Faculty Bibliography

BACKGROUND: A significant proportion of patients with American Joint Committee on Cancer (AJCC)-defined early-stage cutaneous melanoma have disease recurrence and die. A 31-gene expression profile (GEP) that accurately assesses metastatic risk associated with primary cutaneous melanomas has been described. OBJECTIVE: We sought to compare accuracy of the GEP in combination with risk determined using the web-based AJCC Individualized Melanoma Patient Outcome Prediction Tool. METHODS: GEP results from 205 stage I/II cutaneous melanomas with sufficient clinical data for prognostication using the AJCC tool were classified as low (class 1) or high (class 2) risk. Two 5-year overall survival cutoffs (AJCC 79% and 68%), reflecting survival for patients with stage IIA or IIB disease, respectively, were assigned for binary AJCC risk. RESULTS: Cox univariate analysis revealed significant risk classification of distant metastasis-free and overall survival (hazard ratio range 3.2-9.4, P < .001) for both tools. In all, 43 (21%) cases had discordant GEP and AJCC classification (using 79% cutoff). Eleven of 13 (85%) deaths in that group were predicted as high risk by GEP but low risk by AJCC. LIMITATIONS: Specimens reflect tertiary care center referrals; more effective therapies have been approved for clinical use after accrual. CONCLUSIONS: The GEP provides valuable prognostic information and improves identification of high-risk melanomas when used together with the AJCC online prediction tool.

Importance: Sun-protective behavior affects skin cancer prevention. Shade works by physically shielding skin from direct harmful UV rays; however, skin may still remain exposed to reflected and indirect UV rays. There is no current standard metric to evaluate shade for its effectiveness in sun protection, and there is insufficient clinical evidence that a beach umbrella alone can provide adequate sun protection. Objective: To directly measure sunburn protection offered by a standard beach umbrella compared with that provided by sunscreen with a high sun protection factor under actual use conditions. Design, Setting, and Participants: A single-center, evaluator-blinded, randomized clinical study was conducted from August 13 to 15, 2014, in Lake Lewisville, Texas (elevation, 159 m above sea level), among 81 participants with Fitzpatrick skin types I (n = 1), II (n = 42), and III (n = 38). Participants were randomly assigned to 2 groups: 1 using only a beach umbrella, and the other using only sunscreen with a sun protection factor of 100. All participants remained at a sunny beach for 3(1/2) hours at midday. Clinical sunburn evaluation of each individual for all exposed body sites was conducted 22 to 24 hours after sun exposure. Interventions: The shade provided by a beach umbrella or protection provided by sunscreen with a sun protection factor of 100. Main Outcomes and Measures: Sunburn on all exposed body sites 22 to 24 hours after sun exposure. Results: Among the 81 participants (25 male and 56 female; mean [SD] age, 41 [16] years) for all body sites evaluated (face, back of neck, upper chest, arms, and legs), the umbrella group showed a statistically significant increase in clinical sunburn scores compared with baseline and had higher postexposure global scores than the sunscreen group (0.75 vs 0.05; P < .001). There was a total of 142 sunburn incidences in the umbrella group vs 17 in the sunscreen group. Thirty-two of the 41 participants (78%) in the umbrella group showed erythema in 1 or more sites vs 10 of the 40 participants (25%) in the sunscreen group (P < .001). Neither umbrella nor sunscreen alone completely prevented sunburn. Conclusions and Relevance: A beach umbrella alone may not provide sufficient protection for extended UV exposure. It is important to educate the public that combining multiple sun protection measures may be needed to achieve optimal protection. Trial Registration: isrctn.org Identifier: ISRCTN19177299.

Generalized essential telangiectasia (GET) is a notoriously difficult to treat disorder with no current satisfactory treatments. This case and discussion report the use of 6-mercaptopurine (6-MP) as a successful treatment for GET. Moreover, we show that GET may represent a state of increased angiogenesis, a paradigm shift from the current understanding that these telangiectasias represent dilatations of only pre-existing vessels. This new view of GET may drive others to look at novel agents for treatment

J Drugs Dermatol. 2017;16(3):280-282

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A 31-gene expression profile (GEP) test to predict metastasis risk has been validated with over 900 cutaneous melanoma (CM) tumor samples. The test generates Class 1 (low-risk) or 2 (highrisk) results, which are associated with significantly different 5- year distant metastasis free survival rates (91% versus 57%, resp). 157 dermatologists who attended a national educational dermatology conference were presented with the clinical validity evidence for the 31-GEP test, followed by a description of a 30- year-old male with a thigh lesion that was biopsy confirmed melanoma, without ulceration or atypical features and no family or personal history of skin cancer. They were asked to provide the Breslow thickness (BT; ranging from 0.7-1.5 mm) at which they would recommend sentinel lymph node biopsy (SLNB), oncology referral, or imaging. The majority of respondents (62%, 57%, and 55%, resp) indicated a BT of 1.0 mm as the thickness to manage a patient with each modality, reflecting an adherence to current management guidelines. Respondents were then asked the same question in the context of a Class 1 or Class 2 result. After inclusion of a Class 1 result, responses reflecting the BT inflection points for guiding SLNB, oncology referral and imaging were changed in 23%, 18% and 19% of cases, resp, with risk-appropriate changes (increased BT) of 87%, 83% and 59%. Following addition of a Class 2 outcome to patient characteristics, the initial BT used to guide SLNB, medical oncology referral, and imaging was changed in 47%, 50% and 47% of the responses, resp, with 95%, 84% and 97% of the cases changed in a risk-appropriate direction (decreased BT). The results indicate that the 31-GEP test may have a significant and appropriate impact upon CM patient management while remaining within the context of the established practice guidelines that exist today

BACKGROUND: Guidelines exist for the management of cutaneous malignant melanoma, but their adoption, prevalence, and impact have not yet been determined. OBJECTIVE: To determine current melanoma clinical management practices of US dermatologists and the variance from guidelines that might exist. METHODS: A cross-sectional e-mail survey study assessing preferred biopsy methods for lesions suspicious for melanoma, margins used for excision, and recommended follow-up intervals were sent to 6177 US dermatologists (540 responding). The representative nature of the responding subset was verified by comparing their demographics to that from the American Academy of Dermatology (AAD) membership. RESULTS: Management varied from published guidelines. Shave biopsy (35%) was the most commonly used method followed by narrow excisional biopsy (31%), saucerization/scoop shave (12%), punch (11%), and wide excision (3%). Excisional margins narrower than recommended were noted and follow-up intervals varied. There were significant management differences noted for dermatologists by practice setting and by years in practice. LIMITATIONS: The impact of patient history, lesion anatomic site, and size of lesion were not assessed. Recall and nonresponder sampling bias may exist. CONCLUSION: Variations in dermatologists' approaches to melanoma management and variance from current guidelines suggest that a knowledge gap may exist representing an educational opportunity. However, emerging data may also justify deviations from existing guidelines, suggesting a reassessment of the guidelines may be indicated.

The American Academy of Dermatology and dermatologists' themselves, have recommended public education and patient counseling regarding sunscreen. The purpose of this study was to determine US dermatologists' actual sunscreen perceptions as well as their recommendations and personal usage. 540 practicing US dermatologists responded to an online survey that assessed each physician's perception of safety and efficacy of sunscreen, recommendation factors, and personal usage. Dermatologists have an overall positive view of sunscreen. 99% of dermatologists agree that regular sunscreen use helps lower skin cancer risk, reduces subsequent photoaging, and recommend their family/friends use sunscreen. Most dermatologists believe that oxybenzone and retinyl palmitate are safe in sunscreen (86% and 85%, respectively). Dermatologists used multiple sunscreen recommendation criteria including Sun Protection Factor (SPF) level, broad spectrum protection, cosmetic elegance/feel, and photostability (96%, 98%, 85%, and 68%, respectively). The use of sunscreen remains a critical part of sun protection. Therefore, it is important to assess and understand the perspective and patient recommendations provided by dermatologists.

J Drugs Dermatol 2016;15(9):1121-1123.