DAY 1 - DAILY SUMMARY
June 11, 2021
A Patient-Centered and Evidence-Based Approach to Field Pre-Cancerization
Seaver Soon, M.D.
Dr. Soon lead us through an evidence-based discussion of therapy for field pre-cancerization. He first emphasized field pre-cancerization as a chronic disease. We should focus on patient-centered care which includes increasing quality-of-life, decreasing downtime, and preventing progression to squamous cell carcinoma (SCC). 
 
Dr. Soon revealed his treatment algorithm for pre-cancerization therapy. We must first determine if patients are a high risk for poor outcomes from SCC. High risk patients include those with a history of Brigham and Women’s Hospital stage T2b SCC, immunosuppression, and >10 SCCs per year. To reduce incidence of nonmelanoma skin cancers, both niacinamide 500mg twice daily and acitretin 10-25mg daily seem to be effective. Unfortunately, acitretin is costly—up to $6000 annually.
 
If a patient has lower risk for poor SCC outcomes, we can consider 5% 5-flurouracil cream (5-FU), which appears to be the most efficacious and cost-effective over other topical therapies. The new kid on the block is a combined 5% 5-FU cream plus calcipotriol, which showed reduction in SCC incidence in a 3 year follow up period. There have also been advances in photodynamic therapy (PDT). Dr. Soon performs “daylight PDT.” After incubation with ALA and chemical-based sunscreen, patients sit outside for 2 hours. It appears to be more efficient and less painful for patients. Other treatments on Dr. Soon’s algorithm include medium depth chemical peels, topical tirbanibulin 1% for patients who want less downtime, and chemowraps with 5-FU for pre-cancerization therapy on the legs. 
High-Risk Skin Cancer: Merkel Cell Carcinoma, Basal Cell Carcinoma, Squamous Cell Carcinoma
Seaver Soon, M.D.
Dr. Soon provided an excellent overview and update on high-risk skin cancers including Merkel cell carcinoma (MCC), squamous cell carcinoma (SCC), and basal cell (BCC) carcinoma.

MCC may be induced by Merkel Cell Polyomavirus (MCPyV) (80% of cases) or UV radiation (20% of cases). The AEIOU mnemonic outlines characteristics associated: asymptomatic, enlarging nodule, immunosuppressed patient, older patient, UV radiation. The status of MCPyV is clinically relevant – Nghiem et. al found that virus (-) patients are at increased risk for disease progression and disease-specific death and have an overall worse survival trend. Thus, virus (-) patients may warrant more aggressive surveillance with imaging. Nghiem et. al also demonstrated that viral oncoprotein antibodies may be monitored as a marker for recurrence in MCC, since half of MCPyV patients make antibodies to the ST antigen. Serologies should be obtained within 3 months of treatment, and repeated q3months in place of routine imaging. Increasing titers should then trigger imaging studies to evaluate for progression. Dr. Soon also highlighted that single fraction radiation is an effective and durable option in metastatic MCC and may induce abscopal effect with concurrent immune checkpoint therapy, even in patients with progression. 

For SCC, a recent study demonstrates the positive effect of imaging for Brigham and Women’s Hospital Stage T2B/T3 SCC. Lack of imaging is statistically significantly associated with nodal metastasis and eventual development of any poor SCC outcome. Multivariate analysis adjusting for sex, tumor location, and tumor stage, patients with imaging had a 50% less risk of developing a disease-related outcome. Those who did not receive imaging also had poorer survival. With regard to adjuvant radiation (ART), another recent retrospective study found no difference in disease-related outcomes for surgically monitored vs surgically monitored + ART in node-negative primary cutaneous SCC with clear histologic margins.  In the subgroup analysis of SCC with large-caliber peripheral nerve involvement, there were still no difference in outcomes.

Finally, high risk BCC has increased risk of local recurrence, metastasis, and death if associated with diameter >4cm, head and neck location, and invasion beyond subcutaneous fat. A recent meta-analysis study shows vismodegib outperforms sonidegib in both safety and efficacy for locally advanced BCC. Alternate dosing of hedgehog inhibitors increases tolerability without compromising efficacy. In cases of disease progression on hedgehog inhibitor, or intolerance, immune checkpoint therapy may be useful.
Cases from the Derm-Rheum Clinic
Tara Paravar, M.D.
Dr. Paravar lead us through a case-based discussion of some of her more complex rheum-derm patients. The first case was a patient with history of breast cancer who was diagnosed with dermatomyositis (DM) and found to have positive anti-TIF-1 gamma antibodies. Dr. Paravar highlighted that DM patients with these antibodies have an increased incidence of malignancy as well as other unique skin findings. She also presented the hypothesis that skin trauma may be pathogenic to the formation of gottrons papules. Dr. Paravar then used a case to highlight the increased incidence of cutaneous adverse events in DM patients taking plaquenil. 
 
Case 3 described a patient with SLE who developed cutaneous lupus at the site of a prior healed shingles eruption. It was determined that this was an isotonic response, or a new cutaneous disease erupting at the site of a prior healed rash. This is different than an isomorphic response, which we typically describe as Koebner phenomenon. 
 
Case 4 described a patient with urticarial vasculitis (UV). Dr. Paravar urged us to check complement levels in this condition as hypocomplementemic UV can have severe systemic manifestations. Patients with UV can be distinguished from urticaria by the presence of lesions which last longer than 24 hours, are painful or burning rather than pruritic, and heal with post inflammatory hyperpigmentation or purpura. However, we should consider a biopsy in patients with chronic urticaria not responsive to antihistamines, as not all patients with UV have these aforementioned characteristics. 
Financial Tips for the Dermatology Practice
Jashin Wu, M.D.
Dr. Jashin Wu discussed that it’s important to teach your children about money matters, as this very important topic is not taught in school.  He feels it’s best to learn about money yourself then have pay somebody to manage it for you.  Even though they are supposed to look out for you, they still have to look out for their own income.
 
Dr. Wu felt one should have 3-6 months of cash for living expenses in case of emergencies, and not to have too much in cash which earns little interest and loses value due to inflation, which is usually 2-3% each year. 
 
Gold is a hedge against inflation, because its price tends to rise when the cost-of-living increases or the local currency is losing value.  As storage of gold bars is an issue, it may be simpler to buy gold miner stocks. 
 
It’s important to own your primary home, as the value of the property goes up over time, and there are tax benefits in owning a home and when selling a home.  Interest rates are at historic lows, so mortgages may be more manageable.  
 
However, in comparison to equities (stocks/mutual funds/ETFs), real estate won’t appreciate in value as much over time (can’t get 5-10x or more return in a few years).  Equities (stocks/mutual funds/ETFs) are an have more upside, but losses can be real, and stocks can go bankrupt.
Historically, equities have beaten real estate over time.  To diversify, it’s good to have both, but Dr. Wu prefers equities since they are simple to trade, have free commissions, and have higher potential for returns.  One would need to check out real estate in person, and real estate has more upfront and ongoing costs.
 
Most people will have ~10 mutual funds offered in their 401k.  He recommends picking just 1 or 2 index funds.  For taxable accounts, for the investor who doesn’t have the time or inclination to pick stocks or bonds: he recommends Vanguard Total Stock Market Index Fund Institutional Shares (VITSX) (expense ratio 0.03%) and Vanguard Total Bond Market Index Fund Institutional Shares (VBTIX) (expense ratio 0.035%).
 
In order to determine how much equities vs bonds to have, use 100 and 120 minus your age to get the percent in equities, and the rest is in bonds. For example, for a 40 yo person, it would be 100-40= 60 to 120-40= 80, so 60-80% should be in equities, so then 20-40% would be in bonds.  One can then put more or less in equities based on their personality
Dermatology Research and Education Foundation