Partial Biopsy Research Articles

Incomplete Excision Rate for Lentigo Maligna and Associated Risk Factors.

Standard treatment for lentigo maligna (LM) is surgical excision, yet insights into the frequency of and risk factors for incomplete excisions remain limited. The primary objectives were to assess the incomplete excision rate (IER) in primary LM and to explore potential risk factors for incomplete excisions. A retrospective analysis was conducted encompassing consecutive histopathologically confirmed LMs from 2014-2020. Descriptive statistics were used for LM characteristics and IER, while uni- and multivariate analyses were used for calculating risk factors. The study included 395 LMs with an IER of 16.7% (n = 66). Risk factors for higher incomplete excision rates included: head and neck lesions (p = 0.0014), clinical excision margins < 5 mm (p = 0.040), and utilization of preoperative partial biopsies (p = 0.023). Plastic surgeons had higher IERs than dermatologists (p = 0.036). Lesion diameter (p = 0.20) and surgeon experience (p = 0.20) showed no associations with incomplete excisions, yet LMs with a diameter ≥ 20 mm exhibited higher incomplete excision rates (23.2%) compared witho those < 10 mm (12.9%). LMs should be excised with at least 5-mm clinical margins, especially in the head and neck area. LMs ≥ 20 mm may be more surgically challenging. High-er incomplete excision rates associated with the use of preoperative biopsies and/or plastic surgeons may reflect challenging anatomical locations, larger lesion diameter, and/or ill-defined borders.

Predictors of Local Invasion in Infiltrative Basal Cell Carcinoma: Tumour Budding Outperforms the WHO Subtyping.

Tumour budding (TB) correlates with increased local invasion in various neoplasms. Certain basal cell carcinomas (BCCs) exhibit local aggressiveness. Detecting adverse prognostic factors in partial biopsies could aid in identifying cases with heightened local risk. The absolute number of TB (≤ 3 tumour cells) in excision specimens of 271 infiltrative BCCs (0: absent; 1: 1-2 foci; 2: ≥ 3 foci; 3: ≥ 10 foci), the histopathological subtype and depth of infiltration, perineural invasion, and other histological features were evaluated. A significant correlation was found between TB and both depth of infiltration (rho 0.445, p < 0.001) and perineural invasion (p = 0.009). In the multivariate analysis of depth and perineural invasion (multiple regression, stepwise), TB was identified as a significant covariate together with diameter, inflammation, and perineural invasion for the former, and depth for the latter. Conversely, no correlation existed between the WHO histological subtypes (infiltrating, sclerosing, and micronodular), and depth of infiltration or perineural invasion. This study demonstrates the value of TB as a biomarker for local invasiveness in BCC. In routine practice, a count of ≥ 3 TB foci in lesions incompletely excised or with narrow tumour-free surgical margins would be a straightforward and reproducible method to guide BCC treatment.

Seven Plus One Steps to Assess Pigmented Nail Bands (Melanonychia Striata Longitudinalis).

Melanonychia striata longitudinalis might involve one or more fingers and/or toes and might result from several different causes, including benign and malignant tumors, trauma, infections, and activation of melanocytes that might be reactive or related to the pigmentary trait, drugs and some rare syndromes. This broad differential diagnosis renders the clinical assessment of melanonychia striata particularly challenging. Nail matrix melanoma is relatively rare, occurs almost always in adults involves more frequently the first toe or thumb. The most common nail unit cancer, squamous cell carcinoma / Bowen disease (SCC) of the nail matrix is seldom pigmented. Histopathologic examination remains the gold standard for melanoma and SCC diagnosis, but excisional or partial biopsies from the nail matrix require training and is not routinely performed by the majority of clinicians. Furthermore, the histopathologic evaluation of melanocytic lesions of the nail matrix is particularly challenging, since early melanoma has only bland histopathologic alterations. Dermatoscopy of the nail plate and its free edge significantly improves the clinical diagnosis, since specific patterns have been associated to each one of the causes of melanonychia. Based on knowledge generated and published in the last decades, we propose herein a stepwise diagnostic approach for melanonychia striata longitudinalis: 1) Hemorrhage first 2) Age matters 3) Number of nails matters 4) Free edge matters 5) Brown or gray? 6) Size matters 7) Regular or irregular and, finally, "follow back".

MAXILLARY METASTASIS OF BREAST CANCER

Metastatic tumor in the oral cavity represents approximately 1% of all oral tumors and usually affects soft tissues or jawbones. A 45-year-old female sought an oral medicine service due to a painful well-defined ulcerated lesion with oroantral communication in the hard palate. The lesion measured 1.5 × 1.0cm and had a 21-day history. The patient reported headache, dysphagia, and left breast sectorectomy three years earlier for treating triple-negative breast cancer positive for BRCA2 mutation. The diagnostic hypotheses included metastatic lesion of breast adenocarcinoma, necrotizing sialometaplasia, and malignant salivary gland tumor. A partial biopsy was performed and the histopathological and immunohistochemistry analyses confirmed the mammary origin of the tumor. The patient was referred to the medical team for managing the recurrence of the disease. Further evaluation showed metastatic lesions in the skin, lungs, bones, liver and brain. Considering the disease was disseminated and uncontrolled, the patient was referred to palliative care. Metastatic tumor in the oral cavity represents approximately 1% of all oral tumors and usually affects soft tissues or jawbones. A 45-year-old female sought an oral medicine service due to a painful well-defined ulcerated lesion with oroantral communication in the hard palate. The lesion measured 1.5 × 1.0cm and had a 21-day history. The patient reported headache, dysphagia, and left breast sectorectomy three years earlier for treating triple-negative breast cancer positive for BRCA2 mutation. The diagnostic hypotheses included metastatic lesion of breast adenocarcinoma, necrotizing sialometaplasia, and malignant salivary gland tumor. A partial biopsy was performed and the histopathological and immunohistochemistry analyses confirmed the mammary origin of the tumor. The patient was referred to the medical team for managing the recurrence of the disease. Further evaluation showed metastatic lesions in the skin, lungs, bones, liver and brain. Considering the disease was disseminated and uncontrolled, the patient was referred to palliative care.

A phase 2 study to determine the pathological (path) response to neoadjuvant nivolumab (nivo) and relatlimab (rela) in high-risk stage II cutaneous melanoma: NeoReNi II.

TPS9610 Background: Patients diagnosed with stage II melanoma account for ~50% of those who develop metastatic disease and die (Poklepovic et al., 2020). Neoadjuvant therapy (NAT) is a powerful treatment platform to rapidly assess drug activity in resectable cancers using the International Neoadjuvant Melanoma Consortium (INMC) path response criteria (Tetzlaff et al., 2018), wherein a major path response (≤10% viable tumor) correlates with low risk of recurrence in resectable stage III melanoma (Menzies et al., 2021). Other benefits include early insight into response, feedback to pts regarding their individual response and prognosis, ability to tailor subsequent management, and collection of translational specimens to explore mechanisms of response and resistance (Amaria et al., 2019). NAT for stage II melanoma is an opportunity to improve survival rates beyond the gains achieved with adjuvant therapy, as illustrated by the phase II SWOG 1801 trial (Patel et al., 2022) for pts with stage III melanoma. The NeoReNi II trial will examine whether combination PD-1 blockade plus lymphocyte-activation 3 (LAG3) checkpoint inhibition will achieve a high rate of path response with manageable toxicity. Methods: Pts with histologically confirmed AJCC (8th ed.) clinical stage IIA (T2b, T3A), IIB (T3b, T4a), or IIC (T4b) primary cutaneous melanoma from a partial biopsy, with residual macroscopic disease at study entry, are eligible (N = 20). Pts with IIA disease must have an estimated ≥20% risk of recurrence at 5 years, according to the Melanoma Institute Australia stage II risk calculator (melanomarisk.org.au). All pts undergo wide excision and sentinel lymph node resection (RES) at wk 6 following NAT with 2 doses of nivo (480 mg, IV) plus rela (160 mg, IV). Pts with no ( &gt; 50% viable tumor) or partial path response ( &gt; 10% - ≤50% viable tumor) receive a further 11 cycles (Q4W) of adjuvant nivo (480 mg) plus rela (160 mg), and radiological and clinical surveillance. Pts with complete (pCR; 0% viable tumor) or near-complete (≤10% viable tumor) path response will undergo radiological and clinical surveillance after RES. All pts will be followed for recurrence (6 monthly CT) and survival for 10 years. Lymphatic mapping, dermoscopy, in vivo confocal microscopy, CT, and FDG PET/CT will be performed at baseline (BL) and prior to RES to measure response to NAT. Tumour and fecal samples are collected at BL, RES, and recurrence. Blood samples are collected at BL, wk 4, RES, and recurrence. The primary endpoint is the rate of pCR at RES after 6 wks of NAT using INMC response criteria (Tetzlaff et al., 2018). Secondary endpoints include assessing the feasibility of NAT in a stage II pt population, RFS, OS, safety/tolerability, surgical outcomes, changes in confocal microscopy and dermoscopy, rate of sentinel node positivity and changes in lymphatic mapping, QOL, and biomarker analyses. Clinical trial information: NCT05418972 .

Junctional Nevus and Early Melanoma on Sun-Damaged Skin of the Head/Neck: a Clinico-Pathologic Challenge.

Melanoma on the head/neck area can show subtle clinical, dermoscopic and histologic features at early stages, being difficult to differentiate from junctional nevi. This case series aims to raise awareness on the topic of misdiagnosis of early lentigo maligna as junctional nevi. From the databases of three pigmented lesion clinics in Italy, Australia, and France, we retrieved all cases of lesions of the head/neck area with an initial histopathologic diagnosis of junctional nevus (JN) or dysplastic junctional nevus (DJN) which subsequently recurred and were ultimately diagnosed as melanoma. Moreover, we also retrieved those cases with an initial diagnosis of JN/DJN made on a partial biopsy that were diagnosed as melanoma after complete surgical removal. Here we report 14 cases in which the initial histologic diagnosis was junctional nevus or dysplastic junctional nevus. The lesions recurred over time with a final diagnosis of lentigo maligna. Clinicians should critically question a given histologic diagnosis of junctional or dysplastic junctional nevus on the head/neck area if the clinical or dermoscopic features are discordant. Clinico-pathologic correlation is the best way to increase diagnostic accuracy and optimize management for the patient.

Clinical Impact and Accuracy of Shave Biopsy for Initial Diagnosis of Cutaneous Melanoma

IntroductionEffective treatment of malignant melanomas is dependent upon accurate histopathological staging of preoperative biopsy specimens. While narrow excision is the gold standard for melanoma diagnosis, superficial shave biopsies have become the preferred method by dermatologists but may transect the lesion and result in inaccurate Breslow thickness assessment. This is a retrospective cohort study evaluating an initial method of biopsy for diagnosis of cutaneous melanoma and indication for reoperation based on inaccurate initial T-staging. MethodsWe retrospectively analyzed consecutive patients referred to the Medical College of Wisconsin, a tertiary cancer center, with a diagnosis of primary cutaneous melanoma. Adult patients seen between 2015 and 2018 were included. Fisher's exact test was used to assess the association between method of initial biopsy and need for unplanned reoperation. ResultsThree hundred twenty three patients with cutaneous melanoma from the head and neck (H&N, n = 101, 31%), trunk (n = 90, 15%), upper extremity (n = 84, 26%), and lower extremity (n = 48, 28%) were analyzed. Median Breslow thickness was 0.54 mm (interquartile range = 0.65). Shave biopsy was the method of initial biopsy in 244 (76%), excision in 23 (7%), and punch biopsy in 56 (17%). Thirty nine (33%) shave biopsies had a positive deep margin, as did seven (23%) punch biopsies and 0 excisional biopsies. Residual melanoma at definitive excision was found in 131 (42.5%) of all surgical specimens: 95 (40.6%) shave biopsy patients, 32 (60.4%) punch biopsy patients, and four (19.0%) excision biopsy patients. Recommendations for excision margin or sentinel lymph node biopsy changed in 15 (6%) shave biopsy patients and five (9%) punch biopsy patients. ConclusionsShave biopsy is the most frequent method of diagnosis of cutaneous melanoma in the modern era. While shave and punch biopsies may underestimate true T-stage, there was no difference in need for reoperation due to T-upstaging based on initial biopsy type, supporting current diagnostic practices. Partial biopsies can thus be used to guide appropriate treatment and definitive wide local excision when adjusting for understaging.

Representativeness of initial skin biopsies showing pure desmoplastic melanoma: implications for management

Desmoplastic melanoma (DM) is an uncommon subtype of melanoma with distinct clinicopathological features. It is classified into pure desmoplastic melanoma (PDM) when the proportion of desmoplastic melanoma is ≥90% of the dermally-invasive component, and mixed desmoplastic melanoma (MDM) when the proportion of desmoplastic melanoma is <90%. Studies have reported a lower sentinel lymph node biopsy (SLNB)-positivity rate in PDM compared to MDM and non-DM. As a result, some have recommended not performing SLNB in PDM patients. When PDM is identified in a partial biopsy of a melanoma, there is a risk that sampling bias may under-recognise MDM, but to the best of our knowledge this has not been previously assessed or quantified. The aim of this study was to assess the concordance of the proportion of desmoplastic melanoma in an initial partial biopsy of PDM with the proportion in the entire tumour following complete excision, in patients with cutaneous melanoma. A secondary aim was to determine how frequently this potentially resulted in a patient not receiving a SLNB. Seventy-eight cases of cutaneous melanoma were identified from the Melanoma Institute Australia (MIA) database and 23 cases from the Memorial Sloan Kettering Cancer Centre (MSKCC), where an initial biopsy contained PDM and a subsequent wide excision had residual invasive melanoma. Clinicopathological features were analysed in all patients, including whether a SLNB was performed, the results of SLNB, and any subsequent recurrence. Ninety percent (91/101) of cases were still classified as PDM in the complete wide excision specimen while 10% (10/101) of cases were reclassified as MDM, which was a significant change in classification of final desmoplastic melanoma subtype (p<0.001). The proportion of desmoplastic melanoma was also significantly different between the initial and excisional biopsies (p=0.004). Forty-eight (48/101) patients had a SLNB, of which two (4.5%) were positive for metastatic melanoma; both cases were PDM in the excision specimen. Of the 10 cases demonstrating MDM in the excision specimen, the initial biopsy was a punch biopsy in six cases, shave biopsy in two cases and subcutaneous tissue was sampled in two patients (one punch biopsy, one incisional biopsy). Four of these 10 patients underwent SLNB which was negative in all cases. Twenty-two patients developed recurrence in the follow-up period (median 30 months, range 1-192 months), three with MDM in their excision specimen. One patient did not have a SLNB and developed regional lymph node recurrence. In this study there was a 10% risk that the percentage of desmoplastic melanoma in an initial biopsy of PDM was not representative of the entire lesion, resulting in reclassification as MDM in the excision specimen. If a SLNB is not performed in such cases, a positive SLNB may be missed (one patient in our study) which could impact treatment options for the patient. We recommend caution in not offering a SLNB in the setting of an initial biopsy of PDM if the biopsy is small compared with the overall lesion. If a SLNB is not procured at the time of wide excision in such cases, the SLNs should still be mapped by lymphoscintigraphy to facilitate careful follow up and to enable earlier detection and treatment of nodal disease.

Primary cutaneous CD4+ small/medium-sized pleomorphic T-cell lymphoproliferative disorder in a young woman.

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (CD4+PCSM-LPD) is a low-grade cutaneous T cell disorder. There is no standardized approach to treatment of CD4+ PCSM-LPD due to its rarity. Herein, we discuss a 33-year-old woman with CD4+PCSM-LPD which resolved after a partial biopsy. We highlight that conservative and local treatment modalities should be considered prior to utilizing more aggressive and invasive treatment options.

Posterior femoral condylar separation: Is it a particular type of osteochondritis dissecans in adolescents?

Introduction. Dissecting osteochondritis (RO) is based on damage to the subchondral bone, leading to its detachment and sequestration separately or together with articular cartilage with the possible formation of a free bone-cartilage fragment. The disease occurs more often in adolescents, accompanied by an increased risk of early arthrosis of the knee joint. Chronic traumatization of the subchondral bone leads to insufficient blood supply to a certain area of the growth zone of the secondary point of ossification of the femoral epiphysis, to ischemia and subsequent necrosis of the subchondral bone, which, according to modern literature, is the leading cause of the formation of the lesion. The typical localization of the RO focus is the lateral part of the medial condyle of the femur along the supporting surface. The present clinical analysis presents cases of atypical localization of dissecting osteochondritis with clinical features, specific signs on MRI, as well as various tactical approaches to treatment.Material and methods. This clinical review presents 3 cases of sequestration of the posterior lateral condyle of the femur in adolescents. Despite the similarity of the clinical picture and the MRI data, the features of the foci of RO were found in all children, which determined the need for an individual approach to therapeutic tactics. All children required surgical treatment, which was performed in the Department of Traumatology and Orthopedics of the N.F. Filatov DGKB in different volumes in each case: from transchondral osteoperforations and fixation of an osteochondral fragment with a screw to debridement of a fragmented focus with removal of osteochondral fragments.Results. All 3 clinical cases are united by atypical localization of the focus in the posterior lateral condyles of the femurs, the clinical course of the disease in the form of a low-intensity long-term pain syndrome, as well as the results of MRI of the knee joint. Most researchers adhere to the classical multifactorial etiological theory of dissecting osteochondritis, according to which the main mechanism of the origin of the lesion is mechanical overload of the subchondral bone with subsequent disruption of blood supply in it at the border with the secondary point of ossification of the femoral epiphysis. However, there is also data in the literature on congenital ossification disorder in the cartilaginous part of the growth zone of the secondary ossification point as the morphological basis of dissecting osteochondritis. The presented clinical cases cast doubt on the generally accepted model of primary damage to the subchondral bone as the only possible cause of the formation of the focus of RO, since patients have, among other things, signs of impaired ossification of the secondary ossification point of the femoral condyle, in one of whom a violation of ossification of the secondary ossification center was also determined in the patella in the form of patella bipartita.Conclusion. Inspite of all similarities connecting these cases there is still lack of data to judge about separate type of the OCD because every separate type of disease usually have particular morphological basis. There is a need of partial biopsy of these lesions to confirm or refute our hypothesis of posterior condylar separation being separate type of OCD. However these cases undoubtedly require particular managementwith special attention to timing of appropriate diagnostic procedures and surgical management to perform in time prior to osteochondral fragment separation. In case of the absence of any complaintswith particular MRI appearance of fragmented bone in the lesion with impaired ossificationindividual treatment planneeds to be defined.

Correction: Does Residual Invasive Disease in Wide Local Excision after Diagnosis with Partial Biopsy Technique Influence Survival in Melanoma? Matched-Pair Analysis of Multicenter Selective Lymphadenectomy Trial I and II.

Journal of the American College of Surgeons 235(6):p 973-974, December 2022. | DOI: 10.1097/XCS.0000000000000411

UNUSUAL ORAL MANIFESTATION OF PARACOCCIDIOIDOMYCOSIS MIMICKING ORAL SYPHILIS

A 38-year-old White man, rural dweller, presented to the stomatology service reporting a painful nodule with ulcerated areas in the buccal mucosa on the right side extending to the upper and lower lips about 1 year ago. He reported mouth opening limitation and difficulty eating. Facial asymmetry was also noticed in the extraoral examination. Some oral infectious diseases were considered as diagnostic hypotheses. Laboratory exams and partial biopsy were conducted. Serological tests were compatible with syphilis and microscopic features were inconclusive. Treatment with penicillin G benzathine intramuscular and dipyrone was prescribed. The patient returned 3 months later for follow-up examination without regression of signs and symptoms. A new biopsy was performed, and microscopic features confirmed oral paracoccidioidomycosis. The patient was referred to an infectologist and pneumologist. Treatment with itraconazole 100 mg was performed. Partial remission of oral lesions was observed after 2 months.

Does Residual Invasive Disease in Wide Local Excision after Diagnosis with Partial Biopsy Technique Influence Survival in Melanoma? Matched-Pair Analysis of Multicenter Selective Lymphadenectomy Trial I and II.

Current guidelines recommend excisional/complete biopsy for melanoma diagnosis, owing to high rates of residual disease found at wide local excision (WLE) after partial biopsy techniques. We sought to determine any survival disadvantage associated with the presence of residual invasive melanoma in the WLE after diagnosis with a partial biopsy technique. Data were examined from Multicenter Selective Lymphadenectomy Trials I and II (MSLT-I and -II), 2 large melanoma trials. Patients diagnosed with excisional/complete biopsy were excluded. Clinicopathologic characteristics, melanoma-specific survival (MSS), distant disease-free survival (DDFS), and disease-free survival (DFS) of those with residual invasive melanoma in the definitive WLE and those with no residual melanoma were compared. Matched pairing was used to reduce variability between groups. From 1994 through 2014, 3,939 patients were enrolled in these trials and 874 (22%) were diagnosed using partial biopsy techniques. Of these, 399 (46%) had residual tumor in the WLE. Only 6 patients had residual tumor in their WLE resulting in T-upstaging of their tumor. Match-pairing formed two cohorts (1:1) of patients with and without residual invasive tumor after WLE. A total of 514 patients were paired; 288 (56%) males, 148 (28.8%) aged 60 or older, 192 (37.4%) with truncal melanomas, 214 (41.6%) had Breslow thickness 2 mm or greater, and 376 (73.2%) had positive sentinel nodes. Kaplan-Meier analysis showed no statistical difference in 10-year MSS (73.6% ± 3.3% vs 73.9% ± 3.7%, p = 0.891), DDFS (68.7% ± 3.4% vs 65.3% ± 4.0%, p = 0.548), or DFS (59.6% ± 3.7% vs 59.4% ± 3.9%, p = 0.783). Survival in patients with primary melanoma does not appear to be worse in patients who undergo a partial biopsy technique and are later found to have residual invasive tumor in the WLE specimen.

ETS-related Gene (ERG) is Differentially Expressed in Dermatofibroma (Fibrous Histiocytoma) as Compared With Dermatofibrosarcoma Protuberans and Hypertrophic Scars: A Pilot Immunohistochemical Study.

Immunohistochemical staining can be of great utility in differentiating various cutaneous spindle cell neoplasms, particularly when the histomorphologic appearance of the lesions is inconclusive. Nuclear staining for ETS-related gene (ERG), a highly sensitive endothelial cell marker, has seldom been studied in the context of cutaneous spindle cell neoplasms. Little is known about its specificity for vascular differentiation. In this pilot study, immunohistochemical analysis for ERG was performed on 15 dermatofibromas (DF), 10 keloids, and 9 dermatofibrosarcoma protuberans (DFSP) tumors. Consistent nuclear expression of ERG was found in DF [100% (15/15) of the lesions demonstrated >50% labeling of tumor cells with moderate to strong intensity]. However, ERG expression was largely absent in DFSP [89% (8/9) of the lesions demonstrating <50% labeling staining, generally of mild intensity] and hypertrophic scars-keloids [80% (8/10) without expression]. On the basis of the results of this pilot study, immunohistochemical staining for ERG may prove useful in helping to differentiate DF from DFSP and hypertrophic scars in the context of partial biopsy sampling. If replicated in a larger number of samples, this finding could mitigate the use of costly sequencing panels and potentially avoid unnecessary reexcisions in certain contexts.

Misdiagnosis of Human Herpes Virus-8-Associated Kaposi's Sarcoma as Adverse Drug Eruptions.

Kaposi's sarcoma (KS) is a cancer that causes patches of abnormal tissue to grow under the skin. It also occurs in the immunosuppressive population. KS is currently believed to be caused by infection with human herpes virus-8 (HHV-8) in non-human immunodeficiency virus patient. A 79-year-old female visited the outpatient clinic presenting with increasing number and size of palpable masses on both upper and lower extremities. She was first diagnosed as drug-erupted dermatitis and stopped her medications, but the symptoms got worse. We did partial biopsy, and KS with HHV-8 was diagnosed histopathologically. She planned to undergo further evaluations and proper treatments. This rare case suggests the need to consider a classic type of KS in the differential diagnosis of specific dermatologic symptoms such as macular, nodular, and darkish patches of upper or lower extremities in elderly patients. It is believed that this case helps to strengthen awareness of this rare disease.

“LIP SHAVE” TECHNIQUE: LITERATURE REVIEW AND CASE PRESENTATION

Introduction: Actinic cheilitis is a pre-malignant condition, mostly located on the lower lip, and can progress to squamous cell carcinoma, with higher tendency for metastasis than cutaneous squamous cell carcinoma. Several methods of treatment have been proposed, like electrosurgery and excision of the actinic damage via laser treatment. However, all methods have limitations. On the other hand, the surgical technique known as “lip shave”, achieves complete removal of the lesion, and promotes the reconstruction of the vermilion border. Case presentation: A 65-years old patient was referred to our Department for treatment of a lesion extended to the whole lower lip, diagnosed as actinic cheilitis after partial biopsy and histopathological examination. Under local anesthesia the outlined lesion was entirely excised, while the lip is was firmly immobilised with the thumb. After the mucosa was first elevated by sharp dissection from one corner, it was then conveniently removed by curved, pointed scissors down to the muscular layer. After securing haemostasis, three “key sutures” were first placed, in order to achieve an even symmetrical closure. The final closure of the wound was achieved with continuous locking suture. Conclusion: The "lip shave" is a non-deforming plastic and reconstructive procedure of great value for prophylaxis and treatment of lip cancer, and for cosmetic correction of certain congenital, neoplastic, and traumatic lip deformities.

A prospective comparison of adaptive and fixed boost plans in radiotherapy for glioblastoma

PurposeTo analyze the efficacy of adaptive radiotherapy (ART) for glioblastoma.MethodsSixty-one glioblastoma patients who received ART were prospectively evaluated. The initial clinical target volume (CTVinitial) was represented by T2 hyperintensity on postoperative MRIs (pre-RT MRI [MRIpre])plus 10 mm. The initial planning target volume (PTVinitial) was the CTVinitial plus a 5-mm margin. The PTVinitial received 40 Gy. An MRI and a second planning CT were performed during radiotherapy (MRImid). Two types of boost CTVs (the resection cavity and residual tumor on enhanced T1-weighted MRI plus 10 mm) were created based on the MRIpre and MRImid (CTVboost-pre and -mid). The boost PTV (PTVboost) was the CTVboost plus 5 mm. Two types of boost plans (fixed and adaptive boost plans in the first and second planning CT, respectively) of 20 Gy were created. The PTV based on the post-RT MRI (PTVboost-post) was created, and the dose-volume histograms of the PTVboost-post in the fixed and adaptive boost plans were compared. Additionally, the conformity indices (CIs) of the fixed and adaptive boost plans were compared.ResultsThe median V95 of the PTVboost-post of the fixed and adaptive boost plans (V95pre and V95mid) were 95.6% and 98.3%, respectively (P < 0.01). The median V95pre and V95mid of patients after gross total resection (GTR) were 97.4% and 98.8%, respectively (P = 0.41); in contrast, the median values of patients after non-GTR were 91.9% and 98.2%, respectively (P < 0.01). The median CIs of the fixed and adaptive boost plans in all patients were 1.45 and 1.47, respectively (P = 0.31). The median CIs of the fixed and adaptive boost plans in patients after GTR were 1.61 and 1.48, respectively (P = 0.01); in contrast, those in patients after non-GTR were 1.36 and 1.44, respectively (P = 0.13).ConclusionART for glioblastoma improved the target coverage and dose reduction for the normal brain. By analyzing the results according to the resection rate, we can expect a decrease in normal brain dose in patients with GTR and an increase in coverage in those with partial resection or biopsy.

Residual melanoma in wide local excision specimens after 'complete' excision of primary cutaneous in situ and invasive melanomas.

Wide local excision (WLE) to achieve adequate clearance margins is the standard initial definitive treatment for patients with biopsy-proven primary cutaneous melanoma. Residual melanoma in WLE specimens after prior complete excision-biopsy (CEB) is reported in 0-6.3% of cases. However, studies evaluating the prevalence, clinicopathological features and relevance of persistent disease in WLE specimens are limited. This study sought to determine the frequency of and clinicopathological characteristics associated with residual melanoma in WLE specimens performed after a CEB of primary cutaneous or acral melanoma (in situ or invasive) with clinically and histologically tumour-free margins, and assess its relevance. A review of the research database and pathology archives of a large Australian tertiary referral melanoma treatment centre was performed. Eligible patients were those for whom a definitive WLE was performed after CEB of a primary melanoma (in situ or invasive) with negative clinical and histological margins, between May 2013 and May 2015. All partial biopsies were excluded. Of 640 eligible patients, 510 (79.7%) had invasive melanoma and 130 (20.3%) had melanoma in situ. Residual disease was identified in 20 cases (20/640, 3.1%), of which three (15%) were melanoma in situ on CEB and 17 (85%) were invasive melanoma. On univariate analysis, the presence of residual disease in WLE specimens was associated with lentigo maligna (LM)/LM melanoma (LMM) subtype [odds ratio (OR) 10.33; 95% confidence interval (CI) 2.84-37.54; p=0.004], nodular melanoma (NM) subtype (OR 4.92; 95% CI 1.53-15.85; p=0.0076) and, for invasive tumours, higher tumour mitotic rate (mean 7.7, SD 7.51 vs 3.4, SD 4.83; OR 1.11; 95% CI 1.04-1.18; p=0.0014). Breslow thickness >4 mm was associated with a higher risk of residual disease (OR 7.30; 95% CI 1.88, 28.26; p=0.004). Cases with residual disease had primary tumours with a significantly larger diameter (median 14 mm, range 4-25) than those without residual disease (median 9 mm, range 2-60), (OR 1.07; 95% CI 1.03-1.11; p≤0.001) and were also more likely to be amelanotic (38% vs 14%), (OR 3.69; 95% CI 1.17, 11.60; p=0.026). Residual disease was associated with assessment of >3 slides of tissue (OR 6.98; 95% CI 1.54-31.62; p=0.0118) and complete blocking of the scar (OR 31.69; 95% CI 3.98-252.21; p=0.0011). Residual melanoma in WLE specimens is an infrequent occurrence. Risk factors for residual disease are LM/LMM and NM melanoma subtypes, higher mitotic rate, larger lesion diameter and amelanosis. Tumours with these features warrant more extensive pathological sampling. WLE after CEB for melanoma remains an important procedure to reduce local recurrence; however, limited pathological sampling of the WLE scar is probably appropriate for cases lacking high risk features.

What Is a Solitary Keratoacanthoma? A Benign Follicular Neoplasm, Frequently Associated with Squamous Cell Carcinoma.

We present histopathological criteria for diagnosing keratoacanthoma (KA). In KA, four histological stages are recognized, which are the early/proliferative stage, well-developed stage, regressing stage and regressed stage. In diagnosing KA, we emphasize that KA consists of the proliferation of enlarged pale pink cells with ground glass-like cytoplasm without nuclear atypia, other than crateriform architecture. KA sometimes exhibits malignant transformation within the lesions. We describe the characteristics of benign and malignant epithelial crateriform tumors that should be differentiated from KA. We also present the data of histopathological diagnosis of lesions clinically diagnosed as KA, its natural course and related lesions after partial biopsy, and incidence of crateriform epithelial neoplasms. Based on these data, we recommend complete excision of the lesion when KA is clinically suspected, especially when the lesion is located on a sun-exposed area of an elderly patient. If complete excision is impossible, partial excision of a sufficient specimen with intact architecture is required. In such a case, however, careful investigation after biopsy will be needed, even if the histopathological diagnosis is KA, because there is some possibility that a conventional SCC lesion remains in the residual tissue.

Value of intraoperative pathological diagnosis in decision-making regarding resection of well-differentiated retropharyngeal liposarcoma: A case report.

Introduction and importancePreoperative diagnosis of well-differentiated liposarcoma (WDLS) in the retropharyngeal space is challenging because of the difficulty in obtaining a biopsy tissue specimen that will yield the microscopic findings necessary for a definitive pathological diagnosis. This report describes a case of retropharyngeal WDLS that was successfully diagnosed intraoperatively, which allowed radical resection.Case presentationThe patient was a 60-year-old man suspected of having a lipomatous tumor in the retropharyngeal space. On imaging, the tumor contained linear septum-like structures that were prominent behind the larynx. Pathological examination was performed using fine-needle aspiration cytology and core needle biopsy specimens. However, no malignant features were found. Given that partial biopsy of the retropharyngeal tumor by puncture was anatomically limited, we decided to collect appropriate tissue specimens for intraoperative pathological examination. During the operation, we biopsied the tumor, including the hard portion behind the larynx, anticipating inclusion of the septum-like structures seen on imaging. A pathological diagnosis of WDLS was successfully made and the tumor was completely excised.Clinical discussionThe fibrous septum with induration is important for intraoperative diagnosis of WDLS. The fibrous septum within the tumor was palpable as a rubbery hard portion.ConclusionWDLS in the retropharyngeal space could be successfully resected surgically by making a rapid intraoperative pathological diagnosis using appropriately selected tissue sampled from a hard portion of the tumor.