Thomas L. Hocker

Favorable long-term outcomes in patients with histologically dysplastic nevi that approach a specimen border

BACKGROUND Patients with multiple clinically dysplastic nevi are at increased risk for development of melanoma. However, the risk of melanoma arising in a histologically dysplastic nevus (HDN) is unknown. OBJECTIVE We sought to determine the rate of melanoma development in patients with HDNs that approached a microscopic border but were not re-excised. METHODS We performed a retrospective study of patients evaluated in our dermatology department from January 1, 1980, to December 31, 1989, who had a HDN that extended to within 0.2 mm of a microscopic punch, shave, or excision border and was not re-excised. RESULTS The average follow-up in our cohort of 115 patients was 17.4 years (range: 0.0-29.9): 82 patients (71.3%) were followed up for longer than 10 years, 78 (67.8%) longer than 15 years, and 73 (63.4%) had more than 20 years of follow-up; 66 of 115 nevi were mildly dysplastic, 42 moderately dysplastic, and 7 had severe dysplasia. No patient developed metastatic melanoma or melanoma at the site of removal of a HDN. LIMITATIONS This was a retrospective study performed at 1 large academic medical center. CONCLUSION During a long-term follow-up period, no patient developed melanoma at the site of an incompletely or narrowly removed HDN, providing evidence that routine re-excision of mildly or moderately dysplastic nevi may not be necessary.

Leiomyosarcoma of the skin: Clinical, histopathologic, and prognostic factors that influence outcomes

BACKGROUND Superficial leiomyosarcoma (LMS) is a rare tumor with important clinical, pathologic, and treatment features. Previous LMS studies have included few patients, included minimal follow-up, and typically combined the superficial and subfascial (deep) forms. OBJECTIVE We sought to characterize clinical features, effectiveness of treatment approaches, and long-term outcomes for LMS stratified by depth of invasion. METHODS In all, 71 cases of primary superficial LMS, 48 dermal and 23 subcutaneous (mean follow-up of 8 years), were examined and clinical, histopathologic, and treatment factors reported. RESULTS Tumor size and subcutaneous classification correlated with greater likelihood of metastasis and death at 5 years. When superficial LMS metastasizes, other skin sites are the most common distant location. Treatment with wide local excision with minimum 1-cm margins showed statistically lower rates of recurrences and metastasis compared with excision with narrow surgical margins. Fourteen cases of Mohs micrographic surgery had no recurrences or metastases. Five cases of dermal LMS metastasized, 2 of which resulted in death. LIMITATIONS This study is a retrospective review of a relatively small number of patients. CONCLUSION LMS can metastasize and warrants surgical intervention and long-term follow-up. Wide local excision, and Mohs micrographic surgery in particular, appear to provide the best management approach for definitive treatment.

Treatment of Porocarcinoma With Mohs Micrographic Surgery: The Mayo Clinic Experience.

BACKGROUND Eccrine porocarcinoma (EPC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment. OBJECTIVE This study reviews the clinical characteristics and outcomes of patients with EPC treated with Mohs micrographic surgery (MMS). MATERIALS AND METHODS The authors performed a retrospective chart review of patients with EPC treated by MMS at the Mayo Clinic from 1995 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality. RESULTS A total of 9 patients underwent MMS for EPC in 19 years. The average age was 64.2 years, with 6 males and 3 females. All patients were Caucasian. The head and lower extremity were the most common locations (44% each), with 1 on the forearm. Of the 9 tumors, 8 were located on the right side of the body. The mean preoperative tumor size and postoperative defect were 2.9 and 7.8 cm2, respectively, when 2 outliers were excluded. An average of 1.3 MMS stages was required for clearance. The mean postoperative follow-up was 3.3 years (range: 1–60 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality. CONCLUSION Mohs micrographic surgery seems to be a useful treatment modality for EPC. This is one of the largest single-center series of EPC treated with MMS.

Mohs micrographic surgery in the treatment of trichilemmal carcinoma: The Mayo Clinic experience

REFERENCES 1. Accetta P, Accetta J, Kostecki J. The use of digital cameras by US dermatologists. J Am Acad Dermatol. 2013;69:837-838. 2. Hubbard VG, Goddard DJ, Walker SL. An online survey of the use of digital cameras by members of the British Association of Dermatologists. Clin Exp Dermatol. 2009;34:492-494. 3. Kunde L, McMeniman E, Parker M. Clinical photography in dermatology: ethical and medico-legal considerations in the age of digital and smartphone technology. Australas J Dermatol. 2013;54:192-197.

Expression of T-cell receptor-γδ in normal human skin, inflammatory dermatoses and mycosis fungoides.

Background: T cells expressing the γδ T‐cell receptor (TCR) (γδ T cells) are found in normal epithelial tissues such as the skin. However, the proportions of γδ T cells that may be observed in commonly encountered cutaneous diseases with a prominent lymphocytic infiltrate have not been elucidated.

Mohs Micrographic Surgery for the Treatment of Hidradenocarcinoma: The Mayo Clinic Experience From 1993 to 2013

BACKGROUND Hidradenocarcinoma (HAC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment. OBJECTIVE To review clinical characteristics and outcomes of patients with HAC treated with Mohs micrographic surgery (MMS). MATERIALS AND METHODS The authors performed a retrospective chart review of patients with HAC treated by MMS at Mayo Clinic from 1993 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality. RESULTS Ten patients underwent MMS for HAC more than 20 years. The average age was 62.8 years, with 6 females and 4 males. Occipital scalp was the most common location (40%), followed by extremities (30%) and face (20%). In 5 of 7 cases (71%), “cyst” was the working clinical diagnosis. The average preoperative lesion area was 3.18 cm2, with an average of 1.5 MMS stages required for clearance. Mean postoperative follow-up was 7 years (range, 5–205 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality. CONCLUSION Mohs micrographic surgery seems to be a useful treatment modality for HAC. This is the largest reported series of HAC treated with MMS with long-term follow-up.

Comparison of MITF and Melan-A Immunohistochemistry During Mohs Surgery for Lentigo Maligna-Type Melanoma In Situ and Lentigo Maligna Melanoma.

BACKGROUND Mohs micrographic surgery (MMS) with frozen section immunohistochemistry is a treatment option for malignant melanoma in situ (MMIS) and lentigo maligna melanoma (LMM). Melan-A is a cytoplasmic melanocyte immunostain useful on frozen sections but may lack specificity. Microphthalmia transcription factor (MITF) is a more specific nuclear melanocyte immunostain less frequently used in MMS. OBJECTIVE To quantify melanocyte density in chronic sun-damaged skin (CSDS), negative margin, and tumor from patients undergoing MMS for MMIS and LMM using MITF and melan-A. METHODS Sixteen patients with MMIS or LMM had frozen sections from CSDS, negative margin, and 12 tumor samples, stained with MITF and melan-A. Melanocyte counts were performed. RESULTS Chronic sun-damaged skin mean melanocyte count (MMC) for MITF and melan-A was 9.8 and 13.7, respectively, (p < .001). Negative margin MMC for MITF and melan-A was 8.84 and 14.06, respectively, (p < .001). Tumor MMC for MITF and melan-A was 63.5 and 62.4, respectively. CONCLUSION Although both MITF and melan-A facilitate the identification of tumor during MMS for MMIS and LMM, the apparent melanocyte density on tumor-free CSDS appears higher with melan-A than MITF. Microphthalmia transcription factor provides a crisp outline of melanocyte nuclei and is a useful alternative stain to melan-A for MMS of melanoma.

Relapsed hepatosplenic T-cell lymphoma heralded by a solitary skin nodule

Hepatosplenic T‐cell lymphoma (HSTL) represents a rare form of peripheral T‐cell lymphoma composed of lymphocytes that typically express the γδ T‐cell receptor. This form of lymphoma rarely involves the skin. We report the case of a 23‐year‐old man with a history of HSTL that was presumed to be in remission who presented with a solitary cutaneous nodule. Skin biopsy showed an atypical lymphocytic infiltrate arranged in a perivascular and periappendageal pattern with associated vacuolar epidermal interface change. The constituent T cells expressed CD2, CD3, CD7, CD8, β‐F1, γδ T‐cell receptor, Tia‐1 and granzyme B. The cells lacked the expression of CD4, CD5 and CD56. Fluorescence in situ hybridization (FISH) showed a characteristic chromosomal abnormality, namely isochromosome 7q, which confirmed the diagnosis of cutaneous HSTL. On restaging his disease, widespread progression was noted. To our knowledge, this report provides the first detailed account of cutaneous involvement by HSTL. We show the novel utility of FISH to identify isochromosome 7q in the lesional skin of HSTL patients.

Carbon dioxide laser treatment for Hailey-Hailey disease: a retrospective chart review with patient-reported outcomes.

Hailey–Hailey disease (HHD) is an autosomal dominant genodermatosis that leads to skin breakdown and blister formation, usually in intertriginous areas. Laser ablation is a known surgical treatment for HHD.

Outcomes of basal cell carcinomas directly invading the parotid gland.

BACKGROUND Parotid involvement by basal cell carcinoma (BCC) is rare, and therefore management is controversial. OBJECTIVE To review the treatment and outcomes of patients with BCC involving the parotid by direct infiltration. METHODS AND MATERIALS The authors performed a retrospective chart review of BCC cases involving the parotid. RESULTS From 1994 to 2007, there were 19 cases of BCC involving the parotid gland by direct extension. Nine were primary tumors, and 10 recurrent (nonprimary). Eight tumors were treated with Mohs micrographic surgery (MMS), and 11 with wide local excision (WLE). One patient died of unrelated causes 5 months after treatment, and 2 did not follow up. The remaining 16 cases had an average follow-up of 55.2 months (range, 18–112 months). No primary BCC recurred after treatment. Six of 10 nonprimary BCC (60%) recurred, 2 of 10 metastasized, and 1 of 10 died of metastatic BCC. Two recurrences occurred after MMS, and 4 occurred after WLE with or without parotidectomy. CONCLUSION Mohs micrographic surgery or WLE with intra-operative margin control seems to be an acceptable first-line treatment for primary BCC involving the parotid. Recurrent BCC involving the parotid gland through direct infiltration has high rates of future recurrence, and adjuvant treatment may be required.