Correspondence

Comments on the giant basal cell carcinoma^*

Comentários sobre o carcinoma basocelular gigante

Authorship SCIMAGO INSTITUTIONS RANKINGS

To the Editor,

It was with great interest that we read about the recent case reported by Nasser et al.¹ The authors defined giant basal cell carcinoma (GBCC) as a lesion larger than 5 cm at its greatest diameter according to the American Joint Committee on Cancer (AJCC).¹ However, because the 7^th edition of the AJCC Cancer Staging Manual was recently published with a modification of the TNM system for BCC staging,² some information should be reconsidered. The major change was that the 5-cm diameter cutoff was eliminated.² In the previous edition, a lesion > 5 cm was classified as T3. Now, bony invasion is determinant to characterize a tumor as T3.² Some studies^3-5 on BCC patients with a long-term follow-up have shown that size alone is not the main determinant of poor prognosis, which is consistent⁵ with the modified staging system by AJCC.²

Radical surgical excision with microscopically tumor-free margins remains the treatment of choice for GBCC because it is associated with a satisfactory disease-free survival, as reported by Nasser et al.^3-5 Since these tumors can be destructive and infiltrative, they often create problems of oncologic radicality.^3-5 Therefore, wide surgical excision often results in large complex defects, which can pose a significant reconstructive challenge, particularly when lesions occur in aesthetically or functionally important areas.^3-5 Thus, doctors who deal with these patients should master reconstruction techniques so that optimal oncologic results can be achieved with maintenance of function and aesthetics.

REFERENCES

• ¹
  Nasser N, Nasser Filho N, Trauczynski Neto B, Silva LM. Giant basal cell carcinoma. An Bras Dermatol. 2012;87:469-71.
• ²
  Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010.
• ³
  Archontaki M, Stavrianos SD, Korkolis DP, Arnogiannaki N, Vassiliadis V, Liapakis IE, et al. Giant Basal Cell Carcinoma Clinicopathological analysis of 51 cases and review of the literature. Anticancer Res. 2009;29:2655-63.
• ⁴
  Codazzi D, Bruschi S, Bocchiotti MA, Robotti E. Giant basal cell carcinoma: a series of 37 cases without metastasis. Plast Reconstr Surg. 2012;129:999e-1000e; author reply 1000e-1001e.
• ⁵
  Manstein CH, Manstein ME, Beidas OE. Giant basal cell carcinoma: 11-year follow-up and seven new cases. Plast Reconstr Surg. 2011;128:1105-6.

• * Work conducted at Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medical Sciences, University of Marília (Universidade de Marília UNIMAR) - Marília (SP), Brazil.

Reply

Nilton Nasser

Dear Sir, We would like to thank you for your great collaboration in order to clarify rare cases such as this one. The studies to which the author of the letter refers explain the success of surgical excision, with complete cure, despite the size of the lesion. These studies are a source of knowledge and instruction to everyone. Congratulations on the observations that cooperate with the educational and therapeutic aspect of the case.

Sincerely,

History

• Received
  20 July 2012
• Accepted
  27 July 2012

Training young surgeons in sectioning scalp for hair transplantation; a simple method^*

Treinamento de jovens cirurgiões na divisão do couro cabeludo para transplante capilar: um método simples

About the SCIMAGO INSTITUTIONS RANKINGS

Dear Sir,

Surgical hair transplantation is now a commonly performed procedure. It is done by harvesting an elliptical strip of scalp which is then dissected into small slivers of 1 or 2 follicular unit width (1-2 mm) under a microscope or loupe. This is a crucial step, and meticulous microscopic dissection needs to be done to avoid transaction of hairs.^1,2 The slivers are then dissected into units of one, two, three or four hair units. It has been generally recognized that stereomicroscopic dissection is needed for proper identification and dissection in order to minimize transaction.³ However, training in an equipped laboratory is necessary for performance of dissection.

Excised scalp skin can be used to train surgeons to perform microscopic dissection. Scalp excision is done for several reasons, including cases of swellings like sebaceous cysts and vascular lesions. These are generally excised as an ellipse. The area of uninvolved scalp around the swelling in the ellipse can be used for training purposes (Figure 1). Surgeons can then practice cutting slivers and harvesting follicular units under magnification. Hair dissection is a skilled job, and dissectors require proper training. This simple use of excised scalp skin can serve to train young surgeons.

FIGURE 1
Potential areas of scalp available for training include the scalp skin adjacent to a lesion being excised in an ellipse and the scalp skin being sacrificed in triangulating a defect for transposition flap

REFERENCES

• 1. Seager D. Binocular stereoscopic dissecting microscopes: should we use them? Hair Transplant Forum Int.1996;6:2-5.
• 2. Cooley J, Vogel J. Loss of the dermal papilla during graft dissection and placement: Another cause of x-factor? Hair Transplant Forum Int. 1997;7:20-1.
• 3. Bernstein RM, Rassman WR. Dissecting microscope vs. magnifying loops with transillumination in the preparation of follicular unit grafts: a bilateral controlled study. Dermatol Surg. 1998;24:875-80.

History

• Received
  02 Sept 2012
• Accepted
  26 Nov 2012

Consultation due to Pruritus: still a challenge^*

Pruritus: ainda um desafio

Authorship SCIMAGO INSTITUTIONS RANKINGS

We have read the review paper by Prof. Cunha et al. about pruritus and have learned a lot from it. However, the comment "Tacrolimus has been found to have no effect beyond that of the vehicle control", has confused us. Our clinical practice, along with some other original articles, has confirmed the efficacy of topical tacrolimus as an antipruritus drug. Studies on animal models, clinical practice from several comparative studies, and the exploration of the possible mechanism of the disease have shown that tacrolimus can relieve itching. Therefore, we think that the comment could be more specific if reference to the treatment of hemodialysis-related pruritus was made. This would be more suitable and avoid misunderstanding.

We have learned a lot from the review entitled "Pruritus: still a challenge" by prof. Cunha PR. ¹ The authors concluded "Tacrolimus has been found to have no effect beyond that of the vehicle control". This made us confused. Based on our clinical practice, tacrolimus can relieve itching. Therefore, we checked the references and realized that it is in reference to haemodialysis-related pruritus. ²

Some articles have confirmed its potential antipruritus effect. In an animal model, Samukawa ³ et al. concluded that topical treatment with tacrolimus significantly inhibited scratching. As to clinical practice, Suys E ⁴ proposed topical tacrolimus as a possible treatment for resistant idiopathic pruritus ani.

>Although skin burning and pruritus are common adverse events during the early stages of treatment, tacrolimus is still an effective and well-tolerated option for patients with atopic dermatitis (AD). AD is a common disease with a hereditary disposition to a lowered threshold for pruritus and manifested by lichenification, excoriation, and crusting. Kim KH ⁵ et al. confirmed that tacrolimus improved the life quality of AD patients in Asia and other areas. To investigate its possible mechanism, NI Chun-ya⁶ et al. used immunohistochemistry to determine the expression of proteinase activated receptor 2 (PAR-2) in skin specimens. They concluded that the expression of PAR-2 is enhanced in the keratinocytes of lesions from AD patients, which is positively correlated with itching, and affirmed that tacrolimus may suppress its overexpression.

Therefore, topical tacrolimus sometimes can be effective against pruritus. We believe that the comment could be more specific to avoid misunderstanding.

REFERENCES

• 1. Cunha PR, Delfini Filho O. Pruritus: still a challenge. An Bras Dermatol. 2012;87:735-41.
• 2. Duque MI, Yosipovitch G, Fleischer Jr AB, Willard J, Freedman BI. Lack of efficacy of Tracolimus ointment 0.1% for treatment of haemodialysis-related pruritus: a randomized , double-blind, vehicle-controlled study. J Am Acad Dermatol. 2005; 52:519-21.
• 3. Samukawa K, Izumi Y, Shiota M, Nakao T, Osada-Oka M, Miura K, et al. Red ginseng inhibits scratching behavior associated with atopic dermatitis in experimental animal models. J Pharmacol Sci. 2012;118:391-400.
• 4. Suys E. Randomized study of topical tacrolimus ointment as possible treatment for resistant idiopathic pruritus ani. J Am Acad Dermatol. 2012;66:327-8.
• 5. Kim KH, Kono T. Overview of efficacy and safety of tacrolimus ointment in patients with atopic dermatitis in Asia and other areas. Int J Dermatol. 2011;50:1153-61.
• 6. NI Chun-ya, TU Ping, WU Ling-shen, LIU Ling-ling. Effects of tacrolimus on the expression of proteinase activated receptor 2 in lesions of atopic dermatitis. Chinese Journal of Dermatology. 2012;45:22-5.

• *Department of Dermatovenereology, West China Hospital, Si Chuan University, Cheng Du, Si chuan, China.

Reply

Paulo R Cunha ^I Oswaldo Delfini Filho ^II

Dear Sir, We would like to thank you for your great collaboration in order to clarify rare cases such as this one. The studies to which the author of the letter refers explain the success of surgical excision, with complete cure, despite the size of the lesion. These studies are a source of knowledge and instruction to everyone. Congratulations on the observations that cooperate with the educational and therapeutic aspect of the case.

Sincerely,

History

• Received
  06 Nov 2012
• Accepted
  30 Jan 2012

Publication Dates

• Publication in this collection
  Apr 2013