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Atrophic dermatofibrosarcoma protuberans in an adult: an uncommon, misleading variant1
P462
P464
MALIGNANT MELANOMA RELATED TO LONGTERM USE OF TANNING BEDS Donna H Ward, MD, Henry Ford Health Sciences Center, Detroit, MI, United States, Edward Krull, MD, Henry Ford Health Sciences Center, Detroit, MI, United States, Thomas Downham III, MD, Henry Ford Health Sciences Center, Detroit, MI, United States Malignant Melanoma Related to Longterm Use of Tanning Beds Presented by: Donna H. Ward, MD and Edward Krull, MD One in 80 Americans will develop a melanoma during their lifetime. Over the past 50 years the incidence of melanoma has increased by 1000%. This is in part due to increased exposure to ultraviolet radiation. Risk factors for development of melanoma include light complexion, light eyes, blond or red hair, blistering sunburns in childhood, heavy freckling, and a tendency to tan poorly and sunburn easily. Additional predisposing factors include use of tanning lamps, genetic disorders, and acquired immunodeficiency states. We report a case of a 55 year old caucasian female with Fitzpatrick skin type II developing malignant melanoma on the buttock after greater than 10 years of tanning bed use. The patient presented to the clinic with a one week history of growth in a preexisting nevus. She had visited tanning beds regularly for more than 10 years. She denied any history of sunbathing but states that she had worked as a lifeguard in her youth. She reported one blistering sunburn involving only the face. She also denied any personal or family history of melanoma or skin carcinoma. An excisional biopsy was performed and revealed malignant melanoma with extension to the papillary dermis.
ATROPHIC DERMATOFIBROSARCOMA PROTUBERANS IN AN ADULT: AN UNCOMMON, MISLEADING VARIANT Mohsin M Malik, Department of Dermatology, Drogheda, Ireland, Jason K. Wu, MBBS, Department of Dermatology, Drogheda, Ireland, Conleth A. Egan, MD, Department of Dermatology, Drogheda, Ireland Dermatofibrosarcoma protuberans typically presents as a slowly growing indurated plaque, with subsequent protrusion of nodules from the surface. It may rarely present as an atrophic plaque which can pose diagnostic difficulties. We report a case of atrophic dermatofibrosarcoma protuberans and review the literature. A 23 year old man presented with a greater than 10 year history of an atrophic lesion on his left anterior shoulder. A previous biopsy had suggested a fibrohistiocytic origin, however clinically it resembled morphea or atrophoderma, and the lesion was observed. A repeat biopsy performed after it had grown slightly showed dermatofibrosarcoma protuberans, with a storiform spindle cell proliferation and positive CD34 staining. The lesion was excised with a 3 cm margin. Awareness of this rare presentation may assist in earlier diagnosis. Disclosure not available at press time.
Disclosure not available at press time.
Non-melanoma Skin Cancer P463 TOPICAL PHOTODYNAMIC THERAPY WITH THE IRON CHELATOR, CP94, FOR NODULAR BASAL CELL CARCINOMA Colin A Morton, MD, Falkirk Royal Infirmary, Falkirk, Scotland, Sandra Campbell, MD, Royal Cornwall Hospital, Truro, England, David Gould, MD, Royal Cornwall Hospital, Truro, England, Alison Curnow, PhD, Royal Cornwall Hospital, Truro, England In 1999, the FDA approved the use of 5-aminolaevulinic acid (ALA) induced-photodynamic therapy (PDT) for the treatment of actinic keratoses. PDT involves the activation of a photosensitizing drug by visible light to produce activated oxygen species within target cells, resulting in their destruction. Extensive research in Europe supports the efficacy of ALA-PDT in actinic keratoses, Bowen’s disease and superficial basal cell carcinoma (BCC). Several ALA preparations have been used along with a variety of light sources, especially red light so as to enhance tissue penetration. Excellent cosmesis on healing is commonly reported. Efficacy for thicker nodular BCC appears inferior to the high rates of clearance for superficial BCC, unless prior debulking or repeat treatments are performed. The aim of this study was to increase the efficacy of the ALA-PDT for nodular BCC, by using a novel iron-chelating agent (CP94-synthesised by King’s College London) to temporarily increase the accumulation of the active photosensitiser and to also ensure the safety of this treatment modification. Two clinical centres have conducted a dose escalation pilot study in parallel. Each centre has treated 12 nodular BCCs with standard 20% ALA-PDT and increased the amount of iron chelator (0%, 5%, 10% and 20% CP94 respectively) incorporated into the cream in groups of 3. Red light (630 nm ⫹/⫺ 15 nm, 100 J/cm2) was delivered 6 hours after cream application using a xenon lamp and included irradiation of a 1 cm margin of healthy surrounding tissue. Clearance of disease was assessed at 6 weeks, prior to surgical excision of the whole treatment site for histological examination. Current results indicate that CP94 can be used safely in combination with ALA-PDT to improve outcomes in nodular BCC, whilst still maintaining the benefits of good cosmesis. The results of this pilot study will be used to inform the design of a fully randomised controlled trial to confirm that this simple treatment modification can be used to improve ALA-PDT efficacy in nodular BCC patients. This simple treatment modification may therefore significantly improve dermatological ALA-PDT use.
SUCCESSFUL NON-SURGICAL “SALVAGE THERAPY” OF MORPHEAFORM BASAL CELL CARCINOMA IN PATIENTS REFUSING SURGERY Rebecca B. O’Sullivan, MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, United States, Vincent Li, MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, United States We report two cases of morpheaform basal cell carcinoma of the face which were successfully treated with imiquimod 5% cream when conventional Mohs micrographic surgical excision was declined. Imiquimod 5% cream was used as monotherapy in the first case (morpheaform BCC on the forehead). A combination regimen of imiquimod 5% cream plus diclofenac solution was utilized in order to optimize therapy in the second case (morpheaform BCC on the lateral nose and medial canthal region) which demonstrated perineural invasion. Clincal and histologic clearance were seen after 16 weeks of topical drug application. Tolerable side effects included site specific tissue reaction. This is the first report to our knowledge of successful clearance of morpheaform BCC on the face using topical therapy. If close long term follow-up of these two cases supports this initial outcome without recurrence, this topical regimen targeting immunomodulatory and antiangiogenic pathways may represent an alternative “salvage” option for patients with aggressive cutaneous neoplasms who are unable or unwilling to undergo conventional surgical therapy. Imiquimod monotherapy and its use in combination therapy warrants further study in various BCC subtypes.
Disclosure not available at press time.
Disclosure not available at press time.
P120
J AM ACAD DERMATOL
P465
MARCH 2004
P464
MALIGNANT MELANOMA RELATED TO LONGTERM USE OF TANNING BEDS Donna H Ward, MD, Henry Ford Health Sciences Center, Detroit, MI, United States, Edward Krull, MD, Henry Ford Health Sciences Center, Detroit, MI, United States, Thomas Downham III, MD, Henry Ford Health Sciences Center, Detroit, MI, United States Malignant Melanoma Related to Longterm Use of Tanning Beds Presented by: Donna H. Ward, MD and Edward Krull, MD One in 80 Americans will develop a melanoma during their lifetime. Over the past 50 years the incidence of melanoma has increased by 1000%. This is in part due to increased exposure to ultraviolet radiation. Risk factors for development of melanoma include light complexion, light eyes, blond or red hair, blistering sunburns in childhood, heavy freckling, and a tendency to tan poorly and sunburn easily. Additional predisposing factors include use of tanning lamps, genetic disorders, and acquired immunodeficiency states. We report a case of a 55 year old caucasian female with Fitzpatrick skin type II developing malignant melanoma on the buttock after greater than 10 years of tanning bed use. The patient presented to the clinic with a one week history of growth in a preexisting nevus. She had visited tanning beds regularly for more than 10 years. She denied any history of sunbathing but states that she had worked as a lifeguard in her youth. She reported one blistering sunburn involving only the face. She also denied any personal or family history of melanoma or skin carcinoma. An excisional biopsy was performed and revealed malignant melanoma with extension to the papillary dermis.
ATROPHIC DERMATOFIBROSARCOMA PROTUBERANS IN AN ADULT: AN UNCOMMON, MISLEADING VARIANT Mohsin M Malik, Department of Dermatology, Drogheda, Ireland, Jason K. Wu, MBBS, Department of Dermatology, Drogheda, Ireland, Conleth A. Egan, MD, Department of Dermatology, Drogheda, Ireland Dermatofibrosarcoma protuberans typically presents as a slowly growing indurated plaque, with subsequent protrusion of nodules from the surface. It may rarely present as an atrophic plaque which can pose diagnostic difficulties. We report a case of atrophic dermatofibrosarcoma protuberans and review the literature. A 23 year old man presented with a greater than 10 year history of an atrophic lesion on his left anterior shoulder. A previous biopsy had suggested a fibrohistiocytic origin, however clinically it resembled morphea or atrophoderma, and the lesion was observed. A repeat biopsy performed after it had grown slightly showed dermatofibrosarcoma protuberans, with a storiform spindle cell proliferation and positive CD34 staining. The lesion was excised with a 3 cm margin. Awareness of this rare presentation may assist in earlier diagnosis. Disclosure not available at press time.
Disclosure not available at press time.
Non-melanoma Skin Cancer P463 TOPICAL PHOTODYNAMIC THERAPY WITH THE IRON CHELATOR, CP94, FOR NODULAR BASAL CELL CARCINOMA Colin A Morton, MD, Falkirk Royal Infirmary, Falkirk, Scotland, Sandra Campbell, MD, Royal Cornwall Hospital, Truro, England, David Gould, MD, Royal Cornwall Hospital, Truro, England, Alison Curnow, PhD, Royal Cornwall Hospital, Truro, England In 1999, the FDA approved the use of 5-aminolaevulinic acid (ALA) induced-photodynamic therapy (PDT) for the treatment of actinic keratoses. PDT involves the activation of a photosensitizing drug by visible light to produce activated oxygen species within target cells, resulting in their destruction. Extensive research in Europe supports the efficacy of ALA-PDT in actinic keratoses, Bowen’s disease and superficial basal cell carcinoma (BCC). Several ALA preparations have been used along with a variety of light sources, especially red light so as to enhance tissue penetration. Excellent cosmesis on healing is commonly reported. Efficacy for thicker nodular BCC appears inferior to the high rates of clearance for superficial BCC, unless prior debulking or repeat treatments are performed. The aim of this study was to increase the efficacy of the ALA-PDT for nodular BCC, by using a novel iron-chelating agent (CP94-synthesised by King’s College London) to temporarily increase the accumulation of the active photosensitiser and to also ensure the safety of this treatment modification. Two clinical centres have conducted a dose escalation pilot study in parallel. Each centre has treated 12 nodular BCCs with standard 20% ALA-PDT and increased the amount of iron chelator (0%, 5%, 10% and 20% CP94 respectively) incorporated into the cream in groups of 3. Red light (630 nm ⫹/⫺ 15 nm, 100 J/cm2) was delivered 6 hours after cream application using a xenon lamp and included irradiation of a 1 cm margin of healthy surrounding tissue. Clearance of disease was assessed at 6 weeks, prior to surgical excision of the whole treatment site for histological examination. Current results indicate that CP94 can be used safely in combination with ALA-PDT to improve outcomes in nodular BCC, whilst still maintaining the benefits of good cosmesis. The results of this pilot study will be used to inform the design of a fully randomised controlled trial to confirm that this simple treatment modification can be used to improve ALA-PDT efficacy in nodular BCC patients. This simple treatment modification may therefore significantly improve dermatological ALA-PDT use.
SUCCESSFUL NON-SURGICAL “SALVAGE THERAPY” OF MORPHEAFORM BASAL CELL CARCINOMA IN PATIENTS REFUSING SURGERY Rebecca B. O’Sullivan, MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, United States, Vincent Li, MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, MA, United States We report two cases of morpheaform basal cell carcinoma of the face which were successfully treated with imiquimod 5% cream when conventional Mohs micrographic surgical excision was declined. Imiquimod 5% cream was used as monotherapy in the first case (morpheaform BCC on the forehead). A combination regimen of imiquimod 5% cream plus diclofenac solution was utilized in order to optimize therapy in the second case (morpheaform BCC on the lateral nose and medial canthal region) which demonstrated perineural invasion. Clincal and histologic clearance were seen after 16 weeks of topical drug application. Tolerable side effects included site specific tissue reaction. This is the first report to our knowledge of successful clearance of morpheaform BCC on the face using topical therapy. If close long term follow-up of these two cases supports this initial outcome without recurrence, this topical regimen targeting immunomodulatory and antiangiogenic pathways may represent an alternative “salvage” option for patients with aggressive cutaneous neoplasms who are unable or unwilling to undergo conventional surgical therapy. Imiquimod monotherapy and its use in combination therapy warrants further study in various BCC subtypes.
Disclosure not available at press time.
Disclosure not available at press time.
P120
J AM ACAD DERMATOL
P465
MARCH 2004