Leishmaniasis cutánea agresiva en paciente con esclerosis múltiple tratada con fingolimod / Aggressive cutaneous leishmaniasis in a patient with multiple sclerosis treated with fingolimod

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Evaluación del coste económico de la técnica de la biopsia selectiva del ganglio centinela en melanoma / Cost Analysis of Sentinel Lymph Node Biopsy in Melanoma

INTRODUCCIÓN Y OBJETIVO: La técnica de la biopsia selectiva del ganglio centinela (BSGC) es la mejor herramienta para la estadificación ganglionar en el melanoma, permitiendo la realización de una linfadenectomía selectiva, es decir, reservada solo a aquellos pacientes que muestran el GC positivo para metástasis. Nuestro objetivo fue evaluar el coste económico de la técnica de la BSGC, ya que se ha convertido en el procedimiento recomendado como estándar en la atención al paciente con melanoma, y es necesaria para la inclusión de los pacientes en los ensayos clínicos. Existe además escasa bibliografía en nuestro medio sobre su relevancia económica. MÉTODO: De forma prospectiva se recogieron 100 pacientes a los que se realizó la técnica entre los años 2007-2010 con un procesamiento histológico transhiliar bivalvo multisecciones. Realizamos un cálculo aproximado del precio de la técnica utilizando las tarifas de precios oficiales de la Región de Murcia. RESULTADOS: El porcentaje de positividad de nuestra serie fue del 20%, con un número medio de ganglios de 1,96 y un 44% de melanomas delgados. El precio total de la técnica es de 9.486,57- 10.471,29 euros, siendo una parte muy importante de la misma atribuible al procesamiento histopatológico (5.769,36 euros). DISCUSIÓN: La técnica de la BSGC tiene un precio muy considerable, aunque en consonancia con otras referencias americanas previamente descritas. La optimización de la técnica vendrá dada en función de la selección cada vez más adecuada de los pacientes que deben someterse a ella, y a la estandarización de un modelo histopatológico sensible en la detección, pero a la vez sencillo en el procesamiento

INTRODUCTION AND OBJECTIVE: Sentinel lymph node biopsy (SLNB) is the most useful tool for node staging in melanoma. SLNB facilitates selective dissection of lymph nodes, that is, the performance of lymphadenectomy only in patients with sentinel nodes positive for metastasis. Our aim was to assess the cost of SLNB, given that this procedure has become the standard of care for patients with melanoma and must be performed whenever patients are to be enrolled in clinical trials. Furthermore, the literature on the economic impact of SLNB in Spain is scarce. METHOD: From 2007 to 2010, we prospectively collected data for 100 patients undergoing SLNB followed by transhilar bivalving and multiple-level sectioning of the node for histology. Our estimation of the cost of the technique was based on official pricing and fee schedules for the Spanish region of Murcia. RESULTS: The rate of node-positive cases in our series was 20%, and the mean number of nodes biopsied was 1.96; 44% of the patients in the series had thin melanomas. The total cost was estimated at between D 9486.57 and D 10 471.29. Histopathology accounted for a considerable portion of the cost (D 5769.36). DISCUSSION: The cost of SLNB is high, consistent with amounts described for a US setting. Optimaluse of SLNB will come with the increasingly appropriate selection of patients who should undergo the procedure and the standardization of a protocol for histopathologic evaluation that is both sensitive and easy to perform

Cost analysis of sentinel lymph node biopsy in melanoma.

INTRODUCTION AND OBJECTIVE: Sentinel lymph node biopsy (SLNB) is the most useful tool for node staging in melanoma. SLNB facilitates selective dissection of lymph nodes, that is, the performance of lymphadenectomy only in patients with sentinel nodes positive for metastasis. Our aim was to assess the cost of SLNB, given that this procedure has become the standard of care for patients with melanoma and must be performed whenever patients are to be enrolled in clinical trials. Furthermore, the literature on the economic impact of SLNB in Spain is scarce. METHOD: From 2007 to 2010, we prospectively collected data for 100 patients undergoing SLNB followed by transhilar bivalving and multiple-level sectioning of the node for histology. Our estimation of the cost of the technique was based on official pricing and fee schedules for the Spanish region of Murcia. RESULTS: The rate of node-positive cases in our series was 20%, and the mean number of nodes biopsied was 1.96; 44% of the patients in the series had thin melanomas. The total cost was estimated at between €9486.57 and €10471.29. Histopathology accounted for a considerable portion of the cost (€5769.36). DISCUSSION: The cost of SLNB is high, consistent with amounts described for a US setting. Optimal use of SLNB will come with the increasingly appropriate selection of patients who should undergo the procedure and the standardization of a protocol for histopathologic evaluation that is both sensitive and easy to perform.

Excellent response of basal cell carcinomas and pigmentary changes in xeroderma pigmentosum to imiquimod 5% cream.

Xeroderma pigmentosum (XP) is an autosomal recessive disease in which patients have a 1000-fold increased risk of developing cutaneous neoplasms. Management of patients with XP is a difficult therapeutic challenge as they usually present with many cutaneous malignancies and continue to form skin tumours at a high rate. We describe a 19-year-old woman with XP who had been previously treated with many different therapeutic approaches. She had an excellent clinical response of her multiple small pigmented basal cell carcinomas and pigmentary changes using imiquimod 5% cream with only minor side-effects.

[Selective sentinel node biopsy in melanoma using preoperative lymphoscintigraphy location and intraoperative detection gamma probe]. / Biopsia selectiva del ganglio centinela en el melanoma mediante localización con linfogammagrafía preoperatoria y sonda de detección gamma intraoperatoria.

BACKGROUND: The experience in detection of sentinel lymph node in melanoma using preoperative scintigraphy and intraoperative gamma probe is referred. PATIENTS AND METHODS: We studied 60 patients with stage I-II melanoma who underwent sentinel lymph node biopsy performed using 99m-Tc-labelled sulphur colloid as radioactive tracer. A preoperative scintigraphy was performed and intraoperative gamma probe was used to localize the sentinel node in all cases. Scintigraphy results, effectiveness of intraoperative detection (technical efficacy), pathological results, and follow-up have been studied. RESULTS: Preoperative detection was 98.3% and the mean basin detected was 1.17. There were multiple basins especially when melanomas were on the trunk. Technical efficacy was 98.4% and intraoperative detection was more difficult in parotid gland region. HMB-45 immunohistochemical staining was essential in pathological studies, in whom 10% were positives. Lymphadenectomy could be avoided in 90% of the patients. Recurrences were not detected during follow-up and metastases were found only in non biopsied cases. Sentinel node biopsy morbidity was significative lesser than that of lymphadenectomy. CONCLUSIONS: Preoperative scintigraphy and intraoperative gamma probe use to localize sentinel node in melanoma have a high efficacy. They can reveal multiple basins and they allow a more selective surgical approach and a minimal dissection.

Does injection distance of the radiocolloid modify lymphatic mapping in melanoma?

BACKGROUND: An important factor to be considered when performing lymphogammagraphy in melanoma patients is the adequate distance of injection of the radiopharmaceutical from the biopsy excision site or the primary lesion. OBJECTIVE: To test the reproducibility of lymphatic mapping in patients with primary cutaneous melanoma who had undergone narrow excisional biopsy by injecting a technetium marker at different distances from the biopsy scar. METHODS: After informed consent, two lymphoscintigraphies were performed on each of 19 melanoma patients, following narrow excisional biopsy. Four aliquots of the radiocolloid were intradermally injected in each procedure, surrounding the biopsy excision site at 1.5 and 0.5 cm, respectively. RESULTS: Both lymphoscintigraphies showed similar lymph channels and sentinel node(s). CONCLUSION: In melanoma patients who have undergone narrow excisional biopsy, lymphoscintigraphy marks with accuracy the sentinel node, at least when the radiopharmaceutical is injected at a distance of less than 1.5 cm from the limits of the biopsy scar.

Serum ceruloplasmin in melanoma patients.

We have studied the serum ceruloplasmin levels as a possible diagnostic factor or marker for detection, diagnosis and follow-up of patients with melanoma. Ceruloplasmin concentration was determined in 64 melanoma patients (MP) and in 37 healthy persons (HP) by nephelometry. We found a mean value of 29.85 +/- 5.47 mg/dl in MP and 26.10 +/- 5.22 mg/dl in HP. A significant increase in the levels of serum ceruloplasmin was observed in MP in comparison to those in HP (P = 0.0011). In order to check whether this test could discriminate between MP and HP, a complete statistical Receiver Operating Characteristic (ROC) curve analysis was performed. The cut-off value was 25.10 mg/dl. The area under the curve was 0.689. According to these results, the test could discriminate adequately between the two groups.

Finasteride increases anagen hair in men with androgenetic alopecia.

BACKGROUND: The growth of scalp hair is a cyclical process of successive phases of growth (anagen) and rest (telogen). In previous clinical trials in men with androgenetic alopecia, treatment with finasteride increased scalp hair counts in a defined area (i.e. increased hair density). OBJECTIVES: The current study used a phototrichogram methodology to assess the effect of finasteride on the phases of the hair growth cycle. PATIENTS/METHODS: Two hundred and twelve men, age 18-40 years, with androgenetic alopecia were randomized to receive finasteride 1 mg daily or placebo for 48 weeks. At baseline and at 24 and 48 weeks, macrophotographs were taken to measure total and anagen hair count in a 1-cm(2) target area of the scalp. RESULTS: At baseline, mean total and anagen hair counts in the finasteride group were 200 and 124 hairs, respectively (% anagen = 62%) and the anagen to telogen ratio was 1.74 (geometric mean). In the placebo group, the respective values were 196 and 119 hairs (% anagen = 60%) and 1.57. At week 48, the finasteride group had a net improvement (mean +/- SE) compared with placebo in total and anagen hair counts of 17.3 +/- 2.5 hairs (8.3% +/- 1.4%) and 27.0 +/- 2.9 hairs (26% +/- 3.1%), respectively (P < 0.001). Furthermore, treatment with finasteride resulted in a net improvement in the anagen to telogen ratio of 47% (P < 0.001). In this study, treatment with finasteride 1 mg day(-1) for 48 weeks increased both total and anagen hair counts, and improved the anagen to telogen ratio. CONCLUSIONS: These data provide direct evidence that finasteride 1 mg daily promotes the conversion of hairs into the anagen phase. These data support that finasteride treatment results in favourable effects on hair quality that contribute to the visible improvements in hair growth observed in treated patients.

Whole blood glutathione peroxidase activity in melanoma patients.

We have studied whole blood glutathione peroxidase activity as a possible diagnostic factor or marker for detection and diagnosis of patients with melanoma. This activity was determined in 40 melanoma patients (MP) and in 40 healthy persons (HP) using an enzymatic method. We found a mean value of 17.90+/-6.82 units/ml in MP and 27.07+/-14.35 units/ml in HP. A very significant decrease in whole blood glutathione peroxidase activity was observed in MP in comparison to the enzymatic activity in HP (P = 0.0005). In order to check whether this test could discriminate between MP and HP, a complete statistical Receiver Operating Characteristic (ROC) curve analysis was performed. The cut-off value was 14.26 units/ml. The area under the curve was 0.737. According to these results, the test could discriminate adequately between both groups. However, the high specificity and low sensitivity values associated with that cut-off value would make this test a very valuable tool for confirming the detection, rather than for primary screening.

Serum sialic acid in malignant melanoma patients: an ROC curve analysis.

We have studied the total serum sialic acid as a possible diagnostic factor for the prognosis of patients with melanoma. The sialic acid concentration was determined in the sera of fifty melanoma patients (MP) and forty healthy persons (HP), by using an enzymatic method. We found a mean value of 67.52 +/- 17.32 mg/dl in MP and 57.11 +/- 12.98 mg/dl in HP (p < 0.005). In order to check whether this test could discriminate adequately between MP and HP, a complete statistical Receiver Operating Characteristic (ROC) curve analysis was performed. The cut-off value was 62.39 mg/dl. The area under the curve was 0.661. According to these results, the test could discriminate between both groups. However, due to the rise of sialic acid-rich acute-phase proteins in inflammatory processes, determination of total serum sialic acid would be more useful for diagnosis of melanoma stage and prognosis rather than for early detection and screening.

Serum tyrosine hydroxylase activity is increased in melanoma patients. An ROC curve analysis.

We have studied the serum tyrosine hydroxylase activity of tyrosinase, the key enzyme in the melanogenesis via, as a possible diagnostic factor or marker for detection, prognosis and follow-up of patients with melanoma. This activity was determined in 30 melanoma patients (MP) and in 30 healthy persons (HP) by using a radiometric method. We found mean values of 10.8+/-3.0 and 7.65+/-2.32 mU/l for serum tyrosine hydroxylase activity in MP and HP, respectively. A very significant increase in serum tyrosine hydroxylase activity was observed in MP in comparison to the enzymatic activity in HP (P < 0.00001). Although these data seem very conclusive, we wanted to know whether this test could discriminate adequately between MP and HP. In order to reach this aim, a complete statistical study was performed by using receiver operating characteristic (ROC) curve analysis. The cut-off value obtained was 8.47 mU/l. According to our results and after analytical treatment of the data, we can confirm that evaluation of tyrosine hydroxylase activity in serum could be a quick and reliable diagnostic method for detection, prognosis and follow-up in melanoma patients.

Serum zinc levels are increased in melanoma patients.

We studied the levels of serum copper and zinc as possible diagnostic factors or markers for the early detection of patients with melanoma. Levels were determined in 35 melanoma patients at various clinical stages and in 39 healthy persons. Measurements were performed by atomic absorption spectroscopy using 5100-PC-Perkin-Elmer equipment. We found that serum copper levels were very similar in the melanoma patients and the healthy individuals, the medium values being 118.32 +/- 25.32 micrograms/dl and 117.94 +/- 28.01 micrograms/dl, respectively. Therefore, no significant differences were observed with regard to copper levels. On the other hand, we obtained a medium value of 82.32 +/- 25.38 micrograms/dl for serum zinc levels in the melanoma patients and 56.72 +/- 11.79 micrograms/dl in the healthy persons, which represents a very significant increase in the serum levels of zinc in melanoma patients (P < 0.0001). A receiver operating characteristic (ROC) curve statistical analysis was also performed; the cut-off value obtained was 60.9 micrograms/dl. According to our results, zinc is increased in 86.5% of melanoma patients. Although further investigations are needed to assess its value in prognosis and follow-up, evaluation of serum zinc level could be a good tool to check for the presence of melanoma.

Granuloma faciale: an ultrastructural study.

Granuloma faciale is an uncommon process that can easily be confused with other skin diseases. To avoid incorrect treatment, correct diagnosis is of primary importance. A diagnosis of granuloma faciale can be made by a microscopic study of the dense granulomatous infiltrate in the reticular dermis with abundant polynuclear eosinophils and by an ultrastructural study of the eosinophils, which show characteristic alterations in their cytoplasmatic granules. The absence of Langerhans granules differentiates granuloma faciale from histiocytosis X.

Olmsted syndrome: report of a new case.

We report the case of a 20-year-old man, who was born with an intense erythema of the genital area, unresponsive to any treatment employed. When he was 9 months old, he presented with well-defined hyperkeratotic erythematous plaques around the mouth, eyes, nose, and perianal area, with similar plaques on the lateral aspect of the neck and axillae. At the same time the erythema of the genital area became hyperkeratotic. When he was 2 years old, he presented with a disabling palmoplantar keratoderma, initially focal, and later diffuse, also unresponsive to local or systemic treatments employed. The lesions have varied during the course of the disease without ever clearing completely. The axillary and inguinal plaques have shown spontaneous resolution on occasion. Six skin biopsies have been performed with no conclusive histological diagnosis of any of the typical disorders of keratinization. All treatments, topical and systemic, including etretinate and acitretin, have failed to improve the condition. We believe that this patient has Olmsted syndrome, a rare form of palmoplantar keratoderma with periorificial keratotic plaques.