Hubert T. Greenway

Treatment of basal cell carcinoma with intralesional interferon

Eight patients with basal cell carcinomas were treated with recombinant alpha-2 interferon. Each patient had a biopsy-proved basal cell carcinoma of the nodular or superficial type that was injected intralesionally three times a week for 3 weeks (9 total injections) with 1.5 X 10(6) IU (0.15 ml) of alpha-2 interferon per injection (total dose, 13.5 X 10(6) IU). Excisional biopsy 2 months after completion of therapy revealed no evidence of basal cell carcinoma in any patient. Minimal side effects were observed. In these eight patients alpha-2 interferon was therefore an effective and safe modality of treatment. The encouraging results of this pilot study suggest that additional evaluation of interferon in the treatment of basal cell carcinoma is warranted.

Intralesional interferon therapy for basal cell carcinoma

In a clinical trial of 172 patients at four medical centers, interferon alfa-2b (1.5 x 10(6) IU) or a placebo was injected directly into biopsy-proved noduloulcerative or superficial basal cell carcinomas three times weekly for 3 weeks, for a cumulative dose of 13.5 million IU. Efficacy of treatment was determined at 16 to 20 weeks by examination of biopsy specimens that demonstrated cure of lesions in 86% of interferon-treated patients and in only 29% of placebo-treated patients. During the treatment course and follow-up, an initial inflammatory response was observed at the treatment sites, followed by diminished erythema, improvement in overall appearance, and a decrease in size of lesions. Side effects of treatment, mainly flu-like symptoms, were usually mild and transient and occurred more commonly in the interferon-treated group. Only three patients, all in the interferon-treated group, discontinued therapy because of side effects. One year after initiation of therapy, 81% of interferon recipients and 20% of those given the placebo remained tumor free. Noduloulcerative and superficial lesions were equally responsive to treatment with interferon. For some patients with noduloulcerative or superficial basal cell carcinomas, intralesional interferon alfa-2b may be an alternative, effective treatment.

The effect of intralesional 5-fluorouracil therapeutic implant (MPI 5003) for treatment of basal cell carcinoma.

BACKGROUND Basal cell carcinomas (BCCs) are usually treated with ablative procedures. A nonsurgical treatment alternative would be of value in selected patients. OBJECTIVE We evaluated the safety and efficacy of a new preparation for intralesional sustained-release chemotherapy with MPI 5003, 5-Fluorouracil Therapeutic Implant, for treatment of BCCs. METHODS Two doses of intralesional MPI 5003 (0.25 and 0.5 ml) were compared in a double-blind study of 20 patients with biopsy-proven BCC. One BCC per patient was treated weekly for up to 6 weeks and followed up monthly for 3 months until excisional biopsy for histologic examination. Before excision the cosmetic appearance of the test site was graded. RESULTS Eighty percent of 10 BCCs treated with 0.5 ml of MPI 5003 had histologically confirmed cures as compared with 60% of 10 tumors treated with the lower dose (0.25 ml). Cosmetic assessments before excision were typically good to excellent. No systemic side effects occurred. CONCLUSION Results indicate the potential of MPI 5003 for targeted local chemotherapy for BCC.

Treatment of dermatofibroma sarcoma protuberans using modified Mohs micrographic surgery: no recurrences and smaller defects.

OBJECTIVES The purpose of this study was to evaluate the use of modified Mohs micrographic surgery (MMS) for dermatofibromasarcoma protuberans (DFSP) in a single institution by a single surgeon. METHODS The authors conducted a retrospective analysis of 25 patients with DFSP who were treated with modified MMS over the past 19 years at Scripps Clinic. RESULTS Of the 25 patients treated with modified MMS for DFSP, there were no identifiable recurrences. The mean follow-up time was 101 months. The defect sizes of DFSP lesions treated by modified MMS are smaller than if the lesions had been treated with the standard wide local excision (WLE) margins of 3 cm. LIMITATIONS This is a retrospective analysis using the data of one surgeon. Five of the 25 patients were not examined in our office. Not all patients had 5-year follow-up. There were no cases of the fibrosarcomatous variant. CONCLUSION Our data support the growing literature that modified MMS achieves excellent local control for DFSP with a possible benefit of smaller defects when compared with treatment with WLE.

Infection Rates of Wound Repairs During Mohs Micrographic Surgery Using Sterile Versus Nonsterile Gloves: A Prospective Randomized Pilot Study

BACKGROUND Mohs micrographic surgery (MMS) is a multistep outpatient procedure that has become the treatment of choice for the removal of many cutaneous malignancies. The surgeon initially removes the tumor with nonsterile gloves in MMS. Sterile or nonsterile gloves are then used during the final repairs. OBJECTIVE This prospective patient‐blinded single‐institution pilot study was performed to evaluate whether there is a difference in infection rate when using clean, nonsterile gloves versus sterile gloves during tumor removal and the wound repair phases of MMS. MATERIALS AND METHODS This study randomized 60 patients undergoing MMS. Data on age, sex, anatomic location, number of Mohs stages, closure type, size of final defect, operative time, number of pairs of gloves used, and type of glove used were recorded and evaluated. RESULTS Three infections were identified. Two infections occurred in the sterile glove arm and one in the clean glove arm. Overall, there was no greater infection rate when using clean, nonsterile gloves than sterile gloves (p=.99). CONCLUSIONS Our study supports the use of clean, nonsterile gloves as a safe alternative to sterile gloves during all steps of MMS, at a significant cost savings. A larger confirmatory study comparing the equivalence in infection rates between clean and sterile gloves is warranted. The authors have indicated no significant interest with commercial supporters.

Modified Mohs Micrographic Surgery for Periocular Melanoma and Melanoma In Situ: Long‐Term Experience at Scripps Clinic

BACKGROUND Excision of invasive melanoma and melanoma in situ (MIS) using variations of the Mohs micrographic surgery (MMS) technique is becoming increasingly common in difficult areas, such as the periocular area, where standard surgical margins may not be feasible, and clinical margins are poorly defined. However, little long‐term data evaluating the treatment of periocular melanoma are available in the literature. OBJECTIVE To present our long‐term experience in the treatment of periocular melanoma using a staged, modified Mohs excision technique with rush permanent, paraffin‐embedded tissue sections. MATERIALS AND METHODS A total of 35 patients with periocular melanoma and MIS were treated using modified MMS during a 15‐year period. Twenty‐nine patients were available with adequate follow‐up of greater than 5 years duration. The mean follow‐up duration was 94 months. RESULTS There were a total of five recurrences (17.2%) detected an average of 85 months after excision. Four of the five recurrent tumors had been previously excised. The recurrence rate for primary tumors was 5% (1/20). The recurrence rate for previously excised tumors was 44.4% (4/9). CONCLUSION Margin‐control surgery is favored in the treatment of periocular melanoma to maximize the cure rate and minimize postoperative morbidity by sparing normal tissue. Ample follow‐up intervals are required to adequately assess recurrence rates. The best opportunity for cure is associated with the first tumor excision. The authors have indicated no significant interest with commercial supporters.

Calcium Hydroxylapatite Tissue Filler Discovered 6 Years after Implantation into the Nasolabial Fold: Case Report and Review

BACKGROUND Injectable calcium hydroxylapatite is becoming increasingly popular as a facial soft tissue filler, due in part to its purported longevity of esthetic correction compared with other materials, but little is known about its long‐term histologic appearance and persistence in facial skin. We recently encountered calcium hydroxylapatite microspheres incidentally during Mohs surgery of the nasolabial fold 6 years after implantation. OBJECTIVE To describe the long‐term histologic appearance of calcium hydroxylapatite microspheres in human facial skin and review the relevant literature with a consideration of clinical implications. METHOD Routine hematoxylin and eosin staining was performed on frozen and fixed excised tissue containing calcium hydroxylapatite microspheres. Additional fixed sections were stained using Movats pentachrome method. RESULTS Numerous 4‐ to 20‐μm round vacuoles were present throughout the reticular dermis associated with focal fibrosis, interstitial mucin, and little surrounding inflammation. CONCLUSION Calcium hydroxylapatite microspheres and associated fibrosis may persist in facial dermis at least 6 years after implantation, long after its clinical effects are thought to subside. Dermatologists and dermatopathologists must be mindful of dermal implants because it is likely that incidental encounters will be an increasingly common occurrence. The authors have indicated no significant interest with commercial supporters.

Floaters in Mohs micrographic surgery.

Background Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. Objective To understand the common causes of floaters and identify management strategies. Methods An initial virtual consensus conference of Mohs surgeons based on a 60‐item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. Results Based on retrospective reporting of 230 surgeon‐years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. Conclusion Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.

RECOGNITION AND MANAGEMENT OF HIGH-RISK CUTANEOUS TUMORS

The majority of cutaneous malignancies can be treated by the military dermatologist in a clinical setting. Recognition of tumors at high risk for recurrence or metastasis is important for any dermatologist but especially list care. Providing optimal care includes knowledge about which patients should be medavacced to larger medical centers for advanced surgical and medical treatments.

Rare case of acral calcified angioleiomyoma with macroscopic calcium extrusion

Acral calcified angioleiomyoma is an uncommon tumor that presents as a non-descript papule or subcutaneous nodule, classically on the foot. Biopsy or excision is typically the diagnostic method of choice as well as the treatment for these sometimes painful tumors. We report an uncommon clinical presentation of acral calcified angioleiomyoma with considerable extrusion of calcium perforating through the skin.