p < .01). Complexity of repair was independently associated with more layers (p < .01), larger initial area (p = .01), and larger final area (p = .02). Sex did not affect repair type. CONCLUSION SCCIS of the ear predominantly affects men in our referral base of 85% to 90% private patients and 10% to 15% veterans. Recurrent tumors were associated with larger initial size and subclinical spread of tumor. Primary tumors on average required 1.6 layers, validating the utility of MMS in this population in delineating the subclinical spread of SCCIS of the ear.

Epidemiology and Natural History

Lentigo maligna is on the rise, with an increasing incidence rate over the past few decades. Areas of high UV flux, such as the southern United States or Hawaii tend to have a higher incidence than areas with lower UV flux, such as the northern United States. Among other risk factors, a higher cumulative UV exposure is associated with development of lentigo maligna, helping to explain its propensity towards chronically sun exposed areas such as the head and neck. The risk of progression from lentigo maligna to lentigo maligna melanoma has been reported to range from 5–20 %. The evolving role of genetics may help providers to better understand lentigo maligna, as compared to other forms of melanoma in situ.

Effective Technique for Periosteal Removal During Mohs Micrographic Surgery

Keratinocyte carcinomas, although typically confined to the skin and underlying soft tissue, may invade into deeper structures when they are large, recurrent, or aggressive. (p45) This may pose a challenge for Mohs micrographic surgeons particularly when accurately determiningwhether or not a deeply invasive tumorhas spread to involve this thin and adherent layer of tissue encasing the bone. Herein, the authors present a method of lifting and removing the periosteum that allows for appropriate histologic evaluation.

Recurrent Tumors Referred for Mohs Micrographic Surgery: A 12-Year Experience at a Single Academic Center

BACKGROUND Mohs micrographic surgery (MMS) is used for treatment of primary and recurrent tumors. Compared with primary tumors, recurrent tumors are often more aggressive. OBJECTIVE To understand differing characteristics between primary versus recurrent tumors treated by MMS. MATERIALS AND METHODS The authors conducted a retrospective review of a 12-year period at 1 academic center. Recurrent tumors were defined as recurrent if previously treated with cryotherapy, topical chemotherapeutics, electrodesiccation and curettage, or excision. Statistical analysis was conducted with p ⩽ .05 considered significant. RESULTS A total of 17,971 cases were reviewed, of which 10.5% represented recurrent tumors. Recurrent tumors occurred more commonly in men (ratio 2.2:1). They presented in older individuals (p < .01) and occurred more commonly on the scalp (p < .0001), neck (p < .0001), and trunk (p < .0001). Primary tumors were more commonly located on the periocular (p < .0001), nose (p < .0001), and perioral areas (p < .0001). Squamous cell carcinoma more commonly presented as primary tumors (p = .02) while squamous cell carcinoma in situ more commonly presented as recurrent tumors (p < .001). CONCLUSION Distinct characteristics separate primary and recurrent tumors treated by MMS. Primary tumors were more commonly located in Area H, compared with recurrent tumors, which were more commonly located in Area M. This suggests appropriate usage of MMS based on appropriate use criteria.

Melanoma in situ

Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Similarly, the approach to treatment should take into account the potential for MIS to transform into invasive melanoma, which has a significant impact on morbidity and mortality. Part II of this continuing medical education article reviews the histologic features, treatment, and management of MIS.