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.

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.

Hormones, nevi, and melanoma: an approach to the patient

For many years, clinicians have been concerned about a potential adverse effect of pregnancy-associated hormones and exogenous hormones on melanocytic nevi and malignant melanoma. Today, these issues are more significant as women have delayed childbearing into their 30's and 40's, and the likelihood of diagnosis with melanoma during pregnancy is enhanced. More recent clinical, epidemiologic, and laboratory studies have shed some light on the relationship among hormones, nevi, and melanoma in pregnancy.

Dermatologic diseases of the breast and nipple.

Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.

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.

Unusual presentation of a Merkel cell carcinoma.

Merkel cell carcinoma (MCC) is an uncommon, potentially lethal, cutaneous tumor that mainly occurs in sun-exposed skin of the head and neck area of the elderly. We report a case of MCC presenting as a 2-mm crusted erosion on the nose of an elderly patient, the smallest MCC reported thus far in the literature. The optimal management of MCC has not been clearly established. In view of its high local recurrence rate, predilection to metastasis, and significant mortality, aggressive treatment has been advocated. Identification of this tumor at such a small size posed a management dilemma because of lack of prospective treatment data involving biologic markers of prognostic significance for MCC.

The misdiagnosis of malignant melanoma.

Despite the increasing awareness of malignant melanoma over the last 40 years, clinical diagnostic accuracy remains disappointing. Malignant melanoma can masquerade clinically as benign lesions (false negatives), and benign pigmented lesions can clinically simulate malignant melanoma (false positives). Histologic examination of pigmented lesions is therefore important to ensure proper diagnosis and treatment. We review many of the published reports of benign lesions mimicking melanoma and melanoma masquerading as other entities as well as present additional cases of clinical misdiagnoses of melanoma.

Diagnosis: alopecia areata or not?

Alopecia areata is a common cause of hair loss in children and adults. In most cases, the diagnosis is straight forward and is easily made based on the patient's history and clinical presentation. However, in two specific scenarios, the diagnosis can be difficult and may require a scalp biopsy. We present four cases that illustrate these two problematic differentials: alopecia areata versus trichotillomania in adolescent females; and diffuse alopecia areata versus telogen effluvium versus androgenetic alopecia in adult women. Tables compare and contrast the clinical and histopathologic features of these nonscarring localized and diffuse alopecias.

Histopathology of an adverse reaction to a eutectic mixture of the local anesthetics lidocaine and prilocaine.

A unique histopathologic reaction to the topical application of a eutectic mixture of the local anesthetics lidocaine and prilocaine (EMLA), used for topical anesthesia prior to biopsy in two children is described. Standard application of EMLA cream under occlusion for 1 h was given to both patients. The biopsies in both cases demonstrate focal vacuolization of the upper spinous and granular layers. The epidermis was focally separated from the dermis in areas of basal vacuolar alteration. Electron microscopy performed in one case demonstrated the dermal-epidermal cleft to be secondary to alteration of the basal cells with condensation of the cytoplasm and cytologic degeneration similar to that seen in epidermolysis bullosa simplex.

Mucocutaneous reactions to chemotherapy.

UNLABELLED: Chemotherapeutic agents are a widely used treatment modality. Side effects range from common to unusual and may be confused with other cutaneous sequelae of oncologic treatment. The goal of this communication is to elaborate on previous descriptions of the cutaneous manifestations of chemotherapeutic treatment and to discuss more recent findings. LEARNING OBJECTIVE: At the conclusion of this learning activity, participants should be able to generate a differential diagnosis of possible etiologies for varying patterns of cutaneous involvement in patients receiving chemotherapy and identify the various cutaneous side effects of chemotherapeutic treatment. In addition, they should be able to distinguish life-threatening side effects that require immediate management from more benign manifestations of chemotherapeutic treatment.

The relationship of pregnancy, hormones, and melanoma.

There has been considerable interest in the relationship of pregnancy and melanoma. Since 1951, a number of case reports have suggested that pregnancy may induce or exacerbate melanoma. Likewise, there has been concern over the relationship between exposure to oral contraceptives (OCs) or hormone replacement therapy (HRT) and possible increased risk of melanoma. We critically reviewed: (1) controlled clinical trials to assess the effect of pregnancy on the prognosis of melanoma; and (2) epidemiological data to evaluate the risk of melanoma after exposure to OCs or HRT. Pregnancy before, during, or after the diagnosis of melanoma does not appear to influence 5-year survival rates. Exposure to OCs or HRT does not appear to increase the risk of melanoma.