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Competing Interests: Conflicts of interest None disclosed.

Background: Minimally invasive nail unit melanoma (NUM) can be treated with functional surgery (FS) instead of amputation., Objective: To determine risk factors associated with recurrence in NUM., Methods: We retrospectively reviewed patients with NUM between 2008 and 2022 at a tertiary referral center. Multivariable Cox regression models adjusted for male sex and Breslow thickness (BT) were generated. Receiver operating characteristic analysis was performed to determine optimal cut-off points of the BT for stratifying recurrence risk., Results: We evaluated 140 NUM cases (33 amputation and 107 FS). The mean BT values were 3.14 ± 2.62 mm (amputation) and 0.70 ± 1.36 mm (FS). Recurrence occurred in 10 (30.30%) patients with amputation and 23 (21.5%) with FS. Distant disease occurred in 10 (30.30%) patients with amputation and 8 (7.48%) with FS. Male sex, greater BT, amelanotic color, ulcers, and nodules were associated with greater risk for recurrence or distant disease. A BT of 0.8 mm was deemed the optimal cut-off for stratifying recurrence risk after surgery (odds ratio, 5.32; 95% CI, 2.04-13.85)., Limitations: Small sample., Conclusion: FS can be considered for NUM with a BT < 0.8 mm, providing an amputation-sparing benefit. However, NUM with risk factors for recurrence requires patient counselling and close follow-ups., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2023 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Limited data are available to assist the selection between immune checkpoint inhibitors and BRAF/mitogen-activated protein kinase kinase inhibitors as first-line treatment for patients with BRAF-mutant advanced malignant melanoma., Objective: To investigate the outcomes associated with first-line pembrolizumab or dabrafenib/trametinib treatment for advanced melanoma with activating BRAF V600 mutation., Methods: Data of patients with BRAF V600-mutant melanoma who were treated with first-line pembrolizumab (n = 40) or dabrafenib/trametinib (n = 32) were analyzed. Tumor response, progression-free survival, and overall survival were evaluated. Immune evasion accompanied with emerging resistance to BRAF/mitogen-activated protein kinase kinase inhibitors was assessed., Results: A longer overall survival was observed after first-line pembrolizumab treatment than after first-line dabrafenib/trametinib treatment (hazard ratio = 2.910, 95% CI: 1.552-5.459), although there were no significant differences in progression-free survival (P = .375) and response rate (P = .123). Emergence of resistance to dabrafenib/trametinib co-occurred with immune evasion, enabling melanoma cells to escape recognition and killing by Melan-A-specific CD8 + T cells., Limitations: Analysis was conducted in a retrospective manner., Conclusion: Pembrolizumab may be recommended over BRAF/mitogen-activated protein kinase kinase inhibitors as the first-line treatment in patients with advanced BRAF V600-mutant melanoma., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: The prognostic significance of tumor size in thymic epithelial tumors (TETs) has not been fully evaluated. We aimed to clarify the prognostic value of tumor size in limited-stage and advanced-stage TETs., Methods: Clinical records of patients with completely resected TETs were retrospectively collected from 4 tertiary centers between January 2000 and February 2013. Information on the Masaoka-Koga stage was available for 1215 patients (M-K group), and 433 patients were classified according to the eighth edition of the Tumor-Node-Metastasis staging system (TNM group). Limited-stage and advanced-stage TETs were defined according to whether they were confined within the surrounding fatty tissues without invasion. The optimal cutoff value was selected using a maximally selected log-rank statistic., Results: The median tumor size was 6.0 ± 2.8 cm in the M-K group and 6.5 ± 3.0 cm in the TNM group. In the multivariable analysis, tumor size had a significant effect on both overall survival (P = .003) and recurrence-free survival (P < .001) for limited-stage tumors (M-K stage I or II or TNM stage I), but not for advanced-stage tumors (M-K stage III or IV or TNM stage II-IV; P = .349 for overall survival and P = .439 for recurrence-free survival). The optimal cutoff value for tumor size was >5.5 cm for both overall survival and recurrence-free survival in limited-stage TETs., Conclusions: Tumor size is an independent prognostic factor in patients with completely resected limited-stage TETs and a cutoff value >5.5 cm might help clinicians enact proper treatment strategies and surveillance., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Predicting the recurrence of localized melanoma is important; however, studies investigating risk factors for recurrence of localized melanoma are lacking in Asian populations., Objective: To identify risk factors for recurrence of localized melanoma in Korean patients., Methods: We retrospectively reviewed patients with cutaneous melanoma without evidence of metastasis from 2000 to 2017. Logistic and Cox regression analyses were conducted for recurrence. The average follow-up time was 46.2 months., Results: We reviewed the data of 340 patients diagnosed with cutaneous melanoma and staged as melanoma in situ, stages I and II. Acral melanoma (70.3%, 239/340) was the predominant subtype. Ninety-two patients (27.1%) had a recurrence after primary melanoma removal (29 local recurrences, 49 regional metastases, and 28 distant metastases). Some patients had multiple types of recurrence at the same time. Male sex (P = .030) and Breslow thickness greater than 1 mm (P = .008) correlated with an increased risk of recurrence. Breslow thickness greater than 2.5 mm in males and greater than 4 mm in females showed a higher predictive value for recurrence than traditional stages IIB and IIC (hazard ratio 3.743 vs 2.972)., Limitations: This was a single-center retrospective study., Conclusion: In patients with localized cutaneous melanoma, male sex and Breslow thickness are the most important prognostic factors for recurrence in Korean populations. Different cutoff values of Breslow thickness may better predict recurrence according to sex., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Although various laser treatments have been tried for congenital melanocytic nevi (CMNs), only small retrospective studies with short-term follow-up had been done to assess outcomes., Objective: We analyzed the long-term outcomes of laser treatment for CMN and compared these outcomes with those of a combination treatment including partial excision and lasers., Methods: Patients with CMN treated with lasers were retrospectively reviewed, and patients with >3 years of follow-up were grouped as the long-term follow-up group., Results: A total of 67 cases of CMN were reviewed. Among 20 patients (20/52, 38.5%) with near total clearance during laser-only treatment, 11 patients were in the long-term follow-up group, and 5 of 11 showed repigmentation. In total, 15 patients showed repigmentation regardless of clearance, and the mean period until repigmentation was 3.93 years from the initial treatment. Patients with partial excision and laser combination treatment showed higher Investigator's Global Assessment scores, fewer laser treatments, and shorter treatment periods compared with patients with laser-only treatment., Limitations: This is a retrospective study, and various laser devices were used., Conclusion: More than 4 years of follow-up is required to evaluate the efficacy of lasers in CMN, and partial excision and laser combination treatment might be an effective treatment option., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Melanoma of unknown primary (MUP) is a condition of metastatic melanoma without a primary lesion., Objective: We sought to identify the prognosis of MUP compared with melanoma of known primary (MKP)., Methods: We searched for observational studies containing at least 10 patients with MUP from MEDLINE and EMBASE from inception to December 22, 2012. The outcomes of interest were overall and disease-free survival; meta-analyses of hazard ratio stratified by stage using a random effects model were performed. In addition, second systematic review identified risk factors influencing the survival of patients with MUP., Results: Eighteen studies including 2084 patients with MUP and 5894 with MKP were included. MUP had a better overall survival compared with MKP in stage III (15 studies; hazard ratio 0.83, 95% confidence interval 0.73-0.96, P = .010) and stage IV (6 studies; hazard ratio 0.85, 95% confidence interval 0.75-0.96, P = .008). Secondly, 22 studies including 3312 patients with MUP were reviewed, and increased stage and old age were the risk factors in patients with MUP., Limitations: Diverse observational studies were reviewed, and selection and reporting biases are possible., Conclusions: The current meta-analyses suggest better survival outcomes in patients with MUP than those in patients with MKP with the same corresponding tumor stage., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Allergen-specific immunotherapy (allergen-SIT) is the only treatment directed at the cause of IgE-mediated allergic diseases. However, there is controversy over the use of SIT for patients with atopic dermatitis., Objective: We performed a systematic review and meta-analysis to assess the efficacy of SIT for patients with atopic dermatitis., Methods: We performed manual searches of reference lists and computerized searches of the MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane databases (through December 10, 2012) for randomized controlled trials that compared SIT with placebo for patients with atopic dermatitis. The outcome of interest was a dichotomous variable, in terms of treatment success; a meta-analysis was performed by using a random-effects analysis. Subgroup analyses were carried out to evaluate the effects of long-term treatment (more than 1 year), SIT for severe atopic dermatitis, SIT for children, and subcutaneous and sublingual administration of immunotherapy., Results: We analyzed 8 randomized controlled trials that comprised a total of 385 subjects. We found that SIT has a significant positive effect on atopic dermatitis (odds ratio [OR], 5.35; 95% CI, 1.61-17.77; number needed to treat, 3; 95% CI, 2-9). SIT also showed significant efficacy in long-term treatment (OR, 6.42; 95% CI, 1.50-27.52) for patients with severe atopic dermatitis (OR, 3.13; 95% CI, 1.31-7.48), and when administered subcutaneously (OR, 4.27; 95% CI, 1.36-13.39)., Conclusions: A meta-analysis provides moderate-level evidence for the efficacy of SIT against atopic dermatitis. However, these findings are based on an analysis of a small number of randomized controlled trials, with considerable heterogeneity among trials., (Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.)

Background: Extramammary Paget disease (EMPD) is a rare intraepithelial neoplasm of the skin characterized by ill-defined margins and high recurrence rates after wide local excision. Although Mohs micrographic surgery (MMS) has been proposed to decrease the rate of local recurrence, the efficacy of MMS for this condition has not yet been established., Objective: We sought to assess the efficacy of MMS for the treatment of EMPD., Methods: A comprehensive systematic review and individual patient data meta-analysis was performed including all available clinical studies and case reports with 5 or more subjects describing the use of MMS for EMPD., Results: Eight studies were identified and included in the current review: 3 retrospective studies and 5 case series. In all, 81 patients with 90 cases of MMS were included from these 8 studies. The overall recurrence rate for EMPD after MMS was 12.2% correlating with an estimated 5-year tumor-free rate of 83.6% by using Kaplan-Meier curve analysis. The treatment of EMPD with MMS resulted in significantly lower recurrence rates than wide local excision in this meta-analysis of 3 observational studies with comparators (odds ratio 0.20; 95% confidence interval 0.05-0.81)., Limitations: Limitations include lack of controlled trials, small sample sizes in the included studies, and publication bias., Conclusion: The current evidence supports the efficacy of MMS in the treatment of EMPD. Further controlled clinical trials are needed., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Objective: To assess the feasibility and safety of robot-assisted thoracoscopic esophagectomy for esophageal cancer in the prone position., Methods: Twenty-one patients underwent robot-assisted thoracoscopic esophagectomy in the prone position by a surgical oncologist who had no prior experience with thoracoscopic esophagectomy. Hemodynamic and respiratory parameters were serially recorded to monitor changes in prone positioning., Results: All thoracoscopic procedures were completed with a robot-assisted technique followed by cervical esophagogastrostomy. R0 resection was achieved in 20 patients (95.2%), and the number of dissected nodes was 38.0 + or - 14.2. Robot console time was significantly reduced from 176.3 + or - 12.3 minutes in the initial 6 patients (group 1) to 81.7 + or - 16.5 minutes in the latter 15 patients (group 2) (P = .000). In group 2, there was less blood loss (P = .018), more patients could be extubated in the operating room (P = .004), and the number of dissected mediastinal nodes tended to be increased (P = .093). There was no incidence of pneumonia or 90-day mortality. Major complications included anastomotic leakage in 4 patients, vocal cord palsy in 6 patients, and intra-abdominal bleeding in 1 patient. The prone position led to an elevation of central venous pressure and mean pulmonary arterial pressure and a decrease in static lung compliance. However, cardiac index and mean arterial pressure were well maintained with the acceptable range of partial pressure of arterial oxygen and carbon dioxide., Conclusion: Robotic assistance in the prone position is technically feasible and safe. Prone positioning was well tolerated, but preoperative risk assessment and meticulous anesthetic manipulation should be carried out., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: This study was conducted to assess the risk of surgical treatment and to evaluate surgical resection in patients with pulmonary aspergilloma., Method: We reviewed 240 patients with pulmonary aspergilloma who were diagnosed between 1990 and 2006. Of these, 135 patients underwent surgical procedure (group A) and 105 patients were managed with conservative treatment (group B)., Result: Forty complications (29.6%) and 6 operative mortalities (4.4%) developed in group A. During the follow-up period, there were 5 recurrences (3.9%) after surgical procedure. The overall 10-year survival rates of group A and group B were 84.8% and 56.7% (P < .001). In multivariate analysis, age, sex, and surgical treatment were favorable prognostic factors. Symptoms of hemoptysis and blood-tinged sputum were not significant prognostic factor even in univariate analysis., Conclusion: Our results indicate that (1) early morbidity and mortality rates of surgical treatment for pulmonary aspergilloma are acceptable, and (2) surgical treatment is helpful not only to reduce symptoms but also to prolong the survival of patients with pulmonary aspergilloma. Although more studies are needed, our data support the conclusion that surgical resection should be considered for all patients with pulmonary aspergilloma who have acceptable pulmonary reserve.

Objective: During one-lung ventilation, surgical positions significantly affect deterioration of oxygenation, and the lateral decubitus position is superior in preventing dangerous hypoxemia compared with the supine position. However, additional head-down tilt causes more compression of the dependent ventilated lung by the abdominal contents and may result in dangerous hypoxemia, as occurs in the supine position. Therefore, we evaluated the effect of head-down tilt on intrapulmonary shunt and oxygenation during one-lung ventilation in the lateral decubitus position., Methods: Thirty-four patients requiring one-lung ventilation were randomly allocated to the control group (n = 17) or the head-down tilt group (n = 17). Hemodynamic and respiratory variables were measured 15 minutes after one-lung ventilation in the lateral decubitus position (baseline), 5 and 10 minutes after a 10-degree head-down tilt (T5 and T10, respectively), and 10 minutes after the patient was returned to a horizontal position (T20) in the head-down tilt group. Measurements were done at the same time points in the control group without head-down tilting., Results: In the head-down tilt group, cardiac filling pressures were increased after head-down tilt without any changes in cardiac index. Percent change of shunt to baseline value was significantly increased at T10 and T20 in the head-down tilt group. Percent change of arterial oxygen tension to baseline value was significantly decreased at T5, T10, and T20 in the head-down tilt group, whereas it was decreased only at T20 in the control group., Conclusion: Head-down tilt during one-lung ventilation in the lateral decubitus position caused a significant increase in shunt and a decrease in percent change of arterial oxygen tension, without causing dangerous hypoxemia.

Whole body 18 F-fluorodeoxyglucose (FDG) positron emission tomography was performed for staging in 7 extramammary Paget's disease patients and 4 tests showed mild FDG uptake at the primary sites. Histologically, all 4 tumors were found to be thicker than 2 cm. Among the 4 patients, 2 showed multiple hypermetabolic foci of skeletal metastasis and lymph node involvement.

Erosive adenomatosis of the nipple (EAN) is a rare, benign tumor that resembles Paget's disease and well-differentiated adenocarcinoma. Total excision of the nipple has been the usual treatment modality because of the high incidence of recurrence when removal is incomplete, and complete excision generally mandates a reconstructive procedure. We report a case of a 56-year-old woman with EAN treated with Mohs micrographic surgery (MMS). We suggest that MMS is the first choice of treatment for EAN because it can be effectively used to remove the tumor completely and at the same time preserve the nipple, if performed early enough, before the tumor is widely spread.

Background: A peculiar type of fat necrosis was noted in some patients with various skin diseases., Objective: We attempted to develop a classification of membranous lipodystrophy combining the results of our study and a review of other articles., Methods: Five cases of skin diseases with membranous lipodystrophy were studied and their clinical and histopathologic features were analyzed. Previous reports of similar findings were reviewed., Results: Membranous lipodystrophic changes were noted in morphea profunda, lupus panniculitis, and factitial ulcer. Microcysts were formed by the coalescence of the destroyed fat cells and were lined by amorphous, eosinophilic material. Some of the linings had a crenelated appearance. Microgranules were found in the histiocytes and in the hyalinized collagen stroma. The linings and microgranules stained positively with periodic acid-Schiff, were resistant to diastase, and also stained with Sudan black B., Conclusion: We propose the use of the term secondary membranous lipodystrophy to describe the local subcutaneous membranous lipodystrophic change that occurs as a result of other skin diseases, in contrast to primary idiopathic membranous lipodystrophy, which occurs without any antecedent factors.

We recently saw a case of Behçet's syndrome in an 11-year-old Korean boy who had severe bullous necrotizing vasculitis as a skin manifestation. The patient exhibited three major criteria of the Shimizu classification, namely, oral and genital ulcerations, uveitis, and bullous necrotizing vasculitis as the skin manifestation. Immunologic laboratory data showed an increased OKT4/OKT8 ratio and a lymphocyte stimulation index with phytohemagglutinin. A skin specimen taken from a developing lesion showed features of lymphocytic vasculitis extending into the panniculus.

Because of the decrease in the overall incidence of syphilis, syphilitic involvement of stomach is seldom reported in the modern literature. Because of the nonspecific symptoms and signs of the disease, it is necessary to demonstrate Treponema pallidum in the gastric lesions to confirm the diagnosis. With the use of immunofluorescence and immunoperoxidase methods we have succeeded in identifying T. pallidum in the gastric wall of a patient who initially had cutaneous manifestations of secondary syphilis and gastric symptoms.