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1.
J Am Acad Dermatol ; 2020 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-33096134

RESUMO

BACKGROUND: There are no well-defined clinical factors to predict the risk of occult invasion in melanoma of the lentigo maligna type (LM) prior to complete histopathologic analysis. OBJECTIVE: To evaluate whether clinical size was a predictor of invasion in LM and subclinical extension. METHODS: Consecutive cases of LM were recorded in a prospectively maintained database from 2006 to 2019. Patient and tumor data were recorded during initial evaluation. 'LM clinical area' was calculated in square millimeters (length x width). All patients were treated with staged excision. RESULTS: We included 600 patients. Mean age was 65.9 years (SD 12.3; range 27 - 95 years); 62.8% (n=377) were males. The mean LM clinical area was 128.32 mm2 for in situ lesions vs 200.14 mm for invasive lesions (p=0.1). Based on quantile regression, the median margin required for complete removal increased with LM clinical area. LIMITATIONS: study performed in a tertiary cancer center with possible referral bias and more complex cases. CONCLUSIONS: LM can present with variable clinical size which may correlate with subclinical extension; however, the presence of invasion is not well estimated by LM clinical area.

2.
J Am Acad Dermatol ; 83(2): 463-468, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32320764

RESUMO

BACKGROUND: Functional status assessment may help estimate which patients ≥85 years of age will benefit from surgical treatment for keratinocyte carcinoma (KC), but predictive value for short-term survival in this population has not been determined. OBJECTIVE: We sought to assess the predictive value of functional status for short-term survival in patients ≥85 years of age who have KC. METHODS: This was a retrospective cohort review of 238 patients ≥85 years of age who presented for the management of KC between 2010 and 2015. Functional status was assessed with the Karnofsky Performance Scale (KPS) and Katz Activities of Daily Living (ADL) index. Overall survival was determined. RESULTS: Lower functional status scores of KPS ≤40 and Katz ADL ≤4 were associated with 37% and 53% survival at 2 years, respectively. LIMITATIONS: Retrospective design and single-center study. CONCLUSION: In this study, KPS and Katz ADL predicted short-term survival. Patients with low functional status scores had significantly decreased survival at 2 years, with double the death rate of patients with high functional status. Functional status should be considered during shared decision-making for elderly individuals who are seeking treatment for KC.

3.
Dermatol Surg ; 45(11): 1345-1352, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-30893175

RESUMO

BACKGROUND: The rate of occult invasive disease within biopsy-proven squamous cell carcinoma in situ (SCCIS) is not well defined. OBJECTIVE: To examine the rate of occult invasion in SCCIS. METHODS: An institutional-wide pathology database was retrospectively searched for "squamous cell carcinoma in situ" over a 6-year period, and the treatment modality and final pathology results were analyzed for evidence of invasion. In addition, consecutive tumor blocks from Mohs micrographic surgery (MMS) cases of SCCIS were prospectively analyzed for invasion. RESULTS: The rate of occult invasion for biopsy-proven SCCIS treated with excision was 4.0% (N = 49) and for the MMS margins was 3.5% (N = 310). For the prospective MMS tumor block analysis, the rate of occult invasion was 10.1% (N = 69). No clinical factors (age, sex, location, or size) correlated with increased risk of invasion. All invasive SCCs detected were superficial and well differentiated. CONCLUSION: The rate of occult invasion for biopsy-proven SCCIS ranged from 3.5% to 10.1%. The detected rate of invasion varies based on the method of excision and pathology processing of specimens. The rate of invasion should be considered when managing SSCIS.


Assuntos
Carcinoma in Situ/patologia , Carcinoma de Células Escamosas/patologia , Cirurgia de Mohs/estatística & dados numéricos , Neoplasias Cutâneas/patologia , Idoso , Biópsia , Carcinoma in Situ/cirurgia , Carcinoma de Células Escamosas/cirurgia , Feminino , Humanos , Masculino , Margens de Excisão , Invasividade Neoplásica/patologia , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco , Pele/patologia , Neoplasias Cutâneas/cirurgia , Centros de Atenção Terciária/estatística & dados numéricos
5.
J Am Acad Dermatol ; 80(2): 532-537, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30266559

RESUMO

BACKGROUND: Follicular involvement of lentigo maligna (LM) is considered a histopathologic hallmark, but its prevalence and characteristics have not been well defined. The depth of intrafollicular extension by neoplastic melanocytes may have clinical importance in the treatment of LM. OBJECTIVE: To describe the prevalence and features of follicular involvement in LM, including depth of follicular growth by melanocytes. METHODS: A single-center retrospective study of 100 consecutive cases of surgically excised LM that was treated from 2013 to 2015. The slide review for cases with residual LM on the debulk specimen was performed by a dermatologic surgeon and dermatopathologist to characterize follicular involvement. RESULTS: Of 100 specimens, 72 met the inclusion criteria for histopathologic evaluation. Follicular involvement was seen in 95.8% of specimens (95% confidence interval, 88.3%-99.1%), with a mean of 68% of follicles involved in a single specimen. The mean depth of intrafollicular growth by lesional melanocytes was 0.45 mm (standard deviation, 0.23; range, 0.1-1.1 mm). Tumor cells were confined to the infundibular portion of the hair follicle in 60.9% of specimens. CONCLUSION: Superficial follicular involvement is a ubiquitous finding in LM. When treatment options for LM with a depth-dependent modality aiming for tumor clearance are being considered, mean and maximum depths of involvement should be taken into consideration.


Assuntos
Folículo Piloso/patologia , Sarda Melanótica de Hutchinson/patologia , Sarda Melanótica de Hutchinson/cirurgia , Melanoma/patologia , Neoplasias Cutâneas/patologia , Idoso , Biópsia por Agulha , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Humanos , Imuno-Histoquímica , Modelos Lineares , Masculino , Melanoma/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Neoplasias Cutâneas/fisiopatologia , Inclusão do Tecido
6.
JAMA Dermatol ; 155(1): 85-89, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30422228

RESUMO

Importance: Surgical excision is the standard-of-care treatment for Tis and T1a melanomas of the head and neck. Currently, however, the association of diagnosis and surgical treatment of these typically slowly progressive and nonfatal melanomas with a patient's health-related quality of life (HRQoL) is unknown. Objective: To characterize and assess HRQoL in patients with Tis and T1a head and neck melanoma, evaluate changes in HRQoL over the surgical treatment course, and identify patient characteristics associated with lower HRQoL. Design, Setting, and Participants: This longitudinal, prospective cohort study involved patients with Tis or T1a melanoma of the head and neck who underwent staged excision at a single tertiary care center (Memorial Sloan Kettering Cancer Center, New York, New York) and were recruited from June 1, 2016, to February 28, 2017. Patients were followed up for 1 year after their surgical procedure. Participants were asked to complete 2 patient-reported outcome measure questionnaires, Skindex-16 and Skin Cancer Index (SCI), at 4 time points: baseline, perioperative (1 to 2 weeks after surgery), and 6-month and 1-year follow-up. Main Outcomes and Measures: Scores on the Skindex-16 and SCI questionnaires. Results: In total, 56 patients were included in the study, among whom 24 (43%) were female and 32 (57%) were male, with a mean (range) age of 67.2 (32-88) years; all patients self-identified as white. Forty-one (73%) questionnaires at perioperative, 49 (88%) at 6-month postoperative, and 41 (73%) at 1-year postoperative time points were completed. At baseline, female patients and those younger than 65 years had statistically significantly worse HRQoL on the Skindex-16 questionnaire (mean score, 14.2 [95% CI, 9.1-21.9] and 16.1 [95% CI, 9.8-26.4]) and on the SCI questionnaire (mean score, 57.2 [95% CI, 48.3-67.6] and 53.2 [95% CI, 44.1-64.3]) compared with males (mean Skindex-16 score, 7.0 [95% CI, 4.8-10.3]; mean SCI score, 73.5 [95% CI, 66.0-81.7]) and those aged 65 years or older (mean Skindex-16 score 7.1 [95% CI, 5.0-10.0]; mean SCI score, 74.3 [95% CI, 67.7-81.6]). Questions that demonstrated the worst scores at baseline were worry about skin condition (Skindex-16) and worry about future skin cancers (SCI). The emotions subscale scores on the Skindex-16 questionnaire showed the greatest improvement from baseline to 1-year follow-up levels (26.6 vs 15.3; P < .001) and so did the appearance subscale scores on the SCI questionnaire (64.0 vs 84.6; P < .001). The score difference in HRQoL by sex diminished over time, whereas the score difference by age persisted through the first year. Conclusions and Relevance: Improvement in HRQoL at the 6-month and 1-year follow-up was associated with surgical excision in patients with early-stage head and neck melanoma, and younger and female patients experienced worse HRQoL. These results may be used in tailoring counseling for this patient population.


Assuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Neoplasias de Cabeça e Pescoço/cirurgia , Melanoma/cirurgia , Estadiamento de Neoplasias , Qualidade de Vida , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Neoplasias de Cabeça e Pescoço/diagnóstico , Humanos , Masculino , Melanoma/diagnóstico , Pessoa de Meia-Idade , Estudos Prospectivos , Neoplasias Cutâneas/diagnóstico , Inquéritos e Questionários , Resultado do Tratamento
9.
J Am Acad Dermatol ; 78(6): 1119-1124, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29288096

RESUMO

BACKGROUND: There is controversy regarding treatment of nonmelanoma skin cancer (NMSC) in very elderly individuals, with some suggesting that this population may not live long enough to benefit from invasive treatments. Tools to assess limited life expectancy (LLE) exist, but performance in the population of very elderly individuals with NMSC has not been well defined. OBJECTIVE: Define comorbidity scores associated with LLE in very elderly individuals presenting for management of NMSC. METHODS: A retrospective review of 488 patients age 85 or older presenting for NMSC management between July 1999 through December 2014 was performed. Comorbidities were scored by using the Adult Comorbidity Evaluation-27 (ACE-27) and age-adjusted Charlson comorbidity index (ACCI). Dates of death, follow-up, and overall survival were determined. RESULTS: ACE-27 and ACCI scores were associated with overall survival; at scores of 3 and 7+, respectively, both were associated with less than 50% survival at 4 years. Patients who underwent Mohs micrographic surgery survived a median of 20 months longer than patients who did not. LIMITATIONS: Retrospective study design and referral bias. CONCLUSIONS: ACE-27 and ACCI scores predicted LLE. The cohort presenting for Mohs micrographic surgery had improved survival, despite similar intercohort comorbidity. This suggests that additional factors contributed to survival and that age and comorbidities alone are inadequate for making NMSC treatment decisions in very elderly individuals.


Assuntos
Carcinoma Basocelular/mortalidade , Carcinoma de Células Escamosas/mortalidade , Comorbidade , Expectativa de Vida , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/patologia , Idoso de 80 Anos ou mais , Carcinoma Basocelular/patologia , Carcinoma Basocelular/cirurgia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Estudos de Coortes , Feminino , Avaliação Geriátrica , Humanos , Masculino , Cirurgia de Mohs/métodos , Cirurgia de Mohs/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Neoplasias Cutâneas/cirurgia , Análise de Sobrevida , Fatores de Tempo
11.
Lasers Surg Med ; 49(9): 819-826, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28555933

RESUMO

INTRODUCTION: Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes. STUDY DESIGN AND METHODS: Retrospective review of biopsy-proven LM presenting over a 10-year-period (2006-2015). Prior cosmetic treatment and biopsies were recorded. Records were reviewed for demographic data, clinical characteristics, and surgical outcomes. RESULTS: 37/503 (7.4%) patients with LM reported prior cosmetic therapy. Most (95%) were on the head and neck; mean size 1.9 cm. Most patients reported cryotherapy (73%), followed by laser (29.7%), topical bleaching agents (18.9%), and electrodessication, and/or curettage (5.3%). Ten patients (27%) received two or more modalities. Eight patients (21.6%) reported prior benign biopsies. Six patients (16%) had invasive disease, two on initial biopsy and 4/34 (11.7%) upstaged upon excision. Average margin for clearance was 9.1 mm. CONCLUSION: Prior cosmetic treatment of LM is not uncommon, and may delay diagnosis and obscure borders, resulting in wider surgical margins. Clinicians should consider a biopsy confirming the benign nature of equivocal lesions prior to cosmetic treatment. Lasers Surg. Med. 49:819-826, 2017. © 2017 Wiley Periodicals, Inc.


Assuntos
Técnicas Cosméticas , Procedimentos Cirúrgicos Dermatológicos , Neoplasias de Cabeça e Pescoço/cirurgia , Sarda Melanótica de Hutchinson/cirurgia , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Sarda Melanótica de Hutchinson/patologia , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias Cutâneas/patologia , Resultado do Tratamento
12.
Dermatol Surg ; 43(6): 792-797, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28296789

RESUMO

BACKGROUND: Various studies have reported local recurrence (LR) rates after surgical treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM). However, the time to LR of LM/LMM is not currently known, as few studies report time to LR and have long-term follow-up. OBJECTIVE: To define time to LR in LM/LMM after surgical treatment, and to describe features of observed LR. MATERIALS AND METHODS: Retrospective single-center study of consecutive patients presenting with locally recurrent LM/LMM. RESULTS: Six hundred forty-nine cases of LM/LMM were reviewed; 29 (21 LM, and 8 LMM) of 41 locally recurrent cases had original histology reports and were included. The mean time to LR was 57.5 months (range 7-194). For cases presenting as primary LM, LR was also in situ in 14/21 (67%) of cases. Seven of 21 LM recurred as LMM. Of the 8 primary LMM, 3/8 (37.5%) presented with subsequent LMM and all were slightly deeper on re-excision. CONCLUSION: The mean time to LR of LM/LMM is at least 57.5 months, underscoring the importance of long-term follow-up. Seven of 21 LM recurred as invasive disease, but the lack of development of LMM from LM in most recurrent cases confirms LM is slowly progressive.


Assuntos
Sarda Melanótica de Hutchinson/patologia , Sarda Melanótica de Hutchinson/cirurgia , Recidiva Local de Neoplasia/patologia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Idoso , Feminino , Humanos , Sarda Melanótica de Hutchinson/epidemiologia , Masculino , Recidiva Local de Neoplasia/epidemiologia , Estudos Retrospectivos , Neoplasias Cutâneas/epidemiologia , Fatores de Tempo
13.
Dermatol Surg ; 43(6): 798-804, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28296790

RESUMO

BACKGROUND: Clinical and dermatoscopic guidelines are used to differentiate between benign longitudinal melanonychia (LM) and subungual melanoma; however, the frequency of malignancy among patients undergoing a biopsy for LM is not well defined. OBJECTIVE: To describe the histologic diagnoses and malignancy among patients undergoing a biopsy for clinical LM. METHODS: Retrospective cohort study of consecutive patients who underwent a nail biopsy for LM at a single cancer center between 2000 and 2014. Clinical features, biopsy techniques, and histopathologic results were reviewed. RESULTS: Forty-two patients with 43 biopsied lesions were included. Three of the 43 biopsies revealed melanoma (mean depth 2.1 mm). The mean age among patients with malignant lesions was 60 years compared with 58.1 years for benign lesions. The mean width of all biopsied lesions was 4.2 mm, with a mean of 10.7 mm for malignant and 3.4 mm for benign. The first digit was the most commonly involved nail in both malignant and benign lesions. CONCLUSION: Most nail biopsies performed for LM revealed benign pathology; however, melanoma was diagnosed in a small subgroup. Although clinical and dermatoscopic guidelines help guide biopsies, they should not replace clinical judgment as malignant lesions can deviate from these guidelines.


Assuntos
Melanoma/patologia , Doenças da Unha/patologia , Neoplasias Cutâneas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Estudos de Coortes , Feminino , Humanos , Masculino , Melanoma/epidemiologia , Pessoa de Meia-Idade , Doenças da Unha/epidemiologia , Estudos Retrospectivos , Neoplasias Cutâneas/epidemiologia , Adulto Jovem
15.
Plast Reconstr Surg ; 139(1): 181e-190e, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28027254

RESUMO

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify clinical features of nonmelanoma skin cancer; 2. Distinguish low-risk versus high-risk basal cell carcinoma and squamous cell carcinoma; 3. Define appropriate management based on current guidelines for various types of basal cell and squamous cell carcinoma. SUMMARY: Skin malignancies are the most prevalent cancers, and plastic surgeons are often the primary physicians engaged in diagnosis and management of these lesions. Proper management includes distinguishing between high-risk and low-risk lesions and determining treatment accordingly. The aim of this Continuing Medical Education article is to review the diagnosis and management of common and uncommon facial skin malignancies, including basal cell carcinoma, squamous cell carcinoma, actinic keratosis, keratoacanthoma, Merkel cell carcinoma, atypical fibroxanthoma, sebaceous carcinoma, and microcystic adnexal carcinoma.


Assuntos
Neoplasias Faciais/diagnóstico , Neoplasias Faciais/terapia , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/terapia , Carcinoma Basocelular/diagnóstico , Carcinoma Basocelular/terapia , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/terapia , Diagnóstico Diferencial , Medicina Baseada em Evidências , Humanos
18.
J Am Acad Dermatol ; 75(3): 590-594, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27125530

RESUMO

BACKGROUND: Intraoperative pain during Mohs micrographic surgery (MMS) has not been characterized. However, many patients report postoperative pain on the day of MMS. OBJECTIVE: We sought to determine if patients experience pain during their MMS visit. METHODS: In phase I of this study, patients were asked to report intraoperative pain level using the verbal numerical rating scale (0-10) at discharge. In phase II, pain levels were assessed before each Mohs layer and at discharge, to determine whether pain was experienced throughout the day. RESULTS: Pain was reported at some point during the MMS day for 32.8% of patients (n = 98). The mean pain number reported was 3.7 (range 1-8) out of 10. Pain was more commonly reported by patients who spent a longer time in the office, had 3 or more Mohs layers, and had a flap or graft repair. Patients most frequently reported pain with surgical sites of the periorbital area and nose. LIMITATIONS: Time between Mohs layers was not measured. There was nonstandardized use of intraoperative local anesthesia volume and oral pain medications. CONCLUSION: Some patients experience pain during MMS. However, the majority of patients report a low level of pain. Additional preventative measures could be considered in patients at higher risk.


Assuntos
Cirurgia de Mohs/efeitos adversos , Medição da Dor/métodos , Dor/diagnóstico , Assistência ao Paciente/métodos , Neoplasias Cutâneas/cirurgia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Período Intraoperatório , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Cirurgia de Mohs/métodos , Monitorização Intraoperatória/métodos , Razão de Chances , Duração da Cirurgia , Dor/etiologia , Dor Pós-Operatória/fisiopatologia , Projetos Piloto , Melhoria de Qualidade , Medição de Risco , Neoplasias Cutâneas/patologia , Resultado do Tratamento
20.
Photodermatol Photoimmunol Photomed ; 31(6): 289-95, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26052743

RESUMO

BACKGROUND/PURPOSE: Ultraviolet A1 (UVA1) phototherapy has been used for over 15 years in the United States, primarily for the treatment of localized sclerosis and various sclerosing disorders. The objective was to describe use of UVA1 for dermatoses beyond localized sclerosis at two academic institutions. METHODS: Data from 83 patients treated with low- (20-40 J/cm(2) ), medium- (>40-80 J/cm(2) ), and high- (>80-120 J/cm(2) ) dose UVA1 phototherapy was retrospectively analyzed. The mean individual treatment dose (J/cm(2) ), the mean number of sessions, and the mean total dose (J/cm(2) ) were evaluated. Effectiveness was assessed by reviewing clinical examination notes from office visits. RESULTS: Good therapeutic efficacy was seen in patients with systemic sclerosis (SS, 16 patients), graft-versus-host disease (GVHD, 25 patients), and nephrogenic systemic fibrosis (NSF, 17 patients). A statistically significant a dose-response association was observed in the cases of SS, GVHD and NSF. Likelihood of clinical improvement from UVA1 phototherapy was very likely for medium- and high-dose regimens in SS, while this level of improvement was only observed in GVHD and NSF patients receiving high-dose UVA1. CONCLUSION: UVA1 phototherapy is effective and safe in the treatment of GVHD, NSF, SS, and mast cell disorders. High-dose regimens appear to be more effective than medium- and low-dose regimens for NSF and GVHD, while medium- and high-dose regimens outperform low-dose UVA1 in SS.


Assuntos
Doença Enxerto-Hospedeiro/radioterapia , Dermopatia Fibrosante Nefrogênica/radioterapia , Escleroderma Sistêmico/radioterapia , Terapia Ultravioleta/métodos , Relação Dose-Resposta à Radiação , Feminino , Humanos , Masculino , Doses de Radiação , Estudos Retrospectivos , Terapia Ultravioleta/efeitos adversos
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