Melanoma

The brochure "Radiation Therapy for Skin Cancer" includes the up-to-date information for skin cancer patients who are deciding whether radiation therapy is the best option for them. It contains information about the different treatments available for these tumors. The brochure is available for download free at www.RTAnswers.org

The brochure "Radiation Therapy for Skin Cancer" includes the up-to-date information for skin cancer patients who are deciding whether radiation therapy is the best option for them. It contains information about the different treatments available for these tumors. The brochure is available for download free at www.RTAnswers.org

The brochure "Radiation Therapy for Skin Cancer" includes the up-to-date information for skin cancer patients who are deciding whether radiation therapy is the best option for them. It contains information about the different treatments available for these tumors. The brochure is available for download free at www.RTAnswers.org

SAN DIEGO — If you're confident that a primary lesion is melanoma, do an excisional biopsy and send the entire specimen to a pathologist.

If you're less certain about the diagnosis, you can do an incisional biopsy of the primary lesion and send the specimen for evaluation, Dr. Avis B. Yount said at an update on melanoma sponsored by the Scripps Clinic. "The goals of biopsy are to establish the diagnosis, determine the best treatment and prognosis for the patient, and determine the type of melanoma, accurate tumor thickness, and information on ulceration and regression," said Dr. Yount of the department of dermatology at the Medical College of Georgia, Augusta.

She defined excisional biopsy as a full thickness biopsy that conservatively excises the entire lesion; its margin is 2–3 mm around the lesion and includes subcutaneous fat. "I try to orient the excision to facilitate future wide excision while maintaining optimal cosmetic and functional results," she said.

Wide excision is not initially recommended because "the lesion may be benign, the excision may be insufficient because of the tumor thickness, and it may interfere with further treatment such as sentinel node biopsy," she said.

If the lesion is located where complete removal would cause substantial disfigurement or a skin graft or flap would be needed for repair, consider proceeding with incisional biopsy. "You can do an elliptical incision through part of the lesion, giving the pathologist the part that will give the best diagnosis, or you can do a punch biopsy or a saucerization-type biopsy," she said. Recent studies have suggested that saucerization might be the most effective approach (J. Am. Acad. Dermatol. 2005;52:798–802).

For incisional biopsy, "you want to biopsy the most nodular or deeply pigmented area into the subcutaneous fat," said Dr. Yount, who also practices in Augusta and Evans, Ga. "Biopsy by shaving, scissor excision, or curettage is not recommended."

She pointed out that there is no evidence that an incisional biopsy has a detrimental influence on the survival of the patient or on the rate of metastases.

When Dr. Yount detects a suspicious lesion on the nail, she removes the entire plate and submits it to the pathologist. "You want to do a transverse biopsy in the nail matrix and a longitudinal biopsy in the nail bed," she said. "Before I remove the nail plate I mark the area of pigment, so that I don't lose the lesion after the nail plate is removed."

Biopsies that are too small create certain challenges. "They may compromise histological assessment, including the accurate assessment of Breslow depth," she said. "You may see a dysplastic or congenital nevus but not the melanoma. I've had seborrheic keratoses abut against a melanoma."

Another problem of small biopsies is that in situ melanoma might coexist with an unidentified invasive component.

"After you've done the biopsy then you need to proceed with excision," Dr. Yount said. "The goals of excision are to cure the patient with low-risk disease, provide local control in patients with probably incurable disease, minimize functional impairment, and minimize cosmetic disfigurement."

Treatment is based primarily on the Breslow depth. "Use judgment in determining margins according to tumor thickness, anatomic location, and skin laxity," Dr. Yount said. She had no relevant conflicts of interest to disclose.

SAN DIEGO — If you're confident that a primary lesion is melanoma, do an excisional biopsy and send the entire specimen to a pathologist.

If you're less certain about the diagnosis, you can do an incisional biopsy of the primary lesion and send the specimen for evaluation, Dr. Avis B. Yount said at an update on melanoma sponsored by the Scripps Clinic. "The goals of biopsy are to establish the diagnosis, determine the best treatment and prognosis for the patient, and determine the type of melanoma, accurate tumor thickness, and information on ulceration and regression," said Dr. Yount of the department of dermatology at the Medical College of Georgia, Augusta.

She defined excisional biopsy as a full thickness biopsy that conservatively excises the entire lesion; its margin is 2–3 mm around the lesion and includes subcutaneous fat. "I try to orient the excision to facilitate future wide excision while maintaining optimal cosmetic and functional results," she said.

Wide excision is not initially recommended because "the lesion may be benign, the excision may be insufficient because of the tumor thickness, and it may interfere with further treatment such as sentinel node biopsy," she said.

If the lesion is located where complete removal would cause substantial disfigurement or a skin graft or flap would be needed for repair, consider proceeding with incisional biopsy. "You can do an elliptical incision through part of the lesion, giving the pathologist the part that will give the best diagnosis, or you can do a punch biopsy or a saucerization-type biopsy," she said. Recent studies have suggested that saucerization might be the most effective approach (J. Am. Acad. Dermatol. 2005;52:798–802).

For incisional biopsy, "you want to biopsy the most nodular or deeply pigmented area into the subcutaneous fat," said Dr. Yount, who also practices in Augusta and Evans, Ga. "Biopsy by shaving, scissor excision, or curettage is not recommended."

She pointed out that there is no evidence that an incisional biopsy has a detrimental influence on the survival of the patient or on the rate of metastases.

When Dr. Yount detects a suspicious lesion on the nail, she removes the entire plate and submits it to the pathologist. "You want to do a transverse biopsy in the nail matrix and a longitudinal biopsy in the nail bed," she said. "Before I remove the nail plate I mark the area of pigment, so that I don't lose the lesion after the nail plate is removed."

Biopsies that are too small create certain challenges. "They may compromise histological assessment, including the accurate assessment of Breslow depth," she said. "You may see a dysplastic or congenital nevus but not the melanoma. I've had seborrheic keratoses abut against a melanoma."

Another problem of small biopsies is that in situ melanoma might coexist with an unidentified invasive component.

"After you've done the biopsy then you need to proceed with excision," Dr. Yount said. "The goals of excision are to cure the patient with low-risk disease, provide local control in patients with probably incurable disease, minimize functional impairment, and minimize cosmetic disfigurement."

Treatment is based primarily on the Breslow depth. "Use judgment in determining margins according to tumor thickness, anatomic location, and skin laxity," Dr. Yount said. She had no relevant conflicts of interest to disclose.

SAN DIEGO — If you're confident that a primary lesion is melanoma, do an excisional biopsy and send the entire specimen to a pathologist.

If you're less certain about the diagnosis, you can do an incisional biopsy of the primary lesion and send the specimen for evaluation, Dr. Avis B. Yount said at an update on melanoma sponsored by the Scripps Clinic. "The goals of biopsy are to establish the diagnosis, determine the best treatment and prognosis for the patient, and determine the type of melanoma, accurate tumor thickness, and information on ulceration and regression," said Dr. Yount of the department of dermatology at the Medical College of Georgia, Augusta.

She defined excisional biopsy as a full thickness biopsy that conservatively excises the entire lesion; its margin is 2–3 mm around the lesion and includes subcutaneous fat. "I try to orient the excision to facilitate future wide excision while maintaining optimal cosmetic and functional results," she said.

Wide excision is not initially recommended because "the lesion may be benign, the excision may be insufficient because of the tumor thickness, and it may interfere with further treatment such as sentinel node biopsy," she said.

If the lesion is located where complete removal would cause substantial disfigurement or a skin graft or flap would be needed for repair, consider proceeding with incisional biopsy. "You can do an elliptical incision through part of the lesion, giving the pathologist the part that will give the best diagnosis, or you can do a punch biopsy or a saucerization-type biopsy," she said. Recent studies have suggested that saucerization might be the most effective approach (J. Am. Acad. Dermatol. 2005;52:798–802).

For incisional biopsy, "you want to biopsy the most nodular or deeply pigmented area into the subcutaneous fat," said Dr. Yount, who also practices in Augusta and Evans, Ga. "Biopsy by shaving, scissor excision, or curettage is not recommended."

She pointed out that there is no evidence that an incisional biopsy has a detrimental influence on the survival of the patient or on the rate of metastases.

When Dr. Yount detects a suspicious lesion on the nail, she removes the entire plate and submits it to the pathologist. "You want to do a transverse biopsy in the nail matrix and a longitudinal biopsy in the nail bed," she said. "Before I remove the nail plate I mark the area of pigment, so that I don't lose the lesion after the nail plate is removed."

Biopsies that are too small create certain challenges. "They may compromise histological assessment, including the accurate assessment of Breslow depth," she said. "You may see a dysplastic or congenital nevus but not the melanoma. I've had seborrheic keratoses abut against a melanoma."

Another problem of small biopsies is that in situ melanoma might coexist with an unidentified invasive component.

"After you've done the biopsy then you need to proceed with excision," Dr. Yount said. "The goals of excision are to cure the patient with low-risk disease, provide local control in patients with probably incurable disease, minimize functional impairment, and minimize cosmetic disfigurement."

Treatment is based primarily on the Breslow depth. "Use judgment in determining margins according to tumor thickness, anatomic location, and skin laxity," Dr. Yount said. She had no relevant conflicts of interest to disclose.

SAN DIEGO — What is an adequate margin for surgical excision of melanoma?

Beyond a clear margin, "we really don't know," Dr. Duane C. Whitaker said at a melanoma update sponsored by the Scripps Clinic.

That's why there's a place for Mohs surgery in the treatment of melanoma.

"Mohs for melanoma has not caught on terribly widely, but on the other hand I don't believe it will ever disappear because there are times when you simply need Mohs surgery to be able to treat the primary melanoma in a reasonable way," said Dr. Whitaker, a dermatologist and Mohs surgeon who practices in Tucson, Ariz.

He described Mohs surgery as "the best method we have to establish tumor-free margins when we remove any type of visible tumor. Any time that we don't truly know what margin beyond clear should be achieved to help the patient, then probably there is some role for Mohs surgery."

The best studies to date have demonstrated that the cure rate with Mohs surgery in stage I and stage II melanomas is at least equivalent to local excision with a predetermined margin, he said.

Mohs surgery has several traditional advantages. It spares tissue in the ear, nose, and other critical anatomic sites; determines margins precisely; allows for immediate reconstruction; allows minimum wound and repair; and allows physicians to start additional and adjunctive therapies right away.

The technique is especially useful for neurotrophic and desmoplastic melanomas since "they're often deeper and wider than you would anticipate," he said.

A key factor when deciding whether to perform Mohs or not "is your comfort with following [the patients], talking about the issues involved, and being ready for that patient who may come back with a lump that you didn't expect," continued Dr. Whitaker, who is the current vice president of the American College of Mohs Surgery.

Beyond the realm of melanoma, Mohs surgery seems to have applications as the method to establish free margins of a primary tumor when evidence does not support a survival benefit achieved by more radical surgery. "If all melanomas occurred in the trunk or proximal extremities where we can do a wider local excision with 3-cm margins, they wouldn't be so difficult to treat," he said, "but when they occur on the digits, the nose, or the periocular areas," that adds complexity.

Mohs surgery seems to be the most reliable method to obtain local free margins at the time of surgery. "It is considered one component of treatment for those tumors which have substantial metastatic risk," Dr. Whitaker said. "Assessment of the host and tumor characteristics will help you determine the full therapeutic plan."

Mohs is 'the best method we have to establish tumor-free margins when we remove any type of visible tumor.' DR. WHITAKER

A melanoma lesion on a patient's nose is shown before Mohs surgery.

The same patient is shown after Mohs was performed to remove the lesion. Photos courtesy Dr. Duane C. Whitaker

SAN DIEGO — What is an adequate margin for surgical excision of melanoma?

Beyond a clear margin, "we really don't know," Dr. Duane C. Whitaker said at a melanoma update sponsored by the Scripps Clinic.

That's why there's a place for Mohs surgery in the treatment of melanoma.

"Mohs for melanoma has not caught on terribly widely, but on the other hand I don't believe it will ever disappear because there are times when you simply need Mohs surgery to be able to treat the primary melanoma in a reasonable way," said Dr. Whitaker, a dermatologist and Mohs surgeon who practices in Tucson, Ariz.

He described Mohs surgery as "the best method we have to establish tumor-free margins when we remove any type of visible tumor. Any time that we don't truly know what margin beyond clear should be achieved to help the patient, then probably there is some role for Mohs surgery."

The best studies to date have demonstrated that the cure rate with Mohs surgery in stage I and stage II melanomas is at least equivalent to local excision with a predetermined margin, he said.

Mohs surgery has several traditional advantages. It spares tissue in the ear, nose, and other critical anatomic sites; determines margins precisely; allows for immediate reconstruction; allows minimum wound and repair; and allows physicians to start additional and adjunctive therapies right away.

The technique is especially useful for neurotrophic and desmoplastic melanomas since "they're often deeper and wider than you would anticipate," he said.

A key factor when deciding whether to perform Mohs or not "is your comfort with following [the patients], talking about the issues involved, and being ready for that patient who may come back with a lump that you didn't expect," continued Dr. Whitaker, who is the current vice president of the American College of Mohs Surgery.

Beyond the realm of melanoma, Mohs surgery seems to have applications as the method to establish free margins of a primary tumor when evidence does not support a survival benefit achieved by more radical surgery. "If all melanomas occurred in the trunk or proximal extremities where we can do a wider local excision with 3-cm margins, they wouldn't be so difficult to treat," he said, "but when they occur on the digits, the nose, or the periocular areas," that adds complexity.

Mohs surgery seems to be the most reliable method to obtain local free margins at the time of surgery. "It is considered one component of treatment for those tumors which have substantial metastatic risk," Dr. Whitaker said. "Assessment of the host and tumor characteristics will help you determine the full therapeutic plan."

Mohs is 'the best method we have to establish tumor-free margins when we remove any type of visible tumor.' DR. WHITAKER

A melanoma lesion on a patient's nose is shown before Mohs surgery.

The same patient is shown after Mohs was performed to remove the lesion. Photos courtesy Dr. Duane C. Whitaker

SAN DIEGO — What is an adequate margin for surgical excision of melanoma?

Beyond a clear margin, "we really don't know," Dr. Duane C. Whitaker said at a melanoma update sponsored by the Scripps Clinic.

That's why there's a place for Mohs surgery in the treatment of melanoma.

"Mohs for melanoma has not caught on terribly widely, but on the other hand I don't believe it will ever disappear because there are times when you simply need Mohs surgery to be able to treat the primary melanoma in a reasonable way," said Dr. Whitaker, a dermatologist and Mohs surgeon who practices in Tucson, Ariz.

He described Mohs surgery as "the best method we have to establish tumor-free margins when we remove any type of visible tumor. Any time that we don't truly know what margin beyond clear should be achieved to help the patient, then probably there is some role for Mohs surgery."

The best studies to date have demonstrated that the cure rate with Mohs surgery in stage I and stage II melanomas is at least equivalent to local excision with a predetermined margin, he said.

Mohs surgery has several traditional advantages. It spares tissue in the ear, nose, and other critical anatomic sites; determines margins precisely; allows for immediate reconstruction; allows minimum wound and repair; and allows physicians to start additional and adjunctive therapies right away.

The technique is especially useful for neurotrophic and desmoplastic melanomas since "they're often deeper and wider than you would anticipate," he said.

A key factor when deciding whether to perform Mohs or not "is your comfort with following [the patients], talking about the issues involved, and being ready for that patient who may come back with a lump that you didn't expect," continued Dr. Whitaker, who is the current vice president of the American College of Mohs Surgery.

Beyond the realm of melanoma, Mohs surgery seems to have applications as the method to establish free margins of a primary tumor when evidence does not support a survival benefit achieved by more radical surgery. "If all melanomas occurred in the trunk or proximal extremities where we can do a wider local excision with 3-cm margins, they wouldn't be so difficult to treat," he said, "but when they occur on the digits, the nose, or the periocular areas," that adds complexity.

Mohs surgery seems to be the most reliable method to obtain local free margins at the time of surgery. "It is considered one component of treatment for those tumors which have substantial metastatic risk," Dr. Whitaker said. "Assessment of the host and tumor characteristics will help you determine the full therapeutic plan."

Mohs is 'the best method we have to establish tumor-free margins when we remove any type of visible tumor.' DR. WHITAKER

A melanoma lesion on a patient's nose is shown before Mohs surgery.

The same patient is shown after Mohs was performed to remove the lesion. Photos courtesy Dr. Duane C. Whitaker

ORLANDO — Topical 5% imiquimod is an effective treatment for squamous cell carcinoma in situ and should be considered as an option for this disease, Dr. Theodore Rosen reported at the annual meeting of the Florida Society of Dermatologic Surgeons.

Imiquimod (Aldara) is approved for the treatment of superficial basal cell carcinomas, and although it has been used for Bowen's disease, data are lacking on its efficacy for this use, said Dr. Rosen, who is professor of dermatology at Baylor College of Medicine in Houston.

A review of 49 of his patients with Bowen's disease who were compliant with their treatment showed that nearly 90% had a complete response at an average follow-up of 2 years. About one-third of the cleared cases were verified on biopsy.

Importantly, five patients who were believed to be compliant had no response whatsoever. This supports the premise that about 1% of the population will fail to respond to imiquimod, Dr. Rosen noted.

An alternative approach to treatment should be used in such patients, he said.

In general, though, the response rate with imiquimod is reasonable. Findings from the three best studies of this treatment suggest that the overall response rate is about 85%, which is enough to warrant its consideration by physicians, Dr. Rosen said.

In his study, patients ranged in age from 48 to 85 years, and 96% were male.

The lesion was located on the extremities in 30% of patients, on the face in 25%, on the trunk or neck in 18%, on the genitalia in 11%, on the scalp in 9%, on the ears in 5%, and on the lips in 2%, he reported.

Lesions on the genitalia had a significantly greater risk of progressing to invasive disease (10% vs. 3% for other areas), yet all of the genital lesions in this study cleared with imiquimod treatment, he noted (Dermatol. Surg. 2007;33:427–31).

Patients were treated daily for 6–16 weeks (every other day for patients with genital lesions) until the target area was heavily crusted and eroded.

"I tend to push it a little bit," Dr. Rosen said of the therapy, adding that it is important to monitor patients.

There have been a few case reports of Bowen's disease ostensibly being cleared with imiquimod, only to have a subsequent invasive lesion develop, he noted.

Patients who undergo treatment with imiquimod for Bowen's disease are at high risk and "shouldn't be out of your grasp," Dr. Rosen said.

Although some cases of invasive squamous cell carcinoma have been treated with imiquimod and the overall treatment success rate appears to be about 70%, it is not his treatment of choice for invasive disease, as it is for Bowen's disease, he said.

Dr. Rosen disclosed that he has served on the speakers bureau for Graceway Pharmaceuticals, the maker of Aldara, and has received honoraria from the company.

ORLANDO — Topical 5% imiquimod is an effective treatment for squamous cell carcinoma in situ and should be considered as an option for this disease, Dr. Theodore Rosen reported at the annual meeting of the Florida Society of Dermatologic Surgeons.

Imiquimod (Aldara) is approved for the treatment of superficial basal cell carcinomas, and although it has been used for Bowen's disease, data are lacking on its efficacy for this use, said Dr. Rosen, who is professor of dermatology at Baylor College of Medicine in Houston.

A review of 49 of his patients with Bowen's disease who were compliant with their treatment showed that nearly 90% had a complete response at an average follow-up of 2 years. About one-third of the cleared cases were verified on biopsy.

Importantly, five patients who were believed to be compliant had no response whatsoever. This supports the premise that about 1% of the population will fail to respond to imiquimod, Dr. Rosen noted.

An alternative approach to treatment should be used in such patients, he said.

In general, though, the response rate with imiquimod is reasonable. Findings from the three best studies of this treatment suggest that the overall response rate is about 85%, which is enough to warrant its consideration by physicians, Dr. Rosen said.

In his study, patients ranged in age from 48 to 85 years, and 96% were male.

The lesion was located on the extremities in 30% of patients, on the face in 25%, on the trunk or neck in 18%, on the genitalia in 11%, on the scalp in 9%, on the ears in 5%, and on the lips in 2%, he reported.

Lesions on the genitalia had a significantly greater risk of progressing to invasive disease (10% vs. 3% for other areas), yet all of the genital lesions in this study cleared with imiquimod treatment, he noted (Dermatol. Surg. 2007;33:427–31).

Patients were treated daily for 6–16 weeks (every other day for patients with genital lesions) until the target area was heavily crusted and eroded.

"I tend to push it a little bit," Dr. Rosen said of the therapy, adding that it is important to monitor patients.

There have been a few case reports of Bowen's disease ostensibly being cleared with imiquimod, only to have a subsequent invasive lesion develop, he noted.

Patients who undergo treatment with imiquimod for Bowen's disease are at high risk and "shouldn't be out of your grasp," Dr. Rosen said.

Although some cases of invasive squamous cell carcinoma have been treated with imiquimod and the overall treatment success rate appears to be about 70%, it is not his treatment of choice for invasive disease, as it is for Bowen's disease, he said.

Dr. Rosen disclosed that he has served on the speakers bureau for Graceway Pharmaceuticals, the maker of Aldara, and has received honoraria from the company.

ORLANDO — Topical 5% imiquimod is an effective treatment for squamous cell carcinoma in situ and should be considered as an option for this disease, Dr. Theodore Rosen reported at the annual meeting of the Florida Society of Dermatologic Surgeons.

Imiquimod (Aldara) is approved for the treatment of superficial basal cell carcinomas, and although it has been used for Bowen's disease, data are lacking on its efficacy for this use, said Dr. Rosen, who is professor of dermatology at Baylor College of Medicine in Houston.

A review of 49 of his patients with Bowen's disease who were compliant with their treatment showed that nearly 90% had a complete response at an average follow-up of 2 years. About one-third of the cleared cases were verified on biopsy.

Importantly, five patients who were believed to be compliant had no response whatsoever. This supports the premise that about 1% of the population will fail to respond to imiquimod, Dr. Rosen noted.

An alternative approach to treatment should be used in such patients, he said.

In general, though, the response rate with imiquimod is reasonable. Findings from the three best studies of this treatment suggest that the overall response rate is about 85%, which is enough to warrant its consideration by physicians, Dr. Rosen said.

In his study, patients ranged in age from 48 to 85 years, and 96% were male.

The lesion was located on the extremities in 30% of patients, on the face in 25%, on the trunk or neck in 18%, on the genitalia in 11%, on the scalp in 9%, on the ears in 5%, and on the lips in 2%, he reported.

Lesions on the genitalia had a significantly greater risk of progressing to invasive disease (10% vs. 3% for other areas), yet all of the genital lesions in this study cleared with imiquimod treatment, he noted (Dermatol. Surg. 2007;33:427–31).

Patients were treated daily for 6–16 weeks (every other day for patients with genital lesions) until the target area was heavily crusted and eroded.

"I tend to push it a little bit," Dr. Rosen said of the therapy, adding that it is important to monitor patients.

There have been a few case reports of Bowen's disease ostensibly being cleared with imiquimod, only to have a subsequent invasive lesion develop, he noted.

Patients who undergo treatment with imiquimod for Bowen's disease are at high risk and "shouldn't be out of your grasp," Dr. Rosen said.

Although some cases of invasive squamous cell carcinoma have been treated with imiquimod and the overall treatment success rate appears to be about 70%, it is not his treatment of choice for invasive disease, as it is for Bowen's disease, he said.

Dr. Rosen disclosed that he has served on the speakers bureau for Graceway Pharmaceuticals, the maker of Aldara, and has received honoraria from the company.

SAN DIEGO — There's no need to grade the level of architectural disorder when assessing dysplastic nevi. Just acknowledge if it's present or not.

"It doesn't matter how much architectural disorder is there; it only matters that it's present or absent," Dr. Terry L. Barrett said at an update on melanoma sponsored by the Scripps Clinic. "It's like being pregnant. Every single person in the world can be divided into one of two categories: You're either pregnant or you're not."

His minimal criterion for defining the presence of architectural disorder in a lesion is a well-defined junctional nevus with nests at the base of the rete and lentiginous proliferation. Concentric eosinophilic fibroplasia and lamellar fibroplasia are commonly seen.

In addition to architectural disorder, dysplastic nevi may or may not have cytologic atypia, which may include large nuclei with variation of nuclear size; irregular nuclear membrane; variably staining chromatin; large eosinophilic nucleoli; and fine dusty melanin pigment in cytoplasm.

Some experts recommend that cytologic atypia be graded as mild, moderate, or severe, but Dr. Barrett does not use the term moderate. "If there's none there's none, but if there's some cytologic atypia it's either mild or severe," said Dr. Barrett of the departments of pathology and dermatology at the University of Texas, Dallas.

He favors a modified version of Dr. Arthur R. Rhodes' atypia grading system (Mod. Pathol. 1989;2:306–19). Cytologic atypia is considered mild if the size of the nucleus of the melanocyte is 1.5–2 times the size of the nucleus of the keratinocyte and if nucleoli are not present; if they are present, there should be no more than one per cell, he explained.

"I can tell that in 2 microseconds," Dr. Barrett said. "It's very easy."

Cytologic atypia is severe if there are multiple nucleoli per cell, or if the nucleus is more than two times the size of the basal keratinocyte nucleus, or if there is chromatin clumping or nuclear membrane notching.

"I can tell that very quickly," said Dr. Barrett, who also directs an outpatient pathology group in Dallas.

"More importantly, it's reproducible. I'll grant you that it's arbitrary. But the important thing is, no matter which one of the dermatopathologists who works with me signs this case out, it's going to be the same. For the dermatologist who gets the report, it's always going to be the same. If they ask me to review the case later because they want to know what I think, it's going to be the same because it's easy to do and it's reproducible."

Common acquired nevi begin to appear in childhood and increase in number from approximately 6 months of age until the third decade. At that point, they begin to decline in number. "They usually stabilize at 3–5 mm and rarely develop in patients over age 40," said Dr. Barrett, who had no relevant conflicts of interest to disclose.

In contrast, dysplastic nevi begin to appear near puberty and continue to develop throughout adulthood. "If you do serial photography of these lesions, they will increase and decrease in atypicality," he said. "They are usually greater than 5 mm."

Dysplastic nevi were originally classified as familial dysplastic nevi syndrome and sporadic nevus syndrome. Current concepts include the familial atypical mole/melanoma syndrome, which came out of the 1992 National Institutes of Health consensus statement on the diagnosis and treatment of early melanoma, and the abnormal mole phenotype. The latter definition was developed by researchers who proposed a spectrum approach that considers both the number and atypicality of nevi (West. J. Med. 1994;160:343–50). Melanoma risk increases along this continuum.

Initially, that theory "went nowhere because people didn't believe that you could have large numbers of common acquired nevi and no dysplastic nevi, and you [would nevertheless be] at increased risk for melanoma. But we now know that is absolutely true, and a number of studies have shown that patients who have large numbers of common acquired nevi have an increased risk of developing melanoma," Dr. Barrett said.

Melanoma risk also appears to increase in the presence of dysplastic nevi. A significant factor is the presence or absence of family history of either condition.

Intermittent sun exposure correlates with the risk of developing malignant melanoma and with the risk of developing multiple nevi. "Whether melanoma arises from nevi or not is unclear, but it appears that the stimulus for formation of both is the same," he said.

The risk of melanoma in a patient who has "one dysplastic nevus and nothing else" is the about the same as someone who has red or blond hair. "Not everybody with red or blond hair is going to get melanoma, but they are at an increased risk," he said.

Dr. Barrett likened dysplastic lesions to amoebae. These lesions "go through quiescent phases and they go through active phases," he said. "If we do serial photographs, we can document this change. If the lesion is quiescent and you biopsy it, you see no atypia because there is minimal cellular activity. If you biopsy it in an active phase, it's going to have some degree of atypia. That doesn't mean that atypia equates with dysplasia or premalignancy. That's what I think is happening."

No cytologic atypia can be seen in this slide from a patient with dysplastic nevi, per Dr. Terry L. Barrett.

The atypia seen above is considered mild according to Dr. Barrett's modified dysplastic nevi grading system.

This patient has severe cytologic atypia. Dr. Barrett avoids the term moderate when assessing atypia. Photos courtesy Dr. Terry L. Barrett

SAN DIEGO — There's no need to grade the level of architectural disorder when assessing dysplastic nevi. Just acknowledge if it's present or not.

"It doesn't matter how much architectural disorder is there; it only matters that it's present or absent," Dr. Terry L. Barrett said at an update on melanoma sponsored by the Scripps Clinic. "It's like being pregnant. Every single person in the world can be divided into one of two categories: You're either pregnant or you're not."

His minimal criterion for defining the presence of architectural disorder in a lesion is a well-defined junctional nevus with nests at the base of the rete and lentiginous proliferation. Concentric eosinophilic fibroplasia and lamellar fibroplasia are commonly seen.

In addition to architectural disorder, dysplastic nevi may or may not have cytologic atypia, which may include large nuclei with variation of nuclear size; irregular nuclear membrane; variably staining chromatin; large eosinophilic nucleoli; and fine dusty melanin pigment in cytoplasm.

Some experts recommend that cytologic atypia be graded as mild, moderate, or severe, but Dr. Barrett does not use the term moderate. "If there's none there's none, but if there's some cytologic atypia it's either mild or severe," said Dr. Barrett of the departments of pathology and dermatology at the University of Texas, Dallas.

He favors a modified version of Dr. Arthur R. Rhodes' atypia grading system (Mod. Pathol. 1989;2:306–19). Cytologic atypia is considered mild if the size of the nucleus of the melanocyte is 1.5–2 times the size of the nucleus of the keratinocyte and if nucleoli are not present; if they are present, there should be no more than one per cell, he explained.

"I can tell that in 2 microseconds," Dr. Barrett said. "It's very easy."

Cytologic atypia is severe if there are multiple nucleoli per cell, or if the nucleus is more than two times the size of the basal keratinocyte nucleus, or if there is chromatin clumping or nuclear membrane notching.

"I can tell that very quickly," said Dr. Barrett, who also directs an outpatient pathology group in Dallas.

"More importantly, it's reproducible. I'll grant you that it's arbitrary. But the important thing is, no matter which one of the dermatopathologists who works with me signs this case out, it's going to be the same. For the dermatologist who gets the report, it's always going to be the same. If they ask me to review the case later because they want to know what I think, it's going to be the same because it's easy to do and it's reproducible."

Common acquired nevi begin to appear in childhood and increase in number from approximately 6 months of age until the third decade. At that point, they begin to decline in number. "They usually stabilize at 3–5 mm and rarely develop in patients over age 40," said Dr. Barrett, who had no relevant conflicts of interest to disclose.

In contrast, dysplastic nevi begin to appear near puberty and continue to develop throughout adulthood. "If you do serial photography of these lesions, they will increase and decrease in atypicality," he said. "They are usually greater than 5 mm."

Dysplastic nevi were originally classified as familial dysplastic nevi syndrome and sporadic nevus syndrome. Current concepts include the familial atypical mole/melanoma syndrome, which came out of the 1992 National Institutes of Health consensus statement on the diagnosis and treatment of early melanoma, and the abnormal mole phenotype. The latter definition was developed by researchers who proposed a spectrum approach that considers both the number and atypicality of nevi (West. J. Med. 1994;160:343–50). Melanoma risk increases along this continuum.

Initially, that theory "went nowhere because people didn't believe that you could have large numbers of common acquired nevi and no dysplastic nevi, and you [would nevertheless be] at increased risk for melanoma. But we now know that is absolutely true, and a number of studies have shown that patients who have large numbers of common acquired nevi have an increased risk of developing melanoma," Dr. Barrett said.

Melanoma risk also appears to increase in the presence of dysplastic nevi. A significant factor is the presence or absence of family history of either condition.

Intermittent sun exposure correlates with the risk of developing malignant melanoma and with the risk of developing multiple nevi. "Whether melanoma arises from nevi or not is unclear, but it appears that the stimulus for formation of both is the same," he said.

The risk of melanoma in a patient who has "one dysplastic nevus and nothing else" is the about the same as someone who has red or blond hair. "Not everybody with red or blond hair is going to get melanoma, but they are at an increased risk," he said.

Dr. Barrett likened dysplastic lesions to amoebae. These lesions "go through quiescent phases and they go through active phases," he said. "If we do serial photographs, we can document this change. If the lesion is quiescent and you biopsy it, you see no atypia because there is minimal cellular activity. If you biopsy it in an active phase, it's going to have some degree of atypia. That doesn't mean that atypia equates with dysplasia or premalignancy. That's what I think is happening."

No cytologic atypia can be seen in this slide from a patient with dysplastic nevi, per Dr. Terry L. Barrett.

The atypia seen above is considered mild according to Dr. Barrett's modified dysplastic nevi grading system.

This patient has severe cytologic atypia. Dr. Barrett avoids the term moderate when assessing atypia. Photos courtesy Dr. Terry L. Barrett

SAN DIEGO — There's no need to grade the level of architectural disorder when assessing dysplastic nevi. Just acknowledge if it's present or not.

"It doesn't matter how much architectural disorder is there; it only matters that it's present or absent," Dr. Terry L. Barrett said at an update on melanoma sponsored by the Scripps Clinic. "It's like being pregnant. Every single person in the world can be divided into one of two categories: You're either pregnant or you're not."

His minimal criterion for defining the presence of architectural disorder in a lesion is a well-defined junctional nevus with nests at the base of the rete and lentiginous proliferation. Concentric eosinophilic fibroplasia and lamellar fibroplasia are commonly seen.

In addition to architectural disorder, dysplastic nevi may or may not have cytologic atypia, which may include large nuclei with variation of nuclear size; irregular nuclear membrane; variably staining chromatin; large eosinophilic nucleoli; and fine dusty melanin pigment in cytoplasm.

Some experts recommend that cytologic atypia be graded as mild, moderate, or severe, but Dr. Barrett does not use the term moderate. "If there's none there's none, but if there's some cytologic atypia it's either mild or severe," said Dr. Barrett of the departments of pathology and dermatology at the University of Texas, Dallas.

He favors a modified version of Dr. Arthur R. Rhodes' atypia grading system (Mod. Pathol. 1989;2:306–19). Cytologic atypia is considered mild if the size of the nucleus of the melanocyte is 1.5–2 times the size of the nucleus of the keratinocyte and if nucleoli are not present; if they are present, there should be no more than one per cell, he explained.

"I can tell that in 2 microseconds," Dr. Barrett said. "It's very easy."

Cytologic atypia is severe if there are multiple nucleoli per cell, or if the nucleus is more than two times the size of the basal keratinocyte nucleus, or if there is chromatin clumping or nuclear membrane notching.

"I can tell that very quickly," said Dr. Barrett, who also directs an outpatient pathology group in Dallas.

"More importantly, it's reproducible. I'll grant you that it's arbitrary. But the important thing is, no matter which one of the dermatopathologists who works with me signs this case out, it's going to be the same. For the dermatologist who gets the report, it's always going to be the same. If they ask me to review the case later because they want to know what I think, it's going to be the same because it's easy to do and it's reproducible."

Common acquired nevi begin to appear in childhood and increase in number from approximately 6 months of age until the third decade. At that point, they begin to decline in number. "They usually stabilize at 3–5 mm and rarely develop in patients over age 40," said Dr. Barrett, who had no relevant conflicts of interest to disclose.

In contrast, dysplastic nevi begin to appear near puberty and continue to develop throughout adulthood. "If you do serial photography of these lesions, they will increase and decrease in atypicality," he said. "They are usually greater than 5 mm."

Dysplastic nevi were originally classified as familial dysplastic nevi syndrome and sporadic nevus syndrome. Current concepts include the familial atypical mole/melanoma syndrome, which came out of the 1992 National Institutes of Health consensus statement on the diagnosis and treatment of early melanoma, and the abnormal mole phenotype. The latter definition was developed by researchers who proposed a spectrum approach that considers both the number and atypicality of nevi (West. J. Med. 1994;160:343–50). Melanoma risk increases along this continuum.

Initially, that theory "went nowhere because people didn't believe that you could have large numbers of common acquired nevi and no dysplastic nevi, and you [would nevertheless be] at increased risk for melanoma. But we now know that is absolutely true, and a number of studies have shown that patients who have large numbers of common acquired nevi have an increased risk of developing melanoma," Dr. Barrett said.

Melanoma risk also appears to increase in the presence of dysplastic nevi. A significant factor is the presence or absence of family history of either condition.

Intermittent sun exposure correlates with the risk of developing malignant melanoma and with the risk of developing multiple nevi. "Whether melanoma arises from nevi or not is unclear, but it appears that the stimulus for formation of both is the same," he said.

The risk of melanoma in a patient who has "one dysplastic nevus and nothing else" is the about the same as someone who has red or blond hair. "Not everybody with red or blond hair is going to get melanoma, but they are at an increased risk," he said.

Dr. Barrett likened dysplastic lesions to amoebae. These lesions "go through quiescent phases and they go through active phases," he said. "If we do serial photographs, we can document this change. If the lesion is quiescent and you biopsy it, you see no atypia because there is minimal cellular activity. If you biopsy it in an active phase, it's going to have some degree of atypia. That doesn't mean that atypia equates with dysplasia or premalignancy. That's what I think is happening."

No cytologic atypia can be seen in this slide from a patient with dysplastic nevi, per Dr. Terry L. Barrett.

The atypia seen above is considered mild according to Dr. Barrett's modified dysplastic nevi grading system.

This patient has severe cytologic atypia. Dr. Barrett avoids the term moderate when assessing atypia. Photos courtesy Dr. Terry L. Barrett

SAN DIEGO — For patients with regionally advanced melanoma, the current standard of care is high-dose interferon.

"It's an imperfect standard, but nonetheless it is the standard," Dr. Michael P. Kosty said at a melanoma update sponsored by the Scripps Clinic.

To date, five randomized trials of high-dose interferon have shown a recurrence-free survival advantage, but an overall survival advantage "has been harder to demonstrate," said Dr. Kosty, program director of the hematology/oncology fellowship training program at the Scripps Clinic.

"One of the things about survival as an end point is that if you have a patient population and you treat them with your experimental therapy and they progress or recur, a lot of patients will go on standard therapy, which will impact your ability to assess their survival," he said.

Two studies have shown a survival advantage for high-dose interferon. In one study, patients were randomized to either 52 weeks of observation or to an induction phase of 20 megaunits/m

A more recent study assessed the impact of low-dose and high-dose interferon on overall survival compared with no treatment. It found that only high-dose interferon conferred a survival advantage: a median of 20 months, compared with a median of 9.6 months among those who did not receive treatment (J. Clin. Oncol. 2000; 18: 2444–58). A similar association was seen in the rates of recurrence-free survival.

"There is a dose-response relationship between the higher doses of interferon and the higher likelihood of recurrence-free benefit," said Dr. Kosty, who had no relevant conflicts of interest to disclose.

At this time, patients with stage III or stage IV disease are ideal candidates for systemic therapy. "If you look at the current data, there is no evidence in stage II disease of efficacy of adjuvant therapy, either in terms of progression free or overall survival," he noted.

The most common adverse events from high-dose interferon treatment include fatigue and depressive symptoms. Despite aggressive antidepressive therapy, "this impacts the function of many patients. Some are unable to work, particularly if they have physically demanding jobs or mentally challenging jobs," said Dr. Kosty.

In an effort to find a better alternative, a trial of 400 patients to compare standard high-dose interferon treatment to a chemoimmunotherapy combination has completed accrual. Results are expected in the coming year.

So far, no vaccine trial has shown improvement in overall survival, although some trials have shown an improvement in relapse-free survival. "There is about a 20% reduction in relapse rate and perhaps as high as a 10% reduction in death rate, although that 10% is probably the most optimistic number," he said. "Vaccines will probably have their ultimate utility in patients who have a very high risk of either developing melanoma or developing recurrence from their surgically treated melanoma, as opposed to patients with more advanced disease."

Effective treatment options for metastatic melanoma remain a challenge for researchers. Current therapies have little impact on median survival, although the combination of chemotherapy, interleukin-2, and interferon has "a fairly high response rate," Dr. Kosty said.

"That therapy might be useful if you have somebody with metastatic disease that is significantly symptomatic from the disease, such as somebody with bony metastasis and pain or somebody with liver metastasis and diminished appetite. They may benefit symptomatically but will not benefit from that therapy in terms of survival," he noted.

Recurrence-free survival has been shown, but overall survival 'has been harder to demonstrate.' DR. KOSTY

SAN DIEGO — For patients with regionally advanced melanoma, the current standard of care is high-dose interferon.

"It's an imperfect standard, but nonetheless it is the standard," Dr. Michael P. Kosty said at a melanoma update sponsored by the Scripps Clinic.

To date, five randomized trials of high-dose interferon have shown a recurrence-free survival advantage, but an overall survival advantage "has been harder to demonstrate," said Dr. Kosty, program director of the hematology/oncology fellowship training program at the Scripps Clinic.

"One of the things about survival as an end point is that if you have a patient population and you treat them with your experimental therapy and they progress or recur, a lot of patients will go on standard therapy, which will impact your ability to assess their survival," he said.

Two studies have shown a survival advantage for high-dose interferon. In one study, patients were randomized to either 52 weeks of observation or to an induction phase of 20 megaunits/m

A more recent study assessed the impact of low-dose and high-dose interferon on overall survival compared with no treatment. It found that only high-dose interferon conferred a survival advantage: a median of 20 months, compared with a median of 9.6 months among those who did not receive treatment (J. Clin. Oncol. 2000; 18: 2444–58). A similar association was seen in the rates of recurrence-free survival.

"There is a dose-response relationship between the higher doses of interferon and the higher likelihood of recurrence-free benefit," said Dr. Kosty, who had no relevant conflicts of interest to disclose.

At this time, patients with stage III or stage IV disease are ideal candidates for systemic therapy. "If you look at the current data, there is no evidence in stage II disease of efficacy of adjuvant therapy, either in terms of progression free or overall survival," he noted.

The most common adverse events from high-dose interferon treatment include fatigue and depressive symptoms. Despite aggressive antidepressive therapy, "this impacts the function of many patients. Some are unable to work, particularly if they have physically demanding jobs or mentally challenging jobs," said Dr. Kosty.

In an effort to find a better alternative, a trial of 400 patients to compare standard high-dose interferon treatment to a chemoimmunotherapy combination has completed accrual. Results are expected in the coming year.

So far, no vaccine trial has shown improvement in overall survival, although some trials have shown an improvement in relapse-free survival. "There is about a 20% reduction in relapse rate and perhaps as high as a 10% reduction in death rate, although that 10% is probably the most optimistic number," he said. "Vaccines will probably have their ultimate utility in patients who have a very high risk of either developing melanoma or developing recurrence from their surgically treated melanoma, as opposed to patients with more advanced disease."

Effective treatment options for metastatic melanoma remain a challenge for researchers. Current therapies have little impact on median survival, although the combination of chemotherapy, interleukin-2, and interferon has "a fairly high response rate," Dr. Kosty said.

"That therapy might be useful if you have somebody with metastatic disease that is significantly symptomatic from the disease, such as somebody with bony metastasis and pain or somebody with liver metastasis and diminished appetite. They may benefit symptomatically but will not benefit from that therapy in terms of survival," he noted.

Recurrence-free survival has been shown, but overall survival 'has been harder to demonstrate.' DR. KOSTY

SAN DIEGO — For patients with regionally advanced melanoma, the current standard of care is high-dose interferon.

"It's an imperfect standard, but nonetheless it is the standard," Dr. Michael P. Kosty said at a melanoma update sponsored by the Scripps Clinic.

To date, five randomized trials of high-dose interferon have shown a recurrence-free survival advantage, but an overall survival advantage "has been harder to demonstrate," said Dr. Kosty, program director of the hematology/oncology fellowship training program at the Scripps Clinic.

"One of the things about survival as an end point is that if you have a patient population and you treat them with your experimental therapy and they progress or recur, a lot of patients will go on standard therapy, which will impact your ability to assess their survival," he said.

Two studies have shown a survival advantage for high-dose interferon. In one study, patients were randomized to either 52 weeks of observation or to an induction phase of 20 megaunits/m

A more recent study assessed the impact of low-dose and high-dose interferon on overall survival compared with no treatment. It found that only high-dose interferon conferred a survival advantage: a median of 20 months, compared with a median of 9.6 months among those who did not receive treatment (J. Clin. Oncol. 2000; 18: 2444–58). A similar association was seen in the rates of recurrence-free survival.

"There is a dose-response relationship between the higher doses of interferon and the higher likelihood of recurrence-free benefit," said Dr. Kosty, who had no relevant conflicts of interest to disclose.

At this time, patients with stage III or stage IV disease are ideal candidates for systemic therapy. "If you look at the current data, there is no evidence in stage II disease of efficacy of adjuvant therapy, either in terms of progression free or overall survival," he noted.

The most common adverse events from high-dose interferon treatment include fatigue and depressive symptoms. Despite aggressive antidepressive therapy, "this impacts the function of many patients. Some are unable to work, particularly if they have physically demanding jobs or mentally challenging jobs," said Dr. Kosty.

In an effort to find a better alternative, a trial of 400 patients to compare standard high-dose interferon treatment to a chemoimmunotherapy combination has completed accrual. Results are expected in the coming year.

So far, no vaccine trial has shown improvement in overall survival, although some trials have shown an improvement in relapse-free survival. "There is about a 20% reduction in relapse rate and perhaps as high as a 10% reduction in death rate, although that 10% is probably the most optimistic number," he said. "Vaccines will probably have their ultimate utility in patients who have a very high risk of either developing melanoma or developing recurrence from their surgically treated melanoma, as opposed to patients with more advanced disease."

Effective treatment options for metastatic melanoma remain a challenge for researchers. Current therapies have little impact on median survival, although the combination of chemotherapy, interleukin-2, and interferon has "a fairly high response rate," Dr. Kosty said.

"That therapy might be useful if you have somebody with metastatic disease that is significantly symptomatic from the disease, such as somebody with bony metastasis and pain or somebody with liver metastasis and diminished appetite. They may benefit symptomatically but will not benefit from that therapy in terms of survival," he noted.

Recurrence-free survival has been shown, but overall survival 'has been harder to demonstrate.' DR. KOSTY

VIENNA — Treatment with methyl aminolevulinate-photodynamic therapy was as effective as surgery for superficial basal cell carcinoma, Dr. Rolf-Markus Szeimies reported in a poster session at the 16th Congress of the European Academy of Dermatology and Venereology.

Among the methods for removal of basal cell carcinomas are simple excision, Mohs surgery, radiotherapy, curettage/electrodessication, and cryosurgery, with the choice of treatment depending on type, size, depth, and location of the lesion.

Methyl aminolevulinate-photodynamic therapy (MAL-PDT) has previously been shown to be as effective as cryotherapy for removal of these lesions and to have superior cosmetic results. Now, in the first multicenter randomized trial comparing MAL-PDT with simple excision, similar findings have been found, according to Dr. Szeimies of the department of dermatology, Regensburg (Germany) University Hospital.

A total of 196 patients whose mean age was 63.8 years were included in the study. The mean number of lesions per patient was 1.4, and the mean diameter of the lesions was 12.4 mm.

Patients randomized to MAL-PDT underwent two treatment sessions 7 days apart, with the option of repeat treatment at 3 months if clinical response was incomplete. Those randomized to surgery underwent simple elliptical excision with 3-mm margins from the estimated edge of the lesion.

The lesion complete response rate was 87% with MAL-PDT and 89% with excision, confirming the noninferiority of MAL-PDT to surgery, wrote Dr. Szeimies.

Results were similar in the two groups for lesions on the trunk and neck, with MAL-PDT and excision having complete response rates of 85% and 89%, respectively. For lesions on the face and scalp, MAL-PDT and excision showed complete response rates of 95% and 67%.

Complete response was not related to size of the lesion.

Investigator-rated cosmetic outcome favored MAL-PDT, with 87% of lesions having good to excellent outcome, compared with 58% of those in the surgery group.

Patients also preferred the cosmetic outcome with MAL-PDT, with 93% rating the outcome as good to excellent, compared with 81% of the patients in the excision group.

The study was sponsored by Galderma, which makes the MAL-PDT used in the study.

In a recent review of experience with MAL-PDT for basal cell carcinoma, Dr. Szeimies noted that, while surgery remains the preferred method of treatment, some patients—such as those with large lesions, poor vasculature, and concomitant use of anticoagulants or immunosuppressives—may be poor candidates for surgery.

Moreover, postsurgical keloid or dystrophic scarring is common, particularly on the trunk. "Because of the relatively low-risk nature of superficial [basal cell carcinoma], scarring problems should be taken into consideration when choosing a suitable therapy. Therefore, PDT may offer significant advantages over surgical or other destructive techniques" he wrote (Dermatol. Clin. 2007;25:89–94).

Dr. Szeimies disclosed no conflicts of interest.

VIENNA — Treatment with methyl aminolevulinate-photodynamic therapy was as effective as surgery for superficial basal cell carcinoma, Dr. Rolf-Markus Szeimies reported in a poster session at the 16th Congress of the European Academy of Dermatology and Venereology.

Among the methods for removal of basal cell carcinomas are simple excision, Mohs surgery, radiotherapy, curettage/electrodessication, and cryosurgery, with the choice of treatment depending on type, size, depth, and location of the lesion.

Methyl aminolevulinate-photodynamic therapy (MAL-PDT) has previously been shown to be as effective as cryotherapy for removal of these lesions and to have superior cosmetic results. Now, in the first multicenter randomized trial comparing MAL-PDT with simple excision, similar findings have been found, according to Dr. Szeimies of the department of dermatology, Regensburg (Germany) University Hospital.

A total of 196 patients whose mean age was 63.8 years were included in the study. The mean number of lesions per patient was 1.4, and the mean diameter of the lesions was 12.4 mm.

Patients randomized to MAL-PDT underwent two treatment sessions 7 days apart, with the option of repeat treatment at 3 months if clinical response was incomplete. Those randomized to surgery underwent simple elliptical excision with 3-mm margins from the estimated edge of the lesion.

The lesion complete response rate was 87% with MAL-PDT and 89% with excision, confirming the noninferiority of MAL-PDT to surgery, wrote Dr. Szeimies.

Results were similar in the two groups for lesions on the trunk and neck, with MAL-PDT and excision having complete response rates of 85% and 89%, respectively. For lesions on the face and scalp, MAL-PDT and excision showed complete response rates of 95% and 67%.

Complete response was not related to size of the lesion.

Investigator-rated cosmetic outcome favored MAL-PDT, with 87% of lesions having good to excellent outcome, compared with 58% of those in the surgery group.

Patients also preferred the cosmetic outcome with MAL-PDT, with 93% rating the outcome as good to excellent, compared with 81% of the patients in the excision group.

The study was sponsored by Galderma, which makes the MAL-PDT used in the study.

In a recent review of experience with MAL-PDT for basal cell carcinoma, Dr. Szeimies noted that, while surgery remains the preferred method of treatment, some patients—such as those with large lesions, poor vasculature, and concomitant use of anticoagulants or immunosuppressives—may be poor candidates for surgery.

Moreover, postsurgical keloid or dystrophic scarring is common, particularly on the trunk. "Because of the relatively low-risk nature of superficial [basal cell carcinoma], scarring problems should be taken into consideration when choosing a suitable therapy. Therefore, PDT may offer significant advantages over surgical or other destructive techniques" he wrote (Dermatol. Clin. 2007;25:89–94).

Dr. Szeimies disclosed no conflicts of interest.

VIENNA — Treatment with methyl aminolevulinate-photodynamic therapy was as effective as surgery for superficial basal cell carcinoma, Dr. Rolf-Markus Szeimies reported in a poster session at the 16th Congress of the European Academy of Dermatology and Venereology.

Among the methods for removal of basal cell carcinomas are simple excision, Mohs surgery, radiotherapy, curettage/electrodessication, and cryosurgery, with the choice of treatment depending on type, size, depth, and location of the lesion.

Methyl aminolevulinate-photodynamic therapy (MAL-PDT) has previously been shown to be as effective as cryotherapy for removal of these lesions and to have superior cosmetic results. Now, in the first multicenter randomized trial comparing MAL-PDT with simple excision, similar findings have been found, according to Dr. Szeimies of the department of dermatology, Regensburg (Germany) University Hospital.

A total of 196 patients whose mean age was 63.8 years were included in the study. The mean number of lesions per patient was 1.4, and the mean diameter of the lesions was 12.4 mm.

Patients randomized to MAL-PDT underwent two treatment sessions 7 days apart, with the option of repeat treatment at 3 months if clinical response was incomplete. Those randomized to surgery underwent simple elliptical excision with 3-mm margins from the estimated edge of the lesion.

The lesion complete response rate was 87% with MAL-PDT and 89% with excision, confirming the noninferiority of MAL-PDT to surgery, wrote Dr. Szeimies.

Results were similar in the two groups for lesions on the trunk and neck, with MAL-PDT and excision having complete response rates of 85% and 89%, respectively. For lesions on the face and scalp, MAL-PDT and excision showed complete response rates of 95% and 67%.

Complete response was not related to size of the lesion.

Investigator-rated cosmetic outcome favored MAL-PDT, with 87% of lesions having good to excellent outcome, compared with 58% of those in the surgery group.

Patients also preferred the cosmetic outcome with MAL-PDT, with 93% rating the outcome as good to excellent, compared with 81% of the patients in the excision group.

The study was sponsored by Galderma, which makes the MAL-PDT used in the study.

In a recent review of experience with MAL-PDT for basal cell carcinoma, Dr. Szeimies noted that, while surgery remains the preferred method of treatment, some patients—such as those with large lesions, poor vasculature, and concomitant use of anticoagulants or immunosuppressives—may be poor candidates for surgery.

Moreover, postsurgical keloid or dystrophic scarring is common, particularly on the trunk. "Because of the relatively low-risk nature of superficial [basal cell carcinoma], scarring problems should be taken into consideration when choosing a suitable therapy. Therefore, PDT may offer significant advantages over surgical or other destructive techniques" he wrote (Dermatol. Clin. 2007;25:89–94).

Dr. Szeimies disclosed no conflicts of interest.

CHICAGO — Atrophic dermatofibrosarcoma protuberans is an underrecognized variant that must be treated with wide local excision, Dr. Shari Clarke said at the annual meeting of the American Society for Dermatologic Surgery.

Although both wide local excision and Mohs micrographic surgery are considered treatments of choice, the latter quickly is becoming the favored method because of its lower rate of recurrence, she said.

In presenting three cases of the atrophic variant of dermatofibrosarcoma protuberans (DFSP), she explained that these lesions are slow-growing, locally aggressive fibrohistiocytic tumors that rarely metastasize but have a marked tendency toward local recurrence.

"Clinically, DFSP presents as indurated violaceous plaques which later develop nodules, and they're most commonly located on the trunk," explained Dr. Clarke of the department of dermatology at the Milton S. Hershey Medical Center, Pennsylvania State University, Hershey.

Histologically, DFSPs are characterized by monomorphous spindle cells in a storiform pattern that infiltrate between adipocytes. Later, the tumor can involve the upper dermis, deeper subcutaneous fat, or striated muscle, which correlates with the development of nodules and, as "we've demonstrated in our cases, the CD34 staining is very useful in distinguishing DFSPs from other fibrohistiocytic tumors," Dr. Clarke explained.

A total of five distinct early clinical variants of DFSP have been described in the literature, including confluent nodules forming sclerotic plaques, keloidlike sclerotic plaques, tumor, angiomalike, and atrophic DFSP. As exemplified in three cases described by Dr. Clarke, atrophic DFSP may or may not develop nodules in the later stages. In the first two cases, wide excision was used because the procedures were performed by a plastic surgeon.

The third case, involving the crural fold, was performed by a Mohs surgeon.

The first patient, a 43-year-old woman with a 13-year history of asymptomatic nodules that began as an atrophic plaque on the back of her neck, was clinically diagnosed as having multiple neurofibromas. She presented for a second opinion as the nodules continued to enlarge.

A punch biopsy showed monomorphous spindle cells in a fibrous stroma infiltrating the septa between the adipose. CD34 stains were positive and she was given a diagnosis of DFSP, but since her original clinical exam showed atrophic plaque, the diagnosis was changed to atrophic DFSP, Dr. Clarke explained.

A wide excision with 2-cm margins was performed, producing a gross examination specimen measuring 20 by 15 cm. Intraoperative frozen sections with CD34 showed clear 2-cm margins and the wound was reconstructed with a transverse rectus abdominal muscle cutaneous flap utilizing the inferior epigastric artery and vein for blood supply.

The second patient was a 14-year-old girl who presented with a 7-year history of an enlarging, asymptomatic plaque on her right thigh. She was clinically diagnosed as having a keloid and treated without improvement. Surveillance was stopped for a number of years because the patient thought it was "just a scar," Dr. Clarke said, but the nodules continued to enlarge.

On examination, there was an atrophic plaque with scattered nodules that was found on biopsy to be a DFSP.

As with the first patient, the diagnosis was changed to atrophic DFSP.

"She had an excision with 2-cm margins, and the excised specimen was about 30 by 15 cm. Resection was performed down to the quadriceps complex with the 2-cm margins and intraoperative frozen sections showed clear margins," Dr. Clarke said. Reconstruction consisted of a split thickness skin graft from the uninvolved leg.

The third patient was a 40-year-old woman with a 4-by-2.5 cm violaceous atrophic plaque of the right crural fold, said Dr. Clarke, explaining that the patient initially was biopsied and misdiagnosed as having a dermatofibroma.

A repeat biopsy and tumor appearance confirmed atrophic DFSP, which was cleared in two stages using Mohs surgery. The final defect measured 11 by 6 cm. The reconstruction used an advancement flap. Histology showed spindle cells, and a CD34 stain was grossly positive. There has been no evidence of recurrence in the intervening 8 years, said Dr. Clarke, who had no relevant conflicts to disclose.

"Atrophic DFSP, otherwise known as DFSP nonprotuberans or morpheaform DFSP, has been reported infrequently in the dermatologic literature, and like typical DFSP, the atrophic variant has an insidious and aggressive local growth pattern, a similar age of onset, and predominant truncal location," she said, noting that there appears to be a slight female predominance.

Although the atrophic variety is clinically distinct, the treatment and histology are the same as they are for typical DFSP. Adjuvant treatment with imatinib looks promising for very difficult cases.

"Exciting advances in the molecular genetics behind DFSPs have recently been elucidated and have important implications for treatment," she explained, adding that 90% of DFSPs overexpress platelet-derived growth factor β.

"This is important because imatinib mesylate [Gleevec] currently approved for treating chronic myeloid leukemia, acts as a selective tyrosine kinase inhibitor of the platelet-derived growth factor receptor β and has been used successfully in isolated case reports for the presurgical treatment of locally advanced DFSPs and inoperable recurrent or metastatic disease," she said.

Dr. Clarke suggested using 400 mg of imatinib mesylate, the dose used for gastrointestinal stromal tumors, either daily or twice daily. "The side effects are typically mild, although severe edema and liver toxicity have been reported in the elderly," she said.

A patient with DFSPis shown before undergoing wide local excision (left) and 3-months post excision (right). Photos courtesy Rogerio Neves, M.D., Ph.D.

CHICAGO — Atrophic dermatofibrosarcoma protuberans is an underrecognized variant that must be treated with wide local excision, Dr. Shari Clarke said at the annual meeting of the American Society for Dermatologic Surgery.

Although both wide local excision and Mohs micrographic surgery are considered treatments of choice, the latter quickly is becoming the favored method because of its lower rate of recurrence, she said.

In presenting three cases of the atrophic variant of dermatofibrosarcoma protuberans (DFSP), she explained that these lesions are slow-growing, locally aggressive fibrohistiocytic tumors that rarely metastasize but have a marked tendency toward local recurrence.

"Clinically, DFSP presents as indurated violaceous plaques which later develop nodules, and they're most commonly located on the trunk," explained Dr. Clarke of the department of dermatology at the Milton S. Hershey Medical Center, Pennsylvania State University, Hershey.

Histologically, DFSPs are characterized by monomorphous spindle cells in a storiform pattern that infiltrate between adipocytes. Later, the tumor can involve the upper dermis, deeper subcutaneous fat, or striated muscle, which correlates with the development of nodules and, as "we've demonstrated in our cases, the CD34 staining is very useful in distinguishing DFSPs from other fibrohistiocytic tumors," Dr. Clarke explained.

A total of five distinct early clinical variants of DFSP have been described in the literature, including confluent nodules forming sclerotic plaques, keloidlike sclerotic plaques, tumor, angiomalike, and atrophic DFSP. As exemplified in three cases described by Dr. Clarke, atrophic DFSP may or may not develop nodules in the later stages. In the first two cases, wide excision was used because the procedures were performed by a plastic surgeon.

The third case, involving the crural fold, was performed by a Mohs surgeon.

The first patient, a 43-year-old woman with a 13-year history of asymptomatic nodules that began as an atrophic plaque on the back of her neck, was clinically diagnosed as having multiple neurofibromas. She presented for a second opinion as the nodules continued to enlarge.

A punch biopsy showed monomorphous spindle cells in a fibrous stroma infiltrating the septa between the adipose. CD34 stains were positive and she was given a diagnosis of DFSP, but since her original clinical exam showed atrophic plaque, the diagnosis was changed to atrophic DFSP, Dr. Clarke explained.

A wide excision with 2-cm margins was performed, producing a gross examination specimen measuring 20 by 15 cm. Intraoperative frozen sections with CD34 showed clear 2-cm margins and the wound was reconstructed with a transverse rectus abdominal muscle cutaneous flap utilizing the inferior epigastric artery and vein for blood supply.

The second patient was a 14-year-old girl who presented with a 7-year history of an enlarging, asymptomatic plaque on her right thigh. She was clinically diagnosed as having a keloid and treated without improvement. Surveillance was stopped for a number of years because the patient thought it was "just a scar," Dr. Clarke said, but the nodules continued to enlarge.

On examination, there was an atrophic plaque with scattered nodules that was found on biopsy to be a DFSP.

As with the first patient, the diagnosis was changed to atrophic DFSP.

"She had an excision with 2-cm margins, and the excised specimen was about 30 by 15 cm. Resection was performed down to the quadriceps complex with the 2-cm margins and intraoperative frozen sections showed clear margins," Dr. Clarke said. Reconstruction consisted of a split thickness skin graft from the uninvolved leg.

The third patient was a 40-year-old woman with a 4-by-2.5 cm violaceous atrophic plaque of the right crural fold, said Dr. Clarke, explaining that the patient initially was biopsied and misdiagnosed as having a dermatofibroma.

A repeat biopsy and tumor appearance confirmed atrophic DFSP, which was cleared in two stages using Mohs surgery. The final defect measured 11 by 6 cm. The reconstruction used an advancement flap. Histology showed spindle cells, and a CD34 stain was grossly positive. There has been no evidence of recurrence in the intervening 8 years, said Dr. Clarke, who had no relevant conflicts to disclose.

"Atrophic DFSP, otherwise known as DFSP nonprotuberans or morpheaform DFSP, has been reported infrequently in the dermatologic literature, and like typical DFSP, the atrophic variant has an insidious and aggressive local growth pattern, a similar age of onset, and predominant truncal location," she said, noting that there appears to be a slight female predominance.

Although the atrophic variety is clinically distinct, the treatment and histology are the same as they are for typical DFSP. Adjuvant treatment with imatinib looks promising for very difficult cases.

"Exciting advances in the molecular genetics behind DFSPs have recently been elucidated and have important implications for treatment," she explained, adding that 90% of DFSPs overexpress platelet-derived growth factor β.

"This is important because imatinib mesylate [Gleevec] currently approved for treating chronic myeloid leukemia, acts as a selective tyrosine kinase inhibitor of the platelet-derived growth factor receptor β and has been used successfully in isolated case reports for the presurgical treatment of locally advanced DFSPs and inoperable recurrent or metastatic disease," she said.

Dr. Clarke suggested using 400 mg of imatinib mesylate, the dose used for gastrointestinal stromal tumors, either daily or twice daily. "The side effects are typically mild, although severe edema and liver toxicity have been reported in the elderly," she said.

A patient with DFSPis shown before undergoing wide local excision (left) and 3-months post excision (right). Photos courtesy Rogerio Neves, M.D., Ph.D.

CHICAGO — Atrophic dermatofibrosarcoma protuberans is an underrecognized variant that must be treated with wide local excision, Dr. Shari Clarke said at the annual meeting of the American Society for Dermatologic Surgery.

Although both wide local excision and Mohs micrographic surgery are considered treatments of choice, the latter quickly is becoming the favored method because of its lower rate of recurrence, she said.

In presenting three cases of the atrophic variant of dermatofibrosarcoma protuberans (DFSP), she explained that these lesions are slow-growing, locally aggressive fibrohistiocytic tumors that rarely metastasize but have a marked tendency toward local recurrence.

"Clinically, DFSP presents as indurated violaceous plaques which later develop nodules, and they're most commonly located on the trunk," explained Dr. Clarke of the department of dermatology at the Milton S. Hershey Medical Center, Pennsylvania State University, Hershey.

Histologically, DFSPs are characterized by monomorphous spindle cells in a storiform pattern that infiltrate between adipocytes. Later, the tumor can involve the upper dermis, deeper subcutaneous fat, or striated muscle, which correlates with the development of nodules and, as "we've demonstrated in our cases, the CD34 staining is very useful in distinguishing DFSPs from other fibrohistiocytic tumors," Dr. Clarke explained.

A total of five distinct early clinical variants of DFSP have been described in the literature, including confluent nodules forming sclerotic plaques, keloidlike sclerotic plaques, tumor, angiomalike, and atrophic DFSP. As exemplified in three cases described by Dr. Clarke, atrophic DFSP may or may not develop nodules in the later stages. In the first two cases, wide excision was used because the procedures were performed by a plastic surgeon.

The third case, involving the crural fold, was performed by a Mohs surgeon.

The first patient, a 43-year-old woman with a 13-year history of asymptomatic nodules that began as an atrophic plaque on the back of her neck, was clinically diagnosed as having multiple neurofibromas. She presented for a second opinion as the nodules continued to enlarge.

A punch biopsy showed monomorphous spindle cells in a fibrous stroma infiltrating the septa between the adipose. CD34 stains were positive and she was given a diagnosis of DFSP, but since her original clinical exam showed atrophic plaque, the diagnosis was changed to atrophic DFSP, Dr. Clarke explained.

A wide excision with 2-cm margins was performed, producing a gross examination specimen measuring 20 by 15 cm. Intraoperative frozen sections with CD34 showed clear 2-cm margins and the wound was reconstructed with a transverse rectus abdominal muscle cutaneous flap utilizing the inferior epigastric artery and vein for blood supply.

The second patient was a 14-year-old girl who presented with a 7-year history of an enlarging, asymptomatic plaque on her right thigh. She was clinically diagnosed as having a keloid and treated without improvement. Surveillance was stopped for a number of years because the patient thought it was "just a scar," Dr. Clarke said, but the nodules continued to enlarge.

On examination, there was an atrophic plaque with scattered nodules that was found on biopsy to be a DFSP.

As with the first patient, the diagnosis was changed to atrophic DFSP.

"She had an excision with 2-cm margins, and the excised specimen was about 30 by 15 cm. Resection was performed down to the quadriceps complex with the 2-cm margins and intraoperative frozen sections showed clear margins," Dr. Clarke said. Reconstruction consisted of a split thickness skin graft from the uninvolved leg.

The third patient was a 40-year-old woman with a 4-by-2.5 cm violaceous atrophic plaque of the right crural fold, said Dr. Clarke, explaining that the patient initially was biopsied and misdiagnosed as having a dermatofibroma.

A repeat biopsy and tumor appearance confirmed atrophic DFSP, which was cleared in two stages using Mohs surgery. The final defect measured 11 by 6 cm. The reconstruction used an advancement flap. Histology showed spindle cells, and a CD34 stain was grossly positive. There has been no evidence of recurrence in the intervening 8 years, said Dr. Clarke, who had no relevant conflicts to disclose.

"Atrophic DFSP, otherwise known as DFSP nonprotuberans or morpheaform DFSP, has been reported infrequently in the dermatologic literature, and like typical DFSP, the atrophic variant has an insidious and aggressive local growth pattern, a similar age of onset, and predominant truncal location," she said, noting that there appears to be a slight female predominance.

Although the atrophic variety is clinically distinct, the treatment and histology are the same as they are for typical DFSP. Adjuvant treatment with imatinib looks promising for very difficult cases.

"Exciting advances in the molecular genetics behind DFSPs have recently been elucidated and have important implications for treatment," she explained, adding that 90% of DFSPs overexpress platelet-derived growth factor β.

"This is important because imatinib mesylate [Gleevec] currently approved for treating chronic myeloid leukemia, acts as a selective tyrosine kinase inhibitor of the platelet-derived growth factor receptor β and has been used successfully in isolated case reports for the presurgical treatment of locally advanced DFSPs and inoperable recurrent or metastatic disease," she said.

Dr. Clarke suggested using 400 mg of imatinib mesylate, the dose used for gastrointestinal stromal tumors, either daily or twice daily. "The side effects are typically mild, although severe edema and liver toxicity have been reported in the elderly," she said.

A patient with DFSPis shown before undergoing wide local excision (left) and 3-months post excision (right). Photos courtesy Rogerio Neves, M.D., Ph.D.

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS

LAS VEGAS — Recurrence can be a problem when aminolevulinic acid and light are used to treat patients with nodular basal cell carcinomas, largely because the drug does not penetrate to the deeper nodules, Dr. E. Victor Ross Jr. said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Photodynamic therapy using aminolevulinic acid "is somewhat unpredictable with some of these skin cancers, particularly the nodular ones in the absence of curettage prior to the application," said Dr. Ross, director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego.

In a recent study that compared surgical excision to photodynamic therapy at 5 years after treatment in 97 patients who had primary nodular basal cell carcinoma, investigators found a 14% recurrence rate with the light-activated therapy, versus a 4% rate with surgical excision (Arch. Dermatol. 2007;143:1131–6).

"We find the relapse rate is reasonably high, so you have to be careful in interpreting the statistics sometimes," he said. Paying attention to certain aspects of treatment, however, can probably improve the results.

In treating skin cancers, the aminolevulinic acid must be applied and left on for at least 4–6 hours before the light application.

For nodular basal cell carcinoma, curettage should be performed on the lesion before applying the aminolevulinic acid, Dr. Ross said.

Removing the stratum corneum, at the very least, is important before applying aminolevulinic acid because it greatly inhibits penetration of the cream, he pointed out.

Use of red light (630 nm) may be better than using blue light (400–450 nm) because it penetrates deeper.

The trade-off, however, is that it does not activate the protoporphyrin-9 created from the aminolevulinic acid as well as blue light, he said at the meeting.

From his experience working with a red-light, potassium-titanyl-phosphate (KTP) pump-dye laser, Dr. Ross has found that the red light is preferable.

It is not as much better as it should be, but it is a little better. "Blue light does not work for those lesions that are further than about a millimeter down," he commented.

"Theoretically, red light should work a lot better, despite the fact that [it] does not activate the protoporphyrin-9 as well, simply because it penetrates a lot better," he added.

Dr. Ross said that he uses a cream base for the aminolevulinic acid (specifically Eucerin lotion) instead of the ethanol/water solution that is contained in Levulan Kerastick.

"We get better fluorescence in the basal cells at the treatment time," said Dr. Ross, who reported relevant conflicts of interest involving Palomar Medical Technologies and Alma Laser.

'Blue light does not work for those lesions that are further than about a millimeter down.' DR. ROSS