BACKGROUND AND PURPOSE:In patients with metastatic melanoma who respond to anti-PD-1 therapy, the proliferation of intra-tumour CD8+ T cells is directly correlated with the clinical response, making tumour-infiltrating lymphocytes (TILs) a treatment of interest in combination with a PD-1 inhibitor, which is the undisputed gold standard in the management of metastatic melanoma. The aim of this trial was, therefore, to evaluate the safety and efficacy of sequential combination therapy consisting of nivolumab (a PD-1 inhibitor) and TILs adoptive T cells in patients with metastatic melanoma. MATERIALS AND METHODS:We performed an exploratory, prospective, single-centre, open-label, non-randomised, uncontrolled phase I/II study. We enrolled 10 previously untreated patients with advanced melanoma. The treatment regimen was neoadjuvant anti-PD-1 therapy followed by 2 injections of TILs and a second sequence of anti-PD-1 therapy. RESULTS AND INTERPRETATION:Among the four patients who received the autologous TILs + nivolumab combination, three (75%) achieved an objective response (two achieved a partial response [PR] at the end of the study, two achieved a complete response [CR]), and one achieved a CR at the end of the study. Among these three patients, one had a PR, and two had stable disease (SD) after the nivolumab course and before any TILs administration, reinforcing the importance of the tumour response after TILs injection. These responses were persistent, ranging from 9 months to 3.4 years.

Acne in adult females is triggered mainly by hormones. Doxycycline is a reference treatment in acne. Spironolactone targets the androgen receptor of sebaceous glands and is prescribed off-label for female adult acne. This multicentre, controlled, randomized, double-blind prospective and parallel study assessed the efficacy of spironolactone compared with doxycycline in adult female acne. A total of 133 women with moderate acne were randomized to receive treatment with: (i) doxycycline and benzoyl peroxide for 3 months followed by a 3-month treatment with its placebo and benzoyl peroxide, or (ii) spironolactone and benzoyl peroxide for 6 months. Successfully treated patients continued with benzoyl peroxide or spironolactone alone for a further 6 months. Primary endpoints were treatment success at month 4 and month 6 with the AFAST score. At all visits, the ECLA score, lesion counts, local and systemic safety and quality of life were assessed. Spironolactone performed better at month 4 and showed a statistically significant better treatment success after 6 months than doxycycline (p = 0.007). Spironolactone was 1.37-times and 2.87-times more successful compared with doxycycline at respective time-points. AFAST and ECLA scores, as well as lesion counts always improved more with spironolactone. Patients’ quality of life was better with spironolactone at month 4 and month 6. Spironolactone was very well tolerated. This is the first study to show that, in female adults with moderate acne, treatment with spironolactone is significantly more successful than doxycycline and very well tolerated.

INTRODUCTION:Coronary heart disease remains one of the leading causes of morbidity and mortality, and is responsible for significant social costs. Resumption of work is an essential objective when this pathology concerns working patients. French data remain patchy and relatively old. The French Society of Cardiology's Exercise, Rehabilitation, Sport and Prevention Group has proposed a multicentre study to update these data. METHODS:Following an acute coronary syndrome (ACS), the cardiology team asked the patient, who was currently working, to complete a questionnaire on his or her pathology, occupation and plans to return to work. An interview after 6 months enabled the clinical and professional situation of the patient to be analyzed, in order to study the factors predictive of a return to work. RESULTS:364 patients were included in 6 interventional and 17 cardiac rehabilitation centres between 2018 and 2019. The resumption rate was 81% (n = 295), 93% of them in the same position, with a mean delay of 106 ± 56 days. The cardiologic independent factors for non-return were left ventricular ejection fraction, the presence of an anticoagulant, angina or heart failure, and occupational factors, shift work, exposure to cold, and imposed work rates. Factors that lengthened the time taken to return to work included delayed access to rehabilitation, the carrying of heavy loads, difficult postures and imposed work rates, as well as the patient's lack of a project, the absence of a cardiologist's opinion and the request for a modified workstation. CONCLUSION:The rate of return to work remains fairly stable despite the evolution of disease management, and the time to return to work relatively high. One way of improving the situation is to enhance access to cardiac rehabilitation programs, for example by offering alternatives such as tele-rehabilitation for a proportion of patients. This will free up more time for more severe patients, to better prepare them physically and psychologically for a return to work, which will also have a beneficial economic effect.

L’incidence du mélanome augmente dans le monde entier. L’efficacité du traitement est liée aux délais diagnostiques et thérapeutiques. Dans ce contexte, la télédermatologie (TD), en particulier la télé-expertise, est une technologie prometteuse, car elle est susceptible d’accélérer le processus de soins. Cependant, plusieurs études ont indiqué que l’efficacité et la fiabilité de cette pratique dans les cas de lésions cutanées pigmentées n’étaient pas prouvées et ont appelé à des travaux supplémentaires. L’objectif principal de cette étude était d’évaluer la concordance de prise en charge inter- et intra-évaluateur parmi les télédermatologues concernant le délai de consultation à proposer devant des photographies de lésions cutanées pigmentées suspectes prises avec un smartphone par un médecin généraliste (MG). Nous avons analysé la concordance de la prise en charge entre différents télédermatologues ayant une expérience en TD. Les télédermatologues ont déterminé le délai de consultation à proposer à 110 patients présentant des lésions cutanées pigmentées suspectes visualisées en ligne sur la base de 241 photographies prises par des médecins généralistes dans un contexte réel. Les praticiens devaient choisir entre 4 possibilités de prise en charge : (1). Besoin urgent de consultation, (2). Besoin non urgent de consultation, (3). Pas de besoin de consultation, et (4). Impossible à évaluer : demande d’informations ou de photographies supplémentaires au médecin généraliste. Une discordance « majeure » a été définie comme suit : un télédermatologue a décidé que le patient avait besoin d’une consultation dans les 15 jours, tandis qu’un autre télédermatologue a décidé qu’il n’était pas nécessaire de voir le patient (« simple lettre au médecin traitant »). Nous avons effectué la même analyse deux ans plus tard pour évaluer la concordance intra-évaluateur. Cette étude a révélé une faible concordance entre les télédermatologues lorsqu’ils évaluent des photographies prises par un médecin généraliste à l’aide d’un smartphone. La concordance inter-juges était faible quelle que soit la modalité d’analyse utilisée. La concordance de gestion inter-télédermatologues 2 à 2 a révélé un faible kappa de Cohen (entre 0,11 et 0,43). La concordance globale était faible (kappa de Fleiss 0,24 en 2020 et 0,27 en 2022). Nous avons observé une discordance majeure concernant la prise en charge des soins pour 38 % des patients en 2020 et 25 % des patients en 2022. Ces résultats ont été confirmés par la seconde analyse en 2022. La concordance intra-évaluateur était également faible avec des kappas de Cohen bas (entre 0,37 et 0,465). Cette étude complète les résultats préliminaires que nous avions présentés en 2021 aux JDP. La faible concordance intra-évaluateur indique que la variabilité des prises en charge observée n’est pas liée à des habitudes de travail différentes selon les centres. Cette étude s’inscrit dans la lignée d’études récentes appelant à la mise en garde concernant la télé-expertise pour la prise en charge des lésions cutanées pigmentées suspectes, sans dermoscopie, jusqu’à ce que des études supplémentaires aient été réalisées.

BACKGROUND:Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease of the follicles in the apocrine glands and is associated with a deficiency in the innate immunity of the skin. It is characterized by the occurrence of nodules, abscesses, fistulas, scars.OBJECTIVE:Although a relationship has already been demonstrated between HS and innate immunity, IGF-1 status in patients with HS is still unknown. The objective of this pilot study was to determine IGF-1 status in patients with HS as well as its potential relationship with the clinical profile of the disease.METHODS:This monocentric and cross-sectional study involved 39 patients hospitalized at the Dermatology Department of CHU Nantes between November 2014 and January 2018. Clinical data and IGF1 status were collected during the follow-up consultation.RESULTS:Forty-nine percent of the patients had very low levels of IGF-1. At the clinical level, these patients were young and with a short duration of disease. The major difference was that IGF1-deficient patients had a higher BMI than others. The others factors differing between the two patient groups did not reach statistical significance.CONCLUSION:This exploratory pilot study indicates that HS with a low level of IGF-1 could represent a specific phenotype of patients with HS. These preliminary results have to be confirmed with a larger cohort, as they could have practical consequences in the therapeutic care of these patients.

Le mélanome de Dubreuilh ou lentigo malin (LM) est une prolifération mélanocytaire survenant sur une peau photo-exposée qui peut évoluer vers un mélanome invasif. La chirurgie est recommandée comme traitement de première intention, avec des marges d'exérèse de 5 à 10 mm, sans consensus international. Plusieurs études ont montré que l'imiquimod, un immunomodulateur, pouvait induire une régression du LM. Nous avons donc mené une étude visant à évaluer l'effet de l'imiquimod par rapport à un placebo en néoadjuvant dans le traitement du LM. Il s'agit d'une étude prospective, randomisée, multicentrique, de phase III. Les patients ont été randomisés avec un rapport 1:1 pour recevoir de l'imiquimod ou un placebo pendant 4 semaines, suivi d'une exérèse du LM, 4 semaines après la dernière application d'imiquimod ou de placebo. Le critère de jugement principal était l'exérèse extra-lésionnelle, avec une marge de 5 mm par rapport à la pigmentation résiduelle après traitement. Les critères d'évaluation secondaires comprenaient la différence de surface d'exérèse entre les deux groupes, le nombre de reprise nécessaire pour obtenir une exérèse complète, le nombre de rechutes et leur délai et le nombre de rémissions complètes après le traitement. Au total, 283 patients ont participé à cette étude ; 247 patients ont été randomisés, 121 dans le groupe placebo et 126 dans le groupe imiquimod. L'exérèse était extra-lésionnelle chez 116 (92 %) patients du groupe imiquimod et chez 102 (84 %) patients du groupe placebo ; la différence n'était pas significative (p = 0,0743). En ce qui concerne la taille de lésion, l'imiquimod a permis une réduction de la surface du LM (4,6 cm2 à 3,1 cm2) par rapport au placebo (3,9 cm2 à 4,1 cm2) de manière très significative (p < 0,001). Les patients du groupe imiquimod ont eu significativement moins de reprise chirurgicale et plus de rémission complète après traitement topique. Le taux de récidive était similaire dans les deux groupes. L'imiquimod, appliqué sur la lésion et en périphérie, permet de traiter l'invasion infraclinique représentée par les mélanocytes atypiques et donc de proposer une marge d'exérèse de 5 mm et non 1 cm sans augmenter le risque d'exérèse intra-lésionnelle. Par ailleurs, la diminution de taille du LM sous traitement contribue à limiter le préjudice fonctionnel et esthétique de la chirurgie. Il n'existe pas de différence entre les deux bras concernant le taux de récidive sur la période des trois ans de suivi, mais il serait pertinent de l'analyser sur une période plus longe étant donné l'histoire naturelle du LM. Un traitement néoadjuvant par imiquimod pendant 1 mois avant une chirurgie d'exérèse avec des marges de 5 mm permet de réduire la surface du LM et donc d'améliorer le résultat fonctionnel et esthétique de la chirurgie, sans augmenter le risque d'exérèse incomplète.

Abstract Introduction: Metastatic melanoma patients responding to anti-PD-1 therapy showed proliferation of intra tumoral CD8+ T-cells directly correlated with clinical response, making Tumor-infiltrating lymphocytes (TILs) a potential curative treatment with adoptive cell transfer (ACT). The aim of this trial is therefore to evaluate the safety and efficacy of a sequential combination therapy of Nivolumab (PD-1 inhibitor) and TIL adoptive T-cells in patients with metastatic melanoma. Materials and methods: We performed an explorative, prospective, single-center, open-label, non-randomized, uncontrolled phase I/II study. We enrolled 10 patients with advanced melanoma. Treatment regimen was anti-PD-1 neoadjuvant followed by 2 injections of TILs and a second sequence of anti-PD-1. Results and discussion: Among the 4 patients who received the autologous TILs + Nivolumab combination, 3 (75%) showed an objective response (2 PR at the end of the study followed by 2 CR) and 1 CR at the end of the study. Of these 3, one was PR, and 2 were SD after Nivolumab course and before any TIL administration, reinforcing the value of tumor response after TILs injection. These responses were persistent, from 9 months to 3.4 years.

The advent of targeted therapies and immunotherapies has revolutionized metastatic melanoma (MM) management but their use is associated with high daily costs compared to chemotherapies: €2 for dacarbazine versus €175 for immunotherapies and €413 for targeted therapies. While overall survival (OS) has increased, healthcare expenditures are expected to double by 2030.The aim of this study was to estimate the median OS and costs for MM patients in order to evaluate the effectiveness of new biological or targeted therapies (NT) used since 2013 compared to chemotherapies.This was a retrospective monocentric cost-effectiveness analysis performed in CHU Nantes (Nantes University Hospital). All MM patients treated with conventional chemotherapy as first-line treatment between 2008 and 2012 were included (CHEMO group). The same number of patients treated with NT as first-line between 2013 and 2017 were included (NT group).In total, 161 patients were included in each group. The mean age at diagnosis was 64.7±2.4 years in the CHEMO group and 65.3±2.4 years in the NT group (not significant). The men/women ratio was 1.48 and 1.27, respectively, (not significant). The median OS was 158 days in the CHEMO group and 395 days in the NT group (p<0.001). Treatment cost was €10,280/patient versus €94,676/patient, respectively. The mean incremental cost-effectiveness ratio was €90,184/LY (95% CI: €59,637; €166,395).Our study assessed clinical and economic features associated with MM management before and after the advent of NT. Costs and life expectancy have increased. NT appears to be cost-effective.

The incidence of melanoma is increasing worldwide. The effectiveness of treatment is associated with diagnostic and therapeutic delays. In this context, teledermatology (TD), especially store-and-forward TD, is a promising technology, as it can accelerate the care process. However, several studies have indicated that the efficiency and reliability of this practice in cases of pigmented skin lesions is not proven and have called for further work. The main objective of this study was to evaluate inter- and intra-rater management concordance among teledermatologists concerning the appropriate consultation delay when reviewing photographs of suspicious pigmented skin lesions taken with a smartphone by a general practitioner (GP). We first analyzed management concordance among different teledermatologists with experience in TD in 2020. The teledermatologists determined the consultation delay to propose to 110 patients with suspicious pigmented skin lesions viewed online based on 241 photographs taken by GPs in a real-life context. The practitioners had to decide among 4 possibilities for care management: 1. urgent need for consultation (15 days), 2. non-urgent need for consultation, 3. no need for consultation ("simple letter to the attending physician"), and 4. impossible to assess: request for additional information or photographs from the GP. "Major" discordance was defined as follows: one teledermatologist decided that the patient needed a consultation within 15 days, while another teledermatologist decided that it was not necessary to see the patient. We performed the same analysis two years after to evaluate the intra-rater concordance. This study revealed poor agreement among dermatologists when they assessed photographs taken by a GP using a smartphone. The interrater agreement was poor regardless of the analytical modality used. The 2-to-2 interdermatologist management concordance revealed a low Cohen's kappa (between 0.11 and 0.43). Overall agreement was low (Fleiss’ kappa 0.24 in 2020 et 0.27 in 2022). We observed major discordance regarding care management for 38% of the patients in 2020 and 25% of the patients in 2022. Those results of interrater agreement were confirmed by the second analysis in 2022. The intra-rater concordance was poor also with low Cohen's kappa indices (between 0.37 and 0.46). The poor inter- and intra-rater agreement calls into question the relevance of the store and forward dermatology, without the use of dermoscopy, for suspicious pigmented lesions. This study is in line with recent studies calling for postponement of the development of store-and-forward TD for the management of suspicious pigmented skin lesions until additional studies have been carried out.

Purpose: The purpose of this study was to evaluate the percentage of coronary angiography that can be securely avoided by the interpretation of coronary arteries on pre transcatheter aortic valve implantation CT (TAVI-CT), using CT images obtained with deep-learning reconstruction and motion correction algorithms. Material and method: All consecutive patients who underwent TAVI-CT and coronary angiography, from December 2021 to July 2022 were screened for inclusion in the study. Patients who had previous coronary artery revascularization or who did not undergo TAVI were excluded. All TAVI-CT examinations were obtained using deep-learning reconstruction and motion correction algorithms. On TAVI-CT examinations, quality and stenosis of coronary artery were analyzed retrospectively. When insufficient image quality and/ or when diagnosis or doubt of one significant coronary artery stenosis, patients were considered as having possible coronary artery stenosis. The results of coronary angiography were used as the standard of reference for significant CAS. Results: A total of 206 patients (92 men; mean age, 80.6 years) were included; of these 27/206 (13%) had significant coronary artery stenosis on coronary angiography and were referred for potential revascularization. Sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of TAVI-CT to identify patients requiring coronary artery revascularization was 100% (95% confidence interval [CI]: 87.2-100%), 100% (95% CI: 96.3-100%), 54% (95% CI: 46.6-61.6), 25% (95% CI: 17.0-34.0%) and 60% (95% CI: 53.1-66.9%) respectively. Intra- and inter observer variability was substantial agreement for quality and decision to recommend coronary angiography. Mean reading time was 2 1.2 (standard deviation) min (range: 1-5 min). Overall, TAVI-CT could potentially rule out indication for revascularization for 97 patients (47%). Conclusion: Analysis of coronary artery on TAVI-CT using deep-learning reconstruction and motion correction algorithms can potentially safely avoid coronary angiography in 47% of patients. (c) 2023 Societe francaise de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Background: Deep brain stimulation (DBS) is an effective technique to treat patients with advanced Parkinson’s disease. The surgical procedure of DBS implantation is generally performed under local anesthesia due to the need for intraoperative clinical testing. However, this procedure is long (5–7 h on average) and, therefore, the objective that the patient remains co-operative and tolerates the intervention well is a real challenge. Objective: To evaluate the additional benefit of electroacupuncture (EA) performed intraoperatively to improve the comfort of parkinsonian patients during surgical DBS implantation. Methods: This single-center randomized study compared two groups of patients. In the first group, DBS implantation was performed under local anesthesia alone, while the second group received EA in addition. The patients were evaluated preoperatively, during the different stages of the surgery, and 2 days after surgery, using the 9-item Edmonton Symptom Assessment System (ESAS), including a total sum score and physical and emotional subscores. Results: The data of nine patients were analyzed in each group. Although pain and tiredness increased in both groups after placement of the stereotactic frame, the ESAS item “lack of appetite”, as well as the ESAS total score and physical subscore increased after completion of the first burr hole until the end of the surgical procedure in the control group only. ESAS total score and physical subscore were significantly higher at the end of the intervention in the control group compared to the EA group. After the surgical intervention (D2), anxiety and ESAS emotional subscore were improved in both groups, but the feeling of wellbeing improved in the EA group only. Finally, one patient developed delirium during the intervention and none in the EA group. Discussion: This study shows that intraoperative electroacupuncture significantly improves the tolerance of DBS surgery in parkinsonian patients. This easy-to-perform procedure could be fruitfully added in clinical practice.

Background: Targeted therapy is used to treat patients with a BRAF-mutated metastatic melanoma and is continued until disease progression or severe toxicity. No robust data on the management of patients achieving a complete remission (CR) are available. Main Objective: To determine the relapse rate in the first year after targeted therapy discontinuation in patients in CR. Secondary Objectives: To determine the relapse rates throughout the follow-up and to identify prognostic factors for relapse at 1 year. Methods: A retrospective, monocentric observational study was conducted in patients with advanced melanoma included in the RIC-Mel database who discontinued targeted therapy after achieving a CR confirmed by CT scan and PET/CT scan. Results: Twenty-nine patients were included. Seventeen (58.6%) patients were treated with BRAF inhibitor (BRAFi) alone and 12 (41.4%) with a BRAFi combined with a MEK inhibitor (BRAFi + MEKi). The median treatment duration was 9.7 months. The relapse rates after discontinuation were 69% at 12 months (BRAFi: 70.6%; BRAFi + MEKi: 66.7%) and 76% at 36 months (BRAFi: 76.5%; BRAFi + MEKi: 75%). A non-significant trend towards a higher risk of relapse was found in women (p = 0.1; RR 3.36; 95% CI 0.77–17.07), in patients with an LDH level greater than the upper limits of normal (p = 0.58; RR 2.43; 95% CI 0.10–56.71), and when more than two metastatic sites were involved (p = 0.19; RR 4.6; 95% CI 0.46–46.51). After relapse, targeted therapy was resumed in 17 patients (7 with BRAFi; 10 with BRAFi + MEKi) with a response rate of 53%. Conclusions: This real-life study provided long-term data in patients who discontinued targeted therapy after CR. Most patients experienced a relapse in the first year after targeted therapy discontinuation, of whom 50% were in the first 3 months. After targeted therapy resumption, 53% of relapsing patients achieved an objective response. Patients should be followed during the first year after treatment discontinuation. In addition, patients with less than 3 metastatic sites, a baseline LDH level with normal ranges, men, and patients responding rapidly to treatment would be more likely to maintain a CR after treatment discontinuation.

Acne is a common benign inflammatory disease, but it has a significant psychosocial impact. The role of the diet in the development of acne is controversial. Some daily foods such as milk and fast-release sugars tend to promote acne. The Mediterranean Diet (MD) is based on virgin olive oil and nuts that are rich in polyphenols with anti-inflammatory properties. The aim of this study was to assess an association between the adherence to the MD and the severity of facial acne in French women. A case-control observational study was conducted in Nantes Hospital (France). Based on a validated PREvención con DIeta MEDiterránean questionnaire, the adherence to the MD was assessed. The Global Evaluation Acne severity score was assessed by a trained dermatologist. Forty women with mild-to-severe acne and 40 control subjects were included. A global linear model identified a significant negative correlation between the severity of acne and the adherence to the MD in acne patients (regression coefficient = −0.17; P = 0.017). This was the first study conducted in France to investigate the relationship between the adherence to the MD and the severity of facial acne in women. This study confirmed the importance of using a holistic approach for acne management. Further studies are needed to confirm our findings.

Background Vismodegib is indicated for the treatment of advanced or metastatic basal cell carcinoma (BCC). The predictive factors of response to vismodegib have so far been poorly described. Objectives The primary objective was to determine the profile of patients responding to vismodegib and the duration of response. Secondary objectives were to assess whether there is a correlation between the duration of treatment and the risk of relapse, and to define factors associated with relapse. Materials & Methods We included 61 patients with locally advanced BCC (laBCC) or multiple BCC, treated with vismodegib (150 mg per day), from July 2011 to November 2015, in the Oncodermatology Department of Nantes University Hospital in France. Tumour response was assessed using Response Evaluation Criteria in Solid Tumours version 1.1. Results Thirty-nine patients had advanced BCC (64%) and 22 patients multiple BCC (36%), including 10 patients with Gorlin syndrome. No factor predicted response to vismodegib. The median progression-free survival (PFS) was 69.5 months for the total population. In multivariate analysis, multiple BCC was the only factor associated with an increased risk of relapse (HR: 13.80 [CI95%, 1.93-98.64, p < 0.01]). Treatment duration decreased the risk of relapse (HR 0.95 [CI95%, 0.90-0.99, p = 0.0467]). Among the 20 patients who experienced relapse during follow-up, 15 (75%) were re-treated with vismodegib, with a response rate of 66%. Conclusion Although we were unable to establish predictive factors for the response to vismodegib, we demonstrate for the first time that increased treatment duration correlates with a decreased risk of relapse.

Introduction Only a small amount of published data regarding truncal acne is available, and no proper tool to assess its severity exists. Aim The aim of the study was to provide dermatologists with an easy-to-use tool to assess truncal acne (TRASS, truncal acne severity scale) using a global approach. Methods A scoring tool that assesses the severity of acne (based on GEA and ECLA scales) on the trunk using a global approach was built, including three sub-scores: family history, clinical signs and quality of life (QoL). In order to test TRASS, the experts used photographs of 47 patients attending their clinics with truncal acne. The regression optimized (ROP) model was applied to assess the diagnosis performance of TRASS and to identify items contributing to the classification of the patients. Internal testing was made to demonstrate the robustness of the model. Correlation analyses between the different items were performed to evaluate the interaction between the different items and their impact on the severity grading of truncal acne. Results Patients with the most severe acne were identified by TRASS. The error level was 6.6% after internal validation and 10.4% when using the median value or the centile 75th (6.6% and 10.4%). Correlation was significant between systemic treatment and scars (P = 0.0025) and nodules (P = 0.01988) and between location and QoL (P = 0.0095). Conclusion Truncal acne severity scale is the first global, patient-centred approach to evaluate truncal acne by scoring the importance of each factor independently from its clinical severity. TRASS may allow the practitioner to choose and validate the most suitable therapy together with the patient in order to treat his or her truncal acne successfully and to limit treatment failure.

The incidence of melanoma is increasing worldwide. The effectiveness of treatment is associated with diagnostic and therapeutic delays. In this context, teledermatology (TD), especially store-and-forward TD, is a promising technology, as it can accelerate the care process. However, several studies indicate that the efficiency and reliability of this practice in cases of pigmented skin lesions is not proven and call for further work. The main objective of this study was to evaluate management concordance among teledermatologists concerning the appropriate consultation delay when reviewing photographs of suspicious pigmented skin lesions taken with a smartphone by a general practitioner (GP). Methods: We conducted management concordance analysis among different teledermatologists with experience in TD. The teledermatologists determined the consultation delay to propose to 110 patients with suspicious pigmented skin lesions viewed online based on 241 photographs taken by GPs in a real-life context. The practitioners had to decide among 4 possibilities for care management: 1. urgent need for consultation, 2. nonurgent need for consultation, 3. no need for consultation, and 4. impossible to assess: request for additional information or photographs from the GP. "Major" discordance was defined as follows: one teledermatologist decided that the patient had to receive a consultation within 15 days, while another teledermatologist decided that it was not necessary to see the patient ("simple letter to the attending physician"). This study revealed poor agreement among dermatologists when they assessed photographs taken by a GP using a smartphone. The interrater agreement was poor regardless of the analysis modality used. The 2-to-2 interdermatologist management concordance revealed a low Cohen's kappa (between 0.11 and 0.43). Overall agreement was low (Fleiss’ kappa 0.24). We observed major discordance regarding care management for 42 clinical cases (38% of patients). This study is in line with recent studies calling for postponement of the development of store-and-forward TD for the management of skin cancers until additional studies have been carried out.

BACKGROUND:Immune checkpoint inhibitors have improved the management of metastatic melanoma, however, we have witnessed an emergence of adverse cardiac events such as myocarditis.OBJECTIVES:We first aimed to assess the prevalence of adverse cardiac events in patients treated with anti-PD-1 for metastatic melanoma. Our second objective was to determine the role of troponin monitoring in the diagnosis of these events.MATERIALS & METHODS:We retrospectively analysed the prevalence of patients treated with anti-PD-1 in a real-life setting based on a cohort of 183 patients. We then performed a prospective cohort, in which clinical and biological profiles of patients were collected, along with monthly monitoring of troponin levels.RESULTS:The prevalence of adverse cardiac events in the retrospective cohort was 2.2%, with three cases of myocarditis and one of myocardial infarction. In the prospective cohort, 14/52 patients had an abnormal baseline troponin T level. All patients had a history of cardiac or vascular complaints. Six patients showed an increase in troponin T level during follow-up, in two patients associated with clinical symptoms.CONCLUSION:Adverse cardiac events with immunotherapy are both frequent and life-threatening. Troponin T may be of interest to detect early adverse cardiac events before any clinical sign, however, the data supporting this remain to be confirmed.

BACKGROUND:Treatment of lentigo maligna (LM) is challenging because of the potential functional and esthetic surgical sequelae. Imiquimod has been proposed as a treatment for LM. Reflectance confocal microscopy (RCM) is a noninvasive method for the diagnosis of LM and margin assessment.OBJECTIVES:To compare the overall LM score (LMS) assessed by RCM before and 1 month after the start of imiquimod treatment compared to placebo and to define the immunohistochemical (IHC) profile of responders to imiquimod.METHODS:A controlled randomized study was conducted. Forty patients underwent RCM examination with calculation of the LMS at baseline and after 1 month of treatment. An IHC analysis of excised tissues was performed.RESULTS:The 1-month LMS was significantly lower in patients treated with imiquimod compared to those treated with placebo (P < .001). The criteria in the imiquimod-treated patients that demonstrated significant decrease were nonedged papillae; large, round pagetoid cells; atypical cells at the dermoepidermal junction; and follicular location of atypical cells. IHC analysis showed a higher level of interferon gamma in the resected specimens of patients responding to imiquimod (P = .04).LIMITATIONS:Sample size was small.CONCLUSION:Assessing the LMS by RCM was useful to monitor LM response to imiquimod accurately.

L’incidence du mélanome augmente dans le monde entier. L’efficacité du traitement est associée aux délais diagnostiques et thérapeutiques. Dans ce contexte, la télédermatologie est une technologie prometteuse car elle pourrait accélérer le processus de soins. Cependant, plusieurs études indiquent que l’efficacité et la fiabilité de cette pratique, en cas de lésions cutanées pigmentées suspectes, ne sont pas prouvées et appellent à des travaux complémentaires. L’objectif principal de cette étude était d’évaluer la concordance entre les télédermatologues sur le délai de consultation proposé face à des photographies de lésions cutanées pigmentées suspectes prises avec un smartphone par un médecin généraliste. Nous avons réalisé une analyse de concordance de prise en charge entre différents télédermatologues ayant une expérience en télédermatologie. Les télédermatologues ont déterminé en ligne le délai de consultation à proposer à 110 patients présentant des lésions cutanées pigmentées suspectes, à partir de 241 photographies prises par des médecins généralistes en conditions réelles. Ils devaient décider parmi 4 possibilités de prise en charge : (1) à convoquer en urgence ; (2) à convoquer sans urgence ; (3) à ne pas convoquer ; (4) impossible à évaluer : demande d’informations ou de photographies complémentaires au médecin généraliste. Une discordance « majeure » était définie comme le fait qu’un télé-dermatologue réponde que le patient devait être convoqué à une consultation en urgence, alors qu’un autre télé-dermatologue répondait qu’il n’était pas nécessaire de recevoir le patient en consultation. L’étude a révélé une faible concordance entre les dermatologues lorsqu’ils évaluent des photographies prises par un médecin généraliste à l’aide d’un smartphone. La concordance inter-dermatologues était faible, quelle que soit la modalité d’analyse. La concordance interdermatologue de gestion 2 à 2 a trouvé un kappa de Cohen faible, entre 0,11 et 0,43. La concordance globale était faible (kappa de Fleiss à 0,24). Nous avons observé une discordance majeure sur le parcours de soins dans 42 cas cliniques, soit 38 % des patients. Cette étude va dans le sens des études récentes demandant de suspendre le développement de la télé-expertise pour la prise en charge des lésions suspectes de mélanome jusqu’à ce que des études complémentaires aient été réalisées.