A DERMATOLOGY FOUNDATION PUBLICATION SPONSORED BY MEDICIS, A DIVISION OF VALEANT PHARMACEUTICALS VOL. 32 NO. 2 SUMMER 2013 DERMATOLOGYDERMATOLOGY ™ DF Also In This Issue DF President FOCUSFOCUS Michael D. Tharp, MD, Shares Vision for Future 2014 Research Funding DF Clinical Symposia: Applications Due October 15 56 New Proceedings 2013–Part II Leaders Society Members how critical this is, Elston described a study in which a bisected acral ADVANCES IN DERMATOLOGY nevus was shown to 10 excellent university-based surgical patholo- The Dermatology Foundation presented its annual gists. Half of the lesion was bisected correctly, and a separate slide 3-day symposia series in February. This highly regarded was made with the other half bisected incorrectly (parallel to the der- matoglyphs). The half that was correctly bisected was unanimously cutting-edge CME program provides the most clinically called benign, while the half that was bisected parallel to the der- relevant knowledge and guidance for making the matoglyphs—the same lesion—was unanimously diagnosed as newest research advances accessible and usable. A melanoma, misdiagnosed based purely on the plane of section. daily provocative keynote talk precedes topic-focused, An acral melanocytic lesion should be completely excised peer-reviewed caliber presentations. This year’s with a narrow margin, using saucerization or scooping it out to re- topics were: Women’s & Children’s Dermatology; duce morbidity on an acral site. Do the bisection yourself if neces- CPC; Emerging Therapies; Revisiting Old Therapies; sary to ensure that it is bisected across the dermatoglyphs, and Medical Dermatology; and Cutaneous Oncology & write on the bottle that it has already been bisected. Immunology. The Proceedings appear in the Spring Spitz Nevus. The majority of Spitz nevi can be diagnosed (Part I) and Summer (Part II) issues. in H&E sections, but the three most predictive features are at the lesion’s sides and base—areas often not included in the biopsy Janet A. Fairley, MD, and spe-cimen. At the base, a Spitz nevus disperses into single file while Jack S. Resneck, Jr., MD—Program Co-Chairs spitzoid melanomas remain as a large aggregate. A Spitz nevus rarely contains deep mitoses, while spitzoid melanomas may have mitoses or atypical mitotic figures. And a Spitz nevus shows sharp lateral KEYNOTE ADDRESS circumscription, ending in a nest, while malignant lesions trickle off with individual cells. Because this lesion’s sides and base are Controversies Surrounding Pigmented often omitted, immunostains and genome analysis may be needed. Lesion Biopsies Dirk M. Elston, MD Biopsy Technique Errors Leading Introduction. “There are situations in which how we biopsy makes a difference that can profoundly affect the interpretation of the to Misdiagnosis specimen,” Dr. Elston stated, speaking from his 30 years of practice as both clinician and dermatopathologist. Most often, an inadequate biopsy specimen delays diagnosis. Less frequently, but of far greater importance, is a mistaken diagnosis. Elston focused on four pig- mented lesions—acral nevus, Spitz nevus, lentigo maligna, and dys- plastic nevus—that are particularly vulnerable to inadequate biopsy and for which an incorrect diagnosis carries serious consequences. Acral Nevus. In an acral nevus, linear nests follow the der- Left: If this benign acral nevus is bisected parallel to the dermatoglyphs instead matoglyphs and the lesion must be bisected across them. When bi- of across them, it could be misdiagnosed as melanoma. Right: Because each section is parallel to the dermatoglyphs, the histologic appearance color in this mottled lesion of lentigo maligna may reflect a different pathology, becomes one of confluence with long, irregular nests and an sample each color to avoid sampling error and misdiagnosis. inaccurate rete ridge pattern, simulating melanoma. Illustrating (Continued on page 3) 2014 DF Clinical Symposia ADVANCES IN DERMATOLOGY February 5–9, 2014 The Ritz-Carlton, Naples, Florida Registration Begins in September! Visit www.dermatologyfoundation.org/symposia RAVE REVIEWS “This meeting teaches real dermatology.” “Chock full of cutting-edge knowledge—the most concentrated presentation of new, pertinent information for dermatology.” “Great coverage of the modern scope of derm—balance of basic science, clinical, surgical, and cosmetic.” “Great speakers and latest material in an efficient, high yield setting.” “Best meeting I attend all year.” COMPELLING TOPICS Surgery and Aesthetics Difficult Diseases in Medical Dermatology Immunologic Skin Diseases Pediatric Dermatology Infectious Diseases and the Skin Cutaneous Oncology: Clinical Challenges How to Avoid Harming Your Patient: Safety Issues in Dermatology Plus 3 provocative Keynote Talks EXPERT FACULTY Marc D. Brown, MD John E. Harris, MD, PhD Brian Schwartz, MD University of Rochester University of Massachusetts University of California, San Francisco Brett M. Coldiron, MD Daniela Kroshinsky, MD University of Cincinnati Harvard Medical School Bruce E. Strober, MD, PhD University of Connecticut Health Center Ilona J. Frieden, MD Naomi Lawrence, MD University of California, Cooper University James R. Treat, MD San Francisco University of Pennsylvania Laura B. Pincus, MD Joel M. Gelfand, MD, MSCE University of California, Hensin Tsao, MD, PhD University of Pennsylvania San Francisco Harvard Medical School The DF Clinical Symposia provides 16 AMA PRA Category 1 Credits™. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Yale School of Medicine and the DF Dermatology Foundation. The Yale School of Medicine is accredited by the ACCME to provide continuing medical education to physicians. Shaping the Future of Dermatology 2 Summer 2013 Dermatology Foundation Dr. Elston illustrated this with a highly pleomorphic, purely epithelioid lesion from an 11-year-old girl that lacked both the spin- dle cells typical of a Spitz nevus and the junctional component DERMATOLOGY FOCUS typical of a primary melanoma. A lesion removed 3 years earlier A PUBLICATION OF THE DERMATOLOGY FOUNDATION DF Sponsored by was highly atypical and since then, atypical serial lesions in the regional drainage basin had appeared. Because of the transected Medicis, A Division of Valeant Pharmaceuticals base immunostaining proved to be helpful, confirming a high pro- Editors-in-Chief liferative fraction and poor staining with S100A6. David J. Leffell, MD—Professor of Dermatology Lentigo Maligna (LM). Almost half of all cases of lentigo Yale School of Medicine, New Haven, CT maligna occur in collision with a pigmented actinic keratosis or Mary M. Tomayko, MD, PhD—Assistant Professor of Dermatology benign lentigo, and each color in a mottled lesion may actually repre- Yale School of Medicine, New Haven, CT sent a different pathology. Unless the biopsy method demonstrates Heidi A. Waldorf, MD—Director, Laser and Cosmetic Dermatology eachmorphologywithinthelesion,theriskofsamplingerrorisextremely The Mount Sinai Medical Center, New York, NY high. Elston documented this in two studies. One study inspected 96 Executive Director Mohs debulking specimens and 51 broad shave biopsies of LM that Sandra Rahn Benz contained only the clinical lesion, with no adjacent sun-damaged skin. Deputy Executive Director Almost 50% were in collision with a second pigmented lesion—mostly a Christine M. Boris benign solar lentigo or pigmented AK—in at least one-fifth of the lesion. Please address correspondence to: The darkest area merely represented the greatest pigment inconti- Editors-in-Chief nence,notthegreatestlikelihoodofdemonstratingthemelanoma.The Dermatology Focus second study demonstrated that lichenoid regression within lentigo c/o The Dermatology Foundation maligna can easily be interpreted as benign lichenoid keratosis. 1560 Sherman Avenue, Evanston, Illinois 60201 Tel: 847-328-2256 Fax: 847-328-0509 Use of a 4-mm punch biopsy in the setting of LM is associated with e-mail: [email protected] up to an 80% risk of a false negative biopsy result. In a biopsy for LM, Published for the Dermatology Foundation by “one needs a significant area of the dermoepidermal junction.” Elston Robert B. Goetz—Designer, Production recommends either a very broad, paper-thin shave biopsy or his per- Sheila Sperber Haas, PhD—Managing Editor, Writer sonal preference—a small shave of every color in the lesion. All pieces go in the same bottle and are processed as a single specimen. This issue of Dermatology Focus is distributed without charge through Dysplastic Nevus. Beginning a shave biopsy at the edge of an educational grant from Medicis, A Division of Valeant Pharmaceuticals. The opinions expressed in this publication do not necessarily reflect those of the visible brown border actually truncates the lesion, and as most the Dermatology Foundation or Medicis, A Division of Valeant Pharmaceuticals. of the atypia and confluence are at the outer edge, pathologists © Copyright 2013 by the Dermatology Foundation may “upgrade” the lesion when it extends broadly to a margin. For the best assessment of margins and eliminating diagnostic prob- The Delayed Tie. Arpey described wounds requiring buried lems, a saucerized biopsy technique can be used to remove the absorbable sutures but with inadequate space for inserting the nee- lesion plus a border of 0.5–2 mm of normal-appearing skin. This dle for the last