Background: The use of immunohistochemical (IHC) stains in dermatopathology is commonplace; however, little is known regarding utilization trends in melanoma diagnosis. Current Medicare local coverage determinations (LCDs) state that most pigmented lesions, including melanoma, can be diagnosed using H&E alone.Methods: Histopathology reports for all biopsy-proven melanomas excised between January 1, 2017 and June 30, 2018, at a single dermatology clinic, were identified with the following parameters abstracted: laboratory/dermatopathologist rendering the diagnosis, whether IHC was performed, type/number of stains utilized, presence/depth of invasion, and melanoma subtype. The association of characteristics with IHC utilization was evaluated using χ 2 test for categorical variables.Results: Three hundred and fifty six eligible melanomas were identified. IHC was employed in 228 (64%) of the diagnoses. Invasive melanoma was diagnosed in 199 cases (55.9%) while 157 (44.1%) were identified as melanoma in situ (MIS). Of the 228 that utilized IHC, 117 were performed on invasive melanoma (58.8%) and 111 were performed on MIS (70.7%).Conclusion: Our findings suggest a higher IHC usage for the diagnosis of melanoma than previously reported. Existing LCDs regarding IHC utilization in melanoma do not reflect the current state of practice. Further investigation regarding IHC utilization and the development of appropriate-use criteria for melanoma IHC is necessary. K E Y W O R D Simmunohistochemistry, local coverage determination, melanoma, utilization

The WHO declared coronavirus disease 2019 (COVID-19) a global pandemic in early 2020. As the pandemic has continued to evolve over a period of several months, many cases of unusual presentations are now emerging, which pose a greater challenge for physicians in terms of quickly identifying COVID-19 patients based on initial signs and symptoms. In this report, we present one such unusual presentation in a patient with sudden intraperitoneal hemorrhage and spontaneous splenic rupture with COVID-19 as the likely etiology and contributing factor.The patient was a 75-year-old Caucasian woman who presented to the emergency department (ED) with complaints of severe left-sided abdominal pain for several days without any preceding trauma. A CT of the abdomen/pelvis revealed a large amount of fluid in the abdomen, which raised suspicion of bleeding. An exploratory laparotomy revealed splenic rupture with hemoperitoneum, and the patient subsequently underwent an emergent splenectomy. The patient's COVID-19 antigen test returned positive during the surgery and was subsequently confirmed with a polymerase chain reaction (PCR) test.COVID-19 has been found to result primarily in respiratory symptoms through its ability to invade endothelial cells via angiotensin-converting enzyme 2 affinity. It is speculated that this mechanism may cause a predisposition to micro-thromboses, which can eventually lead to manifestations such as large lymphoid organ thrombosis. Based on this case presentation and the evolving literature on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spontaneous splenic rupture is an emergent differential diagnosis that should be considered in COVID-19 patients presenting with gastrointestinal complaints such as abdominal pain and nausea.

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Purpose Patients with small cell lung cancer (SCLC) who have brain metastases require whole-brain radiation therapy (WBRT). When there is no emergent indication for WBRT, patients may receive systemic therapy first and WBRT afterward. In scenarios when systemic therapy is initiated first, it has not been previously investigated whether delaying WBRT is harmful. Methods and Materials The National Cancer Database was queried (2004-2016) for patients with SCLC with brain metastases who received 30 Gy in 10 fractions of WBRT. Patients were divided into groups based on whether they received early WBRT (3-14 days after initiation of chemotherapy) or late WBRT (15-90 days after initiation of chemotherapy). Demographic and clinicopathologic categorical variables were compared between those who had early WBRT (3-14 days) and those who had late WBRT (15-90 days). Factors predictive for late WBRT were determined. Overall survival (OS), which was defined as days from diagnosis to death, was evaluated and variables prognostic for OS were determined. Results A total of 1082 patients met selection criteria; 587 (54%) had early WBRT and 495 (46%) received late WBRT. Groups were similarly distributed aside from days from initiating chemotherapy to initiating WBRT ( P < .001). The early WBRT group had a median of 7 days (interquartile range [IQR], 5-10 days) from initiating chemotherapy to initiating WBRT and the late WBRT group had a median of 34 days (IQR, 21-57 days). On binary logistic regression analysis, a longer time interval between diagnosis and the start of systemic therapy was predictive for later WBRT. Median OS was 8.7 months for early WBRT and 7.5 months for late WBRT (hazard ratio [HR], 1.165; P = .008). Early WBRT ( P = .02), female sex ( P = .045), and private insurance ( P = .04) were favorable prognostic factors for OS on multivariable analysis, whereas older age ( P = .006) was an unfavorable prognostic factor. Conclusions Patients with SCLC and brain metastases who received early WBRT were found to have a modest improvement in OS compared with patients who received late WBRT. These findings suggest that early WBRT should be offered to patients who have brain metastases, even in the absence of an indication for emergent WBRT.

Pagetoid reticulosis is a rare form of cutaneous T cell lymphoma, a malignancy of T lymphocytes, that invades the skin leading to a multitude of dermatologic manifestations. Pagetoid reticulosis commonly presents as a localized slow-growing or indolently manifesting hyperkeratotic patch/plaque on the extremities that is confined to the epidermis. Diagnosis is confirmed via a skin biopsy of the affected area followed by a cytologic examination. Treatment typically entails topical corticosteroids, alkylating agents, and retinoids. With disseminated disease, a multidisciplinary approach involving chemotherapy and radiation is necessary. To raise awareness about pagetoid reticulosis, its diagnosis, and management, we report a case localized to the left forehead and earlobe of a 57-year-old female.

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