Aesthetic Dermatology

SAN DIEGO — End-to-side anastomosis to the internal jugular vein in head and neck reconstruction has many technical advantages compared with end-to-end anastomosis, Dr. Eric G. Halvorson reported during a poster session at the annual meeting of the American Head and Neck Society.

One advantage is the fact that the internal jugular vein "is usually present and already dissected by the resecting team," Dr. Halvorson said in an interview. "It has a large caliber and excellent patency rate in most series of patients undergoing reconstruction. Multiple venotomies can be made of any size, and at any place along the entire length of the internal jugular vein.

"Theoretical advantages include the respiratory venous pump effect and the high flow, which may wash away microthrombi," he added.

Dr. Halvorson based his remarks on a study of 320 patients (mean age, 56 years) who underwent free tissue transfer for head and neck reconstruction of oncologic defects with end-to-side anastomosis to the internal jugular vein.

The procedures were performed by Dr. Halvorson's associate, Dr. Peter G. Cordeiro, at Memorial Sloan-Kettering Cancer Center, New York, between 1996 and 2006.

Patients received intravenous heparin before flap harvest and took aspirin for 5 days postoperatively. All of the procedures were performed with 9–0 nylon continuous suture.

The types of flaps that were most commonly used were the rectus flap (33%), the forearm flap (28%), and the fibula flap (21%), said Dr. Halvorson, who conducted the study during his fellowship in reconstructive microsurgery at Memorial Sloan-Kettering Cancer Center.

The mandible with or without floor of mouth was the most common recipient site (27%), followed by the pharyngoesophagus (25%), the tongue (17%), and the cheek (17%).

Dr. Halvorson reported that problems with minor wound healing occurred in 5% of patients, whereas hematoma and death occurred in slightly less than 3% of patients.

Partial flap loss occurred in 2% of patients, whereas total flap loss, arterial thrombosis, and venous thrombosis occurred in fewer than 1% of patients.

The researchers concluded that "the size, constant anatomy, availability, patency, and possibility for multiple anastomoses of any size at any site along its course in the neck make use of the internal jugular vein very advantageous for venous anastomosis during head and neck free tissue transfer."

Dr. Halvorson is now a plastic surgeon at the University of North Carolina, Chapel Hill.

Reconstruction using a radial forearm flap is performed with end-to-side anastomosis to the internal jugular vein. Courtesy Dr. Eric G. Halvorson

SAN DIEGO — End-to-side anastomosis to the internal jugular vein in head and neck reconstruction has many technical advantages compared with end-to-end anastomosis, Dr. Eric G. Halvorson reported during a poster session at the annual meeting of the American Head and Neck Society.

One advantage is the fact that the internal jugular vein "is usually present and already dissected by the resecting team," Dr. Halvorson said in an interview. "It has a large caliber and excellent patency rate in most series of patients undergoing reconstruction. Multiple venotomies can be made of any size, and at any place along the entire length of the internal jugular vein.

"Theoretical advantages include the respiratory venous pump effect and the high flow, which may wash away microthrombi," he added.

Dr. Halvorson based his remarks on a study of 320 patients (mean age, 56 years) who underwent free tissue transfer for head and neck reconstruction of oncologic defects with end-to-side anastomosis to the internal jugular vein.

The procedures were performed by Dr. Halvorson's associate, Dr. Peter G. Cordeiro, at Memorial Sloan-Kettering Cancer Center, New York, between 1996 and 2006.

Patients received intravenous heparin before flap harvest and took aspirin for 5 days postoperatively. All of the procedures were performed with 9–0 nylon continuous suture.

The types of flaps that were most commonly used were the rectus flap (33%), the forearm flap (28%), and the fibula flap (21%), said Dr. Halvorson, who conducted the study during his fellowship in reconstructive microsurgery at Memorial Sloan-Kettering Cancer Center.

The mandible with or without floor of mouth was the most common recipient site (27%), followed by the pharyngoesophagus (25%), the tongue (17%), and the cheek (17%).

Dr. Halvorson reported that problems with minor wound healing occurred in 5% of patients, whereas hematoma and death occurred in slightly less than 3% of patients.

Partial flap loss occurred in 2% of patients, whereas total flap loss, arterial thrombosis, and venous thrombosis occurred in fewer than 1% of patients.

The researchers concluded that "the size, constant anatomy, availability, patency, and possibility for multiple anastomoses of any size at any site along its course in the neck make use of the internal jugular vein very advantageous for venous anastomosis during head and neck free tissue transfer."

Dr. Halvorson is now a plastic surgeon at the University of North Carolina, Chapel Hill.

Reconstruction using a radial forearm flap is performed with end-to-side anastomosis to the internal jugular vein. Courtesy Dr. Eric G. Halvorson

SAN DIEGO — End-to-side anastomosis to the internal jugular vein in head and neck reconstruction has many technical advantages compared with end-to-end anastomosis, Dr. Eric G. Halvorson reported during a poster session at the annual meeting of the American Head and Neck Society.

One advantage is the fact that the internal jugular vein "is usually present and already dissected by the resecting team," Dr. Halvorson said in an interview. "It has a large caliber and excellent patency rate in most series of patients undergoing reconstruction. Multiple venotomies can be made of any size, and at any place along the entire length of the internal jugular vein.

"Theoretical advantages include the respiratory venous pump effect and the high flow, which may wash away microthrombi," he added.

Dr. Halvorson based his remarks on a study of 320 patients (mean age, 56 years) who underwent free tissue transfer for head and neck reconstruction of oncologic defects with end-to-side anastomosis to the internal jugular vein.

The procedures were performed by Dr. Halvorson's associate, Dr. Peter G. Cordeiro, at Memorial Sloan-Kettering Cancer Center, New York, between 1996 and 2006.

Patients received intravenous heparin before flap harvest and took aspirin for 5 days postoperatively. All of the procedures were performed with 9–0 nylon continuous suture.

The types of flaps that were most commonly used were the rectus flap (33%), the forearm flap (28%), and the fibula flap (21%), said Dr. Halvorson, who conducted the study during his fellowship in reconstructive microsurgery at Memorial Sloan-Kettering Cancer Center.

The mandible with or without floor of mouth was the most common recipient site (27%), followed by the pharyngoesophagus (25%), the tongue (17%), and the cheek (17%).

Dr. Halvorson reported that problems with minor wound healing occurred in 5% of patients, whereas hematoma and death occurred in slightly less than 3% of patients.

Partial flap loss occurred in 2% of patients, whereas total flap loss, arterial thrombosis, and venous thrombosis occurred in fewer than 1% of patients.

The researchers concluded that "the size, constant anatomy, availability, patency, and possibility for multiple anastomoses of any size at any site along its course in the neck make use of the internal jugular vein very advantageous for venous anastomosis during head and neck free tissue transfer."

Dr. Halvorson is now a plastic surgeon at the University of North Carolina, Chapel Hill.

Reconstruction using a radial forearm flap is performed with end-to-side anastomosis to the internal jugular vein. Courtesy Dr. Eric G. Halvorson

SANTA ANA PUEBLO, N.M. — Curettage followed by imiquimod therapy continues to show promise at 2 years as a way to treat nodular and superficial basal cell carcinoma, Dr. Darrell S. Rigel said at a meeting of the American Society for Mohs Surgery.

In a study that he and his associates first presented at the 2006 annual meeting of the American Academy of Dermatology, the researchers performed curettage on 57 patients who had nodular and superficial basal cell carcinomas. A week after curettage treatment, the patients were asked to apply imiquimod to the lesions five times a week for a total of 6 weeks.

After 1 year there were no disease recurrences. Mild hypopigmentation occurred at the site of about half of the lesions but overall the cosmetic results "were excellent," said Dr. Rigel, who is in private practice in New York. "The cosmetic results were superior to curettage and electrodesiccation," he said, adding that the study was limited to one lesion per patient.

At 2 years' follow-up, there remain no recurrences in the patients. "Combination therapy is going to change the way we're treating a lot of these lesions in the future," said Dr. Rigel, who is also president-elect of the American Society for Dermatologic Surgery. He noted that 60% of recurrent basal cell carcinomas clinically appear within 1 year of treatment. At 2 years, 90% of clinical recurrences will appear.

Dr. Rigel disclosed that he has served as a paid adviser and investigator for 3M Graceway Pharmaceuticals, Doak Dermatologics (a subsidiary of Bradley Pharmaceuticals Inc.), and DUSA Pharmaceuticals Inc.

SANTA ANA PUEBLO, N.M. — Curettage followed by imiquimod therapy continues to show promise at 2 years as a way to treat nodular and superficial basal cell carcinoma, Dr. Darrell S. Rigel said at a meeting of the American Society for Mohs Surgery.

In a study that he and his associates first presented at the 2006 annual meeting of the American Academy of Dermatology, the researchers performed curettage on 57 patients who had nodular and superficial basal cell carcinomas. A week after curettage treatment, the patients were asked to apply imiquimod to the lesions five times a week for a total of 6 weeks.

After 1 year there were no disease recurrences. Mild hypopigmentation occurred at the site of about half of the lesions but overall the cosmetic results "were excellent," said Dr. Rigel, who is in private practice in New York. "The cosmetic results were superior to curettage and electrodesiccation," he said, adding that the study was limited to one lesion per patient.

At 2 years' follow-up, there remain no recurrences in the patients. "Combination therapy is going to change the way we're treating a lot of these lesions in the future," said Dr. Rigel, who is also president-elect of the American Society for Dermatologic Surgery. He noted that 60% of recurrent basal cell carcinomas clinically appear within 1 year of treatment. At 2 years, 90% of clinical recurrences will appear.

Dr. Rigel disclosed that he has served as a paid adviser and investigator for 3M Graceway Pharmaceuticals, Doak Dermatologics (a subsidiary of Bradley Pharmaceuticals Inc.), and DUSA Pharmaceuticals Inc.

SANTA ANA PUEBLO, N.M. — Curettage followed by imiquimod therapy continues to show promise at 2 years as a way to treat nodular and superficial basal cell carcinoma, Dr. Darrell S. Rigel said at a meeting of the American Society for Mohs Surgery.

In a study that he and his associates first presented at the 2006 annual meeting of the American Academy of Dermatology, the researchers performed curettage on 57 patients who had nodular and superficial basal cell carcinomas. A week after curettage treatment, the patients were asked to apply imiquimod to the lesions five times a week for a total of 6 weeks.

After 1 year there were no disease recurrences. Mild hypopigmentation occurred at the site of about half of the lesions but overall the cosmetic results "were excellent," said Dr. Rigel, who is in private practice in New York. "The cosmetic results were superior to curettage and electrodesiccation," he said, adding that the study was limited to one lesion per patient.

At 2 years' follow-up, there remain no recurrences in the patients. "Combination therapy is going to change the way we're treating a lot of these lesions in the future," said Dr. Rigel, who is also president-elect of the American Society for Dermatologic Surgery. He noted that 60% of recurrent basal cell carcinomas clinically appear within 1 year of treatment. At 2 years, 90% of clinical recurrences will appear.

Dr. Rigel disclosed that he has served as a paid adviser and investigator for 3M Graceway Pharmaceuticals, Doak Dermatologics (a subsidiary of Bradley Pharmaceuticals Inc.), and DUSA Pharmaceuticals Inc.

AMSTERDAM — There has been "very little good quality research" overall on treatments for basal cell carcinoma, according to the latest Cochrane Systematic Review on the topic.

This is particularly hard to fathom since basal cell carcinoma (BCC) is the most common form of cancer in humans and an enormous volume of physician work is devoted to its treatment, Fiona J. Bath-Hextall, Ph.D., the review's lead author, noted at the 11th World Congress on Cancers of the Skin.

The review encompassed 27 published and unpublished randomized controlled trials involving surgical excision, radiotherapy, cryotherapy, photodynamic therapy (PDT), intralesional interferon, the plant-derived mixture of solasodine glycosides known as BEC-5 cream, topical 5-fluorouracil, and imiquimod.

The clear winners in terms of efficacy as reflected in the primary end point adopted for the review—BCC recurrence rates at 3–5 years—were surgery and radiotherapy. And in the sole head-to-head comparative trial of these two therapies, surgery had significantly fewer residual tumors and histologically proven recurrences as well as consistently better cosmetic outcomes than radiotherapy, said Dr. Bath-Hextall of the University of Nottingham (England).

Few of the other therapies have been compared directly with surgery, which is the most widely used form of treatment as well as the one supported by the strongest evidence of efficacy.

Most of the clinical trials involved only BCCs in low-risk locations. Only one focused on high-risk facial BCCs. Moreover, many of the studies didn't make it clear what type of BCC was included. Nor did most trials consider recurrent or morpheic BCCs separately, as is warranted given their lower treatment success rates.

Although the seven PDT trials included in the review collectively indicate that it is a promising modality with cosmetic outcomes significantly better than surgery, PDT also has a relatively high failure rate and is expensive. Longer-term efficacy data are needed before it is appropriate for PDT to enter routine clinical practice, according to the Cochrane reviewers (Cochrane Database Syst. Rev. 2007 Jan. 24;CD003412).

Eight of nine studies on imiquimod for BCCs were industry sponsored. They suggest an 88% success rate for a once-daily 6-week regimen in superficial BCC and a more modest 76% treatment response in nodular BCC with 12 weeks of therapy. An ongoing trial of imiquimod versus surgery should help determine whether the topical therapy is a useful option, the reviewers said.

Dr. Bath-Hextall also presented a first look at a new Cochrane Systematic Review of interventions for prevention of nonmelanoma skin cancers in high-risk groups, namely organ transplant recipients and patients with xeroderma pigmentosa or a history of prior nonmelanoma skin cancers. Ten published randomized studies totalling more than 7,200 participants were identified. Only one focused on xeroderma pigmentosa: The 30-patient trial showed reductions in new actinic keratoses and BCCs during 1 year of topical T4N5, a repair enzyme specific for UV-induced DNA damage.

Several studies demonstrated preventive efficacy for retinoids. One study of a 24-month low-fat diet showed no difference in the rate of nonmelanoma skin cancer in year 1, versus controls, but a trend for fewer tumors in years 2–5, Dr. Bath-Hextall said at the congress, cosponsored by the Skin Cancer Foundation and Erasmus University, Rotterdam.

One particularly intriguing trial, she continued, involved more than 1,300 patients with a history of nonmelanoma skin cancer who were randomized in double-blind fashion to 10 years of supplemental selenium or placebo. The selenium group showed a nonsignificant increase in skin cancers, but a highly significant 37% reduction in nonskin cancers, including marked reductions in lung, colorectal, and prostate cancer and an adjusted 21% reduction in all-cause mortality (JAMA 1996;276:1957–63).

Audience members expressed puzzlement at selenium's divergent impacts on skin and internal malignancies. This prompted session chairman Dr. H.A. Martino Neumann, professor of dermatology and venereology at Erasmus, to propose an explanation: Perhaps participation in this study of an oral agent for skin cancer prevention caused some patients to feel a false sense of confidence and become more casual about sun protection.

In the sole head-to-head comparison of surgery and radiotherapy, surgery had fewer residual tumors. DR. BATH-HEXTALL

AMSTERDAM — There has been "very little good quality research" overall on treatments for basal cell carcinoma, according to the latest Cochrane Systematic Review on the topic.

This is particularly hard to fathom since basal cell carcinoma (BCC) is the most common form of cancer in humans and an enormous volume of physician work is devoted to its treatment, Fiona J. Bath-Hextall, Ph.D., the review's lead author, noted at the 11th World Congress on Cancers of the Skin.

The review encompassed 27 published and unpublished randomized controlled trials involving surgical excision, radiotherapy, cryotherapy, photodynamic therapy (PDT), intralesional interferon, the plant-derived mixture of solasodine glycosides known as BEC-5 cream, topical 5-fluorouracil, and imiquimod.

The clear winners in terms of efficacy as reflected in the primary end point adopted for the review—BCC recurrence rates at 3–5 years—were surgery and radiotherapy. And in the sole head-to-head comparative trial of these two therapies, surgery had significantly fewer residual tumors and histologically proven recurrences as well as consistently better cosmetic outcomes than radiotherapy, said Dr. Bath-Hextall of the University of Nottingham (England).

Few of the other therapies have been compared directly with surgery, which is the most widely used form of treatment as well as the one supported by the strongest evidence of efficacy.

Most of the clinical trials involved only BCCs in low-risk locations. Only one focused on high-risk facial BCCs. Moreover, many of the studies didn't make it clear what type of BCC was included. Nor did most trials consider recurrent or morpheic BCCs separately, as is warranted given their lower treatment success rates.

Although the seven PDT trials included in the review collectively indicate that it is a promising modality with cosmetic outcomes significantly better than surgery, PDT also has a relatively high failure rate and is expensive. Longer-term efficacy data are needed before it is appropriate for PDT to enter routine clinical practice, according to the Cochrane reviewers (Cochrane Database Syst. Rev. 2007 Jan. 24;CD003412).

Eight of nine studies on imiquimod for BCCs were industry sponsored. They suggest an 88% success rate for a once-daily 6-week regimen in superficial BCC and a more modest 76% treatment response in nodular BCC with 12 weeks of therapy. An ongoing trial of imiquimod versus surgery should help determine whether the topical therapy is a useful option, the reviewers said.

Dr. Bath-Hextall also presented a first look at a new Cochrane Systematic Review of interventions for prevention of nonmelanoma skin cancers in high-risk groups, namely organ transplant recipients and patients with xeroderma pigmentosa or a history of prior nonmelanoma skin cancers. Ten published randomized studies totalling more than 7,200 participants were identified. Only one focused on xeroderma pigmentosa: The 30-patient trial showed reductions in new actinic keratoses and BCCs during 1 year of topical T4N5, a repair enzyme specific for UV-induced DNA damage.

Several studies demonstrated preventive efficacy for retinoids. One study of a 24-month low-fat diet showed no difference in the rate of nonmelanoma skin cancer in year 1, versus controls, but a trend for fewer tumors in years 2–5, Dr. Bath-Hextall said at the congress, cosponsored by the Skin Cancer Foundation and Erasmus University, Rotterdam.

One particularly intriguing trial, she continued, involved more than 1,300 patients with a history of nonmelanoma skin cancer who were randomized in double-blind fashion to 10 years of supplemental selenium or placebo. The selenium group showed a nonsignificant increase in skin cancers, but a highly significant 37% reduction in nonskin cancers, including marked reductions in lung, colorectal, and prostate cancer and an adjusted 21% reduction in all-cause mortality (JAMA 1996;276:1957–63).

Audience members expressed puzzlement at selenium's divergent impacts on skin and internal malignancies. This prompted session chairman Dr. H.A. Martino Neumann, professor of dermatology and venereology at Erasmus, to propose an explanation: Perhaps participation in this study of an oral agent for skin cancer prevention caused some patients to feel a false sense of confidence and become more casual about sun protection.

In the sole head-to-head comparison of surgery and radiotherapy, surgery had fewer residual tumors. DR. BATH-HEXTALL

AMSTERDAM — There has been "very little good quality research" overall on treatments for basal cell carcinoma, according to the latest Cochrane Systematic Review on the topic.

This is particularly hard to fathom since basal cell carcinoma (BCC) is the most common form of cancer in humans and an enormous volume of physician work is devoted to its treatment, Fiona J. Bath-Hextall, Ph.D., the review's lead author, noted at the 11th World Congress on Cancers of the Skin.

The review encompassed 27 published and unpublished randomized controlled trials involving surgical excision, radiotherapy, cryotherapy, photodynamic therapy (PDT), intralesional interferon, the plant-derived mixture of solasodine glycosides known as BEC-5 cream, topical 5-fluorouracil, and imiquimod.

The clear winners in terms of efficacy as reflected in the primary end point adopted for the review—BCC recurrence rates at 3–5 years—were surgery and radiotherapy. And in the sole head-to-head comparative trial of these two therapies, surgery had significantly fewer residual tumors and histologically proven recurrences as well as consistently better cosmetic outcomes than radiotherapy, said Dr. Bath-Hextall of the University of Nottingham (England).

Few of the other therapies have been compared directly with surgery, which is the most widely used form of treatment as well as the one supported by the strongest evidence of efficacy.

Most of the clinical trials involved only BCCs in low-risk locations. Only one focused on high-risk facial BCCs. Moreover, many of the studies didn't make it clear what type of BCC was included. Nor did most trials consider recurrent or morpheic BCCs separately, as is warranted given their lower treatment success rates.

Although the seven PDT trials included in the review collectively indicate that it is a promising modality with cosmetic outcomes significantly better than surgery, PDT also has a relatively high failure rate and is expensive. Longer-term efficacy data are needed before it is appropriate for PDT to enter routine clinical practice, according to the Cochrane reviewers (Cochrane Database Syst. Rev. 2007 Jan. 24;CD003412).

Eight of nine studies on imiquimod for BCCs were industry sponsored. They suggest an 88% success rate for a once-daily 6-week regimen in superficial BCC and a more modest 76% treatment response in nodular BCC with 12 weeks of therapy. An ongoing trial of imiquimod versus surgery should help determine whether the topical therapy is a useful option, the reviewers said.

Dr. Bath-Hextall also presented a first look at a new Cochrane Systematic Review of interventions for prevention of nonmelanoma skin cancers in high-risk groups, namely organ transplant recipients and patients with xeroderma pigmentosa or a history of prior nonmelanoma skin cancers. Ten published randomized studies totalling more than 7,200 participants were identified. Only one focused on xeroderma pigmentosa: The 30-patient trial showed reductions in new actinic keratoses and BCCs during 1 year of topical T4N5, a repair enzyme specific for UV-induced DNA damage.

Several studies demonstrated preventive efficacy for retinoids. One study of a 24-month low-fat diet showed no difference in the rate of nonmelanoma skin cancer in year 1, versus controls, but a trend for fewer tumors in years 2–5, Dr. Bath-Hextall said at the congress, cosponsored by the Skin Cancer Foundation and Erasmus University, Rotterdam.

One particularly intriguing trial, she continued, involved more than 1,300 patients with a history of nonmelanoma skin cancer who were randomized in double-blind fashion to 10 years of supplemental selenium or placebo. The selenium group showed a nonsignificant increase in skin cancers, but a highly significant 37% reduction in nonskin cancers, including marked reductions in lung, colorectal, and prostate cancer and an adjusted 21% reduction in all-cause mortality (JAMA 1996;276:1957–63).

Audience members expressed puzzlement at selenium's divergent impacts on skin and internal malignancies. This prompted session chairman Dr. H.A. Martino Neumann, professor of dermatology and venereology at Erasmus, to propose an explanation: Perhaps participation in this study of an oral agent for skin cancer prevention caused some patients to feel a false sense of confidence and become more casual about sun protection.

In the sole head-to-head comparison of surgery and radiotherapy, surgery had fewer residual tumors. DR. BATH-HEXTALL

CHICAGO — Screening melanoma patients by ultrasound and fine needle aspiration cytology can avoid sentinel lymph node biopsies in half of node-positive patients, according to the results of a prospective study.

All 503 consecutive patients in a German and Dutch study underwent scintigraphy followed by ultrasound prior to scheduled sentinel lymph node biopsy. If ultrasound revealed a suspicious deposit, the patient went on to fine needle aspiration in an attempt to determine whether the node was positive, Dr. Gregor Schäfer-Hesterberg reported at the annual meeting of the American Society of Clinical Oncology.

Interim data on 400 patients for whom outcomes were available showed that ultrasound identified positive sentinel nodes in 51 of 79 (65%) patients who turned out to be node positive after dissection. Fine needle aspiration confirmed nodal disease in 40 of these patients—a group the investigators concluded could have skipped their scheduled biopsies and gone directly to total lymph node dissection.

"If we can verify that there is a metastasis in the sentinel node or another node, we can spare the patient an operation," Dr. Schäfer-Hesterberg said in an interview.

The majority of biopsied patients are node negative, added Dr. Schäfer-Hesterberg, a dermatologist at Charité Universitätsmedizin Berlin. In this study, 321 patients still underwent the surgical procedure without a positive finding.

The investigators, led by Dr. Christiane Voit of the same institution, previously reported an overall sensitivity of 82% for the combination of ultrasound and fine needle aspiration cytology (Ann. Surg. Oncol. 2006;13:1682–9). In the new data based on outcomes collected at an average of 30 months' follow-up, the group reported the combination became more sensitive in higher-staged tumors. Sensitivity was 65% overall, ranging from 40% in T1 disease to 79% in T4. Overall specificity was 99% with a range of 100% in T1 disease to 97% in T4.

Measurement of histologic nest sizes in 65 of the node-positive patients showed submicroscopic involvement of less than 0.1 mm in 13 patients, only 3 of whom were identified by ultrasound and fine needle aspiration cytology. As tumor load increased, the combination became more sensitive, identifying 11 of 24 tumors (46%) in the 0.1- to 1.0-mm range and 24 of 28 tumors (86%) larger than 1 mm.

"Ultrasound of the sentinel node and ultrasound guided fine needle aspiration cytology is highly accurate," the authors concluded in their poster.

In a discussion of the study, Dr. Vernon K. Sondak called for "further exploration but with a healthy skepticism."

Preoperative ultrasound has many potential roles in evaluating melanoma, particularly when patients are not eligible for sentinel lymph node biopsy, said Dr. Sondak, chief of cutaneous oncology at the H. Lee Moffitt Cancer Center in Tampa, Fla.

On the basis of the total study population, however, only a small percentage of all patients would be diverted from sentinel lymph node biopsy. At his own institution, Dr. Sondak said the experience with preoperative ultrasound in 93 patients would have spared no more than 8%.

"The numbers are very much against us when we do this in an unselected fashion," Dr. Sondak said.

Using ultrasound, the needle is guided into a suspicious lymph node. Courtesy Dr. Gregor Schäfer-Hesterberg

If a metastasis in the sentinel node or another nodeis verified, an operation canbe avoided. DR. SCHÄFER-HESTERBERG

CHICAGO — Screening melanoma patients by ultrasound and fine needle aspiration cytology can avoid sentinel lymph node biopsies in half of node-positive patients, according to the results of a prospective study.

All 503 consecutive patients in a German and Dutch study underwent scintigraphy followed by ultrasound prior to scheduled sentinel lymph node biopsy. If ultrasound revealed a suspicious deposit, the patient went on to fine needle aspiration in an attempt to determine whether the node was positive, Dr. Gregor Schäfer-Hesterberg reported at the annual meeting of the American Society of Clinical Oncology.

Interim data on 400 patients for whom outcomes were available showed that ultrasound identified positive sentinel nodes in 51 of 79 (65%) patients who turned out to be node positive after dissection. Fine needle aspiration confirmed nodal disease in 40 of these patients—a group the investigators concluded could have skipped their scheduled biopsies and gone directly to total lymph node dissection.

"If we can verify that there is a metastasis in the sentinel node or another node, we can spare the patient an operation," Dr. Schäfer-Hesterberg said in an interview.

The majority of biopsied patients are node negative, added Dr. Schäfer-Hesterberg, a dermatologist at Charité Universitätsmedizin Berlin. In this study, 321 patients still underwent the surgical procedure without a positive finding.

The investigators, led by Dr. Christiane Voit of the same institution, previously reported an overall sensitivity of 82% for the combination of ultrasound and fine needle aspiration cytology (Ann. Surg. Oncol. 2006;13:1682–9). In the new data based on outcomes collected at an average of 30 months' follow-up, the group reported the combination became more sensitive in higher-staged tumors. Sensitivity was 65% overall, ranging from 40% in T1 disease to 79% in T4. Overall specificity was 99% with a range of 100% in T1 disease to 97% in T4.

Measurement of histologic nest sizes in 65 of the node-positive patients showed submicroscopic involvement of less than 0.1 mm in 13 patients, only 3 of whom were identified by ultrasound and fine needle aspiration cytology. As tumor load increased, the combination became more sensitive, identifying 11 of 24 tumors (46%) in the 0.1- to 1.0-mm range and 24 of 28 tumors (86%) larger than 1 mm.

"Ultrasound of the sentinel node and ultrasound guided fine needle aspiration cytology is highly accurate," the authors concluded in their poster.

In a discussion of the study, Dr. Vernon K. Sondak called for "further exploration but with a healthy skepticism."

Preoperative ultrasound has many potential roles in evaluating melanoma, particularly when patients are not eligible for sentinel lymph node biopsy, said Dr. Sondak, chief of cutaneous oncology at the H. Lee Moffitt Cancer Center in Tampa, Fla.

On the basis of the total study population, however, only a small percentage of all patients would be diverted from sentinel lymph node biopsy. At his own institution, Dr. Sondak said the experience with preoperative ultrasound in 93 patients would have spared no more than 8%.

"The numbers are very much against us when we do this in an unselected fashion," Dr. Sondak said.

Using ultrasound, the needle is guided into a suspicious lymph node. Courtesy Dr. Gregor Schäfer-Hesterberg

If a metastasis in the sentinel node or another nodeis verified, an operation canbe avoided. DR. SCHÄFER-HESTERBERG

CHICAGO — Screening melanoma patients by ultrasound and fine needle aspiration cytology can avoid sentinel lymph node biopsies in half of node-positive patients, according to the results of a prospective study.

All 503 consecutive patients in a German and Dutch study underwent scintigraphy followed by ultrasound prior to scheduled sentinel lymph node biopsy. If ultrasound revealed a suspicious deposit, the patient went on to fine needle aspiration in an attempt to determine whether the node was positive, Dr. Gregor Schäfer-Hesterberg reported at the annual meeting of the American Society of Clinical Oncology.

Interim data on 400 patients for whom outcomes were available showed that ultrasound identified positive sentinel nodes in 51 of 79 (65%) patients who turned out to be node positive after dissection. Fine needle aspiration confirmed nodal disease in 40 of these patients—a group the investigators concluded could have skipped their scheduled biopsies and gone directly to total lymph node dissection.

"If we can verify that there is a metastasis in the sentinel node or another node, we can spare the patient an operation," Dr. Schäfer-Hesterberg said in an interview.

The majority of biopsied patients are node negative, added Dr. Schäfer-Hesterberg, a dermatologist at Charité Universitätsmedizin Berlin. In this study, 321 patients still underwent the surgical procedure without a positive finding.

The investigators, led by Dr. Christiane Voit of the same institution, previously reported an overall sensitivity of 82% for the combination of ultrasound and fine needle aspiration cytology (Ann. Surg. Oncol. 2006;13:1682–9). In the new data based on outcomes collected at an average of 30 months' follow-up, the group reported the combination became more sensitive in higher-staged tumors. Sensitivity was 65% overall, ranging from 40% in T1 disease to 79% in T4. Overall specificity was 99% with a range of 100% in T1 disease to 97% in T4.

Measurement of histologic nest sizes in 65 of the node-positive patients showed submicroscopic involvement of less than 0.1 mm in 13 patients, only 3 of whom were identified by ultrasound and fine needle aspiration cytology. As tumor load increased, the combination became more sensitive, identifying 11 of 24 tumors (46%) in the 0.1- to 1.0-mm range and 24 of 28 tumors (86%) larger than 1 mm.

"Ultrasound of the sentinel node and ultrasound guided fine needle aspiration cytology is highly accurate," the authors concluded in their poster.

In a discussion of the study, Dr. Vernon K. Sondak called for "further exploration but with a healthy skepticism."

Preoperative ultrasound has many potential roles in evaluating melanoma, particularly when patients are not eligible for sentinel lymph node biopsy, said Dr. Sondak, chief of cutaneous oncology at the H. Lee Moffitt Cancer Center in Tampa, Fla.

On the basis of the total study population, however, only a small percentage of all patients would be diverted from sentinel lymph node biopsy. At his own institution, Dr. Sondak said the experience with preoperative ultrasound in 93 patients would have spared no more than 8%.

"The numbers are very much against us when we do this in an unselected fashion," Dr. Sondak said.

Using ultrasound, the needle is guided into a suspicious lymph node. Courtesy Dr. Gregor Schäfer-Hesterberg

If a metastasis in the sentinel node or another nodeis verified, an operation canbe avoided. DR. SCHÄFER-HESTERBERG

SANTA ANA PUEBLO, N.M. — Perineural invasion can occur in 2.5%–15% of patients with squamous cell carcinoma, and 60%–70% of patients are asymptomatic on presentation, Dr. Tri. H. Nguyen said at a meeting of the American Society for Mohs Surgery.

Patients who present with symptomatic perineural involvement most commonly have paresthesia, followed by sharp or achy pain, motor deficits, and formication (sensation of bugs crawling on the skin), said Dr. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

Clinical risk factors for perineural invasion include male gender, large tumor size (2 cm or greater), central face location, and recurrent tumor. Histologic risk factors for perineural invasion include moderate to poorly differentiated histology, intravascular or lymphatic invasion, deep invasion, and extensive subcutaneous infiltration.

Imaging studies are valuable in staging and prognosis. For bony invasion, a CT scan is best. To evaluate lymph nodes, a CT scan followed by MRI is preferred. "However, if you have access to an expert radiologist and ultrasound, then [ultrasound] is also an excellent technique to evaluate lymph nodes in the head and neck," Dr. Nguyen said.

Ultrasonography of the head and neck permits fine-needle aspiration of suspicious nodes in real time. If large nerve involvement is suspected, consider an MRI, he said.

"There is greater tissue destruction with perineural squamous cell cancers, which results in a larger defect size, higher rates of recurrences and metastasis—up to 50% in some studies—and definitely a worse prognosis," said Dr. Nguyen, who also directs the procedural dermatology fellowship program at M.D. Anderson.

This is why adjuvant radiation therapy is recommended for these higher-risk squamous cell cancers.

Perineural disease alone, however, is not an absolute indication for radiation. "Only when there are other risk factors should radiation be considered in the adjuvant setting," he said. (See box.)

Radiation therapy "is not a benign process," he said. "There is significant cost ranging from $1,000 to $3,000 per treatment dose. There are logistics to work out, with treatments ranging from three to five times per week."

Radiation dermatitis, delayed wound healing, and functional impairment may occur with radiation.

Despite such risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. "When you're talking about radiating oral, pharyngeal, or laryngeal cancer, that's a whole different ball game," he said.

In one early study, when radiation was added to wide local excision in patients with squamous cell carcinoma of the head and neck and perineural invasion, the 5-year local control rate was 38%, compared with 20% with radiation alone (Head Neck 1989;11:301–8). "I look at radiation as only one tool to treat these higher-risk squamous cell cancers," Dr. Nguyen said.

He divides perineural involvement of squamous cell carcinoma into two groups: incidental disease and clinical disease. Patients with incidental disease are asymptomatic, have isolated perineural involvement of small peripheral nerves in the high dermis, and are imaging negative. "In this group, the local control rate without radiation is 78%–87%," he said.

Patients with clinical disease have perineural tumor of larger nerve trunks, have more extensive perineural involvement, are asymptomatic, and are imaging positive. "These patients have a positive MRI or CT and a worse prognosis," he said. "The local control rate without radiation therapy is 50%–55%."

Tumors that are recurrent worsen the prognosis, especially in the setting of perineural disease. "For example, the local control rate is 50%–75% in a primary squamous cell cancer with perineural disease," he said. "Contrast this to the local control rates of 11%–50% in a recurrent squamous cell cancer with perineural disease."

Despite the risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. DR. NGUYEN

Perineural involvement in a stage IV squamous cell carcinoma can be seen in the above pathology image. Courtesy Dr. Tri. H. Nguyen

Indications for Adjuvant Radiation Therapy After Surgery

Dr. Nguyen refers patients for postoperative adjuvant radiotherapy if:

▸ Recurrence morbidity would be catastrophic.

▸ Perineural involvement of large or extensive nerve trunks is confirmed.

▸ There is extensive microscopic disease or subcutaneous extension.

▸ The size of the tumor is greater than 2 cm and is located on the central face.

▸ The tumor is recurrent.

▸ The tumor is poorly differentiated or has deep invasion.

▸ Disease involves the lymph nodes.

▸ The patient is immunosuppressed.

SANTA ANA PUEBLO, N.M. — Perineural invasion can occur in 2.5%–15% of patients with squamous cell carcinoma, and 60%–70% of patients are asymptomatic on presentation, Dr. Tri. H. Nguyen said at a meeting of the American Society for Mohs Surgery.

Patients who present with symptomatic perineural involvement most commonly have paresthesia, followed by sharp or achy pain, motor deficits, and formication (sensation of bugs crawling on the skin), said Dr. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

Clinical risk factors for perineural invasion include male gender, large tumor size (2 cm or greater), central face location, and recurrent tumor. Histologic risk factors for perineural invasion include moderate to poorly differentiated histology, intravascular or lymphatic invasion, deep invasion, and extensive subcutaneous infiltration.

Imaging studies are valuable in staging and prognosis. For bony invasion, a CT scan is best. To evaluate lymph nodes, a CT scan followed by MRI is preferred. "However, if you have access to an expert radiologist and ultrasound, then [ultrasound] is also an excellent technique to evaluate lymph nodes in the head and neck," Dr. Nguyen said.

Ultrasonography of the head and neck permits fine-needle aspiration of suspicious nodes in real time. If large nerve involvement is suspected, consider an MRI, he said.

"There is greater tissue destruction with perineural squamous cell cancers, which results in a larger defect size, higher rates of recurrences and metastasis—up to 50% in some studies—and definitely a worse prognosis," said Dr. Nguyen, who also directs the procedural dermatology fellowship program at M.D. Anderson.

This is why adjuvant radiation therapy is recommended for these higher-risk squamous cell cancers.

Perineural disease alone, however, is not an absolute indication for radiation. "Only when there are other risk factors should radiation be considered in the adjuvant setting," he said. (See box.)

Radiation therapy "is not a benign process," he said. "There is significant cost ranging from $1,000 to $3,000 per treatment dose. There are logistics to work out, with treatments ranging from three to five times per week."

Radiation dermatitis, delayed wound healing, and functional impairment may occur with radiation.

Despite such risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. "When you're talking about radiating oral, pharyngeal, or laryngeal cancer, that's a whole different ball game," he said.

In one early study, when radiation was added to wide local excision in patients with squamous cell carcinoma of the head and neck and perineural invasion, the 5-year local control rate was 38%, compared with 20% with radiation alone (Head Neck 1989;11:301–8). "I look at radiation as only one tool to treat these higher-risk squamous cell cancers," Dr. Nguyen said.

He divides perineural involvement of squamous cell carcinoma into two groups: incidental disease and clinical disease. Patients with incidental disease are asymptomatic, have isolated perineural involvement of small peripheral nerves in the high dermis, and are imaging negative. "In this group, the local control rate without radiation is 78%–87%," he said.

Patients with clinical disease have perineural tumor of larger nerve trunks, have more extensive perineural involvement, are asymptomatic, and are imaging positive. "These patients have a positive MRI or CT and a worse prognosis," he said. "The local control rate without radiation therapy is 50%–55%."

Tumors that are recurrent worsen the prognosis, especially in the setting of perineural disease. "For example, the local control rate is 50%–75% in a primary squamous cell cancer with perineural disease," he said. "Contrast this to the local control rates of 11%–50% in a recurrent squamous cell cancer with perineural disease."

Despite the risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. DR. NGUYEN

Perineural involvement in a stage IV squamous cell carcinoma can be seen in the above pathology image. Courtesy Dr. Tri. H. Nguyen

Indications for Adjuvant Radiation Therapy After Surgery

Dr. Nguyen refers patients for postoperative adjuvant radiotherapy if:

▸ Recurrence morbidity would be catastrophic.

▸ Perineural involvement of large or extensive nerve trunks is confirmed.

▸ There is extensive microscopic disease or subcutaneous extension.

▸ The size of the tumor is greater than 2 cm and is located on the central face.

▸ The tumor is recurrent.

▸ The tumor is poorly differentiated or has deep invasion.

▸ Disease involves the lymph nodes.

▸ The patient is immunosuppressed.

SANTA ANA PUEBLO, N.M. — Perineural invasion can occur in 2.5%–15% of patients with squamous cell carcinoma, and 60%–70% of patients are asymptomatic on presentation, Dr. Tri. H. Nguyen said at a meeting of the American Society for Mohs Surgery.

Patients who present with symptomatic perineural involvement most commonly have paresthesia, followed by sharp or achy pain, motor deficits, and formication (sensation of bugs crawling on the skin), said Dr. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

Clinical risk factors for perineural invasion include male gender, large tumor size (2 cm or greater), central face location, and recurrent tumor. Histologic risk factors for perineural invasion include moderate to poorly differentiated histology, intravascular or lymphatic invasion, deep invasion, and extensive subcutaneous infiltration.

Imaging studies are valuable in staging and prognosis. For bony invasion, a CT scan is best. To evaluate lymph nodes, a CT scan followed by MRI is preferred. "However, if you have access to an expert radiologist and ultrasound, then [ultrasound] is also an excellent technique to evaluate lymph nodes in the head and neck," Dr. Nguyen said.

Ultrasonography of the head and neck permits fine-needle aspiration of suspicious nodes in real time. If large nerve involvement is suspected, consider an MRI, he said.

"There is greater tissue destruction with perineural squamous cell cancers, which results in a larger defect size, higher rates of recurrences and metastasis—up to 50% in some studies—and definitely a worse prognosis," said Dr. Nguyen, who also directs the procedural dermatology fellowship program at M.D. Anderson.

This is why adjuvant radiation therapy is recommended for these higher-risk squamous cell cancers.

Perineural disease alone, however, is not an absolute indication for radiation. "Only when there are other risk factors should radiation be considered in the adjuvant setting," he said. (See box.)

Radiation therapy "is not a benign process," he said. "There is significant cost ranging from $1,000 to $3,000 per treatment dose. There are logistics to work out, with treatments ranging from three to five times per week."

Radiation dermatitis, delayed wound healing, and functional impairment may occur with radiation.

Despite such risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. "When you're talking about radiating oral, pharyngeal, or laryngeal cancer, that's a whole different ball game," he said.

In one early study, when radiation was added to wide local excision in patients with squamous cell carcinoma of the head and neck and perineural invasion, the 5-year local control rate was 38%, compared with 20% with radiation alone (Head Neck 1989;11:301–8). "I look at radiation as only one tool to treat these higher-risk squamous cell cancers," Dr. Nguyen said.

He divides perineural involvement of squamous cell carcinoma into two groups: incidental disease and clinical disease. Patients with incidental disease are asymptomatic, have isolated perineural involvement of small peripheral nerves in the high dermis, and are imaging negative. "In this group, the local control rate without radiation is 78%–87%," he said.

Patients with clinical disease have perineural tumor of larger nerve trunks, have more extensive perineural involvement, are asymptomatic, and are imaging positive. "These patients have a positive MRI or CT and a worse prognosis," he said. "The local control rate without radiation therapy is 50%–55%."

Tumors that are recurrent worsen the prognosis, especially in the setting of perineural disease. "For example, the local control rate is 50%–75% in a primary squamous cell cancer with perineural disease," he said. "Contrast this to the local control rates of 11%–50% in a recurrent squamous cell cancer with perineural disease."

Despite the risks, most adjuvant radiotherapy for cutaneous skin cancer is relatively well tolerated. DR. NGUYEN

Perineural involvement in a stage IV squamous cell carcinoma can be seen in the above pathology image. Courtesy Dr. Tri. H. Nguyen

Indications for Adjuvant Radiation Therapy After Surgery

Dr. Nguyen refers patients for postoperative adjuvant radiotherapy if:

▸ Recurrence morbidity would be catastrophic.

▸ Perineural involvement of large or extensive nerve trunks is confirmed.

▸ There is extensive microscopic disease or subcutaneous extension.

▸ The size of the tumor is greater than 2 cm and is located on the central face.

▸ The tumor is recurrent.

▸ The tumor is poorly differentiated or has deep invasion.

▸ Disease involves the lymph nodes.

▸ The patient is immunosuppressed.

NAPLES, FLA. — In situ melanomas that were incompletely and inadequately removed at the time of initial treatment recurred at the surgical margin with an invasive component nearly one-quarter of the time, according to a 25-year review of surgery for such lesions presented at the annual meeting of the American College of Mohs Surgery.

The finding from the single-center study suggests that wider surgical margins are necessary to prevent recurrences, said Dr. James R. DeBloom II, who is in private practice in Greenville, S.C.

Of 202 marginally recurrent melanomas that Dr. DeBloom and his colleagues have seen since 1980, the lesions have appeared most commonly on the cheek (34%). Standard excision has been the most commonly failed initial treatment (48%).

A total of 84 these lesions were biopsy-proven melanoma in situ, and 19 of these (23%) revealed an invasive component at the time of the salvage surgery. Another 24 lesions were treated initially as biopsy-proven invasive melanoma. Of these, 15 (63%) recurred with a shallower Breslow depth or as melanoma in situ, 1 (4%) recurred at the exact same level of invasion, and 8 (33%) recurred at a greater Breslow depth than before.

The overall mean Breslow depth for these initially invasive melanomas increased from 1.53 mm to 2.8 mm at the time of recurrence, Dr. DeBloom reported.

These results show "that residual disease cannot only persist, but it can also invade and worsen the patient's prognosis and should not be taken lightly," he said.

Instead of using the confusing term locally recurrent melanoma, which has been given many different definitions, he and his colleagues prefer to use more specific terms—residual or marginally recurrent melanoma—to describe "a clinical reappearance of previously treated melanoma that is immediately adjacent to the scar of primary treatment," he said.

Of all diagnosed melanomas, 17%–25% are on the head and neck. Melanomas on those locations have a marginal recurrence rate after excision of 9%–13%. "This tells us that our current treatment protocols for head and neck melanoma may be insufficient," Dr. DeBloom said.

Marginal recurrences may develop because surgeons can "cheat on margins and make them small for cosmetic and functional reasons," he said.

It also is hard to determine where the clinical margin is, especially on sun-damaged skin that may have many other pigmented lesions and a high frequency of amelanotic melanomas at the margin. Also, routine pathologic examination looks at less than 1% of the total margin, "so when we get a negative report we all feel good about that but it does not preclude a true positive margin," Dr. DeBloom said.

He also said that the 1992 recommendation from the National Institutes of Health for 5-mm surgical margins is "not sufficient for melanoma in situ and [is] not evidence based." That is why he and his associates recommend a wider margin of 1 cm for melanoma in situ on the head and neck.

NAPLES, FLA. — In situ melanomas that were incompletely and inadequately removed at the time of initial treatment recurred at the surgical margin with an invasive component nearly one-quarter of the time, according to a 25-year review of surgery for such lesions presented at the annual meeting of the American College of Mohs Surgery.

The finding from the single-center study suggests that wider surgical margins are necessary to prevent recurrences, said Dr. James R. DeBloom II, who is in private practice in Greenville, S.C.

Of 202 marginally recurrent melanomas that Dr. DeBloom and his colleagues have seen since 1980, the lesions have appeared most commonly on the cheek (34%). Standard excision has been the most commonly failed initial treatment (48%).

A total of 84 these lesions were biopsy-proven melanoma in situ, and 19 of these (23%) revealed an invasive component at the time of the salvage surgery. Another 24 lesions were treated initially as biopsy-proven invasive melanoma. Of these, 15 (63%) recurred with a shallower Breslow depth or as melanoma in situ, 1 (4%) recurred at the exact same level of invasion, and 8 (33%) recurred at a greater Breslow depth than before.

The overall mean Breslow depth for these initially invasive melanomas increased from 1.53 mm to 2.8 mm at the time of recurrence, Dr. DeBloom reported.

These results show "that residual disease cannot only persist, but it can also invade and worsen the patient's prognosis and should not be taken lightly," he said.

Instead of using the confusing term locally recurrent melanoma, which has been given many different definitions, he and his colleagues prefer to use more specific terms—residual or marginally recurrent melanoma—to describe "a clinical reappearance of previously treated melanoma that is immediately adjacent to the scar of primary treatment," he said.

Of all diagnosed melanomas, 17%–25% are on the head and neck. Melanomas on those locations have a marginal recurrence rate after excision of 9%–13%. "This tells us that our current treatment protocols for head and neck melanoma may be insufficient," Dr. DeBloom said.

Marginal recurrences may develop because surgeons can "cheat on margins and make them small for cosmetic and functional reasons," he said.

It also is hard to determine where the clinical margin is, especially on sun-damaged skin that may have many other pigmented lesions and a high frequency of amelanotic melanomas at the margin. Also, routine pathologic examination looks at less than 1% of the total margin, "so when we get a negative report we all feel good about that but it does not preclude a true positive margin," Dr. DeBloom said.

He also said that the 1992 recommendation from the National Institutes of Health for 5-mm surgical margins is "not sufficient for melanoma in situ and [is] not evidence based." That is why he and his associates recommend a wider margin of 1 cm for melanoma in situ on the head and neck.

NAPLES, FLA. — In situ melanomas that were incompletely and inadequately removed at the time of initial treatment recurred at the surgical margin with an invasive component nearly one-quarter of the time, according to a 25-year review of surgery for such lesions presented at the annual meeting of the American College of Mohs Surgery.

The finding from the single-center study suggests that wider surgical margins are necessary to prevent recurrences, said Dr. James R. DeBloom II, who is in private practice in Greenville, S.C.

Of 202 marginally recurrent melanomas that Dr. DeBloom and his colleagues have seen since 1980, the lesions have appeared most commonly on the cheek (34%). Standard excision has been the most commonly failed initial treatment (48%).

A total of 84 these lesions were biopsy-proven melanoma in situ, and 19 of these (23%) revealed an invasive component at the time of the salvage surgery. Another 24 lesions were treated initially as biopsy-proven invasive melanoma. Of these, 15 (63%) recurred with a shallower Breslow depth or as melanoma in situ, 1 (4%) recurred at the exact same level of invasion, and 8 (33%) recurred at a greater Breslow depth than before.

The overall mean Breslow depth for these initially invasive melanomas increased from 1.53 mm to 2.8 mm at the time of recurrence, Dr. DeBloom reported.

These results show "that residual disease cannot only persist, but it can also invade and worsen the patient's prognosis and should not be taken lightly," he said.

Instead of using the confusing term locally recurrent melanoma, which has been given many different definitions, he and his colleagues prefer to use more specific terms—residual or marginally recurrent melanoma—to describe "a clinical reappearance of previously treated melanoma that is immediately adjacent to the scar of primary treatment," he said.

Of all diagnosed melanomas, 17%–25% are on the head and neck. Melanomas on those locations have a marginal recurrence rate after excision of 9%–13%. "This tells us that our current treatment protocols for head and neck melanoma may be insufficient," Dr. DeBloom said.

Marginal recurrences may develop because surgeons can "cheat on margins and make them small for cosmetic and functional reasons," he said.

It also is hard to determine where the clinical margin is, especially on sun-damaged skin that may have many other pigmented lesions and a high frequency of amelanotic melanomas at the margin. Also, routine pathologic examination looks at less than 1% of the total margin, "so when we get a negative report we all feel good about that but it does not preclude a true positive margin," Dr. DeBloom said.

He also said that the 1992 recommendation from the National Institutes of Health for 5-mm surgical margins is "not sufficient for melanoma in situ and [is] not evidence based." That is why he and his associates recommend a wider margin of 1 cm for melanoma in situ on the head and neck.

ELSEVIER GLOBAL MEDICAL NEWS

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ELSEVIER GLOBAL MEDICAL NEWS

NAPLES, FLA. — Microwave-assisted processing of permanent paraffin sections takes much less time than the conventional paraffin embedding process for Mohs surgery specimens, yet preserves its advantages over frozen sections in visualizing melanoma in situ, Dr. Raj Mallipeddi said at the annual meeting of the American College of Mohs Surgery.

Permanent paraffin sections are considered the standard for assessing histology, but the long time required to process them may make Mohs surgery inefficient because patients must return at least 24 hours later for additional Mohs stages or the repair procedure. Frozen sections also are considered by some clinicians to be inadequate to identify atypical melanocytes reliably, said Dr. Mallipeddi, a procedural dermatology fellow at the University of Texas Southwestern Medical Center, Dallas. Microwave tissue processing is "nothing new," and has been used in a variety of histologic procedures in the past few decades.

Dr. Mallipeddi and his associates divided 13 specimens of melanoma in situ from the initial debulking stage of surgery into 4 pieces each. They processed the pieces from each specimen using four different methods. The conventional method was used to create permanent paraffin sections, as was the group's rapid microwave technique. The researchers also made frozen sections stained with hematoxylin and eosin, and frozen sections immunostained with antibodies against MART-1, a protein found on melanocytes.

An experienced Mohs surgeon and a dermatopathologist compared all of the sections in a blind fashion to determine if there were any differences in the ability to visualize normal and abnormal melanocytes, and in the overall ability to see the epidermis and dermis.

There were no significant differences between the two paraffin techniques on those three criteria. The microwave paraffin sections proved to be significantly better than the frozen hematoxylin and eosin sections on all three criteria. Abnormal melanocytes could be visualized significantly better with the microwave paraffin technique than with frozen MART-1 sections, but the microwave method was similar to frozen MART-1 sections in identifying normal melanocytes. At 200× magnification, the morphology of atypical melanocytes was seen clearly with the microwave technique. MART-1 immunostaining on frozen sections showed melanocyte density well, but individual cell morphology was "not so well depicted," Dr. Mallipeddi said.

The method produces permanent paraffin sections in about 2 hours. The procedure involves fixing fresh tissue for 30 minutes, microwave processing for another 30 minutes, embedding the tissue in paraffin, and then staining the specimen with hematoxylin and eosin for about 10 minutes.

"We believe this technique should be investigated further in the context of Mohs micrographic surgery—not just for melanoma in situ," Dr. Mallipeddi said.

NAPLES, FLA. — Microwave-assisted processing of permanent paraffin sections takes much less time than the conventional paraffin embedding process for Mohs surgery specimens, yet preserves its advantages over frozen sections in visualizing melanoma in situ, Dr. Raj Mallipeddi said at the annual meeting of the American College of Mohs Surgery.

Permanent paraffin sections are considered the standard for assessing histology, but the long time required to process them may make Mohs surgery inefficient because patients must return at least 24 hours later for additional Mohs stages or the repair procedure. Frozen sections also are considered by some clinicians to be inadequate to identify atypical melanocytes reliably, said Dr. Mallipeddi, a procedural dermatology fellow at the University of Texas Southwestern Medical Center, Dallas. Microwave tissue processing is "nothing new," and has been used in a variety of histologic procedures in the past few decades.

Dr. Mallipeddi and his associates divided 13 specimens of melanoma in situ from the initial debulking stage of surgery into 4 pieces each. They processed the pieces from each specimen using four different methods. The conventional method was used to create permanent paraffin sections, as was the group's rapid microwave technique. The researchers also made frozen sections stained with hematoxylin and eosin, and frozen sections immunostained with antibodies against MART-1, a protein found on melanocytes.

An experienced Mohs surgeon and a dermatopathologist compared all of the sections in a blind fashion to determine if there were any differences in the ability to visualize normal and abnormal melanocytes, and in the overall ability to see the epidermis and dermis.

There were no significant differences between the two paraffin techniques on those three criteria. The microwave paraffin sections proved to be significantly better than the frozen hematoxylin and eosin sections on all three criteria. Abnormal melanocytes could be visualized significantly better with the microwave paraffin technique than with frozen MART-1 sections, but the microwave method was similar to frozen MART-1 sections in identifying normal melanocytes. At 200× magnification, the morphology of atypical melanocytes was seen clearly with the microwave technique. MART-1 immunostaining on frozen sections showed melanocyte density well, but individual cell morphology was "not so well depicted," Dr. Mallipeddi said.

The method produces permanent paraffin sections in about 2 hours. The procedure involves fixing fresh tissue for 30 minutes, microwave processing for another 30 minutes, embedding the tissue in paraffin, and then staining the specimen with hematoxylin and eosin for about 10 minutes.

"We believe this technique should be investigated further in the context of Mohs micrographic surgery—not just for melanoma in situ," Dr. Mallipeddi said.

NAPLES, FLA. — Microwave-assisted processing of permanent paraffin sections takes much less time than the conventional paraffin embedding process for Mohs surgery specimens, yet preserves its advantages over frozen sections in visualizing melanoma in situ, Dr. Raj Mallipeddi said at the annual meeting of the American College of Mohs Surgery.

Permanent paraffin sections are considered the standard for assessing histology, but the long time required to process them may make Mohs surgery inefficient because patients must return at least 24 hours later for additional Mohs stages or the repair procedure. Frozen sections also are considered by some clinicians to be inadequate to identify atypical melanocytes reliably, said Dr. Mallipeddi, a procedural dermatology fellow at the University of Texas Southwestern Medical Center, Dallas. Microwave tissue processing is "nothing new," and has been used in a variety of histologic procedures in the past few decades.

Dr. Mallipeddi and his associates divided 13 specimens of melanoma in situ from the initial debulking stage of surgery into 4 pieces each. They processed the pieces from each specimen using four different methods. The conventional method was used to create permanent paraffin sections, as was the group's rapid microwave technique. The researchers also made frozen sections stained with hematoxylin and eosin, and frozen sections immunostained with antibodies against MART-1, a protein found on melanocytes.

An experienced Mohs surgeon and a dermatopathologist compared all of the sections in a blind fashion to determine if there were any differences in the ability to visualize normal and abnormal melanocytes, and in the overall ability to see the epidermis and dermis.

There were no significant differences between the two paraffin techniques on those three criteria. The microwave paraffin sections proved to be significantly better than the frozen hematoxylin and eosin sections on all three criteria. Abnormal melanocytes could be visualized significantly better with the microwave paraffin technique than with frozen MART-1 sections, but the microwave method was similar to frozen MART-1 sections in identifying normal melanocytes. At 200× magnification, the morphology of atypical melanocytes was seen clearly with the microwave technique. MART-1 immunostaining on frozen sections showed melanocyte density well, but individual cell morphology was "not so well depicted," Dr. Mallipeddi said.

The method produces permanent paraffin sections in about 2 hours. The procedure involves fixing fresh tissue for 30 minutes, microwave processing for another 30 minutes, embedding the tissue in paraffin, and then staining the specimen with hematoxylin and eosin for about 10 minutes.

"We believe this technique should be investigated further in the context of Mohs micrographic surgery—not just for melanoma in situ," Dr. Mallipeddi said.

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen

PALM BEACH, FLA. — Cosmetic dermatology techniques can be used to improve postsurgical scarring, said Dr. Joel L. Cohen.

Cosmetic dermatology and dermatologic surgery share some common principles, including an appreciation for maintaining anatomy, symmetry, and aesthetic subunits, Dr. Cohen said. The increased risk of skin cancer among patients seeking treatment for signs of photodamage is another area of overlap. Dermatologists well versed in both realms will be particularly adept at improving postsurgical outcomes in their skin cancer patients, he said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"It's nice for me to have lasers, fillers, and botulinum toxin in our armamentarium to help with scars," said Dr. Cohen, director of AboutSkin Dermatology and DermSurgery in Englewood, Colorado.

"Scars are clearly permanent but there are things we can do to minimize them or fine-tune their appearance," he said. For example, botulinum toxin can minimize the muscular tension vectors across a large and tight forehead closure from skin cancer by immobilizing the frontalis muscle.

Fillers can be used to improve depressed surgical scars after reconstruction. For example, after initial subcision, scars or contour changes on a patient's ear helical rim can be improved with fillers. The depth of the scar and the anatomic location can determine the choice of filler, he said.

Scar abrasion is another option for some patients. "Sometimes sanding devices are clearly needed and are helpful for textural changes," Dr. Cohen said. Diamond fraise dermabrasion is an example, as well as ablative and fractional resurfacing lasers. "Sometimes I even use a curet to sand a scar if there is a big concern about airborne infectious particles."

Residual erythema following skin cancer repairs can also be significantly improved with lasers. "Postoperative redness is a reality. We all see it, and sometimes intervening and using either a pulsed dye laser or even a pulsed light device can have dramatic results" said Dr. Cohen, who is also an assistant clinical professor of dermatology at the University of Colorado, Denver. Sometimes more than one modality is required to satisfy a patient. One young skin cancer patient wanted to quickly improve the bilobed flap scar on her nose in the few months before her wedding, for example. A combination of erbium laser and fractional resurfacing proved to be very helpful in helping to blend the scar line.

He tried several means to improve a hypopigmented full-thickness skin graft scar on the lower eyelid of a middle-aged woman after Mohs surgery. A combination of trichloroacetic acid peels and hydroquinone to the surrounding skin has provided the best results so far, he noted. "This is a great example of how sometimes the older and less expensive treatments are most effective."

"Once you are comfortable treating these types of surgical scars, this knowledge can be very helpful with other common dermatology patients, such as those with acne scars," Dr. Cohen said.

Dermatologists who want to offer aesthetic, surgical, and medical dermatology services may need to adjust their schedule, staff training, and office layout, Dr. Cohen said. Decide what percentage of each type of patient you want to treat on a typical day and cross-train your staff so they are comfortable explaining the different procedures.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); a consultant and clinical trial investigator for BioForm (Radiesse); and was a consultant for Palomar (LUX1540 fractional laser).

The woman above is pictured immediately following Mohs surgery to remove a large morpheaform basal cell carcinoma.

After flap reconstruction, Botox is used to immobilize the frontalis muscle and prevent muscular contraction tension.

One week after Mohs surgery and reconstruction—at the time of suture removal—the forehead surgery site is healing well.

After 3 months, the surgery site is still healing well. Fractional laser therapy for the scar is discussed at this time. Photos courtesy Dr. Joel L. Cohen