Factors Shifting Preference Toward Telemedicine in the Delivery of Skin Cancer Reconstruction Care.

OBJECTIVES: Identify which delivery modality for skin reconstruction care, face-to-face (FTF) in-person versus two telemedicine modalities, store-and-forward (S&F) and live video chat (LVC), is patient preferred and how cost, access, wait time, and demographics influence this preference. STUDY DESIGN: Cross-sectional survey. METHODS: A 16-question survey querying demographics and five scenario-specific preferences questions for the delivery of skin cancer reconstruction care was created and distributed via Amazon Mechanical Turk (MTurk), a crowdsourcing online marketplace, and in-person to Mohs micrographic surgery patients. RESULTS: 1394 MTurk and 55 in-person responses were included. While 82.1% of online respondents prefer FTF clinic visits, this decreases to 58.3% with an in-person visit cost (p < 0.01) and furthermore to a minority 43.5% with both an in-person visit cost and wait time (p < 0.01) despite 77.8% believing that usefulness to the surgeon would improve FTF. Both the MTurk and in-person cohorts demonstrated similar response patterns despite considerable demographic differences. Multivariable analyses revealed that telemedicine was preferred by MTurk respondents with Medicaid (adjusted OR [95% CI]: 1.97 [1.18-3.31]) or Medicare (1.69 [1.10-2.59]) versus private insurance, and prior skin cancer (2.01 [1.18-3.42]) and less preferred by those earning $140,000+ per year (0.49 [0.29-0.82]) compared to those earning <$20,000 per year. CONCLUSIONS: FTF visits are preferred for skin cancer reconstruction care; this shifts toward virtual care with a cost and wait time in spite of the perceived quality of care. Individuals with socioeconomic barriers to access prefer telemedicine. MTurk can be a valuable tool for behavioral research in FPRS. LEVEL OF EVIDENCE: NA Laryngoscope, 133:294-301, 2023.

Presence of Mast Cells and Mast Cell Degranulation in Scalp Biopsies of Telogen Effluvium.

BACKGROUND: Telogen effluvium (TE) is a type of acquired, diffuse alopecia that occurs due to an abnormal shift of scalp hair follicles from anagen to telogen, leading to premature shedding of hair. Previous studies have suggested the existence of a neuroimmunologic "brain-hair follicle" axis, in which mast cells have been implicated as an important link between the nervous system and immunologic system. OBJECTIVE: The current study sought to investigate the role of mast cell presence and mast cell degranulation in the pathogenesis of TE. MATERIALS AND METHODS: Mast cells were counted using Giemsa and tryptase immunohistochemical stains in scalp biopsy specimens with the pathologic diagnosis of TE (TE, n = 10), alopecia areata (AA, n = 7), and androgenic alopecia (ANDRO, n = 9). RESULTS: We found significant (P < 0.001) group-level differences between the mean mast cell counts per high-power fields for each type of alopecia studied. Tukey post hoc analysis showed the mean mast cell count for TE to be significantly larger than AA for both Giemsa (P = 0.002) and tryptase (P = 0.006); significantly larger than ANDRO for both Giemsa (P < 0.001) and tryptase (P < 0.001); and significantly larger when compared to normal scalp skin for both Giemsa (P < 0.001) and tryptase (P < 0.001). No significant difference of mean mast cell counts was observed for AA compared to ANDRO for Giemsa (P = 0.373) or tryptase (P = 0.598) stains. CONCLUSION: Our findings suggest that mast cells could play a role in mediating stress-induced hair loss seen in TE.

Adipose Triglyceride Lipase (ATGL) Expression Is Associated with Adiposity and Tumor Stromal Proliferation in Patients with Pancreatic Ductal Adenocarcinoma.

BACKGROUND: Obesity is an established risk factor for the development of pancreatic ductal adenocarcinoma (PDAC). However, the pathophysiology of how increased adiposity increases the risk for PDAC has not been fully elucidated. Adipose triglyceride lipase (ATGL) is a lipase that catabolizes triglyceride hydrolysis and has been implicated in the development of breast cancer. We hypothesized that overweight patients with PDAC would demonstrate higher tumor ATGL expression compared to non-overweight patients with PDAC. MATERIALS AND METHODS: Immunohistochemical analysis for ATGL expression was performed on PDAC tissues from 44 patients after Whipple procedure or distal pancreatectomy. Correlation of ATGL expression with clinicopathological features was evaluated. RESULTS: A total of 23/44 (52.2%) PDACs showed low level ATGL immunoreactivity, while 21/44 (47.8%) showed a high level, with moderate to strong positive ATGL immunoreactivity in more than 50% of the tumor cells. Chi-squared testing revealed a statistically significant association between high ATGL expression and both BMI >25 kg/m2 (χ2=5.74, p=0.017) and increased tumor stroma (χ2=19.14, p<0.001). Chi-squared testing failed to reveal a statistically significant association when comparing ATGL expression by lymph node metastasis, histological grade, tumor size, patient age, patient sex and presence of fat invasion. CONCLUSION: Our results suggest that increased ATGL expression is associated with increased adiposity and stromal proliferation in patients with PDAC, making it a possible key protein in how obesity increases the risk of PDAC.

p53 Is a Helpful Marker in Distinguishing Langerhans Cell Histiocytosis From Langerhans Cell Hyperplasia.

Langerhans cell histiocytosis (LCH) is a proliferative disorder of Langerhans cells that can be challenging to distinguish histologically from Langerhans cell (LC) hyperplasia, seen in a variety of inflammatory dermatoses. Lesional cells in both entities demonstrate positive staining for CD1a and S100. Previous studies have demonstrated positive staining of fascin, CD31, and p53 in cases of LCH, but currently, no studies have compared the staining profiles of these markers between LCH and LC hyperplasia. The authors compared immunohistochemical staining profiles of LCH (n = 15) and various inflammatory dermatoses with LC hyperplasia (n = 15) using fascin, CD31, and p53. Fascin, CD31, and p53 were graded as a percentage of CD1a staining cells in the epidermis and dermis of each specimen. Fascin showed no significant differences in staining between the 2 entities. CD31 was positive in the dermal infiltrate in 40% of cases of LCH and negative in all cases of LC hyperplasia. p53 was positive in the epidermal infiltrate in 50% of cases of LCH, and positive in the dermal infiltrate in 93% of cases of LCH, whereas negative in all cases of LC hyperplasia. Fascin was not a helpful marker in distinguishing LCH from LC hyperplasia. CD31, if positive in the dermal infiltrate, is suggestive of a diagnosis of LCH, but exhibits a relatively low sensitivity for this purpose. p53 proved to be a helpful and accurate diagnostic immunohistochemical stain when distinguishing between LCH and LC hyperplasia.

Synchronous Quadruple Primary Neoplasms: Colon Adenocarcinoma, Collision Tumor of Neuroendocrine Tumor and Schwann Cell Hamartoma and Sessile Serrated Adenoma of the Appendix.

Quadruple synchronous primary neoplasms are very rare with only three cases reported in the English-speaking literature to date. Collision tumors are also rare entities, especially of the appendix. We herein report a case of synchronous quadruple primary neoplasm in a 95-year-old female. She was diagnosed with colon adenocarcinoma, sessile serrated adenoma of the appendix and a collision tumor composed of a well-differentiated neuroendocrine tumor and Schwann cell hamartoma. Histological examination and immunohistochemistry supported these four lesions as separate entities. This case is unique because we report the diagnosis of quadruple synchronous primary, an extremely rare occurrence, in addition to a collision tumor of the appendix. We also provide a review of the literature for synchronous neoplasms and collision tumors.

Synchronous quadruple primary neoplasms: glioblastoma, neuroendocrine tumor, schwannoma and sessile serrated adenoma in a patient with history of prostate cancer.

Quadruple synchronous primary neoplasms are exceedingly rare with only one case reported in the English literature. We herein report a case of synchronous quadruple primary neoplasms in a 70-year-old Arabic male with a history of prostate cancer who presented to our hospital for work-up of a brain mass found at an outside hospital. Subsequent (18)Fluorodeoxyglucose (FDG) positron emission tomography demonstrated a 5.9-cm temporoparietal mass and three additional lesions, each with increased maximum standardized uptake value (SUV(max)). Histologic examination, immunohistochemistry and cytogenetic analyses of the lesional tissue revealed four primary neoplastic lesions: primary glioblastoma, inguinal schwannoma, well-differentiated neuroendocrine tumor of the terminal ileum and an appendiceal sessile serrated adenoma/polyp. This case is unique among previous reports as our patient presented with four primary neoplasms synchronously. To the best of our knowledge, this combination of synchronous multiple primary neoplasms has not been reported in the English literature.