Association of age with survival in older patients with cutaneous melanoma treated with immune checkpoint inhibitors

INTRODUCTION

Several types of immune checkpoint inhibitors (ICIs) are approved to treat advanced melanoma, but their effectiveness has not been compared in older patients treated outside of a clinical trial. Moreover, evidence suggests that a patient's response to ICI therapy may vary by age and type of ICI. The purpose of this study was to compare survival by ICI type in older patients with melanoma and to investigate treatment effect modification by age.

MATERIALS AND METHODS

Using the SEER-Medicare database, we identified patients with cutaneous melanoma (2012-2015) treated with an ICI (CTLA-4, PD-1, or combination CTLA-4 + PD-1 inhibitors). Cox proportional hazards regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for ICI types. We used an interaction term and stratified models to test for treatment effect modification by age.

RESULTS

Of the 1435 patients included in our analysis, 790 (55.1%) received CTLA-4 inhibitors, 512 (35.7%) received PD-1 inhibitors, and 133 (9.3%) were treated with combination ICIs. Median survival ranged from 13.4 months (95%CI: 10.7-16.3) for CTLA-4 inhibitors to 23.5 months (95%CI: 16.2-30.0) for combination ICIs. In multivariable models, the risk of death was lower with PD-1 inhibitors compared to CTLA-4 inhibitors (HR = 0.78, 95%CI: 0.68-0.89). An age*ICI type interaction term was significant (p < 0.001), and survival gains were greater the older age group (≥80) compared to the younger group (65-79).

DISCUSSION

In a population-based setting, we identified important differences in survival by ICI type in older patients with melanoma treated with ICIs, with prolonged survival associated with PD-1 inhibitors compared to CTLA-4 inhibitors.

Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: A registry-based study

Background

Cutaneous reactions after COVID-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized.

Methods

We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns.

Results

Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym “V-REPP” (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5).

Limitations

Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence.

Conclusion

Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases

Background

Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized.

Objective

To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines.

Methods

A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination.

Results

From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions.

Limitations

Registry analysis does not measure incidence. Morphologic misclassification is possible.

Conclusions

We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.

Sebaceous Carcinoma of the Eyelid: A Systematic Review and Meta-Analysis

BACKGROUND

Sebaceous carcinoma (SC) of the eyelid is a rare, aggressive malignancy associated with high rates of recurrence, metastasis, and tumor-related mortality.

OBJECTIVE

Provide a collective analysis of clinical presentations, management techniques, and outcomes, and compare outcomes of common treatment methods.

METHODS AND MATERIALS

Observational studies reporting management and outcomes of SC of the eyelid were included. Patient and clinical data were extracted, and meta-analysis of proportions was performed.

RESULTS

One thousand three hundred thirty-three subjects were included with a mean age of 65.2 years and 803 (60.2%) women. Of 647 initial diagnoses reported, 277 (42.8%) were correct, and the mean diagnostic delay was 14.7 months (range 8.5-34.8). The tumor location was reported in 1,246 subjects and involved the upper eyelid in 780 (62.6%), lower eyelid in 409 (32.8%), and 57 (4.8%) involved both. Overall rates of recurrence, metastasis, and tumor-related mortality were 15.9%, 12.1%, and 6.2%, respectively. There were no statistically significant differences in wide local excision (WLE) versus Mohs micrographic surgery (MMS) outcomes.

CONCLUSION

Sebaceous carcinoma of the eyelid is more common in women, on the upper eyelid, and is frequently misdiagnosed initially. Rate of recurrence, metastasis, and tumor-related mortality were similar in subjects managed with WLE versus MMS.

A cohort study of personal and family history of skin cancer in relation to all-cause and cancer-specific mortality

PURPOSE

Even though the fatality rate from skin cancers is low, evidence from a few cohort studies has raised the possibility that people with a personal history of skin cancer may have a higher all-cause mortality rate compared with those without a personal history of skin cancer. The purpose of the present study was to investigate the potential links between a personal history or family history of skin cancer and all-cause and cancer-specific mortality METHODS: A prospective cohort (n = 8,622) was assembled within the NHANES I follow-up study. Cox Proportional Hazard Regression analysis was used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for the association for personal and family history of skin cancer and all-cause and cancer-specific mortality.

RESULTS

After adjustment for several potential confounding variables, a personal history of skin cancer was associated with decreased risk for all-cause mortality (HR 0.72, 95% CI 0.61-0.85), whereas the results for cancer-specific mortality were consistent with a null association (HR 0.97, 95% CI 0.74-1.27). A family history of skin cancer was not significantly associated with all-cause mortality (HR 0.97, 95% CI 0.76-1.24) or cancer-specific mortality (HR 0.69, 95% CI 0.38-1.24).

CONCLUSION

The results of the present study do not support the hypothesis that a personal history or family history of skin cancer is associated with an increased risk of all-cause or cancer-specific mortality. The high prevalence of skin cancer adds to the public health significance of this question, providing a strong rationale for further research to resolve this question.

The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries

BACKGROUND

Coronavirus disease 2019 (COVID-19) has associated cutaneous manifestations.

OBJECTIVE

To characterize the diversity of cutaneous manifestations of COVID-19 and facilitate understanding of the underlying pathophysiology.

METHODS

Case series from an international registry from the American Academy of Dermatology and International League of Dermatological Societies.

RESULTS

The registry collected 716 cases of new-onset dermatologic symptoms in patients with confirmed/suspected COVID-19. Of the 171 patients in the registry with laboratory-confirmed COVID-19, the most common morphologies were morbilliform (22%), pernio-like (18%), urticarial (16%), macular erythema (13%), vesicular (11%), papulosquamous (9.9%), and retiform purpura (6.4%). Pernio-like lesions were common in patients with mild disease, whereas retiform purpura presented exclusively in ill, hospitalized patients.

LIMITATIONS

We cannot estimate incidence or prevalence. Confirmation bias is possible.

CONCLUSIONS

This study highlights the array of cutaneous manifestations associated with COVID-19. Many morphologies were nonspecific, whereas others may provide insight into potential immune or inflammatory pathways in COVID-19 pathophysiology.

Pernio-like skin lesions associated with COVID-19: A case series of 318 patients from 8 countries

Background

Increasing evidence suggests pernio-like lesions are cutaneous manifestations of coronavirus infectious disease 2019 (COVID-19).

Objective

To describe clinical and pathologic findings of pernio-like lesions in patients with confirmed or suspected COVID-19.

Methods

An international dermatology registry was circulated to health care providers worldwide through the American Academy of Dermatology, International League of Dermatologic Societies, and other organizations.

Results

We documented 505 patients with dermatologic manifestations associated with COVID-19, including 318 (63%) with pernio-like lesions. Patients with pernio-like lesions were generally young and healthy, with relatively mild COVID-19. Of 318 patients with confirmed or suspected COVID-19 by providers, 23 (7%) were laboratory-confirmed COVID-19 positive, and 20 others (6%) were close contacts of patients with confirmed COVID-19. Given current testing criteria, many patients lacked COVID-19 testing access. For 55% of patients, pernio-like lesions were their only symptom. In patients with other COVID-19 symptoms, pernio-like lesions typically appeared after other symptoms. Pernio-like lesions lasted a median of 14 days (interquartile range, 10-21 days).

Limitations

A case series cannot estimate population-level incidence or prevalence. In addition, there may be confirmation bias in reporting. We cannot exclude an epiphenomenon.

Conclusions

Pernio-like skin changes of the feet and hands, without another explanation, may suggest COVID-19 infection and should prompt confirmatory testing.

Automatic diagnosis of melanoma using machine learning methods on a spectroscopic system

Background

Early and accurate diagnosis of melanoma, the deadliest type of skin cancer, has the potential to reduce morbidity and mortality rate. However, early diagnosis of melanoma is not trivial even for experienced dermatologists, as it needs sampling and laboratory tests which can be extremely complex and subjective. The accuracy of clinical diagnosis of melanoma is also an issue especially in distinguishing between melanoma and mole. To solve these problems, this paper presents an approach that makes non-subjective judgements based on quantitative measures for automatic diagnosis of melanoma.

Methods

Our approach involves image acquisition, image processing, feature extraction, and classification. 187 images (19 malignant melanoma and 168 benign lesions) were collected in a clinic by a spectroscopic device that combines single-scattered, polarized light spectroscopy with multiple-scattered, un-polarized light spectroscopy. After noise reduction and image normalization, features were extracted based on statistical measurements (i.e. mean, standard deviation, mean absolute deviation, L₁ norm, and L₂ norm) of image pixel intensities to characterize the pattern of melanoma. Finally, these features were fed into certain classifiers to train learning models for classification.

Results

We adopted three classifiers – artificial neural network, naïve bayes, and k-nearest neighbour to evaluate our approach separately. The naive bayes classifier achieved the best performance - 89% accuracy, 89% sensitivity and 89% specificity, which was integrated with our approach in a desktop application running on the spectroscopic system for diagnosis of melanoma.

Conclusions

Our work has two strengths. (1) We have used single scattered polarized light spectroscopy and multiple scattered unpolarized light spectroscopy to decipher the multilayered characteristics of human skin. (2) Our approach does not need image segmentation, as we directly probe tiny spots in the lesion skin and the image scans do not involve background skin. The desktop application for automatic diagnosis of melanoma can help dermatologists get a non-subjective second opinion for their diagnosis decision.

Cutaneous manifestations of internal malignancy

The skin often mirrors changes in the organism it envelops. Many neoplastic diseases that affect internal organs display cutaneous manifestations, which may be the presenting signs and symptoms of the underlying malignancy. These may reflect direct involvement of the skin by the tumor (ie, tumor metastasis) or indirect involvement, in which changes in the skin occur in the absence of malignant cells. This review focuses on the latter conditions, which are often referred to as paraneoplastic dermatoses. Included in the discussion are the cutaneous manifestations of inherited syndromes that are associated with an increased risk of internal malignancy, cutaneous changes in patients with hormone-secreting tumors, and the wide spectrum of proliferative and inflammatory dermatoses that have been associated with internal cancer.

Upregulation of the human alkaline ceramidase 1 and acid ceramidase mediates calcium-induced differentiation of epidermal keratinocytes

Extracellular calcium (Ca2+(o)) potently induces the growth arrest and differentiation of human epidermal keratinocytes (HEKs). We report that Ca2+(o) markedly upregulates the human alkaline ceramidase 1 (haCER1) in HEKs; and its upregulation mediates the Ca2+(o)-induced growth arrest and differentiation of HEKs. haCER1 is the human ortholog of mouse alkaline ceramidase 1 that we previously identified. haCER1 catalyzed the hydrolysis of very long-chain ceramides to generate sphingosine (SPH). This in vitro activity required Ca2+. Ectopic expression of haCER1 in HEKs decreased the levels of D-e-C(24:1)-ceramide and D-e-C(24:0)-ceramide but elevated the levels of both SPH and its phosphate (S1P), whereas RNA interference-mediated knockdown of haCER1 caused the opposite effects on the levels of these sphingolipids in HEKs. Similar to haCER1 overexpression, Ca2+(o) increased the levels of SPH and S1P, and this was attenuated by haCER1 knockdown. haCER1 knockdown also inhibited the Ca2+(o)-induced growth arrest of HEKs and the Ca2+(o)-induced expression of keratin 1 and involucrin in HEKs. In addition, the acid ceramidase (AC) was also upregulated by Ca2+(o); and its knockdown attenuated the Ca2+(o)-induced expression of keratin 1 and involucrin in HEKs. These results strongly suggest that upregulation of haCER1 and AC mediates the Ca2+(o)-induced growth arrest and differentiation of HEKs by generating SPH and S1P.

Cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a neoplasm of helper T cells whose first manifestations usually appear in the skin. The various forms of CTCL are distinguished by both clinical features and histopathology. Early on, the diagnosis may be difficult to establish because of its numerous, and often non-specific, clinical presentations. Further, the pathological findings of early lesions may lack the diagnostic features observed in well-developed or advanced disease. The diagnosis of CTCL must be considered in any patient with a chronic, therapy-resistant condition of the skin. In patients with non-specific histological findings, a high index of suspicion and multiple biopsies may eventually lead to a diagnosis of CTCL. Once the diagnosis of CTCL is established, accurate staging is essential both for its effect on treatment decisions and for its prognostic value. In general, CTCL is a chronic, slowly progressive disease with a long evolution. The development of tumours is a poor prognostic sign, as is erythroderma. The Sezary syndrome is a distinct form of erythrodermic CTCL that is characterized by exfoliative erythroderma, lymphadenopathy, lymphocytosis, intense pruritus, and circulating large, abnormal lymphocytes (Sezary cells). When death does occur, it is most often due to septicemia. Treatment of CTCL must be tailored to the individual patient. The most commonly employed treatment options are photochemotherapy and topical chemotherapy.

Panniculitis

The classification of inflammatory disorders of the subcutaneous tissue has mystified dermatologists for decades. Overlapping clinical and histologic features, and a lack of specific treatments have added to the confusion. This article initially classifies the various panniculititides by their primary histopathologic pattern: (1) septal panniculitis without vasculitis, (2) septal panniculitis with vasculitis, (3) lobular panniculitis without vasculitis, and (4) lobular panniculitis with vasculitis. Subsequently, we describe the key clinical findings in the most important forms of panniculitis. We begin with the most common form of panniculitis, erythema nodosum. Indeed, in many patients suspected of having panniculitis, a worthwhile question to consider initially might be, "Is this, or is this not, erythema nodosum?" before engaging in an elaborate (and expensive) exercise in differential diagnosis.

Dermatology therapy update

New treatments for skin disease continue to evolve. This article summarizes recent advances in dermatologic therapy and suggests various alternative approaches for situations in which more conventional modalities are unavailable, ineffective, or contraindicated.

Once-weekly fluconazole (450 mg) for 4, 6, or 9 months of treatment for distal subungual onychomycosis of the toenail

BACKGROUND

Fluconazole is a bis-triazole antifungal agent approved for the treatment of oropharyngeal, esophageal, and vaginal candidiasis, serious systemic candidal infections, and cryptococcal meningitis.

OBJECTIVE

The purpose of this study was to evaluate three different durations of once-weekly fluconazole for the treatment of onychomycosis of the toenail caused by dermatophytes.

METHODS

In a multicenter, randomized, double-blind, parallel, placebo-controlled trial, 384 patients with distal subungual onychomycosis of the toenail received fluconazole, 450 mg once weekly, or placebo for 4, 6, or 9 months. For inclusion, patients were required to have mycologically confirmed distal subungual onychomycosis of the toenail with a large toenail at least 25% clinically affected but having at least 2 mm of healthy nail between the nail fold and the proximal onychomycotic border. Efficacy was assessed by clinical and mycologic (microscopic and microbiologic) measures at screening, at every treatment visit starting at month 3, and at months 2, 4, and 6 after therapy. Observed or volunteered adverse events were recorded and classified at all visits.

RESULTS

At the end of treatment, very significantly superior clinical and mycologic results were achieved in all fluconazole groups compared with placebo (p=0.0001). This superiority was largely maintained over 6 months of follow-up. The clinical and mycologic responses of the 9-month treatment duration were significantly superior to the 4- and 6-month durations. Similar percentages of patients in the fluconazole and placebo groups reported adverse experiences for all three durations of the study.

CONCLUSION

Results of this study support the efficacy and safety of fluconazole in the treatment of distal subungual onychomycosis of the toenail.

Compounding is still appropriate in clinical practice

Compounding involves the mixing of an active drug and preservatives into an appropriate base, or vehicle. All topical drugs are compounded. In the past, most patients with skin disease were treated with "custom made" topical preparations prescribed by their dermatologist; more recently, responsibility for this has been ceded to pharmaceutical companies that manufacture standardized products created from a set formula. Unfortunately, these commercial entities often do not supply all the medications needed by our patients, and under these circumstances, dermatologists can and should maintain the knowledge to extemporaneously compound these preparations themselves.

The use of topical calcipotriene/calcipotriol in conditions other than plaque-type psoriasis

BACKGROUND

Topical calcipotriene ointment has been approved for the treatment of plaque-type psoriasis.

OBJECTIVE

This article explores the possible use of topical calcipotriene ointment in the treatment of nail and intertriginous psoriasis, palmoplantar and pustular psoriasis, Reiter's syndrome, pityriasis rubra pilaris, and disorders of keratinization.

METHODS

The recent literature is reviewed.

RESULTS

Recent reports suggest that certain ichthyoses (particularly the hyperproliferative variants) and keratodermas may respond to topical calcipotriene ointment. The activity of calcipotriene relates to a dose-dependent decrease in proliferation and an increase in terminal differentiation of keratinocytes.

CONCLUSION

Patients with other disorders characterized by epidermal hyperproliferation may also be candidates for treatment. The use of calcipotriene in treating congenital hyperproliferative disorders is limited by the theoretical risk of hypercalcemia from absorption of the drug after application to extensive areas of skin.

Therapeutic approaches in cutaneous lymphoma

Standard therapy of the CTCL MF and SS consists of topical glucocorticosteroids, PUVA, topical chemotherapy, and total skin electron beam irradiation in stages Ia and IIa; local radiation or total skin electron beam irradiation in stage IIb; and systemic chemotherapy in stages III and IV. The experimental treatment modalities, interferon-alpha and retinoids, especially arotinoid, are most effective in early stages of CTCL; in advanced stages, the effectiveness can be increased by combination regimens. Up to now, the most promising results are obtained by combination therapy of interferon and PUVA. When serotherapy is considered as a therapeutic alternative for patients in stage IIb to IVb, the benefit/risk ratio must be carefully analyzed. Anti-thymocyte-globulin and monoclonal antibodies, either alone or conjugated to radioisotopes or toxin, have shown some therapeutic effect but are still under investigation. Extracorporal photopheresis is well established in erythrodermic patients. Initial reports also have shown encouraging results with this treatment for stage Ib and in combination with methotrexate or interferon. Hexadecylphosphocholine, a new, well-tolerated topical agent, induced a remission rate of 50%, with 25% complete remission in CTCL patients of stage Ia to IIb.

Orbital multiple myeloma mimicking acquired angio-oedema

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Acyclovir in the treatment of herpesvirus infections

The development of the synthetic acyclic purine nucleoside analog acyclovir was a milestone in the field of antiviral chemotherapy. Acyclovir possesses unique biologic properties that make it especially useful for the treatment of herpesvirus infections. This article presents guidelines for the use of acyclovir in both immunocompetent and immunocompromised patients. The problem of acyclovir resistance is also discussed.

Topical steroid therapy of atopic skin diseases

The development of effective topical steroid preparations was a major advance in the therapy of atopic skin diseases. More recently, alterations in the hydrocortisone molecule have produced increasingly potent preparations with the associated risk of local and systemic side effects, including suppression of the hypothalamic-pituitary-adrenal axis. When used judiciously as part of a carefully planned therapeutic regimen including emollients and, when indicated, antihistamines and antibiotics, topical steroids can play an important role in the management of atopic skin diseases.

Antiretroviral therapy

Research into the biology of human immunodeficiency virus type 1 (HIV-1), the causative agent of the acquired immunodeficiency syndrome, has yielded valuable information about the replicative cycle of the virus. The steps involved are (1) attachment of the virus to a receptor protein on the surface of the target cell, (2) entry of the virus into the cell, (3) replication of the viral genome through a DNA intermediary, (4) entry of proviral DNA into the nucleus of the host cell, (5) integration of proviral DNA into the host cell genome, (6) transcription of proviral DNA to viral genomic and messenger RNA, (7) translation of viral messenger RNA to viral proteins, and (8) assembly of viral components into new virions that are released by budding from the host cell membrane. Each step in the HIV-1 replicative cycle offers a potential target for antiviral chemotherapy. Although many drugs have been developed, none appears singularly effective against all stages of HIV-1 infection. Many obstacles remain in the quest for an effective vaccine against HIV-1.

Physician drug dispensing

We have reviewed the issue of physician drug dispensing by focusing upon quality of care, economic considerations, drug availability, patient compliance, safety, and increased governmental regulation. From a quality of care perspective, the increased use of pharmacist assistants, the tendency toward generic and therapeutic drug substitution, and the less specialized clinical education of pharmacists all pose hazards rather than safety checks upon physician prescribing. There is no evidence that pharmacists charge less than physicians. If they did, there would be no need to protect their incomes legislatively by restricting physician dispensing. Economic motivation per se is less important to a physician than providing a true convenience for his patients and thus encouraging a closer doctor-patient relationship. Physician dispensing adds to the availability of medication and may minimize the number of patients shuttling between pharmacies to obtain complex multi-ingredient preparations. Compliance is enhanced as availability increases. Prepackaged pharmaceuticals prepared under the auspices of pharmacists and dispensed by physicians are at least as safe as those prepared by the ungloved hands of a pharmacist hidden behind store counters. Thus, restricting the physician's right to dispense can negatively affect the quality of medical care, the cost of medications, safety, the availability of pharmaceuticals, and patient compliance. Such limitation is certainly not in the best interest of our patients.

Dermatologic therapy in the 1980s

Some of the new therapeutic agents of the 1980s, such as acyclovir and etretinate, will have a long-lasting impact on the treatment of skin diseases. Others have seemingly fallen from grace after an initial period of popularity. This article reviews a number of new agents and provides sources of further information. As with all new treatments, any physician unfamiliar with a product should consult these references and the manufacturer's labeling.

A new method for the comprehensive automatic morphologic image analysis of Langerhans cells

Standard techniques used to study Langerhans cell (LC) populations are tedious and time-consuming. We developed a rapid and comprehensive method to evaluate LC using automatic digital image analysis. Human epidermal sheets were stained with OKT6 monoclonal antibody and evaluated on an IBAS 2000 computerized automatic digital image analysis system. The fields were imaged on a Photomicroscope I using a high-resolution monochrome video camera. Each field was digitized, normalized, and filtered. The LC were discriminated by density; each field was interactively edited to separate overlapping cells and to bridge small gaps in the dendrites. The discriminated binary image of the LC was measured for number of cells per field, total area of individual cells per field, and percent of the field occupied by LC. The cell bodies were then separately discriminated and subtracted from the thinned cell image to allow a separate measurement of number and length of dendrites per cell. Finally, the binary cell image in a reference section was dilated to occupy approximately the total field area. This degree of dilation was then applied to all subjects to give the "area of influence." This methodology provides a rapid and comprehensive tool for the evaluation of LC.