Howard K Steinman
@Campbell University
Adjunct Associate Professor of Surgery
RESEARCH INTERESTS
Mohs surgery
Skin cancer
Scopus Publications
Scopus Publications
Anthony J. Dixon, Athanassios Kyrgidis, Howard K. Steinman, John B. Dixon, Michael Sladden, Claus Garbe, Aimilios Lallas, Christopher B. Zachary, Ulrike Leiter‐Stöppke, Harvey Smith,et al.
Wiley
AbstractBackgroundMelanoma disease patterns vary with patient age.AimTo evaluate sentinel lymph node biopsy (SLNB) in managing melanoma at differing patient ages.MethodsOnline prediction tools were applied to compare SLNB positivity (SLNB+) and survival risk at patient ages 20–80. Tübingen melanoma data were used to determine variations in the hazard ratio of SLNB+ for mortality at different patient ages.ResultsRegardless of tumour thickness, predicted SLNB+ rates were markedly higher than mortality rates for 20‐year‐old patients. For 80‐year‐old patients, it is the opposite.DiscussionIf 1000 20‐year‐olds with a 0.4 mm thickness non‐ulcerated melanoma underwent SLNB, 100 would likely be positive. If all 100 were to be offered adjuvant drug therapy (ADT), fewer than three more melanoma deaths in those 1000 patients would be avoided. In total, 97 patients would have received medication they may never have needed. If 1000 80‐year‐olds with a 3 mm thickness non‐ulcerated melanoma underwent SLNB, only 40 would likely be positive. In total, 274 patients would be predicted to die of melanoma, 245 being SLNB negative and 29 SLNB+. ADT linked to SLNB+ could deny treatment to 89% of these high‐risk patients.LimitationsThe authors relied on published risk data.ConclusionSLNB has poor specificity at predicting mortality in young melanoma patients and poor sensitivity in older patients. SLNB is not indicated in managing cutaneous melanoma for patients under 40 or over 60 years of age. Many such patients could be managed with wide local excision alone in their clinician's office‐based practice. For all cutaneous melanoma patients at all ages, linking ADT to BAUSSS biomarker, (an algorithm of Breslow thickness, age, ulceration, subtype, sex and Site) rather than SLNB+ is likely more appropriate. BAUSSS provides a more accurate melanoma‐specific mortality risk assessment for patients without burdening them with added surgery, hospitalization, costs or morbidity risk.
Anthony Joseph Dixon, Michael Sladden, Christos C. Zouboulis, Catalin M. Popescu, Alexander Nirenberg, Howard K. Steinman, Caterina Longo, Zoe Lee Dixon, and Joseph Meirion Thomas
MDPI AG
Background: Maximizing survival for patients with primary cutaneous melanomas (melanomas) depends on an early diagnosis and appropriate management. Several new drugs have been shown to improve survival in high-risk melanoma patients. Despite well-documented guidelines, many patients do not receive optimal management, particularly when considering patient age. Objective: to provide an update on melanoma management from the time of the decision to biopsy a suspicious skin lesion. Methods: We reviewed melanoma-management research published between 2018 and 2023 and identified where such findings impact and update the management of confirmed melanomas. Pubmed, Google Scholar, Ovid and Cochrane Library were used as search tools. Results: We identified 81 publications since 2017 that have changed melanoma management; 11 in 2018, 12 in 2019, 10 in 2020, 12 in 2021, 17 in 2022 and 18 in 2023. Discussion: Delayed or inaccurate diagnosis is more likely to occur when a partial shave or punch biopsy is used to obtain the histopathology. Wherever feasible, a local excision with a narrow margin should be the biopsy method of choice for a suspected melanoma. The Breslow thickness of the melanoma remains the single most important predictor of outcome, followed by patient age and then ulceration. The BAUSSS biomarker, (Breslow thickness, Age, Ulceration, Subtype, Sex and Site) provides a more accurate method of determining mortality risk than older currently employed approaches, including sentinel lymph node biopsy. Patients with metastatic melanomas and/or nodal disease should be considered for adjuvant drug therapy (ADT). Further, high-risk melanoma patients are increasingly considered for ADT, even without disease spread. Invasive melanomas less than 1 mm thick are usually managed with a radial excision margin of 10 mms of normal skin. If the thickness is 1 to 2 mm, select a radial margin of 10 to 20 mm. When the Breslow thickness is over 2 mm, a 20 mm clinical margin is usually undertaken. In situ melanomas are usually managed with a 5 to 10 mm margin or Mohs margin control surgery. Such wide excisions around a given melanoma is the only surgery that can be regarded as therapeutic and required. Patients who have had one melanoma are at increased risk of another melanoma. Ideal ongoing management includes regular lifelong skin checks. Total body photography should be considered if the patient has many naevi, especially when atypical/dysplastic naevi are identified. Targeted approaches to improve occupational or lifestyle exposure to ultraviolet light are important. Management also needs to include the consideration of vitamin D supplementary therapy.
Anthony J. Dixon, Athanassios Kyrgidis, Michael Sladden, Alexander Nirenberg, Howard K. Steinman, Harvey Smith, Christopher B. Zachary, Stuart Anderson, Ulrike Leiter‐Stöppke, Caterina Longo,et al.
Wiley
C. C. Zouboulis, A. J. Dixon, H. K. Steinman, M. Sladden, and A. Kyrgidis
Wiley
A. Dixon, H. K. Steinman, A. Kyrgidis, H. Smith, M. Sladden, C. Zouboulis, G. Argenziano, Z. Apalla, A. Lallas, C. Longo,et al.
Wiley
BACKGROUND
Breslow thickness, patient age and ulceration are the three most valuable clinical and pathological predictors of melanoma survival. A readily available reliable online tool that accurately considers these and other predictors could be valuable for clinicians managing melanoma patients.
OBJECTIVE
To compare online melanoma survival prediction tools that request user input of clinical and pathological features.
METHODS
Search engines were used to identify available predictive nomograms. For each, clinical and pathological predictors were compared.
RESULTS
Three tools were identified. The American Joint Committee on Cancer tool inappropriately rated thin tumors as higher risk than intermediate tumors. The University of Louisville tool was found to have six shortcomings: a requirement for sentinel node biopsy, unavailable input of thin melanoma or patients over 70 years of age and less reliable hazard ratio calculations for age, ulceration, and tumor thickness. The LifeMath.net tool was found to appropriately consider tumor thickness, ulceration, age, sex, site and tumor subtype in predicting survival.
LIMITATIONS
The authors did not have access to the base data used to compile various prediction tools.
CONCLUSION
The LifeMath.net prediction tool is the most reliable for clinicians in counselling patients with newly diagnosed primary cutaneous melanoma regarding their survival prospects.
A. J. Dixon, H. K. Steinman, A. Kyrgidis, H. Smith, M. Sladden, C. Zouboulis, G. Argenziano, Z. Apalla, A. Lallas, C. Longo,et al.
Wiley
Dear Editor, Sentinel lymph node biopsy (SLNB) benefits are said to include identifying the presence and degree of micrometastases, improving staging, predicting prognosis and determining eligibility for adjuvant drug therapy. Sentinel lymph node biopsy is an invasive procedure, which needs nuclear medicine and operating room facilities. Neither SLNB nor early identification of micrometastases provides an overall survival benefit for melanoma patients.1,2 Adverse events in the order of 11% are expected.3 Predicting the likelihood of mortality can assist patient selection for adjuvant drug therapy. Breslow thickness, ulceration status and other clinical and pathologic predictors (CAPP) assist predicting melanoma survival.4 Sentinel lymph node biopsy status (SLNBS) might contribute only a marginal survival predictability above that of an algorithm of CAPP.5,6 Until recently, no quality research has been available to test this hypothesis. El Sharouni et al (ESS)7 recently detailed the prognostic value of CAPP, with or without SLNBS, for calculating overall survival (OS) for melanoma patients. Predictors including Breslow thickness, tumour, ulceration, patient age, sex, mitotic activity, regression, tumour subtype and location were evaluated in 9272 Dutch patients. The findings were validated in 5644 Australian patients.7 El Sharouni et al evaluated the accuracy of each CAPP in predicting OS using appropriate Area Under Curve (AUC) cstatistic methodology.7 The higher the Cstatistic, the better the model separates patients who will die from those who will not die. Combined CAPP was significantly superior to SLNBS at predicting OS. Combining SLNBS with CAPP increased cstatistic for OS by only 3%, with overlapping confidence intervals indicating an absence of statistical significance (Figure 1). El Sharouni et al found Breslow thickness to be the most accurate OS predictor followed by patient age. Subsequently, SLNBS and ulceration were similar. Mitotic activity and regression fell below 0.54, suggesting they might not provide relevant information7 (Figure 2). El Sharouni et al also reported that SLNBS detected 1.4 more net highrisk melanoma patients (HRMP) for every 100 patients experiencing recurrence within 3 years when used in combination with CAPP.7 Recurrence rates of approximately 13%– 15% have been reported in HRMP.8 Assuming a 14% rate, 510 patients would need to undergo SLNB to predict one more HRMP compared with using CAPP alone. The added cost of SLNB above wide local excision (WLE) is estimated to be approximately US$3000.9 This indicates the added cost to detect one additional HRMP with SLNB in this ESS analysis would be over US$1.5 M, excluding costs for managing SLNB complications. This casts doubt on the cost benefit analysis of the addition SLNBS to CAPP when an assessing an individual's prognosis. Gene expression analyses (GSA) have recently been demonstrated to be independent reliable predictors of melanoma survival. When added to the CAPP, GSA will likely produce nomograms superior to those currently including SLNB.10 The data provided by ESS suggest the use of SLNB in melanoma management merits major reconsideration. Some HRMP, identified by CAPP, are currently being denied adjuvant drug therapy because they did not undergo SLNB or their SLNB was negative. Sentinel lymph node biopsy currently acts as a gatekeeper to adjuvant drug therapy trials. In many trials, not undergoing or a negative SLNB denies entry. Reorientating trials around CAPP alone would increase eligible patients whilst reducing costs and harm to the broader community. Received: 24 December 2022 | Accepted: 8 February 2023
Anthony Dixon, Athanassios Kyrgidis, Christopher Zachary, John Dixon, Catalin Popescu, Michael Sladden, Zoe Apalla, Stuart Anderson, Giuseppe Argenziano, Demitrios Ioannides,et al.
Wiley
Howard K. Steinman, Anthony Dixon, and Christopher B. Zachary
Elsevier BV
Howard K. Steinman, Anthony Dixon, and Christopher B. Zachary
Ovid Technologies (Wolters Kluwer Health)
We read with interest Petersen and colleagues’s study examining primary superficial basal cell carcinoma (sBCC) cases treated with Mohs micrographic surgery (MMS) for the presence of more aggressive mixed histology (MH). An impetus for their study was to counter assertions that the Mohs surgery appropriate use criteria (MAUC) for sBCC merited reclassification as either “uncertain” or “inappropriate.” They noted that proponents of maintaining the current MAUC offer the counterargument that sBCC containing this mixed histology share the recurrence risk of the more aggressive BCC subtypes noted within. They further stated that there are no previous studies in the literature establishing benchmarks for the incidence of MH in sBCC. Petersen and colleagues evaluated 247 MMS cases of sBCC and found statistically significantly higher incidences of MH in (1) facial versus trunk and extremities lesions, (2) MAUCAreaH versus Area L, and (3) AreaMversus area L. They concluded this justifies continuing to score sBCCs as “appropriate” for Mohs surgery in high-risk areas. Their results confirm those of Pyne and colleagues, who in 2017 evaluated MH in 3150 consecutive sBCC excisions. 48.5% showed sBCC alone, 34.3% showedMHwith sBCC 1 nodular subtypes, and 17.1% sBCC1 aggressive subtypes (defined as “infiltrating, morpheic, and micronodular.”) 84% of head and neck cases showed MH, whereas 16% showed sBCC alone.Head sites showed a higher incidence of MH versus trunk and limb tumors (p , .0001). Because MH in sBCC likely affects all treatment studies equally, Pyne’s and Petersen’s studies suggest that MH likely has little bearing on treatment outcomes as the reported cure rates of nonexcisional surgical treatments (NEST) for sBCC are often equal or superior to those of MMS irrespective of the presence of MH. There is a paucity of studies treating sBCC with NEST and MMS, and there are no studies comparing MMS with alternative treatments. Barlow and colleagues retrospectively evaluated sBCCs treated with curettage alone with a minimum follow-up of 5 years. Fifty-six percent were on the head or neck. The recurrence rate for 68 sBCCwith noMH was 1.5% and for 106 sBCC with MH was 2.8%. Lindemalm-Lunstram and Dalenback prospectively evaluated 73 sBCC on the scalp and face treated with curettage and cryotherapy, with a mean follow-up of 42 months. No recurrences were noted. These recurrence rates closely approximate numerous published cure rates for MMS of BCC. The few studies of MMS for sBCC suggest it requires a higher average number of stages for clearance than for other, more penetrating and aggressive BCC subtypes. MMS for sBCC often leaves larger wound sizes when compared withMMS for other histological types.Mina and colleagues evaluated 158 sBCC of the head and neck treated with MMS of which 124 cases were primary lesions. Average number of stages to clear margins was 2.8 with a range of 2.2 stages on the lateral face to 2.9 stages on the forehead. Postoperative wound sizes were 2.5 to 38.5 fold larger than tumor sizes (except on the scalp and ears). They concluded that “Mohs surgeons need to be familiar with these tumors on the head and neck given their propensity for skip lesions, higher recurrence rates, and significantly larger defect sizes than would be expected clinically. Orengo and colleagues found that 54% of sBCC treated with MMS required 3 or more stages for tumor clearance with wide wound extensions found beyond clinical pretreatment margins. They noted that only 18% of nodular BCC and 37% of invasive BCC required 3 or more stages. Cerci and colleagues in 2020 evaluated 295 BCCs for the average number of stages to clear margins. When tumors were categorized into superficial, nodular, and aggressive as per the MAUC criteria, the average surgical margins were 3.1, 2.0, and 2.9 mm, respectively (p , .001). The average number of stages to clear margins was 1.8, 1.2, and 1.6, respectively (p , .001). The average for all 295 BCC was 1.38 (range 1–8). This increased the number of stages to clearance and larger final defect sizes for MMS of sBCC may relate to many sBCC being discontiguous, multifocal tumors. These studies of MMS for sBCC support the view that sBCC MAUC merit re-evaluation. Petersen and colleagues incorrectly argue that changing MAUCscoring from“appropriate” to“uncertain”woulddeny access toMMS for sBCC in“high-risk” locations.MAUC state
Alexander Nirenberg, Howard Steinman, and Anthony Dixon
Ovid Technologies (Wolters Kluwer Health)
ABSTRACT
Keratoacanthoma (KA) is a cutaneous tumor with a biphasic pattern of growth. A rapidly growing phase is usually followed by involution. KA occurs on sun-damaged skin. There are many listed causative associations, which include some therapeutic agents. Debate continues as to whether KA is a variant of squamous carcinoma (SCC) or a separate entity. Reporting of KA versus SCC is markedly inconsistent. Reasons for inconsistency include overlapping microscopic criteria, variants of KA with more aggressive features, and possibly medicolegal concerns. Genetic studies have shown some differences between the 2 entities. Activation of apoptotic pathways has been demonstrated in KA. Genetic studies have shown a possible role of human polyomavirus 6 in the pathogenesis of at least some KAs. Given that some cases of KA have components that behave as conventional SCCs, KA can be considered as a low-grade variant of SCC with some genetic differences.
A. Nirenberg, H. Steinman, and A. Dixon
Wiley
Extravascular migratory metastasis (EVMM) is the spread of metastases on the external surfaces of microvascular channels, a phenomenon noted by Recamier in 1829, and by Borst (cited by Handley in 1907)1 . We present a case of an 83-year old male with a pathology-confirmed invasive melanoma on the anterior aspect of his shoulder, Breslow thickness 1.4 mm, dermal mitotic rate of 6/mm. There was EVMM but no intravascular invasion [FIG 1], confirmed with a combined CD34/SOX10 immunohistochemical stain. [FIG 2].
A. Nirenberg, H. Steinman, J. Dixon, and A. Dixon
Wiley
Merkel cell carcinoma (MCC) is an aggressive tumour with neuroendocrine differentiation. Clinically significant differences within the entity we know as MCC are apparent. This review aims to evaluate the evidence for differences in tumours within Merkel cell carcinoma and to stratify these. A literature search of research pertaining to various characteristics MCC was undertaken from 1972, when Merkel cell carcinoma was first described, to 2018, using PubMed and similar search engines. A total of 41 papers were analysed, including clinical trials, laboratory‐based research and reviews. A proportion of MCC has Merkel cell polyomavirus genome integrated (MCPyV+) while others do not (MCPyV−). Both types have a different mutation burden. MCPyV+ tumours are likely true neuroendocrine carcinomas, with a dermal origin, probably from fibroblasts which have been transformed by integration of the viral genome. MCPyV−tumours are likely derived from either keratinocytes or epidermal stem cells, are probably squamous cell carcinomas with neuroendocrine differentiation, and are related to sun damage. Prognostic factors (apart from tumour stage) include the MCPyV status, with MCPyV+ tumours having a better prognosis. P63 expression confers a worse prognosis in most studies. CD8+ lymphocytes play an important role, providing a possible target for PD1/PD‐L1 blockade treatment. The incidence of MCC varies from country to country. Countries such as Australia have a high rate and a far greater proportion of MCPyV− tumours than places such as the United Kingdom. MCC doubtlessly encompasses two tumours. The two tumours have demonstrated differences in prognosis and management. One is a neuroendocrine carcinoma related to MCPyV integration likely derived from fibroblasts, and the other is a UV‐related squamous cell carcinoma with neuroendocrine differentiation, presumptively derived from either keratinocytes or epidermal stem cells. We propose naming the former Merkel type sarcoma and the latter squamous cell carcinoma, Merkel type.
Anthony J Dixon, Howard K Steinman, Alexander Nirenburg, Stuart Anderson, and John B Dixon
The Royal Australian College of General Practitioners
BACKGROUND
Several new medications have shown improved survival rates in high-risk patients with melanoma.
OBJECTIVE
The aim of this article is to discuss the new medications and outline their roles, the expected benefit from each and the risk of adverse events. We explain the place of sentinel lymph node biopsy (SLNB) and ultrasonography with fine needle aspiration (US-FNA) in assessing and treating patients with melanoma.
DISCUSSION
Ipilimumab has limited efficacy and a very concerning complication profile. More than 50% of patients taking ipilimumab have severe or life-threatening adverse events. BRAF inhibitors have greater efficacy and fewer adverse events than ipilimumab. Combining BRAF inhibitors with mitogen-activated protein kinase inhibitors enhances their effect and improves the overall adverse event profile. BRAF inhibitors are only effective when the melanoma has a BRAF gene mutation, something that occurs in only 50% of cases. Programmed cell death protein 1 medications are also more effective and have a much more acceptable adverse event profile than ipilimumab. Both SLNB and US-FNA can detect early node involvement in patients with melanoma, although US-FNA is a safer procedure.
Anthony J Dixon, Howard K Steinman, Alexander Nirenberg, Zoe L Dixon, Stuart Anderson, and John B Dixon
The Royal Australian College of General Practitioners
BACKGROUND
Maximising survival for patients with invasive melanoma hinges on early diagnosis of primary melanoma and appropriate management. Despite well-documented guidelines, many patients with melanoma have not been managed ideally.
OBJECTIVE
The aim of this paper is to identify suboptimal aspects of melanoma management.
DISCUSSION
Delayed or erroneous diagnosis is more likely to occur when a shave or punch biopsy is used to obtain histopathology. Wherever feasible, local excision with a narrow margin is the preferred biopsy choice for a suspected melanoma. The Breslow thickness of the primary melanoma remains the greatest predictor of outcome. Ulceration is associated with a poorer prognosis. Most invasive melanomas are managed with a margin of ≥10 mm of normal tissue. Patients who have developed one primary melanoma are at high risk of a second tumour. Ongoing management includes regular lifelong skin checks. Targeted approaches to improve occupational or lifestyle exposure to ultraviolet radiation are useful. Imaging is largely used when metastases are suspected on the basis of clinical symptoms or signs.
Howard K. Steinman, Anthony Dixon, and Christopher B. Zachary
American Medical Association (AMA)
Howard K. Steinman, Anthony Dixon, and Christopher B. Zachary
American Medical Association (AMA)
Howard. K. Steinman, Henry Clever, and Anthony Dixon
Informa UK Limited
Little is known about the practice characteristics of Mohs surgery performed by physicians who learned the procedure during their dermatology residency training or through postresidency courses and observational preceptorships. All published reports have investigated Mohs surgeons trained in postresidency fellowships. This report presents the results of a multicenter prospective cohort study evaluating 1834 consecutive Mohs surgery cases performed during the same 6-month period by 9 Mohs surgeons who learned the technique in residency or in postresidency courses and observational preceptorships. One major complication was reported, a hematoma requiring outpatient drainage in an emergency room. There were 54 (2.9%) short-term complications, including 20 (1.1%) infections, 17 (0.9%) wound dehiscences, 9 (0.5%) cases of skin flap necrosis, and 8 (0.4%) hematomas or postoperative bleeding episodes. These complication rates and the data evaluating tumor type, anatomic location, primary vs. recurrent tumor status, tumor size, postoperative wound size, number of Mohs surgery stages, and repair type compare favorably to previously published reports.
A. Dixon, H. Steinman, S. Anderson, A. Nirenberg, J. Dixon, and M. Sladden
Wiley
We thank Mr. Saleh for his comments and are pleased he agrees that acceptance into melanoma therapeutic trials should not be contingent on undergoing sentinel node biopsy (SNB). We disagree with his assertion that SNB still has a viable role in melanoma management. Suppose SNB followed by completion lymphadenectomy (CL) was a drug therapy for melanoma, subjected to a ten-year randomized controlled trial involving 2000 patients where a survival benefit was not found.
This article is protected by copyright. All rights reserved.
A. Dixon, H. Steinman, S. Anderson, A. Nirenberg, and J. Dixon
Wiley
Sentinel lymph node biopsy (SNB) was first popularized in the 1990s because it might save lives. However, the Multicenter Selective Lymphadenectomy Trial (MSLT) demonstrated that SNB and subsequent completion lymphadenectomy do not improve either 5-year or 10-year melanoma-specific survival. Sentinel lymph node biopsy is expensive and can affect ongoing quality of life. Complication rates of 10% can include anaphylaxis, persistent seroma, lymphoedema, tattooing at the primary site from dye, mobility impairment, recurrent infection, chronic site pain, joint pain and nerve damage. Sentinel lymph node biopsy is still offered because it can provide added prognostic information in a subset of patients with melanoma. But now patients with melanoma are being urged to undergo SNB for inclusion in clinical trials. Our significant ethical concern is that patients with high-risk primary melanoma could be ‘den[ied] participation in clinical trials of potentially curative therapy’ because they choose not to have a further surgical procedure that has no survival impact. Surely patients with cancer should be encouraged to undertake procedures and therapies only when they have a demonstrated therapeutic benefit. Pathological assessment of excised melanomas alone provides an array of accurate mortality prognostic information. Such prognostic information includes Breslow thickness [hazard ratio (HR) 1 59 per 1 mm increase, 95% confidence interval (CI) 1 21–2 09], ulceration (HR 1 79, 95% CI 1 24– 2 58), tumour site (trunk HR 1 91, 95% CI 1 26–2 88), vascular invasion, age (HR 1 01 per year, 95% CI 0 99–1 02) and mitotic activity (HR 1 04). SNB positivity is associated with a hazard ratio of 2 4 (95% CI 1 61–3 56). It is yet to be demonstrated and seems implausible that SNB, requiring a separate surgical procedure, is necessary to identify patients for drug trials, rather than using an algorithm of all information obtained from excision alone. When some current pharmaceutical trials were developed and commenced there were realistic prospects that SNB would be confirmed to have a therapeutic benefit in its own right. Hence it was reasonable at that stage to select SNB for a role in identifying patients with high-risk melanoma for experimental drug trials. However, the prospect of SNB having a therapeutic benefit ended when the MSLT final results were published in 2014. Two years after the final MSLT data, some current clinical trials continue to accept patients with early occult sentinel lymph node involvement, but will not accept patients with high-risk melanoma who choose not to have SNB. In addition they exclude some high-risk patients with a false-negative SNB. Examples of such clinical trials include NCT01682083, NCT01972347 and ACTRN12613000737730. These trials will accept very low-risk patients with thin primary melanoma as long as they have a positive SNB. Alarmingly these trials also require patients to have completion lymphadenectomy. The patients must have major surgery that has been demonstrated not to improve their survival significantly, in order to get a drug that might benefit their survival. Requiring an ineffective survival intervention in order to enter a trial for a novel therapy has major ethical issues for both current patients and future patients through applicability of study results. We are concerned that patients are encouraged or required to have SNB to enter trials. If prospects of enrolment in trials are the key reason for the surgery, and not improved health outcomes, then health insurers, governments and patients should be alerted to the ethical, equity and financial issues arising from such a clinical trial design. If these trials demonstrate a benefit for the intervention, then applicability may be erroneously restricted to those having positive nodes. We may find that we develop a cemented clinical role for a procedure without proven survival value, which will thus have far-reaching ethical and resource allocation implications for future patients who may be able to benefit from new interventions. Patients who decline to have unnecessary surgery (SNB) could then be denied access to drugs that may be able to treat their disease. Like other authors, we are concerned about inappropriate influence on our patients by practitioners with vested interests. Any practitioner still routinely encouraging patients to have SNB and gaining financially from SNB has a conflict of interest. We are therefore concerned by the suggestion that ‘SNB should be presented to all patients who could possibly benefit from the procedure, by a clinician who has experience both with the procedure and in melanoma management’. We are similarly concerned by the suggestion that ‘to not refer patients for a discussion of SNB with a clinician who is skilled in the technique and in the management of patients with stage III melanoma is unacceptable’. Any clinician managing melanoma should have adequate knowledge of all current forms of melanoma diagnosis and management, including skills in dermoscopy (as the highest risk to most patients is the development of a new primary melanoma), knowledge of the current recommendations for surgical care and an awareness of the current medical oncology and radiation oncology options. To suggest that patients with melanoma
Anthony J. Dixon, Stuart J. Anderson, Jason D. Mazzurco, and Howard K. Steinman
Ovid Technologies (Wolters Kluwer Health)
OBJECTIVES To determine whether field photodynamic therapy (PDT) of actinic keratoses using a novel preparation of 5‐aminolevulonic acid (novel ALA) results in fewer subsequent invasive skin cancers developing on the face of individuals with previous facial cutaneous malignancy in a prospective randomized controlled trial. METHODS AND MATERIALS Intervention patients received two treatments of novel ALA 2 weeks apart. Controls were observed. Patients were followed up with biopsy of any suspicious lesions for 3 years. RESULTS The trial was suspended early because of problems with trial governance and the reporting of severe adverse events. Sixty‐four patients who were recruited at that time at one center were monitored. Their average age was 71, and 57% were male. Patients were randomized to intervention (n = 34) or observation (n = 29). Over the subsequent 3 years, 13 intervention patients (38%) developed 30 new cutaneous malignancies in the field treated, and 11 control patients (38%) developed 22 new malignancies. Some intervention patients experienced prolonged adverse events, including permanent scarring. CONCLUSION Novel ALA made no difference in the likelihood of new malignancies developing. The risks without benefit of this novel ALA are troubling. Lack of efficacy and safety of novel ALA cannot be extrapolated to other PDT products.