Melanoma Registry of the Spanish Academy of Dermatology and Venereology (REGESMEL): Description and Data in its First Year of Operation

INTRODUCTION

The incidence of melanoma is rising in Spain. The prognostic stages of patients with melanoma are determined by various biological factors, such as tumor thickness, ulceration, or the presence of regional or distant metastases. The Spanish Academy of Dermatology and Venereology (AEDV) has encouraged the creation of a Spanish Melanoma Registry (REGESMEL) to evaluate other individual and health system-related factors that may impact the prognosis of patients with melanoma. The aim of this article is to introduce REGESMEL and provide basic descriptive data for its first year of operation.

METHODS

REGESMEL is a prospective, multicentre cohort of consecutive patients with invasive cutaneous melanoma that collects demographic and staging data as well as individual and healthcare-related baseline data. It also records the medical and surgical treatment received by patients.

RESULTS

A total of 450 cases of invasive cutaneous melanoma from 19 participant centres were included, with a predominance of thin melanomas≤1mm thick (54.7%), mainly located on the posterior trunk (35.2%). Selective sentinel lymph node biopsy was performed in 40.7% of cases. Most cases of melanoma were suspected by the patient (30.4%), or his/her dermatologist (29.6%). Patients received care mainly in public health centers (85.2%), with tele-dermatology resources being used in 21.6% of the cases.

CONCLUSIONS

The distribution of the pathological and demographic variables of melanoma cases is consistent with data from former studies. REGESMEL has already recruited patients from 15 Spanish provinces and given its potential representativeness, it renders the Registry as an important tool to address a wide range of research questions.

Immunotherapy and Targeted Therapy in Patients With Advanced Melanoma and the V600 BRAF Mutation: Which One First?

Systemic treatment with immunotherapy or targeted therapy can significantly improve survival in patients with advanced (metastatic or high-risk) melanoma. Fifty percent of patients with melanoma have a BRAF mutation. Decisions on optimal sequencing of systemic treatments should take into account drug- and tumor-related factors and patient characteristics. Although the combination of ipilimumab and nivolumab is associated with the best survival outcomes, it is associated with significant toxicity. Targeted therapy may be a more favorable option in certain clinical situations. We review the literature on immunotherapy and targeted therapy in melanoma and present an algorithm for guiding decision-making on their use as first-line systemic treatments for advanced BRAF-mutated melanoma.

[Translated article] Immunotherapy and Targeted Therapy in Patients With Advanced Melanoma and the V600 BRAF Mutation: Which One First?

Systemic treatment with immunotherapy or targeted therapy can significantly improve survival in patients with advanced (metastatic or high-risk) melanoma. Fifty percent of patients with melanoma have a BRAF mutation. Decisions on optimal sequencing of systemic treatments should take into account drug- and tumor-related factors and patient characteristics. Although the combination of ipilimumab and nivolumab is associated with the best survival outcomes, it is associated with significant toxicity. Targeted therapy may be a more favorable option in certain clinical situations. We review the literature on immunotherapy and targeted therapy in melanoma and present an algorithm for guiding decision-making on their use as first-line systemic treatments for advanced BRAF-mutated melanoma.

[[Tranlated article]]Selection of Quality Indicators for the Certification of Dermato-Oncology Units: The CUDERMA Project Delphi Consensus Study

Quality indicators are crucial for standardizing and guaranteeing the quality of health care practices. The Spanish Academy of Dermatology and Venereology (AEDV) launched the CUDERMA Project to define quality indicators for the certification of specialized units in dermatology; the first 2 areas selected were psoriasis and dermato-oncology. The aim of this study was to achieve consensus on what should be evaluated by these indicators using a structured process comprising a literature review and selection of an initial list of indicators to be evaluated in a Delphi consensus study following review by a multidisciplinary group of experts. The selected indicators were evaluated by a panel of 28 dermatologists and classified as either "essential" or "of excellence". The panel agreed on 84 indicators, which will be standardized and used to develop the certification standard for dermato-oncology units.

Selection of Quality Indicators for the Certification of Dermato-Oncology Units: The CUDERMA Project Delphi Consensus Study

Quality indicators are crucial for standardizing and guaranteeing the quality of health care practices. The Spanish Academy of Dermatology and Venereology (AEDV) launched the CUDERMA Project to define quality indicators for the certification of specialized units in dermatology; the first 2 areas selected were psoriasis and dermato-oncology. The aim of this study was to achieve consensus on what should be evaluated by these indicators using a structured process comprising a literature review and selection of an initial list of indicators to be evaluated in a Delphi consensus study following review by a multidisciplinary group of experts. The selected indicators were evaluated by a panel of 28 dermatologists and classified as either "essential" or "of excellence". The panel agreed on 84 indicators, which will be standardized and used to develop the certification standard for dermato-oncology units.

Teledermatology-driven topical therapy of actinic keratosis: a comparative study of clinical effectiveness and compliance

BACKGROUND

Teledermatology (TD) provides efficient care for skin cancer patients.

OBJECTIVE

To compare the clinical effectiveness of imiquimod 5% for the treatment of AK with in-person care and through TD.

METHODS

Longitudinal prospective controlled study including patients with single AK diagnosed and treated at face-to-face visits (FTF group) or through teledermatology (TD group) with imiquimod 5% cream. The main outcome measures assessed were the complete and global response percentage (CR and GR) under per-protocol (PP) and intention-to-treat (ITT) analysis.

RESULTS

A total of 157 patients were enrolled (FTF = 75, TD = 82). PP analysis showed CR in 66.7% of FTF patients and 65.6% in TD patients (P > 0.05). The ITT yielded CR in 64.0% and 51.2% in FTF visits and TD, respectively (P = 0.073). The analysis showed an advantage of FTF care against TD in achieving GR (84.0% vs. 70.7%; P = 0.036). Facial location and local adverse reactions were the only explanatory factors of complete response in the ITT approach. Treatment completion was found in 90.7% and 72.0% in the FTF and TD groups, respectively (P = 0.004).

CONCLUSIONS

Improvements in patient counselling at the primary care centre are needed before the implementation of TD as a routine methodology for the management of AK.

Redefining the therapeutic objective in psoriatic patients candidates for biological therapy

The advances in psoriasis management currently allow achieving a good control of the disease. In particular, with the latest developed molecules, available evidence suggests that it is possible to pose an ambitious therapeutic goal, such as a Dermatology Life Quality Index 0/1, a Physician Global Assessment 0/1, or a Psoriasis Area and Severity Index 90/100 response. However, patients often fail to achieve the complete clearance of their cutaneous lesions or the improvement of disease factors that impair their quality of life. To optimize the treatment of psoriasis, it is not enough to define precisely the therapeutic objective, but also to adapt the therapeutic strategy to make the necessary modifications in case of not achieving it at the time point (at the end of the induction phase, or every 3-6 months) to be agreed with the patient (the so-called treat-to-target approach). In the present report, based on the Delphi methodology, 11 dermatologists from the Spanish Psoriasis Group addressed key issues that could be involved in the achievement and maintenance of the therapeutic goals of patients with moderate to severe psoriasis. The document provides 27 consensus statements intended to support clinical decision-making by healthcare professionals for patients who might be candidates to receive biologic therapy.

Reliability of the MDi Psoriasis® Application to Aid Therapeutic Decision-Making in Psoriasis

BACKGROUND

Therapeutic decisions in psoriasis are influenced by disease factors (e.g., severity or location), comorbidity, and demographic and clinical features.

OBJECTIVE

We aimed to assess the reliability of a mobile telephone application (MDi-Psoriasis) designed to help the dermatologist make decisions on how to treat patients with moderate to severe psoriasis.

METHOD

We analyzed interobserver agreement between the advice given by an expert panel and the recommendations of the MDi-Psoriasis application in 10 complex cases of moderate to severe psoriasis. The experts were asked their opinion on which treatments were most appropriate, possible, or inappropriate. Data from the same 10 cases were entered into the MDi-Psoriasis application. Agreement was analyzed in 3 ways: paired interobserver concordance (Cohen's κ), multiple interobserver concordance (Fleiss's κ), and percent agreement between recommendations.

RESULTS

The mean percent agreement between the total of 1210 observations was 51.3% (95% CI, 48.5-54.1%). Cohen's κ statistic was 0.29 and Fleiss's κ was 0.28. Mean agreement between pairs of human observers only, excluding the MDi-Psoriasis recommendations, was 50.5% (95% CI, 47.6-53.5%). Paired agreement between the recommendations of the MDi-Psoriasis tool and the majority opinion of the expert panel (Cohen's κ) was 0.44 (68.2% agreement).

CONCLUSIONS

The MDi-Psoriasis tool can generate recommendations that are comparable to those of experts in psoriasis.

Yield of Computed Tomography at Baseline Staging of Melanoma

BACKGROUND

Current guidelines call for baseline imaging only for very high-risk (T4b) primary cutaneous melanomas.

OBJECTIVES

To estimate the frequency of computed tomography (CT) at baseline staging of primary cutaneous melanoma and the diagnostic yield of CT; and to describe the types and frequencies of incidentaloma findings.

MATERIAL AND METHODS

Cross-sectional study of cutaneous melanoma cases (tumor classifications Tis to T4bN0M0) attended between 2008 and 2014 in a specialized melanoma unit. Reports of CT scans performed during baseline staging were reviewed to determine the frequency of positive scan results, incidentaloma findings, unit cost for detection of metastasis, and factors associated with the decision to order CT.

RESULTS

CT results were available for 310 of the 419 patients included (73.99%). The tumor classifications were as follows: Tis, 17; T1, 137; T2, 71; T3, 48; and T4, 37. The CT results were negative in 81.61%, and incidentalomas were found in 18.06%. Additional primary tumors were found in 2 patients (0.64%), and metastasis was identified in one patient (0.32%). The cost of finding the case of metastasis was €71,234.90. A T2 tumor classification (odds ratio [OR], 8.73) and age under 70 years (OR, 3.53) were associated with greater likelihood of CT being ordered. Excision of the primary tumor in the melanoma unit (OR, 0.08) was associated with less likelihood of ordering CT.

CONCLUSIONS

The results for this patient series support current recommendations restricting CT at baseline to cases where there is high risk of metastasis (stagesiiC-iii).

[Study and treatment of locally advanced melanoma]

Locally advanced melanoma is characterized clinically by the appearance of in-transit or satellite metastases, and is considered stage IIIB or IIIC according to the 2002 classification of the American Joint Committee on Cancer. Despite the absence of distant metastases, the management of locally advanced melanoma is complicated and the disease is associated with a reduction in overall survival. The initial step in the approach to the patient with locally advanced melanoma involves the restaging in order to exclude the presence of distant metastases. Positron emission tomography-computed tomography is currently accepted as the most accurate restaging technique. Surgical excision of the metastases continues to be the treatment of choice for locally advanced melanoma. In the case of unresectable metastases, hyperthermic isolated limb perfusion with melphalan with or without tumor necrosis factor has achieved complete responses in up to 60% of patients treated, with very rare severe locoregional and systemic toxic effects. Radiation therapy, chemotherapy, and biochemotherapy are options that, even though they have not been tested in patients with only in-transit metastases, may have a role in unresectable, locally advanced melanoma without distant metastases.In any case, therapeutic options for locally advanced melanoma should be individualized, and should take into consideration the availability of each of these techniques as well as the experience of the health care team.

[An economic analysis of presurgical teledermatology in patients with nonmelanoma skin cancer]

INTRODUCTION

In patients with nonmelanoma skin cancer, store-and-forward teledermatology allows satisfactory diagnosis and surgical planning, thus shortening waiting lists and reducing travel requirements for patients in special situations.

OBJECTIVE

The aim of this study was to undertake an economic analysis of presurgical teledermatology, comparing it with a conventional health care approach.

MATERIAL AND METHODS

The cost and cost-effectiveness of presurgical teledermatology were analyzed from a societal perspective in the setting of a public hospital with a corporate intranet. The mean delay in surgery was used to measure effectiveness. Over a 12-month period, teledermatology was used in 134 patients with nonmelanoma skin cancer. The unit cost of each intervention (teledermatology and conventional health care approach), the cost ratio between the most and least expensive alternative, and the incremental cost-effectiveness ratio were calculated. We distinguished between 2 groups of patients: those with and those without physical impediments for travel.

RESULTS

The unit cost of the patients in whom teledermatology was used was euro 156.40 compared to euro 278.42 per patient in the conventional system; the conventional system was therefore 1.78 times more expensive than presurgical teledermatology. Teledermatology was more cost-effective, with an incremental cost-effectiveness ratio of euro 3.10 per patient and per day of delay avoided in patients without impediments for travel and euro 4.87 in those with impediments for travel.

CONCLUSION

Teledermatology used for remote presurgical planning and preparation in patients with nonmelanoma skin cancer is more cost-effective than the conventional referral system in a health setting with a communication network available.

[Diagnostic and therapeutic assessment of frontal fibrosing alopecia]

Frontal fibrosing alopecia is a clinical entity characterized by recession of the frontotemporal hairline in middle-aged and older women. Since it was first described in 1994, more than 100 cases have been reported describing other clinical manifestations such as eyebrow and axillary alopecia, and perifollicular inflammation that help in the diagnosis of the disease and the differential diagnosis with other scarring alopecias. Histopathology reveals an inflammatory infiltrate and perifollicular lamellar fibrosis. Although numerous therapeutic options have been tested, including corticosteroids, finasteride, and minoxidil, none have shown clear benefits in terms of halting the progression of the alopecia.

[Patient with postpartum seizures: differential diagnosis]

Pre-eclampsia is a serious obstetric complication associated with a high rate of maternal and fetal morbidity and mortality. We report the case of a woman with a medical history of insulin-dependent diabetes mellitus and seizures possibly related to hypoglycemia who was admitted for an emergency cesarian due to severe pre-eclampsia and macrosomic fetus. In the first hour after delivery she experienced loss of consciousness and seizure, with vaginal bleeding and hypovolemic shock. Maximum vigilance is required for a patient with several concomitant diseases and a high-risk pregnancy. All prophylactic measures to lower the risk to mother and fetus should be undertaken. We analyze preanesthetic assessment, differential diagnosis, and choice of anesthesia in relation to this case.