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Resumen En ocasiones el carcinoma epidermoide cutaneo se caracteriza por tener un mayor riesgo de desarrollar recurrencia locorregional y ocasionalmente metastasis a distancia. Existen diversos factores clinico-patologicos de reconocido valor pronostico, entre ellos la presencia de infiltracion perineural. Esta consiste en la diseminacion de celulas tumorales a traves de los nervios, siendo en la mayoria de los casos un hallazgo incidental. Cuando aparecen sintomas y/o evidencia radiologica de la extension de la infiltracion perineural, se clasifica como infiltracion perineural clinica y se asocia a un mayor riesgo de recurrencia local y de mortalidad.

Resumen Antecedentes El registro Regesmohs es un registro de ambito nacional, de pacientes evaluados y sometidos a una cirugia de Mohs, en 17 centros espanoles, desde julio de 2013. Como la cirugia de Mohs es el tratamiento que mejores resultados da para el manejo del carcinoma de celulas basales (CCB) de alto riesgo y otros tumores de la piel, queriamos describir los motivos por los que algunos pacientes fueron considerados no aptos para ser sometidos a este tratamiento y que tratamientos alternativos recibieron. Estos datos pueden ser utiles para evitar excluir a pacientes aptos para ser sometidos a una cirugia de Mohs, para calcular la demanda que estos pacientes generan a nivel sanitario, asi como la demanda que hay de tratamientos de inhibidores de la via de Hedgehog en dicho grupo de pacientes. Objetivo Describir a aquellos pacientes que fueron considerados no aptos para ser sometidos a una cirugia de Mohs tras valoracion prequirurgica y los tratamientos que recibieron. Metodos Regesmohs incluye a todos los pacientes consecutivos para ser sometidos a una cirugia de Mohs en los centros participantes, recogiendo datos sobre las caracteristicas de los pacientes, las intervenciones y los resultados a corto y largo plazo. Se hizo una descripcion de los pacientes considerados no aptos para ser sometidos a una cirugia de Mohs tras valoracion prequirurgica. Resultados Tres mil once pacientes fueron incluidos en el registro Regesmohs entre julio de 2013 y octubre de 2016. En 85 pacientes no se realizo cirugia de Mohs porque se consideraron candidatos inadecuados. Sesenta y siete pacientes presentaban CCB. Las razones para ser considerado paciente no apto fueron: contraindicaciones medicas (27,1%, n = 23), tumores de bajo riesgo (18,8%, n = 16) y tumores gigantes e invasion osea (15,3%, n = 13). Solo un paciente (1,2%) revelo compromiso de ganglios linfaticos y ningun paciente metastasis visceral. De los 85 pacientes considerados no aptos 29 (34,1%) fueron sometidos a cirugia convencional, 24 (28,3%) a radioterapia, 4 (4,7%) a inhibidores de la via de Hedgehog (solo indicado para el CCB) y 2 (2,4%) a tratamiento paliativo. No hubo datos de seguimiento de 14 pacientes (16,5%). Conclusion Las comorbilidades medicas fueron la razon mas habitual para retener la cirugia de Mohs. Retener un tratamiento en funcion de una propagacion a lugares distantes no es algo habitual. La mayoria de los pacientes considerados no aptos recibieron tratamientos mas sencillos: cirugia convencional o radioterapia, siendo los inhibidores de la via de Hedgehog una opcion novedosa.

Cutaneous squamous cell carcinoma is sometimes characterized by an increased risk of locoregional recurrence and occasionally distant metastasis. Several clinical and pathological factors, including perineural invasion, have been shown to have prognostic value in this setting. Perineural invasion, that is, the spread of tumor cells into the space surrounding a nerve, is usually an incidental finding. In the presence of symptoms or radiographic evidence of perineural spread, the diagnosis is clinical perineural invasion, which is associated with an increased risk of local recurrence and mortality.

Resumen Introduccion En julio de 2013 se inicio la recogida de datos del registro espanol de cirugia micrografica de Mohs, que describe la aplicacion y los resultados de esta tecnica en Espana. En este articulo se describen las caracteristicas del paciente y de los tumores tratados. Material y metodos Se trata de un estudio de cohortes prospectivo en el que participan centros en los que se practica al menos una intervencion semanal de cirugia micrografica de Mohs. En cada centro se incluyen todos los pacientes que son valorados para realizar cirugia de Mohs, excepto los declarados judicialmente incapaces. En este articulo describimos las caracteristicas de los pacientes y los tumores incluidos en la cohorte. Resultados El numero de pacientes incluidos desde julio de 2013 hasta octubre de 2014 es de 655. La mayoria de los tumores cutaneos intervenidos correspondieron a carcinoma basocelular, siendo el infiltrante el subtipo histologico mas frecuente. La mayoria de las cirugias se practicaron en tumores localizados en la cara y el cuero cabelludo, siendo la localizacion mas frecuente la nariz. Casi el 40% de los tumores operados son recurrentes o persistentes, y el tamano tumoral prequirurgico es similar en nuestro medio al descrito en otros estudios australianos o europeos. Hasta el 45,5% de los pacientes habia recibido algun tratamiento quirurgico previo. Conclusion Los datos observados son similares a los de otras series publicadas, y son relevantes para poder valorar la aplicabilidad en nuestro contexto de estudios realizados en otros medios.

Background Regesmohs registry is a nationwide registry including patients evaluated for Mohs surgery in 17 Spanish centres since July 2013. Given that Mohs surgery is the therapy with best results for high risk basal cell carcinoma (BCC) and other skin tumours, we wanted to describe the reasons that lead to some patients being excluded from this therapy and the alternative treatments that they received. These data may be useful to avoid excluding patients for Mohs surgery use, to estimate the healthcare demand of these patients and the demand for Hedgehog inhibitors therapy in this group. Objective To describe patients excluded for Mohs surgery after pre-surgical assessment, and the treatments that they received. Methods Regesmohs includes all consecutive patients assessed for Mohs surgery in the participating centres, collecting data on patient characteristics, intervention, and short and long-term results. Patients excluded for Mohs surgery after pre-surgical evaluation were described. Results 3011 patients were included in Regesmohs from July 2013 to October 2016. In 85, Mohs surgery was not performed as they were considered inadequate candidates. 67 had BCC. Reasons for exclusion were: medical contraindication (27.1%, n = 23) low-risk tumour in (18.8%, n = 16) and giant tumour and bone invasion (15.3%, n = 13). Only 1 patient (1.2%) showed lymph node involvement and no patients had visceral metastases. Of the 85 excluded patients, 29 (34.1%) were treated with conventional surgery, 24 (28.3%) with radiotherapy, 4 (4.7%) with inhibitors of the Hedgehog pathway (only indicated for BCC), and 2 (2.4%) received palliative care. We had no follow-up data on 14 patients (16.5%). Conclusion Medical comorbidities were the most common reason for withholding Mohs surgery. Withholding therapy on the basis of distant extension is uncommon. Most excluded patients received simpler therapies: conventional surgery or radiotherapy, with hedgehog inhibitors being a new option.

Resumen El carcinoma epidermoide cutaneo, con una incidencia en la poblacion general de aproximadamente un 10% a lo largo de la vida, es la segunda neoplasia mas frecuente dentro del grupo del cancer cutaneo no melanoma. La mayoria de los carcinomas epidermoides cutaneos muestran un comportamiento benigno y pueden ser completamente erradicados mediante cirugia y otros procedimientos dermatologicos. Sin embargo, existe un subgrupo de esta entidad que se asocia con una mayor capacidad de desarrollar metastasis nodal y, por tanto, con una elevada morbimortalidad. En el presente articulo se analizan los diferentes factores que definen al carcinoma epidermoide cutaneo de comportamiento agresivo. Proponemos un metodo de definicion del carcinoma epidermoide de alto riesgo basado en el establecimiento de una serie de criterios mayores y menores. Este hecho supondra una mejor evaluacion pronostica y un manejo personalizado de este grupo de enfermos, que puede resultar en un aumento de la supervivencia global.

A number of molecular alterations have been described for melanoma. Melanomas with BRAF mutations tend to be located in areas of intermittent sun exposure, whereas melanomas with KIT mutations mostly appear in acral areas, the mucosas, and areas of chronic sun exposure. Sorafenib, a BRAF inhibitor, has a cytostatic effect on most melanomas with mutations affecting the mitogen-activated protein kinase (MAPK) pathway, and is also capable of triggering apoptosis in a small subgroup of these melanomas. By inhibiting KIT, imatinib has a cytostatic and cytotoxic effect on melanomas with KIT mutations, and probably has the same effect on another subgroup of melanomas with other as yet imperfectly understood KIT mutations. For therapy to be effective, agents should be selected according to the pathways associated with the genetic mutations present in the melanoma.

Resumen Actualmente existe un incremento del numero de casos de patologia oral en los servicios de Dermatologia. Dentro de las diversas lesiones que forman parte de esta amplia area de conocimiento destacamos la leucoplasia oral, por ser la lesion mucosa precancerosa mas frecuente y la que mayores problemas origina tanto en su diagnostico como en su manejo terapeutico. En esta revision, ademas de definir la leucoplasia, establecemos un diagnostico diferencial con el resto de las patologias orales mas importantes y analizamos los diversos parametros clinicos, histologicos y moleculares que definen el riesgo de transformacion maligna de esta patologia. Finalmente se establece un algoritmo terapeutico que nos ayuda a optimizar su manejo clinico.

Introduction and objectives. Microcystic adnexal carcinoma is a rare and aggressive tumor that manifests clinically as a subcutaneous nodule located on the head or neck. The tumor can be confused clinically and histologically with other benign and malignant skin lesions, often leading to inappropriate initial treatment. The chief concern with microcystic adnexal carcinoma is the elevated morbidity and the high rate of recurrence after wide local excision. Recent preliminary studies point to higher cure rates with Mohs micrographic surgery. Material and methods. We reviewed the medical histories of 6 consecutive patients with microcystic adnexal carcinoma who underwent Mohs micrographic surgery in our dermatology department between 1995 and 2007. Results. In all cases, lesions were located on the head and were primary tumors. Seventy percent of the tumors were wrongly diagnosed initially as basal cell carcinoma. Perineural invasion was not detected in any patient, and all were free of recurrence after between 1 and 12 years of postoperative follow-up. Conclusions. The absence of perineural involvement and substantial cell atypia can be attributed to the lesions being primary tumors. This would provide a rationale for definitive radical treatment of the primary tumor from the outset to avoid the complications associated with recurrence. The site and the absence of recurrence in all our patients who underwent Mohs micrographic surgery support the use of this technique as the treatment of choice in microcystic adnexal carcinoma.

The Spanish registry of Mohs micrographic surgery started collecting data in July 2013. The aim of the registry is to report on the use of this technique in Spain and the outcomes achieved. In the present article, we describe the characteristics of patients and the tumors treated.This is a prospective cohort study of patients treated with Mohs micrographic surgery. The participating centers are hospitals where at least one intervention of this type is performed each week. All patients considered for Mohs micrographic surgery in participating centers are included in the registry except those who have been declared legally incompetent.Between July 2013 and October 2014, data from 655 patients were included in the registry. The most common tumor involved was basal cell carcinoma, and the most common histological subtype was infiltrative basal cell carcinoma. Most of the tumors treated were located on the face or scalp, and the most common site was the nose. Almost 40% of the tumors treated were recurrent or persistent, and preoperative tumor size was similar to that reported in other European studies and in Australia. In total, 45.5% of patients had received previous surgical treatment.The findings are similar to those reported in other studies, and the data collected are useful for assessing whether the results of studies carried out elsewhere are applicable in Spain.

Adenoid cystic carcinoma is an uncommon tumor of the head and neck. Although it is mainly located in the salivary gland, a skin location has also been described. Metastases are rare, but 50 % of the cases relapse. A 65-year-old male patient had a lesion in the upper lip. After resection, the histological diagnosis was adenoid cystic carcinoma. Treatment was completed with radiotherapy. Ten years later, a nodule was detected in the neck. Its histological diagnosis was lymphatic metastasis due to adenoid cystic carcinoma. Primary cutaneous adenoid cystic carcinoma is a very uncommon tumor in which treatment consists in extensive local excision with free margins. Radiotherapy is not curative and should be reserved for palliative treatments. Multicenter, prospective studies are necessary to determine the best treatment and especially the adjuvant treatment for adenoid cystic carcinoma.

With a lifetime incidence of approximately 10% in the general population, cutaneous squamous cell carcinoma (CSCC) is the second most common type of nonmelanoma skin cancer. Most CSCCs are benign and can be completely eradicated by surgery or other dermatological procedures. There is, however, a subgroup associated with an increased likelihood of lymph node metastases and, therefore, with high morbidity and mortality. This article analyzes the various factors that define aggressive CSCC. We propose a method for defining high-risk SCC on the basis of a series of major and minor criteria. This method will allow better prognostic evaluation and enable personalized management of patients with high-risk SCC, possibly leading to improved overall survival.

A number of molecular alterations have been described for melanoma. Melanomas with BRAF mutations tend to be located in areas of intermittent sun exposure, whereas melanomas with KIT mutations mostly appear in acral areas, the mucosas, and areas of chronic sun exposure. Sorafenib, a BRAF inhibitor, has a cytostatic effect on most melanomas with mutations affecting the mitogen-activated protein kinase (MAPK) pathway, and is also capable of triggering apoptosis in a small subgroup of these melanomas. By inhibiting KIT, imatinib has a cytostatic and cytotoxic effect on melanomas with KIT mutations, and probably has the same effect on another subgroup of melanomas with other as yet imperfectly understood KIT mutations. For therapy to be effective, agents should be selected according to the pathways associated with the genetic mutations present in the melanoma.

Dermatology departments are currently seeing an increase in the number of cases of oral diseases. Of note among the range of lesions covered by this broad area of knowledge is oral leukoplakia-the most common precancerous lesion and the most problematic in terms of both diagnosis and therapeutic management. In addition to defining leukoplakia, this review also establishes a differential diagnosis with the other most important oral diseases and analyzes the different clinical, histologic, and molecular features that can provide an indication of the risk of malignant transformation. Finally, a therapeutic algorithm is presented to help us optimize clinical management of the disease.

Microcystic adnexal carcinoma is a rare and aggressive tumor that manifests clinically as a subcutaneous nodule located on the head or neck. The tumor can be confused clinically and histologically with other benign and malignant skin lesions, often leading to inappropriate initial treatment. The chief concern with microcystic adnexal carcinoma is the elevated morbidity and the high rate of recurrence after wide local excision. Recent preliminary studies point to higher cure rates with Mohs micrographic surgery.We reviewed the medical histories of 6 consecutive patients with microcystic adnexal carcinoma who underwent Mohs micrographic surgery in our dermatology department between 1995 and 2007.In all cases, lesions were located on the head and were primary tumors. Seventy percent of the tumors were wrongly diagnosed initially as basal cell carcinoma. Perineural invasion was not detected in any patient, and all were free of recurrence after between 1 and 12 years of postoperative follow-up.The absence of perineural involvement and substantial cell atypia can be attributed to the lesions being primary tumors. This would provide a rationale for definitive radical treatment of the primary tumor from the outset to avoid the complications associated with recurrence. The site and the absence of recurrence in all our patients who underwent Mohs micrographic surgery support the use of this technique as the treatment of choice in microcystic adnexal carcinoma.

Adenoid cystic carcinoma is an uncommon tumor of the head and neck. Although it is mainly located in the salivary gland, a skin location has also been described. Metastases are rare, but 50 % of the cases relapse. A 65-year-old male patient had a lesion in the upper lip. After resection, the histological diagnosis was adenoid cystic carcinoma. Treatment was completed with radiotherapy. Ten years later, a nodule was detected in the neck. Its histological diagnosis was lymphatic metastasis due to adenoid cystic carcinoma. Primary cutaneous adenoid cystic carcinoma is a very uncommon tumor in which treatment consists in extensive local excision with free margins. Radiotherapy is not curative and should be reserved for palliative treatments. Multicenter, prospective studies are necessary to determine the best treatment and especially the adjuvant treatment for adenoid cystic carcinoma.

Varon de 50 anos que ingreso para reconstruccion de una colostomia realizada tres meses antes por un cancer colorrectal (T3N0M0). Durante el ingreso inicio un cuadro febril de 37,8 °C con hemocultivos positivos para Staphylococcus aureus, administrandose tratamiento antibiotico intravenoso con ceftazidima (1 g/8 horas) y con paracetamol (1 g/8 horas). Tras dos semanas del inicio del antibiotico se produjo un nuevo episodio febril de 38,5 °C asociado a escalofrios y linfadenopatias laterocervicales dolorosas, junto al desarrollo de manifestaciones cutaneas.