Successful Outpatient Management of Diffuse Photosensitive Bullous Dermatitis Following Pembrolizumab Therapy.

Immune checkpoint inhibitors including programmed death protein 1 inhibitors show great therapeutic benefit for numerous advanced malignancies but can cause a spectrum of immune-related adverse events, with cutaneous toxicity being a common presentation. This report includes two cases of lung adenocarcinoma treated with pembrolizumab that developed rare presentations of diffuse bullous lichenoid dermatitis involving >50% total body surface area. These cases were successfully treated in the outpatient setting with oral dexamethasone and minimal interruption of pembrolizumab therapy, a more conservative approach than current guidelines suggest. J Drugs Dermatol. 2022;21(6):668-670. doi:10.36849/JDD.6715.

The utility of initial staging PET-CT as a baseline scan for surveillance imaging in stage II and III melanoma.

BACKGROUND: This study evaluates the utility of whole-body PET-CT for the initial staging and subsequent surveillance imaging of patients with completely resected stage II and stage III melanoma. METHODS: A single-center, retrospective review of patients who received perioperative whole-body PET-CT from January 1, 2005 to December 1, 2019 within three months of initial melanoma diagnosis was performed. RESULTS: Of 258 total patients with completely resected melanoma who had a PET-CT within 3 months after their melanoma diagnosis, 113 had stage II and 145 had stage III melanoma. PET-CT detected distant metastasis in 3 (2.7%) of 113 stage II patients and 7 (4.8%) of 145 stage III patients. 179 of 258 patients had adequate follow-up time to determine whether they received surveillance cross-sectional imaging and whether they had a melanoma recurrence. 143 (79.9%) received subsequent surveillance imaging, 74 of whom developed a recurrence. In 64 (86.5%) of 74 cases, recurrence was detected by routine surveillance. 26 (34.2%) of 76 stage II and 65 (63.1%) of 103 stage III patients developed a recurrence. The median time to recurrence among the 179 patients for stage II and III was 16.3 and 13.0 months, respectively. CONCLUSIONS: These findings indicate that baseline staging with whole-body PET-CT rarely provides information that changes initial management. Rather, the value of the initial PET-CT is as a baseline for subsequent surveillance scans. Therefore, it may be premature to discourage cross-sectional imaging for patients with stage II and III melanoma without supportive evidence or a reliable biomarker of recurrent disease.

Clinical Acuity Shorthand System: a standardized classification tool to facilitate handoffs.

BACKGROUND: The handoff of medical information from one provider to another can be inefficient and error prone, potentially undermining patient safety. Although several tools for structuring handoffs exist, none provide a brief, standardized framework for ensuring that patient acuity is efficiently and reliably communicated. We aim to introduce and perform initial testing of the Clinical Acuity Shorthand System (CLASS) (Copyright 2015, Duke University. All rights reserved.) for surgery, a patient classification tool intended to facilitate efficient communication of key patient information during handoffs. MATERIALS AND METHODS: Surgical trainees at a single center were asked to perform an exercise involving application of CLASS to 10 theoretical patient scenarios and to then complete a brief survey. Responses were scored based on similarity to target answers. Performance was evaluated overall and between groups of trainees. Time required to complete the exercise was also determined and perceived utility of the system was assessed based on survey responses. RESULTS: The study task was completed by 17 participants. Mean time to task completion was 10.3 ± 8.4 min. Accuracy was not decreased, and was in fact superior, in junior trainees. Most respondents indicated that such a system would be feasible and could prevent medical errors. CONCLUSIONS: CLASS is a novel system that can be learned quickly and implemented readily by trainees and can be used to convey patient information concisely and with acceptable fidelity regardless of level of training. Further study examining application of this system on clinical surgical services is warranted.

Management of a cutaneous squamous cell carcinoma overlying an AV fistula.

Cutaneous squamous cell carcinoma (cSCC) currently affects over 700 000 patients per year in the USA alone, and its incidence continues to rise in recent years. A known risk factor for cSCC is chronic inflammation; a cSCC that develops at a site of chronic inflammation is known as Marjolin's ulcer. We present the case of a 76-year-old man with end-stage renal disease requiring chronic haemodialysis who developed an invasive cSCC at the cannulation site of an underlying arteriovenous (AV) fistula. In this instance, treatment with standard surgical excision or Mohs surgery would pose unique risks associated with injury to an otherwise functional AV fistula. Thus, the lesion was treated with electron beam radiation therapy, which offers a similar efficacy to surgery while minimising risk to the fistula. This resulted in a successful oncological outcome with no complications.

Isolated Limb Infusion as a Limb Salvage Strategy for Locally Advanced Extremity Sarcoma.

BACKGROUND: Treatment-resistant, locally advanced soft tissue sarcomas often require amputation for complete tumor extirpation. Isolated limb infusion (ILI) selectively delivers high-dose chemotherapy to the extremity in an attempt to achieve limb salvage. The aim of this study was to report perioperative and oncologic outcomes after ILI in patients with extremity soft tissue sarcomas. STUDY DESIGN: From 1994 to 2016, 77 patients underwent 84 ILIs at a total of 5 institutions. Melphalan and actinomycin D were circulated for 30 minutes after complete tourniquet occlusion of the limb, then actively washed out to prevent systemic exposure. RESULTS: The procedure was performed in an upper extremity on 19 patients (21 infusions) and in a lower extremity on 58 patients (63 infusions). The 3-month overall response rate (ORR) for the entire cohort was 58%, and there was a statistically significant difference (p = 0.03) between upper (37%) and lower extremity (66%) ORR. With median follow-up of 20.6 months (range 0.6 to 146.1 months), the overall limb salvage rate was 77.9%. For those who underwent amputation due to progression of disease, the median time to amputation was 4.5 months. With a median follow-up of 20.6 months, the median overall survival for the entire cohort was 44.3 months. The distant metastatic-free survival was longer for responders than nonresponders (p = 0.01), though the disease-specific survival was not different for the same groups (p = 0.2). CONCLUSIONS: Isolated limb infusion for extremity soft tissue sarcoma results in an objective response for half of the patients who are otherwise facing amputation, and offers prolonged limb salvage for the vast majority of patients. The procedure is well tolerated without serious complications.

Computed Tomography-Based Limb Volume Measurements for Isolated Limb Infusion in Melanoma.

BACKGROUND: Despite advances in cross-sectional imaging, chemotherapeutic dosing for isolated limb infusion (ILI) in melanoma is currently calculated through cumbersome and potentially imprecise manual measurements. The primary objective of this study was to examine the feasibility of using computed tomography (CT) to calculate limb volume, its concordance with manual measurement, and its ability to predict clinical response and toxicity in patients undergoing ILI. METHODS: A retrospective analysis of all patients undergoing lower extremity ILI at Duke University Medical Center between 2003 and 2014 was performed. Data pertaining to manually measured limb volume, chemotherapeutic dosing, and patient outcome was obtained. CT-based measurements of limb volume were performed in all patients for whom imaging was available and subsequently compared with manually measured values. RESULTS: CT data were sufficient for measurement in 73 patients. The mean measurement time was 4.61 ± 2.13 min. Although average CT-based measurements were 1.20 L higher in the case of lower limbs, they correlated well with those obtained manually (r (2) = 0.90). Unlike manual measurement, patients with complete responses to chemotherapy had smaller limb volumes than those with disease progression as measured by CT (9.3 vs. 10.7 L; p = .038). Patients suffering grade 3 and 4 toxicities also had statistically lower limb volumes as measured by CT than those who did not (p < .05). CONCLUSIONS: CT-based limb volume measurement is feasible for chemotherapy dosing in patients undergoing ILI for melanoma and has predictive value with respect to clinical response and toxicity.