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Melanoma Sinks Hook Into Coral Reef Trout
Riddle me this: How is a fish like a canary?
As you know, miners used canaries underground, where they functioned as warning systems – when toxic gases leaked into the shaft, the birds would die, signaling a need for the minors to leave the shaft.
Today, it seems prudent to heed the plight of the Great Barrier Reef coral trout, Plectropomus leopardus.
According to Dr. Michael Sweet, a marine research associate at Newcastle (Australia) University, 15% of coral trout caught in two reef locations in Australia were found to have skin cancer. This is the first report of melanoma occurring in a wild fish population, he noted.
Coral trout are a valuable food and sport fish that live at a depth of up to 30 m in unpolluted, clear water – well within the 60-m reach of Australia’s strong UVB radiation, wrote Dr. Sweet.
Several decades ago, there was no problem. But today, a hovering ozone hole seems to have compromised the fish’s health, he noted.
After he heard of coral trout with dark skin lesions, Dr. Sweet went reef fishing. He and his colleagues pulled in 136; 20 of the fish showed visible skin lesions that were raised and darkly pigmented. He took samples from each fish and tested them for microbial, fungal, and parasitic infections (PLoS ONE 2012 Aug. 1 [doi: 10.1371/journal.pone.0041989])
The fish had no infections or disease. But, histologically, they showed disorganized pleomorphic cells, melanocytes, epithelioid-like cells, melanophores, and macromelanophore cells, consistent with lesions induced in a fish cancer model.
The fishes’ behavior seemed unaffected, and all the lesions appeared to be stage I or II. But that isn’t necessarily reassuring, Dr. Sweet reported. Fish exhibiting stage III, IV, or V cancers may show behavioral differences in the wild and may, therefore, have not been caught.
So – other than a general concern for the health of the Great Barrier Reef – why should we care about wild fish developing melanoma?
Jen Makin, a research and evaluation manager for Australia’s SunSmart program, cited unsettling figures about the Australian UV situation and skin cancer (Health Promot. J. Austr. 2011;22:S39-41).
"It is estimated that nearly 450,000 Australians get skin cancer every year," she wrote – 95% of the cancers are directly related to UV radiation.
The ozone layer is slowly recovering its health, but an ever-hotter Earth may undo that skin-protecting change. "Before recovery, it is expected that higher levels of UV radiation will continue in most Australian regions, with an associated higher risk of skin cancer. Indeed, recent data show increases in surface UV radiation throughout Australia since the 1970s. Second, mean temperatures in Australia have increased over the past 30 years and are projected to rise further by 2030," she wrote.
In hot weather, adults spend more time outdoors, are less likely to cover up, and are more likely to get burned. And – as the coral trout have proved – there seem to be few places to hide.
–Michele Sullivan (on Twitter @Alz_Gal)
Riddle me this: How is a fish like a canary?
As you know, miners used canaries underground, where they functioned as warning systems – when toxic gases leaked into the shaft, the birds would die, signaling a need for the minors to leave the shaft.
Today, it seems prudent to heed the plight of the Great Barrier Reef coral trout, Plectropomus leopardus.
According to Dr. Michael Sweet, a marine research associate at Newcastle (Australia) University, 15% of coral trout caught in two reef locations in Australia were found to have skin cancer. This is the first report of melanoma occurring in a wild fish population, he noted.
Coral trout are a valuable food and sport fish that live at a depth of up to 30 m in unpolluted, clear water – well within the 60-m reach of Australia’s strong UVB radiation, wrote Dr. Sweet.
Several decades ago, there was no problem. But today, a hovering ozone hole seems to have compromised the fish’s health, he noted.
After he heard of coral trout with dark skin lesions, Dr. Sweet went reef fishing. He and his colleagues pulled in 136; 20 of the fish showed visible skin lesions that were raised and darkly pigmented. He took samples from each fish and tested them for microbial, fungal, and parasitic infections (PLoS ONE 2012 Aug. 1 [doi: 10.1371/journal.pone.0041989])
The fish had no infections or disease. But, histologically, they showed disorganized pleomorphic cells, melanocytes, epithelioid-like cells, melanophores, and macromelanophore cells, consistent with lesions induced in a fish cancer model.
The fishes’ behavior seemed unaffected, and all the lesions appeared to be stage I or II. But that isn’t necessarily reassuring, Dr. Sweet reported. Fish exhibiting stage III, IV, or V cancers may show behavioral differences in the wild and may, therefore, have not been caught.
So – other than a general concern for the health of the Great Barrier Reef – why should we care about wild fish developing melanoma?
Jen Makin, a research and evaluation manager for Australia’s SunSmart program, cited unsettling figures about the Australian UV situation and skin cancer (Health Promot. J. Austr. 2011;22:S39-41).
"It is estimated that nearly 450,000 Australians get skin cancer every year," she wrote – 95% of the cancers are directly related to UV radiation.
The ozone layer is slowly recovering its health, but an ever-hotter Earth may undo that skin-protecting change. "Before recovery, it is expected that higher levels of UV radiation will continue in most Australian regions, with an associated higher risk of skin cancer. Indeed, recent data show increases in surface UV radiation throughout Australia since the 1970s. Second, mean temperatures in Australia have increased over the past 30 years and are projected to rise further by 2030," she wrote.
In hot weather, adults spend more time outdoors, are less likely to cover up, and are more likely to get burned. And – as the coral trout have proved – there seem to be few places to hide.
–Michele Sullivan (on Twitter @Alz_Gal)
Riddle me this: How is a fish like a canary?
As you know, miners used canaries underground, where they functioned as warning systems – when toxic gases leaked into the shaft, the birds would die, signaling a need for the minors to leave the shaft.
Today, it seems prudent to heed the plight of the Great Barrier Reef coral trout, Plectropomus leopardus.
According to Dr. Michael Sweet, a marine research associate at Newcastle (Australia) University, 15% of coral trout caught in two reef locations in Australia were found to have skin cancer. This is the first report of melanoma occurring in a wild fish population, he noted.
Coral trout are a valuable food and sport fish that live at a depth of up to 30 m in unpolluted, clear water – well within the 60-m reach of Australia’s strong UVB radiation, wrote Dr. Sweet.
Several decades ago, there was no problem. But today, a hovering ozone hole seems to have compromised the fish’s health, he noted.
After he heard of coral trout with dark skin lesions, Dr. Sweet went reef fishing. He and his colleagues pulled in 136; 20 of the fish showed visible skin lesions that were raised and darkly pigmented. He took samples from each fish and tested them for microbial, fungal, and parasitic infections (PLoS ONE 2012 Aug. 1 [doi: 10.1371/journal.pone.0041989])
The fish had no infections or disease. But, histologically, they showed disorganized pleomorphic cells, melanocytes, epithelioid-like cells, melanophores, and macromelanophore cells, consistent with lesions induced in a fish cancer model.
The fishes’ behavior seemed unaffected, and all the lesions appeared to be stage I or II. But that isn’t necessarily reassuring, Dr. Sweet reported. Fish exhibiting stage III, IV, or V cancers may show behavioral differences in the wild and may, therefore, have not been caught.
So – other than a general concern for the health of the Great Barrier Reef – why should we care about wild fish developing melanoma?
Jen Makin, a research and evaluation manager for Australia’s SunSmart program, cited unsettling figures about the Australian UV situation and skin cancer (Health Promot. J. Austr. 2011;22:S39-41).
"It is estimated that nearly 450,000 Australians get skin cancer every year," she wrote – 95% of the cancers are directly related to UV radiation.
The ozone layer is slowly recovering its health, but an ever-hotter Earth may undo that skin-protecting change. "Before recovery, it is expected that higher levels of UV radiation will continue in most Australian regions, with an associated higher risk of skin cancer. Indeed, recent data show increases in surface UV radiation throughout Australia since the 1970s. Second, mean temperatures in Australia have increased over the past 30 years and are projected to rise further by 2030," she wrote.
In hot weather, adults spend more time outdoors, are less likely to cover up, and are more likely to get burned. And – as the coral trout have proved – there seem to be few places to hide.
–Michele Sullivan (on Twitter @Alz_Gal)
Pregnancy-Related Cancers: Rise Is Largely Unrelated to Delayed Childbearing
MINNEAPOLIS – Pregnancy-associated cancers are increasing, although the phenomenon of delayed childbirth is only partially responsible, researchers suggest.
From 1994 to 2008, the crude incidence of pregnancy-associated cancer increased from 112 to 192 per 100,000 pregnancies (P less than .001) in an analysis of 787,907 Australian women.
During the same period, the number of Australian mothers aged 35 years or more nearly doubled from 13% to 24%, including an increase from 2% to 4% of mothers over age 40, Christine L. Roberts, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.
After the cancer rate was standardized to the age of the 1994 population, however, only 14% of the increase in cancer was explained by increasing maternal age, said Dr. Roberts of the University of Sydney, New South Wales, Australia.
"Improved diagnostic techniques, detection, and interracial health services likely contribute to the unexplained portion," she said. "The increasing incidence of cancer confirmed a clinical impression that obstetricians were seeing women with cancer more frequently, although of course it remains uncommon."
The growing number of women postponing childbearing has raised concerns that the incidence of pregnancy-associated cancer would rise. The incidence is generally reported to be about 1 in 1,000 pregnancies, but estimates based largely on cancer reports have been imprecise, Dr. Roberts said.
The investigators obtained cancer and maternal information from linked cancer registry, birth, and hospital records for 1.31 million pregnancies and 1.33 million infants among 781,907 women in Australia.
During the study period, 1,798 women had a new cancer diagnosis: 499 during pregnancy and 1,299 within 12 months of delivery. This equates to 137.3 cancers per 100,000 pregnancies, Dr. Roberts said.
There were 42 cancer deaths, or 3.2 deaths per 100,000 pregnancies.
The highest proportion of cancers (14.5%) was diagnosed in the first 2 months post partum, lending support to the rationale that women and physicians may incorrectly attribute cancer-related symptoms to the physiologic changes of pregnancy and may be reluctant to use radiographs or invasive procedures during pregnancy, she observed.
The cancers were predominantly melanoma (599) or breast cancer (377), followed by thyroid/endocrine (228) and lymphohematopoietic (151) cancers.
Melanoma was twice as likely to be observed in pregnant women as in women of similar reproductive age (observed to expected ratio, 2.2), according to the authors, led by Dr. Yuen Yi (Cathy) Lee of the New South Wales Ministry of Health in North Sydney, Australia.
In prior studies, breast and thyroid cancer were the most common pregnancy-related cancers in California in the 1990s (Am. J. Obstet. Gynecol. 2003;189:1128-35), whereas more recently, melanoma and cervical cancer were the most common cancers during pregnancy in Norway (J. Clin. Oncol. 2009;27:45-51), Dr. Roberts noted.
In logistic regression analysis adjusted for age, country of birth, socioeconomic status, rural residence, parity, plurality, previous cancer, and assisted reproductive technology, significant risk factors for a pregnancy-associated cancer were previous cancer diagnosis (adjusted odds ratio, 3.8), multiple pregnancy (OR, 1.5), age 30-34 years (OR, 2.1), age 35-39 years (OR, 3.0), and age 40 years or older (OR, 3.6).
Women with a cancer diagnosis had a significantly higher risk of thromboembolic events (OR, 10.2), sepsis (OR, 4.3), and life-threatening maternal morbidity (OR, 6.9) after adjustment for maternal age, socioeconomic status, plurality, parity, previous preterm birth, diabetes, and hypertension.
A novel finding was that cancer during pregnancy also was associated with large-for-gestational age infants (OR, 1.5), said Dr. Roberts, who pointed out that large-for-gestational age is also a risk factor for pediatric cancer.
"Elevated levels of maternal hormone angiogenic factors during pregnancy may influence both infant size and tumor growth," she speculated.
Dr. Roberts said there is an Australian national policy on cervical screening recommending that Pap smears be offered to every woman presenting for antenatal care who has not had cervical screening within the past 2 years; however, this was introduced in 2008 at the end of the study period. "We are not aware of other policies for screening during pregnancy," she added.
Full details of the study are expected to be published in the coming weeks (BJOG 2012 [doi: 10.111/j.1471-0528.2012.03475.x]).
The authors report no conflicts of interest.
postponing childbearing, pregnancy-associated cancer,
MINNEAPOLIS – Pregnancy-associated cancers are increasing, although the phenomenon of delayed childbirth is only partially responsible, researchers suggest.
From 1994 to 2008, the crude incidence of pregnancy-associated cancer increased from 112 to 192 per 100,000 pregnancies (P less than .001) in an analysis of 787,907 Australian women.
During the same period, the number of Australian mothers aged 35 years or more nearly doubled from 13% to 24%, including an increase from 2% to 4% of mothers over age 40, Christine L. Roberts, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.
After the cancer rate was standardized to the age of the 1994 population, however, only 14% of the increase in cancer was explained by increasing maternal age, said Dr. Roberts of the University of Sydney, New South Wales, Australia.
"Improved diagnostic techniques, detection, and interracial health services likely contribute to the unexplained portion," she said. "The increasing incidence of cancer confirmed a clinical impression that obstetricians were seeing women with cancer more frequently, although of course it remains uncommon."
The growing number of women postponing childbearing has raised concerns that the incidence of pregnancy-associated cancer would rise. The incidence is generally reported to be about 1 in 1,000 pregnancies, but estimates based largely on cancer reports have been imprecise, Dr. Roberts said.
The investigators obtained cancer and maternal information from linked cancer registry, birth, and hospital records for 1.31 million pregnancies and 1.33 million infants among 781,907 women in Australia.
During the study period, 1,798 women had a new cancer diagnosis: 499 during pregnancy and 1,299 within 12 months of delivery. This equates to 137.3 cancers per 100,000 pregnancies, Dr. Roberts said.
There were 42 cancer deaths, or 3.2 deaths per 100,000 pregnancies.
The highest proportion of cancers (14.5%) was diagnosed in the first 2 months post partum, lending support to the rationale that women and physicians may incorrectly attribute cancer-related symptoms to the physiologic changes of pregnancy and may be reluctant to use radiographs or invasive procedures during pregnancy, she observed.
The cancers were predominantly melanoma (599) or breast cancer (377), followed by thyroid/endocrine (228) and lymphohematopoietic (151) cancers.
Melanoma was twice as likely to be observed in pregnant women as in women of similar reproductive age (observed to expected ratio, 2.2), according to the authors, led by Dr. Yuen Yi (Cathy) Lee of the New South Wales Ministry of Health in North Sydney, Australia.
In prior studies, breast and thyroid cancer were the most common pregnancy-related cancers in California in the 1990s (Am. J. Obstet. Gynecol. 2003;189:1128-35), whereas more recently, melanoma and cervical cancer were the most common cancers during pregnancy in Norway (J. Clin. Oncol. 2009;27:45-51), Dr. Roberts noted.
In logistic regression analysis adjusted for age, country of birth, socioeconomic status, rural residence, parity, plurality, previous cancer, and assisted reproductive technology, significant risk factors for a pregnancy-associated cancer were previous cancer diagnosis (adjusted odds ratio, 3.8), multiple pregnancy (OR, 1.5), age 30-34 years (OR, 2.1), age 35-39 years (OR, 3.0), and age 40 years or older (OR, 3.6).
Women with a cancer diagnosis had a significantly higher risk of thromboembolic events (OR, 10.2), sepsis (OR, 4.3), and life-threatening maternal morbidity (OR, 6.9) after adjustment for maternal age, socioeconomic status, plurality, parity, previous preterm birth, diabetes, and hypertension.
A novel finding was that cancer during pregnancy also was associated with large-for-gestational age infants (OR, 1.5), said Dr. Roberts, who pointed out that large-for-gestational age is also a risk factor for pediatric cancer.
"Elevated levels of maternal hormone angiogenic factors during pregnancy may influence both infant size and tumor growth," she speculated.
Dr. Roberts said there is an Australian national policy on cervical screening recommending that Pap smears be offered to every woman presenting for antenatal care who has not had cervical screening within the past 2 years; however, this was introduced in 2008 at the end of the study period. "We are not aware of other policies for screening during pregnancy," she added.
Full details of the study are expected to be published in the coming weeks (BJOG 2012 [doi: 10.111/j.1471-0528.2012.03475.x]).
The authors report no conflicts of interest.
MINNEAPOLIS – Pregnancy-associated cancers are increasing, although the phenomenon of delayed childbirth is only partially responsible, researchers suggest.
From 1994 to 2008, the crude incidence of pregnancy-associated cancer increased from 112 to 192 per 100,000 pregnancies (P less than .001) in an analysis of 787,907 Australian women.
During the same period, the number of Australian mothers aged 35 years or more nearly doubled from 13% to 24%, including an increase from 2% to 4% of mothers over age 40, Christine L. Roberts, Ph.D., said at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.
After the cancer rate was standardized to the age of the 1994 population, however, only 14% of the increase in cancer was explained by increasing maternal age, said Dr. Roberts of the University of Sydney, New South Wales, Australia.
"Improved diagnostic techniques, detection, and interracial health services likely contribute to the unexplained portion," she said. "The increasing incidence of cancer confirmed a clinical impression that obstetricians were seeing women with cancer more frequently, although of course it remains uncommon."
The growing number of women postponing childbearing has raised concerns that the incidence of pregnancy-associated cancer would rise. The incidence is generally reported to be about 1 in 1,000 pregnancies, but estimates based largely on cancer reports have been imprecise, Dr. Roberts said.
The investigators obtained cancer and maternal information from linked cancer registry, birth, and hospital records for 1.31 million pregnancies and 1.33 million infants among 781,907 women in Australia.
During the study period, 1,798 women had a new cancer diagnosis: 499 during pregnancy and 1,299 within 12 months of delivery. This equates to 137.3 cancers per 100,000 pregnancies, Dr. Roberts said.
There were 42 cancer deaths, or 3.2 deaths per 100,000 pregnancies.
The highest proportion of cancers (14.5%) was diagnosed in the first 2 months post partum, lending support to the rationale that women and physicians may incorrectly attribute cancer-related symptoms to the physiologic changes of pregnancy and may be reluctant to use radiographs or invasive procedures during pregnancy, she observed.
The cancers were predominantly melanoma (599) or breast cancer (377), followed by thyroid/endocrine (228) and lymphohematopoietic (151) cancers.
Melanoma was twice as likely to be observed in pregnant women as in women of similar reproductive age (observed to expected ratio, 2.2), according to the authors, led by Dr. Yuen Yi (Cathy) Lee of the New South Wales Ministry of Health in North Sydney, Australia.
In prior studies, breast and thyroid cancer were the most common pregnancy-related cancers in California in the 1990s (Am. J. Obstet. Gynecol. 2003;189:1128-35), whereas more recently, melanoma and cervical cancer were the most common cancers during pregnancy in Norway (J. Clin. Oncol. 2009;27:45-51), Dr. Roberts noted.
In logistic regression analysis adjusted for age, country of birth, socioeconomic status, rural residence, parity, plurality, previous cancer, and assisted reproductive technology, significant risk factors for a pregnancy-associated cancer were previous cancer diagnosis (adjusted odds ratio, 3.8), multiple pregnancy (OR, 1.5), age 30-34 years (OR, 2.1), age 35-39 years (OR, 3.0), and age 40 years or older (OR, 3.6).
Women with a cancer diagnosis had a significantly higher risk of thromboembolic events (OR, 10.2), sepsis (OR, 4.3), and life-threatening maternal morbidity (OR, 6.9) after adjustment for maternal age, socioeconomic status, plurality, parity, previous preterm birth, diabetes, and hypertension.
A novel finding was that cancer during pregnancy also was associated with large-for-gestational age infants (OR, 1.5), said Dr. Roberts, who pointed out that large-for-gestational age is also a risk factor for pediatric cancer.
"Elevated levels of maternal hormone angiogenic factors during pregnancy may influence both infant size and tumor growth," she speculated.
Dr. Roberts said there is an Australian national policy on cervical screening recommending that Pap smears be offered to every woman presenting for antenatal care who has not had cervical screening within the past 2 years; however, this was introduced in 2008 at the end of the study period. "We are not aware of other policies for screening during pregnancy," she added.
Full details of the study are expected to be published in the coming weeks (BJOG 2012 [doi: 10.111/j.1471-0528.2012.03475.x]).
The authors report no conflicts of interest.
postponing childbearing, pregnancy-associated cancer,
postponing childbearing, pregnancy-associated cancer,
AT THE ANNUAL MEETING OF THE SOCIETY FOR PEDIATRIC AND PERINATAL EPIDEMIOLOGIC RESEARCH
A Musical Marketing Plan: The Skinny Podcast
In this month's program, Dr. Jeffrey Curtis discusses his study, which found new evidence supporting the safety of the shingles vaccine for patients on biologics.
Then, Dr. Jonathan Silverberg talks about the best climates for children with eczema.
Dr. Bruce Brod of the American Academy of Dermatology reports on which states have the toughest laws on indoor tanning, and he highlights the latest legislation on the matter.
Meanwhile, Dr. Lily Talakoub talks about a common summer skin condition, Pityrosporum folliculitis, and Dr. Alan Rockoff presents his musical marketing plan.
Don't miss another episode of The Skinny Podcast; subscribe for free on iTunes!
In this month's program, Dr. Jeffrey Curtis discusses his study, which found new evidence supporting the safety of the shingles vaccine for patients on biologics.
Then, Dr. Jonathan Silverberg talks about the best climates for children with eczema.
Dr. Bruce Brod of the American Academy of Dermatology reports on which states have the toughest laws on indoor tanning, and he highlights the latest legislation on the matter.
Meanwhile, Dr. Lily Talakoub talks about a common summer skin condition, Pityrosporum folliculitis, and Dr. Alan Rockoff presents his musical marketing plan.
Don't miss another episode of The Skinny Podcast; subscribe for free on iTunes!
In this month's program, Dr. Jeffrey Curtis discusses his study, which found new evidence supporting the safety of the shingles vaccine for patients on biologics.
Then, Dr. Jonathan Silverberg talks about the best climates for children with eczema.
Dr. Bruce Brod of the American Academy of Dermatology reports on which states have the toughest laws on indoor tanning, and he highlights the latest legislation on the matter.
Meanwhile, Dr. Lily Talakoub talks about a common summer skin condition, Pityrosporum folliculitis, and Dr. Alan Rockoff presents his musical marketing plan.
Don't miss another episode of The Skinny Podcast; subscribe for free on iTunes!
Let Lip Defect Size Drive Treatment
SAN DIEGO – Principles for lip repair are based on size and location of the defect, etiology of the lesions, and patient age and gender, said Dr. Michael A. Keefe.
Surgical goals of lip reconstruction are to cover the skin and oral lining, leave a semblance of a vermilion and an adequate stomal diameter, make sure sensation is intact, and ensure that the patient has a competent oral sphincter. "The vermilion is the most visible component of the lips, and it’s also the sensory unit of the lip," Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery. The meeting was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic.
"Scars are very well hidden at the vermilion-cutaneous border. If you have to cross the vermilion-cutaneous junction, cross at 90 degrees."
Lower Lip
The lower vermilion is the most affected target of solar radiation injury. In cases of premalignant lesions such as actinic cheilitis or leukoplakia, Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego, said he often performs a total vermilionectomy (lip shave). This involves resection from the white roll to the contact area with opposite lip. "Primary closure is possible," he said. "You can get tension and dehiscence and flattening of the lip, but generally it heals up pretty well. An option for vermilion reconstruction of larger defects is the buccal mucosal advancement flap, which involves elevating the mucosa deep to salivary glands and superficial to the orbicularis oris muscle."
An advantage of treating the lower lip is that there is increased soft tissue laxity and there is no Cupid’s bow, philtrum, or nose, "so it’s nice that there are no dominant central structures," he said. "The downside is that you have to be mindful of the effect of gravity on the repair, so there is a greater need for tone to prevent drooling and incompetence."
He recommends a staged approach based on the extent of the defect and the age of the patient. For small defects (those less than one-third of the lip size) he uses primary closure. Options for medium defects (those that involve one-third to two-thirds of the lip size) include the Estlander flap, the Abbe flap, Bernard Burow’s procedure, the Karapandzic flap, and the stairstep repair, while the options for large defects (those that involve more than two-thirds of the lip size) include Bernard Burow’s procedure, the Karapandzic flap, and the free flap. "You have a lot of tools, depending on what you feel comfortable with," Dr. Keefe said.
Upper Lip
Cancerous tumors of the upper lip are less common, "but there are some unique structures to pay attention to, including the nose, columella, Cupid’s bow, and the philtrum," he said. "In men there’s a hair-bearing skin issue, but scars can be disguised in a mustache."
The aesthetic subunits to keep in mind, he continued, are the medial subunit, which is one-half of the philtrum, and the lateral subunit, which consists of the philtral column, the nostril sill, the alar base, and the nasolabial crease. Primary closure is used for upper lip defects that involve less than one-third of the lip size. "You can make some perialar crescentic skin excisions, which can help advance things," Dr. Keefe said.
For centrally located medium-sized defects of the upper lip, he often uses primary closure with perialar crescentic skin excisions. "If it’s greater than one-half of the lip size, you can add an Abbe flap," he said. "That’s nice because that recreates the philtrum area."
For medially located medium-sized defects of the upper lip, "you can use the Abbe flap if the commissure is not involved and the Estlander flap if the commissure is involved."
Options for cases with large defects and adequate cheek tissue, he said, include the reverse Karapandzic flap, the reverse fan flap, inverted Bernard Burow’s procedure, superiorly based cheek flaps, and the bilateral levator anguli oris flap combined with the Abbe flap. Options for cases with inadequate cheek tissue include the distal pedicle flap and the free flap.
Repair Risks
A lot of these patients have medical problems," he said. "When you do your first injection to resect the tumor or put the lip back together, make sure you don’t cause a myocardial infarction. Generally you should be comfortable with patients who have an INR [International Normalized Ratio] of 2.5 and below."
For patients with large cancerous tumors of the lip, be mindful of lymphatic drainage, because larger tumors have an increased risk of metastases, said Dr. Keefe. For tumors larger than 2 cm in length or 6 mm in spread, or if there is perineural spread, the patient should be referred for radiation therapy.
Dr. Keefe said that he had no relevant financial conflicts to disclose.
SAN DIEGO – Principles for lip repair are based on size and location of the defect, etiology of the lesions, and patient age and gender, said Dr. Michael A. Keefe.
Surgical goals of lip reconstruction are to cover the skin and oral lining, leave a semblance of a vermilion and an adequate stomal diameter, make sure sensation is intact, and ensure that the patient has a competent oral sphincter. "The vermilion is the most visible component of the lips, and it’s also the sensory unit of the lip," Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery. The meeting was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic.
"Scars are very well hidden at the vermilion-cutaneous border. If you have to cross the vermilion-cutaneous junction, cross at 90 degrees."
Lower Lip
The lower vermilion is the most affected target of solar radiation injury. In cases of premalignant lesions such as actinic cheilitis or leukoplakia, Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego, said he often performs a total vermilionectomy (lip shave). This involves resection from the white roll to the contact area with opposite lip. "Primary closure is possible," he said. "You can get tension and dehiscence and flattening of the lip, but generally it heals up pretty well. An option for vermilion reconstruction of larger defects is the buccal mucosal advancement flap, which involves elevating the mucosa deep to salivary glands and superficial to the orbicularis oris muscle."
An advantage of treating the lower lip is that there is increased soft tissue laxity and there is no Cupid’s bow, philtrum, or nose, "so it’s nice that there are no dominant central structures," he said. "The downside is that you have to be mindful of the effect of gravity on the repair, so there is a greater need for tone to prevent drooling and incompetence."
He recommends a staged approach based on the extent of the defect and the age of the patient. For small defects (those less than one-third of the lip size) he uses primary closure. Options for medium defects (those that involve one-third to two-thirds of the lip size) include the Estlander flap, the Abbe flap, Bernard Burow’s procedure, the Karapandzic flap, and the stairstep repair, while the options for large defects (those that involve more than two-thirds of the lip size) include Bernard Burow’s procedure, the Karapandzic flap, and the free flap. "You have a lot of tools, depending on what you feel comfortable with," Dr. Keefe said.
Upper Lip
Cancerous tumors of the upper lip are less common, "but there are some unique structures to pay attention to, including the nose, columella, Cupid’s bow, and the philtrum," he said. "In men there’s a hair-bearing skin issue, but scars can be disguised in a mustache."
The aesthetic subunits to keep in mind, he continued, are the medial subunit, which is one-half of the philtrum, and the lateral subunit, which consists of the philtral column, the nostril sill, the alar base, and the nasolabial crease. Primary closure is used for upper lip defects that involve less than one-third of the lip size. "You can make some perialar crescentic skin excisions, which can help advance things," Dr. Keefe said.
For centrally located medium-sized defects of the upper lip, he often uses primary closure with perialar crescentic skin excisions. "If it’s greater than one-half of the lip size, you can add an Abbe flap," he said. "That’s nice because that recreates the philtrum area."
For medially located medium-sized defects of the upper lip, "you can use the Abbe flap if the commissure is not involved and the Estlander flap if the commissure is involved."
Options for cases with large defects and adequate cheek tissue, he said, include the reverse Karapandzic flap, the reverse fan flap, inverted Bernard Burow’s procedure, superiorly based cheek flaps, and the bilateral levator anguli oris flap combined with the Abbe flap. Options for cases with inadequate cheek tissue include the distal pedicle flap and the free flap.
Repair Risks
A lot of these patients have medical problems," he said. "When you do your first injection to resect the tumor or put the lip back together, make sure you don’t cause a myocardial infarction. Generally you should be comfortable with patients who have an INR [International Normalized Ratio] of 2.5 and below."
For patients with large cancerous tumors of the lip, be mindful of lymphatic drainage, because larger tumors have an increased risk of metastases, said Dr. Keefe. For tumors larger than 2 cm in length or 6 mm in spread, or if there is perineural spread, the patient should be referred for radiation therapy.
Dr. Keefe said that he had no relevant financial conflicts to disclose.
SAN DIEGO – Principles for lip repair are based on size and location of the defect, etiology of the lesions, and patient age and gender, said Dr. Michael A. Keefe.
Surgical goals of lip reconstruction are to cover the skin and oral lining, leave a semblance of a vermilion and an adequate stomal diameter, make sure sensation is intact, and ensure that the patient has a competent oral sphincter. "The vermilion is the most visible component of the lips, and it’s also the sensory unit of the lip," Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery. The meeting was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic.
"Scars are very well hidden at the vermilion-cutaneous border. If you have to cross the vermilion-cutaneous junction, cross at 90 degrees."
Lower Lip
The lower vermilion is the most affected target of solar radiation injury. In cases of premalignant lesions such as actinic cheilitis or leukoplakia, Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego, said he often performs a total vermilionectomy (lip shave). This involves resection from the white roll to the contact area with opposite lip. "Primary closure is possible," he said. "You can get tension and dehiscence and flattening of the lip, but generally it heals up pretty well. An option for vermilion reconstruction of larger defects is the buccal mucosal advancement flap, which involves elevating the mucosa deep to salivary glands and superficial to the orbicularis oris muscle."
An advantage of treating the lower lip is that there is increased soft tissue laxity and there is no Cupid’s bow, philtrum, or nose, "so it’s nice that there are no dominant central structures," he said. "The downside is that you have to be mindful of the effect of gravity on the repair, so there is a greater need for tone to prevent drooling and incompetence."
He recommends a staged approach based on the extent of the defect and the age of the patient. For small defects (those less than one-third of the lip size) he uses primary closure. Options for medium defects (those that involve one-third to two-thirds of the lip size) include the Estlander flap, the Abbe flap, Bernard Burow’s procedure, the Karapandzic flap, and the stairstep repair, while the options for large defects (those that involve more than two-thirds of the lip size) include Bernard Burow’s procedure, the Karapandzic flap, and the free flap. "You have a lot of tools, depending on what you feel comfortable with," Dr. Keefe said.
Upper Lip
Cancerous tumors of the upper lip are less common, "but there are some unique structures to pay attention to, including the nose, columella, Cupid’s bow, and the philtrum," he said. "In men there’s a hair-bearing skin issue, but scars can be disguised in a mustache."
The aesthetic subunits to keep in mind, he continued, are the medial subunit, which is one-half of the philtrum, and the lateral subunit, which consists of the philtral column, the nostril sill, the alar base, and the nasolabial crease. Primary closure is used for upper lip defects that involve less than one-third of the lip size. "You can make some perialar crescentic skin excisions, which can help advance things," Dr. Keefe said.
For centrally located medium-sized defects of the upper lip, he often uses primary closure with perialar crescentic skin excisions. "If it’s greater than one-half of the lip size, you can add an Abbe flap," he said. "That’s nice because that recreates the philtrum area."
For medially located medium-sized defects of the upper lip, "you can use the Abbe flap if the commissure is not involved and the Estlander flap if the commissure is involved."
Options for cases with large defects and adequate cheek tissue, he said, include the reverse Karapandzic flap, the reverse fan flap, inverted Bernard Burow’s procedure, superiorly based cheek flaps, and the bilateral levator anguli oris flap combined with the Abbe flap. Options for cases with inadequate cheek tissue include the distal pedicle flap and the free flap.
Repair Risks
A lot of these patients have medical problems," he said. "When you do your first injection to resect the tumor or put the lip back together, make sure you don’t cause a myocardial infarction. Generally you should be comfortable with patients who have an INR [International Normalized Ratio] of 2.5 and below."
For patients with large cancerous tumors of the lip, be mindful of lymphatic drainage, because larger tumors have an increased risk of metastases, said Dr. Keefe. For tumors larger than 2 cm in length or 6 mm in spread, or if there is perineural spread, the patient should be referred for radiation therapy.
Dr. Keefe said that he had no relevant financial conflicts to disclose.
AT A MEETING ON SUPERFICIAL ANATOMY AND CUTANEOUS SURGERY
Blood Pressure Meds Linked to Lip Cancer
Commonly used photosensitizing antihypertensive drugs increase the risk for lip cancer by two- to fourfold, according to a study published online Aug. 6 in Archives of Internal Medicine.
"Lip cancer is rare, and an increased risk of its development is generally outweighed by the benefits of drugs that are effective for other conditions. However, physicians prescribing photosensitizing drugs should ascertain whether patients are at high risk of lip cancer because of their fair skin and long-term sun exposure, and discuss lip protection with them," wrote Dr. Gary D. Friedman of the division of research, Kaiser Permanente Medical Care Program, Oakland Calif., and his colleagues. "Likely preventive measures are simple: a hat with a sufficiently wide brim to shade the lips, and lip sunscreens," they added.
The diuretics hydrochlorothiazide and hydrochlorothiazide-triamterene, as well as the calcium channel blocker nifedipine, were associated with at least a doubling in the risk for lip cancer in a study involving 23,616 hypertensive non-Hispanic white adults. The association between lip cancer and the ACE inhibitor lisinopril, which also is photosensitizing, was characterized as "equivocal." And atenolol, a beta-adrenergic blocker that is not photosensitizing, was not linked to a higher risk.
Dr. Friedman and his colleagues used prescription data from the Kaiser Permanente pharmacy database and information from its cancer registry to perform a case-control study examining the relationship between the four classes of antihypertensive medications and lip cancer. They assessed the period from 1994 through 2008. The database includes an ethnically and socioeconomically diverse population of residents in the San Francisco and central valley regions of California.
There were few cases of lip cancer among nonwhite patients, so the analysis was restricted to white patients. Those with human immunodeficiency virus infection and those taking immunosuppressants after receiving organ transplants also were excluded because these factors were likely to be confounders.
The study population comprised 712 patients with lip cancer and 22,904 age-matched control patients. Nearly all malignancies were squamous cell. As expected, cigarette smokers in both study groups were more likely than nonsmokers to develop lip cancer.
The risk of developing lip cancer showed a dose-response relationship with the use of certain antihypertensive drugs, with the risk increasing as the duration of drug use increased. For patients treated with hydrochlorothiazide for 5 years or more, the odds ratio of developing lip cancer was 4.22. The OR for the combination drug hydrochlorothiazide-triamterene was 2.82, and the OR for nifedipine was 2.50. The OR was of borderline significance for lisinopril (1.42).
In contrast, for patients treated with atenolol for 5 years or more, the risk of developing lip cancer was reduced, with an odds ratio of 0.54, the investigators reported (Arch. Intern. Med. 2012 Aug. 6 [doi:10.1001/archinternmed.2012.2754]).
It should not be surprising that previous large clinical trials of these drugs’ efficacy failed to find an association with lip cancer, because of the rarity of the malignancy, they added.
For example, one study of antihypertensive medications involved more than 33,000 patients followed for a mean of 5 years. And after the investigators excluded the nonwhite patients, adjusted for the much lower incidence of lip cancer in women (who comprised half of the study population) than in men, and considered the low background incidence of the malignancy, they found that only seven lip cancers would have been expected to be detected in all the treatment groups combined, reported Dr. Friedman, also of the department of health research and policy, Stanford (Calif.) University, and his associates.
"Although the relatively high odds ratios, the evidence for specificity, and the biological mechanism are consistent with a causal relationship, causality cannot usually be established by a single observational study such as ours. Further investigations are needed to confirm and characterize relationships between photosensitizing antihypertensive agents and lip cancer," the researchers noted.
The study was limited because the researchers were unable to account for patients’ sun exposure, which is the most important factor contributing to lip cancer risk. "However, it does not seem likely that users of the antihypertensive drugs associated with lip cancer experience a great deal more sun exposure than nonusers or than users of atenolol," they wrote.
This study was supported by the National Cancer Institute. Dr. Friedman reported ties to Allergan, and his associates reported ties to Genentech, Merck, Sanofi-Aventis, and Takeda.
In addition to having an increased risk for lip cancer, patients taking photosensitizing antihypertensive agents are probably also at an increased risk for basal and squamous cell cancers of the skin, noted Dr. Mitchell H. Katz.
Physicians should remind their patients of the simple measures available to reduce sun exposure. The findings of Dr. Friedman and his colleagues "are important because simple interventions, such as lip protector, sunscreen, large-brim hats, rash guard swim shirts, and avoiding times of the day when the sun is most intense, are likely to decrease the harmful effects of the sun for everyone, regardless of whether they are receiving a photosensitizing agent," he wrote.
Dr. Katz is a deputy editor of Archives of Internal Medicine and director of the Los Angeles County Department of Health Services. He reported no relevant financial conflicts. His remarks were taken from the Editor’s Note accompanying Dr. Friedman’s report.
In addition to having an increased risk for lip cancer, patients taking photosensitizing antihypertensive agents are probably also at an increased risk for basal and squamous cell cancers of the skin, noted Dr. Mitchell H. Katz.
Physicians should remind their patients of the simple measures available to reduce sun exposure. The findings of Dr. Friedman and his colleagues "are important because simple interventions, such as lip protector, sunscreen, large-brim hats, rash guard swim shirts, and avoiding times of the day when the sun is most intense, are likely to decrease the harmful effects of the sun for everyone, regardless of whether they are receiving a photosensitizing agent," he wrote.
Dr. Katz is a deputy editor of Archives of Internal Medicine and director of the Los Angeles County Department of Health Services. He reported no relevant financial conflicts. His remarks were taken from the Editor’s Note accompanying Dr. Friedman’s report.
In addition to having an increased risk for lip cancer, patients taking photosensitizing antihypertensive agents are probably also at an increased risk for basal and squamous cell cancers of the skin, noted Dr. Mitchell H. Katz.
Physicians should remind their patients of the simple measures available to reduce sun exposure. The findings of Dr. Friedman and his colleagues "are important because simple interventions, such as lip protector, sunscreen, large-brim hats, rash guard swim shirts, and avoiding times of the day when the sun is most intense, are likely to decrease the harmful effects of the sun for everyone, regardless of whether they are receiving a photosensitizing agent," he wrote.
Dr. Katz is a deputy editor of Archives of Internal Medicine and director of the Los Angeles County Department of Health Services. He reported no relevant financial conflicts. His remarks were taken from the Editor’s Note accompanying Dr. Friedman’s report.
Commonly used photosensitizing antihypertensive drugs increase the risk for lip cancer by two- to fourfold, according to a study published online Aug. 6 in Archives of Internal Medicine.
"Lip cancer is rare, and an increased risk of its development is generally outweighed by the benefits of drugs that are effective for other conditions. However, physicians prescribing photosensitizing drugs should ascertain whether patients are at high risk of lip cancer because of their fair skin and long-term sun exposure, and discuss lip protection with them," wrote Dr. Gary D. Friedman of the division of research, Kaiser Permanente Medical Care Program, Oakland Calif., and his colleagues. "Likely preventive measures are simple: a hat with a sufficiently wide brim to shade the lips, and lip sunscreens," they added.
The diuretics hydrochlorothiazide and hydrochlorothiazide-triamterene, as well as the calcium channel blocker nifedipine, were associated with at least a doubling in the risk for lip cancer in a study involving 23,616 hypertensive non-Hispanic white adults. The association between lip cancer and the ACE inhibitor lisinopril, which also is photosensitizing, was characterized as "equivocal." And atenolol, a beta-adrenergic blocker that is not photosensitizing, was not linked to a higher risk.
Dr. Friedman and his colleagues used prescription data from the Kaiser Permanente pharmacy database and information from its cancer registry to perform a case-control study examining the relationship between the four classes of antihypertensive medications and lip cancer. They assessed the period from 1994 through 2008. The database includes an ethnically and socioeconomically diverse population of residents in the San Francisco and central valley regions of California.
There were few cases of lip cancer among nonwhite patients, so the analysis was restricted to white patients. Those with human immunodeficiency virus infection and those taking immunosuppressants after receiving organ transplants also were excluded because these factors were likely to be confounders.
The study population comprised 712 patients with lip cancer and 22,904 age-matched control patients. Nearly all malignancies were squamous cell. As expected, cigarette smokers in both study groups were more likely than nonsmokers to develop lip cancer.
The risk of developing lip cancer showed a dose-response relationship with the use of certain antihypertensive drugs, with the risk increasing as the duration of drug use increased. For patients treated with hydrochlorothiazide for 5 years or more, the odds ratio of developing lip cancer was 4.22. The OR for the combination drug hydrochlorothiazide-triamterene was 2.82, and the OR for nifedipine was 2.50. The OR was of borderline significance for lisinopril (1.42).
In contrast, for patients treated with atenolol for 5 years or more, the risk of developing lip cancer was reduced, with an odds ratio of 0.54, the investigators reported (Arch. Intern. Med. 2012 Aug. 6 [doi:10.1001/archinternmed.2012.2754]).
It should not be surprising that previous large clinical trials of these drugs’ efficacy failed to find an association with lip cancer, because of the rarity of the malignancy, they added.
For example, one study of antihypertensive medications involved more than 33,000 patients followed for a mean of 5 years. And after the investigators excluded the nonwhite patients, adjusted for the much lower incidence of lip cancer in women (who comprised half of the study population) than in men, and considered the low background incidence of the malignancy, they found that only seven lip cancers would have been expected to be detected in all the treatment groups combined, reported Dr. Friedman, also of the department of health research and policy, Stanford (Calif.) University, and his associates.
"Although the relatively high odds ratios, the evidence for specificity, and the biological mechanism are consistent with a causal relationship, causality cannot usually be established by a single observational study such as ours. Further investigations are needed to confirm and characterize relationships between photosensitizing antihypertensive agents and lip cancer," the researchers noted.
The study was limited because the researchers were unable to account for patients’ sun exposure, which is the most important factor contributing to lip cancer risk. "However, it does not seem likely that users of the antihypertensive drugs associated with lip cancer experience a great deal more sun exposure than nonusers or than users of atenolol," they wrote.
This study was supported by the National Cancer Institute. Dr. Friedman reported ties to Allergan, and his associates reported ties to Genentech, Merck, Sanofi-Aventis, and Takeda.
Commonly used photosensitizing antihypertensive drugs increase the risk for lip cancer by two- to fourfold, according to a study published online Aug. 6 in Archives of Internal Medicine.
"Lip cancer is rare, and an increased risk of its development is generally outweighed by the benefits of drugs that are effective for other conditions. However, physicians prescribing photosensitizing drugs should ascertain whether patients are at high risk of lip cancer because of their fair skin and long-term sun exposure, and discuss lip protection with them," wrote Dr. Gary D. Friedman of the division of research, Kaiser Permanente Medical Care Program, Oakland Calif., and his colleagues. "Likely preventive measures are simple: a hat with a sufficiently wide brim to shade the lips, and lip sunscreens," they added.
The diuretics hydrochlorothiazide and hydrochlorothiazide-triamterene, as well as the calcium channel blocker nifedipine, were associated with at least a doubling in the risk for lip cancer in a study involving 23,616 hypertensive non-Hispanic white adults. The association between lip cancer and the ACE inhibitor lisinopril, which also is photosensitizing, was characterized as "equivocal." And atenolol, a beta-adrenergic blocker that is not photosensitizing, was not linked to a higher risk.
Dr. Friedman and his colleagues used prescription data from the Kaiser Permanente pharmacy database and information from its cancer registry to perform a case-control study examining the relationship between the four classes of antihypertensive medications and lip cancer. They assessed the period from 1994 through 2008. The database includes an ethnically and socioeconomically diverse population of residents in the San Francisco and central valley regions of California.
There were few cases of lip cancer among nonwhite patients, so the analysis was restricted to white patients. Those with human immunodeficiency virus infection and those taking immunosuppressants after receiving organ transplants also were excluded because these factors were likely to be confounders.
The study population comprised 712 patients with lip cancer and 22,904 age-matched control patients. Nearly all malignancies were squamous cell. As expected, cigarette smokers in both study groups were more likely than nonsmokers to develop lip cancer.
The risk of developing lip cancer showed a dose-response relationship with the use of certain antihypertensive drugs, with the risk increasing as the duration of drug use increased. For patients treated with hydrochlorothiazide for 5 years or more, the odds ratio of developing lip cancer was 4.22. The OR for the combination drug hydrochlorothiazide-triamterene was 2.82, and the OR for nifedipine was 2.50. The OR was of borderline significance for lisinopril (1.42).
In contrast, for patients treated with atenolol for 5 years or more, the risk of developing lip cancer was reduced, with an odds ratio of 0.54, the investigators reported (Arch. Intern. Med. 2012 Aug. 6 [doi:10.1001/archinternmed.2012.2754]).
It should not be surprising that previous large clinical trials of these drugs’ efficacy failed to find an association with lip cancer, because of the rarity of the malignancy, they added.
For example, one study of antihypertensive medications involved more than 33,000 patients followed for a mean of 5 years. And after the investigators excluded the nonwhite patients, adjusted for the much lower incidence of lip cancer in women (who comprised half of the study population) than in men, and considered the low background incidence of the malignancy, they found that only seven lip cancers would have been expected to be detected in all the treatment groups combined, reported Dr. Friedman, also of the department of health research and policy, Stanford (Calif.) University, and his associates.
"Although the relatively high odds ratios, the evidence for specificity, and the biological mechanism are consistent with a causal relationship, causality cannot usually be established by a single observational study such as ours. Further investigations are needed to confirm and characterize relationships between photosensitizing antihypertensive agents and lip cancer," the researchers noted.
The study was limited because the researchers were unable to account for patients’ sun exposure, which is the most important factor contributing to lip cancer risk. "However, it does not seem likely that users of the antihypertensive drugs associated with lip cancer experience a great deal more sun exposure than nonusers or than users of atenolol," they wrote.
This study was supported by the National Cancer Institute. Dr. Friedman reported ties to Allergan, and his associates reported ties to Genentech, Merck, Sanofi-Aventis, and Takeda.
FROM ARCHIVES OF INTERNAL MEDICINE
Major Finding: The odds ratio of patients developing lip cancer was 4.22 with hydrochlorothiazide, 2.82 with combination hydrochlorothiazide-triamterene, and 2.50 with nifedipine.
Data Source: An observational case-control study was conducted involving 712 patients taking antihypertensive medications for at least 5 years who developed lip cancer during a 14-year period and 22,904 control patients who did not.
Disclosures: This study was supported by the National Cancer Institute. Dr. Friedman reported ties to Allergan, and his associates reported ties to Genentech, Merck, Sanofi-Aventis, and Takeda.
Isotretinoin Quells EGFR Inhibitor-Related Rash
ORLANDO – Oral isotretinoin holds potential as a bridge therapy for cancer patients who develop severe rashes during treatment, according to Dr. Milan J. Anadkat.
Dermatologists can play an integral role here. "Most oncologists see these patients first, and most oncologists are not enrolled in the iPledge program," said Dr. Anadkat of the division of dermatology at Washington University in St. Louis.
He noted that all treatment options are off label because there are no Food and Drug Administration–approved agents to treat chemotherapy-related cutaneous toxicities.
Getting patients through rashes that occur within a week or two of beginning targeted chemotherapy is important, as patients who develop the greatest reactions tend to have cancers that respond best to treatment, said Dr. Anadkat at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery. For this reason, the management of these patients is more complicated than simple drug cessation.
"The problem with just taking them off the drug is that they have cancer. Ultimately, the big goal here is treating the cancer, not avoiding the rash," he said.
Tetracycline or doxycycline can also reduce the severity of the rash, but the timing of administration is important. Better outcomes are associated with prophylaxis that is timed with the initiation of EGFR (epidermal growth factor receptor) inhibitors (Cancer 2008;113:847-53). "Waiting for the rash to appear is not the time to give it. It makes a difference if you give at day 0, not in terms of incidence but in the severity of the rash," he said.
Educate patients that the rash typically appears in an estimated 60%-90% of people within 8-10 days of EGFR inhibitor initiation, with a peak presentation at 2-4 weeks. "Bridging them through with something as effective as isotretinoin is useful," said Dr. Anadkat.
The rash generally appears on the face and upper trunk, but be careful not to confuse the presentation with a photo-exposure phenomenon.
Although some oncologists will describe the skin eruptions as "acnelike," histology will show mixed inflammatory infiltrate and follicular rupture. For this reason, "topical acne medications do very little," Dr. Anadkat said. Also, rule out infection, except when patients present with pustules on their arms, legs, or other non–EGFR receptor areas.
EGFR inhibitors can cause inflammatory alopecia, eyelash trichomegaly, and periungual and nail alterations.
About one in six patients will develop periungual or nail abnormalities, typically on their first finger or toe. These effects can be painful, Dr. Anadkat said. Culture is mandatory to rule out superinfection.
Again, the approach is to get patients through the adverse events with petroleum jelly, high-dose topical steroids, or oral tetracyclines. "Tumor markers are going down; [oncologists] are not going to want to stop chemotherapy for a painful thumb or toe," he said. "I recommend antimicrobial soaks with bleach or vinegar to prevent paronychia superinfection."
Dry, itchy skin is another concern with long-term EGFR inhibitor treatment. Histology shows "stark differences" in the stratum corneum. "This is the No. 1 side effect for patients on long-term EGFR – 3 months or longer; [it is] not a grade 3 or higher toxicity, but it is annoying."
Investigators compared oral minocycline and topical tazarotene prophylaxis in a study of 48 patients with cetuximab associated rash (J. Clin. Oncol. 2007:25:5390-6). Although oral minocycline was associated with reduced lesion counts, topical tazarotene yielded no significant benefit. "Again, this is not acne," Dr. Anadkat said.
He disclosed being a consultant or speaker for AstraZeneca, Bristol-Myers Squibb, Eisai, Genentech, and ImClone regarding strategies for managing skin toxicities from chemotherapy. He has never prescribed chemotherapy agents.
ORLANDO – Oral isotretinoin holds potential as a bridge therapy for cancer patients who develop severe rashes during treatment, according to Dr. Milan J. Anadkat.
Dermatologists can play an integral role here. "Most oncologists see these patients first, and most oncologists are not enrolled in the iPledge program," said Dr. Anadkat of the division of dermatology at Washington University in St. Louis.
He noted that all treatment options are off label because there are no Food and Drug Administration–approved agents to treat chemotherapy-related cutaneous toxicities.
Getting patients through rashes that occur within a week or two of beginning targeted chemotherapy is important, as patients who develop the greatest reactions tend to have cancers that respond best to treatment, said Dr. Anadkat at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery. For this reason, the management of these patients is more complicated than simple drug cessation.
"The problem with just taking them off the drug is that they have cancer. Ultimately, the big goal here is treating the cancer, not avoiding the rash," he said.
Tetracycline or doxycycline can also reduce the severity of the rash, but the timing of administration is important. Better outcomes are associated with prophylaxis that is timed with the initiation of EGFR (epidermal growth factor receptor) inhibitors (Cancer 2008;113:847-53). "Waiting for the rash to appear is not the time to give it. It makes a difference if you give at day 0, not in terms of incidence but in the severity of the rash," he said.
Educate patients that the rash typically appears in an estimated 60%-90% of people within 8-10 days of EGFR inhibitor initiation, with a peak presentation at 2-4 weeks. "Bridging them through with something as effective as isotretinoin is useful," said Dr. Anadkat.
The rash generally appears on the face and upper trunk, but be careful not to confuse the presentation with a photo-exposure phenomenon.
Although some oncologists will describe the skin eruptions as "acnelike," histology will show mixed inflammatory infiltrate and follicular rupture. For this reason, "topical acne medications do very little," Dr. Anadkat said. Also, rule out infection, except when patients present with pustules on their arms, legs, or other non–EGFR receptor areas.
EGFR inhibitors can cause inflammatory alopecia, eyelash trichomegaly, and periungual and nail alterations.
About one in six patients will develop periungual or nail abnormalities, typically on their first finger or toe. These effects can be painful, Dr. Anadkat said. Culture is mandatory to rule out superinfection.
Again, the approach is to get patients through the adverse events with petroleum jelly, high-dose topical steroids, or oral tetracyclines. "Tumor markers are going down; [oncologists] are not going to want to stop chemotherapy for a painful thumb or toe," he said. "I recommend antimicrobial soaks with bleach or vinegar to prevent paronychia superinfection."
Dry, itchy skin is another concern with long-term EGFR inhibitor treatment. Histology shows "stark differences" in the stratum corneum. "This is the No. 1 side effect for patients on long-term EGFR – 3 months or longer; [it is] not a grade 3 or higher toxicity, but it is annoying."
Investigators compared oral minocycline and topical tazarotene prophylaxis in a study of 48 patients with cetuximab associated rash (J. Clin. Oncol. 2007:25:5390-6). Although oral minocycline was associated with reduced lesion counts, topical tazarotene yielded no significant benefit. "Again, this is not acne," Dr. Anadkat said.
He disclosed being a consultant or speaker for AstraZeneca, Bristol-Myers Squibb, Eisai, Genentech, and ImClone regarding strategies for managing skin toxicities from chemotherapy. He has never prescribed chemotherapy agents.
ORLANDO – Oral isotretinoin holds potential as a bridge therapy for cancer patients who develop severe rashes during treatment, according to Dr. Milan J. Anadkat.
Dermatologists can play an integral role here. "Most oncologists see these patients first, and most oncologists are not enrolled in the iPledge program," said Dr. Anadkat of the division of dermatology at Washington University in St. Louis.
He noted that all treatment options are off label because there are no Food and Drug Administration–approved agents to treat chemotherapy-related cutaneous toxicities.
Getting patients through rashes that occur within a week or two of beginning targeted chemotherapy is important, as patients who develop the greatest reactions tend to have cancers that respond best to treatment, said Dr. Anadkat at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery. For this reason, the management of these patients is more complicated than simple drug cessation.
"The problem with just taking them off the drug is that they have cancer. Ultimately, the big goal here is treating the cancer, not avoiding the rash," he said.
Tetracycline or doxycycline can also reduce the severity of the rash, but the timing of administration is important. Better outcomes are associated with prophylaxis that is timed with the initiation of EGFR (epidermal growth factor receptor) inhibitors (Cancer 2008;113:847-53). "Waiting for the rash to appear is not the time to give it. It makes a difference if you give at day 0, not in terms of incidence but in the severity of the rash," he said.
Educate patients that the rash typically appears in an estimated 60%-90% of people within 8-10 days of EGFR inhibitor initiation, with a peak presentation at 2-4 weeks. "Bridging them through with something as effective as isotretinoin is useful," said Dr. Anadkat.
The rash generally appears on the face and upper trunk, but be careful not to confuse the presentation with a photo-exposure phenomenon.
Although some oncologists will describe the skin eruptions as "acnelike," histology will show mixed inflammatory infiltrate and follicular rupture. For this reason, "topical acne medications do very little," Dr. Anadkat said. Also, rule out infection, except when patients present with pustules on their arms, legs, or other non–EGFR receptor areas.
EGFR inhibitors can cause inflammatory alopecia, eyelash trichomegaly, and periungual and nail alterations.
About one in six patients will develop periungual or nail abnormalities, typically on their first finger or toe. These effects can be painful, Dr. Anadkat said. Culture is mandatory to rule out superinfection.
Again, the approach is to get patients through the adverse events with petroleum jelly, high-dose topical steroids, or oral tetracyclines. "Tumor markers are going down; [oncologists] are not going to want to stop chemotherapy for a painful thumb or toe," he said. "I recommend antimicrobial soaks with bleach or vinegar to prevent paronychia superinfection."
Dry, itchy skin is another concern with long-term EGFR inhibitor treatment. Histology shows "stark differences" in the stratum corneum. "This is the No. 1 side effect for patients on long-term EGFR – 3 months or longer; [it is] not a grade 3 or higher toxicity, but it is annoying."
Investigators compared oral minocycline and topical tazarotene prophylaxis in a study of 48 patients with cetuximab associated rash (J. Clin. Oncol. 2007:25:5390-6). Although oral minocycline was associated with reduced lesion counts, topical tazarotene yielded no significant benefit. "Again, this is not acne," Dr. Anadkat said.
He disclosed being a consultant or speaker for AstraZeneca, Bristol-Myers Squibb, Eisai, Genentech, and ImClone regarding strategies for managing skin toxicities from chemotherapy. He has never prescribed chemotherapy agents.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE FLORIDA SOCIETY OF DERMATOLOGY AND DERMATOLOGIC SURGERY
Labs Find Evidence of Cancer Stem Cells
In an era of targeted cancer therapies, laboratory scientists working with mice may have found the ultimate target – a reservoir of stem cells that drive cancers to grow and metastasize.
Separate reports in the journals Science and Nature document the presence of cancer stem cells in intestinal adenomas (Science 2012 Aug. 1 [doi:10.1126/science.1224676]), squamous skin cancer, (Nature 2012 Aug. 1 [doi:10.1038/nature11344]), and glioblastoma multiforme (Nature 2012 Aug. 1 [doi:10.1038/nature11287]).
In the last study, mice with these highly lethal brain tumors were given temozolomide (Temodar), an approved treatment in humans, along with ganciclovir, an antiviral. Despite a transient therapeutic response to chemotherapy, the cancers continued to grow, driven by "a relatively quiescent subset of endogenous glioma cells, with properties similar to those proposed for cancer stem cells," the authors wrote.
Whether these reports will resolve controversy over the existence of stem cells or lead to clinically meaningful treatments remains to be seen. There is no doubt, however, that they will lead to further investigation.
In an era of targeted cancer therapies, laboratory scientists working with mice may have found the ultimate target – a reservoir of stem cells that drive cancers to grow and metastasize.
Separate reports in the journals Science and Nature document the presence of cancer stem cells in intestinal adenomas (Science 2012 Aug. 1 [doi:10.1126/science.1224676]), squamous skin cancer, (Nature 2012 Aug. 1 [doi:10.1038/nature11344]), and glioblastoma multiforme (Nature 2012 Aug. 1 [doi:10.1038/nature11287]).
In the last study, mice with these highly lethal brain tumors were given temozolomide (Temodar), an approved treatment in humans, along with ganciclovir, an antiviral. Despite a transient therapeutic response to chemotherapy, the cancers continued to grow, driven by "a relatively quiescent subset of endogenous glioma cells, with properties similar to those proposed for cancer stem cells," the authors wrote.
Whether these reports will resolve controversy over the existence of stem cells or lead to clinically meaningful treatments remains to be seen. There is no doubt, however, that they will lead to further investigation.
In an era of targeted cancer therapies, laboratory scientists working with mice may have found the ultimate target – a reservoir of stem cells that drive cancers to grow and metastasize.
Separate reports in the journals Science and Nature document the presence of cancer stem cells in intestinal adenomas (Science 2012 Aug. 1 [doi:10.1126/science.1224676]), squamous skin cancer, (Nature 2012 Aug. 1 [doi:10.1038/nature11344]), and glioblastoma multiforme (Nature 2012 Aug. 1 [doi:10.1038/nature11287]).
In the last study, mice with these highly lethal brain tumors were given temozolomide (Temodar), an approved treatment in humans, along with ganciclovir, an antiviral. Despite a transient therapeutic response to chemotherapy, the cancers continued to grow, driven by "a relatively quiescent subset of endogenous glioma cells, with properties similar to those proposed for cancer stem cells," the authors wrote.
Whether these reports will resolve controversy over the existence of stem cells or lead to clinically meaningful treatments remains to be seen. There is no doubt, however, that they will lead to further investigation.
Skin Flaps Remedy Defects of the Ear
SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.
The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.
"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."
And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."
Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.
Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.
A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."
The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.
He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.
Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.
Dr. Keefe said that he had no relevant financial conflicts to disclose.
SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.
The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.
"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."
And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."
Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.
Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.
A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."
The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.
He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.
Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.
Dr. Keefe said that he had no relevant financial conflicts to disclose.
SAN DIEGO – In the clinical experience of Dr. Michael A. Keefe, 70%-80% of ear defects from auricular cancer treatment can be easily remedied with skin flaps.
The most common locations of auricular cancer are the helix, the posterior auricle skin, and the antihelix, Dr. Keefe said at a meeting on superficial anatomy and cutaneous surgery.
"More than 70% of lesions are smaller than 3 cm in size, and auricular lesions make up an estimated 8% of all skin cancers," said Dr. Keefe, a plastic surgeon with the division of head and neck surgery at Sharp Rees-Stealy Medical Group in San Diego. "The defects are unique, and the underlying cartilage structure makes it all the more interesting."
And challenging – defects may be located on the skin of the ear only, on the lateral side, or on the posterior side, or they may involve a combination of skin and cartilage. Healing by secondary intention is effective for concave defects, but the size of the defect drives the reconstruction options. "If there is no perichondrium, punch holes through cartilage with a 2-3 mm punch to allow granulation tissue to grow through, and then use a skin graft or allow it to heal with secondary intention," he said. "Keep the area moist with antibiotic ointment."
Options for reconstruction of defects in the middle one-third of the ear include primary closure, full-thickness skin grafts (FTSGs), the helical advancement flap, and the retroauricular composite advancement flap, while options for defects in the lower one-third of the ear include primary closure and the preauricular tubed flap. Options for reconstruction of defects in the upper one-third of the ear include primary closure, FTSGs, the helical advancement flap, the retroauricular and preauricular tubed flaps, and constructing an autogenous cartilage framework with FTSGs.
Dr. Keefe said that most small helical rim defects limited to the skin can be closed primarily. "There might be slight rim asymmetry [after closure]," he said at the meeting, which was sponsored by the University of California, San Diego, School of Medicine and the Scripps Clinic. "Some patients might not care [about this], but you have to advise them of that," he added.
A bilobed advancement flap is another option for helical rim defects limited to the skin. This flap "works well for cutaneous defects 2 cm or smaller in the helical rim or the posterior auricle," he said. "The other thing you can do with these bilobed flaps is advance them over the edge to correct helical rim defects."
The banner flap is another effective flap for helical rim defects, especially those located on the superior helix. It does not replace cartilage, but it conceals the incision well. For small composite helix and anterior defects, Dr. Keefe favors the chondrocutaneous advancement flap.
He said that he favors using FTSGs on the anterior surface of the helix for skin defects whenever possible. "You can use a composite skin graft as well, especially to replace cartilage or skin defects that are smaller than 1 cm in size," he said. "A FTSG is easy to harvest and has minimal contraction. Common donor sites include the preauricular, postauricular, supraclavicular, and clavicular regions. Make sure you trim off the fat." For posterior surface defects, the bilobe or advancement flaps work well.
Grafts must be placed on tissue with an adequate blood supply. Effective grafts establish imbibition in the first 24 hours, inosculation within 48-72 hours, and restoration of circulation within 4-7 days.
Dr. Keefe said that he had no relevant financial conflicts to disclose.
EXPERT ANALYSIS FROM A MEETING ON SUPERFICIAL ANATOMY AND CUTANEOUS SURGERY
Expert: Reclaim Radiation for Skin Cancer
ORLANDO – Careful patient selection is key to treating nonmelanoma skin cancer patients with superficial radiation therapy, according to Dr. William I. Roth.
"If you pick the right patients for radiation therapy, you can get great results," Dr. Roth said. An elderly patient with a basal cell or squamous cell carcinoma on the face or leg can be a good candidate, for example, especially if there are other comorbidities that make that person less than ideal as a candidate for surgery.
The typical skin cancer patient at Dr. Roth’s practice in Boynton Beach, Fla., is between 75 and 80 years old, and many are very active and play golf or tennis several times a week. They prefer radiation therapy over surgery because it is less likely to limit their activities or impinge on their lifestyle, he said.
Reduced risk of bleeding and infection are other advantages of radiation therapy compared with surgery, Dr. Roth said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.
"Radiation therapy is not going to replace Mohs. [But] I think skin cancer practices need both," said Dr. Roth, a volunteer clinical professor in the department of dermatology at the University of Miami.
Cure rates of up to 95% or more are possible with superficial radiation therapy. "Radiation oncologists in my area are advertising 98% cure rates," Dr. Roth said. "I do still send a lot of patients to radiation oncologists, but I think you get excellent results [within dermatology] as long as you pick the right patient. It’s a great therapy."
Referral is appropriate when a lesion is deep and significantly large, and its depth and width cannot be accurately determined, Dr. Roth said. Patients also should be referred to a specialist if there is any evidence of perineural involvement.
Patients should be advised that some immediate posttreatment hypopigmentation is possible and that it generally improves quickly. The treated area usually looks its worst at about 2 weeks post treatment, Dr. Roth said. Some patients experience late effects, even up to a decade post treatment.
"I always scallop my port in the lead shielding so that 10 years later when the person gets some hypopigmentation it’s not going to be sharply defined," he said.
Four weeks post therapy skin can still appear thick, said Dr. Roth. "I would not rush to rebiopsy these patients, especially on the legs where there is a low turnover."
Although some physicians avoid radiation treatment of basal cell or squamous cell carcinoma on the legs, Dr. Roth has found value to this approach. "The legs are not absolutely a piece of cake, but as you move [treatment] up from the middle of the leg it becomes easier and easier." He added that grafting can be a challenge on the legs and surgical sutures can sometime pull through the skin. "I’m happy to do surgery. But to be honest with you, radiation therapy on the legs generally is less of a hassle for the patient."
However, use caution when treating lesions directly over the anterior tibial surface, he advised. "You have to be more careful ... right over the bone." He encountered two patients treated in this area whose skin healed nicely but they still experienced some sensitivity in their tibia. Dr. Roth suggested less aggressive treatment near the anterior tibia because "bone absorbs radiation to a much greater degree than the skin."
Dr. Roth gave an example of a patient with two well differentiated SCC lesions on her leg that he treated with radiation therapy. Twelve fractions of radiation were delivered with the SRT-100 (Sensus Healthcare, Boca Raton, Fla.). The patient ulcerated and had a fairly brisk response but did not report any pain. Follow-up was conducted at months 1,2 and 5. "From my standpoint, it was a remarkably good response."
Results with the SRT-100 are very reproducible, Dr. Roth said. Energy imparted across the port or opening in the metal shield is consistent. The device delivers a flat field of radiation with a fairly fast drop-off deeper into the skin. The depth of the nonmelanoma skin cancer lesion generally determines the setting, Dr. Roth said.
The control unit is outside the radiation room, thus avoiding the need to work behind a leaded glass window. The control unit counts down duration of treatment and features an emergency stop. "I use a baby monitor to speak with patients during treatment," Dr. Roth said. "I did have one patient who yelled that her eye shields fell off. I hit the emergency button, entered the room, and put the shields back on." The unit holds the reading (pauses therapy) and then allows physicians to continue when ready.
"Radiation therapy has been a part of dermatology basically forever. We have been treating skin cancers since before I was born," Dr. Roth said. "Now that we have some more choices, this should be a part of dermatology again. We should take this back."
Dr. Roth is a consultant and researcher for Sensus, but purchased his SRT-100 at full price.
ORLANDO – Careful patient selection is key to treating nonmelanoma skin cancer patients with superficial radiation therapy, according to Dr. William I. Roth.
"If you pick the right patients for radiation therapy, you can get great results," Dr. Roth said. An elderly patient with a basal cell or squamous cell carcinoma on the face or leg can be a good candidate, for example, especially if there are other comorbidities that make that person less than ideal as a candidate for surgery.
The typical skin cancer patient at Dr. Roth’s practice in Boynton Beach, Fla., is between 75 and 80 years old, and many are very active and play golf or tennis several times a week. They prefer radiation therapy over surgery because it is less likely to limit their activities or impinge on their lifestyle, he said.
Reduced risk of bleeding and infection are other advantages of radiation therapy compared with surgery, Dr. Roth said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.
"Radiation therapy is not going to replace Mohs. [But] I think skin cancer practices need both," said Dr. Roth, a volunteer clinical professor in the department of dermatology at the University of Miami.
Cure rates of up to 95% or more are possible with superficial radiation therapy. "Radiation oncologists in my area are advertising 98% cure rates," Dr. Roth said. "I do still send a lot of patients to radiation oncologists, but I think you get excellent results [within dermatology] as long as you pick the right patient. It’s a great therapy."
Referral is appropriate when a lesion is deep and significantly large, and its depth and width cannot be accurately determined, Dr. Roth said. Patients also should be referred to a specialist if there is any evidence of perineural involvement.
Patients should be advised that some immediate posttreatment hypopigmentation is possible and that it generally improves quickly. The treated area usually looks its worst at about 2 weeks post treatment, Dr. Roth said. Some patients experience late effects, even up to a decade post treatment.
"I always scallop my port in the lead shielding so that 10 years later when the person gets some hypopigmentation it’s not going to be sharply defined," he said.
Four weeks post therapy skin can still appear thick, said Dr. Roth. "I would not rush to rebiopsy these patients, especially on the legs where there is a low turnover."
Although some physicians avoid radiation treatment of basal cell or squamous cell carcinoma on the legs, Dr. Roth has found value to this approach. "The legs are not absolutely a piece of cake, but as you move [treatment] up from the middle of the leg it becomes easier and easier." He added that grafting can be a challenge on the legs and surgical sutures can sometime pull through the skin. "I’m happy to do surgery. But to be honest with you, radiation therapy on the legs generally is less of a hassle for the patient."
However, use caution when treating lesions directly over the anterior tibial surface, he advised. "You have to be more careful ... right over the bone." He encountered two patients treated in this area whose skin healed nicely but they still experienced some sensitivity in their tibia. Dr. Roth suggested less aggressive treatment near the anterior tibia because "bone absorbs radiation to a much greater degree than the skin."
Dr. Roth gave an example of a patient with two well differentiated SCC lesions on her leg that he treated with radiation therapy. Twelve fractions of radiation were delivered with the SRT-100 (Sensus Healthcare, Boca Raton, Fla.). The patient ulcerated and had a fairly brisk response but did not report any pain. Follow-up was conducted at months 1,2 and 5. "From my standpoint, it was a remarkably good response."
Results with the SRT-100 are very reproducible, Dr. Roth said. Energy imparted across the port or opening in the metal shield is consistent. The device delivers a flat field of radiation with a fairly fast drop-off deeper into the skin. The depth of the nonmelanoma skin cancer lesion generally determines the setting, Dr. Roth said.
The control unit is outside the radiation room, thus avoiding the need to work behind a leaded glass window. The control unit counts down duration of treatment and features an emergency stop. "I use a baby monitor to speak with patients during treatment," Dr. Roth said. "I did have one patient who yelled that her eye shields fell off. I hit the emergency button, entered the room, and put the shields back on." The unit holds the reading (pauses therapy) and then allows physicians to continue when ready.
"Radiation therapy has been a part of dermatology basically forever. We have been treating skin cancers since before I was born," Dr. Roth said. "Now that we have some more choices, this should be a part of dermatology again. We should take this back."
Dr. Roth is a consultant and researcher for Sensus, but purchased his SRT-100 at full price.
ORLANDO – Careful patient selection is key to treating nonmelanoma skin cancer patients with superficial radiation therapy, according to Dr. William I. Roth.
"If you pick the right patients for radiation therapy, you can get great results," Dr. Roth said. An elderly patient with a basal cell or squamous cell carcinoma on the face or leg can be a good candidate, for example, especially if there are other comorbidities that make that person less than ideal as a candidate for surgery.
The typical skin cancer patient at Dr. Roth’s practice in Boynton Beach, Fla., is between 75 and 80 years old, and many are very active and play golf or tennis several times a week. They prefer radiation therapy over surgery because it is less likely to limit their activities or impinge on their lifestyle, he said.
Reduced risk of bleeding and infection are other advantages of radiation therapy compared with surgery, Dr. Roth said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.
"Radiation therapy is not going to replace Mohs. [But] I think skin cancer practices need both," said Dr. Roth, a volunteer clinical professor in the department of dermatology at the University of Miami.
Cure rates of up to 95% or more are possible with superficial radiation therapy. "Radiation oncologists in my area are advertising 98% cure rates," Dr. Roth said. "I do still send a lot of patients to radiation oncologists, but I think you get excellent results [within dermatology] as long as you pick the right patient. It’s a great therapy."
Referral is appropriate when a lesion is deep and significantly large, and its depth and width cannot be accurately determined, Dr. Roth said. Patients also should be referred to a specialist if there is any evidence of perineural involvement.
Patients should be advised that some immediate posttreatment hypopigmentation is possible and that it generally improves quickly. The treated area usually looks its worst at about 2 weeks post treatment, Dr. Roth said. Some patients experience late effects, even up to a decade post treatment.
"I always scallop my port in the lead shielding so that 10 years later when the person gets some hypopigmentation it’s not going to be sharply defined," he said.
Four weeks post therapy skin can still appear thick, said Dr. Roth. "I would not rush to rebiopsy these patients, especially on the legs where there is a low turnover."
Although some physicians avoid radiation treatment of basal cell or squamous cell carcinoma on the legs, Dr. Roth has found value to this approach. "The legs are not absolutely a piece of cake, but as you move [treatment] up from the middle of the leg it becomes easier and easier." He added that grafting can be a challenge on the legs and surgical sutures can sometime pull through the skin. "I’m happy to do surgery. But to be honest with you, radiation therapy on the legs generally is less of a hassle for the patient."
However, use caution when treating lesions directly over the anterior tibial surface, he advised. "You have to be more careful ... right over the bone." He encountered two patients treated in this area whose skin healed nicely but they still experienced some sensitivity in their tibia. Dr. Roth suggested less aggressive treatment near the anterior tibia because "bone absorbs radiation to a much greater degree than the skin."
Dr. Roth gave an example of a patient with two well differentiated SCC lesions on her leg that he treated with radiation therapy. Twelve fractions of radiation were delivered with the SRT-100 (Sensus Healthcare, Boca Raton, Fla.). The patient ulcerated and had a fairly brisk response but did not report any pain. Follow-up was conducted at months 1,2 and 5. "From my standpoint, it was a remarkably good response."
Results with the SRT-100 are very reproducible, Dr. Roth said. Energy imparted across the port or opening in the metal shield is consistent. The device delivers a flat field of radiation with a fairly fast drop-off deeper into the skin. The depth of the nonmelanoma skin cancer lesion generally determines the setting, Dr. Roth said.
The control unit is outside the radiation room, thus avoiding the need to work behind a leaded glass window. The control unit counts down duration of treatment and features an emergency stop. "I use a baby monitor to speak with patients during treatment," Dr. Roth said. "I did have one patient who yelled that her eye shields fell off. I hit the emergency button, entered the room, and put the shields back on." The unit holds the reading (pauses therapy) and then allows physicians to continue when ready.
"Radiation therapy has been a part of dermatology basically forever. We have been treating skin cancers since before I was born," Dr. Roth said. "Now that we have some more choices, this should be a part of dermatology again. We should take this back."
Dr. Roth is a consultant and researcher for Sensus, but purchased his SRT-100 at full price.
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE FLORIDA SOCIETY OF DERMATOLOGY AND DERMATOLOGIC SURGERY
Washington Post Blasts Proliferation of ESAs for Anemia
Anemia drugs sold under the brand names of Procrit, Aranesp, and Epogen come under new and scathing scrutiny in an exclusive report published July 20 in the Washington Post.
The investigative article by Peter Whoriskey alleges that pharmaceutical giants Amgen and Johnson & Johnson "wildly overstated" benefits while understating potentially lethal side effects of these erythropoiesis-stimulating agents (ESAs).
While safety trials required by the Food and Drug Administration lagged for more than a decade, the companies successfully lobbied for a payment system that rewarded physicians for giving large doses of their high-priced drugs, according to the report.
Use of the drugs declined in recent years after studies showed higher mortality rates in patients given ESAs. Epoetin-alfa (Procrit and Epogen) and darbepoetin alfa (Aranesp) are used to treat anemia in patients undergoing cancer chemotherapy or dialysis for chronic kidney disease.
Anemia drugs sold under the brand names of Procrit, Aranesp, and Epogen come under new and scathing scrutiny in an exclusive report published July 20 in the Washington Post.
The investigative article by Peter Whoriskey alleges that pharmaceutical giants Amgen and Johnson & Johnson "wildly overstated" benefits while understating potentially lethal side effects of these erythropoiesis-stimulating agents (ESAs).
While safety trials required by the Food and Drug Administration lagged for more than a decade, the companies successfully lobbied for a payment system that rewarded physicians for giving large doses of their high-priced drugs, according to the report.
Use of the drugs declined in recent years after studies showed higher mortality rates in patients given ESAs. Epoetin-alfa (Procrit and Epogen) and darbepoetin alfa (Aranesp) are used to treat anemia in patients undergoing cancer chemotherapy or dialysis for chronic kidney disease.
Anemia drugs sold under the brand names of Procrit, Aranesp, and Epogen come under new and scathing scrutiny in an exclusive report published July 20 in the Washington Post.
The investigative article by Peter Whoriskey alleges that pharmaceutical giants Amgen and Johnson & Johnson "wildly overstated" benefits while understating potentially lethal side effects of these erythropoiesis-stimulating agents (ESAs).
While safety trials required by the Food and Drug Administration lagged for more than a decade, the companies successfully lobbied for a payment system that rewarded physicians for giving large doses of their high-priced drugs, according to the report.
Use of the drugs declined in recent years after studies showed higher mortality rates in patients given ESAs. Epoetin-alfa (Procrit and Epogen) and darbepoetin alfa (Aranesp) are used to treat anemia in patients undergoing cancer chemotherapy or dialysis for chronic kidney disease.