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M. Alexander Otto began his reporting career early in 1999 covering the pharmaceutical industry for a national pharmacists' magazine and freelancing for the Washington Post and other newspapers. He then joined BNA, now part of Bloomberg News, covering health law and the protection of people and animals in medical research. Alex next worked for the McClatchy Company. Based on his work, Alex won a year-long Knight Science Journalism Fellowship to MIT in 2008-2009. He joined the company shortly thereafter. Alex has a newspaper journalism degree from Syracuse (N.Y.) University and a master's degree in medical science -- a physician assistant degree -- from George Washington University. Alex is based in Seattle.
Magnetic LES augmentation for Barrett’s regression debated
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
REPORTING FROM WCE 2018
Key clinical point: Magnetic lower esophageal sphincter augmentation might offer an easier and more effective fix for gastroesophageal reflux than the current standard, Nissen fundoplication.
Major finding: The overall regression rate of Barrett’s esophagus topped 70%.
Study details: Review of 67 patients
Disclosures: There was no industry funding, and the presenter had no disclosures. Two authors are consultants for Torax Medical, the company that makes the device.
Source: Alicuben E et al. WCE 2018, Abstract S095
FDA approves pembrolizumab for cervical cancer
with disease progression on or after chemotherapy whose tumors express programmed cell death ligand 1, as determined by an FDA approved test.
“This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials,” the FDA said in updated labeling.
Two patients (2.6%) had a complete response, and nine (11.7%) had a partial response. Of these 11 patients, 10 had response durations of 6 months or longer. Patients were treated with 200 mg every 3 weeks until unacceptable toxicity or documented disease progression. Over a third had serious adverse reactions, most frequently anemia, fistula, hemorrhage, and infection.
“Keytruda is now the first anti-PD-1 [anti–programmed cell death 1] therapy approved for the treatment of advanced cervical cancer, providing an important new second-line option for certain patients with this disease,” Roy Baynes, MD, a Merck executive, said in a company press release.
with disease progression on or after chemotherapy whose tumors express programmed cell death ligand 1, as determined by an FDA approved test.
“This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials,” the FDA said in updated labeling.
Two patients (2.6%) had a complete response, and nine (11.7%) had a partial response. Of these 11 patients, 10 had response durations of 6 months or longer. Patients were treated with 200 mg every 3 weeks until unacceptable toxicity or documented disease progression. Over a third had serious adverse reactions, most frequently anemia, fistula, hemorrhage, and infection.
“Keytruda is now the first anti-PD-1 [anti–programmed cell death 1] therapy approved for the treatment of advanced cervical cancer, providing an important new second-line option for certain patients with this disease,” Roy Baynes, MD, a Merck executive, said in a company press release.
with disease progression on or after chemotherapy whose tumors express programmed cell death ligand 1, as determined by an FDA approved test.
“This indication is approved under accelerated approval based on tumor response rate and durability of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials,” the FDA said in updated labeling.
Two patients (2.6%) had a complete response, and nine (11.7%) had a partial response. Of these 11 patients, 10 had response durations of 6 months or longer. Patients were treated with 200 mg every 3 weeks until unacceptable toxicity or documented disease progression. Over a third had serious adverse reactions, most frequently anemia, fistula, hemorrhage, and infection.
“Keytruda is now the first anti-PD-1 [anti–programmed cell death 1] therapy approved for the treatment of advanced cervical cancer, providing an important new second-line option for certain patients with this disease,” Roy Baynes, MD, a Merck executive, said in a company press release.
Nevus count tied to BCC risk
ORLANDO – The more , according to a review of over 200,000 subjects in decades-long health professional cohorts.
It’s well known that nevi increase the risk of melanoma, and the study confirmed that fact. The basal cell carcinoma finding, however, is novel. “The relationship between nevi and non-melanoma skin cancer has not [previously] been clearly demonstrated in large population cohorts,” said lead investigator Erin X. Wei, MD, a dermatologist at Brigham and Women’s Hospital, Boston.
“Nevus count serves as a convenient maker to identify patients at risk for both melanoma and basal cell carcinoma. Providers should be aware of these increased risks in patients with any nevi on the extremity, particularly 15 or more,” she said at the International Investigative Dermatology meeting.
There was no association, meanwhile, between nevus counts and squamous cell carcinoma (SCC).
The team reviewed 176,317 women in the Nurses’ Health Study 1 and 2, as well as 32,383 men in the Health Professionals Follow-up Study. Subjects were enrolled in the 1980s and followed through 2012. They reported nevus counts on their arms or legs at baseline, and filled out questionnaires on a regular basis that, among many other things, asked about new skin cancer diagnoses.
Overall, there were 30,457 incident basal cell carcinomas (BCCs), 1,704 incident melanomas, and 2,296 incident SCCs. Melanomas and SCCs – as well as a portion of BCCs – were confirmed by histology.
The team correlated the skin cancer incidence with how many moles subjects reported at baseline: zero, 1-5, 6-14, or 15 or more.
“Surprisingly, having any nevi on an extremity was associated with a significant increase in the risk of basal cell carcinoma,” in a dose-dependent manner, with 15 or more conferring a 40% increased risk of BCC, compared to subjects with no extremity nevi, Dr. Wei said (P less than .0001).
Even one mole also increased the risk of melanoma; having six or more nearly tripled it, again in a dose-dependent fashion (P less than .0001). Extremity nevi increased the risk of melanoma across all anatomic sites, including head, neck, and trunk.
The findings were statistically significant, and adjusted for age, body mass index, smoking, sun exposure, sunburn history, and other confounders.
There was no industry funding for the work, and the investigators had no relevant disclosures.
SOURCE: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233
ORLANDO – The more , according to a review of over 200,000 subjects in decades-long health professional cohorts.
It’s well known that nevi increase the risk of melanoma, and the study confirmed that fact. The basal cell carcinoma finding, however, is novel. “The relationship between nevi and non-melanoma skin cancer has not [previously] been clearly demonstrated in large population cohorts,” said lead investigator Erin X. Wei, MD, a dermatologist at Brigham and Women’s Hospital, Boston.
“Nevus count serves as a convenient maker to identify patients at risk for both melanoma and basal cell carcinoma. Providers should be aware of these increased risks in patients with any nevi on the extremity, particularly 15 or more,” she said at the International Investigative Dermatology meeting.
There was no association, meanwhile, between nevus counts and squamous cell carcinoma (SCC).
The team reviewed 176,317 women in the Nurses’ Health Study 1 and 2, as well as 32,383 men in the Health Professionals Follow-up Study. Subjects were enrolled in the 1980s and followed through 2012. They reported nevus counts on their arms or legs at baseline, and filled out questionnaires on a regular basis that, among many other things, asked about new skin cancer diagnoses.
Overall, there were 30,457 incident basal cell carcinomas (BCCs), 1,704 incident melanomas, and 2,296 incident SCCs. Melanomas and SCCs – as well as a portion of BCCs – were confirmed by histology.
The team correlated the skin cancer incidence with how many moles subjects reported at baseline: zero, 1-5, 6-14, or 15 or more.
“Surprisingly, having any nevi on an extremity was associated with a significant increase in the risk of basal cell carcinoma,” in a dose-dependent manner, with 15 or more conferring a 40% increased risk of BCC, compared to subjects with no extremity nevi, Dr. Wei said (P less than .0001).
Even one mole also increased the risk of melanoma; having six or more nearly tripled it, again in a dose-dependent fashion (P less than .0001). Extremity nevi increased the risk of melanoma across all anatomic sites, including head, neck, and trunk.
The findings were statistically significant, and adjusted for age, body mass index, smoking, sun exposure, sunburn history, and other confounders.
There was no industry funding for the work, and the investigators had no relevant disclosures.
SOURCE: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233
ORLANDO – The more , according to a review of over 200,000 subjects in decades-long health professional cohorts.
It’s well known that nevi increase the risk of melanoma, and the study confirmed that fact. The basal cell carcinoma finding, however, is novel. “The relationship between nevi and non-melanoma skin cancer has not [previously] been clearly demonstrated in large population cohorts,” said lead investigator Erin X. Wei, MD, a dermatologist at Brigham and Women’s Hospital, Boston.
“Nevus count serves as a convenient maker to identify patients at risk for both melanoma and basal cell carcinoma. Providers should be aware of these increased risks in patients with any nevi on the extremity, particularly 15 or more,” she said at the International Investigative Dermatology meeting.
There was no association, meanwhile, between nevus counts and squamous cell carcinoma (SCC).
The team reviewed 176,317 women in the Nurses’ Health Study 1 and 2, as well as 32,383 men in the Health Professionals Follow-up Study. Subjects were enrolled in the 1980s and followed through 2012. They reported nevus counts on their arms or legs at baseline, and filled out questionnaires on a regular basis that, among many other things, asked about new skin cancer diagnoses.
Overall, there were 30,457 incident basal cell carcinomas (BCCs), 1,704 incident melanomas, and 2,296 incident SCCs. Melanomas and SCCs – as well as a portion of BCCs – were confirmed by histology.
The team correlated the skin cancer incidence with how many moles subjects reported at baseline: zero, 1-5, 6-14, or 15 or more.
“Surprisingly, having any nevi on an extremity was associated with a significant increase in the risk of basal cell carcinoma,” in a dose-dependent manner, with 15 or more conferring a 40% increased risk of BCC, compared to subjects with no extremity nevi, Dr. Wei said (P less than .0001).
Even one mole also increased the risk of melanoma; having six or more nearly tripled it, again in a dose-dependent fashion (P less than .0001). Extremity nevi increased the risk of melanoma across all anatomic sites, including head, neck, and trunk.
The findings were statistically significant, and adjusted for age, body mass index, smoking, sun exposure, sunburn history, and other confounders.
There was no industry funding for the work, and the investigators had no relevant disclosures.
SOURCE: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233
REPORTING FROM IID 2018
Key clinical point: The more nevi a person has, the greater the risk of basal cell carcinoma.
Major finding: Having 15 or more moles on the arms and legs increased the risk 40% (P less than .0001).
Study details: Review of over 200,000 subjects in decades-long health professional cohorts
Disclosures: There was no industry funding for the work, and the investigators had no relevant disclosures.
Source: Wei EX et al. 2018 International Investigative Dermatology meeting abstract 233
Pemphigus remission rate tops 80% with rituximab
ORLANDO – , and could be approved for the indication soon.
With approval pending, “rituximab is quickly emerging as frontline therapy” for pemphigus, so “we should begin to prepare to answer our patients’ questions. It’s likely they will be interested in its use,” said Carolyn Kushner, a medical student and dermatology research fellow at the University of Pennsylvania, Philadelphia. Rituximab manufacturer Genentech announced the priority review for this indication in a Feb. 2018 press release.
“We get a lot of questions in the clinic,” she said at the International Investigative Dermatology meeting. Patients with pemphigus want to know how well rituximab will work, and if they’ll be able to go off other medications. They wonder if it’s safe, and when they’ll need to be retreated. The goal of the study was to provide information for both clinicians and patients regarding what to expect from the treatment.
Overall, 54 patients (48%) achieved a complete response off therapy (CROT) after their first treatment cycle, meaning they had no new lesions for at least 2 months off of all systemic and topical treatments. The median time to a complete response was 7.4 months, and the median time to relapse was 20.9 months after the first infusion. An additional 15 patients (13%) had a complete remission with minimal therapy after one cycle.
In short, “61% of patients achieved complete healing of their skin after one cycle,” Ms. Kushner said. The number rose to 82% (93 patients) when those who had more than one cycle were included. The maximum in the study was seven. Among all patients, the median time from the first to second rituximab dose was 25.1 months.
When age, sex, and disease duration were controlled for, patients who received lymphoma dosing – 375 mg/m2 weekly for 4 weeks – were 2.7 times more likely to achieve CROT than those on the rheumatoid arthritis dosing, two 1,000 mg IV infusions 2 weeks apart (P = .037). “We almost never use RA dosing now,” she said.
The odds of success also increased with age, with patients 45 years and older 3.5 to almost 7 times more likely to achieve CROT than younger patients, also a statistically significant finding.
There were four serious adverse events across 155 cycles of the lymphoma regimen, and one with 90 cycles of arthritis dosing, all infectious and none fatal. Ms. Kushner cautioned the true rate was probably higher, since their review data might have missed some cases.
Race, sex, and disease duration had no significant effect on response rates. About 60% of the patients were women.
Rituximab, approved in 1997, is a CD20-directed cytolytic antibody.
There was no industry funding for the work, and Ms. Kushner didn’t have any disclosures.
SOURCE: Kushner CJ et al. IID 2018, Abstract 552.
ORLANDO – , and could be approved for the indication soon.
With approval pending, “rituximab is quickly emerging as frontline therapy” for pemphigus, so “we should begin to prepare to answer our patients’ questions. It’s likely they will be interested in its use,” said Carolyn Kushner, a medical student and dermatology research fellow at the University of Pennsylvania, Philadelphia. Rituximab manufacturer Genentech announced the priority review for this indication in a Feb. 2018 press release.
“We get a lot of questions in the clinic,” she said at the International Investigative Dermatology meeting. Patients with pemphigus want to know how well rituximab will work, and if they’ll be able to go off other medications. They wonder if it’s safe, and when they’ll need to be retreated. The goal of the study was to provide information for both clinicians and patients regarding what to expect from the treatment.
Overall, 54 patients (48%) achieved a complete response off therapy (CROT) after their first treatment cycle, meaning they had no new lesions for at least 2 months off of all systemic and topical treatments. The median time to a complete response was 7.4 months, and the median time to relapse was 20.9 months after the first infusion. An additional 15 patients (13%) had a complete remission with minimal therapy after one cycle.
In short, “61% of patients achieved complete healing of their skin after one cycle,” Ms. Kushner said. The number rose to 82% (93 patients) when those who had more than one cycle were included. The maximum in the study was seven. Among all patients, the median time from the first to second rituximab dose was 25.1 months.
When age, sex, and disease duration were controlled for, patients who received lymphoma dosing – 375 mg/m2 weekly for 4 weeks – were 2.7 times more likely to achieve CROT than those on the rheumatoid arthritis dosing, two 1,000 mg IV infusions 2 weeks apart (P = .037). “We almost never use RA dosing now,” she said.
The odds of success also increased with age, with patients 45 years and older 3.5 to almost 7 times more likely to achieve CROT than younger patients, also a statistically significant finding.
There were four serious adverse events across 155 cycles of the lymphoma regimen, and one with 90 cycles of arthritis dosing, all infectious and none fatal. Ms. Kushner cautioned the true rate was probably higher, since their review data might have missed some cases.
Race, sex, and disease duration had no significant effect on response rates. About 60% of the patients were women.
Rituximab, approved in 1997, is a CD20-directed cytolytic antibody.
There was no industry funding for the work, and Ms. Kushner didn’t have any disclosures.
SOURCE: Kushner CJ et al. IID 2018, Abstract 552.
ORLANDO – , and could be approved for the indication soon.
With approval pending, “rituximab is quickly emerging as frontline therapy” for pemphigus, so “we should begin to prepare to answer our patients’ questions. It’s likely they will be interested in its use,” said Carolyn Kushner, a medical student and dermatology research fellow at the University of Pennsylvania, Philadelphia. Rituximab manufacturer Genentech announced the priority review for this indication in a Feb. 2018 press release.
“We get a lot of questions in the clinic,” she said at the International Investigative Dermatology meeting. Patients with pemphigus want to know how well rituximab will work, and if they’ll be able to go off other medications. They wonder if it’s safe, and when they’ll need to be retreated. The goal of the study was to provide information for both clinicians and patients regarding what to expect from the treatment.
Overall, 54 patients (48%) achieved a complete response off therapy (CROT) after their first treatment cycle, meaning they had no new lesions for at least 2 months off of all systemic and topical treatments. The median time to a complete response was 7.4 months, and the median time to relapse was 20.9 months after the first infusion. An additional 15 patients (13%) had a complete remission with minimal therapy after one cycle.
In short, “61% of patients achieved complete healing of their skin after one cycle,” Ms. Kushner said. The number rose to 82% (93 patients) when those who had more than one cycle were included. The maximum in the study was seven. Among all patients, the median time from the first to second rituximab dose was 25.1 months.
When age, sex, and disease duration were controlled for, patients who received lymphoma dosing – 375 mg/m2 weekly for 4 weeks – were 2.7 times more likely to achieve CROT than those on the rheumatoid arthritis dosing, two 1,000 mg IV infusions 2 weeks apart (P = .037). “We almost never use RA dosing now,” she said.
The odds of success also increased with age, with patients 45 years and older 3.5 to almost 7 times more likely to achieve CROT than younger patients, also a statistically significant finding.
There were four serious adverse events across 155 cycles of the lymphoma regimen, and one with 90 cycles of arthritis dosing, all infectious and none fatal. Ms. Kushner cautioned the true rate was probably higher, since their review data might have missed some cases.
Race, sex, and disease duration had no significant effect on response rates. About 60% of the patients were women.
Rituximab, approved in 1997, is a CD20-directed cytolytic antibody.
There was no industry funding for the work, and Ms. Kushner didn’t have any disclosures.
SOURCE: Kushner CJ et al. IID 2018, Abstract 552.
REPORTING FROM IID 2018
Key clinical point: Rituximab puts the majority of pemphigus patients in remission, with a median time between doses of about 2 years.
Major finding: Sixty-one percent of patients achieved complete healing of their skin after one cycle, increasing to 82% when those who had more than one cycle were included.
Study details: A single-center review of 113 patients
Disclosures: There was no industry funding, and the lead investigator had no disclosures.
Source: Kushner CJ et al. IID 2018, Abstract 552.
Cutaneous lupus: Switching antimalarials can delay immunosuppressive therapy
ORLANDO – , according to Anthony Fernandez, MD, PhD, director of medical and inpatient dermatology at the Cleveland Clinic.
A switch to chloroquine, or adding quinacrine, might do the trick, saving at least some patients from having to move on to immunosuppressive therapy, Dr. Fernandez said at the International Conference on Cutaneous Lupus Erythematosus.
“What we are learning from the literature is that we can switch from one antimalarial to another. We need to think about this in our algorithms before reaching for potentially more toxic immunosuppressives,” Dr. Fernandez said.
As for quinacrine, about two-thirds of patients who fail hydroxychloroquine or chloroquine will have a positive response to quinacrine if added (Br J Dermatol. 2017 Jul;177[1]:188-96). “It’s important to remember that we are not adding any ocular toxicity” with quinacrine, he said.
Quinacrine does come with a major concern of its own: the risk of aplastic anemia. However, this seems to occur with doses higher than 100 mg/day, which are no longer recommended; there have been no reports of aplastic anemia in patients on 100 mg/day or less.
Quinacrine “is an underutilized antimalarial. I think a lot of people don’t know about it or know how to get it. It can be compounded into capsules for patients,” and for a reasonable price, at about $20 for a month supply at some pharmacies, Dr. Fernandez said.
Meanwhile, because of the risk of retinal toxicity with hydroxychloroquine, there’s been a shift in recent years from dosing up to 6.5 mg/kg per day of ideal body weight to a ceiling of 5 mg/kg per day of actual body weight (JAMA Ophthalmol. 2014 Dec;132[12]:1453-60), and a ceiling of 2.3 mg/kg per day actual body weight for chloroquine.
The idea was to prevent overdosing in people who are under their ideal body weight, but there have been concerns about the efficacy of the new dosing regimen in other patients. Dr. Fernandez has not seen evidence of this. “We do adhere to the new dosing recommendations” at the Cleveland Clinic, and “personally, I think we are seeing similar efficacy,” he said.
The most important risk factor for retinal toxicity is cumulative dose. The risk seems to be extremely low in the first 5 years, but increases afterwards. Most patients who develop retinal toxicity have taken a cumulative hydroxychloroquine dose of 1,000 g, equal to about 400 mg/d for 7 years. “The longer you are on the medicine, the higher your risk of developing retinal toxicity,” he noted.
Regardless of weight, it’s recommended to limit hydroxychloroquine to 400 mg daily and chloroquine to 250 mg daily, with a baseline ocular exam, and – barring any intervening problems – annual screening after 5 years.
In patients with highly active skin disease at baseline, Dr. Fernandez said he will sometimes start hydroxychloroquine higher than 400 mg initially but will bring patients back down to 400 mg after a few months.
Dr. Fernandez had no relevant disclosures.
ORLANDO – , according to Anthony Fernandez, MD, PhD, director of medical and inpatient dermatology at the Cleveland Clinic.
A switch to chloroquine, or adding quinacrine, might do the trick, saving at least some patients from having to move on to immunosuppressive therapy, Dr. Fernandez said at the International Conference on Cutaneous Lupus Erythematosus.
“What we are learning from the literature is that we can switch from one antimalarial to another. We need to think about this in our algorithms before reaching for potentially more toxic immunosuppressives,” Dr. Fernandez said.
As for quinacrine, about two-thirds of patients who fail hydroxychloroquine or chloroquine will have a positive response to quinacrine if added (Br J Dermatol. 2017 Jul;177[1]:188-96). “It’s important to remember that we are not adding any ocular toxicity” with quinacrine, he said.
Quinacrine does come with a major concern of its own: the risk of aplastic anemia. However, this seems to occur with doses higher than 100 mg/day, which are no longer recommended; there have been no reports of aplastic anemia in patients on 100 mg/day or less.
Quinacrine “is an underutilized antimalarial. I think a lot of people don’t know about it or know how to get it. It can be compounded into capsules for patients,” and for a reasonable price, at about $20 for a month supply at some pharmacies, Dr. Fernandez said.
Meanwhile, because of the risk of retinal toxicity with hydroxychloroquine, there’s been a shift in recent years from dosing up to 6.5 mg/kg per day of ideal body weight to a ceiling of 5 mg/kg per day of actual body weight (JAMA Ophthalmol. 2014 Dec;132[12]:1453-60), and a ceiling of 2.3 mg/kg per day actual body weight for chloroquine.
The idea was to prevent overdosing in people who are under their ideal body weight, but there have been concerns about the efficacy of the new dosing regimen in other patients. Dr. Fernandez has not seen evidence of this. “We do adhere to the new dosing recommendations” at the Cleveland Clinic, and “personally, I think we are seeing similar efficacy,” he said.
The most important risk factor for retinal toxicity is cumulative dose. The risk seems to be extremely low in the first 5 years, but increases afterwards. Most patients who develop retinal toxicity have taken a cumulative hydroxychloroquine dose of 1,000 g, equal to about 400 mg/d for 7 years. “The longer you are on the medicine, the higher your risk of developing retinal toxicity,” he noted.
Regardless of weight, it’s recommended to limit hydroxychloroquine to 400 mg daily and chloroquine to 250 mg daily, with a baseline ocular exam, and – barring any intervening problems – annual screening after 5 years.
In patients with highly active skin disease at baseline, Dr. Fernandez said he will sometimes start hydroxychloroquine higher than 400 mg initially but will bring patients back down to 400 mg after a few months.
Dr. Fernandez had no relevant disclosures.
ORLANDO – , according to Anthony Fernandez, MD, PhD, director of medical and inpatient dermatology at the Cleveland Clinic.
A switch to chloroquine, or adding quinacrine, might do the trick, saving at least some patients from having to move on to immunosuppressive therapy, Dr. Fernandez said at the International Conference on Cutaneous Lupus Erythematosus.
“What we are learning from the literature is that we can switch from one antimalarial to another. We need to think about this in our algorithms before reaching for potentially more toxic immunosuppressives,” Dr. Fernandez said.
As for quinacrine, about two-thirds of patients who fail hydroxychloroquine or chloroquine will have a positive response to quinacrine if added (Br J Dermatol. 2017 Jul;177[1]:188-96). “It’s important to remember that we are not adding any ocular toxicity” with quinacrine, he said.
Quinacrine does come with a major concern of its own: the risk of aplastic anemia. However, this seems to occur with doses higher than 100 mg/day, which are no longer recommended; there have been no reports of aplastic anemia in patients on 100 mg/day or less.
Quinacrine “is an underutilized antimalarial. I think a lot of people don’t know about it or know how to get it. It can be compounded into capsules for patients,” and for a reasonable price, at about $20 for a month supply at some pharmacies, Dr. Fernandez said.
Meanwhile, because of the risk of retinal toxicity with hydroxychloroquine, there’s been a shift in recent years from dosing up to 6.5 mg/kg per day of ideal body weight to a ceiling of 5 mg/kg per day of actual body weight (JAMA Ophthalmol. 2014 Dec;132[12]:1453-60), and a ceiling of 2.3 mg/kg per day actual body weight for chloroquine.
The idea was to prevent overdosing in people who are under their ideal body weight, but there have been concerns about the efficacy of the new dosing regimen in other patients. Dr. Fernandez has not seen evidence of this. “We do adhere to the new dosing recommendations” at the Cleveland Clinic, and “personally, I think we are seeing similar efficacy,” he said.
The most important risk factor for retinal toxicity is cumulative dose. The risk seems to be extremely low in the first 5 years, but increases afterwards. Most patients who develop retinal toxicity have taken a cumulative hydroxychloroquine dose of 1,000 g, equal to about 400 mg/d for 7 years. “The longer you are on the medicine, the higher your risk of developing retinal toxicity,” he noted.
Regardless of weight, it’s recommended to limit hydroxychloroquine to 400 mg daily and chloroquine to 250 mg daily, with a baseline ocular exam, and – barring any intervening problems – annual screening after 5 years.
In patients with highly active skin disease at baseline, Dr. Fernandez said he will sometimes start hydroxychloroquine higher than 400 mg initially but will bring patients back down to 400 mg after a few months.
Dr. Fernandez had no relevant disclosures.
EXPERT ANALYSIS FROM ICCLE 2018
Hydroxychloroquine throws off Quantiferon-TB Gold results, study finds
ORLANDO – according to investigators from the University of Pennsylvania, Philadelphia.
Among 46 patients with lupus, dermatomyositis, or blistering diseases who had been on hydroxychloroquine within a year of testing, QuantiFERON-TB Gold (QFT-G) – the go-to TB test in many places – yielded indeterminate results in 37%. Meanwhile, just 9.6% of tests were indeterminate among 73 patients with those diseases who had not been on hydroxychloroquine (P less than .001). The findings could not be explained by concomitant use of prednisone and other immunosuppressives; there were no statistically significant differences between the groups. “This was shocking to us. We need to come up with a better screening test in this patient population,” said lead investigator Rebecca Gaffney, a research fellow at the University of Pennsylvania, and a medical student at Robert Wood Johnson Medical School, New Brunswick, NJ.*
It’s widely known that immunosuppressives interfere with QFT-G results, but antimalarials are considered immunomodulators, not immunosuppressives. The new study is probably the first to investigate the issue. The team is now pitting QFT-G against another TB blood test, the T-SPOT, in 100 patients to see if it’s a better option, in a trial that they expect to complete in 2018.
The investigators have a hunch that the T-SPOT might be better because, while QFT-G measures interferon-gamma concentrations in response to TB antigens, the T-SPOT “counts cells first to make sure you have a standard amount of cells, then looks at how many cells are releasing interferon-gamma,” Ms. Gaffney said, adding that “it seems like a more sensitive test,” especially for lymphocytopenic autoimmune patients. “We are really excited to see if there’s a better test for our patients, given all the clinical trials we do. We want to see what’s best, so there’s no barrier to receiving therapy.”
Subjects were around 50 years old on average, and the majority were women. Most were white, and about 20% were black.
There was no industry funding for the work, and Ms. Gaffney reported no disclosures.
*This article was updated on June 13. 2018.
ORLANDO – according to investigators from the University of Pennsylvania, Philadelphia.
Among 46 patients with lupus, dermatomyositis, or blistering diseases who had been on hydroxychloroquine within a year of testing, QuantiFERON-TB Gold (QFT-G) – the go-to TB test in many places – yielded indeterminate results in 37%. Meanwhile, just 9.6% of tests were indeterminate among 73 patients with those diseases who had not been on hydroxychloroquine (P less than .001). The findings could not be explained by concomitant use of prednisone and other immunosuppressives; there were no statistically significant differences between the groups. “This was shocking to us. We need to come up with a better screening test in this patient population,” said lead investigator Rebecca Gaffney, a research fellow at the University of Pennsylvania, and a medical student at Robert Wood Johnson Medical School, New Brunswick, NJ.*
It’s widely known that immunosuppressives interfere with QFT-G results, but antimalarials are considered immunomodulators, not immunosuppressives. The new study is probably the first to investigate the issue. The team is now pitting QFT-G against another TB blood test, the T-SPOT, in 100 patients to see if it’s a better option, in a trial that they expect to complete in 2018.
The investigators have a hunch that the T-SPOT might be better because, while QFT-G measures interferon-gamma concentrations in response to TB antigens, the T-SPOT “counts cells first to make sure you have a standard amount of cells, then looks at how many cells are releasing interferon-gamma,” Ms. Gaffney said, adding that “it seems like a more sensitive test,” especially for lymphocytopenic autoimmune patients. “We are really excited to see if there’s a better test for our patients, given all the clinical trials we do. We want to see what’s best, so there’s no barrier to receiving therapy.”
Subjects were around 50 years old on average, and the majority were women. Most were white, and about 20% were black.
There was no industry funding for the work, and Ms. Gaffney reported no disclosures.
*This article was updated on June 13. 2018.
ORLANDO – according to investigators from the University of Pennsylvania, Philadelphia.
Among 46 patients with lupus, dermatomyositis, or blistering diseases who had been on hydroxychloroquine within a year of testing, QuantiFERON-TB Gold (QFT-G) – the go-to TB test in many places – yielded indeterminate results in 37%. Meanwhile, just 9.6% of tests were indeterminate among 73 patients with those diseases who had not been on hydroxychloroquine (P less than .001). The findings could not be explained by concomitant use of prednisone and other immunosuppressives; there were no statistically significant differences between the groups. “This was shocking to us. We need to come up with a better screening test in this patient population,” said lead investigator Rebecca Gaffney, a research fellow at the University of Pennsylvania, and a medical student at Robert Wood Johnson Medical School, New Brunswick, NJ.*
It’s widely known that immunosuppressives interfere with QFT-G results, but antimalarials are considered immunomodulators, not immunosuppressives. The new study is probably the first to investigate the issue. The team is now pitting QFT-G against another TB blood test, the T-SPOT, in 100 patients to see if it’s a better option, in a trial that they expect to complete in 2018.
The investigators have a hunch that the T-SPOT might be better because, while QFT-G measures interferon-gamma concentrations in response to TB antigens, the T-SPOT “counts cells first to make sure you have a standard amount of cells, then looks at how many cells are releasing interferon-gamma,” Ms. Gaffney said, adding that “it seems like a more sensitive test,” especially for lymphocytopenic autoimmune patients. “We are really excited to see if there’s a better test for our patients, given all the clinical trials we do. We want to see what’s best, so there’s no barrier to receiving therapy.”
Subjects were around 50 years old on average, and the majority were women. Most were white, and about 20% were black.
There was no industry funding for the work, and Ms. Gaffney reported no disclosures.
*This article was updated on June 13. 2018.
REPORTING FROM ICCLE 2018
Timely dermatomyositis diagnosis, treatment remain elusive
ORLANDO – There was a median 1-year delay between the onset of symptoms and diagnosis of classic dermatomyositis, and a 17-month delay before diagnosis of amyopathic dermatomyositis, based on a review of 232 dermatomyositis patients seen at the University of Pennsylvania, Philadelphia.
Just 103 (44.4%) patients were diagnosed with dermatomyositis (DM) right out of the gate. Among the other 129, 48 (37.2%) were diagnosed with lupus, 38 (29.5%) with undifferentiated connective tissue disease, 10 (7.8%) went undiagnosed, and 33 (25.5%) were diagnosed with rosacea, psoriasis, rheumatoid arthritis, fibromyalgia, lichen planus, and a number of other conditions. By the time the DM diagnosis was finally confirmed, almost every patient had Gottron’s papules or sign.
Misdiagnosis of dermatomyositis (DM) is nothing new, but the study brings home just how common the problem is, even at a major academic medical institution.
One of the take homes is that , and remain vigilant for erythema on the lateral thighs or nasolabial fold, Gottron’s papules, and other diagnostic giveaways, the researchers said.
Interface dermatitis, in particular, can’t be relied on to differentiate the conditions. A better option is checking for lupus bands and membrane attack complexes on direct immunofluorescence.
There’s also just not enough awareness that dermatomyositis can present without the classic muscle symptoms and findings, i.e. clinically amyopathic DM. While 49 of 120 patients with classic dermatomyositis (40.8%) were misdiagnosed or undiagnosed in the study, the number rose to 80 of 112 (71.4%) among amyopathic patients.
“We saw that there was a much higher rate of misdiagnosis in patients who didn’t have any muscle disease. We have to raise awareness that amyopathic dermatomyositis is a very prevalent condition,” Dr. Patel said at the International Conference on Cutaneous Lupus Erythematosus.
“There might be some level of subclinical muscle activity where, if you did an MRI, you might see inflammation, but the patient doesn’t report any symptoms. There are also patients that don’t have any muscle findings on MRI, or elevated muscle enzymes, but still have the skin findings,” he said.
Perhaps the markedly increased risk of cancer in DM, especially within a year or 2 of symptom onset, is the strongest argument for earlier diagnosis. “There’s also a risk of interstitial lung disease, so making sure that you’re getting pulmonary function tests and age-appropriate malignancy screening in a timely fashion is very important,” Dr. Patel said.
Also, although many of the initial treatments for DM – sun protection and topical steroids and calcineurin inhibitors, for instance – are the same as for cutaneous lupus, medications like mycophenolate mofetil and methotrexate are used more readily. The sooner DM is recognized for what it is, the sooner patients can get relief, he said.
Almost all the patients were white women. The majority were 40-80 years old.
There was no industry funding for the work, and Dr. Patel didn’t have any disclosures.
SOURCE: da Silva DM et al. Presented at the 2018 International Conference on Cutaneous Lupus Erythematosus
ORLANDO – There was a median 1-year delay between the onset of symptoms and diagnosis of classic dermatomyositis, and a 17-month delay before diagnosis of amyopathic dermatomyositis, based on a review of 232 dermatomyositis patients seen at the University of Pennsylvania, Philadelphia.
Just 103 (44.4%) patients were diagnosed with dermatomyositis (DM) right out of the gate. Among the other 129, 48 (37.2%) were diagnosed with lupus, 38 (29.5%) with undifferentiated connective tissue disease, 10 (7.8%) went undiagnosed, and 33 (25.5%) were diagnosed with rosacea, psoriasis, rheumatoid arthritis, fibromyalgia, lichen planus, and a number of other conditions. By the time the DM diagnosis was finally confirmed, almost every patient had Gottron’s papules or sign.
Misdiagnosis of dermatomyositis (DM) is nothing new, but the study brings home just how common the problem is, even at a major academic medical institution.
One of the take homes is that , and remain vigilant for erythema on the lateral thighs or nasolabial fold, Gottron’s papules, and other diagnostic giveaways, the researchers said.
Interface dermatitis, in particular, can’t be relied on to differentiate the conditions. A better option is checking for lupus bands and membrane attack complexes on direct immunofluorescence.
There’s also just not enough awareness that dermatomyositis can present without the classic muscle symptoms and findings, i.e. clinically amyopathic DM. While 49 of 120 patients with classic dermatomyositis (40.8%) were misdiagnosed or undiagnosed in the study, the number rose to 80 of 112 (71.4%) among amyopathic patients.
“We saw that there was a much higher rate of misdiagnosis in patients who didn’t have any muscle disease. We have to raise awareness that amyopathic dermatomyositis is a very prevalent condition,” Dr. Patel said at the International Conference on Cutaneous Lupus Erythematosus.
“There might be some level of subclinical muscle activity where, if you did an MRI, you might see inflammation, but the patient doesn’t report any symptoms. There are also patients that don’t have any muscle findings on MRI, or elevated muscle enzymes, but still have the skin findings,” he said.
Perhaps the markedly increased risk of cancer in DM, especially within a year or 2 of symptom onset, is the strongest argument for earlier diagnosis. “There’s also a risk of interstitial lung disease, so making sure that you’re getting pulmonary function tests and age-appropriate malignancy screening in a timely fashion is very important,” Dr. Patel said.
Also, although many of the initial treatments for DM – sun protection and topical steroids and calcineurin inhibitors, for instance – are the same as for cutaneous lupus, medications like mycophenolate mofetil and methotrexate are used more readily. The sooner DM is recognized for what it is, the sooner patients can get relief, he said.
Almost all the patients were white women. The majority were 40-80 years old.
There was no industry funding for the work, and Dr. Patel didn’t have any disclosures.
SOURCE: da Silva DM et al. Presented at the 2018 International Conference on Cutaneous Lupus Erythematosus
ORLANDO – There was a median 1-year delay between the onset of symptoms and diagnosis of classic dermatomyositis, and a 17-month delay before diagnosis of amyopathic dermatomyositis, based on a review of 232 dermatomyositis patients seen at the University of Pennsylvania, Philadelphia.
Just 103 (44.4%) patients were diagnosed with dermatomyositis (DM) right out of the gate. Among the other 129, 48 (37.2%) were diagnosed with lupus, 38 (29.5%) with undifferentiated connective tissue disease, 10 (7.8%) went undiagnosed, and 33 (25.5%) were diagnosed with rosacea, psoriasis, rheumatoid arthritis, fibromyalgia, lichen planus, and a number of other conditions. By the time the DM diagnosis was finally confirmed, almost every patient had Gottron’s papules or sign.
Misdiagnosis of dermatomyositis (DM) is nothing new, but the study brings home just how common the problem is, even at a major academic medical institution.
One of the take homes is that , and remain vigilant for erythema on the lateral thighs or nasolabial fold, Gottron’s papules, and other diagnostic giveaways, the researchers said.
Interface dermatitis, in particular, can’t be relied on to differentiate the conditions. A better option is checking for lupus bands and membrane attack complexes on direct immunofluorescence.
There’s also just not enough awareness that dermatomyositis can present without the classic muscle symptoms and findings, i.e. clinically amyopathic DM. While 49 of 120 patients with classic dermatomyositis (40.8%) were misdiagnosed or undiagnosed in the study, the number rose to 80 of 112 (71.4%) among amyopathic patients.
“We saw that there was a much higher rate of misdiagnosis in patients who didn’t have any muscle disease. We have to raise awareness that amyopathic dermatomyositis is a very prevalent condition,” Dr. Patel said at the International Conference on Cutaneous Lupus Erythematosus.
“There might be some level of subclinical muscle activity where, if you did an MRI, you might see inflammation, but the patient doesn’t report any symptoms. There are also patients that don’t have any muscle findings on MRI, or elevated muscle enzymes, but still have the skin findings,” he said.
Perhaps the markedly increased risk of cancer in DM, especially within a year or 2 of symptom onset, is the strongest argument for earlier diagnosis. “There’s also a risk of interstitial lung disease, so making sure that you’re getting pulmonary function tests and age-appropriate malignancy screening in a timely fashion is very important,” Dr. Patel said.
Also, although many of the initial treatments for DM – sun protection and topical steroids and calcineurin inhibitors, for instance – are the same as for cutaneous lupus, medications like mycophenolate mofetil and methotrexate are used more readily. The sooner DM is recognized for what it is, the sooner patients can get relief, he said.
Almost all the patients were white women. The majority were 40-80 years old.
There was no industry funding for the work, and Dr. Patel didn’t have any disclosures.
SOURCE: da Silva DM et al. Presented at the 2018 International Conference on Cutaneous Lupus Erythematosus
REPORTING FROM ICCLE 2018
Key clinical point: Clinicians need to do a better job of catching DM early.
Major finding: It took a median of 12.2 months after the start of symptoms to diagnose classic dermatomyositis, and 17.1 months to diagnose amyopathic dermatomyositis.
Study details: Review of 232 patients
Disclosures: There was no industry funding, and the presenter didn’t have any disclosures.
Source: da Silva DM et al. Presented at the 2018 International Conference on Cutaneous Lupus Erythematosus
Median time to progression from discoid to systemic lupus may be less than a year
ORLANDO – Progression from cutaneous to systemic lupus happens far more quickly than is commonly reported in the literature, according to an investigation from Brigham and Women’s Hospital, Boston.
Most studies have emphasized mean time to progression, which is generally said to be about 8 years. The problem is that the range is broad, anywhere from a few months to 30 or more years, so “the outliers influence the mean, and therefore, may not provide a fully accurate representation of the interval in which [most] patients progress” from discoid lupus erythematosus (DLE) to systemic lupus erythematosus (SLE), lead investigator Scott Elman, MD, said at the International Conference on Cutaneous Lupus Erythematosus.
He and his team thought it would be more useful to instead look at median time to progression, the point at which half of patients develop systemic disease. They found that , with the first quartile progressing by 303 days. The mean time to progression, meanwhile, was over 4 years, because of outliers who progressed at anywhere from 27 days to 30 years.
“The median progression of DLE to SLE occurs much sooner than previously reported” with mean progression times, said Dr. Elman, an internal medicine and dermatology resident at Brigham and Women’s. “We believe the use of median [time] is [more] clinically useful for both providers and patients in their understanding of what a diagnosis of DLE means for the risk of developing systemic disease.
“As clinicians seeing DLE patients, the primary question we are asking ourselves is how frequently we should be monitoring for signs and symptoms of systemic lupus,” he said. Relying on mean time instead of median time might give a false sense of security – and even delay checking for arthritis, nephritis, and other manifestations. There’s no current standard of practice about when monitoring should occur, but “I certainly think that closer monitoring of new patients with a diagnosis of DLE, especially in their first couple of years,” is a good idea, he noted, adding that for most patients, “it seems that if it’s going to happen, it’s going to happen sooner” rather than later. At Brigham and Women’s, newly diagnosed patients are generally brought back every 3-6 months for lab tests and a thorough review of symptoms, Dr. Elman said.
The next step is to identify risk factors for early progression. The study did not find any significant differences in lab values, medication exposures, or disease manifestations between early and late progressors, perhaps because of the small sample size. The work continues.
There was no external funding for the work. Dr. Elman had no disclosures.
ORLANDO – Progression from cutaneous to systemic lupus happens far more quickly than is commonly reported in the literature, according to an investigation from Brigham and Women’s Hospital, Boston.
Most studies have emphasized mean time to progression, which is generally said to be about 8 years. The problem is that the range is broad, anywhere from a few months to 30 or more years, so “the outliers influence the mean, and therefore, may not provide a fully accurate representation of the interval in which [most] patients progress” from discoid lupus erythematosus (DLE) to systemic lupus erythematosus (SLE), lead investigator Scott Elman, MD, said at the International Conference on Cutaneous Lupus Erythematosus.
He and his team thought it would be more useful to instead look at median time to progression, the point at which half of patients develop systemic disease. They found that , with the first quartile progressing by 303 days. The mean time to progression, meanwhile, was over 4 years, because of outliers who progressed at anywhere from 27 days to 30 years.
“The median progression of DLE to SLE occurs much sooner than previously reported” with mean progression times, said Dr. Elman, an internal medicine and dermatology resident at Brigham and Women’s. “We believe the use of median [time] is [more] clinically useful for both providers and patients in their understanding of what a diagnosis of DLE means for the risk of developing systemic disease.
“As clinicians seeing DLE patients, the primary question we are asking ourselves is how frequently we should be monitoring for signs and symptoms of systemic lupus,” he said. Relying on mean time instead of median time might give a false sense of security – and even delay checking for arthritis, nephritis, and other manifestations. There’s no current standard of practice about when monitoring should occur, but “I certainly think that closer monitoring of new patients with a diagnosis of DLE, especially in their first couple of years,” is a good idea, he noted, adding that for most patients, “it seems that if it’s going to happen, it’s going to happen sooner” rather than later. At Brigham and Women’s, newly diagnosed patients are generally brought back every 3-6 months for lab tests and a thorough review of symptoms, Dr. Elman said.
The next step is to identify risk factors for early progression. The study did not find any significant differences in lab values, medication exposures, or disease manifestations between early and late progressors, perhaps because of the small sample size. The work continues.
There was no external funding for the work. Dr. Elman had no disclosures.
ORLANDO – Progression from cutaneous to systemic lupus happens far more quickly than is commonly reported in the literature, according to an investigation from Brigham and Women’s Hospital, Boston.
Most studies have emphasized mean time to progression, which is generally said to be about 8 years. The problem is that the range is broad, anywhere from a few months to 30 or more years, so “the outliers influence the mean, and therefore, may not provide a fully accurate representation of the interval in which [most] patients progress” from discoid lupus erythematosus (DLE) to systemic lupus erythematosus (SLE), lead investigator Scott Elman, MD, said at the International Conference on Cutaneous Lupus Erythematosus.
He and his team thought it would be more useful to instead look at median time to progression, the point at which half of patients develop systemic disease. They found that , with the first quartile progressing by 303 days. The mean time to progression, meanwhile, was over 4 years, because of outliers who progressed at anywhere from 27 days to 30 years.
“The median progression of DLE to SLE occurs much sooner than previously reported” with mean progression times, said Dr. Elman, an internal medicine and dermatology resident at Brigham and Women’s. “We believe the use of median [time] is [more] clinically useful for both providers and patients in their understanding of what a diagnosis of DLE means for the risk of developing systemic disease.
“As clinicians seeing DLE patients, the primary question we are asking ourselves is how frequently we should be monitoring for signs and symptoms of systemic lupus,” he said. Relying on mean time instead of median time might give a false sense of security – and even delay checking for arthritis, nephritis, and other manifestations. There’s no current standard of practice about when monitoring should occur, but “I certainly think that closer monitoring of new patients with a diagnosis of DLE, especially in their first couple of years,” is a good idea, he noted, adding that for most patients, “it seems that if it’s going to happen, it’s going to happen sooner” rather than later. At Brigham and Women’s, newly diagnosed patients are generally brought back every 3-6 months for lab tests and a thorough review of symptoms, Dr. Elman said.
The next step is to identify risk factors for early progression. The study did not find any significant differences in lab values, medication exposures, or disease manifestations between early and late progressors, perhaps because of the small sample size. The work continues.
There was no external funding for the work. Dr. Elman had no disclosures.
REPORTING FROM ICCLE 2018
Key clinical point: Progression from cutaneous to systemic lupus happens far more quickly than is commonly reported in the literature.
Major finding: The median time to progression was 398 days, among a group of patients diagnosed with discoid lupus erythematosus.
Study details: A review of 32 patients who converted to systemic disease.
Disclosures: There was no external funding for the work, and the lead investigator had no disclosures.
Don’t trust interface dermatitis to diagnose dermatomyositis
ORLANDO – (DM), according to David Fiorentino, MD, PhD, professor of dermatology, rheumatology, and immunology at Stanford (Calif.) University.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Interface dermatitis on skin biopsy is “felt to be almost required by many people to make the diagnosis,” but he and his associates found that it was not present in about a quarter of a cohort of patients with DM. “We don’t want a clinician” to rule out the diagnosis based on its absence on a biopsy, “when its actually quite possible that the patient could have disease,” Dr. Fiorentino said at the International Conference on Cutaneous Lupus Erythematosus.
In general, skin biopsies in DM are tricky. “All of us take them, but we don’t really know how to interpret the information that comes back ... because we don’t really know how often many of [the associated] findings are seen” in DM patients, he noted.
One of the main concerns is to rule out lupus, but interface dermatitis is found in many of its cutaneous forms, as well as in graft-versus-host disease and other diseases.
So what’s a clinician to do? Fortunately, direct immunofluorescence can help. A positive lupus band test helps rule out DM, and the membrane attack complex helps rule it in, both with a good degree of certainty. In a video interview, Dr. Fiorentino explained these tests and how to use them.
Dr. Fiorentino had no relevant disclosures.
[email protected]
ORLANDO – (DM), according to David Fiorentino, MD, PhD, professor of dermatology, rheumatology, and immunology at Stanford (Calif.) University.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Interface dermatitis on skin biopsy is “felt to be almost required by many people to make the diagnosis,” but he and his associates found that it was not present in about a quarter of a cohort of patients with DM. “We don’t want a clinician” to rule out the diagnosis based on its absence on a biopsy, “when its actually quite possible that the patient could have disease,” Dr. Fiorentino said at the International Conference on Cutaneous Lupus Erythematosus.
In general, skin biopsies in DM are tricky. “All of us take them, but we don’t really know how to interpret the information that comes back ... because we don’t really know how often many of [the associated] findings are seen” in DM patients, he noted.
One of the main concerns is to rule out lupus, but interface dermatitis is found in many of its cutaneous forms, as well as in graft-versus-host disease and other diseases.
So what’s a clinician to do? Fortunately, direct immunofluorescence can help. A positive lupus band test helps rule out DM, and the membrane attack complex helps rule it in, both with a good degree of certainty. In a video interview, Dr. Fiorentino explained these tests and how to use them.
Dr. Fiorentino had no relevant disclosures.
[email protected]
ORLANDO – (DM), according to David Fiorentino, MD, PhD, professor of dermatology, rheumatology, and immunology at Stanford (Calif.) University.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Interface dermatitis on skin biopsy is “felt to be almost required by many people to make the diagnosis,” but he and his associates found that it was not present in about a quarter of a cohort of patients with DM. “We don’t want a clinician” to rule out the diagnosis based on its absence on a biopsy, “when its actually quite possible that the patient could have disease,” Dr. Fiorentino said at the International Conference on Cutaneous Lupus Erythematosus.
In general, skin biopsies in DM are tricky. “All of us take them, but we don’t really know how to interpret the information that comes back ... because we don’t really know how often many of [the associated] findings are seen” in DM patients, he noted.
One of the main concerns is to rule out lupus, but interface dermatitis is found in many of its cutaneous forms, as well as in graft-versus-host disease and other diseases.
So what’s a clinician to do? Fortunately, direct immunofluorescence can help. A positive lupus band test helps rule out DM, and the membrane attack complex helps rule it in, both with a good degree of certainty. In a video interview, Dr. Fiorentino explained these tests and how to use them.
Dr. Fiorentino had no relevant disclosures.
[email protected]
REPORTING FROM ICCLE 2018
Regular skin exams reduced advanced KCs in posttransplant patients
ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.
Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.
Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.
“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.
Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.
To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.
Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).
Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.
Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.
“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.
There was no industry funding for the work, and Dr. Chan had no relevant disclosures.
SOURCE: Chan A et al. IID 2018, Abstract 522.
ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.
Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.
Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.
“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.
Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.
To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.
Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).
Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.
Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.
“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.
There was no industry funding for the work, and Dr. Chan had no relevant disclosures.
SOURCE: Chan A et al. IID 2018, Abstract 522.
ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.
Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.
Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.
“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.
Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.
To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.
Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).
Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.
Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.
“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.
There was no industry funding for the work, and Dr. Chan had no relevant disclosures.
SOURCE: Chan A et al. IID 2018, Abstract 522.
REPORTING FROM IID 2018
Key clinical point: Transplant patients need help to ensure they get annual dermatology checkups.
Major finding: Just 2.1% of the patients in the review had annual exams, and less than half saw a dermatologist even once during an average of 5-years follow-up.
Study details: A review of 10,198 solid organ transplant cases.
Disclosures: There was no industry funding, and the lead investigator had no disclosures.
Source: Chan A et al. IID 2018, Abstract 522