Nicotinamide for Skin-Cancer Chemoprevention in Transplant Recipients.

BACKGROUND: Immunosuppressed organ-transplant recipients have an increased incidence of, and mortality from, skin cancer. Nicotinamide (vitamin B3) enhances the repair of ultraviolet (UV) radiation-induced DNA damage, reduces the cutaneous immunosuppressive effects of UV radiation, and reduces the incidence of keratinocyte cancers (including squamous-cell and basal-cell carcinomas) and actinic keratoses among high-risk immunocompetent patients. Whether oral nicotinamide is useful for skin-cancer chemoprevention in organ-transplant recipients is unclear. METHODS: In this phase 3 trial, we randomly assigned, in a 1:1 ratio, organ-transplant recipients who had had at least two keratinocyte cancers in the past 5 years to receive 500 mg of nicotinamide or placebo twice daily for 12 months. Participants were examined for skin lesions by dermatologists at 3-month intervals for 12 months. The primary end point was the number of new keratinocyte cancers during the 12-month intervention period. Secondary end points included the numbers of squamous-cell and basal-cell carcinomas during the 12-month intervention period, the number of actinic keratoses until 6 months after randomization, safety, and quality of life. RESULTS: A total of 158 participants were enrolled, with 79 assigned to the nicotinamide group and 79 to the placebo group. The trial was stopped early owing to poor recruitment. At 12 months, there were 207 new keratinocyte cancers in the nicotinamide group and 210 in the placebo group (rate ratio, 1.0; 95% confidence interval, 0.8 to 1.3; P = 0.96). No significant between-group differences in squamous-cell and basal-cell carcinoma counts, actinic keratosis counts, or quality-of-life scores were observed. Adverse events and changes in blood or urine laboratory variables were similar in the two groups. CONCLUSIONS: In this 12-month, placebo-controlled trial, oral nicotinamide therapy did not lead to lower numbers of keratinocyte cancers or actinic keratoses in immunosuppressed solid-organ transplant recipients. (Funded by the National Health and Medical Research Council; ONTRANS Australian New Zealand Clinical Trials Registry number, ACTRN12617000599370.).

Immunostained Frozen Sections Vs Traditional Permanent Paraffin Sections for Lentigo Maligna Treated With Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery (MMS) has risen in popularity as a management option for treating lentigo maligna (LM) because of its ability to accurately detect subclinical spread while conserving tissue. The primary concern for opponents of MMS in melanoma remains the difficulty associated with interpretation of frozen sections compared with traditional paraffin sections; this has been made easier with the advent of immunostaining. OBJECTIVE: Our study aims to assess the concordance in clearance reporting of LM in immunostained frozen sections compared with permanent paraffin sections and hematoxylin and eosin staining. METHODS: We conducted a retrospective analysis of 38 LM cases treated by MMS between 2017 and 2020 in Melbourne, Australia. Immunostained frozen sections were assessed by a Mohs surgeon, whereas permanent paraffin sections were assessed by an external dermatopathologist. RESULTS: We report 86% agreement in reporting of LM in immunostained frozen sections compared with permanent paraffin sections. In 5/38 cases, permanent paraffin sections were reported as clear for LM, but the Mohs surgeon had detected positive margins, requiring further excision. CONCLUSION: For LM treated with MMS, there is a high agreement of clearance reporting between immunostained stained frozen sections and permanent paraffin sections without immunostaining; however, immunostained frozen sections may be more sensitive.

Solid organ transplant recipients presenting for Mohs micrographic surgery: a retrospective case-control study.

BACKGROUND: Solid organ transplant recipients (SOTR) have a high risk of cutaneous malignancy. Mohs micrographic surgery (MMS) is recommended for the treatment of skin cancers in this group. The characteristics of the tumors in SOTR presenting for MMS are not well documented. OBJECTIVE: To describe the characteristics of tumors in SOTR presenting to a single institution over an 11-year period and compare them with tumors of non-SOTR who have also undergone MMS. METHODS: A database query captured patients with a current organ transplant who underwent MMS. These patients (cases) were matched to controls who also underwent MMS. Statistical models were used to identify tumor and operative characteristics significantly associated with SOTR compared with matching controls. RESULTS: Ninety-two SOTR underwent MMS for 432 skin cancers; 163 controls had 269 skin cancers. Squamous cell carcinoma (SCC) was the most common tumor in SOTR, with a reversal of the usual ratio of basal cell carcinoma to SCC. Mean tumor and defect sizes were similar in SOTR and controls. Cardiac transplants were the predominant transplant. CONCLUSIONS: SOTR referred for MMS have disproportionately more and different types of skin cancers than controls.

Primary cutaneous carcinosarcoma: dermoscopic and immunohistochemical features.

A 73-year-old man presented a 9-month history of an enlarging nodule on his right temple. Dermoscopy revealed a non-pigmented lesion with ulceration, fibrosis and pale globules. An excisional biopsy was carried out and histology showed a biphasic tumour with a basal cell carcinoma like epithelial component and a dermal undifferentiated sarcoma, with pleomorphic spindle cells and numerous osteoclast-like giant cells. Based on immunohistochemistry findings, a diagnosis of primary cutaneous carcinosarcoma was made and the patient underwent wide local excision.

Rudimentary polydactyly in an adult: an unusual presentation to a dermatological surgery unit.

Accessory digits or polydactyly present uncommonly to dermatologists. Usually they are treated by ligature in the neonatal period or by surgery in childhood. We report a 38-year-old man who presented to a dermatological surgery unit for treatment of a lifelong lesion on the ulnar aspect of his right fifth finger. Clinically this appeared to be a miniature accessory digit and this was discussed with the patient. Subsequent histological examination of the excision specimen confirmed the clinical diagnosis. Further questioning of the patient revealed a strong family history of polydactyly.

Is schizophrenia associated with narcolepsy?

OBJECTIVE: To determine the nature of the relationship between schizophrenia-like psychosis and narcolepsy. BACKGROUND: A relationship between schizophrenia and narcolepsy has long been postulated due to the association of schizophrenia-like psychosis with narcolepsy and its treatment. METHOD: We report two patients who presented with schizophrenia-like psychosis of narcolepsy and review the literature regarding possible shared neurobiology between the two disorders that might explain their co-occurrence. RESULTS: There appears to be little in the way of common pathology between these two conditions when symptoms, human leukocyte antigen associations, rapid eye movement sleep architecture, D2-dopamine receptor changes, and hypocretinergic function are examined. CONCLUSIONS: The available literature suggests that schizophrenia-like psychosis in narcolepsy is most commonly medication related or a chance co-occurrence, with limited evidence for a separate psychosis of narcolepsy.

Unilateral acheiria and fatal primary pulmonary hypertension in a girl with incontinentia pigmenti.

We describe a newborn girl with incontinentia pigmenti (IP, MIM308300), unilateral acheiria, and fatal primary pulmonary hypertension. Limb deficiency has not been described previously in IP and pulmonary hypertension only on two previous occasions. A review of the cause of IP shows that these rare manifestations may not be unexpected, given the many roles of the underlying gene product.

Spinal cord ischaemic stroke associated with vertebral body infarction.

Only eight cases of spinal cord ischaemic stroke causing paraplegia with associated vertebral body infarction have been previously described. We describe a ninth case with histopathology confirming the Magnetic Resonance Imaging (MRI) appearance of vertebral body infarction. We have reviewed the literature concerning this condition and discuss its diagnosis and aetiology.

Negative pressure pulmonary edema in healthy cosmetic surgery patients.

Anesthetic complications are uncommon in young and healthy patients undergoing cosmetic surgery. We report 2 cases of negative pressure pulmonary edema (NPPE) in young patients, 1 who underwent rhinoplasty and another who underwent augmentation mammaplasty and suction-assisted lipoplasty of the thighs and buttocks This rare and potentially fatal complication requires admission to an intensive-care unit and delayed discharge. Although cases of NPPE have been reported in the medical and anesthetic literature, NPPE in plastic surgery has never been reported previously.