Shared decision-making quality and decisional regret in patients with low-risk superficial basal cell carcinoma: A prospective, multicenter cohort study

Background

Many therapies are available to treat low-risk superficial basal cell carcinoma (lr-sBCC), which may complicate the shared decision-making (SDM) process.

Objective

To assess the SDM process of patients and physicians when deciding lr-sBCC therapy as well as the factors that may influence the SDM process.

Methods

A prospective, multicenter cohort study was conducted over 18 months, from October 2018 to April 2020, in 3 tertiary university hospitals and 1 private hospital.

Results

This study included 107 patients. There was a weak positive correlation between Shared Decision-Making Questionnaire-Patient version (SDM-Q-9) and Shared Decision-Making Questionnaire-Physician version (SDM-Q-Doc) (Spearman's correlation coefficient [rs] [105] = 0.21; P = .03). Most patients (71%) chose a nonsurgical treatment after the SDM process. Patients with higher satisfaction with the SDM had lower decisional conflict and decisional regret (P < .001). Patients aged >80 years had higher rates of significant decisional conflict. When evaluating treatment decisions, the highest median score for decisional conflict (22, IQR [16]; P = .01) was observed among patients who chose a surgical excision.

Limitations

Patients may have self-selected to participate.

Conclusion

This study suggests that some patients may prefer less invasive therapies for lr-sBCC. The SDM process may reduce decisional conflict and decisional regret.

Detection of novel therapies using a multi-national, multi-institutional registry of cutaneous immune-related adverse events and management

BACKGROUND

Cutaneous immune-related adverse events (cirAEs) remain a prevalent and common sequelae of immune checkpoint inhibitor (ICI) therapy, often necessitating treatment interruption and prolonged immune suppression. Treatment algorithms are still poorly defined, based on single-institution case reports without adequate safety assessments, and subject to publication bias.

METHODS

Data in this registry were collected through a standardized REDCap form distributed to dermatologists via email listserv.

RESULTS

Ninety-seven cirAEs were reported from 13 institutions in this registry. Topical and systemic steroids were the most common treatments used; however, targeted treatment matched to disease morphology was identified at numerous sites. Novel cirAE therapy uses that to our knowledge have not been previously described were captured including tacrolimus for the treatment of follicular, bullous, and eczematous eruptions and phototherapy for eczematous eruptions. Moreover, further evidence of cirAE treatment applications sparsely described in literature were also captured in this study including dupilumab and rituximab for bullous eruptions, phototherapy for lichenoid and psoriasiform eruptions, and acitretin for psoriasiform eruptions, among others. No serious adverse events were reported. Numerous targeted therapeutics including dupilumab, rituximab, and psoriasis biologics, among others, were associated with a cirAE grade improvement of ≥2 grades in every patient treated.

CONCLUSION

This study suggests that a multi-institutional registry of cirAEs and management is not only feasible but that the information collected can be used to detect, evaluate, and rigorously assess targeted treatments for cirAEs. Further expansion and modification to include treatment progression may allow for sufficient data for specific treatment recommendations to be made.

Drug reactions with eosinophilia and systemic symptoms induced by immune checkpoint inhibitors: an international cohort of 13 cases

Among dermatologic adverse events induced by immune checkpoint inhibitors (ICI), drug reactions with eosinophilia and systemic symptoms (DRESS) have been very rarely reported. The objective of this study is to better define the clinical and histologic features, treatment and prognosis of ICI-related DRESS. This retrospective case series was conducted between 01 January 2015 and 31 December 2021 by the dermatology departments of five international networks involved in drug reactions. Inclusion criteria were age ≥18 years old, DRESS with Regiscar score ≥4 (probable or certain) and ICI as a suspect drug. Clinical, biologic and follow-up data were extracted from the medical charts. Thirteen patients were included. The median time to onset was 22 days (3-11). No patients had a high-risk drug introduced in the past 3 months. A majority of patients presented fever (92%), diffuse exanthema (77%) and facial edema (69%). Biologic features included hypereosinophilia in eight patients (61.5%), hyperlymphocytosis in 3 (23%), elevated liver function tests in 11 (85%, grade 1 or 2 in most cases) and renal involvement in 5 (38%). Two patients (15%) had lung involvement. PCR evidence of viral replication was detected in five patients (38.5%). Treatment involved discontinuation of the suspect ICI and systemic steroids with variable dose and duration regimens. Among the four patients in which ipilimumab + nivolumab combination therapy was initially suspected, one was rechallenged with nivolumab monotherapy with good tolerance. Five patients were switched to another anti-PD-1 plus low-dose systemic steroids, with good tolerance in four cases. No patient died because of DRESS. DRESS induced by ICI are rare and of moderate severity. A consensus for management is still pending.

Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations

Acute radiation dermatitis is a frequent adverse effect of radiotherapy, but standardisation of care for acute radiation dermatitis is lacking. Due to the conflicting evidence and variability in current guidelines, a four-round Delphi consensus process was used to compile opinions of 42 international experts on care for people with acute radiation dermatitis on the basis of the evidence in existing medical literature. Interventions for acute radiation dermatitis prevention or management that reached at least 75% consensus were recommended for clinical use. Six interventions could be recommended for the prevention of acute radiation dermatitis: photobiomodulation therapy and Mepitel film in people with breast cancer, Hydrofilm, mometasone, betamethasone, and olive oil. Mepilex Lite dressings were recommended for the management of acute radiation dermatitis. Most interventions were not recommended due to insufficient evidence, conflicting evidence, or lack of consensus to support use, suggesting a need for further research. Clinicians can consider implementing recommended interventions in their practice to prevent and manage acute radiation dermatitis until additional evidence becomes available.

Clinical associations and classification of immune checkpoint inhibitor-induced cutaneous toxicities: a multicentre study from the European Academy of Dermatology and Venereology Task Force of Dermatology for Cancer Patients

BACKGROUND

Cutaneous immune-related adverse events (irAEs) represent the most frequent toxicities induced by immune checkpoint inhibitors (ICIs).

OBJECTIVES

To investigate clinical associations of cutaneous toxicities induced by different ICI therapies.

METHODS

This was a multicentre retrospective international cohort study of patients with cancer who developed cutaneous irAEs under ICI therapy. Analysis was performed of the rates and basic characteristics of all cutaneous toxicities, and identification of any associations was performed using univariate and multivariate models.

RESULTS

In total, 762 patients were included, who developed 993 cutaneous toxicities. Forty different types of skin toxicities were identified. Psoriasis (175 patients, 23·0%) and pruritus (171 patients, 22·4%) were the most common toxicities, followed by macular rash (161 patients, 21·1%) and eczematous-type reactions (150 patients, 19·7%). Multivariate analysis showed that among patients with macular rash, vitiligo or multiple toxicities, patients received ICIs more frequently for melanoma than for NSCLC. Moreover, anti-CTLA4 was less frequent than anti-programmed death 1 treatment in patients with macular rash [odds ratio (OR) 0·11, 95% confidence interval (CI) 0·01-0·76] and vitiligo (OR 0·07, 95% CI 0·006-0·78). A significant association was also seen in patients treated with a combination of ICI and chemotherapy vs. ICI monotherapy. They less frequently developed psoriasis (OR 0·08, 95% CI 0·02-0·31), lichenoid reactions (OR 0·15, 95% CI 0·03-0·77) and eczematous reactions (OR 0·24, 95% CI 0·07-0·78), all compared with pruritic rash.

CONCLUSIONS

Our study showed that skin-oriented toxicities do not share a single pattern and are related to several factors, including the specific agent administered and the underlying malignancy treated. Follow-up plans should be individualized in order to minimize the risk for severe reactions that could compromise optimum therapeutic outcome. What is already known about this topic? Patients with cancer treated with different immune checkpoint inhibitors (ICIs) carry an increased risk of developing various types of skin toxicities. What are the clinical implications of this work? In this multicentre cohort study we showed that ICI-related skin toxicities do not share a single pattern and may depend on several factors, including the specific agent administered and the underlying malignancy. Among patients with macular rash, vitiligo or multiple skin toxicities, patients received ICIs more frequently for melanoma than for non-small cell lung cancer. The combination of ICI and chemotherapy compared with ICI monotherapy occurred to a lesser extent in patients with psoriatic rash lichenoid and eczematous reactions, compared with patients with pruritus. Clinical awareness and specialized dermatological consultation should be advocated.

Shared decision making for patients with breast and gynecologic malignancies undergoing chemotherapy associated with persistent alopecia

Objective

To assess patient-perceived involvement in shared decision making among those diagnosed with breast or gynecologic malignancies undergoing chemotherapy associated with persistent chemotherapy-induced alopecia (pCIA). We also sought to identify factors that influence shared decision making.

Methods

We recruited patients from the Gynecologic Medical Oncology and Breast Medicine Services at a large academic center for this prospective cohort study. All patients were scheduled to start chemotherapy between June 1, 2017 and December 31, 2017. Following medical consultation, including discussion of the risk of pCIA, patients completed the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Clinical and sociodemographic information was also collected. Univariate analysis was used to evaluate SDM-Q-9 total scores and their constituents for all variables.

Results

Sixty-one patients completed the survey. The median total SDM-Q-9 score was 95.6 (95% CI: 90-100). Most patients (n = 57, 93%) reported a high level of involvement (SDM-Q-9 total score > 66). There was no difference in total scores between patients with breast compared with gynecologic cancer (P > .05). By individual item, the scores for item Q1 ("My doctor made clear that a decision needs to be made") were significantly lower for Black patients and those with advanced disease (P < .05).

Conclusions

Most patients indicated they were adequately involved in shared decision making regarding chemotherapy treatment options and their risk for pCIA. Patients from underrepresented populations and those with advanced disease may benefit from additional support from their clinicians to better address the anticipated psychosocial impacts of pCIA and facilitate the provision of optimal and equitable care.

European recommendations for management of immune checkpoint inhibitors-derived dermatologic adverse events. The EADV task force 'Dermatology for cancer patients' position statement

The introduction of immune checkpoint inhibitors (ICIs) opened a new era in oncologic therapy. The favourable profile of ICIs in terms of efficacy and safety can be overshadowed by the development of immune-related adverse events (irAEs). Dermatologic irAEs (dirAEs) appear in about 40% of patients undergoing immunotherapy and mainly include maculopapular, psoriasiform, lichenoid and eczematous rashes, auto-immune bullous disorders, pigmentary disorders, pruritus, oral mucosal lesions, hair and nail changes, as well as a few rare and potentially life-threatening toxicities. The EADV task force Dermatology for Cancer Patients merged the clinical experience of the so-far published data, incorporated the quantitative and qualitative characteristics of each specific dirAEs, and released dermatology-derived, phenotype-specific treatment recommendations for cutaneous toxicities (including levels of evidence and grades of recommendation). The basic principle of management is that the interventions should be tailored to serve the equilibrium between patients' relief from the symptoms and signs of skin toxicity and the preservation of an unimpeded oncologic treatment.

Assessment and Treatment Outcomes of Persistent Radiation-Induced Alopecia in Patients With Cancer

Importance

Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described.

Objective

To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma.

Design, Setting, and Participants

A retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA.

Main Outcomes and Measures

The clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans.

Results

Of the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, -0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (-0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction.

Conclusions and Relevance

Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.

Nonmelanoma Skin Cancer in Childhood and Young Adult Cancer Survivors Previously Treated With Radiotherapy

BACKGROUND

Radiotherapy (RT) is a risk factor for nonmelanoma skin cancer (NMSC), specifically basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), but whether features, histology, or recurrence of NMSC after RT resemble those observed in the general population is unknown.

METHODS

A retrospective review (1994-2017) was performed within the Adult Long-Term Follow-Up Program and Dermatology Service at Memorial Sloan Kettering Cancer Center. Demographics, clinical features, histology, treatment, and recurrence were collected for this patient cohort that was under close medical surveillance. Pathology images were reviewed when available.

RESULTS

A total of 946 survivors (mean age, 40 years [SD, 13]) were assessed for NMSC. The mean age at first cancer diagnosis was 16 years (range, 0-40 years [11]), and the most common diagnosis was Hodgkin lymphoma (34%; n=318). In 63 survivors, 281 primary in-field lesions occurred, of which 273 (97%) were BCC and 8 (3%) were SCC. Mean intervals from time of RT to BCC and SCC diagnosis were 24 years (range, 2-44 years) and 32 years (range, 14-46 years), respectively. The most common clinical presentation of BCC was macule (47%; n=67), and the most common histologic subtypes were superficial for BCC (48%; n=131) and in situ for SCC (55%; n=5). Mohs surgery predominated therapeutically (42%; n=117), the mean duration of follow-up after treatment was 6 years (range, 12 days-23 years), and the 5-year recurrence rate was 1% (n=1).

CONCLUSIONS

Most NMSCs arising in sites of prior RT were of low-risk subtypes. Recurrence was similar to that observed in the general population. Current guidelines recommend surgical intervention for tumors arising in sites of prior RT because they are considered to be at high risk for recurrence. These findings suggest that an expanded role for less aggressive therapy may be appropriate, but further research is needed.

Outpatient dermatology consultations for oncology patients with acute dermatologic adverse events impact anticancer therapy interruption: a retrospective study

BACKGROUND

Dermatologic adverse events (dAEs) of anticancer therapies may negatively impact dosing and quality of life. While therapy interruption patterns due to dAEs have been studied in hospitalized cancer patients, similar outcomes in outpatient oncodermatology are lacking.

OBJECTIVES

To analyse the therapy interruption patterns, clinico-histopathologic characteristics and management outcomes of outpatient dermatology consultations for acute dAEs attributed to the most frequently interrupted class of oncologic agents.

METHODS

We performed a retrospective cohort study of all cancer patients who received a same-day outpatient dermatology consultation for acute dAEs at our institution from 1 January to 30 June 2015. Relevant data were abstracted from electronic medical records, including demographics, oncologic history and explicit recommendations by both the referring clinician and consulting dermatologist on anticancer therapy interruption. Consultations with the most frequently interrupted class of oncologic treatment were characterized according to clinico-histopathologic features, dermatologic management and clinical outcomes.

RESULTS

There were 426 same-day outpatient dermatology consultations (median age 59, 60% female, 30% breast cancer), of which 295 (69%) had systemic anticancer therapy administered within 30 days prior. There was weak inter-rater agreement between referring clinicians and consulting dermatologists on interruption of anticancer treatment (n = 150, κ = 0.096; 95% CI -0.02 to 0.21). Seventy-three (25%) consultations involved interruption by the referring clinician, most commonly targeted therapy (24, 33%). Maculopapular rash was commonly observed in 23 consultations with 25 dAEs attributed to targeted agents (48%), and topical corticosteroids were most frequently utilized for management (22, 38%). The majority (83%) of consultations with targeted therapy-induced dAEs responded to dermatologic treatment and 84% resumed oncologic therapy, although three (19%) at a reduced dose. Rash recurred only in two instances (13%).

CONCLUSIONS

A high frequency of positive outcomes in the management of targeted therapy-induced dAEs by outpatient consulting dermatologists and low recurrence of skin toxicity suggests impactful reductions in interruption of anticancer therapy.

Treatment Outcomes of Immune-Related Cutaneous Adverse Events

PURPOSE

The aim of the current study was to report the efficacy of topical and systemic treatments for immune-related cutaneous adverse events (ircAEs) attributed to checkpoint inhibitors in an uncontrolled cohort of patients referred to oncodermatology clinics.

METHODS

A retrospective analysis of patients with ircAEs evaluated by dermatologists from January 1, 2014, to December 31, 2017, at three tertiary care hospitals and cancer centers were identified through electronic medical records. Clinicopathologic characteristics, dermatologic therapy outcome, and laboratory data were analyzed.

RESULTS

A total of 285 patients (median age, 65 years [range, 17 to 89 years]) with 427 ircAEs were included: pruritus (n = 138; 32%), maculopapular rash (n = 120; 28%), psoriasiform rash (n = 22; 5%), and others (n = 147; 34%). Immune checkpoint inhibitor class was associated with ircAE phenotype (P = .007), where maculopapular rash was predominant in patients who received combination therapy. Severity of ircAEs was significantly reduced (mean Common Terminology Criteria for Adverse Events grade: 1.74 v 0.71; P < .001) with dermatologic interventions, including topical corticosteroids, oral antipruritics, and systemic immunomodulators. A total of 88 ircAEs (20%) were managed with systemic immunomodulators. Of these, 22 (25%) of 88 persisted or worsened. In seven patients with corticosteroid-refractory ircAEs, improvement resulted from targeted biologic immunomodulatory therapies that included rituximab and dupilumab. Serum interleukin-6 (IL-6) was elevated in 34 (52%) of 65 patients; grade 3 or greater ircAEs were associated with increased absolute eosinophils (odds ratio, 4.1; 95% CI, 1.3 to 13.4) and IL-10 (odds ratio, 23.8; 95% CI, 2.1 to 262.5); mean immunoglobulin E serum levels were greater in higher-grade ircAEs: 1,093 kU/L (grade 3), 245 kU/L (grade 2), and 112 kU/L (grade 1; P = .043).

CONCLUSION

Most ircAEs responded to symptom- and phenotype-directed dermatologic therapies, whereas biologic therapies were effective in patients with corticosteroid-refractory disease. Increased eosinophils, IL-6, IL-10, and immunoglobulin E were associated with ircAEs, and they may represent actionable therapeutic targets for immune-related skin toxicities.

Endocrine Therapy-Induced Alopecia in Patients With Breast Cancer

Importance

Endocrine therapy-induced alopecia (EIA) has been anecdotally reported but not systematically described.

Objective

To characterize EIA in patients with breast cancer.

Design, Setting, and Participants

Retrospective cohort study of 112 patients with breast cancer, diagnosed with EIA from January 1, 2009, to December 31, 2016, the patients were examined at the dermatology service in a large tertiary care hospital and comprehensive cancer center.

Main Outcomes and Measures

The clinical features, alopecia-related quality of life (QoL), and response to minoxidil of EIA in patients with breast cancer were assessed. Data from the Hairdex Questionnaire was used to assess the impact of the alopecia on patients QoL. Higher score indicates lower QoL (0-100 score). Efficacy of minoxidil was measured at 3 or 6 months by a single-blinded investigator through standardized clinical photographs of the scalp.

Results

A total of 112 female patients with breast cancer were included (median [range] age, 60 [34-90] years). A total of 104 patients (93%) had standardized clinical photographs; of these, 59 patients (53%) had trichoscopy images available at baseline, and 46 patients (41%) were assessed for response to minoxidil. Alopecia was attributed to aromatase inhibitors in 75 patients (67%) and tamoxifen in 37 (33%). Severity was grade 1 in 96 of 104 patients (92%), and the pattern was similar to androgenetic alopecia. The predominant trichoscopic feature at baseline was the presence of vellus hairs and intermediate- and thick-diameter terminal hair shafts. A negative impact on QoL was reported, with a higher effect in the emotion domain according to the Hairdex score (mean [SD], 41.8 [21.3]; P < .001). After treatment with topical minoxidil, moderate or significant improvement in alopecia was observed in 37 of 46 patients (80%).

Conclusions and Relevance

Endocrine therapies are associated with a pattern alopecia similar to androgenetic-type, consistent with the mechanism of action of causal agents. A significant negative impact on QoL was reported by patients, despite mostly mild alopecia severity.

Assessment of Quality of Life and Treatment Outcomes of Patients With Persistent Postchemotherapy Alopecia

Importance

Persistent alopecia occurs in a subset of patients undergoing chemotherapy, yet the quality of life (QOL) of these patients and their response to therapy have not been described in a large patient cohort.

Objective

To characterize the clinical presentation of patients with persistent chemotherapy-induced alopecia (pCIA) or endocrine therapy-induced alopecia after chemotherapy (EIAC) and their QOL and treatment outcomes.

Design, Setting, and Participants

A retrospective multicenter cohort of 192 women with cancer treated with cytotoxic agents who received a clinical diagnosis of persistent alopecia (98 with pCIA and 94 with EIAC) between January 1, 2009, and July 31, 2017, was analyzed. All patients were from the dermatology service in 2 comprehensive cancer centers and 1 tertiary-care hospital. Data on demographics, chemotherapy regimens, severity, clinical patterns, and response to hair-growth promoting agents were assessed. Data from the Hairdex questionnaire were used to assess the QOL of patients with alopecia.

Main Outcomes and Measures

The clinical presentation, response to dermatologic therapy, and QOL of patients with pCIA were assessed and compared with those of patients with EIAC.

Results

A total of 98 women with pCIA (median age, 56.5 years [range, 18-83 years]) and 94 women with EIAC (median age, 56 years [range, 29-84 years]) were included. The most common agents associated with pCIA were taxanes for 80 patients (82%); the most common agents associated with EIAC were aromatase inhibitors for 58 patients (62%). Diffuse alopecia was predominant in patients with pCIA compared with patients with EIAC (31 of 75 [41%] vs 23 of 92 [25%]; P = .04), with greater severity (Common Terminology Criteria for Adverse Events, version 4.0, grade 2) among patients with pCIA (29 of 75 [39%] vs 12 of 92 [13%]; P < .001). A negative emotional effect was reported by both groups. After treatment with topical minoxidil or spironolactone, moderate to significant improvement was observed for 36 of 54 patients with pCIA (67%) and for 32 of 42 patients with EIAC (76%).

Conclusions and Relevance

Persistent chemotherapy-induced alopecia is frequently more severe and diffuse when compared with EIAC, and both groups of patients experienced a negative effect. A modest benefit was observed with dermatologic therapy. Additional studies are warranted to develop effective strategies for prevention and effective therapy for pCIA and EIAC.

Abstract P4-16-07: The CHANCE study: Mechanical skin changes among women with non-metastatic breast cancer receiving chemotherapy and endocrine therapy

Background: The persistent effects on skin hydration and elasticity resulting from cytotoxic and endocrine agents used in early stages of breast cancer are poorly understood. The objective of this preliminary analysis of the CHANCE study is to describe the pattern of persistent biomechanical skin changes in non-metastatic breast cancer patients treated with cytotoxic chemotherapies and/or endocrine therapies.

Methods: This is an ongoing single-center, prospective, longitudinal cohort study of non-metastatic breast cancer patients treated with cytotoxic chemotherapies and/or endocrine therapies. Objective skin hydration and elasticity measurements of the forearm were measured using Tewameter® (TM 300; Courage & Khazaka) and Cutometer® (MPA 580; Courage & Khazaka) devices under a controlled ambient environment at baseline and 6 months after chemotherapy completion, or one year after initiation of endocrine therapy.

Results: A total of 107 patients were assessed at baseline and follow-up for transepidermal water loss (TEWL) (median age 53, range 26-82) and 106 patients for skin elasticity (median age 53.5, range 26-82). Fifty-three healthy controls were evaluated at baseline with median age 47 (range, 22-73). The mean TEWL at baseline and follow-up among patients were 6.922 g/h/m2 and 8.521 g/h/m2, respectively (p&lt;.0001). Skin firmness (0.420 versus 0.421 mm, p=0.949) and elasticity (77.2% versus 77.4%, p=0.836) did not significantly change during follow-up. When comparing chemotherapy recipients with endocrine therapy recipients, chemotherapy patients had a mildly lower TEWL at follow-up (8.369 versus 8.928 g/h/m2, p=.247) but a greater net increase in TEWL (1.687 versus 1.359 g/h/m2, p=.5) compared to endocrine patients over the study period.

Conclusions: An increase in TEWL was observed in patients receiving cytotoxic and endocrine therapies, suggesting a deterioration of the protective skin barrier possibly attributed to these therapies. No significant changes in skin firmness or elasticity were found in this preliminary analysis. Further studies are needed to elucidate the pathophysiologic mechanisms involved in persistent skin changes after systemic breast cancer therapies.

Objective skin hydration and elasticity in patients receiving breast cancer therapy Control (n=53)Baseline (n=107)Follow-Up (n=107)p-value*TEWL (g/h/m2)9.4626.9228.521&lt;.0001Cutometer Baseline (n=106)Follow-Up (n=106) Immediate recovery, R0 (mm)0.4150.4200.4210.949Gross elasticity, R2 (%)79.3%77.2%77.4%0.836*p-value calculated from baseline and follow-up only

Citation Format: Lacouture ME, Phillips GS, Freites-Martinez A, Patil S, Samuels A, Shapiro J, Kukoyi O, Goldfarb S. The CHANCE study: Mechanical skin changes among women with non-metastatic breast cancer receiving chemotherapy and endocrine therapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-07.

Safety of 5α-reductase inhibitors and spironolactone in breast cancer patients receiving endocrine therapies

PURPOSE

To provide dermatologists and oncologists with a foundation for practical understanding and uses of 5α-reductase inhibitors and spironolactone for breast cancer patients and survivors receiving endocrine therapies (ETs), including the effect of these treatments on sex hormone levels, any reported drug interactions, and any risk of malignancy.

METHODS

All published studies from January 1978 through April 2018 were considered, using databases such as PubMed, Google Scholar, and Science Direct. Forty-seven studies were included in this review.

RESULTS

There is no evidence of interactions between 5α-reductase inhibitors and spironolactone with ETs used in breast cancer. Sex hormone alteration with 5α-reductase inhibitor or spironolactone use is variable. Three randomized controlled trials, 1 case-control study, and 6 retrospective cohort studies, including 284 female patients, studied the effects of 5α-reductase inhibitors on serum estrogen levels. Levels were increased in 97 of 284 (34%) patients, decreased in 15 of 284 (5.3%) patients, and unchanged in 162 of 284 (57%) patients. Four retrospective cohort studies, 1 case study, and 1 double-blinded crossover study, including 95 female patients, assessed the effect of spironolactone on estrogen levels. Levels were increased in 25 of 95 (26%) patients, decreased in 6 of 95 (6.3%) patients, and unchanged in 64 of 95 (67%) patients. Ultimately, most patients did not have a significant alteration in the level of estrogen when using 5α-reductase inhibitors or spironolactone. No consistent evidence of increased risk of female breast cancer while on spironolactone was reported in 3 studies including 49,298 patients; the risk of breast cancer with the use of 5α-reductase inhibitors has not been studied.

CONCLUSIONS

Most patients did not show increased estrogen levels with spironolactone and there were no data suggesting increased risk of breast cancer. Based on hormonal and pharmacological activity, spironolactone may be considered for further research on alopecia and hirsutism in breast cancer patients.

In-vivo assessment of a case of cutaneous sarcoidosis using reflectance confocal microscopy

Reflectance confocal microscopy (RCM) is a noninvasive imaging technique that allows visualization of the epidermis and papillary dermis with cellular-level resolution. Granulomatous reactions such as sarcoidosis could be assessed using RCM. The identification of bright beaded-like structures that could correspond to reticulin fibers overlying granulomas, in association with dermoscopy, may be a very useful approach in the diagnosis of sarcoidosis and for the differentiation of this granulomatous entity with superficial cutaneous metastasis.

Podiatric Adverse Events and Foot Care in Cancer Patients and Survivors Awareness, Education, and Literature Review

Cancer is one of the leading causes of mortality and morbidity worldwide. Recent improved therapies have resulted in more patients surviving cancer and living longer. Despite these advances, the majority of patients will develop adverse events from anticancer therapies. Foot alterations, including nail toxicities, hand-foot syndrome, edema, xerosis, hyperkeratosis, and neuropathy, are frequent among cancer patients. These untoward conditions may negatively impact quality of life, and in some cases may result in the interruption or discontinuation of cancer treatments. Appropriate prevention, diagnosis, and management of podiatric adverse events are essential to maintain foot function and health-related quality of life, both of which are critical for the care of cancer patients and survivors. This article shows results related to complaint and impact on quality of life of the Oncology Foot Care program and reviews publications specific to podiatric adverse events related to cancer treatments.

Inflammatory dermatoses, infections, and drug eruptions are the most common skin conditions in hospitalized cancer patients

BACKGROUND

Dermatologic conditions cause morbidity and mortality among hospitalized cancer patients. An improved understanding is critical for implementing clinical and research programs in inpatient oncodermatology.

OBJECTIVE

To characterize inpatient dermatology consultations at a large comprehensive cancer center.

METHODS

Retrospective database query of new admissions and medical record review of initial inpatient dermatology consultations comparing inpatients consulted and not consulted during January-December 2015.

RESULTS

In total, 412 of 11,533 inpatients received 471 dermatology consultations (54% male, median age 59.5 years). Patients with hematologic cancers were 6 times more likely to receive dermatologic consultations compared with nonhematologic cancers (odds ratio 6.56, 95% confidence interval 5.35-8.05, P < .0001). Patients consulted by a dermatologist had a significantly longer length of stay than inpatients not consulted by dermatology (median 11 vs 5 days, P < .0001). Among the 645 dermatologic conditions diagnosed, the most common categories were inflammatory diseases, infections, and drug reactions; the most frequent conditions were contact dermatitis, herpes zoster, and chemotherapy-induced drug eruptions.

LIMITATIONS

The study's retrospective nature and single-institution setting are potential limitations.

CONCLUSION

Hematologic malignancies are a significant risk factor for dermatology inpatient consultations. A significantly longer length of stay was associated with dermatology consultations, suggesting high comorbidities in these patients. Increased dermatologic care of these inpatients might improve quality of life, dermatologic health, and ability to receive anticancer agents.

Hair disorders in cancer survivors

With increasing survival rates across all cancers, survivors represent a growing population that is frequently affected by persistent or permanent hair growth disorders as a result of systemic therapies, radiotherapy, surgical procedures, and therapeutic transplants. These hair disorders include persistent chemotherapy-induced alopecia, persistent radiotherapy-induced alopecia, endocrine therapy-induced alopecia and hirsutism, postsurgery alopecia and localized hypertrichosis, and persistent stem cell transplantation and targeted therapy-induced alopecia. The information contained in this continuing medical education series should facilitate a better understanding on hair disorders in cancer survivors so that adequate support and therapies may be provided.

Hair disorders in patients with cancer

Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

Non-melanoma skin cancer in childhood cancer survivors previously treated with radiotherapy: Clinical findings, histology, and management

131

Background: Radiotherapy is a well-known risk factor for non-melanoma skin cancer (NMSC), but whether diagnosis, histologic features, or natural history of NMSC after radiotherapy resemble those observed in the general population is unknown. This study aims to describe clinical findings, histology, and management of NMSC on the skin of childhood cancer survivors previously treated with radiotherapy. Methods: A retrospective chart review (2000-2017) was performed including adult survivors of childhood cancer referred to the Adult Long-Term Follow-Up Program or the dermatology service at Memorial Sloan Kettering Cancer Center. Data was obtained from electronic medical records, including demographics, histologic subtype and treatment received for NMSC (basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)). Clinical features were assessed with clinical images. Results: 960 (mean age 40 years, SD ± 13) patients were assessed for the diagnosis of BCC/SCC after radiotherapy for cancer. The mean age of cancer diagnosis was 15 years (range: birth-39 years). The most common primary diagnosis was Hodgkin lymphoma. 82 patients developed NMSC; 67 of these developed NMSC in the field of prior radiotherapy. 283 in-field lesions were counted, of which 275 were BCC and 8 were SCC. Of the 275 BCC, 261 (95%) were primary lesions and 14 (5%) were recurrent lesions. All SCC were primary lesions. Based on clinical images, 30% of BCC were clinically pigmented; the most common presentation was macule (46%). The mean intervals for BCC and SCC from time of radiotherapy to diagnosis of the first in-field lesion were 24 years (range, 2-44 years) and 32 years (range, 14-46 years), respectively. Histologically, superficial subtype was most prevalent in the BCC subgroup, comprising 47% of all cases. Mohs surgery was the most common therapy (43% of BCC cases; 37% of SCC cases). Conclusions: Among survivors of childhood and young adult cancer, BCC was the most prevalent NMSC. Most of BCC arising in sites of prior radiotherapy for cancer treatment were of low-risk histologic subtype and had low rates of recurrence. An expanded role for topical therapy may be appropriate, but further research is needed.

Eruptive Keratoacanthomas Associated With Pembrolizumab Therapy

Importance

To our knowledge, there have been no previous reports of eruptive keratoacanthomas (KAs) in patients receiving pembrolizumab.

Objective

To report the cases of 3 consecutive patients with pembrolizumab-induced eruptive KAs and their management.

Design, Setting, and Participants

Case report study of 3 patients from 2 centers with pembrolizumab-treated cancer who all developed eruptive KAs.

Interventions

All 3 patients had AK treatment with clobetasol ointment and intralesional triamcinolone; 2 patients also underwent open superficial cryosurgery.

Results

Three consecutive patients with cancer, 2 men and 1 woman (median age, 83 years; range 77-91 years), experienced pembrolizumab-associated eruptive KAs. All patients presented with a sudden onset of multiple lesions on sun-exposed areas of their extremities after a median of 13 months (range, 4-18 months) of pembrolizumab therapy. On lesional biopsy, a lichenoid infiltrate was observed in the underlying dermis, predominantly composed of CD3+ T cells, scattered CD20+ B cells, and relatively few PD-1+ (programmed cell death 1-positive) T cells, an immunophenotypic pattern also observed in other cases of anti-PD-1-induced lichenoid dermatitis. Patients were treated with clobetasol ointment and intralesional triamcinolone, alone or in combination with open superficial cryosurgery. All KAs resolved in all patients, and no new lesions occurred during close follow-up. Pembrolizumab treatment was continued without disruption in all 3 cases, and all patients had complete responses of their primary cancers.

Conclusions and Relevance

Pembrolizumab is used in advanced melanoma, advanced non-small-cell lung cancer, and in head and neck cancer. A variety of dermatologic immune-related adverse events including maculopapular eruption, lichenoid reactions, pruritus, and vitiligo have been described. This case series demonstrates that pembrolizumab therapy may also be associated with eruptive KAs with characteristic dermal inflammation, which improved with corticosteroid treatment (topical and intralesional) alone or in combination with cryosurgery, allowing patients to continue therapy with pembrolizumab.

Successful treatment of plantar warts with intralesional bleomycin and electroporation: pilot prospective study

BACKGROUND

Numerous studies have been performed to evaluate the efficacy of intralesional bleomycin for the treatment of warts with inconsistent result. Nevertheless, it is well known that the cytotoxicity of bleomycin can be enhanced in vivo by 300 to 700-fold by electroporation.

OBJECTIVE AND METHODS

In this article, we present an interventional, one-center, prospective case series, clinical trial of the effectiveness of intralesional bleomycin combined with electroporation for the treatment of plantar warts, in comparison to the use of intralesional bleomycin alone.

RESULTS

The study's cohort included 12 men and 10 women, with a mean age of 53.8 years. A total of 22 warts were treated. In dividing the patients in two groups (complete remission against all the others) and analyzing the different outcomes in the two arms of patients, a statistical significant difference was found (p=0.0015), proving a greater efficacy of the treatment with bleomycin combined with ECT as opposed to bleomycin alone. Electroporation was always well tolerated by the patients with no discomfort.

CONCLUSIONS

This study serves as a basis for the application of novel protocols in the treatment of different benign and locally malignant skin lesion by means of electroporation.

Dermatologic adverse events in breast cancer patients receiving endocrine therapies

e12533

Background: Endocrine therapies are known to cause adverse events including hot flashes, arthralgias, and dyspareunia. Dermatologic adverse events (dAE), including alopecia are infrequently reported, despite their potential impact on quality of life (QoL). This study aims to characterize endocrine therapy-related dAE including alopecia, acne, xerosis, and onychodystrophy. Methods: A retrospective chart review (2005-2015) of patients referred to the dermatology service for dermatologic conditions developing during endocrine therapies was performed. Relevant data was abstracted from each patient’s medical record including demographics, primary cancer diagnosis, and dAEs by grade (CTCAE v4.03). The psychosocial impact of alopecia was assessed in a subset of patients using a QoL questionnaire (Hairdex), which includes the following domains: ‘emotions’, ‘functioning’, ‘symptoms’, ‘stigmatization’ and ‘self-confidence’. Results: A total of 74 breast cancer patients treated with endocrine therapies were included (median age 62yrs. [range, 34-85]). Alopecia was the reason for a dermatologic consultation in all patients, and was attributable to aromatase inhibitors (AI) in 49 patients (66.2%) and tamoxifen in 22 (29.3%). The mean duration of treatment at the time of alopecia diagnosis was 24 months (SD ±14.3). In 93.2% of the patients, alopecia was grade 1 in severity, and in 6.8% it was grade 2 (the latter was attributable to AIs only). All grade xerosis was identified in 34 (45.9%), onychodystrophy in 21 (28.4%) and acne in 9 patients (12.2%). In patients who completed the Hairdex questionnaire (n = 44), a high ‘emotions’ (52.6, p < 0.05) and ‘stigmatization’ (46, p < 0.05) domains score were found, while ‘symptoms’ (22.1, p < 0.05) and ‘functioning’ (24.5, p < 0.05) domains score were lower. Conclusions: Endocrine therapies are associated with alopecia and dAEs, with a greater severity with AIs. A psychosocial impact on emotions was seen in patients with alopecia. Moreover, xerosis, acne, and onychodystrophy were also observed. These findings underscore the need for increased attention to dAE in breast cancer patients receiving endocrine agents, in order to maintain quality of life and adherence to therapies.

Angioma serpiginosum: report of an unusual acral case and review of the literature

We report the case of a 35-year-old woman with deep-red asymptomatic macules on the plantar and dorsal skin of the right great toe. Histopathologic fi ndings were compatible with Angioma serpiginosum. Immunohistochemical stains for estrogens and progesterone receptors were negative. Dermoscopy showed an erythematous parallel ridge pattern with double rows of irregular dots and globules. We report an unusual case of angioma serpiginosum with acral volar skin involvement. The dermoscopic features described may aid in the diagnosis of AS in this specifi c skin area. Acral volar skin involvement must be included in the clinical spectrum of Angioma serpiginosum and in the differential diagnosis of acral vascular lesions.

[Cutaneous and subcutaneous leiomyosarcoma: report of two cases]

Cutaneous leiomyosarcomas are uncommon malignant tumors of smooth muscle. We report herein two cases of cutaneous leiomyosarcoma, one of dermal and other of subcutaneous vascular origin, confirmed by histology and immunohistochemistry. Both cases were treated with wide surgical excision, one with local recurrence. No metastases were detected at follow-up. Leiomyosarcomas should be considered in lesions with histologic features of spindle cell malignancy. It is necessary in most of the cases a histological differentiation with specific immunohistochemical markers. The treatment of choice is radical excision with wide margins, achieving satisfactory results.

Dermoscopy of acral angioma serpiginosum

Angioma serpiginosum (AS) is an unusual vascular disorder that typically affects female patients, begins in childhood and stabilizes in adulthood and not frequently involve acral skin. We herein present a 13 year-old girl with an asymptomatic erythematous punctuate first noticed on the right palm three years ago, with a proximal serpiginous progression up to the forearm. On examination there was a nonblanching erythematous punctuate on the palm and the inner aspect of right hand and forearm. Dermoscopy showed an erythematous parallel ridge pattern with some red globules and dots spreading on a linear arrangement, and the acrosyringia openings were not affected. Histopathological study showed dilated capillaries in the dermal papillae. This feature is consistent with angioma serpiginosum (AS). To the best of our knowledge, this is the first report that shows a dermoscopic image of a palmar AS. The dermoscopic pattern described in this case could aid in the diagnosis of AS and could add a value in the differential diagnosis with vascular lesions on acral skin.