P6387Cost effectiveness analysis of Mohs micrographic surgery versus tradi-tional surgical excision for head and neck basal cell carcinoma

Deshan Sebaratnam, MBBS, University of Sydney, Sydney, Australia; PabloFern�andez Pe~nas, PhD, University of Sydney, Sydney, Australia; RachaelMorton, PhD, University of Sydney, Sydney, Australia; Robert Paver, MD, Skinand Cancer Foundation Australia, Westmead, Australia

Mohs micrographic surgery (MMS) is regarded as the intervention offering thelowest recurrence rates for basal cell carcinoma (BCC) management, however it isperceived to be expensive relatively. To determine the cost effectiveness of MMScompared with traditional excision (TE) for head and neck BCC, a modelled costutility analysis was performed from the perspective of the Australian health caresystem over a time horizon of 5 years. The criterion standard in health economicevaluations is to determine cost/quality adjusted life year (QALY) and this outcomewas accordingly sought in this analysis. A Markov model simulating the naturalhistory of BCC was constructed using TreeAge software populated with the likelyoutcomes for primary BCC treated with MMS or TSE. Recurrence rates wereidentified from data obtained from the Skin and Cancer Foundation Australia. Whererequired data were not available, a systematic review was performed and bestavailable data used. A 5-year recurrence rate of 5% for primary BCC and 17% forrecurrent BCC was used for TE and 1% for primary BCC and 4% for recurrent BCCused for MMS, with all rates converted to annual probabilities. Literature reviewwasperformed to determine the QALY-weighting associated with BCC recurrence and afigure of 0.98 employed. Resource use was obtained from a retrospective review ofall head and neck BCC treated at the Skin and Cancer Foundation Westmead 2009-2010 using the Medicare Benefits Schedule to determine mean costs. Sensitivityanalysis was performed incorporating a range of plausible values for all variablesconsidered. An incremental cost effectiveness ratio of AUD $22,276/QALY wascalculated. This provisional figure falls well within the threshold put forward by theAustralian health care system in terms of cost effectiveness of medical interventions.Accordingly, over a 5-year horizon MMS would be considered a cost effectiveintervention for head and neck BCC compared to TE from an Australian health caresystem perspective.

APRIL 20

cial support: None identified.

Commer

P6282Cutaneous Agent Orange syndrome

Mark Clemens, MD, University of Texas, M.D. Anderson Cancer Center, Houston,TX, United States; Andrew Kochuba, MD, Montefiore Medical Center, New York,NY, United States; Jun Liu, MD, University of Texas, M.D. Anderson CancerCenter, Houston, TX, United States; Karen Evans, MD, Medstar GeorgetownUniversity Hospital, Washington, DC, United States; Kevin Han, MD, MedstarGeorgetown University Hospital, Washington, DC, United States; Mary EllaCarter, MD, Veterans Affairs Medical Center, Washington, DC, United States

Background: Agent Orange, or TCDD (2, 3, 7, 8-tetrachlorodibenzodioxin), has beenlinked to many different malignancies. This study was designed to study whetherdioxin exposure leads to an increased incidence nonmelanotic skin cancers.

Methods: A retrospective review of 100 consecutive males with Fitzpatrick skintypes I to IV from August 2009 to January 2010 at Washington DC Veterans AffairMedical Center. Patient demographics, skin cancer, associated malignancies, timing,and location of dioxin exposure were collected. Data were compared to normativedata established nationally.

Results: Out of a total 100 patients with an average age of 65.7, average elapsed timesince dioxin exposure was 41 years. Average length of exposure was 2 years. Type ofdioxin exposure included working in contaminated areas (49%), spraying AgentOrange (30%), traveling in contaminated areas (14%), and living in contaminatedfacilities (7%). 26% of patients demonstrated associated malignancies. Patientsdemonstrated chloracne (43%) and non-melanotic invasive skin cancers (50%). HighFitzpatrick score, darker eye color, and light-exposure were associated with lowernonmelanotic invasive skin cancer incidence (P¼.01, .036, and .003, respectively).Chloracne was correlated to higher nonmelanotic invasive skin cancer incidencerates (81% vs 26%; P\.01). Average year to onset from exposure was 28 years. Theincidence rate of the study population (51.8%) was significantly higher than thenational incidence rate (23.8%; P\.001).

Discussion: This is the first time one has shown a link between Agent Orange andnonmelanotic skin cancers. In addition to associated malignancies, service person-nel with previous dioxin exposure need to be counseled on the cutaneous sequelaeof dioxin exposure. Length and degree of exposure appear to be associated with thedevelopment of carcinomas. Frequent screenings (every 6 months) are essential forsurveillance of these rapidly growing and invasive cancers. Lesions may be treatedwith aggressive IPL (intense pulsed light) therapy, flourouracils, cryotherapy, andearly surgical excision; however, recurrence is high. Additional studies arewarranted to determine a relative risk within this large patient population and todetermine appropriate management strategies.

cial support: None identified.

Commer

13

P6200Cutaneous histiocytic sarcoma: A case report

Mariam Mafee, University of Illinois at Chicago, Chicago, IL, United States; DavidLortscher, MD, University of California, San Diego, San Diego, CA, United States;Robert Lee, MD, PhD, University of California, San Diego, San Diego, CA, UnitedStates

Histiocytic sarcoma (HS) is a rare hematopoietic neoplasm that most commonlypresents extranodally, often at a gastrointestinal or cutaneous site. It has beendocumented in the literature through a limited number of case reports and caseseries. We present the case of a 34-year-old man with a history of 2 kidneytransplants and a recent diagnosis of histiocytic sarcoma of Waldeyer’s ring that wasreferred for lesions on his extremities and trunk. Upon his initial diagnosis of HS,therewere 2 subcutaneous nodules on his lower extremities that were thought to becysts. While on CHOP chemotherapy, he continued to develop new nodules thatwere found to be FDG-avid on PET scan, and he was referred to dermatology.Examination revealed a total of 10 nodules on his trunk and extremities; they weremobile, moderately firm, and they ranged between 0.5 to 1cm. There was nodrainage or ulceration. Punch biopsy revealed dermal nodules consisting ofmarkedly atypical epithelioid histiocytes with foamy, eosinophilic cytoplasm.These cells were present in a background of a mixed inflammatory infiltrate, andthere were areas of fibrosis and tissue necrosis. The atypical cells stained positivelyfor CD68 and lysozyme, and were negative for S-100, CD1a, CD34, cytokeratinAE1/3, CD3, CD20, CD30, and MART-1. These findings were consistent with HS thathad metastasized to the skin from his primary pharyngeal tumor. Currently hissiblings are undergoing HLA typing in anticipation of a possible allogeneichematopoietic stem cell transplant. The World Health Organization defines histio-cytic sarcoma as a malignant neoplasm with morphologic and immunophenotypicfeatures of histiocytes. The morphology is very similar to that of other large cellneoplasms such as diffuse large B-cell lymphoma or anaplastic large cell lymphoma.Therefore, immunohistochemical staining is necessary, and lesions should stain forone or more histiocytic markers such as CD68 and lysozyme. HS tends to take anaggressive course, as seen in our patient. The prognosis of HS is poor because of latepresentation and the lack of proven, standardized therapy. Currently, the mosteffective treatments are combination chemotherapy regimens used to treat non-Hodgkin lymphoma. However despite aggressive chemotherapy, the morality rateranges between 50% and 70%.

cial support: None identified.

Commer

P6531Cutaneous metastasis of papillary thyroid carcinoma after totalthyroidectomy

Sang Hyun Song, MD, Chosun University Hospital, Gwang-ju, South Korea; BongSeok Shin, Chosun University Hospital, Gwangju, South Korea; Chan Ho Na, MD,Chosun University Hospital, Gwangju, South Korea; Kyu Chul Choi, MD, ChosunUniversity Hospital, Gwangju, South Korea; Min Sung Kim, MD, ChosunUniversity Hospital, Gwangju, South Korea

Although skin is the largest organ of the body, cutaneous metastasis of internalmalignancies is rare (0.7-9.0%). Cutaneous metastasis of thyroid carcinoma havebeen reported under 1%. Papillary thyroid carcinoma is the most common type ofthe thyroid cancer, mainly involving the regional lymph nodes and might show theenlargement of cervical lymph nodes as the first manifestation. If papillary thyroidcarcinoma showed cutaneous metastasis, it is the marker for a wide disseminatedstate. A 62-year-old Korean woman presented with asymptomatic, solitary, beansized bluish nodule on the right anterior neck. She had noticed the lesion 2 years agoand the nodule had been steadily enlarging. Five years ago, she experienced the rightlobectomy because of a suspected tumor of the right thyroid lobe. She wasdiagnosed with papillary thyroid carcinoma, stage II and then received totalthyroidectomy of the remnant lobe. Since then, she received the radioactive iodinetreatments 3 times and checked the whole body PET-CT scan twice for 3 years thatrevealed nonspecific findings. CBC, LFT and urinary analysis were normal. A biopsyspecimen showed well demarcated nodule that consisted of many tumor cells withmultiple follicular structures in the dermis. Tumor cells had ground glass nuclei,nuclear pseudoinclusions and nuclear grooves. Immunohistochemical analysisshowed positivity for thyroglobulin and thyroid transcription factor-1. Above thesefindings, we made a diagnosis as cutaneous metastasis of papillary thyroidcarcinoma. She performed PET-CT scan for evaluation of metastasis, but the resultshowed normal findings. Herein, we report a case of cutaneous metastasis ofpapillary thyroid carcinoma without wide disseminated state. We hypothesized thecause of the skin metastasis may be the seeding of cancer cell during or after rightthyroid lobectomy because she had only cutaneous metastatic nodule around rightside of thyroidectomy scar without any systemic problems and other metastases.

cial support: None identified.

Commer

J AM ACAD DERMATOL AB159