Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

High-Grade Spindle Cell Sarcoma of the Scalp With an MGA::NUTM1 Gene Fusion in a Pediatric Patient.

ABSTRACT: NUT carcinoma (NC) is a rare and aggressive neoplasm associated with a poor prognosis. NC is characterized by a NUTM1- rearrangement on chromosome 15q14, commonly fused with the BRD4 or BRD3 gene . A rare subset of NC defined by fusion of NUTM1 with the MGA gene has been identified, showing mesenchymal differentiation on histology. Few cases of spindle cell sarcomas harboring MGA::NUTM1 gene fusions have been reported in the literature. We describe a case of spindle cell sarcoma harboring an MGA::NUTM1 fusion in a 6-year-old male patient. In contrast to typical cases of spindle cell carcinomas or NC, NUTM1 fusion-positive sarcomas are associated with a better prognosis. This report highlights the importance of diagnostic workup of undifferentiated neoplasms, as identification of the MGA::NUTM1 fusion in spindle cell sarcoma could be used in treatment algorithms and lead to better outcomes, to the benefit of patients.

Clinical Presentation of Atopic Dermatitis.

Atopic dermatitis, commonly known as eczema, is a chronic inflammatory dermatosis that can affect individuals from infancy to adulthood. Also referred to as "the itch that rashes," atopic dermatitis is classically associated with significant pruritus that is accompanied by characteristic cutaneous and other clinical findings. The diagnosis of atopic dermatitis can be challenging due to the wide range of clinical presentations based on patient factors such as age, skin type, ethnicity, and other comorbid conditions. This chapter reviews the classical findings as well as the less common manifestations of atopic dermatitis.

Recurrent Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Induced by Levamisole-Adulterated Cocaine.

ABSTRACT: Levamisole, an anthelmintic and immunomodulatory drug, was withdrawn from the US market in 1999 due to adverse effects, including agranulocytosis and vasculitis. In recent years, levamisole has been used as a common cocaine adulterant, and its use has led to an autoimmune syndrome characterized by an antineutrophil cytoplasmic antibody-associated vasculitis presenting with necrotic retiform purpura on the face and extremities. We present a case of recurrent levamisole-induced vasculitis initially misdiagnosed as systemic lupus erythematosus to highlight this easily misdiagnosed entity and to demonstrate re-exposure leading to recurrent vasculitis with more extensive clinical manifestations.

Neuromuscular ultrasound for taxane peripheral neuropathy in breast cancer.

BACKGROUND: Our study aim was to evaluate neuromuscular ultrasound (NMUS) for the assessment of taxane chemotherapy-induced peripheral neuropathy (CIPN), the dose-limiting toxicity of this agent. METHODS: This cross-sectional study of breast cancer patients with taxane CIPN measured nerve cross-sectional area (CSA) by NMUS and compared with healthy historical controls. Correlations were determined between CSA and symptom scale, nerve conduction studies, and intraepidermal nerve fiber density (IENFD). RESULTS: A total of 20 participants reported moderate CIPN symptoms at a median of 3.8 months following the last taxane dose. Sural nerve CSA was 1.2 mm2 smaller than healthy controls (P ≤ .01). Older age and time since taxane were associated with smaller sural nerve CSA. For each 1 mm2 decrease in sural nerve CSA, distal IENFD decreased by 2.1 nerve/mm (R2 0.30; P = .04). CONCLUSIONS: These data support a sensory predominant taxane neuropathy or neuronopathy and warrant future research on longitudinal NMUS assessment of CIPN.

Morphea With Keloidal Features: A Case Report and Review of the Literature.

Keloidal morphea is a rare variant of scleroderma, which often can be clinically confused with keloid or scar formation. We report a 34-year-old woman with a medical history of asthma and Raynaud's phenomenon, presented for the evaluation and management of multiple erythematous hyperpigmented annular plaques reportedly developed after taking trimethoprim/sulfamethoxazole. An initial skin biopsy showed findings supportive of a drug eruption. She was treated with oral prednisone and achieved some improvement. She presented 1 year later with enlargement of the plaques and emergence of new lesions. Skin biopsies revealed an unremarkable epidermis with marked fibrosis of the mid-to-deep dermis with sparing of the papillary dermis, and superficial and deep perivascular and perieccrine lymphoplasmacytic inflammation. Verhoeff-Van Gieson staining demonstrated the loss of elastin fibers within the fibrotic areas of the biopsy specimens, which supported the diagnosis of keloidal morphea. Her laboratory tests were positive for antinuclear antibody (greater than 1:1280). She continued treatment with oral prednisone and topical steroids, and she showed improvement. This case highlights the importance of differentiating keloidal scleroderma from a hypertrophic scar or keloid to reveal an underlying systemic process. A correlation of clinical and histopathological findings is paramount to reach a correct diagnosis, ensure appropriate treatment, and monitor for comorbid disease.

Financial Margins for Prostate Cancer Surgery: Quantifying the Impact of Modifiable Cost Inputs in an Episode Based Reimbursement Model.

PURPOSE: The United States health care system is rapidly moving away from fee for service reimbursement in an effort to improve quality and contain costs. Episode based reimbursement is an increasingly relevant value based payment model of surgical care. We sought to quantify the impact of modifiable cost inputs on institutional financial margins in an episode based payment model for prostate cancer surgery. MATERIALS AND METHODS: A total of 157 consecutive patients underwent robotic radical prostatectomy in 2016 at a tertiary academic medical center. We compiled comprehensive episode costs and reimbursements from the most recent urology consultation for prostate cancer through 90 days postoperatively and benchmarked the episode price as a fixed reimbursement to the median reimbursement of the cohort. We identified 2 sources of modifiable costs with undefined empirical value, including preoperative prostate magnetic resonance imaging and perioperative functional recovery counseling visits, and then calculated the impact on financial margins (reimbursement minus cost) under an episode based payment. RESULTS: Although they comprised a small proportion of the total episode costs, varying the use of preoperative magnetic resonance imaging (33% vs 100% of cases) and functional recovery counseling visits (1 visit in 66% and 2 in 100%) reduced average expected episode financial margins up to 22.6% relative to the margin maximizing scenario in which no patient received these services. CONCLUSIONS: Modifiable cost inputs have a substantial impact on potential operating margins for prostate cancer surgery under an episode based payment model. High cost health systems must develop the capability to analyze individual cost inputs and quantify the contribution to quality to inform value improvement efforts for multiple service lines.

An Atypical Presentation of PLEVA: Case Report and Review of the Literature

Pityriasis lichenoides et varioliformis acuta (PLEVA) is a rare, self-limited, cutaneous disorder of unknown etiology. Clinically, PLEVA is characterized by the sudden onset of scaly, erythematous macules and papules localized to the trunk and proximal extremities. We report the case of a patient who presented with multiple erythematous papules and plaques on the palms, forearms, and dorsal feet. J Drugs Dermatol. 2019;18(7):690-691.

Oncocytic Metaplasia in Melanocytic Tumors.

Oncocytic metaplasia represents a histopathologic feature that can be observed in normal tissue such as salivary and lacrimal glands but may also constitute a degenerative metaplastic process as a result of repeated oxidative damage during cellular aging. Although cutaneous oncocytic metaplasia has been considered rare, the finding was seen in over one-third of melanocytic nevi prospectively evaluated, in one study. This case series reports on a small series of oncocytic melanocytic tumors, with the aim of describing this phenomenon in varied contexts and also describing the use of a mitochondrial antigen immunostain, which has not been previously reported.

Clinical Presentation of Atopic Dermatitis.

Atopic dermatitis, commonly known as eczema, is a chronic inflammatory dermatosis that can affect individuals from infancy to adulthood. Also referred to as "the itch that rashes", atopic dermatitis is classically associated with significant pruritus that is accompanied by characteristic cutaneous and other clinical findings. The diagnosis of atopic dermatitis can be challenging due to the wide range of clinical presentations based on patient factors such as age, skin type, ethnicity, and other comorbid conditions. This chapter reviews the classical findings as well as the less common manifestations of atopic dermatitis.

Retrospective Study of Rocky Mountain Spotted Fever in Children.

BACKGROUND/OBJECTIVES: Rocky Mountain spotted fever (RMSF), a lethal tick-borne illness, is prevalent in the south central United States. Children younger than 10 years old have the greatest risk of fatal outcome from RMSF. The objective of the current study was to review pediatric cases of RMSF seen in the dermatology consult service and to evaluate dermatology's role in the diagnosis and management of this disease. METHODS: A retrospective review was performed of inpatient dermatology consultations at a tertiary care center in North Carolina from 2001 to 2011. Data collected included patient demographic characteristics, symptoms, pre- and postconsultation diagnoses, diagnostic procedures, length of hospital stay, and outcome. RESULTS: A total of 3,912 consultations were conducted in the dermatology service over 10 years. Six patients with RMSF, ranging in age from 22 months to 10 years (mean 5.1 years), were evaluated during April, May, and June. All preconsultation diagnoses included RMSF in the differential diagnosis. All patients underwent skin biopsies, and a culture was obtained in one case. Fifty percent of patients died within 4 days of hospitalization. CONCLUSIONS: Variables associated with mortality from RMSF are delayed diagnosis and initiation of antirickettsial therapy. Physicians should consider RMSF in children presenting with fever and rash during the summer months. Dermatology consultation is useful in evaluating patients with suspicious clinical features of RMSF with skin findings.

Melanocytic Nevi of Special Sites.

Melanocytic nevi located on specific regions of the body can demonstrate unusual histopathological features such as asymmetry, irregular nesting patterns, pagetoid spread, cytologic atypia, and rarely, mitotic activity. However, despite these features that may raise concern for malignant melanoma, these lesions follow a benign clinical course and do not require intervention. Also known as nevi of special sites or nevi with site-related atypia, these melanocytic nevi were initially described on acral sites and genitalia. Now, additional anatomical sites with known site-related atypia include the ear, conjunctivae, scalp, breast, flexural skin, legs, and back and shoulder. This continuing medical education article presents a review of the histopathological characteristics of special site nevi based on anatomic location. It is imperative for dermatologists, pathologists, and dermatopathologists to distinguish benign melanocytic nevi with site-related atypia from malignant melanoma to avoid unnecessary surgical intervention or treatment.