A comparison of Mohs micrographic surgery and wide excision for the treatment of atypical fibroxanthoma

Mohs micrographic surgery in rare cutaneous tumors: a retrospective study at a Brazilian tertiary university hospital

BACKGROUND

Mohs micrographic surgery is an established technique in the treatment of cutaneous neoplasms. It offers higher cure rates and the main indications are non-melanoma malignant skin tumors. Few studies have been performed on the treatment of rare tumors through this technique.

OBJECTIVE

To study rare skin tumors and rare variants of basal cell carcinoma and squamous cell carcinoma submitted to Mohs micrographic surgery in a tertiary service in relation to frequency, disease-free evolution, and applicability of this surgical procedure for this group of tumors.

METHODS

This was a retrospective observational study including rare skin tumors and less common variants of basal cell carcinoma and squamous cell carcinoma treated using Mohs micrographic surgery, between October 2008 and April 2021.

RESULTS

During the study period, 437 tumors were treated using Mohs micrographic surgery, and 22 (5%) rare skin tumors were selected. The tumors comprised three dermatofibrosarcomas protuberans, two atypical fibroxanthomas, two spiradenomas, two hypercellular fibrohistiocytomas, one primary cutaneous adenocarcinoma, one trichoblastoma, one porocarcinoma, one chondroid syringoma, one cutaneous angiosarcoma, one Merkel cell carcinoma, and one sebaceous carcinoma. Six other cases of rare basal cell carcinoma variants with trichoepitheliomatous differentiation, metatypical basal cell carcinoma, and clear cell squamous cell carcinoma were included. There were no cases of recurrence after an average of six years of follow-up.

STUDY LIMITATIONS

This is a retrospective study on rare neoplasms carried out in a single referral center, and this surgical technique isn't widely available in the public service.

CONCLUSION

This retrospective case series showed that Mohs micrographic surgery is an appropriate treatment for rare skin tumors. They corresponded to 5% of the tumors treated by the technique during a 12-year-period, with no recurrences identified.

Hemato-Oncological Diseases as Risk Factor for Recurrence or Metastasis of Pleomorphic Dermal Sarcoma

Background

Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are increasingly common sarcomas of the skin with a genetic UV signature. Immunosuppression is a known risk factor for developing other UV-induced skin cancers such as cutaneous squamous cell carcinoma (cSCC), basal cell carcinoma (BCC), and Merkel cell carcinoma with increased mortality. In case reports or small case series of AFX/PDS patients, immunosuppression has been hypothesized as a risk factor for the development of distant metastases. The aim of the present study was to analyze immunosuppression as a risk factor for AFX/PDS in a large patient cohort.

Methods

A cohort of 164 patients with AFX/PDS (47 AFX and 117 PDS) was collected between 2003 and 2021 and analyzed for clinicopathological data with a special focus on immunosuppression.

Results

Of all patients, 29.9% had any kind of immunosuppression; 6.4% of the AFX and 12.0% of the PDS patients had underlying hemato-oncological diseases. Patients with immunosuppression due to an underlying hemato-oncological disease had a significantly increased risk of progressing to (p = 0.010) and developing distant organ metastases (p = 0.000).

Conclusions

Immunosuppression seems to be a risk factor for developing AFX/PDS with worse clinical outcomes. Therefore, immunosuppression, especially underlying hemato-oncological diseases, should be considered in the treatment and follow-up care of patients with AFX/PDS.

Atypical Fibroxanthoma Resected without Auricular Deformity in an Elderly Patient: A Case Study

Atypical fibroxanthoma (AFX) is a dermal spindle-cell cutaneous malignancy, which is a relatively benign type of skin cancer that occurs in the elderly with sun-damaged skin. This is a case study of a rapidly enlarged left auricular mass lesion in an elderly patient who was diagnosed with AFX based on histopathological and immunohistochemical findings, and then treated by complete excision to prevent recurrence or metastasis. There was no recurrence during the 1-year follow-up. For otolaryngologists or plastic surgeons, recognizing the clinical and pathologic characteristics of AFX is important for accurate diagnosis and treatment.

Pleomorphic dermal sarcoma: Clinicopathological features and outcomes from a 5-year tertiary referral centre experience

BACKGROUND

Pleomorphic dermal sarcoma (PDS) describes rare dermal-based malignant tumours that are morphologically similar to atypical fibroxanthoma (AFX). PDS may be differentiated from AFX by the presence of one or more of the following histologic features: subcutaneous invasion, tumour necrosis, lymphovascular invasion (LVI), and/or perineural infiltration (PNI).

AIMS

To further define the clinicopathological features, surgical management, and outcomes of PDS primary tumours.

METHODS AND RESULTS

This study was a retrospective observational case series using a database search from 2012 to 2017. Inclusion criteria required all cases to meet the histopathologic criteria for PDS as confirmed by a specialist soft-tissue histopathologist. A total of n = 17 cases were included with a median age of 78 years (range 66-85). All tumours were located on the head and neck, with 13/17 located on the scalp. Primary treatment was with wide local excision (WLE) in all cases. Median follow-up was 48 months. Local recurrence occurred in 4/17 cases (24%) and distant metastasis in 2/17 cases (12%).

CONCLUSION

PDS behaves more aggressively than atypical fibroxanthoma with which it shares a biologic continuum. The optimal surgical management approach is yet to be determined.

Surgical excision margins for fibrohistiocytic tumors, including atypical fibroxanthoma and undifferentiated pleomorphic sarcoma: A probability model based on a systematic review

BACKGROUND

Mohs micrographic surgery or wide local excision is the treatment of choice for fibrohistiocytic tumors with metastatic potential, including atypical fibroxanthoma (AFX) and cutaneous undifferentiated pleomorphic sarcoma (cUPS). Since margin clearance is the strongest predictor of clinical recurrence, improved recommendations for appropriate surgical margins help delineate uniform excision margins when intraoperative margin assessment is not available.

OBJECTIVE

To determine appropriate surgical wide local excision margins for AFX and cUPS.

METHODS

Literature search (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library from inception to March 2020) to detect case-level data. Estimation of margins required using a mathematical model based on extracted cases without recurrences.

RESULTS

Probabilistic modeling based on 100 cases extracted from 37 studies showed peripheral clearance margin (ie, wide local excision margin) calculated to clear 95% of all tumors was 2 cm for AFX and 3 cm for cUPS. AFX tumors 1 cm or less required a margin of 1 cm.

LIMITATIONS

Data were extracted from published cases.

CONCLUSIONS

Atypical fibroxanthoma removed with at least a 2-cm peripheral excision margin is less likely to recur. Smaller tumors 1 cm or less can be treated with a more conservative margin. Margin-control surgical techniques are recommended to ensure complete removal while minimizing surgical morbidity.

Clinicopathological and Genomic Profiles of Atypical Fibroxanthoma and Pleomorphic Dermal Sarcoma Identify Overlapping Signatures with a High Mutational Burden

Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are rare tumors developing in chronically sun-exposed skin. Clinicopathological features are similar, but they differ in prognosis, while PDS has a more aggressive course with a higher risk for local recurrence and metastases. In current clinical practice, they are diagnosed by exclusion using immunohistochemistry. Thus, stringent diagnostic criteria and correct differentiation are critical in management and treatment for optimal outcomes. This retrospective single-center study collected clinicopathological data and tumor samples of 10 AFX and 18 PDS. Extracted genomic DNA from tumor specimens was analyzed by a next-generation sequencing (NGS) platform (FoundationOne-CDx™). Among 65 identified mutations, TP53 inactivating mutations were observed in all tumor specimens. In both AFX and PDS, the known pathogenic gene alterations in CDKN2A, TERT promoter, and NOTCH1 were frequently present, along with high mutational burden and stable Micro-Satellite Instability status. The mutational profiles differed only in ASXL1, which was only present in AFX. Further differences were identified in likely pathogenic and unknown gene alterations. Similarities in their genomic signatures could help to distinguish them from other malignancies, but they are not distinguishable between each other using the FoundationOne-CDx™ NGS panel. Therefore, histological criteria to determine diagnosis remain valid. For further insight, performing deep tumor profiling may be necessary.

Atypisches Fibroxanthom oder pleomorphes dermales Sarkom – eine Frage der Infiltrationstiefe

Das atypische Fibroxanthom (AFX) ist eine seltene, niedrig-maligne mesenchymale Neoplasie der Haut. Die Abgrenzung zum malignen fibrösen Histiozytom bzw. pleomorphen dermalen Sarkom (PDS) wurde seit der Erstbeschreibung Anfang der 1960er-Jahre immer wieder kontrovers diskutiert. Mittlerweile wird der Begriff des pleomorphen dermalen Sarkoms für Tumore verwendet, die eine Infiltration der Subkutis, nekrotische Anteile oder eine perineurale oder lymphovaskuläre Infiltration aufweisen. Die Unterscheidung der beiden Entitäten erfolgt folglich vorwiegend histologisch, eine immunhistochemische Abgrenzung ist bisher nicht möglich.

Wir berichten über 2 Patienten mit atypischem Fibroxanthom und pleomorphem dermalem Sarkom. Beide Tumorentitäten sollten mittels weiter Exzision oder mikrografisch kontrollierter Chirurgie vollständig exzidiert werden. Insbesondere beim pleomorphen dermalen Sarkom kommt es häufiger zu Rezidiven und Metastasierung, deshalb sollte der Sicherheitsabstand größer als beim AFX gewählt werden und v. a. in den ersten 3 Jahren nach der Behandlung eine engmaschige Nachsorge erfolgen.

Eine einheitliche Klassifikation der beiden Tumorentitäten, die das aggressivere Verhalten des tiefer infiltrierenden pleomorphen dermalen Sarkoms berücksichtigt, wäre erstrebenswert.

Zudem sollten beide Tumore der Meldepflicht unterliegen, um weitere epidemiologische Daten sammeln zu können.

Atypical Fibroxanthoma: An unexpected cause of hemoptysis

Atypical fibroxanthoma is an infrequent, low-grade superficial cutaneous neoplasm, usually presenting as a nodule or plaque of red color. It is considered as a superficial variant of pleomorphic dermal sarcoma. Although atypical fibroxanthoma has similar histologic features to pleomorphic dermal sarcoma, it has less aggressive behavior. Atypical fibroxanthoma usually occurs on sun-exposed regions of the head and neck of elderly patients. Ultraviolet light, specific genetic mutations and administration of immunosuppressive agents to transplant recipients have been associated with the pathogenesis of the tumor. The prognosis is typically excellent when treated with complete excision of the primary lesion. This report describes the rare case of a 84-year-old man with hemoptysis due to metastatic cutaneous atypical fibroxanthoma.

Cutaneous mesenchymal tumors treated with Mohs micrographic surgery: a comprehensive review

Cutaneous mesenchymal tumors (CMT) are rare tumors with wide clinicopathologic heterogeneity. Treatment of malignant cutaneous mesenchymal tumors traditionally includes wide local excision (WLE), though Mohs micrographic surgery (MMS) has been increasingly used. A PubMed literature review of articles from inception until September 2019 related to malignant CMT and surgical treatment with MMS or WLE was completed. Dermatofibrosarcoma protuberans treated with MMS recurred in 1.2% of patients with no reported metastasis. Atypical fibroxanthoma treated with MMS recurred and metastasized in 2.7 and 2.5%, respectively. Undifferentiated pleomorphic sarcoma treated with MMS recurred in 32% with an unknown metastatic rate. Superficial leiomyosarcoma treated with MMS recurred in 3.8% with no reported metastasis. Cutaneous angiosarcoma and myofibrosarcoma treated with MMS have shown no recurrence or metastatic disease, but literature is sparse. The rarity of malignant CMT and the lack of comparative data on treatment make conclusive treatment recommendations difficult. However, recent literature suggests MMS is a useful option and potentially a superior treatment for primary cutaneous mesenchymal tumors.

Malignant Fibrous Histiocytoma of the Scalp with Skull Invasion: A Rare and Aggressive Presentation

Malignant fibrous histiocytoma (MFH) is an undifferentiated high-grade pleomorphic sarcoma and is considered the most common primary soft tissue sarcoma in adults. MFH is known to arise in the trunk, extremities and retroperitoneum although it can arise anywhere in the body.MFH of the skin is uncommon and even less frequent is the involvement of the scalp, especially with skull invasion. Most of the MFH cases present as a gradually growing lesion over a period of one to two years and is associated with ulceration and hemorrhage in most of the cases. Treatment of MFH is usually surgical resection.

We present a case of MFH in an 85-year-old gentleman that was invading the skull which required a multidisciplinary surgical treatment for resection and microvascular free flap reconstruction.

Atypical fibroxanthoma: Systematic review and meta-analysis of treatment with Mohs micrographic surgery or excision

BACKGROUND

Atypical fibroxanthoma (AFX) is a fibrohistiocytic tumor with relatively high local recurrence rates but low metastatic potential. Wide local excision (WLE) and Mohs micrographic surgery (MMS) are common treatments, although no consensus exists regarding optimal therapy.

OBJECTIVE

To systematically review evidence of AFX recurrence and metastatic rates after different surgical modalities.

METHODS

A comprehensive search was performed for articles published from 1946 or database inception to March 20, 2017. Studies selected included those that had 5 or more patients with atypical fibroxanthoma treated surgically. Two reviewers independently abstracted the data. Risk of bias was assessed with the Newcastle-Ottawa scale. Main outcomes and measures included recurrence and metastasis.

RESULTS

In total, 23 studies were selected (907 patients and 914 tumors); 175 patients were treated with MMS (recurrence rate 2.0%, 95% confidence interval [CI] 0%-4.1%; metastatic rate 1.9%, 95% CI 0.1%-3.8%), and 732 were treated with WLE (recurrence rate 8.7%, 95% CI 5%-12.3%; metastasis rate 1%, 95% CI 0.2%-1.9%). Among immunocompromised patients, no recurrence or metastases developed in the MMS subgroup, although 4 of 10 recurred and 1 of 10 metastasized in the WLE subgroup.

LIMITATIONS

Low quality of the studies published.

CONCLUSION

MMS for atypical fibroxanthoma is associated with a lower recurrence rate than WLE.

Mohs Micrographic Surgery: Development, Technique, and Applications in Cutaneous Malignancies

Mohs micrographic surgery (MMS) is a specialized technique for treating skin malignancies that offers the highest cure rate by allowing histological evaluation of the entire peripheral and deep margins. MMS also maximally preserves as much uninvolved, normal adjacent tissue as possible, allowing for the best cosmetic and functional outcomes. When used for appropriate indications, this technique is also more cost-effective than other treatment modalities. In this article, the authors will discuss the development of MMS, the steps involved in this procedure, and the indications for this technique. They will also review the use of MMS for basal cell carcinoma, squamous cell carcinoma, melanoma in situ, and some less common skin malignancies.

Conception and Management of a Poorly Understood Spectrum of Dermatologic Neoplasms: Atypical Fibroxanthoma, Pleomorphic Dermal Sarcoma, and Undifferentiated Pleomorphic Sarcoma

OPINION STATEMENT

Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) tumors share many clinical, etiologic, and histologic features and likely represent components of a tumor spectrum. In dermatologic oncology, differentiating between AFX and PDS is pivotal as tumors with histological features consistent with PDS are more likely to behave in a clinically aggressive manner. Importantly, the term "pleomorphic dermal sarcoma" (PDS) is a more appropriate designation than "undifferentiated pleomorphic sarcoma" (UPS) for describing deeper, more aggressive, histologically high-grade cutaneous tumors that otherwise resemble AFX. Surgery remains the gold standard for treatment. In the setting of AFX, excision with the Mohs micrographic technique appears to offer superior tumor control rates while maintaining greater tissue preservation over wide local excision and should be considered first line. In the setting of PDS, optimal management is less clear given the paucity of available data. However, due to its greater propensity to recur and metastasize, extirpation with complete tumor margin control appears paramount. The roles of imaging and SLNB in management and clinical outcomes of AFX and PDS are unclear given the lack of available data. In reality, these tools are unlikely to be helpful in most cases of AFX. However, in the setting of PDS, emerging literature indicates that these tumors are inherently higher risk, and thus, imaging and SLNB may be helpful in select cases. Additionally, radiation therapy may be of adjuvant benefit for these tumors when clear surgical margins cannot be obtained. While traditional chemotherapy has been largely ineffectual, the recent discovery of key oncogenetic mutations has allowed for the identification of several potential molecular drug targets that may have a therapeutic role with future study. In the unfortunate setting of metastatic disease, a multidisciplinary approach is optimal. Further studies are needed to establish definitive conclusions regarding risk stratification and best management practices.

Incidence and Clinical Features of Rare Cutaneous Malignancies in Olmsted County, Minnesota, 2000 to 2010

BACKGROUND

The incidence of rare cutaneous malignancies is unknown. Current estimates of rare cutaneous malignancy incidences are based on broad epidemiologic data or single institution experiences, not population-based data.

OBJECTIVE

To determine the incidence of several rare nonmelanoma skin cancers.

MATERIALS AND METHODS

The authors conducted a retrospective chart review of a population-based cohort between the years 2000 and 2010. Residents of Olmsted County, Minnesota, who were diagnosed with a biopsy-proven nonmelanoma skin cancer-excluding basal cell carcinoma and squamous cell carcinoma-were included in this study. The primary outcome was tumor incidence. Additionally, the authors extracted patient demographics, tumor characteristics, treatment modalities, and outcomes.

RESULTS

The age-adjusted and sex-adjusted incidences per 100,000 persons of multiple rare cutaneous malignancies were: atypical fibroxanthoma (1.8), sebaceous carcinoma (0.8), dermatofibrosarcoma protuberans (0.4), microcystic adnexal carcinoma (0.7), eccrine carcinoma (0.4), eccrine porocarcinoma (0.2), and leiomyosarcoma (0.2).

CONCLUSION

The authors report population-based incidences and clinical characteristics for these rare cutaneous malignancies. The immune status and smoking status of patients and the treatment and outcomes of these tumors are reported. Additional studies in a broader population are needed to further define the epidemiology and outcomes of these malignancies.

Keloidal Atypical Fibroxanthoma: Case and Review of the Literature

Keloidal atypical fibroxanthoma (KAF) has recently been categorized as a variant of atypical fibroxanthoma. This paper will emphasize the importance of including KAF in both clinical and histological differential diagnosis of benign and malignant lesions which exhibit keloidal collagen and will also review the current literature on epidemiology, pathogenesis, histology, immunochemistry and treatments.

Clear cell atypical fibroxanthoma: a case report and review of the literature

Atypical fibroxanthoma (AFX) is a group of cutaneous tumors characterized by a population of fusiform, epithelioid and pleomorphic cells. Clinically, AFX is commonly found on the head and neck of older adults as a solitary ulcerated nodule. Clear cell atypical fibroxanthoma is a very rare variant of AFX, with only 13 cases reported to date. The differential diagnoses often include dermal neoplasms composed of clear cells, such as squamous cell carcinoma, basal cell carcinoma, metastatic renal cell carcinoma and balloon cell malignant melanoma. These diagnoses can be ruled out by the typical immunohistochemical profile of clear cell AFX, which is negative for specific epithelial and melanocytic markers. Herein, we describe a rare and unusual case of clear cell AFX arising on the ear of a relatively young adult patient. Histologically, the dermis was completely replaced by an atypical population of vacuolated cells with numerous atypical mitoses. Immunohistochemical stains were negative forpancytokeratin, CK5/6, CK7, and p63 S100 and Melan-A stains. CD10 and CD68 stains were positive, making the findings consistent with the diagnosis of clear cell atypical fibroxanthoma.

Atypical Fibroxanthoma: A case series and review of literature

INTRO/OBJECTIVE

Atypical Fibroxanthoma (AFX) is a rare cutaneous neoplasm arising from myofibroblast or fibroblast-like cells that predominantly affects the head and neck region. It commonly mimics more invasive neoplasms and is a diagnostic challenge to clinicians. The aim of this study was to develop a better understanding of AFX, focusing on recent developments in diagnosis and management.

METHODS

A retrospective case series and review of recent literature were carried out.

RESULTS

Over a 17-year period, seven cases were identified (six male, mean age at presentation was 75.9 years). Two patients underwent complete excision and five patients had curettage and cauterisation. Two patients developed local recurrence but none demonstrated signs suggestive of metastatic spread. Histologically all seven lesions displayed a spindle cell pattern. Where performed, immunohistochemical staining was positive for Vimentin, CD10, CD68 and actin, and negative for CAM 5.2, CD34, Melan-A, S100 protein, HMB45, Cytokeratin A1/A3.

CONCLUSION

Our patient demographics, histopathology and immunohistochemistry are comparable to previous studies. Although advances have been made in immunohistochemical analysis, we are yet to discover a specific diagnostic immunostain for AFX. Clinical findings should therefore be correlated with histology and a panel of immunohistochemical stains should be used. Given the potential for recurrence or metastases, Moh's Micrographic Surgery with regular follow-up may be the preferred management.

Malignant cutaneous adnexal tumours of the head and neck: an update on management

Adnexal tumours form a heterogeneous group of relatively rare neoplasms. Many of them have a poor prognosis and treatment can sometimes be difficult and controversial. We summarise the latest publications relating to malignant cutaneous adnexal tumours of the head and neck, and give an update on their management. We discuss Merkel cell carcinoma and other rare malignant adnexal tumours including dermatofibrosarcoma protuberans and atypical fibroxanthoma.

Atypical fibroxanthoma: new insights

Atypical fibroxanthoma (AFX) is an ultraviolet radiation-associated dermal neoplasm. To address the clinicopathologic and molecular features of this particular neoplasm. The author conducted a literature review using PubMed searching for articles relating to AFX. AFX usually appears as a rapidly growing nodular or nodulo-ulcerative lesion. It occurs on sun-exposed skin of elderly peoples. AFX may be composed predominantly of pleomorphic, spindle, epithelioid cells, or admixture of these cells. The differential diagnosis of AFX includes pleomorphic dermal sarcoma, squamous cell carcinoma, malignant melanoma and leiomyosarcoma. Several observations favor a mesenchymal origin for AFX. These reviews address the clinicopathologic features, molecular pathology, prognosis and treatment of this neoplasm.

Atypical fibroxanthoma in head and neck

Atypical fibroxanthoma is a pleomorphic spindle cell tumor of the dermis and it's been known to be a benign lesion clinically in spite of malignant histologic features. But recurrence is estimated at between 2%-20% and metastasis has been reported. We are about to describe a 70-year-old man with the lesion developed on the left infra-auricular area. The lesion was located superficially and is composed of compact pleomorphic spindle cells and several bizarre multinucleated giant cells. The patient was treated with wide excision. We would like to discuss about this case with a review of literatures.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Dermatoscopic features of cutaneous atypical fibroxanthoma: three cases

Atypical fibroxanthoma (AFX) is an uncommon, low-grade, malignant, spindle-cell tumour of fibrohistiocytic histogenesis, which can mimic other malignant skin tumours, such as basal and squamous cell carcinoma (CC), melanoma, and Merkel cell carcinoma (MCC). Three cases of AFX were examined by dermatoscopy, which revealed white areas and an atypical polymorphous vascular pattern characterized by the concurrence of different structures: linear, dotted, hairpin, arborescent and highly tortuous vessels, irregularly distributed over the surface. Seborrhoeic elements and photoageing may be accompanying features depending on the anatomical location of the AFX. AFX may be added to the list of slightly pigmented, reddish, malignant cutaneous tumours, such as SCC, MCC, amelanotic/hypomelanotic melanoma and eccrine porocarcinoma, which display prominent and chaotic dermatoscopic neoangiogenetic features in more advanced stages of proliferation.

Atypical fibroxanthoma: a series of 25 cases

OBJECTIVE

Atypical fibroxanthoma is a rare mesenchymal tumour of skin that develops on skin of elderly patients. We analysed our patients with atypical fibroxanthoma over the last 8 years.

PATIENTS AND METHODS

We analysed the pathology files of our hospital for the period 2001-2009. In all cases, histology and immunohistology were performed. Data on co-morbidities, treatment and outcome were obtained.

RESULTS

We identified 25 patients (except two female patients, the rest were men) aged 52-95 years (mean: 79.5 years; standard deviation +/- 9.06 years). All tumours were localized in the head and neck region, except a single tumour on the shoulder. Fourteen patients had a cancer history, six had actinic keratoses or Bowen's disease (n = 1). Five patients had cardiac surgery or pacemaker, one each had a renal transplant, systemic sarcoidosis or non-Hodgkin's lymphoma. Medical history was positive for radiotherapy or chemotherapy in four patients. Histology showed a spindle-shaped dermal and subcutaneous tumour growth intermingled with multinucleated giant cells. The phenotype of tumour cells was vimentin-positive, but S100- and keratin-negative. Some tumours showed a focal expression of CD68. Complete microhistographic controlled surgery ('Mohs like') was possible in all cases followed by mesh-graft transplantation in three patients. Eighteen patients showed a complete remission. Four patients had a relapse within 2 years of follow-up treated by surgery. One patient is still under radiotherapy. All patients with a safety margin of 2 cm had no recurrence or relapse during follow-up.

CONCLUSIONS

Micrographic controlled surgery with wide 2 cm safety margins is the treatment of choice. A regular follow-up for the next 5 years is recommended.

Atypical fibroxanthoma/malignant fibrous histiocytoma

Atypical fibroxanthoma (AFX) is an unusual spindle cell tumor occurring on actinically damaged skin of the head and neck. Clinically, it is often confused with basal cell carcinoma, squamous cell carcinoma, or even melanoma. Although initially thought to be a diagnosis of exclusion histologically, newer immunostains have helped in the identification of AFX. Mohs micrographic surgery has been utilized for the treatment due to its tissue sparing ability along with lower recurrence rate.

Management of cutaneous tumors with mohs micrographic surgery

Since the inception of Mohs micrographic surgery in the 1930s, this technique has proved its utility in the treatment of cutaneous tumors. This review describes the technique of Mohs micrographic surgery and the various indications for which it is used. We discuss the use of Mohs micrographic surgery for the following cutaneous tumors: basal cell carcinoma, squamous cell carcinoma, melanoma in situ, dermatofibrosarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, atypical fibroxanthoma, and sebaceous carcinoma. Mohs micrographic surgery is cost effective in the U.S. health care system because billing for the surgeon-pathologist and laboratory processing is bundled together. However, Mohs micrographic surgery may be more expensive in European systems because the Mohs technique surgeon, pathologist, and laboratory fees may be billed separately.

Current progress of immunostains in Mohs micrographic surgery: a review

Mohs micrographic surgery is often considered the treatment of choice for a variety of skin malignancies. In recent years, the application of immunostaining techniques has facilitated the successful removal of a number of common and less common cutaneous malignancies, including basal cell carcinoma, squamous cell carcinoma, malignant melanoma, dermatofibrosarcoma protuberans, microcystic adnexal carcinoma, sebaceous carcinoma, atypical fibroxanthoma, extramammary Paget's disease, and even sarcomas. Immunostains highlight the tumor cells and allow the Mohs surgeons to pinpoint and eliminate the residual tumor at the surgical margin. It is especially helpful when a tumor presents with subtle or nonspecific histologic features or when a tumor is masked in a pocket of dense inflammation. However, the cost, the labor, and the time consumption are of concern to many of our peers, as are the diversity of antigens, which may overwhelm some. This article serves as a review of the literature on current uses of immunostaining in Mohs micrographic surgery and as a summary of their realistic applications in the dermatologic surgeon's practice. We conclude that immunohistochemical technique has played an important role in Mohs surgery advancement. With greater use and more cost-effective staining methods, we believe that the use of immunostains in a Mohs practice will become routine.

Atypical fibroxanthoma presenting in a patient with stage III mycosis fungoides

The association of atypical fibroxanthoma (AFX) and mycosis fungoides (MF) has never been reported. We report a 77-year-old female who was referred for Mohs micrographic surgery (MMS) of an AFX on the right hand. At the time of presentation, this patient had stage III MF, with erythroderma and palpable lymph nodes. Our patient's AFX measured 1.5x2.8 cm. The tumor was removed by MMS with clear margins. The pathologic specimen revealed a relatively well-circumscribed neoplasm in the upper dermis composed of atypical spindle cells with pleomorphism, hyperchromatic nuclei, and brisk mitotic activity. Immunohistochemical stains were focally positive for CD68, and negative for S-100, Melan-A, desmin, smooth muscle actin and neurofilament. Perilesional skin revealed epidermal hyperplasia, parakeratosis, and multiple epidermotropic lymphocytes with enlarged and hyperchromatic nuclei. One year after the initial MMS, our patient developed another tumor on the right hand, which measured 4x6 mm. This neoplasm underwent a fusiform excision with clear margins. Histological examination revealed evidence of MF and an AFX. To our knowledge, this is the first report of an AFX arising in a patient with MF.

More than 2 decades of treating atypical fibroxanthoma at mayo clinic: what have we learned from 91 patients?

BACKGROUND

Atypical fibroxanthoma (AFX) typically occurs on the head and neck of elderly white men. Usually considered a malignancy, it is treated with wide local excision (WLE) or total margin control using Mohs micrographic surgery (MMS).

OBJECTIVE

To determine the most appropriate treatment for this tumor based on a review of cases treated at Mayo Clinic.

METHODS

We reviewed the medical records of patients with AFX treated at Mayo Clinic from 1980 to 2004.

RESULTS

We identified 91 patients with 93 tumors. Treatment information was available for 88 tumors (59 treated with MMS, 23 with WLE, and 6 by other means). There were no recurrences in the patients treated with MMS, with a median follow-up of 4.5 years (range 1.0-16.1 years). Two patients treated with WLE had single recurrences, with a median follow-up of 8.7 years (range 1.5-26.3 years).

CONCLUSIONS

Total microscopic margin control using MMS was the most effective means of treating AFX.

Atypical fibroxanthoma

Atypical fibroxanthoma (AFX) is a nodular dermal ulcerative lesion with a favorable prognosis. AFX most commonly occurs on sun-exposed skin in elderly individuals. AFX is characterized by its association with ultraviolet radiation, not only from a clinical aspect, but also from a molecular aspect. Making a diagnosis of AFX is challenging, and it is important to differentiate it from squamous cell carcinoma and malignant melanoma. Histological features and combined immunohistochemical markers are necessary for a definitive diagnosis (i.e., an absence of immunostaining for cytokeratins, S100 and HMB45 in AFX is helpful for excluding both squamous cell carcinoma and malignant melanoma). AFX, as well as MFH (malignant fibrous histiocytoma), is a fibrohistiocytic lesion with myofibroblastic differentiation. AFX is considered to be a different lesion from MFH. AFX and MFH might share the same pathway which determines their morphology. However, they may have different pathways in development which determine their biological behavior.

A Primer of Mohs Micrographic Surgery: Uncommon Indications

Mohs micrographic surgery has been used for the treatment of tumors other than basal and squamous cell carcinomas. Parameters to be considered when deciding on a treatment include location, size, growth pattern, and recurrence rates. It is important to consider that sometimes the high-risk nature of the tumor is more significant than the need for tissue sparing. Modifications to the Mohs micrographic surgery technique may be used to ensure diagnostic accuracy and confirm complete removal of the lesion (e.g., immunohistochemical staining and paraffin-embedded sections).

Atypical fibroxanthoma in a young woman: An unusual case presentation

Atypical fibroxanthoma (AFX) is an uncommon neoplasm, identified as a spindle cell tumour that is generally found in elderly patients on sun-exposed areas. The majority of cases of AFX are benign, and metastasis is a rare phenomenon. The first case in the literature of AFX is described in a young woman with no previous risk factors who presented with a three-month history of an enlarging nodule of the left nasal alar. Excision showed the lesion to be composed of hyperchromatic, pleomorphic, vacuolated spindle cells and multinucleated giant cells. The tumour cells stained positive for macrophage-histiocyte antigen alpha(1)-antitrypsin, neurokinin-1, CD68 and alpha(1)-antichymotrypsin. The present case report highlights the importance of correct diagnosis for AFX with adequate excision and by considering the histopathology and immunohisto-chemistry of its clinical differential diagnosis.

Sarcomas cutâneos primários

Os sarcomas com apresentação cutânea primária são tumores raros e de grande heterogeneidade histológica. Com a evolução da oncologia cutânea e da cirurgia dermatológica, os dermatologistas têm sido cada vez mais requisitados para o diagnóstico e orientação terapêutica de tumores menos freqüentes. Este artigo de revisão analisa os sarcomas cutâneos primários observando suas características clínicas, etiopatogênicas e histológicas, bem como aspectos do tratamento e evolução. Enfatiza os sarcomas de maior relevância para o dermatologista, como angiossarcoma, dermatofibrossarcoma protuberans, fibroxantoma atípico, leiomiossarcoma, lipossarcoma, tumor maligno de bainha de nervo periférico e sarcoma epitelióide. O sarcoma de Kaposi não é abordado devido a suas características individuais específicas.

Multiple Atypical Fibroxanthomas in a Cardiac Transplant Recipient

BACKGROUND

Solid organ transplant recipients have an increased incidence of multiple cutaneous neoplasms.

OBJECTIVE

We hope to draw attention to the potential risk for organ transplant recipients to develop atypical fibroxanthomas.

METHODS

A review of the patient's medical record was performed and summarized as a case report.

RESULTS

We present the case of a cardiac transplant recipient who developed three atypical fibroxanthomas. This is the first reported case of multiple atypical fibroxanthomas in an organ transplant recipient.

CONCLUSION

Atypical fibroxanthomas are uncommon cutaneous malignancies for which transplant recipients may be at increased risk.