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2020 dermMentors™ Resident of Distinction Award™

Sponsored by Beiersdorf Inc

The dermMentors™ Resident of Distinction Award™ was presented to 5 dermatology residents at the 19th Annual Caribbean Dermatology Symposium, January 21–25, 2020, in Paradise Island, Bahamas.


 

The dermMentors™ Resident of Distinction Award™ recognizes top residents in dermatology. DermMentors.org and the dermMentors™ Resident of Distinction Award™ are sponsored by Beiersdorf Inc and administered by DermEd, Inc. The 2020 dermMentors™ Residents of Distinction™ presented new scientific research during the general sessions of the 19th Annual Caribbean Dermatology Symposium on January 25, 2020.

Overall Grand Prize
Topical Imiquimod in Combination With Brachytherapy for Unresectable Cutaneous Melanoma Metastases

Jennifer E. Yeh, MD, PhD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Marilyn T. Wan, MBChB, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts; Allireza Alloo, MD, Department of Dermatology, Northwell Health, Lake Success, New York; Nageatte Ibrahim, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Phillip M. Devlin, MD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Patrick A. Ott, MD, PhD, Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts; Jennifer Y. Lin MD, Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusetts, and Dana-Farber Cancer Institute, Melanoma Program, Boston, Massachusetts
Disclosures: None.


Background

Jennifer Yeh, MD, PhD

Despite numerous advances in the treatment of advanced melanoma, several management challenges remain. Large cutaneous metastases are often unresectable and previously described local therapies have not consistently led to disease control. Topical imiquimod, a synthetic immune modifier, has been found to be safe and effective in treating both cutaneous malignancies and cutaneous metastases of other tumor types. Moreover, radiotherapy can be used for palliation or as adjuvant therapy to reduce regional nodal recurrence. Brachytherapy is radiation delivered via sources within or close to the target, achieving more homogeneous doses and minimizing injury to adjacent structures. Here, we posit the utility of combining topical imiquimod with brachytherapy for locoregional control of cutaneous metastases.


Case Presentation
Three patients with scalp melanoma initially treated with wide local excision and found to have negative sentinel lymph node biopsy presented with scalp lesions adjacent to the initial melanoma consistent with in-transit metastases. Given the presence of multiple metastatic lesions including 1 patient with numerous cutaneous metastases on reconstructed skin, each patient was treated with brachytherapy (5 fractions of 600 cGy over 2 to 3 weeks), followed by imiquimod cream 5% for 12 weeks. One patient’s excision showed residual melanoma as close as 1.4 mm to the nearest margin. All 3 patients achieved complete response and have been disease free for more than 2 years. Adverse effects were limited to pruritus and low-grade dermatitis. Of note, 2 patients later developed distant metastases that subsequently resolved with systemic immunotherapy.

Conclusions
While surgical excision is the first-line treatment of single, discrete cutaneous metastases, it may not be practical in patients with multiple foci of disease distributed over large areas, as seen in the 3 patients presented here who achieved complete resolution of their cutaneous metastatic burden with concurrent topical imiquimod and brachytherapy. Brachytherapy may be especially beneficial for cutaneous metastases on complex surfaces such as the scalp, reducing excessive brain irradiation by using moldable applicators that allow precise targeting. Moreover, one of the cases presented here suggests that brachytherapy may have utility for close-margin excisions. Although further investigations using larger patient cohorts are needed to determine the reproducibility of our findings, concomitant use of topical imiquimod and brachytherapy may represent a promising strategy for control of cutaneous melanoma metastases.

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