Letters to the Editor
gnier-Rosencher,1 I. Boutron,2 M.F. Avril,1 N. Dupin1,* E. Re ^pital Cochin, APHP, Universite Ren Department of Dermatology, Ho e Descartes Paris V, Paris 75014, France, 2Clinical Epidemiology Center, ^pital Ho ^tel Dieu, Paris 75013, France Ho *Correspondence: N. Dupin. E-mail: [email protected] 1
References 1 Puppin D Jr, Rybojad M, de la Chapelle C, Morel P. Kaposi’s sarcoma associated with captopril. Lancet 1990; 336: 1251–1252. 2 Dervis E, Demirkesen C. Kaposi’s sarcoma in a patient with psoriasis vulgaris. Acta Dermatovenerol Alp PanonAdriat. 2010; 19: 31–34. 3 Larbre JP, Nicolas JF, Collet P, Larbre B, Llorca G. Kaposi’s sarcoma in a patient with rheumatoid arthritis possible responsibility of captopril in the development of lesions. J Rheumatol 1991; 18: 476–477. 4 Bilen N, Bayramg€ urler D, Aydeniz B, Apaydin R, Ozkara SK. Possible causal role of lisinopril in a case of Kaposi’s sarcoma. Br J Dermatol 2002; 147: 1042–1044. 5 Bernstein KE, Ong FS, Blackwell W-LB et al. A modern understanding of the traditional and nontraditional biological functions of angiotensinconverting enzyme. Pharmacol Rev 2013; 65: 1–46. 6 Sugiyama E, Iwata M, Yamashita N, Yoshikawa T, Maruyama M, Yano S. Immunosuppression by captopril in vitro: inhibition of human natural killer activity by copper-dependent generation of hydrogen peroxide. Jpn J Med 1986; 25: 149–154. 7 Swartz SL, Williams GH. Angiotensin-converting enzyme inhibition and prostaglandins. Am J Cardiol 1982; 49: 1405–1409. 8 Ebrahimian TG, Tamarat R, Clergue M, Duriez M, Levy BI, Silvestre J-S. Dual effect of angiotensin-converting enzyme inhibition on angiogenesis in type 1 diabetic mice. Arterioscler Thromb Vasc Biol 2005; 25: 65–70. 9 Willis LM, El-Remessy AB, Somanath PR, Deremer DL, Fagan SC. Angiotensin receptor blockers and angiogenesis: clinical and experimental evidence. Clin Sci 2011; 120: 307–319. 10 Yoshiji H, Yoshii J, Ikenaka Y et al. Suppression of the renin-angiotensin system attenuates vascular endothelial growth factor-mediated tumor development and angiogenesis in murine hepatocellular carcinoma cells. Int J Oncol 2002; 20: 1227–1231.
1201
rate concerning total tumour excision which was completely omitted by the authors. The aim of this study was to emphasize on immediate reconstruction which apparently would not be possible after Mohs surgery because of sloughing. Immediate reconstruction is one of the main principles in Mohs Surgery and all the different Societies (ESMS, ASMS and ACMS) insist on this point in their statues and guidelines. Sloughing of tissue after Mohs surgery is not mentioned neither in literature nor is known to me in my 22 years of experience in Mohs surgery. It refers probably to the outdated technique of using zinc chloride paste, which is no longer used. The use of the paste prevents immediate reconstruction until the fixed tissue was sloughed. Todays MMS uses freezing techniques similar to what is used in frozen sections as the authors are pretending to use, so therefore there should be no difference for reconstruction. The authors are completely mislead in their appreciation on Mohs Surgery and are not aware that the technique of MMS has evolved and does not anymore use the original technique of Frederic Mohs will be introduced later. The series shows a recurrence rate of 11.5% in a mean follow-up of 2 years. Oncologic surgeons know that in large tumours followed by complex reconstructions, the covering of the excision bed needs thick flaps, therefore the recurrence of tumour is often several years delayed (as seen with their second (a)
DOI: 10.1111/jdv.13120
Standard excision and reconstruction as an alternative to MMS for giant basal cell carcinoma? Editor, I read with interest the article of Tuerdi et al.1 on standard excision as an alternative to MMS. Despite the point that giant basal cell carcinoma may profit from staged surgery or slow Mohs because of technical reasons 2, which are unfortunately not discussed in this article, there are several basic errors which I would like to discuss step by step. The authors mention the advantages of MMS because of tissue sparing, but the most important advantage is high security
JEADV 2016, 30, 1195–1252
(b)
Figure 1 (a) A giant BBC after MMS in a 71-year-old patient. (b) Immediate reconstruction in a one-time procedure and 6 weeks later.
© 2015 European Academy of Dermatology and Venereology
Letters to the Editor
1202
(a)
the reviewers have accepted such a study full of scientifically incorrect arguments. This kind of publication harms the effort of a great number of dermatologists who try to promote the utility of MMS with scientific correct arguments. A.M. Skaria* Centre de Dermatochirurgie, University of Bern, 1800 Vevey, Switzerland *Correspondence: A.M. Skaria. E-mail: [email protected]
References
(b)
1 Tuerdi M, Yarbag A, Maimaiti A et al. Standard surgical excision and reconstruction of giant basal cell carcinoma of the face: may be an alternative to the Mohs micrographic surgery. J Eur Acad Dermatol Venereol 2014; 28: 1572–1573. 2 Skaria A. Staged surgical therapy of basal cell carcinoma in the head and neck region. Swiss Med Wkly 2010; 140: 31–33. 3 Ravitskiy L, Brodland DG, Zitelli JA. Cost analysis: Mohs micrographic surgery. Dermatol Surg 2012; 38: 585–594. 4 Basal Cell and Squamous Cell Skin Cancers http://www.nccn.org/professionals/. . .gls/f_guidelines.asp 5 Acosta AE. Clinical parameters of tumescent anesthesia in skin cancer reconstructive surgery. A review of 86 patients. Arch Dermatol 1997; 133: 451–454. DOI: 10.1111/jdv.13122
Figure 2 (a) Giant BBC after excision with MMS in a 43-year-old patient . (b) Reconstruction with a medial forehead flap 1 year later.
case of recurrence (3 years)) and the re-excison of these tumours are mostly very difficult. This leads us to another point that the secure lateral tumour margin control is in this tumour a far less important aspect than the deep tumour margin control. The authors are not discussing how to manage correctly these aspects because a 1 cm security margin in the deep is often not possible without damage to the noble structures. The authors pretend that the investigation was done with intra-operative frozen sections, which does not provoke sloughing of the tissue, and argue that MMS would be more expensive. There are several studies which have shown that intra-operative frozen sections are much more expensive and far less efficient.3 The authors argue that MMS should only be used for highrisk tumours. It seems that the authors and the reviewers are not aware of the criteria of high-risk tumours which is not only a question of localization but also a question of size.4 The authors are pretending that this kind of tumour cannot be operated under local anaesthesia, which is incorrect. I suggest the literature of Acosta et al. on tumescent anaesthesia in skin cancer reconstuctive surgery from 1997.5 Although I can agree that in large tumours eventually slow Mohs can show some advantages because of the difficulty of freezing big tumour parts. This problem can be solved but would need more slides because the excised tumour has to be divided into smaller parts (Figs. 1 and 2). Finally, it is astonishing that
JEADV 2016, 30, 1195–1252
Sexually transmitted infections in older adults – raising awareness for better screening and prevention strategies Editor, Although sexually transmitted infections (STIs) are commonly associated with adolescents and young adults, sexually active older adults are also at risk of infection.1 Data regarding epidemiology, clinical presentation and diagnosis of STIs in older adults is still lacking, although a number of studies show that the incidence of STIs, including Human Immunodeficiency Virus (HIV) infection, is significant and may be increasing over the years.2–5 All patients aged 60 years or older attending the STI Clinic of a University Hospital (Centro Hospitalar S~ao Jo~ao, Porto) for the first time between December 2003 and November 2013 were included in this study. Clinical information recorded by a doctor is subsequently entered onto a database which was previously approved by the ethical committee of the hospital. Controls were defined as attendees of the STI Clinic without any STI diagnosed. Different stages of syphilis were classified according to ECDC criteria.6 During the study period, 2703 patients attended the STI Clinic, 267 (9.9%) of them were 60 years old or older. Four
© 2015 European Academy of Dermatology and Venereology
gnier-Rosencher,1 I. Boutron,2 M.F. Avril,1 N. Dupin1,* E. Re ^pital Cochin, APHP, Universite Ren Department of Dermatology, Ho e Descartes Paris V, Paris 75014, France, 2Clinical Epidemiology Center, ^pital Ho ^tel Dieu, Paris 75013, France Ho *Correspondence: N. Dupin. E-mail: [email protected] 1
References 1 Puppin D Jr, Rybojad M, de la Chapelle C, Morel P. Kaposi’s sarcoma associated with captopril. Lancet 1990; 336: 1251–1252. 2 Dervis E, Demirkesen C. Kaposi’s sarcoma in a patient with psoriasis vulgaris. Acta Dermatovenerol Alp PanonAdriat. 2010; 19: 31–34. 3 Larbre JP, Nicolas JF, Collet P, Larbre B, Llorca G. Kaposi’s sarcoma in a patient with rheumatoid arthritis possible responsibility of captopril in the development of lesions. J Rheumatol 1991; 18: 476–477. 4 Bilen N, Bayramg€ urler D, Aydeniz B, Apaydin R, Ozkara SK. Possible causal role of lisinopril in a case of Kaposi’s sarcoma. Br J Dermatol 2002; 147: 1042–1044. 5 Bernstein KE, Ong FS, Blackwell W-LB et al. A modern understanding of the traditional and nontraditional biological functions of angiotensinconverting enzyme. Pharmacol Rev 2013; 65: 1–46. 6 Sugiyama E, Iwata M, Yamashita N, Yoshikawa T, Maruyama M, Yano S. Immunosuppression by captopril in vitro: inhibition of human natural killer activity by copper-dependent generation of hydrogen peroxide. Jpn J Med 1986; 25: 149–154. 7 Swartz SL, Williams GH. Angiotensin-converting enzyme inhibition and prostaglandins. Am J Cardiol 1982; 49: 1405–1409. 8 Ebrahimian TG, Tamarat R, Clergue M, Duriez M, Levy BI, Silvestre J-S. Dual effect of angiotensin-converting enzyme inhibition on angiogenesis in type 1 diabetic mice. Arterioscler Thromb Vasc Biol 2005; 25: 65–70. 9 Willis LM, El-Remessy AB, Somanath PR, Deremer DL, Fagan SC. Angiotensin receptor blockers and angiogenesis: clinical and experimental evidence. Clin Sci 2011; 120: 307–319. 10 Yoshiji H, Yoshii J, Ikenaka Y et al. Suppression of the renin-angiotensin system attenuates vascular endothelial growth factor-mediated tumor development and angiogenesis in murine hepatocellular carcinoma cells. Int J Oncol 2002; 20: 1227–1231.
1201
rate concerning total tumour excision which was completely omitted by the authors. The aim of this study was to emphasize on immediate reconstruction which apparently would not be possible after Mohs surgery because of sloughing. Immediate reconstruction is one of the main principles in Mohs Surgery and all the different Societies (ESMS, ASMS and ACMS) insist on this point in their statues and guidelines. Sloughing of tissue after Mohs surgery is not mentioned neither in literature nor is known to me in my 22 years of experience in Mohs surgery. It refers probably to the outdated technique of using zinc chloride paste, which is no longer used. The use of the paste prevents immediate reconstruction until the fixed tissue was sloughed. Todays MMS uses freezing techniques similar to what is used in frozen sections as the authors are pretending to use, so therefore there should be no difference for reconstruction. The authors are completely mislead in their appreciation on Mohs Surgery and are not aware that the technique of MMS has evolved and does not anymore use the original technique of Frederic Mohs will be introduced later. The series shows a recurrence rate of 11.5% in a mean follow-up of 2 years. Oncologic surgeons know that in large tumours followed by complex reconstructions, the covering of the excision bed needs thick flaps, therefore the recurrence of tumour is often several years delayed (as seen with their second (a)
DOI: 10.1111/jdv.13120
Standard excision and reconstruction as an alternative to MMS for giant basal cell carcinoma? Editor, I read with interest the article of Tuerdi et al.1 on standard excision as an alternative to MMS. Despite the point that giant basal cell carcinoma may profit from staged surgery or slow Mohs because of technical reasons 2, which are unfortunately not discussed in this article, there are several basic errors which I would like to discuss step by step. The authors mention the advantages of MMS because of tissue sparing, but the most important advantage is high security
JEADV 2016, 30, 1195–1252
(b)
Figure 1 (a) A giant BBC after MMS in a 71-year-old patient. (b) Immediate reconstruction in a one-time procedure and 6 weeks later.
© 2015 European Academy of Dermatology and Venereology
Letters to the Editor
1202
(a)
the reviewers have accepted such a study full of scientifically incorrect arguments. This kind of publication harms the effort of a great number of dermatologists who try to promote the utility of MMS with scientific correct arguments. A.M. Skaria* Centre de Dermatochirurgie, University of Bern, 1800 Vevey, Switzerland *Correspondence: A.M. Skaria. E-mail: [email protected]
References
(b)
1 Tuerdi M, Yarbag A, Maimaiti A et al. Standard surgical excision and reconstruction of giant basal cell carcinoma of the face: may be an alternative to the Mohs micrographic surgery. J Eur Acad Dermatol Venereol 2014; 28: 1572–1573. 2 Skaria A. Staged surgical therapy of basal cell carcinoma in the head and neck region. Swiss Med Wkly 2010; 140: 31–33. 3 Ravitskiy L, Brodland DG, Zitelli JA. Cost analysis: Mohs micrographic surgery. Dermatol Surg 2012; 38: 585–594. 4 Basal Cell and Squamous Cell Skin Cancers http://www.nccn.org/professionals/. . .gls/f_guidelines.asp 5 Acosta AE. Clinical parameters of tumescent anesthesia in skin cancer reconstructive surgery. A review of 86 patients. Arch Dermatol 1997; 133: 451–454. DOI: 10.1111/jdv.13122
Figure 2 (a) Giant BBC after excision with MMS in a 43-year-old patient . (b) Reconstruction with a medial forehead flap 1 year later.
case of recurrence (3 years)) and the re-excison of these tumours are mostly very difficult. This leads us to another point that the secure lateral tumour margin control is in this tumour a far less important aspect than the deep tumour margin control. The authors are not discussing how to manage correctly these aspects because a 1 cm security margin in the deep is often not possible without damage to the noble structures. The authors pretend that the investigation was done with intra-operative frozen sections, which does not provoke sloughing of the tissue, and argue that MMS would be more expensive. There are several studies which have shown that intra-operative frozen sections are much more expensive and far less efficient.3 The authors argue that MMS should only be used for highrisk tumours. It seems that the authors and the reviewers are not aware of the criteria of high-risk tumours which is not only a question of localization but also a question of size.4 The authors are pretending that this kind of tumour cannot be operated under local anaesthesia, which is incorrect. I suggest the literature of Acosta et al. on tumescent anaesthesia in skin cancer reconstuctive surgery from 1997.5 Although I can agree that in large tumours eventually slow Mohs can show some advantages because of the difficulty of freezing big tumour parts. This problem can be solved but would need more slides because the excised tumour has to be divided into smaller parts (Figs. 1 and 2). Finally, it is astonishing that
JEADV 2016, 30, 1195–1252
Sexually transmitted infections in older adults – raising awareness for better screening and prevention strategies Editor, Although sexually transmitted infections (STIs) are commonly associated with adolescents and young adults, sexually active older adults are also at risk of infection.1 Data regarding epidemiology, clinical presentation and diagnosis of STIs in older adults is still lacking, although a number of studies show that the incidence of STIs, including Human Immunodeficiency Virus (HIV) infection, is significant and may be increasing over the years.2–5 All patients aged 60 years or older attending the STI Clinic of a University Hospital (Centro Hospitalar S~ao Jo~ao, Porto) for the first time between December 2003 and November 2013 were included in this study. Clinical information recorded by a doctor is subsequently entered onto a database which was previously approved by the ethical committee of the hospital. Controls were defined as attendees of the STI Clinic without any STI diagnosed. Different stages of syphilis were classified according to ECDC criteria.6 During the study period, 2703 patients attended the STI Clinic, 267 (9.9%) of them were 60 years old or older. Four
© 2015 European Academy of Dermatology and Venereology
