The Perils of Skin Biopsy

Arch Dermatol. 2007 Oct;143(10):1267-71.
Wound complications following diagnostic skin biopsies in dermatology inpatients.Wahie S, Lawrence CM.
Department of Dermatology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, England. shyamalwahie@hotmail.com

OBJECTIVES: To prospectively determine the wound complication rate for dermatology inpatients undergoing diagnostic skin biopsies during their admission and to determine significant host and procedural risk factors. DESIGN: Prospective assessment, by a single observer, of 100 postdiagnostic skin biopsy wounds in dermatology inpatients. The following data were recorded for each patient: age and sex, presence of comorbidities, smoking status, dermatologic diagnosis, use of immunosuppressive or antibiotic therapy, place of biopsy (whether in the operation theater or in the ward), grade of physician performing biopsy, biopsy site on the body, type of biopsy (whether elliptical incision, punch, shave, or curettage), and wound closure technique. MAIN OUTCOME MEASURE: Wounds were designated as having had no complication or as being complicated by infection, dehiscence, and/or hematoma. SETTING: A dedicated dermatology inpatient ward in a university teaching hospital. RESULTS: Wound complications occurred in 29 (29%) biopsies, 27 (93%) of which were the result of wound infection. Complications occurred significantly more frequently when biopsies were performed below the waist compared with above the waist (P < .02), in the ward compared with the outpatient operating theater (P < .001), in smokers compared with nonsmokers (P < .001), and in those taking corticosteroids compared with those who were not (P < .001). In addition, elliptical incisional biopsies developed complications more frequently when subcutaneous sutures were not used compared with when they had been used (P < .001).
CONCLUSIONS: This study has demonstrated a high rate of wound complications after diagnostic dermatologic surgery on dermatology inpatients with significant host and procedural risk factors. These findings are relevant for other centers with inpatient units where diagnostic biopsies are performed.

Endometriosis and risk of cutaneous melanoma

Arch Intern Med. 2007 Oct 22;167(19):2061-5.
Personal history of endometriosis and risk of cutaneous melanoma in a large prospective cohort of French women.Kvaskoff M, Mesrine S, Fournier A, Boutron-Ruault MC, Clavel-Chapelon F.Institut National de la Santé et de la Recherche Médicale, ERI 20, Institut Gustave Roussy, 39 rue Camille Desmoulins, F94805 Villejuif CEDEX, France.

BACKGROUND: An association between melanoma and endometriosis has been reported, but most findings relied on case-control studies or a limited number of melanoma cases, and therefore the available evidence is weak. Moreover, the effect of other benign gynecological diseases on melanoma risk is unknown. METHODS: We prospectively studied data from the Etude Epidémiologique auprès de femmes de la Mutuelle Générale de l'Education Nationale cohort, which includes 98 995 French women, insured by a national health scheme mostly covering teachers, aged 40 to 65 years at inclusion. Data on history of endometriosis and other benign gynecological diseases were regularly collected, starting in 1990. Relative risks and 95% confidence intervals were computed using Cox proportional hazards regression models. RESULTS: During 12 years of follow-up, 363 melanoma cases were ascertained among 91 965 subjects. A history of endometriosis (n = 5949) was significantly associated with a higher risk of melanoma (relative risk, 1.62; 95% confidence interval, 1.15-2.29). There was also a significantly increased risk among women with a history of fibroma (n = 24 375), compared with those who had no such history (relative risk, 1.33; 95% confidence interval, 1.06-1.67). A history of ovarian cyst, uterine polyp, breast adenoma/fibroadenoma, or breast fibrocystic disease was not significantly associated with risk.
CONCLUSIONS: These data provide the strongest evidence to date of a positive association between a history of endometriosis and melanoma risk. The association between fibroma and melanoma, which has not been previously described, warrants further investigation

Melanoma management in Victoria 1996 and 2000

This is an interesting article looking at how melanoma was managed before and after the introduction of melanoma management guidelines. It makes depressing reading. The guidelines had little effect but perhaps this was due to not enough time between issuing them and this survey. They look at biopsy type, excision margins etc. Worth reading in full HERE. It would be interesting to carry this survey out on members of the Society. Perhaps the audit can look at this.IMCC

The management of primary cutaneous melanoma in Victoria in 1996 and 2000
John W Kelly, Michael A Henderson, Vicky J Thursfield, John Slavin, Jill Ainslie and Graham G Giles
Abstract
Objective:

To describe tumour characteristics and clinical management of melanomas newly diagnosed in 1996 and in 2000 — before and after publication of the clinical practice Guidelines for the management of cutaneous melanoma by the Australian Cancer Network (1997), and their endorsement by the National Health and Medical Research Council (NHMRC) and republication (1999).
Design and setting:

Survey of clinicians involved in the management of patients with melanoma sampled from the Victorian Cancer Registry. The Registry is notified of all cases of cancer diagnosed by pathology laboratories and hospitals in both the public and private health sectors in the state of Victoria.
Patients:

People with a cutaneous melanoma newly diagnosed in 1996 and 2000. All invasive melanomas > 1.50 mm in thickness were included, and for each year random samples were selected of 100 each of invasive melanomas 0.76–1.50 mm in thickness, invasive melanomas ≤ 0.75 mm, and in-situ melanomas, plus 50 melanomas of unknown thickness.
Main outcome measures:

Biopsy method, adequacy of pathology reporting, adequacy of definitive excision (compared with margins recommended by the Guidelines), and follow-up procedures.
Results:

The use of partial biopsies increased between 1996 and 2000. Recommended margins of definitive excision were used in only 33.6% of cases. Margins were smaller than recommended for 36% of in-situ melanomas, risking recurrence of primary melanoma. Documented follow-up examinations for subsequent primary skin malignancy were uncommon (6%).
Conclusions:

Many aspects of the management of primary cutaneous melanoma appear not to meet the recommendations of the published Guidelines. Further studies to explore the reasons for failure to meet the Guideline recommendations are needed.

Multipeptide melanoma vaccines

Clinical Cancer Research 13, 6386-6395, November 1, 2007. doi: 10.1158/1078-0432.CCR-07-0486
(This article validates the use of multipeptide vaccines in melanoma vaccine research. It does not say that the technique is clinically effective. IMCC)


Immunologic and Clinical Outcomes of a Randomized Phase II Trial of Two Multipeptide Vaccines for Melanoma in the Adjuvant Setting
Craig L. Slingluff, Jr.1, Gina R. Petroni2, Kimberly A. Chianese-Bullock1, Mark E. Smolkin2, Sarah Hibbitts3, Cheryl Murphy1, Naomi Johansen1, William W. Grosh4, Galina V. Yamshchikov1, Patrice Y. Neese1, James W. Patterson5, Robyn Fink3 and Patrice K. Rehm6

Authors' Affiliations: Departments of 1 Surgery and 2 Public Health Sciences; 3 Cancer Center; and 4 Division of Hematology-Oncology, Department of Medicine; and Departments of 5 Pathology and 6 Radiology, University of Virginia, Charlottesville, Virginia

Requests for reprints: Craig L. Slingluff, Jr., Department of Surgery, Human Immune Therapy Center, University of Virginia, 1352 Jordan Hall, P.O. Box 801457, Charlottesville, VA 22908. Phone: 434-243-2611; Fax: 434-982-3276; E-mail: cls8h@virginia.edu.

Purpose: Human melanoma cells express shared antigens recognized by CD8+ T lymphocytes, the most common of which are melanocytic differentiation proteins and cancer-testis antigens. However, peptide vaccines for melanoma usually target only one or two MHC class I–associated peptide antigens. Because melanomas commonly evade immune recognition by selective antigen loss, optimization of melanoma vaccines may require development of more complex multipeptide vaccines.

Experimental Design: In a prospective randomized clinical trial, we have evaluated the safety and immunogenicity of a vaccine containing a mixture of 12 peptides from melanocytic differentiation proteins and cancer-testis antigens, designed for human leukocyte antigen types that represent 80% of the melanoma patient population. This was compared with a four-peptide vaccine with only melanocytic differentiation peptides. Immune responses were assessed in peripheral blood and in vaccine-draining lymph nodes.

Results: These data show that (a) the 12-peptide mixture is immunogenic in all treated patients; (b) immunogenicity of individual peptides is maintained despite competition with additional peptides for binding to MHC molecules; (c) a broader and more robust immune response is induced by vaccination with the more complex 12-peptide mixture; and (d) clinical outcome in this peptide vaccine trial correlates with immune responses measured in the peripheral blood lymphocytes.

Conclusions: These data support continued investigation of complex multipeptide vaccines for melanoma.