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BACKGROUND Extramammary Paget disease (EMPD) poses treatment challenges. Invasive and noninvasive treatment modalities exist with variable success reported. Reflectance confocal microscopy (RCM) is emerging as an adjuvant diagnostic tool. OBJECTIVE To evaluate the treatment of EMPD patients and the role of RCM. METHODS Prospective study. Demographic and tumor characteristics were recorded. Handheld-RCM was performed and correlated with histology. Treatment, clearance, pathology, and follow-up were all recorded. RESULTS Thirty-six EMPD lesions in 33 patients were included. Mean age was 71.7 years, and 23 were men. Mean number of surgical stages needed to clear margins was 1.9 (SD, 0.9; 1.0-3.0 stages), and mean margin needed to clear was 1.8 cm. Reflectance confocal microscopy correlated well with scouting punch biopsies (kappa, 0.93; p < .001). Disruption of the dermoepidermal junction was associated with invasive EMPD versus in situ (83.3% vs 25.9%) on histology (p = .01). LIMITATIONS Relatively small sample size. CONCLUSION Extramammary Paget disease is challenging, and lesion demarcation is of the utmost importance. Using a staged surgical excision approach, the mean margins needed were 1.8 cm, less than previously reported. Nonsurgical modalities, including radiation therapy, imiquimod, or photodynamic therapy can be considered if surgery is not pursued. Reflectance confocal microscopy is a valuable noninvasive imaging modality for the management of EMPD.

BACKGROUND The rate of occult invasive disease within biopsy-proven squamous cell carcinoma in situ (SCCIS) is not well defined. OBJECTIVE To examine the rate of occult invasion in SCCIS. METHODS An institutional-wide pathology database was retrospectively searched for "squamous cell carcinoma in situ" over a 6-year period, and the treatment modality and final pathology results were analyzed for evidence of invasion. In addition, consecutive tumor blocks from Mohs micrographic surgery (MMS) cases of SCCIS were prospectively analyzed for invasion. RESULTS The rate of occult invasion for biopsy-proven SCCIS treated with excision was 4.0% (N = 49) and for the MMS margins was 3.5% (N = 310). For the prospective MMS tumor block analysis, the rate of occult invasion was 10.1% (N = 69). No clinical factors (age, sex, location, or size) correlated with increased risk of invasion. All invasive SCCs detected were superficial and well differentiated. CONCLUSION The rate of occult invasion for biopsy-proven SCCIS ranged from 3.5% to 10.1%. The detected rate of invasion varies based on the method of excision and pathology processing of specimens. The rate of invasion should be considered when managing SSCIS.

Background Solitary large keratoacanthomas (KAs) of the head and neck present a management dilemma, as no reliable means to predict the clinical course is available. Although typically considered a low-grade tumor, KAs are reported to invade/metastasize, prompting more aggressive treatment. There is little published regarding factors that predict when a KA behaves more like an aggressive squamous cell carcinoma (SCC). Objective To study the clinical and pathologic features of large solitary head and neck KAs and assess response to intralesional methotrexate (IL-MTX) as well as predictors of clinical course. Materials and methods An observation study of 14 patients with large solitary head and neck KAs were treated with IL-MTX and then excised by Mohs micrographic surgery (MMS) at a later time point. Clinical presentation, treatment, response, and pathology were recorded. Features of classic KAs were compared with those with an aggressive SCC course. Results Ten of fourteen lesions responded with necrosis, a decrease in size and/or pain, and histological clearance on MMS. However, 4/14 lesions continued to have progression despite IL-MTX therapy. These showed persistent pain, perineural invasion, moderate/poor differentiation, and an infiltrative growth. Limitations Small sample size. Conclusion Significant pain, or continued growth may suggest an underlying aggressive SCC in clinically classic large KAs. In these cases, surgical management with assessment for high-risk tumor features is recommended.

Various studies have reported local recurrence (LR) rates after surgical treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM). However, the time to LR of LM/LMM is not currently known, as few studies report time to LR and have long-term follow-up. To define time to LR in LM/LMM after surgical treatment, and to describe features of observed LR. Retrospective single-center study of consecutive patients presenting with locally recurrent LM/LMM. Six hundred forty-nine cases of LM/LMM were reviewed; 29 (21 LM, and 8 LMM) of 41 locally recurrent cases had original histology reports and were included. The mean time to LR was 57.5 months (range 7–194). For cases presenting as primary LM, LR was also in situ in 14/21 (67%) of cases. Seven of 21 LM recurred as LMM. Of the 8 primary LMM, 3/8 (37.5%) presented with subsequent LMM and all were slightly deeper on re-excision. The mean time to LR of LM/LMM is at least 57.5 months, underscoring the importance of long-term follow-up. Seven of 21 LM recurred as invasive disease, but the lack of development of LMM from LM in most recurrent cases confirms LM is slowly progressive.

Background Determining the biopsy site location of a skin cancer before treatment is often challenging. Objective To study the implementation and effectiveness of biopsy site selfies as a quality improvement measure for correct surgical site identification. Materials and methods In the first phase, the ability of dermatologic surgeon and patient to definitively identify the biopsy site and whether photography was needed to ensure site agreement were recorded. In the second phase, patients were requested to take biopsy site selfies, and after implementation, similar data were collected including whether a biopsy site selfie was helpful for definitive site identification. Results In the first phase, the physician and patient were unable to identify the biopsy site 17.6% (49/278) and 25.5% (71/278) of cases, respectively. A photograph was needed in 22.7% of cases (63/278). After implementation of biopsy site selfies, the physician and patient were unable to identify the biopsy site 17.4% (23/132) and 15.2% (20/132) of cases, respectively. Biopsy site selfies were available for 64.1% of cases for which no internal image was available and critical for site identification in 21.4% of these cases. Conclusion Biopsy site selfies has proven to be helpful for correct surgical site identification by both the physician and the patient and may also provide further reassurance and confidence for patients.

During Mohs micrographic surgery (MMS), situations can arise in which paraffin sections may be used in conjunction with frozen sections.To determine the clinical value of paraffin sections in association with MMS, including frequency, reasons, and information obtained.Single-center retrospective cohort study at a cancer center. MMS cases for nonmelanoma skin cancers over a 5-year period in which paraffin sections were used were identified. Reasons for submitting paraffin sections were reviewed. Initial biopsy, Mohs frozen section, and paraffin section diagnoses and histologic subtypes were compared.In 258 (7.8%) cases, paraffin sections were used in association with MMS. The most common reasons were to further assess high-risk histologic features or unusual frozen section findings, to complete tumor staging of cutaneous squamous cell carcinomas, and to assess perineural invasion (PNI). Initial biopsy diagnosis differed from the Mohs frozen and paraffin section diagnoses in 20% to 22% of cases. The initial biopsy histologic subtype changed from low or indeterminate to high risk in Mohs frozen and paraffin sections in 24% to 29% of cases.In MMS for select high-risk or unusual nonmelanoma skin cancers, paraffin sections are useful in more accurately documenting tumor histology, completing cutaneous squamous cell carcinoma staging, and detecting PNI.