Melanoma

AUSTIN, TEX. — The public does not appear to perceive that Mohs surgeons are as capable as plastic surgeons when it comes to removing cutaneous lesions and repairing facial defects, according to a survey of 467 patients.

Dr. Vinh Q. Chung of the department of dermatology at Emory University, Atlanta, said that he often has been asked what he called an "absurd" question by patients—whether they should see a plastic surgeon. To determine why they did not consider a Mohs surgeon to be capable, he and his colleagues conducted a prospective survey of 250 patients at the Emory Student Center and 217 at the Emory Dermatology Clinic.

In the first part, they were asked to rate seven questions about specialists' training and surgical skills on a visual analog scale. Survey respondents were asked to rate dermatologists, plastic surgeons, general surgeons, emergency physicians, and family practitioners.

When they were asked which specialist had the greatest ability to create absolutely no scar, 63% (136) of derm clinic patients and 64% (160) of students said that they had a high confidence in plastic surgeons; a little more than 20% of each group gave the same marks to dermatologists. The scores were significantly higher for plastic surgeons on every question, Dr. Chung said at the annual meeting of the American College of Mohs Surgery.

In the second part of the survey, patients were given a series of images of surgical scars. The images were all the same, but each was labeled with a specialty. The goal was to see if the label biased the patient's perception, he said.

Respondents were asked to rate the image on a scale of 1–10, with 10 being the highest score. Interestingly, scores were fairly consistent among all the images, with dermatologists and plastic surgeons ranking the highest. The dermatology clinic patients' mean score for plastic surgeons was 5.86, compared with 5.48 for the students. Derm clinic patients' mean score for dermatologists was 5.91, compared with 5.28 assigned by the students.

"Our study supports our suspicion that the public has more confidence in the brand 'plastic surgery' than the brand 'dermatology' when it comes to cutaneous surgeries," he said. This was especially surprising since it came from patients in the dermatology clinic. On the other hand, patients were able to be objective when they evaluated the scars.

Students should be required to spend at least a day in the operating room to see what Mohs surgery is, and dermatologic surgeons should continue to "promote our reputation as the experts for skin surgeries," he said.

AUSTIN, TEX. — The public does not appear to perceive that Mohs surgeons are as capable as plastic surgeons when it comes to removing cutaneous lesions and repairing facial defects, according to a survey of 467 patients.

Dr. Vinh Q. Chung of the department of dermatology at Emory University, Atlanta, said that he often has been asked what he called an "absurd" question by patients—whether they should see a plastic surgeon. To determine why they did not consider a Mohs surgeon to be capable, he and his colleagues conducted a prospective survey of 250 patients at the Emory Student Center and 217 at the Emory Dermatology Clinic.

In the first part, they were asked to rate seven questions about specialists' training and surgical skills on a visual analog scale. Survey respondents were asked to rate dermatologists, plastic surgeons, general surgeons, emergency physicians, and family practitioners.

When they were asked which specialist had the greatest ability to create absolutely no scar, 63% (136) of derm clinic patients and 64% (160) of students said that they had a high confidence in plastic surgeons; a little more than 20% of each group gave the same marks to dermatologists. The scores were significantly higher for plastic surgeons on every question, Dr. Chung said at the annual meeting of the American College of Mohs Surgery.

In the second part of the survey, patients were given a series of images of surgical scars. The images were all the same, but each was labeled with a specialty. The goal was to see if the label biased the patient's perception, he said.

Respondents were asked to rate the image on a scale of 1–10, with 10 being the highest score. Interestingly, scores were fairly consistent among all the images, with dermatologists and plastic surgeons ranking the highest. The dermatology clinic patients' mean score for plastic surgeons was 5.86, compared with 5.48 for the students. Derm clinic patients' mean score for dermatologists was 5.91, compared with 5.28 assigned by the students.

"Our study supports our suspicion that the public has more confidence in the brand 'plastic surgery' than the brand 'dermatology' when it comes to cutaneous surgeries," he said. This was especially surprising since it came from patients in the dermatology clinic. On the other hand, patients were able to be objective when they evaluated the scars.

Students should be required to spend at least a day in the operating room to see what Mohs surgery is, and dermatologic surgeons should continue to "promote our reputation as the experts for skin surgeries," he said.

AUSTIN, TEX. — The public does not appear to perceive that Mohs surgeons are as capable as plastic surgeons when it comes to removing cutaneous lesions and repairing facial defects, according to a survey of 467 patients.

Dr. Vinh Q. Chung of the department of dermatology at Emory University, Atlanta, said that he often has been asked what he called an "absurd" question by patients—whether they should see a plastic surgeon. To determine why they did not consider a Mohs surgeon to be capable, he and his colleagues conducted a prospective survey of 250 patients at the Emory Student Center and 217 at the Emory Dermatology Clinic.

In the first part, they were asked to rate seven questions about specialists' training and surgical skills on a visual analog scale. Survey respondents were asked to rate dermatologists, plastic surgeons, general surgeons, emergency physicians, and family practitioners.

When they were asked which specialist had the greatest ability to create absolutely no scar, 63% (136) of derm clinic patients and 64% (160) of students said that they had a high confidence in plastic surgeons; a little more than 20% of each group gave the same marks to dermatologists. The scores were significantly higher for plastic surgeons on every question, Dr. Chung said at the annual meeting of the American College of Mohs Surgery.

In the second part of the survey, patients were given a series of images of surgical scars. The images were all the same, but each was labeled with a specialty. The goal was to see if the label biased the patient's perception, he said.

Respondents were asked to rate the image on a scale of 1–10, with 10 being the highest score. Interestingly, scores were fairly consistent among all the images, with dermatologists and plastic surgeons ranking the highest. The dermatology clinic patients' mean score for plastic surgeons was 5.86, compared with 5.48 for the students. Derm clinic patients' mean score for dermatologists was 5.91, compared with 5.28 assigned by the students.

"Our study supports our suspicion that the public has more confidence in the brand 'plastic surgery' than the brand 'dermatology' when it comes to cutaneous surgeries," he said. This was especially surprising since it came from patients in the dermatology clinic. On the other hand, patients were able to be objective when they evaluated the scars.

Students should be required to spend at least a day in the operating room to see what Mohs surgery is, and dermatologic surgeons should continue to "promote our reputation as the experts for skin surgeries," he said.

MIAMI BEACH — Minimizing bleeding during and after Mohs surgery can be a challenge, according to Dr. Susan H. Weinkle.

"In Bradenton [Fla.] where I practice, almost everyone is taking an anticoagulant," Dr. Weinkle said. As a Mohs surgeon "we realize that the risk of a thrombotic event is much worse for the patient than the risk of bleeding." She recommended that patients with a history of a transient ischemic attack or thrombotic event, in particular, be allowed to continue their anticoagulant therapy.

Ask patients to provide a comprehensive list of all the medications and supplements they take, Dr. Weinkle said at the South Beach Symposium. "Sometimes patients do not tell you the whole story, so you need a complete history." Patients may be taking ginkgo biloba or consuming a lot of cinnamon, which can thin the blood.

Meticulous hemostasis is important; do your best to maintain a dry field intraoperatively during Mohs surgery, said Dr. Weinkle, a private practice dermatologist in Bradenton. Epidermal sutures often can halt superficial bleeding along the edge of a wound. If excessive bleeding occurs intraoperatively, you may need to tie off a larger vessel. Also, avoid placing a patient in the Trendelenburg position.

How you bandage is also important to minimize the risk of postoperative bleeding. Provide pressure with a large bandage because "as the anesthetic goes away, you can get rebound vasodilatation," Dr. Weinkle said. Consider using flesh-colored bandages, and provide written instructions to leave bandages in place for 48 hours and to restrict activities.

Other strategies to prevent or manage postoperative bleeding include the application of ice, direct pressure for 15 minutes, and the use of Surgicel Absorbable Hemostat (Ethicon Inc.).

Surgicel looks like a little piece of gauze, Dr. Weinkle said. "One of my patients [who lives] 2 hours away went to the ED. They laid this on top of his sutured wound and it stopped" bleeding.

"One thing I want you to take home today—Surgicel is absolutely magical stuff," Dr. Weinkle said. (She stated that she had no relevant disclosures.) It is particularly helpful for controlling bleeding on more challenging wound sites.

Consider using flesh-colored bandages, and provide written instructions to leave them on for 48 hours. DR. WEINKLE

MIAMI BEACH — Minimizing bleeding during and after Mohs surgery can be a challenge, according to Dr. Susan H. Weinkle.

"In Bradenton [Fla.] where I practice, almost everyone is taking an anticoagulant," Dr. Weinkle said. As a Mohs surgeon "we realize that the risk of a thrombotic event is much worse for the patient than the risk of bleeding." She recommended that patients with a history of a transient ischemic attack or thrombotic event, in particular, be allowed to continue their anticoagulant therapy.

Ask patients to provide a comprehensive list of all the medications and supplements they take, Dr. Weinkle said at the South Beach Symposium. "Sometimes patients do not tell you the whole story, so you need a complete history." Patients may be taking ginkgo biloba or consuming a lot of cinnamon, which can thin the blood.

Meticulous hemostasis is important; do your best to maintain a dry field intraoperatively during Mohs surgery, said Dr. Weinkle, a private practice dermatologist in Bradenton. Epidermal sutures often can halt superficial bleeding along the edge of a wound. If excessive bleeding occurs intraoperatively, you may need to tie off a larger vessel. Also, avoid placing a patient in the Trendelenburg position.

How you bandage is also important to minimize the risk of postoperative bleeding. Provide pressure with a large bandage because "as the anesthetic goes away, you can get rebound vasodilatation," Dr. Weinkle said. Consider using flesh-colored bandages, and provide written instructions to leave bandages in place for 48 hours and to restrict activities.

Other strategies to prevent or manage postoperative bleeding include the application of ice, direct pressure for 15 minutes, and the use of Surgicel Absorbable Hemostat (Ethicon Inc.).

Surgicel looks like a little piece of gauze, Dr. Weinkle said. "One of my patients [who lives] 2 hours away went to the ED. They laid this on top of his sutured wound and it stopped" bleeding.

"One thing I want you to take home today—Surgicel is absolutely magical stuff," Dr. Weinkle said. (She stated that she had no relevant disclosures.) It is particularly helpful for controlling bleeding on more challenging wound sites.

Consider using flesh-colored bandages, and provide written instructions to leave them on for 48 hours. DR. WEINKLE

MIAMI BEACH — Minimizing bleeding during and after Mohs surgery can be a challenge, according to Dr. Susan H. Weinkle.

"In Bradenton [Fla.] where I practice, almost everyone is taking an anticoagulant," Dr. Weinkle said. As a Mohs surgeon "we realize that the risk of a thrombotic event is much worse for the patient than the risk of bleeding." She recommended that patients with a history of a transient ischemic attack or thrombotic event, in particular, be allowed to continue their anticoagulant therapy.

Ask patients to provide a comprehensive list of all the medications and supplements they take, Dr. Weinkle said at the South Beach Symposium. "Sometimes patients do not tell you the whole story, so you need a complete history." Patients may be taking ginkgo biloba or consuming a lot of cinnamon, which can thin the blood.

Meticulous hemostasis is important; do your best to maintain a dry field intraoperatively during Mohs surgery, said Dr. Weinkle, a private practice dermatologist in Bradenton. Epidermal sutures often can halt superficial bleeding along the edge of a wound. If excessive bleeding occurs intraoperatively, you may need to tie off a larger vessel. Also, avoid placing a patient in the Trendelenburg position.

How you bandage is also important to minimize the risk of postoperative bleeding. Provide pressure with a large bandage because "as the anesthetic goes away, you can get rebound vasodilatation," Dr. Weinkle said. Consider using flesh-colored bandages, and provide written instructions to leave bandages in place for 48 hours and to restrict activities.

Other strategies to prevent or manage postoperative bleeding include the application of ice, direct pressure for 15 minutes, and the use of Surgicel Absorbable Hemostat (Ethicon Inc.).

Surgicel looks like a little piece of gauze, Dr. Weinkle said. "One of my patients [who lives] 2 hours away went to the ED. They laid this on top of his sutured wound and it stopped" bleeding.

"One thing I want you to take home today—Surgicel is absolutely magical stuff," Dr. Weinkle said. (She stated that she had no relevant disclosures.) It is particularly helpful for controlling bleeding on more challenging wound sites.

Consider using flesh-colored bandages, and provide written instructions to leave them on for 48 hours. DR. WEINKLE

MONTREAL — The incidence of melanoma in the United States increased rapidly over a 10-year period, regardless of tumor thickness and socioeconomic status, reported Dr. Eleni Linos.

"This has implications for preventive screening and primary care," she said at the annual meeting of the Society for Investigative Dermatology.

Dr. Linos and her coinvestigators examined data from the Surveillance, Epidemiology, and End Results (SEER) registry between 1992 and 2004 (J. Invest. Derm. 2009 Jan. 8 [doi:10.1038/jid.2008.423

During the study period, the incidence of melanoma of all thicknesses increased from 18 per 100,000 in 1992 to 26 per 100,000 in 2004—an annual increase of 3%, said Dr. Linos of Stanford (Calif.) University. The steepest increase was seen in men aged 65 years and older, in whom the incidence rose from 73 to 126 new cases per 100,000. "The vast majority of melanomas that are diagnosed are thin, and that is why we have not seen such a dramatic increase in mortality rates," she explained. Overall mortality rose by 0.4% annually.

Melanoma trends were examined according to socioeconomic status to determine whether the findings could be explained by better screening in those with a higher status. Similarly, tumor thickness was examined to determine whether the increased incidence could be explained by more diagnoses of thin, clinically insignificant tumors.

"We found parallel increases across all socioeconomic groups and thicknesses, representing a true increase in clinically significant tumors," she said.

MONTREAL — The incidence of melanoma in the United States increased rapidly over a 10-year period, regardless of tumor thickness and socioeconomic status, reported Dr. Eleni Linos.

"This has implications for preventive screening and primary care," she said at the annual meeting of the Society for Investigative Dermatology.

Dr. Linos and her coinvestigators examined data from the Surveillance, Epidemiology, and End Results (SEER) registry between 1992 and 2004 (J. Invest. Derm. 2009 Jan. 8 [doi:10.1038/jid.2008.423

During the study period, the incidence of melanoma of all thicknesses increased from 18 per 100,000 in 1992 to 26 per 100,000 in 2004—an annual increase of 3%, said Dr. Linos of Stanford (Calif.) University. The steepest increase was seen in men aged 65 years and older, in whom the incidence rose from 73 to 126 new cases per 100,000. "The vast majority of melanomas that are diagnosed are thin, and that is why we have not seen such a dramatic increase in mortality rates," she explained. Overall mortality rose by 0.4% annually.

Melanoma trends were examined according to socioeconomic status to determine whether the findings could be explained by better screening in those with a higher status. Similarly, tumor thickness was examined to determine whether the increased incidence could be explained by more diagnoses of thin, clinically insignificant tumors.

"We found parallel increases across all socioeconomic groups and thicknesses, representing a true increase in clinically significant tumors," she said.

MONTREAL — The incidence of melanoma in the United States increased rapidly over a 10-year period, regardless of tumor thickness and socioeconomic status, reported Dr. Eleni Linos.

"This has implications for preventive screening and primary care," she said at the annual meeting of the Society for Investigative Dermatology.

Dr. Linos and her coinvestigators examined data from the Surveillance, Epidemiology, and End Results (SEER) registry between 1992 and 2004 (J. Invest. Derm. 2009 Jan. 8 [doi:10.1038/jid.2008.423

During the study period, the incidence of melanoma of all thicknesses increased from 18 per 100,000 in 1992 to 26 per 100,000 in 2004—an annual increase of 3%, said Dr. Linos of Stanford (Calif.) University. The steepest increase was seen in men aged 65 years and older, in whom the incidence rose from 73 to 126 new cases per 100,000. "The vast majority of melanomas that are diagnosed are thin, and that is why we have not seen such a dramatic increase in mortality rates," she explained. Overall mortality rose by 0.4% annually.

Melanoma trends were examined according to socioeconomic status to determine whether the findings could be explained by better screening in those with a higher status. Similarly, tumor thickness was examined to determine whether the increased incidence could be explained by more diagnoses of thin, clinically insignificant tumors.

"We found parallel increases across all socioeconomic groups and thicknesses, representing a true increase in clinically significant tumors," she said.

SAN FRANCISCO — The use of moderate to large volumes of dilute lidocaine for tumescent anesthesia during Mohs surgery on the face and neck was free of signs of lidocaine toxicity in a prospective single-center study.

Of 19 patients who underwent Mohs surgery for medium to large tumors on the face, scalp, or neck, none had a plasma lidocaine level anywhere close to the 5-mcg/mL threshold above which early signs of systemic lidocaine toxicity can occur, Dr. Murad Alam reported at the annual meeting of the American Academy of Dermatology.

The patients received injections totaling 5–48 mL of 1% lidocaine with 1:100,000 epinephrine and 1:10 sodium bicarbonate. Each patient had six blood draws for measurement of lidocaine levels; they were obtained before the first anesthetic injection and again immediately before and after each surgical stage, with the final draw an average of 4.4 hours following the first. In addition, active inquiry was repeatedly made of patients regarding any possible signs or symptoms of lidocaine toxicity.

Plasma lidocaine levels remained undetectable—below 0.1 mcg/mL—at all time points in three-quarters of the patients and never exceeded the 3.0-mcg/mL mark in the rest, according to Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

He explained that this study was undertaken because large volumes of tumescent anesthesia, akin to those widely utilized in liposuction, are increasingly being employed for excision of large skin cancers. Lidocaine injections to the face, neck, and scalp result in faster systemic absorption and higher peak levels than elsewhere in the body.

At plasma lidocaine levels above 5 mcg/mL, patients show the early signs of lidocaine toxicity, including tinnitus, muscle twitches, tongue numbness, a metallic taste, dizziness, diplopia, and visual halos. Levels above 10 mcg/mL put patients at risk for seizures, respiratory and cardiac arrest, and coma, Dr. Alam noted.

The pattern of rising plasma lidocaine levels over time documented in this study suggests that peak levels in patients undergoing Mohs surgery above-the-shoulders occur 3–5 hours after the start of surgery, he added.

SAN FRANCISCO — The use of moderate to large volumes of dilute lidocaine for tumescent anesthesia during Mohs surgery on the face and neck was free of signs of lidocaine toxicity in a prospective single-center study.

Of 19 patients who underwent Mohs surgery for medium to large tumors on the face, scalp, or neck, none had a plasma lidocaine level anywhere close to the 5-mcg/mL threshold above which early signs of systemic lidocaine toxicity can occur, Dr. Murad Alam reported at the annual meeting of the American Academy of Dermatology.

The patients received injections totaling 5–48 mL of 1% lidocaine with 1:100,000 epinephrine and 1:10 sodium bicarbonate. Each patient had six blood draws for measurement of lidocaine levels; they were obtained before the first anesthetic injection and again immediately before and after each surgical stage, with the final draw an average of 4.4 hours following the first. In addition, active inquiry was repeatedly made of patients regarding any possible signs or symptoms of lidocaine toxicity.

Plasma lidocaine levels remained undetectable—below 0.1 mcg/mL—at all time points in three-quarters of the patients and never exceeded the 3.0-mcg/mL mark in the rest, according to Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

He explained that this study was undertaken because large volumes of tumescent anesthesia, akin to those widely utilized in liposuction, are increasingly being employed for excision of large skin cancers. Lidocaine injections to the face, neck, and scalp result in faster systemic absorption and higher peak levels than elsewhere in the body.

At plasma lidocaine levels above 5 mcg/mL, patients show the early signs of lidocaine toxicity, including tinnitus, muscle twitches, tongue numbness, a metallic taste, dizziness, diplopia, and visual halos. Levels above 10 mcg/mL put patients at risk for seizures, respiratory and cardiac arrest, and coma, Dr. Alam noted.

The pattern of rising plasma lidocaine levels over time documented in this study suggests that peak levels in patients undergoing Mohs surgery above-the-shoulders occur 3–5 hours after the start of surgery, he added.

SAN FRANCISCO — The use of moderate to large volumes of dilute lidocaine for tumescent anesthesia during Mohs surgery on the face and neck was free of signs of lidocaine toxicity in a prospective single-center study.

Of 19 patients who underwent Mohs surgery for medium to large tumors on the face, scalp, or neck, none had a plasma lidocaine level anywhere close to the 5-mcg/mL threshold above which early signs of systemic lidocaine toxicity can occur, Dr. Murad Alam reported at the annual meeting of the American Academy of Dermatology.

The patients received injections totaling 5–48 mL of 1% lidocaine with 1:100,000 epinephrine and 1:10 sodium bicarbonate. Each patient had six blood draws for measurement of lidocaine levels; they were obtained before the first anesthetic injection and again immediately before and after each surgical stage, with the final draw an average of 4.4 hours following the first. In addition, active inquiry was repeatedly made of patients regarding any possible signs or symptoms of lidocaine toxicity.

Plasma lidocaine levels remained undetectable—below 0.1 mcg/mL—at all time points in three-quarters of the patients and never exceeded the 3.0-mcg/mL mark in the rest, according to Dr. Alam, chief of cutaneous and aesthetic surgery at Northwestern University, Chicago.

He explained that this study was undertaken because large volumes of tumescent anesthesia, akin to those widely utilized in liposuction, are increasingly being employed for excision of large skin cancers. Lidocaine injections to the face, neck, and scalp result in faster systemic absorption and higher peak levels than elsewhere in the body.

At plasma lidocaine levels above 5 mcg/mL, patients show the early signs of lidocaine toxicity, including tinnitus, muscle twitches, tongue numbness, a metallic taste, dizziness, diplopia, and visual halos. Levels above 10 mcg/mL put patients at risk for seizures, respiratory and cardiac arrest, and coma, Dr. Alam noted.

The pattern of rising plasma lidocaine levels over time documented in this study suggests that peak levels in patients undergoing Mohs surgery above-the-shoulders occur 3–5 hours after the start of surgery, he added.

MONTREAL — Actinic keratoses are dynamic lesions and their expression varies over time, based on the results of an 11-month study of the natural course of the lesions in people with extensive actinic damage.

"At any one time, less than half of the lesions are evident clinically," said Dr. Craig Elmets, who reported his findings at the annual meeting of the Society for Investigative Dermatology.

The pattern of regression and recurrence of actinic keratoses (AK) has implications for the treatment of the lesions, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

"If one is going to treat individual lesions, then they need to be treated aggressively because at any one time only a minority of the [visible] AKs are present," he said. "In patients with extensive actinic damage, peel treatment may be a very good approach to treating these lesions."

Dr. Elmets did not disclose any conflicts of interest in regard to this study, but he serves on the advisory boards of several pharmaceutical companies.

The study followed AK lesions for 11 months in 26 individuals with extensive actinic damage.

At baseline, the subjects had 10–40 actinic lesions and at least one prior histological diagnosis of an AK or a nonmelanoma skin cancer.

The subjects' AKs were mapped at baseline and again at 3, 6, 9, and 11 months.

The lesions also were biopsied at baseline and the end of the study. "If a lesion that had been selected for biopsy was no longer present clinically, the site where it had been was still biopsied," Dr. Elmets explained.

At baseline, there were a total of 610 AKs in the study group (mean 23.5 per individual). At the end of the study, this number was not significantly different despite the development of 973 new lesions over the 11-month period.

About 40% of the lesions present at baseline had regressed by month 11, and nearly 200 of the lesions that were present at baseline regressed and then recurred, he said. "A total of 51 of the lesions regressed twice."

Using a histologic grading scheme that was based on a cervical dysplasia model, Dr. Elmets noted little progression in the severity of lesions in terms of proliferation, atypia, or both features. "The histologic appearance seems to accurately correlate with the clinical appearance, and over the course of 11 months there was little evidence of histologic progression."

AKs have been thought to be precursors to squamous cell carcinomas in some cases.

The presence of AKs is strongly predictive of individuals who are at increased risk for basal cell and squamous cell carcinomas, noted Dr. Elmets.

The pattern of regression and recurrence of actinic keratoses may have implications for the treatment of the lesions. Courtesy Dr. Roger I. Ceilley

MONTREAL — Actinic keratoses are dynamic lesions and their expression varies over time, based on the results of an 11-month study of the natural course of the lesions in people with extensive actinic damage.

"At any one time, less than half of the lesions are evident clinically," said Dr. Craig Elmets, who reported his findings at the annual meeting of the Society for Investigative Dermatology.

The pattern of regression and recurrence of actinic keratoses (AK) has implications for the treatment of the lesions, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

"If one is going to treat individual lesions, then they need to be treated aggressively because at any one time only a minority of the [visible] AKs are present," he said. "In patients with extensive actinic damage, peel treatment may be a very good approach to treating these lesions."

Dr. Elmets did not disclose any conflicts of interest in regard to this study, but he serves on the advisory boards of several pharmaceutical companies.

The study followed AK lesions for 11 months in 26 individuals with extensive actinic damage.

At baseline, the subjects had 10–40 actinic lesions and at least one prior histological diagnosis of an AK or a nonmelanoma skin cancer.

The subjects' AKs were mapped at baseline and again at 3, 6, 9, and 11 months.

The lesions also were biopsied at baseline and the end of the study. "If a lesion that had been selected for biopsy was no longer present clinically, the site where it had been was still biopsied," Dr. Elmets explained.

At baseline, there were a total of 610 AKs in the study group (mean 23.5 per individual). At the end of the study, this number was not significantly different despite the development of 973 new lesions over the 11-month period.

About 40% of the lesions present at baseline had regressed by month 11, and nearly 200 of the lesions that were present at baseline regressed and then recurred, he said. "A total of 51 of the lesions regressed twice."

Using a histologic grading scheme that was based on a cervical dysplasia model, Dr. Elmets noted little progression in the severity of lesions in terms of proliferation, atypia, or both features. "The histologic appearance seems to accurately correlate with the clinical appearance, and over the course of 11 months there was little evidence of histologic progression."

AKs have been thought to be precursors to squamous cell carcinomas in some cases.

The presence of AKs is strongly predictive of individuals who are at increased risk for basal cell and squamous cell carcinomas, noted Dr. Elmets.

The pattern of regression and recurrence of actinic keratoses may have implications for the treatment of the lesions. Courtesy Dr. Roger I. Ceilley

MONTREAL — Actinic keratoses are dynamic lesions and their expression varies over time, based on the results of an 11-month study of the natural course of the lesions in people with extensive actinic damage.

"At any one time, less than half of the lesions are evident clinically," said Dr. Craig Elmets, who reported his findings at the annual meeting of the Society for Investigative Dermatology.

The pattern of regression and recurrence of actinic keratoses (AK) has implications for the treatment of the lesions, said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

"If one is going to treat individual lesions, then they need to be treated aggressively because at any one time only a minority of the [visible] AKs are present," he said. "In patients with extensive actinic damage, peel treatment may be a very good approach to treating these lesions."

Dr. Elmets did not disclose any conflicts of interest in regard to this study, but he serves on the advisory boards of several pharmaceutical companies.

The study followed AK lesions for 11 months in 26 individuals with extensive actinic damage.

At baseline, the subjects had 10–40 actinic lesions and at least one prior histological diagnosis of an AK or a nonmelanoma skin cancer.

The subjects' AKs were mapped at baseline and again at 3, 6, 9, and 11 months.

The lesions also were biopsied at baseline and the end of the study. "If a lesion that had been selected for biopsy was no longer present clinically, the site where it had been was still biopsied," Dr. Elmets explained.

At baseline, there were a total of 610 AKs in the study group (mean 23.5 per individual). At the end of the study, this number was not significantly different despite the development of 973 new lesions over the 11-month period.

About 40% of the lesions present at baseline had regressed by month 11, and nearly 200 of the lesions that were present at baseline regressed and then recurred, he said. "A total of 51 of the lesions regressed twice."

Using a histologic grading scheme that was based on a cervical dysplasia model, Dr. Elmets noted little progression in the severity of lesions in terms of proliferation, atypia, or both features. "The histologic appearance seems to accurately correlate with the clinical appearance, and over the course of 11 months there was little evidence of histologic progression."

AKs have been thought to be precursors to squamous cell carcinomas in some cases.

The presence of AKs is strongly predictive of individuals who are at increased risk for basal cell and squamous cell carcinomas, noted Dr. Elmets.

The pattern of regression and recurrence of actinic keratoses may have implications for the treatment of the lesions. Courtesy Dr. Roger I. Ceilley

MONTREAL — A twice-daily dose of celecoxib given over a period of 9 months was associated with a 60% reduction in the incidence of nonmelanoma skin cancer, according to the results of a new study.

“Inhibition of COX-2 [cyclo-oxygenase-2] is an effective means of limiting the development of cutaneous squamous and basal cell carcinomas in humans,” reported Dr. Craig Elmets at the annual meeting of the Society for Investigative Dermatology.

The findings suggest that pharmaceutical agents such as celecoxib may offer greater protection against skin cancer than sunscreens, which are only “modestly effective,” said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

“There's only about a 35% reduction in squamous cell carcinomas when sunscreens are used on a regular basis over a 5-year period of time, and there's no reduction in basal cell carcinomas.”

The multicenter, randomized, placebo-controlled study was funded by the National Cancer Institute and the National Institute of Arthritis and Musculoskeletal and Skin Diseases, with additional funding from Pfizer through a contractual agreement with the National Institutes of Health, he said. Dr. Elmets did not disclose any personal conflicts of interest.

The study enrolled 238 patients with nonmelanoma skin cancers from eight U.S. centers. The mean age of the patients was 65 years, most were male, and virtually all were white.

“The study was terminated somewhat early because of concerns of cardiovascular effects due to another COX-2 inhibitor,” he noted.

Subjects in the study had Fitzpatrick skin types I-III, extensive actinic damage with 10–40 actinic keratoses (AK), and a prior histologic diagnosis of either AK or nonmelanoma skin cancer. Subjects were excluded if they required treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), although cardioprotective doses of aspirin were allowed.

At entry, patients had a mean number of 22 AKs, as well as between 2.1 and 2.5 nonmelanoma skin cancers, he said.

Patients were randomized to either placebo or celecoxib 200 mg twice daily, which is the approved dosage for arthritis, said Dr. Elmets. “We were concerned about cardiovascular abnormalities and GI abnormalities, and if anything there was a bias towards patients in the celecoxib group having a prior history of that.”

A comparison of the number of AKs at baseline and completion showed a lack of effect of celecoxib, compared to placebo, he noted. However, the development of new cutaneous basal and squamous cell carcinomas was much reduced. “We were delighted to find that celecoxib was quite effective, with a 58% reduction, compared to placebo-treated controls,” he said.

Looking at the two types of lesions separately, treatment with celecoxib resulted in a 58% reduction in squamous cell carcinomas (SCC), and a 62% reduction in basal cell carcinomas (BCC).

“The difference between the [placebo and treated] groups started to become apparent quite rapidly, at 3 months, and persisted throughout the study.

“We were concerned that there might be one or two outliers that were skewing the results, so rather than looking at the total number of skin cancers, we also looked at the number of individuals who developed BCC or SCC or both. Again we found that patients with celecoxib had fewer BCCs and SCCs than” placebo patients.

There were no differences in adverse events including cardiovascular adverse events between the two groups, Dr. Elmets reported. During the question period, he acknowledged that there were higher blood pressures reported in the treatment group.

Of the 238 patients enrolled, 36 withdrew from the treatment group and 24 withdrew from the placebo group. The major reasons for withdrawal were disease progression, withdrawal of consent, the use of an excluded medication, an adverse event, and loss to follow up.

“The data is very compelling,” said Dr. Maryam Asgari of Kaiser Permanente in Oakland, Calif., in an interview. But she suggested perhaps the study was too short to have such dramatic conclusions. “I know that typically for most cancers you would need a study to last 2–5 years before you would expect to measure an effect,” she said. Similarly, adverse events from COX-2 inhibitors would likely need longer to develop.

Dr. Asgari said her research in the same field has produced the opposite results.

A study that she has just completed found no protective effect for all NSAIDs—both selective and nonselective COX inhibitors—on the incidence of squamous cell carcinoma. And a previous paper published by her group also found no protective effect of these drugs on melanomas (J. Natl. Cancer Inst. 2008;100[13]:967–71).

In addition, she said celecoxib's lack of effect on AKs is a puzzling result. “You would think that if COX-2 inhibitors are working to prevent new cancers from arising that they would also have a pretty dramatic effect on actinic keratoses because they both share the same pathway.”

MONTREAL — A twice-daily dose of celecoxib given over a period of 9 months was associated with a 60% reduction in the incidence of nonmelanoma skin cancer, according to the results of a new study.

“Inhibition of COX-2 [cyclo-oxygenase-2] is an effective means of limiting the development of cutaneous squamous and basal cell carcinomas in humans,” reported Dr. Craig Elmets at the annual meeting of the Society for Investigative Dermatology.

The findings suggest that pharmaceutical agents such as celecoxib may offer greater protection against skin cancer than sunscreens, which are only “modestly effective,” said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

“There's only about a 35% reduction in squamous cell carcinomas when sunscreens are used on a regular basis over a 5-year period of time, and there's no reduction in basal cell carcinomas.”

The multicenter, randomized, placebo-controlled study was funded by the National Cancer Institute and the National Institute of Arthritis and Musculoskeletal and Skin Diseases, with additional funding from Pfizer through a contractual agreement with the National Institutes of Health, he said. Dr. Elmets did not disclose any personal conflicts of interest.

The study enrolled 238 patients with nonmelanoma skin cancers from eight U.S. centers. The mean age of the patients was 65 years, most were male, and virtually all were white.

“The study was terminated somewhat early because of concerns of cardiovascular effects due to another COX-2 inhibitor,” he noted.

Subjects in the study had Fitzpatrick skin types I-III, extensive actinic damage with 10–40 actinic keratoses (AK), and a prior histologic diagnosis of either AK or nonmelanoma skin cancer. Subjects were excluded if they required treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), although cardioprotective doses of aspirin were allowed.

At entry, patients had a mean number of 22 AKs, as well as between 2.1 and 2.5 nonmelanoma skin cancers, he said.

Patients were randomized to either placebo or celecoxib 200 mg twice daily, which is the approved dosage for arthritis, said Dr. Elmets. “We were concerned about cardiovascular abnormalities and GI abnormalities, and if anything there was a bias towards patients in the celecoxib group having a prior history of that.”

A comparison of the number of AKs at baseline and completion showed a lack of effect of celecoxib, compared to placebo, he noted. However, the development of new cutaneous basal and squamous cell carcinomas was much reduced. “We were delighted to find that celecoxib was quite effective, with a 58% reduction, compared to placebo-treated controls,” he said.

Looking at the two types of lesions separately, treatment with celecoxib resulted in a 58% reduction in squamous cell carcinomas (SCC), and a 62% reduction in basal cell carcinomas (BCC).

“The difference between the [placebo and treated] groups started to become apparent quite rapidly, at 3 months, and persisted throughout the study.

“We were concerned that there might be one or two outliers that were skewing the results, so rather than looking at the total number of skin cancers, we also looked at the number of individuals who developed BCC or SCC or both. Again we found that patients with celecoxib had fewer BCCs and SCCs than” placebo patients.

There were no differences in adverse events including cardiovascular adverse events between the two groups, Dr. Elmets reported. During the question period, he acknowledged that there were higher blood pressures reported in the treatment group.

Of the 238 patients enrolled, 36 withdrew from the treatment group and 24 withdrew from the placebo group. The major reasons for withdrawal were disease progression, withdrawal of consent, the use of an excluded medication, an adverse event, and loss to follow up.

“The data is very compelling,” said Dr. Maryam Asgari of Kaiser Permanente in Oakland, Calif., in an interview. But she suggested perhaps the study was too short to have such dramatic conclusions. “I know that typically for most cancers you would need a study to last 2–5 years before you would expect to measure an effect,” she said. Similarly, adverse events from COX-2 inhibitors would likely need longer to develop.

Dr. Asgari said her research in the same field has produced the opposite results.

A study that she has just completed found no protective effect for all NSAIDs—both selective and nonselective COX inhibitors—on the incidence of squamous cell carcinoma. And a previous paper published by her group also found no protective effect of these drugs on melanomas (J. Natl. Cancer Inst. 2008;100[13]:967–71).

In addition, she said celecoxib's lack of effect on AKs is a puzzling result. “You would think that if COX-2 inhibitors are working to prevent new cancers from arising that they would also have a pretty dramatic effect on actinic keratoses because they both share the same pathway.”

MONTREAL — A twice-daily dose of celecoxib given over a period of 9 months was associated with a 60% reduction in the incidence of nonmelanoma skin cancer, according to the results of a new study.

“Inhibition of COX-2 [cyclo-oxygenase-2] is an effective means of limiting the development of cutaneous squamous and basal cell carcinomas in humans,” reported Dr. Craig Elmets at the annual meeting of the Society for Investigative Dermatology.

The findings suggest that pharmaceutical agents such as celecoxib may offer greater protection against skin cancer than sunscreens, which are only “modestly effective,” said Dr. Elmets, professor and chair of the department of dermatology and director of the Skin Disease Research Center at the University of Alabama, Birmingham.

“There's only about a 35% reduction in squamous cell carcinomas when sunscreens are used on a regular basis over a 5-year period of time, and there's no reduction in basal cell carcinomas.”

The multicenter, randomized, placebo-controlled study was funded by the National Cancer Institute and the National Institute of Arthritis and Musculoskeletal and Skin Diseases, with additional funding from Pfizer through a contractual agreement with the National Institutes of Health, he said. Dr. Elmets did not disclose any personal conflicts of interest.

The study enrolled 238 patients with nonmelanoma skin cancers from eight U.S. centers. The mean age of the patients was 65 years, most were male, and virtually all were white.

“The study was terminated somewhat early because of concerns of cardiovascular effects due to another COX-2 inhibitor,” he noted.

Subjects in the study had Fitzpatrick skin types I-III, extensive actinic damage with 10–40 actinic keratoses (AK), and a prior histologic diagnosis of either AK or nonmelanoma skin cancer. Subjects were excluded if they required treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), although cardioprotective doses of aspirin were allowed.

At entry, patients had a mean number of 22 AKs, as well as between 2.1 and 2.5 nonmelanoma skin cancers, he said.

Patients were randomized to either placebo or celecoxib 200 mg twice daily, which is the approved dosage for arthritis, said Dr. Elmets. “We were concerned about cardiovascular abnormalities and GI abnormalities, and if anything there was a bias towards patients in the celecoxib group having a prior history of that.”

A comparison of the number of AKs at baseline and completion showed a lack of effect of celecoxib, compared to placebo, he noted. However, the development of new cutaneous basal and squamous cell carcinomas was much reduced. “We were delighted to find that celecoxib was quite effective, with a 58% reduction, compared to placebo-treated controls,” he said.

Looking at the two types of lesions separately, treatment with celecoxib resulted in a 58% reduction in squamous cell carcinomas (SCC), and a 62% reduction in basal cell carcinomas (BCC).

“The difference between the [placebo and treated] groups started to become apparent quite rapidly, at 3 months, and persisted throughout the study.

“We were concerned that there might be one or two outliers that were skewing the results, so rather than looking at the total number of skin cancers, we also looked at the number of individuals who developed BCC or SCC or both. Again we found that patients with celecoxib had fewer BCCs and SCCs than” placebo patients.

There were no differences in adverse events including cardiovascular adverse events between the two groups, Dr. Elmets reported. During the question period, he acknowledged that there were higher blood pressures reported in the treatment group.

Of the 238 patients enrolled, 36 withdrew from the treatment group and 24 withdrew from the placebo group. The major reasons for withdrawal were disease progression, withdrawal of consent, the use of an excluded medication, an adverse event, and loss to follow up.

“The data is very compelling,” said Dr. Maryam Asgari of Kaiser Permanente in Oakland, Calif., in an interview. But she suggested perhaps the study was too short to have such dramatic conclusions. “I know that typically for most cancers you would need a study to last 2–5 years before you would expect to measure an effect,” she said. Similarly, adverse events from COX-2 inhibitors would likely need longer to develop.

Dr. Asgari said her research in the same field has produced the opposite results.

A study that she has just completed found no protective effect for all NSAIDs—both selective and nonselective COX inhibitors—on the incidence of squamous cell carcinoma. And a previous paper published by her group also found no protective effect of these drugs on melanomas (J. Natl. Cancer Inst. 2008;100[13]:967–71).

In addition, she said celecoxib's lack of effect on AKs is a puzzling result. “You would think that if COX-2 inhibitors are working to prevent new cancers from arising that they would also have a pretty dramatic effect on actinic keratoses because they both share the same pathway.”

AUSTIN, TEX. — The commonly accepted standard of using 5-mm margins for surgical excision of melanoma in situ may not be enough to clear the large majority of tumors, said Dr. Joy Kunishige.

Speaking at the annual meeting of the American College of Mohs Surgery, Dr. Kunishige, a dermatologist in private practice in Pittsburgh, said that since several studies have shown a 5-mm margin to be inadequate, she and her colleagues gathered the latest evidence on clearance rates to update previous National Institutes of Health guidelines, set in 1992 (NIH Consens. Statement 1992 Jan 27–29;10[1]:1–26). The goal was to clear at least 97% of tumors.

They evaluated all primary melanoma in situ cases that were collected as part of a prospective database started in 1982 at the practice. The database included 1,072 patients with 1,120 primary tumors. Of the patients, 675 (63%) were male, and mean age was 65 years, and mean follow-up was 4.7 years. A total of 593 (53%) of the lesions were on the face, 235 (21%) were on the extremities, and 201 (18%) were on the trunk, with the remainder in other locations.

All lesions were excised using the fresh tissue technique of Mohs, with frozen section examination of the margin.

Using 6-mm margins, 86% of the tumors were cleared. With a 9-mm margin, there was a 98% clearance rate; and with a 12-mm margin, a 99.4% clearance rate, said Dr. Kunishige.

The 9-mm margin was equally effective regardless of sex, location, or diameter of the lesion. The overall 5-year survival was 93%; the 5-year melanoma in situ survival was 99.5%. Three patients died of melanoma in situ. Two died from a separate invasive melanoma and 90 died of other causes, free of melanoma, she said.

The investigators concluded that a 9-mm margin was superior to 6 mm.

She reported no disclosures.

A 5-mm margin may not be adequate for removing the majority of tumors. Courtesy Dr. Joy Kunishige

AUSTIN, TEX. — The commonly accepted standard of using 5-mm margins for surgical excision of melanoma in situ may not be enough to clear the large majority of tumors, said Dr. Joy Kunishige.

Speaking at the annual meeting of the American College of Mohs Surgery, Dr. Kunishige, a dermatologist in private practice in Pittsburgh, said that since several studies have shown a 5-mm margin to be inadequate, she and her colleagues gathered the latest evidence on clearance rates to update previous National Institutes of Health guidelines, set in 1992 (NIH Consens. Statement 1992 Jan 27–29;10[1]:1–26). The goal was to clear at least 97% of tumors.

They evaluated all primary melanoma in situ cases that were collected as part of a prospective database started in 1982 at the practice. The database included 1,072 patients with 1,120 primary tumors. Of the patients, 675 (63%) were male, and mean age was 65 years, and mean follow-up was 4.7 years. A total of 593 (53%) of the lesions were on the face, 235 (21%) were on the extremities, and 201 (18%) were on the trunk, with the remainder in other locations.

All lesions were excised using the fresh tissue technique of Mohs, with frozen section examination of the margin.

Using 6-mm margins, 86% of the tumors were cleared. With a 9-mm margin, there was a 98% clearance rate; and with a 12-mm margin, a 99.4% clearance rate, said Dr. Kunishige.

The 9-mm margin was equally effective regardless of sex, location, or diameter of the lesion. The overall 5-year survival was 93%; the 5-year melanoma in situ survival was 99.5%. Three patients died of melanoma in situ. Two died from a separate invasive melanoma and 90 died of other causes, free of melanoma, she said.

The investigators concluded that a 9-mm margin was superior to 6 mm.

She reported no disclosures.

A 5-mm margin may not be adequate for removing the majority of tumors. Courtesy Dr. Joy Kunishige

AUSTIN, TEX. — The commonly accepted standard of using 5-mm margins for surgical excision of melanoma in situ may not be enough to clear the large majority of tumors, said Dr. Joy Kunishige.

Speaking at the annual meeting of the American College of Mohs Surgery, Dr. Kunishige, a dermatologist in private practice in Pittsburgh, said that since several studies have shown a 5-mm margin to be inadequate, she and her colleagues gathered the latest evidence on clearance rates to update previous National Institutes of Health guidelines, set in 1992 (NIH Consens. Statement 1992 Jan 27–29;10[1]:1–26). The goal was to clear at least 97% of tumors.

They evaluated all primary melanoma in situ cases that were collected as part of a prospective database started in 1982 at the practice. The database included 1,072 patients with 1,120 primary tumors. Of the patients, 675 (63%) were male, and mean age was 65 years, and mean follow-up was 4.7 years. A total of 593 (53%) of the lesions were on the face, 235 (21%) were on the extremities, and 201 (18%) were on the trunk, with the remainder in other locations.

All lesions were excised using the fresh tissue technique of Mohs, with frozen section examination of the margin.

Using 6-mm margins, 86% of the tumors were cleared. With a 9-mm margin, there was a 98% clearance rate; and with a 12-mm margin, a 99.4% clearance rate, said Dr. Kunishige.

The 9-mm margin was equally effective regardless of sex, location, or diameter of the lesion. The overall 5-year survival was 93%; the 5-year melanoma in situ survival was 99.5%. Three patients died of melanoma in situ. Two died from a separate invasive melanoma and 90 died of other causes, free of melanoma, she said.

The investigators concluded that a 9-mm margin was superior to 6 mm.

She reported no disclosures.

A 5-mm margin may not be adequate for removing the majority of tumors. Courtesy Dr. Joy Kunishige

SAN FRANCISCO — Acral lentiginous is the rarest of the major histologic subtypes of melanoma, but is the most common subtype in blacks, according to a national study.

The study showed that the age-adjusted incidence of acral lentiginous melanoma (ALM) is similar in black and non-Hispanic white patients at about 1.8 cases per 1 million person-years. But ALM accounted for close to 40% of all cutaneous melanomas in blacks, whereas two-thirds of melanomas in non-Hispanic whites were of the superficial spreading subtype and ALM accounted for less than 2%, Dr. Porcia Bradford reported at the annual meeting of the American Academy of Dermatology.

Her analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database for 1986-2005 turned up 1,413 cases of histologically-confirmed ALM in 16 participating cancer registries. This was the first population-based study focusing on ALM, according to Dr. Bradford of the division of cancer and epidemiology, National Cancer Institute, Bethesda, Md.

The incidence of ALM was greatest in Hispanic whites, at 2.5 cases per 1 million person-years. The rate was lowest in Asian/Pacific Islanders at 1.1 cases per 1 million person-years. ALM comprised about 20% of all melanomas in Asian/Pacific Islanders and 10% of those in Hispanic whites.

The prognosis for individuals with ALM was significantly worse than for cutaneous melanoma as a whole. Five- and 10-year melanoma-specific survival rates for cutaneous melanomas overall were 91% and 87%, respectively, compared with 80% and 68% for ALM.

This disparity in outcomes was related in part to the fact that ALMs tended to be thicker at diagnosis. For example, 70% of all cutaneous melanomas were 1 mm thick or less, and 10-year melanoma-specific survival for patients with such tumors was 95%, whereas only 41% of all ALMs were 1 mm thick or less, and their associated 10-year survival was 88%. Mortality in Asian/Pacific Islanders and Hispanic whites was worse than in blacks or non-Hispanic whites with ALM. This appeared to be a result of the greater tumor thickness and more advanced stage at presentation of ALM in Asian/Pacific Islanders and Hispanics; after controlling for these variables, there were no longer significant racial differences in 5- and 10-year melanoma-specific survival for ALM.

The analysis demonstrated that the incidence of ALM has remained steady during the last couple of decades, while rates of other forms of melanoma have increased steadily.

Acral lentiginous melanoma accounted for almost 40% of all cutaneous melanomas in black patients and 2% in non-Hispanic white patients. Photos courtesy Dr. Gary Peck/Dr. Cherie Young

SAN FRANCISCO — Acral lentiginous is the rarest of the major histologic subtypes of melanoma, but is the most common subtype in blacks, according to a national study.

The study showed that the age-adjusted incidence of acral lentiginous melanoma (ALM) is similar in black and non-Hispanic white patients at about 1.8 cases per 1 million person-years. But ALM accounted for close to 40% of all cutaneous melanomas in blacks, whereas two-thirds of melanomas in non-Hispanic whites were of the superficial spreading subtype and ALM accounted for less than 2%, Dr. Porcia Bradford reported at the annual meeting of the American Academy of Dermatology.

Her analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database for 1986-2005 turned up 1,413 cases of histologically-confirmed ALM in 16 participating cancer registries. This was the first population-based study focusing on ALM, according to Dr. Bradford of the division of cancer and epidemiology, National Cancer Institute, Bethesda, Md.

The incidence of ALM was greatest in Hispanic whites, at 2.5 cases per 1 million person-years. The rate was lowest in Asian/Pacific Islanders at 1.1 cases per 1 million person-years. ALM comprised about 20% of all melanomas in Asian/Pacific Islanders and 10% of those in Hispanic whites.

The prognosis for individuals with ALM was significantly worse than for cutaneous melanoma as a whole. Five- and 10-year melanoma-specific survival rates for cutaneous melanomas overall were 91% and 87%, respectively, compared with 80% and 68% for ALM.

This disparity in outcomes was related in part to the fact that ALMs tended to be thicker at diagnosis. For example, 70% of all cutaneous melanomas were 1 mm thick or less, and 10-year melanoma-specific survival for patients with such tumors was 95%, whereas only 41% of all ALMs were 1 mm thick or less, and their associated 10-year survival was 88%. Mortality in Asian/Pacific Islanders and Hispanic whites was worse than in blacks or non-Hispanic whites with ALM. This appeared to be a result of the greater tumor thickness and more advanced stage at presentation of ALM in Asian/Pacific Islanders and Hispanics; after controlling for these variables, there were no longer significant racial differences in 5- and 10-year melanoma-specific survival for ALM.

The analysis demonstrated that the incidence of ALM has remained steady during the last couple of decades, while rates of other forms of melanoma have increased steadily.

Acral lentiginous melanoma accounted for almost 40% of all cutaneous melanomas in black patients and 2% in non-Hispanic white patients. Photos courtesy Dr. Gary Peck/Dr. Cherie Young

SAN FRANCISCO — Acral lentiginous is the rarest of the major histologic subtypes of melanoma, but is the most common subtype in blacks, according to a national study.

The study showed that the age-adjusted incidence of acral lentiginous melanoma (ALM) is similar in black and non-Hispanic white patients at about 1.8 cases per 1 million person-years. But ALM accounted for close to 40% of all cutaneous melanomas in blacks, whereas two-thirds of melanomas in non-Hispanic whites were of the superficial spreading subtype and ALM accounted for less than 2%, Dr. Porcia Bradford reported at the annual meeting of the American Academy of Dermatology.

Her analysis of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database for 1986-2005 turned up 1,413 cases of histologically-confirmed ALM in 16 participating cancer registries. This was the first population-based study focusing on ALM, according to Dr. Bradford of the division of cancer and epidemiology, National Cancer Institute, Bethesda, Md.

The incidence of ALM was greatest in Hispanic whites, at 2.5 cases per 1 million person-years. The rate was lowest in Asian/Pacific Islanders at 1.1 cases per 1 million person-years. ALM comprised about 20% of all melanomas in Asian/Pacific Islanders and 10% of those in Hispanic whites.

The prognosis for individuals with ALM was significantly worse than for cutaneous melanoma as a whole. Five- and 10-year melanoma-specific survival rates for cutaneous melanomas overall were 91% and 87%, respectively, compared with 80% and 68% for ALM.

This disparity in outcomes was related in part to the fact that ALMs tended to be thicker at diagnosis. For example, 70% of all cutaneous melanomas were 1 mm thick or less, and 10-year melanoma-specific survival for patients with such tumors was 95%, whereas only 41% of all ALMs were 1 mm thick or less, and their associated 10-year survival was 88%. Mortality in Asian/Pacific Islanders and Hispanic whites was worse than in blacks or non-Hispanic whites with ALM. This appeared to be a result of the greater tumor thickness and more advanced stage at presentation of ALM in Asian/Pacific Islanders and Hispanics; after controlling for these variables, there were no longer significant racial differences in 5- and 10-year melanoma-specific survival for ALM.

The analysis demonstrated that the incidence of ALM has remained steady during the last couple of decades, while rates of other forms of melanoma have increased steadily.

Acral lentiginous melanoma accounted for almost 40% of all cutaneous melanomas in black patients and 2% in non-Hispanic white patients. Photos courtesy Dr. Gary Peck/Dr. Cherie Young

MAUI, HAWAII — Good old cost-effective hematoxylin and eosin staining remains perfectly adequate for diagnosis of most melanomas in the modern molecular era, but help is on the way for the toughest cases in the form of novel tests that assess chromosome copy alterations.

These new tests include a comparative genomic hybridization, which compares the DNA in the full genome of the tumor to that of normal control DNA, and fluorescence in situ hybridization (FISH).

"These tests are just starting to become available in routine clinical practice," Dr. Maxwell A. Fung said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The FISH test (Abbott Laboratories), although marketed in Europe, isn't yet approved for use in the United States, but it has performed well on an investigational basis at the University of California, San Francisco, Dr. Fung said. The test probes four specific gene loci that are of particular interest because abnormalities at those sites are strongly associated with melanoma.

Three of the loci are on chromosome 6, and one is on chromosome 11. Although this combination doesn't include some of the mutations that figure prominently in melanoma, it does offer a desirable blend of technical ease along with a reported sensitivity and specificity of about 80%, said Dr. Fung of the University of California, Davis.

Distinguishing nevi from melanomas by using conventional histologic criteria is often straightforward, but there are challenges, as illustrated by a recent report by Dr. Saurabh Lodha and colleagues at Columbia University, New York.

They presented a retrospective analysis of 6 years' worth of Columbia dermatopathology consultation reports. The investigators showed that in cases in which a dermatopathologist sought consultation with a colleague regarding a tumor, there was complete agreement as to whether the lesion was a nevus or melanoma only 55% of the time (J. Cutan. Pathol. 2008;35:349-52).

"It's hard enough to decide what lesions to biopsy, but then in a small percentage of the lesions that get biopsied we just don't know what to call them," Dr. Fung said.

Dr. Fung disclosed having no relevant relationships with industry. SDEF and this news organization are owned by Elsevier.

MAUI, HAWAII — Good old cost-effective hematoxylin and eosin staining remains perfectly adequate for diagnosis of most melanomas in the modern molecular era, but help is on the way for the toughest cases in the form of novel tests that assess chromosome copy alterations.

These new tests include a comparative genomic hybridization, which compares the DNA in the full genome of the tumor to that of normal control DNA, and fluorescence in situ hybridization (FISH).

"These tests are just starting to become available in routine clinical practice," Dr. Maxwell A. Fung said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The FISH test (Abbott Laboratories), although marketed in Europe, isn't yet approved for use in the United States, but it has performed well on an investigational basis at the University of California, San Francisco, Dr. Fung said. The test probes four specific gene loci that are of particular interest because abnormalities at those sites are strongly associated with melanoma.

Three of the loci are on chromosome 6, and one is on chromosome 11. Although this combination doesn't include some of the mutations that figure prominently in melanoma, it does offer a desirable blend of technical ease along with a reported sensitivity and specificity of about 80%, said Dr. Fung of the University of California, Davis.

Distinguishing nevi from melanomas by using conventional histologic criteria is often straightforward, but there are challenges, as illustrated by a recent report by Dr. Saurabh Lodha and colleagues at Columbia University, New York.

They presented a retrospective analysis of 6 years' worth of Columbia dermatopathology consultation reports. The investigators showed that in cases in which a dermatopathologist sought consultation with a colleague regarding a tumor, there was complete agreement as to whether the lesion was a nevus or melanoma only 55% of the time (J. Cutan. Pathol. 2008;35:349-52).

"It's hard enough to decide what lesions to biopsy, but then in a small percentage of the lesions that get biopsied we just don't know what to call them," Dr. Fung said.

Dr. Fung disclosed having no relevant relationships with industry. SDEF and this news organization are owned by Elsevier.

MAUI, HAWAII — Good old cost-effective hematoxylin and eosin staining remains perfectly adequate for diagnosis of most melanomas in the modern molecular era, but help is on the way for the toughest cases in the form of novel tests that assess chromosome copy alterations.

These new tests include a comparative genomic hybridization, which compares the DNA in the full genome of the tumor to that of normal control DNA, and fluorescence in situ hybridization (FISH).

"These tests are just starting to become available in routine clinical practice," Dr. Maxwell A. Fung said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The FISH test (Abbott Laboratories), although marketed in Europe, isn't yet approved for use in the United States, but it has performed well on an investigational basis at the University of California, San Francisco, Dr. Fung said. The test probes four specific gene loci that are of particular interest because abnormalities at those sites are strongly associated with melanoma.

Three of the loci are on chromosome 6, and one is on chromosome 11. Although this combination doesn't include some of the mutations that figure prominently in melanoma, it does offer a desirable blend of technical ease along with a reported sensitivity and specificity of about 80%, said Dr. Fung of the University of California, Davis.

Distinguishing nevi from melanomas by using conventional histologic criteria is often straightforward, but there are challenges, as illustrated by a recent report by Dr. Saurabh Lodha and colleagues at Columbia University, New York.

They presented a retrospective analysis of 6 years' worth of Columbia dermatopathology consultation reports. The investigators showed that in cases in which a dermatopathologist sought consultation with a colleague regarding a tumor, there was complete agreement as to whether the lesion was a nevus or melanoma only 55% of the time (J. Cutan. Pathol. 2008;35:349-52).

"It's hard enough to decide what lesions to biopsy, but then in a small percentage of the lesions that get biopsied we just don't know what to call them," Dr. Fung said.

Dr. Fung disclosed having no relevant relationships with industry. SDEF and this news organization are owned by Elsevier.

SAN FRANCISCO — Follow-up on 219 patients with Spitz nevi found that 7 (3%) developed malignant melanoma, and in each case the original biopsy showed an atypical or desmoplastic Spitz nevus.

The patients who developed melanoma also were older (aged 34-66 years) at the time the Spitz nevi were diagnosed, compared with patients who did not develop melanoma (whose Spitz nevi appeared predominantly between ages 6 and 30 years), Dr. Lori Prok said at a meeting of the Society for Pediatric Dermatology.

Follow-up of the patients from three clinical sites in Colorado ranged from 1 month to more than 11 years. Many of the Spitz nevi were located on the extremities, especially the lower extremities, "which was a little bit surprising to me," said Dr. Prok, a pediatric dermatopathologist who also handles adult dermatopathology cases at the University of Colorado Hospital, Denver.

Six of the malignant melanomas appeared at different anatomic sites than the Spitz nevus location. One melanoma was re-excised and found to be malignant melanoma in situ. Two patients underwent sentinel node biopsy, with negative results. One patient died of causes unrelated to the tumors.

Dr. Prok and her associates have been studying Spitz nevi to try to better understand the lesion, which histologically shows features of malignant melanoma but is clinically associated with a favorable prognosis. They now are reviewing the charts of the 219 patients to see if the original diagnoses were correct or if melanomas were mistaken for atypical or desmoplastic Spitz nevi. They also will be following these patients for longer-term outcomes.

Dermatopathologists are easily confused by Spitz nevi, as illustrated in a study of 10 dermatopathologists who reviewed 30 melanocytic lesions (including 17 Spitzoid lesions) and were blinded to clinical data and patient outcomes. They were asked to choose a label for each lesion from five categories: Spitz nevus, atypical Spitz nevus, malignant melanoma, neoplasm of uncertain behavior, or other.

Only one case engendered agreement by six or more dermatopathologists. At least seven pathologists scored 13 normal lesions as melanomas, and some fatal lesions were categorized by most of the pathologists as Spitz nevi or atypical Spitz nevi (Hum. Pathol. 1999;30:513-20).

"The take-home message is that the pathologists were just not very good," Dr. Prok said. "It's not that pathologists are stupid, it's that it's really difficult" to categorize Spitzoid lesions.

Physicians also are confused by Spitz nevi because they raise unanswered questions in management. If Spitz nevi really are benign, why did a meta-analysis of 716 Spitz nevi conclude that all Spitz nevi should be completely excised, with re-excision of positive margins (J. Am. Acad. Dermatol. 1993;29:667-8)? How wide should those margins be? One paper suggests 1-cm margins, Dr. Prok noted.

Separate, unpublished data analyzed by two of her associates—a dermatopathologist and a cutaneous oncologist at the university—found that 100% of patients who were treated for Spitzoid melanomas or melanomas with Spitzoid features or atypical melanoma tumors were disease-free 7 years later. In comparison, around 75% of patients who were treated for classical, unequivocal melanoma were disease-free 7 years later.

Sentinel lymph node biopsies in 57 patients with atypical Spitz tumors were positive in 27 (47%), a separate study found. The patients with positive nodes were younger (an average 18 years old versus 29 years old in node-negative patients) and had good outcomes at a median follow-up of 44 months. All 27 node-positive patients were alive and disease-free at follow-up (Cancer 2009;115:631-41).

The authors concluded that atypical Spitz tumors do not behave like conventional melanoma, and they questioned the role of sentinel lymph node biopsy in managing atypical Spitz nevi.

SAN FRANCISCO — Follow-up on 219 patients with Spitz nevi found that 7 (3%) developed malignant melanoma, and in each case the original biopsy showed an atypical or desmoplastic Spitz nevus.

The patients who developed melanoma also were older (aged 34-66 years) at the time the Spitz nevi were diagnosed, compared with patients who did not develop melanoma (whose Spitz nevi appeared predominantly between ages 6 and 30 years), Dr. Lori Prok said at a meeting of the Society for Pediatric Dermatology.

Follow-up of the patients from three clinical sites in Colorado ranged from 1 month to more than 11 years. Many of the Spitz nevi were located on the extremities, especially the lower extremities, "which was a little bit surprising to me," said Dr. Prok, a pediatric dermatopathologist who also handles adult dermatopathology cases at the University of Colorado Hospital, Denver.

Six of the malignant melanomas appeared at different anatomic sites than the Spitz nevus location. One melanoma was re-excised and found to be malignant melanoma in situ. Two patients underwent sentinel node biopsy, with negative results. One patient died of causes unrelated to the tumors.

Dr. Prok and her associates have been studying Spitz nevi to try to better understand the lesion, which histologically shows features of malignant melanoma but is clinically associated with a favorable prognosis. They now are reviewing the charts of the 219 patients to see if the original diagnoses were correct or if melanomas were mistaken for atypical or desmoplastic Spitz nevi. They also will be following these patients for longer-term outcomes.

Dermatopathologists are easily confused by Spitz nevi, as illustrated in a study of 10 dermatopathologists who reviewed 30 melanocytic lesions (including 17 Spitzoid lesions) and were blinded to clinical data and patient outcomes. They were asked to choose a label for each lesion from five categories: Spitz nevus, atypical Spitz nevus, malignant melanoma, neoplasm of uncertain behavior, or other.

Only one case engendered agreement by six or more dermatopathologists. At least seven pathologists scored 13 normal lesions as melanomas, and some fatal lesions were categorized by most of the pathologists as Spitz nevi or atypical Spitz nevi (Hum. Pathol. 1999;30:513-20).

"The take-home message is that the pathologists were just not very good," Dr. Prok said. "It's not that pathologists are stupid, it's that it's really difficult" to categorize Spitzoid lesions.

Physicians also are confused by Spitz nevi because they raise unanswered questions in management. If Spitz nevi really are benign, why did a meta-analysis of 716 Spitz nevi conclude that all Spitz nevi should be completely excised, with re-excision of positive margins (J. Am. Acad. Dermatol. 1993;29:667-8)? How wide should those margins be? One paper suggests 1-cm margins, Dr. Prok noted.

Separate, unpublished data analyzed by two of her associates—a dermatopathologist and a cutaneous oncologist at the university—found that 100% of patients who were treated for Spitzoid melanomas or melanomas with Spitzoid features or atypical melanoma tumors were disease-free 7 years later. In comparison, around 75% of patients who were treated for classical, unequivocal melanoma were disease-free 7 years later.

Sentinel lymph node biopsies in 57 patients with atypical Spitz tumors were positive in 27 (47%), a separate study found. The patients with positive nodes were younger (an average 18 years old versus 29 years old in node-negative patients) and had good outcomes at a median follow-up of 44 months. All 27 node-positive patients were alive and disease-free at follow-up (Cancer 2009;115:631-41).

The authors concluded that atypical Spitz tumors do not behave like conventional melanoma, and they questioned the role of sentinel lymph node biopsy in managing atypical Spitz nevi.

SAN FRANCISCO — Follow-up on 219 patients with Spitz nevi found that 7 (3%) developed malignant melanoma, and in each case the original biopsy showed an atypical or desmoplastic Spitz nevus.

The patients who developed melanoma also were older (aged 34-66 years) at the time the Spitz nevi were diagnosed, compared with patients who did not develop melanoma (whose Spitz nevi appeared predominantly between ages 6 and 30 years), Dr. Lori Prok said at a meeting of the Society for Pediatric Dermatology.

Follow-up of the patients from three clinical sites in Colorado ranged from 1 month to more than 11 years. Many of the Spitz nevi were located on the extremities, especially the lower extremities, "which was a little bit surprising to me," said Dr. Prok, a pediatric dermatopathologist who also handles adult dermatopathology cases at the University of Colorado Hospital, Denver.

Six of the malignant melanomas appeared at different anatomic sites than the Spitz nevus location. One melanoma was re-excised and found to be malignant melanoma in situ. Two patients underwent sentinel node biopsy, with negative results. One patient died of causes unrelated to the tumors.

Dr. Prok and her associates have been studying Spitz nevi to try to better understand the lesion, which histologically shows features of malignant melanoma but is clinically associated with a favorable prognosis. They now are reviewing the charts of the 219 patients to see if the original diagnoses were correct or if melanomas were mistaken for atypical or desmoplastic Spitz nevi. They also will be following these patients for longer-term outcomes.

Dermatopathologists are easily confused by Spitz nevi, as illustrated in a study of 10 dermatopathologists who reviewed 30 melanocytic lesions (including 17 Spitzoid lesions) and were blinded to clinical data and patient outcomes. They were asked to choose a label for each lesion from five categories: Spitz nevus, atypical Spitz nevus, malignant melanoma, neoplasm of uncertain behavior, or other.

Only one case engendered agreement by six or more dermatopathologists. At least seven pathologists scored 13 normal lesions as melanomas, and some fatal lesions were categorized by most of the pathologists as Spitz nevi or atypical Spitz nevi (Hum. Pathol. 1999;30:513-20).

"The take-home message is that the pathologists were just not very good," Dr. Prok said. "It's not that pathologists are stupid, it's that it's really difficult" to categorize Spitzoid lesions.

Physicians also are confused by Spitz nevi because they raise unanswered questions in management. If Spitz nevi really are benign, why did a meta-analysis of 716 Spitz nevi conclude that all Spitz nevi should be completely excised, with re-excision of positive margins (J. Am. Acad. Dermatol. 1993;29:667-8)? How wide should those margins be? One paper suggests 1-cm margins, Dr. Prok noted.

Separate, unpublished data analyzed by two of her associates—a dermatopathologist and a cutaneous oncologist at the university—found that 100% of patients who were treated for Spitzoid melanomas or melanomas with Spitzoid features or atypical melanoma tumors were disease-free 7 years later. In comparison, around 75% of patients who were treated for classical, unequivocal melanoma were disease-free 7 years later.

Sentinel lymph node biopsies in 57 patients with atypical Spitz tumors were positive in 27 (47%), a separate study found. The patients with positive nodes were younger (an average 18 years old versus 29 years old in node-negative patients) and had good outcomes at a median follow-up of 44 months. All 27 node-positive patients were alive and disease-free at follow-up (Cancer 2009;115:631-41).

The authors concluded that atypical Spitz tumors do not behave like conventional melanoma, and they questioned the role of sentinel lymph node biopsy in managing atypical Spitz nevi.