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Determining useful predictors for management decisions in basal cell carcinoma
3785
2480
Correlation between microscopic localization of inflammation in frozen sections and subsequent site of nonmelanoma skin cancer Ramya Tripuraneni, MD, Northwestern University, Chicago, IL, United States; Misbah Khan, MD, Northwestern University, Chicago, IL, United States; Arthur Flores, MD, Northwestern University, Chicago, IL, United States; Meghan Dubina, MD, Northwestern University, Chicago, IL, United States; Emir Veledar, PhD, Emory University, Atlanta, GA, United States; Murad Alam, MD, Northwestern University, Chicago, IL, United States Background: During Mohs micrographic surgery of nonmelanoma skin cancer (NMSC), inflammation present in histologic frozen sections has been found to occasionally presage detection of tumor on frozen sections of adjacent excision specimens. Previous work has indicated that inflammation can precede detection of additional tumor; the relationship between the microscopic location of the inflammation and the site of the additional tumor has yet to be elucidated.
Description and approach to a rare case of linear pigmented basal cell carcinoma Flavia Bittencourt, Faculdade de Medicina do ABC, S~ao Paulo, Brazil; Juliana Weis, Faculdade de Medicina do ABC, S~ao Paulo, Brazil; Francisco Paschoal, Faculdae de Medicina do ABC, Santo Andre, Brazil; Carlos D’Apparecida Machado, Faculdade de Medicina do ABC, S~ao Paulo, Brazil; Caio Parente Barbosa, Faculdade de Medicina do ABC, Santo Andre, Brazil The linear basal cell carcinoma was first described by Lewis in 1985. It is a rare and distinct morphology variant. Since 1985, only 37 cases have been reported. The periocular region was the most affected, especially the lower eyelid and malar region, and they were followed by cervical and trunk. It occurs in equal proportion of men and women aged 40-87 years being 92% over 60 years. The case to be presented is a 47-year-old female patient, phototype III. The dermatologic examination detected a 2 years old lesion which was 2 cm long (in its longest axis) linear pigmented, in the left periocular region. Coloring from erythematous to gray, lightly pearled edges, precise limits. The patient denied symptoms and local trauma. The dermatoscopic examination concluded the absence of diagnostic criteria for a melanocytic lesion, presence of gray ovoid nests and sheet structures, characteristics consistent with basal cell carcinoma. Then it was held a confocal microscopy which showed blocks of basaloid cells, gap between the blocks and peripheral basaloid with the presence of large vessels and high flow. For treatment of the injury, it was decided to perform Mohs micrographic surgery, with complete resolution of the clinical picture. In histologic sections were shown features of nodular subtype of pigmented basal cell carcinoma. The case report describes a rare form of pigmented basal cell carcinoma, with characteristics that corroborate data found in literature. The dermoscopy allowed ascertain the ovoid nests, spider veins and leaf structures. Confocal microscopy showed tumor island and the palisade cells, allowing a more detailed analysis of the injury, aiding in the diagnosis and enabling better surgical planning. The surgical technique used was recommended by the literature: Mohs micrographic surgery. The histologic sections showed nodular subtype, which corresponds to the described subtype followed by pigmented (in 17 cases of BCC linear periocular only 2 were pigmented).
Objective: To quantify the correlation between the location of inflammation without visible tumor on histologic frozen section and the location of subsequently detected NMSC. Methods: In an urban academic medical center, from the period of June 2008 to October 2009, a retrospective cohort study was carried out. Two independent investigators reviewed glass slides and medical records pertaining to frozen sections associated with the staged excision of NMSC. Each clock-faced stage of Mohs was measured as (1) the proportion of cases with inflammation at this location that subsequently had tumor at the same location; (2) the proportion of cases that had neither inflammation nor subsequent tumor at the same location; (3) the probability of subsequent tumor at this location given that inflammation was previously seen at the same location; and (4) the probability that in the absence of preexisting inflammation at this location, the location was clear of tumor. Results: Of the 3148 NMSC cases that were reviewed, 60 cases that exhibited inflammation on histologic frozen section of an excision specimen were followed by tumor in the subsequent excision specimen. There was a significant positive correlation between the presence of inflammation and the presence of nearby tumor at 6 of 12 segments (Pearson correlations, P \ .05), with correlation coefficients from 0.196-0.323. The probability that tumor was absent when inflammation was not seen in preceding sections was 91%, with segment-specific values from 82-96%.
Commercial support: None identified.
Conclusion: During Mohs micrographic surgery of NMSC with frozen sections, presence of histologic inflammation is modestly predictive of adjacent tumor, but lack of inflammation is a strong predictor that no additional tumor will be found. Commercial support: None identified.
2914
3783 Cutaneous squamous cell carcinoma with invasion through ear cartilage Julie Boisen, University of Texas Medical Branch at Galveston, Galveston, TX, United States; C. Helen Malone, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States; Richard Wagner, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States; Brent Kelly, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States Cutaneous squamous cell carcinoma (cSCC) of the ear represents a high-risk tumor location with an increased risk of metastasis and local tissue invasion. It is uncommon for these cancers to invade through nearby cartilage. A 76-year-old man presented to the dermatology department with a nonhealing tumor on the anterior aspect of his left superior ear with symptoms including pain and bleeding. A diagnostic biopsy showed a moderately differentiated squamous cell carcinoma. Following curettage, a small full thickness defect in the cartilage of the left scapha could be seen. Permanent sections through the eroded cartilage revealed tumor invasion into the posterior ear skin. Although a uniform definition of high-risk cSCC does not exist, several key features are consistently considered high-risk. These risk factors include clinical tumor size, location, tumor invasion depth, rate of tumor growth, tumor recurrence, degree of cytologic differentiation, presence of perineural invasion by tumor, and histologic subtype. Invasion by high-risk tumors is facilitated by matrix metalloproteases (MMP), specifically MMP-13 (collagenase 3) which preferentially degrades type II collagen found in cartilage. MMP-13 is expressed in malignant keratinocytes found in cSCC. Primary squamous cell carcinoma of the ear has a metastatic rate of approximately 15.5%. Cartilage destruction is a significant risk factor for metastatic disease. Tumor depth, large nerve perineural tumor invasion, and tumor diameter are the most important prognostic factors for determining risk of local recurrence and metastasis. Elective neck dissection or sentinel lymph node biopsy may be used to evaluate for metastases, however this issue is controversial. Histopathologic confirmation of a primary cSCC of the anterior ear with full thickness cartilage invasion extending to the posterior auricular skin appears to represent an interesting addition to the dermatology literature. Commercial support: None identified.
MAY 2016
Determining useful predictors for management decisions in basal cell carcinoma Benjamin Rostami, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Scott Worswick, MD, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States; Chandra Smart, MD, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States; Nicholas Jackson, MPH, Department of Medicine Statistics Core, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States; Carolyn Goh, MD, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States Background: Basal cell carcinoma (BCC) is a common skin cancer that affects 3 out of 10 whites in the US. BCCs are categorized histologically and can be treated invasively, with excision, Mohs micrographic surgery (MMS), or surgery, or conservatively, with electrodessication and curettage (EDC), topical chemotherapeutics, radiation, or cryosurgery. Objectives: To determine if age, sex, biopsy margin status, lesion location (areas H, M, L as from the MMS appropriate use criteria), and BCC subtype are useful predictors of which treatment to pursue. Methods: A retrospective chart review was done of 499 cases of BCC at the UCLA dermatology clinics from 2014. A logistic regression model was applied to examine how age, sex, margin status, location, and BCC subtype predict treatment route. Results: 26 cases were eliminated due to lack of information. Of the remaining 473, 87 had excisions, 290 had MMS, 9 had surgery, 57 had EDC, 20 used topical therapy, 5 had radiation, and 2 had cryosurgery. Increasing age was found to significantly increase the probability of having an invasive procedure; for every year of age the odds increased by 3%. There was no difference in management between men and women. Due to low variability in margin status such that only three had clear margins, this variable could not be analyzed. Of those with positive margins, 42% of cases treated with excision or MMS had no residual tumor. 95% of lesions from Area H, 61% from Area M, and 90% from Area L were treated invasively. Nodular and aggressive types of BCC were 7-9 times more likely to be treated invasively relative to the superficial type (P \.0001). Conclusion: Younger patients may be less likely to opt for invasive procedures due to aesthetic concerns. While our data indicate adherence to the MMS appropriate use criteria at UCLA, the discrepancy between the guidelines and our findings for area M are likely also the result of aesthetic considerations, as patients might be less willing to have a scar in an M area, which is usually exposed. As such, patients’ concerns about aesthetics provide a reason that a shift away from the suggested guidelines to treating BCC might be considered. Lastly, pathologic reporting of margin status was found to have no bearing on treatment decision-making or outcomes, and does not appear to be necessary. Instead, histopathologic subtyping does appear to guide clinician decision-making. Commercial support: None identified.
J AM ACAD DERMATOL
AB195
2480
Correlation between microscopic localization of inflammation in frozen sections and subsequent site of nonmelanoma skin cancer Ramya Tripuraneni, MD, Northwestern University, Chicago, IL, United States; Misbah Khan, MD, Northwestern University, Chicago, IL, United States; Arthur Flores, MD, Northwestern University, Chicago, IL, United States; Meghan Dubina, MD, Northwestern University, Chicago, IL, United States; Emir Veledar, PhD, Emory University, Atlanta, GA, United States; Murad Alam, MD, Northwestern University, Chicago, IL, United States Background: During Mohs micrographic surgery of nonmelanoma skin cancer (NMSC), inflammation present in histologic frozen sections has been found to occasionally presage detection of tumor on frozen sections of adjacent excision specimens. Previous work has indicated that inflammation can precede detection of additional tumor; the relationship between the microscopic location of the inflammation and the site of the additional tumor has yet to be elucidated.
Description and approach to a rare case of linear pigmented basal cell carcinoma Flavia Bittencourt, Faculdade de Medicina do ABC, S~ao Paulo, Brazil; Juliana Weis, Faculdade de Medicina do ABC, S~ao Paulo, Brazil; Francisco Paschoal, Faculdae de Medicina do ABC, Santo Andre, Brazil; Carlos D’Apparecida Machado, Faculdade de Medicina do ABC, S~ao Paulo, Brazil; Caio Parente Barbosa, Faculdade de Medicina do ABC, Santo Andre, Brazil The linear basal cell carcinoma was first described by Lewis in 1985. It is a rare and distinct morphology variant. Since 1985, only 37 cases have been reported. The periocular region was the most affected, especially the lower eyelid and malar region, and they were followed by cervical and trunk. It occurs in equal proportion of men and women aged 40-87 years being 92% over 60 years. The case to be presented is a 47-year-old female patient, phototype III. The dermatologic examination detected a 2 years old lesion which was 2 cm long (in its longest axis) linear pigmented, in the left periocular region. Coloring from erythematous to gray, lightly pearled edges, precise limits. The patient denied symptoms and local trauma. The dermatoscopic examination concluded the absence of diagnostic criteria for a melanocytic lesion, presence of gray ovoid nests and sheet structures, characteristics consistent with basal cell carcinoma. Then it was held a confocal microscopy which showed blocks of basaloid cells, gap between the blocks and peripheral basaloid with the presence of large vessels and high flow. For treatment of the injury, it was decided to perform Mohs micrographic surgery, with complete resolution of the clinical picture. In histologic sections were shown features of nodular subtype of pigmented basal cell carcinoma. The case report describes a rare form of pigmented basal cell carcinoma, with characteristics that corroborate data found in literature. The dermoscopy allowed ascertain the ovoid nests, spider veins and leaf structures. Confocal microscopy showed tumor island and the palisade cells, allowing a more detailed analysis of the injury, aiding in the diagnosis and enabling better surgical planning. The surgical technique used was recommended by the literature: Mohs micrographic surgery. The histologic sections showed nodular subtype, which corresponds to the described subtype followed by pigmented (in 17 cases of BCC linear periocular only 2 were pigmented).
Objective: To quantify the correlation between the location of inflammation without visible tumor on histologic frozen section and the location of subsequently detected NMSC. Methods: In an urban academic medical center, from the period of June 2008 to October 2009, a retrospective cohort study was carried out. Two independent investigators reviewed glass slides and medical records pertaining to frozen sections associated with the staged excision of NMSC. Each clock-faced stage of Mohs was measured as (1) the proportion of cases with inflammation at this location that subsequently had tumor at the same location; (2) the proportion of cases that had neither inflammation nor subsequent tumor at the same location; (3) the probability of subsequent tumor at this location given that inflammation was previously seen at the same location; and (4) the probability that in the absence of preexisting inflammation at this location, the location was clear of tumor. Results: Of the 3148 NMSC cases that were reviewed, 60 cases that exhibited inflammation on histologic frozen section of an excision specimen were followed by tumor in the subsequent excision specimen. There was a significant positive correlation between the presence of inflammation and the presence of nearby tumor at 6 of 12 segments (Pearson correlations, P \ .05), with correlation coefficients from 0.196-0.323. The probability that tumor was absent when inflammation was not seen in preceding sections was 91%, with segment-specific values from 82-96%.
Commercial support: None identified.
Conclusion: During Mohs micrographic surgery of NMSC with frozen sections, presence of histologic inflammation is modestly predictive of adjacent tumor, but lack of inflammation is a strong predictor that no additional tumor will be found. Commercial support: None identified.
2914
3783 Cutaneous squamous cell carcinoma with invasion through ear cartilage Julie Boisen, University of Texas Medical Branch at Galveston, Galveston, TX, United States; C. Helen Malone, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States; Richard Wagner, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States; Brent Kelly, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States Cutaneous squamous cell carcinoma (cSCC) of the ear represents a high-risk tumor location with an increased risk of metastasis and local tissue invasion. It is uncommon for these cancers to invade through nearby cartilage. A 76-year-old man presented to the dermatology department with a nonhealing tumor on the anterior aspect of his left superior ear with symptoms including pain and bleeding. A diagnostic biopsy showed a moderately differentiated squamous cell carcinoma. Following curettage, a small full thickness defect in the cartilage of the left scapha could be seen. Permanent sections through the eroded cartilage revealed tumor invasion into the posterior ear skin. Although a uniform definition of high-risk cSCC does not exist, several key features are consistently considered high-risk. These risk factors include clinical tumor size, location, tumor invasion depth, rate of tumor growth, tumor recurrence, degree of cytologic differentiation, presence of perineural invasion by tumor, and histologic subtype. Invasion by high-risk tumors is facilitated by matrix metalloproteases (MMP), specifically MMP-13 (collagenase 3) which preferentially degrades type II collagen found in cartilage. MMP-13 is expressed in malignant keratinocytes found in cSCC. Primary squamous cell carcinoma of the ear has a metastatic rate of approximately 15.5%. Cartilage destruction is a significant risk factor for metastatic disease. Tumor depth, large nerve perineural tumor invasion, and tumor diameter are the most important prognostic factors for determining risk of local recurrence and metastasis. Elective neck dissection or sentinel lymph node biopsy may be used to evaluate for metastases, however this issue is controversial. Histopathologic confirmation of a primary cSCC of the anterior ear with full thickness cartilage invasion extending to the posterior auricular skin appears to represent an interesting addition to the dermatology literature. Commercial support: None identified.
MAY 2016
Determining useful predictors for management decisions in basal cell carcinoma Benjamin Rostami, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Scott Worswick, MD, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States; Chandra Smart, MD, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States; Nicholas Jackson, MPH, Department of Medicine Statistics Core, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States; Carolyn Goh, MD, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States Background: Basal cell carcinoma (BCC) is a common skin cancer that affects 3 out of 10 whites in the US. BCCs are categorized histologically and can be treated invasively, with excision, Mohs micrographic surgery (MMS), or surgery, or conservatively, with electrodessication and curettage (EDC), topical chemotherapeutics, radiation, or cryosurgery. Objectives: To determine if age, sex, biopsy margin status, lesion location (areas H, M, L as from the MMS appropriate use criteria), and BCC subtype are useful predictors of which treatment to pursue. Methods: A retrospective chart review was done of 499 cases of BCC at the UCLA dermatology clinics from 2014. A logistic regression model was applied to examine how age, sex, margin status, location, and BCC subtype predict treatment route. Results: 26 cases were eliminated due to lack of information. Of the remaining 473, 87 had excisions, 290 had MMS, 9 had surgery, 57 had EDC, 20 used topical therapy, 5 had radiation, and 2 had cryosurgery. Increasing age was found to significantly increase the probability of having an invasive procedure; for every year of age the odds increased by 3%. There was no difference in management between men and women. Due to low variability in margin status such that only three had clear margins, this variable could not be analyzed. Of those with positive margins, 42% of cases treated with excision or MMS had no residual tumor. 95% of lesions from Area H, 61% from Area M, and 90% from Area L were treated invasively. Nodular and aggressive types of BCC were 7-9 times more likely to be treated invasively relative to the superficial type (P \.0001). Conclusion: Younger patients may be less likely to opt for invasive procedures due to aesthetic concerns. While our data indicate adherence to the MMS appropriate use criteria at UCLA, the discrepancy between the guidelines and our findings for area M are likely also the result of aesthetic considerations, as patients might be less willing to have a scar in an M area, which is usually exposed. As such, patients’ concerns about aesthetics provide a reason that a shift away from the suggested guidelines to treating BCC might be considered. Lastly, pathologic reporting of margin status was found to have no bearing on treatment decision-making or outcomes, and does not appear to be necessary. Instead, histopathologic subtyping does appear to guide clinician decision-making. Commercial support: None identified.
J AM ACAD DERMATOL
AB195