Publications by authors named "Mark R Pittelkow"

165 Publications

Panniculitis in a patient with metastatic renal cell carcinoma on a tyrosine kinase inhibitor.

Anticancer Drugs 2020 Dec 7. Epub 2020 Dec 7.

Dermatology.

A 71-year-old female was diagnosed with localized renal cell carcinoma in July 2008 with subsequent metastasis in 2012 to the right adrenal gland, lungs, and brain. Due to disease progression, she was started on pazopanib 800 mg daily in October 2012. In November 2016, the patient developed an ill-defined, red, 10 × 15 cm indurated plaque on the left lateral upper thigh with a discrete 3 cm firm tender tumor without ulceration. An incisional biopsy was performed and showed panniculitis with features resembling sclerosing lipogranuloma. Alternative causes including rheumatologic disease and trauma were ruled out. We report the first case of pazopanib-induced panniculitis. Key clinical and histopathological features include tender subcutaneous nodules, exclusion of other causes, and fatty microcysts within a densely sclerotic background on pathology. As targeted therapies are becoming increasingly common in the field of oncology, prompt identification and reporting of adverse reactions is critical for proper management.
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http://dx.doi.org/10.1097/CAD.0000000000000999DOI Listing
December 2020

Toward allele-specific targeting therapy and pharmacodynamic marker for spinocerebellar ataxia type 3.

Sci Transl Med 2020 10;12(566)

Department of Neuroscience, Mayo Clinic, Jacksonville, FL 32224, USA.

Spinocerebellar ataxia type 3 (SCA3), caused by a CAG repeat expansion in the ataxin-3 gene (), is characterized by neuronal polyglutamine (polyQ) ATXN3 protein aggregates. Although there is no cure for SCA3, gene-silencing approaches to reduce toxic polyQ ATXN3 showed promise in preclinical models. However, a major limitation in translating putative treatments for this rare disease to the clinic is the lack of pharmacodynamic markers for use in clinical trials. Here, we developed an immunoassay that readily detects polyQ ATXN3 proteins in human biological fluids and discriminates patients with SCA3 from healthy controls and individuals with other ataxias. We show that polyQ ATXN3 serves as a marker of target engagement in human fibroblasts, which may bode well for its use in clinical trials. Last, we identified a single-nucleotide polymorphism that strongly associates with the expanded allele, thus providing an exciting drug target to abrogate detrimental events initiated by mutant ATXN3. Gene-silencing strategies for several repeat diseases are well under way, and our results are expected to improve clinical trial preparedness for SCA3 therapies.
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http://dx.doi.org/10.1126/scitranslmed.abb7086DOI Listing
October 2020

Identification of stage I/IIA melanoma patients at high risk for disease relapse using a clinicopathologic and gene expression model.

Eur J Cancer 2020 11 5;140:11-18. Epub 2020 Oct 5.

Mayo Clinic, Rochester, MN, USA. Electronic address:

Purpose: Patients with stage I/IIA cutaneous melanoma (CM) are currently not eligible for adjuvant therapies despite uncertainty in relapse risk. Here, we studied the ability of a recently developed model which combines clinicopathologic and gene expression variables (CP-GEP) to identify stage I/IIA melanoma patients who have a high risk for disease relapse.

Patients And Methods: Archival specimens from a cohort of 837 consecutive primary CMs were used for assessing the prognostic performance of CP-GEP. The CP-GEP model combines Breslow thickness and patient age, with the expression of eight genes in the primary tumour. Our specific patient group, represented by 580 stage I/IIA patients, was stratified based on their risk of relapse: CP-GEP High Risk and CP-GEP Low Risk. The main clinical end-point of this study was five-year relapse-free survival (RFS).

Results: Within the stage I/IIA melanoma group, CP-GEP identified a high-risk patient group (47% of total stage I/IIA patients) which had a considerably worse five-year RFS than the low-risk patient group; 74% (95% confidence interval [CI]: 67%-80%) versus 89% (95% CI: 84%-93%); hazard ratio [HR] = 2.98 (95% CI: 1.78-4.98); P < 0.0001. Of patients in the high-risk group, those who relapsed were most likely to do so within the first 3 years.

Conclusion: The CP-GEP model can be used to identify stage I/IIA patients who have a high risk for disease relapse. These patients may benefit from adjuvant therapy.
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http://dx.doi.org/10.1016/j.ejca.2020.08.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655519PMC
November 2020

COVID-19: An opportunity to build dermatology's digital future.

Dermatol Ther 2020 11 4;33(6):e14149. Epub 2020 Sep 4.

Mayo Clinic Office of Artificial Intelligence in Dermatology, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1111/dth.14149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435563PMC
November 2020

Trends in Medicare utilization and reimbursement for electronic brachytherapy following 2016 billing code changes.

J Am Acad Dermatol 2020 Jul 16. Epub 2020 Jul 16.

Department of Dermatology, Mayo Clinic, Scottsdale, Arizona. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2020.07.034DOI Listing
July 2020

A case of pediatric lymphomatoid papulosis treated with photodynamic therapy and narrowband ultraviolet B.

Pediatr Dermatol 2020 Sep 3;37(5):881-883. Epub 2020 Jul 3.

Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA.

We report a case of a 13-year-old boy with extensive lymphomatoid papulosis (LyP) involving his elbows, forearms, proximal thighs, and right hip, with treatment-resistant nodules on his right forearm. He was treated with full-body narrowband ultraviolet B and targeted photodynamic therapy (PDT) with 20% aminolevulinic acid (ALA). After two months, there was complete resolution of the right forearm nodules. Due to its minimal toxicity, PDT offers unique advantages and may be considered for pediatric LyP patients with symptomatic, localized disease resistant to conventional treatments.
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http://dx.doi.org/10.1111/pde.14244DOI Listing
September 2020

Deep Learning for Dermatologists: Part I Fundamental Concepts.

J Am Acad Dermatol 2020 May 17. Epub 2020 May 17.

Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota; Mayo Clinic Office of Artificial Intelligence in Dermatology (AIDE).

Artificial intelligence (AI) is generating substantial interest in the field of medicine. One form of artificial intelligence, deep learning, has led to rapid advances in automated image analysis. In 2017, an algorithm demonstrated the ability to diagnose certain skin cancers from clinical photographs with the accuracy of an expert dermatologist. Subsequently, deep learning has been applied to a range of dermatology applications. Though experts will never be replaced by AI, it will certainly impact the specialty of dermatology. In this first article of a two-part series, the basic concepts of deep learning will be reviewed with the goal of laying the groundwork for effective communication between clinicians and technical colleagues. In part two of the series, the clinical applications of deep learning in dermatology will be reviewed considering limitations and opportunities.
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http://dx.doi.org/10.1016/j.jaad.2020.05.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669702PMC
May 2020

Deep learning for dermatologists: Part II. Current applications.

J Am Acad Dermatol 2020 May 16. Epub 2020 May 16.

Mayo Clinic Office of Artificial Intelligence in Dermatology, Rochester, Minnesota; Department of Health Sciences Research, Division of Digital Health Sciences, Mayo Clinic, Rochester, Minnesota.

Because of a convergence of the availability of large data sets, graphics-specific computer hardware, and important theoretical advancements, artificial intelligence has recently contributed to dramatic progress in medicine. One type of artificial intelligence known as deep learning has been particularly impactful for medical image analysis. Deep learning applications have shown promising results in dermatology and other specialties, including radiology, cardiology, and ophthalmology. The modern clinician will benefit from an understanding of the basic features of deep learning to effectively use new applications and to better gauge their utility and limitations. In this second article of a 2-part series, we review the existing and emerging clinical applications of deep learning in dermatology and discuss future opportunities and limitations. Part 1 of this series offered an introduction to the basic concepts of deep learning to facilitate effective communication between clinicians and technical experts.
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http://dx.doi.org/10.1016/j.jaad.2020.05.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669658PMC
May 2020

Model Combining Tumor Molecular and Clinicopathologic Risk Factors Predicts Sentinel Lymph Node Metastasis in Primary Cutaneous Melanoma.

JCO Precis Oncol 2020 14;4:319-334. Epub 2020 Apr 14.

Mayo Clinic, Rochester, MN, USA.

Purpose: More than 80% of patients who undergo sentinel lymph node (SLN) biopsy have no nodal metastasis. Here we describe a model that combines clinicopathologic and molecular variables to identify patients with thin and intermediate thickness melanomas who may forgo the SLN biopsy procedure due to their low risk of nodal metastasis.

Patients And Methods: Genes with functional roles in melanoma metastasis were discovered by analysis of next generation sequencing data and case control studies. We then used PCR to quantify gene expression in diagnostic biopsy tissue across a prospectively designed archival cohort of 754 consecutive thin and intermediate thickness primary cutaneous melanomas. Outcome of interest was SLN biopsy metastasis within 90 days of melanoma diagnosis. A penalized maximum likelihood estimation algorithm was used to train logistic regression models in a repeated cross validation scheme to predict the presence of SLN metastasis from molecular, clinical and histologic variables.

Results: Expression of genes with roles in epithelial-to-mesenchymal transition (glia derived nexin, growth differentiation factor 15, integrin β3, interleukin 8, lysyl oxidase homolog 4, TGFβ receptor type 1 and tissue-type plasminogen activator) and melanosome function (melanoma antigen recognized by T cells 1) were associated with SLN metastasis. The predictive ability of a model that only considered clinicopathologic or gene expression variables was outperformed by a model which included molecular variables in combination with the clinicopathologic predictors Breslow thickness and patient age; AUC, 0.82; 95% CI, 0.78-0.86; SLN biopsy reduction rate of 42% at a negative predictive value of 96%.

Conclusion: A combined model including clinicopathologic and gene expression variables improved the identification of melanoma patients who may forgo the SLN biopsy procedure due to their low risk of nodal metastasis.
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http://dx.doi.org/10.1200/po.19.00206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220172PMC
April 2020

Improving Access to Care Through the Establishment of a Local, Teledermatology Network.

Telemed J E Health 2020 Jul 15;26(7):935-940. Epub 2019 Oct 15.

Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA.

Access to dermatologic care is a major issue in the United States, especially within the un- and underinsured populations; technology, including teledermatology, will pay a role in improving access to care. We performed a prospective study between November 2016 and September 2017. We leveraged a partnership between Mayo Clinic and Mountain Park Health Clinic, a community clinic that primarily serves un- and underinsured populations. We implemented a mobile phone-based store and forward (SAF) teledermatology service, which integrated an external community health clinic to an existing electronic health record (EHR) using standardized data capture forms, real-time support, and simple workflows. Thirty-seven patients were enrolled in the study, 65% female and 35% male with an average age of 47.9 (SD = 15.9). The ethnic breakdown was: 81.1% Hispanic, 13.5% Caucasian, and 5.4% African American. The majority, 62.2%, did not have a high school education, 45.9% were unemployed, and 51.4% were uninsured. 64.9% earned less than $25,000 for annual household income. Teledermatology consultation increased the absolute diagnostic and management concordance by 36.6% (pp p We successfully implemented a SAF teledermatology consultative service in a community health clinic outside our EHR. A similar approach can be used by other large health care organizations to provide integrated, high-quality consultation to clinics with rural, un- and underinsured populations.
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http://dx.doi.org/10.1089/tmj.2019.0051DOI Listing
July 2020

Cutaneous Eruption Heralding Squamous Cell Carcinoma of the Lung: Answer.

Am J Dermatopathol 2019 Oct;41(10):773-774

Departments of Dermatology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1097/DAD.0000000000001189DOI Listing
October 2019

Prognostic value of inositol polyphosphate-5-phosphatase expression in recurrent and metastatic cutaneous squamous cell carcinoma.

J Am Acad Dermatol 2020 Apr 19;82(4):846-853. Epub 2019 Aug 19.

Department of Dermatology, Mayo Clinic, Scottsdale, Arizona. Electronic address:

Background: Inositol polyphosphate-5-phosphatase (INPP5A) has been shown to play a role in the progression of actinic keratosis to cutaneous squamous cell carcinoma (cSCC) and the progression of localized disease to metastatic disease. Currently, no cSCC biomarkers are able to risk stratify recurrent and metastatic disease.

Objective: To determine the prognostic value of INPP5A expression in cSCC recurrent and metastatic disease.

Methods: We conducted a multicenter, single-institutional, retrospective cohort study within the Mayo Clinic Health System on the use of immunohistochemical staining to examine cSCC INPP5A protein expression in primary tumors and recurrent and metastatic disease. Dermatologists and dermatopathologists were blinded to outcome.

Results: Low staining expression of INPP5A in recurrent and metastatic disease tumors was associated with poor overall survival (OS) (31.0 months for low versus 62.0 months for high expression; P = .0272). A composite risk score (calculated as score of primary tumor + score of recurrent or metastatic disease tumor, with tumors with high expression scoring a zero and low expression a 1, score range 0-2) of 0 was predictive of improved OS compared with a composite risk score of ≥1 (hazard ratio 0.42, 95% confidence interval 0.21-0.84; P = .0113).

Limitations: This is a multicenter but single institution study of a white population.

Conclusion: Loss of INPP5A expression predicts poor OS in recurrent and metastatic disease of cSCC.
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http://dx.doi.org/10.1016/j.jaad.2019.08.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043906PMC
April 2020

Impact of standardized templates and skin cancer learning modules for teledermatology consultations.

Int J Dermatol 2019 Dec 27;58(12):1423-1429. Epub 2019 Mar 27.

Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA.

Background: Little research has been done in teledermatology to examine the effects of standardized templates and subject-specific learning modules.

Methods: We performed a prospective study examining the effects of standardized templates and standardized cutaneous oncology learning modules on teledermatology referrals at Mayo Clinic. This data was then compared to previous teledermatology referrals before standardized templates were adopted.

Results: A total of 42 teledermatology consultations were performed during the 4-month study period. The use of standardized templates resulted in an absolute reduction in face-to-face referrals. Teledermatology consultation increased the absolute diagnostic and management concordance by 26.2% (P = 0.02) and 33.3% (P < 0.01), respectively, and decreased the absolute diagnostic and management discordance by 19.1% (P = 0.03) and 31.0% (P < 0.01), respectively. The largest knowledge gaps were identified in cutaneous oncology. Educational intervention improved theoretical referral rates and confidence in diagnosis and management overall.

Conclusion: The implementation of standardized intake templates reduces the rate of face-to-face referrals. Teledermatology improves primary care-based dermatological care and reduces theoretical referral rates.
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http://dx.doi.org/10.1111/ijd.14437DOI Listing
December 2019

Clinical Experience with Rituximab and Intravenous Immunoglobulin for Pretibial Myxedema: A Case Series.

Thyroid 2019 05 8;29(5):692-699. Epub 2019 Apr 8.

1 Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota.

Severe pretibial myxedema (PTM) can be difficult to manage, highlighting the need to investigate newer therapies. Rituximab (RTX) and intravenous immunoglobulin (IVIg) have been tried in Graves' orbitopathy. Since PTM and orbitopathy share a similar underlying pathophysiology, this study aimed to explore these therapies for progressive PTM. The electronic database was screened for PTM patients evaluated at the Mayo Clinic, Rochester, from 2002 to 2016, and three patients who received IVIg and five who received RTX are reported. PTM pattern was classified as non-pitting edema, plaque and induration, nodular/nummular, and elephantiasis. PTM was confirmed by biopsy in six patients. The patients' median age was 53.8 years, 75% were female, and all but one patient were either active or former smokers. All patients were euthyroid and had progressed despite various therapies prior to starting these agents. Six patients had a plaque and induration pattern, and two had a nodular pattern with elephantiasis. After therapy, six (75%) patients had PTM stability or improvement both subjectively and objectively (80% with RTX and 66% with IVIg). The three patients (one in the IVIg group and two in the RTX group) who had subjective improvement had a plaque pattern. One patient with elephantiasis had a transient response to IVIg and another had stability after RTX. Thyrotropin receptor antibody values and orbitopathy also improved in patients who demonstrated PTM improvement. No serious adverse events were reported, but one patient each had transient hypertension and injection-site thrombophlebitis after IVIg. Immunomodulation therapy was followed by PTM improvement or stability in most patients, with a slightly better response after RTX compared to IVIg. A validated response assessment instrument and larger series of patients are required to determine if the underlying disease process could be curtailed with these agents.
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http://dx.doi.org/10.1089/thy.2018.0706DOI Listing
May 2019

Cutaneous Eruption Heralding Squamous Cell Carcinoma of the Lung: Challenge.

Am J Dermatopathol 2019 Oct;41(10):e104-e105

Departments of Dermatology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1097/DAD.0000000000001190DOI Listing
October 2019

The prognostic value of inositol polyphosphate 5-phosphatase in cutaneous squamous cell carcinoma.

J Am Acad Dermatol 2019 Mar 22;80(3):626-632.e1. Epub 2018 Oct 22.

Department of Dermatology, Mayo Clinic, Scottsdale, Arizona. Electronic address:

Background: Inositol polyphosphate 5-phosphatase (INPP5A) has been shown to play a role in development and progression of cutaneous squamous cell carcinoma (cSCC). The goal of the current study was to explore the prognostic value of INPP5A expression in cSCC.

Methods: A total of 189 cases of actinic keratosis and SCC in 174 patients were identified; clinical and outcome data were abstracted, histopathology was rereviewed, and immunohistochemical staining and interpretation was performed for INPP5A.

Results: The majority of tumors (89.4%) had an INPP5A score of 2 or 3. No patients had complete loss of INPP5A. Tumors with an INPP5A score of 1 were more likely to be intermediate- to high-risk tumors (Brigham and Women's Hospital stage ≥T2a 85.0% vs 23.7% [P < .0001]) characterized by a larger diameter (2.4 cm vs 1.3 cm [P = .0004]), moderate-to-poor differentiation (86.7% vs 17.6% [P < .0001]), and perineural invasion (37.5% vs 5.3%, [P < .0001]). An INPP5A score of 1 was associated with a worse 3-year survival (a rate of 42.3% [hazard ratio, 2.81, P = .0006]) and a local metastasis rate of 48.0% (hazard ratio, 4.71; P < .0001).

Conclusions: Low INPP5A scores are predictive of aggressive tumors and may be a useful adjunct to guide clinical management of cSCC.
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http://dx.doi.org/10.1016/j.jaad.2018.10.018DOI Listing
March 2019

Follicular Dendritic Cell Sarcoma With Indolent T-Lymphoblastic Proliferation Is Associated With Paraneoplastic Autoimmune Multiorgan Syndrome.

Am J Surg Pathol 2018 12;42(12):1647-1652

Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.

Nonclonal expansions of immature T cells outside of the thymus, termed indolent T-lymphoblastic proliferation (iT-LBP), have been identified in rare lymphoproliferative disorders. We report that iT-LBP is a frequent finding in cases of follicular dendritic cell sarcoma (FDCS), and shows an association with paraneoplastic autoimmune multiorgan syndrome (PAMS). We studied 31 cases of FDCS by paraffin immunohistochemistry using antibodies to CD21, CD23, CD35, clusterin, CXCL13, podoplanin, CD3, CD4, CD8, CD20, CD1a, and TdT. Chart review was performed to characterize the clinical behavior including evidence of autoimmune disease. FDCS occurred in a wide variety of nodal and extranodal sites. Fourteen of 31 (45%) cases contained immature TdT-positive T cells; in 5 cases these cells were numerous and present throughout the tumor. Four of these 5 patients with numerous immature T cells developed autoimmune disease, clinically categorized as PAMS and/or myasthenia gravis. PAMS persisted after tumor resection, causing severe morbidity and mortality. These findings suggest that the neoplastic follicular dendritic cells can recruit or foster the proliferation of immature T cells and that these cells may play a role in mediating PAMS. Recognition of iT-LBP in FDCS is important to avoid misdiagnosis as thymoma or T-lymphoblastic lymphoma, and may predict serious autoimmune complications in some patients.
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http://dx.doi.org/10.1097/PAS.0000000000001158DOI Listing
December 2018

Density and distribution of acral melanocytic nevi and acral melanomas on the plantar surface of the foot.

J Am Acad Dermatol 2019 03 25;80(3):790-792.e2. Epub 2018 Jul 25.

Department of Dermatology, Mayo Clinic, Scottsdale, Arizona. Electronic address:

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http://dx.doi.org/10.1016/j.jaad.2018.07.019DOI Listing
March 2019

Clinical and histopathologic features of paraneoplastic granuloma annulare in association with solid organ malignancies: A case-control study.

J Am Acad Dermatol 2018 Nov 18;79(5):913-920.e1. Epub 2018 Jun 18.

Department of Dermatology, Mayo Clinic Arizona, Scottsdale, Arizona.

Background: Granuloma annulare (GA) is a granulomatous skin eruption rarely associated with cancer. We report seven cases of paraneoplastic GA in association with solid organ malignancy.

Objective: To compare the clinical and histopathological features of paraneoplastic GA to case-matched controls of classic GA.

Methods: Retrospective chart and histopathological review of 7 individuals and 13 age- and sex-matched controls. Paraneoplastic GA was defined as GA occurring within 6 months of the diagnosis of solid organ malignancy and/or persistent GA that resolved with cancer treatment.

Results: Most cases of paraneoplastic GA were associated with lung cancer (4/7). The clinical and histopathological features of paraneoplastic and classic GA were similar. Compared to classic GA, paraneoplastic GA cases were more often generalized disease (6/7 vs 6/13), refractory to treatment, and had a perivascular inflammatory cell infiltrate (5/7 vs 2/13). All cases of paraneoplastic GA that underwent definitive treatment of their cancer improved.

Limitations: Single-institution, retrospective review with a small sample size.

Conclusion: Paraneoplastic GA is rare, similar to classic GA, and refractory to treatment. We advocate for age-appropriate screening in individuals with GA that is nonresponsive to multiple lines of systemic treatment and evaluating patients with concerning signs or symptoms for an underlying neoplasm.
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http://dx.doi.org/10.1016/j.jaad.2018.06.022DOI Listing
November 2018

An effective game-based learning intervention for improving melanoma recognition.

J Am Acad Dermatol 2018 Sep 5;79(3):587-588. Epub 2018 Mar 5.

Department of Dermatology, Mayo Clinic Arizona, Scottsdale, Arizona.

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http://dx.doi.org/10.1016/j.jaad.2018.02.068DOI Listing
September 2018

Dermoscopic features of cutaneous Langerhans cell histiocytosis.

Eur J Dermatol 2018 02;28(1):88-89

Mayo Clinic Arizona, Department of Dermatology, 13400 E Shea Blvd, Scottsdale, Arizona 85259, USA.

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http://dx.doi.org/10.1684/ejd.2017.3153DOI Listing
February 2018

Skin-Limited Graft-versus-Host Disease after Pancreatic Transplantation.

Case Rep Transplant 2017 18;2017:4823870. Epub 2017 Jul 18.

Department of Dermatology, Mayo Clinic, Scottsdale, AZ, USA.

Introduction: The phenomenon of graft-versus-host disease, a solid organ transplant recipient, is a rare development with a very poor prognosis.

Case Presentation: A 40-year-old woman with type 1 diabetes developed cutaneous graft-versus-host disease following second pancreas transplantation.

Conclusion: The development of a nonspecific rash in the early posttransplant period following a pancreas transplant warrants suspicion for graft-versus-host disease.
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http://dx.doi.org/10.1155/2017/4823870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540464PMC
July 2017

Acral Melanoma and Mechanical Stress on the Plantar Surface of the Foot.

N Engl J Med 2017 07;377(4):395-396

Mayo Clinic, Scottsdale, AZ

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http://dx.doi.org/10.1056/NEJMc1706162DOI Listing
July 2017