Artificial intelligence algorithms and 3D volumetric rendering for basal cell carcinoma detection and tumor depth assessment in RCM-OCT images: a pilot study

The Reflectance Confocal Microscopy - Optical Coherence Tomography (RCM-OCT) device has shown utility in detecting and assessing depth of basal cell carcinoma (BCC) in vivo but is challenging for novices to interpret. Artificial intelligence (AI) applied to RCM-OCT could aid readers. We trained artificial intelligence (AI) models, using OCT rasters of biopsy-confirmed BCC, to detect and create 3D BCC rendering and automatically measure tumor depth. Trained AI models were applied to a separate test set containing rasters of BCC, benign lesions, and normal skin. Blinded reader analysis and tumor depth correlation with histopathology were conducted. BCC detection improved from viewing OCT rasters only (sensitivity 73.3%, specificity 45.5%) to viewing rasters with AI-generated BCC rendering (sensitivity 86.7%, specificity 48.5%). A Pearson Correlation r2 = 0.59 (p=0.02) was achieved for the tumor depth measurement between AI and histologic measured depths. Thus, addition of AI to the RCM-OCT device may expand its utility widely.

Pruritus related to trastuzumab and pertuzumab in HER2 + breast cancer patients

PURPOSE

The combination of trastuzumab and pertuzumab (HP) as part of a taxane-based regimen has shown benefit in the adjuvant and metastatic HER2 + breast cancer setting. In the CLEOPATRA trial, pruritus was reported in 11-17.6% of patients. The clinical phenotype and potential treatment strategies for this event have not been reported.

METHODS

A retrospective review of 2583 patients receiving trastuzumab and pertuzumab for the treatment of HER2 + breast cancer from 11/23/2011 to 6/21/2021 was performed at Memorial Sloan Kettering Cancer Center (MSKCC). Patient demographics, pruritus characteristics, and treatments as documented in the electronic medical record (EMR) were included in this analysis.

RESULTS

Of 2583 pts treated with HP, 122 (4.72%) with pruritus were identified. On average, patients experienced pruritus 319.0 days (8-3171) after initiation of HP. The upper extremities (67.4%), back (29.3%), lower extremities (17.4%), and shoulders (14.1%) were the most commonly affected regions. Grade 1/2 pruritus (97.6%) occurred in most cases. Patients responded primarily to treatment with topical steroids (52.2%), antihistamines (29.9%), emollients (20.9%), and gabapentinoids (16.4%). Of those with pruritus, 4 patients (3.3%) required treatment interruption or discontinuation.

CONCLUSIONS

Pruritus is uncommon in patients on trastuzumab and pertuzumab, generally a chronic condition, with gabapentinoids or antihistamines representing effective therapies.

IL12/23 Blockade with Ustekinumab as a Treatment for Immune-Related Cutaneous Adverse Events

Background: Immune-related cutaneous adverse events (ircAEs) are frequent and may reduce quality of life and consistent dosing. IL12/23 has been implicated in psoriasis, which is reminiscent of the psoriasiform/lichenoid ircAE phenotype. We report the use of ustekinumab as a therapeutic option. Methods: Patients at Memorial Sloan Kettering Cancer Center, New York, who received immune checkpoint inhibitors and were treated with ustekinumab or had the keywords "ustekinumab" or "Stelara" in their clinical notes between 1 March 2017 and 1 December 2022 were retrospectively identified via a database query. Documentation from initial and follow-up visits was manually reviewed, and response to ustekinumab was categorized into complete cutaneous response (CcR, decrease to CTCAE grade 0), partial cutaneous response (PcR, any decrease in CTCAE grade exclusive of decrease to grade 0), and no cutaneous response (NcR, no change in CTCAE grade or worsening). Labs including complete blood count (CBC), cytokine panels, and IgE were obtained in a subset of patients as standard of care. Skin biopsies were reviewed by a dermatopathologist. Results: Fourteen patients with psoriasiform (85.7%), maculopapular (7.1%), and pyoderma gangrenosum (7.1%) ircAEs were identified. Ten (71.4%) receiving ustekinumab had a positive response to treatment. Among these 10 responders, 4 (40%) demonstrated partial cutaneous response and 6 (60%) demonstrated complete cutaneous resolution. Six patients (42.9%) experienced interruptions to their checkpoint inhibitor treatment as a result of intolerable ircAEs, and following ircAE management with ustekinumab, two (33.3%) were successfully rechallenged with their checkpoint inhibitors. On histopathology, patients primarily had findings of interface or psoriasiform dermatitis. No patients reported an adverse event related to ustekinumab. Conclusions: Ustekinumab showed a benefit in a subset of patients with psoriasiform/lichenoid ircAEs. No safety signals were identified. However, further prospective randomized controlled trials are needed to confirm our findings.

PRO-CTCAE reveals under-recognition of dermatologic symptom burden in hospitalized cancer patients

PURPOSE

Dermatologic adverse events (dAEs) occur frequently in hospitalized patients and can significantly reduce quality of life. Physicians grade dAEs using the Common Terminology Criteria of Adverse Events (CTCAE). However, they often underestimate symptom frequency and severity. The patient-reported outcomes (PRO) version of the CTCAE (PRO-CTCAE) was developed to assess symptoms from the patient's perspective. In this study, we assessed the patient-reported burden of dAEs via the PRO-CTCAE questionnaire and compared results with dAE assessment by treating oncologists and dermatologists.

METHODS

Patients admitted to Memorial Sloan Kettering Cancer Center from 6/1/2018 to 4/30/2019 and received a dermatology consultation were eligible. Once enrolled, participants completed a PRO-CTCAE questionnaire on 14 dermatologic symptoms. CTCAE grades assigned by oncology and dermatology were obtained from clinical notes, and kappa statistics were calculated to evaluate the level of agreement between physician and patient evaluations.

RESULTS

A total of 100 patients (mean age 59.4, 55% male) were prospectively enrolled. The most common patient-reported dAEs were rash (72%), swelling (67%), pruritus (64%), bruising (53%), and hives (37%). Oncologists and dermatologists underreported dAEs except for rash (median kappa values 0.3 [0.02-0.84] and 0.32 [0.02-0.87], respectively). Oncologists and dermatologists were concordant with each other's documented assessment of dAEs (median kappa value 0.985 [0.55-1]).

CONCLUSION

Oncology patient-reported dAEs in a tertiary academic oncologic referral center were under-recognized by providers. PRO-CTCAE may be a useful tool to optimize inpatient dermatologic care for cancer patients by detecting and allowing management of patient-reported dAEs.

Ergonomic and psychosocial risk factors associated with work-related musculoskeletal disorders in Mohs histotechs

Mohs histotechs are at high risk for work-related musculoskeletal disorders (WRMSDs) due to repetitive motions, forceful exertions, and fixed postures required for their work. Psychosocial factors such as perceptions of pressure to achieve deadlines may exacerbate risk of occupational injury. To assess the prevalence of and risk factors for WRMSD in Mohs histotechs, an online survey was created using literature review, expert opinion, and two validated instruments (the Nordic Musculoskeletal Questionnaire and the Oldenburg Burnout Inventory) and distributed to Mohs histotechs. 88% of respondents reported musculoskeletal problems in 2 or more of the 9 body sites assessed in the past year. Standing during specimen processing was correlated with having neck pain and upper back pain, while sitting was protective against lower back pain. Individuals that felt that they could not take breaks or slow their pace of work were more likely to report pain at multiple body sites. Total pain scores were significantly lower in those reporting extensive ergonomic training. There is a high prevalence of WRMSD in Mohs histotechs. Addressing poor posture as well as psychosocial risk factors could further reduce injury.

Pruritus Related to Trastuzumab and Pertuzumab in HER2+ Breast Cancer Patients

Purpose

The combination of trastuzumab and pertuzumab (HP) as part of a taxane-based regimen has shown benefit in the adjuvant and metastatic HER2+ breast cancer setting. In the CLEOPATRA trial, pruritus was reported in 11-17.6% of patients. The clinical phenotype and potential treatment strategies for this event have not been reported.

Methods

A retrospective review of 2583 patients receiving trastuzumab and pertuzumab for the treatment of HER2+ breast cancer from 11/23/2011 to 6/21/2021 was performed at Memorial Sloan Kettering Cancer Center (MSKCC). Patient demographics, pruritus characteristics, and treatments as documented in the electronic medical record (EMR) were included in this analysis.

Results

Of 2583 pts treated with HP, 122 (4.72%) with pruritus were identified. On average, patients experienced pruritus 319.0 days (8-3171) after initiation of HP. The upper extremities (67.4%), back (29.3%), lower extremities (17.4%), and shoulders (14.1%) were the most commonly affected regions. Grade 1/2 pruritus (97.6%) occurred in most cases. Patients responded primarily to treatment with topical steroids (52.2%), antihistamines (29.9%), emollients (20.9%), and gabapentinoids (16.4%). Of those with pruritus, 4 patients (3.3%) required treatment interruption or discontinuation.

Conclusions

Pruritus is uncommon in patients on trastuzumab and pertuzumab, generally a chronic condition, with gabapentinoids or antihistamines representing effective therapies.

The long-term evolution of melanocytic nevi among high-risk adults

BACKGROUND

There is little understanding regarding the long-term natural history of melanocytic nevi among adults.

OBJECTIVE

The objective of the study was to describe the long-term natural history of individual nevi located on the torso of high-risk patients.

METHODS

All patients attending Memorial Sloan Kettering Cancer Center (MSKCC) who underwent two total body photography (TBP) sessions 15+ years apart were included ('retrospective' group). To account for a potential selection bias, we also included consecutive patients who had TBP 15+ years ago and consented to undergo follow-up TBP ('prospective' group). We compared baseline and follow-up torso images on the TBPs and evaluated the number of total, new and disappearing nevi; number of seborrheic keratoses and actinic keratoses; each nevus' diameter at both time points; each nevus' colour change; the presence of clinical atypia; and when dermoscopy was available, the dermoscopic features at each time point.

RESULTS

One hundred six patients were included in the study. Although the average age of the patients was 40 at baseline TBP, most patients developed new nevi between imaging sessions (median 16.4 years) with an average of 2.6 (SD = 4.8) nevi per participant. The average number of disappearing nevi was 0.3 (SD = 0.6). In addition, 62/106 (58%) patients had an absolute increase, and 9/106 (8%) patients had an absolute decrease in their total nevus count. Roughly half (49%: 1416/2890) of the nevi that could be evaluated at both time points increased in diameter by at least 25%. Only 6% (159/2890) of nevi shrunk in diameter by at least 25%. Patients with a history of melanoma had a higher rate of disappearing nevi, and their nevi were more likely to grow. Most nevi demonstrated no significant dermoscopic changes.

CONCLUSIONS

High-risk patients acquire new nevi throughout life with very few nevi disappearing over time. Contrary to prior reports, most nevi in adults increase in diameter, while few nevi shrink.

Dermatologic adverse events associated with IDH inhibitors ivosidenib and enasidenib for the treatment of acute myeloid leukemia

Two novel inhibitors of isocitrate dehydrogenase (IDHi), ivosidenib and enasidenib, significantly improve survival for AML patients with an IDH1 or IDH2 mutation, respectively; however, rash has been reported as a toxicity of IDHi. The objective of our study is to determine the incidence, grade, clinical, and histopathologic features of dermatologic adverse events (DAEs) secondary to IDHi. This study is a retrospective analysis of 169 patients who were treated with either ivosidenib or enasidenib as single agent or in combination with induction chemotherapy at Memorial Sloan Kettering Cancer Center from January 1, 2013 to April 1, 2021. DAEs thought to be possibly, probably, or definitely related to IDHi occurred in 55 of 169 patients [0.32, 95 % CI: 0.25 - 0.40]. Of a total 81 DAEs observed, the most common DAE types were inflammatory dermatoses (27 %); cutaneous vascular manifestations (8%); cutaneous infections (7%); and pruritus (2%). Notably, 50% of infections and 15.5% of rashes were high grade. Knowledge of these findings is critical to optimize the treatment and quality of life of patients with AML on IDHi.

In vivo tumor immune microenvironment phenotypes correlate with inflammation and vasculature to predict immunotherapy response

Response to immunotherapies can be variable and unpredictable. Pathology-based phenotyping of tumors into ‘hot’ and ‘cold’ is static, relying solely on T-cell infiltration in single-time single-site biopsies, resulting in suboptimal treatment response prediction. Dynamic vascular events (tumor angiogenesis, leukocyte trafficking) within tumor immune microenvironment (TiME) also influence anti-tumor immunity and treatment response. Here, we report dynamic cellular-level TiME phenotyping in vivo that combines inflammation profiles with vascular features through non-invasive reflectance confocal microscopic imaging. In skin cancer patients, we demonstrate three main TiME phenotypes that correlate with gene and protein expression, and response to toll-like receptor agonist immune-therapy. Notably, phenotypes with high inflammation associate with immunostimulatory signatures and those with high vasculature with angiogenic and endothelial anergy signatures. Moreover, phenotypes with high inflammation and low vasculature demonstrate the best treatment response. This non-invasive in vivo phenotyping approach integrating dynamic vasculature with inflammation serves as a reliable predictor of response to topical immune-therapy in patients.

Standard assessment of immune infiltration of biopsies is not sufficient to accurately predict response to immunotherapy. Here, the authors show that reflectance confocal microscopy can be used to quantify dynamic vasculature and inflammatory features to better predict treatment response in skin cancers.

Pilot Survey of Adoption of Telemedicine in Mohs Surgery During the COVID-19 Pandemic

BACKGROUND

The Covid-19 Pandemic prompted the widespread implementation of telemedicine across healthcare.

OBJECTIVE

To analyze telemedicine adoption by Mohs Micrographic surgeons (MMS) during the COVID-19 pandemic; to analyze the attitudes and perceived barriers to its long-term continuation by MMS practices.

METHODS AND MATERIALS

An online multiple-choice survey was distributed to members of the American College of Mohs Surgeons.

RESULTS

86.1% of surveyed Mohs surgeons initiated telemedicine during the pandemic surge. The most common uses for telemedicine amongst respondents were post-surgery management (77.4%), "spot checks" (60.9%), and surgical consultations (59.1%). 73.1% report patients were receptive to telemedicine. 68.6% believe that telemedicine has a place in dermatologic surgery; 49.5% plan to incorporate telemedicine into their surgical practices long-term. Physical exam limitations, fitting telemedicine into practice workflow, and patient reception/patient training were viewed as the most significant barriers to long-term implementation.

CONCLUSIONS

While valuable use cases for telemedicine were identified with most Mohs surgeon respondents feeling that telemedicine has a place in their practices, there is uncertainty in how to implement telemedicine into the dermatologic surgery practice workflow.

Combined PARP1-targeted nuclear contrast and reflectance contrast enhances confocal microscopic detection of basal cell carcinoma

Reflectance confocal microscopy (RCM) with endogenous backscattered contrast can noninvasively image basal cell carcinomas (BCCs) in skin. However, BCCs present with high nuclear density and the relatively weak backscattering from nuclei impose a fundamental limit on contrast, detectability, and diagnostic accuracy. We investigated PARPi-FL, an exogenous nuclear poly (ADP-ribose) polymerase (PARP1)-targeted fluorescent contrast agent and fluorescence confocal microscopy (FCM) towards improving BCC diagnosis. Methods: We tested PARP1 expression in 95 BCC tissues using immunohistochemistry, followed by PARPi-FL staining in 32 fresh surgical BCC specimens. Diagnostic accuracy of PARPi-FL contrast was evaluated in 83 surgical specimens. Optimal parameters for trans-epidermal permeability of PARPi-FL through intact skin was tested ex vivo on 5 human skin specimens and in vivo in 3 adult Yorkshire pigs. Results: We found significantly higher PARP1 expression and PARPi-FL binding in BCCs, as compared to normal skin structures. Blinded reading of RCM-and-FCM images by two experts demonstrated a higher diagnostic accuracy for BCCs with combined fluorescence and reflectance contrast, as compared to RCM-alone. Optimal parameters (time and concentration) for PARPi-FL trans-epidermal permeation through intact skin were successfully determined. Conclusion: Combined fluorescence and reflectance contrast may improve noninvasive BCC diagnosis with confocal microscopy.

Abstract 2814: Dynamic imaging of tumor-immune microenvironment (TiME) and microvasculature identifies ‘hot' and ‘cold' tumor phenotypes in vivo in patients

Investigating the dynamic crosstalk between the tumor-immune microenvironment (TiME) and microvasculature in vivo in patients can lead to important insights into the underlying biology, help identify tumor phenotypes and reveal attractive druggable targets.

Dynamic non-invasive label-free imaging of TiME and microvasculature in real-time directly in patients using reflectance confocal microscopy (RCM) was investigated on 60 skin cancer patients (basal cell carcinoma, BCC; squamous cell carcinoma, SCC), followed by automated and machine-learning based quantification of TiME and microvasculature features such as vascular density, leukocyte trafficking and immune cell density. Manual (two readers) and histopathological evaluation (dermatopathologist) of these features was also performed. Molecular correlation of imaging features and phenotypes was performed using anti-CD3/anti-CD20 IHC staining for tertiary lymphoid structures (TLS) and total lymphocyte density (n=33), flow cytometry for immune cells (n=3), and differential RNA expression (n=14). Correlation of RCM features and phenotypes at baseline (before treatment) with treatment response was also evaluated on 9 cancer lesions undergoing topical immunotherapy imiquimod. High agreement for feature presence on RCM and Histology, and manual and automated RCM features was observed. Unsupervised clustering on total TiME and microvasculature features on RCM using principal component analysis (PCA) indicates four distinct tumor phenotypes (PCA 1). The phenotype with high inflammation, high trafficking and higher density of vessels or the denoted ‘hot' phenotype correlated with higher activated CD8+ Granzyme B+ cells (67% of total CD8+cells). The clustering pattern on RCM was compared to TLS and lymphocyte density (PCA 2) and gene expression following CIBERSORT analysis (PCA 3). The clustering in RCM correlated better with gene expression (PCA 1 and 3, 100% agreement) than TLS and lymphocyte density (PCA 1 and 2, 86% agreement). The ‘hot' phenotype in RCM correlated with higher immune gene signatures and higher TLS/lymphocyte density. Increased plasma, CD8, activated CD4 memory and activated NK cells, M1 macrophages and monocytes, along with up-regulation of JAK-STAT, chemokine and cell adhesion signaling cascade were found in the ‘hot' RCM phenotype. Statistical modeling for correlating phenotypes with treatment outcomes was performed using principal component-linear discriminant analysis (PC-LDA). Two responders with tumor regression were predicted as ‘hot' phenotype while the non-responding patients (remaining 7) were classified as cold phenotype; suggesting that RCM 'hot' phenotype correlates with better treatment response. Thus, we demonstrate the potential utility of noninvasive RCM imaging in identifying ‘hot' and ‘cold' tumor phenotypes directly in patients.

Citation Format: Aditi Sahu, Melissa Gill, Miguel Cordova, Anthony Santella, Kivanc Kose, Teguru Tembo, Anabel Alfonso, Pratik Chandrani, Christi Fox, Salvador Gonzalez, Nicholas Kurtansky, Melissa Pulitzer, William Phillips, Madison Li, Kimeil King, Stephen Dusza, Shuaitong Liu, Ning Yang, Haaris Jilani, Paras Mehta, Ashfaq Marghoob, Allan Halpern, Anthony Rossi, Liang Deng, Chih-Shan Jason Chen, Milind Rajadhyaksha. Dynamic imaging of tumor-immune microenvironment (TiME) and microvasculature identifies ‘hot' and ‘cold' tumor phenotypes in vivo in patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2814.

A patient-centric dataset of images and metadata for identifying melanomas using clinical context

Prior skin image datasets have not addressed patient-level information obtained from multiple skin lesions from the same patient. Though artificial intelligence classification algorithms have achieved expert-level performance in controlled studies examining single images, in practice dermatologists base their judgment holistically from multiple lesions on the same patient. The 2020 SIIM-ISIC Melanoma Classification challenge dataset described herein was constructed to address this discrepancy between prior challenges and clinical practice, providing for each image in the dataset an identifier allowing lesions from the same patient to be mapped to one another. This patient-level contextual information is frequently used by clinicians to diagnose melanoma and is especially useful in ruling out false positives in patients with many atypical nevi. The dataset represents 2,056 patients (20.8% with at least one melanoma, 79.2% with zero melanomas) from three continents with an average of 16 lesions per patient, consisting of 33,126 dermoscopic images and 584 (1.8%) histopathologically confirmed melanomas compared with benign melanoma mimickers.

Angulated small nests and cords: Key diagnostic histopathologic features of infiltrative basal cell carcinoma can be identified using integrated reflectance confocal microscopy-optical coherence tomography

BACKGROUND

Accurate basal cell carcinoma (BCC) subtyping is requisite for appropriate management, but non-representative sampling occurs in 18% to 25% of biopsies. By enabling non-invasive diagnosis and more comprehensive sampling, integrated reflectance confocal microscopy-optical coherence tomography (RCM-OCT) may improve the accuracy of BCC subtyping and subsequent management. We evaluated RCM-OCT images and histopathology slides for the presence of two key features, angulation and small nests and cords, and calculated (a) sensitivity and specificity of these features, combined and individually, for identifying an infiltrative BCC subtype and (b) agreement across modalities.

METHODS

Thirty-three RCM-OCT-imaged, histopathologically-proven BCCs (17 superficial and/or nodular; 16 containing an infiltrative component) were evaluated.

RESULTS

The presence of angulation or small nests and cords was sufficient to identify infiltrative BCC on RCM-OCT with 100% sensitivity and 82% specificity, similar to histopathology (100% sensitivity, 88% specificity, kappa = 0.82). When both features were present, the sensitivity for identifying infiltrative BCC was 100% using either modality and specificity was 88% on RCM-OCT vs 94% on histopathology, indicating near-perfect agreement between non-invasive and invasive diagnostic modalities (kappa = 0.94).

CONCLUSIONS

RCM-OCT can non-invasively identify key histopathologic features of infiltrative BCC offering a possible alternative to traditional invasive biopsy.

Functional status and survival in patients ≥85 years of age who have keratinocyte carcinoma: A retrospective cohort study

BACKGROUND

Functional status assessment may help estimate which patients ≥85 years of age will benefit from surgical treatment for keratinocyte carcinoma (KC), but predictive value for short-term survival in this population has not been determined.

OBJECTIVE

We sought to assess the predictive value of functional status for short-term survival in patients ≥85 years of age who have KC.

METHODS

This was a retrospective cohort review of 238 patients ≥85 years of age who presented for the management of KC between 2010 and 2015. Functional status was assessed with the Karnofsky Performance Scale (KPS) and Katz Activities of Daily Living (ADL) index. Overall survival was determined.

RESULTS

Lower functional status scores of KPS ≤40 and Katz ADL ≤4 were associated with 37% and 53% survival at 2 years, respectively.

LIMITATIONS

Retrospective design and single-center study.

CONCLUSION

In this study, KPS and Katz ADL predicted short-term survival. Patients with low functional status scores had significantly decreased survival at 2 years, with double the death rate of patients with high functional status. Functional status should be considered during shared decision-making for elderly individuals who are seeking treatment for KC.

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.

Dermatology-specific and all-cause 30-day and calendar-year readmissions and costs for dermatologic diseases from 2010 to 2014

BACKGROUND

Readmissions for skin disease, particularly for the same diagnosis and over time, have not been well studied.

OBJECTIVE

To characterize hospital readmissions for skin disease.

METHODS

A cross-sectional observational study examined the Nationwide Readmissions Database from 2010 to 2014, a national sample of hospital discharges in the United States.

RESULTS

Of the patients in 3,602,599 dermatologic hospitalizations from 2010 to 2014, 9.8% were readmitted for any cause, 3.3% were admitted for the same diagnosis within 30 days, and 7.8% were readmitted for the same diagnosis within the calendar year (CY). The cost of all CY same-cause readmissions was $508 million per year. Mycosis fungoides had the highest 30-day all-cause readmission rate (32%), vascular hamartomas and dermatomyositis had the highest 30-day same-cause readmission rates (21% and 18%, respectively), and dermatomyositis and systemic lupus erythematosus had the highest CY same-cause readmission rates (31% and 24%, respectively). Readmission rates stayed stable from 2010 to 2014. Readmission for the same diagnosis was strongly associated with Medicaid and morbid obesity.

LIMITATIONS

This study is a broad description of hospitalizations for skin disease. Conclusions for individual diseases are not intended.

CONCLUSION

The rates and costs of readmissions for skin diseases remained high from 2010 to 2014. This study identifies diseases associated with high risk of hospital readmission, but disease-specific studies are needed. The diseases and risk factors presented should guide additional studies focused on strategies to reduce readmissions in specific skin diseases.

Follicular involvement is frequent in lentigo maligna: Implications for treatment

BACKGROUND

Follicular involvement of lentigo maligna (LM) is considered a histopathologic hallmark, but its prevalence and characteristics have not been well defined. The depth of intrafollicular extension by neoplastic melanocytes may have clinical importance in the treatment of LM.

OBJECTIVE

To describe the prevalence and features of follicular involvement in LM, including depth of follicular growth by melanocytes.

METHODS

A single-center retrospective study of 100 consecutive cases of surgically excised LM that was treated from 2013 to 2015. The slide review for cases with residual LM on the debulk specimen was performed by a dermatologic surgeon and dermatopathologist to characterize follicular involvement.

RESULTS

Of 100 specimens, 72 met the inclusion criteria for histopathologic evaluation. Follicular involvement was seen in 95.8% of specimens (95% confidence interval, 88.3%-99.1%), with a mean of 68% of follicles involved in a single specimen. The mean depth of intrafollicular growth by lesional melanocytes was 0.45 mm (standard deviation, 0.23; range, 0.1-1.1 mm). Tumor cells were confined to the infundibular portion of the hair follicle in 60.9% of specimens.

CONCLUSION

Superficial follicular involvement is a ubiquitous finding in LM. When treatment options for LM with a depth-dependent modality aiming for tumor clearance are being considered, mean and maximum depths of involvement should be taken into consideration.

Effect of laser therapy on quality of life in patients with radiation-induced breast telangiectasias

OBJECTIVE

To evaluate the effects of laser monotherapy on quality of life in breast cancer patients with chronic radiation dermatitis.

STUDY DESIGN

A prospective, IRB-approved study was conducted at Memorial Sloan Kettering Cancer Center. Breast cancer patients with chronic radiation dermatitis completed health-related quality of life (HR-QOL) questionnaires before and after laser monotherapy for radiation-induced breast telangiectasias (RIBT).

METHODS

After informed consent, all patients were issued the Skindex-16 and Breast-Q Adverse Effects of Radiation HR-QOL questionnaires prior to receiving laser treatment. Patients were treated with a 595 nm pulsed dye laser at 4- to 6-week intervals, with percent telangiectasia clearance and adverse events recorded at each visit. Post-treatment HR-QOL questionnaires were collected after clinician-assessed telangiectasia clearance of >50%. Median HR-QOL scores before and after therapy were reported for individual HR-QOL domains (Skindex-16) and HR-QOL totals (Skindex-16 and Breast-Q Adverse Effects of Radiation). Before- and after-differences were calculated using the Wilcoxon Signed-Rank Test.

RESULTS

Twenty-two female patients (average age 56 years) enrolled in this study. A majority (13/22, 59%) exhibited telangiectasias across the décolletage and axilla in addition to the breast. Sixteen patients reached the 50% RIBT clearance threshold during the study period, and 11 of these patients (69%) completed follow-up HR-QOL questionnaires. Patients showed statistically significant improvements in emotional and functional Skindex-16 HR-QOL domains and in overall Skindex-16 HR-QOL score. Breast-Q scores also improved significantly, illustrating a decrease in specific physical and cosmetic concerns common to radiated breast skin. Common adverse events were transient post-treatment pain and redness.

CONCLUSION

Breast cancer patients with RIBT presented with substantial deficits in several HR-QOL arenas. Laser monotherapy effectively treated the appearance of radiation dermatitis in these patients and also significantly improved HR-QOL. Lasers Surg. Med. 50:284-290, 2018. © 2017 Wiley Periodicals, Inc.

Implementation and impact of ultraviolet environmental disinfection in an acute care setting

BACKGROUND

Multiple-drug-resistant organisms (MDROs) and Clostridium difficile (CD) are significant problems in health care. Evidence suggests that these organisms are transmitted to patients by the contaminated environment.

METHODS

This is a retrospective study of the implementation of ultraviolet environmental disinfection (UVD) following discharge cleaning of contact precautions rooms and other high-risk areas at Westchester Medical Center, a 643-bed tertiary care academic medical center. Incidence rates of hospital-acquired MDROs plus CD before and during the UVD use were evaluated using rate ratios and piecewise regression.

RESULTS

The average time per UVD was 51 minutes, and machines were in use 30% of available time. UVD was used 11,389 times; 3,833 (34%) of uses were for contact precautions discharges. UVD was completed for 76% of contact precautions discharges. There was a significant 20% decrease in hospital-acquired MDRO plus CD rates during the 22-month UVD period compared with the 30-month pre-UVD period (2.14 cases/1,000 patient-days vs 2.67 cases per 1,000 patient-days, respectively; rate ratio, 0.80; 95% confidence interval: 0.73-0.88, P < .001).

CONCLUSION

During the time period UVD was in use, there was a significant decrease in overall hospital-acquired MDRO plus CD in spite of missing 24% of opportunities to disinfect contact precautions rooms. This technology was feasible to use in our acute care setting and appeared to have a beneficial effect.

Redefining the number needed to excise

The number needed to excise (NNE) is a metric used to convey the efficiency of dermatological practice by serving as a gauge for the diagnostic accuracy of melanoma. Rather than an NNE for melanoma alone, we assert that the NNE should measure all skin cancer types and we present data on NNE from two clinical sites demonstrating the utility and trends in NNE over time.

Developing an interactive web-based learning program on skin cancer: the learning experiences of clinical educators

Web-based learning in medical education is rapidly growing. However, there are few firsthand accounts on the rationale for and development of web-based learning programs. We present the experience of clinical educators who developed an interactive online skin cancer detection and management course in a time-efficient and cost-efficient manner without any prior skills in computer programming or technical construction of web-based learning programs. We review the current state of web-based learning including its general advantages and disadvantages as well as its specific utility in dermatology. We then detail our experience in developing an interactive online skin cancer curriculum for primary care clinicians. Finally, we describe the main challenges faced and lessons learned during the process. This report may serve medical educators who possess minimal computer programming and web design skills but want to employ the many strengths of web-based learning without the huge costs associated with hiring a professional development team.

Fluorescence In Situ Hybridization (FISH) Analysis of Melanocytic Nevi and Melanomas

A 4-color fluorescence in situ hybridization (FISH) assay, using probes to chromosomes 11q, 6p, 6q, and 6 cent, has recently been proposed as an ancillary tool for the diagnosis of melanoma. The authors report herein their experience with this assay. To determine the sensitivity and specificity of the assay for histopathologically unequivocal cases, they analyzed 50 melanocytic nevi, 50 primary melanomas, and 15 metastatic melanomas. Of 50 melanocytic nevi, 47 were FISH negative on initial readout (test sensitivity, 94%); 49 were FISH negative after correction for tetraploidy (test specificity, 98%). Of 50 primary melanomas, 41 were FISH positive (test sensitivity, 82%). Of 15 metastatic lesions, 13 were FISH positive (test sensitivity, 85%). Of the 9 FISH-negative melanomas, 6 metastasized. The tumors of the 5 patients who had survived thick primary melanoma for more than 5 years without recurrence were all FISH positive. Half of the patients whose primary melanoma was tested by FISH had undergone sentinel lymph node (SLN) biopsy. When the authors compared the FISH results of those 25 melanomas with the SLN status, no statistically significant correlation was found. These findings document limitations of the current FISH assay. A rare nevus may be FISH positive. Some primary metastasizing melanomas are FISH negative. Even metastatic melanomas can be FISH negative. Awareness of the limitations in test sensitivity and specificity of the FISH assay is important to avoid an erroneous diagnosis by overreliance on cytogenetic findings. Correlation with clinical and histopathological findings is paramount for accurate diagnosis.

Use of Fluorescence In Situ Hybridization to Distinguish Metastatic Uveal From Cutaneous Melanoma

Metastatic lesions of malignant melanoma can on occasion be difficult to classify with regard to the primary site of origin. Given the lack of specificity of light microscopic features, ancillary studies are needed. In this study, the authors explored the possibility of distinguishing metastatic tumors derived from uveal primaries from those known to have originated from a cutaneous melanoma by fluorescence in situ hybridization (FISH) using probes for chromosome 3, 8q24, and 1p36. A total of 32 metastatic tumors were analyzed by FISH. Monosomy 3 was detected in 9 out of 16 (56.3%) cases of metastatic uveal melanoma but was not found in any of the 16 metastatic cutaneous melanomas ( P < .001). With regard to 1p36, amplifications were found in 8 out of 16 (50%) cases of metastatic cutaneous melanoma but not in any case of uveal melanoma ( P < .05). 1p36 was deleted in 3 cases of uveal and 1 case of cutaneous melanoma. Amplifications of 8q were found in 15 out of 16 (94%) cases of uveal melanoma metastases and in 12 out of 16 (75%) cases of cutaneous metastases. The findings suggest that FISH for monosomy 3 is a useful adjunct tool in the differential diagnosis of metastatic uveal versus cutaneous melanoma.

Skin cancer education for primary care physicians: a systematic review of published evaluated interventions

BACKGROUND

Early detection of melanoma may provide an opportunity to positively impact melanoma mortality. Numerous skin cancer educational interventions have been developed for primary care physicians (PCPs) to improve diagnostic accuracy. Standardized training is also a prerequisite for formal testing of melanoma screening in the primary care setting.

OBJECTIVE

We conducted a systematic review to determine the extent of evaluated interventions designed to educate PCPs about skin cancer, including melanoma.

DESIGN

Relevant studies in the English language were identified through systemic searches performed in MEDLINE, EMBASE, BIOSIS, and Cochrane through December 2010. Supplementary information was obtained from corresponding authors of the included studies when necessary.

APPROACH

Studies eligible for inclusion formally evaluated skin cancer education interventions and were designed primarily for PCPs. Excluded studies lacked a specified training intervention, used decision-making software, focused solely on risk factor identification, or did not directly educate or assess participants. Twenty studies met the selection criteria. Data were extracted according to intervention content and delivery format, and study outcomes.

KEY RESULTS

All interventions included instructions about skin cancer diagnosis, but otherwise varied in content. Curricula utilized six distinct educational techniques, usually incorporating more than one. Intervention duration varied from 12 min to over 6 h. Eight of the 20 studies were randomized trials. Most studies (18/20, 90%) found a significant improvement in at least one of the following five outcome categories: knowledge, competence, confidence, diagnostic performance, or systems outcomes. Competence was most commonly measured; no study evaluated all categories. Variability in study design, interventions, and outcome measures prevented correlation of outcomes with intervention characteristics.

CONCLUSIONS

Despite the development of many isolated educational interventions, few have been tested rigorously or evaluated under sufficient standardized conditions to allow for quantitative comparison. Improved and rigorously tested skin cancer educational interventions for PCPs with outcome measures focusing on changes in performance are needed.

Number of Satellite Nevi as a Correlate for Neurocutaneous Melanocytosis in Patients With Large Congenital Melanocytic Nevi

BACKGROUND

Patients with large congenital melanocytic nevi (LCMN) are at risk for neurocutaneous melanocytosis (NCM). Patients with LCMN on the posterior axis or in conjunction with many satellite melanocytic nevi seem to represent subgroups at greatest risk.

OBJECTIVE

To determine the relationship between LCMN location, number of satellite nevi, and risk of NCM.

DESIGN

Descriptive survey study.

SETTING

An Internet Web-based registry of patients with LCMN, maintained by a nevus support group (Nevus Outreach Inc).

PARTICIPANTS

Individuals with LCMN or their guardians visiting the Nevus Outreach Web site were provided the opportunity to complete the questionnaire.

OUTCOME MEASURES

Location of LCMN, number of satellite nevi, and NCM as assessed by patient self-report.

RESULTS

A total of 379 patients with LCMN were evaluated, 26 of whom had NCM. A significantly higher percentage of patients with NCM had their LCMN on the posterior axis compared with patients without NCM (96% and 70%, respectively). Patients with NCM had significantly more satellite melanocytic nevi compared with non-NCM patients (median, 68.5 and 18, respectively). Furthermore, patients with LCMN and more than 20 satellites had a 5.1-fold (95% confidence interval, 1.9-14.0) increased risk for NCM compared with LCMN patients with 20 or fewer satellites. Logistic regression analysis, controlling for age, sex, number of satellite nevi, and LCMN location, identified number of satellite nevi as the only significant risk factor for NCM.

CONCLUSIONS

The presence of large numbers of satellite nevi is the most important risk factor for NCM in patients with LCMN. Although location of the LCMN on the posterior axis was a moderate risk factor for NCM in univariate analysis, the strength of the relationship was attenuated in the multivariate analysis.

Serologic evidence for West Nile virus infection in birds in Staten Island, New York, after an outbreak in 2000

After an outbreak of West Nile virus (WNV) infections in people, horses, and wildlife in Staten Island, NY, during the summer of 2000, we surveyed the bird population of the island for evidence of infection. Neutralizing antibodies were detected in 59 of 257 (23.0%) resident birds and none of 96 transient (migrating) birds sampled in early October. Species with the greatest seroprevalence were northern cardinal (Cardinalis cardinalis) (69.2%) and rock dove (Columba livia) (54.5%). House sparrows (Passer domesticus) and chickens (Gallus gallus) had lower than expected seroprevalences, 8.6% and 5.5%, respectively. The geographic distribution of seropositivity suggested focal transmission at several locations on the island. The concentration of seropositive birds among resident bird populations on Staten Island supports the concept that many birds survive WNV infection and that some of these play an important role in the WNV-bird-mosquito transmission cycle.

Use of and beliefs about baseline photography in the management of patients with pigmented lesions: a survey of dermatology residency programmes in the United States

Medical photography is often used in dermatology to aid in the clinical surveillance of patients with pigmented lesions. This study aimed to assess the utilization, logistics, rationale and beliefs about the usefulness of baseline photography in patients with pigmented lesions by physicians in dermatology residency programmes, and to compare current utilization to that reported in the last decade. Questionnaires were mailed to directors of all accredited dermatology residency programmes in the United States (n = 105). Eighty-three physicians responded to the questionnaire (79%). Utilization of total body and individual lesion photography was reported by 63% and 75% of the respondents, respectively; 16% of the respondents did not use any method of photography. Reasons for using photography included the following beliefs: that it helps detect early melanoma, it results in fewer biopsies, and it reduces patient anxiety. Financial and logistical constraints were reasons why some programmes were not utilizing photography. Thus baseline photography is currently used in a majority of academic dermatology programmes as an aid in the early detection of melanoma.

Issues in the epidemiology of melanoma

Cutaneous melanoma is a significant health problem throughout the developing world. Primary and secondary prevention are discussed. The wavelengths of the ultraviolet radiation spectrum and their association with melanoma are discussed. Although excessive sun exposure during childhood is a critical risk factor, excessive sun exposure during adult years is also important. The major risk factors for melanoma--numerous or atypical moles and a sun-sensitive phenotype--are genetic. Their interaction with sun exposure is currently being examined, as well as the interaction of other genetic factors, such as alterations in the melanocortin receptor and the familial melanoma gene, INK4A. Secondary prevention strategies include self-examination and physician examination. New technologies are being developed to supplement visual examination of suspected lesions. These technologies are discussed in detail and include digital photography, digital dermoscopy, confocal scanning laser microscopy and automated diagnosis systems.