Enrique Herrera-Acosta

Photodynamic therapy in the treatment of extensive Bowen's disease

Abstract Background: Surgical excision is the preferred method of eradicating Bowen´s disease (BD). Photodynamic therapy (PDT) has been successfully used for treatment of actinic keratosis, basal cell carcinoma, and BD. Objective: Our aim was to evaluate the efficacy and tolerability of PDT for treatment of extensive BD. Method: Eighteen patients with 23 biopsy-proven BD lesions were treated with PDT. We defined as extensive those lesions large than 3 cm. Methyl aminolevulinate cream was applied for 3 h before illumination with an light emitting diode light source at a wavelength of 630 nm (energy density of 37 J/cm²). Treatment was repeated 1 week later. Results: After 12 weeks of treatment, 22 of 23 BD lesions (90%) showed complete clinical response. Only three lesions recurred after a follow-up period of 12 months. Cosmetic outcome at 12 months was good or excellent in 94% of patients. Conclusion: Methyl aminolevulinate PDT is an effective treatment option for extensive BD with excellent cosmesis.

Prediction of sentinel lymph node positivity by growth rate of cutaneous melanoma.

OBJECTIVE To determine whether growth rate (GR) of cutaneous melanoma predicts the histological sentinel lymph node (SLN) positivity. DESIGN Retrospective cohort study. SETTING Two tertiary melanoma referral centers. PATIENTS A total of 698 patients with invasive primary cutaneous melanoma in whom the SLN was identified between January 1, 2000, and June 30, 2010. MAIN OUTCOME MEASURE Based on previous studies, a surrogate measure for GR in primary invasive melanoma was calculated as the ratio of Breslow thickness to time to melanoma development. RESULTS The SLN was positive in 20.2% of patients. Multivariate logistic regression analysis revealed that GR, Breslow thickness, and the presence of microscopic satellitosis were independently associated with SLN positivity. The probability of SLN positivity was 8.2% for slow-growth melanomas (<0.10 mm/mo) compared with 19.8% for intermediate-growth melanomas (0.10-0.50 mm/mo) and 37.7% for fast-growth melanomas (>0.50 mm/mo). Growth rate was not an independent predictive factor for survival. CONCLUSION Growth rate of primary cutaneous melanoma, together with Breslow thickness and the presence of microscopic satellitosis, predicts the histological SLN positivity.

Erosive pustular dermatosis of the scalp: a successful treatment with photodynamic therapy.

Erosive pustular dermatosis of the scalp (EPDS) is a rare inflammatory disease of unknown aetiology that usually occurs in the elderly. It is characterized by sterile pustules, chronic crusted erosions, cicatricial alopecia, and skin atrophy. The histopathology is nonspecific, and its pathophysiology remains undetermined, with various types of local trauma possibly acting as the triggering factor. We describe a case of EPDS in a 75‐year‐old female in whom there was a marked response to photodynamic therapy with methyl 5‐aminolaevulinic acid.

Correlation of the growth rate of melanoma with the temporal appearance of metastasis.

Editor In our daily clinical practice, we see that melanomas grow at different speeds. Following resection of the primary tumour, some tumours recur within a few months whereas others reappear several years later. The growth rate (GR) of a melanoma, calculated from the thickness of the lesion and its period of evolution as provided by the patient, is the only tool currently available to estimate this speed. A rapid GR is related with a more aggressive phenotype of melanoma as well as with male gender and older persons. GR has also been shown to be an independent prognostic factor for overall survival, and is directly related with the temporal appearance of systemic metastasis and the death of the patient. From a retrospective historical cohort of 416 patients with localized melanoma (levels I and II) seen at the Dermatology Department of the Virgen de la Victoria hospital in Malaga, Spain, between 1990 and 2004, we studied those cases that developed systemic metastasis leading to death (N = 31 patients). The patients were grouped according to the GR of their tumours. For each group, data were collected on the means of three different time intervals: (i) time of clinical evolution of the lesion from its appearance as noticed by the patient to excision, (ii) the clinical appearance of systemic metastasis and (iii) date of patient death. Representation of the melanomas according to their GR (Fig. 1) showed that the period of evolution until excision was inversely proportional to the growth rate. Thus, this period was just 4.6 months for melanomas with a GR > 1.01 mm per month, 22 months for melanomas with a GR of 0.11–0.3 mm per month, 15.6 months for melanomas with a GR of 0.31–0.5 mm per month, 8.4 months for melanomas with a GR of 0.51–1 mm per month and 76.8 months for melanomas with a GR < 0.1 mm per month. Systemic metastasis appeared earlier the faster the melanoma grew. Thus, for melanomas with a GR of > 1.01 mm per month the metastasis appeared after 10.2 months, 30.3 months for melanomas with a GR of 0.51–1 mm per month, 36.6 months for melanomas with a GR of 0.31–0.5 mm per month, 39 months for melanomas with a GR of 0.11–0.3 mm per month, and 113.8 months for melanomas with a GR < 0.1 mm per month. The information obtained from the clinical history provided a wider view of the evolution of a melanoma since the time it became visible. The GR, although it is subjectively based on the patient’s observations, correlated very well with cell proliferation markers. This type of scheme could be useful for the elaboration of future follow-up protocols. The current protocols are based on strict controls during the first years after diagnosis with later half-yearly or yearly controls. We may be able to adjust the frequency of physical examinations and complementary tests according to the GR of the melanoma. Another possible implication concerns the design of clinical trials, for example, if we know the GR of the melanoma, we can select the patients according to the estimated time of relapse. This way we could avoid long periods of follow-up or even what has been termed the myth of cure at 5 years given the presence of tumours able to recur beyond this period.

Effect of time to sentinel-node biopsy on the prognosis of cutaneous melanoma.

INTRODUCTION In patients with primary cutaneous melanoma, there is generally a delay between excisional biopsy of the primary tumour and sentinel-node biopsy. The objective of this study is to analyse the prognostic implications of this delay. PATIENTS AND METHOD This was an observational, retrospective, cohort study in four tertiary referral hospitals. A total of 1963 patients were included. The factor of interest was the interval between the date of the excisional biopsy of the primary melanoma and the date of the sentinel-node biopsy (delay time) in the prognosis. The primary outcome was melanoma-specific survival and disease-free survival. RESULTS A delay time of 40 days or less (hazard ratio (HR), 1.7; confidence interval (CI), 1.2-2.5) increased Breslow thickness (Breslow ⩾ 2 mm, HR, > 3.7; CI, 1.4-10.7), ulceration (HR, 1.6; CI, 1.1-2.3), sentinel-node metastasis (HR, 2.9; CI, 1.9-4.2), and primary melanoma localised in the head or neck were independently associated with worse melanoma-specific survival (all P < 0.03). The stratified analysis showed that the effect of delay time was at the expense of the patients with a negative sentinel-node biopsy and without regression. CONCLUSION Early sentinel-node biopsy is associated with worse survival in patients with cutaneous melanoma.

Pigmented mammary Paget disease mimicking cutaneous melanoma

A 55-year-old Spanish woman was referred to our department regarding a 3-year history of asymptomatic progressively enlarging pigmented lesion on her left mammary nipple and areola, without associated discharge. Physical examination revealed a 4.5 · 3 cm, dark brown, well-defined plaque involving the 80% of the areola and the nipple had disappeared (Fig. 1). On dermoscopy, the lighter portion of the lesion corresponded to a whitish-pink area with irregular linear vessels resembling an area of regression, whereas the darker portion was characterized by dark brown diffuse pigmentation with irregular black dots and small graywhite structures (Fig. 2). Although the criteria were not completely specific, the dermoscopic features suggested a

Chronology of Metastasis in Cutaneous Melanoma: Growth Rate Model

In humans, it is not possible to obtain experimental evidence of when a cancer begins to metastasize. The purpose of this study was to estimate the time of onset of metastatic dissemination in cutaneous melanoma using a model based on its growth rate (GR). The critical time of onset of metastatic dissemination below which no cases of fatal melanomas were seen may be described with a potential function in which this time is inversely proportional to the GR. The critical time of development beyond which a melanoma may metastasize presents great variation. This time was just 1 month for those melanomas with a fast GR, whereas it was over 5 years for those with a very slow GR. Quantitatively, the fastest-growing melanomas began metastasizing with a greater thickness than the slowest-growing melanomas. A correlation exists between the critical time of onset of metastatic potential and the GR of the melanoma. These results may well have relevance to the understanding of mechanisms of tumor dissemination and for the design of future studies on melanomas, irrespective of whether they are basic studies on biomolecular mechamisms or clinical studies.

Factores predictivos del estado del ganglio centinela en el melanoma cutáneo: análisis mediante un árbol de clasificación y regresión

OBJECTIVE The main aim of this study was to identify predictors of sentinel lymph node (SN) metastasis in cutaneous melanoma. PATIENTS AND METHODS This was a retrospective cohort study of 818 patients in 2 tertiary-level hospitals. The primary outcome variable was SN involvement. Independent predictors were identified using multiple logistic regression and a classification and regression tree (CART) analysis. RESULTS Ulceration, tumor thickness, and a high mitotic rate (≥6 mitoses/mm(2)) were independently associated with SN metastasis in the multiple regression analysis. The most important predictor in the CART analysis was Breslow thickness. Absence of an inflammatory infiltrate, patient age, and tumor location were predictive of SN metastasis in patients with tumors thicker than 2mm. In the case of thinner melanomas, the predictors were mitotic rate (>6 mitoses/mm(2)), presence of ulceration, and tumor thickness. Patient age, mitotic rate, and tumor thickness and location were predictive of survival. CONCLUSIONS A high mitotic rate predicts a higher risk of SN involvement and worse survival. CART analysis improves the prediction of regional metastasis, resulting in better clinical management of melanoma patients. It may also help select suitable candidates for inclusion in clinical trials.

Change over time in the rates of adverse events in patients receiving systemic therapy for psoriasis: A cohort study

To the Editor: How the incidence of adverse events in patients with psoriasis treated with systemic drugs varies over time is not well established. Information on trends in adverse events would be useful in clinical practice to inform the frequency of follow-up visits and laboratory tests. Our objective was to describe the incidence of adverse events over time. We used a cohort of patients with psoriasis who were receiving systemic therapy, the Spanish Registry of Adverse Events for Biological Therapy in Dermatological Diseases (BIOBADADERM) cohort, to calculate the incidence rate of adverse events by period of time. Incidence rate ratios were obtained by using a Poissonmixed-model regression considering the center as a random effect to take within-center clustering of patients into account. Data on 2084 patients and 7282 person-years with 5018 adverse events were included. Detailed baseline characteristics of patients exposed to each drug are described in Table I. Some drugs, such as cyclosporine or infliximab, were associated with higher rates of overall adverse events. For most drugs, rates of overall adverse events were higher in the first year (Table II). This first-year peak was especially marked for cyclosporine, although it is barely used beyond 1 year. If we focused on serious adverse events (SAEs), rates were much lower than the rates of overall adverse events and higher for cyclosporine and infliximab overall. Rates of abnormal laboratory results showed an increase in the first year in the case of classic drugs, whereas for

Survival rate of etanercept for psoriasis in real life: a multicentre observational study.

The classic systemic treatments for psoriasis, such as cyclosporine, methotrexate and phototherapy, are limited by their accumulative toxicity [1] and the new generation of monoclonal antibody-based treatments is in trial. The concept of treatment survival is defined as the time for which a drug remains a suitable option for a given patient [2] and is considered a therapeutic success factor, depending on its efficacy, the presence of adverse events and patient satisfaction [3-5]. A few drug-survival [...]