Melanoma and melanoma in-situ diagnosis after excision of atypical intraepidermal melanocytic proliferation: A retrospective cross-sectional analysis.

BACKGROUND: There is little evidence to guide surgical management of biopsies yielding the histologic descriptor atypical intraepidermal melanocytic proliferation (AIMP). OBJECTIVE: Determine frequency of and factors associated with melanoma and melanoma in-situ (MIS) diagnoses after excision of AIMP and evaluate margins used to completely excise AIMP. METHODS: Retrospective, cross-sectional study of 1127 biopsies reported as AIMP and subsequently excised within one academic institution. RESULTS: Melanoma (in situ, stage 1A) was diagnosed after excision in 8.2% (92/1127) of AIMP samples. Characteristics associated with melanoma/MIS diagnosis included age 60-79 years (odds ratio [OR] 8.1, 95% confidence interval [CI] 2.5-26.2), age ≥80 years (OR 7.2, 95% CI 1.7-31.5), head/neck location (OR 4.9, 95% CI 3.1-7.7), clinical lesion partially biopsied (OR 11.0, 95% CI 6.7-18.1), and lesion extending to deep biopsy margin (OR 15.1, 95% CI 1.7-136.0). Average ± standard deviation surgical margin used to excise AIMP lesions was 4.5 ± 1.8 mm. LIMITATIONS: Single-site, retrospective, observational study; interobserver variability across dermatopathologists. CONCLUSION: Dermatologists and pathologists can endeavor to avoid ambiguous melanocytic designations whenever possible through excisional biopsy technique, interdisciplinary communication, and ancillary studies. In the event of AIMP biopsy, physicians should consider the term a histologic description rather than a diagnosis, and, during surgical planning, use clinicopathologic correlation while bearing in mind factors that might predict true melanoma/MIS.

Reflectance confocal microscopy-guided carbon dioxide laser ablation of low-risk basal cell carcinomas: A prospective study.

BACKGROUND: Basal cell carcinoma (BCC) treatment modalities can be stratified by tumor subtype and recurrence risk. The main limitation of nonsurgical treatment modalities is the lack of histopathologic confirmation. Reflectance confocal microscopy (RCM) is a noninvasive imaging device that provides quasihistologic images. OBJECTIVE: To evaluate the feasibility and efficacy of RCM-guided carbon dioxide (CO2) laser ablation of low-risk BCCs. METHODS: Prospective study with biopsy specimen-proven low-risk BCCs imaged with RCM. RCM was performed on these sites before and after ablation. If residual tumor was found, a new series of laser passes were performed. The patients were then monitored for recurrence clinically and with RCM. RESULTS: Twenty-two tumor sites in 9 patients (5 men, 4 women) were imaged and treated. Median age was 59 ± 12.9 years (range, 30-74 years). Mean tumor size was 7.7 mm (range, 5-10 mm). Residual tumor was identified in 5 of 22 cases (22.7%) under RCM on immediate first-pass postablation sites, prompting additional laser passes. Median follow-up was 28.5 months (range, 22-32 months) with no recurrences found. CONCLUSIONS: Addition of RCM to laser ablation workflow can detect subclinical persistent tumor after initial ablation and may serve as an aid to increase the efficacy of laser ablation.

Effect of laser therapy on quality of life in patients with radiation-induced breast telangiectasias.

OBJECTIVE: To evaluate the effects of laser monotherapy on quality of life in breast cancer patients with chronic radiation dermatitis. STUDY DESIGN: A prospective, IRB-approved study was conducted at Memorial Sloan Kettering Cancer Center. Breast cancer patients with chronic radiation dermatitis completed health-related quality of life (HR-QOL) questionnaires before and after laser monotherapy for radiation-induced breast telangiectasias (RIBT). METHODS: After informed consent, all patients were issued the Skindex-16 and Breast-Q Adverse Effects of Radiation HR-QOL questionnaires prior to receiving laser treatment. Patients were treated with a 595 nm pulsed dye laser at 4- to 6-week intervals, with percent telangiectasia clearance and adverse events recorded at each visit. Post-treatment HR-QOL questionnaires were collected after clinician-assessed telangiectasia clearance of >50%. Median HR-QOL scores before and after therapy were reported for individual HR-QOL domains (Skindex-16) and HR-QOL totals (Skindex-16 and Breast-Q Adverse Effects of Radiation). Before- and after-differences were calculated using the Wilcoxon Signed-Rank Test. RESULTS: Twenty-two female patients (average age 56 years) enrolled in this study. A majority (13/22, 59%) exhibited telangiectasias across the décolletage and axilla in addition to the breast. Sixteen patients reached the 50% RIBT clearance threshold during the study period, and 11 of these patients (69%) completed follow-up HR-QOL questionnaires. Patients showed statistically significant improvements in emotional and functional Skindex-16 HR-QOL domains and in overall Skindex-16 HR-QOL score. Breast-Q scores also improved significantly, illustrating a decrease in specific physical and cosmetic concerns common to radiated breast skin. Common adverse events were transient post-treatment pain and redness. CONCLUSION: Breast cancer patients with RIBT presented with substantial deficits in several HR-QOL arenas. Laser monotherapy effectively treated the appearance of radiation dermatitis in these patients and also significantly improved HR-QOL. Lasers Surg. Med. 50:284-290, 2018. © 2017 Wiley Periodicals, Inc.

A Contrasting Dark Background for Nail Sampling.

Accurate testing for onychomycosis requires procurement of ample subungal debris, which can be difficult to visually quantify. Specimen collection on a dark background-a black sticky note pad, for example-to contrast with light-colored nail debris can help ensure an adequate specimen for fungal culture or polymerase chain reaction.

Association of Quality of Life With Surgical Excision of Early-Stage Melanoma of the Head and Neck.

Importance: Surgical excision is the standard-of-care treatment for Tis and T1a melanomas of the head and neck. Currently, however, the association of diagnosis and surgical treatment of these typically slowly progressive and nonfatal melanomas with a patient's health-related quality of life (HRQoL) is unknown. Objective: To characterize and assess HRQoL in patients with Tis and T1a head and neck melanoma, evaluate changes in HRQoL over the surgical treatment course, and identify patient characteristics associated with lower HRQoL. Design, Setting, and Participants: This longitudinal, prospective cohort study involved patients with Tis or T1a melanoma of the head and neck who underwent staged excision at a single tertiary care center (Memorial Sloan Kettering Cancer Center, New York, New York) and were recruited from June 1, 2016, to February 28, 2017. Patients were followed up for 1 year after their surgical procedure. Participants were asked to complete 2 patient-reported outcome measure questionnaires, Skindex-16 and Skin Cancer Index (SCI), at 4 time points: baseline, perioperative (1 to 2 weeks after surgery), and 6-month and 1-year follow-up. Main Outcomes and Measures: Scores on the Skindex-16 and SCI questionnaires. Results: In total, 56 patients were included in the study, among whom 24 (43%) were female and 32 (57%) were male, with a mean (range) age of 67.2 (32-88) years; all patients self-identified as white. Forty-one (73%) questionnaires at perioperative, 49 (88%) at 6-month postoperative, and 41 (73%) at 1-year postoperative time points were completed. At baseline, female patients and those younger than 65 years had statistically significantly worse HRQoL on the Skindex-16 questionnaire (mean score, 14.2 [95% CI, 9.1-21.9] and 16.1 [95% CI, 9.8-26.4]) and on the SCI questionnaire (mean score, 57.2 [95% CI, 48.3-67.6] and 53.2 [95% CI, 44.1-64.3]) compared with males (mean Skindex-16 score, 7.0 [95% CI, 4.8-10.3]; mean SCI score, 73.5 [95% CI, 66.0-81.7]) and those aged 65 years or older (mean Skindex-16 score 7.1 [95% CI, 5.0-10.0]; mean SCI score, 74.3 [95% CI, 67.7-81.6]). Questions that demonstrated the worst scores at baseline were worry about skin condition (Skindex-16) and worry about future skin cancers (SCI). The emotions subscale scores on the Skindex-16 questionnaire showed the greatest improvement from baseline to 1-year follow-up levels (26.6 vs 15.3; P < .001) and so did the appearance subscale scores on the SCI questionnaire (64.0 vs 84.6; P < .001). The score difference in HRQoL by sex diminished over time, whereas the score difference by age persisted through the first year. Conclusions and Relevance: Improvement in HRQoL at the 6-month and 1-year follow-up was associated with surgical excision in patients with early-stage head and neck melanoma, and younger and female patients experienced worse HRQoL. These results may be used in tailoring counseling for this patient population.

Correlation of Handheld Reflectance Confocal Microscopy With Radial Video Mosaicing for Margin Mapping of Lentigo Maligna and Lentigo Maligna Melanoma.

Importance: The management of lentigo maligna (LM) and LM melanoma (LMM) is challenging because of extensive subclinical spread and its occurrence on cosmetically sensitive areas. Reflectance confocal microscopy (RCM) improves diagnostic accuracy for LM and LMM and can be used to delineate their margins. Objectives: To evaluate whether handheld RCM with radial video mosaicing (HRCM-RV) offers accurate presurgical assessment of LM and LMM margins. Design, Setting, and Participants: This prospective study included consecutive patients with biopsy-proven LM and LMM located on the head and neck area who sought consultation for surgical management from March 1, 2016, through March 31, 2017, at the Dermatology Service of the Memorial Sloan Kettering Cancer Center. Thirty-two patients underwent imaging using HRCM-RV, and 22 patients with 23 LM or LMM lesions underwent staged surgery and contributed to the analysis. Main Outcomes and Measures: Clinical lesion size and area, LM and LMM area based on HRCM-RV findings, surgical defect area estimated by HRCM-RV, and observed surgical defect area. In addition, the margins measured in millimeters estimated for tumor clearance in each quadrant based on HRCM-RV findings were calculated and compared with the surgical margins. Results: Among the 22 patients (12 men and 10 women; mean [SD] age, 69.0 [8.6] years [range, 46-83 years]) with 23 lesions included in the final analysis, the mean (SD) surgical defect area estimated with HRCM-RV was 6.34 (4.02) cm2 and the mean (SD) area of surgical excision with clear margins was 7.74 (5.28) cm2. Overall, controlling for patient age and previous surgery, surgical margins were a mean of 0.76 mm (95% CI, 0.67-0.84 mm; P < .001) larger than the HRCM-RV estimate. Conclusions and Relevance: Mapping of LM and LMM with HRCM-RV estimated defects that were similar to but slightly smaller than those found in staged excision. Thus, mapping of LM using HRCM-RV can help spare healthy tissue by reducing the number of biopsies needed in clinically uncertain areas and may be used to plan treatment of LM and LMM and counsel patients appropriately.

Rising rates of vaccine exemptions: problems with current policy and more promising remedies.

Parents of school-age children are increasingly claiming nonmedical exemptions to refuse vaccinations required for school entry. The resultant unvaccinated pockets in many areas of the country have been linked with outbreaks of vaccine-preventable diseases. Many states are now focused on reducing rates of nonmedical exemptions by making exemption processes more restrictive or burdensome for the exemptor. These strategies, however, pose ethical problems and may ultimately be inadequate. A shift to strategies that raise the financial liabilities of exemptors may lead to better success and prove ethically more sound. Potential areas of reform include tax law, health insurance, and private school funding programs. We advocate an approach that combines this type of incentive with more effective vaccination education.

Exempting schoolchildren from immunizations: states with few barriers had highest rates of nonmedical exemptions.

Rates of nonmedical exemptions from school immunizations are increasing and have been associated with resurfacing clusters of vaccine-preventable diseases, such as measles. Historically, state-level school immunization policies successfully suppressed such diseases. We examined state immunization exemption regulations across the United States. We assessed procedures for exempting schoolchildren and whether exemption rates were associated with the complexity of the procedures. We also analyzed legal definitions of religious objections and state legislatures' recent modifications to exemption policies. We found that states with simpler immunization exemption procedures had nonmedical exemption rates that were more than twice as high as those in states with more-complex procedures. We also found that the stringency of legal definitions of religious exemptions was not associated with exemption procedure complexity. Finally, we found that although there were more attempts by state legislatures to broaden exemptions than to tighten them in 2011-13, only bills tightening exemptions passed. Policy makers seeking to control exemption rates to achieve public health goals should consider tightening nonmedical exemption procedures and should add vaccine education components to the procedures by either mandating or encouraging yearly educational sessions in schools for parents reluctant to have their children vaccinated.