Difficult to Diagnose Cutaneous Melanoma in a Patient with BAP1 Tumor Predisposition Syndrome.

BRCA1-associated protein 1 (BAP1)-inactivated melanomas can occur sporadically or in germline contexts, particularly in recently recognized BAP1-tumor predisposition syndrome. Diagnosis represents a clinical and histopathological challenge, requiring comprehensive analysis of morphology and sometimes molecular analysis in addition to immunohistochemistry. We report a BAP1-inactivated cutaneous melanoma initially diagnosed as an atypical Spitz tumor on the auricle in a patient with BAP1-tumor predisposition syndrome. Immunohistochemistry, fluorescence in situ hybridization, and comparative genomic hybridization allowed diagnosis. Cutaneous BAP1-inactivated melanocytic tumors, previously classified as atypical Spitz Nevi, may have a dermal mitotic activity that can resemble melanoma and on the other hand, atypical Spitz tumors are sometimes difficult to differentiate from BAP1-inactivated melanoma. Specific criteria, requiring molecular diagnosis have been proposed in order to support melanoma diagnosis.

Surgery for Cutaneous Squamous Cell Carcinoma and its Limits in Advanced Disease.

Surgery remains the first-line therapeutic option for most patients with cutaneous squamous cell carcinoma (cSCC). However, in the current therapeutic landscape, surgery must attempt to the complete tumor resection (R0 resection) with the lowest risk of surgical complications. This double aim is usually accomplished through standard excision with clinical margins in patients with low-risk tumors or by some of the micrographically controlled surgery procedures for patients with tumors at high-risk of local recurrence and metastasis. Surgery is also a first-line treatment for nodal metastases of cSCC as well as an option to consider in patients who develop recurrences while receiving immunotherapy, or as a palliation procedure in patients with advanced tumors. Neoadjuvant immunotherapy, that is the use of a medical treatment before surgery, is under investigation in patients with cSCC. The decision-making process and guidelines recommendations regarding cSCC surgery are reviewed in this manuscript.

Sentinel Lymph Node Biopsy vs. Observation in Thin Melanoma: A Multicenter Propensity Score Matching Study.

The therapeutic value of sentinel lymph node biopsy (SLNB) in thin melanoma remains controversial. The aim of this study is to determine the role of SLNB in the survival of thin melanomas (≤1 mm). A multicenter retrospective observational study was designed. A propensity score matching was performed to compare patients who underwent SLNB vs. observation. A multivariate Cox regression was used. A total of 1438 patients were matched by propensity score. There were no significant differences in melanoma-specific survival (MSS) between the SLNB and observation groups. Predictors of MSS in the multivariate model were age, tumor thickness, ulceration, and interferon treatment. Results were similar for disease-free survival and overall survival. The 5- and 10-year MSS rates for SLN-negative and -positive patients were 98.5% vs. 77.3% (p < 0.001) and 97.3% vs. 68.7% (p < 0.001), respectively. SLNB does not improve MSS in patients with thin melanoma. It also had no impact on DSF or OS. However, a considerable difference in MSS, DFS, and OS between SLN-positive and -negative patients exists, confirming its value as a prognostic procedure and therefore we recommend discussing the option of SLNB with patients.

Feasibility and cost of a telemedicine-based short-term plan for initial access in general dermatology in Andalusia, Spain.

BACKGROUND: In developed countries, health care delivery in dermatology is hampered by the low availability of dermatologists. OBJECTIVE: To analyze the feasibility of a teledermatology-based action plan to provide initial dermatologic care in areas with low availability of dermatologists. METHODS: A cross-sectional study describing the feasibility and cost of a 12-month action plan based on a store-and-forward teledermatology (TD) connecting primary care centers and a TD center. Teleconsultations from patients complaining of any cutaneous condition were included. The primary outcome measure was the percentage of patients not referred to the local dermatologist. RESULTS: Among the total of 15,523 teleconsultations attended in the TD-based action plan, 3360 (21.65%) required a face-to-face visit with a local dermatologist. In 32.32% (n = 5017) of the cases, a therapeutic and follow-up plan report was issued. The most common conditions managed were melanocytic nevi (15.63%, n = 2426), followed by seborrheic keratosis (14.89%, n = 2312), and actinic keratosis (8.65%, n = 1342). The average response time was 14.52 days (95% CI 14.35-15.23). The additional total investment in this action plan was $142,681.01, with a unit cost of 9.20$/patient. LIMITATIONS: Noncontrolled study. CONCLUSIONS: Experienced dermatologists working with store-and-forward TD can deliver a fast and effective response in health care areas with access limitations.

Factors associated with sentinel lymph node status and prognostic role of completion lymph node dissection for thick melanoma.

INTRODUCTION: Sentinel lymph node (SLN) biopsy is useful for the prognostic stratification of patients with thick melanoma. Identifying which variables are associated with SLN involvement and establishing risk in different subgroups of patients could be useful for guiding the indication of SLN biopsy. The value of complete lymph node dissection (CLND) in patients with a positive SLN biopsy is currently under debate. MATERIALS AND METHODS: To identify factors associated with SLN involvement in thick melanoma we performed a multicentric retrospective cohort study involving 660 patients with thick melanoma who had undergone SLN biopsy. To analyze the role of CLND in thick melanoma patients with a positive SLN biopsy, we built a multivariate Cox proportional hazards model for melanoma-specific survival (MSS) and disease-free survival (DFS) and compared 217 patients who had undergone CLND with 44 who had not. RESULTS: The logistic regression analysis showed that age, histologic subtype, ulceration, microscopic satellitosis, and lymphovascular invasion were associated with nodal disease. The CHAID (Chi-squared Automatic Interaction Detection) decision tree showed ulceration to be the most important predictor of lymphatic involvement. For nonulcerated melanomas, the histologic subtype lentigo maligna melanoma was associated with a low rate of SLN involvement (4.3%). No significant differences were observed for DFS and MSS between the CLND performed and not-performed groups. Nodal status on CLND was associated with differences in DFS and MSS rates. CONCLUSION: We identified subgroups of thick melanoma patients with a low likelihood of SLN involvement. CLND does not offer survival benefit, but provides prognostic information.

Increasing Frequency of Seborrheic Keratosis Diagnoses as a Favorable Consequence of Teledermatology-Based Skin Cancer Screening: A Cross-sectional Study of 34,553 Patients.

BACKGROUND: Screening of skin cancer by teledermatology (TD) has improved the early detection of skin cancer by enhancing access to skin cancer clinics. OBJECTIVE: We sought to analyze how TD-based skin cancer screening has changed the frequency of consultations for benign lesions. PATIENTS AND METHODS: A cross-sectional study including teleconsultations received during a 7-year period was conducted to analyze and compare the trendlines of each lesion type over the study period. Trendlines were analyzed using a linear regression model with the R-squared (R 2) test for goodness of fit. RESULTS: A total of 34,553 teleconsultations were included in the study. Seborrheic keratoses, followed by benign melanocytic lesions, were the most frequent lesions diagnosed. The pick-up rate for malignant lesions was 1:8.6 teleconsultations. Seborrheic keratoses and precancerous lesions showed a positive trendline with good fit to the linear model (R 2 = 0.8 and R 2 = 0.8, respectively). Tis-T1 malignant melanoma (in situ melanoma or melanoma with a Breslow thickness <1 mm) showed an increasing trendline with moderate-to-low fit to the model (R 2 = 0.4). CONCLUSIONS: TD-based screening of skin cancer is associated with an increasing rate of consultations involving seborrheic keratoses, which can be considered a consequence of improved access to dermatologists resulting from TD implementation.

Composite cutaneous hemangioendothelioma on the back.

Composite cutaneous hemangioendothelioma (HE) is the most recently described variant of the lesions known as HEs. It is characterized by a mixture of histologic patterns, namely, epithelioid HE, retiform HE, and spindle cell hemangioma. We report a new case of this rare tumor located on the back of a 23-year-old woman. This neoplasm is considered to be of borderline or low-grade malignancy, because despite its frequency it rarely metastasizes.