8203
Synovial sarcoma presenting as an enlarging dermal tumor
Elizabeth Veasey, MD, University of Louisville, Division of Dermatology;
Jeffrey P. Callen, MD, University of Louisville, Division of Dermatology;
Melissa Atkinson, PA-C, University of Louisville, Division of
Dermatology; Janine Malone, MD, University of Louisville, Division of
Dermatology; Courtney Schadt, MD, University of Louisville, Division of
Dermatology
Introduction: Synovial sarcomas are an aggressive type of sarcoma, constituting
approximately 10% of all soft tissue sarcomas. They are most common on the
extremities with a mean age of 30 years at diagnosis. Although synovial sarcomas are
typically localized at the time of diagnosis, they metastasize more frequently than
other soft tissue sarcomas to the lungs, lymph nodes and bone.
Report of Case: A 40-year-old otherwise healthy woman presented to our
dermatology clinic with a 4 year history of a nontender lesion on the left forearm.
It had enlarged within the past year, which she attributed to trauma that occurred
when she slammed the lesion in a car door several months prior. The lesion
occasionally bled and had foul smelling drainage. She denied weight loss, fevers,
night sweats, limb weakness, or limb numbness. Physical examination revealed a 27
cm by 21.5 cm firm nonpulsatile erythematous tumor with overlying crust located
on the left ulnar forearm. Radial pulses were present bilaterally with brisk capillary
refill. She had intact flexion and extension at the elbow. CT scan demonstrated a
necrotic heterogeneous soft tissue mass with superficial ulceration at the left ulnar
forearm. MRI revealed a soft tissue mass infiltrating into the muscle and in contact
with ulnar periosteum. Due to its size, she was referred to an orthopedic surgeon
who performed a biopsy. The biopsy specimen of the mass revealed spindle cells
arranged in short intersecting fascicles with areas of palisading in a collagenous
stroma. There were fragments of fibroadipose tissue with chronic inflammation and
reactive changes. Immunohistochemical staining showed positivity for EMA, BCL-2,
CD99, CD56 and negativity for SMA, S100, SOX-10, calretinin, CK7, KHMW, CD117,
CD34, STAT6. Molecular gene rearrangement via FISH for the SYT-SSX fusion gene
was positive, which is a diagnostic marker for a synovial sarcoma. Our patient had a
complicated surgical course after excision with free flap failures and osteomyelitis.
However, her histopathologic surgical margins were negative, and both staging
imaging and an ultrasound guided lymph biopsy of her axillary lymph nodes were
negative for metastatic disease. She has now completed adjuvant radiation
treatment, and is recovering from a pedicled deep inferior epigastric perforator flap.
Comment: It is the exception that synovial sarcomas present as large in size as in our
patient, as most patients present with only a subtle soft tissue swelling. While one
third of patients will have associated pain, rapid enlargement is a common symptom.
Independent predictors of metastatic disease for synovial type sarcomas are tumors
that are greater than 5 cm at diagnosis and tumor invasion in bone, vasculature, or
neural structures. Due to the aggressive nature of soft tissue sarcomas, such as the
synovial type, it is imperative that as dermatologists we seek histopathologic analysis
for any changing subcutaneous nodule or tumor.
Commercial support: None identified.
10384
Systematized verrucous epidermal nevus partially responsive to
acitretin: A case report
Felix Paolo J. Lizarondo, MD, Resident Physician, University of the
Philippines-Philippine General Hospital Section of Dermatology; Eileen
Liesl A. Cubillan, MD, Clinical Associate Professor, University of the Philippines-
Philippine General Hospital Section of Dermatology
Introduction: Verrucous epidermal nevus, also known as a nonorganoid nevus, is a
hamartomatous proliferation of the epithelium of which the predominant histologic
components are keratinocytes. It usually presents as asymptomatic solitary linear
papillomatous papules or plaques following Blaschko’s lines but can also uncom-
monly present with extensive distribution as systemized or systematized verrucous
epidermal nevus.
Case Description: A 5-year-old Filipino female was brought in due to generalized
brown-dark brown verrucous plaques distributed along the Blaschko’s lines. Lesions
appeared at age one as generalized brown patches gradually thickening into dark,
papillomatous plaques more pronounced on the neck and bilateral axillae.
Histopathology of a verrucous plaque on the arm was consistent with a verrucous
epidermal nevus showing acanthosis and papillomatosis; there was no presence of
epidermolytic hyperkeratosis. Systemic, neurological and ophthalmological exam-
ination were all normal. Baseline electrolytes including calcium and phosphate
levels were all within normal limits which was collected since hypophosphatemia
can be seen in patients with multiple verrucous epidermal nevus. Topical treatment
was started with tretinoin 0.05% cream for 2 months but with no significant
response. Patient was started on acitretrin initially at 0.5 mg/kg/day (10 mg a day) 1
month with noted slight decrease of the lesions eventually increased to 1 mg/kg/day
(20 mg a day) for 2 months with partial decrease in thickness of the lesions and
becoming less verrucous. Acitretin was well tolerated, noting only mild dryness of
the lips.
Conclusion: This case demonstrates an unusual presentation of a common benign
hamartoma, a systematized verrucous epidermal nevus. Although the lesions were
extensive, they were not associated with any other abnormalities. In this case, due to
the extent of the lesions, surgical management was not feasible. Patient was started
on acitretin, showing a partial response. This case demonstrates that acitretin is a
viable alternative for systematized verrucous epidermal nevus.
Commercial support: None identified.
AB282 J AM ACAD DERMATOL
9795
Tanning attitudes and behaviors in adolescent and young adults
Valerie Shiu, MD, University of Texas Health San Antonio; Daniel Glade,
BS, University of Texas Health San Antonio; Austin Smith, BS,
University of Texas Health San Antonio; Robert Gilson, MD,
University of Texas Health San Antonio
Introduction: Skin cancer rates have been steadily increasing over the last 20 years
despite persistent efforts to educate the public on skin cancer prevention and sun
safety. Teens and young adults are an especially important demographic to reach as
increased UV exposure during these years leads to greatly increased risks of
developing skin cancer. Since the advent of social media, a correlation between
social media use and increased indoor tanning behaviors has been reported. Our
survey aims to investigate the attitudes and behaviors regarding sun protection and
tanning among adolescents and young adults. We also aim to determine which
avenues would be most effective to promote skin cancer awareness and sun
protection to this at-risk population including social media outlets.
Methods: A 15-question survey was administered to 43 teens and young adults with
ages between 13 and 28 who are registered patients at the University of Texas Health
San Antonio Cancer Center dermatology clinic. Data were collected from June to
August 2018.
Results: 43 surveys were collected, 15 male and 28 female respondents. A minority
of respondents felt that tan skin was attractive (17.1%). 73.2% and 70.7% responded
that an effective way to receive information about skin care would be from their
primary care physician and dermatologist, respectively. Television (34.1%) and
Instagram (31.7%) were the two most selected options of effective ways for
receiving skin care education. One respondent reported using a tanning bed in the
last year while 34.1% reported deliberately tanning outdoors. Only 11.6% of patients
surveyed wear sunscreen daily, whereas 74.4% wear it only in anticipation of
recreational activities.
Conclusions: A small percentage of surveyed adolescents and young adults find tan
skin to be attractive, which may reflect a paradigm shift from previous generations.
Seemingly fewer young people used indoor tanning devices, but many still go
outdoors for tanning. While it appears indoor-tanning education has been success-
ful, this shows that there is still a need for sun protection education. Most patients
surveyed do not protect their skin with daily sunscreen use. Primary care physicians
and dermatologist are regarded as important educators on skin protection, however
other modalities should be explored including social media outlets such as
Instagram.
Limitations: Limitations include small sample size, a single study site, and all
respondents being current dermatology patients.
Commercial support: None identified.
8012
Technology in dermatology education: A cross-sectional survey
of dermatology residents
Sarah Mattessich, BS, University of Connecticut School of Medicine;
Michael Payette, MD, University of Connecticut School of Medicine,
Department of Dermatology; Rong Wu, PhD, The Biostatistics Center,
Connecticut Institute for Clinical and Translational Science (CICATS), Michael
Murphy, MD, University of Connecticut School of Medicine, Department of
Dermatopathology
Advances in technology continue to revolutionize the study and practice of
medicine. While some residencies are technology-dependent in nature, others
may be slower or more-hesitant to incorporate innovative technologies into their
teaching paradigms. While new technologies in dermatology are skyrocketing, the
extent to which these tools are currently integrated into dermatology resident
education is unknown. Here we survey dermatology residents about the access and
use of mobile devices and newer dermatology technology in their training programs.
We created an online, anonymous, 10-question survey that was distributed to
dermatology residents through email. Statistical analyses were performed using
nonzero correlation to analyze trends in PGY level and survey answers. PGY levels 1
and 2 were grouped and PGY levels 4 and 5 were grouped for analysis purposes. P
values \ .1 were considered ‘‘marginally significant,’’ and P values \ .05 were
considered ‘‘significant.’’ Mean score test was conducted to assess differences in
specific PGY level and choosing ‘‘agree’’ for questions with a Likert-type response
scale. 112 residents responded to the survey. We found that greater than 60% of
these respondents ‘‘strongly agreed’’ or ‘‘agreed’’ that the use of mobile devices is
advantageous to their education. The specific advantage of mobile devices serving as
an ‘‘educational tool for clinic patients’’ was significantly more likely to be ranked as
‘‘agree’’ by higher PGY levels than lower PGY levels (P ¼.039). Residents reported
that their programs most frequently provided them with a stipend for purchasing
devices (47%), followed by dermatocope (38%), and no device or stipend provided
(35%). According, the most desired device was a dermatoscope (43.75%). Residents
were most likely to have access to glass slide microscopes (79%) and lasers (70%)
and least likely to have access to computer-aided diagnosis programs (0.89%). We
found a marginal significance showing that higher PGY levels were more likely
content with the access that their residency provides to dermatology-specific
technology than lower PGY levels (P ¼.0895). Understanding the current status of
technology permeation into dermatology education is critical in standardizing
curriculums and ensuring that programs are adapting to incorporate important
cutting-edge clinical tools.
Commercial support: None identified.
OCTOBER 2019