Mary E. Maloney

Histologic pattern analysis of basal cell carcinoma: Study of a series of 1039 consecutive neoplasms

This study attempts to define histologic patterns in 1039 consecutive cases of basal cell carcinoma and to correlate these patterns with adequacy of margins of surgical excision. Five major histologic patterns were identified: nodular, 218 cases (21%); superficial, 181 cases (17%); micronodular, 151 cases (15%); infiltrative, 77 cases (7%); and morpheic, 11 cases (1%). A mixed pattern (two or more major histologic patterns) was present in 401 cases (38.5%). Our study indicates that nodular and superficial basal cell carcinomas can be completely removed by simple surgical excision in a high percentage of cases (93.6% and 96.4%, respectively) whereas the micronodular, infiltrative, and morpheic basal cell carcinomas have a higher incidence of positive tumor margins (18.6%, 26.5%, and 33.3%, respectively) after excision. Mixed patterns that consisted of combinations of the nodular, micronodular, or infiltrative types exhibited a behavior similar to the pattern that resulted in a greater chance of incomplete surgical removal.

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.

Angiosarcoma: Current review

Angiosarcoma (AS) is a rare malignant tumor of the skin and soft tissues. Due to this lesionss histopathologic similarity to other soft tissue and skin neoplasms, several names had been previously used to describe AS. In the following article, we present a comprehensive review of the literature and prior studies pertaining to AS. The purpose of this article is to provide the reader with a better understanding of the causative factors, clinical findings, and histological features of this uncommon but potentially lethal tumor. Furthermore, we discuss present therapeutic options and outcomes as well as summarize recent advances in AS tumor biology and cytogenetics.

Pigmented basal cell carcinoma: Investigation of 70 cases

BACKGROUND Pigmented basal cell carcinoma (PBCC) is a clinical and histologic variant of BCC. OBJECTIVE Our purpose was to identify the histologic subtypes of BCC that were most often associated with pigment and to determine whether this correlated with outcome after excision. METHODS A series of PBCC was identified and the histologic subtype noted. Margins of all excisions were examined for residual tumor. These results were then compared with a series of nonpigmented BCCs. RESULTS In a series of 1039 consecutive BCCs, 70 (6.7%) contained pigment. The histologic growth pattern most frequently associated with pigment was the nodular/micronodular pattern (12.4%) followed by the nodular (7.7%), superficial (7.2%), micronodular (4.0%), and the nodular/micronodular/infiltrative (3.4%) patterns. Margins were examined for evidence of residual tumor in the 40 cases that were excised. In only one case (2.5%) was the margin positive for tumor. This was statistically significant (p less than 0.05) compared with 388 excisions of nonpigmented BCCs with comparable growth patterns in which 69 (17.7%) showed positive margins. CONCLUSION PBCC, as a clinical variant, is more frequently excised with adequate margins than are tumors of comparable histologic subtypes that do not contain pigment.

Arsenic in Dermatology

BACKGROUND Arsenic is a chemical carcinogen that exists naturally and in the workplace. OBJECTIVES Review exposure, clinical signs of arsenic exposure, and the carcinogenic potential. METHOD Review of literature. RESULTS Arsenic is a known carcinogen that occurs both naturally and in the workplace. It causes cutaneous malignancies, hyperpigmentation, palmer and plantar keratosis, and internal malignancies, especially of the lung and bladder. CONCLUSION Exposure risks need to be well publicized. Those people with known exposure need regular full skin exams as well as close follow‐up by their primary care physician.

Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: Time to ban the tan

The incidence of melanoma skin cancer is increasing rapidly, particularly among young women in the United States. Numerous studies have documented an association between the use of indoor tanning devices and an increased risk of skin cancer, especially in young women. Studies have shown that ultraviolet exposure, even in the absence of erythema or burn, results in DNA damage. Countries and regulatory bodies worldwide have recognized the health risks associated with indoor tanning. In the United States, 32 states have passed legislation to regulate the indoor tanning industry, but there is an urgent need to restrict the use of indoor tanning devices at the federal level. The Food and Drug Administration is currently reviewing the classification of these devices. For all of these reasons, the Food and Drug Administration should prohibit the use of tanning devices by minors and reclassify tanning devices to at least class II to protect the public from the preventable cancers and other adverse effects caused by ultraviolet radiation from indoor tanning.

Malignant melanoma with clinical and histologic features of Merkel cell carcinoma

We describe a patient with malignant melanoma that resembled a Merkel cell carcinoma both clinically and histologically. Immunohistochemical studies showed focally positive staining with S-100 protein and strongly positive staining with HMB-45. Ultrastructural study confirmed the diagnosis by demonstrating premelanosomes and melanosomes. Although the tumor appeared to be clinically unimpressive, it was a deep melanoma with a Breslow level of 3.8 mm that necessitated aggressive treatment. Small cell melanoma must be considered in the differential diagnosis of small cell tumors, which also includes lymphoma, eccrine carcinoma, squamous cell carcinoma, and Merkel cell carcinoma. The diagnosis of amelanotic melanoma, including the small cell variant, may require electron microscopic studies.

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.

Isotretinoin and iPledge: a view of results

Abbreviations used: FDA: Food and Drug Administration PPP: Pregnancy Prevention Program REMS: Risk Evaluation and Mitigation Strategies SMART: System to Manage Accutane-Related Teratogenicity S ince its approval by the Food and Drug Administration (FDA) in 1982, isotretinoin has positively affected the lives of countless patients. Of course, any pharmaceutical agent has both its desired effect as well as undesirable side effects. The prescription of any given drug for any individual patient depends on the risk-benefit analysis for that patient. The side effect of teratogenicity has naturally moved to the forefront of safety standards for isotretinoin. It is important to remember that fetal exposure is the problem, not pregnancy itself, and all attention and efforts should be focused on preventing such exposure. In the United States, 4 programs have been developed over time in an effort to prevent fetal exposure. These programs have been evaluated in terms of the numbers of pregnancies that occur, which is used as a proxy for potential fetal exposure. As we discuss the problem of teratogenicity with isotretinoin and the various programs to protect against it, we will use the term ‘‘pregnancies’’ as a representation of fetal exposure. The first program put in place to prevent pregnancy during the course of treatment with isotretinoin was a voluntary one in which the manufacturer, Roche Inc (Nutley, NJ) provided brochures to patients describing the risks of taking isotretinoin, particularly its teratogenic effects. This was followed by the Pregnancy Prevention Program (PPP), also created by Roche in 1988. PPP required the patient to sign a consent form, get a pregnancy test before starting isotretinoin, and choose two methods of birth control. Concern about the number of reported pregnancies remained,

Surgical pearl : Surgical planing in the treatment of chondrodermatitis nodularis chronica helicis of the antihelix

Chondrodermatitis nodularis chronica helicis (CNCH) is a common condition involving the auricle in middle-aged and elderly patients. It typically presents as a solitary, tender, erythematous nodule, usually with central crusting and ulceration, on the helical rim in men and the antihelix in women. 1 A biopsy specimen reveals epidermal acanthosis with a central, crested ulcer containing necrotic dermal debris and perichondral thickening. 2 Degenerative changes in the underlying cartilage may also be present. CNCH has been described as both a transepidermal perforating disorder 3 and a necrobiotic granuloma with secondary epithelial changes. 4 The anatomy of the auricle makes it susceptible to environmental and mechanical injury. Relative ischemia as a result of pressure may occur because of the small dermal blood vessels supplying the epidermis, dermis, perichondrium, and cartilage. The lack of a thick cushioning subcutaneous layer in the auricle further predisposes it to pressure-induced ischemia and to trauma. 5 Various treatments, both medical and surgical, have been described for CNCH. Medical approaches include cryotherapy, topical corticosteroids, intralesional corticosteroids, and intralesional injection of collagen. 5-7 Surgical therapies include wedge resection with suturing, curettage and electrocauterization, carbon dioxide laser ablation, and excision of skin followed by scalpel resection or curettage of cartilage. 8-13 The method described by Lawrence 14