A growing era of alternative medicine is upon us. All who practice medicine have a small population of patients who eschew Western medicine and prefer alternative approaches, including botanical remedies, to treat their medical problems. Many alternative practitioners advertise and sell products on the Internet. Indeed, this trend now includes a growing number of topical treatments for skin cancer, including escharotic agents.
Self-treatment of skin cancer requires a substance that will destroy tissue, usually indiscriminately. Escharotic agents are caustic, corrosive substances that produce a thick coagulated crust (an eschar) and subsequently a scar.
The following case illustrates one representative situation.
Surgical scissors are a necessary component of the surgical tray. It is optimal to maintain one plane of cutting or dissection when excising a lesion or undermining tissue. This is particularly important when removing a melanoma, large lesion, or Mohs micrographic surgery layer. Traditionally iris, gradle, and Stevens tenotomy scissors have been the preferred instruments for cutaneous surgery in small shallow areas. These instruments accommodate more delicate anatomic areas well. Many dermatologic surgeons use Metzenbaum or Mayo scissors when undermining larger, deeper defects and cutting thicker, more resilient skin (such as that on the scalp, back, or extremities). These scissors have a longer shank and tips than the aforementioned instruments and are more efficient in cutting and manipulating deeper tissue and larger lesions. In certain situations, however, their long tips may feel clumsy and provide less precise cutting and undermining. When used to cut the subcutaneous tissue, these scissors tend to catch a nodule of fat deep in the defect instead of maintaining a level, even cutting surface through the fat.
BACKGROUND: Physicians inevitably receive a pathology report after excision of a basal cell carcinoma that indicates that it is incompletely excised. The physician and patient are then left with the dilemma of whether immediate re-excision or close clinical follow-up is indicated.
OBJECTIVE: Our purpose was to identify characteristics of incompletely excised basal cell carcinomas that are at low risk for recurrence.
METHODS: We retrospectively reviewed the charts and pathology slides of all incompletely excised basal cell carcinomas from 1991 to 1994 in a university hospital tumor registry.
RESULTS: Incompletely excised basal cell carcinomas of superficial or nodular subtype, less than 1 cm in diameter, located anywhere except the nose or ears, with less than 4% marginal involvement on the initial inadequate excision had no evidence of tumor persistence.
CONCLUSION: When physicians receive a pathology report indicating the incomplete excision of a basal cell carcinoma, they face the dilemma of further management. The majority of patients should undergo immediate re-excision or Mohs micrographic surgery because tumor persistence was found in 28% of cases. Occasionally, for a small group of select patients, close clinical follow-up may be indicated if the risk of recurrence is very low.
Basal cell carcinoma is the most common of the cutaneous malignancies, accounting for 65 to 75% of all skin cancers. The natural history of this disease is one of chronic local invasion. Metastatic basal cell carcinoma is a rare clinical entity, with a reported incidence of only 0.0028 to 0.5%. Approximately 85% of all metastatic basal cell carcinomas arise in the head and neck region. We present a case of basal cell carcinoma that spread to the parotid gland in a man who had multiple lesions on his scalp and face. We also review the literature on metastatic basal cell carcinoma of the head and neck, and we discuss its epidemiology, etiology, histopathology, and treatment.
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 histological subtype, roughly 40% change in their microscopic appearance at the subclinical extension. This finding has the potential to alter therapy.
BACKGROUND: The basosquamous cell carcinoma (BSCC) is a poorly defined and often misunderstood cutaneous malignancy.
OBJECTIVE: The purpose of this study was to compare, using immunohistochemical techniques, the BSCC, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).
METHODS: BSCC occurring at Pennsylvania State University over the past 10 years were identified. Choosing seven BCC, and nine SCC as controls, all specimens were stained for keratin, lack of apoptosis, glycoproteins, and altered gene products using the avidin/biotin and strep-avidin immunoperoxidase techniques. Each malignancy was then graded for the percentage of cells stained with each marker.
RESULTS: Of the markers studied, all stained to varying degrees the malignant aspects of the specimens. There were similar patterns between tumors, with the BSCC showing a transition zone between typical BCC and SCC. This was most striking for Ber-EP4, where over two-thirds of the BCC stained, none of the SCC, and half of the BSCC showed reactivity.
CONCLUSION: BSCC has staining patterns similar to both the BCC and SCC. The presence of a transition zone does not support the concept that all BSCC are collision tumors, but rather a differentiation of one tumor into another. We confirm earlier reports that Ber-EP4 could be used to distinguish between classic BCC and SCC. AE1/AE3, bcl-2, TGF-alpha, and p53 were not helpful in separating the tumors.
BACKGROUND: The factors determining a basal cell carcinoma's (BCC's) growth pattern and invasive potential are not known. In other tumors it has been shown recently that the expression of cellular adhesion molecules may determine a tumor's invasive and metastatic potential. Integrins, cell surface molecules important in cell stroma interactions, are present on BCCs and may help regulate the tumor's growth pattern.
OBJECTIVE: We compared the expression of cellular adhesion molecules alpha 2 integrin, beta 1 integrin, intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), leukocyte function antigen 1a (LFA-1a), and E-selectin in different histological subtypes of basal cell carcinomas.
METHODS: BCCs were obtained from patients undergoing Mohs surgery. The BCCs were classified as nodular, micronodular, mixed, infiltrative, and basosquamous types and stained using an avidin-biotin-immunoperoxidase technique with antibodies against alpha 2 integrin, beta 1 integrin, ICAM, LFA-1a, VCAM-1, and E-selectin.
RESULTS: BCCs expressed alpha 2 and beta 1 integrin, but no significant differences in the amount or pattern of expression was seen in the different histologic subtypes.
CONCLUSION: The expression of integrins by BCCs by binding to the surrounding stroma may limit BCC's growth; however, their expression does not appear to correlate with their histological pattern.
Trichilemmal carcinoma is an uncommon cutaneous neoplasm that occurs in sun-exposed areas of older persons. It is thought to be related to the external root sheath of the hair follicle and to be the malignant counterpart of a trichilemmoma. We describe a case of trichilemmal carcinoma treated with Mohs micrographic surgery.
Microcystic adnexal carcinoma is an aggressive, locally destructive cutaneous neoplasm with a high rate of recurrence. This tumor is often misdiagnosed clinically and histologically. It usually occurs in middle-aged to older adults. We describe a 44-year-old man with a large microcystic adnexal carcinoma that was present for more than 20 years. The tumor invaded the perichondrium, muscle, nerve, and blood vessel adventitia. A review of the literature suggests that these tumors are often histologically misdiagnosed because the biopsy specimens may be too small to reveal all the characteristic histologic features. The clinical presence of marked induration, a smooth surface, and, possibly, sensory changes should alert the clinician to the possibility of this neoplasm. The initial biopsy specimen must be large enough to demonstrate the identifying histologic features. Mohs surgery is currently the treatment of choice for microcystic adnexal carcinoma, as it often spreads far beyond clinically evident tumor.
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.
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.
BACKGROUND: Hidradenomas are adnexal tumors that may grow to be very large and frequently recur after excision. Malignant transformation and metastatic spread can occur and histologic distinction of benign from malignant hidradenomas can be very difficult. Some tumors with bland histology have demonstrated aggressive behavior.
OBJECTIVE: To decide the benefits of management with Mohs micrographic surgery of large hidradenomas.
METHODS: The literature was reviewed, including both the clinical course of the tumor and histologic features. The case of our report was interpreted in light of the review.
RESULTS: Three stages of Mohs surgery were required for complete removal of the hidradenoma. The patient remains free of recurrence.
CONCLUSION: This report highlights the difficulties in distinguishing benign from malignant hidradenomas and emphasizes the benefits of Mohs surgery for large or recurrent tumors.
BACKGROUND AND DESIGN: Topical antibiotics are one of the most common causes of allergic contact dermatitis and are frequently used in postoperative wound care. We prospectively followed up patients having cutaneous surgery to determine the frequency of allergic contact dermatitis to topical antibiotics used on postoperative wound care.
RESULTS: Nine (4.2%) of 215 patients who had undergone surgery who were using a topical antibiotic had an eruption develop postoperatively that was consistent with an allergic contact dermatitis from the topical antibiotic. Seven of the nine patients agreed to patch testing with the standard tray and selected topical antibiotics. Five patients had a positive patch test to neomycin sulfate and four had a positive patch test to bacitracin. The frequency of allergic contact dermatitis proved by patch testing to neomycin and bacitracin is five (5.3%) of 94 and four (2%) of 198, respectively, in the patients who used these antibiotics. All proved sensitivities to bacitracin occurred in patients using a topical antibiotic that also contained neomycin and were patch tested positive to the neomycin. No patients using only pure bacitracin had allergic contact dermatitis.
CONCLUSIONS: Allergic contact dermatitis to a topical antibiotic, especially neomycin, should be considered in any patient who has development of a dermatitis after cutaneous surgery. Because of the frequency of allergic contact dermatitis, neomycin-containing antibiotics should be avoided in postoperative wound care.
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.
Cytomegalovirus inclusions have been reported in perineal ulcers from immunosuppressed adults. The importance of this finding is unknown. We report the first pediatric case of cutaneous cytomegalovirus infection in an infant with congenital human immunodeficiency virus infection, presenting as a diaper dermatitis. Cytomegalovirus was cultured from the skin biopsy specimen, and characteristic inclusions were seen on hematoxylin-eosin-stained sections. Results of this biopsy specimen analysis prompted further investigation revealing disseminated cytomegalovirus infection, including retinitis. Aggressive pursuit of a pathogen in common conditions such as diaper dermatitis is strongly recommended in immunosuppressed pediatric patients.
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.