Adjuvant Cytokeratin Staining in Mohs Micrographic Surgery for Basal Cell Carcinoma

BACKGROUND: Mohs micrographic surgery (MMS) is a technique that offers excellent cure rates in the treatment of basal cell carcinoma (BCC). One of the reasons for its success is the 100% visualization of the resection margins. Still, recurrences do occur in 2% to 5% of the treated BCCs. It has been suggested that BCC cells in frozen sections stained with hematoxylin and eosin (H&E) may be missed. OBJECTIVE: To determine whether an additional immunohistochemical staining with a cytokeratin marker (MNF 116) indicates BCC cells in sections in which the H&E-stained frozen sections were negative. METHODS: The Mohs procedure was performed under standard conditions in which H&E-stained slides were judged by the Mohs surgeon and the pathologist. After the H&E slides where judged negative, an extra slide was stained using immunohistochemistry and a monoclonal antibody against cytokeratin (MNF 116). RESULTS: A total of 143 complete slides were stained and judged by two Mohs surgeons and a pathologist. One of the 143 slides stained with MNF 116 showed positive staining where the H&E slides were negative, which is 0.7% of the slides. However, this single slide represents a failure of nearly 2% of the treated patients. CONCLUSION: Frozen sections stained with H&E in MMS offer enough security in detecting BCC cells during surgery; however, adjuvant cytokeratin staining can be useful in very selected cases of aggressive growing BCC.     

Potential Utility of Adjunctive Histopathologic Evaluation of Some Tumors Treated by Mohs Micrographic Surgery

BACKGROUND: Mohs micrographic surgery is a highly effective, tissue-conserving method for removing certain cutaneous neoplasms. Horizontal Mohs tissue sectioning permits complete histologic evaluation of the true surgical margin, but does not aim to evaluate the overall morphology of the tumor. Mohs surgery is designed primarily to answer the question "Is it all out?" as opposed to "What is it?" A preoperative biopsy is relied on, in most cases, to provide an accurate diagnosis. The histology from this biopsy might be the only view of the tumor if the first Mohs stage is clear. However, histopathologic review of small biopsies may sometimes give incomplete information about the entirety of the tumor. OBJECTIVE: To illustrate the potential utility of adjunctive histopathologic examination of some tumors treated by Mohs surgery. METHODS: We present four cases to illustrate situations where pre-Mohs biopsy provided incomplete information. The limitations of these biopsies was clarified after the tumor was visualized on a positive first Mohs layer and/or when the tissue was subsequently sectioned vertically. RESULTS: Cases of tumors where preoperative biopsies gave incomplete information are presented: sebaceous carcinoma versus basal cell carcinoma (BCC), invasive versus in situ squamous cell carcinoma (SCC), and SCC versus keratoacanthoma. CONCLUSION: The Mohs technique allows histologic examination of the complete surgical margin around cutaneous neoplasms, optimizing tissue sparing and resulting in superior cure rates. However, in rare cases additional evaluation of the tissue by vertical sectioning can provide important adjunctive histopathologic information that can effect ultimate patient management.     

Topical Imiquimod Treatment for Nodular Basal Cell Carcinomas: An Open-Label Series

BACKGROUND: Imiquimod has been used for basal cell carcinomas (BCCs). This is the first open-label series using imiquimod for nodular BCC with Mohs surgery resection for confirmation of treatment. OBJECTIVE: To evaluate the efficacy of topical imiquimod in patients with biopsy-proven nodular BCC. RESULTS: After 12 weeks for three times a week application, treatment sites at week 15 were surgically excised using Mohs micrographic surgery. All 15 treatment subjects were clear of BCC. At the 18-month follow-up, no patients had recurrent tumor. CONCLUSION: Imiquimod 5% cream may be another treatment modality for nodular BCC.     

Post-Mohs micrographic surgical margin tissue evaluation with permanent histopathologic sections.

BACKGROUND: Incomplete resection of nonmelanoma skin cancer is associated with a relatively high rate of recurrent tumors. Mohs micrographic surgery provides microscopic evaluation of tumor margins to ensure complete excision of nonmelanoma skin cancers at high risk of recurrence. OBJECTIVE: This purpose of this study is to confirm the histologic accuracy of Mohs excision of facial skin cancers by evaluating an additional layer of tissue with permanent histopathologic sections after Mohs excision. METHODS: Two hundred ninety-six Mohs cases were identified, which, after excision, were sent to a single plastic surgeon for reconstruction. This plastic surgeon routinely takes an additional layer and sends for permanent histopathologic evaluation at the time of reconstruction. A review of the pathology reports and tissue specimens on these patients provides valuable data on tumor margins and the effectiveness of the Mohs technique for tumor excision. RESULTS: Two excisions of nodular basal cell cancer were determined by the pathologist to have positive tumor involvement on post-Mohs permanent tissue. On additional review, one specimen was interpreted to be more consistent with follicular epithelium, and the second was verified as a focus of nodular basal cell cancer. CONCLUSION: These data support the high reliability of Mohs surgery for margin control.     

Use of Dynamic Telepathology in Mohs Surgery: A Feasibility Study

BACKGROUND: Telepathology is an emerging technology for remote pathology consultation and diagnosis. OBJECTIVE: To assess the diagnostic accuracy and utility of a dynamic telepathology system in the setting of Mohs surgery. METHODS: Using a dynamic telepathology system, a single dermatopathologist at a remote site assessed the following cases: (1) 50 fixed-tissue slides of basal and squamous cell carcinomas for pathologic diagnosis; (2) 40 frozen-section slides from Mohs surgery for the presence or absence of tumor; (3) 20 frozen-section slides from Mohs surgery for intraoperative consultation with the Mohs surgeon. All 110 slides were then randomly reviewed by the same dermatopathologist by conventional light microscopy. Telepathology and conventional light microscopy diagnoses were then compared. RESULTS: There was complete agreement between telepathology and conventional light microscopy diagnoses. CONCLUSION: Dynamic telepathology is a convenient, useful, and accurate system for remote diagnosis and consultation in the setting of Mohs surgery.     

Peritumoral Fibrosis in Basal Cell and Squamous Cell Carcinoma Mimicking Perineural Invasion: Potential Pitfall in Mohs Micrographic Surgery

Background. Perineural invasion (PI) in cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) is linked to an aggressive course. We describe a histologic mimic for PI that we termed peritumoral fibrosis (PF).
Objective. To describe the morphologic changes associated with PF and to determine the incidence of PF and PI in Mohs frozen sections of BCC and SCC.
Material and Methods. All cases of BCC and SCC that were treated by Mohs micrographic surgery (MMS) at the Skin and Cancer Center, University of Florida College of Medicine, Gainesville, Florida, and the Center for Dermatology and Skin Surgery, Tampa, Florida, during the period from January 1, 2003, to August 1, 2004, were reviewed for the presence of PI and PF. The latter was defined as the presence of concentric layers of fibrous tissue that either surround and/or were surrounded by tumor formations mimicking perineural or intraneural invasion. Seven hundred six cases of BCC and 264 cases of SCC were surveyed. Eleven cases (10 BCC and 1 SCC) with equivocal areas were destained, and immunohistochemical staining with S-100 protein was performed, proving actual PI in all of these cases. Available original hematoxylin-eosin biopsy slides were correlated with the MMS frozen sections.
Results. PF was noticed in 4.5% of SCCs and 5.8% of BCCs. The incidence of unequivocal PI was noted to be 2.6% in SCC and 2.1% in BCC.
Conclusion. We describe a specific pattern of fibrosis noted in BCC and SCC that we called PF. It shows concentric layers of fibrous tissue surrounding and/or surrounded by tumor formations and resembles carcinomatous perineural and/or intraneural invasion. Moreover, PF was found to be a sensitive marker for PI. Mohs micrographic surgeons should be aware of this phenomenon to avoid triggering unnecessary steps in managing these cases, such as irradiation.     

Post–Mohs Micrographic Surgical Margin Tissue Evaluation with Permanent Histopathologic Sections

Background. Incomplete resection of nonmelanoma skin cancer is associated with a relatively high rate of recurrent tumors. Mohs micrographic surgery provides microscopic evaluation of tumor margins to ensure complete excision of nonmelanoma skin cancers at high risk of recurrence.
Objective. This purpose of this study is to confirm the histologic accuracy of Mohs excision of facial skin cancers by evaluating an additional layer of tissue with permanent histopathologic sections after Mohs excision.
Methods. Two hundred ninety-six Mohs cases were identified, which, after excision, were sent to a single plastic surgeon for reconstruction. This plastic surgeon routinely takes an additional layer and sends for permanent histopathologic evaluation at the time of reconstruction. A review of the pathology reports and tissue specimens on these patients provides valuable data on tumor margins and the effectiveness of the Mohs technique for tumor excision.
Results. Two excisions of nodular basal cell cancer were determined by the pathologist to have positive tumor involvement on post-Mohs permanent tissue. On additional review, one specimen was interpreted to be more consistent with follicular epithelium, and the second was verified as a focus of nodular basal cell cancer.
Conclusion. These data support the high reliability of Mohs surgery for margin control.     

In Vivo Real-Time Confocal Reflectance Microscopy: A Noninvasive Guide for Mohs Micrographic Surgery Facilitated by Aluminum Chloride, an Excellent Contrast Enhancer

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.     

The Efficacy of Curettage in Delineating Margins of Basal Cell Carcinoma Before Mohs Micrographic Surgery

BACKGROUND: Curettage may be helpful as a preliminary step to outline the gross subclinical extensions of high-risk basal cell carcinomas (BCCs) before the first stage of Mohs micrographic surgery. Although many Mohs surgeons use curettage in the Mohs surgical setting, no prospective studies have as yet been performed that demonstrate the efficacy of curettage in delineating tumor margins before Mohs surgery. OBJECTIVE: To document the efficacy of curettage in delineating BCC margins before Mohs micrographic surgery. METHODS: This was a prospective evaluation of 599 patients with biopsy-proven BCCs treated with Mohs surgery. The preoperative dimensions of each tumor, the curetted dimensions before the first surgical stage, the proposed excisional margins before each surgical stage, and the final defect dimensions after each surgical stage were measured. The maximum curetted margin around each tumor was calculated and compared with typical Mohs excisional margins of 1, 2, 3, and 4 mm. A hypothetical 1-, 2-, 3-, or 4-mm excisional margin was added to the preoperative X and Y dimensions of each tumor, and the actual final defect sizes were compared with the hypothetical final defect sizes to determine whether an additional surgical stage would have been needed had curettage not been performed. The amount of tissue stretch occurring after specimen removal was calculated to determine whether tissue stretch falsely elevated the number of instances in which an additional surgical stage would have been needed had curettage not been performed. RESULTS: The curetted margin around the observed extent of each tumor exceeded 1 mm in 87.6% of cases, 2 mm in 47.1% of cases, 3 mm in 19.7% of cases, and 4 mm in 5.7% of cases. The mean curetted margin was 1.7 mm. Taking a 1-mm margin in the first stage of Mohs surgery without first performing curettage would have necessitated an extra surgical stage in 99.2% of cases, whereas taking a 2-, 3-, or 4-mm margin would have necessitated an extra surgical stage in 93.0%, 88.1%, and 49.4% of cases, respectively. After calculating and eliminating the effects of tissue stretch, it was found that a 1-mm excisional margin taken in the first stage of Mohs surgery without first performing curettage would have necessitated an extra surgical stage in 99.0% of the cases. Taking a 2-, 3-, or 4-mm margin would have necessitated an extra surgical stage in 87.5%, 57.9%, and 29.5% of cases, respectively. CONCLUSION: Careful debulking and palpation with the curette significantly reduce the number of Mohs surgical stages required for BCC clearance. Even after taking the effects of tissue stretch into consideration, a significant proportion of tumors would still require an additional stage for tumor clearance without aggressive presurgical curettage.     

Basosquamous Carcinoma

BACKGROUND: Basosquamous carcinoma (BSC) is a rare cutaneous tumor that has been poorly described in the dermatologic literature. It has been depicted as an aggressive tumor with a high incidence of distant metastasis. OBJECTIVE: To examine the average extent of local tissue invasion and presence of distant metastases in cases of BSC compared with those of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). METHODS: One thousand consecutive Mohs surgery cases performed between January 1993 and May 1995 at the Oschner Clinic in New Orleans, Louisiana, for histologically confirmed BCC, SCC, and BSC were reviewed. Each case was retrospectively evaluated for tumor type, anatomic location, number of Mohs stages performed, and presence of metastases at the time of surgery, as determined by chest radiograph. RESULTS: Seven hundred forty-five BCCs, 228 SCCs, and 27 BSCs (1,000 tumors total) were treated in 580 patients. The average number of stages required for clear margins in cases of BCC, SCC, and BSC was 1.62, 1.51, and 2.00, respectively. The prevalence of metastasis was 0.87% for SCC and 7.4% for BSC, which was statistically significant (P<0.001). CONCLUSION: In this retrospective study, BSCs displayed tissue invasion similar to that of BCC or SCC but had a higher frequency of pulmonary metastasis than SCC.     

Cost-Effective Dynamic Telepathology in the Mohs Surgery Laboratory Utilizing iChat AV Videoconferencing Software

BACKGROUND: Dynamic telepathology is the real-time transmission of histologic images from one pathologist to another by means of telecommunications technology. OBJECTIVE: The objective was to determine whether dynamic telepathology can be accomplished accurately and inexpensively by use of readily available off-the-shelf consumer products and software. METHODS: We attached a standard, consumer-grade, digital video camera to a microscope in the Mohs surgery laboratory and then transmitted via the Internet real-time histologic video images and audio to a consultant dermatopathologist by means of iChat AV videoconferencing software (Apple Computer Inc., Cupertino, CA). In the first part of the study, 20 unknown formalin-fixed, paraffin-embedded slides from tumors typically seen in a Mohs practice were evaluated by the consultant dermatopathologist. In the second part of the study, the Mohs surgeon consulted the dermatopathologist on 20 Mohs frozen section slides in which the surgeon had a particular question (e.g., "Is this part of a pilosebaceous unit or is this basal cell carcinoma?"). RESULTS: The video images were adequate for pathologic interpretation. There was agreement between conventional light microscopy and dynamic telepathology diagnosis in 19 of 20 tumors. There was complete agreement for all 20 Mohs frozen section consultations. CONCLUSION: Dynamic telepathology can be accomplished accurately and inexpensively by use of readily available consumer products and software.     

三维可视化重建技术在机器人辅助巨大嗜铬细胞瘤/副节瘤切除术中的应用价值(附11例报告)

目的:探讨三维可视化重建技术在机器人辅助腹腔镜下巨大嗜铬细胞瘤/副节瘤切除术中的应用价值。方法:回顾性分析2019年7月—2020年1月我院收治的11例嗜铬细胞瘤/副节瘤患者的临床资料。其中男5例,女6例,中位年龄44(21~68)岁;肿瘤最大径中位值7.1(6.2~10.2)cm;病变位于右肾上腺3例,左肾上腺5例,右肾门旁腔静脉后方2例,左肾门旁1例。术前所有患者均行CT增强扫描,并采集dicom数据通过VitaWorks重建技术完成三维可视化模型。借助模型,观察肿瘤大小、受累脏器以及术中可能干涉的组织器官和血管,模拟手术路径,指定三维可视化指导的手术方案。结果:利用VitaWorks技术得到了所有肿瘤的精细、完整的三维可视化模型,结合肿瘤大小、部位指定精准手术方案。8例行机器人辅助经腹径路腹腔镜嗜铬细胞瘤切除术;2例行机器人辅助经腹径路腹腔镜副节瘤切除术;1例行机器人辅助经腹腹腔镜左肾上腺嗜铬细胞瘤切除术加左肾切除术。所有手术均顺利完成,无术中转开放。结论:基于CT增强扫描检查的三维可视化重建技术在机器人辅助腹腔镜下巨大嗜铬细胞瘤/副节瘤切除术方面具有应用价值,帮助术者制订精准的个体化手术方案,减少了围手术期间并发症的发生风险,提高了手术的成功率及安全性。     

Treatment of extensive extramammary Paget disease of male genitalia with Mohs micrographic surgery

It is often difficult to accurately judge the clinical tumor margins for extramammary Paget disease. Mohs micrographic surgery was used to extirpate a tumor which clinically measured 159.5 cm2. Following Mohs micrographic surgery, it was found that the actual dimensions of the tumor had been underestimated by 97 per cent. Since the Mohs micrographic surgeon microscopically examines the entire subcutaneous margin of the resected tumor, this technique provides an accurate method of determining the depth of tumor penetration. Mohs micrographic surgery allows for maximal conservation of normal tissue and yields higher cure rates than other conventional methods of treatment. When approaching tumors of the genitalia which may display poorly defined clinical margins, Mohs micrographic surgery should be considered the technique of choice.     

Difference between Pigmented and Nonpigmented Basal Cell Carcinoma Treated with Mohs Micrographic Surgery

BACKGROUND: There have been several articles characterizing cases of pigmented basal cell carcinomas (PBCC). Previous studies have also evaluated the relationship between histologic pattern and frequency of basal cell carcinoma (BCC) associated with pigment formation. No specific studies, however, have examined the subclinical extension and surgical margins of PBCC tumors. OBJECTIVE: A prospective study of 345 Mohs micrographic BCC surgical cases revealed 67 PBCC cases. Analysis of patient details included patient age and sex, the lesional site, histologic subtype, tumor size, final surgical margin, and the number of stages required to achieve tumor-free margins together with the presence or absence of pigment. METHODS: This study was performed between May 2004 and January 2005 at the Department of Dermatology and Cutaneous Surgery, University of Miami, Mohs Surgery Center. RESULTS: Total mean surgical margin was smaller in the PBCC than the nonpigmented BCC (NPBCC) group (3.89 mm vs. 5.85 mm; p<0.05). In lesions less than 2 cm in size, there were even more significant differences between the two groups (3.32 mm vs. 5.33 mm; p<0.05), and also between the aggressive and nonaggressive histologically diagnosed groups (3.13 mm vs. 5.01 mm; p<0.05). CONCLUSIONS: We have demonstrated that PBCC requires a smaller surgical margin for complete tumor excision than NPBCC, especially in smaller tumors and in the nonaggressive histologic subtype group. Treatment within the early growth stages also involves less subclinical microscopic invasion and a smaller surgical margin in PBCC.     

Lymphocytic Infiltrates and Subclinical Epithelial Tumor Extension in Patients With Chronic Leukemia and Solid-Organ Transplantation

BACKGROUND: Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins. OBJECTIVE: The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure. METHODS: Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group. RESULTS: Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P=0.029) and in transplant recipients (P=0.55). CONCLUSION: Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.     

鼻唇沟区域软组织的三维可视化重建

目的 通过获取鼻唇沟区域连续软组织切片图像,初步建立鼻唇沟区域软组织三维可视化模型.方法 将鼻唇沟区域软组织标本行连续切片,染色后用专业微距照相系统获取切片图像数据,进行三维重建及重建后可视化应用.结果 ①成功探索了大块软组织标本石蜡切片的制作方法;②组织学显示鼻唇沟内外侧纤维及脂肪含量、肌肉附着有明显差别;③重建出的鼻唇沟区域数字化模型有良好的展示特性,并可进行简单的可视化应用.结论 三维重建软件对大块软组织进行可视化应用是可行的.三维模型为临床解剖的学习和外科医师的手术模拟提供了良好的平台.     

Economic Impact of Preoperative Curettage before Mohs Micrographic Surgery for Basal Cell Carcinoma

BACKGROUND: The role of curettage before Mohs micrographic surgery for basal cell carcinoma (BCC) remains controversial. Preoperative curettage may allow the surgeon to better delineate the subclinical extensions of high-risk BCCs, thereby enabling a more precise first-stage excision around tumor-containing tissue. OBJECTIVE: To assess the economic impact of preoperative curettage for high-risk BCCs treated with Mohs micrographic surgery on patients, providers, and insurers. METHODS: Given the enormous variability in practice styles, it was estimated that the time required to complete a second stage of Mohs surgery was 25, 50, or 75% of that required to complete the first stage. New York City Medicare and Standard reimbursement rates were used to approximate the cost of an additional stage of Mohs surgery for high-risk BCCs. RESULTS: Assuming that preoperative curettage increases operative efficiency by reducing the number of required Mohs stages from 2 to 1, the time saved can be quantified. Thus, if the Mohs surgeon estimates that the time required to remove a second stage is 75% of that of the first stage, the time savings with preoperative curettage equals 75% of the duration of a one-stage Mohs surgery. Similarly, when a second stage requires 50 or 25% of the time needed to complete the first stage, the time saved equals 50 or 25% of the duration of a one-stage Mohs surgery. Reducing the number of stages from 2 to 1 saves insurers and privately paying patients approximately $250 and $500, respectively. CONCLUSIONS: Whether preoperative curettage can offer a more precise first-stage excision without compromising tissue conservation remains a subject of debate. Preoperative curettage may reduce the number of Mohs surgical stages required for tumor clearance, potentially shortening patient encounters and allowing surgeons to treat additional patients, while decreasing costs for patients and insurers.     

A Pilot Feasibility Study of a Rare Skin Tumor Database

BACKGROUND: In the United States melanoma is the only individually reported skin cancer. There are no large state or national registries for nonmelanoma skin cancer. Nevertheless, rare, that is, nonmelanoma, nonepithelial, tumors can also be locally aggressive and metastasize. OBJECTIVES: This study's purpose was to demonstrate that Mohs surgeons can share data to create a rare skin tumor database. This database may serve as a model for a nationwide database. MATERIALS AND METHODS: We retrospectively reviewed the surgery logs of five Mohs surgery practices in the Houston, Texas, area for rare-nonmelanoma, nonepithelial-skin cancers. A total of 42,279 biopsy-proven cancers of the skin treated with Mohs micrographic surgery were reviewed. Tumor data including type, prevalence, year of treatment, and the treating Mohs surgeon(s) were compiled and analyzed. RESULTS: Forty-three types of rare tumors were identified. A total of 317 rare tumors were treated. No practice saw more than 28 rare tumor types. Atypical fibroxanthoma was the rare tumor most often treated. CONCLUSIONS: Colleagues can cooperate to create a database of rare tumors removed by Mohs micrographic surgery. A range of tumors greater than that seen in any single practice is now available for study. This should provide the impetus for a nationwide rare skin tumor database.     

Defects of the nasal internal lining: etiology and repair

OBJECTIVES: To analyze risk factors leading to full-thickness (FT) defects, to review methods of repair, and to present guidelines for management of aggressive basal cell carcinomas (BCCs) of the nose. DESIGN: Retrospective medical chart review of patients who underwent nasal reconstruction by the Department of Otolaryngology-Head and Neck Surgery between 1996 and 2003. RESULTS: Two hundred ten patients underwent nasal reconstruction; 183 had complete medical records and were included in this study. There were 53 patients with FT nasal defects, 38 (71.7%) of which were due to BCC. Among all patients presenting with an aggressive histologic subtype of BCC, 30.1% (22/73) developed FT defects. In contrast, 14.5% (16/100) with a nonaggressive subtype had FT involvement (P < .05). CONCLUSIONS: Internal lining defects are more likely to occur from aggressive histologic subtypes of BCC (infiltrative, morpheaform, and micronodular) than nonaggressive subtypes (P < .05). For BCCs 1 to 2 cm2 located on the nasal ala, histologic subtype is a significant risk factor for resulting in a FT defect, which should influence the method of excision (direct vs Mohs micrographic surgery) and the anticipated reconstruction. Large lesions (> 2 cm2) involving the ala have a high rate of internal lining involvement independent of pathologic subtype.     

Intraoperative three-dimensional reconstruction of power Doppler vascular images.

We have developed a simple method for reconstructing a three-dimensional (3D) image in the operating room from sequentially scanned intraoperative two-dimensional (2D) power Doppler images using a personal computer and commercially available software. During three operations, 2 for cerebral aneurysm and 1 for cerebral tumor, intracranial vessel images were digitally transferred to a personal computer by freehand scanning over the dura mater or surface of the brain with a 7.5-MHz linear probe. A series of 2D images were converted to a smaller file, and 3D image was reconstructed with volume-rendering software. It took about 15 minutes to reconstruct of the initial 3D image. In the cases of cerebral aneurysm, the vessels connected to the lesion or running nearby were easily identified on the image. In the tumor case, the anatomical relation between the vascular structures and the tumor was clear. This simple 3D reconstruction method provides spatial information about intracranial vascular structures that is useful in intraoperative surgical planning.