Updates in Skin Cancer in Transplant Recipients and Immunosuppressed Patients: Review of the 2022-2023 Scientific Symposium of the International Immunosuppression and Transplant Skin Cancer Collaborative.

The International Immunosuppression and Transplant Skin Cancer Collaborative (ITSCC) and its European counterpart, Skin Care in Organ Transplant Patients-Europe (SCOPE) are comprised of physicians, surgeons, and scientist who perform integrative collaborative research focused on cutaneous malignancies that arise in solid organ transplant recipients (SOTR) and patients with other forms of long-term immunosuppression. In October 2022, ITSCC held its biennial 4-day scientific symposium in Essex, Massachusetts. This meeting was attended by members of both ITSCC and SCOPE and consisted of specialists including Mohs micrographic and dermatologic oncology surgeons, medical dermatologists, transplant dermatologists, transplant surgeons, and transplant physicians. During this symposium scientific workshop groups focusing on consensus standards for case reporting of retrospective series for invasive squamous cell carcinoma (SCC), defining immunosuppressed patient status for cohort reporting, development of multi-institutional registry for reporting rare tumors, and development of a KERACON clinical trial of interventions after a SOTRs' first cutaneous SCC were developed. The majority of the symposium focused on presentation of the most up to date research in cutaneous malignancy in SOTR and immunosuppressed patients with specific focus on chemoprevention, immunosuppression regimens, immunotherapy in SOTRs, spatial transcriptomics, and the development of cutaneous tumor registries. Here, we present a summary of the most impactful scientific updates presented at the 2022 ITSCC symposium.

Surgical margins and outcomes for eyelid melanoma: a systematic review and meta-analysis.

No randomized trials exist to inform the peripheral surgical margins or depth of wide excision for eyelid melanoma. We performed a meta-analysis examining surgical margins and Breslow depth for eyelid melanomas. A systematic review was performed in August 2022 using PubMed, Cochrane, and Medline databases (1/1/1990 to 8/1/2022). Inclusion criteria included studies reporting surgical treatment of primary cutaneous melanomas of the eyelid with reported surgical margins. Ten articles were included. The studies were examined by surgical margin size (group 1: ≤ 0.5 cm; group 2 > 0.5 cm and ≤ 1.5 cm) and Breslow depth (group 1: ≤ 1 mm; group 2: > 1 mm). The odds ratio (OR) for local recurrence was 2.55 [95% CI 0.36-18.12], p = 0.18; regional metastasis was 0.70 [95% CI 0.00-23671.71], p = 0.48; and distant metastasis was 2.47 [95% CI 0.00-1687.43], p = 0.66. When examining by Breslow depth, the OR for local recurrence was 0.53 [95% CI 0.14-1.94], p = 0.34; regional metastasis was 0.14 [0.00-176.12], p = 0.54; and the OR for distant metastasis was 0.24 [95% CI 0.01-8.73], p = 0.46. There was a trend toward higher likelihood of recurrence and metastasis in the ≤ 0.5 cm group. Similarly, there is a trend toward higher likelihood of recurrence and metastasis with Breslow depth > 1 mm. A surgical margin of at least 0.5 cm and achievement of negative margins via permanent sections or MMS are likely needed to prevent adverse outcomes. En face sectioning may be a superior method of histological processing for eyelid melanoma.

Postoperative Bleeding Complications Associated With Novel Oral Anticoagulants in Mohs Micrographic Surgery.

BACKGROUND: Novel oral anticoagulants (NOACs) are commonly prescribed, recently developed anticoagulants, but limited data exist on NOAC-related bleeding complications in Mohs micrographic surgery (MMS). OBJECTIVE: To assess the risk of postoperative bleeding in patients taking NOACs compared with patients taking no antithrombotic medications. METHODS/MATERIALS: A 5-year retrospective chart review of all MMS cases performed by a single surgeon was conducted. Patient and surgery characteristics, anticoagulant use, and bleeding complications were recorded. RESULTS: Two thousand one hundred eighty-one MMS cases in 1,545 patients were included. There were 696/2,181 cases in which patients were taking at least 1 antithrombotic medication, with 149 on NOAC monotherapy and 15 on NOAC and aspirin combination therapy. Bleeding complications occurred in 22/2,181 cases. Patients on NOAC monotherapy did not have an increased risk of bleeding complications compared with patients on no antithrombotic medications (odds ratio [OR]:1.70, 95% confidence interval [CI]: 0.36-7.97, p = .50). In contrast, patients on NOAC and aspirin combination therapy exhibited an increased bleeding risk (OR: 20.5, 95% CI: 3.99-105.7, p < .001). CONCLUSION: Novel oral anticoagulant use alone during MMS was not associated with an increased postoperative bleeding risk, supporting the safety of continuing NOAC therapy during MMS. However, NOAC and aspirin combination therapy was associated with a high postoperative bleeding risk. Nonetheless, these bleeding events did not lead to adverse long-term outcomes.

Improving Diagnostic Accuracy in Skin of Color Using an Educational Module.

Dermatologic disparities disproportionately affect patients with skin of color (SOC). This study evaluated the effectiveness of a focused educational module for improving diagnostic accuracy and confidence in the treatment of patients with SOC among interprofessional health care providers. An SOC educational module involving a pretest, 15-minute lecture, immediate posttest, and 3-month posttest was created. One hundred participants completed the pretest and immediate posttest; 36 of them also completed the 3-month post-test. Our results suggest that a focused educational module may provide long-term improvements in diagnostic accuracy and confidence for conditions presenting in patients with SOC.

A comparison of international treatment guidelines for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are rare and life-threatening mucocutaneous diseases that occur almost exclusively as a result of adverse drug reactions, although there are rare cases attributed to infection, immunization, or malignancy.1,2 Given the low incidence of these diseases as well as the high level of morbidity and mortality, randomized controlled clinical trials are difficult to perform, making it difficult to establish a "gold-standard" treatment. To date, there are only five published articles in the literature detailing evidence-based guidelines for the treatment of SJS and TEN, one of which is specifically tailored to pediatric and young adult patients.3-7 These guidelines have significant overlap in regards to the importance of prompt discontinuation of the offending drug and the need for supportive care, but there are differences in regards to the ideal supportive care measures. Additionally, there is still no clear consensus agreement on the pharmacological treatment of SJS and TEN.4-7 Herein, we aim to compare the international treatment guidelines for management of SJS and TEN as well as promote continued discussion and a multidisciplinary approach to establish consensus recommendations for these mucocutaneous emergencies.

A case of multiple, bilateral Becker's Nevi of the trunk and lower extremities in a young girl: A case report.

A Becker's nevus typically appears as a single unilateral, well-demarcated, hyperpigmented patch over the upper trunk during adolescence. It uncommonly presents as multiple and bilateral patches and rarely involves a lower extremity. We describe the unusual case of a child with multiple, bilateral Becker's nevi of the trunk and lower extremities present since birth.

An innovative approach in the treatment of trigeminal trophic syndrome.

BACKGROUND: Trigeminal trophic syndrome (TTS) is a rare disorder that presents as ulceration of the nasal ala, and less often ipsilateral cheek, cutaneous lip, and forehead, following damage to the trigeminal nerve. TTS is often very difficult to treat due to anesthesia and paresthesia along the distribution of the trigeminal nerve, which often leads to a large behavioral component of this disease. METHODS: In this single case report, a thermoplastic mask was sutured in place overlying the chronic ulcerations of TTS in a 57-year-old man. RESULTS: Significant re-epithelization of the chronic ulcerations of TTS was seen after only 6 weeks of thermoplastic mask attachment. CONCLUSION: While TTS is a chronic and difficult to treat disease, the use of a thermoplastic mask in the treatment of this disease can significantly decrease the self-manipulation component and allow for re-epithelization and healing of the chronic ulcerations.

Cutaneous Manifestations of "Lupus": Systemic Lupus Erythematosus and Beyond.

Lupus, Latin for "wolf," is a term used to describe many dermatologic conditions, some of which are related to underlying systemic lupus erythematosus, while others are distinct disease processes. Cutaneous lupus erythematosus includes a wide array of visible skin manifestations and can progress to systemic lupus erythematosus in some cases. Cutaneous lupus can be subdivided into three main categories: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus. Physical exam, laboratory studies, and histopathology enable differentiation of cutaneous lupus subtypes. This differentiation is paramount as the subtype of cutaneous lupus informs upon treatment, disease monitoring, and prognostication. This review outlines the different cutaneous manifestations of lupus erythematosus and provides an update on both topical and systemic treatment options for these patients. Other conditions that utilize the term "lupus" but are not cutaneous lupus erythematosus are also discussed.

Unusual Case of Nail Unit Melanoma.

We present a case of a nail unit melanoma with chondroid differentiation that was initially misdiagnosed as a benign chondroid neoplasm. A 67-year-old Caucasian woman presented to an outside dermatologist with a tender subungual nodule on the right index finger with overlying nail plate changes that had been present and enlarging for 1 year. Initial histopathological evaluation rendered a diagnosis of benign chondroid neoplasm. On arrival to our institution, magnetic resonance imaging was performed, and the lesion appeared consistent with a glomus tumor. Plastic surgery performed a surgical resection with intraoperative frozen sections revealing a hypocellular cartilaginous mass, but pathology was unable to comment on the presence of malignant cells. On permanent sectioning of the excised lesion, a lentiginous proliferation of melanocytes overlying a dermal aggregate of atypical cells with conspicuous mitoses embedded in a chondroid matrix was seen. A panel of immunohistochemical stains was performed, including SOX-10, HMB-45, S-100, MITF and MART1 was performed with SOX-10, HMB-45, and S-100 staining the junctional melanocytes and dermal cells, rendering a diagnosis of primary chondroid melanoma.