Henry W. Randle

Basal Cell Carcinoma Identification and Treatment of the High-Risk Patient

BACKGROUND Some cutaneous basal cell carcinomas have a significant potential to recur, disfigure, and nietastasize. OBJECTIVE AND METHODS The identification and selection of treatment of these high risk carcinomas is based on a review of studies of recurrence, giant size, metastasis, and mortality. ERESULTS Basal cell carcinomas with any of the following: long duration, location in the mid face or ear, larger than 2 cm, with aggressive histologic subtype, previous treatment, neglected, or a history of radiation exposure, should be considered “high risk,” CONCLUSION For basal cell carcinomas with this high risk profile, complete excision by margin control or total destruction should be considered.

A Comparison of Mohs Micrographic Surgery and Wide Excision for the Treatment of Atypical Fibroxanthoma

background Atypical fibroxanthoma (AFX) is an uncommon spindle cell neoplasm occurring most often in actinically damaged skin of elderly patients. This tumor has invasive potential, may recur locally after excision, and rarely metastasizes. To conserve tissue and improve the likelihood of cure, Mohs micro–graphic surgery (MMS) has been used for treatment. objective We review and discuss the Mayo Clinic experience treating AFX with MMS and retrospectively compare the clinical outcome with that in a similar cohort of patients treated with wide local excision (WE). methods The medical records of 45 patients were reviewed at three Mayo Clinic practices. Follow–up data were available for 44 patients: 19 treated with MMS and 25 with WE. results In patients treated with MMS, there were no recurrences after a mean follow–up of 29.6 months. There were three first recurrences in 25 patients (12%) treated with WE after a mean follow–up of 73.6 months. One patient had a single local recurrence, and two patients each had two local recurrences. Parotid node metastasis eventually developed in one of the patients with two local recurrences, so that the regional metastatic rate in this series was 4% (1 in 25 patients). conclusion Microscopic control of the surgical margins with MMS in the treatment of AFX results in a lower recurrence rate than that with WE and conserves normal tissue.

Exaggerated arthropod-bite lesions in patients with chronic lymphocytic leukemia: A clinical, histopathologic, and immunopathologic study of eight patients ☆ ☆☆ ★

BACKGROUND Unusual papulovesicular lesions resembling arthropod bites have been described in patients with chronic lymphocytic leukemia (CLL). OBJECTIVE Our purpose was to describe and characterize further the clinical, histopathologic, and immunopathologic features of these lesions. METHODS Eight patients were identified retrospectively who had CLL and characteristic skin lesions. Clinical and histologic features were recorded. Skin biopsy specimens were analyzed immunohistochemically for eosinophil granule major basic protein, eosinophil-derived neurotoxin, neutrophil elastase, and mast cell tryptase. RESULTS The clinical features, including the lesional distribution, suggested arthropod bites, although most patients could not recall having been bitten. Mixed T- and B-cell lymphoid cell infiltrates were present within lesions, along with prominent eosinophil infiltration and eosinophil granule protein deposition. CONCLUSION Exuberant papulovesicular lesions develop in patients with CLL apparently as an exaggerated response to arthropod bites. Prominent eosinophil infiltration and degranulation within these lesions likely contribute to the severity of symptoms.

Cutaneous micrographic surgery : mohs procedure

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.

Giant basal cell carcinoma (T3): Who is at risk?

Background. Giant basal cell carcinomas can cause extensive local invasion and disfigurement. This study determines in whom giant basal cell carcinomas develop.

The therapeutic response of urticarial vasculitis to indomethacin

Ten patients with urticarial vasculitis, characterized clinically by persistent painful urticarial lesions, angioedema, recurrent arthralgia, abdominal pain, and low-grade fever, were selected for study. All patients had histologic evidence of leukocytoclastic vasculitis in the urticarial lesions. Results of direct immunofluorescence microscopy of urticarial lesions were positive in all nine of the patients tested. Treatment with indomethacin in dosages from 25 mg three times daily to 50 mg four times daily resulted in complete clearing of all disease manifestations in six of ten patients within 17 days and partial improvement in three. In eight of the ten patients, disease activity recurred within 48 hours after discontinuation of the use of indomethacin. Gastrointestinal irritation was the only side effect noted. Indomethacin is proposed as an effective mode of therapy in a disorder unresponsive to treatment with conventional medications for urticaria, including high-dose corticosteroids.

High-Risk Nonmelanoma Skin Cancers

background. Some nonmelanoma skin cancers are at high risk to recur after treatment, metastasize, and cause death. objective. To provide profiles of nonmelanoma skin cancers that are at high risk of aggressive behavior. methods. Review the studies of nonmelanoma skin cancers associated with calculated recurrences after treatment, metastasis, and patient mortality. results. Profiles have been developed for nonmelanoma skin cancers considered to be at high risk. conclusions. Physician awareness of nonmelanoma skin cancers that can behave aggressively is increased by establishing high‐risk profiles for these cancers.

Eruptive Epidermoid Cysts Resulting from Treatment with Imiquimod

Background Because of its unique mechanism of action and safety profile, imiquimod, a topical immune response modifier, is used for many benign and malignant dermatologic conditions. Adverse effects are typically limited to treatment site erythema and erosion. Objective To describe a newly recognized adverse effect of imiquimod. Methods A 79-year-old woman being treated with imiquimod 5 days per week for a nodular basal cell developed a verrucous plaque over the treatment area after 7 weeks of therapy. Results Scouting biopsies demonstrated multiple comedones and ruptured epidermoid cysts. There was no evidence of residual basal cell carcinoma. Conclusions Imiquimod is a new and novel treatment option for cutaneous malignancies. We report its successful use in the treatment of a nodular basal cell carcinoma. The multiple comedones and ruptured epidermoid cysts are newly reported adverse effects of imiquimod therapy.

Dermabrasion of the Hyperkeratotic Foot

BACKGROUND Keratoderma is a common problem. Its treatment is difficult and may be associated with systemic side effects. OBJECTIVE AND METHOD To describe the use of dermabrasion for hyperkeratotic conditions of the palms and soles. RESULTS Dermabrasion of keratoderma is an easy, quick, and safe method that brings immediate relief to patients, allows improved penetration of topical medications, and facilitates the control of the underlying disease with simple measures. CONCLUSIONS Dermabrasion should be considered among the treatment options for keratodenna.

Surgical Intervention for Skin Cancer in Organ Transplant Recipients

An important complication of solid organ transplantation and chemical immunosuppression is the potential for the development of multiple skin cancers, especially squamous cell carcinomas [1]. The magnitude and severity of these malignancies are troublesome. They are often multiple, are associated with verrucal lesions, are more likely to occur at a younger age, and have a higher recurrence rate than in those who do not receive transplants, are capable of rapid growth, have an aggressive histological growth pattern [2, 3], and are prone to metastasis on the trunk and extremities as well as the head and neck. More than half of patients receiving organ transplants develop tumors. In most transplant recipients, these tumors occur de novo and are associated with a history of sun exposure, the types of immunosuppressant medications, the degree of immunosuppression, and sometimes the human papillomavirus or human herpesvirus 8 [4]. Usually, in patients with skin cancer, basal cell carcinoma occurs more frequently than squamous cell carcinoma, but in transplant recipients, this frequency is reversed. Compared with generally observed occurrence rates, squamous cell carcinomas are increased between 65- and 250 fold, basal cell carcinomas 10 fold, malignant melanoma 3- to 5 fold, and Kaposi’s sarcoma 84 fold. The severity of Merkel cell carcinoma is increased, as is that of atypical fibroxanthoma. Cancers typically begin 7 to 8 years after the patient receives the transplant, but this interval is shorter, 3 years or less, in heart transplant recipients. The number of malignancies and the percentage of patients involved increase with the duration of immunosuppression. For example, in Australia, 7% of patients had skin cancer after 1 year and 70% after 20 years [5]. The trend is the same in the Netherlands but to a lesser degree; 0.2% had skin cancer after 1 year and 40% after 20 years. The surgical approach to skin cancers in transplant recipients is detailed below. In general, treatment is based on high-risk factors such as rapid growth, potential for or presence of metastasis, and the number of occurrences of the same type of cancer present at the time of the initial dermatological examination. Standard surgical treatments include electrodesiccation and curettage, excision with or without