tag:blogger.com,1999:blog-9870114.post2614616073203960986..comments2024-03-10T08:41:32.400+00:00Comments on VIRTUAL GRAND ROUNDS IN DERMATOLOGY 2.0: Recurrent BCC with Perineural InvasionHumane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-9870114.post-13976985557174640212012-05-01T05:30:45.054+00:002012-05-01T05:30:45.054+00:00This is a great post. I really wanted to know some...This is a great post. I really wanted to know something like this and you gave me what i was looking for.<br /><br /><a href="http://www.sfrollc.com/skin-cancer-treatment" rel="nofollow">Skin Cancer Treatment</a>jhondenhttps://www.blogger.com/profile/13571197040880498028noreply@blogger.comtag:blogger.com,1999:blog-9870114.post-11285590530200591622012-03-31T02:17:10.612+00:002012-03-31T02:17:10.612+00:00I have reviewed the comments by Dr. Stone and Dr. ...I have reviewed the comments by Dr. Stone and Dr. Albom and am in agreement for the most part. I do find less fault in the original biopsy performed in 2008 than the initial Mohs layer performed after the biopsy. A biopsy is a litmus test to diagnose whether of not cancer is present at a clinically suspicious lesion, not to stage a potentially aggressive skin cancer. Shave biopsies are frequently misleading. Scott Fosko once published a paper over 10 years ago I believe that demonstrated up to 40% of basal cell carcinomas read as superficial had infiltrative features when Mohs was performed. Therefore it behooves the Mohs surgeon to take an adequate first layer even in the spirit of tissue conservation.<br />Otherwise, this is classic case for Mohs surgery, i.e. a recurrent aggressive BCC in a cosmetically sensitive area. Mohs is still the treatment of choice for highest cure rate and tissue conservation. I think her reconstuctive prognosis is still very good. Even as a worse case scenario if she requires a paramedian forehead flap and cartilage grafting, these are procedures that can be performed with reproduciably good results by a qualified reconstructive surgeon, whether they are plastic surgey or Mohs surgey trained. <br />Kevin Mott, MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-9870114.post-38710729496780076312012-03-30T13:52:21.092+00:002012-03-30T13:52:21.092+00:00As another Mohs surgeon, I agree with Dr. Stone th...As another Mohs surgeon, I agree with Dr. Stone that the defect may be quite large with significant subclinical extension. However, her best chance at completely and definitively removing her cancer is still with Mohs surgery. Post op radiation may not have additional benefit (the cited reference has no control arm, so the true incidence of recurrence in this group without radiation is unknown). However, radiation's effects on the skin have other deleterious effects (which are important to consider if aesthetics are an issue), the treatments are costly, and time-consuming. I would be hesitant to pursue this after nasal reconstruction if the Mohs sections were of good quality and clearly negative. Finally, regarding reconstruction, many Mohs surgeons are comfortable with large complex repairs for catastrophic nasal wounds. If her Mohs surgeon is in this bracket I would not expect any additional benefit in having plastics perform the repair (she should have a frank discussion with him or her prior to surgery obviously). We routinely do forehead flaps and other advanced techniques for nasal reconstruction the same day as Mohs surgery, under local (avoiding the need for general anesthesia & its complications) and without the additional cost to the patient or insurance company that seeing a separate surgeon necessitates. We do what is best for the patient regardless of the multiple surgery reduction rule.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-9870114.post-32747103067139708792012-03-26T14:18:50.190+00:002012-03-26T14:18:50.190+00:00Dr. Michael Albom has commented. Here is an extra...Dr. Michael Albom has commented. Here is an extract (a pdf of his full comments is in the case report above): "This is a difficult case for several reasons. As you point out, the shave bx that was done in 2008 was inadequate. As such the Mohs surgeon made the assumption that this lesion was of minor consequence. He or she should have initially removed full thickness skin as part of the treatment in 2008. <br />As of this time, there is no clinical way to determine the actual extent of this recurrence. An MRI might be helpful to discover if the lesion has tracked to the anterior medial septum. However, scans have limitations and may not give clear cut findings as to the spread of disease. Confocal microscopy is being used in a limited number of centers, but, with recurrent disease as this, I don’t know if a significant number of these types of difficult cases have been done with long term follow-up to corroborate successful outcomes. When I refer to long term follow-up, I mean a minimum of 5 years." see pdf for fullcommentsHumane Medicine Huihttps://www.blogger.com/profile/07113291188306363130noreply@blogger.comtag:blogger.com,1999:blog-9870114.post-54436466900383641762012-03-26T09:46:35.109+00:002012-03-26T09:46:35.109+00:00from Dr. Jenny Stone, Mohs Surgeon: "This in...from Dr. Jenny Stone, Mohs Surgeon: "This indeed may be a recurrence and I would warn the patient that the post-op defect may be much larger than what is visible clinically (which is not much at present). Therefore, it may be wise to set her up with plastics for repair. Tumors with perineural involvement may have skip areas and may be the reason for the recurrence - skip areas may be difficult to see on Mohs sections. It would probably give her an extra margin of safety to do adjunctive radiation to the area once everything is healed, esp. since Mohs was done before."Humane Medicine Huihttps://www.blogger.com/profile/07113291188306363130noreply@blogger.com