Extensive Perineural Invasion vs Nerve Caliber to Assess Cutaneous Squamous Cell Carcinoma Prognosis

Importance

Perineural invasion (PNI) is an adverse risk feature in cutaneous squamous cell carcinoma (CSCC) that affects patient prognosis and disease management. However, research comparing different PNI patterns on patient outcomes is limited.

Objective

To compare 4 assessments of PNI in CSCC, their associations with poor outcomes, and implications for their inclusion in the Brigham and Women's Hospital (BWH) staging system.

Design, Setting, and Participants

This retrospective cohort study was performed at a single tertiary care institution and compared 4 PNI assessments: nerve caliber, number of involved nerves per section, PNI maximal depth, and PNI location with respect to tumor. Patients with primary, localized, invasive CSCC with PNI diagnosed between January 1, 2000, and December 31, 2017, were identified via an electronic in-house database. Available pathology slides were secondarily reviewed by study authors. Relevant patient and tumor characteristics and outcomes were abstracted from the medical record. Data analysis was performed between September 6 and October 20, 2022.

Main Outcomes and Measures

Risks of recurrence, disease-specific death, and a composite end point (any poor outcome) were calculated via multivariable stepwise Fine and Gray competing-risks regression. Considered revisions to the BWH staging system were assessed via receiver operating characteristic curves and test characteristics.

Results

This study included 140 patients with CSCC, with a mean (SD) age of 75.1 (11.2) years. More than half of the patients were men (93 [66.4%]), and most identified as White (132 [94.3%]). Of the 4 PNI assessments studied, only involvement of multiple nerves was associated with poor outcomes. Perineural invasion of 5 or more distinct nerves (extensive PNI [ePNI]) was independently associated with local recurrence (subhazard ratio [SHR], 13.83 [95% CI, 3.50-54.62]; P < .001), disease-specific death (SHR, 6.20 [95% CI, 1.59-24.21]; P = .009), and any poor outcome (SHR, 10.21 [95% CI, 2.88-36.15]; P < .001). A revised BWH staging system with substitution of ePNI for large-caliber PNI resulted in improved area under the curve and test characteristics compared with current BWH staging criteria that use nerve caliber as the measure of PNI.

Conclusions and Relevance

The findings of this cohort study suggest that ePNI is the best prognostic measure of PNI. Because ePNI obviated the need for a micrometer and had superior prognostic capacity to nerve caliber in this cohort, ePNI should be considered for inclusion in CSCC tumor staging. Inclusion of ePNI as a high-risk factor in CSCC staging systems may optimize patient selection for primary treatment and adjuvant interventions.

Complementary and alternative medicine for alopecia areata: A systematic review

BACKGROUND

Despite high use of complementary and alternative medicine (CAM) for alopecia areata (AA), efficacy and safety remain unclear.

OBJECTIVE

To identify all CAM therapies studied for treatment of AA. Outcomes of interest included disease course and psychologic well-being.

METHODS

PubMed and Embase were searched to identify English articles containing original data investigating CAM in individuals with AA from 1950-2018. Quality was assessed with Oxford Centre for Evidence Based Medicine criteria.

RESULTS

Of 1015 initial citations, 16 articles met inclusion criteria: 5 randomized controlled trials, 5 prospective controlled cohorts, 4 prospective noncontrolled cohorts, 1 retrospective cohort, and 1 case series. CAM therapies with best evidence and efficacy for hair growth in AA include essential oil aromatherapy, topical garlic, and oral glucosides of peony with compound glycyrrhizin. Hypnosis and mindfulness psychotherapy represent low-quality evidence for improvement of psychologic and quality of life outcomes. Adverse events were rare and mild for all therapies evaluated.

LIMITATIONS

Inconsistent or poorly reported study methodology and nonstandardized outcomes limit the conclusions that can be made from these studies.

CONCLUSIONS

This work serves to inform physician treatment of patients with AA seeking CAM while encouraging further investigation into these therapies to address some of the therapeutic challenges of AA.

Factors associated with suspected nonmelanoma skin cancers, dysplastic nevus, and cutaneous melanoma among first-time SpotMe screening program participants during 2009-2010

BACKGROUND

There have been no studies of the American Academy of Dermatology's SpotMe skin cancer screening program to collectively analyze and determine the factors associated with suspected basal cell carcinoma (BCC), squamous cell carcinoma (SCC), dysplastic nevus (DN), and cutaneous melanoma (CM) diagnoses.

OBJECTIVE

Describe the demographics, risk factors, and access to care profiles associated with suspected diagnoses of BCC, SCC, DN, and CM among first-time SpotMe screenees during 2009-2010.

METHODS

We conducted a cross-sectional analysis of data from the SpotMe skin cancer screenings conducted in 2009 and 2010. We performed multivariable logistic regression analysis for each diagnosis, incorporating standard demographic, access to care, and risk factor variables in the models.

RESULTS

Men, those without a regular dermatologist, persons reporting recently changing moles, and those with a personal history of melanoma were at increased risk for each of the suspected diagnoses analyzed. Uninsured persons were at increased risk for suspected malignancies (BCC, SCC, and CM).

LIMITATIONS

Lack of histologic confirmation for diagnoses and cross-sectional design.

CONCLUSION

Among first-time SpotMe participants, suspected diagnoses of BCC, SCC, DN, and CM shared several associated factors, which may be considered when planning outreach and screening for populations at risk for skin cancer.

Innovation interest within dermatology: a needs assessment for novel thought processes

Medical innovation is crucial to advancing our field, and physicians have the potential to play a leading role due to their daily patient care experiences. The objective of this study was to evaluate the interest in, and barriers to participating in innovation. Two surveys were conducted; the first cross-sectional survey was conducted among attendees of the Advancing Innovation in Dermatology Forum in Feburary 2019. The second survey was conducted among trainees (resident/fellows) and faculty dermatologists at Brown, Emory, Iowa, Stanford, and Vanderbilt Universities between June and November 2019. Demographic data were collected, as well as factors involved with identifying problems, developing solutions, training in innovation, and perceived barriers to innovation. In the first survey, the greatest perceived benefits include bringing joy to one's work and increasing professional fulfillment with work. Innovation was also perceived to decrease burnout. In the second survey of academic centers, faculty more commonly expressed interest in identifying problems (p  = 0.04), and was also more confident in their ability to generate solutions to these problems as compared to trainees (p < 0.01). Major barriers to participating in innovation processes included lack of time and lack of training or education in innovation. Both trainees and faculty groups noted a lack of knowledge in creating prototypes, understanding regulatory approval for medical products, and inexperience with pitching to investors or obtaining funding. These cross-sectional needs assessment surveys found a strong interest in innovation coupled with a lack of education in innovation processes. These findings suggest an urgent need and opportunity for providing formal training to empower dermatologists with the tools to lead innovation within our field.

Impact of skin biopsy on the management of acute graft-versus-host disease in a pediatric population

BACKGROUND/OBJECTIVES

Acute graft-versus-host disease (GVHD) of the skin is a common complication of hematopoietic stem cell transplantation (HSCT) but often represents a diagnostic challenge. The adult literature suggests that histopathology rarely dictates management decisions, but the clinical utility of skin biopsies in pediatric patients with suspected acute GVHD is unknown. The objective of this study was to determine the frequency with which skin biopsy leads to a definitive diagnosis of acute GVHD and changes the management of acute GVHD in the pediatric population.

METHODS

We conducted a retrospective analysis of histopathology results and the associated impact on clinical management based on chart review of pediatric patients who underwent skin biopsy for cutaneous eruptions suspicious for acute GVHD from 1995 to 2016.

RESULTS

Among 27 pediatric HSCT patients, skin biopsy yielded definitive diagnoses (GVHD or otherwise) in only 15% (4/27) of cases. Overall, dermatology consultation was associated with clinical management changes in 78% (21/27) of cases. A change in management was definitively based on skin biopsy results in only 7.4% (2/27) of cases. The mean duration of time between dermatology consultation and return of biopsy results was 4.8 days (range 1-17).

CONCLUSIONS

Our results suggest that skin biopsy of pediatric HSCT patients with findings concerning for acute skin GVHD rarely yields a definitive diagnosis or change in management.

Association Between Alopecia Areata, Anxiety, and Depression: A Systematic Review and Meta-analysis

BACKGROUND

To date, there is no comprehensive meta-analysis analyzing the association between alopecia areata, anxiety, and depression.

OBJECTIVE

We sought to analyze the existing literature to examine the association between alopecia areata, anxiety, and depression.

METHODS

We extracted literature from 4 databases including MEDLINE, Embase, PsychINFO, and Web of Science. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (ie, PRISMA) reporting guidelines to finalize a list of relevant articles to be included in our systematic review and meta-analysis. There were no restrictions placed on publication year or age of participants.

RESULTS

Eight studies that included 6010 patients with AA and 20 961 control individuals were included in the quantitative analysis. These included 4 cross-sectional studies and 4 case-control studies. Analysis of these studies showed a positive association with anxiety (pooled odds ratio, 2.50; 95% confidence interval, 1.54-4.06) and depression (pooled odds ratio, 2.71; 95% confidence interval, 1.52-4.82).

LIMITATIONS

Publication bias may be a limitation of the study.

CONCLUSION

This study suggests that patients with AA are at higher risk of both anxiety and depression. Health care professionals must be cognizant of this higher risk and consider routine assessment of these conditions and referral to appropriate providers when indicated.

The ALT-70 cellulitis model maintains predictive value at 24 and 48 hours after presentation

BACKGROUND

Cellulitis has many potential mimickers, and its misdiagnosis often leads to unnecessary hospitalizations and higher health care costs. The ALT-70 predictive model offers an objective tool to help differentiate between cellulitis and other clinically similar conditions at the time of initial emergency department (ED) presentation.

OBJECTIVE

To evaluate the performance of the ALT-70 predictive model at 24 and 48 hours following ED presentation.

METHODS

We performed a retrospective review of our prior cohort and expanded our data collection to include data at 24 and 48 hours after initial ED presentation. We compared classification measures for the ALT-70 at the time of initial ED presentation, 24 hours after presentation, and 48 hours after presentation.

RESULTS

There was a statistically significant difference in median ALT-70 score between patients with true cellulitis and those with mimickers of cellulitis at all time points. Sensitivity, specificity, positive predictive value, and negative predictive value of the ALT-70 score was similar across all 3 time points.

LIMITATIONS

Single-center design may reduce generalizability.

CONCLUSION

At 24 and 48 hours, the ALT-70 performed similarly to the way it performed at the time of initial ED presentation, allowing for its use in a wider array of clinical settings.

A pink enlarging plaque on the plantar foot: amelanotic acral lentiginous melanoma

Acral lentiginous melanomas account for less than 5% of all melanomas, whereas amelanotic melanomas account for around 2-8% of all melanomas. Amelanotic acral lentiginous melanomas are even less common and can often be mistaken for other clinical entities, including pyogenic granulomas, non-melanoma skin cancers, and warts. We describe a man in his 50s with a twenty-year history of a skin-colored plaque on the right plantar foot; after enlargement and failure of wart treatment, a shave biopsy revealed an amelanotic melanoma. A subsequent wide local excision and sentinel lymph node biopsy revealed melanoma in 4 lymph nodes and the patient underwent an abbreviated course of interferon-alpha therapy. The patient remained stable until 2 ? years after diagnosis, at which time he presented with in-transit metastases on the foot and right thigh; he has since been stable on nivolumab. This case represents the challenge of diagnosing amelanotic melanomas on acral surfaces and highlights the importance of considering a skin biopsy for diagnosis of any changing, atypical amelanotic lesions on the feet or hands.

Clinicopathologic, misdiagnosis, and survival differences between clinically amelanotic melanomas and pigmented melanomas

BACKGROUND

Amelanotic malignant melanoma (AMM) is challenging to diagnose. Clinical risk factors for AMM are not well defined.

OBJECTIVE

To investigate clinicopathologic, misdiagnosis, and survival differences between patients with AMM and those with pigmented malignant melanoma (PMM).

METHODS

A cross-sectional retrospective medical record review at a tertiary academic medical center.

RESULTS

A total of 933 patients with melanoma with known presenting tumor color were identified (342 with AMM vs 591 with PMM). AMM was associated with older age, history of nonmelanoma skin cancer, and red hair, whereas AMM was inversely associated with a family history of melanoma, more than 50 nevi, and a history of dysplastic nevi. Compared with PMM, AMM was more likely to be located on the head and/or neck, had more aggressive pathologic features (greater Breslow depth and/or mitoses, ulceration, nodular subtype), and was less likely to be associated with a precursor nevus or regression. Finally, patients with AMM were more likely to be misdiagnosed than were patients with PMM (25% vs 12% clinically and 12% vs 7% pathologically), and they had poorer melanoma-specific survival (5-year overall survival rate, 0.77 [95% confidence interval, 0.72-0.82] vs 0.84 [95% confidence interval, 0.80-0.87]).

LIMITATIONS

Retrospective study design, single-institutional study.

CONCLUSION

Greater clinician awareness, lower biopsy thresholds, and increased patient education may be useful to enhance AMM detection in patients with certain characteristics.

Preclinical Studies Support Combined Inhibition of BET Family Proteins and Histone Deacetylases as Epigenetic Therapy for Cutaneous T-Cell Lymphoma

Advanced-stage cutaneous T-cell lymphoma (CTCL) is usually a fatal malignancy despite optimal use of currently available treatments. In this preclinical study of novel CTCL therapy, we performed in vitro and ex vivo experiments to determine the efficacy of combination treatment with a panel of BET bromodomain inhibitors (BETi) (JQ1, OTX015, CPI-0610, I-BET762) and HDAC inhibitors (HDACi) (SAHA/Vorinostat, Romidepsin). BETi/HDACi combinations were synergistic (combination index <1) against cell viability and induced G0/G1 cell cycle arrest. Apoptosis was uniformly enhanced. From a mechanistic standpoint, proliferative drivers c-Myc, Cyclin D1, NFkB, and IL-15Rα were reduced. Inhibitory CDKN1A was increased. CDKN1B, IL-7R, IL-17Rα, STAT3, and STAT5 alterations varied. There were significant increases in extrinsic apoptotic pathway death receptors and ligands (FasL, DR4, DR5, TRAIL, and TNFR1). At clinically tolerable levels of single agents, Romidepsin (1 nM) + OTX015 (125 nM) induced the greatest apoptosis (60%_80%) at 96 hours. Ex vivo studies of leukemic CTCL cells obtained from patients with Sezary syndrome also showed higher levels of apoptosis (about 60%-90%) in response to combination treatments relative to single agents. In contrast, combination treatment of normal CD4+ T cells induced only minimal apoptosis (<10%). Our findings show that the mechanism of action of BETi/HDACi therapy in CTCL involves induction of both cell cycle arrest and apoptosis with reduced proliferative drivers and enhanced expression of apoptotic extrinsic pathway death receptors and ligands. Relative to single agents, the superior anti-CTCL effects of BETi/HDACi combinations in vitro and ex vivo provide a rationale for clinical trials exploring their efficacy as therapy for CTCL.

The first 30 years of the American Academy of Dermatology skin cancer screening program: 1985-2014

BACKGROUND

The incidence of melanoma is rising faster than that of any other preventable cancer in the United States. The American Academy of Dermatology has sponsored free skin cancer education and screenings conducted by volunteer dermatologists in the United States since 1985.

OBJECTIVE

We aimed to assess the American Academy of Dermatology's national skin cancer screening program from 1986 to 2014 by analyzing the risk factor profile, access to dermatologic services, and examination results.

METHODS

We conducted several detailed statistical analyses of the screening population.

RESULTS

From 1986 to 2014, records were available for 2,046,531 screenings, 1,963,141 (96%) of which were subjected to detailed analysis. Men comprised 38% of all participants. The number of annual screenings reached approximately 100,000 in 1990 and remained relatively stable thereafter. From 1991 to 2014 (data for 1995, 1996 and 2000 were unavailable), clinical diagnoses were rendered for 20,628 melanomas, 156,087 dysplastic nevi, 32,893 squamous cell carcinomas, and 129,848 basal cell carcinomas. Only 21% of screenees had a regular dermatologist. Those with a clinical diagnosis of skin cancer were more likely than the general screening population to be uninsured.

LIMITATIONS

Inability to verify clinical diagnoses histopathologically.

CONCLUSION

Our findings suggest that the SPOTme program has detected thousands of skin cancers that may have gone undetected or experienced a delay in detection.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network Consortium (PPACMAN) Survey: Benefits and Challenges of Combined Rheumatology-dermatology Clinics

Optimal management of patients with both psoriasis and psoriatic arthritis (PsA) necessitates collaboration among dermatologists and rheumatologists. In this manuscript, we discuss challenges and opportunities for dual care models for patients with psoriasis and PsA and the results of a survey of combined clinics based in North America.

Polycystic Ovary Syndrome: Special Diagnostic and Therapeutic Considerations for Children

Polycystic ovary syndrome (PCOS) is an endocrine syndrome with variable phenotypic expression and important systemic associations and sequelae, including obesity, insulin resistance, infertility, risk of endometrial cancer, and possible risk of cardiovascular events. PCOS is recognized as a condition influenced by genetic and environmental factors and distinct manifestations in all stages of life, including the prenatal period, childhood, adolescence, and adulthood. Identification of this disorder in childhood and adolescence has received growing attention, in part because of emerging evidence of the benefit of early intervention, but the diagnosis and management of PCOS in children and adolescents can be challenging. Diagnostic and therapeutic considerations of PCOS in children are reviewed to enhance identification and evaluation of patients suspected of having this disorder. When a diagnosis of PCOS is suspected in a child but cannot be confirmed, a provisional diagnosis is strongly recommended so as to prompt ongoing monitoring with an emphasis on important early interventions such as obesity reduction.

Lipedema: A Review of the Literature

Lipedema is a disorder of adipose tissue that primarily affects females and is often misdiagnosed as obesity or lymphedema. Relatively few studies have defined the precise pathogenesis, epidemiology, and management strategies for this disorder, yet the need to successfully identify this disorder as a unique entity has important implications for proper treatment. In this review, we sought to review and identify information in the existing literature with respect to the epidemiology, pathogenesis, clinical presentation, differential diagnosis, and management strategies for lipedema. The current literature suggests that lipedema appears to be a clinical entity thought to be related to both genetic factors and fat distribution. While distinct from lymphedema and obesity, there are some existing treatments such as complex decongestive physiotherapy, liposuction, and laser-assisted lipolysis. Management of lipedema is complex and distinct from lymphedema. The role of newer randomized controlled studies to further explore the management of this clinical entity remains promising.

Evaluation of serum B-cell maturation antigen in multiple myeloma

e18549

Background: B cell maturation antigen (BCMA) is a receptor whose expression increases during B-cell development and is found on malignant cells from multiple myeloma (MM) patients; however, it has not been identified in human serum. Methods: Bone marrow (BM) aspirates and peripheral blood were obtained from patients with MM, monoclonal gammopathy of undetermined significance (MGUS) and healthy control subjects following informed consent (Western IRB BIO 001). Serum was isolated and analyzed with a BCMA enzyme‑linked immunosorbent assay. Values represent the mean of triplicate experiments. BM mononuclear cells (MCs) were isolated using density‑gradient centrifugation and cultured for 72 h in RPMI1640 supplemented with 10% fetal bovine serum. Our human MM xenograft (LAGκ-2)was grown in SCID mice and treated with bortezomib (BORT) with cyclophosphamide (CY); tumor volume and BCMA levels were determined. Statistical significance of differences observed was determined using a Student’s t test and analysis was determined using GraphPad prism software. Results: We showed that the supernatants of cultured BMMCs from MM patients had high concentrations of BCMA (median = 2,250 pg/ml) whereas normal subjects showed minimal amounts (56 ng/ml; P < 0.0001). The serum BCMA levels from newly diagnosed MM patients (n = 51) had much higher levels (13.74 ng/ml) than among controls (n = 40; median 2.58 ng/ml; P < 0.0001) and MGUS subjects (n = 26; median 5.40 ng/ml; P = 0.005). Notably, protein levels were much higher among patients with relapsed or refractory (R/R) disease (n = 79; median 20.02 ng/ml) compared to those with responsive (> partial response) disease (n = 80; median 4.14 ng/ml; P = 0.0038). Following treatment, patients with responsive disease showed decreases in BCMA levels whereas those with R/R disease showed increases. Following treatment with BORT and CY, we also showed a marked decrease in tumor volume and serum human BCMA levels in mice bearing the LAGκ-2 xenograft whereas untreated animals showed marked increases in tumor size and serum BCMA. Conclusions: This is the first report identifying serum BCMA in any human disease and suggests that these levels may be a novel biomarker for monitoring disease status and therapeutic response of MM patients.