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Suspicious lesion with rhomboid flap closure is excised
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An 88-year-old white male presented for his comprehensive annual eye exam with concerns of hazy vision, watery eyes and a few “pimples” on the right side of his face that have grown larger since his last exam 1 year ago.
His past ocular history was remarkable for spectacle correction, bilateral cataract extraction with posterior chamber intraocular lens (PCIOL) implants, Fuch’s corneal dystrophy with Descemet’s-stripping endothelial keratoplasty (DSEK) of the right eye and macular cellophane retinopathy of the right eye.
Alexandra Bavasi
His systemic medical history was positive for transient ischemic attack, congestive heart failure (CHF), myocardial infarction, coronary artery disease, atrial fibrillation (AF), hypertension (HTN), hyperlipidemia, peripheral vascular disease, depression, benign prostatic hyperplasia (BPH) and a variety of benign skin lesions. His medication list was extensive, including oral paroxetine 20 mg once daily for depression, oral tamsulosin 0.4 mg once daily for BPH, oral digoxin 0.125 mg once daily for CHF and AF, oral furosemide 40 mg once daily for CHF, oral metoprolol 50 mg twice daily for HTN and oral warfarin sodium to improve blood flow. He was also taking oral ergocalciferol 50,000 units daily to regulate blood calcium levels, oral ascorbic acid 1,000 mg twice daily to support immune function, oral acetaminophen 650 mg as needed to manage pain and buccal nitroglycerin 0.4 mg as needed to relieve erratic heart symptoms. He was allergic to iodinated radiocontrast dye, other iodine-containing compounds and morphine.
Appearance of right temple lesion.
Histology slide showing a cyst-like tumor extending into the dermis with a base of irregular cell groups and nuclear atypia.
Images: Bavasi A
His entering corrected visual acuity was 20/125 with improvement to 20/80 on pinhole in the right eye and 20/70 with improvement to 20/60 on pinhole in the left eye. Without his glasses, his visual acuity improved to 20/30 in the right eye. Pupils were equal, round and reactive to light with no afferent pupillary defect. Extraocular motilities were full with no restrictions, and the visual field was grossly full upon confrontation. His habitual spectacles read +3.25 -0.75 x 099 OD and +2.00 -2.00 x 098 OS. The manifest refraction improved his vision to 20/25 OD with +1.75 -1.25 x 095 and to 20/60 OS with +1.50 -1.50 x 080. Anterior segment examination revealed a DSEK graft in the right eye that showed no signs of rejection, trace corneal thickening with guttata in the left eye and stable PCIOLs with open posterior capsules in both eyes.
The patient then pointed out the pimples that were bothering him. What appeared to be a verruca was on the lateral aspect of his right lower eyelid. A small cutaneous horn protruded from the right upper cheek. Although small, the patient was concerned with these lesions because they seemed to be getting larger.
He then directed our attention to a larger, elevated lesion on his right temple. The lesion measured 1.7 cm x 1.3 cm and appeared to have the beginnings of an ulcerated center. The nonpigmented lesion did not move upon palpation and was unable to be transilluminated. The edges of the lesion appeared sloped and vascular. It was slightly painful to touch.
The patient was scheduled to have all three lesions excised 5 weeks later. The two small lesions were excised with simple ellipsoid incisions. The edges were easily apposed using 6-0 sutures. The samples were sent to the pathologist for frozen-section analysis. The right lower eyelid lesion was identified as a benign seborrheic keratosis. The right upper cheek lesion was identified as benign keratosis with a slight actinic component. Both were completely excised.
Leonid Skorin
Because of its suspicious characteristics and size, a simple ellipsoid incision would not be adequate for the removal of the right temple lesion. The lack of mobile skin around the temple and forehead area also would not permit adequate closure of a larger ellipsoid incision. Thus, a rhomboid flap tissue transfer was created to effectively excise and close the defect. The lesion and immediate surrounding tissue measuring 2 cm x 2 cm was excised and analyzed under frozen section. The histologic slides showed an infundibulocystic tumor extending into the dermis with a base of irregular cell groups with nuclear atypia.
The results indicated squamous cell carcinoma with possible deep tissue involvement. Two additional specimens of the deeper dermal tissue were excised and analyzed. These deep tissue margins were not involved, so it was determined that all margins were clear and the lesion was completely excised.
The rhomboid pedicle flap for the adjacent tissue graft was created, the edges were reappproximated, and the wound was securely closed with multiple interrupted 4-0 nylon and 5-0 nylon sutures. The patient was instructed to use ciprofloxacin ophthalmic ointment around the eyelid and cheek excision sites and bacitracin ointment for the temple site. He returned in 1 week for suture removal. The surgical site healed well and the tissue transfer graft was secure with all edges approximated.
Epidemiology
Squamous cell carcinoma (SCC) is the second most common type of skin cancer after basal cell carcinoma, accounting for approximately 20% of all non-melanoma skin cancers (Lim et al.). It is estimated that there may be up to 700,000 new SCC cases per year. Approximately 4% of cases develop nodal metastases, and 1.5% of cases are fatal (Karia et al.). The incidence of SCC has increased due to higher levels of sun exposure, tanning bed use and an increase in the aging population. Improved skin cancer screening and detection has helped identify lesions that may not have otherwise been acknowledged.
Rhomboid flap tissue transfer template.
Excision of the lesion including a couple of millimeters of surrounding normal tissue.
Rhomboid flap pedicle being fashioned.
The corners of the rhombus are sutured first followed by equally-spaced interrupted sutures to close the wound.
Complete closure of the rhomboid flap tissue transfer.
Among light-skinned individuals, cumulative UV exposure and age are the biggest risk factors for developing SCC. Other risk factors include geographic location, ethnicity, ionizing radiation, immunosuppression, inherited disorders and some medications. Reducing direct sunlight exposure and using adequate sun block and protective clothing is the primary prevention for SCC. Other preventive methods include chemoprevention with oral or topical retinoids and oral nonsteroidal anti-inflammatory drugs.
Diagnosis
SCC lesions are most commonly found on sun-exposed areas of the body, such as on the face, scalp, ears, neck, arms and hands, but they can occur anywhere. These lesions are generally characterized by a crusted or scaly bump that may or may not be inflamed. Oftentimes they may mimic a non-healing sore. The skin may become itchy, tender or painful. SCC can also progress from other benign skin lesions including actinic keratoses and cutaneous horns.
SCC cannot be diagnosed based on appearance alone. A biopsy is required to determine the type and depth of the tumor cells. If the size of the lesion permits, surgeons usually opt to perform an excisional biopsy where the entire lesion and the immediate surrounding normal tissue are removed. The lesion or specimen is then sent to pathology for analysis.
To determine if all of the margins of the excisional biopsy are clear and that the entire tumor has been excised, a frozen section analysis can be performed during surgery. It is also used for rapid intraoperative diagnosis. This is useful in cases where the extent of the tumor is not well-defined.
The suspicious mass and a few millimeters of surrounding healthy tissue is first excised by the surgeon. The specimen is then given to a pathologist who systematically cuts and stains the margins of lesion. The prepared tissue is then rapidly frozen in a cryostat. The frozen tissue is then thinly sliced with a microtome, fixed to glass microscope slides and stained with various dyes. In about 12 to 15 minutes, the pathologist is able to examine the slides under a microscope to determine if the tissue is cancerous or benign and if the entire lesion was removed. If the pathologist finds abnormal cells along any of the margins, the surgeon can then remove more tissue from the appropriate area. The process is then repeated until all margins are clear.
Treatment
There are many different treatment options for SCC. Treatment is more versatile for small, superficial lesions, including electrodesiccation and curettage, laser therapy, cryotherapy, photodynamic therapy and medicated creams. Larger and deeper lesions need to be surgically excised.
A simple excision involves removing the cancerous tissue and a surrounding margin of healthy skin. The margins of the wound are then approximated and sutured together. Depending on the location of the lesion, tissue transfers or grafts may be needed to close the wound. Mohs surgery involves removing the cancerous tissue layer by layer and examining each layer under a microscope until no abnormal cells remain. This reduces the amount of healthy skin that is removed. Radiation therapy may be used alone or in combination with surgical excision. High-energy beams (normally X-rays) are aimed at the lesion to kill cancerous cells. Radiation is useful for deeper lesions or for patients who are unable to undergo surgery.
Because many SCC lesions develop on the face, reapproximating the edges of a surgical excision can be difficult due to the lack of subcutaneous fat and elastic tissue. Effective facial reconstruction can be achieved by creating local skin flaps to help close larger incisions. The purpose of creating an adjacent skin flap vs. using a skin graft is to maintain a robust vascular supply to expedite healing.
A common local flap used on the face is known as the Limberg rhombic flap, or rhomboid flap. To properly construct this flap, a rhombus is designed around the defect with angles of approximately 60 degrees and 120 degrees. The area of adjacent skin extending from one of the 120-degree corners is fashioned into a flap that is rotated to fill the rhomboid defect. The dermal layers surrounding the edges of the incisions need to be sufficiently undermined to approximate the edges without excessive tension. The corners of the rhombus are sutured first followed by equally spaced interrupted sutures to close the wound. Sutures are removed 1 week after closure.
Cancers of the skin are common on the face and periorbital areas. Although some skin lesions may have telltale characteristics, it is often difficult to determine if a lesion is malignant or benign. An excisional biopsy combined with frozen section analysis is an effective strategy to quickly diagnose and simultaneously treat a cancerous lesion.
It is important for optometrists to carefully examine their patients and inquire about any suspicious lumps or bumps seen on the face. An appropriate and timely referral to an ophthalmologist or a facial reconstructive surgeon for further assessment and treatment is imperative, as there is a risk for metastasis.