Part 1: Management of Antithrombotic Medications in Dermatologic Surgery

Perioperative management of antithrombotic agents requires practical and medical considerations. Discontinuing antithrombotic therapies increases the risk of thrombotic adverse events including cerebrovascular accidents, myocardial infarction, pulmonary embolism, deep vein thrombosis, and retinal artery occlusion. Conversely, continuation of antithrombotic therapy during surgical procedures has associated bleeding risks. Currently, no guidelines exist regarding management of antithrombotic agents in the perioperative period for cutaneous surgeries and practice differs by surgeon. Here, we review the data on antithrombotic medications in patients undergoing cutaneous surgery including medication-specific surgical and postoperative bleeding risk if the medications are continued, and thromboembolic risk if the medications are interrupted. Specifically, we focus on vitamin K antagonist (VKA) (warfarin), direct-acting oral anticoagulants (DOAC) (rivaroxaban, apixaban, edoxaban, dabigatran), antiplatelet medications (aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole), unfractionated heparin, low molecular weight heparin (enoxaparin and dalteparin), fondaparinux, bruton tyrosine kinase inhibitors (BTKi) (ibrutinib, acalabrutinib), and dietary supplements (i.e., garlic, ginger, gingko).

Surgical margins and outcomes for eyelid melanoma: a systematic review and meta-analysis

No randomized trials exist to inform the peripheral surgical margins or depth of wide excision for eyelid melanoma. We performed a meta-analysis examining surgical margins and Breslow depth for eyelid melanomas. A systematic review was performed in August 2022 using PubMed, Cochrane, and Medline databases (1/1/1990 to 8/1/2022). Inclusion criteria included studies reporting surgical treatment of primary cutaneous melanomas of the eyelid with reported surgical margins. Ten articles were included. The studies were examined by surgical margin size (group 1: ≤ 0.5 cm; group 2 > 0.5 cm and ≤ 1.5 cm) and Breslow depth (group 1: ≤ 1 mm; group 2: > 1 mm). The odds ratio (OR) for local recurrence was 2.55 [95% CI 0.36-18.12], p = 0.18; regional metastasis was 0.70 [95% CI 0.00-23671.71], p = 0.48; and distant metastasis was 2.47 [95% CI 0.00-1687.43], p = 0.66. When examining by Breslow depth, the OR for local recurrence was 0.53 [95% CI 0.14-1.94], p = 0.34; regional metastasis was 0.14 [0.00-176.12], p = 0.54; and the OR for distant metastasis was 0.24 [95% CI 0.01-8.73], p = 0.46. There was a trend toward higher likelihood of recurrence and metastasis in the ≤ 0.5 cm group. Similarly, there is a trend toward higher likelihood of recurrence and metastasis with Breslow depth > 1 mm. A surgical margin of at least 0.5 cm and achievement of negative margins via permanent sections or MMS are likely needed to prevent adverse outcomes. En face sectioning may be a superior method of histological processing for eyelid melanoma.

Ethical Considerations for Artificial Intelligence in Dermatology: A Scoping Review

The field of dermatology is experiencing the rapid deployment of artificial intelligence (AI), from mobile applications for skin cancer detection to large language models like ChatGPT that can answer generalist or specialist questions about skin diagnoses. With these new applications, ethical concerns have emerged. In this scoping review, we aim to identify the applications of AI to the field of dermatology and to understand their ethical implications. We utilized a multifaceted search approach, searching PubMed, Medline, Cochrane, and Google Scholar for primary literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Extension for Scoping Reviews. Our advanced query included terms related to dermatology, artificial intelligence, and ethical considerations. Our search yielded a total of 202 papers. After initial screening, 68 studies were included. Thirty-two related to clinical image analysis and raised ethical concerns for misdiagnosis, data security, violations of privacy, and replacement of dermatologist jobs. Seventeen discussed limited skin of color representation in datasets leading to potential misdiagnosis in the general population. Nine articles about teledermatology raised ethical concerns, including the exacerbation of health disparities, lack of standardized regulations, informed consent for AI use, and privacy challenges. Seven addressed inaccuracies of responses of large language models. Seven examined attitudes and trust towards AI, with most patients requesting supplemental assessment by a physician to ensure reliability and accountability. Benefits of artificial intelligence integration into clinical practice include increased patient access, improved clinical decision making, efficiency, and many others. However, safeguards must be implemented to ensure ethical applications of artificial intelligence.

Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery

PURPOSE

Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms.

METHODS

Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes.

RESULTS

Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups.

CONCLUSIONS

One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

Postoperative Bleeding Complications Associated With Novel Oral Anticoagulants in Mohs Micrographic Surgery

BACKGROUND

Novel oral anticoagulants (NOACs) are commonly prescribed, recently developed anticoagulants, but limited data exist on NOAC-related bleeding complications in Mohs micrographic surgery (MMS).

OBJECTIVE

To assess the risk of postoperative bleeding in patients taking NOACs compared with patients taking no antithrombotic medications.

METHODS/MATERIALS

A 5-year retrospective chart review of all MMS cases performed by a single surgeon was conducted. Patient and surgery characteristics, anticoagulant use, and bleeding complications were recorded.

RESULTS

Two thousand one hundred eighty-one MMS cases in 1,545 patients were included. There were 696/2,181 cases in which patients were taking at least 1 antithrombotic medication, with 149 on NOAC monotherapy and 15 on NOAC and aspirin combination therapy. Bleeding complications occurred in 22/2,181 cases. Patients on NOAC monotherapy did not have an increased risk of bleeding complications compared with patients on no antithrombotic medications (odds ratio [OR]:1.70, 95% confidence interval [CI]: 0.36-7.97, p = .50). In contrast, patients on NOAC and aspirin combination therapy exhibited an increased bleeding risk (OR: 20.5, 95% CI: 3.99-105.7, p < .001).

CONCLUSION

Novel oral anticoagulant use alone during MMS was not associated with an increased postoperative bleeding risk, supporting the safety of continuing NOAC therapy during MMS. However, NOAC and aspirin combination therapy was associated with a high postoperative bleeding risk. Nonetheless, these bleeding events did not lead to adverse long-term outcomes.

Surgical management of dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive cutaneous malignancy. Complete resection is the primary treatment but there is debate over the optimal method. Wide local excision was traditionally the standard of care; however, National Comprehensive Cancer Network guidelines now recommend Mohs micrographic surgery as the preferred approach. Medical therapy with imatinib can be used in advanced or unresectable disease. This review will discuss the current management of DFSP, focusing on optimal surgical approach.

Predictors of Time to Definitive Surgery and Survival in Merkel Cell Carcinoma: Analysis of National Cancer Database

BACKGROUND

Effects of delays in treatment for Merkel cell carcinoma (MCC) are not yet fully understood.

OBJECTIVES

To determine the effect of time to treatment initiation (TTI) on mortality in MCC and predictors of TTI itself.

METHODS

Retrospective cohort analysis of the National Cancer Database (NCDB) for cases of MCC from 2004-2016, excluding individuals with Stage IV MCC as surgery is not the preferred treatment for this group.

RESULTS

A total of 12,157 patients (average age:74.4 years, SD:10.9) were included in the study, 7,491(61.6%) were male and 4,666 (38.4%) were female. Risk of higher TTI was seen in Blacks (odds ratio [OR]:1.7, 95% CI:1.2,2.6) and elderly individuals over 70 years (OR:1.7, 95% CI:1.2,2.5). On Kaplan-Meier survival analysis, individuals with TTI <30 days had a significantly longer overall survival than those with TTI >120 days (6.1 vs. 4.8 years, p=0.0002). However, after controlling for clinical and tumor factors in Cox multivariable analysis, no difference in survival was noted for TTI <30 days and TTI >120 days (Hazard Ratio [HR]:0.9, 95% CI:0.8,1.1). Worse outcomes were also associated with increasing age (HR:2.0, 95% CI:1.7,2.5), male sex (HR:1.2, 95% CI:1.2-1.3), higher CDCC (HR:1.4, 95% CI:1.3,1.5), lack of radiation therapy (HR:0.8, 95% CI:0.8-0.9), lack of private insurance (HR:0.7, 95% CI:0.6-1.0), and surgical technique other than Mohs or WLE (HR:1.2, 95% CI:1.2-1.3).

CONCLUSIONS

Although TTI is a useful prognostic metric in isolated survival analysis, its utility declines when controlling for other factors. Age, radiotherapy, type of surgery performed, co-morbidities, tumor size, and lymph node involvement may be important predictors of survival.

Patient Satisfaction of General Dermatology Providers: A Quantitative and Qualitative Analysis of 38,008 Online Reviews

Measuring patient satisfaction of general dermatology providers is an important goal because it can lead to improved clinical outcomes. Online reviews are emerging as the newest forum for evaluating physicians in real time and provide a valuable tool for measuring patient satisfaction. We analyzed both quantitative and qualitative online reviews of general dermatology providers at 121 Accreditation Council for Graduate Medical Education‒accredited dermatology programs across the country to determine which elements are most discussed in online ratings using the online platforms Vitals, US News, WebMD, Google Reviews, and Healthgrades. There were 38,008 online reviews included from general dermatology providers at Accreditation Council for Graduate Medical Education‒accredited programs. The median average overall quantitative rating of providers was 4.35 of 5. There were more positive (77%) than negative (23%) comments. The overall ratings of general dermatology providers were favorable. The most influential factors in both positive and negative comments were patient’s perceived experience and physician’s bedside manner (26% and 17%, respectively). Less important factors included office space, treatment by auxiliary staff, wait time, costs, and time spent with patients. This suggests that a provider’s personality, expressed compassion, empathy, and kindness may overcome other issues and create an overall positive experience.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement

IMPORTANCE

There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs).

OBJECTIVE

To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs.

EVIDENCE REVIEW

Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses.

FINDINGS

The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC.

CONCLUSIONS AND RELEVANCE

Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Combination checkpoint blockade for metastatic cutaneous malignancies in kidney transplant recipients

BACKGROUND

Immune checkpoint blockade has emerged as a highly effective treatment for patients with metastatic melanoma and cutaneous squamous cell carcinoma. Nivolumab blocks the interactions between programmed cell death protein 1 and programmed death ligand 1 allowing for activation of a latent immune response against the malignancy. Ipilimumab binds to and blocks cytotoxic T-lymphocyte-associated protein 4, alleviating the negative regulation of T-cell activation that is mediated by that checkpoint. Combination therapy with nivolumab and ipilimumab is associated with longer overall survival at 5 years compared with nivolumab monotherapy. Solid organ transplant recipients have a significantly higher risk of malignancies compared with the general population. There is limited data surrounding the efficacy of combination immunotherapy in solid organ transplant recipients, as these patients were excluded from seminal trials due to risk of organ rejection.

CASE PRESENTATIONS

Here we present four cases of combination immunotherapy in kidney transplant recipients. Three patients had metastatic melanoma, and one patient had metastatic cutaneous squamous cell carcinoma. Two patients had radiographic responses from immunotherapy, one patient had stable disease, and one patient had disease progression. Only one patient had biopsy-proven rejection. At last follow-up, three patients had functioning grafts, though one required hemodialysis after treatment, and one patient succumbed to disease, but graft function remained intact throughout her course.

CONCLUSIONS

These cases describe the use of ipilimumab and nivolumab combination immunotherapy for cutaneous malignancies in kidney transplant recipients. They highlight the potential to preserve kidney graft function while effectively treating the disease.

TRIAL REGISTRATION NUMBER

NCT03816332.

UV biomarker genes for classification and risk stratification of cutaneous actinic keratoses and squamous cell carcinoma subtypes

Currently, there is no sensitive molecular test for identifying transformation-prone actinic keratoses (AKs) and aggressive squamous cell carcinoma (SCC) subtypes. Biomarker-based molecular testing represents a promising tool for risk stratifying these lesions. We evaluated the utility of a panel of ultraviolet (UV) radiation-biomarker genes in distinguishing between benign and transformation-prone AKs and SCCs. The expression of the UV-biomarker genes in 31 SCC and normal skin (NS) pairs and 10 AK/NS pairs was quantified using the NanoString nCounter system. Biomarker testing models were built using logistic regression models with leave-one-out cross validation in the training set. The best model to classify AKs versus SCCs (area under curve (AUC) 0.814, precision score 0.833, recall 0.714) was constructed using a top-ranked set of 13 UV-biomarker genes. Another model based on a 15-gene panel was developed to differentiate histologically concerning from less concerning SCCs (AUC 1, precision score 1, recall 0.714). Finally, 12 of the UV-biomarker genes were differentially expressed between AKs and SCCs, while 10 genes were uniquely expressed in the more concerning SCCs. UV-biomarker gene subsets demonstrate dynamic utility as molecular tools to classify and risk stratify AK and SCC lesions, which will complement histopathologic diagnosis to guide treatment of high-risk patients.

Conjunctival Melanoma: Current Treatments and Future Options

Conjunctival melanoma is a rare tumor of the conjunctival epithelium with a heterogenous clinical presentation and a propensity for regional and distant metastatic spread. Guidelines for the treatment of local conjunctival melanoma are well-established, but there are no standard efficacious therapies for metastatic disease. Given that conjunctival melanoma is genetically similar to cutaneous melanoma and mucosal melanomas, targeted therapies effective in the treatment of these diseases, such as BRAF inhibitors and KIT inhibitors, may be effective in the treatment of patients with metastatic conjunctival melanoma. Other targeted small-molecule drugs in the drug development pipeline for the treatment of more prevalent melanomas could also be applicable to conjunctival melanoma. Furthermore, systemic immunotherapy treatments that are now a mainstay in the treatment of cutaneous melanoma, such as programmed cell death-1 and cytotoxic T lymphocyte-associated antigen-4 inhibitors, could also stand to benefit patients with metastatic conjunctival melanoma. Limited case reports provide clues about the effectiveness of both targeted small-molecule inhibitors and immunotherapy in patients with advanced local and metastatic conjunctival melanoma and give credence to the argument that conjunctival melanoma patients should be included in major trials studying new therapies in both cutaneous and mucosal melanomas where applicable.

Advances in Prevention and Surveillance of Cutaneous Malignancies

Skin cancer affects 1 in 5 Americans, resulting in significant morbidity and mortality. Treatment costs and rates of skin cancer and melanoma continue to rise, making preventative measures increasingly important. However, there is conflicting evidence about efficacy of primary and secondary prevention strategies in decreasing incidence and improving early diagnosis. The US Preventative Services Task Force 2016 guidelines did not endorse routine skin cancer screening because of "insufficient evidence." Yet, countries like Australia have shown the feasibility and cost-effectiveness of primary sun safety interventions and secondary prevention measures such as routine skin cancer surveillance. Additional emerging evidence shows that regular skin cancer screening in high-risk populations improves early detection and decreases melanoma mortality. New technology may enhance prevention, promote accurate diagnoses, and improve management of melanoma and nonmelanoma skin cancers. Here, we place rising rates of melanoma within historical context, review costs, efficacy, and evidence for primary and secondary skin cancer prevention and examine the evolving role of novel technologies in the field.

Cutaneous metastasis of hepatocellular carcinoma following liver transplantation

Cutaneous metastases from hepatocellular carcinoma (HCC) are extremely rare and can represent a sign of an underlying malignancy or relapse/progression from an existing tumor. We report a case of a cutaneous metastasis arising in a patient with metastatic HCC following orthotopic liver transplantation. Diagnosis is a multistep process as cutaneous HCC metastases must be differentiated from primary cutaneous malignancies as well as other cutaneous metastases. Making this even more challenging, HCC metastases have heterogeneous clinical and histologic appearances. Therefore, the use of immunohistochemical stains, including hepatocyte paraffin-1, arginase-1, and glypican-3, and correlation with the clinical context are essential for a correct diagnosis.

Fall risk assessment and injury prevention in the Mohs surgery clinic: a review of the literature and recommendations for improving patient safety

Patient falls remain a major cause of adverse events in the medical setting. Many patients receiving Mohs micrographic surgery are at high risk, both for falling and resultant injuries. Although the incidence of patient falls in dermatologic surgery is low, falls can have significant consequences for both patient and provider. Therefore, effective interventions to improve organizational safety are critical. Though there is a considerable amount of research pertaining to fall prevention strategies, the majority of studies have been confined to the inpatient setting and long-term care facilities. Implementation of fall prevention initiatives in the outpatient setting has rarely been evaluated and no studies have focused on the Mohs patient population to date.

METHODS

We reviewed the literature pertaining to fall risk and prevention guidelines in the inpatient and outpatient settings as it applies to the dermatologic surgery environment.

RESULTS

Herein we will discuss patient risk factors for falling relevant to the Mohs setting and review existing validated fall risk assessment tools and strategies for fall prevention.

CONCLUSION

Identifying fall risk factors can improve patient safety and reduce falls in the dermatologic surgery clinic.

Characteristics of non-melanoma skin cancers of the cutaneous perioral and vermilion lip treated by Mohs micrographic surgery

BACKGROUND

The lip and surrounding perioral region are susceptible to non-melanoma skin cancer, but the distribution of basal cell and squamous cell carcinoma on the cutaneous and vermilion lips has not been fully elucidated.

OBJECTIVE

To investigate the distribution of cutaneous and vermilion lip non-melanoma skin cancer and to better describe risk factors, anatomic location, treatment characteristics and oncologic outcomes.

METHODS

A retrospective comparative case series of patients undergoing Mohs micrographic surgery (MMS) at a single academic centre for lip and perioral basal cell and squamous cell carcinoma was performed over a 5-year period. Demographics, medical comorbidities, surgical characteristics and recurrence status were extracted.

RESULTS

Forty-five vermilion and 116 cutaneous lip cancers were identified. Basal cell carcinoma (BCC) was more common in the cutaneous perioral region, while squamous cell carcinoma (SCC) was more common on the vermilion lip (P < 0.001). BCCs were more common on the upper vermilion lip and SCCs were more common on the lower vermilion lip (P < 0.001). Within the cutaneous perioral region, both BCCs and SCCs were more common on the upper perioral surface (P = 0.002). Male gender was associated with lower lip SCC (P = 0.015). Smoking, immunosuppression, anticoagulant use and hydrochlorothiazide use were not associated with cancer type or location. Recurrences were rare, but more common in vermilion lip cancers (6.6%) compared to perioral cutaneous cancers (0.8%). Outcomes for all groups were similar; BCCs of the vermilion lip had significantly greater mean MMS stages (P < 0.001) as did SCCs (P = 0.05).

CONCLUSION

Basal cell carcinoma is more commonly encountered on the cutaneous lip, whereas SCC is more common on the vermilion lip. Within the vermilion lip, BCC favours the upper lip, while SCC favours the lower lip. Within the cutaneous perioral region, both BCC and SCC favour the upper cutaneous tissue. Early stage lip cancers are curable by Mohs micrographic surgery with rare recurrences.

Reconstruction of a surgical defect in the popliteal fossa: A case report

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Popliteal tumors and their associated defects present the dermatologic surgeon with rare and unique surgical and reconstruction challenges.

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When planning reconstruction in the popliteal fossa, prolonged wound care and functional impairment are concerns.

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In such an area with little tissue laxity, a random patterned bilobed with an undersized secondary lobe is an excellent solution to this challenge.

Introduction

Surgical defects of the popliteal fossa pose a reconstructive challenge to the surgeon, given the intimate relationship of this area with the knee joint and underlying vital neuro-vasculature.

Case presentation

An 88-year-old woman was treated for a biopsy proven invasive squamous cell carcinoma of the right popliteal fossa with Mohs micrographic surgery. The resultant defect (4.5 × 4.3 cm) was repaired using a random patterned bilobed flap with an undersized secondary lobe and porcine xenograft with excellent functional and cosmetic outcome.

Discussion

Numerous approaches to reconstruction of the popliteal fossa have been proposed, including primary closure, secondary intent healing, skin grafting, random flaps, muscle flaps, fasciocutaneous flaps, freeflaps, and tissue expansion. Sub-optimal repair of the popliteal fossa can reduce mobility of the knee joint, carry a high risk of wound dehiscence and may result in significant scarring. Here, we present the use of a bilobed flap with an undersized secondary lobe, in a patient with limited tissue laxity, for the repair of the popliteal fossa.

Conclusion

Utilizing a random pattern bilobed flap with an undersized secondary lobe is an excellent alternative for the repair of moderate sized popliteal fossa defects.

A review of non-invasive imaging in extramammary Paget's disease

Extramammary Paget's Disease (EMPD) is a rare intraepithelial adenocarcinoma that classically manifests with pruritic, erythematous and scaling plaques. The clinical picture frequently mimics inflammatory or infectious conditions and is thus commonly misdiagnosed. The assessment of tumour margins is equally challenging as tumours have a propensity to spread beyond clinically visible boundaries. Appropriate non-invasive diagnostic tools can assist in the early detection, diagnosis and management of EMPD. This paper will review the literature on non-invasive imaging modalities used in EMPD. Articles from the PubMed database were selected based on relevance to the topic of this review. Articles that were not specific to EMPD and non-invasive imaging were excluded. Search strategy is further described in the methods section below. Eighteen articles were selected for this review: six PET/CT, five reflectance confocal microscopy (RCM), two photodynamic diagnosis (PDD), two dermoscopy, two MRI and one optical coherence tomography (OCT) paper(s). Dermoscopy, PDD, RCM and OCT can help to distinguish malignant conditions, including EMPD, from benign conditions. RCM and OCT can identify atypical cells in real-time, and have the potential to improve the accuracy of surgical margins intraoperatively and overall management. Distinctive confocal characteristics of EMPD have been described using RCM. The sensitivity and specificity of these findings require additional validation. Radiographic techniques also play a central role in the diagnosis of EMPD and assessment of disease spread. PET/CT and MRI can detect primary disease, nodal and distant metastases, with superior delineation of disease spread on MRI. Limitations of PET/CT are mainly related to primary tumour thickness, and size and FDG-avidity of nodal and distant metastases. Limitations of MRI include the fact that few studies have examined its use in EMPD; additional research is warranted. Randomized controlled trials and large prospective studies evaluating the use of non-invasive imaging in EMPD are needed.

Sentinel lymph node biopsy in periocular merkel cell carcinoma: a case report

Background

The National Comprehensive Cancer Network guidelines for Merkel cell carcinoma recommend performance of the sentinel lymph node biopsy in all patients with clinically negative nodal disease for staging and treatment. Nevertheless, sentinel lymph node biopsy in the periocular region is debated as tumors are typically smaller and lymphatic variability can make performance procedurally problematic.

Case presentation

We present a case of a Caucasian patient in their seventies who presented with a 1.0 cm periocular Merkel cell carcinoma, who underwent Mohs surgery with a Tenzel flap repair, that was found to have a positive sentinel lymph node biopsy, but who, despite parotidectomy, selective neck dissection, and radiation, succumbed to the disease.

Conclusions

Evidence in both the site-specific and non-specific literature demonstrates: (1) Worsening prognosis with extent of lymph node burden, (2) improvements in our abilities to perform lymphoscintigraphy, (3) locoregional and distant metastatic disease in patients with tumor sizes ≤1 cm, and (4) significant rates of sentinel lymph node positivity in patients with tumor sizes ≤1 cm. Our case supports that sentinel lymph node biopsy should be considered in all clinically nodal negative periocular Merkel cell carcinoma, regardless of size, and despite limited site-specific studies on the subject.

Applying a Visual Assessment Tool to Facial Linear Scars

Previous scar scales have focused on verbal descriptions. A nonverbal visual assessment tool would provide a simple way for patients and physicians to quantify scar appearance. The authors sought to use a validated visual assessment tool for linear surgical scars to assess linear scars on the face and to determine whether patients and surgeons rate scars similarly. A total of 143 patients with linear facial scars resulting from repair of Mohs micrographic surgery defects used the visual assessment tool to rate their surgical scar. Six physicians used the tool to rate a subset of the patients' scar photographs. The scar ratings for patients and physicians were compared. Among the scars rated by both the patients and physicians (n = 79), patients had a significantly lower mean (i.e., more favorable) rating compared with the physicians. This was a single-center study including only Caucasian patients. The visual assessment tool to rate linear surgical scars provided a simple method for both patients and physicians to assess the overall appearance of postsurgical scars. Difference in the scar ranking between patients and physicians indicate the importance of incorporating both patient and physician point of view when assessing scars.

Cutaneous adverse effects of the immune checkpoint inhibitors

The immune checkpoint targeted agents, anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) and anti-programed cell death 1 (PD-1) or anti-programmed death ligand 1 (PD-L1) inhibitors are frequently associated with cutaneous side effects that are often dose limiting and can lead to discontinuation of therapy. Ipilimumab, a CTLA-4 inhibitor, is most commonly associated with a morbilliform eruption on the trunk and extremities and pruritus. More severe cutaneous toxicities reported include toxic epidermal necrolysis and severe drug rash with eosinophila and systemic symptoms. Recent case reports of Sweet syndrome and cutaneous sarcoidosis have also recently been described after treatment with ipilimumab. The cutaneous events usually occur early in the course of treatment and are dose dependent. PD-1 inhibitors, nivolumab and pembrolizumab, induce similar but less severe toxicities compared with the CTLA-4 inhibitors. The most common cutaneous adverse events include lichenoid reactions, eczema, vitiligo, and pruritus. Lichenoid oral mucosal lesions located on the tongue, buccal mucosa, lips, or gingivae or located on all of these have also recently been described. The time of onset of the cutaneous events with the PD-1 inhibitors occurs later than that seen with the CTLA-4 inhibitors. Anti-PD-L1 antibodies, such as atezolizumab, have a similar side effect profile compared with the PD-1 inhibitors. Combination of immune checkpoint inhibitors, ipilimumab and nivolumab, has recently been approved for the treatment of advanced melanoma. The combination therapy is associated with a more severe side effect profile compared with the agents used as monotherapy. We discuss the most frequently encountered cutaneous side effects of the immune checkpoint inhibitors and review the recommended management strategies.