Maressa C. Criscito

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.

The selfie skin examination

CLINICAL CHALLENGE Skin self-examination (SSE) has been associatedwith a reduced risk ofmelanoma incidence and a decrease in melanoma mortality. Technological advances have made SSE more convenient, allowing patients to take photographs of their nevi on mobile devices for review with a dermatologist. In an effort to improve visualization of hard-to-see areas, such as the back of the body, the use of 2 mirrors during SSE was previously recommended. However, patients using this 2-mirror technique still lack the ability to get a close-up view of nevi in these areas. The back is recognized as one of the most common sites of melanoma in men. In addition, thicker melanomas present more often on the areas not easily visualized during SSE. Thus, an effective and efficient modality to better visualize these hard-to-see areas is necessary.

A population-based cohort study on the association of dermatologist density and Merkel cell carcinoma survival

To the Editor: Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine tumor. Although dermatologist density has been associated with melanoma mortality, the relationship with other skin cancers like MCC has not been established. Herein, we examine the impact of dermatologist density on MCC survival. We linked histologically confirmed cases of cutaneous MCC (International Classification of Diseases for Oncology code 8247) from the National Cancer Institute Surveillance, Epidemiology, and End Results Program’s 18 registries from 2004 through 2012 to the Area Health Resource File, which was used to calculate the mean number of dermatologists, primary care physicians, and hospitals with oncology services by county. Data sets were also linked to the American Community Survey by census tract to define median household income and to the Department of Agriculture’s Rural/Urban Continuum Codes to define county status. We categorized dermatologist density as ‘‘none’’ (counties with no dermatologists), ‘‘low’’ (0.1-11 dermatologists/100,000), ‘‘intermediate-low’’ (11.132 dermatologists/100,000), ‘‘intermediate-high’’ (32.1-82 dermatologists/100,000), and ‘‘high’’ (82.1422 dermatologists/100,000). County status included metropolitan, nonmetropolitan, or urban counties. Tumor stage was derived from the American Joint Committee on Cancer (AJCC) stage, 6th edition, and was categorized as ‘‘early’’ (I/II) and ‘‘advanced’’ (III/IV). We used 2 and analysis of variance to calculate univariate differences. Overall survival analysis was conducted usingKaplan-Meiermethodwith log-rank statistic and Cox proportional hazards modeling. The data were analyzed using statistical software (SPSS, Version 23.0, IBM Corp, Armonk, NY). We examined 2709 patients with MCC. Increased dermatologist density was significantly associated with better overall survival for patients with MCC (P 1⁄4 .048). Higher median household income, metropolitan status, and increased density of primary care physicians and hospitals with oncologists were also associated with increased dermatologist density. Tumor stage did not significantly differ with regard to dermatologist density (Table I). In a multivariable survival analysis, patients with MCC living in areas of intermediate-low (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.62-0.96) or high (HR 0.78, 95% CI 0.63-0.96) dermatologist density had a decreased rate of death when compared with patients living in areas of no dermatologists. Older age (HR 1.05, 95% CI 1.05-1.06), male gender (HR 1.44, 95% CI 1.28-1.62), black race (HR 1.88, 95% CI 1.28-2.76), and advanced stage (HR 2.06, 95% CI 1.85-2.30) were associated with worse survival (Table II). Our results demonstrate that patients with MCC living in areas of intermediate-low or high dermatologist density have improved survival when compared with patients living in areas of no dermatologists. Interestingly, there was no significant difference in survival for patients living in areas of intermediate-high dermatologist density. Importantly, median household income, county status, and access to both primary care physicians and oncologists were not associated with survival, supporting the critical role of dermatologists in MCC survival. Paradoxically, our analysis did not reveal an association between dermatologist density and tumor stage at diagnosis, however we interpret these results with caution. AJCC 6th edition, over 7th edition, staging was used as it was available for far more cases. The AJCC 6th edition groups MCC with cutaneous squamous carcinoma and 80 other cutaneous neoplasms and thus may not be an adequate gauge of disease severity. Limitations of this study include an information bias because of the use of registry and census tract data. Further studies are necessary to confirm and further explore this association.

Dermoscopic features of a solitary fibrofolliculoma on the left cheek

CLINICAL PRESENTATION A 72-year-old woman with no skin cancer history requested a total body skin examination at her initial visit. A 4-mm dome-shaped flesh-colored papule was noted on her left cheek (Fig 1). Reportedly, the lesion was present for several years without change. She denied any associated symptoms or precipitating trauma. No other concerning skin lesions were noted. She denied a personal or family history of Birt-Hogg-Dub e syndrome or any associated stigmata.

Melanoma risk after in vitro fertilization: A review of the literature

Background: The role of female sex hormones in the pathogenesis of malignant melanoma (MM) remains controversial. Although melanocytes appear to be hormonally responsive, the effect of estrogen on MM cells is less clear. Available clinical data does not consistently demonstrate that increased endogenous hormones from pregnancy or increased exogenous hormones from oral contraceptive pills and hormone replacement affect MM prevalence and outcome. Objective: We sought to examine potential associations between in vitro fertilization (IVF) and melanoma. Methods: A literature review was conducted. Primary outcomes were reported as associations between IVF and melanoma risk compared with the general population. Secondary outcomes included associations stratified by type of IVF regimen and subgroup, such as parous versus nulliparous patients. Results: Eleven studies met our inclusion criteria. Five studies found no increased risk for MM among IVF users compared with the general population. Two studies found an increase in MM in clomiphene users, and 4 studies found an increase in MM among patients who were gravid or parous either before or after IVF. Conclusion: The reviewed studies do not reveal consistent patterns of association between IVF and MM among all infertile women. However, the data indicates a potential increased risk for MM in ever‐parous patients treated with IVF. High‐quality studies including a large number of MM cases that control for well‐established MM risk factors are needed to adequately assess the relationship between IVF and MM, particularly among ever‐parous women.

Improving the diagnosis and treatment of acral melanocytic lesions

Melanocytic lesions of acral sites are common, with an estimated prevalence of 28-36% in the USA. While the majority of these lesions are benign, differentiation from acral melanoma (AM) is often challenging. AM is a unique subtype of melanoma, with distinct molecular characteristics that are thought to contribute to its high rate of locoregional recurrence and worse prognosis. The advent of dermoscopy has since improved the diagnostic accuracy of AM, resulting in earlier detection and arguably improved survival. Additionally, the identification of unique genomic amplifications in AM invites the potential for future AM-specific targeted therapies. Herein, we discuss the importance of dermoscopy in the diagnosis of acral melanocytic lesions and review the treatment strategies for AM.

A population-based cohort study of the influence of socioeconomic factors and race on survival in Merkel cell carcinoma

AJCC, American Joint Committee on Cancer; MHI, median household income. *The percentages indicate the proportion of individuals of a specific covariate who were classified as either above or below the MHI. yThe ‘‘other’’ group included persons of Asian/Pacific Islander (92; 3.4%) and American Indian/Alaskan native (7; 0.3%) background. zTumor stages were categorized as ‘‘early’’ (stage I/II) and ‘‘advanced’’ (stage III/IV). To the Editor: Merkel cell carcinoma (MCC) is an aggressive neuroendocrine tumor that commonly occurs on sun-exposed skin of elderly white patients. For patients with other skin cancers, like melanoma, race and socioeconomic status (SES) play a role in survival, because nonwhite patients and those with lower SES are more often diagnosed with thicker and more advanced tumors compared to white patients and those of higher SES, respectively. We sought to examine the role of SES and race in MCC survival using a large, US populatione based registry. We used the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program’s 9 original registries from 1973 through 2011 to identify patients with MCC using International Classification of DiseaseseOncology (ICD-O) codes (8247/3). Patients with histologic confirmation and primary site of the skin were included. SEER data were linked to the US Census Bureau’s 2008 to 2012 American Community Survey by county of residence at time of diagnosis. We dichotomized SES based on the median household income (MHI) of the cohort. Univariate analyses were conducted using Fisher exact and Wilcoxon rank-sum tests. Overall survival (OS) analysis was conducted using the KaplaneMeier method with log-rank statistic and Cox proportional hazards modeling. Interaction term analysis was performed to assess the combined risk of race and SES on survival. We identified 2763 cases of MCC in the SEER database using the ICD-O code. Only cases with histologic confirmation and a primary site of the skin were included in our analysis, totaling 2689. The median household income was

Systemic lupus erythematosus–associated neutrophilic dermatosis with palmoplantar involvement

62,872. Patients below MHI (vs above MHI) were more often black (P\.01), had tumors of the head and neck (P1⁄4 .03), and were staged higher (P \ .01). There were no differences in MHI by age (P 1⁄4 .66) or sex (P 1⁄4 .48; Table I). Patients with truncal tumors were more often black, whereas patients with tumors of the head and neck were more commonly white (P 1⁄4 .03). Stage did not differ with regard to race (P 1⁄4 .57). Patients below the MHI had lower OS univariately (P 1⁄4 .01). There was also a significant difference in OS by race (P \ .01; Fig 1). In our multivariable survival analysis, older age (hazard ratio [HR], 1.04; P 1⁄4 .01), black race (vs white; HR, 3.63; P1⁄4 .03), and advanced stage (HR, 3.48; P\.01) were significantly associated with poorer survival. MHI (P 1⁄4 .64), sex (P 1⁄4 .60), and site of tumor (P 1⁄4 .26), as well as an interaction term combining race and MHI (P 1⁄4 .24), were not associated with survival. Our results include two key findings. First, patients with MCC with lower SES present more commonly with tumors of the head and neck and advanced stage. Second, compared with white patients, black patients with MCC had a significantly increased risk of death. While SES did not independently influence survival in our study, patients with lower SES were more commonly black. Our results may reflect racial and socioeconomic disparities in access to care and health literacy. Limitations of our study must be considered and include the lack of case-specific detail because of the use of registry and census tract data.

Prognostic factors, treatment, and survival in dermatofibrosarcoma protuberans: A population-based cohort study.

Neutrophilic infiltrates in the setting of systemic lupus erythematosus (SLE) are commonly associated with bullous or vasculitic disease. Recently, an increasing number of reports describe a nonbullous, nonvasculitic SLE-associated neutrophilic dermatosis. Prior cases of SLE-associated neutrophilic dermatosis describe an urticarial eruption involving the trunk and extremities. Here we report the case of a 27-year-old woman with SLE-associated neutrophilic dermatosis with palmoplantar involvement, thus, expanding the clinical spectrum of this disease. Neutrophilic dermatosis may represent the initial cutaneous manifestation of systemic disease in one-third of patients. Thus, prompt recognition of this distinct cutaneous entity should promote screening for SLE.