Susan London

VANCOUVER, B.C. — The transition from palliative care to comfort care is a key patient management issue that hospitalists must often face, according to Dr. Wendy Yeomans, medical manager of the palliative care unit at Vancouver Acute Health Services.

While palliative care may include such active treatments as surgery, antibiotics, and transfusions, comfort care entails only symptom control at the end of life.

In many cases, the process of changing the goals of care from palliation to comfort care “takes lots of discussion with the family,” she said, recommending that clinicians start these discussions early on.

“As hospitalists, you face the challenge that you don't have long-standing relationships with these patients,” Dr. Yeomans said at the annual Canadian Hospitalist Conference. “It's very difficult sometimes to change the goals of care in the middle of the night instead of just giving the patient an antibiotic. It's a challenge that we all struggle with.”

To undertake these discussions, Dr. Yeomans recommends being proactive when addressing patients' and families' fears that ending active treatment will lead to greater suffering.

“We have to be prepared to explain what comfort care is and that these are the things we are going to do to make them more comfortable,” she said.

When discussing with families the positive side of not doing cardiac resuscitation, for example, it's helpful to explain “that it is most appropriate not to resuscitate someone when they are dying.” Similarly, withdrawing an IV is often in the patient's best interests if he or she is edematous and congested.

Families concerned that withdrawing a feeding tube will lead to starvation can be reassured that the patient is dying of his or her illness and that loss of appetite is part of the natural process of death, Dr. Yeomans said.

“You can also say that when someone is dying, tube feeding is sometimes harmful—it increases secretions, it makes them have lots of cramps, and it increases their nausea.”

Keep the patient's best interests as your focal point, she advised. “Just because we're not going to give [dying patients] antibiotics doesn't mean that we're not going to deal with their fever, cough, and shortness of breath.”

When dealing with pain, a common challenge is the need to switch from one opioid to another because of adverse effects. Dr. Yeomans contended the key to achieving good pain control is relying on just a few drugs and using them appropriately.

When moving from oral morphine to subcutaneous or intravenous morphine, only half the dose is needed because digestive metabolism of the drug is bypassed. Hydromorphone, a more potent derivative of morphine, should be given at even lower doses.

When switching to a parental dose will require subcutaneous administration of large volumes of fluid, consider using the intravenous route instead, she said.

“Opioid toxicity comes about because there are certain types of pain that are not opioid responsive,” she observed. When patients with such pain get only partial relief with an opioid, they take more and more of the drug, eventually leading to neurotoxicity.

The conventional approach to managing opioid toxicity has been to switch opioids and hydrate the patient. “But I would say what you need to do, especially in patients [with complex pain], is to use adjuvant therapy,” an approach that often allows a reduction in opioid dose.

For colicky pain, Dr. Yeomans recommended using an anticholinergic agent such as hyoscine. Antimotility agents and octreotide are also considerations, but both can exacerbate constipation.

Neuropathic pain can be controlled with tricyclics; gabapentin; steroids; or clonazepam, which is especially effective for retroperitoneal pain, according to Dr. Yeomans. However, patients at the end of life have often exhausted these options by the time they are hospitalized. In that case, additional options include methadone, ketamine, and lidocaine, all of which require expertise and close collaboration with palliative care colleagues.

Dr. Yeomans reported that she had no conflicts of interest regarding her presentation. The conference was sponsored by the University of British Columbia.

VANCOUVER, B.C. — The transition from palliative care to comfort care is a key patient management issue that hospitalists must often face, according to Dr. Wendy Yeomans, medical manager of the palliative care unit at Vancouver Acute Health Services.

While palliative care may include such active treatments as surgery, antibiotics, and transfusions, comfort care entails only symptom control at the end of life.

In many cases, the process of changing the goals of care from palliation to comfort care “takes lots of discussion with the family,” she said, recommending that clinicians start these discussions early on.

“As hospitalists, you face the challenge that you don't have long-standing relationships with these patients,” Dr. Yeomans said at the annual Canadian Hospitalist Conference. “It's very difficult sometimes to change the goals of care in the middle of the night instead of just giving the patient an antibiotic. It's a challenge that we all struggle with.”

To undertake these discussions, Dr. Yeomans recommends being proactive when addressing patients' and families' fears that ending active treatment will lead to greater suffering.

“We have to be prepared to explain what comfort care is and that these are the things we are going to do to make them more comfortable,” she said.

When discussing with families the positive side of not doing cardiac resuscitation, for example, it's helpful to explain “that it is most appropriate not to resuscitate someone when they are dying.” Similarly, withdrawing an IV is often in the patient's best interests if he or she is edematous and congested.

Families concerned that withdrawing a feeding tube will lead to starvation can be reassured that the patient is dying of his or her illness and that loss of appetite is part of the natural process of death, Dr. Yeomans said.

“You can also say that when someone is dying, tube feeding is sometimes harmful—it increases secretions, it makes them have lots of cramps, and it increases their nausea.”

Keep the patient's best interests as your focal point, she advised. “Just because we're not going to give [dying patients] antibiotics doesn't mean that we're not going to deal with their fever, cough, and shortness of breath.”

When dealing with pain, a common challenge is the need to switch from one opioid to another because of adverse effects. Dr. Yeomans contended the key to achieving good pain control is relying on just a few drugs and using them appropriately.

When moving from oral morphine to subcutaneous or intravenous morphine, only half the dose is needed because digestive metabolism of the drug is bypassed. Hydromorphone, a more potent derivative of morphine, should be given at even lower doses.

When switching to a parental dose will require subcutaneous administration of large volumes of fluid, consider using the intravenous route instead, she said.

“Opioid toxicity comes about because there are certain types of pain that are not opioid responsive,” she observed. When patients with such pain get only partial relief with an opioid, they take more and more of the drug, eventually leading to neurotoxicity.

The conventional approach to managing opioid toxicity has been to switch opioids and hydrate the patient. “But I would say what you need to do, especially in patients [with complex pain], is to use adjuvant therapy,” an approach that often allows a reduction in opioid dose.

For colicky pain, Dr. Yeomans recommended using an anticholinergic agent such as hyoscine. Antimotility agents and octreotide are also considerations, but both can exacerbate constipation.

Neuropathic pain can be controlled with tricyclics; gabapentin; steroids; or clonazepam, which is especially effective for retroperitoneal pain, according to Dr. Yeomans. However, patients at the end of life have often exhausted these options by the time they are hospitalized. In that case, additional options include methadone, ketamine, and lidocaine, all of which require expertise and close collaboration with palliative care colleagues.

Dr. Yeomans reported that she had no conflicts of interest regarding her presentation. The conference was sponsored by the University of British Columbia.

VANCOUVER, B.C. — The transition from palliative care to comfort care is a key patient management issue that hospitalists must often face, according to Dr. Wendy Yeomans, medical manager of the palliative care unit at Vancouver Acute Health Services.

While palliative care may include such active treatments as surgery, antibiotics, and transfusions, comfort care entails only symptom control at the end of life.

In many cases, the process of changing the goals of care from palliation to comfort care “takes lots of discussion with the family,” she said, recommending that clinicians start these discussions early on.

“As hospitalists, you face the challenge that you don't have long-standing relationships with these patients,” Dr. Yeomans said at the annual Canadian Hospitalist Conference. “It's very difficult sometimes to change the goals of care in the middle of the night instead of just giving the patient an antibiotic. It's a challenge that we all struggle with.”

To undertake these discussions, Dr. Yeomans recommends being proactive when addressing patients' and families' fears that ending active treatment will lead to greater suffering.

“We have to be prepared to explain what comfort care is and that these are the things we are going to do to make them more comfortable,” she said.

When discussing with families the positive side of not doing cardiac resuscitation, for example, it's helpful to explain “that it is most appropriate not to resuscitate someone when they are dying.” Similarly, withdrawing an IV is often in the patient's best interests if he or she is edematous and congested.

Families concerned that withdrawing a feeding tube will lead to starvation can be reassured that the patient is dying of his or her illness and that loss of appetite is part of the natural process of death, Dr. Yeomans said.

“You can also say that when someone is dying, tube feeding is sometimes harmful—it increases secretions, it makes them have lots of cramps, and it increases their nausea.”

Keep the patient's best interests as your focal point, she advised. “Just because we're not going to give [dying patients] antibiotics doesn't mean that we're not going to deal with their fever, cough, and shortness of breath.”

When dealing with pain, a common challenge is the need to switch from one opioid to another because of adverse effects. Dr. Yeomans contended the key to achieving good pain control is relying on just a few drugs and using them appropriately.

When moving from oral morphine to subcutaneous or intravenous morphine, only half the dose is needed because digestive metabolism of the drug is bypassed. Hydromorphone, a more potent derivative of morphine, should be given at even lower doses.

When switching to a parental dose will require subcutaneous administration of large volumes of fluid, consider using the intravenous route instead, she said.

“Opioid toxicity comes about because there are certain types of pain that are not opioid responsive,” she observed. When patients with such pain get only partial relief with an opioid, they take more and more of the drug, eventually leading to neurotoxicity.

The conventional approach to managing opioid toxicity has been to switch opioids and hydrate the patient. “But I would say what you need to do, especially in patients [with complex pain], is to use adjuvant therapy,” an approach that often allows a reduction in opioid dose.

For colicky pain, Dr. Yeomans recommended using an anticholinergic agent such as hyoscine. Antimotility agents and octreotide are also considerations, but both can exacerbate constipation.

Neuropathic pain can be controlled with tricyclics; gabapentin; steroids; or clonazepam, which is especially effective for retroperitoneal pain, according to Dr. Yeomans. However, patients at the end of life have often exhausted these options by the time they are hospitalized. In that case, additional options include methadone, ketamine, and lidocaine, all of which require expertise and close collaboration with palliative care colleagues.

Dr. Yeomans reported that she had no conflicts of interest regarding her presentation. The conference was sponsored by the University of British Columbia.

VANCOUVER — Compared with the lidocaine concentration typically used for local anesthesia during Mohs surgery, a lower concentration achieved equivalent pain relief with a 53% reduction in the total dose administered in a randomized, double-blind trial of 149 patients.

"We found in our clinic that 10%-15% of our patients were actually exceeding the recommended lidocaine dose of 7 mg/kg when we used 1% lidocaine with 1:100,000 epinephrine, which is the most common concentration of lidocaine used for Mohs surgery," explained Pamela Morganroth, noting that the patients nonetheless did not experience any symptoms.

"These patients often have large tumors, multiple sites, and extensive reconstructions," she said at the annual meeting of the American College of Mohs Surgery.

Minimizing lidocaine dose is important because symptoms of lidocaine toxicity occur in a dose-dependent manner; moreover, exceeding the recommended limit—even if symptoms do not occur or occur as a result of other conditions—exposes surgeons to medicolegal risk, observed Ms. Morganroth, a medical student at the University of Pennsylvania, Philadelphia.

"Unfortunately, multiple factors influence lidocaine dose," including older age; pregnancy; and renal, cardiac, and hepatic impairment, she added, "so it's virtually impossible to set a uniform maximum recommended lidocaine dose."

In the study, patients undergoing Mohs surgery were randomly assigned to local anesthesia consisting of 1.0% lidocaine with 1:100,000 epinephrine or 0.5% lidocaine with 1:200,000 epinephrine. Surgery was performed by a single physician who was unaware of the patient's assignment. The surgical field was infiltrated immediately before each Mohs layer and the reconstruction, with use of local infiltration and field blocks instead of regional nerve blocks. Excision began as soon as the patient reported no pain to a pinprick stimulus.

Outcomes included the total lidocaine dose administered (including all stages of Mohs surgery and the reconstruction) and patient comfort, which was measured subjectively with a 100-mm visual analog scale and objectively according to the volume of "rescue" lidocaine administered during the surgery. Analyses were based on 74 patients (with 83 tumors) in the 1.0% lidocaine group and 75 patients (with 85 tumors) in the 0.5% lidocaine group.

The mean total dose of lidocaine administered to patients in the 0.5% group was significantly lower, by 53%, than that administered to patients in the 1.0% group (139 mg vs. 297 mg). Mean scores for patient-rated pain (3.88 vs. 3.11 mm, respectively) or mean volume of rescue lidocaine administered (0.85 vs. 0.33 cc) did not differ significantly, Ms. Morganroth reported.

It appears that "0.5% lidocaine provides equivalent patient comfort at half the total dose of lidocaine as compared to 1.0% lidocaine," she said, while also acknowledging that the study did not measure blood levels of the drug.

"Our study demonstrates that 0.5% lidocaine decreases the risk of dose-dependent lidocaine toxicity without compromising patient comfort during Mohs surgery," said Ms. Morganroth, who reported having no conflicts of interest.

VANCOUVER — Compared with the lidocaine concentration typically used for local anesthesia during Mohs surgery, a lower concentration achieved equivalent pain relief with a 53% reduction in the total dose administered in a randomized, double-blind trial of 149 patients.

"We found in our clinic that 10%-15% of our patients were actually exceeding the recommended lidocaine dose of 7 mg/kg when we used 1% lidocaine with 1:100,000 epinephrine, which is the most common concentration of lidocaine used for Mohs surgery," explained Pamela Morganroth, noting that the patients nonetheless did not experience any symptoms.

"These patients often have large tumors, multiple sites, and extensive reconstructions," she said at the annual meeting of the American College of Mohs Surgery.

Minimizing lidocaine dose is important because symptoms of lidocaine toxicity occur in a dose-dependent manner; moreover, exceeding the recommended limit—even if symptoms do not occur or occur as a result of other conditions—exposes surgeons to medicolegal risk, observed Ms. Morganroth, a medical student at the University of Pennsylvania, Philadelphia.

"Unfortunately, multiple factors influence lidocaine dose," including older age; pregnancy; and renal, cardiac, and hepatic impairment, she added, "so it's virtually impossible to set a uniform maximum recommended lidocaine dose."

In the study, patients undergoing Mohs surgery were randomly assigned to local anesthesia consisting of 1.0% lidocaine with 1:100,000 epinephrine or 0.5% lidocaine with 1:200,000 epinephrine. Surgery was performed by a single physician who was unaware of the patient's assignment. The surgical field was infiltrated immediately before each Mohs layer and the reconstruction, with use of local infiltration and field blocks instead of regional nerve blocks. Excision began as soon as the patient reported no pain to a pinprick stimulus.

Outcomes included the total lidocaine dose administered (including all stages of Mohs surgery and the reconstruction) and patient comfort, which was measured subjectively with a 100-mm visual analog scale and objectively according to the volume of "rescue" lidocaine administered during the surgery. Analyses were based on 74 patients (with 83 tumors) in the 1.0% lidocaine group and 75 patients (with 85 tumors) in the 0.5% lidocaine group.

The mean total dose of lidocaine administered to patients in the 0.5% group was significantly lower, by 53%, than that administered to patients in the 1.0% group (139 mg vs. 297 mg). Mean scores for patient-rated pain (3.88 vs. 3.11 mm, respectively) or mean volume of rescue lidocaine administered (0.85 vs. 0.33 cc) did not differ significantly, Ms. Morganroth reported.

It appears that "0.5% lidocaine provides equivalent patient comfort at half the total dose of lidocaine as compared to 1.0% lidocaine," she said, while also acknowledging that the study did not measure blood levels of the drug.

"Our study demonstrates that 0.5% lidocaine decreases the risk of dose-dependent lidocaine toxicity without compromising patient comfort during Mohs surgery," said Ms. Morganroth, who reported having no conflicts of interest.

VANCOUVER — Compared with the lidocaine concentration typically used for local anesthesia during Mohs surgery, a lower concentration achieved equivalent pain relief with a 53% reduction in the total dose administered in a randomized, double-blind trial of 149 patients.

"We found in our clinic that 10%-15% of our patients were actually exceeding the recommended lidocaine dose of 7 mg/kg when we used 1% lidocaine with 1:100,000 epinephrine, which is the most common concentration of lidocaine used for Mohs surgery," explained Pamela Morganroth, noting that the patients nonetheless did not experience any symptoms.

"These patients often have large tumors, multiple sites, and extensive reconstructions," she said at the annual meeting of the American College of Mohs Surgery.

Minimizing lidocaine dose is important because symptoms of lidocaine toxicity occur in a dose-dependent manner; moreover, exceeding the recommended limit—even if symptoms do not occur or occur as a result of other conditions—exposes surgeons to medicolegal risk, observed Ms. Morganroth, a medical student at the University of Pennsylvania, Philadelphia.

"Unfortunately, multiple factors influence lidocaine dose," including older age; pregnancy; and renal, cardiac, and hepatic impairment, she added, "so it's virtually impossible to set a uniform maximum recommended lidocaine dose."

In the study, patients undergoing Mohs surgery were randomly assigned to local anesthesia consisting of 1.0% lidocaine with 1:100,000 epinephrine or 0.5% lidocaine with 1:200,000 epinephrine. Surgery was performed by a single physician who was unaware of the patient's assignment. The surgical field was infiltrated immediately before each Mohs layer and the reconstruction, with use of local infiltration and field blocks instead of regional nerve blocks. Excision began as soon as the patient reported no pain to a pinprick stimulus.

Outcomes included the total lidocaine dose administered (including all stages of Mohs surgery and the reconstruction) and patient comfort, which was measured subjectively with a 100-mm visual analog scale and objectively according to the volume of "rescue" lidocaine administered during the surgery. Analyses were based on 74 patients (with 83 tumors) in the 1.0% lidocaine group and 75 patients (with 85 tumors) in the 0.5% lidocaine group.

The mean total dose of lidocaine administered to patients in the 0.5% group was significantly lower, by 53%, than that administered to patients in the 1.0% group (139 mg vs. 297 mg). Mean scores for patient-rated pain (3.88 vs. 3.11 mm, respectively) or mean volume of rescue lidocaine administered (0.85 vs. 0.33 cc) did not differ significantly, Ms. Morganroth reported.

It appears that "0.5% lidocaine provides equivalent patient comfort at half the total dose of lidocaine as compared to 1.0% lidocaine," she said, while also acknowledging that the study did not measure blood levels of the drug.

"Our study demonstrates that 0.5% lidocaine decreases the risk of dose-dependent lidocaine toxicity without compromising patient comfort during Mohs surgery," said Ms. Morganroth, who reported having no conflicts of interest.

SEATTLE — Initial improvements in anorexia nervosa and bulimia nervosa achieved in an intensive residential treatment program are largely sustained an average of 4 to 5 years later, researchers reported.

“Data on long-term follow-up of individuals with anorexia nervosa and bulimia nervosa following intensive inpatient or residential treatment are limited,” said Dr. Timothy D. Brewerton, a psychiatrist at the Medical University of South Carolina, Charleston.

Dr. Brewerton and his colleagues surveyed patients with eating disorders who had received at least 30 days of treatment in the Monte Nido Residential Treatment Program, in Malibu, Calif. Dr. Brewerton reported that he was paid as a consultant by Monte Nido to collate, analyze, and present the survey data.

Outcomes on the Eating Disorder Inventory-2 (EDI-2), Beck Depression Inventory (BDI), and a structured eating disorder assessment were evaluated at admission, discharge, and the most recent of 13 postgraduate follow-ups (range from 1 to 10 years).

The analyses were based on 85 patients with anorexia and 71 patients with bulimia. The mean time between discharge and postgraduate follow-up was 4.5 and 4.1 years, respectively. On average, the patients in each group were aged about 30 years (range, 17–57).

In the anorexia group, mean body mass index (BMI) scores increased significantly between admission and discharge (from 16 to 18 kg/m

By discharge, anorexia patients had significant improvements in 9 of 11 EDI-2 subscales, with further significant improvements in five of the subscales—body dissatisfaction, drive for thinness, interoceptive awareness, immaturity fears, and asceticism—between discharge and postgraduate follow-up.

The percentage of anorexia patients with a good outcome, defined as a return of BMI to at least 18 and normal menses, increased between discharge and postgraduate follow-up (from 19% to 41%). There also was a decrease in the percentages with an intermediate outcome, defined as restoration of BMI or normal menses (from 48% to 46%), and a poor outcome, defined as restoration of neither BMI nor menses (from 33% to 12%).

The frequency of 3 of 10 eating- disordered behaviors—bingeing, laxative use, and vomiting—was significantly higher at postgraduate follow-up than at discharge, and the values remained significantly or marginally lower than those at admission.

Scores on the BDI decreased significantly between admission and discharge, and remained so at postgraduate follow-up. About 85% of patients reported they were improved or significantly improved at the latter assessment.

Patients in the bulimia group had significant improvements in all 11 EDI-2 subscales by discharge, and the benefits persisted to postgraduate follow-up, reported Dr. Brewerton, who also is in private practice in Mt. Pleasant, S.C. Their BMIs were in the normal range at all three assessments.

Between discharge and postgraduate follow-up, there was a decrease in the percentage of bulimic patients with a good outcome, defined as complete cessation of bingeing, purging, and other compensatory behaviors (from 97% to 62%) and an increase in the percentages with an intermediate outcome, defined as a reduction in those behaviors by at least half (from 3% to 19%) and a poor outcome, defined as a reduction of less than half (from 0% to 19%).

The frequency of 7 of the 10 eating-disordered behaviors decreased significantly by discharge and remained at that level at the postgraduate follow-up. BDI scores in this group also fell by discharge and remained steady. About 85% of patients said they were improved or significantly improved.

Receipt of therapy during follow-up is still being analyzed, said Dr. Brewerton.

SEATTLE — Initial improvements in anorexia nervosa and bulimia nervosa achieved in an intensive residential treatment program are largely sustained an average of 4 to 5 years later, researchers reported.

“Data on long-term follow-up of individuals with anorexia nervosa and bulimia nervosa following intensive inpatient or residential treatment are limited,” said Dr. Timothy D. Brewerton, a psychiatrist at the Medical University of South Carolina, Charleston.

Dr. Brewerton and his colleagues surveyed patients with eating disorders who had received at least 30 days of treatment in the Monte Nido Residential Treatment Program, in Malibu, Calif. Dr. Brewerton reported that he was paid as a consultant by Monte Nido to collate, analyze, and present the survey data.

Outcomes on the Eating Disorder Inventory-2 (EDI-2), Beck Depression Inventory (BDI), and a structured eating disorder assessment were evaluated at admission, discharge, and the most recent of 13 postgraduate follow-ups (range from 1 to 10 years).

The analyses were based on 85 patients with anorexia and 71 patients with bulimia. The mean time between discharge and postgraduate follow-up was 4.5 and 4.1 years, respectively. On average, the patients in each group were aged about 30 years (range, 17–57).

In the anorexia group, mean body mass index (BMI) scores increased significantly between admission and discharge (from 16 to 18 kg/m

By discharge, anorexia patients had significant improvements in 9 of 11 EDI-2 subscales, with further significant improvements in five of the subscales—body dissatisfaction, drive for thinness, interoceptive awareness, immaturity fears, and asceticism—between discharge and postgraduate follow-up.

The percentage of anorexia patients with a good outcome, defined as a return of BMI to at least 18 and normal menses, increased between discharge and postgraduate follow-up (from 19% to 41%). There also was a decrease in the percentages with an intermediate outcome, defined as restoration of BMI or normal menses (from 48% to 46%), and a poor outcome, defined as restoration of neither BMI nor menses (from 33% to 12%).

The frequency of 3 of 10 eating- disordered behaviors—bingeing, laxative use, and vomiting—was significantly higher at postgraduate follow-up than at discharge, and the values remained significantly or marginally lower than those at admission.

Scores on the BDI decreased significantly between admission and discharge, and remained so at postgraduate follow-up. About 85% of patients reported they were improved or significantly improved at the latter assessment.

Patients in the bulimia group had significant improvements in all 11 EDI-2 subscales by discharge, and the benefits persisted to postgraduate follow-up, reported Dr. Brewerton, who also is in private practice in Mt. Pleasant, S.C. Their BMIs were in the normal range at all three assessments.

Between discharge and postgraduate follow-up, there was a decrease in the percentage of bulimic patients with a good outcome, defined as complete cessation of bingeing, purging, and other compensatory behaviors (from 97% to 62%) and an increase in the percentages with an intermediate outcome, defined as a reduction in those behaviors by at least half (from 3% to 19%) and a poor outcome, defined as a reduction of less than half (from 0% to 19%).

The frequency of 7 of the 10 eating-disordered behaviors decreased significantly by discharge and remained at that level at the postgraduate follow-up. BDI scores in this group also fell by discharge and remained steady. About 85% of patients said they were improved or significantly improved.

Receipt of therapy during follow-up is still being analyzed, said Dr. Brewerton.

SEATTLE — Initial improvements in anorexia nervosa and bulimia nervosa achieved in an intensive residential treatment program are largely sustained an average of 4 to 5 years later, researchers reported.

“Data on long-term follow-up of individuals with anorexia nervosa and bulimia nervosa following intensive inpatient or residential treatment are limited,” said Dr. Timothy D. Brewerton, a psychiatrist at the Medical University of South Carolina, Charleston.

Dr. Brewerton and his colleagues surveyed patients with eating disorders who had received at least 30 days of treatment in the Monte Nido Residential Treatment Program, in Malibu, Calif. Dr. Brewerton reported that he was paid as a consultant by Monte Nido to collate, analyze, and present the survey data.

Outcomes on the Eating Disorder Inventory-2 (EDI-2), Beck Depression Inventory (BDI), and a structured eating disorder assessment were evaluated at admission, discharge, and the most recent of 13 postgraduate follow-ups (range from 1 to 10 years).

The analyses were based on 85 patients with anorexia and 71 patients with bulimia. The mean time between discharge and postgraduate follow-up was 4.5 and 4.1 years, respectively. On average, the patients in each group were aged about 30 years (range, 17–57).

In the anorexia group, mean body mass index (BMI) scores increased significantly between admission and discharge (from 16 to 18 kg/m

By discharge, anorexia patients had significant improvements in 9 of 11 EDI-2 subscales, with further significant improvements in five of the subscales—body dissatisfaction, drive for thinness, interoceptive awareness, immaturity fears, and asceticism—between discharge and postgraduate follow-up.

The percentage of anorexia patients with a good outcome, defined as a return of BMI to at least 18 and normal menses, increased between discharge and postgraduate follow-up (from 19% to 41%). There also was a decrease in the percentages with an intermediate outcome, defined as restoration of BMI or normal menses (from 48% to 46%), and a poor outcome, defined as restoration of neither BMI nor menses (from 33% to 12%).

The frequency of 3 of 10 eating- disordered behaviors—bingeing, laxative use, and vomiting—was significantly higher at postgraduate follow-up than at discharge, and the values remained significantly or marginally lower than those at admission.

Scores on the BDI decreased significantly between admission and discharge, and remained so at postgraduate follow-up. About 85% of patients reported they were improved or significantly improved at the latter assessment.

Patients in the bulimia group had significant improvements in all 11 EDI-2 subscales by discharge, and the benefits persisted to postgraduate follow-up, reported Dr. Brewerton, who also is in private practice in Mt. Pleasant, S.C. Their BMIs were in the normal range at all three assessments.

Between discharge and postgraduate follow-up, there was a decrease in the percentage of bulimic patients with a good outcome, defined as complete cessation of bingeing, purging, and other compensatory behaviors (from 97% to 62%) and an increase in the percentages with an intermediate outcome, defined as a reduction in those behaviors by at least half (from 3% to 19%) and a poor outcome, defined as a reduction of less than half (from 0% to 19%).

The frequency of 7 of the 10 eating-disordered behaviors decreased significantly by discharge and remained at that level at the postgraduate follow-up. BDI scores in this group also fell by discharge and remained steady. About 85% of patients said they were improved or significantly improved.

Receipt of therapy during follow-up is still being analyzed, said Dr. Brewerton.

SEATTLE — Money and time are the leading barriers to seeking weight-loss treatment among overweight and obese adults. But stigma and a belief that one is too heavy for treatment become more influential barriers the heavier a person is.

Little is known from the literature about patterns of treatment seeking for obesity over time, and little is known about barriers that might prevent treatment seeking from taking place, Anna C. Ciao, a graduate student at the University of Hawaii, Honolulu, said at an international conference sponsored by the Academy for Eating Disorders.

Ms. Ciao was reporting on an anonymous online survey offered to overweight or obese men and women aged 18 years or older in which the participants were asked about seven treatments of increasing intensity (based on level of professional involvement): treatment on one's own by taking steps such as reducing caloric intake, reading self-help books, using self-help online programs, turning to commercial programs such as Weight Watchers, seeking help from professionals other than medical doctors such as nutritionists and psychotherapists, turning to medical doctors, and having weight-loss surgery.

They were also asked about five barriers to seeking treatment: money, time, stigma, shame, and a belief that one is too heavy for the treatment.

Of the 154 respondents, 76% were white, 16% were black, 2% were Hispanic, and the rest were of other or mixed ethnicities, and 86% were women, Ms. Ciao said at the conference, cosponsored by the University of New Mexico. Their mean age was 30 years (range was 18–67 years), and their mean body mass index (BMI) was 33 kg/m

Among the seven treatments, treatment on one's own was the most commonly sought, desired, and planned. Overall, 77% of respondents had sought this treatment; 36% desired it but had no current plans, and 51% planned to pursue it in the future. In contrast, surgery was the least commonly sought, desired, and planned treatment; 8% of respondents had sought surgery, 18% desired it, and 8% planned to have it.

“Despite these high levels of endorsement of treatment seeking, a substantial number of people did not say yes to seeking any kind of treatment,” Ms. Ciao said, noting that 11% had not sought any of the treatments, 28% did not desire any, and 25% had no plans for any.

Of the five barriers to treatment, the most commonly cited overall was money and the second was not having enough time. Most respondents reported no barriers to three less-intensive treatments: treatment on one's own, self-help online programs, and self-help books.

With the exception of surgery, the mean number of barriers cited for a treatment increased with intensity, ranging from 0.8 barriers for treatment on one's own to 1.3 barriers for medical doctors. The mean number for surgery was 0.5. Ms. Ciao said surgery might have been an outlier because individuals must qualify for this treatment, so they might have perceived the barriers as irrelevant.

BMI was correlated with the total number of treatments sought but not with the number desired or planned.

“Heavier people sought a greater number of treatments in the past but didn't necessarily plan to seek or desire to seek more treatments in the future,” a disconnect that might suggest “some discouragement from the failed weight-loss attempt,” she said.

BMI also was correlated with the total number of barriers across treatments, indicating that heavier people perceive more barriers to treatment, she said. BMI was also correlated with stigma and being too heavy for treatment individually. “This is consistent with the literature that suggests that individuals are afraid of stigmatization, especially from professionals,” Ms. Ciao said. “Feeling too heavy may reflect an anticipated failure or expectation that weight-loss treatment may not work for them.”

Ms. Ciao reported she had no conflicts of interest in association with the study.

SEATTLE — Money and time are the leading barriers to seeking weight-loss treatment among overweight and obese adults. But stigma and a belief that one is too heavy for treatment become more influential barriers the heavier a person is.

Little is known from the literature about patterns of treatment seeking for obesity over time, and little is known about barriers that might prevent treatment seeking from taking place, Anna C. Ciao, a graduate student at the University of Hawaii, Honolulu, said at an international conference sponsored by the Academy for Eating Disorders.

Ms. Ciao was reporting on an anonymous online survey offered to overweight or obese men and women aged 18 years or older in which the participants were asked about seven treatments of increasing intensity (based on level of professional involvement): treatment on one's own by taking steps such as reducing caloric intake, reading self-help books, using self-help online programs, turning to commercial programs such as Weight Watchers, seeking help from professionals other than medical doctors such as nutritionists and psychotherapists, turning to medical doctors, and having weight-loss surgery.

They were also asked about five barriers to seeking treatment: money, time, stigma, shame, and a belief that one is too heavy for the treatment.

Of the 154 respondents, 76% were white, 16% were black, 2% were Hispanic, and the rest were of other or mixed ethnicities, and 86% were women, Ms. Ciao said at the conference, cosponsored by the University of New Mexico. Their mean age was 30 years (range was 18–67 years), and their mean body mass index (BMI) was 33 kg/m

Among the seven treatments, treatment on one's own was the most commonly sought, desired, and planned. Overall, 77% of respondents had sought this treatment; 36% desired it but had no current plans, and 51% planned to pursue it in the future. In contrast, surgery was the least commonly sought, desired, and planned treatment; 8% of respondents had sought surgery, 18% desired it, and 8% planned to have it.

“Despite these high levels of endorsement of treatment seeking, a substantial number of people did not say yes to seeking any kind of treatment,” Ms. Ciao said, noting that 11% had not sought any of the treatments, 28% did not desire any, and 25% had no plans for any.

Of the five barriers to treatment, the most commonly cited overall was money and the second was not having enough time. Most respondents reported no barriers to three less-intensive treatments: treatment on one's own, self-help online programs, and self-help books.

With the exception of surgery, the mean number of barriers cited for a treatment increased with intensity, ranging from 0.8 barriers for treatment on one's own to 1.3 barriers for medical doctors. The mean number for surgery was 0.5. Ms. Ciao said surgery might have been an outlier because individuals must qualify for this treatment, so they might have perceived the barriers as irrelevant.

BMI was correlated with the total number of treatments sought but not with the number desired or planned.

“Heavier people sought a greater number of treatments in the past but didn't necessarily plan to seek or desire to seek more treatments in the future,” a disconnect that might suggest “some discouragement from the failed weight-loss attempt,” she said.

BMI also was correlated with the total number of barriers across treatments, indicating that heavier people perceive more barriers to treatment, she said. BMI was also correlated with stigma and being too heavy for treatment individually. “This is consistent with the literature that suggests that individuals are afraid of stigmatization, especially from professionals,” Ms. Ciao said. “Feeling too heavy may reflect an anticipated failure or expectation that weight-loss treatment may not work for them.”

Ms. Ciao reported she had no conflicts of interest in association with the study.

SEATTLE — Money and time are the leading barriers to seeking weight-loss treatment among overweight and obese adults. But stigma and a belief that one is too heavy for treatment become more influential barriers the heavier a person is.

Little is known from the literature about patterns of treatment seeking for obesity over time, and little is known about barriers that might prevent treatment seeking from taking place, Anna C. Ciao, a graduate student at the University of Hawaii, Honolulu, said at an international conference sponsored by the Academy for Eating Disorders.

Ms. Ciao was reporting on an anonymous online survey offered to overweight or obese men and women aged 18 years or older in which the participants were asked about seven treatments of increasing intensity (based on level of professional involvement): treatment on one's own by taking steps such as reducing caloric intake, reading self-help books, using self-help online programs, turning to commercial programs such as Weight Watchers, seeking help from professionals other than medical doctors such as nutritionists and psychotherapists, turning to medical doctors, and having weight-loss surgery.

They were also asked about five barriers to seeking treatment: money, time, stigma, shame, and a belief that one is too heavy for the treatment.

Of the 154 respondents, 76% were white, 16% were black, 2% were Hispanic, and the rest were of other or mixed ethnicities, and 86% were women, Ms. Ciao said at the conference, cosponsored by the University of New Mexico. Their mean age was 30 years (range was 18–67 years), and their mean body mass index (BMI) was 33 kg/m

Among the seven treatments, treatment on one's own was the most commonly sought, desired, and planned. Overall, 77% of respondents had sought this treatment; 36% desired it but had no current plans, and 51% planned to pursue it in the future. In contrast, surgery was the least commonly sought, desired, and planned treatment; 8% of respondents had sought surgery, 18% desired it, and 8% planned to have it.

“Despite these high levels of endorsement of treatment seeking, a substantial number of people did not say yes to seeking any kind of treatment,” Ms. Ciao said, noting that 11% had not sought any of the treatments, 28% did not desire any, and 25% had no plans for any.

Of the five barriers to treatment, the most commonly cited overall was money and the second was not having enough time. Most respondents reported no barriers to three less-intensive treatments: treatment on one's own, self-help online programs, and self-help books.

With the exception of surgery, the mean number of barriers cited for a treatment increased with intensity, ranging from 0.8 barriers for treatment on one's own to 1.3 barriers for medical doctors. The mean number for surgery was 0.5. Ms. Ciao said surgery might have been an outlier because individuals must qualify for this treatment, so they might have perceived the barriers as irrelevant.

BMI was correlated with the total number of treatments sought but not with the number desired or planned.

“Heavier people sought a greater number of treatments in the past but didn't necessarily plan to seek or desire to seek more treatments in the future,” a disconnect that might suggest “some discouragement from the failed weight-loss attempt,” she said.

BMI also was correlated with the total number of barriers across treatments, indicating that heavier people perceive more barriers to treatment, she said. BMI was also correlated with stigma and being too heavy for treatment individually. “This is consistent with the literature that suggests that individuals are afraid of stigmatization, especially from professionals,” Ms. Ciao said. “Feeling too heavy may reflect an anticipated failure or expectation that weight-loss treatment may not work for them.”

Ms. Ciao reported she had no conflicts of interest in association with the study.

VANCOUVER, B.C. — Adenosquamous carcinoma often is a misdiagnosed, more aggressive type of skin cancer, which requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary adenosquamous carcinoma.

As skin cancers go, adenosquamous carcinoma (ASC) is somewhat newly recognized and uncommon, observed Dr. Jennifer M. Fu, a dermatology resident at the University of California, San Francisco.

“We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence and, in some case series, distant metastases,” Dr. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of ASC diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50–97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. “Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated,” Dr. Fu said.

“Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case,” she said, adding that SCC was listed in the differential diagnosis in only four cases. “In no case was adenosquamous carcinoma correctly diagnosed,” she said.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant therapy consisting of radiation therapy and cetuximab (Erbitux) for locally advanced disease. For all of these patients, “the Mohs defect postoperatively far exceeded what was evident clinically,” she noted.

Two patients were alive with no evidence of disease, and another patient with brief follow-up (5 days) was alive with persistent disease. The remaining three patients had locoregional recurrences 3 months, 4 months, and 5.5 years after their primary tumor, but there were no cases of distant metastases. Two of these three patients with recurrences were alive with no evidence of disease after 4 and 4.5 years, while one was alive with unclear disease status after 3.5 years.

Dr. Fu reported that she had no conflicts of interest in association with the study.

Recurrent ASC nodules/plaques are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — Adenosquamous carcinoma often is a misdiagnosed, more aggressive type of skin cancer, which requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary adenosquamous carcinoma.

As skin cancers go, adenosquamous carcinoma (ASC) is somewhat newly recognized and uncommon, observed Dr. Jennifer M. Fu, a dermatology resident at the University of California, San Francisco.

“We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence and, in some case series, distant metastases,” Dr. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of ASC diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50–97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. “Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated,” Dr. Fu said.

“Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case,” she said, adding that SCC was listed in the differential diagnosis in only four cases. “In no case was adenosquamous carcinoma correctly diagnosed,” she said.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant therapy consisting of radiation therapy and cetuximab (Erbitux) for locally advanced disease. For all of these patients, “the Mohs defect postoperatively far exceeded what was evident clinically,” she noted.

Two patients were alive with no evidence of disease, and another patient with brief follow-up (5 days) was alive with persistent disease. The remaining three patients had locoregional recurrences 3 months, 4 months, and 5.5 years after their primary tumor, but there were no cases of distant metastases. Two of these three patients with recurrences were alive with no evidence of disease after 4 and 4.5 years, while one was alive with unclear disease status after 3.5 years.

Dr. Fu reported that she had no conflicts of interest in association with the study.

Recurrent ASC nodules/plaques are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — Adenosquamous carcinoma often is a misdiagnosed, more aggressive type of skin cancer, which requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary adenosquamous carcinoma.

As skin cancers go, adenosquamous carcinoma (ASC) is somewhat newly recognized and uncommon, observed Dr. Jennifer M. Fu, a dermatology resident at the University of California, San Francisco.

“We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence and, in some case series, distant metastases,” Dr. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of ASC diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50–97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. “Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated,” Dr. Fu said.

“Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case,” she said, adding that SCC was listed in the differential diagnosis in only four cases. “In no case was adenosquamous carcinoma correctly diagnosed,” she said.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant therapy consisting of radiation therapy and cetuximab (Erbitux) for locally advanced disease. For all of these patients, “the Mohs defect postoperatively far exceeded what was evident clinically,” she noted.

Two patients were alive with no evidence of disease, and another patient with brief follow-up (5 days) was alive with persistent disease. The remaining three patients had locoregional recurrences 3 months, 4 months, and 5.5 years after their primary tumor, but there were no cases of distant metastases. Two of these three patients with recurrences were alive with no evidence of disease after 4 and 4.5 years, while one was alive with unclear disease status after 3.5 years.

Dr. Fu reported that she had no conflicts of interest in association with the study.

Recurrent ASC nodules/plaques are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

SEATTLE – The relative efficacy of three treatments for anorexia nervosa appears to shift with long-term follow-up according to the results of an ongoing analysis of data from a randomized, controlled trial.

The treatment that was the most efficacious at the end of therapy appeared to be the least so at 5 years. But differences among the therapies were much less significant at that point, Virginia V.W. McIntosh, Ph.D., reported at an international conference sponsored by the Academy for Eating Disorders.

Dr. McIntosh, a senior clinical psychologist at the University of Otago, Christchurch, New Zealand, described ongoing analyses of data from a randomized, controlled trial that compared three treatments–cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and specialist supportive clinical management (SSCM)–among 56 patients with anorexia nervosa.

End-of-treatment results showed that among the 35 patients who completed all sessions, SSCM was superior to both CBT and IPT in terms of global anorexia nervosa status (Am. J. Psychiatry 2005;162:741–7).

One of the new analyses focused on therapist adherence to the protocol for a specific treatment.

Dr. McIntosh and her colleagues measured adherence with a modified version of the Collaborative Study Psychotherapy Rating Scale, which had 28 items unique to IPT, 27 unique to CBT, and 3 unique to SSCM. “I think [adherence] speaks to the distinctiveness of CBT and SSCM, which is important here,” Dr. McIntosh said at the meeting, which was cosponsored by the University of New Mexico.

An additional 14 items overlapped both CBT and SSCM. Those overlap items were items that covered the important elements of weight gain, psychoeducation, and the normalization of eating, she said. An additional 18 items were not specific to any of the therapies and reflected aspects such as alliance and therapy process.

Independent raters listened to the recorded psychotherapy sessions from the trial and rated them for adherence on various subscales: CBT (unique plus overlapping items), CBT-only (unique items), IPT, SSCM (unique plus overlapping items), and a therapy-nonspecific subscale.

Results showed that ratings for the therapy-specific subscales did indeed differ significantly, depending on which therapy the patient had received during a session, Dr. McIntosh reported. Ratings were highest for the corresponding therapy in all cases. For example, the CBT subscale scores were highest for CBT sessions.

In contrast, ratings for the therapy-nonspecific subscale did not differ depending on which therapy the patient had received.

Another new, ongoing analysis of the trial data focused on long-term outcomes. Data at 5 years were available for 45 patients (80% of those initially randomized), Dr. McIntosh said. “The differences at 5 years are much less than the differences at end of treatment,” she reported.

“What we see is that the SSCM group has lost some ground in terms of the proportion with a good outcome, CBT has gained some ground at about the same rate at which SSCM has lost ground, and IPT has gained even more ground,” she said.

As a result, the proportion of patients with a good outcome at the 5-year time point was highest for IPT, intermediate for CBT, and lowest for SSCM.

The trial is comparing CBT, IPT, and SSCM among 56 patients with anorexia nervosa. DR. MCINTOSH

SEATTLE – The relative efficacy of three treatments for anorexia nervosa appears to shift with long-term follow-up according to the results of an ongoing analysis of data from a randomized, controlled trial.

The treatment that was the most efficacious at the end of therapy appeared to be the least so at 5 years. But differences among the therapies were much less significant at that point, Virginia V.W. McIntosh, Ph.D., reported at an international conference sponsored by the Academy for Eating Disorders.

Dr. McIntosh, a senior clinical psychologist at the University of Otago, Christchurch, New Zealand, described ongoing analyses of data from a randomized, controlled trial that compared three treatments–cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and specialist supportive clinical management (SSCM)–among 56 patients with anorexia nervosa.

End-of-treatment results showed that among the 35 patients who completed all sessions, SSCM was superior to both CBT and IPT in terms of global anorexia nervosa status (Am. J. Psychiatry 2005;162:741–7).

One of the new analyses focused on therapist adherence to the protocol for a specific treatment.

Dr. McIntosh and her colleagues measured adherence with a modified version of the Collaborative Study Psychotherapy Rating Scale, which had 28 items unique to IPT, 27 unique to CBT, and 3 unique to SSCM. “I think [adherence] speaks to the distinctiveness of CBT and SSCM, which is important here,” Dr. McIntosh said at the meeting, which was cosponsored by the University of New Mexico.

An additional 14 items overlapped both CBT and SSCM. Those overlap items were items that covered the important elements of weight gain, psychoeducation, and the normalization of eating, she said. An additional 18 items were not specific to any of the therapies and reflected aspects such as alliance and therapy process.

Independent raters listened to the recorded psychotherapy sessions from the trial and rated them for adherence on various subscales: CBT (unique plus overlapping items), CBT-only (unique items), IPT, SSCM (unique plus overlapping items), and a therapy-nonspecific subscale.

Results showed that ratings for the therapy-specific subscales did indeed differ significantly, depending on which therapy the patient had received during a session, Dr. McIntosh reported. Ratings were highest for the corresponding therapy in all cases. For example, the CBT subscale scores were highest for CBT sessions.

In contrast, ratings for the therapy-nonspecific subscale did not differ depending on which therapy the patient had received.

Another new, ongoing analysis of the trial data focused on long-term outcomes. Data at 5 years were available for 45 patients (80% of those initially randomized), Dr. McIntosh said. “The differences at 5 years are much less than the differences at end of treatment,” she reported.

“What we see is that the SSCM group has lost some ground in terms of the proportion with a good outcome, CBT has gained some ground at about the same rate at which SSCM has lost ground, and IPT has gained even more ground,” she said.

As a result, the proportion of patients with a good outcome at the 5-year time point was highest for IPT, intermediate for CBT, and lowest for SSCM.

The trial is comparing CBT, IPT, and SSCM among 56 patients with anorexia nervosa. DR. MCINTOSH

SEATTLE – The relative efficacy of three treatments for anorexia nervosa appears to shift with long-term follow-up according to the results of an ongoing analysis of data from a randomized, controlled trial.

The treatment that was the most efficacious at the end of therapy appeared to be the least so at 5 years. But differences among the therapies were much less significant at that point, Virginia V.W. McIntosh, Ph.D., reported at an international conference sponsored by the Academy for Eating Disorders.

Dr. McIntosh, a senior clinical psychologist at the University of Otago, Christchurch, New Zealand, described ongoing analyses of data from a randomized, controlled trial that compared three treatments–cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), and specialist supportive clinical management (SSCM)–among 56 patients with anorexia nervosa.

End-of-treatment results showed that among the 35 patients who completed all sessions, SSCM was superior to both CBT and IPT in terms of global anorexia nervosa status (Am. J. Psychiatry 2005;162:741–7).

One of the new analyses focused on therapist adherence to the protocol for a specific treatment.

Dr. McIntosh and her colleagues measured adherence with a modified version of the Collaborative Study Psychotherapy Rating Scale, which had 28 items unique to IPT, 27 unique to CBT, and 3 unique to SSCM. “I think [adherence] speaks to the distinctiveness of CBT and SSCM, which is important here,” Dr. McIntosh said at the meeting, which was cosponsored by the University of New Mexico.

An additional 14 items overlapped both CBT and SSCM. Those overlap items were items that covered the important elements of weight gain, psychoeducation, and the normalization of eating, she said. An additional 18 items were not specific to any of the therapies and reflected aspects such as alliance and therapy process.

Independent raters listened to the recorded psychotherapy sessions from the trial and rated them for adherence on various subscales: CBT (unique plus overlapping items), CBT-only (unique items), IPT, SSCM (unique plus overlapping items), and a therapy-nonspecific subscale.

Results showed that ratings for the therapy-specific subscales did indeed differ significantly, depending on which therapy the patient had received during a session, Dr. McIntosh reported. Ratings were highest for the corresponding therapy in all cases. For example, the CBT subscale scores were highest for CBT sessions.

In contrast, ratings for the therapy-nonspecific subscale did not differ depending on which therapy the patient had received.

Another new, ongoing analysis of the trial data focused on long-term outcomes. Data at 5 years were available for 45 patients (80% of those initially randomized), Dr. McIntosh said. “The differences at 5 years are much less than the differences at end of treatment,” she reported.

“What we see is that the SSCM group has lost some ground in terms of the proportion with a good outcome, CBT has gained some ground at about the same rate at which SSCM has lost ground, and IPT has gained even more ground,” she said.

As a result, the proportion of patients with a good outcome at the 5-year time point was highest for IPT, intermediate for CBT, and lowest for SSCM.

The trial is comparing CBT, IPT, and SSCM among 56 patients with anorexia nervosa. DR. MCINTOSH

SEATTLE — Methicillin-resistant Staphylococcus aureus is found in one-third of cases of perineal and buttock abscesses in women, and it accounts for fully half of the monomicrobial abscesses, according to one hospital's experience.

“MRSA is a common problem in our hospitals and in our community, and it certainly commands our attention,” study author Dr. Susan M. Lareau said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. She noted that a previous report found that MRSA was the leading cause of skin and soft-tissue infection in most emergency departments but did not address the proportion of perineal infections caused by this pathogen (N. Engl. J. Med. 2006;355:666-74).

Dr. Lareau of the Magee-Womens Hospital in Pittsburgh used diagnostic codes to identify retrospectively all cases of perineal and buttock abscesses seen at the hospital between 2003 and 2007 and then reviewed their characteristics. She included cases involving the vulva, Bartholin glands, and buttocks, and excluded cases involving the perianal and rectal areas.

The process identified 126 patients, Dr. Lareau reported. This group consisted of 64 patients (51%) with vulvar abscesses, 41 patients (33%) with Bartholin gland abscesses, 19 patients (15%) with buttock abscesses, and 2 patients (2%) with combined buttock and vulvar abscesses.

Cultures had been obtained in 72 of the patients and were positive for MRSA in 33%. By site, MRSA was found in 64% of buttock abscesses, 50% of combined buttock and vulvar abscesses, 33% of vulvar abscesses, and 7% of Bartholin gland abscesses.

“It's generally been thought that vulvar abscesses are polymicrobial, and that has driven our treatment, when necessary,” Dr. Lareau said. However, most (69%) of the 72 cases were monomicrobial. MRSA accounted for fully 50% of these infections; the next most common pathogens were group B streptococcus and methicillin-susceptible S. aureus, each of which accounted for only 14% of these infections.

Age, race, body mass index, pregnancy, and several comorbidities (diabetes, cancer, and coronary artery disease) did not significantly predict MRSA infection, but site did, according to Dr. Lareau. Relative to patients with Bartholin gland abscesses, patients with buttock abscesses were significantly more likely to be positive for MRSA (odds ratio 28), and patients with vulvar infections were nonsignificantly more likely to be MRSA positive (OR 7). However, Dr. Lareau said, confidence intervals were wide, probably because of the small sample size.

“We wanted to look at the outcomes associated with MRSA to see if this was a more virulent and more difficult to treat infection,” Dr. Lareau explained. In fact, the data did not support such associations, showing that MRSA-positive and MRSA-negative patients had identical median lengths of hospital stay (2 days) and did not differ significantly with respect to the rate of abscess drainage in the operating room (29% vs. 71%).

An analysis of trends over the 5-year study period showed that the total number of cases of perineal abscess seen at the hospital increased from about 20 to 55 per year. At the same time, the number of cases of MRSA perineal abscess, although still modest, increased at a much faster pace, from 1 to 12 per year.

“MRSA is the dominant pathogen in perineal infections at Magee-Womens Hospital,” Dr. Lareau concluded, adding that the study was unable to find clear demographic predictors of which patients are most likely to have this infection. “I would advocate considering empiric coverage for MRSA when you have a vulvar abscess that requires treatment,” she recommended.

Dr. Lareau reported that she had no conflicts of interest in association with the study.

The number of cases of MRSA perineal abscess increased from 1 to 12 per year. DR. LAREAU

SEATTLE — Methicillin-resistant Staphylococcus aureus is found in one-third of cases of perineal and buttock abscesses in women, and it accounts for fully half of the monomicrobial abscesses, according to one hospital's experience.

“MRSA is a common problem in our hospitals and in our community, and it certainly commands our attention,” study author Dr. Susan M. Lareau said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. She noted that a previous report found that MRSA was the leading cause of skin and soft-tissue infection in most emergency departments but did not address the proportion of perineal infections caused by this pathogen (N. Engl. J. Med. 2006;355:666-74).

Dr. Lareau of the Magee-Womens Hospital in Pittsburgh used diagnostic codes to identify retrospectively all cases of perineal and buttock abscesses seen at the hospital between 2003 and 2007 and then reviewed their characteristics. She included cases involving the vulva, Bartholin glands, and buttocks, and excluded cases involving the perianal and rectal areas.

The process identified 126 patients, Dr. Lareau reported. This group consisted of 64 patients (51%) with vulvar abscesses, 41 patients (33%) with Bartholin gland abscesses, 19 patients (15%) with buttock abscesses, and 2 patients (2%) with combined buttock and vulvar abscesses.

Cultures had been obtained in 72 of the patients and were positive for MRSA in 33%. By site, MRSA was found in 64% of buttock abscesses, 50% of combined buttock and vulvar abscesses, 33% of vulvar abscesses, and 7% of Bartholin gland abscesses.

“It's generally been thought that vulvar abscesses are polymicrobial, and that has driven our treatment, when necessary,” Dr. Lareau said. However, most (69%) of the 72 cases were monomicrobial. MRSA accounted for fully 50% of these infections; the next most common pathogens were group B streptococcus and methicillin-susceptible S. aureus, each of which accounted for only 14% of these infections.

Age, race, body mass index, pregnancy, and several comorbidities (diabetes, cancer, and coronary artery disease) did not significantly predict MRSA infection, but site did, according to Dr. Lareau. Relative to patients with Bartholin gland abscesses, patients with buttock abscesses were significantly more likely to be positive for MRSA (odds ratio 28), and patients with vulvar infections were nonsignificantly more likely to be MRSA positive (OR 7). However, Dr. Lareau said, confidence intervals were wide, probably because of the small sample size.

“We wanted to look at the outcomes associated with MRSA to see if this was a more virulent and more difficult to treat infection,” Dr. Lareau explained. In fact, the data did not support such associations, showing that MRSA-positive and MRSA-negative patients had identical median lengths of hospital stay (2 days) and did not differ significantly with respect to the rate of abscess drainage in the operating room (29% vs. 71%).

An analysis of trends over the 5-year study period showed that the total number of cases of perineal abscess seen at the hospital increased from about 20 to 55 per year. At the same time, the number of cases of MRSA perineal abscess, although still modest, increased at a much faster pace, from 1 to 12 per year.

“MRSA is the dominant pathogen in perineal infections at Magee-Womens Hospital,” Dr. Lareau concluded, adding that the study was unable to find clear demographic predictors of which patients are most likely to have this infection. “I would advocate considering empiric coverage for MRSA when you have a vulvar abscess that requires treatment,” she recommended.

Dr. Lareau reported that she had no conflicts of interest in association with the study.

The number of cases of MRSA perineal abscess increased from 1 to 12 per year. DR. LAREAU

SEATTLE — Methicillin-resistant Staphylococcus aureus is found in one-third of cases of perineal and buttock abscesses in women, and it accounts for fully half of the monomicrobial abscesses, according to one hospital's experience.

“MRSA is a common problem in our hospitals and in our community, and it certainly commands our attention,” study author Dr. Susan M. Lareau said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. She noted that a previous report found that MRSA was the leading cause of skin and soft-tissue infection in most emergency departments but did not address the proportion of perineal infections caused by this pathogen (N. Engl. J. Med. 2006;355:666-74).

Dr. Lareau of the Magee-Womens Hospital in Pittsburgh used diagnostic codes to identify retrospectively all cases of perineal and buttock abscesses seen at the hospital between 2003 and 2007 and then reviewed their characteristics. She included cases involving the vulva, Bartholin glands, and buttocks, and excluded cases involving the perianal and rectal areas.

The process identified 126 patients, Dr. Lareau reported. This group consisted of 64 patients (51%) with vulvar abscesses, 41 patients (33%) with Bartholin gland abscesses, 19 patients (15%) with buttock abscesses, and 2 patients (2%) with combined buttock and vulvar abscesses.

Cultures had been obtained in 72 of the patients and were positive for MRSA in 33%. By site, MRSA was found in 64% of buttock abscesses, 50% of combined buttock and vulvar abscesses, 33% of vulvar abscesses, and 7% of Bartholin gland abscesses.

“It's generally been thought that vulvar abscesses are polymicrobial, and that has driven our treatment, when necessary,” Dr. Lareau said. However, most (69%) of the 72 cases were monomicrobial. MRSA accounted for fully 50% of these infections; the next most common pathogens were group B streptococcus and methicillin-susceptible S. aureus, each of which accounted for only 14% of these infections.

Age, race, body mass index, pregnancy, and several comorbidities (diabetes, cancer, and coronary artery disease) did not significantly predict MRSA infection, but site did, according to Dr. Lareau. Relative to patients with Bartholin gland abscesses, patients with buttock abscesses were significantly more likely to be positive for MRSA (odds ratio 28), and patients with vulvar infections were nonsignificantly more likely to be MRSA positive (OR 7). However, Dr. Lareau said, confidence intervals were wide, probably because of the small sample size.

“We wanted to look at the outcomes associated with MRSA to see if this was a more virulent and more difficult to treat infection,” Dr. Lareau explained. In fact, the data did not support such associations, showing that MRSA-positive and MRSA-negative patients had identical median lengths of hospital stay (2 days) and did not differ significantly with respect to the rate of abscess drainage in the operating room (29% vs. 71%).

An analysis of trends over the 5-year study period showed that the total number of cases of perineal abscess seen at the hospital increased from about 20 to 55 per year. At the same time, the number of cases of MRSA perineal abscess, although still modest, increased at a much faster pace, from 1 to 12 per year.

“MRSA is the dominant pathogen in perineal infections at Magee-Womens Hospital,” Dr. Lareau concluded, adding that the study was unable to find clear demographic predictors of which patients are most likely to have this infection. “I would advocate considering empiric coverage for MRSA when you have a vulvar abscess that requires treatment,” she recommended.

Dr. Lareau reported that she had no conflicts of interest in association with the study.

The number of cases of MRSA perineal abscess increased from 1 to 12 per year. DR. LAREAU

VANCOUVER, B.C. — Capecitabine, an oral prodrug of 5-fluorouracil, can be used to control advanced squamous cell carcinoma of the skin when conventional treatment options have run out, according to the results of two studies involving a total of five patients.

Capecitabine (Xeloda) "was designed to improve upon existing 5-fluorouracil by having increased efficacy, an improved side-effect profile, and increased ease of administration," Dr. Mariah R. Brown, lead investigator of one study, explained at the annual meeting of the American College of Mohs Surgery.

Although capecitabine is currently approved only for treatment of colorectal cancer and breast cancer, research suggests a possible role for the drug in managing several other malignancies, including skin cancer, she noted.

Dr. Brown and her colleagues at the University of Colorado, Denver, studied three patients (two women and one man) aged 60-73 years who had locally advanced squamous cell carcinoma (SCC) of the head and neck. In each case, the cancer was inoperable because of tumor size or limitations imposed by prior surgery or radiation therapy; patients also wanted to avoid aggressive therapy. None of the patients had evidence of metastases.

The patients were treated with multiple courses of capecitabine (1,500 mg twice daily), with each course consisting of 2 weeks on the drug and 1 week off. The total duration of treatment ranged from 2 to 6 months.

All patients had a clinical response, with visible shrinkage of tumors by more than 50% and response beginning within the first course of therapy, Dr. Brown reported.

One patient was clinically disease-free after four courses of therapy. She continued taking capecitabine, albeit at a lower dose, because she experienced severe hand-foot syndrome, and was stable 6 months after starting the lower-dose therapy. Another patient had to discontinue the drug after 21/2 courses because of adverse effects (neutropenia and diarrhea) and experienced rapid regrowth of her tumor. The remaining patient was free of disease after four courses but was then lost to follow-up.

"Capecitabine demonstrates some initial positive results in advanced cutaneous squamous cell carcinoma," Dr. Brown said. "The medication was relatively well tolerated, but side effects may necessitate dose reduction or discontinuation."

The second study, presented as a poster by Dr. Jeffrey E. Petersen of Wright State University in Dayton, Ohio, described use of capecitabine in two patients with SCC.

The first patient was an 87-year-old man who had multiple recurrent SCCs of the scalp and had undergone previous cryotherapy, topical 5-fluorouracil treatment, and multiple excisions including a Mohs procedure. The cancer progressed, despite treatment with a maximum dose of radiation therapy. The patient declined extensive surgery.

The second patient was an 84-year-old man who had previously undergone Mohs surgery down to bone for SCC of the scalp but experienced a recurrence. He had already received radiation to that area. The patient had severe Alzheimer's disease, and his family declined further surgery.

Both patients were treated with capecitabine at 50% of the standard dose of 1,250 mg/m

Although the patients experienced mild nausea and reduced taste while on treatment, the drug was otherwise well tolerated, he noted.

In addition to improving visible disease, capecitabine may be acting on disease that is not yet clinically evident. "Because it's a systemic drug, … in the large tumors where there is a high risk of metastatic disease you may be also treating that microscopic metastatic disease," he explained.

"Capecitabine gives you an option sometimes when you are looking at a patient and thinking, 'I don't have any more options, I don't have anything more to offer these people.' And [now] we do," Dr. Petersen said.

Dr. Brown and Dr. Petersen reported that they had no conflicts of interest in association with their studies.

This 87-year-old patient's recurrent SCC had progressed despite treatment with a maximum dose of radiation.

There is marked improvement of the scalp after four courses of capecitabine, although some ulcers are still present. Photos courtesy Dr. Jeffrey E. Petersen

VANCOUVER, B.C. — Capecitabine, an oral prodrug of 5-fluorouracil, can be used to control advanced squamous cell carcinoma of the skin when conventional treatment options have run out, according to the results of two studies involving a total of five patients.

Capecitabine (Xeloda) "was designed to improve upon existing 5-fluorouracil by having increased efficacy, an improved side-effect profile, and increased ease of administration," Dr. Mariah R. Brown, lead investigator of one study, explained at the annual meeting of the American College of Mohs Surgery.

Although capecitabine is currently approved only for treatment of colorectal cancer and breast cancer, research suggests a possible role for the drug in managing several other malignancies, including skin cancer, she noted.

Dr. Brown and her colleagues at the University of Colorado, Denver, studied three patients (two women and one man) aged 60-73 years who had locally advanced squamous cell carcinoma (SCC) of the head and neck. In each case, the cancer was inoperable because of tumor size or limitations imposed by prior surgery or radiation therapy; patients also wanted to avoid aggressive therapy. None of the patients had evidence of metastases.

The patients were treated with multiple courses of capecitabine (1,500 mg twice daily), with each course consisting of 2 weeks on the drug and 1 week off. The total duration of treatment ranged from 2 to 6 months.

All patients had a clinical response, with visible shrinkage of tumors by more than 50% and response beginning within the first course of therapy, Dr. Brown reported.

One patient was clinically disease-free after four courses of therapy. She continued taking capecitabine, albeit at a lower dose, because she experienced severe hand-foot syndrome, and was stable 6 months after starting the lower-dose therapy. Another patient had to discontinue the drug after 21/2 courses because of adverse effects (neutropenia and diarrhea) and experienced rapid regrowth of her tumor. The remaining patient was free of disease after four courses but was then lost to follow-up.

"Capecitabine demonstrates some initial positive results in advanced cutaneous squamous cell carcinoma," Dr. Brown said. "The medication was relatively well tolerated, but side effects may necessitate dose reduction or discontinuation."

The second study, presented as a poster by Dr. Jeffrey E. Petersen of Wright State University in Dayton, Ohio, described use of capecitabine in two patients with SCC.

The first patient was an 87-year-old man who had multiple recurrent SCCs of the scalp and had undergone previous cryotherapy, topical 5-fluorouracil treatment, and multiple excisions including a Mohs procedure. The cancer progressed, despite treatment with a maximum dose of radiation therapy. The patient declined extensive surgery.

The second patient was an 84-year-old man who had previously undergone Mohs surgery down to bone for SCC of the scalp but experienced a recurrence. He had already received radiation to that area. The patient had severe Alzheimer's disease, and his family declined further surgery.

Both patients were treated with capecitabine at 50% of the standard dose of 1,250 mg/m

Although the patients experienced mild nausea and reduced taste while on treatment, the drug was otherwise well tolerated, he noted.

In addition to improving visible disease, capecitabine may be acting on disease that is not yet clinically evident. "Because it's a systemic drug, … in the large tumors where there is a high risk of metastatic disease you may be also treating that microscopic metastatic disease," he explained.

"Capecitabine gives you an option sometimes when you are looking at a patient and thinking, 'I don't have any more options, I don't have anything more to offer these people.' And [now] we do," Dr. Petersen said.

Dr. Brown and Dr. Petersen reported that they had no conflicts of interest in association with their studies.

This 87-year-old patient's recurrent SCC had progressed despite treatment with a maximum dose of radiation.

There is marked improvement of the scalp after four courses of capecitabine, although some ulcers are still present. Photos courtesy Dr. Jeffrey E. Petersen

VANCOUVER, B.C. — Capecitabine, an oral prodrug of 5-fluorouracil, can be used to control advanced squamous cell carcinoma of the skin when conventional treatment options have run out, according to the results of two studies involving a total of five patients.

Capecitabine (Xeloda) "was designed to improve upon existing 5-fluorouracil by having increased efficacy, an improved side-effect profile, and increased ease of administration," Dr. Mariah R. Brown, lead investigator of one study, explained at the annual meeting of the American College of Mohs Surgery.

Although capecitabine is currently approved only for treatment of colorectal cancer and breast cancer, research suggests a possible role for the drug in managing several other malignancies, including skin cancer, she noted.

Dr. Brown and her colleagues at the University of Colorado, Denver, studied three patients (two women and one man) aged 60-73 years who had locally advanced squamous cell carcinoma (SCC) of the head and neck. In each case, the cancer was inoperable because of tumor size or limitations imposed by prior surgery or radiation therapy; patients also wanted to avoid aggressive therapy. None of the patients had evidence of metastases.

The patients were treated with multiple courses of capecitabine (1,500 mg twice daily), with each course consisting of 2 weeks on the drug and 1 week off. The total duration of treatment ranged from 2 to 6 months.

All patients had a clinical response, with visible shrinkage of tumors by more than 50% and response beginning within the first course of therapy, Dr. Brown reported.

One patient was clinically disease-free after four courses of therapy. She continued taking capecitabine, albeit at a lower dose, because she experienced severe hand-foot syndrome, and was stable 6 months after starting the lower-dose therapy. Another patient had to discontinue the drug after 21/2 courses because of adverse effects (neutropenia and diarrhea) and experienced rapid regrowth of her tumor. The remaining patient was free of disease after four courses but was then lost to follow-up.

"Capecitabine demonstrates some initial positive results in advanced cutaneous squamous cell carcinoma," Dr. Brown said. "The medication was relatively well tolerated, but side effects may necessitate dose reduction or discontinuation."

The second study, presented as a poster by Dr. Jeffrey E. Petersen of Wright State University in Dayton, Ohio, described use of capecitabine in two patients with SCC.

The first patient was an 87-year-old man who had multiple recurrent SCCs of the scalp and had undergone previous cryotherapy, topical 5-fluorouracil treatment, and multiple excisions including a Mohs procedure. The cancer progressed, despite treatment with a maximum dose of radiation therapy. The patient declined extensive surgery.

The second patient was an 84-year-old man who had previously undergone Mohs surgery down to bone for SCC of the scalp but experienced a recurrence. He had already received radiation to that area. The patient had severe Alzheimer's disease, and his family declined further surgery.

Both patients were treated with capecitabine at 50% of the standard dose of 1,250 mg/m

Although the patients experienced mild nausea and reduced taste while on treatment, the drug was otherwise well tolerated, he noted.

In addition to improving visible disease, capecitabine may be acting on disease that is not yet clinically evident. "Because it's a systemic drug, … in the large tumors where there is a high risk of metastatic disease you may be also treating that microscopic metastatic disease," he explained.

"Capecitabine gives you an option sometimes when you are looking at a patient and thinking, 'I don't have any more options, I don't have anything more to offer these people.' And [now] we do," Dr. Petersen said.

Dr. Brown and Dr. Petersen reported that they had no conflicts of interest in association with their studies.

This 87-year-old patient's recurrent SCC had progressed despite treatment with a maximum dose of radiation.

There is marked improvement of the scalp after four courses of capecitabine, although some ulcers are still present. Photos courtesy Dr. Jeffrey E. Petersen

VANCOUVER, B.C. — Adenosquamous carcinoma is an often misdiagnosed and more aggressive type of skin cancer that requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary disease.

"We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence," Dr. Jennifer M. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of adenosquamous carcinoma (ASC) diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50-97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. "Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated," observed Dr. Fu, a dermatology resident at the University of California, San Francisco.

"Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case," she said. "In no case was adenosquamous carcinoma correctly diagnosed."

Histopathologically, many of the features of ASC overlap those of desmoplastic SCC, but ASC differs in having glandular differentiation. "At least at our institution, we feel that adenosquamous carcinoma is probably best considered a variant of SCC and on a spectrum of desmoplastic SCC," Dr. Fu said.

The tumors evaluated in the study typically had an infiltrative pattern with dermal fibrosis or sclerosis: 61% showed elastosis, while 30% were ulcerated. Squamous differentiation was universal, with all tumors exhibiting cytoplasmic cornification and 41% having keratinizing cysts.

Most tumors (92%) had ductular elements, while 58% had glandular elements. Even when a tumor had glandular elements, the percentage of that tumor showing those elements varied from roughly 5% to 80%. In fact, two of the cases were initially interpreted to be SCC but were subsequently determined to have glandular differentiation more consistent with ASC. In such equivocal cases, immunostaining for carcinoembryonic antigen or cytokeratin 7 may help identify glandular foci, she noted.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant radiation therapy and cetuximab (Erbitux) for locally advanced disease. For these patients, "the Mohs defect postoperatively far exceeded what was evident clinically," said Dr. Fu, who had no conflicts of interest in association with the study.

In this patient, recurrent nodules and plaques of adenosquamous carcinoma are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — Adenosquamous carcinoma is an often misdiagnosed and more aggressive type of skin cancer that requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary disease.

"We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence," Dr. Jennifer M. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of adenosquamous carcinoma (ASC) diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50-97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. "Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated," observed Dr. Fu, a dermatology resident at the University of California, San Francisco.

"Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case," she said. "In no case was adenosquamous carcinoma correctly diagnosed."

Histopathologically, many of the features of ASC overlap those of desmoplastic SCC, but ASC differs in having glandular differentiation. "At least at our institution, we feel that adenosquamous carcinoma is probably best considered a variant of SCC and on a spectrum of desmoplastic SCC," Dr. Fu said.

The tumors evaluated in the study typically had an infiltrative pattern with dermal fibrosis or sclerosis: 61% showed elastosis, while 30% were ulcerated. Squamous differentiation was universal, with all tumors exhibiting cytoplasmic cornification and 41% having keratinizing cysts.

Most tumors (92%) had ductular elements, while 58% had glandular elements. Even when a tumor had glandular elements, the percentage of that tumor showing those elements varied from roughly 5% to 80%. In fact, two of the cases were initially interpreted to be SCC but were subsequently determined to have glandular differentiation more consistent with ASC. In such equivocal cases, immunostaining for carcinoembryonic antigen or cytokeratin 7 may help identify glandular foci, she noted.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant radiation therapy and cetuximab (Erbitux) for locally advanced disease. For these patients, "the Mohs defect postoperatively far exceeded what was evident clinically," said Dr. Fu, who had no conflicts of interest in association with the study.

In this patient, recurrent nodules and plaques of adenosquamous carcinoma are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — Adenosquamous carcinoma is an often misdiagnosed and more aggressive type of skin cancer that requires close follow-up for possible recurrences, according to a review that identified 27 patients with primary disease.

"We are starting to get the sense that it can be very clinically aggressive and, in fact, may be more aggressive than conventional cutaneous squamous cell carcinoma [SCC], with a high risk of local recurrence," Dr. Jennifer M. Fu said at the annual meeting of the American College of Mohs Surgery.

A rise in the number of cases at her institution in recent years, with some of them proving to be very locally aggressive, prompted a closer look at this cancer. Dr. Fu and her colleagues searched their institution's records for the past 10 years to identify cases of adenosquamous carcinoma (ASC) diagnosed there. The search identified 27 patients with primary ASC, 7 of whom experienced a recurrence. The patients had a mean age of 74 years (range 50-97 years), and 70% were men.

Some 56% of the primary tumors were on the face, 15% were on the scalp, and 15% were on the arm or shoulder. "Clinically, this was a very difficult diagnosis for people to make, often presenting just as a firm papule or plaque and not infrequently ulcerated," observed Dr. Fu, a dermatology resident at the University of California, San Francisco.

"Most of the clinicians diagnosed this as something else—as basal cell carcinoma, scar, metastatic carcinoma, rosacea in one case, and a spider bite in another case," she said. "In no case was adenosquamous carcinoma correctly diagnosed."

Histopathologically, many of the features of ASC overlap those of desmoplastic SCC, but ASC differs in having glandular differentiation. "At least at our institution, we feel that adenosquamous carcinoma is probably best considered a variant of SCC and on a spectrum of desmoplastic SCC," Dr. Fu said.

The tumors evaluated in the study typically had an infiltrative pattern with dermal fibrosis or sclerosis: 61% showed elastosis, while 30% were ulcerated. Squamous differentiation was universal, with all tumors exhibiting cytoplasmic cornification and 41% having keratinizing cysts.

Most tumors (92%) had ductular elements, while 58% had glandular elements. Even when a tumor had glandular elements, the percentage of that tumor showing those elements varied from roughly 5% to 80%. In fact, two of the cases were initially interpreted to be SCC but were subsequently determined to have glandular differentiation more consistent with ASC. In such equivocal cases, immunostaining for carcinoembryonic antigen or cytokeratin 7 may help identify glandular foci, she noted.

Clinical outcomes were assessed in the six patients who received most of their treatment at her hospital. Five were immunosuppressed. All underwent Mohs surgery at least once, and two received adjuvant radiation therapy and cetuximab (Erbitux) for locally advanced disease. For these patients, "the Mohs defect postoperatively far exceeded what was evident clinically," said Dr. Fu, who had no conflicts of interest in association with the study.

In this patient, recurrent nodules and plaques of adenosquamous carcinoma are visible at the edge of a scar from previous treatment. University of California, San Francisco/Department of Dermatology

VANCOUVER, B.C. — The epidermal growth factor receptor inhibitor cetuximab alone has been found to produce complete response in patients with advanced cutaneous squamous cell carcinoma.

"To date, there have been no trials using the epidermal growth factor receptor inhibitors for treatment of patients with cutaneous squamous cell carcinoma," said Dr. Matthew E. Halpern at the annual meeting of the American College of Mohs Surgery. A previous trial found that cetuximab (Erbitux) plus radiation was efficacious for treating locally advanced squamous cell carcinoma (SCC) of the head and neck (N. Engl. J. Med. 2006;354:567-78).

Study patients had advanced SCC of the back, scalp, temple, and chest, according to Dr. Halpern, a dermatologic surgeon at New York-Presbyterian Medical Center. Two patients had in-transit metastasis alone, one had both in-transit and axillary metastases, and one had pulmonary metastases. Their treatment consisted of weekly infusions of cetuximab, with a total of four infusions planned.

Two patients had a complete clinical response to cetuximab (Erbitux), Dr. Halpern reported. "Really, like magic, the in-transit metastasis absolutely melted before our eyes," he said, describing one of the patients. Another patient, who received only half of the planned number of infusions because of comorbidities, had a partial response. The remaining patient had merely a limited response.

"As you might expect, side effects of this class of medications are largely cutaneous," Dr. Halpern noted, explaining that patients might develop a characteristic acneiform rash, paronychial inflammation, xerosis, pruritus, and trichomegaly. The study's two complete responders developed a severe rash, and the partial responder developed a moderate rash, while the nonresponder did not develop any rash at all. "Interestingly, even though this is a very small series of patients, patient response seemed to correlate with the severity of acneiform eruption," he observed. "It seemed to be a surrogate marker for therapeutic response."

One of the patients with a complete response was alive at 6 months after treatment, while the other died 7 months afterward from a primary lung cancer. The patient with a partial response died 4 months after treatment from chronic rejection of a lung transplant and had additional metastases at that time. The patient who had a minimal response died 4 months after treatment from brain metastases.

The study had limited follow-up related to the recent treatments patients had received and their comorbidities, Dr. Halpern conceded. Nonetheless, he said, "cetuximab has potential benefit for patients with metastatic cutaneous squamous cell carcinoma and is extremely well tolerated in our hands, with minimal side effects, some of which may be predictive of therapeutic benefit."

Dr. Halpern reported that he had no conflicts of interest in association with the study.

'The severity of acneiform eruption … seemed to be a surrogate marker for therapeutic response.' DR. HALPERN

Biopsy of this nodule revealed infiltrating SCC without epidermal involvement.

The patient's in-transit metastasis and axillary metastases cleared after the third cetuximab infusion. The acneiform rash is characteristic of this drug class. Photos courtesy Dr. Matthew E. Halpern

VANCOUVER, B.C. — The epidermal growth factor receptor inhibitor cetuximab alone has been found to produce complete response in patients with advanced cutaneous squamous cell carcinoma.

"To date, there have been no trials using the epidermal growth factor receptor inhibitors for treatment of patients with cutaneous squamous cell carcinoma," said Dr. Matthew E. Halpern at the annual meeting of the American College of Mohs Surgery. A previous trial found that cetuximab (Erbitux) plus radiation was efficacious for treating locally advanced squamous cell carcinoma (SCC) of the head and neck (N. Engl. J. Med. 2006;354:567-78).

Study patients had advanced SCC of the back, scalp, temple, and chest, according to Dr. Halpern, a dermatologic surgeon at New York-Presbyterian Medical Center. Two patients had in-transit metastasis alone, one had both in-transit and axillary metastases, and one had pulmonary metastases. Their treatment consisted of weekly infusions of cetuximab, with a total of four infusions planned.

Two patients had a complete clinical response to cetuximab (Erbitux), Dr. Halpern reported. "Really, like magic, the in-transit metastasis absolutely melted before our eyes," he said, describing one of the patients. Another patient, who received only half of the planned number of infusions because of comorbidities, had a partial response. The remaining patient had merely a limited response.

"As you might expect, side effects of this class of medications are largely cutaneous," Dr. Halpern noted, explaining that patients might develop a characteristic acneiform rash, paronychial inflammation, xerosis, pruritus, and trichomegaly. The study's two complete responders developed a severe rash, and the partial responder developed a moderate rash, while the nonresponder did not develop any rash at all. "Interestingly, even though this is a very small series of patients, patient response seemed to correlate with the severity of acneiform eruption," he observed. "It seemed to be a surrogate marker for therapeutic response."

One of the patients with a complete response was alive at 6 months after treatment, while the other died 7 months afterward from a primary lung cancer. The patient with a partial response died 4 months after treatment from chronic rejection of a lung transplant and had additional metastases at that time. The patient who had a minimal response died 4 months after treatment from brain metastases.

The study had limited follow-up related to the recent treatments patients had received and their comorbidities, Dr. Halpern conceded. Nonetheless, he said, "cetuximab has potential benefit for patients with metastatic cutaneous squamous cell carcinoma and is extremely well tolerated in our hands, with minimal side effects, some of which may be predictive of therapeutic benefit."

Dr. Halpern reported that he had no conflicts of interest in association with the study.

'The severity of acneiform eruption … seemed to be a surrogate marker for therapeutic response.' DR. HALPERN

Biopsy of this nodule revealed infiltrating SCC without epidermal involvement.

The patient's in-transit metastasis and axillary metastases cleared after the third cetuximab infusion. The acneiform rash is characteristic of this drug class. Photos courtesy Dr. Matthew E. Halpern

VANCOUVER, B.C. — The epidermal growth factor receptor inhibitor cetuximab alone has been found to produce complete response in patients with advanced cutaneous squamous cell carcinoma.

"To date, there have been no trials using the epidermal growth factor receptor inhibitors for treatment of patients with cutaneous squamous cell carcinoma," said Dr. Matthew E. Halpern at the annual meeting of the American College of Mohs Surgery. A previous trial found that cetuximab (Erbitux) plus radiation was efficacious for treating locally advanced squamous cell carcinoma (SCC) of the head and neck (N. Engl. J. Med. 2006;354:567-78).

Study patients had advanced SCC of the back, scalp, temple, and chest, according to Dr. Halpern, a dermatologic surgeon at New York-Presbyterian Medical Center. Two patients had in-transit metastasis alone, one had both in-transit and axillary metastases, and one had pulmonary metastases. Their treatment consisted of weekly infusions of cetuximab, with a total of four infusions planned.

Two patients had a complete clinical response to cetuximab (Erbitux), Dr. Halpern reported. "Really, like magic, the in-transit metastasis absolutely melted before our eyes," he said, describing one of the patients. Another patient, who received only half of the planned number of infusions because of comorbidities, had a partial response. The remaining patient had merely a limited response.

"As you might expect, side effects of this class of medications are largely cutaneous," Dr. Halpern noted, explaining that patients might develop a characteristic acneiform rash, paronychial inflammation, xerosis, pruritus, and trichomegaly. The study's two complete responders developed a severe rash, and the partial responder developed a moderate rash, while the nonresponder did not develop any rash at all. "Interestingly, even though this is a very small series of patients, patient response seemed to correlate with the severity of acneiform eruption," he observed. "It seemed to be a surrogate marker for therapeutic response."

One of the patients with a complete response was alive at 6 months after treatment, while the other died 7 months afterward from a primary lung cancer. The patient with a partial response died 4 months after treatment from chronic rejection of a lung transplant and had additional metastases at that time. The patient who had a minimal response died 4 months after treatment from brain metastases.

The study had limited follow-up related to the recent treatments patients had received and their comorbidities, Dr. Halpern conceded. Nonetheless, he said, "cetuximab has potential benefit for patients with metastatic cutaneous squamous cell carcinoma and is extremely well tolerated in our hands, with minimal side effects, some of which may be predictive of therapeutic benefit."

Dr. Halpern reported that he had no conflicts of interest in association with the study.

'The severity of acneiform eruption … seemed to be a surrogate marker for therapeutic response.' DR. HALPERN

Biopsy of this nodule revealed infiltrating SCC without epidermal involvement.

The patient's in-transit metastasis and axillary metastases cleared after the third cetuximab infusion. The acneiform rash is characteristic of this drug class. Photos courtesy Dr. Matthew E. Halpern