Melanoma

PASADENA, Calif. - Two drugs - one old, one new - are showing promise in early clinical trials for the treatment of basal cell carcinomas.

If they prove to be useful, clinicians can thank scientists whose years of research successfully identified abnormalities in the hedgehog signaling pathway as the mechanism of disease for basal cell carcinoma (BCC), Dr. Jean Tang said at the annual meeting of the Pacific Dermatologic Association.

“Every major pharmaceutical company is now interested in the hedgehog pathway, so we may see a lot of treatments in the near future” for BCC and other cancers that have aberrations in this pathway, said Dr. Tang of Stanford (Calif.) University.

She and her associates are conducting a phase II trial of the experimental Genentech drug GDC-0449 in patients with many BCCs from basal cell nevus syndrome (Gorlin’s syndrome), and a separate proof-of-concept study of the antifungal drug itraconazole in patients with small numbers of BCCs who do not have basal cell nevus syndrome. Dr. Tang said she is pleased by the early results with both drugs so far.

For GDC-0449, a previous phase I study in 33 patients with locally advanced or metastatic BCC who took the drug for a median of 10 months found that 50%-60% had partial or complete responses and the drug was generally well tolerated (N. Engl. J. Med. 2009;361:1,164-72).

Of the 41 patients with basal cell nevus syndrome recruited thus far for the phase II trial - and randomized to 18 months of treatment with GDC-0449 or placebo - 23 patients (with 953 BCC tumors) have more than 1 month of data.

Although the study is still blinded, 15 patients in group A have developed a median of one new BCC during that month, compared with a median of 10 new BCCs in each of the 8 patients in group B, a significant difference that suggests group A may have received the drug and it may be working, Dr. Tang suggested.

In group A, patients started with a median of 252 BCCs and had 127 at the most recent follow-up, a 50% decline. In group B, patients started with 217 BCCs and had 267 at follow-up, a 23% increase in BCCs.

The difference between groups is significant, she said. The existing BCCs in group A also seem to have decreased in size.

“In the patients who have responded, it has changed their lives,” Dr. Tang said. “We are really excited about it.”

Patients in group A, however, were significantly more likely to develop dysgeusia (decreased taste sensation). The condition was seen in 14 of 15 patients, compared with none in group B. Seven patients in group A and none in group B reported some hair loss, though this difference was not statistically significant. Two patients in group A stopped treatment due to dysgeusia and hair loss, compared with no patient cessation in group A. Myalgia was also reported in group A but not group B.

These side effects may be acceptable to patients with basal cell nevus syndrome but probably not to patients with only one or two BCCs, Dr. Tang noted.

For the latter group, a proof-of-concept trial has randomized eight patients thus far to 1 month of treatment with 400 mg/day of oral itraconazole, a drug that has been on the market for approximately 2 decades and is considered relatively safe, she said. Patients are followed clinically for changes in their BCCs, and they undergo tumor biopsies before and after the 1-month therapy to measure the treatment’s effects on the hedgehog signaling pathway.

Preliminary data are “somewhat promising” in reducing BCC size, Dr. Tang said. The effect has not been as dramatic as with the GDC-0449 study, but neither have the side effects.

“This is very preliminary data but I wanted to share it with the other dermatologists in case some of them would like to put some patients on itraconazole, and, collectively, we can figure out whether or not it has a true effect” on BCC, she said.

In addition to the studies on itraconazole and GDC-0449, studies are underway by other investigators on experimental oral or topical agents by Novartis, Exelixis, and Infinity Pharmaceuticals that address aberrations in the hedgehog signaling pathway for the treatment of BCC.

PASADENA, Calif. - Two drugs - one old, one new - are showing promise in early clinical trials for the treatment of basal cell carcinomas.

If they prove to be useful, clinicians can thank scientists whose years of research successfully identified abnormalities in the hedgehog signaling pathway as the mechanism of disease for basal cell carcinoma (BCC), Dr. Jean Tang said at the annual meeting of the Pacific Dermatologic Association.

“Every major pharmaceutical company is now interested in the hedgehog pathway, so we may see a lot of treatments in the near future” for BCC and other cancers that have aberrations in this pathway, said Dr. Tang of Stanford (Calif.) University.

She and her associates are conducting a phase II trial of the experimental Genentech drug GDC-0449 in patients with many BCCs from basal cell nevus syndrome (Gorlin’s syndrome), and a separate proof-of-concept study of the antifungal drug itraconazole in patients with small numbers of BCCs who do not have basal cell nevus syndrome. Dr. Tang said she is pleased by the early results with both drugs so far.

For GDC-0449, a previous phase I study in 33 patients with locally advanced or metastatic BCC who took the drug for a median of 10 months found that 50%-60% had partial or complete responses and the drug was generally well tolerated (N. Engl. J. Med. 2009;361:1,164-72).

Of the 41 patients with basal cell nevus syndrome recruited thus far for the phase II trial - and randomized to 18 months of treatment with GDC-0449 or placebo - 23 patients (with 953 BCC tumors) have more than 1 month of data.

Although the study is still blinded, 15 patients in group A have developed a median of one new BCC during that month, compared with a median of 10 new BCCs in each of the 8 patients in group B, a significant difference that suggests group A may have received the drug and it may be working, Dr. Tang suggested.

In group A, patients started with a median of 252 BCCs and had 127 at the most recent follow-up, a 50% decline. In group B, patients started with 217 BCCs and had 267 at follow-up, a 23% increase in BCCs.

The difference between groups is significant, she said. The existing BCCs in group A also seem to have decreased in size.

“In the patients who have responded, it has changed their lives,” Dr. Tang said. “We are really excited about it.”

Patients in group A, however, were significantly more likely to develop dysgeusia (decreased taste sensation). The condition was seen in 14 of 15 patients, compared with none in group B. Seven patients in group A and none in group B reported some hair loss, though this difference was not statistically significant. Two patients in group A stopped treatment due to dysgeusia and hair loss, compared with no patient cessation in group A. Myalgia was also reported in group A but not group B.

These side effects may be acceptable to patients with basal cell nevus syndrome but probably not to patients with only one or two BCCs, Dr. Tang noted.

For the latter group, a proof-of-concept trial has randomized eight patients thus far to 1 month of treatment with 400 mg/day of oral itraconazole, a drug that has been on the market for approximately 2 decades and is considered relatively safe, she said. Patients are followed clinically for changes in their BCCs, and they undergo tumor biopsies before and after the 1-month therapy to measure the treatment’s effects on the hedgehog signaling pathway.

Preliminary data are “somewhat promising” in reducing BCC size, Dr. Tang said. The effect has not been as dramatic as with the GDC-0449 study, but neither have the side effects.

“This is very preliminary data but I wanted to share it with the other dermatologists in case some of them would like to put some patients on itraconazole, and, collectively, we can figure out whether or not it has a true effect” on BCC, she said.

In addition to the studies on itraconazole and GDC-0449, studies are underway by other investigators on experimental oral or topical agents by Novartis, Exelixis, and Infinity Pharmaceuticals that address aberrations in the hedgehog signaling pathway for the treatment of BCC.

PASADENA, Calif. - Two drugs - one old, one new - are showing promise in early clinical trials for the treatment of basal cell carcinomas.

If they prove to be useful, clinicians can thank scientists whose years of research successfully identified abnormalities in the hedgehog signaling pathway as the mechanism of disease for basal cell carcinoma (BCC), Dr. Jean Tang said at the annual meeting of the Pacific Dermatologic Association.

“Every major pharmaceutical company is now interested in the hedgehog pathway, so we may see a lot of treatments in the near future” for BCC and other cancers that have aberrations in this pathway, said Dr. Tang of Stanford (Calif.) University.

She and her associates are conducting a phase II trial of the experimental Genentech drug GDC-0449 in patients with many BCCs from basal cell nevus syndrome (Gorlin’s syndrome), and a separate proof-of-concept study of the antifungal drug itraconazole in patients with small numbers of BCCs who do not have basal cell nevus syndrome. Dr. Tang said she is pleased by the early results with both drugs so far.

For GDC-0449, a previous phase I study in 33 patients with locally advanced or metastatic BCC who took the drug for a median of 10 months found that 50%-60% had partial or complete responses and the drug was generally well tolerated (N. Engl. J. Med. 2009;361:1,164-72).

Of the 41 patients with basal cell nevus syndrome recruited thus far for the phase II trial - and randomized to 18 months of treatment with GDC-0449 or placebo - 23 patients (with 953 BCC tumors) have more than 1 month of data.

Although the study is still blinded, 15 patients in group A have developed a median of one new BCC during that month, compared with a median of 10 new BCCs in each of the 8 patients in group B, a significant difference that suggests group A may have received the drug and it may be working, Dr. Tang suggested.

In group A, patients started with a median of 252 BCCs and had 127 at the most recent follow-up, a 50% decline. In group B, patients started with 217 BCCs and had 267 at follow-up, a 23% increase in BCCs.

The difference between groups is significant, she said. The existing BCCs in group A also seem to have decreased in size.

“In the patients who have responded, it has changed their lives,” Dr. Tang said. “We are really excited about it.”

Patients in group A, however, were significantly more likely to develop dysgeusia (decreased taste sensation). The condition was seen in 14 of 15 patients, compared with none in group B. Seven patients in group A and none in group B reported some hair loss, though this difference was not statistically significant. Two patients in group A stopped treatment due to dysgeusia and hair loss, compared with no patient cessation in group A. Myalgia was also reported in group A but not group B.

These side effects may be acceptable to patients with basal cell nevus syndrome but probably not to patients with only one or two BCCs, Dr. Tang noted.

For the latter group, a proof-of-concept trial has randomized eight patients thus far to 1 month of treatment with 400 mg/day of oral itraconazole, a drug that has been on the market for approximately 2 decades and is considered relatively safe, she said. Patients are followed clinically for changes in their BCCs, and they undergo tumor biopsies before and after the 1-month therapy to measure the treatment’s effects on the hedgehog signaling pathway.

Preliminary data are “somewhat promising” in reducing BCC size, Dr. Tang said. The effect has not been as dramatic as with the GDC-0449 study, but neither have the side effects.

“This is very preliminary data but I wanted to share it with the other dermatologists in case some of them would like to put some patients on itraconazole, and, collectively, we can figure out whether or not it has a true effect” on BCC, she said.

In addition to the studies on itraconazole and GDC-0449, studies are underway by other investigators on experimental oral or topical agents by Novartis, Exelixis, and Infinity Pharmaceuticals that address aberrations in the hedgehog signaling pathway for the treatment of BCC.

CHICAGO – Dr. Richard L. Gallo put on his Myth Busters hat at a recent dermatology meeting to debunk – and in some cases uphold – some of the most popular ideas about vitamin D.

"This subject is nothing new," noted Dr. Gallo, recounting a bit of vitamin D yore. "In 1936, Schlitz beer urged customers to drink the beverage because it contained 100 units of vitamin D, and could ward off colds and flu. So even back then, they were on to something."

But, Dr. Gallo questioned, is the idea that vitamin D can strengthen the immune system a reality – or a myth? And how about other claims touted in the public press, that sunlight is the best source of vitamin D, that the vitamin strengthen bones and protects against cancer.

"Unfortunately, vitamin D information has become something of a shell game, with positions that overstate the strength of the evidence. As dermatologists, for example, we know the carcinogenic potential of sunlight, but there are now opposing groups that advocate health by increasing vitamin D through sun exposure."

Myth No. 1: Fifteen minutes per day of sunlight provides adequate amounts of vitamin D.

"In a test tube, ultraviolet B is the optimal spectrum for converting 25-hydroxy D into vitamin D in the human body," Dr. Gallo said. "But randomized studies on this vary in results."

One frequently cited study examined the issue in Denmark. "Northern latitudes are very useful for studies like this because of the high intensity of the sun during the summer, and the low intensity in winter," said Dr. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California San Diego. "In this study, the 25-hydroxy D in the population varied dramatically with change in sunlight exposure, and tended to lag about 1 month behind the sunlight levels."

But the study also found that 53% of the subjects who sought sun exposure were still suboptimal in their vitamin D levels. "So sun-seeking behavior in one of the most intense sun-exposed areas of the world is not sufficient to cover optimal vitamin D in a population." (Photochem. Photobiol. 2009;85:1,480-4).

A 2009 study looked at sunlight exposure and vitamin D in twins (PLoS One 2010 5(7):e11555 [doi: 10.1371/journal.pone.0011555]). More than 200 twins were evaluated for the seasonal impact of genetic factors on serum 25-hydroxy vitamin D concentrations. "This showed very wide distributions in levels during the different seasons, and concluded that more than 50% of the variation in summer levels was not due to sun or diet, but to genetic influences independent of skin pigment," Dr. Gallo said.

"So, Myth No. 1 – busted," he concluded.

Myth No. 2: Vitamin D improves bone health.

Prospective cohort studies such as the National Health and Nutrition Examination Survey show that hip fracture is reduced by more than one-third in patients with adequate vitamin D levels (more than 60 nmol/L). "However, we still have a lot to learn. Data from a recent 3-year study of 2,000 perimenopasual women concluded that if vitamin D were given as a single annual dose of 500,000 IU, the women had a 15% increased risk of falls and a 26% increase in the risk of fractures." (JAMA 2010;303:1815-22).

"As far as Myth No. 2 goes, I'd say it's true, but we don't understand everything yet."

Myth No. 3: Vitamin D protects against cancer.

"This has been quite a popular theme in the press for years now, but there are no great mechanistic explanations as to why it may be true," Dr Gallo said. "There are a number of randomized controlled trials, but the data are inconsistent."

A 2009 Agency for Healthcare Research and Quality review examined more than 170 studies and reviews for several health outcomes and vitamin D. "Only one study really showed a level of significance [for cancer reduction]. The others showed inconsistent data on cancer and some showed a slight trend toward an increased risk for colon cancer." (Evid. Rep. Technol. Assess. (Full Rep.) 2009;183:1-420).

"Myth No. 3 is still a plausible possibility, but no benefit has been clearly demonstrated."

Myth No. 4: Vitamin D improves immune function.

"We have excellent mechanistic data to support this claim, including a number of observational studies and a few randomized controlled trials," Dr. Gallo said.

He coauthored a 2009 study concluding that vitamin D activates an enzyme on the surface of monocytes and keratinocytes, increasing the cells' pattern recognition and boosting their antimicrobial effect. "This enhances the immune barrier in injured skin," Dr. Gallo said (J. Clin. Invest. 2007;117:803-11).

Animal models also "show quite clearly that the extent of infection can be limited in an animal supplemented with vitamin D compared to a deficient one," he added. "There also seems to be a relative association between viral infections and upper respiratory infections, with the highest incidence occurring at the lowest levels of vitamin D on a seasonal basis. So maybe Schlitz did have an idea there. Therefore I’d say Myth No. 4 is plausible, but not yet clearly defined."

Dr. Gallo did not have any relevant financial disclosures. However, he is a member of the Institute of Medicine’s committee on Dietary Reference Intakes for Vitamin D and Calcium. The committee will release new recommendations for national daily requirements of vitamin D and calcium later this year.

CHICAGO – Dr. Richard L. Gallo put on his Myth Busters hat at a recent dermatology meeting to debunk – and in some cases uphold – some of the most popular ideas about vitamin D.

"This subject is nothing new," noted Dr. Gallo, recounting a bit of vitamin D yore. "In 1936, Schlitz beer urged customers to drink the beverage because it contained 100 units of vitamin D, and could ward off colds and flu. So even back then, they were on to something."

But, Dr. Gallo questioned, is the idea that vitamin D can strengthen the immune system a reality – or a myth? And how about other claims touted in the public press, that sunlight is the best source of vitamin D, that the vitamin strengthen bones and protects against cancer.

"Unfortunately, vitamin D information has become something of a shell game, with positions that overstate the strength of the evidence. As dermatologists, for example, we know the carcinogenic potential of sunlight, but there are now opposing groups that advocate health by increasing vitamin D through sun exposure."

Myth No. 1: Fifteen minutes per day of sunlight provides adequate amounts of vitamin D.

"In a test tube, ultraviolet B is the optimal spectrum for converting 25-hydroxy D into vitamin D in the human body," Dr. Gallo said. "But randomized studies on this vary in results."

One frequently cited study examined the issue in Denmark. "Northern latitudes are very useful for studies like this because of the high intensity of the sun during the summer, and the low intensity in winter," said Dr. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California San Diego. "In this study, the 25-hydroxy D in the population varied dramatically with change in sunlight exposure, and tended to lag about 1 month behind the sunlight levels."

But the study also found that 53% of the subjects who sought sun exposure were still suboptimal in their vitamin D levels. "So sun-seeking behavior in one of the most intense sun-exposed areas of the world is not sufficient to cover optimal vitamin D in a population." (Photochem. Photobiol. 2009;85:1,480-4).

A 2009 study looked at sunlight exposure and vitamin D in twins (PLoS One 2010 5(7):e11555 [doi: 10.1371/journal.pone.0011555]). More than 200 twins were evaluated for the seasonal impact of genetic factors on serum 25-hydroxy vitamin D concentrations. "This showed very wide distributions in levels during the different seasons, and concluded that more than 50% of the variation in summer levels was not due to sun or diet, but to genetic influences independent of skin pigment," Dr. Gallo said.

"So, Myth No. 1 – busted," he concluded.

Myth No. 2: Vitamin D improves bone health.

Prospective cohort studies such as the National Health and Nutrition Examination Survey show that hip fracture is reduced by more than one-third in patients with adequate vitamin D levels (more than 60 nmol/L). "However, we still have a lot to learn. Data from a recent 3-year study of 2,000 perimenopasual women concluded that if vitamin D were given as a single annual dose of 500,000 IU, the women had a 15% increased risk of falls and a 26% increase in the risk of fractures." (JAMA 2010;303:1815-22).

"As far as Myth No. 2 goes, I'd say it's true, but we don't understand everything yet."

Myth No. 3: Vitamin D protects against cancer.

"This has been quite a popular theme in the press for years now, but there are no great mechanistic explanations as to why it may be true," Dr Gallo said. "There are a number of randomized controlled trials, but the data are inconsistent."

A 2009 Agency for Healthcare Research and Quality review examined more than 170 studies and reviews for several health outcomes and vitamin D. "Only one study really showed a level of significance [for cancer reduction]. The others showed inconsistent data on cancer and some showed a slight trend toward an increased risk for colon cancer." (Evid. Rep. Technol. Assess. (Full Rep.) 2009;183:1-420).

"Myth No. 3 is still a plausible possibility, but no benefit has been clearly demonstrated."

Myth No. 4: Vitamin D improves immune function.

"We have excellent mechanistic data to support this claim, including a number of observational studies and a few randomized controlled trials," Dr. Gallo said.

He coauthored a 2009 study concluding that vitamin D activates an enzyme on the surface of monocytes and keratinocytes, increasing the cells' pattern recognition and boosting their antimicrobial effect. "This enhances the immune barrier in injured skin," Dr. Gallo said (J. Clin. Invest. 2007;117:803-11).

Animal models also "show quite clearly that the extent of infection can be limited in an animal supplemented with vitamin D compared to a deficient one," he added. "There also seems to be a relative association between viral infections and upper respiratory infections, with the highest incidence occurring at the lowest levels of vitamin D on a seasonal basis. So maybe Schlitz did have an idea there. Therefore I’d say Myth No. 4 is plausible, but not yet clearly defined."

Dr. Gallo did not have any relevant financial disclosures. However, he is a member of the Institute of Medicine’s committee on Dietary Reference Intakes for Vitamin D and Calcium. The committee will release new recommendations for national daily requirements of vitamin D and calcium later this year.

CHICAGO – Dr. Richard L. Gallo put on his Myth Busters hat at a recent dermatology meeting to debunk – and in some cases uphold – some of the most popular ideas about vitamin D.

"This subject is nothing new," noted Dr. Gallo, recounting a bit of vitamin D yore. "In 1936, Schlitz beer urged customers to drink the beverage because it contained 100 units of vitamin D, and could ward off colds and flu. So even back then, they were on to something."

But, Dr. Gallo questioned, is the idea that vitamin D can strengthen the immune system a reality – or a myth? And how about other claims touted in the public press, that sunlight is the best source of vitamin D, that the vitamin strengthen bones and protects against cancer.

"Unfortunately, vitamin D information has become something of a shell game, with positions that overstate the strength of the evidence. As dermatologists, for example, we know the carcinogenic potential of sunlight, but there are now opposing groups that advocate health by increasing vitamin D through sun exposure."

Myth No. 1: Fifteen minutes per day of sunlight provides adequate amounts of vitamin D.

"In a test tube, ultraviolet B is the optimal spectrum for converting 25-hydroxy D into vitamin D in the human body," Dr. Gallo said. "But randomized studies on this vary in results."

One frequently cited study examined the issue in Denmark. "Northern latitudes are very useful for studies like this because of the high intensity of the sun during the summer, and the low intensity in winter," said Dr. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California San Diego. "In this study, the 25-hydroxy D in the population varied dramatically with change in sunlight exposure, and tended to lag about 1 month behind the sunlight levels."

But the study also found that 53% of the subjects who sought sun exposure were still suboptimal in their vitamin D levels. "So sun-seeking behavior in one of the most intense sun-exposed areas of the world is not sufficient to cover optimal vitamin D in a population." (Photochem. Photobiol. 2009;85:1,480-4).

A 2009 study looked at sunlight exposure and vitamin D in twins (PLoS One 2010 5(7):e11555 [doi: 10.1371/journal.pone.0011555]). More than 200 twins were evaluated for the seasonal impact of genetic factors on serum 25-hydroxy vitamin D concentrations. "This showed very wide distributions in levels during the different seasons, and concluded that more than 50% of the variation in summer levels was not due to sun or diet, but to genetic influences independent of skin pigment," Dr. Gallo said.

"So, Myth No. 1 – busted," he concluded.

Myth No. 2: Vitamin D improves bone health.

Prospective cohort studies such as the National Health and Nutrition Examination Survey show that hip fracture is reduced by more than one-third in patients with adequate vitamin D levels (more than 60 nmol/L). "However, we still have a lot to learn. Data from a recent 3-year study of 2,000 perimenopasual women concluded that if vitamin D were given as a single annual dose of 500,000 IU, the women had a 15% increased risk of falls and a 26% increase in the risk of fractures." (JAMA 2010;303:1815-22).

"As far as Myth No. 2 goes, I'd say it's true, but we don't understand everything yet."

Myth No. 3: Vitamin D protects against cancer.

"This has been quite a popular theme in the press for years now, but there are no great mechanistic explanations as to why it may be true," Dr Gallo said. "There are a number of randomized controlled trials, but the data are inconsistent."

A 2009 Agency for Healthcare Research and Quality review examined more than 170 studies and reviews for several health outcomes and vitamin D. "Only one study really showed a level of significance [for cancer reduction]. The others showed inconsistent data on cancer and some showed a slight trend toward an increased risk for colon cancer." (Evid. Rep. Technol. Assess. (Full Rep.) 2009;183:1-420).

"Myth No. 3 is still a plausible possibility, but no benefit has been clearly demonstrated."

Myth No. 4: Vitamin D improves immune function.

"We have excellent mechanistic data to support this claim, including a number of observational studies and a few randomized controlled trials," Dr. Gallo said.

He coauthored a 2009 study concluding that vitamin D activates an enzyme on the surface of monocytes and keratinocytes, increasing the cells' pattern recognition and boosting their antimicrobial effect. "This enhances the immune barrier in injured skin," Dr. Gallo said (J. Clin. Invest. 2007;117:803-11).

Animal models also "show quite clearly that the extent of infection can be limited in an animal supplemented with vitamin D compared to a deficient one," he added. "There also seems to be a relative association between viral infections and upper respiratory infections, with the highest incidence occurring at the lowest levels of vitamin D on a seasonal basis. So maybe Schlitz did have an idea there. Therefore I’d say Myth No. 4 is plausible, but not yet clearly defined."

Dr. Gallo did not have any relevant financial disclosures. However, he is a member of the Institute of Medicine’s committee on Dietary Reference Intakes for Vitamin D and Calcium. The committee will release new recommendations for national daily requirements of vitamin D and calcium later this year.

141 Introduction
Michael E. Ming

142 Implications of the 2009 American Joint Committee on Cancer Melanoma Staging and Classification on Dermatologists and Their Patients
Mary Alice Nading, Charles M. Balch, and Arthur J. Sober

148 Pigmented Lesions of the Nail Unit: Clinical and Histopathologic Features
Beth S. Ruben

159 The Risk of Melanoma and Neurocutaneous Melanosis Associated with Congenital Melanocytic Nevi
Kara N. Shah

165 Spitz Nevus and Atypical Spitzoid Neoplasm
Maria Miteva and Rossitza Lazova

174 Noninvasive Imaging Technologies in the Diagnosis of Melanoma
Steven Q. Wang and Pantea Hashemi

185 Vitamin D Levels, Dietary Intake, and Photoprotective Behaviors Among Patients With Skin Cancer
Laura K. DeLong, Sarah Wetherington, Nikki Hill, Meena Kumari, Bryan Gammon, Scott Dunbar, Vin Tangpricha, and Suephy C. Chen

190 Genetic Determinants of Cutaneous Melanoma Predisposition
Durga Udayakumar, Bisundev Mahato, Michele Gabree, and Hensin Tsao

196 Targeted Molecular Therapy in Melanoma
Igor Puzanov and Keith T. Flaherty

141 Introduction
Michael E. Ming

142 Implications of the 2009 American Joint Committee on Cancer Melanoma Staging and Classification on Dermatologists and Their Patients
Mary Alice Nading, Charles M. Balch, and Arthur J. Sober

148 Pigmented Lesions of the Nail Unit: Clinical and Histopathologic Features
Beth S. Ruben

159 The Risk of Melanoma and Neurocutaneous Melanosis Associated with Congenital Melanocytic Nevi
Kara N. Shah

165 Spitz Nevus and Atypical Spitzoid Neoplasm
Maria Miteva and Rossitza Lazova

174 Noninvasive Imaging Technologies in the Diagnosis of Melanoma
Steven Q. Wang and Pantea Hashemi

185 Vitamin D Levels, Dietary Intake, and Photoprotective Behaviors Among Patients With Skin Cancer
Laura K. DeLong, Sarah Wetherington, Nikki Hill, Meena Kumari, Bryan Gammon, Scott Dunbar, Vin Tangpricha, and Suephy C. Chen

190 Genetic Determinants of Cutaneous Melanoma Predisposition
Durga Udayakumar, Bisundev Mahato, Michele Gabree, and Hensin Tsao

196 Targeted Molecular Therapy in Melanoma
Igor Puzanov and Keith T. Flaherty

141 Introduction
Michael E. Ming

142 Implications of the 2009 American Joint Committee on Cancer Melanoma Staging and Classification on Dermatologists and Their Patients
Mary Alice Nading, Charles M. Balch, and Arthur J. Sober

148 Pigmented Lesions of the Nail Unit: Clinical and Histopathologic Features
Beth S. Ruben

159 The Risk of Melanoma and Neurocutaneous Melanosis Associated with Congenital Melanocytic Nevi
Kara N. Shah

165 Spitz Nevus and Atypical Spitzoid Neoplasm
Maria Miteva and Rossitza Lazova

174 Noninvasive Imaging Technologies in the Diagnosis of Melanoma
Steven Q. Wang and Pantea Hashemi

185 Vitamin D Levels, Dietary Intake, and Photoprotective Behaviors Among Patients With Skin Cancer
Laura K. DeLong, Sarah Wetherington, Nikki Hill, Meena Kumari, Bryan Gammon, Scott Dunbar, Vin Tangpricha, and Suephy C. Chen

190 Genetic Determinants of Cutaneous Melanoma Predisposition
Durga Udayakumar, Bisundev Mahato, Michele Gabree, and Hensin Tsao

196 Targeted Molecular Therapy in Melanoma
Igor Puzanov and Keith T. Flaherty

The proper diagnosis and management of pigmented lesions and melanoma can be extremely challenging, but significant strides have been made on multiple fronts in our understanding of the best approaches to these lesions. In this issue, Arthur Sober and his colleagues describe the new changes to the AJCC staging system, Beth Ruben discusses the issues surrounding pigmented lesions of the nail, Kara Shah examines the risk of melanoma and neurocutaneous melanosis in congenital nevi, and Rossitza Lazova and Maria Miteva review the difficulties associated with management of Spitz nevi and the “atypical Spitzoid neoplasm.” Steven Wang and Pantea Hashemi review different imaging modalities, and Suephy Chen and her colleagues discuss the literature surrounding photoprotection measures and serum vitamin D levels. Hensin Tsao and his colleagues describe our current knowledge of the genetic determinants of melanoma predisposition, and the issue concludes with Keith Flaherty and Igor Puzanov’s review of the latest information regarding targeted therapy for metastatic melanoma. I hope that the reader will find the authors’ insights to be helpful when faced with similar situations in daily practice, and I thank all the authors for sharing their expertise.

This issue is dedicated to Marie-France Demierre, who was to have been a contributor to this issue before her untimely passing. She was not only an excellent clinician, researcher, and teacher, but also a wonderful colleague and friend, and she is missed.

Michael E. Ming, MD, MSCE
Guest Editor
University of Pennsylvania School of Medicine,
Philadelphia, PA

The proper diagnosis and management of pigmented lesions and melanoma can be extremely challenging, but significant strides have been made on multiple fronts in our understanding of the best approaches to these lesions. In this issue, Arthur Sober and his colleagues describe the new changes to the AJCC staging system, Beth Ruben discusses the issues surrounding pigmented lesions of the nail, Kara Shah examines the risk of melanoma and neurocutaneous melanosis in congenital nevi, and Rossitza Lazova and Maria Miteva review the difficulties associated with management of Spitz nevi and the “atypical Spitzoid neoplasm.” Steven Wang and Pantea Hashemi review different imaging modalities, and Suephy Chen and her colleagues discuss the literature surrounding photoprotection measures and serum vitamin D levels. Hensin Tsao and his colleagues describe our current knowledge of the genetic determinants of melanoma predisposition, and the issue concludes with Keith Flaherty and Igor Puzanov’s review of the latest information regarding targeted therapy for metastatic melanoma. I hope that the reader will find the authors’ insights to be helpful when faced with similar situations in daily practice, and I thank all the authors for sharing their expertise.

This issue is dedicated to Marie-France Demierre, who was to have been a contributor to this issue before her untimely passing. She was not only an excellent clinician, researcher, and teacher, but also a wonderful colleague and friend, and she is missed.

Michael E. Ming, MD, MSCE
Guest Editor
University of Pennsylvania School of Medicine,
Philadelphia, PA

The proper diagnosis and management of pigmented lesions and melanoma can be extremely challenging, but significant strides have been made on multiple fronts in our understanding of the best approaches to these lesions. In this issue, Arthur Sober and his colleagues describe the new changes to the AJCC staging system, Beth Ruben discusses the issues surrounding pigmented lesions of the nail, Kara Shah examines the risk of melanoma and neurocutaneous melanosis in congenital nevi, and Rossitza Lazova and Maria Miteva review the difficulties associated with management of Spitz nevi and the “atypical Spitzoid neoplasm.” Steven Wang and Pantea Hashemi review different imaging modalities, and Suephy Chen and her colleagues discuss the literature surrounding photoprotection measures and serum vitamin D levels. Hensin Tsao and his colleagues describe our current knowledge of the genetic determinants of melanoma predisposition, and the issue concludes with Keith Flaherty and Igor Puzanov’s review of the latest information regarding targeted therapy for metastatic melanoma. I hope that the reader will find the authors’ insights to be helpful when faced with similar situations in daily practice, and I thank all the authors for sharing their expertise.

This issue is dedicated to Marie-France Demierre, who was to have been a contributor to this issue before her untimely passing. She was not only an excellent clinician, researcher, and teacher, but also a wonderful colleague and friend, and she is missed.

Michael E. Ming, MD, MSCE
Guest Editor
University of Pennsylvania School of Medicine,
Philadelphia, PA

Mary Alice Nading, MD, Charles M. Balch, MD, and Arthur J. Sober, MD

The Melanoma Staging and Classification system was recently revised by the American Joint Committee on Cancer (AJCC) and implemented effective January 2010 with changes reflecting new prognostic data gleaned by the significantly larger patient population studied for the 7th edition. This newest analysis yields important long-term outcome data as many of the patients were followed for nearly 2 decades. Additions to edition 7 of the AJCC Melanoma Staging classification highlight several important prognostic factors, particularly the addition of mitotic rate for classifying thin melanomas, the presence of microtumor burden in lymph nodes for stage III disease, and elevated lactate dehydrogenase levels in patients with distant metastatic disease. Although the basic tumor-nodes-metastases (ie, TNM) cancer classification model remains unchanged in this newest edition, the current AJCC Melanoma Staging System has incorporated the latest prognostic data to accurately stratify patients into staging categories. It is important for clinicians and dermatopathologists to familiarize themselves with these changes so that patients are suitably managed and referred to medical and surgical oncologists when appropriate.

*For a PDF of the full article, click on the link to the left of this introduction.

Mary Alice Nading, MD, Charles M. Balch, MD, and Arthur J. Sober, MD

The Melanoma Staging and Classification system was recently revised by the American Joint Committee on Cancer (AJCC) and implemented effective January 2010 with changes reflecting new prognostic data gleaned by the significantly larger patient population studied for the 7th edition. This newest analysis yields important long-term outcome data as many of the patients were followed for nearly 2 decades. Additions to edition 7 of the AJCC Melanoma Staging classification highlight several important prognostic factors, particularly the addition of mitotic rate for classifying thin melanomas, the presence of microtumor burden in lymph nodes for stage III disease, and elevated lactate dehydrogenase levels in patients with distant metastatic disease. Although the basic tumor-nodes-metastases (ie, TNM) cancer classification model remains unchanged in this newest edition, the current AJCC Melanoma Staging System has incorporated the latest prognostic data to accurately stratify patients into staging categories. It is important for clinicians and dermatopathologists to familiarize themselves with these changes so that patients are suitably managed and referred to medical and surgical oncologists when appropriate.

*For a PDF of the full article, click on the link to the left of this introduction.

Mary Alice Nading, MD, Charles M. Balch, MD, and Arthur J. Sober, MD

The Melanoma Staging and Classification system was recently revised by the American Joint Committee on Cancer (AJCC) and implemented effective January 2010 with changes reflecting new prognostic data gleaned by the significantly larger patient population studied for the 7th edition. This newest analysis yields important long-term outcome data as many of the patients were followed for nearly 2 decades. Additions to edition 7 of the AJCC Melanoma Staging classification highlight several important prognostic factors, particularly the addition of mitotic rate for classifying thin melanomas, the presence of microtumor burden in lymph nodes for stage III disease, and elevated lactate dehydrogenase levels in patients with distant metastatic disease. Although the basic tumor-nodes-metastases (ie, TNM) cancer classification model remains unchanged in this newest edition, the current AJCC Melanoma Staging System has incorporated the latest prognostic data to accurately stratify patients into staging categories. It is important for clinicians and dermatopathologists to familiarize themselves with these changes so that patients are suitably managed and referred to medical and surgical oncologists when appropriate.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Beth S. Ruben, MD

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or “streaky” band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Kara N. Shah, MD, PhD

Congenital melanocytic nevi are commonly encountered in clinical practice. Although the development of malignant melanoma arising in small and intermediate congenital melanocytic nevi is rare, there is a significant risk of malignant degeneration associated with large congenital melanocytic nevi, in particular those that arise on the torso in the so-called “bathing trunk” distribution, where the risk is estimated to be about 2.5% to 5%. The risk of malignant melanoma arising within a large congenital melanocytic nevus is highest in the first 5 to 10 years of life and carries a significant mortality. Large congenital melanocytic nevi, in particular those overlying the posterior axis and occurring in the context of multiple satellite melanocytic nevi, are also associated with the development of neurocutaneous melanosis, which may result in neurologic and neurodevelopmental sequelae and is associated with a significant risk of primary central nervous system melanoma and death.

*For a PDF of the full article, click on the link to the left of this introduction.

Kara N. Shah, MD, PhD

Congenital melanocytic nevi are commonly encountered in clinical practice. Although the development of malignant melanoma arising in small and intermediate congenital melanocytic nevi is rare, there is a significant risk of malignant degeneration associated with large congenital melanocytic nevi, in particular those that arise on the torso in the so-called “bathing trunk” distribution, where the risk is estimated to be about 2.5% to 5%. The risk of malignant melanoma arising within a large congenital melanocytic nevus is highest in the first 5 to 10 years of life and carries a significant mortality. Large congenital melanocytic nevi, in particular those overlying the posterior axis and occurring in the context of multiple satellite melanocytic nevi, are also associated with the development of neurocutaneous melanosis, which may result in neurologic and neurodevelopmental sequelae and is associated with a significant risk of primary central nervous system melanoma and death.

*For a PDF of the full article, click on the link to the left of this introduction.

Kara N. Shah, MD, PhD

Congenital melanocytic nevi are commonly encountered in clinical practice. Although the development of malignant melanoma arising in small and intermediate congenital melanocytic nevi is rare, there is a significant risk of malignant degeneration associated with large congenital melanocytic nevi, in particular those that arise on the torso in the so-called “bathing trunk” distribution, where the risk is estimated to be about 2.5% to 5%. The risk of malignant melanoma arising within a large congenital melanocytic nevus is highest in the first 5 to 10 years of life and carries a significant mortality. Large congenital melanocytic nevi, in particular those overlying the posterior axis and occurring in the context of multiple satellite melanocytic nevi, are also associated with the development of neurocutaneous melanosis, which may result in neurologic and neurodevelopmental sequelae and is associated with a significant risk of primary central nervous system melanoma and death.

*For a PDF of the full article, click on the link to the left of this introduction.

Maria Miteva, MD, and Rossitza Lazova, MD

Spitz nevus (SN) and Spitzoid malignant melanoma (SMM) represent benign and malignant counterparts at both ends of the spectrum of Spitzoid lesions. Atypical Spitzoid neoplasm (ASN) is a poorly defined and characterized category of melanocytic tumors with histologic features of both benign Spitz nevi and malignant melanomas. The group of ASN represents a mixture of Spitz nevi with atypical features and Spitzoid melanomas. However, at the current moment in time, histopathologists are not capable of differentiating between the 2 in some cases and are forced to place them in this ambiguous category, where the behavior of these lesions cannot be predicted with certainty. Because this group encompasses both benign and malignant lesions, and perhaps also a separate category of melanocytic tumors that behave better than conventional melanomas, some of these neoplasms can metastasize and kill patients, whereas others have no metastatic potential, and yet others might only metastasize to regional lymph nodes. Although diagnostic accuracy has improved over the years, many of these lesions remain controversial, and there is still poor interobserver agreement in classifying problematic Spitzoid lesions among experienced dermatopathologists. The objective of this review article is to summarize the most relevant information about SN and ASNs. At this time histologic examination remains the golden standard for diagnosing these melanocytic neoplasms. We therefore concentrate on the histopathologic, clinical, and dermoscopic aspects of these lesions. We also review the most recent advances in immunohistochemical and molecular diagnostics as well as discuss the controversies and dilemma regarding whether to consider sentinel lymph node biopsy for diagnostically ambiguous melanocytic neoplasms. 

*For a PDF of the full article, click on the link to the left of this introduction.

Maria Miteva, MD, and Rossitza Lazova, MD

Spitz nevus (SN) and Spitzoid malignant melanoma (SMM) represent benign and malignant counterparts at both ends of the spectrum of Spitzoid lesions. Atypical Spitzoid neoplasm (ASN) is a poorly defined and characterized category of melanocytic tumors with histologic features of both benign Spitz nevi and malignant melanomas. The group of ASN represents a mixture of Spitz nevi with atypical features and Spitzoid melanomas. However, at the current moment in time, histopathologists are not capable of differentiating between the 2 in some cases and are forced to place them in this ambiguous category, where the behavior of these lesions cannot be predicted with certainty. Because this group encompasses both benign and malignant lesions, and perhaps also a separate category of melanocytic tumors that behave better than conventional melanomas, some of these neoplasms can metastasize and kill patients, whereas others have no metastatic potential, and yet others might only metastasize to regional lymph nodes. Although diagnostic accuracy has improved over the years, many of these lesions remain controversial, and there is still poor interobserver agreement in classifying problematic Spitzoid lesions among experienced dermatopathologists. The objective of this review article is to summarize the most relevant information about SN and ASNs. At this time histologic examination remains the golden standard for diagnosing these melanocytic neoplasms. We therefore concentrate on the histopathologic, clinical, and dermoscopic aspects of these lesions. We also review the most recent advances in immunohistochemical and molecular diagnostics as well as discuss the controversies and dilemma regarding whether to consider sentinel lymph node biopsy for diagnostically ambiguous melanocytic neoplasms. 

*For a PDF of the full article, click on the link to the left of this introduction.

Maria Miteva, MD, and Rossitza Lazova, MD

Spitz nevus (SN) and Spitzoid malignant melanoma (SMM) represent benign and malignant counterparts at both ends of the spectrum of Spitzoid lesions. Atypical Spitzoid neoplasm (ASN) is a poorly defined and characterized category of melanocytic tumors with histologic features of both benign Spitz nevi and malignant melanomas. The group of ASN represents a mixture of Spitz nevi with atypical features and Spitzoid melanomas. However, at the current moment in time, histopathologists are not capable of differentiating between the 2 in some cases and are forced to place them in this ambiguous category, where the behavior of these lesions cannot be predicted with certainty. Because this group encompasses both benign and malignant lesions, and perhaps also a separate category of melanocytic tumors that behave better than conventional melanomas, some of these neoplasms can metastasize and kill patients, whereas others have no metastatic potential, and yet others might only metastasize to regional lymph nodes. Although diagnostic accuracy has improved over the years, many of these lesions remain controversial, and there is still poor interobserver agreement in classifying problematic Spitzoid lesions among experienced dermatopathologists. The objective of this review article is to summarize the most relevant information about SN and ASNs. At this time histologic examination remains the golden standard for diagnosing these melanocytic neoplasms. We therefore concentrate on the histopathologic, clinical, and dermoscopic aspects of these lesions. We also review the most recent advances in immunohistochemical and molecular diagnostics as well as discuss the controversies and dilemma regarding whether to consider sentinel lymph node biopsy for diagnostically ambiguous melanocytic neoplasms. 

*For a PDF of the full article, click on the link to the left of this introduction.

Steven Q. Wang, MD, and Pantea Hashemi, MD

The incidence of melanoma has increased during the last few years. Melanoma care and survival can be improved by early diagnosis, which can be facilitated by the use of noninvasive imaging modalities. Here we review 5 modalities available in clinical practice. Total body photography is used to follow patients at high risk for melanoma by detecting new lesions or subtle changes in existing lesions. Dermoscopy is an effective noninvasive technique for the early recognition of melanoma by allowing clinicians to visualize subsurface structures. Computer-assisted diagnostic devices are fully automated analysis systems with the capacity to classify lesions as benign or malignant with limited involvement from clinicians. Confocal scanning laser microscopy is an in vivo and noninvasive technology that examines the skin at a resolution comparable to that of histology. High-resolution ultrasound is an adjunct diagnostic aid mainly for the early detection of lymph node metastasis. Applications and limitations of each technology are discussed.

*For a PDF of the full article, click on the link to the left of this introduction.

Steven Q. Wang, MD, and Pantea Hashemi, MD

The incidence of melanoma has increased during the last few years. Melanoma care and survival can be improved by early diagnosis, which can be facilitated by the use of noninvasive imaging modalities. Here we review 5 modalities available in clinical practice. Total body photography is used to follow patients at high risk for melanoma by detecting new lesions or subtle changes in existing lesions. Dermoscopy is an effective noninvasive technique for the early recognition of melanoma by allowing clinicians to visualize subsurface structures. Computer-assisted diagnostic devices are fully automated analysis systems with the capacity to classify lesions as benign or malignant with limited involvement from clinicians. Confocal scanning laser microscopy is an in vivo and noninvasive technology that examines the skin at a resolution comparable to that of histology. High-resolution ultrasound is an adjunct diagnostic aid mainly for the early detection of lymph node metastasis. Applications and limitations of each technology are discussed.

*For a PDF of the full article, click on the link to the left of this introduction.

Steven Q. Wang, MD, and Pantea Hashemi, MD

The incidence of melanoma has increased during the last few years. Melanoma care and survival can be improved by early diagnosis, which can be facilitated by the use of noninvasive imaging modalities. Here we review 5 modalities available in clinical practice. Total body photography is used to follow patients at high risk for melanoma by detecting new lesions or subtle changes in existing lesions. Dermoscopy is an effective noninvasive technique for the early recognition of melanoma by allowing clinicians to visualize subsurface structures. Computer-assisted diagnostic devices are fully automated analysis systems with the capacity to classify lesions as benign or malignant with limited involvement from clinicians. Confocal scanning laser microscopy is an in vivo and noninvasive technology that examines the skin at a resolution comparable to that of histology. High-resolution ultrasound is an adjunct diagnostic aid mainly for the early detection of lymph node metastasis. Applications and limitations of each technology are discussed.

*For a PDF of the full article, click on the link to the left of this introduction.

Laura K. DeLong, MD, MPH, Sarah Wetherington, BS, Nikki Hill, MD, Meena Kumari, MD, Bryan Gammon, MD, Scott Dunbar, MD, Vin Tangpricha, MD, PhD, and Suephy C. Chen, MD, MS

Photoprotection against ultraviolet light is an important part of our armamentarium against actinically derived skin cancers. However, there has been concern that adherence to photoprotection may lead to low vitamin D status, leading to negative effects on patients’ health. In this work we discuss previous findings in this area, which do not give a clear picture as to the relationship between vitamin D levels and photoprotection measures, as well as research performed by the authors, who did not detect a relationship between serum 25(OH)D levels and adherence to photoprotection measures in subjects with skin cancer, as assessed by the use of sunscreen, clothing, hats, sunglasses, and umbrellas/shade through the Sun Protection Habits Index. Subjects who took vitamin D oral supplementation had greater serum 25(OH)D levels than those who did not, whereas dietary intake through foods did not predict 25(OH)D levels in the authors’ study. However, there was a high prevalence of vitamin D insufficiency and deficiency in the authors’ study population, highlighting the importance of assessing vitamin D status and recommending oral vitamin D supplementation when indicated. 

*For a PDF of the full article, click on the link to the left of this introduction.

Laura K. DeLong, MD, MPH, Sarah Wetherington, BS, Nikki Hill, MD, Meena Kumari, MD, Bryan Gammon, MD, Scott Dunbar, MD, Vin Tangpricha, MD, PhD, and Suephy C. Chen, MD, MS

Photoprotection against ultraviolet light is an important part of our armamentarium against actinically derived skin cancers. However, there has been concern that adherence to photoprotection may lead to low vitamin D status, leading to negative effects on patients’ health. In this work we discuss previous findings in this area, which do not give a clear picture as to the relationship between vitamin D levels and photoprotection measures, as well as research performed by the authors, who did not detect a relationship between serum 25(OH)D levels and adherence to photoprotection measures in subjects with skin cancer, as assessed by the use of sunscreen, clothing, hats, sunglasses, and umbrellas/shade through the Sun Protection Habits Index. Subjects who took vitamin D oral supplementation had greater serum 25(OH)D levels than those who did not, whereas dietary intake through foods did not predict 25(OH)D levels in the authors’ study. However, there was a high prevalence of vitamin D insufficiency and deficiency in the authors’ study population, highlighting the importance of assessing vitamin D status and recommending oral vitamin D supplementation when indicated. 

*For a PDF of the full article, click on the link to the left of this introduction.

Laura K. DeLong, MD, MPH, Sarah Wetherington, BS, Nikki Hill, MD, Meena Kumari, MD, Bryan Gammon, MD, Scott Dunbar, MD, Vin Tangpricha, MD, PhD, and Suephy C. Chen, MD, MS

Photoprotection against ultraviolet light is an important part of our armamentarium against actinically derived skin cancers. However, there has been concern that adherence to photoprotection may lead to low vitamin D status, leading to negative effects on patients’ health. In this work we discuss previous findings in this area, which do not give a clear picture as to the relationship between vitamin D levels and photoprotection measures, as well as research performed by the authors, who did not detect a relationship between serum 25(OH)D levels and adherence to photoprotection measures in subjects with skin cancer, as assessed by the use of sunscreen, clothing, hats, sunglasses, and umbrellas/shade through the Sun Protection Habits Index. Subjects who took vitamin D oral supplementation had greater serum 25(OH)D levels than those who did not, whereas dietary intake through foods did not predict 25(OH)D levels in the authors’ study. However, there was a high prevalence of vitamin D insufficiency and deficiency in the authors’ study population, highlighting the importance of assessing vitamin D status and recommending oral vitamin D supplementation when indicated. 

*For a PDF of the full article, click on the link to the left of this introduction.