Biopsy-proven Basal Cell Carcinoma Research Articles

No Residual Basal Cell Carcinoma after Excision for Biopsy-proven Tumor: Clinical and Medicolegal Implications.

Summary:Our analysis of 127 head and neck region basal cell carcinomas (BCCs) showed that there was no evidence of residual BCC in 15% of patients, one of which is presented in this report. These patients received some type of reconstructive surgery after excision of lesions with negative tumor. Thus, there is a chance that any reexcision after a shave biopsy which is positive for BCC may be negative for tumor. This finding substantiates our realization that sometimes what some would call unnecessary surgery is a common reality. The surgeon’s goal is tumor eradication, and therefore, watchful waiting is usually not a legitimate clinical implication. This report has value in letting our esteemed legal colleagues know what we do not know, which still remains within the standard of appropriate care. However, the finding of no residual tumor in the current report may change our practice habits. Watchful waiting may be an option, particularly in the elderly and fragile patients. Also, one may opt to decrease the safety margins during excision when treating patients with biopsy-proven BCC. However, reconstructive procedures may still be required in the case of nonpersistent tumor. Therefore, it is extremely important that the informed consent should include statements regarding possible reconstructive procedures to avoid medicolegal implications.

Optical coherence tomography imaging of non-melanoma skin cancer undergoing photodynamic therapy reveals subclinical residual lesions

BackgroundPhotodynamic therapy with methyl aminolaevulinate (MAL–PDT) is a widely used non-invasive treatment modality for non-melanoma skin cancer (NMSC). The outcome of MAL–PDT is usually primarily evaluated clinically. Optical coherence tomography (OCT) is a non-invasive imaging technology based on interferiometry. OCT has been proven to provide high accuracy in identifying NMSC lesions and performing thickness measurements of thin tumours. ObjectivesTo describe the OCT morphology in in-vivo NMSC lesions during MAL–PDT treatment and to investigate the use of OCT in evaluating the response of MAL–PDT treated NMSC lesions. MethodsA total of 18 biopsy-proven basal cell carcinomas and actinic keratoses were monitored by OCT during 2 sessions of MAL–PDT treatment. At 3-months follow-up the patients were assessed both by OCT and clinically. If the clinical and OCT evaluation came to different conclusions on recurrence of the lesion, patients were followed more closely at clinical appointments for up to one year after the PDT treatment. ResultsAll lesions displayed at least one OCT characteristic before MAL–PDT treatment. At 3 months follow-up, recurrence was suspected clinically in 5/18 cases, with OCT in 7/18 cases. OCT correctly identified all of the partial responses also found by the clinical examinations. In both cases where recurrence was only found in OCT, this was subsequently confirmed by histology. ConclusionsOur study suggests that OCT identified 29% more recurrences than clinical examination alone. OCT can detect subclinical residual NMSC lesions after MAL–PDT treatment and may therefore be an accurate tool for early detection of residual lesional tissue.

Combined 585 nm pulsed‐dye and 1,064 nm Nd:YAG lasers for the treatment of basal cell carcinoma

Basal cell carcinomas (BCCs) have supporting vasculature that serves as a target for vascular selective lasers. The objective of this study was to determine the effect of repeated treatment with a combined 585 nm pulsed dye laser (PDL) and 1,064 nm Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser on BCCs of superficial and nodular subtypes of varying diameters. Ten subjects with 13 biopsy-proven BCCs received four combined PDL and Nd:YAG at treatments 2-4 week intervals. None of the BCCs met the criteria for Mohs micrographic surgery. The tumor and 4 mm of peripheral skin were treated using standardized parameters delivered with a 7 mm spot with 10% overlap. The treated area was excised and evaluated histologically for residual tumor. The primary study endpoint was histologic clearance of tumor. The secondary study endpoint was blinded investigator assessment of clinical endpoint and adverse effects. Approximately half of all tumors showed a complete response to four combined PDL and Nd:YAG treatments (n = 7/12, 58%). When stratified by size, 75% of all tumors <1 cm in diameter (n = 6/8) showed complete response. Tumor histologic types among the complete responders included superficial and nodular BCCs. All subjects with incompletely responding BCCs were on various forms of anticoagulation, which we hypothesize, may inhibit laser-mediated thrombosis necessary for the clinical effect. Blinded investigator assessment suggests that biopsy related erythema improves with subsequent laser treatments. Combined PDL and Nd:YAG laser is an effective means of reducing tumor burden in patients with BCC and may be a promising, emerging alternative therapy. Factors influencing treatment response includes the concomitant use of anticoagulation. Further studies are needed to investigate and optimize the utility of this treatment protocol.

Use of handheld reflectance confocal microscopy for in vivo diagnosis of solitary facial papules: a case series

Reflectance Confocal Microscopy (RCM) can be useful for evaluation of solitary pink papules that are suspicious for skin cancer. RCM has been challenging to apply to curvy facial areas because of the need for attaining full contact between the skin and RCM probe. A smaller diameter handheld RCM probe has been recently introduced to clinical practice. To describe the utility of RCM handheld probe as a bedside adjunct for clinical diagnosis of solitary facial papules. This is a retrospective descriptive case series of six patients presented with a diagnostically equivocal solitary facial papule. All lesions reported were evaluated and imaged clinically, dermoscopically and with handheld RCM, followed by biopsy for histopathological analysis. The series included biopsy-proven basal cell carcinomas (BCCs) (n=2), squamous cell carcinoma (n=1), sebaceous hyperplasia (n=1), desmoplastic trichoepithelioma (n=1) and compound nevus (n=1). Handheld RCM was easy to apply to the curved facial surfaces and allowed for reaching a correct bedside diagnosis. For clinically and dermoscopically equivocal small papules on curved facial surfaces, handheld RCM may be particularly helpful in differentiating benign lesions from skin cancer.

Reflectance confocal microscopy allowsin vivoreal-time noninvasive assessment of the outcome of methyl aminolaevulinate photodynamic therapy of basal cell carcinoma

Photodynamic therapy (PDT) with methyl aminolaevulinate (MAL) is an approved noninvasive treatment option for basal cell carcinoma (BCC). In vivo reflectance confocal microscopy (RCM) is a noninvasive imaging technique that has proved useful for in vivo real-time cytomorphological analysis of BCC cells infiltrating the epidermis. To investigate the use of in vivo RCM to assess the persistence of BCC cells surviving MAL-PDT. In vivo RCM images of 20 biopsy-proven BCCs were taken before patients underwent a treatment cycle with MAL-PDT. Follow-up after 3months was performed using clinical examination, RCM and conventional dermoscopy. Treated areas also underwent a targeted 3-mm punch biopsy for standard haematoxylin and eosin histology stain to establish the clinical and instrumental correlation of the treatment outcome. Three months after PDT, clinical examination established that two out of 20 BCCs were persistent; dermoscopy found three out of 20 residual BCCs, but RCM showed that one of these lesions was a false positive, and showed persistent BCC foci in five out of 20 lesions. Histological analysis of targeted biopsies confirmed these results. RCM provided noninvasive, early detection of incipient recurrences of BCC after MAL-PDT. RCM findings steered targeted biopsies and surgical removal, or a new MAL-PDT, of these subclinical recurrences with minimal invasiveness.

Single treatment of non‐melanoma skin cancers using a pulsed‐dye laser with stacked pulses

Non-melanoma skin cancers are the most common cause of cancer worldwide. Within this grouping, the most common skin cancer is basal cell carcinoma (BCC) followed by squamous cell carcinoma (SCC). Recent evidence has shown that BCCs can be cleared by a pulsed-dye laser after multiple treatments using a single pass setting. Given the necessity for multiple treatments in the prior studies, we sought to determine whether tumor clearance could instead be achieved using a single treatment of the pulsed-dye laser in a stacked pulse setting. Twenty patients with 23 biopsy-proven BCCs and SCCIS that measured 0.4-3 cm in size and located on the trunk and extremities were recruited for this study. The lesions were randomized into three study arms: a control group (no treatment), first treatment group (S1), and second treatment group (S2). The S1 group was treated using a 595 nM pulsed-dye laser (PDL) at pulse energy of 15 J/cm(2), 3-millisecond pulse length, with no dynamic cooling, using a 7-mm spot size with 10% overlap of pulses and two passes. The S2 group was treated using the same 595 nM PDL at 7.5 J/cm(2), 3-millisecond pulse length, with no dynamic cooling, using a 10-mm spot size with 10% overlap of pulses and double stacked pulses. All the treated lesions were treated with a 4 mm margin of clinically normal skin. The lesions were subsequently surgically excised and examined by histopathology. There was no significant difference in the dimensions of the tumors between the three study arms, with a mean area of 94 mm(2) [SEM ± 15.2] for the control group, 88 mm(2) [SEM ± 12.1] for the S1 treatment group, and 105 mm(2) [SEM ± 23.6] for the S2 treatment group. In the control group, there were two out seven lesions with no residual tumors, representing a background tumor clearance rate of approximately 28%. The S1 treatment group had two out of eight lesions with no residual lesion representing a clearance rate of 25%, similar to the background clearance rate. The S2 treatment group had a clearance rate of five out seven lesions, representing a clearance rate of 71%. The two lesions with residual tumors were noted to be beyond the central treatment zone by histopathology and if excluded, results in a clearance rate of 100%. By the Fisher's exact test with a Bonferroni correction, there is a trend towards significance between the S2 treatment group and the control group with a P-value of 0.028. The results of our pilot study suggest that BCCs and SCCIS can be cleared in a single treatment using a pulsed-laser in a stacked pulse setting. However, given the small sample size of this pilot study, further larger scale studies will be needed to determine statistical significance and long-term recurrence rate and to further validate these findings.

Discrimination of basal cell carcinoma from benign lesions based on extraction of ulcer features in polarized‐light dermoscopy images

Ulcers are frequently visible in magnified, cross-polarized, dermoscopy images of basal cell carcinoma. An ulcer without a history of trauma, a so-called 'atraumatic' ulcer, is an important sign of basal cell carcinoma, the most common skin cancer. Distinguishing such ulcers from similar features found in benign lesions is challenging. In this research, color and texture features of ulcers are analyzed to discriminate basal cell carcinoma from benign lesions. Ulcers in polarized-light dermoscopy images of 49 biopsy-proven basal cell carcinomas were identified and manually selected. For 153 polarized-light dermoscopy images of benign lesions, those areas that most closely mimicked ulcers were similarly selected. Fifteen measures were analyzed over the areas of ulcers and ulcer mimics. Six of those measures were texture measures: energy, variance, smoothness, skewness, uniformity, and entropy. Nine of those measures were color measures: relative measures of red, green, and blue; chromaticity of red, green, and blue; and the ratios blue-to-green, blue-to-red, and green-to-red. A back-propagation artificial neural network was able to discriminate most of the basal cell carcinoma from benign lesions, with an area under the ROC curve as high as 92.46%, using color and texture features of ulcer areas. Separation of basal cell carcinoma from benign cutaneous lesions using image analysis techniques applied to ulcers is feasible. As ulcers are a critical feature in malignant lesions, this finding may have application in the automatic detection of basal cell carcinoma.

Treatment of Basal Cell Carcinomas with Pulsed Dye Laser: A Case Series

Background. Basal cell carcinoma (BCC) is the most prevalent skin cancer. Because of its highly vascular characteristic, it is amendable to treatment with pulse dye laser (PDL). The goal of this study is to determine the safety and efficacy of PDL therapy for mostly facial BCCs. Materials and Methods. Sixteen men and thirteen women (29 total) with 39 biopsy-proven BCCs were treated with 1–4 PDL (595 nm) therapies at 2–4-week intervals. The treatment parameters included pulse energy of 15 J/cm 2, pulse length of 3 millisecond, with no dynamic cooling, and 7 mm spot size. The age of the patients was 30–90 years (mean 73 years). Response rates were evaluated by the clinical assessments with mean followup of 11 months. Results. Twenty-four patients with thirty-two tumors reached at least three months followup: 24/32 (75%) tumors with complete resolution (mean 3 treatment sessions); 5/32 (16%) tumors recurred; 3/32 (9%) tumors with incomplete responses after four treatments. Minimal side effects and discomfort were experienced by the patients with PDL therapy. Conclusion. PDL is a safe, tolerable, and moderately effective method of treating various BCCs. The ideal niche and standardized settings for PDL treatment of BCCs are yet to be determined.

The pulsed dye laser for the treatment of basal cell carcinoma

Basal cell carcinomas (BCC) have a specialized microvasculature system that can be targeted by the 585-nm pulsed dye laser (PDL) utilizing the theory of selective photothermolysis. Seven volunteers with nine well-defined, biopsy-proven BCCs, were treated with the PDL (585-nm wavelength, a single 450-μs pulse, 7-mm spot size, and 9.0 J/cm(2) energy). The lesions, along with a 4-mm border of normal skin were treated. Pain assessment was carried out immediately after the laser treatment. A deep shave biopsy with histological examination occurred 4 weeks after the laser treatment. Pain was assessed on a scale of 0 (no pain) to 10 (worst pain possible). The average patient score was 2.1 (range 1-4). On histology, 5/9 (55.6%) sites demonstrated no evidence of BCC; however, 4/9 (44.4%) sites showed residual BCC. Although the PDL was able to clear over half of the BCCs in this study, there was an unacceptably high persistence rate of 44.4%. The PDL did not achieve the clearance rate that can be attained with current standard BCC treatment modalities. At this time, we do not recommend that a single treatment with the 585-nm PDL can be used as a primary therapy for BCC.

Recurrent basal cell carcinoma following ablative laser procedures

In Korea, many patients diagnosed with basal cell carcinoma (BCC) have a history of laser ablations of undiagnosed lesions. To evaluate the clinical/pathological and surgical features of BCC developing from undiagnosed lesions following laser ablations (not full-face cosmetic ablations) and to compare them with primary BCCs. This study enrolled 359 patients with 373 biopsy-proven BCC lesions. All of the patients were treated by Mohs micrographic surgery (MMS) at the Department of Dermatology, Pusan National University Hospital from 1998 to 2008. BCC was classified by previous treatment history of lesion ablative laser: post-laser BCC vs primary BCC. We conducted a retrospective study through clinical photographs, pathology slides, and MMS sheets. Among 373 BCCs, 58 lesions (15.5%) were post-laser BCCs. The post-laser BCC group was younger (59.9 vs 65.4 years, P = .001), but had a longer disease interval until pathologic diagnosis (7.18 vs 3.33 years, P < .0001) than the primary BCC group. The post-laser BCC group had a greater frequency of the micronodular pattern (22.4% vs 10.8%, P = .01), required more stages of excision (2.69 ± 1.63 vs 2.15 ± 1.05, P < .001), and had fewer cases with one Mohs stage excision (10.3% vs 27%, P = .006) than the primary BCC group. We could not identify the type of laser used in all 58 cases; instead, we supposed that most of the patients were likely treated with the carbon dioxide laser. The results demonstrated that the post-laser BCC group had a longer disease interval to diagnosis, a more aggressive histologic pattern, and required more stages of excision in MMS than the primary BCC group.

The Efficacy of Photodynamic Diagnosis in Defining the Lateral Border Between a Tumor and a Tumor-Free Area During Mohs Micrographic Surgery

Photodynamic diagnosis (PDD) is a preoperative procedure that simplifies Mohs micrographic surgery (MMS) by allowing more accurate demarcation of neoplastic lesions involving the skin. After topical application of aminolevulinic acid (ALA), protoporphyrin IX (PpIX) is selectively induced in neoplastic cells with a high tumor-to-surrounding tissue ratio and can be visualized after excitation using a Wood's lamp. To evaluate the efficacy of PpIX fluorescence images in accurately determining the boundaries of tumors during MMS. A retrospective evaluation of biopsy-proven basal cell carcinoma (BCC; n=163), squamous cell carcinoma (SCC; n=51), and Bowen's disease (n=8) in 222 patients treated with MMS was conducted. In the PDD group, 20% ALA ointment was applied 6 hours before the surgery, and then the boundaries were mapped based on the red fluorescence of the Wood's lamp in the operating room. Each of the PDD (n=142) and non-PDD (n=80) groups was surgically staged and compared. The average number of stages was 1.59, with more in the PDD group (1.66) than the non-PDD group (1.44) (p=.05). The average number of stages was 1.77 in the PDD group and 1.50 in the non-PDD group (p=.06) for BCC, was 1.40 in the PDD group and 1.37 in the non-PDD group (p=.90) for SCC, and 1.25 in the PDD group and 1.00 in the non-PDD group (p=.36) for Bowen's disease. In previous studies, the fluorescence of induced porphyrins was effective in detecting and delineating neoplastic skin areas, but, in the present study, PDD did not support surgical efficacy during MMS.

The effect of 595 nm pulsed dye laser on superficial and nodular basal cell carcinomas

Basal cell carcinomas (BCCs) have supporting vasculature that could serve as a target for 595 nm pulsed dye laser (PDL). The objective of this study was to determine the effect of repeated PDL treatments on BCCs of superficial and nodular subtypes and of varying diameters. Twenty biopsy-proven BCCs received four 595 nm PDL treatments at 2-week intervals. The tumor and 4 mm of peripheral skin were treated using a set of previously optimized laser parameters: one pass, 15 J/cm2 energy, 3 ms pulse length, no cooling, and 7 mm spot size with 10% overlap. The treated area was excised and evaluated histologically for residual tumor. Histologic response rates of the PDL treated BCCs were compared with that of non-PDL treated, matched control tumors. Nearly all BCCs <1.5 cm in diameter (n = 12) showed complete response to four PDL treatments (91.7%; n = 11/12) versus 16.7% of controls (n = 2/12, P-value = 0.0003). BCCs > or =1.5 cm in diameter (n = 8) showed a complete response rate of 25% (n = 2/8) versus 0% of controls (n = 0/8, P-value = 0.2). Mean clinical tumor diameter of the complete responders was 1.1 cm (n = 13) versus 2.2 cm (n = 7) for incomplete responders (P-value = 0.005). Tumor histologic types among the complete responders included superficial, nodular, micronodular, and keratinizing. Incompletely responding BCCs showed a significant reduction in tumor burden after PDL treatment, with residual histologic tumor burden ranging from <1% to 29% of the original clinical tumor diameter, compared to 13-68% residual tumor burden for the corresponding controls (P-value = 0.05). PDL is an effective means of reducing tumor burden in patients with large BCCs and may be an alternative therapy in BCCs <1.5 cm in diameter.

Surgical excision of periocular basal cell carcinomas

The purpose of this study was to determine the histological clearance and clinical recurrence rates following excision of primary periocular biopsy-proven basal cell carcinomas (BCCs) in a teaching hospital in United Kingdom and compare it with other published reports. Records of consecutive patients with a biopsy proven diagnosis of primary periocular BCCs treated surgically at our hospital between 1995 and March 2003 were reviewed. Twenty seven cases (25 patients) were identified. Intra-operative frozen sections (IFS) were performed in 17 (63%) of the cases with clear margins on IFS in 16/17 (94%) of these cases. Histology revealed complete excision in 25/27 (92.5%) of cases. The results of excision of periocular BCCs in our setting particularly with IFS are comparable with other published reports. A reaudit is recommended in 5 years to allow a larger patient population with greater follow up, which would enable us to give more definitive judgment on this treatment modality.

In Vivo Real-Time Confocal Reflectance Microscopy

BACKGROUND Mohs micrographic surgery (MMS) is based on microscopically controlled excision of cutaneous neoplasms and offers the highest cure rates with maximum tissue preservation. In vivo confocal microscopy (CM) allows noninvasive optical imaging of thin sections of living skin, in its native state, in real time, with high resolution and contrast. OBJECTIVE To evaluate the feasibility of the use of in vivo CM as a surgical guide in MMS. METHODS Five patients with a biopsy-proven basal cell carcinoma (BCC) were imaged by in vivo CM on one or two sites from the clinically visible skin cancer. The first Mohs layer was then excised, and the fresh-frozen sections were correlated with the CM findings. Aluminum chloride (AlCl) 20% was applied on the Mohs defect followed by in vivo CM on one site from each lesion. A second Mohs layer was subsequently excised, and fresh-frozen sections were correlated with CM findings. RESULTS The findings of in vivo CM were confirmed by hematoxylin and eosin–stained frozen sections after excisions of the first and second Mohs layers. AlCl was found to provide an excellent contrast between BCC cells and the surrounding tissue, detected readily with both in vivo and ex vivo CM. The tumor cells with AlCl exhibited intensely bright nuclei with an excellent contrast as compared with the low-contrast dark nuclei without AlCl application. CONCLUSION In vivo CM is a potential surgical guide for MMS, and AlCl provides an excellent exogenous agent to enhance tumor contrast for CM.

In vivo real-time confocal reflectance microscopy: a noninvasive guide for Mohs micrographic surgery facilitated by aluminum chloride, an excellent contrast enhancer.

Mohs micrographic surgery (MMS) is based on microscopically controlled excision of cutaneous neoplasms and offers the highest cure rates with maximum tissue preservation. In vivo confocal microscopy (CM) allows noninvasive optical imaging of thin sections of living skin, in its native state, in real time, with high resolution and contrast. To evaluate the feasibility of the use of in vivo CM as a surgical guide in MMS. Five patients with a biopsy-proven basal cell carcinoma (BCC) were imaged by in vivo CM on one or two sites from the clinically visible skin cancer. The first Mohs layer was then excised, and the fresh-frozen sections were correlated with the CM findings. Aluminum chloride (AlCl) 20% was applied on the Mohs defect followed by in vivo CM on one site from each lesion. A second Mohs layer was subsequently excised, and fresh-frozen sections were correlated with CM findings. The findings of in vivo CM were confirmed by hematoxylin and eosin-stained frozen sections after excisions of the first and second Mohs layers. AlCl was found to provide an excellent contrast between BCC cells and the surrounding tissue, detected readily with both in vivo and ex vivo CM. The tumor cells with AlCl exhibited intensely bright nuclei with an excellent contrast as compared with the low-contrast dark nuclei without AlCl application. In vivo CM is a potential surgical guide for MMS, and AlCl provides an excellent exogenous agent to enhance tumor contrast for CM.

Basal cell carcinoma in young women: An evaluation of the association of tanning bed use and smoking

Basal cell carcinomas (BCCs) typically occur in middle-aged to elderly patients but less commonly in younger ones. In our experience, most BCCs seen in patients younger than 40 years are found in women. We evaluated 30 women with biopsy-proven BCC and 30 control patients matched for sex, age, and skin type to determine potential risk factors for this population. Tanning bed visits, pack-years of cigarette smoking, recreational sun exposure, number of blistering sunburns, and use of sunscreens were determined for both groups. Among patients with a BCC, the histologic type of tumor, site of involvement, method of treatment, follow-up period, incidence of recurrence, and presence of actinic keratoses were also evaluated. Patients with a BCC had a statistically greater number of pack years of smoking (P = .045), and a greater percentage of these women had experienced blistering sunburns (P = .028). Although women with a BCC had, on average, almost twice as many tanning salon visits (152.2 vs 83.1), this was not statistically significant. Sunscreen use and amount of recreational ultraviolet light exposure were essentially equal between the two groups. Young women with a BCC are more likely to have a past or current history of cigarette smoking and blistering sunburns. Repeated exposure to tanning beds may also be a contributory factor. (J Am Acad Dermatol 2002;46:709-9.)

A comparison of touch imprint cytology and Mohs frozen-section histology in the evaluation of Mohs micrographic surgical margins

Background: Touch imprint cytology (TIC) is commonly used in the diagnosis of tumors and has been applied to margin analysis of breast lumpectomy specimens with good success.Objective: Our purpose was to determine the diagnostic adequacy of TIC for identifying positive and negative Mohs surgical margins for basal cell carcinoma (BCC) excisions, compared with the “gold” standard, Mohs tangential sectioning.Methods: Fifty-eight patients undergoing 69 Mohs micrographic surgical procedures for biopsy-proven BCC were included in this study between October 1998 and January 1999. Patients were excluded if the neoplasms were of another histologic type, including BCCs with squamous features. One hundred sixty-six touch imprint slides were prepared from 166 fragments of skin tissue excised during MMS. Touch imprint slides were evaluated blindly and independently by two pathologists, one of whom was also a cytopathologist. The slides were diagnosed as positive for tumor, negative for tumor, or, rarely, atypical but suspect for tumor. Discrepancies between the pathologists' interpretations were re-evaluated with the use of a two-headed microscope and a consensus was reached. After all cytologic interpretation was completed, the results were compared with the histologic diagnosis rendered for each fragment of tissue by the Mohs surgeon.Results: The prevalence of a positive margin by histologic confirmation was 55% overall, 60% for recurrent or sclerosing lesions, and 51% for nonsclerosing or recurrent lesions. The overall accuracy of this technique in identifying true positive and true negative margins was 71%. The sensitivity of TIC for identifying a positive margin was approximately 50% for all BCC types. The specificity was approximately 90% for all BCC types.Conclusion: TIC is inadequate for identifying positive margins compared with the “gold” standard, MMS. (J Am Acad Dermatol 2001;44:660-4.)

Mohs micrographic surgery referral patterns: the University of Missouri experience.

Mohs micrographic surgery (MMS) provides a higher cure rate for nonmelanoma skin cancer (NMSC) than other forms of therapy. The American Academy of Dermatology has published recommended guidelines for MMS referral. However, factors other than the location, size, and type of NMSC may often affect the referral process. To tabulate and analyze the rates of referral of NMSC for MMS by the dermatology clinics within the University of Missouri system. Data obtained for every biopsy-proven basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) diagnosed at each of our four dermatology clinics during the 3-year period of October 1993-September 1996 were cross-referenced with our Mohs surgery clinic logbook to identify which patients had been referred for MMS. During the study period, 19.2% of NMSC patients diagnosed were referred for MMS. However, there was significant disparity in referral rates among our four clinics. When the skewed data from our Veterans Administration Hospital clinic were discounted, the overall referral rate from the other clinics was found to be 30.8%. Our finding of a 30.8% referral rate of NMSC for MMS (27. 4% for SCC and 32.9% for BCC) within our university dermatology system is similar to the rates found in previous studies by the Mayo Clinic and Brooke Army Medical Center. MMS referral patterns are affected by many factors besides whether the NMSC meets MMS criteria, including the preference of each individual referring physician, patient, and involved insurance carrier.

A Variation of Composite Grafting for Reconstruction of Full-Thickness Nasal Alar Defects

REPORT OF A CASE A 72-year-old man presented with a biopsy-proven basal cell carcinoma on the right alar rim. Following resection of the tumor, the patient had a 0.9×0.4-cm full-thickness defect of the alar rim ( Figure 1 ). THERAPEUTIC CHALLENGE Removing a malignancy from the alar rim of the nose often results in destruction of the skin, the underlying cartilage, and nasal mucosal lining. These full-thickness defects are difficult to repair because of the need to replace structural support, skin, and nasal lining. SOLUTION This skin and fat variation of a composite graft uses a rectangular-shaped skin and fat graft from the inner upper arm, supraclavicular area, or the earlobe. The graft is removed from the donor site and minimally defatted to approximate the contour of the alar rim. The graft is sutured into the mucosal surface of the defect with 6-0 fast-absorbing chromic gut with the epidermis forming the ''new''

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.