Treatment of patients with late-stage colorectal cancer: ASCO resource-stratified guideline
PURPOSE To provide expert guidance to clinicians and policymakers in resource-constrained settings on the management of patients with late-stage colorectal cancer. METHODS ASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines, conducted a modified ADAPTE process, and used a formal consensus process with additional experts for two rounds of formal ratings. RESULTS Existing sets of guidelines from four guideline developers were identified and reviewed; adapted recommendations from five guidelines form the evidence base and provided evidence to inform the formal consensus process, which resulted in agreement of >= 75% on all recommendations. RECOMMENDATIONS Common elements of symptom management include addressing clinically acute situations. Diagnosis should involve the primary tumor and, in some cases, endoscopy, and staging should involve digital rectal exam and/or imaging, depending on resources available. Most patients receive treatment with chemotherapy, where chemotherapy is available. If, after a period of chemotherapy, patients become candidates for surgical resection with curative intent of both primary tumor and liver or lung metastatic lesions on the basis of evaluation in multidisciplinary tumor boards, the guidelines recommend patients undergo surgery in centers of expertise if possible. On-treatment surveillance includes a combination of taking medical history, performing physical examinations, blood work, and imaging; specifics, including frequency, depend on resource-based setting.
Lichen sclerosus et atrophicus
Morphea and lichen sclerosus et atrophicus (LSA) have similar clinical presentations. Reports of patients with overlapping clinical and histopathologic features of both conditions have led some to speculate that they may represent different presentations along the same disease spectrum. It has been postulated that there is a common etiologic agent, which may involve autoimmunity, response to trauma, or infection. The link between Borrelia infection and both morphea and LSA has been widely studied but remains controversial. We present a case of a patient with lesions characterized by overlapping features of morphea and LSA with rapid decrease in joint mobility.
Livedo reticularis (LR) is a net-like, violaceous, hyperpigmented pattern on the skin that reflects an underlying change in cutaneous blood flow. The causes of LR are many and most commonly include connective tissue diseases, vasculitis, hypercoagulability, and embolic events. We describe a 49-year-old man who presented with painful LR and ulcers on the lower extremities as a manifestation of chronic natural killer cell leukemia (CNKL). There have been only a few cases previously reported in the literature. We report an additional case of a patient with both LR and CNKL and suggest a possible mechanism that explains this association.
We present a case of a 35-year-old woman with a yellow, verrucous, and itchy plaque on her scalp. Within this plaque, there was an erythematous, bleeding papule. Histopathologic findings were compatible with a diagnosis of syringocystadenoma papilliferum within a nevus sebaceous. We present a brief review of the natural history of nevus sebaceus, its pathogenesis, and management.
Successful Treatment of Facial Telangiectasias Using a Micropulse 1,064-nm Neodymium-Doped Yttrium Aluminum Garnet Laser
OBJECTIVES: To evaluate the safety and efficacy of a microsecond 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for the treatment of facial telangiectasias. METHODS: Subjects ages 35-70 with Fitzpatrick skin types I to III and facial telangiectasias underwent two treatments with a micropulse (0.65 ms) 1,064-nm Nd:YAG laser. Treatments were spaced 30 days apart, with a final evaluation 60 days after the second treatment. Evaluation included digital photography and an assessment of the degree of improvement on a scale from 1 to 5 by the subject and a nontreating investigator. RESULTS: Twenty subjects (18 women, two men) with Fitzpatrick skin type II and III completed the study. The nontreating investigator rated the objective clinical response as total clearance (100% clear) in 10% (n = 2) of subjects, significant clearance (>/=50% clear) in 75% (n = 15), and some clearance (0-49% clear) in 15% (n = 3). None of the subjects was rated as having no clearance or worsening. In terms of subjective clearance reported by subjects, 80% (n = 16) reported significant clearance, with the remainder reporting some clearance. No adverse events were reported. CONCLUSION: The micropulse 1,064-nm Nd:YAG successfully treated facial telangiectasias with a high degree of patient satisfaction, minimal discomfort, and no adverse events.
Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin
OBJECTIVE: To evaluate the safety and efficacy of intradermal injection of abobotulinumtoxinA for the treatment of oily skin. METHODS AND MATERIALS: Twenty-five patients with oily skin were treated in the forehead region with intradermal injections of botulinum toxin. Baseline and post-treatment sebum production was measured using a sebometer. Photographs were taken. Patients were also asked to rate their satisfaction with the treatment in terms of improvement in their oily skin. RESULTS: Treatment with botulinum toxin resulted in significantly lower sebum production at 1 week and 1, 2, and 3 months after injection (p < .001, t-test). Twenty-one patients (91%) reported that they were satisfied (50-75% improvement) with intradermal botulinum toxin as a treatment for oily skin. [Correction added after online publication 7-Jan-2013: the number of satisfied patients has been updated] CONCLUSION: Intradermal injection of botulinum toxin significantly reduced sebum production in the forehead region, with a high degree of patient satisfaction. Intradermal botulinum toxin may be an effective treatment to reduce sebum production in patients with oily skin. Larger, randomized, blinded, placebo-controlled studies are warranted.
Esthetic rejuvenation of the temple
Loss of volume in the temples is an early sign of aging that is often overlooked by both the physician and the patient. Augmentation of the temple using soft tissue fillers improves the contours of the upper face with the secondary effect of lengthening and lifting the lateral brow. After replacement of volume, treatment of the overlying skin with skin-tightening devices or laser resurfacing help to complete a comprehensive rejuvenation of the temple and upper one-third of the face.
Necrobiotic xanthogranuloma (NXG) is a rare, chronic, progressive, non-Langerhans histiocytosis that is strongly associated with hematologic malignant conditions. Only about 100 cases have been reported in the literature since it was first described in 1980. It is important for dermatologists to recognize NXG and initiate a prompt hematologic evaluation. IgG kappa is the most frequently discovered monoclonal gammopathy (65%), followed by IgG lambda (35%), and, much less commonly, IgA. Although no modality has been shown to be consistently effective, therapeutic options include glucocorticoids (topical, intralesional, and/or systemic), alkylating agents (chlorambucil and cyclophosphamide). interferon alpha, antimetabolites, antibiotics, thalidomide, and plasmaphersis.
Erythrodermic lichen planus [Case Report]
Lichen planus (LP) is a relatively common papulosquamous disorder that is characterized by pruritic, polygonal papules in a characteristic distribution. We present a case of a 71-year-old man with erythroderma, who was ultimately diagnosed with severe, generalized LP. Treatment of severe LP is challenging, and there are few, robust, clinical trials in the literature to guide the selection of appropriate treatment. We discuss the treatment options for generalized LP and the evidence in support of these agents.
Cheilitis granulomatosa [Case Report]
Melkersson-Rosenthal Syndrome (MRS) is a rare syndrome that is characterized by a triad of facial paralysis, chronic edema of the lip, and a fissured tongue. Most commonly, one element of the triad precedes the development of the other symptoms. We present a case of cheilitis granulomatosa (CG) as a manifestation of incomplete MRS. As the etiology remains unknown, treatment of CG is challenging. Intralesional glucocorticoids remain the first-line treatment, but recurrences are common. We discuss alternative treatment strategies that include combination therapy with other anti-inflammatory agents and biologics, such as infliximab.