Real-time mobile teledermoscopy for skin cancer screening targeting an agricultural population: an experiment on 289 patients in France.

BACKGROUND: The incidence of skin cancer has reached epidemic proportions in the white population and is significantly elevated in agricultural populations, who are exposed to ultraviolet radiation during their professional activities. In 2014, the Agricultural Social Insurance Mutual Benefit Fund (MSA) offered its customers who work in agriculture and live in rural areas with reduced access to dermatologists the ability to participate in a 1-day teledermoscopic (TDS) screening event. OBJECTIVE: This study's aim was to assess the feasibility of real-time mobile TDS triage of a large number of agricultural workers by trained medical officers and occupational physicians. METHODS: Fifteen TDS screening centres were located in different areas of France. Individuals older than 18 years who worked in agriculture and lived in rural area near a TDS screening centre were invited to participate in a 1-day screening event and were examined by an MSA physician. In cases of suspicious skin lesions, clinical and dermoscopic images were obtained and transferred immediately to four dermatologists who were simultaneously present at the tele-platform for diagnosis and decision-making. Low-quality images were retaken. RESULTS: Two-hundred eighty-nine patients underwent skin cancer screening. Among 199 patients (69%), 390 suspicious lesions were identified and generated 412 pictures. All lesions were analysed by dermatologists. For 105 patients (53%), no follow-up was required. Seventeen patients were referred to local dermatologists for rapid examination, including 12 cases of suspected malignant melanocytic lesions. Among the 12 patients with suspected melanoma, face-to-face visits were conducted within 10 days for 11 of them, and 1 case of melanoma was confirmed by histopathology. CONCLUSIONS: Our study suggests that teledermoscopy performed in the context of occupational medicine and targeted to agricultural populations is feasible and could be useful for improving skin cancer screening in at-risk populations while avoiding face-to-face examinations by a dermatologist in 53% of cases.

[Feasibility and technical problems of sentinel node analysis in melanoma]. / Analyse du ganglion sentinelle au cours du mélanome. Etude de faisabilité et problèmes techniques rencontrés: à propos de 97 cas.

BACKGROUND: Development of the sentinel lymph node (SLN) biopsy the last 10 years has changed surgical approach of solid tumor treatment and particularly of melanoma. The aim of our study was to analyze in our hospital, the feasibility of the SLN biopsy technique in order to define a better prognostic classification of melanomas. PATIENTS AND METHODS: Between July 1999 and October 2003, 97 patients were included in this study in our center. Criteria for inclusion were cutaneo-mucosal melanoma of Breslow >or=1,5 mm, and/or Clarck >or=IV, and/or ulceration, and/or signs of regression, before any surgical margins. RESULTS: Lymphoscintigraphy (LS) identified at least 1 SLN in 94 cases/97 (97%), thus permitting intraoperative SLN mapping and sentinel node biopsy of at least 1 lymph node in 88 cases/94 (94%). Failure of the SLN procedure was noted in 9 cases: in 3 cases, no lymph node was individualized by LS, in 1 patient, intraoperative SLN mapping failed to find the previously identified SLN and in 5 cases, a SLN was identified by LS and intraoperative mapping but could not be removed because of its deep location and difficulty of dissection. In 17 patients, removal of one or two "non sentinel lymph node(s)" was (were) made by the surgeon because of its (their) suspected aspect (black or large). Among the 88 patients who had dissection of at least 1 SLN, a micrometastasis was detected by standard histological evaluation and/or immunohistochemical stains in 14 cases (16%) and into a "non SLN" in 2 cases (2,3%). The median follow up of patients was 16 months (1- 48 months). Among the 14 patients with positive SLN, 6 (43%) relapsed. The other eight were in complete remission of their melanoma with a mean follow up of 11,44 months . Among the 74 patients with negative SLN, 7 (9,5%) developed a recurrence. Among the 9 patients in whom any sentinel lymph node have been removed, 3 had a relapse (one in transit than on lymph nodes, and two on lymph nodes). CONCLUSION: Our results are in accordance with the literature, and confirm the feasibility of SLN mapping and of SLN histological analysis in our center. We described in this study technical problems we encountered. Our study also show the prognostic value of this technique. However, advantage in global survey of sentinel node dissection and regional lymph node dissection in cases of micrometastases has still to be demonstrated.

Germline mutations of the INK4a-ARF gene in patients with suspected genetic predisposition to melanoma.

Germline anomalies of the INK4a-ARF and Cdk4 genes were sought in a series of 89 patients suspected of having a genetic predisposition to melanoma. Patients were selected based on the following criteria: (a) familial melanoma (23 cases), (b) multiple primary melanoma (MPM; 18 cases), (c) melanoma and additional unrelated cancers (13 cases), (d) age at diagnosis less than 25 years (21 cases), and (e) nonphoto-induced melanoma (NPIM; 14 cases). Mutations of INK4a-ARF and Cdk4 were characterised by automated sequencing, and germline deletions of INK4a-ARF were also examined by real-time quantitative PCR. Seven germline changes of INK4a-ARF, five of which were novel, were found in seven patients (8%). Four were very likely to be pathogenic mutations and were found in three high-risk melanoma families and in a patient who had a pancreatic carcinoma in addition to melanoma. Three variants of uncertain significance were detected in one MPM patient, one patient <25 years, and one NPIM patient. No germline deletion of INK4a-ARF was found in 71 patients, and no Cdk4 mutation was observed in the 89 patients. This study confirms that INK4a-ARF mutations are infrequent outside stringent familial criteria, and that germline INK4a-ARF deletions are rarely involved in genetic predisposition to melanoma.

[The value of radiological follow-up for stage III melanoma]. / Intérêt du suivi radiologique pour les mélanomes au stade III.

INTRODUCTION: The modalities of follow-up (frequency of consultations and interest of repeated radiological examinations) of patients presenting with glandular metastases of melanoma (stage III of the AJCC classification) have not reached a consensus. PATIENTS AND METHODS: Since 1995, we have proposed clinical follow-up every two months and radiological controls with a thoracic-abdominal-pelvic scan every 4 months, to patients at high risk of relapse for the early screening of an infra-clinical relapse. RESULTS: The median follow-up was of 16 months (range: 1 to 82 months). Eight patients out of 24 (33 p. 100) followed-up in this manner, had asymptomatic metastases discovered by the radiological examinations. Among these 8 patients, three presented with a an operable, single, metastatic localization and two patients underwent surgery. One patient relapsed 3 months later, the other was still alive without relapse 24 months later. DISCUSSION: Surgery remains the treatment of choice for all stages of melanoma. In the absence of clearly effective treatment of metastatic melanoma, the early discovery of an infra-clinical metastatic relapse presents two major advantages. The first is the discovery of a single, operable metastasis, as was the case in two of the patients out of 24. The second is to be able to suspend an eventual adjuvant therapy with interferon alpha, as soon as a relapse has been discovered.

Development of metastases in malignant melanoma is associated with an increase in the plasma L-dopa/L-tyrosine ratio.

In this prospective study we evaluated a new biochemical approach in which the plasma ratio of the melanin precursors L-dopa and L-tyrosine serves as a marker of metastatic dissemination in malignant melanoma. Control values (11.20 x 10(-5) +/- 2.92 x 10(-5)) were determined. The L-dopa/L-tyrosine ratio was evaluated in the plasma of 90 patients with malignant melanoma (stage I/II, n = 33; stage III, n = 33; stage IV, n = 24) classified according to the tumour/node/metastasis (pTNM) classification. A total of 106 samples were studied. Serial measurements were performed in eight stage III-IV patients. The L-dopa/L-tyrosine ratio was significantly elevated in melanoma patients with clinical stage III (15.23 x 10(-5) +/- 3.34 x 10(-5)) compared with stage I (10.88 x 10(-5) +/- 2.52 x 10(-5)). Stage IV patients showed a significant increase in the plasma L-dopa/L-tyrosine ratio (45.73 x 10(-5) +/- 61.75 x 10(-5)) compared with the other groups. The ratio was higher for those with two rather than one metastatic site and markedly higher for those with widespread metastases. The development of metastases was associated with an increase in plasma L-dopa, a decrease in plasma L-tyrosine and a significant increase in the plasma L-dopa/L-tyrosine ratio. These data suggest that the plasma L-dopa/L-tyrosine ratio reflects the tumour burden and correlates with the progression of malignant melanoma.

Prospective study of the incidence of melanoma in the Paris region in 1994. The PETRI Melanoma Group.

The aim of this study was to estimate the incidence of melanoma in the Paris region in 1994 and analyse the main clinical and histological characteristics of these lesions. It took the form of a prospective inquiry, mailed to public and private pathology laboratories, to count as accurately as possible the number of new cases diagnosed by pathologists in the region during the 1994 calendar year. In all, 1089 newly diagnosed Clark level I to V melanomas (excluding precancerous melanosis of Dubreuilh) were studied. Parameters recorded included age, sex, Clark level and Breslow's thickness. The incidence per 100,000 inhabitants was 9.93 for melanoma and 8.62 for invasive melanoma. The female to male ratio was 1.6. Clark level I or thin (< 0.75 mm) melanomas represented 64.8% of the lesions. At the time of diagnosis, the females were significantly younger than the males (P = 0.004). Breslow's thickness increased with age and was significantly lower in women (P = 0.00005), especially those between 40 and 49 years old. The incidence of melanoma in the Paris region in 1994 was close to that observed during the preceding 5 years in England, Scotland and the French department of Haut-Rhin. It was 2.32 times higher for males and 1.69 times higher for females than the rates estimated for France for the period 1978-1982.

[Delay in diagnosing melanoma. A prospective study in 102 patients]. / Délai de diagnostic du mélanome. Etude prospective chez 102 malades.

INTRODUCTION: Knowledge of the causes of melanoma and reasons for diagnosis delay is essential for early management. PATIENTS AND METHODS: One hundred two patients consulting for melanoma at the Saint-Louis Hospital in Paris from January 1, 1994 to December 31, 1995 were asked to respond to a standardized questionnaire. Time to diagnosis and the different time fractions were analyzed by socio-demographic characteristics and by pathology features. RESULTS: Meantime from the first signs of a new lesion or modification of an old lesion to exeresis of melanoma was 20.4 months. Most of the delay prior to diagnosis was patient-related; lack of knowledge about the early clinical signs of melanoma appeared to be the most important cause of delay. Time to diagnosis was not significantly correlated to the thickness of the melanoma. DISCUSSION: Our results are compared with two similar series reported in other countries during the last ten years. The lack of correlation between the thickness of the melanoma and time to diagnosis appears to be explained, at least in part, by the biological variability of melanomas.

Ivermectin-responsive crusted scabies in HTLV1 carrier.

We report a case of HTLV1 infection revealed by crusted scabies and widespread dermatophytosis in an African woman. HTLV1 infection was not complicated by adult T cell leukemia or myelopathy. Crusted scabies is a marker of HTLV1 infection. The importance of oral ivermectin therapy in crusted scabies is emphasized.

Cutaneous T-cell lymphoma associated with granulomatous slack skin.

Granulomatous slack skin disease (GSS) is a rare disorder characterized by bulky cutaneous lesions and epithelioid and giant cell granulomas with destruction of the dermal elastic tissue. We detail the observation of a 29-year-old man with clinical and histological features of GSS. Pendulous skin tumors were associated with typical clinical and immunohistochemical aspects of mycosis fungoides and with clonal rearrangement of the V gamma T-cell receptor gene in lesional skin. This case report supports cutaneous T-cell lymphoma as a cause of GSS.

[Bone marrow autograft in the treatment of cutaneous lymphoma]. / Autogreffe de moelle osseuse dans le traitement des lymphomes cutanés.

INTRODUCTION: The prognosis of advanced stage or high grade cutaneous lymphomas is very poor in case of recurrence after conventional polychemotherapy. Recent studies have confirmed the importance of intensified treatment with autologous bone marrow transplantation in case of recurrence. We used this method in patients with a cutaneous lymphoma with poor prognosis. PATIENTS AND METHODS: Seven patients with a high-grade or disseminated cutaneous lymphoma were given an autologous bone marrow graft in case of recurrence after one or more polychemotherapy protocols. In 4 patients, treatment included total body irradiation and high-dose chemotherapy (cyclophosphamide/etoposide, or aracytine/melphalan) and in the 3 others chemotherapy alone (BEAM or BEAC) was used prior to transplantation. RESULTS: Two complete remissions of 46 and 34 months duration after graft were achieved without complementary treatment. One patient had partial remission. Recurrence was observed in 2 patients 5 months after the graft and in 1 other 30 months later. Prolonged complete remission was observed in patients given total body irradiation and the early recurrences in those given chemotherapy alone. DISCUSSION: This pilot study demonstrates that patients with a poor prognosis cutaneous lymphoma can achieve prolonged complete remission by therapy intensification using autologous bone marrow transplantation after total body irradiation.

[Aggressive cutaneous T-cell lymphoma associated with the presence of Epstein-Barr virus. 2 cases]. / Lymphome T cutané agressif associé à la présence de virus Epstein-Barr. Deux cas.

INTRODUCTION: The factors of prognosis of the cutaneous T-cell lymphomas are less well known as those of the B-cell lymphomas and the role of the Epstein-Barr virus (EBV) is not yet definitively evaluated. CASE REPORTS: Two male patients aged 62 and 82 years had a mycosis fungoides with a lethal outcome. The first patient had mutilating facial tumors; the RNA m of EBV and the genome of EBV were demonstrated in the diseased skin. The second patient had an erythrodermic course with enlarged peripheral lymph nodes and circulating Sézary's cells; the genome of EBV was demonstrated by PCR in the diseased skin. DISCUSSION: The role of the EBV has already been demonstrated in peripheral aggressive T-cell lymphomas. In the mycosis fungoides, the EBV is associated with the lesions in 0 to 32 p. cent according to the published series. EBV associated T-cell lymphomas have a poor survival rate and the EBV infection may be associated with the expression of the multidrug resistant gene-1 (MDR-1) and the risk of a terminal hemophagocytosis. In our both patients the presence of the EBV in the lymphocytes of the skin lesions is also an argument in favour of the pathogenic role of the virus.