Palisaded neutrophilic and granulomatous dermatitis following a long-standing monoclonal gammopathy: A case report.

BACKGROUND: Palisaded neutrophilic granulomatous dermatitis is a rare inflammatory dermatosis with possible underlying systemic conditions including rheumatoid arthritis, autoimmune connective tissue disease, and malignancies. CASE SUMMARY: We report a case of an 84-year-old man presenting with a 3-week eruption of asymptomatic annular plaques on his neck, which progressed to involve his back and legs. Skin biopsies confirmed a diagnosis of palisaded neutrophilic granulomatous dermatitis, and he was treated with prednisone. Full workup related to potential underlying causes of palisaded neutrophilic granulomatous dermatitis was completed. CONCLUSION: Palisaded neutrophilic granulomatous dermatitis may precede the onset of underlying systemic conditions or occur concomitantly. Following the diagnosis, clinicians should perform a comprehensive focused history, physical examination, and laboratory investigation related to the associated underlying diseases.

Radiation for below the knee skin cancers: a single institution experience.

Background: Historically, radiation to skin cancers for the lower legs has been avoided due to the perceived increased risk of radiation toxicity (poor wound healing, radiation necrosis). However, there is a paucity of published data regarding this perceived risk.Purpose: The objective was to review the risk of poor wound healing/radiation necrosis occurring post radiation and to determine rates of complete response (CR), partial response (PR), and progressive disease after radiation therapyMaterials and methods: A retrospective review of patients treated with radiation for skin cancer below the knee was undertaken from January 1, 2013 to May 31, 2018.Results: A total of 25 patients with 39 below the knee skin sites were treated with radiation. Mean follow-up time was 19 months (range 3 months-7.2 years). Crude CR, PR and progression rates for the treated lesions were 65%, 19%, and 16% respectively. Four out of 23 (17%) patients developed Grade 3 skin toxicity. There were no grades 4 or 5 toxicities.Conclusions: For patients not eligible for surgery, radiation therapy is an option with a moderate chance of complete response (65%) and a 17% risk of poor wound healing/radiation necrosis.

Pseudoxanthoma Elasticum-Like Papillary Dermal Elastolysis: A Single Case Report.

BACKGROUND: Pseudoxanthoma elasticum-like papillary dermal elastolysis (PXE-PDE), a rare acquired elastolytic disorder, occurs in postmenopausal, elderly women and is characterized by soft, white-yellow papules that localize on the neck and supraclavicular regions and often coalesce into cobblestone plaques. It has no systemic involvement and is histologically distinct from the clinically similar inherited pseudoxanthoma elasticum. CASE SUMMARY: A 64-year-old Caucasian woman presented with a 2-year history of multiple, asymptomatic soft yellow 1- to 2-mm papules on her neck, which were increasing in number. On histopathology, haemotoxylin and eosin stain showed a normal-appearing papillary dermis; however, Verhoeff-van Gieson elastic stain showed absent elastic fibres in the papillary dermis. Papular elastorrhexis was suggested, but given its clinical picture, PXE-PDE was also considered. There was no resolution after 2 courses of intralesional triamcinolone acetonide (0.1 mL of 5 mg/mL). CONCLUSION: PXE-PDE, which is characterized by complete loss or significant reduction of elastic fibres in the papillary dermis, was consistent with our patient's presentation and histologic findings. Papular elastorrhexis, a paediatric cutaneous disorder, was initially considered, but clinicopathologic correlation led to a diagnosis of PXE-PDE. Intralesional corticosteroids was tried as a treatment but was ineffective at improving the condition. This report documents the importance of histopathology and clinicopathologic correlation when differentiating the overlapping variants of fibroelastolytic disease.

Radiation therapy for the treatment of skin Kaposi sarcoma.

OBJECTIVE: Kaposi sarcoma (KS) lesions are purplish, reddish blue or dark brown/black macules, plaques or nodules which involve the skin and occasionally internal organs. Most patients with KS have a long indolent chronic course. METHODS: A retrospective review was undertaken for all KS skin patients treated with radiotherapy at a tertiary cancer centre from Jan. 2, 1999 to Dec. 31, 2014 (inclusive). RESULTS: A total of 47 patients with KS (43 classical, 0 African, 1 iatrogenic, 3 AIDS related) were seen in the multidisciplinary clinic. Out of this group, 17 patients (5 females and 12 males, 14 classical, 0 African, 0 iatrogenic, 3 AIDS related) with 97 KS skin sites were treated with local external beam radiotherapy. An additional 18 skin sites were treated with repeat radiotherapy. The radiotherapy dose ranged from 6 Gy in 1 fraction to 30 Gy in 10 fractions with the most common dose fractionation scheme being 8 Gy in 1 fraction or 20 Gy in 5 daily fractions. For the previously untreated KS sites, 87% responded to radiation [30% complete response (CR) and 57% partial response (PR)]. Thirteen percent of KS sites treated with radiation progressed. For the skin sites which were treated with repeat radiotherapy, 0% showed CRs, 50% PRs and 50% had continued progression. CONCLUSIONS: The majority of KS skin lesions (87%) responded to radiotherapy. Patients experience minimal side effects from the palliative radiation regimens used. KS skin lesions which progress despite radiation are unlikely to show CR with repeat radiotherapy. In our experience 50% of skin KS will have partial regression with repeat radiotherapy and 50% will have continued progression.

Recommendations for CTV margins in radiotherapy planning for non melanoma skin cancer.

PURPOSE: To provide practice guidelines for delineating clinical target volume (CTV) for radiotherapy planning of non melanoma (NMSC) skin cancers. METHODS AND MATERIALS: A prospective, single arm, study. Preoperatively, a radiation oncologist outlined the boundary of a gross lesion, and drew 5-mm incremental marks in four directions from the delineated border. Under local anesthesia, the lesion was excised, and resection margins were assessed microscopically by frozen section. Once resection margins were clear, the microscopic tumor extent was calculated using the presurgical incremental markings as references. A potential relationship between the distance of microscopic tumor extension and other variables was analyzed. RESULTS: A total of 159 lesions in 150 consecutive patients, selected for surgical excision with frozen section assisted assessment of resection margins, were accrued. The distance of microscopic tumor extension beyond a gross lesion varied from 1mm to 15 mm, with a mean of 5.3mm. The microscopic tumor extent was positively correlated with the size of gross lesion, histology and number of surgical attempts required to obtain a clear margin. To provide a 95% or greater chance of covering microscopic disease we make the following recommendations for CTV margins; 10mm for BCC less than 2 cm, 13 mm for BCC greater than 2 cm, 11 mm for SCC less than 2 cm, and 14 mm for SCC greater than 2 cm. CONCLUSIONS: Tumors greater than 2 cm and SCC histology required larger margins to adequately cover the microscopic extent of disease. This information is crucial in radiation planning of NMSC. Clinicians should be cautioned, as these guidelines may not offer optimum treatment for patients with extremely large or small lesions.

5-year review of a unique multidisciplinary nonmelanoma skin cancer clinic.

BACKGROUND: A multidisciplinary nonmelanoma skin cancer (NMSC) clinic is held weekly at our center, where all new patients are jointly assessed by dermatology/dermatopathology, radiation oncology, and plastic surgery. A new patient database was established in 2004. The purpose of this study was to provide a preliminary report on the patients seen in the NMSC clinic and the treatment recommendations rendered. METHODS: The new patient database was reviewed from January 2004 to December 2008, and patient demographics, tumor characteristics, and treatment recommendations were extracted. Cochran-Mantel-Harnszel (CMH) testing and chi-square analysis were used to detect any associations or relationships between variables within the database. A p value of less than .05 was considered significant. RESULTS: During the 5-year study period, 2,146 new patients were seen in the NMSC clinic. The majority of patients presented with basal cell carcinoma (64%) or squamous cell carcinoma (22%), with a median tumor size of 1 to 2 cm (range 0 to > 9 cm). Tumors were located in the head and neck region (80%), extremities (14%), and torso (6%). Previous treatment included biopsy only (62%), surgery (20%), electrodesiccation and curettage (11%), topical imiquimod (3%), and radiotherapy (1%). Treatment recommendations included surgery (55%) (with either simple excision [31%] or excision with margin control under frozen-section guidance [24%]), radiotherapy (19%), topical imiquimod (10%), observation (7%), and electrodesiccation and curettage (4%). CONCLUSIONS: The NMSC clinic at our center sees a high volume of patients who benefit from the multidisciplinary assessment provided. Treatment recommendations were based on patient and disease characteristics as well as patient preference.

Pyogenic granuloma of the foot with satellitosis: a role for conservative management.

BACKGROUND: Pyogenic granuloma (PG) with satellitosis is a rare phenomenon that typically occurs in children and teenagers. It can be seen after excision or trauma to the original lesion. OBJECTIVE: The aim is to review an atypical case of PG with satellitosis and to highlight a conservative approach to management. METHODS: This article includes a case report of a 48-year-old woman developing PG with satellitosis in her right foot and includes a review of the literature. RESULTS: There are few cases of PG with satellitosis in the literature. Our patient differs from most given her age and the location of the lesions. She was managed differently with a conservative observational approach, and, over time, her symptoms abated. CONCLUSION: PG with satellitosis can occur in varying patient populations with varying presentations. Although several treatment options exist, managing patients conservatively should be considered an approach to management. Early investigations should be conducted to rule out more sinister items in the differential diagnosis.

Outbreak of acupuncture-associated cutaneous Mycobacterium abscessus infections.

BACKGROUND: Cutaneous atypical mycobacterial infections have been increasingly described in association with cosmetic and alternative procedures. OBJECTIVE: We report an outbreak of acupuncture-associated mycobacteriosis. Between April and December 2002, 32 patients developed cutaneous mycobacteriosis after visiting an acupuncture practice in Toronto, Canada. RESULTS: Of 23 patients whose lesions were biopsied, 6 (26.1%) had culture-confirmed infection with Mycobacterium abscessus. These isolates were genetically indistinguishable by amplified fragment length polymorphism. The median incubation period was 1 month. Of 24 patients for whom clinical information was available, 23 (95.8%) had resolution of their infection. All patients developed residual scarring or hyperpigmentation. CONCLUSION: Nontuberculous mycobacteria should be recognized as an emerging, but preventable, cause of acupuncture-associated infections.

What is the microscopic tumor extent beyond clinically delineated gross tumor boundary in nonmelanoma skin cancers?

PURPOSE: To quantify the microscopic tumor extension beyond clinically delineated gross tumor boundary in nonmelanoma skin cancers. METHODS AND MATERIALS: A prospective, single arm, study. Preoperatively, a radiation oncologist outlined the boundary of a gross lesion, and drew 5-mm incremental marks in four directions from the delineated border. Under local anesthesia, the lesion was excised, and resection margins were assessed microscopically by frozen section. Once resection margins were clear, the microscopic tumor extent was calculated using the presurgical incremental markings as references. A potential relationship between the distance of microscopic tumor extension and other variables was analyzed. RESULTS: A total of 71 lesions in 64 consecutive patients, selected for surgical excision with frozen-section-assisted assessment of resection margins, were accrued. The distance of microscopic tumor extension beyond a gross lesion varied from 1 mm to 15 mm, with a mean of 5.2 mm. A margin of 10 mm was required to provide a 95% chance of obtaining clear resection margins. The microscopic tumor extent was positively correlated with the size of gross lesion, but not with other variables. CONCLUSIONS: The distance of microscopic tumor extension beyond a gross nonmelanoma skin cancer was variable, with a mean of 5.2 mm. Such information is critical for the proper radiation planning of skin cancer therapy.