Mark Hyde

Comparative Analysis of Total Body and Dermatoscopic Photographic Monitoring of Nevi in Similar Patient Populations at Risk for Cutaneous Melanoma

BACKGROUND Our previous experience monitoring nevi in high‐risk patients using serial digital epiluminescence microscopy (DELM) photography achieved low biopsy rates but was limited by melanomas presenting as new lesions or arising from nevi that had not been photographed. OBJECTIVE To determine whether biopsy rates, efficiency of melanoma detection, and melanoma origin (de novo vs nevus derived) differed in a similar patient population monitored using total body (TB) photography. METHODS One thousand seventy‐six patients (including 187 from a prior cohort) underwent TB photography and were monitored using photographs obtained at the initial visit. Risk factors and median monitoring periods for these patients were comparable with those of patients previously monitored using DELM photography. RESULTS Two hundred seventy‐five biopsies were performed in 467 patients on follow‐up visits. Of 12 melanomas detected on follow‐up, five were invasive, five presented as changing lesions and two as new lesions, nine arose de novo, and the remainder were nevus derived. CONCLUSIONS In our experience with both approaches, monitoring patients at risk for melanoma using TB photography was associated with lower biopsy rates and lower nevus‐to‐melanoma ratios than using DELM and facilitated detection of new and changing lesions. In both cohorts, the majority of melanomas detected on follow‐up arose de novo. The authors have indicated no significant interest with commercial supporters.

A Randomized Trial of the Off-label Use of Imiquimod, 5%, Cream With vs Without Tazarotene, 0.1%, Gel for the Treatment of Lentigo Maligna, Followed by Conservative Staged Excisions

OBJECTIVE To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. DESIGN Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. SETTING Mohs surgical clinic in an academic institution. PATIENTS Ninety patients with biopsy-confirmed LM. INTERVENTIONS Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. MAIN OUTCOME MEASURE The presence or absence of residual LM at the time of staged excision. RESULTS Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P=.17). There have been no recurrences to date, with a mean follow-up period of 42 months. CONCLUSIONS Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence.

Adequacy of 5-mm surgical excision margins for non-lentiginous melanoma in situ.

To the Editor: The lentigo maligna (LM) subtype of melanoma-in-situ (MIS) develops on chronically sun-exposed skin, with indistinct clinical margins corresponding to single melanocytes trailing along the epidermal-dermal junction (Figure 1A,C,E). Alternatively, the less common non-lentiginous MIS (non-LM MIS) typically occurs in more sun-protected areas with distinct clinical margins corresponding to sharp transition from malignant to normal melanocytes histologically (Figure 1B,D,F). Fig 1 Clinical and histologic photographs of LM and non-LM-MIS. A, Clinical lesion of LM and B, Clinical lesion of non-LM-MIS contrast the relatively indistinct versus distinct clinical margins in these subtypes of MIS. C, Histology of LM demonstrates the lentiginous ... Treatment of MIS has historically been surgical excision with 5-mm margins, however a footnote added in the recent NCCN guidelines indicates that some MIS (i.e. LM) require greater margins to ensure removal and prevent local recurrence.1 Based on their review of MIS lesions treated by Mohs surgery and finding that 14% required a margin of > 6 mm for histologic clearance, Kunishige et al.2 recommended 9-mm margins for standard excision of MIS. Appropriate surgical margins for non-LM MIS using standard excision technique have not been rigorously defined,3 and treating all MIS with 9-mm excisional margins as proposed2 may lead to larger than necessary excisions for non-LM MIS. We initiated an IRB-approved study (RONMIST: Review of non-lentiginous melanoma-in-situ lesions treated) to determine histologic margins and recurrence rates of non-LM-MIS treated by standard excision at our institution. From the University of Utah Dermatology dermatopathology (1990–2010) and Huntsman Cancer Institute Melanoma Program (2000–2010) databases, we identified 268 unique cases reported as non-LM-MIS. Matching biopsy and excision slides were obtained for 81 cases, which were reviewed in blinded fashion by board-certified dermatopathologists (KLD, SRF, ARB) to assess accuracy of initial diagnosis and confirm non-LM MIS. Only 36 biopsies were confirmed as non-LM MIS (Table I). Among the excluded cases, most (40/45) were deemed LM and not non-LM MIS. The biopsy margins were positive in only 16 specimens (11 shaves, 5 punches), and in none of the 6 excisional biopsies. Only 3 of the 16 (19%) biopsy specimens with positive margins demonstrated residual melanoma on re-excision, and none of the specimens with negative biopsy margins demonstrated residual tumor on re-excision. The average histologic excisional margin was 3.80 mm (range 0.2 – 6.5 mm). While our practice is to excise these lesions with 5-mm margins, our data suggests that often the clinical margins are < 5 mm even after normal shrinkage (approximately 15%) from formalin processing is accounted for. The average margin of clearance was 4.38 mm (range 1.30 – 7.75 mm). Table I Histologic margin assessment of non-LM-MIS cases in this study. As summarized in Table II, these lesions were confined to the trunk or extremities and had a median size of 7 mm (range 2–18). Of 34 patients with confirmed follow-up (0.5 to 18 years, median 6.6 years), none had clinical evidence of recurrence. Follow-up times were short for some patients who were seen shortly after surgery and then never returned for additional follow-up. Table II Demographic and clinical information for patients with non-LM-MIS in this study. Most prior studies of MIS did not distinguish between LM and non-LM MIS subtypes. In response to our correspondence,3 Kunishige et al.4 re-analyzed a subset of their cases and reported that 17 of 91 (19%) “other MIS” (non-LM) cases required > 6-mm margins for histologic clearance. A possible explanation for this discrepancy in margin requirements between their study and ours is that some of their “other MIS” lesions may have been LM rather than non-LM MIS. Distinguishing between these two entities on frozen sections is problematic due to freeze artifact, and they do not appear to have re-reviewed permanent paraffin-embedded sections to confirm diagnoses as we did in the present study. We were able to distinguish clearly between these two MIS subtypes upon histologic examination. Our results are consistent with a recent study by Akhtar et al.5 in which 192 cases of MIS (62% were non-LM MIS) were examined; no recurrence of non-LM MIS lesions was found and most were excised with margins of 2–5 mm. In conclusion, LM and non-LM MIS are distinct entities clinically, histologically, and molecularly – thus their optimal treatment is not the same. Based on our findings, we suggest that 5-mm margins are adequate for standard excision of lesions clinically and histologically consistent with non-LM MIS.

Use of Physician Assistants in Mohs Micrographic Surgery: A Survey of Fellowship‐Trained Mohs Micrographic Surgeons

BACKGROUND An increasing number of dermatologists are using physician assistants (PAs) in their practices. A lack of information regarding the use of PAs in Mohs micrographic surgery (MMS) served as the driving force for this research. OBJECTIVES To quantify the extent to which Mohs surgeons are using PAs in MMS. METHODS Five hundred seventy‐six fellows of the American College of Mohs Surgery were sent surveys in the mail in January 2009. The survey was focused on what percentage of Mohs surgeons are using PAs and how those PAs are being used. RESULTS One hundred forty‐three of the 576 surgeons surveyed (24.8%) responded; 43 of those (30.1%) currently employed one or more PAs; and of those 43, 15 (34.9%) reported that PAs in their practice perform preoperative consults, 25 (58.1%) reported that PAs perform postoperative follow‐up, 18 (41.9%) reported that PAs were participating in some aspect of repairs, and 35 (81.4%) reported that PAs were seeing general dermatology patients. CONCLUSION Mohs surgeons are using PAs for perioperative care, as well as seeing general dermatology patients. A smaller percentage of Mohs surgeons are using PAs to perform portions of MMS or the consequent repairs. The authors have indicated no significant interest with commercial supporters.

Anatomic variability in superficial blood vessel and lymphatic vessel density.

To the Editor, It has been difficult to study lymphatic vessels until the development of newer specific markers for lymphatic endothelium. D2-40, a monoclonal antibody to podoplanin, is a relatively specific immunohistochemical marker that can identify lymphatic vessels in paraffin sections.1 Many studies have been published in dermatology, particularly in the melanoma literature, correlating increased lymphatic density and lymphanigiogenesis with metastatic spread and a poorer prognosis of these tumors.2,3 These studies have looked at outcomes based on intratumoral and peritumoral lymphatic density in comparison with other matched melanocytic tumors. However, a study establishing baseline superficial cutaneous lymphatic density with the D2-40 antibody is lacking. The aim of our study was to carry out a comparative analysis of the investiture of blood and lymphatic vessels in the superficial cutaneous tissue of the scalp, torso, and upper extremities. Approval for the study was granted by the institutional review board at the University of Utah. We performed 6 mm punch biopsies from standardized sites on the scalp, chest, and upper extremity of 10 cadavers. All samples came from patients with fair skin, nine were male, and the age ranged from 19 to 68 years. Immunoperoxidase staining to CD-31 (1 : 100 dilution, Dako, Capenteria, CA, USA) and D240 (1 : 500 dilution, Signet, Cambridge, MA, USA) was performed (Fig. 1) with appropriate positive and negative controls. Gross counts of both anti-CD31 and anti-D2-40 positive vessels were performed and total area of the dermis and available subcutis was calculated for each specimen (Olympus DP2-BSW, Version 1.4, 2006, Olympus America, Centre Valley, PA, USA). The vessel counts and area calculations were performed by a single blinded observer (KLD). On the scalp, arm, and torso the average number of CD31 positive vessels per mm2 were 6.74 (SD ± 2.61), 4.32 (SD ± 1.54), and 3.10 (SD ± 0.94) A

Rate of Recurrence of Lentigo Maligna Treated With Off-Label Neoadjuvant Topical Imiquimod, 5%, Cream Prior to Conservatively Staged Excision

Importance Staged excision of lentigo maligna (LM) often requires multiple stages and can result in significant cosmetic morbidity. Imiquimod cream has been used off-label as monotherapy in the treatment of LM and may be used in the neoadjuvant setting prior to staged excision as a strategy to reduce the size of the surgical margins required to confirm negative histologic margins. Objective To examine the rate of recurrence of LM in patients treated with neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions. Design, Setting, and Participants This was a retrospective medical record review of 334 patients with 345 biopsy-confirmed LM tumors from June 2004 to January 2012 who were treated with imiquimod prior to undergoing staged excisions at the University of Utah Medical Center and Huntsman Cancer Institute, large academic hospitals in Salt Lake City. Interventions Patients were treated with off-label imiquimod, 5%, cream 5 nights per week for 2 to 3 months. Those deemed to have an inadequate inflammatory response were also treated with tazarotene, 0.1%, gel twice weekly. Conservatively staged excisions, beginning with 2-mm margins, were then performed. Main Outcomes and Measures The rate of recurrence of LM after long-term follow-up. Results Patients included 235 men (70%) and 99 women (30%) with a mean (SD) age of 67 (13) years. Patients were treated with imiquimod cream for a mean of 2.5 months prior to undergoing conservatively staged excisions. There were 12 local recurrences (a rate of 3.9%) with a mean time to recurrence of 4.3 years and a mean length of follow-up of 5.5 years. Conclusions and Relevance Neoadjuvant topical imiquimod, 5%, cream prior to conservatively staged excisions for LM allowed for negative histologic margins with a median final margin of 2 mm and a rate of recurrence similar to reported recurrence rates with standard staged excisions by either Mohs surgery or en face permanent sections.

PAs in the ED: do physicians think they increase the malpractice risk?

Objective: This study evaluates emergency physicians’ perceptions of the malpractice risk posed by utilization of physician assistants (PAs) in emergency departments (EDs) in 2004 and again in 2009. Methods: A 16‐question survey was mailed to a random sample of 1,000 active members of the American College of Emergency Physicians in 2004 and again in 2009. Results: In both 2004 and 2009, 70% of the emergency physicians did not believe that PAs, when properly supervised, are more likely to commit malpractice than any other clinician. In both surveys, 80% of the respondents did not believe PAs were more likely to be sued for malpractice. A significant negative correlation was found between perceived risk of malpractice by PAs and the number of years physicians had worked with PAs or had worked in emergency medicine. From 2004 to 2009, the number of respondents practicing with PAs increased by 26%, the number directly supervising a PA in the ED increased by 19%, the number who thought PAs decreased patient wait times increased by 13%, and the number who reported that PAs increased patient satisfaction increased by 10%. Conclusion: As physicians gain clinical experience with PAs, their perceived risk of malpractice tends to decrease. These results may have implications for the utilization of PAs, particularly as EDs become more utilized for noncritical situations.

A survey of fellow members of the Society of Dermatology Physician Assistants.

Income and productivity data of physician assistants (PAs) practicing in dermatology were measured by a survey instrument developed by the authors. The median income for PAs in dermatology was

Is this persistent tumor the cause of Bell palsy or something more severe

100,000, and the median annual production was

Roles and responsibilities of physician assistants practicing in Mohs surgery.

500,000. PAs in dermatology appear to generate adequate revenue to be profitable to a dermatology practice.