Current recommendations for prevention and therapy of extravasation reactions in dermato‐oncology

Despite the introduction of many targeted therapies, a wide variety of cytostatic agents are still frequently used in dermato‐oncology. In order to avoid further morbidity in tumor patients, prevention of extravasation reactions is of highest importance. The optimal management of extravasation requires an early diagnosis, the application of specific antidotes and a well‐trained oncology team.     

Acral angiokeratoma‐like pseudolymphoma in a middle‐aged woman

Acral angiokeratoma‐like pseudolymphoma is a rare type of pseudolymphoma presenting as dark‐red papules on the hand or foot. We describe a 59‐year‐old woman who presented with an unusual unilateral, clustered aggregate of scaly violaceous papules on the toe with an indolent course. Skin biopsy showed a prominent vascular proliferation associated with a dermal infiltrate of monoclonally rearranged T‐follicular helper phenotype T‐cells, in keeping with CD4+ small/medium T‐cell lymphoproliferative disorder (SMPTC‐LPD). Based on the unique clinical morphology, distribution of the lesions and dermoscopic appearance, a clinicopathologic diagnosis of acral angiokeratoma‐like pseudolymphoma was favored. This case demonstrates the importance of clinicopathological correlation in such diagnostically challenging patients who present with overlapping features on the spectrum of pseudolymphoma and cutaneous T‐cell lymphoma.     

Optical coherence tomography for presurgical margin assessment of non‐melanoma skin cancer – a practical approach

In the clinical setting, optical coherence tomography (OCT) is applicable for the non‐invasive diagnosis of skin cancer and may in particular be used for margin definition prior to excision. In this regard, OCT may improve the success rate of removing tumor lesions more effectively, preventing repetitive excision, which may subsequently result in smaller excisions. In this study, we have aimed to evaluate the applicability of OCT for in vivo presurgical margin assessment of non‐melanocytic skin tumors (NMSC) and to describe the feasibility of different scanning techniques. A total number of 18 patients planned for excision of lesions suspicious of NMSC were included in this study. Based on OCT, we defined the specific tumor margins on 19 lesions preoperatively using different scanning modalities. Sixty‐one margin points and five complete tumor margins were analysed on 18 patients with a total of 19 lesions including 63% basal cell carcinoma (BCC) (n = 12), 16% (n = 3) squamous cell carcinoma (SCC) and 21% of other types of skin tumors (n = 4) were classified. In 84% of the cases (n = 16), the OCT‐defined lateral margins correctly indicated complete removal of the tumor. The surgical margins chosen by the surgeon never fell below the OCT‐defined margin. Regarding the techniques of marginal definition, punctual tumor border scan in the perpendicular direction, with an extension of free‐run scans for unsure cases can hardly be recommended. This study shows that suspected NMSC can effectively be confirmed, and furthermore, resection margin can be minimized under OCT control without reducing the rate of complete removal.     

Occupational exposure to non‐artificial UV‐light and non‐melanocytic skin cancer – a systematic review concerning a new occupational disease

Background: Although UV exposure is the most important risk factor for cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), a systematic review analyzing the risk of occupational UV exposure is missing. Methods: Based on a systematic literature search in PubMed (until 05/2009) supplemented by hand search, the association between occupational UV exposure and SCC and BCC was analyzed. Literature search and data abstraction was done independently by 2 reviewers. The association between occupational UV exposure and cancer risk is presented as odds ratios (OR). Results: We identified 25 relevant epidemiologic studies (5 cohort studies, 17 case‐control studies, 3 cross‐sectional studies). 12 studies described a positive association between occupational UV exposure and risk of SCC with OR > 3 in 6 studies and OR 1.5–2.0 in another 6 studies. 3 studies did not find a relevant association (OR: 1.0–1.4). A significant positive association between occupational UV exposure and BCC was reported in 5 studies; 11 studies did not find a significant association. Conclusions: The association between occupational UV exposure and SCC is well and consistently documented epidemiologically (approximately 2‐fold increased risk), so that the criteria for a new occupational disease are fulfilled. The association with BCC is unclear due to significant methodological limitations in the published studies.     

Trends of skin diseases in organ‐transplant recipients transplanted between 1966 and 2006: a cohort study with follow‐up between 1994 and 2006

Background Skin diseases are frequently observed in organ‐transplant recipients (OTRs). Objectives To count the registered skin diseases in all 2136 OTRs who had been transplanted in a single centre between 1966 and 2006 and to calculate their relative contribution in relation to the number of years after transplantation. Methods All registered skin diseases which were entered into a computerized system between 1994 and 2006 at the Leiden University Medical Centre were counted and their relative contributions were calculated. Results Between 1994 and 2006, 2408 skin diseases were registered in 801 of 1768 OTRs who were at risk during this specific time period. The most commonly recorded diagnoses were skin infections (24·0%) followed by benign skin tumours (23·3%) and malignant skin lesions (18·2%). The relative contributions of infectious and inflammatory disorders decreased with time after transplantation, whereas the contribution of squamous cell carcinomas strongly increased with time. Conclusions This study gives a systematic overview of the high burden of skin diseases in OTRs. The relative distributions of skin diseases importantly changed with time after transplantation, with squamous cell carcinoma contributing most to the increasing burden of skin diseases with increasing time after transplantation.     

UVA‐1 exposure in vivo leads to an IL‐6 surge within the skin

UVA‐1 is a known promotor of skin ageing. Cytokines like IL‐1α, Il‐1β or TNF‐α, VEGF and IL‐6 orchestrate UV effects, and IL‐6 is furthermore an effector of UVA‐induced photoageing. We investigated how fractionated UVA‐1 doses influence the cytokine milieu and especially the IL‐6 levels in the skin in vivo. In a study with 35 participants, we exposed previously unirradiated human skin to three UVA‐1 irradiation regimes. Cytokine levels in interstitial skin fluid were measured up to 48 hours postexposure and compared to unirradiated control skin fluid. Our results show that IL‐6 levels increased significantly after UVA‐1 exposure at selected time points. The other candidates IL‐1α, Il‐1β or TNF‐α and VEGF show no significant response after UVA‐1 exposure in vivo. UVA‐1 thus raises selectively IL‐6 levels in vivo, a fact that underlines its role in photoageing and has potential implications for its modulatory effect on photoageing pathology.     

Hypofractionated radiotherapy in older patients with non‐melanoma skin cancer: Less is better

Radiotherapy is a non‐surgical option for patients with non‐melanoma skin cancer. Lesions in middle‐aged to older patients with good performance status are typically prescribed 4–5 weeks of outpatient weekday treatment. Daily radiotherapy fraction sizes of 2–3 Gy are recommended to decrease the late cutaneous consequences such as in‐field hypopigmentation and telangiectasia. In elderly, often unwell patients, these concerns are less of an issue and larger fraction sizes (5–7 Gy), referred to as hypofractionation, can be delivered over a shorter time yet still achieve excellent in‐field control and improve a patient's quality of life and avoid the need for surgery. The three case studies presented illustrate this approach along with a review of the evidence to support this.