Current Therapeutic Approaches to DCIS

Abstract

Treatment for ductal carcinoma in-situ (DCIS) has historically been extrapolated from studies of invasive breast cancer. Accepted local therapy approaches range from small local excisions, with or without radiation, to bilateral mastectomies. Systemic treatment with endocrine therapy is often recommended for hormone positive patients. With improvements in imaging, pathologic review, and treatment techniques in the modern era, combined with new information regarding tumor biology, the management of DCIS is rapidly evolving. A multidisciplinary approach to treatment is now more important than ever, with a shift towards de-escalating therapy to reduce treatment related toxicity. This review focuses on nuances of clinical management of DCIS in the modern era, highlighting key differences between DCIS as compared to invasive breast cancer. The American Cancer Society (ACS) currently recommends beginning screening with annual mammograms for women age 45, with the option to start at age 40. As treatment of DCIS has not been shown to impact survival, the USPSTF has more conservative screening recommendations of biennial mammograms from age 50–74. Unlike invasive breast cancer, DCIS is almost exclusively diagnosed by mammographic detection, and lymph node evaluation is not recommended. Pathologic review of biopsy specimens should follow the guidelines of the College of American Pathologists. Surgical management options include breast conservation, mastectomy, or possibly nipple sparing mastectomy, with upfront sentinel lymph node evaluation in the case of mastectomy. Radiation therapy is generally recommended as a component of breast conserving therapy for patients with DCIS, though in some low risk patients, there is trial data to suggest that adjuvant radiation may be omitted. Techniques for minimizing radiation toxicity should always be emphasized. Endocrine therapy is offered to women with hormone positive DCIS who have undergone lumpectomy for risk reduction, and has the benefit of decreasing incidence of events in both the ipsilateral and contralateral breast. More recent studies have explored use of targeted treatments such as trastuzumab in DCIS for HER2 overexpression. Future directions include tailoring therapy based on patient characteristics and tumor biology. With so many different options for treatment, it is also critical to engage in a discussion with the patient to arrive at a treatment decision that balances patient preferences for disease control versus treatment toxicity, financial toxicity, cosmesis, and quality of life.

Current Therapeutic Approaches to DCIS

Abstract

Treatment for ductal carcinoma in-situ (DCIS) has historically been extrapolated from studies of invasive breast cancer. Accepted local therapy approaches range from small local excisions, with or without radiation, to bilateral mastectomies. Systemic treatment with endocrine therapy is often recommended for hormone positive patients. With improvements in imaging, pathologic review, and treatment techniques in the modern era, combined with new information regarding tumor biology, the management of DCIS is rapidly evolving. A multidisciplinary approach to treatment is now more important than ever, with a shift towards de-escalating therapy to reduce treatment related toxicity. This review focuses on nuances of clinical management of DCIS in the modern era, highlighting key differences between DCIS as compared to invasive breast cancer. The American Cancer Society (ACS) currently recommends beginning screening with annual mammograms for women age 45, with the option to start at age 40. As treatment of DCIS has not been shown to impact survival, the USPSTF has more conservative screening recommendations of biennial mammograms from age 50–74. Unlike invasive breast cancer, DCIS is almost exclusively diagnosed by mammographic detection, and lymph node evaluation is not recommended. Pathologic review of biopsy specimens should follow the guidelines of the College of American Pathologists. Surgical management options include breast conservation, mastectomy, or possibly nipple sparing mastectomy, with upfront sentinel lymph node evaluation in the case of mastectomy. Radiation therapy is generally recommended as a component of breast conserving therapy for patients with DCIS, though in some low risk patients, there is trial data to suggest that adjuvant radiation may be omitted. Techniques for minimizing radiation toxicity should always be emphasized. Endocrine therapy is offered to women with hormone positive DCIS who have undergone lumpectomy for risk reduction, and has the benefit of decreasing incidence of events in both the ipsilateral and contralateral breast. More recent studies have explored use of targeted treatments such as trastuzumab in DCIS for HER2 overexpression. Future directions include tailoring therapy based on patient characteristics and tumor biology. With so many different options for treatment, it is also critical to engage in a discussion with the patient to arrive at a treatment decision that balances patient preferences for disease control versus treatment toxicity, financial toxicity, cosmesis, and quality of life.

FDA Approves Cemiplimab, First Drug for Advanced CSCC

The US Food and Drug Administration today approved cemiplimab for the treatment of patients with metastatic cutaneous squamous cell carcinoma (CSCC) or locally advanced, unresectable CSCC.
FDA Approvals

Trichothiodystrophy: A rare association of brittle hair, ichthyosis, and epilepsy

GS Asha, Tapasya S Kini, KS Chandan, P Mahanthesh

Indian Journal of Paediatric Dermatology 2018 19(4):357-359

Trichothiodystrophy (TTD) is a rare autosomal recessive genetic disorder characterized by abnormal synthesis of sulfur-containing keratins and consequently hair dysplasia, associated with numerous symptoms affecting mainly organs derived from the neuroectoderm. The deficiency of cysteine and methionine explains the fragility and the regular undulation of the hair shaft of patients with TTD, appreciated as the characteristic tiger tail appearance on polarized microscopy. We report a case of TTD with a rare association of brittle hair, ichthyosis, and epilepsy, classified as Tay syndrome based on clinical features and complementary examinations.

Seeing beyond, mimicker of genital lesions and a personal view

Ebtisam Elghblawi

Indian Journal of Paediatric Dermatology 2018 19(4):382-383

Allergic contact dermatitis in atopic dermatitis

Sandipan Dhar, Sahana M Srinivas, Ashok K Bajaj

Indian Journal of Paediatric Dermatology 2018 19(4):304-307

Atopic dermatitis (AD) coexisting with allergic contact dermatitis (ACD) is not uncommon. There has been lot of controversies regarding this concept as the prevalence of ACD in AD is similar to that seen in nonatopics. There is increased susceptibility to ACD in AD as AD modulates the exposure to allergens. There is an impaired barrier function that predisposes to the development of ACD in AD. Patch testing is a standard test for detecting allergens in AD.

Eczema herpeticum in a patient with atopic dermatitis, coxsackie B virus, and staphylococcal infection: A double skin damage

Andrea D Pratico, Valentina Fatuzzo, Maria Elena Cucuzza, Flavia M C La Mendola

Indian Journal of Paediatric Dermatology 2018 19(4):369-370

Eczema herpeticum is a rare viral skin scattered infection whose main etiologic agents are HSV1–2 and coxsackievirus, but its association with atopic dermatitis suggests that different factors may play a role in this complex phenotype. When not promptly treated, it can spread to other organs, causing severe complications such as keratoconjunctivitis, encephalitis, and meningitis. We describe the case of a patient with atopic dermatitis who came to our observation presenting with diffuse purulent vesicular lesions, whose bacterial culture was positive for Staphylococcus aureus and whose serologic examinations showed IgM positivity for coxsackie B virus.

Childhood psoriasis: What is new and what is news

Sunil Dogra, Anuradha Bishnoi

Indian Journal of Paediatric Dermatology 2018 19(4):308-314

Psoriasis is a chronic inflammatory disorder that affects around 2%–4% of the general population, and the prevalence can be higher in selected populations. About one-third of the people affected with psoriasis have the onset of their disease in the first and second decades of life. Of the pediatric population, about 0.5%–2% is affected. Infants are affected rarely. The incidence increases with age and is reported to be ~0.55% in the age group of 0–9 years and 1.37% in the age group of 10–19 years. Flexures, face, periauricular area and medial aspect of the upper eyelid are commonly involved in children. In infants, there is predilection for diaper area. Overall, plaque psoriasis is the most common type, followed by guttate and pustular psoriasis. Lesions are more pruritic, but thinner, less erythematous, and less scaly. Follicular lesions are common. Treating psoriatic erythroderma can pose difficulties, especially in pediatric population. Some cases achieve rapid control of disease activity, while others develop chronic erythroderma with frequent disease flares. The impact of disease on psychosocial parameters is significant in this subgroup of psoriasis and affects patients and parents alike with significantly high rates of absenteeism from school. Pediatric psoriasis therefore needs to be managed effectively. However, effective treatment also poses the risk of producing adverse effects, more so in pediatric age group. A delicate balance therefore should be maintained and overzealous treatment should be avoided.

Infantile hemangiomas: An update on pathogenesis, associations, and management

Karina L Vivar, Anthony J Mancini

Indian Journal of Paediatric Dermatology 2018 19(4):293-303

Infantile hemangiomas (IH) are the most common vascular neoplasm in infants. The typical clinical course of IH follows a pattern of growth (proliferation) followed by spontaneous involution. The majority of IH are isolated to the skin; however, some cutaneous IH can be associated with internal organ involvement or anomalies. IH which are functionally impairing, ulcerated or potentially disfiguring require therapy. Treatment options include systemic or topical beta-blockers, systemic or intralesional corticosteroids, pulsed dye laser therapy, or surgical excision. In this article, we review the updated understanding of IH pathogenesis, clinical presentations and associations, and approaches to management.

Does color really matter? Reliability of transcutaneous bilirubinometry in different skin-colored babies

Pearl Mary Varughese, Lalitha Krishnan, Ravichandran

Indian Journal of Paediatric Dermatology 2018 19(4):315-320

Background: Transcutaneous bilirubinometry, in keeping with rapid technological advances, has come a long way as an effective tool for assessing bilirubin levels in newborns. Though the early devices showed changes due to melanin concentration, the new generation devices were based on micro-spectrometry. Color coded scales were rarely used for the comparison. Hence the primary outcome is that TcBI is more reliable in lighter skin color babies than darker skin color babies.Objective: To study the reliability of TcB in different skin color babies. Materials and Methods: The study was conducted in a tertiary newborn center from November 2014 to June 2016. The inclusion criteria included all babies above 34 weeks gestation and exclusion criteria included babies with established direct hyperbilirubinemia, neonatal septicemia, major congenital/ gastrointestinal malformations and those on phototherapy. 396 babies were recruited. At 24 hours, babies were categorized based on Fitzpatrick skin color chart. Statistical analysis was done using the ROC curves Bland Altman charts. Results: Mean TcB was found to be uniformly higher than TSB for all variables like sex, birth weight, gestational age and growth of the baby with an excellent correlation (r = 0.698-0.932). 335 babies (74.4%) were falling in the color code 3. 113 babies (25.1%) were in the color code 4 and 2 babies (0.4%) were in the color code 5. TcB correlates better in light skin tone babies (color code 3) than dark skin tone babies (color code 4) with r= 0.874 and r= 0.856 respectively. Conclusion: Though TcB overestimates; it correlates well with TSB in lighter skin tone babies than babies with darker skin tone.

Klippel–Trenaunay syndrome affecting an uncommon site

Ibrahim Aliyu, Godpower Chinedu Michael

Indian Journal of Paediatric Dermatology 2018 19(4):363-365

Klippel–Trenaunay syndrome (KTS) is characterized by the triad of varicosity of cutaneous veins, port wine stains, and soft tissue/bone overgrowth. It was first described by French physicians Klippel and Trenaunay in 1900. There is often overlap between KTS and Parkes Weber syndrome. The lower extremities are mostly affected and it is usually asymmetric; other sites involved are the upper limbs, trunk, and rarely, the head and face region. Therefore, the case of a 5-year-old girl who presented with KTS symmetrically involving the trunk and lower limbs is reported.

A hospital-based clinical study of childhood psoriasis in a tertiary care center of Northeast India

Seujee Das, Pankaj Adhicari

Indian Journal of Paediatric Dermatology 2018 19(4):321-325

Background: Childhood psoriasis has been reported to differ from that among adults. There are a limited number of studies on childhood psoriasis and none from the north-eastern part of India. A detailed clinical study will help to understand better the disease profile in children, thereby assisting in better diagnosis and treatment. Objective: The objective of this study was the clinical profile of childhood psoriasis. Materials and Methods: The present observational study was conducted in the Dermatology Outpatient Department of Assam Medical College and Hospital, Dibrugarh, during 12 months from June 2014 to May 2015. All children up to 13 years presenting with psoriasis during 1 year were taken as study participants after obtaining the written consent from the sole guardian. A detailed examination and relevant investigations were done, whenever necessary. The findings were recorded in a pro forma for the analysis and interpretation of data. Results: A total of 26 cases of childhood psoriasis were recorded during the study. The prevalence of childhood psoriasis in our outpatient pediatric population was 1.24%. Female cases (19; 73.08%) outnumbered male cases (7; 26.92%). A maximum number of cases were noted in 9–13 years of age group. The lower extremities (11; 42.31%) were the most common site of onset. Plaque type (14; 53.85%) was found to be the most common type. About 7.69% cases had a positive family history. Conclusion: Frequent involvement of soles was noted in childhood psoriasis similar to other parts of India but unlike other parts of the world. Pediatric patients had significantly more involvement of the trunk, face, and groin than did adult patients.

Hot topics in pediatric dermatology

Vishal Thakur, Dipankar De

Indian Journal of Paediatric Dermatology 2018 19(4):375-379

Clinicomycological study of dermatophytoses in children: Presenting at a tertiary care center

Nitin Mishra, Madhur Kant Rastogi, Pratik Gahalaut, Sandhya Yadav, Neeraj Srivastava, Anuj Aggarwal

Indian Journal of Paediatric Dermatology 2018 19(4):326-330

Background: Superficial tinea infections are some of the most common dermatological conditions in children. Recently, few studies done showed abrupt increase in dermatophytic infection in adults; however, similar recent studies describing clinicoepidemiological pattern in pediatric population are lacking. Aims and Objectives: The aims and objectives of this study are to identify the epidemiological profile of the dermatophytoses among pediatric population. Materials and Methods: Pediatric patients with suspected tinea infections presenting in the Department of Dermatology at a tertiary care medical college hospital in Northern India from April 2016 to 2017 were evaluated for inclusion in this study. Samples were collected in two parts; if first part was found to be potassium hydroxide (KOH) positive for septate hyphae, the second part was sent for fungal culture subsequently. Statistical Analysis Used: SPSS version 20 was used for statistical analysis. Results: Out of 235 patients, 152 were male and 83 were female. Only 200/235 (85.1%) KOH positive enrolled patients yielded positive fungal culture. Most common species identified on culture was Trichophyton mentagrophytes, followed by Trichophyton rubrum, and Trichophyton violaceum. Trunk was the most common site affected in 29.4% patients, palms and soles were least affected. Conclusion: More number of patients applied topical steroid for a longer period of time in patients with extensive disease as compared to limited disease. The present study provides evidence that dermatophytosis in pediatric patients is following the pattern of adult dermatophytosis clinically and microbiologically now.

An unusual presentation of congenital melanocytic nevus

Ibrahim Aliyu

Indian Journal of Paediatric Dermatology 2018 19(4):385-386

Epidemiology of pediculosis capitis among schoolchildren in Damascus, Syria

Mohammad Taher Ismail, Mohammad Maher Kabakibi, Abeer Al-Kafri

Indian Journal of Paediatric Dermatology 2018 19(4):331-334

Background: Pediculosis is a common ectoparasitic infection in schoolchildren, causing a public health problem, which is neglected in Syria. Objective: This study aimed to determine the prevalence of infestation with head lice among primary schoolchildren in Damascus, Syria, and explore the predisposing factors of head lice infestation in public schools. Materials and Methods: The present study was to determine the head lice infestation (pediculosis) levels in primary schoolchildren, from March to July 2017. A total of 8689 (females: 4392, males 4297) schoolchildren aged 6–12 years from 18 selected primary school of Damascus city and countryside were examined for head lice. Pediculosis was defined as the presence of at least on living adult, nymph, or viable egg. Results: The overall head lice infestation rate was 14. 3% (1243/8689) and infestation rate was higher in girls (23.72%, 1042/4392) than in boys (4.67%, 201/4297). The infestation rate among schoolchildren varied from 1.4% to 60.7% and depended on the age group is 18.10% (6–8 years), 12.22% (9–10 years), and 13.30% (11–12 years). The infestation rate among girls varied from 22.2% (10–12-year-old group) to 42.8% (6–8-year-old group). Conclusions: Pediculosis is a common public health problem affecting primary schoolchildren in Damascus area, and the levels of infestation are of an endemic significance.

Lymphoplasmacytic plaque in children: An emerging new clinical entity

Sadhika Ganni, Sasi Kiran Attili, Raghurama Rao Gandikota, Kollipara Haritha

Indian Journal of Paediatric Dermatology 2018 19(4):354-356

Pretibial lymphoplasmacytic plaque in children is a rare emerging clinicopathological entity characterized by asymptomatic benign solitary plaque. Most of the cases are reported in healthy females. The treatment of choice is topical steroids.

Reticulate dyschromia, congenital atrichia and speech delay in a child: A diagnostic dilemma

Tasleem Arif, Mohammad Adil, Syed Suhail Amin

Indian Journal of Paediatric Dermatology 2018 19(4):335-338

Disorders of reticulate dyschromia can be diagnosed on the basis of the distribution and type of pigmentation in association with coexisting abnormalities. We describe a 4-year-old male child with reticulate dyschromia of the dorsal aspects of hands and feet and over the axillae, buttocks, and groins. The child had near complete absence of hair over body since birth. Skin-colored firm papules were present over dorsal aspects of hands and feet, and milestones were delayed for speech. We discuss the probable differentials in this article and why it fits none of the existing differentials.

Restrictive dermopathy: Report of two cases

Anisha K Janardhanan, Sarita Sasidharanpillai, Aparna S Vidya, Babu Francis, Mohandas Nair Karippoth

Indian Journal of Paediatric Dermatology 2018 19(4):360-362

Restrictive dermopathy is a rare entity that is fatal in the neonatal period itself. The rigidity of the skin leads to erosions, contractures, and restriction of respiratory movements. Diagnosis is often made clinically with classical features such as low-set ears, micrognathia, small, and persistently open fixed "o"-shaped mouth, translucent, shiny, rigid skin with prominent superficial blood vessels, and pseudocontractures of limb joints. We report two cases of restrictive dermopathy observed in our center within 2 years period and suggest that this condition may not be as rare as believed.

Bleomycin-induced flagellate dermatosis in a 7-Year-Old child: A case report with review of literature

Preeti Sharma, Rajesh Sinha, Dhiraj Kumar, Amit Kumar

Indian Journal of Paediatric Dermatology 2018 19(4):339-341

A 7-year-old female known case of nonseminomatous germ cell tumor was on treatment with bleomycin, etoposide, and cisplatin (BEP) regimen. After completing two cycles of BEP regimen, she developed linear hyperpigmented lesions in flagellate-like pattern on the trunk, neck, arms, and legs. After cessation of bleomycin, the patient started to improve.