Forty-sEventh ISSUE
November 15, 2023
Us: pick a side, ulcerated or nonulcerated
Melanoma: ✨incipient ulceration✨
Ulceration in primary cutaneous melanoma involves a disrupted epidermis above the melanoma with a host reaction and is a significant American Joint Committee on Cancer (AJCC) staging factor. Melanomas with incipient ulceration, meaning they have some ulceration traits but do not meet AJCC ulceration criteria, are staged as non-ulcerated.
Researchers conducted a retrospective case-control study of 340 melanoma patients diagnosed from 2005-2015 to examine incipient ulceration's prognostic impact in primary cutaneous melanoma. Cases (incipient ulceration, defined as severe thinning of the epidermis with evidence of host response) were compared to two control groups (non-ulcerated and ulcerated) in a 1:2 ratio.
What did they find?
Main Takeaway: Incipient ulceration may indicate a more aggressive melanoma and grouping them with a lower-risk pathologic stage may not be suitable.
Melanoma: ✨incipient ulceration✨
Ulceration in primary cutaneous melanoma involves a disrupted epidermis above the melanoma with a host reaction and is a significant American Joint Committee on Cancer (AJCC) staging factor. Melanomas with incipient ulceration, meaning they have some ulceration traits but do not meet AJCC ulceration criteria, are staged as non-ulcerated.
Researchers conducted a retrospective case-control study of 340 melanoma patients diagnosed from 2005-2015 to examine incipient ulceration's prognostic impact in primary cutaneous melanoma. Cases (incipient ulceration, defined as severe thinning of the epidermis with evidence of host response) were compared to two control groups (non-ulcerated and ulcerated) in a 1:2 ratio.
What did they find?
- The analysis cohort included 200 patients: 40 with incipient ulceration, 80 with no ulceration, and 80 with ulceration
- Tumors with incipient ulceration had a thicker Breslow thickness (BT) than non-ulcerated tumors (2.8 vs 1 mm) with a median BT difference of 1.8 mm (95% CI, 1.1-2.8; p < .001), but were thinner than ulcerated melanomas (2.8 vs 5.3 mm) with a median BT difference of 2.5 mm (95% CI, 0.4 – 3.8; p < .001)
- Non-ulcerated tumors had better overall survival (hazard ratio (HR), 0.49; 95% CI, 0.27-0.88; p = .02) and recurrence-free survival (RFS) (HR, 0.37; 95% CI, 0.22-0.64; p < .001) compared to incipient ulceration, while ulcerated tumors had worse RFS (HR, 1.67; 95% CI, 1.07-2.60; p = .03) comparatively
- No statistical differences were seen in survival outcomes between cases and controls on multivariable analysis to adjust for pathological factors
Main Takeaway: Incipient ulceration may indicate a more aggressive melanoma and grouping them with a lower-risk pathologic stage may not be suitable.
External validation of the Melanoma Institute Australia Sentinel Node Metastasis Risk Prediction Tool using the National Cancer Database
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
Finding melanoma's secret hideouts: because detecting metastasis should be as bright as your sunscreen game!
In 2022, 99,780 cases of melanoma were diagnosed in the US; on average, only 31.9% of patients with distant spread achieve remission. To help identify metastatic melanoma earlier and to limit the number of sentinel node (SN) biopsies, the Melanoma Institute of Australia (MIA) created the Sentinel Node Metastasis Risk Prediction Tool. This study sought to expand validation of the predictive tool to the US population via utilization of the National Cancer Database (NCDB).
What factors are included in the algorithm?
A risk of 5-10% indicates a consideration for biopsy while a risk of 10% or higher is indicative of a need to biopsy.
What did they find?
Main takeaway: The Melanoma Institute of Australia Sentinel Node Metastasis Risk Prediction Tool demonstrated acceptable discrimination when utilized in a large data set more representative of the US population. Try the Sentinel Node Metastasis Risk Prediction Tool here!
In 2022, 99,780 cases of melanoma were diagnosed in the US; on average, only 31.9% of patients with distant spread achieve remission. To help identify metastatic melanoma earlier and to limit the number of sentinel node (SN) biopsies, the Melanoma Institute of Australia (MIA) created the Sentinel Node Metastasis Risk Prediction Tool. This study sought to expand validation of the predictive tool to the US population via utilization of the National Cancer Database (NCDB).
What factors are included in the algorithm?
- Age
- Tumor Thickness
- Melanoma Subtype
- Mitoses/mm2
- Ulceration
- Lymphovascular Invasion
A risk of 5-10% indicates a consideration for biopsy while a risk of 10% or higher is indicative of a need to biopsy.
What did they find?
- The MIA Sentinel Node Metastasis Risk Prediction Tool demonstrated strong performance with the NCDB dataset (C-statistic: 0.733 [95% CI: 0.726-0.739]) and exhibited similar efficacy as observed in prior validation studies
- The MIA tool would have recommended SN biopsy in only 50.4% (30,232) of the 60,165 NCDB patients that actually underwent SN biopsy
- Utilizing the 10% predicted probability given by the MIA tool, a total of 1965 (3.3%) patients in the NCDB cohort would have been incorrectly classified as SN negative
- The overall SN-positivity rate would increase from 14.6% to 22.8% in the NCDB cohort
- The overall SN-positivity rate would increase from 14.6% to 22.8% in the NCDB cohort
- The MIA tool overestimated the probability of regional metastasis in the highest-risk decile
Main takeaway: The Melanoma Institute of Australia Sentinel Node Metastasis Risk Prediction Tool demonstrated acceptable discrimination when utilized in a large data set more representative of the US population. Try the Sentinel Node Metastasis Risk Prediction Tool here!
Comparison of melanocyte-associated immunohistochemical markers in acral lentiginous melanoma and acral benign nevi
American Journal of Dermatopathology
American Journal of Dermatopathology
ALM or ABN? Stains can explain
Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma. Prior studies have identified immunohistochemical markers that aid in the differentiation of superficial spreading or nodular malignant melanoma from benign nevi when indistinguishable on H&E. However, the application of these immunohistochemical markers in distinguishing ALM from acral benign nevi (ABN) has not been investigated.
Ki-67 proliferative index, p16, SOX-10, and preferentially expressed antigen in melanoma (PRAME) expression were assessed in 53 cases of ALM and 19 cases of ABM. The diagnosis was confirmed by two dermatopathologists and histopathological features were evaluated.
What did they find?
Limitations: This study included a small sample size and there was no disease control group, so immunohistochemical analysis could not be compared between ALM and other malignant melanoma subtypes.
Main takeaways: Ki-67 proliferative index, PRAME, and p16 expression are immunohistochemical markers that can aid in distinguishing acral lentiginous melanoma from acral benign nevi.
Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma. Prior studies have identified immunohistochemical markers that aid in the differentiation of superficial spreading or nodular malignant melanoma from benign nevi when indistinguishable on H&E. However, the application of these immunohistochemical markers in distinguishing ALM from acral benign nevi (ABN) has not been investigated.
Ki-67 proliferative index, p16, SOX-10, and preferentially expressed antigen in melanoma (PRAME) expression were assessed in 53 cases of ALM and 19 cases of ABM. The diagnosis was confirmed by two dermatopathologists and histopathological features were evaluated.
What did they find?
- Ki-67 proliferative index and PRAME expression were significantly higher in the ALM group compared to the ABN group (p<0.05)
- P16 expression was significantly lower in the ALM group compared to the ABN group (p<0.05)
- There was no significant difference in SOX–10 expression between the ALM and ABN group
Limitations: This study included a small sample size and there was no disease control group, so immunohistochemical analysis could not be compared between ALM and other malignant melanoma subtypes.
Main takeaways: Ki-67 proliferative index, PRAME, and p16 expression are immunohistochemical markers that can aid in distinguishing acral lentiginous melanoma from acral benign nevi.
Is microneedling after an autologous injectable platelet-rich fibrin more efficacious for treating atrophic acne scars than microneedling alone?
Dermatologic Surgery
Dermatologic Surgery
Acne scars being a pain in the ‘you know what’?
Acne scarring is a common cosmetic problem in dermatology. Platelet-rich fibrin (PRF) is an autologous platelet-derived product with many benefits, including extended release growth factors that aid in collagen remodeling. In this split face study of patients with atrophic acne scars (n = 40), PRF was injected at one side of the scar and normal saline was injected into the other side. Each side was subsequently microneedled; the process was performed 4x/month. At every session and during followup, pictures were taken of patients' scars and a blinded Goodman and Baron’s (GB ) grade and Physician Subjective Score were calculated. Patient satisfaction was also obtained at every session.
What did they find?
Limitations: This study was limited by a small sample size and majority of subjects having Fitzpatrick Skin Type III and IV.
Main Takeaways: Autologous injectable PRF followed by microneedling is a safe and more effective treatment than microneedling alone for atrophic acne scars.
Acne scarring is a common cosmetic problem in dermatology. Platelet-rich fibrin (PRF) is an autologous platelet-derived product with many benefits, including extended release growth factors that aid in collagen remodeling. In this split face study of patients with atrophic acne scars (n = 40), PRF was injected at one side of the scar and normal saline was injected into the other side. Each side was subsequently microneedled; the process was performed 4x/month. At every session and during followup, pictures were taken of patients' scars and a blinded Goodman and Baron’s (GB ) grade and Physician Subjective Score were calculated. Patient satisfaction was also obtained at every session.
What did they find?
- Mean GB grade decreased 57.4% (meaning improved scarring score) for treatment areas and 3.6% on control areas
- Mean patient satisfaction was higher for the treatment areas at 5.95 compared to the control side at 5.35 (p = 0.0193)
- Rolling scars improved 38.75% on treatment areas compared to control areas at 1.58% improvement (p < 0.001)
- Box-type scars improved 25.36% on the treatment areas and 2.55% on control areas (p < 0.001)
- Ice-pick scars showed no improvement on either area
Limitations: This study was limited by a small sample size and majority of subjects having Fitzpatrick Skin Type III and IV.
Main Takeaways: Autologous injectable PRF followed by microneedling is a safe and more effective treatment than microneedling alone for atrophic acne scars.
The effectiveness of QR678 Neo formulation in the treatment of seborrheic dermatitis
Journal of Cosmetic Dermatology
Journal of Cosmetic Dermatology
A sprinkle of dandruff? Not on this menu!
Seborrheic dermatitis is a chronic inflammatory disorder that causes scaling to areas rich in sebaceous glands. Researchers aimed to evaluate the efficacy of QR678 Neo formulation, consisting of vitamins and biomimetic polypeptides mimicking various growth factors, on seborrheic dermatitis.
Subjects with moderate-to-severe seborrheic dermatitis who did not respond to conventional treatment (n=40) were administered 1 mL injections of QR678 Neo during 8 sessions over a 3 week period, to erythematous, scaly, and pruritic patches on the scalp. Baseline, mid-treatment, and post-treatment assessments that evaluated severity scores, photography, and scalp dermoscopy, were conducted.
What did they find:
Main takeaway: Administration of QR678 Neo formulation diminishes signs of inflammation, scaling and flaking in individuals with seborrheic dermatitis of the scalp.
Seborrheic dermatitis is a chronic inflammatory disorder that causes scaling to areas rich in sebaceous glands. Researchers aimed to evaluate the efficacy of QR678 Neo formulation, consisting of vitamins and biomimetic polypeptides mimicking various growth factors, on seborrheic dermatitis.
Subjects with moderate-to-severe seborrheic dermatitis who did not respond to conventional treatment (n=40) were administered 1 mL injections of QR678 Neo during 8 sessions over a 3 week period, to erythematous, scaly, and pruritic patches on the scalp. Baseline, mid-treatment, and post-treatment assessments that evaluated severity scores, photography, and scalp dermoscopy, were conducted.
What did they find:
- The severity scores of 39 participants exhibited notable improvement, with a mean value decreasing from 60 at baseline to 38 after 4 sessions and further to 10 after 8 sessions (p=0.01)
- Scalp dermoscopy revealed significant improvement in erythema and scaling after 4 sessions, with sustained improvement observed after 8 sessions (p=0.0001)
- The positive effects of the therapy persisted for over 1 year
- The predominant adverse effect reported was discomfort and pain during the injection process
Main takeaway: Administration of QR678 Neo formulation diminishes signs of inflammation, scaling and flaking in individuals with seborrheic dermatitis of the scalp.
QUESTION OF THE WEEK
NEJM IMAGE CHALLENGE
Dermoscopy question of the week
Racial/ethnic disparities in dermatology research fellowship funding
Journal of Racial and Ethnic Health Disparities
Journal of Racial and Ethnic Health Disparities
Authors: Jenna E. Koblinski, Adina Greene, Jaxon K. Quillen, Nan Zhang, Ilana S. Rosman, Shari A. Ochoa, Collin M. Costello
Dermatology is a highly competitive medical specialty. As the average number of research experiences continues to rise (the current average = 20), more applicants may pursue research fellowships to augment their applications. Furthermore, with the change of the USMLE Step 1 to pass/fail, there may be an even bigger drive to pursue research fellowships to differentiate one’s application. We surveyed prior, current, and future dermatology applicants (n=90) who completed a research fellowship to determine the financial costs of a research year and how they vary for different demographic groups.
What did we find?
Main Takeaway: Given the overall high costs of research years and the disparity in funding of these years, steps should be taken to address the disparities in fellowship funding or de-emphasize the importance of research fellowships in the dermatology residency selection process.
Dermatology is a highly competitive medical specialty. As the average number of research experiences continues to rise (the current average = 20), more applicants may pursue research fellowships to augment their applications. Furthermore, with the change of the USMLE Step 1 to pass/fail, there may be an even bigger drive to pursue research fellowships to differentiate one’s application. We surveyed prior, current, and future dermatology applicants (n=90) who completed a research fellowship to determine the financial costs of a research year and how they vary for different demographic groups.
What did we find?
- Median total fellowship cost ($26,443.20) was higher than the median fellowship income ($23,625.00)
- Minority respondents had significantly lower total income, lower fellowship income, and higher net fellowship cost (p<0.05)
- The majority stated that if given the opportunity, they would choose to do their research year again
Main Takeaway: Given the overall high costs of research years and the disparity in funding of these years, steps should be taken to address the disparities in fellowship funding or de-emphasize the importance of research fellowships in the dermatology residency selection process.