Yehuda D. Eliezri

Occurrence of human papillomavirus type 16 DNA in cutaneous squamous and basal cell neoplasms

Sixty-eight cutaneous squamous cell neoplasms (in situ and invasive) and 26 basal cell carcinomas from 89 patients were analyzed for DNA sequences homologous to the human papillomavirus (HPV) types found predominantly in the genital tract. Thirty-six (53%) of the squamous cell neoplasms contained HPV DNA as detected by filter or in situ hybridization analysis. The frequency of detection of HPV DNA was dependent on the site of the lesion. Of 40 genital squamous cell neoplasms (penile, vulvar, and perianal), 27 (68%) had detectable HPV DNA. In 25 of these, the HPV type was 16 or HPV-16-related, which was similar to the results for the squamous cell neoplasms of the finger (HPV DNA in 9 of 11 tumors with HPV-16 in seven). None of 16 squamous cell neoplasms from sites other than the genital tract or the finger had detectable HPV DNA. HPV DNA was detected in one of the 26 basal cell carcinomas (4%). We conclude that, for cutaneous epithelial malignancies, HPV-16 is restricted to squamous cell neoplasms of the genital tract and finger. These data are consistent with venereal transmission of HPV-16 to the periungual region and suggests a role for this virus in the evolution of squamous cell carcinoma at this site.

Cutaneous Odontogenic Sinus Simulating a Basal Cell Carcinoma: Case Report and Literature Review

A woman was referred for Mohs microscopically controlled surgical excision of a presumptive basal cell carcinoma located on her nasolabial fold. During examination, pus was expressed from the nodulocystic lesion and an intraoral palpation revealed a fibrous sinus tract extending from the skin lesion to the gingiva of a severely carious tooth. There was roentgenographic evidence of a periapical abscess. The diagnosis was revised to that of a cutaneous odontogenic sinus. The possibility of a draining dental sinus to the skin should be seriously considered when evaluating a suspected basal cell carcinoma in the perioral region--especially in an individual with a history of extensive dental treatments, antecedent oral trauma, or markedly carious teeth.

Metastatic periungual squamous cell carcinoma: Detection of human papillomavirus type 35 RNA in the digital tumor and axillary lymph node metastases

Human papillomavirus (HPV) has been associated with benign and malignant cutaneous and mucosal neoplasms including squamous cell carcinoma (SCC) of the anogenital, oral, and periungual regions. 1-6 HPV has been identified in recalcitrant verrucae-like SCCs of the fingernail bed or periungual region. 1,7-9 Although HPV type 16 was the predominant type, in one patient HPV 35 was found. 9 The majority of the SCCs of the nail unit associated with HPV were in situ tumors. Although dermal invasion was occasionally noted, there have been no reports of bone involvement or metastatic disease. 1,7-12 We describe a man with a wartlike SCC of the fingernail bed that metastasized regionally. Prior reports of the association of oncogenic HPV with cutaneous periungual SCC prompted us to search for the virus.

Cancer recurrence following Mohs micrographic surgery : a mechanism of tumor persistence

Recurrence of basal cell carcinomas after Mohs micrographic surgery is rare but known to occur. This report describes the recurrence of a basal cell carcinoma of the forehead after Mohs surgery in order to illustrate a previously undescribed mechanism of tumor persistence and recurrence despite thorough microscopic evaluation of all surgical margins. The value of the surgeons reviewing all prior histologic sections before performing micrographic surgery, the importance of resecting all scar tissue from a previous surgical site prior to determination of tumor-free margins, and the potential usefulness of a three-tiered closure after excision of a cutaneous malignancy that involves the muscular layer are discussed.

Athlete's nodules. Treatment by surgical excision.

SummaryAthlete’s nodules are connective tissue nevi of the collagen type (collagenomas) which appear as thick dermal masses at sites of chronic trauma. They have been described as occurring on the dorsum of the feet, knees, and knuckles of surfers, boxers and marble players. Recurrent minor blunt trauma and pressure are aetiological factors in this condition. We report a 54-year-old man with dermal nodules on the dorsal surface of his feet. These lesions initially appeared during his participation as a player on a high school football team. They were attributed to the chronic pressure of his high-laced athletic sneakers and frequent minor injuries to the involved areas. We describe the successful treatment of our patient’s lesions by surgical excision. We also discuss the differential diagnosis and other therapeutic options for athlete’s nodules.

Surgical Pearl: Temporary suspension suture (Frost suture) to help prevent ectropion after infraorbital reconstruction.

An ectropion is a complication that can arise from reconstruction in the infraorbital region (Fig 1). Often, this complication occurs despite proper positioning of the lower lid at the time of closure. Edema and bleeding postoperatively can cause the lower lid to pull away from the globe. Fibrosis and subsequent contracture in this position can lead to an ectropion. To help prevent this we have incorporated the use of a temporary suspension suture, known in oculoplastics as a Frost suture, 1 for selected closures in the infraorbital area. After an appropriate closure has been executed (Fig 2), a 4-0 nylon suture is passed through the tarsus or just inferior to it. Both ends of the suture are then attached to the skin above the eyebrow (Fig 3). This serves as a sling as the tension of the suture is directed in a manner that most closely approximates the normal anatomic location of the lower lid. The suture may be attached either by sewing it to the skin or by use of adhesive strips. When passing the suture through the lower lid margin, the surgeon should avoid placing the lower end of the suture through the puncta or canaliculus. Likewise, the surgeon should be aware of the supratrochlear or supraorbital neurovascular bundle if sewing the upper end of the suture. Adhesive strips may be preferable because they allow the tension to be easily adjusted, if necessary, in the postoperative period. One should use large strips and a liquid adhesive when attaching the suture by this method. The suture remains in place for approximately 3 days, depending on the clinical appearance and the amount

Keratoacanthoma of the Head and Neck with Perineural Invasion: Incidental Finding or Cause for Concern?

Keratoacanthoma (KA) is generally regarded as a less aggressive variant of cutaneous squamous cell carcinoma (SCC) that has a low propensity to recur or metastasize. This characteristic benign behavior reportedly holds true in cases of KA of the head and neck even when they exhibit perineural invasion (PNI) on histologic examination. There is a paucity of data regarding KA with PNI, but the evidence that exists suggests that PNI is an incidental finding that does not affect patient outcome. For this reason, many dermatologic surgeons do not alter their treatment plan when PNI is encountered in the treatment of KA of the head and neck, whereas they would probably recommend radiation therapy or more aggressive surgery for SCCs that exhibit similar histologic findings.

Suprascapular Nerve Injury During Mohs Surgery and Review of the Surgical Anatomy of the Nervous Structures of the Supraclavicular Triangle

Accurate anatomic knowledge of the nervous structures of the neck is essential to the dermatologic surgeon to avoid serious adverse outcomes postoperatively, including but not limited to injury to the brachial plexus and paresis of the hemidiaphragm. Detailed descriptions of the surgical anatomy of the supraclavicular triangle (SCT) are scarce, and reports of nervous injuries during cutaneous surgery are absent from dermatologic textbooks and journal literature. The primary objective of this article is to provide a brief review of the nervous anatomy of the SCT region.

The use of the SMAS to close Mohs defects invading the parotid gland.

background. Plastic surgery literature reports the use of the superficial musculoaponeurotic system (SMAS) in reconstruction after parotidectomies to prevent the complications of Freys Syndrome and fistula formation. However, there is scant information in the dermatologic literature regarding the use of the SMAS when closing Mohs defects overlying the parotid gland. objective. Our purpose is to introduce to the dermatologic surgery literature the need for plication of the SMAS prior to closure of the overlying tissues when repairing surgical defects which invade the integrity of the parotid gland. methods. We describe a patient with a large basal cell carcinoma located in the right preauricular region. Using text and photographs, we detail our closure of this large defect which invaded the parotid gland. results. Closure of the SMAS over the parotid gland before suturing the overlying tissues provided our patient with an excellent functional and cosmetic result, without the formation of a fistula, sialocele, or Freys Syndrome. conclusion. We propose that the essential first step in the ideal closure of surgical wounds which penetrate the parotid gland involves the isolation and plication of the SMAS. This will create a barrier to the accumulation of parotid secretions which, in turn, may lead to the development of a sialocele and fistula formation. Such a barrier will also prevent the formation of Freys Syndrome. Furthermore, plication of the SMAS serves to improve cosmesis by contributing soft tissue bulk to the wound and avoiding a concave deformity.

Treatment of an oral erythroplastic squamous cell carcinoma with Mohs' micrographic surgery

In the case presented in this article, a large superficial erythroplastic oral carcinoma with vaguely delineated clinical borders and foci of invasive squamous cell carcinoma was treated with Mohs micrographic surgery. This provided a safe, thorough, yet conservative mode of treatment. Mohs micrographic surgery may be considered among the alternative treatments for selected mucosal lesions of squamous cell carcinoma.