Karen L. Connolly

Radiation therapy for synchronous basal cell carcinoma and lentigo maligna of the nose: Response assessment by clinical examination and reflectance confocal microscopy

Radiation therapy (RT) is a noninvasive treatment for a variety of skin cancers. Although surgery is often preferred for basal cell carcinoma (BCC) and lentigo maligna (LM), these conditions often affect patients that are medically inoperable, who decline surgery, or have lesions in challenging anatomic locations. Although nonsurgical treatments can be employed, close monitoring for disease recurrence and progression is of utmost importance. Typically, this is carried out by clinical examination, without adjunctive imaging. Reflectance confocal microscopy (RCM) is an emerging imaging technology that is proving useful to aid in the assessment of treatment response and disease recurrence (Fig 1). RCM has a high

Comorbidity scores associated with limited life expectancy in the very elderly with nonmelanoma skin cancer

Background: There is controversy regarding treatment of nonmelanoma skin cancer (NMSC) in very elderly individuals, with some suggesting that this population may not live long enough to benefit from invasive treatments. Tools to assess limited life expectancy (LLE) exist, but performance in the population of very elderly individuals with NMSC has not been well defined. Objective: Define comorbidity scores associated with LLE in very elderly individuals presenting for management of NMSC. Methods: A retrospective review of 488 patients age 85 or older presenting for NMSC management between July 1999 through December 2014 was performed. Comorbidities were scored by using the Adult Comorbidity Evaluation‐27 (ACE‐27) and age‐adjusted Charlson comorbidity index (ACCI). Dates of death, follow‐up, and overall survival were determined. Results: ACE‐27 and ACCI scores were associated with overall survival; at scores of 3 and 7+, respectively, both were associated with less than 50% survival at 4 years. Patients who underwent Mohs micrographic surgery survived a median of 20 months longer than patients who did not. Limitations: Retrospective study design and referral bias. Conclusions: ACE‐27 and ACCI scores predicted LLE. The cohort presenting for Mohs micrographic surgery had improved survival, despite similar intercohort comorbidity. This suggests that additional factors contributed to survival and that age and comorbidities alone are inadequate for making NMSC treatment decisions in very elderly individuals.

Evidence-based Medicine: Cutaneous Facial Malignancies: Nonmelanoma Skin Cancer.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Identify clinical features of nonmelanoma skin cancer; 2. Distinguish low-risk versus high-risk basal cell carcinoma and squamous cell carcinoma; 3. Define appropriate management based on current guidelines for various types of basal cell and squamous cell carcinoma. SUMMARY Skin malignancies are the most prevalent cancers, and plastic surgeons are often the primary physicians engaged in diagnosis and management of these lesions. Proper management includes distinguishing between high-risk and low-risk lesions and determining treatment accordingly. The aim of this Continuing Medical Education article is to review the diagnosis and management of common and uncommon facial skin malignancies, including basal cell carcinoma, squamous cell carcinoma, actinic keratosis, keratoacanthoma, Merkel cell carcinoma, atypical fibroxanthoma, sebaceous carcinoma, and microcystic adnexal carcinoma.

Lentigo maligna melanoma with a history of cosmetic treatment: Prevalence, surgical outcomes and considerations

Lentigo maligna (LM) is melanoma in situ on sun‐damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes.

A systematic review of comorbidity indices used in the nonmelanoma skin cancer population

they performed TBSE in patients with no personal or family history of skin cancer and thosewith a high risk for skin cancer ( family history of skin cancer; personal history of sunburns, actinic damage, dysplastic nevi, and/or multiple nevi; or fair skin). Participant demographic data were collected including years in practice, location of practice (rural, suburban, urban, or combination), and practice environment (residency training, academic faculty practice, private practice, outpatient-based hospital clinic, or other). Data were analyzed using standard 2 and 95% confidence intervals. Of 6500 dermatologists surveyed, 9.6% (623) responded. The literature supports that our study sample size appears to be large enough to make accurate statistical inferences and representative of the surveyed population. In patients with no personal or family history of skin cancer, 86% of dermatologists reported performing TBSE either annually or every 2 to 3 years, 1% of dermatologists reported performing TBSE every 6 months, and 13% of dermatologists reported rarely/never performing TBSE routinely in this population. In comparison, in patients with high risk for skin cancer, 60% of dermatologists reported performing TBSE annually, with 34% performing TBSE every 6 months. In addition, in the high-risk population, 4% performed TBSE every 3 to 4 months, 2% performed TBSE every 2 to 3 years, and 1% of dermatologists reported rarely or never performing TBSE. Themajority of dermatologists reported screening patients by TBSE at least every 2 to 3 years if not annually. In addition, those at increased risk of skin cancer were predominantly screened at least annually, if not every 6 months. Screening frequency was not associated with dermatologist gender, practice location, number of years in practice, or practice environment, with the exception of female practitioners and younger providers (with\5 years of practice experience) who screened those at normal risk for skin cancer more frequently (P 1⁄4 .00004 and P 1⁄4 .004, respectively). Limitations of this study include selection bias, as those who responded to this survey may have been more interested in this topic, recall bias, which may account for inaccuracy or incompleteness of participant’s responses, and finally systemic bias through which participants may have reported more screening than actually performed. There are no national guidelines regarding frequency of routine TBSE. This survey suggests that the majority of dermatologists routinely perform TBSE in patients at low risk every 2 to 3 years and more frequently in patients at high risk. These data suggest a uniform practice of skin cancer screening in the United States across the broad and diverse population of dermatologists.

Optimizing Outcomes for Cutaneous Head and Neck Melanoma

In this issue, Moyer and colleagues1 report long-term follow-up of a large cohort of patients with head and neck melanoma treated with a “square” staged excision technique using permanent sections for comprehensive margin assessment. The median follow-up of 9.3 years demonstrated excellent long-term disease control of 834 lesions with projected local recurrence rate of 2.2% at 10 years. The mean margin required for histologic clearance of tumor was 9.3 mm for melanoma in situ and 13.7 mm for invasive melanoma. The authors demonstrated that lesion size, presence of invasion, and prior incomplete excision were associated with larger surgical margins required for histologic clearance. Melanoma of the lentigo maligna subtype accounted for nearly 75% of the head and neck melanomas in this series. This is a critical point because melanomas developing in an area of chronic photodamage in the head and neck region present many challenges. Lentigo maligna has had a long, confusing history. It was initially called Hutchinson’s melanotic freckle in the 1800s and felt to be an infectious process. Lentigo maligna is still misconstrued by some as a premalignant lesion. It is now well-recognized as a subtype of melanoma in situ. Once invasion is present, melanoma staging2 and prognosis are directly related to tumor thickness, similar to other melanomas, with potential for metastasis and death, and should be treated according to current melanoma standards.3 Following these guidelines, patients in this study underwent sentinel lymph node biopsy if indicated. It is now well-established, in the dermatologic literature, that standard surgical margins for excision of melanomas on the trunk and extremities are frequently inadequate when applied to melanomas of the head and neck region. This study further supports this finding, because only 25% of melanoma in situ lesions were cleared with a 0.5-cm margin, and only 25% of invasive melanomas were cleared with a 1-cm margin. The National Comprehensive Cancer Network clinical practice guidelines clearly state that for melanomas of the “lentigo maligna type, greater than 0.5 cm may be necessary to achieve histologically negative margins,” and that “exhaustive histologic assessment of margins should be considered.”3 The surgical treatment of melanoma of the lentigo maligna type has therefore evolved from standard wide excision to staged techniques that allow enhanced margin evaluation and reduce local recurrence. However, there remains debate in the field of dermatologic surgery over the ideal method of margin examination for these challenging melanomas, ranging from permanent sections using square, radial,4 or en face sectioning to Mohs frozen sections. Irrespective of the technique used, dermatologic surgeons must understand the biological and histological nuances of melanomas arising in sun-damaged skin. Multiple studies have evaluated the efficacy of various staged treatments for melanoma of the lentigo maligna type, but many are limited by small sample sizes with heterogeneous tumor types, variable follow-up duration, and inconsistent statistical analyses that fail to account for patient compliance with dermatologic follow-up. The study by Moyer et al1 stands out for several reasons. The cohort consisted of 806 patients with 834 melanomas in the head and neck, the largest study to date. The study was allowed to mature, offering extended follow-up (median, 9.3 years, with 75% with 7.3 years) and the sound analytic methods nicely describe the disease process and surveillance methods used by the investigators. The low local recurrence rate confirms that comprehensive margin assessment is necessary. However, it is important to note that local recurrences occur late, with 36% of recurrences developing after 5 years (markedly different from melanoma of other subtypes). In our experience, 4 of 117 local recurrences occurred at a mean of 5.9 years following surgical treatment,5 and a similar study6 showed a mean time to local recurrence of 5.1 years. When considering the reported efficacy of treatments for melanoma in sun-damaged skin, it is important to note how authors define local recurrence. For this melanoma subtype, defining local recurrence can be challenging when differentiating between field damage resulting in multiple primary melanomas vs a true local recurrence. Although there is no accepted standard definition, it is important to critically evaluate studies in this regard. Another issue to consider is whether the margin of clearance matters when treating melanomas in sundamaged skin. In treatment of high-risk facial basal cell carcinoma with Mohs surgery, we readily accept microns of clearance without apparent associated increased rates of local recurrence. But in head and neck melanomas with trailing melanocytic atypia and potential for skip areas, a narrow margin of clearance could lead to recurrence over the long term. In this study,1 additional 5-mm margins were excised when margins were involved and when anatomically feasible. Melanomas arising in severely sun-damaged skin present multipledistinctchallengescomparedwithothermelanomasubtypes. Detecting the invasive component preoperatively is not easily achieved because complete excisional biopsies of these large lesions are not always feasible in anatomically sensitive locations.Upto30%ofcaseshaveoccult invasion,7 andfinalpathologic staging can impact melanoma treatment. In this study, the Related article Opinion

Locally Recurrent Lentigo Maligna and Lentigo Maligna Melanoma: Characteristics and Time to Recurrence After Surgery

BACKGROUND Various studies have reported local recurrence (LR) rates after surgical treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM). However, the time to LR of LM/LMM is not currently known, as few studies report time to LR and have long-term follow-up. OBJECTIVE To define time to LR in LM/LMM after surgical treatment, and to describe features of observed LR. MATERIALS AND METHODS Retrospective single-center study of consecutive patients presenting with locally recurrent LM/LMM. RESULTS Six hundred forty-nine cases of LM/LMM were reviewed; 29 (21 LM, and 8 LMM) of 41 locally recurrent cases had original histology reports and were included. The mean time to LR was 57.5 months (range 7–194). For cases presenting as primary LM, LR was also in situ in 14/21 (67%) of cases. Seven of 21 LM recurred as LMM. Of the 8 primary LMM, 3/8 (37.5%) presented with subsequent LMM and all were slightly deeper on re-excision. CONCLUSION The mean time to LR of LM/LMM is at least 57.5 months, underscoring the importance of long-term follow-up. Seven of 21 LM recurred as invasive disease, but the lack of development of LMM from LM in most recurrent cases confirms LM is slowly progressive.

Frequency of Subungual Melanoma in Longitudinal Melanonychia: A Single-Center Experience

BACKGROUND Clinical and dermatoscopic guidelines are used to differentiate between benign longitudinal melanonychia (LM) and subungual melanoma; however, the frequency of malignancy among patients undergoing a biopsy for LM is not well defined. OBJECTIVE To describe the histologic diagnoses and malignancy among patients undergoing a biopsy for clinical LM. METHODS Retrospective cohort study of consecutive patients who underwent a nail biopsy for LM at a single cancer center between 2000 and 2014. Clinical features, biopsy techniques, and histopathologic results were reviewed. RESULTS Forty-two patients with 43 biopsied lesions were included. Three of the 43 biopsies revealed melanoma (mean depth 2.1 mm). The mean age among patients with malignant lesions was 60 years compared with 58.1 years for benign lesions. The mean width of all biopsied lesions was 4.2 mm, with a mean of 10.7 mm for malignant and 3.4 mm for benign. The first digit was the most commonly involved nail in both malignant and benign lesions. CONCLUSION Most nail biopsies performed for LM revealed benign pathology; however, melanoma was diagnosed in a small subgroup. Although clinical and dermatoscopic guidelines help guide biopsies, they should not replace clinical judgment as malignant lesions can deviate from these guidelines.

Facilitating Healing of Granulating Wounds: Dressings, Dermal Substitutes, and Other Methods

Wounds created by skin cancer surgery often heal by secondary intention. Many novel options to assist in wound healing exist. This article reviews the biology of wound healing, indications for healing by secondary intention, types of dressings, categories, and brand names of tissue-engineered skin substitutes, as well as other wound healing modalities. The cost-benefit analysis must be considered given the expense of these newer technologies.

Association of Quality of Life With Surgical Excision of Early-Stage Melanoma of the Head and Neck

Importance Surgical excision is the standard-of-care treatment for Tis and T1a melanomas of the head and neck. Currently, however, the association of diagnosis and surgical treatment of these typically slowly progressive and nonfatal melanomas with a patient’s health-related quality of life (HRQoL) is unknown. Objective To characterize and assess HRQoL in patients with Tis and T1a head and neck melanoma, evaluate changes in HRQoL over the surgical treatment course, and identify patient characteristics associated with lower HRQoL. Design, Setting, and Participants This longitudinal, prospective cohort study involved patients with Tis or T1a melanoma of the head and neck who underwent staged excision at a single tertiary care center (Memorial Sloan Kettering Cancer Center, New York, New York) and were recruited from June 1, 2016, to February 28, 2017. Patients were followed up for 1 year after their surgical procedure. Participants were asked to complete 2 patient-reported outcome measure questionnaires, Skindex-16 and Skin Cancer Index (SCI), at 4 time points: baseline, perioperative (1 to 2 weeks after surgery), and 6-month and 1-year follow-up. Main Outcomes and Measures Scores on the Skindex-16 and SCI questionnaires. Results In total, 56 patients were included in the study, among whom 24 (43%) were female and 32 (57%) were male, with a mean (range) age of 67.2 (32-88) years; all patients self-identified as white. Forty-one (73%) questionnaires at perioperative, 49 (88%) at 6-month postoperative, and 41 (73%) at 1-year postoperative time points were completed. At baseline, female patients and those younger than 65 years had statistically significantly worse HRQoL on the Skindex-16 questionnaire (mean score, 14.2 [95% CI, 9.1-21.9] and 16.1 [95% CI, 9.8-26.4]) and on the SCI questionnaire (mean score, 57.2 [95% CI, 48.3-67.6] and 53.2 [95% CI, 44.1-64.3]) compared with males (mean Skindex-16 score, 7.0 [95% CI, 4.8-10.3]; mean SCI score, 73.5 [95% CI, 66.0-81.7]) and those aged 65 years or older (mean Skindex-16 score 7.1 [95% CI, 5.0-10.0]; mean SCI score, 74.3 [95% CI, 67.7-81.6]). Questions that demonstrated the worst scores at baseline were worry about skin condition (Skindex-16) and worry about future skin cancers (SCI). The emotions subscale scores on the Skindex-16 questionnaire showed the greatest improvement from baseline to 1-year follow-up levels (26.6 vs 15.3; P < .001) and so did the appearance subscale scores on the SCI questionnaire (64.0 vs 84.6; P < .001). The score difference in HRQoL by sex diminished over time, whereas the score difference by age persisted through the first year. Conclusions and Relevance Improvement in HRQoL at the 6-month and 1-year follow-up was associated with surgical excision in patients with early-stage head and neck melanoma, and younger and female patients experienced worse HRQoL. These results may be used in tailoring counseling for this patient population.