Mary L. Stevenson

Oral allergy syndrome (pollen-food allergy syndrome).

Oral allergy syndrome (OAS) or pollen-food allergy syndrome (PFS) is a hypersensitivity reaction to plant-based foods, manifesting most commonly with pruritus of the lips, tongue, and mouth. Unlike simple food allergy, OAS requires prior sensitization to a cross-reacting inhalant allergen rather than direct sensitization to a specific food protein. In this review, we summarize the clinical features and pathophysiology of OAS and provide an overview of known pollen-food associations.

Expression of Programmed Cell Death Ligand in Cutaneous Squamous Cell Carcinoma and Treatment of Locally Advanced Disease With Pembrolizumab.

Importance Limited therapies are available in patients with inoperable locally advanced cutaneous squamous cell carcinoma (cSCC). Objective To determine the efficacy of programmed cell death 1 receptor (PD-1) inhibitors in locally advanced cSCC. Design, Setting, and Participants A single patient with locally advanced cSCC who declined surgery and radiotherapy underwent treatment with pembrolizumab, an anti–PD-1 antibody, at an academic dermatologic surgery section and cancer center. The patient was followed up for clinical and radiologic regression of cSCC. With the use of NanoString to amplify potential biomarkers, immunohistochemistry, and immunofluorescence, the ex vivo expression of PD-1 and a ligand (PD-L2) was assessed in 38 cSCC biopsy specimens from 24 patients with cSCC. Expression of PD-L1 and PD-L2 in the cSCC microenvironment was defined. Intervention Pembrolizumab, 2 mg/kg every 3 weeks, for 4 cycles. Main Outcomes and Measures Expression of PD-L1 and PD-L2 in the cSCC microenvironment. Results In 1 patient with locally advanced cSCC who was treated with pembrolizumab, nearly complete tumor regression was observed after 4 cycles of therapy. The NanoString technology used in 38 cSCC biopsy specimens from 24 patients with cSCC (19 men and 5 women; mean [SD] age, 76.4 [12.2] years) detected increased PD-1 and PD-L2 expression in high-risk cSCC. Immunohistochemical analysis confirmed enhanced expression of PD-1 and its ligands in cSCC with perineural invasion (mean [SEM] expression, 5.06 [1.27]; P = .05), superficial cSCC (mean [SEM] expression, 3.58 [1.50]; P = .15), organ transplant–associated cSCC (mean [SEM] expression, 3.01 [0.54]; P = .005), and infiltrative cSCC (mean [SD] expression, 2.01 [0.30]; P = .006) compared with normal skin specimens. In double-label immunofluorescence staining, CD11c+, a marker of myeloid dendritic cells, colocalized with PD-L1 and PD-L2 in cSCC lesions. Conclusions and Relevance The favorable treatment response combined with significant involvement of PD-1 and PD ligands in cSCC lesions suggests that PD-1 blockade may be a viable therapeutic option for locally advanced cSCC and provides rationale for further investigation in future clinical trials.

Use of Digitally Stained Multimodal Confocal Mosaic Images to Screen for Nonmelanoma Skin Cancer.

Importance Confocal microscopy has the potential to provide rapid bedside pathologic analysis, but clinical adoption has been limited in part by the need for physician retraining to interpret grayscale images. Digitally stained confocal mosaics (DSCMs) mimic the colors of routine histologic specimens and may increase adaptability of this technology. Objective To evaluate the accuracy and precision of 3 physicians using DSCMs before and after training to detect basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in Mohs micrographic surgery fresh-tissue specimens. Design This retrospective study used 133 DSCMs from 64 Mohs tissue excisions, which included clear margins, residual BCC, or residual SCC. Discarded tissue from Mohs surgical excisions from the dermatologic surgery units at Memorial Sloan Kettering Cancer Center and Oregon Health & Science University were collected for confocal imaging from 2006 to 2011. Final data analysis and interpretation took place between 2014 and 2016. Two Mohs surgeons and a Mohs fellow, who were blinded to the correlating gold standard frozen section diagnoses, independently reviewed the DSCMs for residual nonmelanoma skin cancer (NMSC) before and after a brief training session (about 5 minutes). The 2 assessments were separated by a 6-month washout period. Main Outcomes and Measures Diagnostic accuracy was characterized by sensitivity and specificity of detecting NMSC using DSCMs vs standard frozen histopathologic specimens. The diagnostic precision was calculated based on interobserver agreement and κ scores. Paired 2-sample t tests were used for comparative means analyses before and after training. Results The average respective sensitivities and specificities of detecting NMSC were 90% (95% CI, 89%-91%) and 79% (95% CI, 52%-100%) before training and 99% (95% CI, 99%-99%) (P = .001) and 93% (95% CI, 90%-96%) (P = .18) after training; for BCC, they were 83% (95% CI, 59%-100%) and 92% (95% CI, 81%-100%) before training and 98% (95% CI, 98%-98%) (P = .18) and 97% (95% CI, 95%-100%) (P = .15) after training; for SCC, they were 73% (95% CI, 65%-81%) and 89% (95% CI, 72%-100%) before training and 100% (P = .004) and 98% (95% CI, 95%-100%) (P = .21) after training. The pretraining interobserver agreement was 72% (κ = 0.58), and the posttraining interobserver agreement was 98% (κ = 0.97) (P = .04). Conclusions and Relevance Diagnostic use of DSCMs shows promising correlation to frozen histologic analysis, but image quality was affected by variations in image contrast and mosaic-stitching artifact. With training, physicians were able to read DSCMs with significantly improved accuracy and precision to detect NMSC.

Cutaneous Crohn's disease of the vulva.

A 26-year-old woman was referred to dermatology department from an outside clinic for a 1-year history of recurrent draining lesions of the vulva and buttock treated unsuccessfully with doxycycline for presumed lymphogranuloma venereum. Physical examination was notable for an oedematous vulva (figure 1) with knife-like fissuring of the genitocrural folds (figure 2), superficial erosions and scattered draining papulonodules (figure 1). Biopsy showed granulomatous dermatitis consistent with cutaneous Crohns disease. Colonoscopy revealed normal-appearing mucosa in the colon and terminal ileum, however, random …

Frequency of total body skin examinations among US dermatologists

diagnosis made at the in-person visit by a dermatologist. Diagnostic performance was analyzed in terms of sensitivity, specificity, false-positive rate, and falsenegative rate for the decision regarding the referral of patients to an in-person consultation at the skin cancer unit. The diagnostic confidence level (DCL; 1, uncertain diagnosis; 2, likely diagnosis; 3, confident diagnosis), the nonreferral rate, the time spent by the GP and the remote dermatologist, and the image qualitywere also assessed in each study group. The most common lesion examined by teledermatology was seborrheic keratosis (29.2%, n 1⁄4 73), followed by common acquired melanocytic nevus (26.8%, n 1⁄4 67). Basal cell carcinoma was the most common malignant lesion diagnosed (6.4%, n1⁄4 16), followed by squamous cell carcinoma (4%, n 1⁄4 10). Thus, 10.4% (n 1⁄4 26) of patients were referred because of malignant lesions. In the overall series, 60.8% and 76.8% of the CTC and CTC1DTC groups, respectively, were not referred to the skin cancer clinic (P 1⁄4 .001). The subanalysis of patients having pigmented lesions increased this nonreferral percentage to 69.39% and 89.13%, respectively (P 1⁄4 .001). The average time spent by the operating GPs was 7.44 minutes for CTC patients and 8.7 minutes for CTC1DTC patients (P 1⁄4 .01). The time spent by the dermatologist in the evaluation of CTC or CTC1DTC patients was 1.04 minutes and 1.22 minutes, respectively (P1⁄4 .14). The percentage of cases with the highest DCL (DCL1⁄43) was 61.6% in the CTC group and 79.2% in the CTC1DTC group (P 1⁄4 .001). The frequency of low-quality pictures was 3.2% and 1.6% in the CTC and CTC-DTC groups, respectively (P 1⁄4 .41). The results of the diagnostic performance study are listed in Table I. The interim results of this prospective randomized and blinded study provide meaningful favorable data ahead of the definitive results of a large-scale study on the effect of the addition of dermoscopic images to the routine internet-based skin cancer triage.

Metastatic Cutaneous Squamous Cell Carcinoma: The Importance of T2 Stratification and Hematologic Malignancy in Prognostication.

BACKGROUND While infrequent, nodal metastases in cutaneous squamous cell carcinoma (cSCC) can result in death from disease. Identification of those at risk for metastases is key to improved prognostication and treatment. OBJECTIVE To review metastatic cSCC at the study institution. METHODS AND MATERIALS Sixteen patients with metastatic cSCC were identified at the New York University Dermatologic Associates and Cancer Associates from 1998 to 2013. Patients were staged with American Joint Committee on Cancer (AJCC) and modified Brigham and Womens Hospital (BWH) criteria and compared to 32 control subjects. RESULTS Seven of 16 patients were identified as Stage T2 by AJCC criteria and Stage T2b by BWH criteria; two patients were on Stage T1, three patients were on more advanced T stages, and four patients lacked primary tumor data. Five patients had hematologic malignancy, and one patient had a solid-organ transplant. CONCLUSION The modified BWH criteria aims to better prognosticate the large group of T2 AJCC tumors, resulting in the majority of mortality. In the experience of the authors, the majority of patients with metastatic disease were on T2, stratifying to stage T2b by BWH criteria, or more advanced T stages. The findings of this study support BWH stratification of T2 tumors and also indicate that hematologic malignancy is a significant comorbidity associated with a poor outcome.

Laser treatments of active acne

The utility of laser therapy is increasingly being recognized in the treatment of active acne vulgaris. We aimed to perform a narrative review of the medical literature on the use of laser therapy for the treatment of active acne vulgaris. We performed a PubMed literature search on September 1, 2016 using the search terms “active acne,” “acne,” “laser therapy,” and “laser surgery.” Case reports, case series, cohort, and controlled trials were included. Studies of lasers in the treatment of acne, including erbium glass, Nd:YAG, pulse dye laser (PDL), potassium titanyl phosphate (KTP) laser, and laser-based photodynamic therapy, have been published. While treatment of active acne with lasers has been successful, many studies are limited by small patient number and lack of control populations and comparison to standard therapies for active acne. Laser therapies are increasingly becoming part of or an adjunct to the medical treatment of active acne and are a useful treatment modality.

Procedures in the Diagnosis and Treatment of Skin Cancer

Skin cancer is the most common type of cancer in the United States and constitutes a health burden to the population. Comprised predominately of basal cell carcinoma, cutaneous squamous cell carcinoma, and melanoma, skin cancer accounts for nearly 20,000 deaths annually. Early diagnosis and treatment of skin cancer are critical in limiting morbidity and mortality. Diagnosis is generally made based on close examination and biopsy of suspicious lesions. Appropriate treatment depends on the specific histopathologic diagnosis as well as other considerations including area and size of the lesion and comorbidities of the patient. Treatment modalities include superficial therapies, such as cryotherapy or topical treatment, electrodessication and curettage, and surgical therapies including standard excision and Mohs micrographic surgery. Additionally, for more advanced disease, treatment may require a multidisciplinary approach, often with involvement of medical and radiation oncologists, and may include the use of systemic agents or radiation therapy.

V-Y Advancement Flap for Defects of the Lid–Cheek Junction

Abstract We report a series of 10 patients who underwent inferolaterally based V‐Y advancement flaps for reconstruction of defects involving the lower eyelid and infraorbital cheek junction. Defects ranged from 1.7 to 2.9 cm in largest diameter, and patients ranged from 59 to 84 years of age. All patients had excellent functional and cosmetic outcomes without subsequent surgical or laser revision. There were no instances of flap necrosis, hematoma, or ectropion. Vertically oriented V‐Y flaps are often underused in this setting largely due to the perceived increase risk of ectropion. We describe a modification of the flap with lateral orientation that both diminishes the downward tension vector, which threatens ectropion, and conceals incision scars within resting tension lines, providing superior functional and aesthetic outcomes. Our series demonstrates that a properly designed and well‐executed inferiorly based V‐Y advancement flap can be used as a safe reconstructive modality for defects involving the lid‐cheek junction.

Line scanning, stage scanning confocal microscope (LSSSCM)

For rapid pathological assessment of large surgical tissue excisions with cellular resolution, we present a line scanning, stage scanning confocal microscope (LSSSCM). LSSSCM uses no scanning mirrors. Laser light is focused with a single cylindrical lens to a line of diffraction-limited width directly into the (Z) sample focal plane, which is parallel to and near the flattened specimen surface. Semi-confocal optical sections are derived from the linear array distribution (Y) and a single mechanical drive that moves the sample parallel to the focal plane and perpendicular to the focused line (X). LSSSCM demonstrates cellular resolution in the conditions of high nuclear density within micronodular basal cell carcinoma.