Melanoma and pregnancy.

Herein we analyze three important issues concerning melanoma and pregnancy: 1) While initial case reports and case series predicted a grim prognosis for the woman diagnosed with melanoma during pregnancy, we summarize more recent controlled studies that suggest that pregnancy has no effect on survival in women diagnosed with localized cutaneous melanoma. 2) We review the prognosis for the fetus when a woman is diagnosed with melanoma during pregnancy. While melanoma is the most common malignancy to metastasize to the placenta, metastatic melanoma to the fetus appears to be a rare event. 3) How do we answer questions about future pregnancies and hormonal therapy when counseling women who have been diagnosed with melanoma during pregnancy or the childbearing years? Will future pregnancies worsen prognosis? Based on limited data, pregnancies subsequent to a diagnosis of localized melanoma do not appear to impact prognosis. Are oral contraceptive pills or hormonal replacement therapy contraindicated in these women? Strong epidemiologic evidence suggests that exposure to oral contraceptive pills do not increase the risk for melanoma. Although only a small number of studies have addressed the risk of hormone replacement therapy, the reports demonstrate that this also does not appear to enhance the risk for developing melanoma.

A deep look into thin melanomas: What's new for the clinician and the impact on the patient.

Melanoma incidence and mortality are on the rise and although most new cases of melanoma are thin, a significant percentage of these patients still experience disease progression. The American Joint Committee on Cancer publishes staging criteria for melanoma, which were recently updated to the 8th edition. The most significant revision from the 7th edition affects the T1b classification, which now includes melanomas with a Breslow depth of 0.8 mm to 1.0 mm. The second major revision eliminates mitoses as a criterion to upstage a thin melanoma to T1b. Although mitotic figures have been established as an independent prognostic factor, they do not have a significant correlation with sentinel lymph node (SLN) biopsy positivity. SLN status remains the most important independent prognostic factor in thin melanomas. Nonetheless, the identification of patients who are at the highest risk for having a positive SLN test result remains difficult. Importantly, a positive SLN test result has high positive predictive value, but a negative one has very low negative predictive value. Since there is no proven survival benefit in performing an SLN biopsy in T1 disease, dermatologists need to have a personalized discussion with patients with thin melanomas to review expected risks and benefits before undertaking this procedure.

Skin cancer knowledge, attitudes, beliefs, and prevention practices among medical students: A systematic search and literature review.

BACKGROUND: As future physicians, medical students will play an important role in the prevention of skin cancers by becoming directly involved in skin cancer prevention education and counseling patients about the hazards of ultraviolet light. OBJECTIVE: We assessed the skin cancer-related knowledge, attitudes, beliefs, and prevention practices reported in previous studies of medical students. METHODS: The search for relevant articles was performed in four electronic databases: PubMed (Medline), Cumulative Index to Nursing and Allied Health, ERIC, and PsycINFO. Studies were included if they met the following criteria: 1) targeted medical students; 2) assessed sun avoidance, sun protection, skin self-examination, and/or indoor tanning behaviors; 3) were published in peer-reviewed journals; and 4) complete data were available for extraction. RESULTS: A total of 21 studies are included in this review. Important findings include moderate-to-high levels of skin cancer knowledge and low levels of both sunscreen and ultraviolet light knowledge. The attitudes and knowledge of medical students reflect a low level of concern with regard to the perceived importance of skin cancer compared with other forms of cancer despite a high level of concern for the importance of skin cancer prevention. Furthermore, this review demonstrated that medical students fail to protect themselves routinely from the sun and have a high interest in tanning bed use. CONCLUSION: This review demonstrates the need to educate medical students about skin cancer and skin cancer preventive behaviors. New strategies and educational campaigns should be developed to communicate better information on skin cancer morbidity, mortality, and prevention to medical students. This will pay dividends by improving the practice of these future physicians in all specialties.

Pregnancy and the prognosis of malignant melanoma.

The influence of pregnancy on the prognosis of malignant melanoma (MM) is unclear. Since 1951, a number of case reports have suggested that pregnancy may have an adverse effect on the clinical course of MM. We reviewed the literature on pregnancy and MM and focused on the well-controlled studies. Based on a limited number of controlled trials, pregnancy before, after, or during the time of diagnosis of stage 1 MM does not appear to affect survival. However, these data should be interpreted with caution because the duration of follow-up and number of patients may not be sufficient to observe a true effect.

Erythroderma with spongiotic dermatitis. Association with common variable hypogammaglobulinemia.

Two middle-aged men presented with generalized erythroderma, diffuse alopecia, and hyperkeratosis of the palms and soles. Histopathologic study demonstrated spongiosis (epidermal intercellular edema) with a perivascular lymphohistiocytic infiltrate. Complete immunologic evaluation demonstrated that both patients had panhypogammaglobulinemia and markedly depressed in vitro pokeweed mitogen-induced immunoglobulin secretion. One of the patients also showed poor lymphocyte responses in vitro to T cell mitogens and antigens and had a decreased ratio of helper to suppressor cells. In both patients, the cutaneous lesions improved with systemic corticosteroids, but no significant alteration in the immunologic abnormalities was observed. This report illustrates that chronic erythroderma may be the presenting clinical manifestation of common variable hypogammaglobulinemia.

Non-oral pyogenic granuloma in pregnancy: a report of two cases.

BACKGROUND: Pyogenic granulomas are benign vascular lesions of the skin or mucous membranes. Oral lesions are believed to occur in up to 2% of pregnancies. To the best of our knowledge, non-oral lesions in pregnancy have not been reported in the obstetric literature. CASES: We report two cases of non-oral pyogenic granuloma in pregnancy. The first, involving a finger lesion in a woman with triplets, demonstrated rapid growth and recurred after surgical excision. The second was an inguinal crease lesion, which was excised successfully after becoming symptomatic. CONCLUSION: Clinical experience suggests that the prevalence of pyogenic granulomas in pregnancy is not as high as has been reported in the literature. The relation of non-oral lesions to pregnancy is unknown.

Cutaneous B-cell lymphoma. An unusual presentation.

A patient presented with the clinical and some of the histopathologic findings consistent with a cutaneous T-cell lymphoma. Immunophenotyping, however, clearly demonstrated the B-cell nature of the proliferation. This report emphasizes the importance of immunophenotyping in these lesions, particularly since only these studies can definitely characterize these proliferations. Of greater importance is that therapy, clinical course, and prognosis will vary according to the true nature of the lymphoma. The differential diagnosis of pseudolymphoma, B-cell lymphoma, and T-cell lymphoma is also discussed.

Neutrophilic spongiosis in pemphigus.

BACKGROUND: Acantholysis is the histologic hallmark in the diagnosis of all forms of pemphigus. However, biopsy specimens of early lesions may lack acantholysis and show only eosinophils in the epidermis in areas of spongiosis (eosinophilic spongiosis). We report two cases of pemphigus foliaceus and two cases of unclassified pemphigus (foliaceus vs vulgaris) in which neutrophilic spongiosis was the prominent histologic finding. OBSERVATIONS: Four patients developed blistering skin disorders that spared the mucous membranes. Skin biopsy specimens in all four patients showed striking infiltration of neutrophils into the epidermis. Acantholysis was focal and was absent in some sections. Direct immunofluorescence demonstrated intercellular deposition of IgG and C3 within the epidermis in all cases. There was no IgA deposition. Gram's stains were negative for bacteria in three cases and revealed Gram-positive cocci overlying an eroded area in one case. However, the neutrophilic spongiosis in this case extended well beyond the area of impetiginization. CONCLUSIONS: The histologic differential diagnosis of neutrophils in the epidermis includes pustular psoriasis, subcorneal pustular dermatosis, intraepidermal neutrophilic IgA dermatosis, superficial IgA pemphigus, toxic shock syndrome, Sweet's syndrome, and superficial fungal and bacterial infections. We conclude that pemphigus be added to this differential diagnosis and recommend direct immunofluorescence when neutrophilic spongiosis is observed.

Basosquamous cell carcinoma with leptomeningeal carcinomatosis.

A basal cell carcinoma with prominent focal squamous differentiation of the right nasolabial fold resulted in leptomeningeal carcinomatosis, despite appropriate surgical excision of the primary lesion. The controversy surrounding the origin, diagnosis, and prognosis of a basal cell carcinoma with squamous differentiation is reviewed. Potential routes of metastasis leading to the subsequent leptomeningeal carcinomatosis are discussed.

Extensive calcinosis cutis with systemic lupus erythematosus.

Calcinosis cutis is a common clinical feature of dermatomyositis and scleroderma but is only rarely reported in association with systemic lupus erythematosus (SLE). We describe three patients with long-standing systemic lupus erythematosus in whom extensive calcinosis cutis developed. We identify characteristics our patients share in common with 23 previously described patients.

Issues confronting medicine.

Our representatives in Washington are attempting to deceive the American public with a giant prevarication. The electorate is being told that more patients can obtain better health care at a lower cost. The practicing dermatologist is caught between opposing forces that are demanding improved care in the face of dwindling reimbursements. Concomitantly, the inexorable forces and constraints of escalating office overhead, tort liability, bureaucratic red tape, and managed competition hang like a sword of Damocles over the head of the practicing dermatologist. The independent practitioner stands alone as the only advocate for his patient; however, the physician's plea to maintain the sanctity and dignity of the doctor-patient relationship is being sacrificed on the altar of cost containment.

Significant melanocytic lesions in infancy, childhood, and adolescence.

Malignant melanoma is diagnosed yearly in approximately 300 persons under age 20 in the United States. Relatively recent advances in dermatology include the recognition of lesions felt to be potential precursors of malignant melanoma. Small congenital melanocytic nevi, present in 1 per cent of all newborn infants, may have a small but definite potential for developing malignant melanoma. Furthermore, despite inconclusive data, many leading dermatologists now advocate removal of these small congenital lesions. Giant congenital melanocytic nevi, with their strong predilection for undergoing malignant change, are removed surgically at an early age, often in multistaged procedures. Dermabrasion, once felt to have a role in the treatment of giant congenital nevi, does not remove the malignant potential of these lesions. The dysplastic nevus syndrome, recognized in 1976, identifies individuals at increased risk for developing melanoma. Adolescents who have the dysplastic nevus syndrome or who are members of families with the syndrome require close medical supervision and patient education. The benign Spitz nevus, with its histologic similarity to malignant melanoma, continues to challenge the dermatopathologist and clinician. These lesions--the Spitz nevus, dysplastic nevus, congenital melanocytic nevus, and malignant melanoma--must all be actively considered when regarding the many other benign melanocytic lesions found in infancy, childhood, and adolescence.

Major issues confronting the practicing dermatologist in the 1990s.

Protein issues confront the dermatologic practitioner in this last decade of the twentieth century, including 1) the role of managed care; 2) the decline of direct access to the specialist; 3) malpractice liability and the need for reform; 4) declining reimbursements in the face of escalating practice overhead; and 5) conflict between the individual's right to care and society's ability to subsidize that right. Correcting and improving the American health care system demands a return to the emphasis and values that made that system the envy of the entire world. We must re-emphasize the sanctity of the doctor-patient relationship, halt the incursion upon physician autonomy, and eliminate those third party factors such as insurance companies, bureaucrats, and administrators that accentuate commerce instead of compassion in medicine. It is hoped that by expanding and equalizing the American health care system, it is not made unpalatable and unresponsive to every citizen.

Human ocular anatomy.

An understanding of the anatomy of the eye is the sine qua non for an appreciation of the pathophysiology of ocular disease. This introductory article is a brief review and elucidation of the pertinent aspects of ocular anatomy. Also included is a glossary of opthalmologic terms that may help clarify some of the more esoteric terminology as the reader peruses the various articles in this issue.

Erythroderma.

Erythroderma can be caused by a variety of underlying dermatoses, infections, and systemic diseases. Many of the findings on history, physical examination, and laboratory evaluation are nondiagnostic. Distinctive clinical and laboratory features pointing to a specific disease may be evident, however. Conclusive clinicopathologic correlation may require multiple and repeated skin biopsies. The prognosis of erythroderma has improved with the advent of innovative dermatologic therapies (e.g., cyclosporine and synthetic retinoids) and advances in the management of systemic manifestations. Death from sepsis, cardiac failure, adult respiratory distress syndrome, and capillary leak syndrome continue to be rarely reported. A high index of suspicion for these complications must be maintained to facilitate early medical intervention.

Ocular and cutaneous manifestations of heritable disorders of collagen and elastic tissue.

Ocular and cutaneous stigmata are hallmarks of the heritable disorders of collagen and elastic tissue. Awareness of the oculocutaneous features is essential both to aid diagnosis and to direct management of affected patients. Although the angioid streaks of PXE, blue sclerae of OI, ocular fragility of EDS and ectopia lentis of Marfan syndrome are the best-known ocular signs of these disorders, other relevant ophthalmologic symptoms often accompany such classic findings.

Antimalarial agents and the eye.

Antimalarial compounds have been demonstrated to be both safe and efficacious in the treatment of lupus erythematosus as well as several other dermatologic conditions. It is imperative, however, that physicians familiarize themselves with the potential complications associated with the use of these agents. Furthermore, it is essential that a successful collaborative relationship be developed between the dermatologist and the ophthalmologist who are to treat and monitor the patient to avoid any untoward complications that might afflict the patient. It is important to stress that patients on antimalarial drug therapy be evaluated by an ophthalmologist prior to starting treatment and every 4 to 6 months thereafter. The use of Amsler's grids in compliant patients is recommended. If the patient develops retinal changes consistent with the diagnosis of premaculopathy, then careful consideration should be given to the availability and use of alternative agents.

Important melanocytic lesions in childhood and adolescence.

Melanocytic nevi are common in children and adolescents, and the preponderance of these lesions are benign. Congenital melanocytic nevi, dysplastic nevi, and large numbers of common acquired nevi, however, may indicate an increased risk of malignant melanoma. With the exception, possibly, of giant congenital nevi, melanoma associated with these lesions generally occurs in adulthood. Nonetheless, some patients can be identified as being at increased risk for the development of melanoma during childhood. The poor prognosis associated with advanced melanoma and the curability of early lesions underscore the importance of prompt recognition of melanoma when it does occur in children. Furthermore, physicians who care for children are in a key position to decrease risk of melanoma throughout the lifespan by encouraging avoidance of excessive sun exposure during childhood.