Journal of Clinical and Aesthetic Dermatology

Psoriasis and Cutaneous Supplement 2016

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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S 2 4 S U P P L E M E N T T O T H E J O U R N A L O F C L I N I C A L A N D A E S T H E T I C D E R M AT O L O G Y [ S E P T E M B E R 2 0 1 6 • V O L U M E 9 • N U M B E R 9 ] cases are thought to be caused by the polyoma virus. The MCC presents as a non-tender, solitary, dome-shaped nodule, which may be blue or red in color. Occasionally, it may appear as a plaque-like or subcutaneous mass. It is typically less than 2cm in length, but may be as large as 20cm. It mainly appears on the head and neck area (40% of MCC). On histopathology, MCC is a dermal tumor nodule with small blue cells revealing round or oval hyperchromatic nuclei. It invades the vasculature and there may be evidence of tumor necrosis, perineural invasion, and a high mitotic rate. Immunostains should look for CK-20 and thyroid transcription factor. About 70 percent of patients who present with MCC have localized disease (and about one third of those with clinically negative nodes will actually have microscopic nodal disease). Since MCC is a rare form of cancer, there are few data to guide practice or to verify the validity of prognostic features. In an analysis of 5,823 MCC patients, it was found that five-year survival was 40 percent and that when lesions were <2cm in size, there was a more favorable prognosis. Furthermore, sentinel lymph node biopsy could be an important predictor in that a negative biopsy was associated with a more favorable prognosis. 132 The treatment of MCC can be a subject of some controversy. Mohs surgery is a tissue-sparing procedure to excise the tumor and a modified Mohs procedure with an additional final margin may be appropriate (1 to 2cm margin to fascia with complete circumferential and peripheral deep-margin assessment) to achieve the surgical goal of complete tumor extirpation at initial resection. Unfortunately, there are no controlled clinical trials comparing various surgical margins. Following surgery, a sentinel lymph node biopsy is recommended and postoperative radiation and/or chemotherapy may be appropriate. The prognostic value of a sentinel lymph node biopsy was evaluated in a meta-analysis of 10 studies with MCC. In this study, 67 percent of patients had biopsy-negative and 33 percent of patients had biopsy- positive sentinel lymph nodes and the recurrence rates of cancer were three percent (negative patients, mean follow-up 7.3 months) and 33 percent (positive patients, mean follow-up 12 months). 133 This clearly shows that a biopsy of the sentinel lymph node has predictive value in MCC cancer recurrence. However, of the 10 biopsy-negative patients in this study (n=23 sentinel node biopsies), immunostaining was positive in 22 percent of biopsies in 40 percent of the patients. The greatest sensitivity and specificity for diagnosis of micrometastatic MCC in sentinel lymph nodes is staining for the anti-CK-20 antibody. 134 Thus, following surgery for MCC, a sentinel lymph node biopsy should be performed. For biopsy-positive patients, therapeutic node dissection with or without adjuvant radiation and chemotherapy should be considered. For biopsy-negative patients, immunostaining for the anti- CK-20 antibody should be carried out and then treatment options considered. CONCLUSION The MauiDerm 2016 conference provided an excel- lent overview of the achievements and challenges of 2015 for dermatologists. Psoriasis continues to be a dif- ficult condition for patients, causing extreme distress in some, but new treatment modalities are providing bet- ter avenues for patients to achieve complete or nearly complete skin clearance. The many comorbid condi- tions associated with psoriasis continues to be explored as medicine stops treating psoriasis as "just a skin dis- ease," but rather as a serious systemic condition with wide-ranging effects. Skin cancer continues to be a global public health threat, and our understanding of actinic keratosis as a precursor to squamous cell cancer is increasing the urgency with which we address actinic keratosis. Further, the link between the human papillo- mavirus and skin cancer continues to be better eluci- dated. As dermatologists, we are on the forefront of medical breakthroughs on several fronts that can trans- late into safer, more effective, and more tolerable treat- ments for our patients. These in turn will bring our patients improved outcomes, better health, and enhanced quality of life. REFERENCES 1. Kimball AB, Sundaram M, Samuelson T, Signorovitch JE. Characteristics of psoriasis patients with self-assessed lim- ited disease control despite physician-assessed clear or minimal skin disease. Presented at the 71st Annual Meeting of the American Academy of Dermatology; Miami, FL; March 1–5, 2013. 2. Fredriksson T, Pettersson U. Severe psoriasis—oral therapy with a new retinoid. Dermatologica. 1978;157(4):238–244. 3. Langley RG, Ellis CN. Evaluating psoriasis with Psoriasis Area and Severity Index, Psoriasis Global Assessment, and Lattice System Physician's Global Assessment. J Am Acad Dermatol. 2004;51(4):563–569. 4. Rich P, Sigurgeirsson B, Thaci D, et al. Secukinumab induction and maintenance therapy in moderate-to-severe plaque psoriasis: a randomized, double-blind, placebo- controlled, phase II regimen-finding study. Br J Dermatol. 2013;168(2):402–411. 5. Puzenat E, Bronsard V, Prey S, et al. What are the best outcome measures for assessing plaque psoriasis severity? A systematic review of the literature. J Eur Acad Dermatol Venereol. 2010;24(Suppl 2):10–16. 6. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol. 1994;19(3):210–216. 7. Shikiar R, Bresnahan BW, Stone SP, et al. Validity and reliability of patient reported outcomes used in psoriasis: results from two randomized clinical trials. Health Qual Life Outcomes. 2003;1:53. 8. Lebwohl M, Swensen AR, Nyirady J, et al. The Psoriasis Symptom Diary: development and content validity of a novel patient-reported outcome instrument. Int J

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