SCC and the Medical Oncologist

This editorial looked at ways in which medical oncologists could become involved earlier in the management of aggressive SCCs of the skin. It comments on a paper in that issue of the journal which looked at using oral retinoids combined with Interferon injections 3 times a week with patients with severe aggressive or recurrent SCCs. Unfortunately they did no better than controls
The editorial is a useful summary. It can be viewed here
Randomized Trial of Adjuvant 13-cis-Retinoic Acid and Interferon Alfa for Patients With Aggressive Skin Squamous Cell CarcinomaAbenaa M. Brewster, J. Jack Lee, Gary L. Clayman, John L. Clifford, Mary Jo T. Necesito Reyes, Xian Zhou, Anita L. Sabichi, Sara S. Strom, Robert Collins, Christina A. Meyers, Scott M. Lippman

From the Departments of Clinical Cancer Prevention, Biostatistic and Applied Mathematics, Head and Neck Surgery, Thoracic/Head and Neck Medical Oncology, Epidemiology and Neuro-oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX; and the Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center and Feist-Weiller Cancer Center, Shreveport, LA

Address reprint requests to Scott M. Lippman, MD, Department of Thoracic and Head and Neck Medical Oncology, Unit 432, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77230-1439; e-mail: slippman@mdanderson.org

Purpose: To conduct a phase III trial of adjuvant 13-cis-retinoic acid (13cRA) plus interferon alfa (IFN-) for preventing tumor recurrence and second primary tumors (SPTs) of skin squamous cell carcinoma (SCC) among patients with aggressive skin SCC.

Patients and Methods: Sixty-six patients with aggressive skin SCC were randomly assigned to receive either 6 months of combined 13cRA (1 mg/kg/d orally) and IFN- (3 x 106 U subcutaneously three times per week) or no adjuvant therapy (control group) after SCC surgery and/or radiation.

Results: At 21.5 months median follow-up, treatment did not improve the time to tumor recurrence and SPT versus control (hazard ratio [HR], 1.13; 95% CI, 0.53 to 2.41), time to tumor recurrence (HR, 1.08; 95% CI, 0.43 to 2.72), or time to SPT (HR, 0.89; 95% CI, 0.27 to 2.93). Adjuvant 13cRA and IFN- was moderately tolerable; 29% of patients in the treatment arm required dose reductions for grade 3 or 4 toxicities.

Conclusion: Results of this phase III trial do not support 13cRA plus IFN- for adjuvant therapy of aggressive skin SCC. With high rates of tumor recurrence and SPTs, patients with aggressive skin SCC continue to have an unmet medical need, with devastating mortality, morbidity, and financial consequences. Promising agents with preclinical and early clinical results relevant to aggressive skin SCC deserve a high priority for future clinical drug development.

Margins for Dermatofibrosarcoma Protuberans

This article describes a prospective study of margins and number of attempts to achieve those margins in a group of patients with dermatofibrosarcoma protuberans.
Microscopic Margins and Results of Surgery for Dermatofibrosarcoma Protuberans.

RECONSTRUCTIVE

Plastic & Reconstructive Surgery. 119(6):1779-1784, May 2007.
Popov, Pentscho M.D.; Bohling, Tom M.D., Ph.D.; Asko-Seljavaara, Sirpa M.D., Ph.D.; Tukiainen, Erkki M.D., Ph.D.
Abstract:
Background: Dermatofibrosarcoma protuberans is a rare low-grade sarcoma of the skin with a tendency to recur locally after inadequate excision. Treatment has traditionally been wide excision with a 2- to 3-cm gross margin. Because of the variable results presented in mainly retrospective reports, it has been queried whether local control can be as good with conventional surgery as with micrographic surgery.

Methods: Forty patients with dermatofibrosarcoma protuberans treated by surgical excision were operated on at our center from 1987 to 2001. Data were recorded prospectively. Twenty-seven patients presented with a primary tumor and 13 with a locally recurrent tumor primarily operated on elsewhere. Gross and histologic margins were studied in detail.

Results: At a mean follow-up of 40 months, there were no recurrences. Thirty-four patients required single, five patients two, and one patient three operations before the margins were adequate (mean, 1.2 stages per patient). Twenty-three patients (58 percent) needed reconstructions. Tumor-free margins were obtained in 39 patients. The average thickness of surgical gross margins was 3.1 cm; histologically defined margins averaged 1.6 cm.

Conclusions: Good local control can be achieved with wide surgery. Histologic tumor-free margins differ greatly from gross margins and are difficult to assess clinically and macroscopically. Careful postoperative histologic examination with margins measured in millimeters should be carried out to define the adequacy of excision in all directions. On average, a 1.6-cm histologic margin was adequate for complete local control. Most patients can be operated on in one stage. Reconstructions are often needed.

Diagnostic Fluoroscopy and Skin damage

Fluoroscopy-Induced Chronic Radiation Skin Injury
A Disease Perhaps Often Overlooked Thomas H. Frazier, MD; Jeffrey B. Richardson, MD; Vilma C. Fabré, MD; Jeffrey P. Callen, MD


Arch Dermatol. 2007;143:637-640.

Background Fluoroscopy-induced chronic radiation dermatitis (FICRD) resulting from prolonged exposure to ionizing radiation during interventional procedures has been documented in the radiology and cardiology literature. However, the phenomenon has been rarely reported in the dermatologic literature. Since patients with FICRD often see a dermatologist or a primary care physician to treat their injuries, the diagnosis of FICRD is perhaps often overlooked.

Observations A 62-year-old man with type 2 diabetes mellitus and severe coronary artery disease was seen with a 2-year history of a pruritic, tender, telangiectatic patch lesion over his left scapula. Over the next 2 years, the lesion became indurated and eventually ulcerated. A skin biopsy specimen demonstrated changes consistent with a chronic radiation dermatitis. The patient was unaware of radiation exposure, but persistent questioning from his dermatologists revealed that he had undergone multiple fluoroscopy-guided cardiac procedures. This was confirmed by a review of his medical records.

Conclusion The diagnosis of FICRD should be considered for any patient who is seen with an acquired vascular lesion, a morphealike lesion, or an unexplained ulcer localized over the scapula, the back, or lateral trunk below the axilla.

Is the Siascope any value to Dermatologists for Real time melanoma screening?

Answer is not at all for this particular Dermatologist.The use of a spectrophotometric intracutaneous analysis device in the real-time diagnosis of melanoma in the setting of a melanoma screening clinicM.A. Haniffa, J.J. Lloyd**Regional Medical Physics Department, Royal Victoria Infirmary, Newcastle-upon-Tyne NE1 4LP, U.K. and C.M. LawrenceDepartment of Dermatology and *Regional Medical Physics Department, Royal Victoria Infirmary, Newcastle-upon-Tyne NE1 4LP, U.K.

Background Skin imaging devices to aid melanoma diagnosis have been developed in recent years but few have been assessed clinically.

Objectives To investigate if a spectrophotometric skin imaging device, the SIAscope, could increase a dermatologist's ability to distinguish melanoma from nonmelanoma in a melanoma screening clinic.

Methods Eight hundred and eighty-one pigmented lesions from 860 patients were prospectively assessed clinically and with the aid of the spectrophotometric device by a dermatologist. Assessment before and after spectrophotometric imaging was made and compared with histology, where available, or with the clinical diagnosis of a dermatologist with 20 years of experience.

Results One hundred and seventy-nine biopsies were performed, with 31 melanomas diagnosed. Sensitivity and specificity for melanoma diagnosis before and after spectrophotometry were 94% and 91% vs. 87% and 91%, respectively, with no significant difference in the area under the receiver operating characteristic curves (0·932 and 0·929).

Conclusions Our study provides no evidence for the use of SIAscope by dermatologists to help distinguish melanoma from benign lesions.

Chromosomal Features of Melanoma and Spitz Nevi.

This article shows the chromosomal differences between Spitz evi and Melanoma. It may be helpful in differentiating difficult histological cases some time in the future.(IMCC)
Genetic and epigenetic alterations in the differential diagnosis of malignant melanoma and spitzoid lesion
British Journal of Dermatology
Volume 156 Issue 6 Page 1287 - June 2007

M. Takata, J. Lin, S. Takayanagi, T. Suzuki**Laboratory Medicine, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390–8621, Japan, S. Ansai††Sapporo Institute for Dermatopathology, Sapporo, Japan, T. Kimura††Sapporo Institute for Dermatopathology, Sapporo, Japan, L. Cerroni‡‡Department of Dermatology, Medical University of Graz, Graz, Austria and T. SaidaDepartments of Dermatology and *Laboratory Medicine, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390–8621, Japan
†Sapporo Institute for Dermatopathology, Sapporo, Japan
‡Department of Dermatology, Medical University of Graz, Graz, Austria


Background The histopathological differentiation of malignant melanoma and Spitz naevus often presents diagnostic problems.

Objectives We aimed to find out applicable diagnostic parameters other than routine pathology.

Methods The cases included conventional melanomas and Spitz naevi as well as atypical spitzoid lesions that had posed diagnostic difficulties. We examined hotspots of mutation in the BRAF, NRAS and HRAS genes by polymerase chain reaction-based direct sequencing. We also analysed DNA copy number aberrations and the methylation of CpG sequences in several cancer-related genes by utilizing a novel methylation-specific multiplex ligation-dependent probe amplification method.

Results Twenty three of 24 conventional melanomas showed at least one of the genetic and epigenetic alterations examined, although one acral melanoma did not show any alteration. By sharp contrast, 12 Spitz naevi with an unambiguous histopathology showed no or few chromosomal aberrations, no oncogene mutations and no methylation of CpG sequences. Of the 16 ambiguous spitzoid lesions, most of which were designated atypical Spitz tumour by one of the authors, all but one showed no mutations, no methylations and few copy number aberrations. However, three tumours showed copy number loss of the cyclin-dependent kinase inhibitor 2A gene (CDKN2A), an alteration observed frequently in melanomas but not found in conventional Spitz naevi. These results show that, although most atypical Spitz tumours do not differ from conventional Spitz naevi showing virtually no genetic and epigenetic aberrations, some cases may have chromosomal aberrations that include copy number loss of the CDKN2A gene.

Conclusions Genetic and epigenetic analyses may be useful as an additional diagnostic tool to distinguish between melanoma and Spitz naevus, and may help to define subgroups in atypical Spitz tumours.

The nature of cutaneous metastases

Clinicopathologic correlation of cutaneous metastases
Sariya, D., et al. - To analyze the clinical, histopathologic, and immunohistochemical characteristics of skin metastases.
Cutaneous metastases can have variable clinical appearances and can mimic benign skin lesions. They are usually seen in patients with advanced disease, but they can be the presenting lesion. Although many metastatic adenocarcinomas can be recognized based on histologic findings alone, immunohistochemical analysis is an important diagnostic adjunct in some cases

Methodology
51 patients with biopsy-proven skin metastases and correlative clinical data.
4 dermatopathologists reviewed a random mixture of metastases and primary skin tumors.
Immunohistochemical studies for 12 markers were performed on the metastases, with skin adnexal tumors as controls.

Results
86% of the patients had known stage IV cancer, and skin metastasis was the presenting sign in 12%.
In 45% of the biopsies, the lesions were not suspected of being metastases owing to unusual clinical presentations.
76% of the patients died of disease (median survival, 5 months).
On pathologic review, many metastases from adenocarcinomas were either recognized or suspected, but the primary site was not easily identified based on histologic findings alone.
Metastases from small cell carcinomas and sarcomas were histologically misinterpreted as primary skin tumors.
Immunohistochemical analysis using a panel including p63, B72.3, calretinin, and CK5/6 differentiated metastatic carcinoma from primary skin adnexal tumors.

Why carry out Dermatoscopy?

A compilation of the discussion of this topic in the Archives and replies from Scott Menzies and Iris Zaludeck to a letter critical of their editorial can be found here

Distinguishing early melanoma histochemically.

This is an interesting paper that may point the way ahead in looking at distinguishing early melanoma from Clarke's (dysplastic) nevi. It may be useful in those more severly dysplastic histopathologically. Mind you most of us excise these fully anyway. Simply trying this test with a biopsy would not be the best thing to do!(IMCC)

Cyclooxygenase-2 (COX-2): first immunohistochemical marker distinguishing early cutaneous melanomas from benign melanocytic skin tumours.

ORIGINAL ARTICLES

Melanoma Research. 17(3):139-145, June 2007.
Chwirot, Barbara W.; Kuzbicki, Lukasz
Abstract:
We have reported recently that changes in expression level of COX-2 are correlated with development and progression of human melanoma. In this study, we investigated whether the COX-2 expression level might be a useful immunohistochemical marker for distinguishing cutaneous melanomas from benign melanocytic lesions. Up to now, immunohistochemical markers have not ensured satisfactory sensitivity and specificity of differential pathologic diagnosis of melanoma. The expression of COX-2 was determined immunohistochemically in formalin-fixed, paraffin-embedded specimens of 33 early Clark I/II melanomas and 58 naevi. Mean COX-2 expression in melanomas was significantly stronger than in naevi (P[almost equal to]10-13). A simple diagnostic algorithm using threshold values of the COX-2 expression level allows for differentiation between early melanomas and naevi with high sensitivity (Se) and specificity (Sp) (for Se between 91 and 100%, Sp values change between 96.5 and 51.7%). Areas under the receiver operating characteristic curves were, respectively, 0.97+/-0.02 and 0.86+/-0.04 for the COX-2 expression in central and border regions of the lesions. For all the melanomas (not only the early ones),the respective areas under the ROC curve values were 0.98+/-0.01 and 0.97+/-0.02. In conclusion, COX-2 is the first immunohistochemical marker that allows the distinguishing of early melanomas from benign melanocytic lesions with both high sensitivity and specificity.

Interventions for BCC

Interventions for basal cell carcinoma of the skin.Author(s): Bath-Hextall F; Perkins W; Bong J; Williams H;

BACKGROUND: Basal cell carcinoma (BCC) is the commonest skin cancer. BCCs
are slow-growing, locally invasive, epidermal skin tumours which mainly
affect white skinned people. The first line treatment is usually surgical
excision, but numerous alternatives are available. OBJECTIVES: To assess
the effects of treatments for basal cell carcinoma. SEARCH STRATEGY: We
searched the Cochrane Skin Group Specialised Register (January 2006),
the Cochrane Central Register of Controlled Trials (The Cochrane LIbrary
Issue 1, 2006), the Cochrane Database of Systematic Reviews (The Cochrane
Library Issue 1, 2006), MEDLINE (2004 to January 2006), EMBASE (2005 to
January 2006), the metaRegister of Controlled Trials (February 2006).
Cited references of all trials identified and key review articles were
searched. Pharmaceutical companies were contacted where appropriate for
reviews or unpublished trials. SELECTION CRITERIA: Inclusion criteria
were adults with one or more histologically proven, primary basal cell
carcinoma. The primary outcome measure was recurrence at three to five
years, measured clinically. The secondary outcome included early treatment
failure within six months, measured histologically. Adverse treatment
effects included aesthetic appearance and pain during and after treatment.
DATA COLLECTION AND ANALYSIS: Two authors independantly carried out study
selection and assessment of methodological quality. MAIN RESULTS: Twenty
seven studies were identified. Only one RCT of surgery versus radiotherapy
had primary outcome data at four years, showing significantly more persistent
tumours and recurrences in the radiotherapy group as compared to the surgery
group, (RR 0.09, 95%CI, 0.01 to 0.69). One study found no significant
difference for recurrence at 30 months when Moh's micrographic surgery
was compared to surgery for high risk facial BCCs, (RR 0.64, 95%CI 0.16,2.64).
One study of methylaminolevulinate photodynamic therapy (MAL PDT) versus
cryotherapy found no significant difference in recurrences in the MAL
PDT group when compared to cryotherapy at one year (RR 0.50, 95% CI 0.22,1.12).
Cryotherapy showed no significant difference in recurrences at one year
when compared to surgery on one small study. When radiotherapy was compared
to cryotherapy there were significantly fewer recurrences at one year
in the radiotherapy group compared to the cryotherapy group.Short-term
studies suggest a success rate of 87 to 88% for imiquimod in the treatment
of superficial BCC using a once-daily regimen for 6 weeks and a 76% treatment
response when treating nodular BCC for 12 weeks, when measured histologically.
AUTHORS' CONCLUSIONS: Overall there has been very little good quality
research on treatments for BCC. Most trials have only evaluated BCCs in
low risk locations. Surgery and radiotherapy appear to be the most effective
treatments with surgery showing the lowest failure rates. Although cosmetic
outcomes appear good with PDT, long term follow up data are needed. Other
treatments might have some use but few have been compared to surgery.
An ongoing study comparing imiquimod to surgery should clarify whether
imiquimod is a useful option.

Cochrane database of systematic reviews (Online: Update Software); 2007
1 1;(1)

Number of References: 63

Melanoma in Children

Melanoma in children and teenagers: an analysis of patients from the National Cancer Data Base.

Lange JR, Palis BE, Chang DC, Soong SJ, Balch CM.

Department of Surgery, Johns Hopkins Medicine, Baltimore, MD, USA jlange@jhmi.edu

PURPOSE: This study examines the demographics, presentation, and outcomes of children and teenagers with melanoma using a US hospital-based oncology database. PATIENTS AND METHODS: Data from the National Cancer Data Base from 1985 through 2003 were examined for demographics, presentation, and survival of patients aged 1 to 19 years, as well as a comparison group of patients aged 20 to 24 years. Two-sided linear and Pearson chi2 tests were calculated to examine associations. Proportions were compared using two-sided z tests. Five-year overall observed survival was evaluated using the Kaplan-Meier method and the log-rank test. Cox proportional hazards regression was used to estimate risk of mortality. RESULTS: Of 3,158 patients aged 1 to 19 years, 96.3% had cutaneous melanoma, 3.0% had ocular melanoma, and 0.7% had an unknown primary tumor. Cutaneous melanoma in patients aged 1 to 19 years was more common in girls (55.5%) and patients older than 10 years (90.5%). The demographics and presentation of cutaneous melanoma were age related; younger children were significantly more likely to be nonwhite and male and more likely to present with a head and neck primary tumors and with regional or distant metastases (linear chi2, P < .001 for sex, race, and extent of disease). Poorer survival was associated with higher stage and younger age. In contrast to patients aged 20 to 24 years, survival was not related to thickness in patients aged 1 to 19 years with localized invasive melanoma.
CONCLUSION: Melanoma in children and teenagers differs from melanoma in young adults in demographics, presentation, and survival. Further investigation is warranted to elucidate possible biologic correlates of the unique aspects of melanoma in children and teenagers.

Diet and Skin Cancer

This study from the Queensland group analysing data obtained during the Nambour study suggests that a high fat diet predisposes you to SCC but not BCC. Another explanation might be that people who eat high fat diets are not health conscious anyway and hence less likely to adopt sun safe behaviour. I have not read the whole article ,hence I do not know if they addressed this issue during their analysis of the two groups regarding their behaviour in the sun. I presume they had the same behavious or you would not have a valid study! If anyone knows Adele you might ask her.
Dietary pattern in association with squamous cell carcinoma of the skin: a prospective study
American Journal of Clinical Nutrition, Vol. 85, No. 5, 1401-1408, May 2007
Torukiri I Ibiebele, Jolieke C van der Pols, Maria Celia Hughes, Geoffrey C Marks, Gail M Williams and Adèle C Green
1 From the Cancer and Population Studies Group, Queensland Institute of Medical Research, Brisbane, Australia (TII, JCvdP, MCH, and ACG), and the School of Population Health, University of Queensland, Brisbane, Australia (JCvdP, GCM, and GMW)


Background: The role of diet in the development of skin cancer is inconclusive, and the effect of the combined consumption of foods has never been reported.

Objective: We prospectively investigated the association between dietary patterns and cutaneous basal cell (BCC) and squamous cell (SCC) carcinoma.

Design: Principal components analysis of 38 food groups was used to identify dietary patterns in 1360 adults aged 25–75 y who participated in a community-based skin cancer study in Nambour, Australia, between 1992 and 2002. We obtained baseline information about diet, skin color, and sun exposure factors. Multivariate-adjusted relative risks (RRs) for BCC and SCC tumors were estimated by using negative binomial regression modeling.

Results: Two major dietary patterns were identified: a meat and fat pattern and a vegetable and fruit pattern. The meat and fat pattern was positively associated with development of SCC tumors (RR = 1.83; 95% CI: 1.00, 3.37; P for trend = 0.05) after adjustment for confounders and even more strongly associated in participants with a skin cancer history (RR = 3.77; 95% CI: 1.65, 8.63; P for trend = 0.002) when the third and first tertiles were compared. A higher consumption of the vegetable and fruit dietary pattern appeared to decrease SCC tumor risk by 54% (P for trend = 0.02), but this protective effect was mostly explained by the association with green leafy vegetables. There was no association between the dietary patterns and BCC tumors.

Conclusion: A dietary pattern characterized by high meat and fat intakes increases SCC tumor risk, particularly in persons with a skin cancer history.

JAAD Melanoma Issue

The latest issue of JAAD has a series of articles that might interest bloggers including one challenging our ideas of the differences in distribution of melanomas in men and women the following link will take you to the Science Direct page for easy access to the abstracts of some of these articles.

Merkel cell Carcinoma

This is a rare condition. It is seldom diagnosed clinically. We are still working out the best way to treat it. A combined approach with wide excision and radiotherapy done immediately after the excision appears to be the best approach.

Radiotherapy for localised and advanced Merkel cell carcinoma of the skin: a single institution case series

European Journal of Dermatology. Volume 17, Number 3, 229-33, May-June 2007, Therapy


Author(s) : Falk Roeder, Robert Krempien, Florian Sterzing, Angela Funk, Martina Treiber, Jürgen Debus, Marc Bischof

Summary : Merkel cell carcinoma (MCC) is a rare malignant tumour of the skin with a tendency to rapid local progression, frequent spread to regional lymph nodes and distant metastases. We report results with radiotherapy in the treatment of MCC.Thirty-nine patients with histologically proven MCC were treated. Fifteen patients had stage I disease (12 primary, 3 recurrent tumours). Twenty-one patients had stage II disease (10 primary, 11 recurrent tumours). Thirty patients were treated with surgery and adjuvant radiotherapy. Six patients with inoperable disease received radiotherapy alone. Three patients in stage III with distant metastases were treated with palliative radiotherapy.For stage I patients, 3-year loco-regional control (LC), disease-specific survival (DSS) and overall survival (OS) rates were 90%, 100%, and 100%, respectively. For stage II patients, LC, DSS, and OS were 78%, 55%, and 29%, respectively. LC did not differ significantly between stage I and II patients. But, patients presented to radiotherapy directly after operation showed significantly improved LC compared to patients referred in recurrent situation (p \= 0.039). Two of six inoperable patients treated with radiotherapy alone relapsed locally.In the current study, surgery and immediate adjuvant radiotherapy resulted in strong loco-regional control. Radiotherapy alone is suggested only in inoperable or metastatic MCC.

SCC of the Nail

Squamous cell carcinoma of the nail apparatus: clinicopathological study of 35 cases
Authors: Dalle, S.1; Depape, L.2; Phan, A.1; Balme, B.; Ronger-Savle, S.1; Thomas, L.1

Source: British Journal of Dermatology, Volume 156, Number 5, May 2007, pp. 871-874(4)

Abstract:

Summary Background 

Subungual squamous cell carcinoma (SCC) is rare. Its diagnosis is often missed or delayed because the clinical presentation is often atypical and can mimic other conditions such as verruca vulgaris, onychomycosis, trauma-induced nail dystrophy or exostosis. Objectives 

To define the different clinical presentations and the main pathological features and to evaluate the most appropriate surgical management of subungual SCC. Methods 

A retrospective review of all the cases of subungual SCC seen in our institution over a 5-year period.
Results 
Thirty-five cases were selected. The spectrum of the clinical features encountered was extremely large including leuconychia, subungual hyperkeratosis, trachonychia, subungual tumoral syndrome, longitudinal erythronychia and melanonychia. Most cases (31 of 35) were invasive. Relapse rate after surgical treatment was low after wide surgical excision (5%) of the nail apparatus or amputation of the digit. However, limited surgical excision led to more frequent relapses (56%). Conclusions 

Nail apparatus SCC is often misdiagnosed. Most cases are invasive at the time of diagnosis. Wide surgical excision bears a lower risk of relapse. Micrographic surgery should be considered for a better control in cases treated with limited surgical excision.

Imiquimod and Atypical Nevi

This article tries to draw some conclusions about the treatment of atypical nevi with Imiquimod but there were only three cases. In essence it says do not do it and urges caution about its use in treating lentigo maligna. (IMCC)
Treatment of Atypical Nevi With Imiquimod 5% CreamNajwa Somani, MD, FRCPC; Magdalena Martinka, MD, FRCPC; Richard I. Crawford, MD, FRCPC; Jan P. Dutz, MD, FRCPC; Jason K. Rivers, MD, FRCPC


Arch Dermatol. 2007;143:379-385.

ABSTRACT

Background 5% Imiquimod cream is a topical immune response modifier that has been used off-label to treat malignant melanocytic proliferations such as lentigo maligna. To our knowledge, imiquimod has not been previously used to treat atypical nevi (AN).

Observations Three patients each with 1 selected clinically AN were treated with imiquimod 5 nights per week for 12 weeks. The lesions were subsequently excised and sent for routine histologic and immunohistochemical analysis. None of the lesions cleared. Two were consistent with atypical compound nevus on excisional biopsy and demonstrated inflammation, while the third showed congenital features and demonstrated minimal inflammation. The AN were initially interpreted as displaying more severe histologic atypia on excisional biopsy than was present at baseline. Immunohistochemical studies revealed that the AN but not the congenital-like nevus exhibited increased staining for CD4+ and CD8+ cells and for a surrogate marker of interferon expression.

Conclusions Twelve weeks of imiquimod treatment failed to cause lesional resolution. A differential inflammatory response was observed between the AN and the congenital-like nevus. The character of the inflammatory infiltrate was similar to that observed with halo nevi. Uncertainties remain concerning imiquimod use for chemoprevention of AN, and the posttreatment histologic features may be misinterpreted as severe melanocytic atypia or melanoma.

Melanoma of the Foot and Ankle

This article from Hugh Greenaway from San Diego looks at a series of melanomas on the foot and ankle. You can access the article in a Wordfile here.

Melanoma of the Foot and Ankle: A Case Series of an Underrecognized Entity
Melanoma is the most common malignancy of the foot and is more likely to be misdiagnosed on the foot than in any other location. Clinical mimics include verruca, onychomycosis, subungual hematoma, or ischemic digits.

Report of Cases

Recently at our institution, we treated 8 melanomas of the foot or ankle over a 6-month period. After obtaining institutional review board approval, we gathered the clinical data of patients with melanoma presenting to our clinic between July 1, 2003, and December 31, 2003, from our cutaneous surgery unit database at Scripps Clinic, La Jolla, Calif. Of the 69 melanomas treated in our unit during this 6-month interval, 8 melanomas (12%) were located on the foot and ankle, in contrast to our 21-year incidence of 4% (January 1985–December 2005, unpublished data). Clinical and pathologic characteristics of these 8 patients were reviewed and compared (Table).

Early markers of Mycosis Fungoides

This article explains some of the latest research confirming digitate dermatosis is a T cell lymphoma of the skin.(IMCC)

CD13 and TCR Clone: Markers of Early Mycosis Fungoides
Issue: Volume 87, Issue 2, March 2007

Pages: 155-159

DOI: 10.2340/00015555-0197

Abstract:
Making a differential diagnosis between early mycosis fungoides (MF) and parapsoriasis is often difficult at the clinical and histological level. The aim of this study was to explore markers that could help in this process. A total of 88 patients were included in 2 categories: large plaque parapsoriasis and digitiform parapsoriasis. A histological examination was performed for each patient, and expression of the antigen My7 (CD13), which is lacking in cutaneous T-lymphomas (CTCL) (but not in inflammatory lesions) and rearrangement of the T-cell receptor gene were analysed. A histological aspect of epidermo­tropic CTCL was observed in 23.5% of cases of large plaque parapsoriasis and 15% of cases of digitiform para­psoriasis. A disappearance of My7 antigen was noted in the 2 forms of parapsoriasis, more frequently when there was CTCL histology. A cutaneous clone was observed in 10.3% of cases of large plaque parapsoriasis, but not of digitiform parapsoriasis. For 3 patients, a cutaneous clone and a disappearance of My7 were associated with a non-specific histology. Considering these histological, immunological and molecular biological data, it appears that My7 antigen combined with T-cell clone may help the dermatologist to confirm the diagnosis of early MF. Moreover, further studies will determine whether CD13 is an early prognostic marker of evolution of a para­psoriasis to MF. Finally, these results demonstrate that digitiform parapsoriasis can be an early stage of MF.

Authors:
Claire Bernier, Jean Michel Nguyen, Gaëlle Quéreux, Jean Jaques Renault, Brigine Bureau and Brigitte Dreno

Poopyfield Bleeding Sign

Has anyone confidently seen this sign? (IMCC)
Poppyfield Bleeding: a New Dermatoscopic Sign and its Histopathological Background
Henrik F. Lorentzen, Kaare Weismann, Kristian Rossen and Henrik Klem Thomsen

Dermatoscopy increases the accuracy of diagnosis of melanoma. An atypical vascular pattern may be an indicator of cutaneous malignant melanoma (CMM). During dermatoscopy of certain CMMs numerous ruby droplets of blood appear when the dermatoscope is pressed firmly against the lesion. The aim of this paper was to examine the histopathological background for this observation. CMMs from 8 patients showing the poppyfield sign, i.e. squirts of ruby blood droplets, were paired with 8 CMMs of equal Breslow thickness not showing this sign. The 16 CMMs were placed in an unsystematic sequence and presented to two dermato-pathologists who assessed the lesions independently for confirmation of Breslow thickness, Clark level, ulceration and presence of dilat­ed tumour vessels. There was no disagreement between the pathologists' assessments. Age of the patients and Breslow thickness of the cutaneous malignant melanoma were similar in the two groups. All 8 poppyfield CMMs had dilated tumour vessels compared with 25% (2/8) of the non-poppyfield CMMs (p< 0.007). Histological ulceration was observed in all poppyfield CMMs and none of the non-poppyfield CMMs (p< 0.001). The poppyfield bleeding sign is a dermatoscopic clue to dilated tumour vessels. It may be a dermatoscopic reflection of increased vascular density described in primary CMMs compared with adjacent skin and may also reflect the presence of primitive vessels in CMMs displaying increased fragility.

Dermatoscopy of Pigmmented Actinic Keratoses

Dermatoscopy of pigmented actinic keratosis – A striking similarity to lentigo maligna
Lumír Pock, MD, Lubomír Drlík, MD, and Jana Hercogová, MDFrom the Department of Dermatology, Šumperk, Prague, Department Dermatology and Venerology, Charles University, Prague, Czech Republic
Correspondence Lumír Pock, MD Dermatohistopathologic Laboratory Mazurská 484 181 00 Prague 8 Czech Republic E-mail: lumir.pock@volny.cz
Abstract

Background Pigmented actinic keratosis (PAK) resembles lentigo maligna (LM) clinically and histopathologically in some cases.

Objectives To describe the dermatoscopical characteristics of this uncommon variant of actinic keratosis and evaluate whether these characteristics show common features with LM.

Observations We had the opportunity to examine a 78-year-old woman who presented with a PAK lesion on her face dermatoscopically and histopathologically. The pigmented pseudo-network had black and gray dust in some areas, which were the main dermatoscopical features. The pigmented pseudo-network was formed by an unhomogenous brown background interrupted by regularly distributed hair follicules. The hyperpigmentation was based not only on an increased presence of melanin within the keratinocytes in the basal and spinous layers of epidermis, but also an intensive apoptosis of keratinocytes connected to numerous melanophages.

Conclusions The dermatoscopical picture of PAK in this patient was practically indistinguishable from the early stage of LM. The authors considered that the pigmented atypical melanocytes’ role in LM presenting as black dots in the dermatoscopical picture was displayed by the individually pigmented keratinocytes in PAK. The groups of melanophages presenting as gray dust were present in PAK similarly to their presentation in LM. The character of the pigmented pseudo-network is the same in the both afflictions. There is a need to examine other cases of PAK in order to decide whether our case represents a general pattern of the dermatoscopical picture.

See an example at the Skincancerclinic blog on Friday 13th April.
The purse-string suture revisited: a useful technique for the closure of cutaneous surgical wounds
Philip R. Cohen, MD, Paul T. Martinelli, MD, Keith E. Schulze, MD, and Bruce R. Nelson, MDFrom the Dermatologic Surgery Center of Houston, Houston, Texas and Department of Dermatology, University of Texas-Houston Medical School, Houston, Texas
Correspondence Philip R. Cohen, MD 805 Anderson Street Bellaire, TX 77401-2806 E-mail: mitehead@aol.com
Reprints request to: Bruce R. Nelson, MD Dermatologic Surgery Center of Houston, PA 6655 Travis, Suite 840 Houston, TX 77030 bnelson@dermsurgeryhouston.com

Abstract

The purse-string suture provides complete or partial closure of round postoperative skin defects. It is a rapid and simple procedure to perform. Tension placed on the suture uniformly advances the skin from the entire periphery of the wound, resulting in a significant reduction of the defect size and enhancement of hemostasis at the wound edge. The history, modifications of the technique, advantages, and potential complications of the purse-string suture are reviewed. It is not only useful following the removal of nonmelanoma skin cancer but also after the local excision of melanoma. In addition, this technique is especially suitable for the repair of round surgical wounds for patients who are unable to modify their active lifestyles during the week following surgery, individuals concurrently being treated with anticoagulants, antiplatelet agents or both, and people with extensive postoperative defects that would otherwise require either a skin graft or a large cutaneous flap. Typically, the site of the surgical wound following partial or complete closure with the purse-string suture demonstrates excellent long-term cosmetic and functional results.

Polarised or non polarised dermatoscopes

This is an important paper for all of us who use a dermatoscope and record images. Polarised dermatoscopes such as the Dermlite Pro (non contact) will not highlight milia in seb ks or the blue colour of deeper melanin or more importantly the blue grey veil. The nonpolarised dermatoscopes such as the Heine Delta 20 will highlight these features better. The new Dermlite fluid is equivalent to the Heine Delta 20. Those of you who were at Ash Marghoob's lecture and quiz when he presented the same lesions photographed with different dermatoscopes will appreciate how it made some of us unwittingly change our diagnosis of the same lesion presented at different stages of the quiz! Worrying!
Differences between polarized light dermoscopy and immersion contact dermoscopy for the evaluation of skin lesions.

Author(s): Benvenuto-Andrade C; Dusza S; Agero A; Scope A; Rajadhyaksha M; Halpern A; Marghoob A;

OBJECTIVE: To evaluate dermoscopic features and patterns of skin lesions by using conventional and polarized light dermoscopy (PD). DESIGN: Observational study.
SETTING: Dermatology clinic at Memorial Sloan-Kettering Cancer
Center.
PATIENTS: Ninety patients with skin lesions.
INTERVENTIONS: Skin lesions were imaged via conventional nonpolarized light contact dermoscopy (NPD), polarized light contact dermoscopy (PCD), and polarized light noncontact
dermoscopy (PNCD).
MAIN OUTCOME MEASURES: The images from the 3 modalities
were evaluated by 3 dermoscopists for colors, structures, and patterns. Level of agreement between modalities was assessed by percentage agreement and the kappa statistic. Qualitative differences between modalities were also assessed.
RESULTS: Ninety lesions comprising 55 melanocytic and 35
nonmelanocytic lesions were reviewed. There was excellent agreement for overall dermoscopic patterns between modalities, with kappa values ranging from 0.88 to 1.00. There was moderate to excellent agreement for most dermoscopic colors, with the exception of blue-white veil and pink (red) color. Most dermoscopic structures had fair to perfect agreement, with
the exception of milialike cysts. Qualitative assessment suggested that melanin appeared darker and blue nevi had more shades of blue on PD compared with NPD images; vessels and red areas were better visualized with PD, suggesting that PD may be helpful in identifying malignancies; milialike cysts and comedolike openings were better visualized with NPD, suggesting that NPD is more helpful for identification of seborrheic keratosis; peppering,
lighter colors, and blue-white areas were more evident under NPD, facilitating recognition of regression areas; and shiny-white streaks, possibly representing fibrosis, were seen more clearly under PD.
CONCLUSIONS: The capabilities of NPD, PCD, and PNCD are not equivalent, but complementary. Further studies are needed to evaluate the effect of these differences on clinical diagnosis.

Archives
of dermatology.; 2007 Mar 1;143(3)

Histological evolution of lentiginous melanoma

I doubt that this variant exists. These are all melanoma in situ. It appears that some lesions can remain in this phase for many years but the nature of the lesion is the same. They do point out that significant solar elastosis was not associated with these lesions. I am sure Weedon and Kossard would report these are lentiginous dysplastic nevus of the elderly but these cases were a bit young for that designation!
Histological evolution of lentiginous melanoma: a report of five new cases
Authors: Davis, Tracy1; Zembowicz, Artur

Source: Journal of Cutaneous Pathology, Volume 34, Number 4, April 2007, pp. 296-300(5)

Abstract:

Background: 

The term lentiginous melanoma was recently used for atypical melanocytic proliferations sharing some histological features with lentigo maligna and associated with a protracted in situ stage before invasion. Lentiginous melanoma was characterized by predominantly single-cell lentiginous growth pattern with focal junctional nests and pagetoid spread, preservation of the dermoepidermal junction, limited cytological atypia, and lack of significant solar elastosis. We report five similar cases. Methods: 

Histological review of routine sections with clinicopathological correlation.
Results: 
Three patients were male and two were female. The age at presentation ranged from 24 to 66 years. All lesions arose on the truck or proximal extremities. All five cases fulfilled histological criteria proposed for lentiginous melanoma. None of the lesions showed significant solar elastosis. One lesion was followed clinically and histologically for 16 years without intervening treatment. It had three local recurrences before culminating in invasive melanoma.
Conclusions: 
Our observations support recent efforts to distinguish lentiginous melanoma as a distinct clinicopathological entity. Lentiginous melanoma can remain in situ for a long time before invasion and may be considered an analogue of lentigo maligna occurring on non-severely sun-damaged skin. Familiarity with the histological features of this variant is important for its early recognition and treatment.

This is an interesting observation of multiple dysplastic nevi and in situ melanomas erupting after chemotherapy immunosupression. Worth looking out for. May be more likely in younger individuals Eruptive Post-Chemotherapy In Situ Melanomas and Dysplastic Nevi
Authors: Reutter, Jason C.1; Long, Erin M.2; Morrell, Dean S.2; Thomas, Nancy E.2; Groben, Pamela A.1

Source: Pediatric Dermatology, Volume 24, Number 2, March/April 2007, pp. 135-137(3)

Publisher: Blackwell Publishing 

A 22-year-old white man without a personal or family history of atypical nevi had received chemotherapy for pre-B-cell acute lymphocytic leukemia at age 17 that includedl-asparaginase, prednisone, methotrexate, mercaptopurine, daunorubicin, and cytoxan. Two to three months after completing maintenance chemotherapy, the patient reports he developed many moles, which remained stable for approximately 2 years.

Upon examination, two dark, atypical appearing plaques with irregular borders and numerous pink papules of varying shapes and sizes were noted on his chest, back, and abdomen. Histology of specimens of both types of lesions revealed three moderately atypical compound dysplastic melanocytic nevi and three in situ melanomas. The lesions with only features of dysplastic nevi exhibited dermal fibrosis, cytologic atypia, junctional shoulders, lentiginous spread, and focal pigmentation. The lesions with in situ melanomas in addition demonstrated pagetoid spread, extension down adnexal structures, and more severe cytologic atypia.

Malignant melanoma has been associated with chronic immunosuppression, and benign nevi have been reported to erupt after chemotherapy. We report an occurrence of multiple eruptive dysplastic nevi and in situ melanomas appearing shortly after completion of chemotherapy.
Document Type: Research article

DOI: 10.1111/j.1525-1470.2007.00359.x

Affiliations: 1: Pathology 2: Dermatology, University of North Carolina, Chapel Hill, North Carolina

This is a good article abstract which outlines the dermatoscopic features of nail pigmentation.
Dermoscopy provides useful information for the management of melanonychia striata
Luc Thomas & Stéphane DalleService de Dermatologie, Université Lyon France and Hôtel Dieu de Lyon, Lyon Cedex France
Address correspondence and reprint requests to: Luc Thomas, MD, PhD, Service de Dermatologie, Hôtel Dieu 69288 Lyon Cedex 02 France, or email: luc.thomas@chu-lyon.fr.
KEYWORDS: dermoscopy, melanoma, melanonychia striata, nail disease, nevus, skin cancerAbstract
ABSTRACT: The diagnosis of melanonychia striata is often difficult, and a biopsy of the nail matrix is required in doubtful cases. However, dermoscopic examination of the nail plate offers interesting information in order to better select the cases in which pathologic examination is indicated. In the case of brown longitudinal pigmentation with parallel regular lines, the diagnosis of nail apparatus melanocytic nevus could be made. On the other hand, the presence of a brown pigmentation overlaid by longitudinal lines irregular in their thickness, spacing, color, or parallelism is highly in favor of a melanoma. Gray homogeneous lines are observed in case of lentigo, lentiginoses, ethnic or drug-induced pigmentations, and in post-traumatic pigmentations. Blood spots are characterized by their round-shaped proximal edge and their filamentous distal edge and are highly suggestive of subungual hemorrhages. Dermoscopic examination of the free edge of the nail plate gives information on the lesion location; pigmentation of the dorsum of the nail plate is in favor of a proximal nail matrix lesion, whereas pigmentation the lower part of the nail edge is in favor of a lesion of the distal matrix.

Melanocytic Nevi With Nonsurgical Trauma: A Histopathologic Study

WE ARE AWARE OF RECURRENT NEVI IN THE SKIN OCCURRING AFTER A PIGMENTED LESION HAS BEEN SHAVED AND THE PROBLEMS THIS POSES FOR BOTH THE DERATOSCOPIST AND THE PATHOLOGIST. THIS ARTICLE LOOKS AT HISTOLOGICAL CHANGES AFTER NON SURGICAL TRAUMA TO A MELANOCYTIC NEVUS. NOTE THE COMMENTS ON PAGETOID SPREAD.
Melanocytic Nevi With Nonsurgical Trauma: A Histopathologic Study.

Original Article

American Journal of Dermatopathology. 29(2):134-136, April 2007.
Selim, Maria Angelica MD *; Vollmer, Robin T MS, MD *+; Herman, Christopher M MD ++; Pham, Teresa TN MD *; Turner, John W MD *
Abstract:
There is a belief among dermatopathologists that benign melanocytic nevi (BMN) may display atypical histologic characteristics when traumatized. However, to our knowledge, a systematic study of nonsurgically traumatized melanocytic nevi (TMN) has not been published. We studied a series of 92 TMN. Cases were analyzed for histologic evidence of architectural and cytologic criteria associated with atypia. Of the patients, 54 were female and 37 were male. The mean age was 38 years old (range 8-74 years old). Nevi were present, in order of frequency, on the extremities, trunk, and head/neck, but there were no acral sites. Histologic findings of trauma were as follows: parakeratosis (92%), dermal telangiectasias (61%), ulceration (51%), dermal inflammation (49%), melanin within stratum corneum (24%), and dermal fibrosis (25%). Pagetoid spread of melanocytes was limited to the site of trauma in 20% of cases and was identified away from areas of trauma in 8% of cases. Melanocytic atypia was seen in three cases. Dermal mitoses were rare (one mitotic figure in three cases).Pagetoid spread under a traumatized epidermis was relatively frequent and, in isolation, is compatible with a benign TMN. Any traumatized melanocytic lesion that displays cytologic atypia, pagetoid spread outside of the area of the traumatized epidermis, or dermal mitoses should be treated with caution because these findings were rarely seen in TMN.