Акценти от 1-ви ден

Dr. Silvina Daniela MALDONADO

Dermatologist, Argentina

Laser and light therapy

Combining technologies to treat scars

Dr. Andrés Luque-Ayala (Dermatologist, Colombia)

In the Laser and Light Therapy Workshop, Dr. Andrés Luque spoke about combining technologies to treat scars, and placed a special emphasis on changing the idea of waiting for scars to develop before attempting to improve them, given that lasers help with collagen remodelling during the early stage of scar formation and that the same results cannot be obtained if this intervention occurs later in the fibrosis stage. He also discussed combining light therapies with other tools such as silicones, topical and intralesional corticosteroids, using lasers as soon as the sutures are removed. He also suggests combining a 1550 nm fractional laser with a CO2 laser. His final recommendation is not to extend sessions any longer than 6 months.

 

Rare dermatoses treated with lasers

Dr. Kléber Ollague Murillo (Dermatologist, Ecuador)

Next, Dr. Kléber Murillo discussed Rare dermatoses treated with lasers. With vitiligo, despite the risk of the Koebner phenomenon, good results are obtained with Fractional Erbium YAG with sessions lasting 6 months to 1 year, with melanocyte migration and release of cytokines being observed. Other uses: androgenetic alopecia (Fractional Erbium YAG), alopecia areta, perifolliculitis abscedens (CO2 produces physical breakdown of scar tissue, drainage of necrotic material, collagen regeneration and stimulation of the hair follicle). Also used with solar lentigo (Q-Switched), hypertrophic and keloid scars (Fractional plus Triamcinolone), melasma (only in refractory cases, and is transitory), ocronosis (Fractional Q-Switched), postinflammatory hyperpigmentation (Fractional), pseudoacantosis / acantosis nigricans (Fractional CO2 combined with glycolic acid), REFRACTORY tattoos (Q Switched plus Fractional), morphea (Erbium YAG), lichen amyloidosis (erbium YAG) and onychomycosis (2940 nm Fractional YAG plus intraprocedural amorolfine).

 

Collagenopathy Workshop

Dermatomyositis (DM) with neoplasia

Prof. Jeffrey Callen (Dermatologist, United States of America)

In the Collagenopathy Workshop, Prof. Jeffrey Callen spoke about dermatomyositis (DM) with neoplasia. In general population studies, it was found that 20 to 25% of patients with dermatomyositis have or will develop cancer, and this is also possible with amyopathic DMs. Those with polymyositis (PM) tend to have a lower rate, approximately equal to that seen in the general population. As is well-known, the most significant risk period is between the first and third years, and while the risk declines after that, it does not disappear. The most frequently-occurring cancers are gynaecological cancers, particularly ovarian cancer, and nasopharyngeal cancer in Southeast Asia. According to a Scandinavian study, the most frequent cancers are ovarian, lung and colorectal cancer, followed by pancreatic cancer, breast cancer and non-Hodgkin’s lymphoma. There may also be a relationship between the immunosuppressive drugs used for DM with malignancy, increasing the risk of lymphoproliferative disorders. With regard to how to evaluate a patient to rule out cancer, Prof. Callen notes that although people started saying 10 years ago that PET/CT is sufficient, those conclusions are based on small numbers of patients, and he says that he is not ready to change how he evaluates his patients with conventional tests (X-ray, chest and abdominal CT, faecal occult blood test, pelvic ultrasound and other tests as appropriate for age, symptoms, ethnicity, etc.). He suggests once per year for 3 years and specific advice to the patient about any suspicious symptoms. The antibodies which indicate an increased risk of cancer, especially NXP2 and TIF 1 gamma, are a very interesting topic, but an overlap has been observed between patients with cancer without autoantibodies and others with autoantibodies who do not develop cancer; therefore, he emphasises that the absence of autoantibodies is no reason not to study the patient.

 

Therapeutic innovations for advanced melanoma

Lymph node management with advanced melanoma

Dr. Abel Gonzàlez (Dermatologist, Argentina)

In the workshop on Therapeutic innovations for advanced melanoma, Dr. Abel González spoke about Lymph node management with advanced melanoma. In cases of a positive sentinel lymph node (SLN+), he recommends only observation and consideration of lymphadenectomy in special cases: in the head and neck, when there are monitoring difficulties, and with melanomas with a poor prognosis (high Breslow and ulcerated, high SLN tumour burden). Ultimately, the decision is up to the patient, to whom we must thoroughly explain the results of recent clinical trials. An SLN biopsy remains indicated as a source of prognostic information, for clinical trials and for SIII treatment. For low-risk patients (micrometastasis and low tumour burden), it can be diagnostic and therapeutic, with ultrasound monitoring in experienced hands being a sensible option afterwards. For high-risk patients, we need to talk about cost/benefit ratios, co-morbidity rates, life expectancy, compliance with monitoring and availability of imaging tests, and also consider the prognostic value of complete removal and impact on adjuvant treatments or entry into clinical trials.

In conclusion, SLN currently remains the standard for melanomas with Breslow greater than 0.8mm (N=M=). An SLN is observed except in the cases described (monitoring every 3 months for 3 years, then every 4 months for the next 2 years) and in SIII-B immunotherapy and then developing treatment.

 

Ganglionar management in advanced melanoma

Dr. Matìas Maskin (Dermatologist, Argentina)

New treatments for melanoma. Mechanisms of action and long-term effectiveness.

Dr. Pablo Uribe (Dermatologist, Chile)

Discussion of clinical cases

Dr. Matìas Turienzo (Dermatologist, Argentina)

With regard to new treatments, Dr. Pablo Uribe, Dr. Matìas Turienzo and Dr. Matìas Maskin discussed the benefits of combining pharmacological inhibitors like Vemurafenib, Dabrafenib (BRAF inhibitors), Tramatinib and Cobimetinib (MEK inhibitors), and immunotherapy with Ipilimumab (anti-CTLA4), Nivolumab and Pembrolizumab (anti-PD1). The former require BRAF mutations, are taken orally, with rapid anti-tumour response, but generate resistance. The latter do not require BRAF mutations, and the response is slower (except in combinations) and more prolonged. The combination appears to increase survival, and is used in an adjuvant context. The first line would be for wild-type BRAF, Nivolumab or Pembrolizumab. For BRAF mutations, Dabrafenib/Trametinib, Nivolumab or Pembrolizumab.

In conclusion: determine absence or presence of BRAF mutation; risk/benefit analysis; availability/cost/coverage, logistics and concomitant diseases. It remains to be determined whether adjuvant therapy should be early or late, if more prolonged use is more effective, real effect on survival, and especially whether patients can be re-exposed to the same drugs in case of metastatic disease.

Finally, talimogene laherparepvec (T-VEC) is an oncolytic virus, modified from HSV-1, which replicates selectively in tumour cells, promoting regional and systemic immunity against tumours. It is applied intralesionally. New drugs being studied may offer prospects for the treatment of advanced melanoma.