Dermoscopy structures as predictors of sentinel lymph node positivity in cutaneous melanoma.

BACKGROUND: Histological features such as Breslow thickness, ulceration and mitosis are the main criteria to guide sentinel lymph node biopsy (SLNB) in melanoma. Dermoscopy may add complementary information to these criteria. OBJECTIVES: To evaluate the correlation between dermoscopy structures and SLNB positivity. METHODS: Retrospective analysis of 123 consecutive melanomas with Breslow thickness > 0·75 mm, SLNB performed during follow-up and dermoscopic images. RESULTS: Men were more likely to have a positive SLNB. The presence of ulceration and blotch and the absence of a pigmented network in dermoscopy correlated with positive SLNB. Histological ulceration also correlated with positive SLNB. A dermoscopy SCORE predicted SLN status with a sensitivity of 96·3% and a specificity of 30·2%. When sex and Breslow thickness were added (SCOREBRESEX), the sensitivity remained at 96·3% but the specificity increased to 52·1%. This study is limited by the number of patients and was performed in only one institution. CONCLUSIONS: Dermoscopy allowed a more precise prediction of SLN status. If a combined SCOREBRESEX was used to select patients for SLNB, 41·5% of procedures might be avoided.

Electrochemotherapy in the treatment of melanoma skin metastases: a report on 31 cases.

INTRODUCTION AND OBJECTIVES: Electrochemotherapy is indicated for the treatment of unresectable cutaneous and subcutaneous tumors. The technique involves the synergistic use of electroporation of cell membranes to increase the cytotoxicity of anticancer drugs delivered to the tumor cells. The aim of this study was to analyze the clinical effectiveness and safety of electrochemotherapy in the treatment of unresectable locoregional recurrent or metastatic melanomas. MATERIAL AND METHODS: We studied 31 patients treated between January 2007 and December 2012. The European Standard Operating Procedures of Electrochemotherapy (ESOPE) were applied in all cases. Treatment response was analyzed as overall patient response (mean response based on results for all lesions treated in a given patient). RESULTS: Response was classified as partial in 49% of patients and complete in 23%. At 1 year, the level of response achieved had been maintained in 17 patients. Disease progression was observed in 28% of the series. Immediate local complications (pain, swelling, erythema) were mild and resolved within 48hours in most cases. Eight patients developed subsequent local complications, such as ulcers and secondary infections associated with necrosis of the lesions. These complications were brought under control with topical treatments. CONCLUSIONS: Electrochemotherapy is a very effective, safe, and efficient treatment for advanced locoregional disease in patients with unresectable melanoma lesions.

Ex vivo fluorescence confocal microscopy for fast evaluation of tumour margins during Mohs surgery.

BACKGROUND: Ex vivo fluorescence confocal microscopy (FCM) enables real-time imaging of skin morphology directly in freshly excised tissue. FCM displays wide field-of-view mosaics with cellular resolution, thus enabling a rapid bedside pathology. An application of interest is rapid detection of residual basal cell carcinoma (BCC) in skin excisions during Mohs surgery. OBJECTIVES: We sought to evaluate the sensitivity and specificity of ex vivo imaging with FCM for the detection of residual BCC in Mohs tissue excisions, and to calculate the time invested up to the diagnosis for both FCM and frozen sections. METHODS: Eighty consecutive BCCs were prospectively collected and the margins scanned with ex vivo FCM, including excisions with and without residual BCC of all major subtypes. Each mosaic was divided into two or four, resulting in 480 submosaics for study. Every confocal submosaic was assessed for the presence or absence of BCC and compared with standard frozen sections as the gold standard. Furthermore, the time spent for each technique was calculated and compared. RESULTS: The overall sensitivity and specificity of detecting residual BCC were 88% and 99%, respectively. Moreover, the new technique reduced by almost two-thirds the time invested when compared with the processing of a frozen section (P < 0·001). CONCLUSIONS: The results demonstrate the feasibility of confocal mosaicing microscopy in fresh tissue for rapid surgical pathology, potentially to expedite and guide Mohs surgery with high accuracy. This observation is an important step towards the goal of using real-time surgical pathology for skin tumours.

Desmoplastic melanoma on the nose: electrochemotherapy as an alternative treatment to local advanced disease.

BACKGROUND: Desmoplastic malignant melanoma (DMM) is a rare and usually misdiagnosed type of melanoma. Delayed detection at complicated anatomical locations can lead to the necessity of alternative therapies. OBJECTIVE: Characterization of DMM on the nose, which is the second more frequent type of MM. METHODS: Review of case series of eight pathologically proven DMM on the nose from two referral centres with a mean follow-up of 69 ± 40.5 months. RESULTS: According to a single centre experience, there is a more than 70-fold increased risk of having a DMM on the nose compared with a non-DMM (P < 0.0005, CI99% 16.3-317.3). Clinical and pathological misdiagnoses were frequent, only three of the eight cases were properly diagnosed and treated and indeed they did not experience relapses. Due to non-clinical suspicion and superficial biopsies, three cases were initially pathologically misdiagnosed as basal cell carcinomas and a nevus respectively. Atypical vessels and remnants of pigment on dermoscopy are indicative findings even in non-pigmented cases. Although not significant, the mean disease-free survival differed between cases with a correct initial management (four cases, 66.7 ± 57.3 months) in contrast to improper (four cases, 16.25 ± 18.9 months). Electrochemotherapy achieved a complete local control of disease in two cases unsuitable for surgery. CONCLUSIONS: Use of dermoscopy and correctly selected biopsy of lesions on the face is mandatory to improve early diagnosis of DMM. Improper management of challenging cases implies a more complicated therapy and loco-regional invasion risk. Electrochemotherapy could be a promising therapy in local advanced tumours.

[Neonatal screening of sickle cell disease in the Balearic Islands Autonomous Community. Pilot study in anonymous unrelated population]. / Cribado neonatal de anemia falciforme en la Comunidad Autónoma Balear. Estudio piloto anónimo no relacionado.

INTRODUCTION: Sickle cell disease (SCD) describes a group of inherited disorders caused by the presence of the sickle haemoglobin (HbS) which results from a point mutation affecting codon 6 of the beta globin chain (beta codon 6, Glu 6 Val). The pathophysiology involves polymerisation of HbS under low oxygen conditions causing vaso-occlusion and chronic haemolysis and anaemia. Due to increase in immigrants within our population and the majority of this group being a risk population for different haemoglobinopathies, the aim of our study is to determine the incidence of SCD and others structural haemoglobinopathies in the neonatal population of the Balearic Islands Autonomous Community, by means of an unrelated pilot study and determine the need to include this pathology in a newborn screening program. MATERIAL AND METHODS: The study was performed with the same blood spot specimen dried on filter paper used for congenital hypothyroidism, phenylketonuria and cystic fibrosis screening. High-performance liquid chromatography (HPLC), using the VARIANTs (Biorad) automated system, was used to detect variants haemoglobin variants. RESULTS: The overall incidence was 9.9 per 1000 specimens. The incidence of SCD was 1/6756 (FS) and the incidence of sickle cell traits was 1/199 (FAS). CONCLUSION: These results confirm the need to include screening for SCD and other haemoglobinopathies in our neonatal screening program.

[Annular plaques in the skin folds: 4 cases of lichen planus pigmentosus-inversus]. / Placas anulares en grandes pliegues: cuatro casos de liquen plano pigmentoso-inverso.

We report 4 patients with relatively asymptomatic, annular brownish plaques arising in the skin creases.The lesions had remained stable for months despite many topical treatments. Histological examination revealed an atrophic epidermis with a dermal lichenoid inflammatory infiltrate showing marked pigmentary incontinence.These clinical and pathological features were consistent with lichen planus pigmentosus-inversus,a rare, recently described variant of lichen planus, with only 10 cases reported to date. It has been suggested that he intensity and speed of onset of the inflammatory response could be modulated by keratinocyte surface markers, which could also determine the typical morphology of the lesions of this disease.

[Evaluation of a diagnostic protocol of thyroid dysfunction]. / Valoración de un protocolo diagnóstico de disfunción tiroidea.

OBJECTIVE: To assess a three-stage protocol for the study of thyroid dysfunction. DESIGN: Descriptive and retrospective. SETTING: Primary Care Centres on the island of Mallorca. PATIENTS: 8,818 non-hospital patients without any previous treatment. MEASUREMENTS AND MAIN RESULTS: In the first stage only TSH was determined. In function of its result FT4, considered a confirmation parameter, was proceeded with. Determination of T3 was reserved for the few cases of discrepancy between FT4 and TSH, when the latter was low or suppressed. We studied costs and diagnostic yield and then the possibility of improving the relationship between them by varying the cut-off used in the TSH (< 0.5 or > 4.5 microUI/ml) against the reference values (0.35-5.5 microUI/ml). The results of these two hypotheses were studied, along with a third where the significant difference of the FT4 reference limits was considered. Analytic sensitivity and specificity were acceptable in all cases. Determinations not made because they were inappropriate (FT4 and T3) comprised 45.7% of the requested or "hypothetical" determinations which would have been carried out if the protocol had not been applied, and a year's saving of 3,637,075 pesetas; which would increase by 181,753 pesetas (2.30%) if we changed the TSU cut-off to the reference values. CONCLUSIONS: This study protocol of thyroid dysfunction is adequate, although it could be improved by changing the TSH cut-offs to the reference values.