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The skin epidermis is constantly renewed throughout life 1,2 . Disruption of the balance between renewal and differentiation can lead to uncontrolled growth and tumour initiation 3 . However, the ways in which oncogenic mutations affect the balance between renewal and differentiation and lead to clonal expansion, cell competition, tissue colonization and tumour development are unknown. Here, through multidisciplinary approaches that combine in vivo clonal analysis using intravital microscopy, single-cell analysis and functional analysis, we show how SmoM2-a constitutively active oncogenic mutant version of Smoothened (SMO) that induces the development of basal cell carcinoma-affects clonal competition and tumour initiation in real time. We found that expressing SmoM2 in the ear epidermis of mice induced clonal expansion together with tumour initiation and invasion. By contrast, expressing SmoM2 in the back-skin epidermis led to a clonal expansion that induced lateral cell competition without dermal invasion and tumour formation. Single-cell analysis showed that oncogene expression was associated with a cellular reprogramming of adult interfollicular cells into an embryonic hair follicle progenitor (EHFP) state in the ear but not in the back skin. Comparisons between the ear and the back skin revealed that the dermis has a very different composition in these two skin types, with increased stiffness and a denser collagen I network in the back skin. Decreasing the expression of collagen I in the back skin through treatment with collagenase, chronic UV exposure or natural ageing overcame the natural resistance of back-skin basal cells to undergoing EHFP reprogramming and tumour initiation after SmoM2 expression. Altogether, our study shows that the composition of the extracellular matrix regulates how susceptible different regions of the body are to tumour initiation and invasion., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

We report 2 patients who underwent Mohs micrographic surgery (MMS) and operative closure on the ear. Both cases were complicated by necrosis resulting in the formation of auricular defects. These cases highlight the importance of the auricular vasculature and the associated watershed regions during operative planning for MMS as well as the complications that can arise with vascular compromise. This case report also provides a review of the auricular vasculature with special attention to these vulnerable watershed regions.

Fibrosarcomas are malignant tumors of the connective tissue, which are characterized by proliferation of fibroblasts. Most of these tumors are localized subcutaneously and cause different symptoms depending on their location. The case report describes a dermal tumor on the outside of the pinna in a 7-year-old female Cashmere goat. The tumor was surgically removed and histopathological examination revealed a low grade fibrosarcoma. Although tumors are rare in ruminants because of the animals' short lifespan (age of slaughtering in most cases < 24 months) in modern production processes, they should be considered as a differential diagnosis., Competing Interests: The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of this retrospective study was to investigate sentinel lymph node biopsy in patients with head and neck melanoma., Materials and Methods: Patients who underwent SLNB between 2010 and 2016 were comprised. Epidemiological, radiological, and surgical data were collected and compared to histological findings. Patients who underwent primary complete lymph node dissection were excluded., Results: 74 patients underwent SLNB during this period. The most common tumor localizations were the cheek (20.4%) and ears (20.4%). Overall, 256 sentinel lymph nodes (SLN) were detected and removed, most frequently in Robbins-levels IIA and IIB as well as in the surrounding of the parotid gland. 12.3% of the SLN showed a microscopic or macroscopic metastasis. In preoperative imaging all lymph nodes with macroscopic metastasis were described as suspect but only 4 of 11 lymph nodes with microscopic metastases were described as such., Conclusions: SLNB is an especially good procedure for the diagnosis of microscopically metastases as disease status is an important diagnostic and prognostic factor in early-stage melanoma patients. However, due to the complex lymphatic system in head and neck melanoma, a short follow-up interval is necessary in order to prevent delayed diagnosis of a nodal recurrence due to a false-negative SLN., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

A 65-year-old man presented with an anomaly in his left ear. He had no complaints, but was ashamed of the lesion. On physical examination a pigmented, pedunculated, polypoid tumour of approximately 2 x 2.5 cm was seen, which filled the whole cavum conchae. After excision, histopathological examination showed a verruca seborrhoica.

Extensive cytogenetic testing is slowly unveiling the complexity of the genomics of melanocytic tumors. NRAS mutations have been the first genetic abnormality described in malignant melanomas. We report the cases of two children, presenting a melanocytic lesion located on the ear. One appeared as a combined dermal clone inside a congenital nevus and the other as a centimetric purely dermal tumor. Both tumors were composed of spindled spitzoid melanocytes with atypical histologic features. aCGH and FISH revealed an amplification of the NRAS gene. Sequencing showed an exon 3 NRAS mutation. In the combined case, the amplification was limited to the spitzoid component, underscoring a possible phenotypic shift induced by the alteration. Similarly an overexpression of CyclinD1 and elevation of ki-67 was found in the spitzoid component confirming a raise in proliferation. Such combination of mutation and copy number increase has been previously reported for the HRAS gene in a subset of Spitz nevi. Further studies must evaluate if mutated NRAS is also amplified in melanomas arising in this clinical setting. These combined alterations could represent an early event ultimately leading to malignancy., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The ear is a characteristic location for deposition of uric acid in patients with gout. Pseudocarcinomatous hyperplasia has not been described in this location. We report three patients with tophaceous gout on the ear whose biopsies exhibited epidermal hyperplasia mimicking squamous cell carcinoma, in order to call attention to this potential diagnostic pitfall., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Eryfotona AK-NMSC (ISDIN Spain) is a film-forming medical device in cream or fluid formulation containing the DNA-repair enzyme photolyase and high-protection UV filters in liposomes (repairsomes) indicated in the treatment of cancerization field in patients with actinic keratosis (AK) or non-melanoma skin cancer (NMSC). Photolyase is an enzyme that recognizes and directly repairs UV-induced DNA damage. The most common UV-induced DNA damage is the formation of cyclobutane pyrimidine dimers (CPD). Clinical studies evaluating the histological and cellular effects of Eryfotona AK-NMSC have shown a potential benefit in the treatment of the cancerization field in AK patients. In particular the use of Eryfotona AK-NMSC improves the confocal microscopic appearance of skin at the cancerization field level. In addition, Eryfotona AK-NMSC improves the p53 gene expression at keratinocyte level. In this study we reported a series of 6 cases of patients with AK or NMSC lesions treated with Eryfotona AK-NMSC fluid, both as coadjuvant and as single treatment, applied twice daily in the affected area with photograph documentation. Clinical photographs of the skin lesions at baseline and after Eryfotona AK-NMSC treatment were taken in all cases using a high-definition digital camera. Six patients with multiple AK lesions of the scalp or face with or without NMSC were treated for a mean of 1-3 months with Eryfotona AK-NMSC fluid formulation. Image documentations before and after treatment of this clinical series show a great improvement in AK lesions count and of cancerization field. This clinical series supports the clinical efficacy of the use of photolyase and high-protection UV filters in the treatment of cancerization field and AK lesions in patients with actinic damage.

The aim of this study was to perform a systematic literature review of Merkel cell carcinomas (MCCs) originating exclusively in the ear, nose and throat (ENT) district. An appropriate string was run on PubMed to retrieve articles dealing with ENT presentations of MCC. A double cross-check was performed on citations and full-text articles found using the selected inclusion and exclusion criteria. In total, 43 articles were finally included in the study, describing 51 cases of MCC involving the ENT region: 22/51 (43%) cases involving the ear; 20/51 (39%) cases involving the mucosal sites; 9/51 (18%) cases involving other ENT regions. Patients with mucosal site involvement showed a higher mortality rate from the disease (45%) in comparison with the other two groups, especially when compared with those patients having primary involvement of the ear (22%). The ENT specialist should suspect and consider MCC, especially in elderly patients presenting with a suspicious lesion of the auricular pavilion, so as to avoid misdiagnosis and delayed treatments.

Indolent CD8+ lymphoid proliferation of the ear is a recently described cutaneous lymphoid proliferation that clinically presents with slow growing lesion(s) on the ear(s). In cases reported to date, there has been indolent clinical behavior and no evidence of systemic involvement. Characteristic histopathologic features include a non-epidermotropic diffuse dermal infiltrate of CD8+ T-lymphocytes with a lymphoblast-like appearance. T-cell clonality has also been observed. Herein, we present two patients who show clinical, histopathologic and immunophenotypic features similar to the original index cases described by Petrella et al. In addition, we review the literature regarding this unusual lymphoid proliferation and provide evidence that this entity represents a phenotypic variant of primary cutaneous CD4+ small/medium-sized pleomorphic T-cell lymphoma, a concept proposed by Beltraminelli et al. in 2009. Differentiation between this lymphoproliferative process and other more aggressive CD8+ lymphomas is essential in avoiding excessive treatment of a condition that combines worrisome histopathology with indolent clinical behavior., (Copyright © 2010 John Wiley & Sons A/S.)

Basaloid skin tumors, including basal cell carcinoma (BCC) and basaloid follicular hamartoma, are associated with aberrant Hedgehog (Hh) signaling and, in the case of BCC, an expanding set of genetic variants including keratin 5 (encoded by KRT5), an intermediate filament-forming protein. We here show that genetic ablation of keratin 17 (Krt17) protein, which is induced in basaloid skin tumors and co-polymerizes with Krt5 in vivo, delays basaloid follicular hamartoma tumor initiation and growth in mice with constitutive Hh signaling in epidermis. This delay is preceded by a reduced inflammation and a polarization of inflammatory cytokines from a Th1- and Th17-dominated profile to a Th2-dominated profile. Absence of Krt17 also attenuates hyperplasia and inflammation in models of acute dermatitis. Re-expression of Krt17 in Gli2(tg); Krt17(-/-) keratinocytes induces select Th1 chemokines that have established roles in BCC. Our findings establish an immunomodulatory role for Krt17 in Hh driven basaloid skin tumors that could impact additional tumor settings, psoriasis and wound repair.

Atypical fibroxanthoma (AFX) is a lesion that typically occurs on actinically damaged skin of the head and neck. Histopathology of these neoplasms reveals atypical cells, which often demonstrate positive staining for immunohistochemical markers such as vimentin and CD10. In the case reported, keloidal collagen was discovered on histopathology. To our knowledge, only rare reports in the literature describe an AFX with similar histopathologic findings, suggesting that this is a distinctive presentation of AFX.

3,3'-Diindolylmethane (DIM) is a major acid-condensation product of indole-3-carbinol and is present in cruciferous vegetables. In this study, we evaluated the effects of DIM on antiinflammatory and antitumor promotion activity in mouse skin and explored the relevant mechanisms. When 12-O-tetradecanoylphorbol-13-acetate (TPA) was applied topically to the mouse ear to induce inflammation, DIM pretreatment effectively inhibited TPA-induced ear edema formation. To evaluate the mechanisms underlying DIM's antiinflammatory effects, DIM was topically treated to the shaved backs of mice 30 min before TPA treatment. DIM inhibited the TPA-induced increases in the expression of cyclooxygenase (COX)-2, inducible nitric oxide synthase (iNOS), chemokine (C-X-C motif) ligand (CXCL) 5, and interleukin (IL)-6 in mouse skin. DIM also inhibited nuclear factor-kappa B (NF-kappaB)'s DNA binding activity, the nuclear translocation of p65, and the degradation of inhibitor of kappaB (IkappaB) alpha in TPA-stimulated mouse skin. Furthermore, DIM reduced TPA-induced increases in the activity of extracellular signal regulated protein kinase (ERK)-1/2 and IkappaB kinase (IKK). When mouse skin papillomas were initiated via the topical application of 7,12-dimethylbenz[alpha]anthracene (DMBA) and promoted with repeated topical applications of TPA, repeated topical applications of DIM prior to each TPA treatment significantly suppressed the incidence and multiplicity of the papillomas. DIM also reduced the expression of COX-2 and iNOS, ERK phosphorylation, and the nuclear translocation of p65 in papillomas. Collectively, these results show that DIM exerts antiinflammatory and chemopreventive effects in mouse skin via the downregulation of COX-2, iNOS, CXCL5, and IL-6 expression, which may be mediated by reductions in NF-kappaB activation.

Primary cutaneous marginal zone B-cell lymphoma (PCMZL) is an indolent low grade B cell lymphoma of the skin, with lack of extracutaneous involvement at the time of diagnosis. Herein we report the case of a patient with rheumatoid arthritis (RA) who developed symmetrical PCMZL lesions on both ear lobes. Lesions occurring symmetrically on ear lobes are more specific for cutaneous lymphoid hyperplasia (CLH) and this kind of symmetrical localization hasn't been reported for PCMZL before. PCMZL is considered to arise from a background of reactive lymphoid hyperplasia and this case point out the concept of CLH and PCMZL spectrum. Association of marginal zone lymphoma with rheumatoid arthritis and resolution of lesions together with the resolution of symptoms due to rheumatoid arthritis after rituximab therapy is another interesting point for this case. To the best of our knowledge PCMZL associated with RA has not been reported previously.

A man, 64 years of age, retired and resident on the Spanish Mediterranean coast, without family or personal history of cutaneous tumours, requested primary medical evaluation for a lesion that had been present for a year. The lesion was located on his left ear, and had been growing progressively, without irritation, pain or other significant symptoms. No loss of weight or appetite was present.

Curcuma xanthorrhiza Roxb. (Zingiberaceae) is a medicinal plant widely spread in South East Asia. In particular, it is commonly used not only for food and medicinal purposes in Indonesia, but also for the topical treatment of acne and skin inflammations as Thai traditional medicine. It was found that the methanol extract of C. xanthorrhiza inhibited significantly 7,12-dimethylbenz[a]anthracene (DMBA)-induced bacterial mutagenesis of Salmonella typhimurium TA98 and TA100 in the presence of S9, and the mutagenesis induced by H2O2 and tert-butylhydroperoxide in S. typhimurium TA102, respectively. In addition, 12-O-tetradecanolyphorbol-13-acetate(TPA)-induced mouse ear edema was markedly inhibited by pretreatment with C. xanthorrhiza extract. C. xanthorrhiza extract dose-dependently reduced ODC expression in mouse skin with TPA-induced acute inflammation. Furthermore, repeated treatment with 0.1% C. xanthorrhiza extract reduced the average number of tumors per mouse and the percentage of tumor-bearing mice in a multistage mouse skin carcinogenesis induced by DMBA and TPA. These results demonstrate that the methanol extract of C. xanthorrhiza possesses cancer chemopreventive potential.

A case of low-grade trichoblastic carcinosarcoma was reported in 2004. Here we present the second case of this tumor, which, in contrast to the original example, may be classified as a high-grade neoplasm. A 92-year-old man presented with an ulcerated lesion on the left ear. The tumor was excised, and the patient had no evidence of recurrence or metastasis 6 years after surgery. Microscopically, the neoplasm demonstrated a fenestrated growth pattern with a slightly myxoid matrix in the background. Two clear components were identified: the first component was clearly epithelial with formation of small round nests, lobules, delicate strands, and small cribriform structures of basaloid cells with some degree of peripheral palisading, nuclear atypia, focal nuclear crowding, and frequent mitotic figures including abnormal forms. Each epithelial aggregation was invariably surrounded by one to three rows of cells with oval to round nuclei, which appeared very similar to specific trichogenic stroma seen in anagen follicles or in trichoblastomas; however, these stromal cells manifested atypical mitoses and cellular pleomorphism. The epithelial and stromal units frequently formed structures identical to follicular papillae associated with germs or "continuous germs" contiguous with "continuous papillae." Despite the close association throughout the tumor, the epithelial and the stromal cells were sharply separated, without transition between both elements. In foci, these stromal cells lost their follicular papillae-like arrangement and proliferated in a diffuse fashion and gradually blended with highly pleomorphic mononuclear spindle-shaped cells and bizarre multinucleated cells that grew in sheets in a highly vascular stroma. Immunohistochemically, the epithelial component showed diffuse staining for cytokeratins (AE1/AE3) and was negative for vimentin and CAM5.2. The stromal cells were positive for vimentin and negative for cytokeratin markers (AE1/AE3) and desmin. We view the present case and that previously reported in 2004 as authentic carcinosarcomas, and not as metaplastic (sarcomatoid) basal cell carcinomas. This conclusion is reached after analyzing the embryological development of the hair follicle, its normal histology and the morphology of cutaneous adnexal tumors with follicular differentiation.

Clear cell atypical fibroxanthoma (CCAFX) is a rare variant of atypical fibroxanthoma (AFX), a pleomorphic dermal tumour associated with a good prognosis. A 67-year-old man presented with a rapidly growing nodule on the ear, which had appeared over a 2-week period. Sections showed an ulcerated nodule composed of pleomorphic spindled and polygonal cells with clear cytoplasm, invested by a delicate vascular stroma, reminiscent of clear cell renal cell carcinoma. Numerous mitotic figures were seen. The tumour cells stained with vimentin, CD68 and CD99 and were cytokeratin-negative. The immunohistochemical and ultrastructural features supported a diagnosis of CCAFX. The diagnosis of CCAFX requires the exclusion of other pleomorphic clear cell tumours that can occur in the skin by using a combination of morphology, immunohistochemistry and electronmicroscopy. Murali R, Palfreeman S. Clear cell atypical fibroxanthoma - report of a case with review of the literature.

Objective: To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC)., Design: Prospective cost analysis with each patient serving as his or her own control., Setting: Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center., Patients: A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears., Main Outcome Measures: The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure(because this outcome affects overall cost)., Results: Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs (937 vs 1029 US dollars; P =.16) or a subsequent TSE (937 vs 944 US dollars; P =.53). When facility-based frozen sections were requested for TSE, Mohs was significantly less costly (956 vs 1399 US dollars; P<.001). The cost difference between Mohs and TSE was sensitive to the type of repair chosen., Conclusions: If the end point is clear margins, Mohs is cost comparable to TSE performed by otolaryngologic surgeons. Some caution is needed when evaluating the cost of facial and auricular NMSC treatment because the choice of repair can significantly affect the cost conclusions.

We previously described a transgenic mouse line (TG-3) that spontaneously develops pigmented cutaneous melanoma. The generation of several albino mice that developed amelanotic melanoma has also been reported. In this report, we describe an unanticipated result with crosses between C57BL/6-c2j and TG-3 mice. C57BL/6-c2j has the same genetic background as TG-3 (C57BL/6), except for a single base mutation (nucleotide 291) in the tyrosinase locus, resulting in albino coat colour. Only albino F2 mice generated from (TG-3 x C57BL/6-c2j) F1s were selected for further studies. Mice that contained the transgene showed a very high incidence of tumor development as early as 4-6 weeks of age. Raised amelanotic tumors developed on the ear pinnae and perianal region in young F2 albino mice, similar phenotypes as those described earlier for the other albino inbred strains. However, with time, these amelanotic tumors not only increased in size, but unexpectedly developed foci of dark pigmentation. DNA sequence analysis on reverse transcriptase-polymerase chain reactions (RT-PCRs) of tyrosinase mRNA showed that the original tyrosinase mutation was still present in the tumors, indicating that no reversion at this nucleotide had occurred in the tumors. Two different tyrosinase activity assays were used and tyrosinase activity was detected in most tumor samples. Furthermore, Western blot analysis demonstrated various levels of tyrosinase protein in ear tumor samples. These results suggest that tyrosinase and/or melanin are not directly involved in the establishment of melanoma, but that late events occurring within the tumors may generate some tyrosinase activity and production of melanin.

The ethyl acetate extract of the acetone-soluble Aloe arborescens fraction was found to inhibit 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced ear oedema, putrescine increase and tumour promotion in mouse skin. Chromatographic analyses of this extract revealed that phenolic compounds such as aloenin, barbaloin and isobarbaloin could be useful as cancer chemopreventive agents against tumour promotion., (Copyright 2002 John Wiley & Sons, Ltd.)

Epithelioid hemangioendothelioma described first by Weiss and Enzinger in 1982 is an uncommon vascular tumor usually involving soft tissue, less frequently the lung and the liver and exceptionally the skin. We herein report a 52-year-old woman who presented an isolated moderately painful persistant ulceration of the concha of her left ear. Histopathological findings showed strands and nests of epithelioid endothelial cells typical of cutaneous epithelioid hemangioendothelioma. Immunohistochemical stainings confirmed the vascular nature of the tumor. Surgical excision by ear amputation was performed. In a review of the literature, to our knowledge, this clinical presentation as ulceration has never previously been reported.

We report a patient with a cutaneous large cell T-cell non-Hodgkin's lymphoma of the pinna, a condition that has not been reported before. Despite the large dimensions of the tumour, the patient's ear was restored by electron therapy.

To model human papillomavirus-induced neoplastic progression, expression of the early region of human papillomavirus type 16 (HPV16) was targeted to the basal cells of the squamous epithelium in transgenic mice, using a human keratin 14 (K14) enhancer/promoter. Twenty-one transgenic founder mice were produced, and eight lines carrying either wild-type or mutant HPV16 early regions that did not express the E1 or E2 genes were established. As is characteristic of human cancers, the E6 and E7 genes remained intact in these mutants. The absence of E1 or E2 function did not influence the severity of the phenotype that eventually developed in the transgenic mice. Hyperplasia, papillomatosis, and dysplasia appeared at multiple epidermal and squamous mucosal sites, including ear and truncal skin, face, snout and eyelids, and anus. The ears were the most consistently affected site, with pathology being present in all lines with 100% penetrance. This phenotype also progressed through discernible stages. An initial mild hyperplasia was followed by hyperplasia, which further progressed to dysplasia and papillomatosis. During histopathological progression, there was an incremental increase in cellular DNA synthesis, determined by 5-bromo-2'-deoxyuridine incorporation, and a profound perturbation in keratinocyte terminal differentiation, as revealed by immunohistochemistry to K5, K14, and K10 and filaggrin. These K14-HPV16 transgenic mice present an opportunity to study the role of the HPV16 oncogenes in the neoplastic progression of squamous epithelium and provide a model with which to identify genetic and epigenetic factors necessary for carcinogenesis.

Primary mucoepidermoid carcinomas of the skin are extremely rare tumors. We describe a primary cutaneous mucoepidermoid carcinoma arising in the right ear (posterior mid helix) of a 66-year-old white man. The tumor was 0.6 cm in diameter, ulcerated and nonencapsulated. No other tumors were found in the patient. Histologically the tumor showed the characteristics of a "low grade" mucoepidermoid carcinoma, consisting of lobules of polygonal cells with vesicular nuclei. In the center of the lobules were large vacuolated cells (goblet cells). Transitions between the two cell populations were present throughout the tumor. An epidermal attachment of the tumor, as well as epidermal dysplasia, predominantly at the acrosyringium was present, consistent with the theory of sweat duct histogenesis of these tumors. Immunoperoxidase staining showed positivity for epithelial membrane antigen, keratin and carcinoembryonic antigen. The latter was predominantly positive in the goblet cells. Cutaneous metastasis of mucoepidermoid carcinomas with epidermal attachment has been reported. Our case showed only ear involvement and follow-up at 8 months has revealed no evidence of recurrence. These findings are consistent with the diagnosis of primary cutaneous mucoepidermoid carcinoma.

Five cases of spectacle-frame acanthoma are reported; four were retro-auricular (three unilateral; one bilateral) and one was present on the left side of the nose. Clinical aspects of the lesions are described by the light of all the other cases that have been previously reported in the literature. Histopathological features are compared to those encountered in chondrodermatitis nodularis helicis for which a frictional origin may also be suspected. In the vast majority of cases, spontaneous resolution is obtained when responsible spectacle frames are removed whereas a few lesions persist indefinitely despite of the fact that corrective measures are applied, on the contrary to what has been reported in previous papers. Apart from removing spectacles, these few cases needed surgical excision for a complete cure. Anatomo-clinical confrontations seem to indicate that those persistent lesions are completely fissured acanthomas.

Multiple trichoepithelioma is an uncommon disorder for which treatment is usually bedeviled by the recurrence of tumors. A case of multiple trichoepithelioma is described occurring in the retroauricular area; the condition cleared completely and without relapse following cryotherapy.