BACKGROUND:Poor differentiation predicts adverse outcomes in cutaneous squamous cell carcinoma (CSCC), but there is no standardized, reliable grading system. OBJECTIVE:To explore which histologic features have the greatest impact on CSCC differentiation interrater agreement. MATERIALS AND METHODS:In a prior study, 40 raters graded differentiation for 45 squamous cell carcinomas, and percent interrater agreements were calculated. Cases graded as well/moderately differentiated with 100% agreement (10), those graded as poorly differentiated with ≥80% agreement (5), and those that received a variety of grades with ≤60% agreement (7) were pulled for the current study. Three raters graded individual histologic features for each case, and percent interrater agreements were calculated using both the well/moderately/poorly differentiated grading system and a dichotomized system. RESULTS:The percent interrater agreements were 34.8% for mitoses, 53% for pleomorphism, 59.1% for keratinization, 66.7% for cellular cohesion/intercellular bridges, and 78.8% for tumor edges. Percent agreements improved with dichotomous grading; the largest improvement was seen within the group of cases that had been graded as well/moderately differentiated with 100% agreement in the prior study. CONCLUSION:Future squamous cell carcinoma differentiation grading systems would benefit from eliminating mitotic rate, clearly defining how to grade other features, and dichotomous grading.

BACKGROUND Limited literature exists regarding whether intraoperative analysis of frozen debulk specimens during Mohs micrographic surgery (MMS) improves identification of high-risk features (HRF) of cutaneous squamous cell carcinoma (CSCC). OBJECTIVE Primary: identification of new HRF on debulk specimens. Secondary: CSCC upstaged after considering debulk data. MATERIALS AND METHODS A single-center, retrospective cohort study of patients with biopsy-proven CSCC treated by MMS with intraoperative frozen debulk analysis. Restricted (poor differentiation, new perineural invasion ≥0.1 mm, and Breslow depth >6 mm) and nonrestricted (any worsened tumor differentiation, any new perineural invasion, and Breslow depth >2 mm) analyses were performed. RESULTS In restricted analysis, 3.94% of cases had 1 new HRF on debulk analysis. In nonrestricted analysis, 32.9% of cases had ≥1 new HRF; 7.6% increased by 2 HRF. Approximately 2.0% of cases were upstaged by American Joint Committee on Cancer system, eighth edition criteria, 1.4% by Brigham and Women's Hospital. Tumor size ≥2 cm, male sex, and moderate differentiation on biopsy were significantly associated with new HRF identified on debulk analysis. CONCLUSION Intraoperative frozen debulk analysis can reveal HRF of CSCC not seen on biopsy or MMS stages, particularly among tumors ≥2 cm. American Joint Committee on Cancer system, eighth edition T2 tumors were most likely to be upstaged. Identification of new HRF on debulk analysis can improve CSCC staging and may impact patient treatment and follow-up.

BACKGROUND Cosmetic tattoos such as eyeliner, brow liner, and lip liner have become increasingly popular in the United States and throughout the world. For a variety of reasons, patients frequently regret their tattoos and request their removal; however, removal is often complicated by the aesthetically sensitive location of these specialized tattoos and the fact that they often contain white metallic compounds that darken on pigment-specific laser irradiation. OBJECTIVE To review the clinical use, effectiveness, and safety of an ablative laser technique for cosmetic tattoos. MATERIALS AND METHODS A thorough literature review pertaining to laser treatment of cosmetic tattoos and a discussion of illustrative patient cases showcasing the successful use of ablative carbon dioxide (CO2) laser to treat cosmetic tattoos is presented. RESULTS Cosmetic eyeliner and lip liner tattoos were significantly improved after CO2 laser vaporization. Side effects were limited to erythema, edema, and serosanguinous drainage. No infection, scarring, nor tattoo ink darkening was observed. CONCLUSION Because ablative lasers do not target specific tattoo inks, they do not pose a risk of paradoxical tattoo ink darkening and, thus, can be applied successfully in the treatment of iron oxide– or titanium dioxide–containing cosmetic tattoos.

Importance:Leishmaniasis is recognized as an endemic human disease in Africa, the Middle East, Asia, and South America. Yet despite case reports of endemic human leishmaniasis in the United States, and well-documented occurrences of disease in various animal vectors and reservoirs, the endemicity of leishmaniasis in North America has not yet been established. Moreover, leishmaniasis is not a federally reportable disease in the United States. Clinical awareness of endemic disease therefore remains low, with North American physicians considering leishmaniasis a tropical disease.Objective:To assess the endemicity of human leishmaniasis in the United States.Design, Setting, and Participants:This cross-sectional multicenter observational study reviewed cases of human leishmaniasis occurring in the United States from 2007 through 2017. Previously diagnosed, deidentified cases of leishmaniasis were reported by the institutions of the authors and acknowledged contributors, as well as the Texas Department of State Health Services. Cases of leishmaniasis were identified by searching by disease name (leishmaniasis) or International Classification of Diseases, 9th and 10th Revisions diagnosis codes in the respective laboratory information systems.Exposures:Via examination of deidentified demographics, cases of leishmaniasis were classified as one of the following: (1) documentation of no history of travel outside of the United States within 10 years; (2) positive history of travel outside of the United States within 10 years; or (3) unknown or no documentation of travel history.Main Outcomes and Measures:Cases of leishmaniasis were considered endemic if identified in patients with documentation of no travel history outside of the United States within 10 years.Results:Of the 69 novel cases of human cutaneous leishmaniasis identified in this study, 41 (59%) were endemic; the median age at diagnosis was 61 years (range, 3-89 years), and 28 (68%) of the endemic cases occurred in female patients. Twenty-two (32%) cases had documentation of Leishmania speciation performed by polymerase chain reaction, and in 100% of these cases the infectious organism was identified as Leishmania mexicana.Conclusions and Relevance:Human cutaneous leishmaniasis is endemic in the United States, and, at least regionally, is acquired endemically more frequently than it is via travel. Our data argue in favor of making leishmaniasis a federally reportable disease and may have substantial implications on North American public health initiatives, with climate models predicting the number of citizens exposed to leishmaniasis will double by 2080.

This case report addresses dermatorynchus geneae, a seldom-described deformity of the first branchial arch. Two previous case reports discuss this clinical entity, both of them published in the 1970s. Bittmann and Søgaard1 were the first to report the case of a 1-month-old girl who presented with an unusual 2-cm growth on the skin overlying the zygoma. Histologic analysis of the lesion found that it was composed of mature tissues arising from multiple embryonic germ layers, leading the authors to classify it as a branchial arch deformity.