Giant basal cell carcinoma of the forehead: a case report

Giant basal cell carcinoma (GBCC) is defined as a tumor 5cm or greater in diameter. They present less than 1% of all basal cell carcinomas. We present a case of an 85-year-old male patient with a giant ulcerating tumor of the left forehead (measuring 7x6 cm). Under local anesthesia tumor was surgically excised. No involvement of the underlying periostal or bone structure was noted. Pathohystological exam revealed the giant basal cell carcinoma, with free surgical margins. Giant basal cell carcinomas are rare tumors and are usually result of a long duration and patient neglect. In comparison to the ordinary basal cell carcinoma these tumors have a higher metastatic potential. Surgical resection with negative surgical margin is the best possible treatment option.     

A prospective study of the accuracy of the surgeon's diagnosis and significance of positive margins in nonmelanoma skin cancers

Even with a precise preoperative diagnosis, complete excision of nonmelanoma skin cancer is not always achieved. The conundrum remains the decision for appropriate secondary treatment. Many surgeons, regardless of the nature of the lesion, consider re-excision to be the only option. In a prior 4-year prospective study that ascertained the accuracy of our clinical diagnosis of skin lesions removed in an office setting, one-fifth were found to be malignant and 98 percent (n = 415) of the lesions were nonmelanoma skin cancer. Unfortunately, 65 (15.7 percent) of the malignant nonmelanoma skin cancer lesions had positive margins. The outcome of our management for these specific lesions was followed prospectively over the 7.5 years of this study to determine whether aggressive surgical intervention was justified in every case.Of 65 patients with lesions, early and complete re-excision of margin-positive nonmelanoma skin cancer was performed for 34 (52.3 percent), with residual tumor found in 11 (32.4 percent), followed by a later recurrence in one (2.9 percent). The remaining 31 patients agreed to semiannual office visits, with one (3.2 percent) recurrence in this group. Thus, the overall rate of recurrence for margin-positive nonmelanoma skin cancer was 3.1 percent, with a mean follow-up of 3.6 years (range, 0 to 7.5 years).There were no recurrences for basal cell carcinoma in either treatment group, suggesting that, at least for "simple" primary lesions without confounding risk factors, there is some validity to a "wait and see" attitude, in which treatment of a potential recurrence would be straightforward. Despite our observed infrequent local recurrences of squamous cell cancers (13.3 percent), the small risk of metastases still suggests the appropriateness of complete surgical eradication for these tumors whenever feasible.     

Shave excision of superficial solar skin lesions

Shave excision is a useful technique for the treatment of superficial solar lesions. The most common of these is the solar keratosis, which can be a red or gray scaling lesion. This can at times be difficult to differentiate from the superficial basal cell carcinoma or squamous cell carcinoma or their more infiltrating types. Shave excision gives the advantage of a histopathologic report. Lesions found to be infiltrating or in danger of recurrence can then be further excised. The cosmetic appearance of the healed shave excision site is generally quite good, although it can be paler than the surrounding skin. If this is likely to be a problem, the shave graft can be applied, as with deeper shave excisions. A thin shave graft also can be used to repigment pale scarred areas. A series of 1313 shave excised lesions is analyzed.     

Cutaneous leiomyosarcoma

Cutaneous leiomyosarcoma is a rare soft-tissue sarcoma with negligible metastatic potential, but local recurrence rates after surgical excision have ranged from 14 percent to 42 percent. Unlike other sarcomas, guidelines for the optimal surgical excision margin of cutaneous leiomyosarcoma are not clearly defined in the existing literature. A review of local experience with this condition revealed eight patients over 12 years, none of whom developed local recurrence or distant metastases. This is despite poor prognostic factors in seven patients and excision margins ranging from 1 to 27 mm. These findings are compared with previously published data, and conclusions are drawn based on analysis of the collective results. Complete surgical excision with a narrow margin is recommended, and patients should be observed for a minimum of 5 years after surgery.     

Cancer recurrence following Mohs micrographic surgery: a mechanism of tumor persistence.

Recurrence of basal cell carcinomas after Mohs micrographic surgery is rare but known to occur. This report describes the recurrence of a basal cell carcinoma of the forehead after Mohs surgery in order to illustrate a previously undescribed mechanism of tumor persistence and recurrence despite thorough microscopic evaluation of all surgical margins. The value of the surgeon's reviewing all prior histologic sections before performing micrographic surgery, the importance of resecting all scar tissue from a previous surgical site prior to determination of tumor-free margins, and the potential usefulness of a three-tiered closure after excision of a cutaneous malignancy that involves the muscular layer are discussed.     

Radiation Therapy for Skin Cancer

Local control, cosmesis and functional results were evaluated in 315 cases of skin cancer in 247 patients treated with radiation therapy. The initial recurrence rate for basal cell carcinoma was 7.8 percent and for squamous cell carcinoma was 14.9 percent. Ultimate local control was achieved in 98.7 percent of the cases of basal cell carcinoma and in 94.0 percent of the cases of squamous cell carcinoma with use of further irradiation or other therapeutic modalities. Ultimate local control rates were comparable to other therapeutic modalities. Cosmetic and functional results were excellent. Cartilage necrosis was not a significant problem. Radiation therapy may offer advantages in certain clinical situations and should be considered as a mode of therapy in the treatment of skin cancer.     

Squamous cell carcinoma of the lip

We reviewed 117 consecutive patients with squamous cell carcinoma of the lip. The retrospective review includes age, race, location, risk factors, TNM classification, histologic differentiation, treatment methods, recurrent disease, site of recurrence, and follow-up status. Results reveal prognosis is related to original tumor size, location, local recurrence, histologic grade, and presence of cervical metastasis. The presence of cervical lymph node disease reduces the survival from 90 to 50 percent; the survival after recurrent disease to the neck is 10 percent. When a prophylactic suprahyoid neck dissection shows involvement with tumor, 83 percent of patients have metastasis to cervical lymph nodes. The overall recurrence rate is 20 percent. Over 60 percent of the recurrent disease is due to tumors less than 4 cm in diameter. The local recurrence rate is 7 percent, but reexcision of the local recurrence gives a 75 percent cure rate. Aggressive surgical treatment is recommended for identifiably poor prognostic lesions and includes surgical excision, prophylactic suprahyoid neck dissection, and possible radical neck dissection.     

Skin growths of the head and neck region in elderly patients--analysis of two five-year periods in General Hospital Karlovac, Croatia

Skin lesions, benign and malignant, are more common in the older than younger people. Due to the aging of the skin and greater exposure to the impact of ultraviolet rays, their long-term cumulative negative effect, skin lesions are more common in the head and neck area than on other parts of the skin. This paper analyses the pathohistological diagnosis of material after the surgical excision of tumors of the skin on the head and neck of persons older than 60, at the General Hospital Karlovac through two five-year period. The first period is the period from 2006 to 2010 and the second one from 1996 to 2000. The aim was to determine for each period the type and variety of skin lesions, the prevalence of the disease, the age and gender structure, and finally to compare the two periods. The total number of excisions in the first period was 1200, and in the second 513. In both periods more excisions was done in women than men, if compared it comes to 1.4:1. The ratio of malignant (basocellular carcinoma, squamous cell carcinoma and melanomas), and benign tumors (seborrheic keratoses, moles and others) in the first period was 49.3 to 46.3%, and in the second 56.7 to 42.1%. Precancerous lesions (actinic keratoses and Mb Bowen's disease) accounted for 4.3% of lesions in the first and 1.2% in the second period. The total number of basocellular carcinoma was 481/232, which makes 81.3% of all malignant tumors in the first, or 79.7% in the second period. Our results showed that around half of all skin lesions removed in both periods consisted of malignant tumors, among which the most common were basal cell carcinomas. High prevalence of malignant non-melanoma skin cancers, 48.7 and 56%, indicate the importance of protection from UV radiation, and early detection and treatment of skin cancer and precancerous lesions.     

Using clinicopathological analysis of general practitioner skin surgery to determine educational requirements and guidelines.

OBJECTIVE--To study the impact of skin surgery in general practice on the workload of a pathology laboratory and to identify what further training might be helpful. DESIGN--Analysis of skin biopsy specimens from general practitioners before and after their new contract to determine numbers of specimens, changes in diagnoses, adequacy of treatment of malignant tumours, and areas of low diagnostic accuracy. SETTING--District general hospital. SUBJECTS--All 1017 skin biopsy specimens from general practice for 15 months before and 12 months after the new general practitioner contract. RESULTS--The number of pathology specimens received increased from 16 to 65 per month (median = 6 submitted by each general practitioner in the post-contract year). The proportion of the more common pathological diagnoses was unchanged between the two periods, but the proportion of correctly diagnosed naevi, cysts, and seborrhoeic keratoses increased in the second. Although few diagnoses were overtly incorrect, accurate diagnosis of dermatofibromas and malignancies decreased after the contract, and the overall correct diagnosis rate for seborrhoeic keratoses, dermatofibromas, rashes, and malignancies was below 30%. Only nine out of 21 squamous cell carcinomas were adequately excised with tumour free margins, and follow up of malignant tumours may have been inadequate. CONCLUSIONS--Skin surgery in general practice has advantages but matters of concern are the increase in laboratory workload, the excision of some benign lesions, and the inappropriateness of biopsy of rashes. Squamous cell carcinoma and other malignant tumours submitted for pathological examination were often unsuspected and inadequately excised, and heightened suspicion is recommended. Pathology request forms may need redesigning to encourage provision of clinical details.     

Augmented CD133 expression in distal margin correlates with poor prognosis in colorectal cancer

Pathological assessment of excised tumour and surgical margins in colorectal cancer (CRC) play crucial role in prognosis after surgery. Molecular assessment of margins could be more sensitive and informative than conventional histopathological analysis. Considering this view, we evaluated the distal surgical margins for expression of cancer stem cell (CSC) markers. Cellular and molecular assessment of normal, tumour and distal margin tissues were performed by flow cytometry, real‐time q‐PCR and immuno‐histochemical analysis for CRC patients after tumour excision. CRC patients were evaluated for expression of CSC markers in their normal, tumour and distal tissues. Flow cytometry assay revealed CD133 and CD44 enriched cells in distal margin and tumour compared to normal colorectal tissues, which was further confirmed by immunohistochemistry. Most importantly, immunohistochemistry also revealed the enrichment of CSC markers expression in pathologically negative distal margins. Patients with distal margin enriched for CD133 expression showed an increased recurrence rate and decreased disease‐free survival. This study proposes that although distal margin seems to be tumour free in conventional histopathological analysis, it could harbour cells enriched for CSC markers. Further CD133 could be a promising molecule to be used in molecular pathology for disease prognosis after surgery in CRC patients.     

A comparison of local recurrence and resection margins for stage I primary cutaneous malignant melanomas

A retrospective review of 552 patients with clinical stage I primary cutaneous malignant melanomas was undertaken comparing margins of resection and local recurrence between 1966 and 1981. The overall local recurrence rate was 8 per 552 (1.45 percent). We observed no instances of local recurrence in lesions less than 1.40 mm thick with resection margins of at least 1 cm. A comparison of resection margins greater than 2 cm versus less than 2 cm for lesions less than 1.00 mm thick showed no difference at the 0.05 level of significance for local recurrence (0 per 228 versus 2 per 154; 1.3 percent) or survival. While narrower margins of resection for thinner, low-risk stage I malignant melanomas appear safe, the exact minimum margin of resection needed to satisfy both oncologic and cosmetic considerations, whether 1 or 2 cm, will need to be determined by a large prospective, randomized study.     

Methylation-based molecular margin analysis in hepatocellular carcinoma

The positive surgical margins are associated with postsurgical recurrence in hepatocellular carcinoma patients, and molecular margin analysis is considered more sensitive in detecting preneoplastic lesions than conventional histological margin examination. To evaluate the feasibility of methylation-based molecular margin analysis in HCC and explore its clinical application, we investigated CDKN2A methylation status in the surgical margins of 20 HCC patients using a nested BS-MSP protocol and compared the methylation patterns in resection margins with those in the corresponding tumor and adjacent nonmalignant tissues. The results showed that a considerable frequency (35%, 7 of 20) of CDKN2A methylation was present in histologically negative margins, and methylation pattern analysis might be valuable for studying the cellular origin of recurrent carcinoma. Therefore, methylation-based molecular surgical margin analysis offers a promising tool in prognosis for HCC patients who underwent hepatectomy.     

Cutaneous odontogenic sinus simulating a basal cell carcinoma: case report and literature review

A woman was referred for Mohs' microscopically controlled surgical excision of a presumptive basal cell carcinoma located on her nasolabial fold. During examination, pus was expressed from the nodulocystic lesion and an intraoral palpation revealed a fibrous sinus tract extending from the skin lesion to the gingiva of a severely carious tooth. There was roentgenographic evidence of a periapical abscess. The diagnosis was revised to that of a cutaneous odontogenic sinus. The possibility of a draining dental sinus to the skin should be seriously considered when evaluating a suspected basal cell carcinoma in the perioral region--especially in an individual with a history of extensive dental treatments, antecedent oral trauma, or markedly carious teeth.     

Malignant melanomas of eyelid skin

Four cases of malignant melanoma of eyelid skin are reported. Management of the condition is discussed, with a review of the literature. The conclusions lead us to recommend wide surgical excision for those melanomas arising on the lash margins. If the melanoma is clear of the eyelid margin, smaller margins may be adequate.     

Immunolocalization of lactoferrin in surgically resected pigmented skin lesions

Lactoferrin (Lf) expression was determined immunohistochemically in 57 formalin-fixed paraffin-embedded bioptic samples obtained from an equal number of patients treated by surgery to remove pigmented skin lesions (nevi = 23; melanoma = 12; vulgaris and seborrhoeic warts = 12; basal cell carcinoma = 10); in addition, 10 specimens of normal skin were studied as control. On 3 mm thick sections, depigmentation and antigen retrieval procedures were performed. The Lf immunoreactivity was revealed by a rabbit anti-human Lf. Quantification of Lf immunoreactivity was performed using an intensity-distribution (ID) score. Melanocytic cells, regardless of their benign or malignant nature, were consistently stained, with no significant differences in the Lf ID-score between melanomas or nevi. A different intensity of Lf immunoreactivity was encountered in superficial portions of warts, exclusively inside squamous epithelial cells arranged in sheets or whorls of keratin. On the contrary, basal cell carcinomas were always unstained, while a slight Lf positivity was found in focal keratinized areas present in two tumours showing baso-squamous differentiation. The Lf immunoreactivity was localized in the cytoplasm and only occasionally in the nucleus. The biological meaning of Lf in these cases of human skin specimens remains unexplained, although it cannot be ruled out that Lf might be involved in the defense system against tumours, or alternatively, may be used by cells requiring iron availability for their turnover. Moreover, the immunohistochemical expression of Lf in melanocytic lesions might be also related to a Lf-melanin interaction. Finally, the involvement of Lf in skin squamous non-neoplastic elements could be related to its role as one of the molecules modulating an unspecific inflammatory or anti-oxidant response.     

Expression patterns of α2,3-Sialyltransferase I and α2,6-Sialyltransferase I in human cutaneous epithelial lesions

Skin tumors have become one of the most common cancers in the world and their carcinogenesis is frequently associated with altered glycosylation patterns. The aberrant sialylation, a type of glycosylation, can mediate pathophysiological key events during various stages of tumor progression, including invasion and metastasis. Sialyltransferases play a key role in a variety of biological processes, including cell-cell communication, cell-matrix interaction, adhesion, and protein targeting. In this study, it was evaluated the expression of ST3Gal I and ST6Gal I in cutaneous epithelial lesions that include actinic keratosis (n=15), keratoacanthoma (n=9), squamous cell carcinoma (n=22) and basal cell carcinoma (n=28) in order to evaluate if sialyltransferases expression is different in premalignant and in malignant tumors. The expression of ST3Gal I was observed in actinic keratosis (53%), keratoacanthoma (78%), squamous cell carcinoma (73%) and basal cell carcinoma (32%) with statistic differences between basal cell carcinoma and keratoacanthoma (P=0.0239) and basal cell carcinoma and squamous cell carcinoma (P=0.0096); for ST6Gal I, cytoplasmic expression was noted in actinic keratosis (40%), heterogeneous and cytoplasmic expression was noted in keratoacanthoma (67%), squamous cell carcinoma (41%) and basal cell carcinoma (7%) with statistic differences between basal cell carcinoma and squamous cell carcinoma (P=0.0061) and basal cell carcinoma and keratoacanthoma (P=0.0008). In summary, our results showed that the high expression of ST3Gal I and ST6Gal I, in skin tumors, is associated with tumors with greater potential for invasion and metastasis, as in the case of squamous cell carcinoma, and this may be related to their behavior.Key words: sialic acid, α2,3-sialyltransferases, α2,6-sialyltransferases, basal cell carcinoma, squamous cell carcinoma, actinic keratosis, keratoacanthoma     

Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982-91.

OBJECTIVE--To examine the management of patients who had a malignant melanoma excised initially by general practitioners in south east Scotland over the past 10 years and to assess the impact of the April 1990 contract on this. DESIGN--A retrospective case-control study. SETTING--South east Scotland. SUBJECTS--All patients in south east Scotland who had malignant melanomas excised by general practitioners in 1982-91. OUTCOME MEASURES--Demographic details of patients; Breslow thickness, clearance of excision. RESULTS--42 patients had malignant melanomas excised by general practitioners in 1982-91: 15 in 1982-9 and 27 in 1990-1. These patients were significantly younger than those who had their tumours excised initially in hospital. Although the longest diameter of melanomas excised by general practitioners was significantly less than of those excised in hospital, the Breslow thicknesses were similar. Completeness of initial excision was doubtful or incomplete in nine (23%) general practitioner excisions compared with 4% of hospital excisions, but the time interval between excision biopsy and wide excision was similar. Pathology requests accompanying excision biopsies mentioned melanoma as a possible diagnosis in 15% (6/40) of general practitioner cases compared with 79% of hospital cases. Thirty nine general practitioners responded to a questionnaire and only 12 had considered melanoma in the differential diagnosis. CONCLUSIONS--General practitioners need to think more often of malignant melanoma when they excise pigmented lesions and when they consider this tumour a possibility should perform an excision biopsy with a lateral clearance of at least 2 mm.     

Squamous cell carcinoma of the parotid gland

Squamous cell carcinoma involving the parotid gland is an aggressive and rapidly advancing lesion which if not recognized and treated early will result in a high morbidity and mortality. We reviewed 30 patients with squamous cell carcinoma involving the parotid gland. Twenty-four patients had had previous epidermoid skin lesions in an area known to drain to the parotid gland and three resulted from direct extension into the gland from an overlying skin carcinoma, whereas only three were primary lesions of the gland. Patients who presented with involvement of the gland more than 4 months after excision of the skin lesion had a poor prognosis. Patients with epidermoid skin cancer in areas with a propensity to secondarily involve the parotid gland must be closely followed after treatment of the primary skin lesion.     

Mohs' micrographic surgery of the head and neck.

Mohs'' micrographic surgery, a method originally developed in the 1930s to remove contiguously spreading cutaneous cancers under precise microscopic control, has emerged as the most reliable method for removing certain primary, incompletely excised, and recurrent basal cell and squamous cell carcinomas. Indications for its use have expanded to include many other cutaneous and noncutaneous neoplasms. Usually done as an outpatient procedure and using local anesthesia, a layer of tissue is excised, mapped in relation to the site of removal, sectioned horizontally, and examined for the presence of residual tumor. This sequence is repeated, removing only tissue that contains residual tumor, until a margin completely free of cancer is reached. Extremely high cure rates are achieved, and surrounding tissue is maximally conserved for wound repair.     

Telomerase activity levels in the surgical margin and tumour distant tissue of the squamous cell carcinoma of the head-and-neck.

The survival of patients with a head-and-neck squamous cell carcinoma is determined by loco-regional recurrence and second primary carcinomas. As a complement to histopathology, molecular changes of tumour marginal and tumour distant tissue may confirm curative surgical tumour extirpation. We tested telomerase activity with PCR-ELISA kits.20 tumour margin biopsies were chosen by the surgeon from 20 patients. In addition, 3 tissue samples were taken from each of 20 additional patients, one from the carcinoma centre, the tumour margin and one distant from the tumour. 50% of the carcinoma centres were telomerase-positive. Thirteen of the 40 tumour margin samples showed increased telomerase levels, and in 3 of these residual carcinoma was histopathologically detected. Six of the 20 tumour distant tissues revealed increased telomerase levels. Telomerase positivity in carcinoma-free tumour margins correlated with a good prognosis. Confirmation of the results in a larger patient group is needed.