Cosmetic Surgery Blog Santa Monica

The fact that itch may be associated with internal malignancy has previously been suspected. A recent study looked back at over 16,000 adult patient seen at the Johns Hopkins Health System from 2013-2017. They compared those with itch vs those without. Patients with pruritus (itch) were significantly more likely to have concomitant malignancy than those without pruritus. Most strongly associated were cancers of the liver, gallbladder and biliary tract, hematopoietic (blood) system, and skin. The study did not identify which came first, malignancy or itch, and did not identify the cause of the itch. Was it primarily the malignancy or the treatment or some other factor that cased the itching? None the less, the association has been confirmed such that patients with long term itching of no other apparent cause should be considered for a work up to rule out the most commonly associated malignancies.

Citation

Journal of the American Academy of Dermatology
Association Between Itch and Cancer in 16,925 Pruritus Patients: Experience at a Tertiary Care Center
J Am Acad Dermatol 2018 Sep 11;[EPub Ahead of Print], VA Larson, O Tang, S Stander, S Kang, SG Kwatra

The use of “check point inhibitors” has revolutionized the approach to many advanced malignancies such as advanced melanoma. In fact this years Nobel prize was awarded to scientist who first developed this class of drugs.

These drugs work by allowing the immune-system to see the cancer cells and so initiate an attack against this otherwise hidden enemy. Now a new check point inhibitor, Libtayo (cemiplimab-rwlc) has gained FDA approval for the treatment of advanced squamous cell cancer of the skin.

This is the second most common form of skin cancer, and is usually cured with a relatively simple surgery. But in advanced cases that have metastasized, surgery alone is not adequate. This new check point inhibitor that may make a big difference for these patients. As mentioned in previous blog posts, helping the bodies immune system fight off cancer is likely to be the best chance of cure in many advanced cancers.

Cancer cells, particularly melanoma can be very skillful at avoiding recognition and attack by the bodies defenses. Novel immunotherapy with checkpoint blockade can help the patients’ immune system recognize and attack previously hidden cancer cells. A recent retrospective study demonstrates a significant improvement in 4 year overall survival in patients with advanced metastatic melanoma after FDA approval of these therapies. There is a long way to go, but now we can clearly see light at the end of the tunnel. It seems to me the ultimate “cancer cure” of the future will be through the patients own immune system, not chemotherapy, radiation or surgery.

Citation

Improved Risk-Adjusted Survival for Melanoma Brain Metastases in the Era of Checkpoint Blockade Immunotherapies: Results from a National Cohort
J. Bryan Iorgulescu, Maya Harary, Cheryl K. Zogg, Keith L. Ligon, David A. Reardon, F. Stephen Hodi, Ayal A. Aizer and Timothy R. Smith
Cancer Immunol Res September 1 2018 (6) (9) 1039-1045; DOI:10.1158/2326-6066.CIR-18-0067

Most patients with thin, early melanomas do very well, having a relatively low risk of disease spread or re-occurrence. However some of these “low risk” patients are not so lucky and end up with re-occurrence, or metastasis. In an effort to better predict which of the “low risk” patients were likely to be in this less fortunate sub-group, investigators used a 31-gene expression profile (31-GEP). The results suggest that the 31-GEP test may help identify high-risk individuals within groups previously considered to be low-risk. This could alert the patient and their treating physicians for the need for more careful follow up and even to consider adjunct treatment. Larger prospective studies will be needed to better understand how and when to use these test and what to do with the results. None the less it is getting us one step closer to better predicting patients risk and so will ultimately help guide management.

Citation:

Journal of the American Academy of Dermatology
Identification of Patients at Risk for Metastasis Using a Prognostic 31-Gene Expression Profile in Subpopulations of Melanoma Patients With Favorable Outcomes by Standard Criteria
J Am Acad Dermatol 2018 Aug 03;[EPub Ahead of Print], BR Gastman, P Gerami, SJ Kurley, RW Cook, S Leachman, JT Vetto

We know that UV light is the main driver of most skin cancers. UV rays from the sun or tanning beds causes mutations in the DNA of skin cells that are the cause of most skin cancers. However we also know that some skin cancers are not related to UV exposure. A link between chronic inflammation and skin cancers has long been recognized. Now a mechanism that may explain this has been elucidated in a recent study. Looking at skin samples from children with a rare skin condition, recessive dystrophic epidermolyisis bullosa investigators found that the skin cancers from the chronic inflammation in this condition were related to over activity of a protein called APOBEC. This protein normally plays a role in adding diversity to cellular proteins and is also thought to help defend against viruses. In chronic inflammation it appears to become overactive causing it to introduce mutations across the genome, some of which eventually lead to cancer.

There is hope that this new knowledge will help investigators work on better preventative strategies for the many cancers (in both skin and other tissues) that are related to chronic inflammation.

Citation:

APOBEC mutation drives early-onset squamous cell carcinomas in recessive dystrophic epidermolysis bullosa
Raymond J. Cho et al.
Science Translational Medicine 22 Aug 2018: Vol. 10, Issue 455

The dogma is that we need to encourage our children to use sunscreen not just to avoid the pain of an acute sunburn now but to lessen the risk of melanoma latter in life. But is all the hassle really worth it?. A population-based, case-control family study was conducted in Australia to examine this issue. The identified 603 participants who were diagnosed with melanoma between the ages of 18 and 40 years, and 1088 controls, including 478 unrelated controls and 610 siblings. They questioned all on childhood sunscreen use and found that unprotected sun exposure was significantly associated with melanoma risk (OR, 1.8). This risk was especially strong for people who reported using sunscreen to stay in the sun longer and those with lighter pigmentation. So although they may squirm and scream when you try to slather them up you should know, sun exposure in children without the protection of sunscreen resulted in an increase risk of melanoma as a young adult. So yes, it is worth the hassle!

There are many different potential ingredients in sunscreens. One of the most common is an organic UV filter called oxybezone. Since its wide spread use in sunscreen oxybenzone has been found in water sources and various species of fish worldwide. Oxybenzone has also been shown to contribute to coral reef bleaching. Organic filters such as oxybezone are not easily removed by common waste treatment plant techniques. However there is no evidence that these chemicals in sunscreen are harming humans in the concentrations to which we are exposed. Still, I would recommend when choosing a sunscreen avoid the ones with organic filters such as oxybenzone and favor those with physical blockers such as titanium dioxide or zinc oxide. I addition use sun protective clothing, hats and seek shade. We need to protect ourselves but we dont need to do so at the expense of the environment!

Article Citation

Dermatological and Environmental Toxicological Impact of the Sunscreen Ingredient Oxybenzone/Benzophenone-3
J Cosmet Dermatol 2018 Feb 01;17(1)15-19, JC DiNardo, CA Downs

A UV nail lamp is often used to dry, harden, and cure the nails at home and in the salon. However it is a source of artificial UVA radiation so these lamps may pose a health risk. UVA radiation is known to be mutagenic and can cause damage to the DNA, which may increase the risk of skin cancer. A recent review of the limited data available concluded that, the carcinogenic risk is probably low; “nonetheless, the use of a broad spectrum sunscreen with SPF >30 before UV nail lamp exposure is recommended”. So next time you are getting your nails done think about applying your sunscreen first!

Citation:

Potential Cutaneous Carcinogenic Risk of Exposure to UV Nail Lamp: A Review
Photodermatol Photoimmunol Photomed 2018 Jun 08;[EPub Ahead of Print], N Shihab, HW Lim

A recent study confirms that patients with lots of moles (more than 50) and patients with dysplastic (atypical) moles are at higher risk for melanoma and develop their melanomas at a younger age. However the good news is that these same patients seem to have their melanomas diagnosed earlier and at a less aggressive stage than patients with fewer moles. This is at least partly due to more careful and regular skin cancer surveillance in the “high risk” group. One important lesson from this study is everyone needs to regularly check their moles. Higher risk patients (those with lots of moles and atypical moles) because they are more likely to develop melanoma, and lower risk patients (those with fewer and more typical moles) to avoid latter diagnosis of the melanomas they do develop.

Citation:

Association of Clinicopathological Features of Melanoma With Total Naevus Count and a History of Dysplastic Naevi: A Cross-Sectional Retrospective Study Within an Academic Centre
Clin Exp Dermatol 2018 Jul 01;43(5)566-572, SY Tan, LC Strazzulla, X Li, JJ Park, SJ Lee, CC Kim
More on Melanoma

The importance of which specific bugs you have in your body, your “microbiome” , is becoming increasingly recognized. Now a study has show that patients’ repose to an immune therapy used in advanced melanoma, varied based on their specific microbiome. Investigators used stool samples to get an accurate picture of each patients microbiome before treatment with anti-PD-1 therapy for advanced melanoma. They found a strong correlation between specific bugs in patients’ microbiome and their response to therapy. Further more, microbial reconstitution of germ-free mice with fecal material from responding patients improved tumor control and augmented T-cell responses in mice. It is logical to hope that adjusting human microbimes prior to therapy will improve their subsequent response to this and potential other treatments.

Citation:

The Commensal Microbiome Is Associated With Anti-PD-1 Efficacy in Metastatic Melanoma Patients
Science 2018 Jan 05;359(6371)104-108, V Matson, J Fessler, R Bao, T Chongsuwat, Y Zha, ML Alegre, JJ Luke, TF Gajewski