Jennifer A. Stein

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

Importance Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States. Objective To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Single versus multiple primary melanomas: old questions and new answers.

In patients with multiple primary melanomas (MPM), mean tumor thickness tends to decrease from the first melanoma to the second melanoma, and prognosis may be improved compared with the prognosis for patients who have a single primary melanoma (SPM). In this study, the authors compared the clinicopathologic features of patients with MPM and SPM to better characterize the differences between these 2 groups and to determine whether or not there is an inherent difference in tumor aggression.

Confluent and reticulated papillomatosis associated with tinea versicolor in three siblings

Abstract:  We describe three teenage siblings with confluent and reticulated papillomatosis, all presenting during a 6‐month period. Two of the three patients had confirmed tinea versicolor, with positive potassium hydroxide scrapings, in association with this entity. This is the largest series of siblings with confluent and reticulated papillomatosis, and the only report describing family members having both confluent and reticulated papillomatosis and tinea versicolor. This report lends further evidence to the hypothesis that confluent and reticulated papillomatosis may be etiologically linked to tinea versicolor, and also suggests a genetic predisposition for it.

Patient perspectives on medical photography in dermatology.

BACKGROUND Clinical photography enhances medical care, research, and teaching. Empirical data are needed to guide best practices regarding dermatologic photography. OBJECTIVE To investigate patient opinion about clinical photography and identify demographic factors that influence these opinions. METHODS AND MATERIALS Four hundred patients representing a broad range of ages, self-identified ethnic/racial groups, and socioeconomic levels were recruited from 4 dermatology settings in New York City. Patients were administered a survey about perceptions of photography, willingness to allow photographs to be used in a variety of settings, preferences for photographer and photographic equipment, and methods of consent. RESULTS Eighty-eight percent of patients agreed that photography enhanced their quality of care. Most patients would allow their photographs to be used for medical, teaching, and research purposes with significantly more acceptance when patients were not identifiable. Patients preferred photographs taken by a physician rather than a nurse or student, photographers of the same gender, clinic-owned cameras to personal cameras or cell phones, and written consent to verbal consent. There were significant racial/ethnicity and age-related variations in responses, with white and older patients being more permissive than other groups. CONCLUSION We use the results of this study to recommend best practices for photography in dermatology.

Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy

Melanoma is usually apparent on the skin and readily detected by trained medical providers using a routine total body skin examination, yet this malignancy is responsible for the majority of skin cancer-related deaths. Currently, there is no national consensus on skin cancer screening in the USA, but dermatologists and primary care providers are routinely confronted with making the decision about when to recommend total body skin examinations and at what interval. The objectives of this paper are: to propose rational, risk-based, data-driven guidelines commensurate with the US Preventive Services Task Force screening guidelines for other disorders; to compare our proposed guidelines to recommendations made by other national and international organizations; and to review the US Preventive Services Task Forces 2016 Draft Recommendation Statement on skin cancer screening.

CASH Algorithm for Dermoscopy Revisited

when discussions occur. Content of Discussions. Families report that their discussions about melanoma evolve across time. At first, family conversations typically focus primarily on the patient, including diagnosis and the treatment planned. Family members often turn to the Internet during this time to supplement information learned from the patient or their physician; this is especially true when patients or family members have a desire to obtain information that is potentially upsetting. After the resolution of this acute treatment phase, conversations about family risk and prevention predominate. Discussion goals become firmly centered on avoiding recurrence in the patient or avoiding the illness in unaffected family members, particularly children. Discussion content included scare tactics as well as daily in-the-moment reminders about sun protection. Targets of Melanoma Discussions. Family members report extensive deliberation concerning which family members are most at risk for melanoma, and these family members are singled out for more intensive family conversations about prevention. Discussion targets include blood relatives, relatives with stronger perceived genetic susceptibility, those with lighter skin, those whose severe sunburns are vividly remembered, and those who currently sunbathe and use tanning salons.

Prognostic Factors, Treatment, and Survival in Dermatofibrosarcoma Protuberans

Importance There is limited information regarding the influence of patient demographics, tumor characteristics, and treatment type on the survival of patients with dermatofibrosarcoma protuberans (DFSP). Objective To assess prognostic factors and to evaluate the influence of treatment modality on overall survival of patients with DFSP. Design, Setting, and Participants We examined DFSP using data for 3686 patients with histologically confirmed cases of DFSP diagnosed between 1972 and 2012 from the 18 US regional registries of the National Cancer Institutes Surveillance, Epidemiology, and End Results (SEER) Program, with linkage to demographic data from the US Census Bureau for median household income (MHI). The analysis was performed in February 2016. Main Outcomes and Measures The primary outcome measures were tumor characteristics, prognostic factors, and overall survival in months. Results There were 3686 cases of DFSP examined. Older age (hazard ratio [HR], 1.08; 95% CI, 1.06-1.10; P < .001), male sex (HR, 1.97; 95% CI, 1.09-3.55; P = .03), and tumor size (HR, 1.09; 95% CI, 1.01-1.18; P = .04) were significantly associated with poorer overall survival in a controlled analysis. Older age (odds ratio [OR], 1.01; 95% CI, 1.00-1.02; P = .01), male sex (OR, 1.95; 95% CI, 1.57-2.42; P < .001), and black race (OR, 1.78; 95% CI, 1.37-2.32; P < .001) were associated with larger (≥3.0 cm) tumors at presentation. Treatment modality did not influence overall survival; however, differences in patient characteristics affected the treatment received. Older age at presentation (OR, 1.02; 95% CI, 1.01-1.03; P =.01), black race (OR, 1.82; 95% CI, 1.13-2.92; P = .01), large tumor size (OR, 1.15; 95% CI, 1.09-1.21; P < .001), and head or neck location (OR, 4.63; 95% CI, 2.66-8.07; P <.001) increased the likelihood of a patient receiving surgery and radiation over surgery alone. In addition, white patients (OR, 0.51; 95% CI, 0.30-0.87; P=.01), women (OR, 0.53; 95% CI, 0.36-0.78; P <.001), and patients with a higher MHI (OR, 1.27; 95% CI, 1.11-1.46; P <.001) were more likely to receive Mohs micrographic surgery (MMS) over excision. Conclusions and Relevance Age at diagnosis, male sex, and DFSP tumor size appear to be important prognostic factors. Treatment modality did not significantly influence survival; however, patient and tumor characteristics influence treatment modality.

Pregnancy and melanoma

Malignant melanoma is the most common malignancy during pregnancy, and is diagnosed during childbearing age in approximately one-third of women diagnosed with melanoma. The impact of hormonal changes during pregnancy and from iatrogenic hormones on melanoma is controversial. Women undergo immunologic changes during pregnancy that may decrease tumor surveillance. In addition, hormone receptors are found on some melanomas. In spite of these observations, the preponderance of evidence does not support a poorer prognosis for pregnancy-associated melanomas. There is also a lack of evidence that oral contraceptives or hormone replacement therapy worsens melanoma prognosis.

Keratoacanthomas arising in association with prurigo nodules in pruritic, actinically damaged skin

BACKGROUND There is no known association between the development of keratoacanthomas and prurigo nodules. OBJECTIVE We report a case series of 7 patients with a long-standing history of actinic damage, pruritus, and prurigo nodularis who developed widespread keratoacanthomas within the same affected area. METHODS This was a retrospective case series assessing the clinical characteristics of patients with multiple keratoacanthomas arising in association with prurigo nodules. RESULTS All 7 patients were elderly Caucasian women (mean age 79 ± 3.7 years) with actinically damaged skin and a long-standing history of widespread pruritus and prurigo nodules. All patients had histologically confirmed keratoacanthomas, or squamous cell carcinomas with the clinical appearance of a keratoacanthoma, that developed within the field of prurigo nodules. All 7 patients had a clinical response to acitretin with a decrease in the number of lesions. Four patients had an associated eczematous dermatitis and were also treated with cyclosporine with improvement in pruritus and prurigo nodules and no increase in keratoacanthomas. LIMITATIONS The retrospective design and small number of patients are limitations to this study. CONCLUSION Our case series represents a distinct subset of elderly individuals with extensive actinic damage who we believe are predisposed to developing both prurigo nodules and keratoacanthomas.

Cyclo-oxygenase-2 inhibitors for chemoprevention of nonmelanoma skin cancer: Is there a role for these agents?

AK: actinic keratosis BCC: basal cell carcinoma BCNS: basal cell nevus syndrome COX: cyclo-oxygenase FAP: familial adenomatous polyposis NMSC: nonmelanoma skin cancer XP: xeroderma pigmentosum S elective cyclo-oxygenase (COX)-2 inhibitors have been proposed as potentially useful agents in the chemoprevention of nonmelanoma skin cancer (NMSC). Although COX-2 inhibitors are not without considerable risks, they may hold benefit for certain patient subgroups at risk for NMSC. In this article, we review studies examining the use of these agents in cancer prevention, and offer suggestions for future investigations with oral and topical COX-2 inhibitors in the prevention of NMSC.