Faculty Bibliography

Importance: There is limited information regarding the influence of patient demographics, tumor characteristics, and treatment type on the survival of patients with dermatofibrosarcoma protuberans (DFSP). Objective: To assess prognostic factors and to evaluate the influence of treatment modality on overall survival of patients with DFSP. Design, Setting, and Participants: We examined DFSP using data for 3686 patients with histologically confirmed cases of DFSP diagnosed between 1972 and 2012 from the 18 US regional registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, with linkage to demographic data from the US Census Bureau for median household income (MHI). The analysis was performed in February 2016. Main Outcomes and Measures: The primary outcome measures were tumor characteristics, prognostic factors, and overall survival in months. Results: There were 3686 cases of DFSP examined. Older age (hazard ratio [HR], 1.08; 95% CI, 1.06-1.10; P < .001), male sex (HR, 1.97; 95% CI, 1.09-3.55; P = .03), and tumor size (HR, 1.09; 95% CI, 1.01-1.18; P = .04) were significantly associated with poorer overall survival in a controlled analysis. Older age (odds ratio [OR], 1.01; 95% CI, 1.00-1.02; P = .01), male sex (OR, 1.95; 95% CI, 1.57-2.42; P < .001), and black race (OR, 1.78; 95% CI, 1.37-2.32; P < .001) were associated with larger (>/=3.0 cm) tumors at presentation. Treatment modality did not influence overall survival; however, differences in patient characteristics affected the treatment received. Older age at presentation (OR, 1.02; 95% CI, 1.01-1.03; P =.01), black race (OR, 1.82; 95% CI, 1.13-2.92; P = .01), large tumor size (OR, 1.15; 95% CI, 1.09-1.21; P < .001), and head or neck location (OR, 4.63; 95% CI, 2.66-8.07; P <.001) increased the likelihood of a patient receiving surgery and radiation over surgery alone. In addition, white patients (OR, 0.51; 95% CI, 0.30-0.87; P=.01), women (OR, 0.53; 95% CI, 0.36-0.78; P <.001), and patients with a higher MHI (OR, 1.27; 95% CI, 1.11-1.46; P <.001) were more likely to receive Mohs micrographic surgery (MMS) over excision. Conclusions and Relevance: Age at diagnosis, male sex, and DFSP tumor size appear to be important prognostic factors. Treatment modality did not significantly influence survival; however, patient and tumor characteristics influence treatment modality.

To the Editor: Shain et al. (Nov. 12 issue)(1) report the results of genetic analysis of 37 primary melanomas and their adjacent nonmalignant melanocytic neoplasms. The authors found conservation of genetic alterations among these neoplasms that was consistent with a stepwise model of melanocytic transformation into melanoma. Although this is a landmark study in the field of melanoma pathogenesis, we would like to emphasize the limited evidence supporting the prophylactic removal of benign melanocytic neoplasms (i.e., melanocytic nevi) to prevent melanoma. Patients with increased numbers of nevi are at increased risk for melanoma. The potential for nevi to serve as . . .

OBJECTIVE:Comparatively little attention has been paid to the role of free radical oxidation in acne vulgaris. Here, using the traditional abnormalities cited for acne, the authors address the role of free radical oxidation throughout the pathogenesis by detailing the chemistry that may contribute to clinical changes. To probe the effects of free radical oxidation and test an antioxidant, they conducted a preliminary study of topically applied vitamin E. METHODS:Seventeen patients with mild-to-moderate acne vulgaris were evaluated over an eight-week period in two private dermatology practices in this open-label study. All patients enrolled were on the same baseline regimen of salicylic acid and benzoyl peroxide. This regimen was then supplemented with topical vitamin E in sunflower seed oil. RESULTS:At the end of the eight-week period, all patients demonstrated clinical improvement, as indicated by a reduction in the number of lesions and global mean difference. A statistically significant reduction was noted as early as Week 2. Enrolled patients also expressed a positive experience due to good tolerability and easy application. CONCLUSION/CONCLUSIONS:Although the exact pathogenesis of acne vulgaris remains unknown, the presence of excessive reactive oxygen species can be implicated in each of the major abnormalities involved. This presence, along with the positive results of the authors' preliminary study, demonstrates the need for more exploration on the use of topical antioxidants in limiting free radical oxidation in the acne model. This paper is designed to stimulate academic discussion regarding a new way of thinking about the disease state of acne.

We aimed to characterize the extent and distribution of focal basal left ventricular (LV) hypertrophy in patients with mitral valve prolapse (MVP). Sixty-three patients (mean age: 58 +/- 14 years) with MVP and 20 age-matched normal volunteers (mean age: 53 +/- 11 years) were assessed using cardiac magnetic resonance imaging. We compared the ratio of basal to mid end-diastolic wall thickness in both groups and correlated it with clinical and imaging parameters. Of the 63 patients, 44 (70%) had posterior leaflet prolapse, 2 (3%) had anterior leaflet prolapse, and 17 (27%) had bileaflet prolapse. There was a significantly increased ratio of basal to mid-ventricular end-diastolic wall thickness in all segments of the left ventricle in those with MVP compared to the controls. The inferolateral (2.1 vs 1.0, p <0.01) and anterolateral (2.1 vs 1.1) ratios (p <0.01) were the greatest compared to the other myocardial segments. The degree of mitral annular excursion had a strong positive correlation with the degree of hypertrophy (r(2) = 0.81, p <0.01) and was an independent predictor in adjusted multivariate analysis (p <0.0001). Age, body mass index, LV end-diastolic volume index, LV end -systolic volume index, LV stroke volume index, degree of prolapse, and mitral regurgitation volume did not have any significant correlation with the degree of hypertrophy. In conclusion, MVP is associated with concentric basal LV hypertrophy and good correlation between the excursion of the mitral valve annulus and the degree of relative LV hypertrophy suggests that locally increased myocardial function could be responsible for this remodeling.