Faculty Bibliography

Basal cell carcinoma (BCC) is the most common skin cancer in the Western world. Ultraviolet (UV) exposure, race, age, gender, and decreased DNA repair capacity are known risk factors for the development of BCC. Of these, UVB irradiation from sunlight is the most significant risk factor. The incidence of sporadic BCC increases in individuals older than age 55, with the greatest incidence reported in individuals who are older than 70, and is rare in individuals who are younger than 30. In this study, we analyzed 24 BCC samples from individuals who had BCC diagnosed by the age of 30. Fifteen single-stranded conformation polymorphism variants in the PTCH gene were identified in 13 BCC samples. Sequence analysis of these single-stranded conformation polymorphism variants revealed 13 single nucleotide changes, one AT insertion, and one 15-bp deletion. Most of these nucleotide changes (nine of 15) were predicted to result in truncated PTCH proteins. Fifteen p53 mutations were also found in 11 of the 24 BCC samples. Thirty-three percent (five of 15) and 60% (nine of 15) of the nucleotide changes in the PTCH and p53 genes, respectively, were UV-specific C-->T and CC-->TT nucleotide changes. Our data demonstrate that the p53 and PTCH genes are both implicated in the development of early-onset BCC. The identification of UV-specific nucleotide changes in both tumor suppressor genes suggests that UV exposure is an important risk factor in early onset of BCC.

BACKGROUND:There are a variety of potential hazards with laser technology. METHODS:A review of the literature. OBJECTIVE:To summarize the potential hazards of CO2 and erbium laser technologies and the safety guidelines and equipment developed to minimize them. RESULTS:Laser hazards can be divided into the following categories: mechanical, environmental, macrobiologic, microbiologic, and iatrogenic. CONCLUSION/CONCLUSIONS:At the conclusion of this learning activity, the reader should be able to discuss the mechanical, environmental, macrobiologic, microbiologic, and iatrogenic hazards of resurfacing laser technology, the literature cited to support current safety guidelines, and the equipment developed to promote laser safety.

BACKGROUND:The double-bladed scalpel previously has not been cited in the published literature for use in Mohs micrographic surgery. OBJECTIVE:To allow for maximum tissue conservation and greatest possible intraoperative efficiency for peripheral margin control of a massive tumor. METHODS:We describe the use of the double-bladed scalpel during Mohs surgery for peripheral margin control of a large dermatofibrosarcoma protuberans (DFSP). RESULTS AND CONCLUSION/CONCLUSIONS:While not necessary for the majority of routine Mohs cases, utilization of the double-bladed scalpel may be timesaving, especially when used for peripheral margin control of a massive tumor.

BACKGROUND:Perineural spread is a well-documented feature of cutaneous tumors and may portend a more aggressive course. The incidence of perineural invasion in basal cell carcinoma (BCC) is reportedly 1%. The authors sought to determine whether perineural spread occurs more commonly than previously thought. METHODS:The authors prospectively evaluated 434 patients with BCC treated with Mohs surgery, assessing the presence or absence of perineural inflammation and invasion in tumors requiring more than one stage of surgery. They also documented the demographic features, clinical characteristics, histologic subtype, and operative data in each case. RESULTS:Seventy-eight BCCs required more than one stage of Mohs surgery. Perineural inflammation, perineural tumor invasion, or both were present in 29 of the 78 tumors (37%), or 6.7% of all 434 prospectively evaluated cases. Twenty-one of the 78 tumors (26.9%) exhibited perineural inflammation, 3 (3.8%) demonstrated perineural invasion, and 5 (6.4%) exhibited both. Tumors with perineural invasion required 5.3 surgical stages on average for clearance, in contrast to tumors without perineural invasion, which required 2.2 stages. Tumors with perineural inflammation, inflammation plus tumor invasion, and invasion alone were, respectively, 138%, 149%, and 194% greater in area preoperatively than tumors without perineural involvement, and their mean defect areas after Mohs surgery were, respectively, 151%, 121%, and 605% larger than those of tumors without perineural involvement. CONCLUSIONS:The incidence of perineural invasion among cases of BCC appears higher than previously recognized. Tumor aggressiveness appears to correlate with the presence of perineural invasion. Surgery with horizontal frozen-section margin control enables easy detection of perineural involvement and should therefore be strongly considered for the treatment of high risk BCC patients.

BACKGROUND:Digital photography is emerging as a standard method of documenting preoperative, intraoperative, and postoperative results in the clinical setting. While hard copies of these electronic images can be quickly and easily generated on color laser or inkjet printers, there are times when it is necessary to generate a true photographic print of an image, either for insurance documentation or to meet the publication requirements of a peer-reviewed journal. Standard inkjet and laser printers are unable to generate true photographic prints. OBJECTIVE:To identify a rapid, cost-effective means of generating high-quality photographs of digital images. METHODS:We describe the use of on-line service bureaus with digital photographic printers to obtain high-quality photographic prints of patient images. RESULTS:From as little as 49 cents per print, a color or black-and-white print of a color image can be generated by an on-line service bureau to satisfy the need for a photographic quality hard copy. CONCLUSIONS:While color laser or inkjet printers allow physicians to generate their own hard copies of electronic patient images, photographic quality images are at times needed to satisfy requirements for insurance documentation or publication in peer-reviewed journals. Use of on-line service bureaus is the most cost-effective way that we have found to obtain high-quality photographic color or black-and-white prints from electronically stored patient images.