Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions in the breast ducts. The goal for management of DCIS is to prevent the development of invasive breast cancer. This manuscript focuses on the NCCN Guidelines Panel recommendations for the workup, primary treatment, risk reduction strategies, and surveillance specific to DCIS.

https://www.unitypoint.org/desmoines/filesimages/Cancer%20Education/Oncology%20Nursing%20Conference/2015/2014%20NCCN%20Clin%20Pract%20Guidelines%20Male%20Sex%20Dysf.pdf

Clinical practice guidelines in oncology

Skin cancer is the most common type of cancer in fair-skinned populations in many parts of the world. The incidence, morbidity and mortality rates of skin cancers are increasing and, therefore, pose a significant public health concern. Ultraviolet radiation (UVR) is the major etiologic agent in the development of skin cancers. UVR causes DNA damage and genetic mutations, which subsequently lead to skin cancer. A clearer understanding of UVR is crucial in the prevention of skin cancer. This article reviews UVR, its damaging effects on the skin and its relationship to UV immunosuppression and skin cancer. Several factors influence the amount of UVR reaching the earth's surface, including ozone depletion, UV light elevation, latitude, altitude, and weather conditions. The current treatment modalities utilizing UVR (i.e. phototherapy) can also predispose to skin cancers. Unnecessary exposure to the sun and artificial UVR (tanning lamps) are important personal attributable risks. This article aims to provide a comprehensive overview of skin cancer with an emphasis on carefully evaluated statistics, the epidemiology of UVR-induced skin cancers, incidence rates, risk factors, and preventative behaviors & strategies, including personal behavioral modifications and public educational initiatives.

https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-4632.2010.04474.x

Ultraviolet radiation and skin cancer.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California–Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

https://www.jaad.org/article/S0190-9622(12)00667-6/pdf

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

Purpose Dermatofibrosarcoma protuberans (DFSP) is a dermal sarcoma typically carrying a translocation between chromosomes 17 and 22 that generates functional platelet-derived growth factor B (PDGFB). Patients and Methods Two distinct phase II trials of imatinib (400 to 800 mg daily) in patients with locally advanced or metastatic DFSP were conducted and closed prematurely, one in Europe (European Organisation for Research and Treatment of Cancer [EORTC]) with 14-week progression-free rate as the primary end point and the other in North America (Southwest Oncology Group [SWOG]) with confirmed objective response rate as the primary end point. In the EORTC trial, confirmation of PDGFB rearrangement was required, and surgery was undertaken after 14 weeks if feasible. The SWOG study confirmed t(17; 22) after enrollment. Results Sixteen and eight patients were enrolled onto the EORTC and SWOG trials, respectively. Tumor size ranged from 1.2 to 49 cm. DFSP was located on head/neck, trunk, and limb in seven, 11, and six patients, respectively, and was classic, pigmented, and fibrosarcomatous DFSP in 13, one, and nine patients, respectively. Metastases were present in seven patients (lung involvement was present six patients). Eleven patients (46%) had partial response as best response, and four patients had progressive disease as best response. Median time to progression (TTP) was 1.7 years. Imatinib was stopped in 11 patients because of progression, one patient because of toxicity, and two patients after complete resection of disease. Median overall survival (OS) time has not been reached; 1-year OS rate was 87.5%. Conclusion Imatinib is active in DFSP harboring t(17; 22) including fibrosarcomatous DFSP, with objective response rate approaching 50%. Response rates and TTP did not differ between patients taking 400 mg daily versus 400 mg twice a day. J Clin Oncol 28: 1772-1779. (C) 2010 by American Society of Clinical Oncology

Imatinib Mesylate in Advanced Dermatofibrosarcoma Protuberans: Pooled Analysis of Two Phase II Clinical Trials

Background
In this review, the position of behavioural ecotoxicology within the available means to assess the status of marine environments is described as filling the gap for the needed “early warning” signals. A few examples of studies performed since the 1960s are discussed to highlight the sensitivity of these approaches in investigating the effects of chemicals, including priority pollutants and emerging contaminants, relative to conventional toxicity tests measuring survival.

/pdf/behavioural-ecotoxicology-an-early-warning-signal-to-assess-4yp1e2nwem.pdf

Behavioural ecotoxicology, an “early warning” signal to assess environmental quality

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare sarcoma with a propensity for local recurrence. Treatments with wide excision, Mohs surgery, and other approaches have been reported with widely variable local control rates. The objective of this study was to review the experience with a multidisciplinary approach employing wide excision and Mohs surgery selectively in the treatment of patients with DFSP at a single academic institution over the past 10 years.



METHODS

The records of 62 patients with 63 DFSP tumors who underwent wide excision, Mohs surgery, or a multidisciplinary combination approach from January 1991 to December 2000 were reviewed retrospectively. Primary endpoints included the ability to extirpate the DFSP lesion completely, the tumor recurrence rate, and the need for skin grafts or local tissue flaps. Additional objectives included defining surgical practice patterns at the authors' institution.



RESULTS

Sixty-three DFSP lesions were removed from 62 patients. At a median follow-up of 4.4 years, no local or distant recurrences were detected in any patient. Forty-three lesions were treated with wide local excision, 11 lesions were treated with Mohs surgery, and 9 lesions were treated with a combination approach. Ninety-five percent of lesions that were approached initially with wide local excision were cleared histologically. Two patients (5%) received postoperative radiation for positive margins after undergoing maximal excision. Eighty-five percent of lesions that were approached initially with Mohs surgery were cleared histologically. The remaining 15% of lesions subsequently were cleared surgically with a wide excision. DFSP lesions that were approached initially with Mohs surgery tended to be smaller. Patients with head and neck lesions most often underwent Mohs surgery or were treated with a multidisciplinary combination approach (87%).



CONCLUSIONS

Wide local excision with careful pathologic analysis of margins was found to have a very low recurrence rate and was used for the majority of patients with DFSP lesions at the authors' institution. Wide local excision, Mohs surgery, and a multidisciplinary combination approach, selected based on both tumor and patient factors, were capable of achieving very high local control rates in the treatment of DFSP. The evolution of a multidisciplinary approach has provided a level of expertise that no single individual could achieve for the treatment of the full spectrum of DFSP lesions at the authors' institution. Cancer 2004;100:1008–16. © 2004 American Cancer Society.

Low recurrence rate after surgery for dermatofibrosarcoma protuberans: a multidisciplinary approach from a single institution.

BACKGROUND

Public awareness and education may lead to the detection of thinner melanomas, which may result in a decrease in morbidity and mortality rates. Which detection patterns, lesion, and patient characteristics are associated with early detection?



METHODS

Using the University of Michigan prospective melanoma database, the detection patterns, lesion characteristics, and patient characteristics of 1515 consecutive patients with in situ or invasive cutaneous melanomas were reviewed. Tumor thickness (measured in millimeters) was evaluated in relationship to detection patterns (patient, physician, spouse), lesion characteristics (change in color, size, shape/elevation, ulceration, bleeding, tenderness, itching), and patient characteristics (gender, skin type, number of atypical and clinically benign nevi, history of sunburn, personal and family history of melanoma).



RESULTS

Patient characteristics associated with early detection included female gender, at least one atypical nevus, greater than 20 clinically benign nevi, and/or a personal history of melanoma. Skin types I, II, and III, a history of sunburn, and/or a family history of melanoma were also associated with thinner lesions, but these associations were not statistically significant. Lesion characteristics associated with earlier detection included a change in color, size, shape/elevation, and/or itching. Physician-detected melanomas were significantly thinner than patient or spouse-detected lesions.



CONCLUSIONS

Educational campaigns should include increasing melanoma awareness in males and educating the public on the early signs and symptoms. Education should be directed at both high and low-risk groups. Physicians should consider performing total skin examinations routinely on patients. Although they detect a relatively small percentage of all melanomas, physicians detect significantly thinner lesions. Cancer 2002;95:1562–8. © 2002 American Cancer Society.



DOI 10.1002/cncr.10880

/pdf/thin-primary-cutaneous-melanomas-associated-detection-4tfrshqral.pdf

Thin Primary Cutaneous Melanomas Associated Detection Patterns, Lesion Characteristics, and Patient Characteristics

BACKGROUND

Perineural spread is a well-documented feature of cutaneous tumors and may portend a more aggressive course. The incidence of perineural invasion in basal cell carcinoma (BCC) is reportedly 1%. The authors sought to determine whether perineural spread occurs more commonly than previously thought.



METHODS

The authors prospectively evaluated 434 patients with BCC treated with Mohs surgery, assessing the presence or absence of perineural inflammation and invasion in tumors requiring more than one stage of surgery. They also documented the demographic features, clinical characteristics, histologic subtype, and operative data in each case.



RESULTS

Seventy-eight BCCs required more than one stage of Mohs surgery. Perineural inflammation, perineural tumor invasion, or both were present in 29 of the 78 tumors (37%), or 6.7% of all 434 prospectively evaluated cases. Twenty-one of the 78 tumors (26.9%) exhibited perineural inflammation, 3 (3.8%) demonstrated perineural invasion, and 5 (6.4%) exhibited both. Tumors with perineural invasion required 5.3 surgical stages on average for clearance, in contrast to tumors without perineural invasion, which required 2.2 stages. Tumors with perineural inflammation, inflammation plus tumor invasion, and invasion alone were, respectively, 138%, 149%, and 194% greater in area preoperatively than tumors without perineural involvement, and their mean defect areas after Mohs surgery were, respectively, 151%, 121%, and 605% larger than those of tumors without perineural involvement.



CONCLUSIONS

The incidence of perineural invasion among cases of BCC appears higher than previously recognized. Tumor aggressiveness appears to correlate with the presence of perineural invasion. Surgery with horizontal frozen-section margin control enables easy detection of perineural involvement and should therefore be strongly considered for the treatment of high risk BCC patients. Cancer 2000;88:1605–13. © 2000 American Cancer Society.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/%28SICI%291097-0142%2820000401%2988%3A7%3C1605%3A%3AAID-CNCR15%3E3.0.CO%3B2-Y

Perineural spread of basal cell carcinomas treated with Mohs micrographic surgery.

BACKGROUND

Desmoplastic and neurotropic melanoma (DNMM) occasionally metastasizes to regional lymph nodes and extranodal sites. The value of sentinel lymph node biopsy (SLNB) has not been demonstrated clearly for patients with DNMM. The authors report on the utility of SLNB in the management of patients with DNMM.



METHODS

The authors identified 33 patients with DNMM who were seen during a 5-year period in their institution who underwent lymphatic mapping and SLNB. Clinical and histopathologic data were reviewed.



RESULTS

Thirty-three patients with DNMM underwent SLNB (mean Breslow depth, 4.0 mm; median, 2.8 mm). There were 25 male patients and 8 female patients with a median age of 61 years (range, 31–86 years). Fifty-two percent of tumors presented in the head and neck region, and 24% were associated with lentigo maligna. Four of 33 patients (12%) without clinical evidence of metastatic disease who underwent SLNB had at least 1 positive sentinel lymph node. No additional positive lymph nodes were found in subsequent therapeutic regional lymphadenectomy in any of these four patients.



CONCLUSIONS

SLNB detected subclinical metastases of DNMM to regional lymph nodes. SLNB at the time of resection can provide useful information to guide early treatment and, coupled with lymphadenectomy in positive patients, may limit tumor spread and prevent recurrence at the draining lymph node basin. Cancer 2004. © 2003 American Cancer Society.

/pdf/desmoplastic-and-neurotropic-melanoma-4adeg7tzd9.pdf

Desmoplastic and neurotropic melanoma

BACKGROUND. Adjuvant radiation has been proposed for the treatment of patients with desmoplastic melanoma, who reportedly have local recurrence rates as high as 40 – 60%. The authors investigated local recurrence rates at a tertiary referral center to determine the success of wide excision alone for patients with desmoplastic melanoma. METHODS. A review of a prospectively maintained melanoma clinical data base identified 65 patients between March 1997 and March 2004 with pure cutaneous desmoplastic melanoma. Complete surgical, histopathologic, and staging information was collected along with data on outcome, including local, regional, and distant recurrence and survival. RESULTS. Similar to previous reports, patients with desmoplastic melanoma had a male-to-female ratio of 2 to 1, a mean age of 65.0 years (range, 31–92 yrs), and the majority of their tumors (55%) were located on the head and neck. The mean Breslow depth at diagnosis was 4.21 mm, with 38% of tumors thicker than 4.0 mm. All patients in this series underwent wide excision without radiation therapy. Surgical margins 2 cm were obtained for all trunk and extremity lesions and for 63% of head and neck lesions that measured 1 mm in depth (63%). Margins of 1–2 cm were obtained for the remaining patients. Among 49 patients who had a minimum of 2 years of follow-up (mean, 3.7 yrs), the local recurrence rate was 4% (2 of 49 patients). Seventy-eight percent of the patients studied remained alive with no evidence of disease. CONCLUSIONS. Local recurrence rates in the current series were considerably lower than the historically reported rates. This finding suggests that, for patients with desmoplastic melanoma, wide local excision with careful attention to appropriate margins produces excellent local control rates without the need for adjuvant radiation. Cancer 2005;104:1462–7. © 2005 American Cancer Society.

/pdf/wide-excision-without-radiation-for-desmoplastic-melanoma-27shvqwy15.pdf

Wide excision without radiation for desmoplastic melanoma.

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