Inferior outcomes in immunosuppressed patients with high-risk cutaneous squamous cell carcinoma of the head and neck treated with surgery and radiation therapy.

BACKGROUND: Immunosuppressed patients have higher rates of cutaneous squamous cell carcinoma of the head and neck. OBJECTIVE: This study reviews the effect of immune status on disease characteristics and treatment outcomes. METHODS: Patients with cutaneous squamous cell carcinoma of the head and neck treated with surgery and postoperative radiotherapy between 2000 and 2011 were included. Immunosuppressed patients underwent prior organ transplantation or chemotherapy. Baseline variables were compared using χ(2) and unpaired t tests. Overall survival and disease-free survival were calculated using the Kaplan-Meier method. RESULTS: In this study of 59 patients, 38 (64%) were immunocompetent and 21 (36%) were immunosuppressed. Most patients had recurrent tumors (63%) and node-positive disease (61%), which were well balanced between the groups. Poorly differentiated tumors (62% vs 21%; P = .009), lymphovascular invasion (29% vs 11%; P = .08), and extracapsular extension (57% vs 41%; P = .09) were more frequent in the immunosuppressed group. Two-year disease-free survival (45% vs 62%) and 2-year overall survival (36% vs 67%) were inferior for immunosuppressed patients. LIMITATIONS: Limitations include single institution, retrospective study with small sample size, and potential referral bias. CONCLUSIONS: Immunosuppressed patients with cutaneous squamous cell carcinoma of the head and neck more frequently present with high-risk pathologic features and inferior outcomes. Early multidisciplinary assessment and alternate management strategies merit prospective investigation.

Flaps and grafts reconstruction.

Reconstruction of Mohs surgical defects is a challenging venture. A thorough understanding of skin physiology and anatomy (cosmetic subunits, relaxed skin tension lines, underlying neurovascular structures at risk, potential functional compromise, character of adjacent skin, and so forth), careful wound analysis, and meticulous operative techniques is key to a successful reconstruction. This article discusses in detail the use of local skin flaps and graft reconstruction.

Diagnosis and management of skin resurfacing-related complications.

The field of skin resurfacing is undergoing rapid evolution with many new technologies that have developed, providing more choices for physicians and patients. Knowing the potential adverse effects associated with each skin resurfacing modality is paramount in selecting the appropriate approach for each candidate, thereby minimizing complications and achieving optimal results.

Advances in topical and systemic antifungals.

Topical antifungal agents are generally used for the treatment of superficial fungal infections unless the infection is widespread, involves an extensive area, or is resistant to initial therapy. Systemic antifungals are often reserved for the treatment of onychomycosis, tinea capitis, superficial and systemic candidiasis, and prophylaxis and treatment of invasive fungal infections. With the development of resistant fungi strains and the increased incidence of life-threatening invasive fungal infections in immunocompromised patients, some previously effective traditional antifungal agents are subject to limitations including multidrug interactions, severe adverse effects, and their fungistatic mechanism of actions. Several new antifungal agents have demonstrated significant therapeutic benefits and have broadened clinicians' choices in the treatment of superficial and systemic invasive fungal infections.

Epithelial sheath neuroma: a case report and discussion of the literature.

Here, a case of a rare epithelial sheath neuroma (ESN) is reported. A 49-year-old white female presented with a 5 mm solitary, slightly raised, erythematous, itchy papule on her right upper back. The clinical impression was consistent with an inflamed nevus. The patient had no past medical history of malignancy or a family history of neurofibromatosis. There was no prior trauma, surgical procedures, or skin disease at the site. After excision, the patient has had no recurrence at the surgery site during a 4-months follow-up period. ESN is characterized by enlarged nerve fibers ensheathed by a sometimes keratinized squamous epithelium located in the superficial dermis where large nerves are not normally found. It is believed to be a benign neoplasm and simple excision is curative. The histologic differential diagnosis of ESN is presented, and possible mechanisms of its pathogenesis are discussed. It is important for the pathologist and dermatologist to be cognizant of this lesion to prevent misdiagnosis of perineural invasion.

Transduced monocyte/macrophages targeted to murine skin by UV light.

We have selectively targeted monocyte/macrophages overexpressing an immunomodulatory molecule, latency-associated peptide (LAP), a naturally occurring antagonist for transforming growth factor-beta1, to murine skin utilizing UV light to produce a cutaneous influx of transduced monocyte/macrophages. Bone marrow (BM) cells from BALB/c mice were transduced in vitro with a retroviral construct containing green fluorescent protein (GFP) for detection and human LAP (hLAP) as a test molecule. The transduced BM cells were then cultured in vitro with granulocyte-macrophage colony-stimulating factor (GM-CSF) to produce differentiation to monocyte/macrophages. More than 80% of transduced BM cells were CD11b-positive and MOMA-positive by fluorescence-activated cell-sorter analysis and secreted LAP by ELISA after 10 days of culture in granulocyte-macrophage colony-stimulating factor (GM-CSF). Transduced monocyte/macrophages containing either GFP or hLAP-GFP were then injected intravenously into BALB/c mice. One-half of recipients in each group were exposed to UVB (72 mJ) to induce monocyte/macrophage infiltration into skin. Recipients were sacrificed 60 h after UV irradiation. We found transduced cutaneous macrophages expressing GFP by examining with fluorescence microscopy frozen skin sections of recipient mice immunostained with antibodies to GFP and to macrophage marker F4/80. We identified hLAP sequences by polymerase chain reaction (PCR) of total DNA in recipient blood and UV-irradiated skin but not in unirradiated skin. LAP sequences were also detected at much lower levels in other organs (lung, spleen, and liver) by PCR. Therefore, we have shown that genetically altered monocytic cells can be injected intravenously and targeted to mouse skin by UV exposure. This macrophage-based gene-transfer method may be a potentially useful immunotherapeutic approach for delivering monocyte/macrophage-derived products to skin.