Melanoma

SCOTTSDALE, ARIZ. — If there was an award given for "oldies but goodies" in the dermatologic armamentarium, Dr. Haines Ely would surely nominate bleomycin, a medication he has long relied upon for difficult squamous and Merkel cell lesions.

"My love affair with bleomycin began when I was a senior medical student," he recalled at the annual meeting of the Noah Worcester Dermatological Society.

The experience exposed him to two near-miraculous responses to intralesional bleomycin: the first, in a patient who refused a penectomy for advanced squamous cell carcinoma (SCC) of the penis.

And the second, in a patient with multiple fast-growing metastatic skin lesions from SCC of the lung that had left the patient "screaming in agony" on the hospital ward where Dr. Ely was moonlighting as a phlebotomist.

"By morning, those tumors had resolved. He was sitting up and eating breakfast," said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

Through the years, Dr. Ely's reliance on bleomycin in tough cases has been reconfirmed.

The drug has a profound antiviral effect, demonstrated by the drug's effectiveness for treating Kaposi's sarcoma patients in the early days of HIV therapy.

It has also been useful for treating aggressive acantholytic SCC patients who refused surgery or were poor surgical candidates, he said. But perhaps its greatest utility is in treating patients with Merkel cell carcinoma (MCC), which has recently been linked to a previously unknown polyomavirus that may prove susceptible to bleomycin (Science 2008;319:1096-100).

"The treatment of choice is still surgery," he emphasized, but patients are often unable to undergo surgery because of their advanced age, comorbidities, and immunocompromised state. In several cases he presented, radiation therapy proved unsuccessful or resulted in profound complications.

One such case involved an 84-year-old woman residing in a nursing home who was seen for a "cyst" on her cheek that proved to be a 6-cm MCC. "I called several plastic surgeons in town, but nobody would touch it," he said.

Radiation was followed by "tremendous regrowth," prompting Dr. Ely to inject bleomycin directly into the tumor base in two treatments, 1 week apart.

The tumor resolved. "She lived 5 years with no recurrences," he said.

For tumors that strongly resemble MCC, "I don't even fool around," said Dr. Ely, noting that he injects 3 IU of bleomycin with lidocaine prior to biopsying the site. In one such case sent for referral following prebiopsy intralesional bleomycin, no evidence could be found of MCC by the time of excision.

Dr. Ely said his experience has led him to add to the recently described acronym AEIOU associated with features of MCC: asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than age 50, and UV-exposed site in a fair-skinned person (J. Am. Acad. Dermatol. 2008;58:375-81).

His own acronym, AEIOU-VB, includes "viral associated" and "bleomycin sensitive."

He cautioned that patients must have adequate renal function for bleomycin to be considered, and some patients may have transient side effects such as chills and fever following intralesional injections of the medication. The most serious, albeit rare, complication of bleomycin is pulmonary fibrosis, more commonly seen in elderly patients and those receiving high doses of the chemotherapy.

Dr. Ely reported having no conflicts of interest.

'My love affair with bleomycin began when Iwas a senior medical student.' DR. ELY

SCOTTSDALE, ARIZ. — If there was an award given for "oldies but goodies" in the dermatologic armamentarium, Dr. Haines Ely would surely nominate bleomycin, a medication he has long relied upon for difficult squamous and Merkel cell lesions.

"My love affair with bleomycin began when I was a senior medical student," he recalled at the annual meeting of the Noah Worcester Dermatological Society.

The experience exposed him to two near-miraculous responses to intralesional bleomycin: the first, in a patient who refused a penectomy for advanced squamous cell carcinoma (SCC) of the penis.

And the second, in a patient with multiple fast-growing metastatic skin lesions from SCC of the lung that had left the patient "screaming in agony" on the hospital ward where Dr. Ely was moonlighting as a phlebotomist.

"By morning, those tumors had resolved. He was sitting up and eating breakfast," said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

Through the years, Dr. Ely's reliance on bleomycin in tough cases has been reconfirmed.

The drug has a profound antiviral effect, demonstrated by the drug's effectiveness for treating Kaposi's sarcoma patients in the early days of HIV therapy.

It has also been useful for treating aggressive acantholytic SCC patients who refused surgery or were poor surgical candidates, he said. But perhaps its greatest utility is in treating patients with Merkel cell carcinoma (MCC), which has recently been linked to a previously unknown polyomavirus that may prove susceptible to bleomycin (Science 2008;319:1096-100).

"The treatment of choice is still surgery," he emphasized, but patients are often unable to undergo surgery because of their advanced age, comorbidities, and immunocompromised state. In several cases he presented, radiation therapy proved unsuccessful or resulted in profound complications.

One such case involved an 84-year-old woman residing in a nursing home who was seen for a "cyst" on her cheek that proved to be a 6-cm MCC. "I called several plastic surgeons in town, but nobody would touch it," he said.

Radiation was followed by "tremendous regrowth," prompting Dr. Ely to inject bleomycin directly into the tumor base in two treatments, 1 week apart.

The tumor resolved. "She lived 5 years with no recurrences," he said.

For tumors that strongly resemble MCC, "I don't even fool around," said Dr. Ely, noting that he injects 3 IU of bleomycin with lidocaine prior to biopsying the site. In one such case sent for referral following prebiopsy intralesional bleomycin, no evidence could be found of MCC by the time of excision.

Dr. Ely said his experience has led him to add to the recently described acronym AEIOU associated with features of MCC: asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than age 50, and UV-exposed site in a fair-skinned person (J. Am. Acad. Dermatol. 2008;58:375-81).

His own acronym, AEIOU-VB, includes "viral associated" and "bleomycin sensitive."

He cautioned that patients must have adequate renal function for bleomycin to be considered, and some patients may have transient side effects such as chills and fever following intralesional injections of the medication. The most serious, albeit rare, complication of bleomycin is pulmonary fibrosis, more commonly seen in elderly patients and those receiving high doses of the chemotherapy.

Dr. Ely reported having no conflicts of interest.

'My love affair with bleomycin began when Iwas a senior medical student.' DR. ELY

SCOTTSDALE, ARIZ. — If there was an award given for "oldies but goodies" in the dermatologic armamentarium, Dr. Haines Ely would surely nominate bleomycin, a medication he has long relied upon for difficult squamous and Merkel cell lesions.

"My love affair with bleomycin began when I was a senior medical student," he recalled at the annual meeting of the Noah Worcester Dermatological Society.

The experience exposed him to two near-miraculous responses to intralesional bleomycin: the first, in a patient who refused a penectomy for advanced squamous cell carcinoma (SCC) of the penis.

And the second, in a patient with multiple fast-growing metastatic skin lesions from SCC of the lung that had left the patient "screaming in agony" on the hospital ward where Dr. Ely was moonlighting as a phlebotomist.

"By morning, those tumors had resolved. He was sitting up and eating breakfast," said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

Through the years, Dr. Ely's reliance on bleomycin in tough cases has been reconfirmed.

The drug has a profound antiviral effect, demonstrated by the drug's effectiveness for treating Kaposi's sarcoma patients in the early days of HIV therapy.

It has also been useful for treating aggressive acantholytic SCC patients who refused surgery or were poor surgical candidates, he said. But perhaps its greatest utility is in treating patients with Merkel cell carcinoma (MCC), which has recently been linked to a previously unknown polyomavirus that may prove susceptible to bleomycin (Science 2008;319:1096-100).

"The treatment of choice is still surgery," he emphasized, but patients are often unable to undergo surgery because of their advanced age, comorbidities, and immunocompromised state. In several cases he presented, radiation therapy proved unsuccessful or resulted in profound complications.

One such case involved an 84-year-old woman residing in a nursing home who was seen for a "cyst" on her cheek that proved to be a 6-cm MCC. "I called several plastic surgeons in town, but nobody would touch it," he said.

Radiation was followed by "tremendous regrowth," prompting Dr. Ely to inject bleomycin directly into the tumor base in two treatments, 1 week apart.

The tumor resolved. "She lived 5 years with no recurrences," he said.

For tumors that strongly resemble MCC, "I don't even fool around," said Dr. Ely, noting that he injects 3 IU of bleomycin with lidocaine prior to biopsying the site. In one such case sent for referral following prebiopsy intralesional bleomycin, no evidence could be found of MCC by the time of excision.

Dr. Ely said his experience has led him to add to the recently described acronym AEIOU associated with features of MCC: asymptomatic/lack of tenderness, expanding rapidly, immune suppression, older than age 50, and UV-exposed site in a fair-skinned person (J. Am. Acad. Dermatol. 2008;58:375-81).

His own acronym, AEIOU-VB, includes "viral associated" and "bleomycin sensitive."

He cautioned that patients must have adequate renal function for bleomycin to be considered, and some patients may have transient side effects such as chills and fever following intralesional injections of the medication. The most serious, albeit rare, complication of bleomycin is pulmonary fibrosis, more commonly seen in elderly patients and those receiving high doses of the chemotherapy.

Dr. Ely reported having no conflicts of interest.

'My love affair with bleomycin began when Iwas a senior medical student.' DR. ELY

VANCOUVER, B.C. — Capecitabine, an oral prodrug of 5-fluorouracil, can be used to control advanced squamous cell carcinoma of the skin when conventional treatment options have run out, according to the results of two studies involving a total of five patients.

Capecitabine (Xeloda) "was designed to improve upon existing 5-fluorouracil by having increased efficacy, an improved side-effect profile, and increased ease of administration," Dr. Mariah R. Brown, lead investigator of one study, explained at the annual meeting of the American College of Mohs Surgery.

Although capecitabine is currently approved only for treatment of colorectal cancer and breast cancer, research suggests a possible role for the drug in managing several other malignancies, including skin cancer, she noted.

Dr. Brown and her colleagues at the University of Colorado, Denver, studied three patients (two women and one man) aged 60-73 years who had locally advanced squamous cell carcinoma (SCC) of the head and neck. In each case, the cancer was inoperable because of tumor size or limitations imposed by prior surgery or radiation therapy; patients also wanted to avoid aggressive therapy. None of the patients had evidence of metastases.

The patients were treated with multiple courses of capecitabine (1,500 mg twice daily), with each course consisting of 2 weeks on the drug and 1 week off. The total duration of treatment ranged from 2 to 6 months.

All patients had a clinical response, with visible shrinkage of tumors by more than 50% and response beginning within the first course of therapy, Dr. Brown reported.

One patient was clinically disease-free after four courses of therapy. She continued taking capecitabine, albeit at a lower dose, because she experienced severe hand-foot syndrome, and was stable 6 months after starting the lower-dose therapy. Another patient had to discontinue the drug after 21/2 courses because of adverse effects (neutropenia and diarrhea) and experienced rapid regrowth of her tumor. The remaining patient was free of disease after four courses but was then lost to follow-up.

"Capecitabine demonstrates some initial positive results in advanced cutaneous squamous cell carcinoma," Dr. Brown said. "The medication was relatively well tolerated, but side effects may necessitate dose reduction or discontinuation."

The second study, presented as a poster by Dr. Jeffrey E. Petersen of Wright State University in Dayton, Ohio, described use of capecitabine in two patients with SCC.

The first patient was an 87-year-old man who had multiple recurrent SCCs of the scalp and had undergone previous cryotherapy, topical 5-fluorouracil treatment, and multiple excisions including a Mohs procedure. The cancer progressed, despite treatment with a maximum dose of radiation therapy. The patient declined extensive surgery.

The second patient was an 84-year-old man who had previously undergone Mohs surgery down to bone for SCC of the scalp but experienced a recurrence. He had already received radiation to that area. The patient had severe Alzheimer's disease, and his family declined further surgery.

Both patients were treated with capecitabine at 50% of the standard dose of 1,250 mg/m

Although the patients experienced mild nausea and reduced taste while on treatment, the drug was otherwise well tolerated, he noted.

In addition to improving visible disease, capecitabine may be acting on disease that is not yet clinically evident. "Because it's a systemic drug, … in the large tumors where there is a high risk of metastatic disease you may be also treating that microscopic metastatic disease," he explained.

"Capecitabine gives you an option sometimes when you are looking at a patient and thinking, 'I don't have any more options, I don't have anything more to offer these people.' And [now] we do," Dr. Petersen said.

Dr. Brown and Dr. Petersen reported that they had no conflicts of interest in association with their studies.

This 87-year-old patient's recurrent SCC had progressed despite treatment with a maximum dose of radiation.

There is marked improvement of the scalp after four courses of capecitabine, although some ulcers are still present. Photos courtesy Dr. Jeffrey E. Petersen

VANCOUVER, B.C. — Capecitabine, an oral prodrug of 5-fluorouracil, can be used to control advanced squamous cell carcinoma of the skin when conventional treatment options have run out, according to the results of two studies involving a total of five patients.

Capecitabine (Xeloda) "was designed to improve upon existing 5-fluorouracil by having increased efficacy, an improved side-effect profile, and increased ease of administration," Dr. Mariah R. Brown, lead investigator of one study, explained at the annual meeting of the American College of Mohs Surgery.

Although capecitabine is currently approved only for treatment of colorectal cancer and breast cancer, research suggests a possible role for the drug in managing several other malignancies, including skin cancer, she noted.

Dr. Brown and her colleagues at the University of Colorado, Denver, studied three patients (two women and one man) aged 60-73 years who had locally advanced squamous cell carcinoma (SCC) of the head and neck. In each case, the cancer was inoperable because of tumor size or limitations imposed by prior surgery or radiation therapy; patients also wanted to avoid aggressive therapy. None of the patients had evidence of metastases.

The patients were treated with multiple courses of capecitabine (1,500 mg twice daily), with each course consisting of 2 weeks on the drug and 1 week off. The total duration of treatment ranged from 2 to 6 months.

All patients had a clinical response, with visible shrinkage of tumors by more than 50% and response beginning within the first course of therapy, Dr. Brown reported.

One patient was clinically disease-free after four courses of therapy. She continued taking capecitabine, albeit at a lower dose, because she experienced severe hand-foot syndrome, and was stable 6 months after starting the lower-dose therapy. Another patient had to discontinue the drug after 21/2 courses because of adverse effects (neutropenia and diarrhea) and experienced rapid regrowth of her tumor. The remaining patient was free of disease after four courses but was then lost to follow-up.

"Capecitabine demonstrates some initial positive results in advanced cutaneous squamous cell carcinoma," Dr. Brown said. "The medication was relatively well tolerated, but side effects may necessitate dose reduction or discontinuation."

The second study, presented as a poster by Dr. Jeffrey E. Petersen of Wright State University in Dayton, Ohio, described use of capecitabine in two patients with SCC.

The first patient was an 87-year-old man who had multiple recurrent SCCs of the scalp and had undergone previous cryotherapy, topical 5-fluorouracil treatment, and multiple excisions including a Mohs procedure. The cancer progressed, despite treatment with a maximum dose of radiation therapy. The patient declined extensive surgery.

The second patient was an 84-year-old man who had previously undergone Mohs surgery down to bone for SCC of the scalp but experienced a recurrence. He had already received radiation to that area. The patient had severe Alzheimer's disease, and his family declined further surgery.

Both patients were treated with capecitabine at 50% of the standard dose of 1,250 mg/m

Although the patients experienced mild nausea and reduced taste while on treatment, the drug was otherwise well tolerated, he noted.

In addition to improving visible disease, capecitabine may be acting on disease that is not yet clinically evident. "Because it's a systemic drug, … in the large tumors where there is a high risk of metastatic disease you may be also treating that microscopic metastatic disease," he explained.

"Capecitabine gives you an option sometimes when you are looking at a patient and thinking, 'I don't have any more options, I don't have anything more to offer these people.' And [now] we do," Dr. Petersen said.

Dr. Brown and Dr. Petersen reported that they had no conflicts of interest in association with their studies.

This 87-year-old patient's recurrent SCC had progressed despite treatment with a maximum dose of radiation.

There is marked improvement of the scalp after four courses of capecitabine, although some ulcers are still present. Photos courtesy Dr. Jeffrey E. Petersen

VANCOUVER, B.C. — Capecitabine, an oral prodrug of 5-fluorouracil, can be used to control advanced squamous cell carcinoma of the skin when conventional treatment options have run out, according to the results of two studies involving a total of five patients.

Capecitabine (Xeloda) "was designed to improve upon existing 5-fluorouracil by having increased efficacy, an improved side-effect profile, and increased ease of administration," Dr. Mariah R. Brown, lead investigator of one study, explained at the annual meeting of the American College of Mohs Surgery.

Although capecitabine is currently approved only for treatment of colorectal cancer and breast cancer, research suggests a possible role for the drug in managing several other malignancies, including skin cancer, she noted.

Dr. Brown and her colleagues at the University of Colorado, Denver, studied three patients (two women and one man) aged 60-73 years who had locally advanced squamous cell carcinoma (SCC) of the head and neck. In each case, the cancer was inoperable because of tumor size or limitations imposed by prior surgery or radiation therapy; patients also wanted to avoid aggressive therapy. None of the patients had evidence of metastases.

The patients were treated with multiple courses of capecitabine (1,500 mg twice daily), with each course consisting of 2 weeks on the drug and 1 week off. The total duration of treatment ranged from 2 to 6 months.

All patients had a clinical response, with visible shrinkage of tumors by more than 50% and response beginning within the first course of therapy, Dr. Brown reported.

One patient was clinically disease-free after four courses of therapy. She continued taking capecitabine, albeit at a lower dose, because she experienced severe hand-foot syndrome, and was stable 6 months after starting the lower-dose therapy. Another patient had to discontinue the drug after 21/2 courses because of adverse effects (neutropenia and diarrhea) and experienced rapid regrowth of her tumor. The remaining patient was free of disease after four courses but was then lost to follow-up.

"Capecitabine demonstrates some initial positive results in advanced cutaneous squamous cell carcinoma," Dr. Brown said. "The medication was relatively well tolerated, but side effects may necessitate dose reduction or discontinuation."

The second study, presented as a poster by Dr. Jeffrey E. Petersen of Wright State University in Dayton, Ohio, described use of capecitabine in two patients with SCC.

The first patient was an 87-year-old man who had multiple recurrent SCCs of the scalp and had undergone previous cryotherapy, topical 5-fluorouracil treatment, and multiple excisions including a Mohs procedure. The cancer progressed, despite treatment with a maximum dose of radiation therapy. The patient declined extensive surgery.

The second patient was an 84-year-old man who had previously undergone Mohs surgery down to bone for SCC of the scalp but experienced a recurrence. He had already received radiation to that area. The patient had severe Alzheimer's disease, and his family declined further surgery.

Both patients were treated with capecitabine at 50% of the standard dose of 1,250 mg/m

Although the patients experienced mild nausea and reduced taste while on treatment, the drug was otherwise well tolerated, he noted.

In addition to improving visible disease, capecitabine may be acting on disease that is not yet clinically evident. "Because it's a systemic drug, … in the large tumors where there is a high risk of metastatic disease you may be also treating that microscopic metastatic disease," he explained.

"Capecitabine gives you an option sometimes when you are looking at a patient and thinking, 'I don't have any more options, I don't have anything more to offer these people.' And [now] we do," Dr. Petersen said.

Dr. Brown and Dr. Petersen reported that they had no conflicts of interest in association with their studies.

This 87-year-old patient's recurrent SCC had progressed despite treatment with a maximum dose of radiation.

There is marked improvement of the scalp after four courses of capecitabine, although some ulcers are still present. Photos courtesy Dr. Jeffrey E. Petersen

VANCOUVER, B.C. — Adenosquamous carcinoma is an often misdiagnosed and more aggressive type of skin cancer that requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary disease.

"We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence," Dr. Jennifer M. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of adenosquamous carcinoma (ASC) diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50-97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. "Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated," observed Dr. Fu, a dermatology resident at the University of California, San Francisco.

"Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case," she said. "In no case was adenosquamous carcinoma correctly diagnosed."

Histopathologically, many of the features of ASC overlap those of desmoplastic SCC, but ASC differs in having glandular differentiation. "At least at our institution, we feel that adenosquamous carcinoma is probably best considered a variant of SCC and on a spectrum of desmoplastic SCC," Dr. Fu said.

The tumors evaluated in the study typically had an infiltrative pattern with dermal fibrosis or sclerosis: 61% showed elastosis, while 30% were ulcerated. Squamous differentiation was universal, with all tumors exhibiting cytoplasmic cornification and 41% having keratinizing cysts.

Most tumors (92%) had ductular elements, while 58% had glandular elements. Even when a tumor had glandular elements, the percentage of that tumor showing those elements varied from roughly 5% to 80%. In fact, two of the cases were initially interpreted to be SCC but were subsequently determined to have glandular differentiation more consistent with ASC. In such equivocal cases, immunostaining for carcinoembryonic antigen or cytokeratin 7 may help identify glandular foci, she noted.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant radiation therapy and cetuximab (Erbitux) for locally advanced disease. For these patients, "the Mohs defect postoperatively far exceeded what was evident clinically," said Dr. Fu, who had no conflicts of interest in association with the study.

In this patient, recurrent nodules and plaques of adenosquamous carcinoma are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — Adenosquamous carcinoma is an often misdiagnosed and more aggressive type of skin cancer that requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary disease.

"We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence," Dr. Jennifer M. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of adenosquamous carcinoma (ASC) diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50-97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. "Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated," observed Dr. Fu, a dermatology resident at the University of California, San Francisco.

"Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case," she said. "In no case was adenosquamous carcinoma correctly diagnosed."

Histopathologically, many of the features of ASC overlap those of desmoplastic SCC, but ASC differs in having glandular differentiation. "At least at our institution, we feel that adenosquamous carcinoma is probably best considered a variant of SCC and on a spectrum of desmoplastic SCC," Dr. Fu said.

The tumors evaluated in the study typically had an infiltrative pattern with dermal fibrosis or sclerosis: 61% showed elastosis, while 30% were ulcerated. Squamous differentiation was universal, with all tumors exhibiting cytoplasmic cornification and 41% having keratinizing cysts.

Most tumors (92%) had ductular elements, while 58% had glandular elements. Even when a tumor had glandular elements, the percentage of that tumor showing those elements varied from roughly 5% to 80%. In fact, two of the cases were initially interpreted to be SCC but were subsequently determined to have glandular differentiation more consistent with ASC. In such equivocal cases, immunostaining for carcinoembryonic antigen or cytokeratin 7 may help identify glandular foci, she noted.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant radiation therapy and cetuximab (Erbitux) for locally advanced disease. For these patients, "the Mohs defect postoperatively far exceeded what was evident clinically," said Dr. Fu, who had no conflicts of interest in association with the study.

In this patient, recurrent nodules and plaques of adenosquamous carcinoma are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — Adenosquamous carcinoma is an often misdiagnosed and more aggressive type of skin cancer that requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary disease.

"We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence," Dr. Jennifer M. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of adenosquamous carcinoma (ASC) diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50-97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. "Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated," observed Dr. Fu, a dermatology resident at the University of California, San Francisco.

"Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case," she said. "In no case was adenosquamous carcinoma correctly diagnosed."

Histopathologically, many of the features of ASC overlap those of desmoplastic SCC, but ASC differs in having glandular differentiation. "At least at our institution, we feel that adenosquamous carcinoma is probably best considered a variant of SCC and on a spectrum of desmoplastic SCC," Dr. Fu said.

The tumors evaluated in the study typically had an infiltrative pattern with dermal fibrosis or sclerosis: 61% showed elastosis, while 30% were ulcerated. Squamous differentiation was universal, with all tumors exhibiting cytoplasmic cornification and 41% having keratinizing cysts.

Most tumors (92%) had ductular elements, while 58% had glandular elements. Even when a tumor had glandular elements, the percentage of that tumor showing those elements varied from roughly 5% to 80%. In fact, two of the cases were initially interpreted to be SCC but were subsequently determined to have glandular differentiation more consistent with ASC. In such equivocal cases, immunostaining for carcinoembryonic antigen or cytokeratin 7 may help identify glandular foci, she noted.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant radiation therapy and cetuximab (Erbitux) for locally advanced disease. For these patients, "the Mohs defect postoperatively far exceeded what was evident clinically," said Dr. Fu, who had no conflicts of interest in association with the study.

In this patient, recurrent nodules and plaques of adenosquamous carcinoma are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

WILLIAMSBURG, VA. — Sentinel lymph node biopsy should be reserved only for squamous cell carcinoma patients whose primary tumors have a high-risk profile, according to Dr. Merrick Ross.

"Clearly, the routine use of sentinel node biopsy is not indicated in these patients, but its selective use in high-risk squamous cell carcinoma [SCC] seems rational," said Dr. Ross at a meeting of the American Society for Mohs Surgery. "This is why it's important for us to continue to define exactly what constitutes a high-risk squamous cell tumor."

High-risk features of SCC include anatomical location, thickness, size, perineural invasion, and the immunocompetence of the patient.

Increasing size is associated with decreased local control and the increased presence of positive lymph nodes. A size of 2 cm "seems to be the most relevant break point," said Dr. Ross, professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center, Houston. "Studies have shown that up to 50% of SCCs larger than that will have nodal involvement. However, to date there is no multivariate analysis that demonstrates size as an independent predictor of nodal disease."

Most studies identify 4-5 cm as the high-risk break point for tumor thickness, he said. In a large German study of 550 patients, only 3% of those with tumors less than 5 mm thick had nodal metastasis, compared with more than 17% of those with thicker tumors, Dr. Ross noted (Cancer 1997;79:915-9).

High-grade tumors are more likely than low-grade tumors to have nodal disease, said Dr. Ross, with 17% of high-grade tumors showing metastasis, compared with 4% of lower-grade tumors. When the German investigators looked at grade distribution according to nodal involvement, 44% of node-positive patients had high-grade primary tumors, whereas only 5% of node-negative patients had high-grade tumors.

Local recurrence is strongly associated with nodal involvement, just as it is with larger size, thicker tumors, narrow excision margins, and anatomical site. Up to 45% of recurrent presentations will have nodal disease, Dr. Ross said.

Lesions that arise on the lip, around the ear, and in the anogenital region are particularly risky. A 2006 study found that 27% of SCCs on the external ear had nodal disease, as did more than 20% of T3- and T4-stage lip lesions (Aust. J Derm. 2006;47:28-33).

The overall health of the patient is another important risk factor. "Patients with HIV [disease] or other immunodeficiency diseases are at an increased risk for metastasis, as are those with any chronic hematologic malignancy" Dr. Ross said.

WILLIAMSBURG, VA. — Sentinel lymph node biopsy should be reserved only for squamous cell carcinoma patients whose primary tumors have a high-risk profile, according to Dr. Merrick Ross.

"Clearly, the routine use of sentinel node biopsy is not indicated in these patients, but its selective use in high-risk squamous cell carcinoma [SCC] seems rational," said Dr. Ross at a meeting of the American Society for Mohs Surgery. "This is why it's important for us to continue to define exactly what constitutes a high-risk squamous cell tumor."

High-risk features of SCC include anatomical location, thickness, size, perineural invasion, and the immunocompetence of the patient.

Increasing size is associated with decreased local control and the increased presence of positive lymph nodes. A size of 2 cm "seems to be the most relevant break point," said Dr. Ross, professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center, Houston. "Studies have shown that up to 50% of SCCs larger than that will have nodal involvement. However, to date there is no multivariate analysis that demonstrates size as an independent predictor of nodal disease."

Most studies identify 4-5 cm as the high-risk break point for tumor thickness, he said. In a large German study of 550 patients, only 3% of those with tumors less than 5 mm thick had nodal metastasis, compared with more than 17% of those with thicker tumors, Dr. Ross noted (Cancer 1997;79:915-9).

High-grade tumors are more likely than low-grade tumors to have nodal disease, said Dr. Ross, with 17% of high-grade tumors showing metastasis, compared with 4% of lower-grade tumors. When the German investigators looked at grade distribution according to nodal involvement, 44% of node-positive patients had high-grade primary tumors, whereas only 5% of node-negative patients had high-grade tumors.

Local recurrence is strongly associated with nodal involvement, just as it is with larger size, thicker tumors, narrow excision margins, and anatomical site. Up to 45% of recurrent presentations will have nodal disease, Dr. Ross said.

Lesions that arise on the lip, around the ear, and in the anogenital region are particularly risky. A 2006 study found that 27% of SCCs on the external ear had nodal disease, as did more than 20% of T3- and T4-stage lip lesions (Aust. J Derm. 2006;47:28-33).

The overall health of the patient is another important risk factor. "Patients with HIV [disease] or other immunodeficiency diseases are at an increased risk for metastasis, as are those with any chronic hematologic malignancy" Dr. Ross said.

WILLIAMSBURG, VA. — Sentinel lymph node biopsy should be reserved only for squamous cell carcinoma patients whose primary tumors have a high-risk profile, according to Dr. Merrick Ross.

"Clearly, the routine use of sentinel node biopsy is not indicated in these patients, but its selective use in high-risk squamous cell carcinoma [SCC] seems rational," said Dr. Ross at a meeting of the American Society for Mohs Surgery. "This is why it's important for us to continue to define exactly what constitutes a high-risk squamous cell tumor."

High-risk features of SCC include anatomical location, thickness, size, perineural invasion, and the immunocompetence of the patient.

Increasing size is associated with decreased local control and the increased presence of positive lymph nodes. A size of 2 cm "seems to be the most relevant break point," said Dr. Ross, professor of surgical oncology at the University of Texas M.D. Anderson Cancer Center, Houston. "Studies have shown that up to 50% of SCCs larger than that will have nodal involvement. However, to date there is no multivariate analysis that demonstrates size as an independent predictor of nodal disease."

Most studies identify 4-5 cm as the high-risk break point for tumor thickness, he said. In a large German study of 550 patients, only 3% of those with tumors less than 5 mm thick had nodal metastasis, compared with more than 17% of those with thicker tumors, Dr. Ross noted (Cancer 1997;79:915-9).

High-grade tumors are more likely than low-grade tumors to have nodal disease, said Dr. Ross, with 17% of high-grade tumors showing metastasis, compared with 4% of lower-grade tumors. When the German investigators looked at grade distribution according to nodal involvement, 44% of node-positive patients had high-grade primary tumors, whereas only 5% of node-negative patients had high-grade tumors.

Local recurrence is strongly associated with nodal involvement, just as it is with larger size, thicker tumors, narrow excision margins, and anatomical site. Up to 45% of recurrent presentations will have nodal disease, Dr. Ross said.

Lesions that arise on the lip, around the ear, and in the anogenital region are particularly risky. A 2006 study found that 27% of SCCs on the external ear had nodal disease, as did more than 20% of T3- and T4-stage lip lesions (Aust. J Derm. 2006;47:28-33).

The overall health of the patient is another important risk factor. "Patients with HIV [disease] or other immunodeficiency diseases are at an increased risk for metastasis, as are those with any chronic hematologic malignancy" Dr. Ross said.

KYOTO, JAPAN — Mycophenolate mofetil-based chronic immunosuppression is associated with a markedly lower risk of skin cancer during the first decade post kidney transplant, compared with alternative regimens aimed at preventing graft rejection, Dr. Irma Wisgerhof said at an international investigative dermatology meeting.

By 13 years post transplant, however, the squamous cell carcinoma risk in mycophenolate mofetil-treated organ recipients is equivalent to that of azathioprine, noted Dr. Wisgerhof of Leiden University (the Netherlands) Medical Center.

The mechanisms underlying these very different arcs of skin cancer risk are unclear. Azathioprine (Imuran) has a direct carcinogenic effect and causes accumulation of 6-thioguanine in cellular DNA. Azathioprine begins causing skin cancer in kidney transplant recipients early, and at a rate that remains steady over time. In contrast, mycophenolate mofetil (CellCept) prevents graft rejection by blocking immune surveillance; it suppresses both cellular and humoral immune responses, she explained.

Dr. Wisgerhof reviewed the experience with nonmelanoma skin cancer in 1,111 kidney transplant recipients who received their first donor kidney at the medical center in 1986-2006.

Through 2007, 6.7% of the patients developed a total of 102 invasive squamous cell carcinomas and 121 basal cell carcinomas. The cumulative incidence of nonmelanoma skin cancer was 3% after 5 years, 6% after 10 years, and 10% after 15 years of graft survival, she said.

The risk of squamous cell carcinoma—but not basal cell carcinoma—varied significantly depending upon the chronic immunosuppression regimen used.

The age- and gender-adjusted risk through the first decade post transplant was 88% lower with mycophenolate mofetil than with azathioprine-based regimens, and 65% less with cyclosporine- or tacrolimus-based regimens than with azathioprine-based immunosuppression, Dr. Wisgerhof said at a meeting of the European Society for Dermatological Research, the Japanese Society for Investigative Dermatology, and the Society for Investigative Dermatology.

Dr. Wisgerhof's study was supported by the Dutch Society of Dermatology and Venereology.

The risk of SCC varied depending upon the chronic immuno-suppression regimen used. DR. WISGERHOF

KYOTO, JAPAN — Mycophenolate mofetil-based chronic immunosuppression is associated with a markedly lower risk of skin cancer during the first decade post kidney transplant, compared with alternative regimens aimed at preventing graft rejection, Dr. Irma Wisgerhof said at an international investigative dermatology meeting.

By 13 years post transplant, however, the squamous cell carcinoma risk in mycophenolate mofetil-treated organ recipients is equivalent to that of azathioprine, noted Dr. Wisgerhof of Leiden University (the Netherlands) Medical Center.

The mechanisms underlying these very different arcs of skin cancer risk are unclear. Azathioprine (Imuran) has a direct carcinogenic effect and causes accumulation of 6-thioguanine in cellular DNA. Azathioprine begins causing skin cancer in kidney transplant recipients early, and at a rate that remains steady over time. In contrast, mycophenolate mofetil (CellCept) prevents graft rejection by blocking immune surveillance; it suppresses both cellular and humoral immune responses, she explained.

Dr. Wisgerhof reviewed the experience with nonmelanoma skin cancer in 1,111 kidney transplant recipients who received their first donor kidney at the medical center in 1986-2006.

Through 2007, 6.7% of the patients developed a total of 102 invasive squamous cell carcinomas and 121 basal cell carcinomas. The cumulative incidence of nonmelanoma skin cancer was 3% after 5 years, 6% after 10 years, and 10% after 15 years of graft survival, she said.

The risk of squamous cell carcinoma—but not basal cell carcinoma—varied significantly depending upon the chronic immunosuppression regimen used.

The age- and gender-adjusted risk through the first decade post transplant was 88% lower with mycophenolate mofetil than with azathioprine-based regimens, and 65% less with cyclosporine- or tacrolimus-based regimens than with azathioprine-based immunosuppression, Dr. Wisgerhof said at a meeting of the European Society for Dermatological Research, the Japanese Society for Investigative Dermatology, and the Society for Investigative Dermatology.

Dr. Wisgerhof's study was supported by the Dutch Society of Dermatology and Venereology.

The risk of SCC varied depending upon the chronic immuno-suppression regimen used. DR. WISGERHOF

KYOTO, JAPAN — Mycophenolate mofetil-based chronic immunosuppression is associated with a markedly lower risk of skin cancer during the first decade post kidney transplant, compared with alternative regimens aimed at preventing graft rejection, Dr. Irma Wisgerhof said at an international investigative dermatology meeting.

By 13 years post transplant, however, the squamous cell carcinoma risk in mycophenolate mofetil-treated organ recipients is equivalent to that of azathioprine, noted Dr. Wisgerhof of Leiden University (the Netherlands) Medical Center.

The mechanisms underlying these very different arcs of skin cancer risk are unclear. Azathioprine (Imuran) has a direct carcinogenic effect and causes accumulation of 6-thioguanine in cellular DNA. Azathioprine begins causing skin cancer in kidney transplant recipients early, and at a rate that remains steady over time. In contrast, mycophenolate mofetil (CellCept) prevents graft rejection by blocking immune surveillance; it suppresses both cellular and humoral immune responses, she explained.

Dr. Wisgerhof reviewed the experience with nonmelanoma skin cancer in 1,111 kidney transplant recipients who received their first donor kidney at the medical center in 1986-2006.

Through 2007, 6.7% of the patients developed a total of 102 invasive squamous cell carcinomas and 121 basal cell carcinomas. The cumulative incidence of nonmelanoma skin cancer was 3% after 5 years, 6% after 10 years, and 10% after 15 years of graft survival, she said.

The risk of squamous cell carcinoma—but not basal cell carcinoma—varied significantly depending upon the chronic immunosuppression regimen used.

The age- and gender-adjusted risk through the first decade post transplant was 88% lower with mycophenolate mofetil than with azathioprine-based regimens, and 65% less with cyclosporine- or tacrolimus-based regimens than with azathioprine-based immunosuppression, Dr. Wisgerhof said at a meeting of the European Society for Dermatological Research, the Japanese Society for Investigative Dermatology, and the Society for Investigative Dermatology.

Dr. Wisgerhof's study was supported by the Dutch Society of Dermatology and Venereology.

The risk of SCC varied depending upon the chronic immuno-suppression regimen used. DR. WISGERHOF

VANCOUVER, B.C. — The epidermal growth factor receptor inhibitor cetuximab alone has been found to produce complete response in patients with advanced cutaneous squamous cell carcinoma.

"To date, there have been no trials using the epidermal growth factor receptor inhibitors for treatment of patients with cutaneous squamous cell carcinoma," said Dr. Matthew E. Halpern at the annual meeting of the American College of Mohs Surgery. A previous trial found that cetuximab (Erbitux) plus radiation was efficacious for treating locally advanced squamous cell carcinoma (SCC) of the head and neck (N. Engl. J. Med. 2006;354:567-78).

Study patients had advanced SCC of the back, scalp, temple, and chest, according to Dr. Halpern, a dermatologic surgeon at New York-Presbyterian Medical Center. Two patients had in-transit metastasis alone, one had both in-transit and axillary metastases, and one had pulmonary metastases. Their treatment consisted of weekly infusions of cetuximab, with a total of four infusions planned.

Two patients had a complete clinical response to cetuximab (Erbitux), Dr. Halpern reported. "Really, like magic, the in-transit metastasis absolutely melted before our eyes," he said, describing one of the patients. Another patient, who received only half of the planned number of infusions because of comorbidities, had a partial response. The remaining patient had merely a limited response.

"As you might expect, side effects of this class of medications are largely cutaneous," Dr. Halpern noted, explaining that patients might develop a characteristic acneiform rash, paronychial inflammation, xerosis, pruritus, and trichomegaly. The study's two complete responders developed a severe rash, and the partial responder developed a moderate rash, while the nonresponder did not develop any rash at all. "Interestingly, even though this is a very small series of patients, patient response seemed to correlate with the severity of acneiform eruption," he observed. "It seemed to be a surrogate marker for therapeutic response."

One of the patients with a complete response was alive at 6 months after treatment, while the other died 7 months afterward from a primary lung cancer. The patient with a partial response died 4 months after treatment from chronic rejection of a lung transplant and had additional metastases at that time. The patient who had a minimal response died 4 months after treatment from brain metastases.

The study had limited follow-up related to the recent treatments patients had received and their comorbidities, Dr. Halpern conceded. Nonetheless, he said, "cetuximab has potential benefit for patients with metastatic cutaneous squamous cell carcinoma and is extremely well tolerated in our hands, with minimal side effects, some of which may be predictive of therapeutic benefit."

Dr. Halpern reported that he had no conflicts of interest in association with the study.

'The severity of acneiform eruption … seemed to be a surrogate marker for therapeutic response.' DR. HALPERN

Biopsy of this nodule revealed infiltrating SCC without epidermal involvement.

The patient's in-transit metastasis and axillary metastases cleared after the third cetuximab infusion. The acneiform rash is characteristic of this drug class. Photos courtesy Dr. Matthew E. Halpern

VANCOUVER, B.C. — The epidermal growth factor receptor inhibitor cetuximab alone has been found to produce complete response in patients with advanced cutaneous squamous cell carcinoma.

"To date, there have been no trials using the epidermal growth factor receptor inhibitors for treatment of patients with cutaneous squamous cell carcinoma," said Dr. Matthew E. Halpern at the annual meeting of the American College of Mohs Surgery. A previous trial found that cetuximab (Erbitux) plus radiation was efficacious for treating locally advanced squamous cell carcinoma (SCC) of the head and neck (N. Engl. J. Med. 2006;354:567-78).

Study patients had advanced SCC of the back, scalp, temple, and chest, according to Dr. Halpern, a dermatologic surgeon at New York-Presbyterian Medical Center. Two patients had in-transit metastasis alone, one had both in-transit and axillary metastases, and one had pulmonary metastases. Their treatment consisted of weekly infusions of cetuximab, with a total of four infusions planned.

Two patients had a complete clinical response to cetuximab (Erbitux), Dr. Halpern reported. "Really, like magic, the in-transit metastasis absolutely melted before our eyes," he said, describing one of the patients. Another patient, who received only half of the planned number of infusions because of comorbidities, had a partial response. The remaining patient had merely a limited response.

"As you might expect, side effects of this class of medications are largely cutaneous," Dr. Halpern noted, explaining that patients might develop a characteristic acneiform rash, paronychial inflammation, xerosis, pruritus, and trichomegaly. The study's two complete responders developed a severe rash, and the partial responder developed a moderate rash, while the nonresponder did not develop any rash at all. "Interestingly, even though this is a very small series of patients, patient response seemed to correlate with the severity of acneiform eruption," he observed. "It seemed to be a surrogate marker for therapeutic response."

One of the patients with a complete response was alive at 6 months after treatment, while the other died 7 months afterward from a primary lung cancer. The patient with a partial response died 4 months after treatment from chronic rejection of a lung transplant and had additional metastases at that time. The patient who had a minimal response died 4 months after treatment from brain metastases.

The study had limited follow-up related to the recent treatments patients had received and their comorbidities, Dr. Halpern conceded. Nonetheless, he said, "cetuximab has potential benefit for patients with metastatic cutaneous squamous cell carcinoma and is extremely well tolerated in our hands, with minimal side effects, some of which may be predictive of therapeutic benefit."

Dr. Halpern reported that he had no conflicts of interest in association with the study.

'The severity of acneiform eruption … seemed to be a surrogate marker for therapeutic response.' DR. HALPERN

Biopsy of this nodule revealed infiltrating SCC without epidermal involvement.

The patient's in-transit metastasis and axillary metastases cleared after the third cetuximab infusion. The acneiform rash is characteristic of this drug class. Photos courtesy Dr. Matthew E. Halpern

VANCOUVER, B.C. — The epidermal growth factor receptor inhibitor cetuximab alone has been found to produce complete response in patients with advanced cutaneous squamous cell carcinoma.

"To date, there have been no trials using the epidermal growth factor receptor inhibitors for treatment of patients with cutaneous squamous cell carcinoma," said Dr. Matthew E. Halpern at the annual meeting of the American College of Mohs Surgery. A previous trial found that cetuximab (Erbitux) plus radiation was efficacious for treating locally advanced squamous cell carcinoma (SCC) of the head and neck (N. Engl. J. Med. 2006;354:567-78).

Study patients had advanced SCC of the back, scalp, temple, and chest, according to Dr. Halpern, a dermatologic surgeon at New York-Presbyterian Medical Center. Two patients had in-transit metastasis alone, one had both in-transit and axillary metastases, and one had pulmonary metastases. Their treatment consisted of weekly infusions of cetuximab, with a total of four infusions planned.

Two patients had a complete clinical response to cetuximab (Erbitux), Dr. Halpern reported. "Really, like magic, the in-transit metastasis absolutely melted before our eyes," he said, describing one of the patients. Another patient, who received only half of the planned number of infusions because of comorbidities, had a partial response. The remaining patient had merely a limited response.

"As you might expect, side effects of this class of medications are largely cutaneous," Dr. Halpern noted, explaining that patients might develop a characteristic acneiform rash, paronychial inflammation, xerosis, pruritus, and trichomegaly. The study's two complete responders developed a severe rash, and the partial responder developed a moderate rash, while the nonresponder did not develop any rash at all. "Interestingly, even though this is a very small series of patients, patient response seemed to correlate with the severity of acneiform eruption," he observed. "It seemed to be a surrogate marker for therapeutic response."

One of the patients with a complete response was alive at 6 months after treatment, while the other died 7 months afterward from a primary lung cancer. The patient with a partial response died 4 months after treatment from chronic rejection of a lung transplant and had additional metastases at that time. The patient who had a minimal response died 4 months after treatment from brain metastases.

The study had limited follow-up related to the recent treatments patients had received and their comorbidities, Dr. Halpern conceded. Nonetheless, he said, "cetuximab has potential benefit for patients with metastatic cutaneous squamous cell carcinoma and is extremely well tolerated in our hands, with minimal side effects, some of which may be predictive of therapeutic benefit."

Dr. Halpern reported that he had no conflicts of interest in association with the study.

'The severity of acneiform eruption … seemed to be a surrogate marker for therapeutic response.' DR. HALPERN

Biopsy of this nodule revealed infiltrating SCC without epidermal involvement.

The patient's in-transit metastasis and axillary metastases cleared after the third cetuximab infusion. The acneiform rash is characteristic of this drug class. Photos courtesy Dr. Matthew E. Halpern

WILLIAMSBURG, VA. — Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.

Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.

Neither of the guidelines that address prophylactic antibiotics—the 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infections—specifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.

For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).

Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).

For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.

"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).

The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).

The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.

WILLIAMSBURG, VA. — Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.

Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.

Neither of the guidelines that address prophylactic antibiotics—the 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infections—specifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.

For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).

Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).

For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.

"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).

The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).

The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.

WILLIAMSBURG, VA. — Patients with prosthetic cardiac valves and recently implanted joint prostheses are among the few who should receive prophylactic antibiotics before surgical procedures, according to a dermatologic surgeon.

Prosthetic devices sometimes grow coagulase-negative Staphylococcus aureus, which can cause a life-threatening endocarditis or, in the case of joint prostheses, an intra-articular infection that can necessitate replacement of the device. "If a patient [in these categories] comes to me for surgery and has not been prophylaxed, I will not do the procedure," said Dr. Stephen Spencer of Port Charlotte, Fla.

Neither of the guidelines that address prophylactic antibiotics—the 2007 guidelines for preventing infective carditis and the 2003 guidelines for preventing hematogenous total joint infections—specifically deal with dermatologic surgery, but dermatologists can rationally extrapolate the recommendations to their own patients, Dr. Spencer said at a meeting of the American Society for Mohs Surgery.

For patients with prosthetic cardiac valves, the American Heart Association guidelines recommend 2 g of amoxicillin orally 30-60 minutes before the procedure. Penicillin-allergic patients can take cephalexin, clindamycin, or azithromycin (Circulation 2007;116:1736-54).

Patients who have had a total joint replacement in the past 2 years should take 2 g of cephalexin, cephradine, or amoxicillin 60 minutes before surgery. Penicillin-allergic patients can take clindamycin. Choices for injected antibiotics include clindamycin, cefazolin, or ampicillin, according to guidelines issued by the American Dental Association and the American Academy of Orthopedic Surgeons (J. Am. Dent. Assoc. 2003;134:895-9).

For most other patients, including healthy individuals with joint replacements more than 2 years old, the risks of adverse events associated with antibiotic treatment probably outweigh any potential benefit it might have in preventing infective complications, including infective endocarditis, said Dr. Spencer.

"Very few healthy people need these preoperative antibiotics," he said, citing a 2006 study from Australia that found an extremely low rate of wound infection after dermatologic surgery in the absence of prophylactic antibiotics (Dermatol. Surg. 2006;32:819-26).

The 3-year study included 5,091 lesions treated on 2,424 patients, none of whom received preoperative antibiotics. The overall infection incidence was 1.5%, and many individual procedures had similarly low rates: curettage (0.7%); skin flap repairs (3%); simple excision and closure (0.5%). Skin grafts and wedge excisions had higher rates (9% each).

The investigators concluded that surgery to the nose, ear, fingers, and lips; skin flap surgery; and surgery on diabetics, smokers, and those on anticoagulants did not warrant prophylactic antibiotic treatment. They did recommend antibiotics for procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin, Dr. Spencer noted.

WILLIAMSBURG, VA. — Consistent application of tissue nicks and annotated tissue transfer cards can significantly reduce the chance of error in Mohs surgery.

"Recurrence after Mohs surgery is very low, only 1%-2% at most, but when we look at the reasons behind those recurrences, 75% are due to human error, and of these, 10% are due to incorrect mapping and excision," said Dr. Tri H. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

"This includes tissue-orientation mistakes, mapping inaccuracies, mislabeling of sections or slides, and insufficient resection," Dr. Nguyen said at a meeting of the American Society for Mohs Surgery.

He methodically employs a system of identification strategies that nearly eliminates the chance of orientation errors, but an informal survey of fellowship programs showed that few physicians may be using this same level of caution.

Dr. Nguyen asked his residents about orientation techniques taught in the 14 Mohs fellowship programs for which they applied. Only three programs used preprinted maps, and only one used preprinted tissue transfer cards. Only five programs used tissue nicks to orient the sample, and only two of those used double nicks to add an extra layer of security.

"There are tremendous variations in the way we practice mapping and orientation, and probably all are adequate for primary, low-risk, single-stage Mohs resections," he said. "We run into problems with high-risk tumors with multiple convolutions or convexities, and in surgeries with multiple stages and multiple sites."

Anatomical maps and transfer cards can help reduce these problems. The cards have preprinted maps with illustrations of anatomical areas, and they also absorb moisture from specimens, which decreases the chance that they will shift position or fall off during the transfer. Corresponding paper maps have the same information printed on them.

"We have preprinted maps and transfer cards for every conceivable [anatomical area] on the head and neck, and blank ones for drawing locations on the extremities," Dr. Nguyen said.

Strategic tissue nicking adds a second layer of security to the surgery. "The argument over tissue nicks is pointless. There is no doubt that a properly made nick of the patient and the excised tissue leaves an indelible mark to go back and orient your sample," he said.

Single nicks, however, aren't sufficient. "With a single, there is always a chance the tissue will get dropped or shifted and you will lose the accuracy of your orientation. If you have a second nick consistently placed, you will always know exactly how the tissue is oriented. Two nicks ensure specimen orientation with or without" an anatomical transfer card, Dr. Nguyen said.

In double nicking, there should be a little space between the incisions. "If you place the second nick close to the peripheral edge, you are prone to tissue folding, which can mask tumor," he said.

WILLIAMSBURG, VA. — Consistent application of tissue nicks and annotated tissue transfer cards can significantly reduce the chance of error in Mohs surgery.

"Recurrence after Mohs surgery is very low, only 1%-2% at most, but when we look at the reasons behind those recurrences, 75% are due to human error, and of these, 10% are due to incorrect mapping and excision," said Dr. Tri H. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

"This includes tissue-orientation mistakes, mapping inaccuracies, mislabeling of sections or slides, and insufficient resection," Dr. Nguyen said at a meeting of the American Society for Mohs Surgery.

He methodically employs a system of identification strategies that nearly eliminates the chance of orientation errors, but an informal survey of fellowship programs showed that few physicians may be using this same level of caution.

Dr. Nguyen asked his residents about orientation techniques taught in the 14 Mohs fellowship programs for which they applied. Only three programs used preprinted maps, and only one used preprinted tissue transfer cards. Only five programs used tissue nicks to orient the sample, and only two of those used double nicks to add an extra layer of security.

"There are tremendous variations in the way we practice mapping and orientation, and probably all are adequate for primary, low-risk, single-stage Mohs resections," he said. "We run into problems with high-risk tumors with multiple convolutions or convexities, and in surgeries with multiple stages and multiple sites."

Anatomical maps and transfer cards can help reduce these problems. The cards have preprinted maps with illustrations of anatomical areas, and they also absorb moisture from specimens, which decreases the chance that they will shift position or fall off during the transfer. Corresponding paper maps have the same information printed on them.

"We have preprinted maps and transfer cards for every conceivable [anatomical area] on the head and neck, and blank ones for drawing locations on the extremities," Dr. Nguyen said.

Strategic tissue nicking adds a second layer of security to the surgery. "The argument over tissue nicks is pointless. There is no doubt that a properly made nick of the patient and the excised tissue leaves an indelible mark to go back and orient your sample," he said.

Single nicks, however, aren't sufficient. "With a single, there is always a chance the tissue will get dropped or shifted and you will lose the accuracy of your orientation. If you have a second nick consistently placed, you will always know exactly how the tissue is oriented. Two nicks ensure specimen orientation with or without" an anatomical transfer card, Dr. Nguyen said.

In double nicking, there should be a little space between the incisions. "If you place the second nick close to the peripheral edge, you are prone to tissue folding, which can mask tumor," he said.

WILLIAMSBURG, VA. — Consistent application of tissue nicks and annotated tissue transfer cards can significantly reduce the chance of error in Mohs surgery.

"Recurrence after Mohs surgery is very low, only 1%-2% at most, but when we look at the reasons behind those recurrences, 75% are due to human error, and of these, 10% are due to incorrect mapping and excision," said Dr. Tri H. Nguyen, director of Mohs micrographic and dermatologic surgery at the University of Texas M.D. Anderson Cancer Center, Houston.

"This includes tissue-orientation mistakes, mapping inaccuracies, mislabeling of sections or slides, and insufficient resection," Dr. Nguyen said at a meeting of the American Society for Mohs Surgery.

He methodically employs a system of identification strategies that nearly eliminates the chance of orientation errors, but an informal survey of fellowship programs showed that few physicians may be using this same level of caution.

Dr. Nguyen asked his residents about orientation techniques taught in the 14 Mohs fellowship programs for which they applied. Only three programs used preprinted maps, and only one used preprinted tissue transfer cards. Only five programs used tissue nicks to orient the sample, and only two of those used double nicks to add an extra layer of security.

"There are tremendous variations in the way we practice mapping and orientation, and probably all are adequate for primary, low-risk, single-stage Mohs resections," he said. "We run into problems with high-risk tumors with multiple convolutions or convexities, and in surgeries with multiple stages and multiple sites."

Anatomical maps and transfer cards can help reduce these problems. The cards have preprinted maps with illustrations of anatomical areas, and they also absorb moisture from specimens, which decreases the chance that they will shift position or fall off during the transfer. Corresponding paper maps have the same information printed on them.

"We have preprinted maps and transfer cards for every conceivable [anatomical area] on the head and neck, and blank ones for drawing locations on the extremities," Dr. Nguyen said.

Strategic tissue nicking adds a second layer of security to the surgery. "The argument over tissue nicks is pointless. There is no doubt that a properly made nick of the patient and the excised tissue leaves an indelible mark to go back and orient your sample," he said.

Single nicks, however, aren't sufficient. "With a single, there is always a chance the tissue will get dropped or shifted and you will lose the accuracy of your orientation. If you have a second nick consistently placed, you will always know exactly how the tissue is oriented. Two nicks ensure specimen orientation with or without" an anatomical transfer card, Dr. Nguyen said.

In double nicking, there should be a little space between the incisions. "If you place the second nick close to the peripheral edge, you are prone to tissue folding, which can mask tumor," he said.

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

VANCOUVER, B.C. — Photographing cutaneous lesions before biopsy can help prevent wrong-site surgery when the lesions prove to be malignant and patients must undergo Mohs excision of the remaining tumor, according to an observational study of 271 biopsy sites.

Factors such as healing and actinic skin damage can make it difficult to identify biopsy sites at the time of Mohs surgery, Dr. Jamie L. McGinness, a dermatologic surgeon in Leawood, Kan., and Lee's Summit, Mo., said at the annual meeting of American College of Mohs Surgery.

In a previous survey of Mohs surgeons, other investigators found that 11% of the 300 respondents had been sued and that performing surgery on the wrong site was a leading reason for the malpractice claims, accounting for 14% (Dermatol. Surg. 2006;32:79-83).

For their study, Dr. McGinness and his coinvestigators enrolled patients who were undergoing Mohs surgery with any of four physicians at the center for a previously biopsied, malignant cutaneous lesion who could see their biopsy site using a mirror, and who had preoperative photographs of their biopsy site. Those with conditions that impair memory were excluded.

On the day of Mohs surgery, patients were given a mirror and asked to identify their biopsy site. Next, their Mohs surgeons were asked to identify the site using the anatomic information on the pathology report, the diagrammed location, and palpation. Neither the patient nor the physician was further assisted with the identification process.

In all, 271 biopsy sites were evaluated. Fully 16.6% of sites were incorrectly identified by patients and 5.9% were incorrectly identified by physicians. About 4.4% were incorrectly identified by both parties. In contrast, all sites were correctly identified with the use of preoperative photos. The results suggest that neither patients—even confident ones—nor diagrams are reliable means for identifying biopsy sites, Dr. McGinness said.

If a biopsy site cannot be identified at the time of surgery, the options are to proceed anyway—at the risk of wrong-site surgery—or to cancel surgery. "When surgeries are cancelled, this leads to higher patient inconvenience, untreated tumors that could metastasize, larger tumors when they again become observable, and increased patient morbidity," Dr. McGinness commented.

All of the patients underwent surgery an average of 2-3 weeks after biopsy, and he recommended that future research evaluate the role of this time interval. "With longer wait times between biopsy and surgery, lesions could heal and the rates [of incorrect identification] could actually be even higher," he explained.

Dr. McGinness reported no conflicts of interest related to the study.

Performing surgery on the wrong site was behind 14% of the lawsuits brought against Mohs surgeons. DR. MCGINNESS

Healing and actinic skin damage can make it hard to identify the biopsy site before surgery.

By using a prebiopsy photograph, the surgeon located the biopsy site and removed the tumor. Photos courtesy Dr. Jamie L. McGinness

KYOTO, JAPAN — Blue-light phototherapy for neonatal jaundice could promote development of dysplastic nevi, Dr. Zsanett Csoma asserted at an international investigative dermatology meeting.

His latest contribution to the controversial issue was in the form of a study of 618 healthy Hungarian patients aged 21-71 years. Patients born since 1968—when blue-light phototherapy for neonatal jaundice was introduced in Hungary—were found to have a 2.1-fold greater prevalence of dysplastic nevi than those who were born earlier, Dr. Csoma said at a meeting of the European Society for Dermatological Research, the Japanese Society for Investigative Dermatology, and the Society for Investigative Dermatology.

In an earlier cross-sectional study involving 747 patients aged 14-18 years, he found the prevalence of clinically dysplastic nevi to be 19% in those with no history of phototherapy for neonatal jaundice, compared with 25% in patients with such a history.

The proposed mechanism for the increase in dysplastic nevi lies in the emission spectrum of blue-light photo lamps, according to Dr. Csoma of the University of Szeged (Hungary). Although the spectrum centers on 450 nm, a small proportion of the emitted light—less than 1%—is UVA. Ultraviolet light not only induces melanocyte proliferation, it also has profound immunosuppressive and immunomodulatory effects in the skin and is sufficient to induce melanoma precursors in animals. These immunosuppressive effects could be magnified in the immature skin of neonates, he said.

When the earlier study was published (Pediatrics 2007;119:1036-7), it drew fire from Dr. Phyllis A. Dennery and Dr. Scott Lorch of the University of Pennsylvania, Philadelphia, and Children's Hospital of Philadelphia, who wrote that they found the data unconvincing (Pediatrics 2007;120:247-8).

"We need to remember the devastating consequences of our reduced vigilance for hyperbilirubinemia in the late 1980s and early 1990s. We must seriously weigh the resurgence of kernicterus against the potential for moles and nevi until more strategies are available to prevent hyperbilirubinemia," they cautioned.

Separately, French investigators reported that neonatal phototherapy was associated with a significant increase in melanocytic nevi 2-5 mm in diameter in a study involving 58 children aged 8-9 years. They suggested melanoma surveillance in exposed children (Arch. Dermatol. 2006;142:1599-604).

The French recommendation was deemed "premature" in a follow-up commentary by Dr. Thomas B. Newman of the University of California, San Francisco, and Dr. M. Jeffrey Maisels, chairman of the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich.

"Counseling families of infants exposed to phototherapy that their child needs to be watched for melanoma is not a trivial matter. Much more evidence than was provided … is needed before it can be recommended," they wrote (Arch. Dermatol. 2007;143:1216).

Dr. Csoma's study was supported by the National Fund of the Hungarian Ministry of Health.

KYOTO, JAPAN — Blue-light phototherapy for neonatal jaundice could promote development of dysplastic nevi, Dr. Zsanett Csoma asserted at an international investigative dermatology meeting.

His latest contribution to the controversial issue was in the form of a study of 618 healthy Hungarian patients aged 21-71 years. Patients born since 1968—when blue-light phototherapy for neonatal jaundice was introduced in Hungary—were found to have a 2.1-fold greater prevalence of dysplastic nevi than those who were born earlier, Dr. Csoma said at a meeting of the European Society for Dermatological Research, the Japanese Society for Investigative Dermatology, and the Society for Investigative Dermatology.

In an earlier cross-sectional study involving 747 patients aged 14-18 years, he found the prevalence of clinically dysplastic nevi to be 19% in those with no history of phototherapy for neonatal jaundice, compared with 25% in patients with such a history.

The proposed mechanism for the increase in dysplastic nevi lies in the emission spectrum of blue-light photo lamps, according to Dr. Csoma of the University of Szeged (Hungary). Although the spectrum centers on 450 nm, a small proportion of the emitted light—less than 1%—is UVA. Ultraviolet light not only induces melanocyte proliferation, it also has profound immunosuppressive and immunomodulatory effects in the skin and is sufficient to induce melanoma precursors in animals. These immunosuppressive effects could be magnified in the immature skin of neonates, he said.

When the earlier study was published (Pediatrics 2007;119:1036-7), it drew fire from Dr. Phyllis A. Dennery and Dr. Scott Lorch of the University of Pennsylvania, Philadelphia, and Children's Hospital of Philadelphia, who wrote that they found the data unconvincing (Pediatrics 2007;120:247-8).

"We need to remember the devastating consequences of our reduced vigilance for hyperbilirubinemia in the late 1980s and early 1990s. We must seriously weigh the resurgence of kernicterus against the potential for moles and nevi until more strategies are available to prevent hyperbilirubinemia," they cautioned.

Separately, French investigators reported that neonatal phototherapy was associated with a significant increase in melanocytic nevi 2-5 mm in diameter in a study involving 58 children aged 8-9 years. They suggested melanoma surveillance in exposed children (Arch. Dermatol. 2006;142:1599-604).

The French recommendation was deemed "premature" in a follow-up commentary by Dr. Thomas B. Newman of the University of California, San Francisco, and Dr. M. Jeffrey Maisels, chairman of the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich.

"Counseling families of infants exposed to phototherapy that their child needs to be watched for melanoma is not a trivial matter. Much more evidence than was provided … is needed before it can be recommended," they wrote (Arch. Dermatol. 2007;143:1216).

Dr. Csoma's study was supported by the National Fund of the Hungarian Ministry of Health.

KYOTO, JAPAN — Blue-light phototherapy for neonatal jaundice could promote development of dysplastic nevi, Dr. Zsanett Csoma asserted at an international investigative dermatology meeting.

His latest contribution to the controversial issue was in the form of a study of 618 healthy Hungarian patients aged 21-71 years. Patients born since 1968—when blue-light phototherapy for neonatal jaundice was introduced in Hungary—were found to have a 2.1-fold greater prevalence of dysplastic nevi than those who were born earlier, Dr. Csoma said at a meeting of the European Society for Dermatological Research, the Japanese Society for Investigative Dermatology, and the Society for Investigative Dermatology.

In an earlier cross-sectional study involving 747 patients aged 14-18 years, he found the prevalence of clinically dysplastic nevi to be 19% in those with no history of phototherapy for neonatal jaundice, compared with 25% in patients with such a history.

The proposed mechanism for the increase in dysplastic nevi lies in the emission spectrum of blue-light photo lamps, according to Dr. Csoma of the University of Szeged (Hungary). Although the spectrum centers on 450 nm, a small proportion of the emitted light—less than 1%—is UVA. Ultraviolet light not only induces melanocyte proliferation, it also has profound immunosuppressive and immunomodulatory effects in the skin and is sufficient to induce melanoma precursors in animals. These immunosuppressive effects could be magnified in the immature skin of neonates, he said.

When the earlier study was published (Pediatrics 2007;119:1036-7), it drew fire from Dr. Phyllis A. Dennery and Dr. Scott Lorch of the University of Pennsylvania, Philadelphia, and Children's Hospital of Philadelphia, who wrote that they found the data unconvincing (Pediatrics 2007;120:247-8).

"We need to remember the devastating consequences of our reduced vigilance for hyperbilirubinemia in the late 1980s and early 1990s. We must seriously weigh the resurgence of kernicterus against the potential for moles and nevi until more strategies are available to prevent hyperbilirubinemia," they cautioned.

Separately, French investigators reported that neonatal phototherapy was associated with a significant increase in melanocytic nevi 2-5 mm in diameter in a study involving 58 children aged 8-9 years. They suggested melanoma surveillance in exposed children (Arch. Dermatol. 2006;142:1599-604).

The French recommendation was deemed "premature" in a follow-up commentary by Dr. Thomas B. Newman of the University of California, San Francisco, and Dr. M. Jeffrey Maisels, chairman of the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich.

"Counseling families of infants exposed to phototherapy that their child needs to be watched for melanoma is not a trivial matter. Much more evidence than was provided … is needed before it can be recommended," they wrote (Arch. Dermatol. 2007;143:1216).

Dr. Csoma's study was supported by the National Fund of the Hungarian Ministry of Health.