Update on adjuvant melanoma therapy.

PURPOSE OF REVIEW: We review the results from relevant clinical trials and discuss current strategies in the melanoma adjuvant setting. RECENT FINDINGS: The favorable therapeutic efficacy and the significant less toxicity of nivolumab compared with ipilimumab, fully substitutes today's approval of ipilimumab, regardless mutation status, whereas in BRAF-mutated patients, dabrafenib and trametinib seem to confirm their high efficacy also in adjuvant setting. The use of interferon is restricted to patients with ulcerated melanoma and countries with no access to the new drugs. SUMMARY: Systemic adjuvant treatment after complete disease resection in high-risk melanoma patients aims to increase relapse-free survival (RFS) and overall survival (OS). According to the eighth edition of melanoma classification of American Joint Committee on Cancer (AJCC), the prognosis in stage III patients is heterogeneous and depends not only on N (nodal) but also on T (tumor thickness) category criteria. Recent data from randomized, phase-3 clinical trials analyzing the use of adjuvant anti-programmed death-1 and targeted therapies ultimately affect the standard of care and change the landscape of the adjuvant treatment.

Evaluation of the National Swiss Skin Cancer Screening Campaign 2013: Do We Do the Right Thing.

BACKGROUND: Skin cancer prevention and screening programs are performed in many countries. Their benefit is discussed controversially. OBJECTIVE: Our aim is to evaluate the Skin Cancer Screening Program 2013 in Switzerland by following up screenees upon interventions. METHODS: Quality was assessed by personal follow-up via phone/e-mail of every patient that had been screened during this campaign and histological follow-up of all participants with suspicious skin lesions. RESULTS: Of the 1,087 screenees requiring interventions, 263 agreed to participate in the follow-up. We were able to obtain 66 histology reports. During this campaign 33 malignant lesions (8 melanomas) were removed. CONCLUSION: The overall melanoma detection rate in our free Skin Cancer Screening Program is comparable to those in European public activities. The costs of free screening programs compare favorably with the prevented potential therapeutic costs of late-stage melanoma. The low response rate of screenees agreeing to be followed up limits conclusions of this study.

Keratinocytic Malfunction as a Trigger for the Development of Solar Lentigines.

INTRODUCTION: Solar lentigines (SL) affect chronically UV-radiated skin. Treatment is often refractory. Deeper knowledge on its pathogenesis might improve therapeutic effects. MATERIAL AND METHODS: Morphological characterization of 190 SL was performed and epidermal thickness, pigment distribution, dendricity, and cornification grade were measured. Immunoreactivity was investigated using Melan A, Tyrosinase, MITF, p53, and CD20, as well as Notch1 using immunofluorescence. RESULTS: We found 2 groups of histological patterns, i.e., either acanthotic or atrophic epidermis. Lesions with basket-woven cornification and atrophic epidermis were observed in 6 out of 9 and 14 out of 16 cases from the face, respectively. Consistency of areas with a high pigmentation was observed in 96-97% of the cases. Hyperpigmentation grade and acanthosis or cornification disorders correlated positively in 88.5% of the cases. Overexpressed of p53 was found in 19 out of 20 lesions, presenting in a scattered distribution. A significant correlation of p53 and acanthosis (p = 0.003) and cornification grade (p = 0.0008) was observed. Notch1 was expressed in all SL, with the highest immunoreactivity in atrophic facial lesions. Lesions from the hands expressed Notch1 mainly in acanthotic areas with elongated rete ridges and less compact cornification. DISCUSSION: We suggest that Notch1-dependent keratinocytic malfunction causes the development of SL. Consequently, hyperpigmentation would be a result and not the primary cause of the pathogenesis. Confirmation of these findings might have clinical implications as hitherto treatment has mainly focused on melanocytes and pigmentation and not on the proliferation/differentiation balance of keratinocytes.

Basal Cell Carcinoma Mimicking Desmoplastic Trichoepithelioma: A Case with Correlation of Dermoscopy and Histology.

Basal cell carcinoma (BCC) is the most common cancer in humans worldwide. Many highly specific dermoscopic criteria for BCC are well established in the literature. On the contrary, other malignant or benign skin tumors may mimic BCC by exhibiting similar or even the same dermoscopic features and therefore obscuring the diagnosis of BCC in certain situations. We herein report a case of BCC with dermoscopic features of both BCC and desmoplastic trichoepithelioma (DT). We would like to remind of the often neglected differential diagnosis of DT in a lesion with arborizing vessels and otherwise unusual dermoscopic presentation.

Diagnosis and management of nail pigmentations.

Longitudinal pigmentation of the nail is very common. The differential diagnosis varies from subungual hematoma, to a fungal infection, to a melanocytic lesion (lentigo, nevus melanoma, etc.) to others. Often, dermatologists do not feel at ease with these pathologies and management is often not clear. In many cases, a biopsy is not helpful because an inadequate technique was chosen. The use of noninvasive techniques such as dermoscopy has been described to be useful for the preoperative evaluation and the management decision. Using these technique, one will be able to reduce the number of unnecessary surgeries and to choose the most adequate biopsy technique. In this article, we will review the management, including diagnosis as well as differential diagnosis of nail pigmentations and propose a new algorithm for the non invasive diagnosis of nail pigmentation.

Telemedical wound care using a new generation of mobile telephones: a feasibility study.

BACKGROUND: Leg ulcers are an important cost factor in health care systems. It has been shown that a telemedical wound care consultation can improve quality of care and help reduce costs. In this study, we evaluated the feasibility of telemedical wound care using a new generation of mobile telephones with integrated cameras. OBSERVATIONS: Three physicians separately evaluated 61 leg ulcers for the following 9 variables: epithelialization, fibrin, necrosis, and granulation tissue at the center and normal border, erythema, cyanosis, eczema, and hyperpigmentation at the periphery. One physician performed the face-to-face consultation (gold standard), and 2 others performed the remote evaluation. The image was obtained with the mobile telephone and immediately sent via e-mail. To measure the agreement of the evaluation among the 3 physicians, we used Cohen kappa statistics. Overall, the agreement between the remote and face-to-face evaluations was very good, with kappa values of up to 0.94 The image quality was judged to be good in 36 cases (59%) and very good in 12 (20%). The participants felt comfortable making a diagnosis based on the pictures in 50 cases (82%). CONCLUSION: Although this study was performed with the first generation of these devices, we were able to demonstrate the feasibility of such a telemedical wound care consultation.

Dermoscopy of pigmented skin lesions.

Dermoscopy is an in vivo method for the early diagnosis of malignant melanoma and the differential diagnosis of pigmented lesions of the skin. It has been shown to increase diagnostic accuracy over clinical visual inspection in the hands of experienced physicians. This article is a review of the principles of dermoscopy as well as recent technological developments.

Histopathologic correlation in dermoscopy: a micropunch technique.

BACKGROUND: Dermoscopy is a simple-to-use, in vivo method for the diagnosis of malignant melanoma and the differential diagnosis of pigmented skin lesions. It uses an immersion technique and optical magnification to visualize structures not visible to the naked eye. The anatomoclinical correlation of dermoscopic with histopathologic findings is important, and while many articles have described different techniques to achieve this goal, no direct correlation with a visual control has been described. We recently developed a micropunch technique that allows for the first time this direct correlation. OBSERVATIONS: After applying local anesthesia, the physician makes a superficial round incision using a 1-mm micropunch in the area of interest and leaves the punch in place. The lesion is documented using digital dermoscopy before and after surgery. Using these images, the laboratory technicians can easily visualize the precise site of the punch and its correlation with the initial dermoscopic image, and the sections are chosen in a way that they pass through the punch incision. The punch incision can be easily identified in the histopathologic slides because of its clear-cut borders. Since the punch always stays in place, this technique does not interfere with the interpretation of the slides (eg, measurement of the Breslow thickness). CONCLUSIONS: The advantages of our technique are that it is easy to perform by any clinician in any setting after a short setup and training period for the clinician and the laboratory technicians. Unlike with other techniques, the physician need not be present at the laboratory at the moment of the step sectioning. It can be performed in private practice and for many other indications besides pigmented skin lesions. Finally, since this technique allows for the first time a direct correlation between dermoscopic and histopathologic findings, the clinician will be able to "guide" the pathologist and indicate the precise areas of interest or suspicion.

Dermoscopy of pigmented seborrheic keratosis: a morphological study.

OBJECTIVES: To describe morphological features of seborrheic keratosis as seen by dermoscopy and to investigate their prevalence. DESIGN: Prospective cohort study using macrophotography and dermoscopy for the documentation of seborrheic keratosis. SETTINGS: Seborrheic keratoses were prospectively collected in 2 sites: a private practice in Plantation, Fla (site 1), and the Department of Dermatology at the University Hospital Geneva in Switzerland (site 2). PATIENTS: A total of 203 pigmented seborrheic keratoses (from 192 patients) with complete documentation were collected (111 from site 1 and 93 from site 2). INTERVENTIONS: Screening for new morphological features of seborrheic keratosis and evaluation of all lesions for the prevalence of these criteria. MAIN OUTCOME MEASURES: Identification of new morphological criteria and evaluation of frequency. RESULTS: A total of 15 morphological dermoscopic criteria were identified. Standard criteria such as milialike cysts and comedolike openings were found in a high number of cases (135 and 144, respectively). We found network and networklike structures to be present in 94 lesions (46%). Using standard diagnostic criteria for seborrheic keratosis, 30 lesions would not have been diagnosed as such. CONCLUSIONS: The classic dermoscopic criteria for seborrheic keratosis (milialike cysts and comedolike openings) have a high prevalence but the use of additional dermoscopic criteria such as fissures, hairpin blood vessels, sharp demarcation, and moth-eaten borders improves the diagnostic accuracy. The proper identification of pigment network and networklike structures is important for the correct diagnosis.

Dermoscopy: what's new?

Dermoscopy has been described as a useful tool for the early diagnosis of melanoma and the differential diagnosis of pigmented lesions of the skin. This has been proven by three independent meta analyses of the literature. Dermoscopy is a fast evolving field with a high number of new publications every year. Initially, the use of dermoscopy was limited to pigmented lesions, but it is used more and more in other situations. It has become an important tool for the diagnosis of nail pigmentations, hair and scalp disorders, and so forth. In this article we try to provide an update on recent trends and developments in dermoscopy.

The furrow ink test: a clue for the dermoscopic diagnosis of acral melanoma vs nevus.

BACKGROUND: Dermoscopy is a helpful tool that can assist experienced users improve the diagnostic accuracy for pigmented lesions in acral sites. As a simplification, one can assume that if pigment is found predominantly in the furrows, the lesion can be considered benign, and if the pigmentation is present predominantly on the ridges, the lesion should be considered malignant. The differentiation between furrows and ridges is the main clue for the diagnosis, but this can sometimes be difficult to discern. For this reason, we describe a simple in vivo technique that makes this task much easier for the clinician. OBSERVATIONS: Liquid ink (ie, from a fountain pen) should be applied directly onto the lesion. The ink should be left on the skin for a few seconds to allow the ink to penetrate into the furrows. The excess ink should then be wiped off. The ink will at first diffusely color the entire skin surface. The subsequent cotton swab wiping will only remove the ink on the skin overlying the ridges. The furrows will retain the stain and become clearly visible on dermoscopic examination as thin inked lines. This in turn will make it easy to evaluate whether the melanin pigmentation follows the ink lines (benign pattern) or if the pigmentation is located in between these ink lines (malignant pattern). Conclusion The furrow ink test is a quick and easy method to facilitate the correct identification of furrows and ridges on volar skin and facilitates dermoscopic diagnosis of pigmented lesions in acral sites.

Telemedicina y dermatología / Telemedicine and dermatology

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