Our experience with propranolol for infantile hemangioma.

BACKGROUND/OBJECTIVES: The most frequent benign vascular tumor in children is infantile hemangioma (IH). For severe IHs, propranolol has become the first-line Treatment. Despite the fact that several studies have comprehensive therapy regimens, including the best time to start Treatment, dosage, visit frequency, and treatment duration, there is still controversy about the best time to start and stop propranolol medication. METHODS: Between January 2016 and February 2019, dermatologists experienced hemangioma treatment and recommended propranolol treatment for 232 IHs. A total of 90 patients completed the treatment process after undergoing a color Doppler ultrasound test. RESULTS: Propranolol uniquely affects each IH. Ninety patients were divided into two groups in this study: entire regression (n = 40) and partial regression (n = 50). The entire regression group's initial treatment period (4.3 ± 2.97 months) was substantially shorter than the partial regression group's (5.2 ± 4.57 months) (p < 0.05). Between the entire regression group (23.4 ± 12.8 months) and the partial regression group (24.5 ± 16.6 months), there was no significant difference in time to reduce propranolol. The partial regression group (32.9 ± 25.3month) had a lengthier treatment course than the entire regression group (23.4 ± 13.7 months) (p < 0.05). The partial regression group (22%), like the entire regression group, had a higher recurrence rate (5%). The overall proportion of hemangiomas on the face (particularly periocular hemangioma) in the regression group was greater than in the control group. CONCLUSION: The entire regression group's initial treatment time was significantly shorter than the partial regression group's. As a result, as soon as a hemangioma is discovered, it should be treated. To determine the appropriate time to reduce propranolol, we must evaluate the patient's age and the percentage of tumor regression. Periocular hemangioma may have a better prognosis than other types. Given the small number of patients in our study, we will need to do more research in the future to confirm our findings.

A new clinical and dermoscopic monitoring of infantile hemangiomas treated with oral propranolol.

Oral propranolol (OP) demonstrated high efficacy and safety profile for treatment of critical infantile hemangiomas (IHs). Our aim was to assess the morphologic changes of IHs with standard and high-resolution video dermoscopy (HRVD) from baseline to 18 months either in presence or absence of OP therapy; to investigate if extended anamnestic perinatal data and clinical-dermoscopic characteristics of the IHs can correlate with therapeutic outcome. We enrolled 94 patients (112 IHs): 58 were treated with OP, 35 (42 IHs) for 6 months (group 1), and 23 (25 IHs) for 12-months (group 2); 36 (45 IHs) were followed-up. Clinical-dermoscopic examinations were performed every 3 months during therapy and follow-up. Among 67 treated IHs, superficial and deep IHs with homogenous clinical-dermoscopic aspect developed after the 2 weeks of life achieved the better outcome, stable at 9-month follow-up, independently form treatment duration. Under HRVD, glomerular vessels were prevalent at baseline; corckscrew, comma, and linear-irregular vessels were the prevalent pattern at 1, 3, and 6 months of therapy, respectively. At 12-month follow-up, adequate healing was achieved by 96% of IHs in group 2 and by 78% in group 1, showing dotted vessels. Persistent IHs displayed a reticulated aspect and linear irregular vessels, while arborizing vessels characterized relapsed IHs. A 12-month OP therapy can be considered for newborns presenting with nonhomogenous mixed IHs >3 cm on the perineal area/lower extremities. In conclusion, HRVD allows a real time monitoring of vascular changes in IHs treated with OP and can support physicians in identifying relapses before they become clinically evident.

[Artificial intelligence and smartphone program applications (Apps) : Relevance for dermatological practice]. / Künstliche Intelligenz und Smartphone-Programm-Applikationen (Apps) : Bedeutung für die dermatologische Praxis.

ADVANTAGES OF ARTIFICIAL INTELLIGENCE (AI): With responsible, safe and successful use of artificial intelligence (AI), possible advantages in the field of dermato-oncology include the following: (1) medical work can focus on skin cancer patients, (2) patients can be more quickly and effectively treated despite the increasing incidence of skin cancer and the decreasing number of actively working dermatologists and (3) users can learn from the AI results. POTENTIAL DISADVANTAGES AND RISKS OF AI USE: (1) Lack of mutual trust can develop due to the decreased patient-physician contact, (2) additional time effort will be necessary to promptly evaluate the AI-classified benign lesions, (3) lack of adequate medical experience to recognize misclassified AI decisions and (4) recontacting a patient in due time in the case of incorrect AI classifications. Still problematic in the use of AI are the medicolegal situation and remuneration. Apps using AI currently cannot provide sufficient assistance based on clinical images of skin cancer. REQUIREMENTS AND POSSIBLE USE OF SMARTPHONE PROGRAM APPLICATIONS: Smartphone program applications (apps) can be implemented responsibly when the image quality is good, the patient's history can be entered easily, transmission of the image and results are assured and medicolegal aspects as well as remuneration are clarified. Apps can be used for disease-specific information material and can optimize patient care by using teledermatology.

Nodular melanoma presenting as an exophytic subungual mass.

Despite being recognised and reported in the literature for decades, subungual melanoma of the foot remains a diagnostic pitfall, with it commonly being mistaken for benign conditions. We present an interesting case of delayed diagnosis of subungual melanoma of the hallux that was misdiagnosed in the community for over one year. With melanoma being the fourth most commonly diagnosed cancer in Australia in 2013, this case serves as a reminder to all clinicians about the importance of maintaining a high index of suspicion for melanoma of the foot.

Ultrasonographic findings can identify 'pseudoprogression' under nivolumab therapy.

'Pseudoprogression' is often seen in patients with melanomas who are treated with immune checkpoint inhibitors such as nivolumab or ipilimumab. We sometimes evaluate metastatic lesions by imaging tests such as computed tomography (CT) or positron emission tomography-CT. 'Pseudoprogression' usually occurs upon the initial administration, which may make it difficult for the physician to determine the disease condition. In our two cases of metastatic melanoma treated with nivolumab (antiprogrammed cell death-1 antibody), we examined the ultrasonography (US) of target lesions that could be accessed from the body surface, such as those of the regional lymph node or subcutaneous metastasis. In both cases, the US revealed a lesion approximately 10% greater in size after 40-50 days of nivolumab administration, even though the blood flow inside the tumour was reduced by about 20% within 50 days. From about 100 days after blood flow reduction was detected by US, the tumours began to decrease in size. However, contrast CT was unable to detect the association between tumour size and tumour blood flow. The present cases suggest that US could be a powerful tool for differentiating between 'pseudoprogression' and real progressive disease in patients treated with cancer immunotherapies such as those involving immune checkpoint inhibitors. The misdiagnosis of progressive disease can lead to unnecessary alterations to the current treatment. Therefore, the US findings in our study could be clinically useful and educational for physicians.

Role of (18)F-fluorodeoxyglucose positron emission tomography imaging in the management of primary cutaneous lymphomas.

Primary cutaneous lymphomas (PCLs) include both cutaneous T-cell and B-cell lymphomas and comprise the second most common type of extra-nodal non-Hodgkin's lymphomas. The treatment and prognosis of PCLs typically depend on the extent of disease. In evaluating extent of disease in oncological processes, computed tomography (CT) provides a purely anatomical assessment of disease. In comparison, [(18)F]-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) both visualizes and quantifies the biological processes occurring in the disease at the cellular level. This paper reviews the available literature addressing the clinical role of (18)F-FDG PET both alone and in combination with CT in PCLs and draws several conclusions. While (18)F-FDG PET seems superior to CT in its detection of nodal and cutaneous PCL lesions, (18)F-FDG PET does not seem to adequately detect erythroderma, plaque, or patch cutaneous PCL lesions. In addition, several case series have demonstrated that physicians may be able to use the semi-quantitative measurement of (18)F-FDG uptake provided by (18)F-FDG PET to predict which lesions are most aggressive. Other case series have shown that the integrated (18)F-FDG PET/CT may provide an objective measure of treatment response in patients with PCLs.

The role of artificial intelligence and convolutional neural networks in the management of melanoma: a clinical, pathological, and radiological perspective.

Clinical dermatoscopy and pathological slide assessment are essential in the diagnosis and management of patients with cutaneous melanoma. For those presenting with stage IIC disease and beyond, radiological investigations are often considered. The dermatoscopic, whole slide and radiological images used during clinical care are often stored digitally, enabling artificial intelligence (AI) and convolutional neural networks (CNN) to learn, analyse and contribute to the clinical decision-making. A keyword search of the Medline database was performed to assess the progression, capabilities and limitations of AI and CNN and its use in diagnosis and management of cutaneous melanoma. Full-text articles were reviewed if they related to dermatoscopy, pathological slide assessment or radiology. Through analysis of 95 studies, we demonstrate that diagnostic accuracy of AI/CNN can be superior (or at least equal) to clinicians. However, variability in image acquisition, pre-processing, segmentation, and feature extraction remains challenging. With current technological abilities, AI/CNN and clinicians synergistically working together are better than one another in all subspecialty domains relating to cutaneous melanoma. AI has the potential to enhance the diagnostic capabilities of junior dermatology trainees, primary care skin cancer clinicians and general practitioners. For experienced clinicians, AI provides a cost-efficient second opinion. From a pathological and radiological perspective, CNN has the potential to improve workflow efficiency, allowing clinicians to achieve more in a finite amount of time. Until the challenges of AI/CNN are reliably met, however, they can only remain an adjunct to clinical decision-making.

Extramedullary disease in patients with acute myeloid leukemia assessed by 18F-FDG PET.

BACKGROUND: Prevalence of extramedullary disease (EMD) in acute myeloid leukemia (AML) at the time of diagnosis is unknown. Previous estimates range from 2.5% to 30.5% and are usually based on clinical examination. This may cause an under diagnosis of EMD as not all extramedullary manifestations are easily detectable. Few recent studies have used positron emission tomography (PET) scans for diagnosing EMD in patients AML. METHOD: During a 9-month period, newly diagnosed patients with AML who were candidates for intensive chemotherapy were 18F-Fluoro-deoxy-glucose (FDG) PET-scanned prior to induction treatment. We compared the prevalence of EMD diagnosed by PET scans and by clinical examination. Subsequent PET scans following induction chemotherapy were performed for response evaluation of EMD. RESULTS: Twenty-six patients were included in the study. 18-F-FDG PET scans revealed more than twice as many patients with EMD than found by clinical examination (65% vs. 31%). PET demonstrated 55 EMD lesions compared with 15 diagnosed by clinical examination. In general, the responses of EMD detected by PET scans were concordant with the bone marrow responses assessed by pathology examination. CONCLUSION: 18-F-FDG PET is a useful tool for diagnosing EMD in AML and for assessing treatment responses of EMD in AML.

Intraosseous schwannoma in schwannomatosis.

This study investigates the clinical, radiological, and pathological features of two cases of intraosseous schwannoma that arose in patients with multiple soft tissue schwannomas. In both cases, the patients were adult females and the tibial bone was affected. Vestibular schwannomas were not identified, indicating that these were not cases of neurofibromatosis 2 (NF2). Radiographs showed a well-defined lytic lesion in the proximal tibia; in one case, this was associated with a pathological fracture. Histologically, both cases showed typical features of benign schwannoma. Molecular analysis of one of the excised tumors showed different alterations in the NF2 gene in keeping with a diagnosis of schwannomatosis. Our findings show for the first time that intraosseous schwannomas can occur in schwannomatosis.

[Recurrent fibrosarcomatous dermatofibrosarcoma protuberans. Ultrasound imaging]. / Rezidiv eines fibrosarkomatösen Dermatofibrosarcoma protuberans. Sonographische Darstellung.

Dermatofibrosarcoma protuberans (DFSP) is a rare dermal tumor of intermediate malignancy with a locally aggressive growth behavior with a high rate of recurrence. Wide local excision with histographic margin control as well as regular follow-ups including clinical as well as ultrasound examination are crucial to detect local recurrence or metastasis. Ultrasound imaging can not only identify recurrences but also asses their extent. We report on a patient with a relapse of fibrosarcomatous DFSP, which could be demonstrated by ultrasound imaging.

Advanced vulvar apocrine carcinoma expressing estrogen receptors that responds to tamoxifen therapy.

Primary vulvar carcinoma is rare and thought to arise from either anogenital mammary-like glands or native apocrine sweat glands. The diagnosis is predominantly based on tumor morphology with supportive evidence from immunohistochemical staining and exclusion of a primary breast carcinoma. The primary modality of treatment is surgery, while optimal managment of advanced disease is unclear. We present the case of a lady who had metastatic recurrent apocrine carcinoma expressing estrogen receptors, who had a complete response assessed by PET-CT scanning after 7 months of tamoxifen therapy. The report includes a discussion of the histological diagnosis and assessment of response to treatment by PET-CT scanning.

Topical propranolol therapy for infantile hemangiomas.

The nonselective beta-adrenergic receptor antagonist propranolol is an effective therapy for infantile hemangiomas. Systemic propranolol therapy shows a rapid therapeutic effect with good drug tolerability. We report on the efficacy of local application of propranolol ointment in superficial hemangiomas of the skin. In our outpatient department, 45 children with 65 hemangiomas were treated with 1% propranolol in a hydrophilic ointment topically applied twice a day. Before start of treatment and at each visit, clinical photographs were taken. If ultrasound did not confirm occult deeper components, children were included in the study. Treatment in the proliferative phase within the first 6 months of life (including seven preterm infants) induced regression in 59% and cessation of growth in 26% of the hemangiomas. No response or proliferation of subcutaneous components was observed in 15%. Clinically, no side effects caused by the beta-receptor blocker were noticed. Treatment of two ulcerated hemangiomas of the perineal region twice using a flash lamp pulsed-dye laser and propranolol ointment in the surrounding lesion led to healing of the ulcers in 3 and 6 weeks, respectively. In six patients, topical therapy was started between the ages of 7 and 33 months. Even in these hemangiomas, improvement was obvious after 2 or 3 months. Propranolol administered topically in 1% ointment could have a beneficial effect on superficial hemangiomas of the skin. The treatment was well tolerated without side effects even in preterm infants and in children with numerous or large lesions.

Metastatic malignant melanoma and dermatomyositis: A paraneoplastic phenomenon.

Malignant melanoma has previously been reported with paraneoplastic syndromes including dermatomyositis. We report a case involving a 34-year-old woman who presented with a persistent skin rash over her neck and upper body, with clinical features suggestive of dermatomyositis. The patient had a history of a right shoulder lesion that was previously removed; a solitary axillary lymph node was detected on additional imaging and biopsy results were consistent with malignant melanoma. The following year, surveillance positron emission tomography scan detected a solitary lung metastasis, leading to a partial lobectomy and confirmation of further spread of the malignant melanoma.

Newborn's giant sacrococcigeal teratoma.

A sacrococcigeal tumor was detect at ultrasound maternal exam in 25TH week of pregnancy. The girl was born full term by natural way by the parents' choise. The newborn present a tumor with 12 cm diameter, situated in sacrococcigeal region, with a large base of implantation and with posteroinferior growth. This tumor produced a dislocation of the rectum and a perineal area. In the first day of baby's life, we perform the operation. We removed a large tumor (600 gr) with the coccys bone and we obtained a good repair of anatomy of the region, without postoperatory functional troubles. Postoperatory evolution was good. The newborn lived hospital healed in the 14th day. The histopatologic exam confirmed that the tumor was benign. Later evolution was good.

Clinical Value of PET/CT in Staging Melanoma and Potential New Radiotracers.

BACKGROUND: 18F-FDG PET/CT has been suggested as an effective tool to stage patients affected by melanoma. In the latest years, new radiopharmaceuticals have been proposed and the use of hybrid PET/ceCT has emerged. OBJECTIVE: To review recent evidence on the role of PET/CT in melanoma staging as well as its potential for future developments. METHODS: A comprehensive computer literature search of PubMed/MEDLINE was carried out to find relevant published articles concerning the feasibility of PET/CT in patients with malignant melanoma. RESULTS: Some recent studies about potentials and limitations of 18F-FDG PET/CT in staging melanoma, new PET radiotracers beyond 18F-FDG and application of hybrid PET/ceCT have been reviewed and discussed. CONCLUSION: PET/CT plays an important role in the staging workup of patients affected by melanoma. New radiopharmaceuticals and hybrid PET/ceCT could improve the potential of this diagnostic tool in this field.

18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography for Assessing Tumor Response to Immunotherapy in Solid Tumors: Melanoma and Beyond.

The complexity of the immune response and diversity of targets challenges conventional conceptual frameworks used in selecting and monitoring treatment with immune check-point inhibitors. The limitations of anatomic imaging in assessing response have been recognized. Varying patterns of response have been recognized. These patterns have different implications for the continuation and duration of therapy. Evidence supporting the role of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography as a prognostic biomarker and in characterizing response is presented. An added benefit of this approach is the ability to detect immune-related inflammatory reactions, often in advance of severe or life-threatening clinical manifestations.

Segmental hemangioma of infancy complicated by life-threatening arterial bleed.

Infantile hemangiomas (IHs) are the most common benign vascular tumors of childhood. IH of "segmental" morphology, are clusters of hemangiomas with a configuration involving a broad anatomic territory of skin. They are the least common of all types and generally larger than regular hemangiomas, morphologically characterized as plaque-like lesions. Head and neck segmental hemangiomas have a higher risk of causing life-threatening complications and of having associated structural anomalies, i.e., PHACES syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coartation of the aorta and other cardiac defects, eye abnormalities and sternal clefting or supra abdominal raphe). We present a patient with a segmental IH over the right anterior neck complicated by ulceration and life threatening arterial bleeding. Although segmental hemangiomas of head and neck have high incidence of ulceration, fortunately life threatening bleeding events are rare with only 7 previously recorded cases. We recommend that large, neck IH be followed closely for evidence of ulceration and that MRI/MRA be performed to adequately assess their vascular supply. Direct extension of the ulceration into arterial vessels is a possibility and can lead to severe bleeding. Life-threatening bleeding is an unusual complication of IH and may represents a surgical emergency. In such cases we recommend a multidisciplinary approach to their treatment.