Granular Cell Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common human epithelial malignancy. There are several histologic variants, the rarest being granular cell BCC (GBCC).¹ Granular cell BCC is reported most commonly in men with a mean age of 63 years. Sixty-four percent of cases develop on the face, with the remainder arising on the chest or trunk. Granular cell BCC has distinct histologic features but has no specific epidemiologic or clinical features that differentiate it from more common forms of BCC. Treatment of GBCC is identical to BCC and demonstrates similar outcomes. The presence of granular cells can make GBCC difficult to differentiate from other benign and malignant lesions that display similar granular histologic changes.^1,2 Rarely, tumors that are histologically similar to human GBCC have been reported in animals.¹

Histologically, GBCC commonly demonstrates the architecture of a nodular BCC or may extend from an existing nodular BCC (quiz images A and B). Granular cell BCC is comprised of large islands of basaloid cells extending from the epidermis with rare mitotic activity. Certain variants showing no epidermal attachments have been described,^1,3 as in the current case. Classically, BCC and GBCC both demonstrate a peripheral palisade of blue basal cells; however, GBCC may lack this palisading feature in some cases. Therefore, GBCC may be comprised of granular cells only, which may be more easily confused with other tumors with granular cell differentiation. Even when GBCC retains the traditional peripheral palisade of blue basal cells, the central cells are filled with eosinophilic granules.^1,2

Electron microscopy of GBCC usually reveals bundles of cytoplasmic tonofilaments and desmosomes in both granular cells and the peripherally palisaded cells. Electron microscopy imaging also demonstrates 0.1- to 0.5-µm membrane-bound lysosomelike structures. In certain reports, these structures show focal positivity for lysozymes.^1,2 The etiology of the granules is unclear; however, they are thought to represent degenerative changes related to metabolic alteration and accumulation of lysosomelike structures. These lysosomelike structures have been highlighted with CD68 staining, which was negative in our case.^1,2 The lesional cells in GBCC stain positively for cytokeratins, p63, and Ber-EP4, and negatively for S-100 protein, epithelial membrane antigen, and carcinoembryonic antigen. The granules in GBCC generally are positive on periodic acid–Schiff staining.^1-4

The histologic differential diagnosis for GBCC includes granular cell tumor as well as other tumors that can present with granular cell changes such as ameloblastoma, leiomyoma, leiomyosarcoma, angiosarcoma, malignant peripheral nerve sheath tumor, and granular cell trichoblastoma. Granular cell ameloblastomas have histologic features and staining patterns that are identical to GBCC; however, ameloblastomas are distinguished by their location within the oral cavity. Granular cell tumors and malignant peripheral nerve sheath tumors stain positive for S-100 protein, and angiosarcomas stain positive for D2-40 and CD31. Leiomyomas and leiomyosarcomas can be differentiated by staining with smooth muscle actin or desmin.¹ Granular cell trichoblastomas can be differentiated by the follicular stem cell marker protein PHLDA1 positivity.⁵

Desmoplastic trichilemmoma is difficult to distinguish from BCC. These tumors are comprised of superficial lobules of basaloid cells with a perilobular hyaline mantel surrounding a central desmoplastic stroma (Figure 1). The basaloid cells in desmoplastic trichoepithelioma demonstrate clear cell change; however, granular features are not seen. The cells within the desmoplastic areas are arranged haphazardly in cords and nests and can mimic an invasive carcinoma; however, nuclear atypia and mitotic activity generally are absent in desmoplastic trichilemmoma.⁶

Granular cell tumors generally are poorly circumscribed dermal nodules comprised of large polygonal cells with an eosinophilic granular cytoplasm (Figure 2). The nuclei are generally small and round, and cytological atypia, necrosis, and mitotic activity are uncommon. The cells are positive for S-100 protein and neuron-specific enolase but negative for CD68. The granules are positive for periodic acid–Schiff stain and are diastase resistant. Rarely, these tumors can be malignant.⁷

Sebaceous adenoma is a well-circumscribed tumor comprised of lobules of characteristic mature sebocytes with bubbly or multivacuolated cytoplasm and crenated nuclei (Figure 3). There is an expansion and increased prominence of the peripherally located basaloid cells; however, in contrast to sebaceous epithelioma, less than 50% of the tumor usually is comprised of these basaloid cells.⁸

Xanthogranuloma demonstrates a dense collection of histiocytes in the dermis, commonly with Touton giant cell formation (Figure 4). The cells often have a foamy cytoplasm and cytoplasmic vacuoles are observed. The histiocytes are positive for factor XIIIa and CD68, and generally negative for S-100 protein and CD1a, which allows for differentiation from Langerhans cells.⁹

Granular Cell Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common human epithelial malignancy. There are several histologic variants, the rarest being granular cell BCC (GBCC).¹ Granular cell BCC is reported most commonly in men with a mean age of 63 years. Sixty-four percent of cases develop on the face, with the remainder arising on the chest or trunk. Granular cell BCC has distinct histologic features but has no specific epidemiologic or clinical features that differentiate it from more common forms of BCC. Treatment of GBCC is identical to BCC and demonstrates similar outcomes. The presence of granular cells can make GBCC difficult to differentiate from other benign and malignant lesions that display similar granular histologic changes.^1,2 Rarely, tumors that are histologically similar to human GBCC have been reported in animals.¹

Histologically, GBCC commonly demonstrates the architecture of a nodular BCC or may extend from an existing nodular BCC (quiz images A and B). Granular cell BCC is comprised of large islands of basaloid cells extending from the epidermis with rare mitotic activity. Certain variants showing no epidermal attachments have been described,^1,3 as in the current case. Classically, BCC and GBCC both demonstrate a peripheral palisade of blue basal cells; however, GBCC may lack this palisading feature in some cases. Therefore, GBCC may be comprised of granular cells only, which may be more easily confused with other tumors with granular cell differentiation. Even when GBCC retains the traditional peripheral palisade of blue basal cells, the central cells are filled with eosinophilic granules.^1,2

Electron microscopy of GBCC usually reveals bundles of cytoplasmic tonofilaments and desmosomes in both granular cells and the peripherally palisaded cells. Electron microscopy imaging also demonstrates 0.1- to 0.5-µm membrane-bound lysosomelike structures. In certain reports, these structures show focal positivity for lysozymes.^1,2 The etiology of the granules is unclear; however, they are thought to represent degenerative changes related to metabolic alteration and accumulation of lysosomelike structures. These lysosomelike structures have been highlighted with CD68 staining, which was negative in our case.^1,2 The lesional cells in GBCC stain positively for cytokeratins, p63, and Ber-EP4, and negatively for S-100 protein, epithelial membrane antigen, and carcinoembryonic antigen. The granules in GBCC generally are positive on periodic acid–Schiff staining.^1-4

The histologic differential diagnosis for GBCC includes granular cell tumor as well as other tumors that can present with granular cell changes such as ameloblastoma, leiomyoma, leiomyosarcoma, angiosarcoma, malignant peripheral nerve sheath tumor, and granular cell trichoblastoma. Granular cell ameloblastomas have histologic features and staining patterns that are identical to GBCC; however, ameloblastomas are distinguished by their location within the oral cavity. Granular cell tumors and malignant peripheral nerve sheath tumors stain positive for S-100 protein, and angiosarcomas stain positive for D2-40 and CD31. Leiomyomas and leiomyosarcomas can be differentiated by staining with smooth muscle actin or desmin.¹ Granular cell trichoblastomas can be differentiated by the follicular stem cell marker protein PHLDA1 positivity.⁵

Desmoplastic trichilemmoma is difficult to distinguish from BCC. These tumors are comprised of superficial lobules of basaloid cells with a perilobular hyaline mantel surrounding a central desmoplastic stroma (Figure 1). The basaloid cells in desmoplastic trichoepithelioma demonstrate clear cell change; however, granular features are not seen. The cells within the desmoplastic areas are arranged haphazardly in cords and nests and can mimic an invasive carcinoma; however, nuclear atypia and mitotic activity generally are absent in desmoplastic trichilemmoma.⁶

Granular cell tumors generally are poorly circumscribed dermal nodules comprised of large polygonal cells with an eosinophilic granular cytoplasm (Figure 2). The nuclei are generally small and round, and cytological atypia, necrosis, and mitotic activity are uncommon. The cells are positive for S-100 protein and neuron-specific enolase but negative for CD68. The granules are positive for periodic acid–Schiff stain and are diastase resistant. Rarely, these tumors can be malignant.⁷

Sebaceous adenoma is a well-circumscribed tumor comprised of lobules of characteristic mature sebocytes with bubbly or multivacuolated cytoplasm and crenated nuclei (Figure 3). There is an expansion and increased prominence of the peripherally located basaloid cells; however, in contrast to sebaceous epithelioma, less than 50% of the tumor usually is comprised of these basaloid cells.⁸

Xanthogranuloma demonstrates a dense collection of histiocytes in the dermis, commonly with Touton giant cell formation (Figure 4). The cells often have a foamy cytoplasm and cytoplasmic vacuoles are observed. The histiocytes are positive for factor XIIIa and CD68, and generally negative for S-100 protein and CD1a, which allows for differentiation from Langerhans cells.⁹

Granular Cell Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common human epithelial malignancy. There are several histologic variants, the rarest being granular cell BCC (GBCC).¹ Granular cell BCC is reported most commonly in men with a mean age of 63 years. Sixty-four percent of cases develop on the face, with the remainder arising on the chest or trunk. Granular cell BCC has distinct histologic features but has no specific epidemiologic or clinical features that differentiate it from more common forms of BCC. Treatment of GBCC is identical to BCC and demonstrates similar outcomes. The presence of granular cells can make GBCC difficult to differentiate from other benign and malignant lesions that display similar granular histologic changes.^1,2 Rarely, tumors that are histologically similar to human GBCC have been reported in animals.¹

Histologically, GBCC commonly demonstrates the architecture of a nodular BCC or may extend from an existing nodular BCC (quiz images A and B). Granular cell BCC is comprised of large islands of basaloid cells extending from the epidermis with rare mitotic activity. Certain variants showing no epidermal attachments have been described,^1,3 as in the current case. Classically, BCC and GBCC both demonstrate a peripheral palisade of blue basal cells; however, GBCC may lack this palisading feature in some cases. Therefore, GBCC may be comprised of granular cells only, which may be more easily confused with other tumors with granular cell differentiation. Even when GBCC retains the traditional peripheral palisade of blue basal cells, the central cells are filled with eosinophilic granules.^1,2

Electron microscopy of GBCC usually reveals bundles of cytoplasmic tonofilaments and desmosomes in both granular cells and the peripherally palisaded cells. Electron microscopy imaging also demonstrates 0.1- to 0.5-µm membrane-bound lysosomelike structures. In certain reports, these structures show focal positivity for lysozymes.^1,2 The etiology of the granules is unclear; however, they are thought to represent degenerative changes related to metabolic alteration and accumulation of lysosomelike structures. These lysosomelike structures have been highlighted with CD68 staining, which was negative in our case.^1,2 The lesional cells in GBCC stain positively for cytokeratins, p63, and Ber-EP4, and negatively for S-100 protein, epithelial membrane antigen, and carcinoembryonic antigen. The granules in GBCC generally are positive on periodic acid–Schiff staining.^1-4

The histologic differential diagnosis for GBCC includes granular cell tumor as well as other tumors that can present with granular cell changes such as ameloblastoma, leiomyoma, leiomyosarcoma, angiosarcoma, malignant peripheral nerve sheath tumor, and granular cell trichoblastoma. Granular cell ameloblastomas have histologic features and staining patterns that are identical to GBCC; however, ameloblastomas are distinguished by their location within the oral cavity. Granular cell tumors and malignant peripheral nerve sheath tumors stain positive for S-100 protein, and angiosarcomas stain positive for D2-40 and CD31. Leiomyomas and leiomyosarcomas can be differentiated by staining with smooth muscle actin or desmin.¹ Granular cell trichoblastomas can be differentiated by the follicular stem cell marker protein PHLDA1 positivity.⁵

Desmoplastic trichilemmoma is difficult to distinguish from BCC. These tumors are comprised of superficial lobules of basaloid cells with a perilobular hyaline mantel surrounding a central desmoplastic stroma (Figure 1). The basaloid cells in desmoplastic trichoepithelioma demonstrate clear cell change; however, granular features are not seen. The cells within the desmoplastic areas are arranged haphazardly in cords and nests and can mimic an invasive carcinoma; however, nuclear atypia and mitotic activity generally are absent in desmoplastic trichilemmoma.⁶

Granular cell tumors generally are poorly circumscribed dermal nodules comprised of large polygonal cells with an eosinophilic granular cytoplasm (Figure 2). The nuclei are generally small and round, and cytological atypia, necrosis, and mitotic activity are uncommon. The cells are positive for S-100 protein and neuron-specific enolase but negative for CD68. The granules are positive for periodic acid–Schiff stain and are diastase resistant. Rarely, these tumors can be malignant.⁷

Sebaceous adenoma is a well-circumscribed tumor comprised of lobules of characteristic mature sebocytes with bubbly or multivacuolated cytoplasm and crenated nuclei (Figure 3). There is an expansion and increased prominence of the peripherally located basaloid cells; however, in contrast to sebaceous epithelioma, less than 50% of the tumor usually is comprised of these basaloid cells.⁸

Xanthogranuloma demonstrates a dense collection of histiocytes in the dermis, commonly with Touton giant cell formation (Figure 4). The cells often have a foamy cytoplasm and cytoplasmic vacuoles are observed. The histiocytes are positive for factor XIIIa and CD68, and generally negative for S-100 protein and CD1a, which allows for differentiation from Langerhans cells.⁹

CHICAGO – Do anthracyclines still have a role in treating breast cancer? What are the implications for resistance of extending adjuvant aromatase inhibitors to 10 years or beyond? How best to treat women with metastatic hormone receptor–positive breast cancer, in light of findings on CDK 4/6 and mTOR inhibitors? Does sequence matter? In the case of HER2-positive disease, can a trastuzumab biosimilar be as effective as trastuzumab? And does a regimen with TDM-1 do more than reduce toxicity?

Dr. William A. Gradishar and Dr. Hope S. Rugo reflect on these questions and more in a video roundtable at the annual meeting of the American Society of Clinical Oncology.

Dr. William A. Gradishar is the Betsy Bramsen Professor of Breast Oncology at Northwestern University, Chicago. He had no disclosures to report. Dr. Hope S. Rugo is professor of medicine at the University of California, San Francisco. She disclosed she is on the Speakers’ Bureau for Genomic Health and receives research funding (institutional) from Plexxikon, Macrogenics, OBI Pharma, Eisai, Pfizer, Novartis, Lilly, GlaxoSmithKline, Genentech, Celsion, Nektar, and Merck.

[email protected]

On Twitter @NikolaidesLaura

CHICAGO – Do anthracyclines still have a role in treating breast cancer? What are the implications for resistance of extending adjuvant aromatase inhibitors to 10 years or beyond? How best to treat women with metastatic hormone receptor–positive breast cancer, in light of findings on CDK 4/6 and mTOR inhibitors? Does sequence matter? In the case of HER2-positive disease, can a trastuzumab biosimilar be as effective as trastuzumab? And does a regimen with TDM-1 do more than reduce toxicity?

Dr. William A. Gradishar and Dr. Hope S. Rugo reflect on these questions and more in a video roundtable at the annual meeting of the American Society of Clinical Oncology.

Dr. William A. Gradishar is the Betsy Bramsen Professor of Breast Oncology at Northwestern University, Chicago. He had no disclosures to report. Dr. Hope S. Rugo is professor of medicine at the University of California, San Francisco. She disclosed she is on the Speakers’ Bureau for Genomic Health and receives research funding (institutional) from Plexxikon, Macrogenics, OBI Pharma, Eisai, Pfizer, Novartis, Lilly, GlaxoSmithKline, Genentech, Celsion, Nektar, and Merck.

[email protected]

On Twitter @NikolaidesLaura

CHICAGO – Do anthracyclines still have a role in treating breast cancer? What are the implications for resistance of extending adjuvant aromatase inhibitors to 10 years or beyond? How best to treat women with metastatic hormone receptor–positive breast cancer, in light of findings on CDK 4/6 and mTOR inhibitors? Does sequence matter? In the case of HER2-positive disease, can a trastuzumab biosimilar be as effective as trastuzumab? And does a regimen with TDM-1 do more than reduce toxicity?

Dr. William A. Gradishar and Dr. Hope S. Rugo reflect on these questions and more in a video roundtable at the annual meeting of the American Society of Clinical Oncology.

Dr. William A. Gradishar is the Betsy Bramsen Professor of Breast Oncology at Northwestern University, Chicago. He had no disclosures to report. Dr. Hope S. Rugo is professor of medicine at the University of California, San Francisco. She disclosed she is on the Speakers’ Bureau for Genomic Health and receives research funding (institutional) from Plexxikon, Macrogenics, OBI Pharma, Eisai, Pfizer, Novartis, Lilly, GlaxoSmithKline, Genentech, Celsion, Nektar, and Merck.

[email protected]

On Twitter @NikolaidesLaura

CHICAGO – Agents that target the HER2, BRAF, Hedgehog, or EGFR pathways show promise in nonindicated tumor types that harbor these molecular alterations, according to early findings from the MyPathway study.

Of 129 patients enrolled in the multicenter, open-label, phase IIa study, 29 had a major response, defined as tumor shrinkage of at least 30%, to such treatment. One of those patients had a complete response, and 28 had a partial response. An additional 40 patients had stable disease on treatment. Fourteen of the 29 patients progressed after a median of 6 months’ follow-up, and 15 responses were ongoing at up to 11 months, Dr. John D. Hainsworth reported at the annual meeting of the American Society of Clinical Oncology.

©Gio_tto/Thinkstock.com

No new safety signals were observed, said Dr. Hainsworth of Sarah Cannon Research Institute in Nashville, Tenn.

Treatments evaluated in MyPathway included:

• Trastuzumab + pertuzumab, which targets the HER2 pathway and is currently indicated for breast cancer.

• Vemurafenib, which targets the BRAF pathway and is currently indicated for melanoma.

• Vismodegib, which targets the Hedgehog pathway and is currently indicated for basal cell carcinoma of the skin.

• Erlotinib, which targets the EGFR pathway and is indicated for non–small-cell lung cancer.

Responses have been seen with all four of the treatments, but the best responses were seen among patients with HER2 and BRAF abnormalities.

Among 61 cancers with HER2 amplification/overexpression, trastuzumab + pertuzumab provided a benefit for colorectal, bladder, biliary, non–small-cell lung, pancreas, and head/neck cancers.

Of 20 colorectal tumors, 7 (35%) showed complete or partial response, and 3 (15%) remained stable for at least 120 days (clinical benefit rate, 50%). Complete/partial responses and stable disease, respectively, were also seen in three and two of eight bladder tumors (clinical benefit rate, 63%), in three and three of six biliary tumors (clinical benefit rate, 100%), in two and zero of seven non–small-cell lung tumors (clinical benefit rate, 29%), one and zero of six pancreas tumors (clinical benefit rate, 17%), and one and zero of three head and neck tumors (34%). One of 11 other types of tumors showed disease stability at 120 days (clinical benefit rate, 9%). The overall clinical benefit rate in the study was 43%, Dr. Hainsworth said.

Among 33 cancers with the BRAF mutation, vemurafenib showed activity for non–small-cell lung, ovary, unknown primary, colorectal, pancreas, and head/neck tumors. Of 15 non–small-cell lung tumors, 3 (20%) showed complete or partial responses and 2 (13%) remained stable for at least 120 days (clinical benefit rate, 33%). Complete/partial responses and stable disease, respectively, were also seen in one and two of four ovary tumors (clinical benefit rate, 75%), and complete or partial responses were seen in one each of three unknown primary tumors, two colorectal tumors, two pancreas tumors, and one head/neck tumor (clinical benefit rates of 33%, 50%, 50%, and 100%, respectively). No benefit was seen with tumors at other sites (total clinical benefit rate, 36%), Dr. Hainsworth said.

“Of interest in this group [of patients with BRAF mutations], seven of the eight responses were in V600E mutations, and as you know, that’s the mutation that’s been specifically correlated with high response to BRAF inhibition in melanoma where this treatment is now approved,” he said, adding that the response rate in those patients was 38%.

Based on these early results, enrollment of patients with HER2 abnormalities and colorectal, bladder, or biliary cancer, and of patients with BRAF mutations and lung cancer, will be expanded, he said.

Subjects enrolled in MyPathway have advanced cancer showing abnormalities in any of the pathways of interest. The first 129 received a mean of three prior therapies, and in the 29 who responded, 12 different types of cancer responded to the targeted treatment.

“An increasing number of targeted agents for advanced cancer are in use now based on the presence of molecular abnormalities in the cancer. … We’ve known that the same mutations that are in those cancers are found in a wide variety of other cancers, although at a lower incidence, and it’s been difficult to test how effective these same treatments are for the other cancers due to the difficulty in identifying the patient population,” he said, explaining that an increase in comprehensive genomic profiling in recent years has allowed for identification of more and more of these mutations in other cancers.

“I think we’ve shown now that this trial design is feasible, where patients are selected on the basis of molecular abnormalities in their cancers rather than on their primary tumor type or primary site, and certainly offers opportunities for patients with these molecular abnormalities,” Dr. Hainsworth concluded.

Thus far, MyPathway has enrolled more than 200 patients, and is designed to accrue up to 500, with adjustment of treatment groups based on response rates. Emerging new regimens that target these pathways, such as the MEK inhibitor cobemetinib, will also be added, as will new agents targeting additional molecular abnormalities.

The study design, using this “tumor-agnostic approach,” mirrors that of the ASCO-led TAPUR trial, according to ASCO spokesperson Dr. Sumanta Kumar Pal.

The findings of these and other precision medicine trials may ultimately shift the longstanding cancer treatment paradigm, Dr. Pal said.

MyPathway received funding from Genentech. Dr. Hainsworth reported that his institution has received research funding from Astellas Pharma, AstraZeneca, Celgene, Genentech, Johnson & Johnson, Lilly, and Novartis.

[email protected]

CHICAGO – Agents that target the HER2, BRAF, Hedgehog, or EGFR pathways show promise in nonindicated tumor types that harbor these molecular alterations, according to early findings from the MyPathway study.

Of 129 patients enrolled in the multicenter, open-label, phase IIa study, 29 had a major response, defined as tumor shrinkage of at least 30%, to such treatment. One of those patients had a complete response, and 28 had a partial response. An additional 40 patients had stable disease on treatment. Fourteen of the 29 patients progressed after a median of 6 months’ follow-up, and 15 responses were ongoing at up to 11 months, Dr. John D. Hainsworth reported at the annual meeting of the American Society of Clinical Oncology.

©Gio_tto/Thinkstock.com

No new safety signals were observed, said Dr. Hainsworth of Sarah Cannon Research Institute in Nashville, Tenn.

Treatments evaluated in MyPathway included:

• Trastuzumab + pertuzumab, which targets the HER2 pathway and is currently indicated for breast cancer.

• Vemurafenib, which targets the BRAF pathway and is currently indicated for melanoma.

• Vismodegib, which targets the Hedgehog pathway and is currently indicated for basal cell carcinoma of the skin.

• Erlotinib, which targets the EGFR pathway and is indicated for non–small-cell lung cancer.

Responses have been seen with all four of the treatments, but the best responses were seen among patients with HER2 and BRAF abnormalities.

Among 61 cancers with HER2 amplification/overexpression, trastuzumab + pertuzumab provided a benefit for colorectal, bladder, biliary, non–small-cell lung, pancreas, and head/neck cancers.

Of 20 colorectal tumors, 7 (35%) showed complete or partial response, and 3 (15%) remained stable for at least 120 days (clinical benefit rate, 50%). Complete/partial responses and stable disease, respectively, were also seen in three and two of eight bladder tumors (clinical benefit rate, 63%), in three and three of six biliary tumors (clinical benefit rate, 100%), in two and zero of seven non–small-cell lung tumors (clinical benefit rate, 29%), one and zero of six pancreas tumors (clinical benefit rate, 17%), and one and zero of three head and neck tumors (34%). One of 11 other types of tumors showed disease stability at 120 days (clinical benefit rate, 9%). The overall clinical benefit rate in the study was 43%, Dr. Hainsworth said.

Among 33 cancers with the BRAF mutation, vemurafenib showed activity for non–small-cell lung, ovary, unknown primary, colorectal, pancreas, and head/neck tumors. Of 15 non–small-cell lung tumors, 3 (20%) showed complete or partial responses and 2 (13%) remained stable for at least 120 days (clinical benefit rate, 33%). Complete/partial responses and stable disease, respectively, were also seen in one and two of four ovary tumors (clinical benefit rate, 75%), and complete or partial responses were seen in one each of three unknown primary tumors, two colorectal tumors, two pancreas tumors, and one head/neck tumor (clinical benefit rates of 33%, 50%, 50%, and 100%, respectively). No benefit was seen with tumors at other sites (total clinical benefit rate, 36%), Dr. Hainsworth said.

“Of interest in this group [of patients with BRAF mutations], seven of the eight responses were in V600E mutations, and as you know, that’s the mutation that’s been specifically correlated with high response to BRAF inhibition in melanoma where this treatment is now approved,” he said, adding that the response rate in those patients was 38%.

Based on these early results, enrollment of patients with HER2 abnormalities and colorectal, bladder, or biliary cancer, and of patients with BRAF mutations and lung cancer, will be expanded, he said.

Subjects enrolled in MyPathway have advanced cancer showing abnormalities in any of the pathways of interest. The first 129 received a mean of three prior therapies, and in the 29 who responded, 12 different types of cancer responded to the targeted treatment.

“An increasing number of targeted agents for advanced cancer are in use now based on the presence of molecular abnormalities in the cancer. … We’ve known that the same mutations that are in those cancers are found in a wide variety of other cancers, although at a lower incidence, and it’s been difficult to test how effective these same treatments are for the other cancers due to the difficulty in identifying the patient population,” he said, explaining that an increase in comprehensive genomic profiling in recent years has allowed for identification of more and more of these mutations in other cancers.

“I think we’ve shown now that this trial design is feasible, where patients are selected on the basis of molecular abnormalities in their cancers rather than on their primary tumor type or primary site, and certainly offers opportunities for patients with these molecular abnormalities,” Dr. Hainsworth concluded.

Thus far, MyPathway has enrolled more than 200 patients, and is designed to accrue up to 500, with adjustment of treatment groups based on response rates. Emerging new regimens that target these pathways, such as the MEK inhibitor cobemetinib, will also be added, as will new agents targeting additional molecular abnormalities.

The study design, using this “tumor-agnostic approach,” mirrors that of the ASCO-led TAPUR trial, according to ASCO spokesperson Dr. Sumanta Kumar Pal.

The findings of these and other precision medicine trials may ultimately shift the longstanding cancer treatment paradigm, Dr. Pal said.

MyPathway received funding from Genentech. Dr. Hainsworth reported that his institution has received research funding from Astellas Pharma, AstraZeneca, Celgene, Genentech, Johnson & Johnson, Lilly, and Novartis.

[email protected]

CHICAGO – Agents that target the HER2, BRAF, Hedgehog, or EGFR pathways show promise in nonindicated tumor types that harbor these molecular alterations, according to early findings from the MyPathway study.

Of 129 patients enrolled in the multicenter, open-label, phase IIa study, 29 had a major response, defined as tumor shrinkage of at least 30%, to such treatment. One of those patients had a complete response, and 28 had a partial response. An additional 40 patients had stable disease on treatment. Fourteen of the 29 patients progressed after a median of 6 months’ follow-up, and 15 responses were ongoing at up to 11 months, Dr. John D. Hainsworth reported at the annual meeting of the American Society of Clinical Oncology.

©Gio_tto/Thinkstock.com

No new safety signals were observed, said Dr. Hainsworth of Sarah Cannon Research Institute in Nashville, Tenn.

Treatments evaluated in MyPathway included:

• Trastuzumab + pertuzumab, which targets the HER2 pathway and is currently indicated for breast cancer.

• Vemurafenib, which targets the BRAF pathway and is currently indicated for melanoma.

• Vismodegib, which targets the Hedgehog pathway and is currently indicated for basal cell carcinoma of the skin.

• Erlotinib, which targets the EGFR pathway and is indicated for non–small-cell lung cancer.

Responses have been seen with all four of the treatments, but the best responses were seen among patients with HER2 and BRAF abnormalities.

Among 61 cancers with HER2 amplification/overexpression, trastuzumab + pertuzumab provided a benefit for colorectal, bladder, biliary, non–small-cell lung, pancreas, and head/neck cancers.

Of 20 colorectal tumors, 7 (35%) showed complete or partial response, and 3 (15%) remained stable for at least 120 days (clinical benefit rate, 50%). Complete/partial responses and stable disease, respectively, were also seen in three and two of eight bladder tumors (clinical benefit rate, 63%), in three and three of six biliary tumors (clinical benefit rate, 100%), in two and zero of seven non–small-cell lung tumors (clinical benefit rate, 29%), one and zero of six pancreas tumors (clinical benefit rate, 17%), and one and zero of three head and neck tumors (34%). One of 11 other types of tumors showed disease stability at 120 days (clinical benefit rate, 9%). The overall clinical benefit rate in the study was 43%, Dr. Hainsworth said.

Among 33 cancers with the BRAF mutation, vemurafenib showed activity for non–small-cell lung, ovary, unknown primary, colorectal, pancreas, and head/neck tumors. Of 15 non–small-cell lung tumors, 3 (20%) showed complete or partial responses and 2 (13%) remained stable for at least 120 days (clinical benefit rate, 33%). Complete/partial responses and stable disease, respectively, were also seen in one and two of four ovary tumors (clinical benefit rate, 75%), and complete or partial responses were seen in one each of three unknown primary tumors, two colorectal tumors, two pancreas tumors, and one head/neck tumor (clinical benefit rates of 33%, 50%, 50%, and 100%, respectively). No benefit was seen with tumors at other sites (total clinical benefit rate, 36%), Dr. Hainsworth said.

“Of interest in this group [of patients with BRAF mutations], seven of the eight responses were in V600E mutations, and as you know, that’s the mutation that’s been specifically correlated with high response to BRAF inhibition in melanoma where this treatment is now approved,” he said, adding that the response rate in those patients was 38%.

Based on these early results, enrollment of patients with HER2 abnormalities and colorectal, bladder, or biliary cancer, and of patients with BRAF mutations and lung cancer, will be expanded, he said.

Subjects enrolled in MyPathway have advanced cancer showing abnormalities in any of the pathways of interest. The first 129 received a mean of three prior therapies, and in the 29 who responded, 12 different types of cancer responded to the targeted treatment.

“An increasing number of targeted agents for advanced cancer are in use now based on the presence of molecular abnormalities in the cancer. … We’ve known that the same mutations that are in those cancers are found in a wide variety of other cancers, although at a lower incidence, and it’s been difficult to test how effective these same treatments are for the other cancers due to the difficulty in identifying the patient population,” he said, explaining that an increase in comprehensive genomic profiling in recent years has allowed for identification of more and more of these mutations in other cancers.

“I think we’ve shown now that this trial design is feasible, where patients are selected on the basis of molecular abnormalities in their cancers rather than on their primary tumor type or primary site, and certainly offers opportunities for patients with these molecular abnormalities,” Dr. Hainsworth concluded.

Thus far, MyPathway has enrolled more than 200 patients, and is designed to accrue up to 500, with adjustment of treatment groups based on response rates. Emerging new regimens that target these pathways, such as the MEK inhibitor cobemetinib, will also be added, as will new agents targeting additional molecular abnormalities.

The study design, using this “tumor-agnostic approach,” mirrors that of the ASCO-led TAPUR trial, according to ASCO spokesperson Dr. Sumanta Kumar Pal.

The findings of these and other precision medicine trials may ultimately shift the longstanding cancer treatment paradigm, Dr. Pal said.

MyPathway received funding from Genentech. Dr. Hainsworth reported that his institution has received research funding from Astellas Pharma, AstraZeneca, Celgene, Genentech, Johnson & Johnson, Lilly, and Novartis.

[email protected]

Shoulder arthroplasty (SA), including total SA (TSA) and reverse TSA, is an effective surgical treatment for fracture and primary or secondary degenerative disease of the shoulder.¹ Over the past few decades, use of SA has increased dramatically, from about 5000 cases in 1990 to 7000 in 2000 and more than 26,000 in 2008.^1,2

Complications associated with SA generally are classified as perioperative (occurring during the operative index) or long-term (postdischarge).³ Long-term complications include implant loosening, instability, revision, infection, rotator cuff tear, neural injury, and deltoid detachment.^1,4,5 Perioperative complications, which are less commonly reported, include intraoperative fracture, infection, neural injury, venous thromboembolic events (VTEs, including pulmonary embolism [PE] and deep vein thrombosis [DVT]), transfusion, and death.^3,6-10

SA is an attractive treatment option for patients with rheumatoid arthritis (RA), as the effects of pain on these patients are greater in the shoulder joint than in any other joint.¹¹ Patients with RA pose unique orthopedic surgical challenges, including any combination of decreased bone mineralization, poor capsular tissue integrity, and osteonecrosis.^3,12 In addition, RA patients may be taking immunosuppressive medications that have severe side effects, and they may require multiple surgeries.^12,13 These factors predispose patients with RA to complications that include infection and wound dehiscence.^3,5,12-14

The complex nature of RA has prompted investigators to examine outcome measures in this patient group. Hambright and colleagues³ used the Nationwide Inpatient Sample (NIS) to examine perioperative outcomes in RA patients who underwent TSA between 1988 and 2005.³ They found that TSA patients with RA had shorter and less costly hospital stays and were more likely to have a routine discharge.³ Using the same patient population drawn from the period 2006–2011, we conducted a study to determine if this unexpected trend persists as the number of TSAs and quality of postoperative care continue to increase. Given the potential for anemia of chronic disease and the systemic inflammatory nature of RA, we hypothesized that the perioperative complication profile of RA patients would be worse than that of non-RA patients.

Materials and Methods

NIS data were acquired for the period 2006–2011. The NIS is the largest publicly available all-payer inpatient database, with a random 20% sample of about 1000 US hospitals accounting for 7 to 8 million inpatient stays. The database supplies weights used to estimate national totals, at about 35 million inpatient visits per year. NIS inpatient data are limited to the operative index. Postdischarge information is not available. The NIS is managed by the Healthcare Cost and Utilization Project, which is sponsored by the Agency for Healthcare Research and Quality. The quality of NIS data is assessed and validated by an independent contractor. NIS data have been widely used to examine perioperative outcomes.^15-17

NIS data cover patient and hospital demographics, hospital length of stay (LOS), discharge status, payer information, charges, and perioperative outcomes and procedure/diagnosis codes (ICD-9; International Classification of Diseases, Ninth Revision¹⁸).

As our Institutional Review Board (IRB) reviewed the database and determined the project was not human subject research, IRB involvement was not required. This study paralleled successful efforts with similar RA and non-RA patients who had shoulder and elbow surgery.^3,19 SA patients were identified by ICD-9 procedure code 81.80, but this code does not specify whether the prosthesis was unconstrained, semiconstrained, or constrained. ICD-9 coding also does not specify whether the TSA was traditional or reverse. Patients with RA were identified by ICD-9 diagnosis codes 714.0, 714.1, and 714.2. Patients without one of these codes were placed in the non-RA cohort. Patients with codes associated with pathologic fractures secondary to metastatic cancer or bone malignant neoplasm as a secondary or primary diagnosis and patients who had revision surgery indicated by code 81.83 were excluded, as they have a disproportionately higher comorbidity burden.

After each cohort was defined, demographic data (age, sex, race, income quartile based on ZIP postal code) were compared, as were data on primary payer, hospital demographics, LOS (≤5 days, defined as perioperative index), discharge type, inflation-adjusted charges in 2014 dollars based on the Consumer Price Indexes (http://www.bls.gov/cpi/), and mortality. Perioperative complications—respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related (including embolism, fibrosis, hemorrhage, pain, stenosis, or thrombus caused by any device, implant, or graft), cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, postoperative infection complications, and intraoperative transfusions—were considered using ICD-9 codes (996.X-999.X and 99.X, respectively).²⁰ Although commonly used to determine perioperative comorbidity burden using ICD-9 coding, the modified Charlson index was not considered because RA is a component of the index and would therefore bias the variable.^3,21

Statistical analyses, including χ² tests and 2-sample t tests, were performed for categorical and continuous variables, respectively. P < .05 was considered significant. Fisher exact test was used for cohorts with fewer than 5 occurrences. Multivariate logistic regression models were then calculated to determine the effect of RA on different outcomes and complications, with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. Statistical analyses were performed using the R statistical programming language.22

Results

Of the 34,970 patients who underwent SA between 2006 and 2011, 1674 (4.8%) had a diagnosis of RA and 33,296 (95.2%) did not. On average, patients with RA tended to be younger than patients without RA (66.4 vs 69.1 years; P < .001), and a larger percentage of RA patients were female (75.5% vs 54.4%; P < .001). Compared with non-RA patients, RA patients comprised a different ethnic group and had a different expected primary payer (P < .001). SA patients with and without RA did not differ in income quartile based on ZIP code, total number of hospital beds, hospital region, or hospital teaching status (P = .34, .78, .59, and .82, respectively) (Table 1).

LOS was significantly (P < .001) statistically longer for RA patients (2.196 days) than for non-RA patients (2.085 days). RA patients were significantly less likely to be discharged home (63.0% vs 67.6%; P < .001). (Routine discharge was defined as discharge home, whereas nonroutine discharge was defined as discharge to a short-term hospital, skilled nursing facility, intermediate care, another type of facility, home health care, against medical advice, or death.) In addition, inflation-adjusted charges associated with SA were significantly higher (P = .018) for RA patients ($54,284) than for non-RA patients ($52,663) (Table 1).

Regarding the rates of complications that occurred during the perioperative index, there were no significant differences between RA and non-RA cohorts. These complications included respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related, cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, and postoperative infection (Table 2). In addition, there was no significant difference in mortality between the groups (P = .48).

In TSA, blood transfusions were more likely (P < .001) to be given to RA patients (9.00%) than to non-RA patients (6.16%). Multivariate regression analyses were performed with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. These analyses revealed that transfusion (P < .001), discharge type (P = .002), total inflation-adjusted charges (P < .001), and LOS (P = .047) remained significant (Table 3).

Discussion

Large national databases like NIS allow study of uncommon medical occurrences and help delineate risks and trends that otherwise might be indeterminable. Although it has been suggested that patients with RA may have poorer long-term outcomes after SA, the perioperative risk profile indicates that TSA is well tolerated in RA patients during the operative index.^3,23-25

The data on this study’s 34,970 patients, drawn from the period 2006–2011, demonstrated no significant differences in safety profile with respect to the 14 perioperative complications and outcomes examined, except blood transfusion rate. Rates of postoperative infection (RA, 0.24%; non-RA, 0.14%; P = .303), VTE (RA, 0.30%; non-RA, 0.25%; P = .905), and transfusion (RA, 9.00%; non-RA, 6.16%; P < .001) are of particular interest because of the severity of these situations.

Postoperative infection is a potentially serious complication and often occurs secondary to diabetes, RA, lupus erythematosus, prior surgery, or a nosocomial or remote source.¹ The often costly treatment options include antibiotic suppression, irrigation and debridement with implant retention, 1-stage exchange with antibiotic-impregnated cement fixation, staged reimplantation, resection arthroplasty, arthrodesis, and amputation.¹ The overall 0.14% infection rate determined in this study is lower than the 0.7% reported for SA patients in the literature.¹ Given the nature of the NIS database, this rate underestimates the true postoperative infection rate, as any infection that occurred after the perioperative period is not captured.²⁶ The present study’s perioperative infection rates (RA, 0.24%; non-RA, 0.14%) for the period 2006–2011 are comparable to the rates (RA, 0.17%; non-RA, 0.24%) reported by Hambright and colleagues3 for the same patient population over the preceding, 18-year period (1988–2005) and similarly do not significantly differ between groups. Although infection is uncommon in the immediate perioperative period, the ICD-9 codes used refer specifically to infection resulting from surgery and do not represent concomitant infection.

VTEs, which include PEs and DVTs, are rare but potentially life-threatening surgical complications.^27,28 Mechanical prophylaxis and chemical prophylaxis have been recommended for major orthopedic surgery, particularly lower extremity surgery, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA).^28,29 In the present study, VTE rates were low, 0.30% (RA) and 0.25% (non-RA), and not significantly different in bivariate or multivariate analyses. These rates are comparable to those found in other national-database SA studies.²⁸ VTEs that occur outside the index hospital admission are not captured in this database. Therefore, the rates in the present study may be lower than the true incidence after SA. Mortality secondary to VTE usually occurs within 24 hours but may occur up to 90 days after surgery. DVT rates, on the other hand, are difficult to evaluate because of differences in screening practices.^27,28,30,31

That RA patients were more likely than non-RA patients to receive perioperative blood transfusions supports prior findings that SA patients with RA were more likely than SA patients with osteoarthritis (OA) to receive perioperative blood transfusions.⁸ RA patients have been shown to have high rates of anemia of chronic disease, ranging from 22% to 77%.³² During joint replacement, these patients often require transfusions.^32,33 However, these findings differ from prior findings of no differences between RA and non-RA patients in the same patient population during the period 1988–2005.³ This difference may be a product of the constantly changing transfusion guidelines and increased use; transfusion rates increased 140% between 1997 and 2007, making transfusions the fastest growing common procedure in the United States during that time.³⁴ There was no difference between RA and non-RA patients in household income (as determined by ZIP code analysis), number of hospital beds, hospital region, or hospital teaching status. Compared with non-RA patients, RA patients were more likely to be younger, female, and of a difference race and to have a different expected primary payer (P < .001).These findings are consistent with previous findings in the literature.³ In the present SA study, however, RA patients were more likely than non-RA patients to have longer LOS, higher inflation-adjusted hospital charges, and nonroutine discharge. These findings deviate from those of the study covering the preceding 18 years (1988–2005).³ Despite the findings of a changing environment of care for RA patients, by Hambright and colleagues³ and Weiss and colleagues,³⁵ the trend appears to have shifted. Both groups had shorter average LOS than either group from the preceding 18 years.³ Although statistically significant in bivariate analysis, the difference in LOS between the 2 groups differed by an average of 0.11 day (2 hours 24 minutes) and was not clinically relevant.

In addition, the higher charges for patients with RA represent a deviation from the preceding 18 years.³ Other studies have also shown that RA is associated with increased cost in TSA.³⁶ Patients with RA often have rotator cuff pathology, indicating reverse SA may be used more frequently.^37,38 The increased implant cost associated with reverse SA may account for the increased costs in RA patients.³⁹ As mentioned, TSA type is not captured in the NIS database. In addition, that RA patients were less likely than non-RA patients to have routine discharge may indicate RA cases are more complex because of their complications.^1,5,14,40 A recent study of complications in RA patients (1163 who underwent THA, 2692 who underwent TKA) found that THA patients with RA were significantly more likely than THA patients with OA to dislocate, and TKA patients with RA were significantly more likely than TKA patients with OA to develop an infection after surgery.⁴¹ Postoperative dislocation has been shown to increase hospital costs in other orthopedic procedures.⁴² Also, during TSA, patients with RA are more likely than patients with OA to receive intraoperative blood transfusions.⁸ These complications—combined with the fact that RA is a chronic, progressive, systemic inflammatory disease that can affect soft tissue and blood vessel wall healing and is associated with medications having potential side effects—could contribute to the apparent increased hospital charges and LOS.^3,12,13,43 Factors that include surgeon preference, impact of primary payer, and hospital practice may also affect final charges. Total charges in the NIS database include administrative fees, hospital costs, device-related costs, operating room costs, and ancillary staff costs. Total charges do not include professional fees and differ from the total cost that represents the amount reimbursed by the payer. Charges tend to correlate with but overestimate the total costs.⁴⁴

This study had several important limitations. As mentioned, only events that occur during the operative admission are captured in the NIS database, and thus postoperative complications or serious adverse events that lead to readmission cannot be identified. In addition, outpatient TSAs are not captured in the NIS database, and thus inclusion of only inpatient procedures yields higher average LOS and total charges.⁴⁵ Given the limited granularity of ICD-9 coding, this study could not determine RA severity, estimated blood loss, length of surgery, complication severity, type of TSA procedure/prosthesis, or cause of death. Although commonly used to determine comorbidity burden, the modified Charlson index could not be used, and therefore could not be entered as a covariate in multivariate analysis. Furthermore, the NIS database does not include imaging or patient-reported outcomes information, such as improvements in pain or function, which are of crucial importance in considering surgery.

Conclusion

Our findings corroborated findings that the demographics and the perioperative safety profile for TSA were similar for patients with and without RA. The risk for complications or death in the perioperative period was low. Compared with non-RA patients, RA patients had significantly higher charges and longer LOS and were less likely to be discharged home after surgery. The 0.11-day difference in LOS, though statistically significant, was not clinically relevant. These findings differ from those for the preceding, 18-year period (1988–2005). Future research should focus on the causes of these changes.

Shoulder arthroplasty (SA), including total SA (TSA) and reverse TSA, is an effective surgical treatment for fracture and primary or secondary degenerative disease of the shoulder.¹ Over the past few decades, use of SA has increased dramatically, from about 5000 cases in 1990 to 7000 in 2000 and more than 26,000 in 2008.^1,2

Complications associated with SA generally are classified as perioperative (occurring during the operative index) or long-term (postdischarge).³ Long-term complications include implant loosening, instability, revision, infection, rotator cuff tear, neural injury, and deltoid detachment.^1,4,5 Perioperative complications, which are less commonly reported, include intraoperative fracture, infection, neural injury, venous thromboembolic events (VTEs, including pulmonary embolism [PE] and deep vein thrombosis [DVT]), transfusion, and death.^3,6-10

SA is an attractive treatment option for patients with rheumatoid arthritis (RA), as the effects of pain on these patients are greater in the shoulder joint than in any other joint.¹¹ Patients with RA pose unique orthopedic surgical challenges, including any combination of decreased bone mineralization, poor capsular tissue integrity, and osteonecrosis.^3,12 In addition, RA patients may be taking immunosuppressive medications that have severe side effects, and they may require multiple surgeries.^12,13 These factors predispose patients with RA to complications that include infection and wound dehiscence.^3,5,12-14

The complex nature of RA has prompted investigators to examine outcome measures in this patient group. Hambright and colleagues³ used the Nationwide Inpatient Sample (NIS) to examine perioperative outcomes in RA patients who underwent TSA between 1988 and 2005.³ They found that TSA patients with RA had shorter and less costly hospital stays and were more likely to have a routine discharge.³ Using the same patient population drawn from the period 2006–2011, we conducted a study to determine if this unexpected trend persists as the number of TSAs and quality of postoperative care continue to increase. Given the potential for anemia of chronic disease and the systemic inflammatory nature of RA, we hypothesized that the perioperative complication profile of RA patients would be worse than that of non-RA patients.

Materials and Methods

NIS data were acquired for the period 2006–2011. The NIS is the largest publicly available all-payer inpatient database, with a random 20% sample of about 1000 US hospitals accounting for 7 to 8 million inpatient stays. The database supplies weights used to estimate national totals, at about 35 million inpatient visits per year. NIS inpatient data are limited to the operative index. Postdischarge information is not available. The NIS is managed by the Healthcare Cost and Utilization Project, which is sponsored by the Agency for Healthcare Research and Quality. The quality of NIS data is assessed and validated by an independent contractor. NIS data have been widely used to examine perioperative outcomes.^15-17

NIS data cover patient and hospital demographics, hospital length of stay (LOS), discharge status, payer information, charges, and perioperative outcomes and procedure/diagnosis codes (ICD-9; International Classification of Diseases, Ninth Revision¹⁸).

As our Institutional Review Board (IRB) reviewed the database and determined the project was not human subject research, IRB involvement was not required. This study paralleled successful efforts with similar RA and non-RA patients who had shoulder and elbow surgery.^3,19 SA patients were identified by ICD-9 procedure code 81.80, but this code does not specify whether the prosthesis was unconstrained, semiconstrained, or constrained. ICD-9 coding also does not specify whether the TSA was traditional or reverse. Patients with RA were identified by ICD-9 diagnosis codes 714.0, 714.1, and 714.2. Patients without one of these codes were placed in the non-RA cohort. Patients with codes associated with pathologic fractures secondary to metastatic cancer or bone malignant neoplasm as a secondary or primary diagnosis and patients who had revision surgery indicated by code 81.83 were excluded, as they have a disproportionately higher comorbidity burden.

After each cohort was defined, demographic data (age, sex, race, income quartile based on ZIP postal code) were compared, as were data on primary payer, hospital demographics, LOS (≤5 days, defined as perioperative index), discharge type, inflation-adjusted charges in 2014 dollars based on the Consumer Price Indexes (http://www.bls.gov/cpi/), and mortality. Perioperative complications—respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related (including embolism, fibrosis, hemorrhage, pain, stenosis, or thrombus caused by any device, implant, or graft), cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, postoperative infection complications, and intraoperative transfusions—were considered using ICD-9 codes (996.X-999.X and 99.X, respectively).²⁰ Although commonly used to determine perioperative comorbidity burden using ICD-9 coding, the modified Charlson index was not considered because RA is a component of the index and would therefore bias the variable.^3,21

Statistical analyses, including χ² tests and 2-sample t tests, were performed for categorical and continuous variables, respectively. P < .05 was considered significant. Fisher exact test was used for cohorts with fewer than 5 occurrences. Multivariate logistic regression models were then calculated to determine the effect of RA on different outcomes and complications, with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. Statistical analyses were performed using the R statistical programming language.22

Results

Of the 34,970 patients who underwent SA between 2006 and 2011, 1674 (4.8%) had a diagnosis of RA and 33,296 (95.2%) did not. On average, patients with RA tended to be younger than patients without RA (66.4 vs 69.1 years; P < .001), and a larger percentage of RA patients were female (75.5% vs 54.4%; P < .001). Compared with non-RA patients, RA patients comprised a different ethnic group and had a different expected primary payer (P < .001). SA patients with and without RA did not differ in income quartile based on ZIP code, total number of hospital beds, hospital region, or hospital teaching status (P = .34, .78, .59, and .82, respectively) (Table 1).

LOS was significantly (P < .001) statistically longer for RA patients (2.196 days) than for non-RA patients (2.085 days). RA patients were significantly less likely to be discharged home (63.0% vs 67.6%; P < .001). (Routine discharge was defined as discharge home, whereas nonroutine discharge was defined as discharge to a short-term hospital, skilled nursing facility, intermediate care, another type of facility, home health care, against medical advice, or death.) In addition, inflation-adjusted charges associated with SA were significantly higher (P = .018) for RA patients ($54,284) than for non-RA patients ($52,663) (Table 1).

Regarding the rates of complications that occurred during the perioperative index, there were no significant differences between RA and non-RA cohorts. These complications included respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related, cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, and postoperative infection (Table 2). In addition, there was no significant difference in mortality between the groups (P = .48).

In TSA, blood transfusions were more likely (P < .001) to be given to RA patients (9.00%) than to non-RA patients (6.16%). Multivariate regression analyses were performed with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. These analyses revealed that transfusion (P < .001), discharge type (P = .002), total inflation-adjusted charges (P < .001), and LOS (P = .047) remained significant (Table 3).

Discussion

Large national databases like NIS allow study of uncommon medical occurrences and help delineate risks and trends that otherwise might be indeterminable. Although it has been suggested that patients with RA may have poorer long-term outcomes after SA, the perioperative risk profile indicates that TSA is well tolerated in RA patients during the operative index.^3,23-25

The data on this study’s 34,970 patients, drawn from the period 2006–2011, demonstrated no significant differences in safety profile with respect to the 14 perioperative complications and outcomes examined, except blood transfusion rate. Rates of postoperative infection (RA, 0.24%; non-RA, 0.14%; P = .303), VTE (RA, 0.30%; non-RA, 0.25%; P = .905), and transfusion (RA, 9.00%; non-RA, 6.16%; P < .001) are of particular interest because of the severity of these situations.

Postoperative infection is a potentially serious complication and often occurs secondary to diabetes, RA, lupus erythematosus, prior surgery, or a nosocomial or remote source.¹ The often costly treatment options include antibiotic suppression, irrigation and debridement with implant retention, 1-stage exchange with antibiotic-impregnated cement fixation, staged reimplantation, resection arthroplasty, arthrodesis, and amputation.¹ The overall 0.14% infection rate determined in this study is lower than the 0.7% reported for SA patients in the literature.¹ Given the nature of the NIS database, this rate underestimates the true postoperative infection rate, as any infection that occurred after the perioperative period is not captured.²⁶ The present study’s perioperative infection rates (RA, 0.24%; non-RA, 0.14%) for the period 2006–2011 are comparable to the rates (RA, 0.17%; non-RA, 0.24%) reported by Hambright and colleagues3 for the same patient population over the preceding, 18-year period (1988–2005) and similarly do not significantly differ between groups. Although infection is uncommon in the immediate perioperative period, the ICD-9 codes used refer specifically to infection resulting from surgery and do not represent concomitant infection.

VTEs, which include PEs and DVTs, are rare but potentially life-threatening surgical complications.^27,28 Mechanical prophylaxis and chemical prophylaxis have been recommended for major orthopedic surgery, particularly lower extremity surgery, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA).^28,29 In the present study, VTE rates were low, 0.30% (RA) and 0.25% (non-RA), and not significantly different in bivariate or multivariate analyses. These rates are comparable to those found in other national-database SA studies.²⁸ VTEs that occur outside the index hospital admission are not captured in this database. Therefore, the rates in the present study may be lower than the true incidence after SA. Mortality secondary to VTE usually occurs within 24 hours but may occur up to 90 days after surgery. DVT rates, on the other hand, are difficult to evaluate because of differences in screening practices.^27,28,30,31

That RA patients were more likely than non-RA patients to receive perioperative blood transfusions supports prior findings that SA patients with RA were more likely than SA patients with osteoarthritis (OA) to receive perioperative blood transfusions.⁸ RA patients have been shown to have high rates of anemia of chronic disease, ranging from 22% to 77%.³² During joint replacement, these patients often require transfusions.^32,33 However, these findings differ from prior findings of no differences between RA and non-RA patients in the same patient population during the period 1988–2005.³ This difference may be a product of the constantly changing transfusion guidelines and increased use; transfusion rates increased 140% between 1997 and 2007, making transfusions the fastest growing common procedure in the United States during that time.³⁴ There was no difference between RA and non-RA patients in household income (as determined by ZIP code analysis), number of hospital beds, hospital region, or hospital teaching status. Compared with non-RA patients, RA patients were more likely to be younger, female, and of a difference race and to have a different expected primary payer (P < .001).These findings are consistent with previous findings in the literature.³ In the present SA study, however, RA patients were more likely than non-RA patients to have longer LOS, higher inflation-adjusted hospital charges, and nonroutine discharge. These findings deviate from those of the study covering the preceding 18 years (1988–2005).³ Despite the findings of a changing environment of care for RA patients, by Hambright and colleagues³ and Weiss and colleagues,³⁵ the trend appears to have shifted. Both groups had shorter average LOS than either group from the preceding 18 years.³ Although statistically significant in bivariate analysis, the difference in LOS between the 2 groups differed by an average of 0.11 day (2 hours 24 minutes) and was not clinically relevant.

In addition, the higher charges for patients with RA represent a deviation from the preceding 18 years.³ Other studies have also shown that RA is associated with increased cost in TSA.³⁶ Patients with RA often have rotator cuff pathology, indicating reverse SA may be used more frequently.^37,38 The increased implant cost associated with reverse SA may account for the increased costs in RA patients.³⁹ As mentioned, TSA type is not captured in the NIS database. In addition, that RA patients were less likely than non-RA patients to have routine discharge may indicate RA cases are more complex because of their complications.^1,5,14,40 A recent study of complications in RA patients (1163 who underwent THA, 2692 who underwent TKA) found that THA patients with RA were significantly more likely than THA patients with OA to dislocate, and TKA patients with RA were significantly more likely than TKA patients with OA to develop an infection after surgery.⁴¹ Postoperative dislocation has been shown to increase hospital costs in other orthopedic procedures.⁴² Also, during TSA, patients with RA are more likely than patients with OA to receive intraoperative blood transfusions.⁸ These complications—combined with the fact that RA is a chronic, progressive, systemic inflammatory disease that can affect soft tissue and blood vessel wall healing and is associated with medications having potential side effects—could contribute to the apparent increased hospital charges and LOS.^3,12,13,43 Factors that include surgeon preference, impact of primary payer, and hospital practice may also affect final charges. Total charges in the NIS database include administrative fees, hospital costs, device-related costs, operating room costs, and ancillary staff costs. Total charges do not include professional fees and differ from the total cost that represents the amount reimbursed by the payer. Charges tend to correlate with but overestimate the total costs.⁴⁴

This study had several important limitations. As mentioned, only events that occur during the operative admission are captured in the NIS database, and thus postoperative complications or serious adverse events that lead to readmission cannot be identified. In addition, outpatient TSAs are not captured in the NIS database, and thus inclusion of only inpatient procedures yields higher average LOS and total charges.⁴⁵ Given the limited granularity of ICD-9 coding, this study could not determine RA severity, estimated blood loss, length of surgery, complication severity, type of TSA procedure/prosthesis, or cause of death. Although commonly used to determine comorbidity burden, the modified Charlson index could not be used, and therefore could not be entered as a covariate in multivariate analysis. Furthermore, the NIS database does not include imaging or patient-reported outcomes information, such as improvements in pain or function, which are of crucial importance in considering surgery.

Conclusion

Our findings corroborated findings that the demographics and the perioperative safety profile for TSA were similar for patients with and without RA. The risk for complications or death in the perioperative period was low. Compared with non-RA patients, RA patients had significantly higher charges and longer LOS and were less likely to be discharged home after surgery. The 0.11-day difference in LOS, though statistically significant, was not clinically relevant. These findings differ from those for the preceding, 18-year period (1988–2005). Future research should focus on the causes of these changes.

Shoulder arthroplasty (SA), including total SA (TSA) and reverse TSA, is an effective surgical treatment for fracture and primary or secondary degenerative disease of the shoulder.¹ Over the past few decades, use of SA has increased dramatically, from about 5000 cases in 1990 to 7000 in 2000 and more than 26,000 in 2008.^1,2

Complications associated with SA generally are classified as perioperative (occurring during the operative index) or long-term (postdischarge).³ Long-term complications include implant loosening, instability, revision, infection, rotator cuff tear, neural injury, and deltoid detachment.^1,4,5 Perioperative complications, which are less commonly reported, include intraoperative fracture, infection, neural injury, venous thromboembolic events (VTEs, including pulmonary embolism [PE] and deep vein thrombosis [DVT]), transfusion, and death.^3,6-10

SA is an attractive treatment option for patients with rheumatoid arthritis (RA), as the effects of pain on these patients are greater in the shoulder joint than in any other joint.¹¹ Patients with RA pose unique orthopedic surgical challenges, including any combination of decreased bone mineralization, poor capsular tissue integrity, and osteonecrosis.^3,12 In addition, RA patients may be taking immunosuppressive medications that have severe side effects, and they may require multiple surgeries.^12,13 These factors predispose patients with RA to complications that include infection and wound dehiscence.^3,5,12-14

The complex nature of RA has prompted investigators to examine outcome measures in this patient group. Hambright and colleagues³ used the Nationwide Inpatient Sample (NIS) to examine perioperative outcomes in RA patients who underwent TSA between 1988 and 2005.³ They found that TSA patients with RA had shorter and less costly hospital stays and were more likely to have a routine discharge.³ Using the same patient population drawn from the period 2006–2011, we conducted a study to determine if this unexpected trend persists as the number of TSAs and quality of postoperative care continue to increase. Given the potential for anemia of chronic disease and the systemic inflammatory nature of RA, we hypothesized that the perioperative complication profile of RA patients would be worse than that of non-RA patients.

Materials and Methods

NIS data were acquired for the period 2006–2011. The NIS is the largest publicly available all-payer inpatient database, with a random 20% sample of about 1000 US hospitals accounting for 7 to 8 million inpatient stays. The database supplies weights used to estimate national totals, at about 35 million inpatient visits per year. NIS inpatient data are limited to the operative index. Postdischarge information is not available. The NIS is managed by the Healthcare Cost and Utilization Project, which is sponsored by the Agency for Healthcare Research and Quality. The quality of NIS data is assessed and validated by an independent contractor. NIS data have been widely used to examine perioperative outcomes.^15-17

NIS data cover patient and hospital demographics, hospital length of stay (LOS), discharge status, payer information, charges, and perioperative outcomes and procedure/diagnosis codes (ICD-9; International Classification of Diseases, Ninth Revision¹⁸).

As our Institutional Review Board (IRB) reviewed the database and determined the project was not human subject research, IRB involvement was not required. This study paralleled successful efforts with similar RA and non-RA patients who had shoulder and elbow surgery.^3,19 SA patients were identified by ICD-9 procedure code 81.80, but this code does not specify whether the prosthesis was unconstrained, semiconstrained, or constrained. ICD-9 coding also does not specify whether the TSA was traditional or reverse. Patients with RA were identified by ICD-9 diagnosis codes 714.0, 714.1, and 714.2. Patients without one of these codes were placed in the non-RA cohort. Patients with codes associated with pathologic fractures secondary to metastatic cancer or bone malignant neoplasm as a secondary or primary diagnosis and patients who had revision surgery indicated by code 81.83 were excluded, as they have a disproportionately higher comorbidity burden.

After each cohort was defined, demographic data (age, sex, race, income quartile based on ZIP postal code) were compared, as were data on primary payer, hospital demographics, LOS (≤5 days, defined as perioperative index), discharge type, inflation-adjusted charges in 2014 dollars based on the Consumer Price Indexes (http://www.bls.gov/cpi/), and mortality. Perioperative complications—respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related (including embolism, fibrosis, hemorrhage, pain, stenosis, or thrombus caused by any device, implant, or graft), cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, postoperative infection complications, and intraoperative transfusions—were considered using ICD-9 codes (996.X-999.X and 99.X, respectively).²⁰ Although commonly used to determine perioperative comorbidity burden using ICD-9 coding, the modified Charlson index was not considered because RA is a component of the index and would therefore bias the variable.^3,21

Statistical analyses, including χ² tests and 2-sample t tests, were performed for categorical and continuous variables, respectively. P < .05 was considered significant. Fisher exact test was used for cohorts with fewer than 5 occurrences. Multivariate logistic regression models were then calculated to determine the effect of RA on different outcomes and complications, with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. Statistical analyses were performed using the R statistical programming language.22

Results

Of the 34,970 patients who underwent SA between 2006 and 2011, 1674 (4.8%) had a diagnosis of RA and 33,296 (95.2%) did not. On average, patients with RA tended to be younger than patients without RA (66.4 vs 69.1 years; P < .001), and a larger percentage of RA patients were female (75.5% vs 54.4%; P < .001). Compared with non-RA patients, RA patients comprised a different ethnic group and had a different expected primary payer (P < .001). SA patients with and without RA did not differ in income quartile based on ZIP code, total number of hospital beds, hospital region, or hospital teaching status (P = .34, .78, .59, and .82, respectively) (Table 1).

LOS was significantly (P < .001) statistically longer for RA patients (2.196 days) than for non-RA patients (2.085 days). RA patients were significantly less likely to be discharged home (63.0% vs 67.6%; P < .001). (Routine discharge was defined as discharge home, whereas nonroutine discharge was defined as discharge to a short-term hospital, skilled nursing facility, intermediate care, another type of facility, home health care, against medical advice, or death.) In addition, inflation-adjusted charges associated with SA were significantly higher (P = .018) for RA patients ($54,284) than for non-RA patients ($52,663) (Table 1).

Regarding the rates of complications that occurred during the perioperative index, there were no significant differences between RA and non-RA cohorts. These complications included respiratory, gastrointestinal, genitourinary, accidental puncture/laceration, central nervous system, wound dehiscence, device-related, cardiac, hematoma/seroma, acute respiratory distress syndrome, postoperative shock, VTE, and postoperative infection (Table 2). In addition, there was no significant difference in mortality between the groups (P = .48).

In TSA, blood transfusions were more likely (P < .001) to be given to RA patients (9.00%) than to non-RA patients (6.16%). Multivariate regression analyses were performed with age, race, sex, hospital region, hospital type, number of hospital beds, primary payer, and hospital ownership as covariates. These analyses revealed that transfusion (P < .001), discharge type (P = .002), total inflation-adjusted charges (P < .001), and LOS (P = .047) remained significant (Table 3).

Discussion

Large national databases like NIS allow study of uncommon medical occurrences and help delineate risks and trends that otherwise might be indeterminable. Although it has been suggested that patients with RA may have poorer long-term outcomes after SA, the perioperative risk profile indicates that TSA is well tolerated in RA patients during the operative index.^3,23-25

The data on this study’s 34,970 patients, drawn from the period 2006–2011, demonstrated no significant differences in safety profile with respect to the 14 perioperative complications and outcomes examined, except blood transfusion rate. Rates of postoperative infection (RA, 0.24%; non-RA, 0.14%; P = .303), VTE (RA, 0.30%; non-RA, 0.25%; P = .905), and transfusion (RA, 9.00%; non-RA, 6.16%; P < .001) are of particular interest because of the severity of these situations.

Postoperative infection is a potentially serious complication and often occurs secondary to diabetes, RA, lupus erythematosus, prior surgery, or a nosocomial or remote source.¹ The often costly treatment options include antibiotic suppression, irrigation and debridement with implant retention, 1-stage exchange with antibiotic-impregnated cement fixation, staged reimplantation, resection arthroplasty, arthrodesis, and amputation.¹ The overall 0.14% infection rate determined in this study is lower than the 0.7% reported for SA patients in the literature.¹ Given the nature of the NIS database, this rate underestimates the true postoperative infection rate, as any infection that occurred after the perioperative period is not captured.²⁶ The present study’s perioperative infection rates (RA, 0.24%; non-RA, 0.14%) for the period 2006–2011 are comparable to the rates (RA, 0.17%; non-RA, 0.24%) reported by Hambright and colleagues3 for the same patient population over the preceding, 18-year period (1988–2005) and similarly do not significantly differ between groups. Although infection is uncommon in the immediate perioperative period, the ICD-9 codes used refer specifically to infection resulting from surgery and do not represent concomitant infection.

VTEs, which include PEs and DVTs, are rare but potentially life-threatening surgical complications.^27,28 Mechanical prophylaxis and chemical prophylaxis have been recommended for major orthopedic surgery, particularly lower extremity surgery, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA).^28,29 In the present study, VTE rates were low, 0.30% (RA) and 0.25% (non-RA), and not significantly different in bivariate or multivariate analyses. These rates are comparable to those found in other national-database SA studies.²⁸ VTEs that occur outside the index hospital admission are not captured in this database. Therefore, the rates in the present study may be lower than the true incidence after SA. Mortality secondary to VTE usually occurs within 24 hours but may occur up to 90 days after surgery. DVT rates, on the other hand, are difficult to evaluate because of differences in screening practices.^27,28,30,31

That RA patients were more likely than non-RA patients to receive perioperative blood transfusions supports prior findings that SA patients with RA were more likely than SA patients with osteoarthritis (OA) to receive perioperative blood transfusions.⁸ RA patients have been shown to have high rates of anemia of chronic disease, ranging from 22% to 77%.³² During joint replacement, these patients often require transfusions.^32,33 However, these findings differ from prior findings of no differences between RA and non-RA patients in the same patient population during the period 1988–2005.³ This difference may be a product of the constantly changing transfusion guidelines and increased use; transfusion rates increased 140% between 1997 and 2007, making transfusions the fastest growing common procedure in the United States during that time.³⁴ There was no difference between RA and non-RA patients in household income (as determined by ZIP code analysis), number of hospital beds, hospital region, or hospital teaching status. Compared with non-RA patients, RA patients were more likely to be younger, female, and of a difference race and to have a different expected primary payer (P < .001).These findings are consistent with previous findings in the literature.³ In the present SA study, however, RA patients were more likely than non-RA patients to have longer LOS, higher inflation-adjusted hospital charges, and nonroutine discharge. These findings deviate from those of the study covering the preceding 18 years (1988–2005).³ Despite the findings of a changing environment of care for RA patients, by Hambright and colleagues³ and Weiss and colleagues,³⁵ the trend appears to have shifted. Both groups had shorter average LOS than either group from the preceding 18 years.³ Although statistically significant in bivariate analysis, the difference in LOS between the 2 groups differed by an average of 0.11 day (2 hours 24 minutes) and was not clinically relevant.

In addition, the higher charges for patients with RA represent a deviation from the preceding 18 years.³ Other studies have also shown that RA is associated with increased cost in TSA.³⁶ Patients with RA often have rotator cuff pathology, indicating reverse SA may be used more frequently.^37,38 The increased implant cost associated with reverse SA may account for the increased costs in RA patients.³⁹ As mentioned, TSA type is not captured in the NIS database. In addition, that RA patients were less likely than non-RA patients to have routine discharge may indicate RA cases are more complex because of their complications.^1,5,14,40 A recent study of complications in RA patients (1163 who underwent THA, 2692 who underwent TKA) found that THA patients with RA were significantly more likely than THA patients with OA to dislocate, and TKA patients with RA were significantly more likely than TKA patients with OA to develop an infection after surgery.⁴¹ Postoperative dislocation has been shown to increase hospital costs in other orthopedic procedures.⁴² Also, during TSA, patients with RA are more likely than patients with OA to receive intraoperative blood transfusions.⁸ These complications—combined with the fact that RA is a chronic, progressive, systemic inflammatory disease that can affect soft tissue and blood vessel wall healing and is associated with medications having potential side effects—could contribute to the apparent increased hospital charges and LOS.^3,12,13,43 Factors that include surgeon preference, impact of primary payer, and hospital practice may also affect final charges. Total charges in the NIS database include administrative fees, hospital costs, device-related costs, operating room costs, and ancillary staff costs. Total charges do not include professional fees and differ from the total cost that represents the amount reimbursed by the payer. Charges tend to correlate with but overestimate the total costs.⁴⁴

This study had several important limitations. As mentioned, only events that occur during the operative admission are captured in the NIS database, and thus postoperative complications or serious adverse events that lead to readmission cannot be identified. In addition, outpatient TSAs are not captured in the NIS database, and thus inclusion of only inpatient procedures yields higher average LOS and total charges.⁴⁵ Given the limited granularity of ICD-9 coding, this study could not determine RA severity, estimated blood loss, length of surgery, complication severity, type of TSA procedure/prosthesis, or cause of death. Although commonly used to determine comorbidity burden, the modified Charlson index could not be used, and therefore could not be entered as a covariate in multivariate analysis. Furthermore, the NIS database does not include imaging or patient-reported outcomes information, such as improvements in pain or function, which are of crucial importance in considering surgery.

Conclusion

Our findings corroborated findings that the demographics and the perioperative safety profile for TSA were similar for patients with and without RA. The risk for complications or death in the perioperative period was low. Compared with non-RA patients, RA patients had significantly higher charges and longer LOS and were less likely to be discharged home after surgery. The 0.11-day difference in LOS, though statistically significant, was not clinically relevant. These findings differ from those for the preceding, 18-year period (1988–2005). Future research should focus on the causes of these changes.

Linear Basal Cell Carcinoma

On examination, the lesion was suspected to be a nevocellular nevus, foreign body granuloma, or venous lake; however, a skin biopsy specimen from the lesion on the left wrist revealed a tumor mass of basaloid cells, peripheral palisading arrangement, and scattered pigment granules (Figure 1). Tumor cells were negative for S-100 protein staining. These findings were consistent with a diagnosis of linear basal cell carcinoma (BCC). The lesion was removed by simple excision with primary closure of the wound. The surgical margins were free of tumor cells. The lesion had not recurred at 6-month follow-up. The patient was subsequently lost to follow-up.

Basal cell carcinoma presents with diverse clinical features, and several morphologic and histologic variants have been reported.¹ Linear BCC was described as a distinct clinical entity in 1985 by Lewis² in a 73-year-old man with a 20-mm linear pigmented lesion on the left cheek. Linear BCC often is not recognized or categorized as such by clinicians, as some may think that linear BCC is not a distinct entity but rather is one of the diverse clinical features of BCC.³ Linear BCC is believed to have specific clinical and histologic features and can be regarded as a distinct entity.⁴ Mavrikakis et al⁵ objectively defined linear BCC as a lesion that appeared to extend preferentially in one direction, resulting in a lesion with relatively straight borders and a length much greater than the width (3:1 ratio). Our patient presented with a linearly curved lesion, which is a rare feature of BCC.

Linear BCC occurs in equal proportions in men and women aged 40 to 87 years. More than 92% of reported patients were older than 60 years.⁶ The most common site for linear BCC is the periocular area, with the majority of lesions occurring on the cheek or lower eyelid. The second most common site is the neck, followed by the trunk, lower face, and inguinal skin fold.^3,5

The mechanism of linearity has been speculated. The majority of the reported cases of linear BCC have no history of trauma.⁷ However, focal trauma has been assumed to be a risk factor for the development of linear BCC, so the possibility that the Köbner phenomenon may be related to its linear pattern has been proposed.⁸ The Köbner phenomenon can be implicated in our case, as there was a history of surgery, which resulted in a scar.

Menzies⁹ described dermoscopic features of pigmented BCC and stated that the diagnosis of pigmented BCC required the presence of 1 or more of the following 6 positive features: large blue-gray ovoid nests; multiple blue-gray globules; maple leaf–like areas; spoke wheel areas; ulceration; and arborizing treelike vessels. In our case, there were multiple blue-gray globules and a streak that resembled ginseng (Figure 2).

Linear BCC is an uncommon morphological variant that requires clinical recognition. Our case was unique because of the ginsenglike streak on dermoscopy and possible association with a prior trauma.

Linear Basal Cell Carcinoma

On examination, the lesion was suspected to be a nevocellular nevus, foreign body granuloma, or venous lake; however, a skin biopsy specimen from the lesion on the left wrist revealed a tumor mass of basaloid cells, peripheral palisading arrangement, and scattered pigment granules (Figure 1). Tumor cells were negative for S-100 protein staining. These findings were consistent with a diagnosis of linear basal cell carcinoma (BCC). The lesion was removed by simple excision with primary closure of the wound. The surgical margins were free of tumor cells. The lesion had not recurred at 6-month follow-up. The patient was subsequently lost to follow-up.

Basal cell carcinoma presents with diverse clinical features, and several morphologic and histologic variants have been reported.¹ Linear BCC was described as a distinct clinical entity in 1985 by Lewis² in a 73-year-old man with a 20-mm linear pigmented lesion on the left cheek. Linear BCC often is not recognized or categorized as such by clinicians, as some may think that linear BCC is not a distinct entity but rather is one of the diverse clinical features of BCC.³ Linear BCC is believed to have specific clinical and histologic features and can be regarded as a distinct entity.⁴ Mavrikakis et al⁵ objectively defined linear BCC as a lesion that appeared to extend preferentially in one direction, resulting in a lesion with relatively straight borders and a length much greater than the width (3:1 ratio). Our patient presented with a linearly curved lesion, which is a rare feature of BCC.

Linear BCC occurs in equal proportions in men and women aged 40 to 87 years. More than 92% of reported patients were older than 60 years.⁶ The most common site for linear BCC is the periocular area, with the majority of lesions occurring on the cheek or lower eyelid. The second most common site is the neck, followed by the trunk, lower face, and inguinal skin fold.^3,5

The mechanism of linearity has been speculated. The majority of the reported cases of linear BCC have no history of trauma.⁷ However, focal trauma has been assumed to be a risk factor for the development of linear BCC, so the possibility that the Köbner phenomenon may be related to its linear pattern has been proposed.⁸ The Köbner phenomenon can be implicated in our case, as there was a history of surgery, which resulted in a scar.

Menzies⁹ described dermoscopic features of pigmented BCC and stated that the diagnosis of pigmented BCC required the presence of 1 or more of the following 6 positive features: large blue-gray ovoid nests; multiple blue-gray globules; maple leaf–like areas; spoke wheel areas; ulceration; and arborizing treelike vessels. In our case, there were multiple blue-gray globules and a streak that resembled ginseng (Figure 2).

Linear BCC is an uncommon morphological variant that requires clinical recognition. Our case was unique because of the ginsenglike streak on dermoscopy and possible association with a prior trauma.

Linear Basal Cell Carcinoma

On examination, the lesion was suspected to be a nevocellular nevus, foreign body granuloma, or venous lake; however, a skin biopsy specimen from the lesion on the left wrist revealed a tumor mass of basaloid cells, peripheral palisading arrangement, and scattered pigment granules (Figure 1). Tumor cells were negative for S-100 protein staining. These findings were consistent with a diagnosis of linear basal cell carcinoma (BCC). The lesion was removed by simple excision with primary closure of the wound. The surgical margins were free of tumor cells. The lesion had not recurred at 6-month follow-up. The patient was subsequently lost to follow-up.

Basal cell carcinoma presents with diverse clinical features, and several morphologic and histologic variants have been reported.¹ Linear BCC was described as a distinct clinical entity in 1985 by Lewis² in a 73-year-old man with a 20-mm linear pigmented lesion on the left cheek. Linear BCC often is not recognized or categorized as such by clinicians, as some may think that linear BCC is not a distinct entity but rather is one of the diverse clinical features of BCC.³ Linear BCC is believed to have specific clinical and histologic features and can be regarded as a distinct entity.⁴ Mavrikakis et al⁵ objectively defined linear BCC as a lesion that appeared to extend preferentially in one direction, resulting in a lesion with relatively straight borders and a length much greater than the width (3:1 ratio). Our patient presented with a linearly curved lesion, which is a rare feature of BCC.

Linear BCC occurs in equal proportions in men and women aged 40 to 87 years. More than 92% of reported patients were older than 60 years.⁶ The most common site for linear BCC is the periocular area, with the majority of lesions occurring on the cheek or lower eyelid. The second most common site is the neck, followed by the trunk, lower face, and inguinal skin fold.^3,5

The mechanism of linearity has been speculated. The majority of the reported cases of linear BCC have no history of trauma.⁷ However, focal trauma has been assumed to be a risk factor for the development of linear BCC, so the possibility that the Köbner phenomenon may be related to its linear pattern has been proposed.⁸ The Köbner phenomenon can be implicated in our case, as there was a history of surgery, which resulted in a scar.

Menzies⁹ described dermoscopic features of pigmented BCC and stated that the diagnosis of pigmented BCC required the presence of 1 or more of the following 6 positive features: large blue-gray ovoid nests; multiple blue-gray globules; maple leaf–like areas; spoke wheel areas; ulceration; and arborizing treelike vessels. In our case, there were multiple blue-gray globules and a streak that resembled ginseng (Figure 2).

Linear BCC is an uncommon morphological variant that requires clinical recognition. Our case was unique because of the ginsenglike streak on dermoscopy and possible association with a prior trauma.

CHICAGO – Adding the cytokine IL-2 to front-line therapy with the anti-GD2 antibody ch14.18/CHO provided no additional survival benefit and only added to toxicity in the treatment of pediatric patients with high-risk neuroblastoma (NB), Dr. Ruth Ladenstein reported at the annual meeting of the American Society of Clinical Oncology.

A form of the antibody (dinutuximab) is approved for use in combination with granulocyte-macrophage colony stimulating factor, IL-2, and 13-cis-retinoic acid (RA) to treat high risk NB. A previous study (N Engl J Med. 2010;363:1324-34) showed that a combination of ch14.18 and the cytokines improved event free survival to 66% at 2 years, but the role of cytokines in this context remained unclear. Dr. Ladenstein and associates therefore performed a phase III trial that randomized patients to the antibody with or without subcutaneous (sc) IL-2.

High-risk NB was defined as patients with International Neuroblastoma Staging System stage 4 disease 1 year old or older, stage 4 less than 1 year old with MYCN amplification, or stage 2,3 patients up to age 21 years with MYCN amplification. Patients underwent a rapid induction therapy, followed by peripheral stem cell harvest, local control with complete tumor resection, myeloablative therapy with peripheral stem cell transplant, local control with radiotherapy, and then ch14.18 anti-GD2 monoclonal immunotherapy with RA, with or without sc IL-2.

Inclusion criteria were a complete response or partial response with three or fewer skeletal metastatic spots and no positive bone marrow biopsies on two aspirates. Randomization occurred between day 60 and 90 post stem cell infusion. RA was given on days 1-14 post randomization. For the arm receiving IL-2, it was given as 5 daily injections of 6 x 106 IU/m² per day over 8 hours on days 15-19. IL-2 was repeated on days 22-26. Both groups also received the ch14.18 antibody on days 22-26. All patients received high-dose morphine for pain management.

For event free survival (EFS), the primary endpoint of the trial, “if we look at 3 years, we see with antibody alone it’s 57%. With IL-2, it’s 60%. It’s completely clear that there’s no superiority for the IL-2 arm,” said Dr. Ladenstein, professor of pediatrics at the Children’s Cancer Research Institute, Austria.

At 5 years, the EFS was no different for the two treatment arms, at 51% for antibody alone and 56% for antibody plus IL-2 (P = .561). There were 199/200 patients in the antibody-alone arm with follow-up after randomization and 203/206 in the antibody plus IL-2 arm. The same was true for the secondary endpoint of overall survival, with 66% survival with antibody-alone and 58% in the antibody plus IL-2 at 5 years.

The EFS for patients with a complete response prior to immunotherapy was 66% at 3 years and was 50% for patients with less than a complete response, a significant difference (P = .003) in favor of those with a complete response. IL-2 administration had no effect on the EFS of the patients with a complete response if it was given with the immunotherapy. Similarly, IL-2 made no difference for patients who had had a very good partial response or a partial response prior to immunotherapy. For complete, very good partial, or partial responses prior to immunotherapy, the overall response to immunotherapy was 51%.

“However, feasibility is a concern, particularly in the IL-2 arm. Only 61% of the cycles were completed whereas it was 85% in the antibody-only arm, and the interruptions are definitely related mainly to the IL-2 component,” Dr. Ladenstein said.

Toxicity was higher for those patients receiving IL-2 compared to those getting antibody alone: Lansky performance status of 30% or less was 41% vs. 17%, early termination of therapy was 39% vs. 15%, and Common Terminology Criteria grade 3/4 fever was 41% vs. 14%, respectively (all P less than .001). There were also significantly more grade 3/4 allergic reactions and incidences of capillary leak, as well as diarrhea, hypotension, central nervous toxicity, and pain with IL-2.

The outcomes were favorable with antibody immunotherapy alone, but the higher toxicity with IL-2 shows that “a less toxic treatment schedule therefore is needed for this late treatment phase,” Dr. Ladenstein said.

Commenting on the trial, Dr. Barbara Hero of University Children’s Hospital in Cologne, Germany, asked whether cytokines are a useful part of the regimen “because we know the cytokines add quite a lot of toxicity to the regimens.” Even if they are potentially useful, researchers still do not know which cytokines, route of administration, and at what doses and timing would be best. Also, it is not known if a different induction regimen or antibody treatment could make a difference in using cytokines.

Another question is whether cytokines may be of benefit in patients with a higher tumor burden, e.g., more than three skeletal spots, used as the eligibility cut-off in this trial, Dr. Hero said.

CHICAGO – Adding the cytokine IL-2 to front-line therapy with the anti-GD2 antibody ch14.18/CHO provided no additional survival benefit and only added to toxicity in the treatment of pediatric patients with high-risk neuroblastoma (NB), Dr. Ruth Ladenstein reported at the annual meeting of the American Society of Clinical Oncology.

A form of the antibody (dinutuximab) is approved for use in combination with granulocyte-macrophage colony stimulating factor, IL-2, and 13-cis-retinoic acid (RA) to treat high risk NB. A previous study (N Engl J Med. 2010;363:1324-34) showed that a combination of ch14.18 and the cytokines improved event free survival to 66% at 2 years, but the role of cytokines in this context remained unclear. Dr. Ladenstein and associates therefore performed a phase III trial that randomized patients to the antibody with or without subcutaneous (sc) IL-2.

High-risk NB was defined as patients with International Neuroblastoma Staging System stage 4 disease 1 year old or older, stage 4 less than 1 year old with MYCN amplification, or stage 2,3 patients up to age 21 years with MYCN amplification. Patients underwent a rapid induction therapy, followed by peripheral stem cell harvest, local control with complete tumor resection, myeloablative therapy with peripheral stem cell transplant, local control with radiotherapy, and then ch14.18 anti-GD2 monoclonal immunotherapy with RA, with or without sc IL-2.

Inclusion criteria were a complete response or partial response with three or fewer skeletal metastatic spots and no positive bone marrow biopsies on two aspirates. Randomization occurred between day 60 and 90 post stem cell infusion. RA was given on days 1-14 post randomization. For the arm receiving IL-2, it was given as 5 daily injections of 6 x 106 IU/m² per day over 8 hours on days 15-19. IL-2 was repeated on days 22-26. Both groups also received the ch14.18 antibody on days 22-26. All patients received high-dose morphine for pain management.

For event free survival (EFS), the primary endpoint of the trial, “if we look at 3 years, we see with antibody alone it’s 57%. With IL-2, it’s 60%. It’s completely clear that there’s no superiority for the IL-2 arm,” said Dr. Ladenstein, professor of pediatrics at the Children’s Cancer Research Institute, Austria.

At 5 years, the EFS was no different for the two treatment arms, at 51% for antibody alone and 56% for antibody plus IL-2 (P = .561). There were 199/200 patients in the antibody-alone arm with follow-up after randomization and 203/206 in the antibody plus IL-2 arm. The same was true for the secondary endpoint of overall survival, with 66% survival with antibody-alone and 58% in the antibody plus IL-2 at 5 years.

The EFS for patients with a complete response prior to immunotherapy was 66% at 3 years and was 50% for patients with less than a complete response, a significant difference (P = .003) in favor of those with a complete response. IL-2 administration had no effect on the EFS of the patients with a complete response if it was given with the immunotherapy. Similarly, IL-2 made no difference for patients who had had a very good partial response or a partial response prior to immunotherapy. For complete, very good partial, or partial responses prior to immunotherapy, the overall response to immunotherapy was 51%.

“However, feasibility is a concern, particularly in the IL-2 arm. Only 61% of the cycles were completed whereas it was 85% in the antibody-only arm, and the interruptions are definitely related mainly to the IL-2 component,” Dr. Ladenstein said.

Toxicity was higher for those patients receiving IL-2 compared to those getting antibody alone: Lansky performance status of 30% or less was 41% vs. 17%, early termination of therapy was 39% vs. 15%, and Common Terminology Criteria grade 3/4 fever was 41% vs. 14%, respectively (all P less than .001). There were also significantly more grade 3/4 allergic reactions and incidences of capillary leak, as well as diarrhea, hypotension, central nervous toxicity, and pain with IL-2.

The outcomes were favorable with antibody immunotherapy alone, but the higher toxicity with IL-2 shows that “a less toxic treatment schedule therefore is needed for this late treatment phase,” Dr. Ladenstein said.

Commenting on the trial, Dr. Barbara Hero of University Children’s Hospital in Cologne, Germany, asked whether cytokines are a useful part of the regimen “because we know the cytokines add quite a lot of toxicity to the regimens.” Even if they are potentially useful, researchers still do not know which cytokines, route of administration, and at what doses and timing would be best. Also, it is not known if a different induction regimen or antibody treatment could make a difference in using cytokines.

Another question is whether cytokines may be of benefit in patients with a higher tumor burden, e.g., more than three skeletal spots, used as the eligibility cut-off in this trial, Dr. Hero said.

CHICAGO – Adding the cytokine IL-2 to front-line therapy with the anti-GD2 antibody ch14.18/CHO provided no additional survival benefit and only added to toxicity in the treatment of pediatric patients with high-risk neuroblastoma (NB), Dr. Ruth Ladenstein reported at the annual meeting of the American Society of Clinical Oncology.

A form of the antibody (dinutuximab) is approved for use in combination with granulocyte-macrophage colony stimulating factor, IL-2, and 13-cis-retinoic acid (RA) to treat high risk NB. A previous study (N Engl J Med. 2010;363:1324-34) showed that a combination of ch14.18 and the cytokines improved event free survival to 66% at 2 years, but the role of cytokines in this context remained unclear. Dr. Ladenstein and associates therefore performed a phase III trial that randomized patients to the antibody with or without subcutaneous (sc) IL-2.

High-risk NB was defined as patients with International Neuroblastoma Staging System stage 4 disease 1 year old or older, stage 4 less than 1 year old with MYCN amplification, or stage 2,3 patients up to age 21 years with MYCN amplification. Patients underwent a rapid induction therapy, followed by peripheral stem cell harvest, local control with complete tumor resection, myeloablative therapy with peripheral stem cell transplant, local control with radiotherapy, and then ch14.18 anti-GD2 monoclonal immunotherapy with RA, with or without sc IL-2.

Inclusion criteria were a complete response or partial response with three or fewer skeletal metastatic spots and no positive bone marrow biopsies on two aspirates. Randomization occurred between day 60 and 90 post stem cell infusion. RA was given on days 1-14 post randomization. For the arm receiving IL-2, it was given as 5 daily injections of 6 x 106 IU/m² per day over 8 hours on days 15-19. IL-2 was repeated on days 22-26. Both groups also received the ch14.18 antibody on days 22-26. All patients received high-dose morphine for pain management.

For event free survival (EFS), the primary endpoint of the trial, “if we look at 3 years, we see with antibody alone it’s 57%. With IL-2, it’s 60%. It’s completely clear that there’s no superiority for the IL-2 arm,” said Dr. Ladenstein, professor of pediatrics at the Children’s Cancer Research Institute, Austria.

At 5 years, the EFS was no different for the two treatment arms, at 51% for antibody alone and 56% for antibody plus IL-2 (P = .561). There were 199/200 patients in the antibody-alone arm with follow-up after randomization and 203/206 in the antibody plus IL-2 arm. The same was true for the secondary endpoint of overall survival, with 66% survival with antibody-alone and 58% in the antibody plus IL-2 at 5 years.

The EFS for patients with a complete response prior to immunotherapy was 66% at 3 years and was 50% for patients with less than a complete response, a significant difference (P = .003) in favor of those with a complete response. IL-2 administration had no effect on the EFS of the patients with a complete response if it was given with the immunotherapy. Similarly, IL-2 made no difference for patients who had had a very good partial response or a partial response prior to immunotherapy. For complete, very good partial, or partial responses prior to immunotherapy, the overall response to immunotherapy was 51%.

“However, feasibility is a concern, particularly in the IL-2 arm. Only 61% of the cycles were completed whereas it was 85% in the antibody-only arm, and the interruptions are definitely related mainly to the IL-2 component,” Dr. Ladenstein said.

Toxicity was higher for those patients receiving IL-2 compared to those getting antibody alone: Lansky performance status of 30% or less was 41% vs. 17%, early termination of therapy was 39% vs. 15%, and Common Terminology Criteria grade 3/4 fever was 41% vs. 14%, respectively (all P less than .001). There were also significantly more grade 3/4 allergic reactions and incidences of capillary leak, as well as diarrhea, hypotension, central nervous toxicity, and pain with IL-2.

The outcomes were favorable with antibody immunotherapy alone, but the higher toxicity with IL-2 shows that “a less toxic treatment schedule therefore is needed for this late treatment phase,” Dr. Ladenstein said.

Commenting on the trial, Dr. Barbara Hero of University Children’s Hospital in Cologne, Germany, asked whether cytokines are a useful part of the regimen “because we know the cytokines add quite a lot of toxicity to the regimens.” Even if they are potentially useful, researchers still do not know which cytokines, route of administration, and at what doses and timing would be best. Also, it is not known if a different induction regimen or antibody treatment could make a difference in using cytokines.

Another question is whether cytokines may be of benefit in patients with a higher tumor burden, e.g., more than three skeletal spots, used as the eligibility cut-off in this trial, Dr. Hero said.

The VA has proposed a significant rule change that would grant full practice authority to advanced practice registered nurses (APRNs). According to the VA, this stated goal will “increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services.” The change permits APRNs, nurse practitioners who have completed at least a master’s degree in nursing, to assess and diagnose patients, prescribe medications, and interpret diagnostic tests.

“This is good news for our APRNs, who will be able to perform functions that their colleagues in the private sector are already doing,” Under Secretary of Health David J. Shulkin, said in a statement.

The proposed role of APRNs is not unique in federal health care systems. The Army, Navy, Air Force, and Indian Health Service already give APRNs full practice authority.

The rule is open for comment through July 25, 2016, and has already received nearly 20,000 comments. Physician organizations have been particularly critical of the proposed change. “We believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans. We feel this proposal will significantly undermine the delivery of care within the VA,” the American Medical Association noted in a statement.

Many of the most critical comments concerned the role of certified nurse anesthetists (CRNAs). The American Society of Anesthesiologists strongly criticized the rule, and of the comments to date, 15,906 specifically reference anesthesia.

Dr. Shulkin suggested that much of the criticism was misinformed. “I do not believe they [physicians] understand what our intent in going into this rule-making is,” he told The Washington Post. “We have embraced team-based health care. We believe in the model. We are not looking to destroy that. We are looking to add to our ability to deliver heath care to veterans in places that don’t frankly have health care for them right now.”

Echoing Dr. Shulkin’s comments, the Nurses Organization of Veteran Affairs (NOVA) and other nursing organizations fully support the rule. “The recognition of APRNs as full practice providers will continue to support the current VA team model of care,” Teresa Morris, NOVA director of advocacy & government relations explained. “In this model, each team member is working at the top of his or her education, training and expertise.”

According to Morris, the expanded role for APRNs also may help address disparities in care within the VA system. “There has been a lack of uniformity between VA networks, which can lead to confusion throughout the system and can contribute to issues in relationship to access,” she said. “We believe that this proposed change is resource driven and will help to decrease the variability in care provided by APRNs throughout the VA system.”

The VA has proposed a significant rule change that would grant full practice authority to advanced practice registered nurses (APRNs). According to the VA, this stated goal will “increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services.” The change permits APRNs, nurse practitioners who have completed at least a master’s degree in nursing, to assess and diagnose patients, prescribe medications, and interpret diagnostic tests.

“This is good news for our APRNs, who will be able to perform functions that their colleagues in the private sector are already doing,” Under Secretary of Health David J. Shulkin, said in a statement.

The proposed role of APRNs is not unique in federal health care systems. The Army, Navy, Air Force, and Indian Health Service already give APRNs full practice authority.

The rule is open for comment through July 25, 2016, and has already received nearly 20,000 comments. Physician organizations have been particularly critical of the proposed change. “We believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans. We feel this proposal will significantly undermine the delivery of care within the VA,” the American Medical Association noted in a statement.

Many of the most critical comments concerned the role of certified nurse anesthetists (CRNAs). The American Society of Anesthesiologists strongly criticized the rule, and of the comments to date, 15,906 specifically reference anesthesia.

Dr. Shulkin suggested that much of the criticism was misinformed. “I do not believe they [physicians] understand what our intent in going into this rule-making is,” he told The Washington Post. “We have embraced team-based health care. We believe in the model. We are not looking to destroy that. We are looking to add to our ability to deliver heath care to veterans in places that don’t frankly have health care for them right now.”

Echoing Dr. Shulkin’s comments, the Nurses Organization of Veteran Affairs (NOVA) and other nursing organizations fully support the rule. “The recognition of APRNs as full practice providers will continue to support the current VA team model of care,” Teresa Morris, NOVA director of advocacy & government relations explained. “In this model, each team member is working at the top of his or her education, training and expertise.”

According to Morris, the expanded role for APRNs also may help address disparities in care within the VA system. “There has been a lack of uniformity between VA networks, which can lead to confusion throughout the system and can contribute to issues in relationship to access,” she said. “We believe that this proposed change is resource driven and will help to decrease the variability in care provided by APRNs throughout the VA system.”

The VA has proposed a significant rule change that would grant full practice authority to advanced practice registered nurses (APRNs). According to the VA, this stated goal will “increase veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services.” The change permits APRNs, nurse practitioners who have completed at least a master’s degree in nursing, to assess and diagnose patients, prescribe medications, and interpret diagnostic tests.

“This is good news for our APRNs, who will be able to perform functions that their colleagues in the private sector are already doing,” Under Secretary of Health David J. Shulkin, said in a statement.

The proposed role of APRNs is not unique in federal health care systems. The Army, Navy, Air Force, and Indian Health Service already give APRNs full practice authority.

The rule is open for comment through July 25, 2016, and has already received nearly 20,000 comments. Physician organizations have been particularly critical of the proposed change. “We believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans. We feel this proposal will significantly undermine the delivery of care within the VA,” the American Medical Association noted in a statement.

Many of the most critical comments concerned the role of certified nurse anesthetists (CRNAs). The American Society of Anesthesiologists strongly criticized the rule, and of the comments to date, 15,906 specifically reference anesthesia.

Dr. Shulkin suggested that much of the criticism was misinformed. “I do not believe they [physicians] understand what our intent in going into this rule-making is,” he told The Washington Post. “We have embraced team-based health care. We believe in the model. We are not looking to destroy that. We are looking to add to our ability to deliver heath care to veterans in places that don’t frankly have health care for them right now.”

Echoing Dr. Shulkin’s comments, the Nurses Organization of Veteran Affairs (NOVA) and other nursing organizations fully support the rule. “The recognition of APRNs as full practice providers will continue to support the current VA team model of care,” Teresa Morris, NOVA director of advocacy & government relations explained. “In this model, each team member is working at the top of his or her education, training and expertise.”

According to Morris, the expanded role for APRNs also may help address disparities in care within the VA system. “There has been a lack of uniformity between VA networks, which can lead to confusion throughout the system and can contribute to issues in relationship to access,” she said. “We believe that this proposed change is resource driven and will help to decrease the variability in care provided by APRNs throughout the VA system.”

What does your patient need to know at the first visit? Does it apply to all patients?

All patients should have a total-body skin examination at least once per year; however, the frequency may change based on a prior history of melanoma or skin cancer, number of nevi or dysplastic nevi, and a family history of melanoma.

Patients should be completely undressed, and all nail polish or artificial nails should be removed prior to the examination. A complete cutaneous examination involves inspecting all skin surfaces, scalp, ocular and oral mucosa, fingernails/toenails, and genitalia if the patient agrees. Melanoma can occur in non–UV-exposed areas and the patient should be educated. Explain the ABCDEs of melanoma diagnosis to all patients and discuss concerns of any new or changing lesions, pigmented or not.

The patient should be made aware that a series of digital images will be taken for any suspicious lesions for possible short-term monitoring. The patient also may be offered full-body photography or 3D body imaging if the number of nevi warrants it.

Different patient populations have different risks for melanoma. Although melanoma predominately afflicts patients with a light skin type, there are certain types of melanoma, such as acral melanoma, that can be more common in darker skin types.

If a patient has a history of cutaneous melanoma, then the site should be checked for any local recurrence as well as palpation of the draining lymph nodes and regional lymph nodes.

I also let patients know that I will be using tools such as dermoscopy and/or reflectance confocal microscopy to better diagnose equivocal lesions before pursuing a biopsy. A biopsy may be done if there is a level of suspicion for atypia.

The use of dermoscopy, digital imaging, and reflectance confocal microscopy has changed the way we can detect, monitor, and evaluate atypical nevi. These tools can augment practice and possibly cut down on the rate of biopsies. They also are great for equivocal lesions or lesions that are in cosmetically sensitive areas. I use these tools in my everyday practice.

How do you keep patients compliant?

Empowering patients to perform self-examinations as well as examinations with his/her partner may help to reinforce monitoring by a dermatologist.

Provide patients with reading materials on self-examination while they wait in the office for your examination.

What do you do if they refuse treatment?

If patients defer a full-body skin examination, then I try to educate them about risks for UV exposure and the risk factors for both melanoma and nonmelanoma skin cancer. I also provide information on self-examinations so they can check at home for any irregularly shaped or changing moles.

What resources do you recommend to patients for more information?

It is important for patients to understand the risk factors for melanoma and the long-term prognosis of melanoma. I direct them to the American Academy of Dermatology’s website (http://www.AAD.org) for education and background about melanoma. Also, the Skin Cancer Foundation has inspiring patient stories (http://www.SkinCancer.org).

What does your patient need to know at the first visit? Does it apply to all patients?

All patients should have a total-body skin examination at least once per year; however, the frequency may change based on a prior history of melanoma or skin cancer, number of nevi or dysplastic nevi, and a family history of melanoma.

Patients should be completely undressed, and all nail polish or artificial nails should be removed prior to the examination. A complete cutaneous examination involves inspecting all skin surfaces, scalp, ocular and oral mucosa, fingernails/toenails, and genitalia if the patient agrees. Melanoma can occur in non–UV-exposed areas and the patient should be educated. Explain the ABCDEs of melanoma diagnosis to all patients and discuss concerns of any new or changing lesions, pigmented or not.

The patient should be made aware that a series of digital images will be taken for any suspicious lesions for possible short-term monitoring. The patient also may be offered full-body photography or 3D body imaging if the number of nevi warrants it.

Different patient populations have different risks for melanoma. Although melanoma predominately afflicts patients with a light skin type, there are certain types of melanoma, such as acral melanoma, that can be more common in darker skin types.

If a patient has a history of cutaneous melanoma, then the site should be checked for any local recurrence as well as palpation of the draining lymph nodes and regional lymph nodes.

I also let patients know that I will be using tools such as dermoscopy and/or reflectance confocal microscopy to better diagnose equivocal lesions before pursuing a biopsy. A biopsy may be done if there is a level of suspicion for atypia.

The use of dermoscopy, digital imaging, and reflectance confocal microscopy has changed the way we can detect, monitor, and evaluate atypical nevi. These tools can augment practice and possibly cut down on the rate of biopsies. They also are great for equivocal lesions or lesions that are in cosmetically sensitive areas. I use these tools in my everyday practice.

How do you keep patients compliant?

Empowering patients to perform self-examinations as well as examinations with his/her partner may help to reinforce monitoring by a dermatologist.

Provide patients with reading materials on self-examination while they wait in the office for your examination.

What do you do if they refuse treatment?

If patients defer a full-body skin examination, then I try to educate them about risks for UV exposure and the risk factors for both melanoma and nonmelanoma skin cancer. I also provide information on self-examinations so they can check at home for any irregularly shaped or changing moles.

What resources do you recommend to patients for more information?

It is important for patients to understand the risk factors for melanoma and the long-term prognosis of melanoma. I direct them to the American Academy of Dermatology’s website (http://www.AAD.org) for education and background about melanoma. Also, the Skin Cancer Foundation has inspiring patient stories (http://www.SkinCancer.org).

What does your patient need to know at the first visit? Does it apply to all patients?

All patients should have a total-body skin examination at least once per year; however, the frequency may change based on a prior history of melanoma or skin cancer, number of nevi or dysplastic nevi, and a family history of melanoma.

Patients should be completely undressed, and all nail polish or artificial nails should be removed prior to the examination. A complete cutaneous examination involves inspecting all skin surfaces, scalp, ocular and oral mucosa, fingernails/toenails, and genitalia if the patient agrees. Melanoma can occur in non–UV-exposed areas and the patient should be educated. Explain the ABCDEs of melanoma diagnosis to all patients and discuss concerns of any new or changing lesions, pigmented or not.

The patient should be made aware that a series of digital images will be taken for any suspicious lesions for possible short-term monitoring. The patient also may be offered full-body photography or 3D body imaging if the number of nevi warrants it.

Different patient populations have different risks for melanoma. Although melanoma predominately afflicts patients with a light skin type, there are certain types of melanoma, such as acral melanoma, that can be more common in darker skin types.

If a patient has a history of cutaneous melanoma, then the site should be checked for any local recurrence as well as palpation of the draining lymph nodes and regional lymph nodes.

I also let patients know that I will be using tools such as dermoscopy and/or reflectance confocal microscopy to better diagnose equivocal lesions before pursuing a biopsy. A biopsy may be done if there is a level of suspicion for atypia.

The use of dermoscopy, digital imaging, and reflectance confocal microscopy has changed the way we can detect, monitor, and evaluate atypical nevi. These tools can augment practice and possibly cut down on the rate of biopsies. They also are great for equivocal lesions or lesions that are in cosmetically sensitive areas. I use these tools in my everyday practice.

How do you keep patients compliant?

Empowering patients to perform self-examinations as well as examinations with his/her partner may help to reinforce monitoring by a dermatologist.

Provide patients with reading materials on self-examination while they wait in the office for your examination.

What do you do if they refuse treatment?

If patients defer a full-body skin examination, then I try to educate them about risks for UV exposure and the risk factors for both melanoma and nonmelanoma skin cancer. I also provide information on self-examinations so they can check at home for any irregularly shaped or changing moles.

What resources do you recommend to patients for more information?

It is important for patients to understand the risk factors for melanoma and the long-term prognosis of melanoma. I direct them to the American Academy of Dermatology’s website (http://www.AAD.org) for education and background about melanoma. Also, the Skin Cancer Foundation has inspiring patient stories (http://www.SkinCancer.org).

CHICAGO – After 2 years of maintenance immunotherapy with rituximab, elderly patients with chronic lymphocytic leukemia had better rates of progression-free survival than did patients in an observation group, based on results of the CLL 2007 SA trial from the French FILO (French Innovative Leukemia Organisation) Group.

The two groups did not significantly differ in overall survival, however, with 92.6% estimated 3-year overall survival in the rituximab group and 87.2% in the observation group. Further, the patients given rituximab had more adverse events, based on data presented by Dr. Caroline Dartigeas of the University Hospital in Tours, France, at the annual meeting of the American Society of Clinical Oncology.

Mary Jo Dales/Frontline Medical News

Given the cost and risk for events with rituximab, the findings raise the question of whether there are any meaningful benefits for maintenance rituximab after induction therapy, Dr. Jonathan W. Friedberg of the University of Rochester, N.Y., who was the discussant of the paper, remarked after the presentation. He asked whether there is any evidence that patients feel better if they’re in remission and, thus, their quality of life is improved.

The study included fit, treatment-naive patients aged 65 years and older with B-cell CLL who lacked del17p. Median patient age was 71.3 years, and two-thirds of the patients were men.

Patients received four cycles of induction therapy with fludarabine, cyclophosphamide, and rituximab on a shortened schedule chosen to reduce the risk of cumulative toxicity. At randomization, patients were stratified for immunoglobulin heavy chain variable (IGHV) status (54.8% of patients had unmutated status) and del11q (21.3% of patients had the deletion). Patients who had complete (25.7% of patients) or partial (62.8% of patients) responses were randomly allocated to either maintenance rituximab (202 patients given 500 mg/m² twice per month for 2 years) or to observation (207 patients). Median follow-up from randomization was 43.6 months.

Median progression-free survival in the rituximab arm was 59.3 months (95% confidence interval, 49.6; not reached), compared with 49 months (95% CI, 40.9-60.5) in the observation group (hazard ratio, 0.597; 95% CI, 0.437-0.814; P = .0011), corresponding to 3-year progression-free survival of 83% and 64.2% in each arm, respectively.

Mary Jo Dales/Frontline Medical News

Estimated overall survival at 3 years was 92.6% with rituximab maintenance and 87.2% in the observation group. Rituximab maintenance significantly improved progression-free survival in patients with and without del11q and in those with unmutated IGHV.

Serious adverse events for hematologic toxicity were seen in 6.9% of rituximab-treated patients and 1.9% of patients in the observation group (P = .027). Serious adverse events for infectious toxicity occurred in 18.8% of rituximab-treated patients and 10.1% of the observation group (P = .036). There were 69 deaths post randomization: 32 in the rituximab-treated group and 37 in the observation group. Secondary cancers, excluding basal cell carcinomas of the skin, occurred in 15.3% of the rituximab arm, including five cases of myelodysplastic syndrome, and in 11.1% of the observation group, including three cases of myelodysplastic syndrome.

Dr. Dartigeas is a consultant to Gilead Sciences and has provided expert testimony for Roche/Genentech. Genentech and Biogen jointly market rituximab (Rituxan).

[email protected]

On Twitter @maryjodales

CHICAGO – After 2 years of maintenance immunotherapy with rituximab, elderly patients with chronic lymphocytic leukemia had better rates of progression-free survival than did patients in an observation group, based on results of the CLL 2007 SA trial from the French FILO (French Innovative Leukemia Organisation) Group.

The two groups did not significantly differ in overall survival, however, with 92.6% estimated 3-year overall survival in the rituximab group and 87.2% in the observation group. Further, the patients given rituximab had more adverse events, based on data presented by Dr. Caroline Dartigeas of the University Hospital in Tours, France, at the annual meeting of the American Society of Clinical Oncology.

Mary Jo Dales/Frontline Medical News

Given the cost and risk for events with rituximab, the findings raise the question of whether there are any meaningful benefits for maintenance rituximab after induction therapy, Dr. Jonathan W. Friedberg of the University of Rochester, N.Y., who was the discussant of the paper, remarked after the presentation. He asked whether there is any evidence that patients feel better if they’re in remission and, thus, their quality of life is improved.

The study included fit, treatment-naive patients aged 65 years and older with B-cell CLL who lacked del17p. Median patient age was 71.3 years, and two-thirds of the patients were men.

Patients received four cycles of induction therapy with fludarabine, cyclophosphamide, and rituximab on a shortened schedule chosen to reduce the risk of cumulative toxicity. At randomization, patients were stratified for immunoglobulin heavy chain variable (IGHV) status (54.8% of patients had unmutated status) and del11q (21.3% of patients had the deletion). Patients who had complete (25.7% of patients) or partial (62.8% of patients) responses were randomly allocated to either maintenance rituximab (202 patients given 500 mg/m² twice per month for 2 years) or to observation (207 patients). Median follow-up from randomization was 43.6 months.

Median progression-free survival in the rituximab arm was 59.3 months (95% confidence interval, 49.6; not reached), compared with 49 months (95% CI, 40.9-60.5) in the observation group (hazard ratio, 0.597; 95% CI, 0.437-0.814; P = .0011), corresponding to 3-year progression-free survival of 83% and 64.2% in each arm, respectively.

Mary Jo Dales/Frontline Medical News

Estimated overall survival at 3 years was 92.6% with rituximab maintenance and 87.2% in the observation group. Rituximab maintenance significantly improved progression-free survival in patients with and without del11q and in those with unmutated IGHV.

Serious adverse events for hematologic toxicity were seen in 6.9% of rituximab-treated patients and 1.9% of patients in the observation group (P = .027). Serious adverse events for infectious toxicity occurred in 18.8% of rituximab-treated patients and 10.1% of the observation group (P = .036). There were 69 deaths post randomization: 32 in the rituximab-treated group and 37 in the observation group. Secondary cancers, excluding basal cell carcinomas of the skin, occurred in 15.3% of the rituximab arm, including five cases of myelodysplastic syndrome, and in 11.1% of the observation group, including three cases of myelodysplastic syndrome.

Dr. Dartigeas is a consultant to Gilead Sciences and has provided expert testimony for Roche/Genentech. Genentech and Biogen jointly market rituximab (Rituxan).

[email protected]

On Twitter @maryjodales

CHICAGO – After 2 years of maintenance immunotherapy with rituximab, elderly patients with chronic lymphocytic leukemia had better rates of progression-free survival than did patients in an observation group, based on results of the CLL 2007 SA trial from the French FILO (French Innovative Leukemia Organisation) Group.

The two groups did not significantly differ in overall survival, however, with 92.6% estimated 3-year overall survival in the rituximab group and 87.2% in the observation group. Further, the patients given rituximab had more adverse events, based on data presented by Dr. Caroline Dartigeas of the University Hospital in Tours, France, at the annual meeting of the American Society of Clinical Oncology.

Mary Jo Dales/Frontline Medical News

Given the cost and risk for events with rituximab, the findings raise the question of whether there are any meaningful benefits for maintenance rituximab after induction therapy, Dr. Jonathan W. Friedberg of the University of Rochester, N.Y., who was the discussant of the paper, remarked after the presentation. He asked whether there is any evidence that patients feel better if they’re in remission and, thus, their quality of life is improved.

The study included fit, treatment-naive patients aged 65 years and older with B-cell CLL who lacked del17p. Median patient age was 71.3 years, and two-thirds of the patients were men.

Patients received four cycles of induction therapy with fludarabine, cyclophosphamide, and rituximab on a shortened schedule chosen to reduce the risk of cumulative toxicity. At randomization, patients were stratified for immunoglobulin heavy chain variable (IGHV) status (54.8% of patients had unmutated status) and del11q (21.3% of patients had the deletion). Patients who had complete (25.7% of patients) or partial (62.8% of patients) responses were randomly allocated to either maintenance rituximab (202 patients given 500 mg/m² twice per month for 2 years) or to observation (207 patients). Median follow-up from randomization was 43.6 months.

Median progression-free survival in the rituximab arm was 59.3 months (95% confidence interval, 49.6; not reached), compared with 49 months (95% CI, 40.9-60.5) in the observation group (hazard ratio, 0.597; 95% CI, 0.437-0.814; P = .0011), corresponding to 3-year progression-free survival of 83% and 64.2% in each arm, respectively.

Mary Jo Dales/Frontline Medical News

Estimated overall survival at 3 years was 92.6% with rituximab maintenance and 87.2% in the observation group. Rituximab maintenance significantly improved progression-free survival in patients with and without del11q and in those with unmutated IGHV.

Serious adverse events for hematologic toxicity were seen in 6.9% of rituximab-treated patients and 1.9% of patients in the observation group (P = .027). Serious adverse events for infectious toxicity occurred in 18.8% of rituximab-treated patients and 10.1% of the observation group (P = .036). There were 69 deaths post randomization: 32 in the rituximab-treated group and 37 in the observation group. Secondary cancers, excluding basal cell carcinomas of the skin, occurred in 15.3% of the rituximab arm, including five cases of myelodysplastic syndrome, and in 11.1% of the observation group, including three cases of myelodysplastic syndrome.

Dr. Dartigeas is a consultant to Gilead Sciences and has provided expert testimony for Roche/Genentech. Genentech and Biogen jointly market rituximab (Rituxan).

[email protected]

On Twitter @maryjodales

SCOTTSDALE, ARIZ. – Wiping out the gut microbiome with antibiotics prevented alopecia areata in a study of mice, providing evidence that the gut microbiome may play a role in alopecia, Dr. James Chen reported at the annual meeting of the Society for Investigative Dermatology.

The finding shows that the bacterial culprits in alopecia “reside in the gut microbiome, and not in the skin,” said Dr. Chen, a postdoctoral research fellow in medical genetics at Columbia University, New York.

Alopecia areata is mediated by autoreactive NKG2D+ CD8+ T cells. Aberrations in the human microbiome underlie several other autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and type I diabetes, Dr. Chen noted. “The gut microbiome also has been linked to skin conditions, such as acne, psoriasis, and atopic dermatitis,” he added. “So we asked, if we deplete this microbiome with an antibiotic cocktail, do we see an effect on alopecia?”

To find out, he and his coinvestigators grafted skin from C3H/Hej mice, which spontaneously develop alopecia, onto healthy younger mice, causing them to develop alopecia 6-10 weeks later. “Strikingly, we found that treating unaffected mice with an oral antibiotic cocktail prior to grafting completely prevented the development of alopecia areata, and this remained true through 15 weeks,” he said. “This is the first evidence that the gut microbiome could be implicated in alopecia, based on the absence of the phenotype that we see in treated mice.”

The researchers also evaluated whether the skin microbiomes of antibiotic-treated and control mice differed, and determined that the skin samples resembled each other in terms of overall bacterial load and bacterial taxonomic clustering patterns. That suggests that the skin microbiome is not involved in alopecia areata, Dr. Chen said.

Finally, the investigators transferred NKG2D+ CD8+ T cells from the cutaneous lymph nodes of alopecic mice to normal mice that had been pretreated with antibiotics. The treated mice had little infiltration of these T cells into the skin, and lower overall T-cell levels than control mice, Dr. Chen reported.

The investigators are now testing combinations of antibiotics and fecal transplants to pinpoint which gut bacteria make mice susceptible to hair loss. Doing so “will have significant implications on both our understanding of alopecia areata susceptibility, as well as actionable therapeutic targets for treatment” in humans, Dr. Chen said.

The study was funded by the National Institutes of Health, the Medical Research Council, the Dermatology Foundation, Locks of Love Foundation, and NYSTEM (New York State Stem Cell Science). Dr. Chen had no financial disclosures.

SCOTTSDALE, ARIZ. – Wiping out the gut microbiome with antibiotics prevented alopecia areata in a study of mice, providing evidence that the gut microbiome may play a role in alopecia, Dr. James Chen reported at the annual meeting of the Society for Investigative Dermatology.

The finding shows that the bacterial culprits in alopecia “reside in the gut microbiome, and not in the skin,” said Dr. Chen, a postdoctoral research fellow in medical genetics at Columbia University, New York.

Alopecia areata is mediated by autoreactive NKG2D+ CD8+ T cells. Aberrations in the human microbiome underlie several other autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and type I diabetes, Dr. Chen noted. “The gut microbiome also has been linked to skin conditions, such as acne, psoriasis, and atopic dermatitis,” he added. “So we asked, if we deplete this microbiome with an antibiotic cocktail, do we see an effect on alopecia?”

To find out, he and his coinvestigators grafted skin from C3H/Hej mice, which spontaneously develop alopecia, onto healthy younger mice, causing them to develop alopecia 6-10 weeks later. “Strikingly, we found that treating unaffected mice with an oral antibiotic cocktail prior to grafting completely prevented the development of alopecia areata, and this remained true through 15 weeks,” he said. “This is the first evidence that the gut microbiome could be implicated in alopecia, based on the absence of the phenotype that we see in treated mice.”

The researchers also evaluated whether the skin microbiomes of antibiotic-treated and control mice differed, and determined that the skin samples resembled each other in terms of overall bacterial load and bacterial taxonomic clustering patterns. That suggests that the skin microbiome is not involved in alopecia areata, Dr. Chen said.

Finally, the investigators transferred NKG2D+ CD8+ T cells from the cutaneous lymph nodes of alopecic mice to normal mice that had been pretreated with antibiotics. The treated mice had little infiltration of these T cells into the skin, and lower overall T-cell levels than control mice, Dr. Chen reported.

The investigators are now testing combinations of antibiotics and fecal transplants to pinpoint which gut bacteria make mice susceptible to hair loss. Doing so “will have significant implications on both our understanding of alopecia areata susceptibility, as well as actionable therapeutic targets for treatment” in humans, Dr. Chen said.

The study was funded by the National Institutes of Health, the Medical Research Council, the Dermatology Foundation, Locks of Love Foundation, and NYSTEM (New York State Stem Cell Science). Dr. Chen had no financial disclosures.

SCOTTSDALE, ARIZ. – Wiping out the gut microbiome with antibiotics prevented alopecia areata in a study of mice, providing evidence that the gut microbiome may play a role in alopecia, Dr. James Chen reported at the annual meeting of the Society for Investigative Dermatology.

The finding shows that the bacterial culprits in alopecia “reside in the gut microbiome, and not in the skin,” said Dr. Chen, a postdoctoral research fellow in medical genetics at Columbia University, New York.

Alopecia areata is mediated by autoreactive NKG2D+ CD8+ T cells. Aberrations in the human microbiome underlie several other autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and type I diabetes, Dr. Chen noted. “The gut microbiome also has been linked to skin conditions, such as acne, psoriasis, and atopic dermatitis,” he added. “So we asked, if we deplete this microbiome with an antibiotic cocktail, do we see an effect on alopecia?”

To find out, he and his coinvestigators grafted skin from C3H/Hej mice, which spontaneously develop alopecia, onto healthy younger mice, causing them to develop alopecia 6-10 weeks later. “Strikingly, we found that treating unaffected mice with an oral antibiotic cocktail prior to grafting completely prevented the development of alopecia areata, and this remained true through 15 weeks,” he said. “This is the first evidence that the gut microbiome could be implicated in alopecia, based on the absence of the phenotype that we see in treated mice.”

The researchers also evaluated whether the skin microbiomes of antibiotic-treated and control mice differed, and determined that the skin samples resembled each other in terms of overall bacterial load and bacterial taxonomic clustering patterns. That suggests that the skin microbiome is not involved in alopecia areata, Dr. Chen said.

Finally, the investigators transferred NKG2D+ CD8+ T cells from the cutaneous lymph nodes of alopecic mice to normal mice that had been pretreated with antibiotics. The treated mice had little infiltration of these T cells into the skin, and lower overall T-cell levels than control mice, Dr. Chen reported.

The investigators are now testing combinations of antibiotics and fecal transplants to pinpoint which gut bacteria make mice susceptible to hair loss. Doing so “will have significant implications on both our understanding of alopecia areata susceptibility, as well as actionable therapeutic targets for treatment” in humans, Dr. Chen said.

The study was funded by the National Institutes of Health, the Medical Research Council, the Dermatology Foundation, Locks of Love Foundation, and NYSTEM (New York State Stem Cell Science). Dr. Chen had no financial disclosures.