Adam R. Schmitt

Staging for Cutaneous Squamous Cell Carcinoma as a Predictor of Sentinel Lymph Node Biopsy Results: Meta-analysis of American Joint Committee on Cancer Criteria and a Proposed Alternative System

IMPORTANCE The appropriate clinical setting for the application of sentinel lymph node biopsy (SLNB) in the management of cutaneous squamous cell carcinoma (cSCC) is not well characterized. Numerous case reports and case series examine SLNB findings in patients who were considered to have high-risk cSCC, but no randomized clinical trials have been performed. OBJECTIVE To analyze which stages in the American Joint Committee on Cancer (AJCC) criteria and a recently proposed alternative staging system are most closely associated with positive SLNB findings in nonanogenital cSCC. DESIGN, SETTING, AND PARTICIPANTS Medical literature review and case data extraction from private and institutional practices to identify patients with nonanogenital cSCC who underwent SLNB. Patients were eligible if sufficient tumor characteristics were available to classify tumors according to AJCC staging criteria and a proposed alternative staging system. One hundred thirty patients had sufficient data for AJCC staging, whereas 117 had sufficient data for the alternative system. EXPOSURE Nonanogenital cSCC and SLNB. MAIN OUTCOMES AND MEASURES Positive SLNB findings by cSCC stage, quantified as the number and percentage of positive nodes. RESULTS A positive SLN was identified in 12.3% of all patients. All cSCCs with positive SLNs were greater than 2 cm in diameter. The AJCC criteria identifed positive SLNB findings in 0 of 9 T1 lesions (0%), 13 of 116 T2 lesions (11.2%), and 3 of 5 T4 lesions (60.0%). No T3 lesions were identified. The alternative staging system identified positive SNLB findings in 0 of 9 T1 lesions (0%), 6 of 85 T2a lesions (7.1%), 5 of 17 T2b lesions (29.4%), and 3 of 6 T3 lesions (50.0%). Rates of positive SLNB findings in patients with T2b lesions were statistically higher than those with T2a lesions (P = .02, Fisher exact test) in the alternative staging system. CONCLUSIONS AND RELEVANCE Our findings suggest that most cSCCs associated with positive SLNB findings occur in T2 lesions (in both staging systems) that are greater than 2 cm in diameter. The alternative staging system appears to more precisely delineate high-risk lesions in the T2b category that may warrant consideration of SLNB. Future prospective studies are necessary to validate the relationship between tumor stage and positive SLNB findings and to identify the optimal staging system.

Management of Unusual Cutaneous Malignancies: Atypical Fibroxanthoma, Malignant Fibrous Histiocytoma, Sebaceous Carcinoma, Extramammary Paget Disease

Atypical fibroxanthoma, malignant fibrous histiocytoma, sebaceous carcinoma, and extramammary Paget disease are rare cutaneous tumors. Their recognition and diagnosis are critical in decreasing long-term morbidity and mortality. Surgical excision is the treatment of choice for these tumors, and Mohs micrographic surgery has been shown to be as favorable or better than wide local excision in providing long-term clearance rates.

Solar keratoses: Photodynamic therapy, cryotherapy, 5-fluorouracil, imiquimod, diclofenac, or what? Facts and controversies ☆

Actinic keratosis is a common dermatologic condition that may regress, remain stable, or progress to squamous cell carcinoma. Some question whether all actinic keratoses should be routinely treated, whereas others contend that the unpredictable natural history of this disease necessitates treatment to prevent malignant transformation. Available treatments include photodynamic therapy, cryotherapy, 5-fluorouracil, imiquimod, and diclofenac. Each of these options has its advantages and disadvantages, although they all have a place in the management of actinic keratosis. An overview of these treatment modalities is presented, as are the controversies surrounding the treatment of actinic keratosis.

Incidence and Clinical Features of Rare Cutaneous Malignancies in Olmsted County, Minnesota, 2000 to 2010

BACKGROUND The incidence of rare cutaneous malignancies is unknown. Current estimates of rare cutaneous malignancy incidences are based on broad epidemiologic data or single institution experiences, not population-based data. OBJECTIVE To determine the incidence of several rare nonmelanoma skin cancers. MATERIALS AND METHODS The authors conducted a retrospective chart review of a population-based cohort between the years 2000 and 2010. Residents of Olmsted County, Minnesota, who were diagnosed with a biopsy-proven nonmelanoma skin cancer—excluding basal cell carcinoma and squamous cell carcinoma—were included in this study. The primary outcome was tumor incidence. Additionally, the authors extracted patient demographics, tumor characteristics, treatment modalities, and outcomes. RESULTS The age-adjusted and sex-adjusted incidences per 100,000 persons of multiple rare cutaneous malignancies were: atypical fibroxanthoma (1.8), sebaceous carcinoma (0.8), dermatofibrosarcoma protuberans (0.4), microcystic adnexal carcinoma (0.7), eccrine carcinoma (0.4), eccrine porocarcinoma (0.2), and leiomyosarcoma (0.2). CONCLUSION The authors report population-based incidences and clinical characteristics for these rare cutaneous malignancies. The immune status and smoking status of patients and the treatment and outcomes of these tumors are reported. Additional studies in a broader population are needed to further define the epidemiology and outcomes of these malignancies.

Actinic Neoplasia Syndrome and an Update on the Epidemiology of Basal Cell Carcinoma, Squamous Cell Carcinoma, and Actinic Keratosis

Nonmelanoma skin cancer (NMSC) is the most common cancer in the world, and the incidence is rising. Accurate measures of prevalence and incidence are difficult to obtain and verify, however, because most countries do not keep registries for NMSC. Actinic neoplasia syndrome conceptualizes multiple NMSCs, as well as other signs of extensive ultraviolet radiation exposure, as a chronic illness, rather than a series of individual events. We provide an overview of the epidemiology of basal cell carcinoma and squamous cell carcinoma, as well as actinic keratosis, another exceedingly common consequence of ultraviolet radiation. We also discuss actinic neoplasia syndrome and its implications for patient care.

Case Study E: Multidisciplinary Management of Merkel Cell Carcinoma

A 79-year-old white male with a history of multiple squamous cell and basal cell carcinomas presented to his dermatologist for routine follow-up. Upon examination, a 3×3 mm erythematous dome-shaped papule was noted on the left cheek, approximately 1.0 cm from the left lower eyelid. No palpable lymphadenopathy was found in the head and neck. Biopsy of the lesion revealed Merkel cell carcinoma that stained positive for AE1/AE3 and negative for CK20, TTF1, S100, HMB45, CD45RB, and melan-A. A chest radiograph showed no sign of lung malignancy. The patient was subsequently referred to the author (JSB) for treatment and presented at the University Hospitals Case Medical Center Multidisciplinary Cutaneous Oncology Tumor Board. Sentinel lymph node biopsy (SLNB) and Mohs micrographic surgery were recommended by the group. Mohs micrographic surgery was recommended due to the proximity of the tumor to the eyelid and the morbidity that would result from performing a 1–2 cm wide local excision around the tumor. Mohs micrographic surgery was performed in an outpatient setting under local anesthesia. One stage of Mohs surgery was required to obtain clear margins, resulting in an 8×10 mm surgical defect. The surgery did not interfere with the integrity of the eyelid. The resultant surgical defect was not repaired immediately and the patient subsequently underwent SLNB followed by linear repair of the surgical defect. The SLNB was performed successfully and yielded one node negative for malignancy (the node stained negative for AE1/AE3). The patient was discussed once more at the University Hospitals Case Medical Center Multidisciplinary Cutaneous Oncology Tumor Board. The clinical size of the tumor was <2 cm (T1), the SLNB did not show any tumor (N0), and there was no sign of distant metastasis (M0). Based on AJCC staging criteria, the patient was staged as IA. The tumor board recommended that the patient see a radiation oncologist familiar with the treatment of Merkel cell carcinoma to discuss the advantages and side effects of adjuvant radiation therapy. After consultation the patient decided to undergo radiation therapy to the primary site. He received 50 Gy in 25 fractions of 2 Gy each to the left upper cheek and periorbital region. Though the patient developed erythema in the irradiated region through the entire treatment volume, he did not experience any erythema on the conjunctivae or eyelids, and the treatment was generally well-tolerated. The patient is now being seen every 3 months by his general dermatologist. He has been instructed to palpate the surgery site and examine his head and neck for lymphadenopathy every month. Two years following diagnosis he is free of disease.