ONCOLOGY DERMATOLOGY AND SURGERY Dr. Pedro Redondo

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2 ONCOLOGY DERMATOLOGY AND SURGERY Dr. Pedro Redondo

3 Mohs surgery limitations in large tumors Extension to the bone Tumor characteristics (desmoplastic) Agressive tumors Cutting related problems Wrinkles and folds (risk of false positives) Thick/thin sectioning Poor dehydratation Air bubbles Incomplete sections (epidermis/deep) Slow Mohs: recurrence rate 0,7%

4 Antiseptics Contraindications/Interactions Alcohol: wounds Chlorhexidine: ear (perforations), eye (corneal ulcerations) Povidone iodine: allergy, Hyperthyroidism Sugerences Chlorhexidine in alcohol (+coloring): standard Chlorhexidine water-based: face (CAVEAT: ears and eyes) or wounds Povidone iodine water-based: genito-anal area, axillae

5 Flap Surgery in Eyelid Reconstruction Tripier muculocutaneous flap, and modifications (6) Advantages Provides bulk-muscle fibers and increased vascularity Continuity of orbicularis oris Minimal cutting of the facial nerve branches Good color match One stage procedure Good aesthetic (scar lines placed into natural creases) Good functional results: orbicularis oris recovery

6 A cross-sectional analysis of volume, specialist type, setting, and closure technique following excision and Mohs micrographic surgery This study utilized the Medicare public use file for 2014 A total of inviduals encounters were included Dermatologist account for (2.1%) Dermatologist alone perform more excisions, linear repairs, flaps, and grafts than all other specilities combined Dermatologists perform: More than 15 times the number of intermediate and complex repairs More than 4 times the number of local flaps More than 6 times the number of grafts as plastic surgeons Averaging a significantly larger number of yearly cases than any other specialist group

7 Merkel Cell Carcinoma (MCC) and Polyomavirus More than 80% of MCC are associated with MCPyV MCPyV is the first human polyomavirus to be clonally integrated in the tumor DNA Polyomavirus-negative MCC: a more aggressive subtype Analysis of 282 cases using multimodal tumor virus detection 53 (19%) negative for polyomavirus Increased risk for disease progression and death from MCC Viral oncoprotein antibodies as a marker for recurrence of MCC Antibodies to MCPyV oncoproteins present in 114 of 219 patients (52%) After treatment, rapid falling titers that became negative by a median of 8.4 months Moshiri et al, JID 2017 Paulson KG et al, Cancer 2017

8 Merkel Cell Carcinoma. Avelumab (anti PD-L1): first approved drug for metastatic MCC Patients with progression after a first line of chemotherapy 10 mg/kg IV every 2 weeks 39 patients 16/18 responses (88.9%) occurred after 6 weeks Median follow-up: 5.1 months Safety 8 patients (20.5%) > grade 3 (IRR, elevated ALT/CPK/lipase, nephritis, cholangitis) ESMO, Madrid septiembre 2017

9 ANGIOSARCOMA Locoregional control with ECT Pazopanib in advanced angiosarcoma ANGIOSARCOMA treated successfully with anti-pd1 therapy 63 year-old man Primary angiosarcoma of the nose Recurrent disease for 4 years (facial and liver) Pembrolizumab 2mg/kg every 21 days, x13 Marked shrinkage of liver disease and no new facial lesions Positive PD-L1 expression predicts worse outcome in cutaneous angiosarcoma 52 patients PD-L1 expressed in 40% Significantly associated with tumor cell proliferation Sindhu S. J Immunother Cancer 2017 Shimizu A, J Glob Oncol 2016

10 DFSP prognostic factors 3686 patients Age at diagnosis (older age) Sex (male sex) Tumor size (>3 cm) Were significantly associated with poored overall survival JAMA Dermatol 2016

11 Clinical effects of molecular methods in sarcoma diagnosis (GENSARC): a prospective, multicentre, observational study Molecular genetic testing should be mandatory for diagnostic accuracy of sarcoma and appropriate clinical management, even when histological diagnosis is made by pathologist experts in this field For DFSP: 16% of cases had diagnosis modified by molecular methods Lancet Oncology 2016