Hiding in Plain Sight: A Retrospective Review of Unrecognized Tumors During Dermatologic Surgery.

BACKGROUND: Mohs micrographic surgery requires focused attention that may lead to tunnel vision bias, contributing to not recognizing skin cancer at nearby sites. OBJECTIVE: It is to determine if a subsequently diagnosed skin cancer was visible at the time of Mohs surgery. METHODS: A retrospective chart review was performed at a single academic center from 2008 to 2020. Patients who underwent at least two distinct MMS procedures, separated in time to capture subsequent tumors, were included. RESULTS: Four hundred and four individual patients were identified with at least two distinct Mohs procedures, which generated 1,110 Mohs sequences. Fifty-one (4.6%) clinically apparent tumors went unrecognized and 127 (11.4%) tumors were identified and biopsied during the visit. High-risk tumor histology was identified in 10 (20%) unrecognized tumors and 31 (24%) recognized tumors (p-value 0.491). CONCLUSION: Our study suggests that Mohs surgeons may be overlooking adjacent skin cancers when focusing only on the tumor being surgically treated. Tunnel vision bias may account for part of this phenomenon.

Morphea following treatment with pembrolizumab for melanoma with metastatic lymph nodes: case report and review of literature.

Pembrolizumab is a humanized IgG4 isotype mAb that the targets and blocks the programmed cell death protein 1 receptor on lymphocytes. Its use in treating metastatic melanoma is associated with increased overall survival compared to other older immunotherapies. Several adverse effects have been noted including both systemic and cutaneous manifestations. As a relatively novel treatment option, many new cutaneous manifestations are still being observed, occurring at various times after initiation of therapy. Previously noted cutaneous adverse effects include sarcoid-like reactions, rash, and changes in preexisting lesions or scars. Here we present a case in which biopsy-proven morphea developed after completion of pembrolizumab therapy.

A Case of Valproate-Induced Hyperammonemic Encephalopathy.

A 56-year-old Caucasian male with a history of seizure disorder on long-term prophylaxis with valproate presented with altered mental status, aggressive behavior, decreased oral intake, and frequent myoclonic jerking movements. Electrolyte and other basic metabolic lab testing, liver function testing, and imaging studies were negative for acute abnormalities or infection, though ammonia levels returned markedly elevated, and he also had a macrocytic anemia despite having normal folate and B12 levels. Following discussions with neurology, his valproate was felt to be the inducing factor for his hyperammonemic encephalopathy. After discontinuation of valproate and changing to a new anti-seizure medication, he soon returned to his neurologic baseline. This case report evaluates his presentation and current literature on hyperammonemic encephalopathy induced by valproate.

Association of Patient Proximity to Dermatologic Care With Melanoma Stage at Diagnosis and Outcome.

This cohort study evaluates the association of proximity to dermatologic clinicians with stage at diagnosis and cancer-specific survival among adults with cutaneous melanoma in Iowa.