Teresa Soriano

Where Is It? The Utility of Biopsy-Site Photography

BACKGROUND With wrong‐site surgery being one of the major causes of medical lawsuits in the United States, tools to confirm location are essential. A previous survey of 300 Mohs surgeons revealed that 14% of malpractice cases were due to wrong‐site surgery. In dermatologic surgery, photography is helpful in precisely locating biopsy sites. OBJECTIVES We present a case series of 34 biopsy‐proven cutaneous head and neck malignancies performed in our university‐based dermatology clinic, comparing the reliability of patient and blinded dermatologist identification with that of biopsy‐site photography. RESULTS Of 34 biopsy sites, the patient and the blinded dermatologist incorrectly identified four (12%). The patient alone incorrectly identified an additional six biopsy sites, resulting in a total of 10 (29%) cases incorrectly identified by the patient. There were no instances in which the patient correctly identified the biopsy site and the blinded dermatologist incorrectly identified it. CONCLUSION In our current medical environment, in which more than 90% of health care is delivered in a clinic setting, wrong‐site surgery is certainly underreported. In adopting a zero‐tolerance policy for wrong‐site surgeries, biopsy‐site photography saves time, money, and potential frustration, hopefully eliminating the number of excisions performed on the wrong site. The authors have indicated no significant interest with commercial supporters.

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.

Treatment of port wine stains using the pulsed-dye laser at 585 nm with the dynamic cooling device

Port wine stains (PWS) are common vascular malformations appearing more frequently on the face and neck. One of the most prevalent treatment modalities for PWS is the pulsed-dye laser (PDL). The first generation PDL was limited to a 450 w s pulse width which was inadequate for the treatment of larger caliber vessels. Second generation PDLs have pulsed widths approximately three times longer (1.5 ms). This, along with the dynamic cooling device (DCD), which allows the safe use of higher fluences, should result in more clinical improvement in the treatment of PWS that were previously resistant or minimally responsive to first generation PDL treatment. We report a case of a 29-year-old white male with extensive PWS on the left face, left neck, and back, which displayed only mild changes with the first generation PDL. However, the use of the 1.5 ms PDL at 585 nm at high fluences in conjunction with the DCD resulted in marked improvement of the patients PWS.

Evaluation of procollagen I deposition after intense pulsed light treatments at varying parameters in a porcine model

Several lasers and light sources have been reported to induce dermal collagen remodeling without damaging the epidermis. The intense pulsed light (IPL) system, which emits polychromatic light of wavelengths between 560 and 1200 nm belongs to this group of increasingly popular non‐ablative skin rejuvenation devices. Various IPL treatment parameters can be adjusted to achieve optimal dermal remodeling and clinical improvement. The aim of this study was to evaluate variations in IPL treatment parameters and the effect on procollagen I deposition. Marked areas of a live Yorkshire pigs flank skin were irradiated with a single or double pass of an IPL source using a fluence of 30 or 40 J/cm2 and a cut‐off wavelength filter of 590 nm. Skin biopsies were performed on postoperative days 1, 7, 14, 21, and 42. A statistically significant increase in procollagen I in treated versus untreated sites was found on postoperative days 21 and 42, but not earlier. There was a uniformly significant increase in procollagen I on day 42 using the 590 nm filter at both 30 and 40 J/cm2 with either a single or double pass. The increase in procollagen was greater with a fluence of 40 J/cm2 compared with 30 J/cm2.

Optimal treatments for hyperpigmentation

The current treatment of hyperpigmentation relies on multiple modalities to achieve satisfactory cosmetic results. Patients are savvy consumers who often present to physicians asking about the latest treatments and breakthroughs. By combining topical bleaching agents, chemical peels, laser therapy, and adequate photo‐protection, many pigmentary disorders can be successfully treated. A review of recent trials and new technologies will be discussed.

Voriconazole Increases the Risk for Cutaneous Squamous Cell Carcinoma after Lung Transplantation

Lung transplant recipients (LTR) are at high risk of cutaneous squamous cell carcinoma (SCC). Voriconazole exposure after lung transplant has recently been reported as a risk factor for SCC. We sought to study the relationship between fungal prophylaxis with voriconazole and the risk of SCC in sequential cohorts from a single center. We evaluated 400 adult LTR at UCLA between 7/1/2005 and 12/22/2012. On 7/1/2009, our center instituted a protocol switch from targeted to universal antifungal prophylaxis for at least 6 months post‐transplant. Using Cox proportional hazards models, time to SCC was compared between targeted (N = 199) and universal (N = 201) prophylaxis cohorts. Cox models were also used to assess SCC risk as a function of time‐dependent cumulative exposure to voriconazole and other antifungal agents. The risk of SCC was greater in the universal prophylaxis cohort (HR 2.02, P < 0.01). Voriconazole exposure was greater in the universal prophylaxis cohort, and the cumulative exposure to voriconazole was associated with SCC (HR 1.75, P < 0.01), even after adjustment for other important SCC risk factors. Voriconazole did not increase the risk of advanced tumors. Exposure to other antifungal agents was not associated with SCC. Voriconazole should be used cautiously in this population.

Post-Inflammatory Hyperpigmentation

Optimal treatment for PIH includes prevention of further pigment deposition and clearing of the deposited pigment. Chemical peels work best when used in combination with topical bleaching regimens. Given the propensity of darker skin types to develop post-inflammatory hyperpigmentation, superficial peels work best, while minimizing complications.

Validity of skin cancer malignancy reporting to the Organ Procurement Transplant Network: A cohort study

Background The Organ Procurement Transplant Network (OPTN) registry collects data on posttransplant malignancies in solid organ transplant recipients. Complete and accurate registry data on skin cancer is critical for research on epidemiology and interventions. Objective The study goal was to determine the validity of Organ Procurement Transplant Network skin cancer data. Methods This cohort study compared reporting of posttransplant squamous cell carcinoma (SCC) and malignant melanoma (MM) in OPTN to medical‐record review‐derived data from the Transplant Skin Cancer Network (TSCN) database. In total, 4934 organ transplant recipients from the TSCN database were linked to patient‐level OPTN malignancy data. We calculated sensitivity, specificity, correct classification (CC), positive predictive value (PPV), and negative predictive value (NPV) for SCC and MM reporting in the OPTN database. Results OPTN reporting for SCC (population prevalence 11%) had sensitivity 41%, specificity 99%, PPV 88%, NPV 93%, and CC 93%. OPTN reporting for MM (population prevalence 1%) had sensitivity 22%, specificity 100%, PPV 73%, NPV 99%, and CC 99%. Limitations Only a subset of patients in the TSCN cohort had matched United Network for Organ Sharing cancer registry data for comparison. Conclusion OPTN reporting had poor sensitivity but excellent specificity for SCC and MM. Dermatologists and transplant physicians are encouraged to improve the validity of OPTN skin cancer data through improved communication and reporting.

Update on Staging, Definition, and Chemoprevention of “High-Risk Squamous Cell Carcinoma” in Organ Transplant Recipients

When compared to the general population, organ transplant recipients (OTRs) have a 65- to 250-fold increased risk of developing cutaneous squamous cell carcinoma (SCC). In addition to increased risk of SCC development, OTRs experience a higher tumor burden, more aggressive SCCs, and increased risk of metastasis and skin cancer-related mortality, making staging, prognosis, and treatment determinations in OTR patients especially important, yet lacking full clarity in the literature. High-risk cutaneous SCCs are those tumors associated with a high risk of subclinical metastasis and subsequent adverse events including local recurrence, nodal metastases, and disease-specific death. There is concern that the current staging systems for cutaneous SCCs may not accurately define a “high-risk” SCC, and the lack of prospective data makes it even more difficult to define “high-risk” features in the immunosuppressed OTR population. With no universally accepted standard definition of high-risk features, the different high-risk factors proposed by several consensus guidelines require individual exploration. OTRs also represent a desirable target for chemoprevention of SCCs, and while only oral retinoids have shown benefit specifically in OTR patients, data pertaining to other proposed agents also warrant review.

Cutaneous Sarcoidosis Successfully Treated With Intralesional 5-Fluorouracil.

Traditional low-level laser therapy (LLLT) refers to the use of photons at nonthermal irradiance to alter biological activity by exposing cells or tissue to low levels of red and near-infrared light. This type of laser therapy has been shown to decrease apoptosis and increase vascular perfusion and neocollagenesis. Low-level laser therapy has been used as a prophylactic method to alter the wound healing process, avoid hypertrophic scar formation, and accelerate wound healing. It has also been associated with antimicrobial effects. Overall, the use of LLLT in wound healing still remains controversial. The authors chose low-intensity 595-nm pulsed dye laser application at somewhat higher fluences than associated with traditional LLLT for prevention of hypergranulation tissue, antiseptic effect, and based on own anecdotal evidence of expedited wound healing with this laser at similar settings.