Conventional Excision Research Articles

782 Mohs Micrographic Surgery and Patient Satisfaction in Skin Cancer; a Systematic Review

Abstract Aim Mohs micrographic surgery (MMS) has revolutionised the treatment of skin cancer. It is commonly considered as gold standard, with good cosmesis effect for patients. Patient perception plays an important outcome in skin cancers. This systematic review aims to explore evidence of post-operative patient reported satisfaction after MMS. Method We conducted a systematic search using 10 databases including OVID Medline(R), Pubmed, Cochrane (CENTRAL) of all study types between 2000–2021. Studies were appraised for bias and data was tabulated with a narrative synthesis. Results The literature search generated 1068 studies. After removing duplicates, 728 were screened and 37 underwent full-text review. Thirteen relevant studies comprising 3046 patients undergoing MMS were included. Patients undergoing MMS expressed higher anxiety pre-operatively compared to conventional excision surgery but post-operatively Mohs was associated with a significantly higher skin cancer index (SCI) score. This was both in the short- and long-term follow up. Patients showed overall very high satisfaction with the technical quality, irrespective of reconstructive complexity or the surgeon's expertise. Patients’ main concerns post-operatively included scar skin thickness, colour, and irregularity. Higher satisfaction was observed in those with better pre-operative quality of life (QOL) including skin quality, co-morbidities, mental health, and age. Conclusion Overall patient satisfaction after MMS is high and supports transition to this surgical technique within skin cancer surgery. Higher satisfaction rates are observed in patients with better pre-operative QOL. Post-operatively patients are most concerned of scar thickness, colour, and irregularity. These factors should guide surgeons’ decision-making when aiming to maximise patient satisfaction.

Long-term outcomes after extra-levator versus conventional abdominoperineal excision for low rectal cancer

PurposeExtralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is achieved in patients undergoing ELAPE, the long-term benefits have not been established. In this study we evaluated the safety, pathological and survival outcomes in rectal cancer patients who underwent ELAPE and APE.MethodsOne hundred fourteen patients were enrolled, including 68 in the ELAPE group and 46 in the APE group at the Beijing Chaoyang Hospital, Capital Medical University from January 2011 to November 2020. The baseline characteristics, overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS) were calculated and compared between the two groups.ResultsDemographics and tumor stage were comparable between the two groups. The 5-year PFS (67.2% versus 38.6%, log-rank P = 0.008) were significantly improved in the ELAPE group compared to the APE group, and the survival advantage was especially reflected in patients with pT3 tumors, positive lymph nodes or even those who have not received neoadjuvant chemoradiotherapy. Multivariate analysis showed that APE was an independent risk factor for OS (hazard ratio 3.000, 95% confidence interval 1.171 to 4.970, P = 0.004) and PFS (hazard ratio 2.730, 95% confidence interval 1.506 to 4.984, P = 0.001).Conclusion Compared with APE, ELAPE improved long-term outcomes for low rectal cancer patients, especially among patients with pT3 tumors, positive lymph nodes or those without neoadjuvant chemoradiotherapy.

Management and Treatment of External Hemorrhoidal Thrombosis.

BackgroundExternal hemorrhoidal thrombosis (EHT) is a common complication of hemorrhoidal disease. This condition causes extreme pain, likely resulting from internal anal sphincter hypertonicity, which traps the hemorrhoids below the dentate line thus leading to congestion and swelling. The choice of treatment remains controversial and both conservative and surgical options have been proposed in the last decades.MethodsThis mini-review focuses on the most relevant studies found in literature evaluating conservative and surgical management of EHT. Special conditions such as pregnancy and EHT in elderly patients have been considered.ResultsTraditionally, symptoms duration represents the discriminant in the choice between medical and surgical treatment. Several Coloproctological Societies considered conservative treatment as the first-line approach to EHT and a variety of options have been proposed: wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection and topical application of 0.2% glyceryl trinitrate. Meanwhile, different surgical treatments are recommended when EHT fails to respond to conservative management or when symptoms onset falls within the last 48–72 h: drainage with radial incision, conventional excision, excision under local anesthesia and stapled technique.ConclusionThe management and treatment of EHT is still controversial since no specific guidelines have been published. Both medical and surgical treatment have been proven effective but randomized clinical trials and structured consensus-based guidelines are warranted.

Basal Cell Carcinoma Excision Guided by Dermoscopy: A Retrospective Study in Macau

Objective: Dermoscopic evaluation of tumor margins may help to accurately detect lateral borders before surgical excision. The purpose of this study was to comprehensively evaluate the usefulness of dermoscopically detecting basal cell carcinoma tumor margins before surgical excision. Methods: The authors retrospectively analyzed the outcomes of 60 basal cell carcinomas that were excised after undergoing dermoscopic evaluation of the margins from 2016 to 2018 in a single center in Macau SAR, China. Descriptive statistical analysis was carried out by using frequencies and percentages. Results: All treated tumors were completely excised, although five had safety margins of <1 mm. No re-excisions were performed and during a medium follow-up period of 31 months, none of the 60 tumors showed any evidence of recurrence. Conclusions: Our data suggest that the preoperative dermoscopic evaluation of tumor margins increases the chances of successful and complete tumor excision, while preserving healthy adjacent tissue. Further studies comparing dermoscopy-assisted versus conventional excision are needed to better evaluate the value of this technique.

Comparative Study between Stapled and Excision Haemorrhoidectomy for the Treatment of Haemorrhoids

Introduction: There are different techniques for the treatment of hemorrhoidal diseases. Stapled haemrrhoidectomy is one of the modern technique which has shown little postoperative pain, less hospital stay and early go back to work. This study has been done to compare stapled haemorrhoidectomy with conventional excision hemorrhoidectomy. Methodology: The study was done in the Department of Surgery, Women’s Medical College Hospital and different private clinics in Sylhet District, from July 2016 to December 2017.A total of 42 patients were selected fulfilling the inclusion criteria to the stapled (n=21) and openexcision (n=21) group .Those patients having any other associated anal pathology like fistula, fissure, abscess and neoplasm were excluded from the study. Lithotomy position and spinal anesthesia were chosen for all the patients. Both the procedures were evaluated on the basis of total operative time, pain scores, complications, hospital stay and go back to work. Results: The mean age of patients was similar in both groups , that is 45.02 years (SD 12.30) in the stapled group and 47.54 years (SD13.50) in the open excision group.Male patients were more affected in both the groups ( 80.9%% in the stapled and 85.7% in the open group). Operative time was significantly less in the stapled group than in the open group (P .oo1). The blood loss, pain scores and requirement of analgesics was significantly less in the stapled group (P o.oo1). Average hospital stay was 2.20 days (SD 0.62) ) in the stapled group and 3.25 days (SD 1.01 ) days in the open group( P 0.01). Patients of the stapled group returned to work earlier (8.18days [SD2.24] as compared with 18.87 days [SD5.34] in the open group [P 0.001 ]). Maximum follow-up period was 6 months. Conclusions: Hemorrhoidectomy by stapled procedure is a safe and effective procedure for the treatment of grade II and grade III hemorrhoidaldieases. Early discharge and return to work are possible by this procedure. Furthermore, complications are as like as that of the open technique.

Treatment of Haemorrhoidal Disease by Laser Haemorrhoidoplasty at Dakar Preliminary Study of 21 Patients.

Background:Surgical treatment of haemorrhoidal disease by laser haemorrhoidoplasty is a minimally invasive procedure that facilitates the postoperative course. Due to less aggression on the anoderm and the anal canal mucosa, it causes less significant postoperative pain and low morbidity compared with conventional excision according to the Milligan–Morgan or Fergusson procedure. We report, through a preliminary study, our data on laser haemorrhoidoplasty and discuss the indications and results.Materials and Methods:This is a descriptive prospective study carried out on 21 patients operated on for haemorrhoidal disease by laser haemorrhoidoplasty with or without mucopexy.Results:The series was composed of 17 men and 4 women with a male/female ratio of 4.25:1. The average age was 39.6 years with a range of 27–62 years. The symptomatology was rectal bleeding in 16 cases (76%) and anal swelling in 18 cases (85.7%). These include grade 2 haemorrhoids in 2 cases (9.5%), grade 3 in 12 cases (57%), and grade 4 in 7 cases (33%). It was associated with an anal fissure in four cases (19%) and an anal fistula in three cases (14.2%). Mucopexy and laser coagulation were performed therapeutically in 13 cases (61.9%) and laser coagulation without mucopexy was performed in 8 cases (38%). The energy delivered was on average 1488 or 496 J per pile. It was associated with skin tag excision in 18 cases (85.7%), fissurectomy, sphincterotomy, anoplasty in 4 cases (19.2%), and fistulectomy for low anal fistula in 2 cases (9.5%). Piles retraction was judged sufficient in 17 patients (81%). The postoperative course was simple with no notable complaints in 16 patients (76%). Complications consisted of minimal bleeding in six cases (28%), significant bleeding in two cases with readmission, residual skin tag in six cases (28.5%), and subcutaneous fistula in two cases (9.5%). No recurrence of the symptoms of the haemorrhoidal disease was noted.Conclusion:Laser haemorrhoidoplasty is a minimally invasive alternative for the treatment of haemorrhoidal disease, especially for grade 2 and 3 haemorrhoids without major prolapse. Postoperative pain is minimal, and the risk of stenosis or incontinence is almost non-existent.

Randomized comparative study in the treatment of oral leucoplakia with laser and conventional surgery

Objective: High-energy lasers are used as an alternative to surgical treatment of potentially malignant disorders in the oral cavity. The present article aims to make a prospective randomised comparative clinical assessment of the effect of laser surgery and conventional surgery in the treatment of oral leukoplakia (OL). Materials and methods: In the study were included 89 patients with histologically confirmed oral leukoplakia lesions. Laser excision of the lesions using Er YAG laser was performed in 36 of the patients, while standard surgical excision was used in 53 of the cases. Following clinical assessment comparing the two treatment methods was conducted based on: pain, wound healing, infection and recurrence of the lesions. Results: A statistically significant difference between two groups according pain in the postoperative period was found. Patients treated with laser ablation experienced far less pain than those treated with surgical excision. The healing time was significantly faster in the group treated with Er YAG laser, and regarding the occurrence of postoperative infections, the results of the two methods did not differ significantly. Recurrence was observed earlier in the group treated with laser ablation, but the levels align over a longer period of time. Conclusion: Er YAG laser ablation is a contemporary method for the treatment of oral leukoplakia without dysplasia, providing similar success, compared to conventional surgical excision, with less postoperative discomfort for the patients. Keywords Er YAG laser; Leukoplakia; Potentially malignant disorders.

Machine-learning algorithm to predict multidisciplinary team treatment recommendations in the management of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common human cancer. Facial BCCs most commonly occur on the nose and the management of these lesions is particularly complex, given the functional and complex implications of treatment. Multidisciplinary team (MDT) meetings are routinely held to integrate expertise from dermatologists, surgeons, oncologists, radiologists, pathologists and allied health professionals. The aim of this research was to develop a supervised machine-learning algorithm to predict MDT recommendations for nasal BCC to potentially reduce MDT caseload, provide automatic decision support and permit data audit in a health service context. The study population included all consecutive patients who were discussed at skin cancer-specialised MDT (SSMDT) with a diagnosis of nasal BCC between January 1, 2015 and December 31, 2015. We conducted analyses for gender, age, anatomical location, histological subtype, tumour size, tumour recurrence, anticoagulation, pacemaker, immunosuppressants and therapeutic modalities (Mohs surgery, conventional excision or radiotherapy). We used S-statistic computing language to develop a supervised machine-learning algorithm. We found that 37.5% of patients could be reliably predicted to be triaged to Mohs micrographic surgery (MMS), based on tumour location and age. Similarly, the choice of conventional treatment (surgical excision or radiotherapy) by the MDT could be reliably predicted based on the patient's age, tumour phenotype and lesion size. Accordingly, the algorithm reliably predicted the MDT decision outcome of 45.1% of nasal BCCs. Our study suggests that the machine-learning approach is a potentially useful tool for predicting MDT decisions for MMS vs conventional surgery or radiotherapy for a significant group of patients. We suggest that utilising this algorithm gives the MDT more time to consider more complex patients, where multiple factors, including recurrence, financial costs and cosmetic outcome, contribute to the final decision, but cannot be reliably predicted to determine that outcome. This approach has the potential to reduce the burden and improve the efficiency of the specialist skin MDT and, in turn, improve patient care, reduce waiting times and reduce the financial burden. Such an algorithm would need to be updated regularly to take into account any changes in patient referral patterns, treatment options or local clinical expertise. lPLAS_20-21_A08.

Risk Factors for Infection After Minor Dermatologic Procedures: A Case-Control Study.

There are limited published data regarding the incidence and risk factors for infection after minor dermatologic procedures, such as skin biopsy, shave, and curettage. Prior studies of infection risk after dermatologic procedures have often not specified the method of preparation of local anesthetic. To assess the incidence and risk factors for infection after minor procedures performed in a general dermatology clinic using buffered lidocaine prepared in office. In this retrospective case-control study, the medical record was searched for cases of infection after skin biopsies, shaves, conventional excisions, and destructions performed in a general dermatology clinic over a 4-year period. Patient and procedure characteristics were compared with uninfected controls. Of 9,031 procedures performed during the study period, there were 34 infections (0.4%). The odds of infection for procedures on the arm and leg were 5.29 and 9.28 times higher, respectively, than those on the head/neck. There was no significant effect of age, sex, smoking, immunosuppression, diabetes, or anticoagulation. The incidence of infection is low after minor dermatologic procedures performed with local anesthesia using buffered lidocaine prepared in office. There is a higher risk of infection on the arm and leg compared with the head and neck.

Comparison of Effectiveness and Associated Complications Between Conventional Subdermal Excision and Hydrosurgery (VersajetTM) for Osmidrosis.

Recent studies have shown hydrosurgery (Versajet TM II) is a simple and effective tool with reduced complications in surgical treatment of osmidrosis. Since then, hydrosurgery has been widely used for osmidrosis. However, we have experienced that some complications often occur in patients treated with hydrosurgery. We hypothesized that using a hydrosurgery could lead to excessive resection of the tightly attached apocrine glands and thus more complications. We aimed at evaluating the effectiveness and associated complications of the hydrosurgery method for osmidrosis were compared with those of conventional methods with two parallel incisions. We retrospectively analyzed 31 and 16 patients who underwent conventional and hydrosurgery methods, respectively, for osmidrosis from 2010 to 2020. Two parallel long incisions were identical in both groups. Early complications (hematoma, seroma, wound dehiscence, skin necrosis, revision, scar contracture), late complications (scar, pigmentation, comedones/milia, and sebaceous cysts), and effectiveness (subjective satisfaction, malodor elimination, reduced hair growth, and sweating elimination) were evaluated. Skin necrosis was significantly more frequent in the hydrosurgery group than in the conventional group (p = 0.036). No other significant differences were found between the two groups in terms of other complications and effectiveness. As a result of comparing effectiveness, subjective satisfaction (p = 0.306), malodor elimination (p = 1.000), reduced hair growth (p=1.000), and sweating elimination (p = 0.742) did not show any significant difference between the two groups. Osmidrosis treatment with the use of VERSAJET™ Hydrosurgery System yielded similar and satisfactory results as the conventional subdermal excision method. The incidence of skin necrosis was higher in the hydrosurgery group than in the conventional group with two parallel incisions. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Predictors of surgical treatment burden, outcomes, and overall survival in older adults with basal cell carcinoma: Results from the prospective, multicenter BATOA cohort

Incorporating patient-related factors associated with treatment outcomes could improve personalized care in older patients with basal cell carcinoma (BCC). To evaluate and identify predictors of treatment burden, treatment outcomes, and overall survival in patients aged ≥70years, surgically treated for BCC in the head and neck area. The data from the prospective, multicenter Basal Cell Carcinoma Treatment in Older Adults (BATOA) cohort study were extracted to evaluate the experienced treatment burden (visual analog scale, 0-10cm; lower scores indicating higher treatment burden), treatment outcomes, and mortality. A total of 539 patients were included (median age, 78years). The patients experienced a low overall treatment burden (median, 8.6) and good cosmetic results. The predictors of higher treatment burden were instrumental activities of daily living (iADL) dependency, female sex, complications, larger tumor diameter, and polypharmacy. Thirty-five patients (6.5%) died (none of the deaths were due to BCC) within the follow-up period; the predictors of mortality were increasing comorbidity index and iADL dependency. No difference in these outcomes was seen between Mohs micrographic surgery and conventional excision after correction for covariates. Age was not significantly associated with any outcome. A selection bias may exist owing to the observational design. BCC management decisions based on chronological age alone should be avoided, whereas more attention is recommended for patient-related factors. Based on these data, early BCC intervention isbeneficial for robust and fit patients or those experiencing symptoms.

Basal Cell Carcinoma of the Nose

The purpose of this study of 81 patients with basal cell carcinoma (BCC) of the nose was to present the oncological and cosmetic results of surgical treatment and compare these results with those of other possible treatments.We report a series of 81 cases of histologically proven BCC of the nose located chiefly on the alae nasi and on the lower end of this organ; 42 p. 100 of the tumors had previously been treated and had recurred. The patients' mean age was 63 years, and the shortest follow-up was 3 years. Excision of the tumor under simple or reinforced local anaesthesia was complete in 88 p. 100 of the cases, incomplete or borderline in 12 p. 100 and systematically repeated. Extemporaneous histological examination was performed in 18 p. 100 of the cases. The operative lesion was repaired with a graft or a flap. There was no postsurgical treatment.The recurrence rate was 4 p. 100 with a minimum follow-up of 3 years. The cosmetic result was good in 78 p. 100 of the patients.Numerous treatments have been used against BCC of the nose, the results, advantages and disadvantages of each of these treatments are given below: 1. Cryosurgery. The problem with this method is that it is relatively difficult to perform and requires reliable operators. The cure rate is similar to that of other treatments. 2. Chemotherapy is not frequently used. 3. Electrocoagulation. Contrary to the conventional excision, this method precludes all histological controls, and the common idea of good oncological results is now being revised. 4. Radiotherapy. The recurrence rate varies from 7 to 11.8 p. 100 with fair cosmetic results. It requires numerous sessions, cannot be repeated in case of recurrence and complicates the surgical treatment. In addition, there is a long-term risk of radiodystrophy. 5. Curietherapy by local implantation of 192Iridium has a recurrence rate of 2.5 to 7 p. 100. This treatment requires hospitalization and is costly. It is indicated in cases of complex surgery, difficult conventional radiotherapy and above all, sclerodermatous BCC. 6. Surgery has a recurrence rate which varies from 3.7 to 12.6 p. 100. Recurrences are due to insufficient excision, and this underlines the value of histological control which can be done only at surgery. It is a rapid and ambulatory treatment, usually performed under local anaesthesia. The cosmetic result is good (85 to 90 p. 100) and the patients must be made aware of this preoperatively with some degree of reliability, depending on age, location, size of BCC and on the surgical technique utilized.Surgical treatment of nasal BCC is safe, effective and rapid, with good oncological and cosmetic results, and it has many advantages over the other treatments.

Clinical factors impacting clear margins of primary melanoma in situ with conventional excision in a retrospective cohort

To the Editor: There is a lack of consensus on the optimal surgical margins for the treatment of melanoma in situ (MIS). The current National Comprehensive Cancer Network guidelines recommend clinical margins of 0.5-1.0 cm for MIS, but acknowledge that the margins may be modified for anatomic constraints.1 Several studies using Mohs micrographic surgery or staged excision have reported variable rates of subclinical extension, with 19-59% of MIS extending beyond 0.5-0.6 cm margins.2-4 The purpose of our study was to evaluate the rate and clinical risk factors associated with clear margins after conventional excision of primary MIS.

Treatment of cutaneous basal cell carcinoma with combined laser extirpation and methyl aminolevulinic acid: five-year success rates.

Basal cell carcinoma is the most common cancer. Excisional surgery is associated with a high clearance rate, at the expense of significant functional and aesthetic morbidity, especially within the T-zone or for extensive lesions. We report five-year follow-up outcomes for carbon dioxide laser extirpation of cutaneous basal cell carcinoma, assisted by immediate methyl aminolevulinate photodynamic therapy and cost-benefit considerations. Retrospective cohort database analysis of adult patients with biopsy-proven primary cutaneous basal cell carcinoma, completing five years of follow-up. Direct per-lesion cost was compared with conventional wide local excision. Patients with morphoeic basal cell carcinoma were excluded. Treated lesions were up to 1% total body surface area and up to 3.8mm (1.38 ± 0.695cm, mean ± standard deviation) in biopsy-proven depth. At the five-year follow-up mark, 93.6% of treated areas remained free of recurrence. Nodular basal cell carcinoma was the most common subtype (41.5%). A mean tumour depth greater than 2 ± 0.872mm was significantly associated with recurrence (Mann-Whitney, p = 0.0487). For a service delivered through the NHS at 2015 prices, we report a 43% saving, equating to a saving of £235 per basal cell carcinoma or a national annualised saving of £70 million by 2025 for the NHS. Our results suggest that CO2-assisted photodynamic therapy is non-inferior to excision but may offer better functional and cosmetic preservation at a fraction of the direct like for like cost of operative surgery. Investigation of this method by randomised controlled methodology is warranted.

Practice Variation in Skin Cancer Treatment and Follow-Up Care: A Dutch Claims Database Analysis

Background: Quality indicators are used to benchmark and subsequently improve quality of healthcare. However, defining good quality indicators and applying them to high-volume care such as skin cancer is not always feasible. Objectives: To determine whether claims data could be used to benchmark high-volume skin cancer care and to assess clinical practice variation. Methods: All skin cancer care-related claims in dermatology in 2016 were extracted from a nationwide claims database (Vektis) in the Netherlands. Results: For over 220,000 patients, a skin cancer diagnosis-related group was reimbursed in 124 healthcare centres. Conventional excision reflected 75% of treatments for skin cancer but showed large variation between practices. Large practice variation was also found for 5-fluorouracil and imiquimod creams. The practice variation of Mohs micrographic surgery and photodynamic therapy was low under the 75th percentile, but outliers at the 100th percentile were detected, which indicates that few centres performed these therapies far more often than average. On average, patients received 1.8 follow-up visits in 2016. Conclusions: Claims data demonstrated large practice variation in treatments and follow-up visits of skin cancer and may be a valid and feasible data set to extract quality indicators. The next step is to investigate whether detected practice variation is unwarranted and if a reduction improves quality and efficiency of care.

Hydroceles of the Canal of Nuck in Adults-Diagnostic, Treatment and Results of a Rare Condition in Females.

Nuck’s hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck’s canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck’s hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck’s hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon’s skills. If inguinal channel has been widened by the presence of a Nuck’s hydrocele, a mesh plasty, as performed in hernia surgery, should be considered.

Defining the Histopathological Term Atypical Intraepidermal Melanocytic Proliferation: A Retrospective Cross-Sectional Study.

Atypical intraepidermal melanocytic proliferation (AIMP) is a general term assigned to melanocytic proliferations of uncertain biological potential when a definitive histopathological diagnosis cannot be achieved. There are few data available describing the possibility of malignancy of AIMP, or ways to further define diagnosis. To determine the rate of diagnostic change of AIMP to melanoma or melanoma in situ (MIS) after conventional excision. In addition, to determine the role of immunohistochemistry (IHC) in defining AIMP biopsies. Retrospective cross-sectional, single-center review of biopsies with a diagnosis of AIMP with a follow-up conventional excision from 2012-2016 was performed. In a separate analysis, a search was performed for AIMP biopsied lesions in which IHC was subsequently performed. The rate of diagnostic change of AIMP to MIS was 4.8% (8/167) after excision. Punch biopsy was a risk factor for diagnostic change to MIS (odds ratio 12.94, confidence interval 2.56-65.38, P = 0.008). The rate of diagnostic change of AIMP biopsies after examining with IHC was 21.3% (34/160) to MIS and 4.4% (7/160) to melanoma. The possibility of malignancy of AIMP lesions must be taken into consideration when counseling patients and when planning treatment options. IHC is a useful tool and should be used in the evaluation of AIMP specimens.

Solitary spinal metastasis of renal cell carcinoma and en-bloc resection-A case report

Renal Cell Carcinoma is a challenging condition for clinicians because of its poor response to radiotherapy, chemotherapy and even immunotherapy. Spine is the second most common site of metastasis and is also an indicator of poor prognosis. There is a significant dilemma for brain and spine surgeons about when to undergo aggressive surgical treatment, such as en-bloc resection of oligo-spine metastasis compared to conventional tumor excision by curettage. Here, we report a case of 60-year old female, a diagnosed case of renal cell carcinoma who had undergone right sided nephrectomy (with adrenalectomy) 5 years ago. She presented with history of pain over upper back. MRI revealed metastatic lesion over the thoracic T-7 vertebra. She underwent en-block total vertebral resection and reconstruction with titanium cage and pedicle screw fixation of the T-7 vertebra which healed with good results.

Pleomorphic dermal sarcoma: a retrospective study of 16 cases in a dermato-oncology centre and a review of the literature.

Relatively little is known about the true aggressive potential of pleomorphic dermal sarcoma (PDS) or optimal management strategies. To describe the outcomes of 16 cases of PDS treated at our hospital (14 with modified Mohs micrographic surgery [M-MMS] and two with conventional surgery) and establish an adequate plan for management. We reviewed 16 PDS cases treated at our hospital between October 2007 and June 2019 and compared our results with the available evidence. In total, 69% of cases had recurred after initial conventional surgery, M-MMS led to local disease control in 83% of cases, and 19% of patients developed metastasis. Combining all published PDS cases with ours, we calculated an overall metastasis rate of 12%, and an overall recurrence rate of 35% after conventional surgery and 17% after M-MMS. PDS is more aggressive than previously estimated, with an overall metastatic rate of 12%. Despite high recurrence rates with previous conventional surgery (69%), M-MMS achieved a good rate of local disease control (83%). Given the potential aggressivity of PDS and the importance of clear surgical margins, M-MMS appears to be more adequate than conventional excision. Staging studies and close monitoring are warranted in PDS patients, for which we propose a management algorithm.

Tratamento de hemangioma em mucosa labial por escleroterapia – Relato de caso clínico

O hemangioma é uma lesão vascular, podendo representar-se como uma neoplasia benigna dos vasos sanguíneos, relativamente rara na cavidade oral, podendo causar prejuízo estético e funcional a depender da sua região. Sua localização mais frequente é o lábio superior, mas pode ocorrer em outras regiões, como língua, mucosa jugal e palato. O seu tratamento depende, principalmente, do correto diagnóstico da lesão, bem como da localização anatômica da mesma e pode ser realizado com esclerose química, crioterapia, laserterapia, excisão cirúrgica convencional, embolia arterial ou eletrocautério. O objetivo desse trabalho é apresentar um caso clínico, de um paciente do gênero masculino, 63 anos de idade, apresentando hemangioma desde os 16 anos de idade, com recidiva há dez anos em lábio superior. Ao exame físico intrabucal observou-se uma lesão tumoral, de coloração arroxeada, base séssil, assintomática, com limites bem definidos, medindo aproximadamente 4 cm em seu maior diâmetro, localizada na mucosa labial superior. Foi realizada manobra de vitropressão que apresentou um esmaecimento da coloração arroxeada, permitindo diagnóstico clínico de hemangioma. O tratamento proposto foi a esclerose terapêutica com cinco aplicações de oleato de monoetanolamina 5%, considerando as características clínicas e os métodos de diagnóstico desta lesão. Por meio de um diagnóstico preciso e uma conduta terapêutica adequada, o caso apresenta-se com um acompanhamento de dois meses com significativa redução até o momento, e com um resultado estético funcional satisfatório. Conclui-se que a eficácia da escleroterapia realizada com o uso do oleato de monoetanolamina 5% é uma alternativa terapêutica segura.