Shout Outs

Updated 3/2017--photos and all links (except to my own posts) removed as many no longer active. 

Dr. Jen Dyer, Endogoddess, is hosting this week’s Grand Rounds.   You can read this week’s edition here.

I am a total news junkie and always have been (which is probably why I started out college as a journalism major before deciding that I wanted to be a doctor). So, this week's edition of Grand Rounds features the news themes of the prior week and their relationship to health: politics, football fever, the power of facebook, red heart disease awareness, and the impact of pink. ...….

………………………………….

Head’s up:  @drjohnm is asking for posts for next week’s edition of Grand Rounds which he will be hosting.  Here’s his tweet:

Dear Med Bloggers: Please send me your posts for the Valentine's day version of @grandrounds http://ow.ly/8Xmze

…………………………………….

Updated 3/2017--photos and all links removed as many no longer active. 

Thank you @tbtam  for the information in your post:  Alternatives to Komen for Channeling Your Dollars & Energy to Fight Breast Cancer:

One option, of course, is to give to Planned Parenthood, The other option is to donate to one of the other charities on the front lines in the battle against breast cancer. Komen, after all, is not the only game in town.

Here are a few other places where your dollars will be put to good use fighting breast cancer. All of the following groups get high ratings from the American Institute of Philanthroy and/or Charity Navigator-……..

……………………………………

White Coat is attempting to shine light on the issue of Amanda Trujillo: 

I finally took the time to read some other blogs today. One of the issues that I found disturbing was the case of Amanda Trujillo…………….

I’ve tweeted to Amanda to contact me …..

I’ll request the patient’s permission for release of the patient’s medical records from the hospital. ….

And I’ll get the name of the surgeon who allegedly does not take the legal doctrine of informed consent too seriously and who allegedly uses temper tantrums as a means to bully people into submission. Maybe we can look into his background a little. If he did have a “tantrum” in a patient care area, has the hospital investigated him for his conduct?

Everything will be published here.

And if ends up that Amanda was wrong for what she did I’ll publish that as well.

……………………………

A New York Times article by Melissa Greene:  Wonder Dog

In May 1999, Donnie Kanter Winokur, 43, a writer and multimedia producer, and her husband, Rabbi Harvey Winokur, 49, beheld the son of their dreams, the child infertility denied them.  ……………..“Sometime after their 3rd birthdays, our wonderful fairy tale of adopting two Russian babies began to show cracks,” said Donnie Winokur,……….

For children with autism or behavior disorders, dogs were trained in “behavior disruption.” For children with seizure disorder or diabetes or respiratory issues, dogs were trained to alert the parents at the onset of an episode, and there have been a few able to predict the medical incidents 6 to 24 hours in advance. (How they do this is something of a mystery.)…………..

…………………………………

Dogs are so cool! in my humble opinion.  There’s the above story and then there’s this one I heard tonight on ABC Evening News which made me think of my three dogs who died of cancer.  I actually called a drug company way back when to see if she qualified for a drug trial.  There was no registry then.  Oh well.  Here’s the story:  Canine Cancer Studies Yield Human Insights

Some of the most promising insights into cancer are coming from pet dogs thanks to emerging studies exploring remarkable biological similarities between man and his best friend.

Cancer is the leading cause of death in dogs. Every year, millions of dogs develop lymphomas and malignancies of the bones, blood vessels, skin and breast……………….

Jack Sevey Jr. created the website MyCancerPet.com in January 2011 after his 5-year-old boxer Bull died from T-cell lymphoma. Sevey wanted to create an online community for fellow owners of cancer-stricken pets and also steer them to helpful resources. Those include lists of clinical trials compiled by several organizations: the AKC Canine Health Foundation, Animal Clinical Investigation, the National Cancer Institute's Center for Cancer Research, the Morris Animal Foundation and the Veterinary Cancer Society……………..

Skyes’ Preventive Double Mastectomy

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

When Wanda Skyes, 47, had a bilateral breast reduction in February, the pathology returned with DCIS present in the left breast specimen.  Recently the comedian appeared on  "The Ellen DeGeneres Show" and during the interview revealed her breast cancer diagnosis and her decision to have a double mastectomy.

Sykes continued, "It wasn't until after the reduction that in the lab work, the pathology, that they found that I had DCIS [ductal carcinoma in situ] in my left breast. I was very, very lucky because DCIS is basically stage-zero cancer. So I was very lucky."

But, she added, "Cancer is still cancer. I had the choice of, 'You can go back every three months and get it checked. Have a mammogram, MRI every three months just to see what it's doing.' But, I'm not good at keeping on top of stuff. I'm sure I'm overdue for an oil change and a teeth cleaning already."

Because she has a history of breast cancer on her mother's side of the family, Sykes explained she opted to have a bilateral mastectomy.

"I had both breasts removed, because now I have zero chance of having breast cancer," she said. "It sounds scary up front, but what do you want? Do you want to wait and not be as fortunate when it comes back and it's too late?"

The American Cancer Society has a nice article which reviews the risk factors for breast cancer.  The risks factors for Sykes (which can be garnered from the news article) include a family history of breast cancer (don’t know which relative on mother’s side), a personal history of breast cancer, African-American, and age.

I don’t think I would have advised her to have a bilateral prophylactic mastectomy on this information, but perhaps with more info I would have.  Though an effort is made to remove all breast tissue with a prophylactic mastectomy, it is wrong for us doctors/surgeons to ever suggest that we actually DO get it all.  More truthful to say we have removed most (90% plus).

While we are on the topic of breast cancer, please, take a look at Elaine Schattner, M.D., Medical Lessons, post from Monday:  NEJM Publishes New Review on Breast Cancer Screening.

Related posts:

Risk Factors for Breast Cancer (October 2, 2007)

Prophylactic Mastectomy (January 28, 2009)

Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Is Prophylactic Mastectomy Worth It? (August 2, 2011)

Media Sources

Wanda Sykes' double mastectomy is aggressive treatment for DCIS; Karen Kaplan; Los Angeles Times/For the Booster Shots blog, September 23, 2011

Wanda Sykes has double mastectomy;  Ann Oldenburg; USA Today, Sep 23, 2011

Wanda Sykes: I had a double mastectomy; Jessica Derschowitz; CBS News, Sep 23, 2011

For more information on DCIS

Breast Cancer; PubMed Health, last updated December 2010

DCIS - Ductal Carcinoma In Situ; BreastCancer.org, last updated August 12, 2011

Ductal carcinoma in situ (DCIS); Mayo Clinic, last update June 23, 2011

Nonmelanoma Skin Cancer in IBD Patients

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

I stumbled across this review article (first full reference below) earlier this week.  

Skin cancer is the most common form of cancer in the United States.  Most skin cancers form in older people on parts of the body exposed to the sun or in people who have weakened immune systems (such as inflammatory bowel disease patients on immunosuppressive therapy). 

According to the National Cancer Institute (NCI), in there were more than one million new cases of nonmelanoma skin cancers (NMSC) in the United States in 2010.  There were less than 1,000 NMSC deaths during the same time.

NMSC includes  squamous cell carcinoma (SCC) and basal cell carcinoma (BCC).   Both occur more frequently on sunlight-exposed areas such as the head and neck. BCC is far more common than SCC and accounts for approximately 75% of all NMSC.

The causes of NMSC in the general public are multifactorial, including both environmental and host factors. Known environmental risk factors for NMSC include sun exposure (ultraviolet [UV] light), ionizing radiation, cigarette smoking, and certain chemical exposures such as arsenic. Host risk factors include human papilloma virus infection, genetic susceptibilities, skin type, and immunosuppression. 

That last risk factor mentioned – immunosuppression—is one IBD patients have in common with solid organ transplant patients (kidneys, livers, lungs, face, hands).  Note the third reference below.  The results summary of that article

Two hundred patients developed a first NMSC after a median follow-up of 6.8 years after transplantation. The 3-year risk of the primary NMSC was 2.1%. Of the 200 patients with a primary NMSC, 91 (45.5%) had a second NMSC after a median follow-up after the first NMSC of 1.4 years (range, 3 months to 10 years). The 3-year risk of a second NMSC was 32.2%, and it was 49 times higher than that in patients with no previous NMSC. In a Cox proportional hazards regression model, age older than 50 years at the time of transplantation and male sex were significantly related to the first NMSC. Occurrence of the subsequent NMSC was not related to any risk factor considered, including sex, age at transplantation, type of transplanted organ, type of immunosuppressive therapy, histologic type of the first NMSC, and time since diagnosis of the first NMSC. Histologic type of the first NMSC strongly predicted the type of the subsequent NMSC

Attention is now being paid to other patients (ie IBD, rheumatoid arthritis) on immunosuppression and their increased risk of NMSC.

Millie D. Long, MD and colleagues (first reference) note that  no IBD-specific, evidence-based guidelines for NMSC prevention exist.  The current recommendations for prevention of skin cancer for the general population include sun avoidance and sun protection strategies include protective clothing, hats, sunglasses, and sunscreens.   Sun avoidance should include tanning bed avoidance.

Any skin lesion suspicious for malignancy in a patient with IBD on immunosuppression should be evaluated by a trained dermatologist.  Among solid-organ transplant recipients, annual skin examination is recommended by various transplant organizations.

Long and colleagues note “There are no guidelines for skin cancer screening in patients with IBD, as it is unclear whether the risk–benefit ratio of skin cancer screening in IBD patients correlates with that of the general population, or more closely with that of the solid-organ transplant population. Consideration could be given in the future to skin cancer screening programs for patients with IBD on immunosuppression.” 

REFERENCE
1.  Nonmelanoma skin cancer in inflammatory bowel disease: A review; Millie D. Long, Michael D. Kappelman and Clare A. Pipkin; Inflammatory Bowel Diseases Volume 17, Issue 6, pages 1423–1427, June 2011; Article first published online: 25 OCT 2010 | DOI: 10.1002/ibd.21484
2.  National Cancer Institute; Skin Cancer

3.  Incidence and Clinical Predictors of a Subsequent Nonmelanoma Skin Cancer in Solid Organ Transplant Recipients With a First Nonmelanoma Skin Cancer: A Multicenter Cohort Study; Gianpaolo Tessari; Luigi Naldi; Luigino Boschiero; Francesco Nacchia; Francesca Fior; Alberto Forni; Carlo Rugiu; Giuseppe Faggian; Fabrizia Sassi; Eliana Gotti; Roberto Fiocchi; Giorgio Talamini; Giampiero Girolomoni; Arch Dermatol. 2010;146(3):294-299

ALCL and Breast Implants – an article review

 Updated 3/2017--  all links removed as many are no longer active and it was easier than checking each one.

In light of the recent new regarding the FDA safety alert on the possible association of acute large cell lymphoma (ALCL) with breast implants, the authors of the recently Plastic and Reconstructive Surgery Journal article (full reference below, published online ahead of print) conducted a systematic literature search on the topic.

The search included the literature of PubMed, Embase, and Web of Science (Science Journals & Proceedings) databases.  Dates searched included references from 1966 for PubMed and Embase ; from 1980 for Web of Science; and from 1990 for Web of Science Proceedings, through July 2010 for all of them.

Research (categorized as epidemiologic studies or scientific papers) and non-research (case reports or case series) articles from peer-reviewed journals, conference abstracts, and unpublished manuscripts were retrieved from the literature search.

Only human-based topics and articles written in English were considered. Of the initial 884 titles, 83 articles discussed ALCL and breast implants. Fourteen additional articles were provided by 2 expert plastic surgeons (V.L.Y. and K.C.C.).

Their conclusions:

A form of ALCL, which clinically behaves more like the less-aggressive cutaneous form of ALK-negative ALCL rather than the more-aggressive systemic form, may be associated with breast implants. Future research on the epidemiology and biology of this rare disease is clearly needed to better understand its nature.

What is conclusive:

• ALCL is a rare disease, comprising 2% of all newly-diagnosed non-Hodgkin’s lymphomas (NHLs) worldwide2 and 0.9% of the estimated 65,540 cases of NHL diagnosed in the U.S. in 2010.
• Lymphomas of the breast are extremely rare, comprising 0.04-
  0.5% of all breast cancers and approximately 1-2% of all extranodal lymphomas.
• Despite the rarity of both ALCL and primary breast lymphomas, multiple cases of ALCL developing adjacent to breast implants have been reported, including by Brody et al., who have recently presented but not yet published a series of 34 cases.
• In 2009 alone, a reported 289,328 breast augmentation, 86,424 reconstruction, and 87,386 lift procedures were performed in the U.S.; unfortunately, the exact number of women who received implants is not known because only some breast reconstructions and lift procedures utilized implants.

The literature review noted the case presentation characteristics (bold emphasis is mine):

Fourteen (48%) of 29 ALCL cases were noted to have presented with a seroma, 1 (3%) ALCL case did not present as a seroma and data was not reported in the remaining 14 (48%) ALCL cases.

Seven (24%) of the 29 ALCL cases reported data indicating that the patient had a palpable breast mass on presentation, 5 (17%) reported absence of a mass and information was missing for the remaining 17 (59%) ALCL cases.

Less frequently cited symptoms among ALCL cases were pain [6/29 (21%], redness [4/29 (14%)], and capsule contracture [2/29
(7%)].

Other symptoms (e.g., skin lesions, fever) were reported in only 2 (7%) of 29 ALCL cases but in 5 (71%) of 7 patients with other NHLs [not reported in 27/29 (93%) ALCL and 2/7 (29%) non-
ALCL cases].

Duration of symptoms was rarely noted. In the 7 cases where it was, mean duration in years for ALCL cases was 0.8 (range 0.2-1.7). Mean symptom duration among 5 non-ALCL cases for which it was reported was 5.4 years (range 0.5-17).

…..
Remember the FDA report noted (bold emphasis is mine):

ALCL is a very rare condition; when it occurs, it has been most often identified in patients undergoing implant revision operations for late onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast implant removal in patients without symptoms or other abnormality.

…..
Of interest is this post from Maggie Mahr:  The FDA “Has a Chat” With Plastic Surgeons

………….It is probably not a coincidence that ASPSS and ASAPS repeated the cancer-denial line first promulgated by Allergan: Both organizations have received funding from the company. ASPSS has also received funding from Allergan’s main competitor, J&J, which makes the Mentor implant line. (Mentor’s reaction to the FDA warning was more muted than Allergan’s but its statement also avoided mentioning the C-word.)

Both Allergan and J&J fund provide funds for ASPSS, as noted on its web site.

At ASAPS, Allergan’s funding is more indirect. It has supplied research grants through ASAPS’ research arm, the Aesthetic Surgery Education and Research Foundation. You can see those grant award announcements by searching for “Allergan” here.

The two groups ought to be ashamed of themselves. It is one thing to take funding from drug and device companies . .  . . But the groups ought to represent the medical expertise of the healthcare providers who are their members, not the PR agendas of two companies who are afraid they may lose money from too much blunt but accurate talk about breast cancer.

Previous related posts:
ALCL and Breast Implants (January 31, 2011)
Breast Implants and Lymphoma Risk (June 29, 2009)


REFERENCE

Anaplastic Large Cell Lymphoma and Breast Implants: A Systematic Review; Kim, Benjamin; Roth, Carol; Chung, Kevin C.; Young, V. Leroy; van Busum, Kristin; Schnyer, Christopher; Mattke, Soeren; Plastic & Reconstr Surgery., POST ACCEPTANCE, 25 February 2011; doi: 10.1097/PRS.0b013e3182172418

Breast Cancer Oncogene ZNF703

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Much of gene research is over my head, but the discovery of a new breast cancer oncogene, ZNF703, is exciting.  It appears to have been discovered by two independent research groups (references below) and published alongside one another in the same journal EMBO Molecular Medicine today this past week.

The only other breast oncogene that I am aware of is Her2 which has been very helpful in identifying which patients are most likely to respond to Herceptin.  This greatly helps in tailoring therapy to the individual.

The first group of researcher scientists used ‘microarray technology’ which allows large numbers of tissue samples to be tested simultaneously, picking up subtle differences in gene activity between normal cells and cancer cells.

The researchers had already identified a region on human chromosome eight likely to harbor genes linked to the development of a more aggressive form of estrogen positive breast cancer, because multiple copies of it are commonly found in tumors but not in healthy tissue.

Focusing on this region, they studied the patterns of gene activity in 1172 breast tumors, as well as breast cancer cells grown in the lab. This allowed them to eliminate one gene at a time until there was only one gene left within that region that was overactive in all the samples tested.

The second group specifically studied Luminal B breast cancers which represent a fraction of ER-positive tumors associated with poor recurrence-free and disease-specific survivals in all adjuvant systemic treatment categories including hormone therapy alone.

Using mass spectrometry, they identified ZNF703 as a cofactor of a nuclear complex comprising DCAF7, PHB2, and NCOR2. ZNF703 expression results in the activation of stem-cell related genes expression leading to an increase in cancer stem cells.

They were able to show that ZNF703 is implicated in the regulation of estrogen receptor and E2F1 transcription factor which points to the prominent role of ZNF703 in transcription modulation, stem cell regulation and luminal B oncogenesis.

 

REFERENCES

ZNF703 is a common Luminal B breast cancer oncogene that differentially regulates luminal and basal progenitors in human mammary epithelium;  Carroll JS, Curtis C, Aparicio S, Caldas C, et al; EMBO Molecular Medicine, Article first published online: 18 FEB 2011; DOI: 10.1002/emmm.201100122

ZNF703 gene amplification at 8p12 specifies luminal B breast cancer; Sircoulomb F, Nicolas N, et al; EMBO Molecular Medicine, Article first published online: 18 FEB 2011; DOI: 10.1002/emmm.201000121

Cancer Research UK Press Release, February 18, 2011

Closure of Facial Mohs’ Defects

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.I

t is very likely there will never be a complete consensus on the best or correct way to close defects left by Mohs’ surgical excision of skin cancers on the face. 

Which is best?  Direct linear closure.  Local flap. Skin graft.

In my opinion, it comes down to multiple factors but perhaps the most important are:   Where on the face is the defect?  How lax is the surrounding skin? 

The authors of the recent Plastic & Reconstructive Surgery Journal article on the topic (full reference below) write in their introduction in favor of direct closure (the first step in the reconstructive ladder):

This first step on the reconstructive ladder is often overlooked in favor of more intricate local flap options. If performed properly, direct linear closure results in superior aesthetic results that are more predictable and involve less tissue dissection than local flap options. 

The article is a retrospective review of 1354 reconstructions performed post-Mohs’ facial defects by the senior author (JFT)between 2001 and 2008.  

Forehead (96/125 closed directly in this study) –-their maximum size for direct closure was 3.6 cm.  A nice tip from JFT to determine orientation of the final closure:

The senior author's (J.F.T.) preferred technique for forehead repairs is to place a single silk stitch in both directions, tailor-tack the wound closed, and orient the resultant closure based on which direction yields the least tension, with dog-ear excision following the closure. Dog-ears are meticulously excised on the forehead.

Nose (46/707 closured directly in this study) –- maximum defect size 1.2 cm on nasal dorsum, < 1 cm on tip.

The indications for direct linear closure on the nose are more limited than other anatomical areas on the face because of the relative paucity of skin laxity and the risk of alar distortion.

Lip (37/138 closed directly in this study) – maximum defect 3 cm.

Numerous textbooks have described linear closure of the lip as the preferred technique for defects of 25 percent of the upper lip and up to 30 percent of the lower lip. Our experience has shown that superior aesthetic results can be achieved with defects approaching 40 percent on the upper lip and exceeding 50 percent on the lower lip. This is particularly true in the elderly patient.

Cheek (117/186 closed directly in this study) – maximum defect 4 cm. 

The cheek, particularly in the elderly population, is an ideal area for direct linear closure of very large lateral defects. …..

The inherent laxity in the aging cheek and the ability to generously undermine this well-perfused region contribute to this result.

Chin (4/6 closed directly in this study) – maximum defect 2.2 cm.

Care must be taken with direct closure on the chin, as there is little skin laxity. Direct closure must be avoided in a horizontal plane, to prevent the inadvertent development of extrinsic lip ectropion.

Related posts:
Bilobed Flap for Repair of Nose (March 26, 2008)
Skin Grafting in Lower Third Nasal Reconstruction (April 1, 2010)
Reconstruction of the Lip -- Part I (January 29, 2008)


REFERENCE

The Rationale for Direct Linear Closure of Facial Mohs' Defects; Soliman, Sameer; Hatef, Daniel A.; Hollier, Larry H. Jr.; Thornton, James F.; Plastic & Reconstructive Surgery. 127(1):142-149, January 2011; doi: 10.1097/PRS.0b013e3181f95978

ALCL and Breast Implants

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Last week, the U.S. Food and Drug Administration requested health care professionals to report confirmed cases of anaplastic large cell lymphoma (ALCL) in women with breast implants.

The FDA made this request as they continue to investigate a possible association between breast implants, both saline and silicone gel-filled, and ALCL.

The definition given of ALCL by the National Cancer Institute calls ALCL an aggressive type of non-Hodgkin lymphoma, but oncologist Elaine Schattner, M.D. concludes after studying the FDA’s assessment (bold emphasis is mine)

Most of the ALCL tumors were limited to the area of the implant cap­sules, and could – as best I can tell from the few reports – be treated by removal of the implants and affected, adjacent breast tissue. These don’t appear to be aggressive lym­phomas, as are some ALCL’s. I would go as far as to spec­ulate that these might indeed be antigen-driven tumors; in this light, it would make sense in prin­ciple and in practice to treat these by removal of the implants, at least as a first-line approach.

 

The FDA cites the Surveillance, Epidemiology, and End Results (SEER) Program of the NCI when noting ALCL is diagnosed in the United States in  approximately 1 in 500,000 women each year. ALCL in the breast is even more rare; approximately 3 in 100 million women per year in the United States are diagnosed with ALCL in the breast (Altekruse et al., 2010).

The FDA press release mentions an awareness of about 60 cases of ALCL in women with breast implants worldwide.   The same press release later notes “a review of scientific literature published between January 1997 and May 2010 and information from other international regulators, scientists, and breast implant manufacturers. The literature review identified 34 unique cases of ALCL in women with both saline and silicone breast implants.”

There are an estimated 5 million to 10 million women worldwide who have breast implants.

Among the 34 unique cases, the median age was 51 (28-87, with no age given in 8 cases); implant type (24 silicone, 7 saline, 3 unknown); implant texture (4 textured, 0 smooth, 30 unknown); median time from implant to diagnosis was 8 years (1-23, but not known in 11 cases); reason for implantation (11 reconstructive, 19 augmentation, 4 unknown).

The FDA notes (bold emphasis is mine):

ALCL is a very rare condition; when it occurs, it has been most often identified in patients undergoing implant revision operations for late onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast implant removal in patients without symptoms or other abnormality.

……..

The FDA is requesting health care professionals report all confirmed cases of ALCL in women with breast implants to Medwatch, the FDA’s safety information and adverse event reporting program. Report online or by calling 800-332-1088.

……..….

Women with implants should remember ALCL is extremely rare.  There is no need to change your routine medical care and follow-up.  For more information from the FDA:
Breast Implant Consumer Information
ALCL and Breast Implants Consumer Article



Other blog posts on topic:
An Oncologist Considers Rare Lymphomas in Women With Breast Implants; Medical Lessons Blog (January 28, 2011)
Breast implants and anaplastic large cell lymphoma (ALCL): Is there a link?; Science-Based Medicine Blog (January 31, 2011)

REFERENCES

FDA Review Indicates Possible Association Between Breast Implants and a Rare Cancer; January 26, 2011

Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants: Preliminary FDA Findings and Analyses; FDA

Breast Implants and Lymphoma Risk: A Review of the Epidemiologic Evidence through 2008; Plastic & Reconstructive Surgery. 123(3):790-793, March 2009; Lipworth, Loren Sc.D.; Tarone, Robert E. Ph.D.; McLaughlin, Joseph K. Ph.D.

Anaplastic large-cell lymphoma in women with breast implants; JAMA. 2008;300:2030-2035; De Jong D, Vasmel WLE, de Boer JP, et al.

Maternal Influence

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Not all maternal influence on daughter behavior is good.  Take for example the influence of the unhealthy use of indoor tanning beds as presented in a recent Archives of Dermatology article (full reference below) which “investigated whether indoor tanning with one's mother the first time would influence frequency of tanning later in life and whether it was associated with age of initiation.”

Joel Hillhouse, Ph.D., of East Tennessee State University, Johnson City, and colleagues published a study the May 2010 issue of the Archives of Dermatology which looked at which health-based intervention worked best in reducing skin cancer risks.  They found that “Emphasizing the appearance-damaging effects of UV light, both indoor and outdoor, to young patients who are tanning is important no matter what their pathological tanning behavior status.”

For this study, Hillhouse and colleagues randomly selected a total of 800 female students  who were then sent a screening questionnaire on their indoor tanning history. Those who reported ever indoor tanning (n = 252) were invited to participate in the study and offered an incentive ($5). A total of 227 (mean age, 21.33 years; age range, 18-30 years) agreed, signed informed consent documents, and completed assessments.

One of the questions asked who accompanied the participant the first time they indoor tanned (ie, tanned alone, with friends, with mother, or other).

Of the 227 female participants, 70 were non-tanners; 113 were moderate tanners; and 44 were heavy tanners.

Nearly twice as many participants experienced indoor tanning for the first time with their mother (n = 88) than went alone (n = 45).  First time tanning with their mother was also higher than with a friend (n = 72) or with someone other than their friend or mother (n = 22).

The prevalence of current indoor tanning use among the 88 participants who went with their mother was nearly 81%, with 31.9% reporting heavy tanning.

Adjusting for age and skin type, the researchers found that the participants who reported tanning with their mother during their initial experience were 4.64 times more likely to be heavy current tanners than those who initiated tanning alone or with someone other than their mother

Let’s get out of the tanning beds and go walking or cycling or swimming or dancing or bowling together.  Mothers (and aunts) lets influence our daughters (and nieces) to be more active.

 

Related posts:
Tanning Beds = High Cancer Risk (August 3, 2009)
Skin Cancer: More than Skin Deep – an Article Review (December 14, 2009)
Get Girls to Focus on Skin’s Appearance (May 19, 2010)



REFERENCE

The Effect of Initial Indoor Tanning With Mother on Current Tanning Patterns; Mary Kate Baker, MPH; Joel James Hillhouse, PhD; Xuefeng Liu, PhD; Arch Dermatol. 2010;146(12):1427-1428. doi:10.1001/archdermatol.2010.349

Shout Outs

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Grand Rounds is taking a week off. Next week it will be hosted by Pizaazz. So I’d like to point you to Dr. Wes’ post from yesterday, Time in a Bottle

……………………..

This is a short video honoring some of the scientists who developed the lifesaving combination of breaths and chest compressions now known as CPR. 

 

…………………………………….

MedGadget is has announced the winner of their contest: Imagine Medicine Contest: Please Meet the Winner!

When we announced the Imagine Medicine contest last month, we hoped to see a showcase of photography that imagines medicine from as many angles as possible. …….. So after reviewing all the photos, we are proud to announce that the winner of this year's Imagine Medicine Contest is Inge Vugs for his photograph Beelitz Heilstätten; The former surgery room of the abandoned hospital in Beelitz Heilstätten. ……..

Do take a look at all the submissions below, and we want to thanks all of you who have contributed to this exciting competition. …….

Go take a look at the others and see the winning photo full size.

…………………………….

Cervical cancer is in the forefront of my consciousness these days. A young friend, Sarah, had surgery back in early summer, radical hysterectomy and pelvic lymph node dissection. Hers was Stage IIA. She is doing well. UAMS is taking care of her. She recently shared with me the fact that she has a blog: Cargo. I encouraged her to update it. I hope she will.

Sarah also told me of a friend of hers who has inoperable uterine cancer. This young woman also has a blog: Gray Skies Are Going to Clear Up. I think from what Sarah tells me, this young woman’s is Stage IV.

As Sarah says at the end of one post in her letter to anyone and everyone:

…….I am angry that this happened to me and I am only 29. Cancer sucks.

I am totally grateful. My Cancer could be worse. I have two beautiful healthy kiddos. I learned of the first abnormal pap smear after my 6 week check up after having Margo. …….

There is a song, Bring The Rain, by Mercy Me. I love it.

Ladies, please go to your GYN regularly and take them seriously when they say you need to have something done. I know those tests are no fun but this is seriously not going to be fun. Take care of yourselves because putting it off or skipping a year or two can be devastating.

…………………….……

Doctors and other healthcare providers are not immune to drug and alcohol abuse. This article by Joel Hood is a couple of weeks old, but if you missed it is about a fellow doctor who battled drug addiction now counsels others to kick theirs.

Richard Ready had been a drinker most of his life, but by the time he became chief resident of neurosurgery at a prominent Chicago-area hospital, it was drugs, not alcohol, that kept him going,

Ready took stimulants to keep alert through his daily rounds. He took heavy pain relievers to numb his emotions after his mother's death. He wrote himself a prescription for the sedative Tranxene to calm his nerves before an important seminar. …….

………………………………..

NPR’s series The Long View featured Madhur Jaffrey's Indian Kitchen yesterday. At the end of the interview, she shared her recipe for 'Red Pepper Soup With Ginger And Fennel'

With dozens of cookbooks published and her own cooking shows in the U.S. and Britain, you'd think Madhur Jaffrey had planned all along for a life in the kitchen. But the Indian chef began her career as a classically trained actress. ……….

Jaffrey's cooking career, however, began well before her film days when, at 19, she left her family's comfortable home in Delhi to study at England's Royal Academy of Dramatic Art. Jaffrey, a scholarship student with little money, was expected to eat at the local canteen. But when it came to British college grub, the chef tells NPR's Renee Montagne that she didn't like what she found. ………

……………………………………….

Via twitter and @drjvpoblete: Eyebrows are the frame for your face, here's tricks to maintain them: http://bit.ly/h6E63b

…..eyes are the widows to you soul, but your eyebrows are the frame for your face. ….., having sloppy or non-existent eyebrows may completely ruin your look. Below are some of the top eyebrow tips out there so you can be sure that your brows are in tip-top shape ……

………………………………

The Alliance for American Quilts is hosting another quilt contest. This is the 5th annual contest. I entered the past two years. You can see my finished quilts here and here.

This year's theme, "Alliances: People, Patterns, Passion," is as open-ended as the last and celebrates cooperative relationships that work towards a common goal.

Important: This year's deadline is much earlier: March 7, 2011. The reason: all entries will be exhibited at the American Quilter's Society show in Paducah, April 27-30. Our grand prize winner this year will have their choice of any Handi Quilter quilting machine!! Visit the "Alliances" homepage for full details and the downloadable entry form.

the Eve procedure

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Earlier this week I stumbled across the news of a 12 yo boy with a bone tumor involving his mandible.  Pediatric plastic surgeon Rohit Khosla, MD, Lucile Packard Children's Hospital, and his team performed a new procedure believed to be the first of its kind in the United States.

The procedure originally described by a team in Belgium has been nicknamed "the Eve procedure."   The procedure involves transplanting a rib along with its blood vessels and attach this circulation to an artery and vein in the neck.

It is hoped that as the young boy continues to grow, the transplanted bone will do so also.

The boy’s tumor was a chondromyxoid fibroma,  a non-malignant bone tumor that usually occurs in the limbs and feet.  In this case, it occurred in the boy’s mandible.  Removal involved  about a third of the patient's jaw bone, the section extending forward from the temporomandibular joint near his right ear.

Since the family wanted the boy’s identity protected, there are no photos to be found to show you.  I wish him well as he heals and grows into a young man.

 

 

REFERENCE

The "Eve" Procedure: The Transfer of Vascularized Seventh Rib, Fascia, Cartilage, and Serratus Muscle to Reconstruct Difficult Defects; Guelinckx, P. J.; Sinsel, N. K.; Plastic & Reconstructive Surgery. 97(3):527-535, March 1996.

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

e-Patients is the host for this week’s Grand Rounds! You can read this week’s edition here.

This is e-Patients.net’s first opportunity to host Grand Rounds. which is a collection of some of the medical blogosphere’s best writing over the last week. We asked bloggers to look at our sister website, the peer-reviewed Journal of Participatory Medicine, and create posts inspired by or extending the articles there. We did this not to be self-serving, but because we think it’s important to shine a light on the Journal’s role as a source of peer-reviewed, evidence-based participatory medicine research. A group of us formed the Society of Participatory Medicine to advance the credibility and understanding of patient empowerment and patient advocacy.

We want to dedicate this edition of Grand Rounds to our friend and mentor, Dr. Tom Ferguson, founder of e-Patients.net and direct inspiration for the founding of the Society for Participatory Medicine and the Journal of Participatory Medicine. Tom’s selfless, tireless work in support of the empowered patient culminated in the creation of the seminal, visionary white paper, e-Patients: How They Can Help Us Heal Healthcare (pdf), published just after his death.

Thanks also to Nick Genes and Val Jones, instigators of Grand Rounds.

This week’s posts …

……………………………………….

Slate has a thoughtful article by Elaine Schattner: Who's a Survivor? An oncologist who's had breast cancer considers the problematic phrase "cancer survivor."

A few weeks ago, I stood among 21,000 people at the Susan G. Komen Foundation's annual Race for the Cure in New York City. The participants, including me and 1,500 other breast-cancer survivors, walked, ran, or wheeled their way to the finish line in Central Park. Nearby was a "survivors' village." I wandered about, uncertain whether I belonged.

Survivor seems a strange term for a patient like me, said by her oncologist to be in remission—meaning that there's no overt evidence of persistent cancer cells in the body. The National Cancer Institute defines a "cancer survivor" as someone who's had a malignant tumor and remains alive. …..

…………………………………….

Literature, Arts, and Medicine Blog has a post on October 6, 2010:  Medical Humanities and Live Theater. See It Now! (the post’s link seems to be broken, so it’s a link to the blog itself)

For those living in or near New York City, there is an unusual opportunity to attend one or all of three plays that bear directly on individual experiences of illness, altered bodily states, and the cultural and social context in which those alterations occur. …

Angels in America, by Tony Kushner. Signature Theater Company."This play explores "the state of the nation"-the sexual, racial, religious, political and social issues confronting the country during the Reagan years, as the AIDS epidemic spreads. ….

Three Women, by Sylvia Plath. 59E59.
"three intertwining interior monologues, contextualized by a dramatic setting: " ‘A Maternity Ward and round about.’ . . The three women of the title are patients, and each describes a different experience."

Wings, by Arthur Kopit. Second Stage Theater.
"the sounds and sights inside and outside of Emily as well as her private dialogue are combined masterfully by Kopit to bring about a high degree of verisimilitude to the chaos produced by stroke."

……………………………….

Fellow physician, blogger, twitterer, and "angel" Dr. Krupali Tejura's recent presentation: How the real-time web is changing the lives of my cancer patients

Click To Play

…………………………..

I learned of this blog, Never Lose Spirit,  by a local breast cancer patient via our local newspaper.  I love her header (photo credit).  She is the mother of two daughters.

Welcome to my blog. I've created this blog to keep friends and faraway family up to date on my battle with Inflammatory Breast Cancer. When you’re a writer, there is no need to be reported about - right? So instead, I’m going to be the author of my own story. You keep praying while I fight this nasty disease. We’re going to win!

………………………………….

Dr Anonymous’ show will be about Social Health Track at BlogWorld Expo. The show begins at 9 pm EST.

Upcoming shows:
10/16 : On Location
10/21 : About DigPharm Mtg
10/23 : Saturday Nite
10/28 : About FMEC Mtg
10/30 : On Location

Teenagers Use of Self-Tanners

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Skin cancer rates continue to rise. Exposure to UV radiation and the resulting damage to the skin is major reason. It doesn’t matter whether this exposure is from outdoor or indoor sources.

Use of self-tanners should (intuitively) decrease the exposure to UV radiation as the desired “tan” is obtained from an alternative source. Not necessarily, especially in teens.

The Archives of Dermatology article referenced below reports on a study survey done by Vilma E. Cokkinides, Ph.D., of the American Cancer Society, Atlanta, and colleagues. Their survey was telephone-based conducted, conducted from July 1 through October 30, 2004. A total of 1600 youths and 1589 primary caregiver paired interviews using nearly identical questionnaires were done with an overall response rate of 44.0%.

The Sun Survey assessed the use of sunless tanning products by the adolescents in the past year, along with details about demographics, skin type, attitudes and perceptions of sunless tanning and other sun-related behaviors.

Among the teens surveyed, 10.8% reported using sunless tanning products in the past year. Approximated 14% of their parents used them. Self-reporting teen users tended to be older and female, to perceive a tanned appearance as desirable, to have a parent or caregiver who also used these products and to hold positive beliefs or attitudes about them.

Amazing to me was the finding by the researchers that the teens who used the self-tanners had just as many sunburns the previous summer, were just as likely to use indoor tanning beds, and did not routinely use sunscreen.

The conclusion I draw from this is: Teenagers use self-tanners to augment UV exposure to get (and keep) the level of tan to their skin. Teenagers aren’t thinking about skin cancer.

How do we change this? Gentle nudges as Dr. Luks suggests with exercise. Same thing here – gentle nudges.

Sources
"Use of Sunless Tanning Products Among US Adolescents Aged 11 to 18 Years"; Vilma E. Cokkinides, PhD; Priti Bandi, MS; Martin A. Weinstock, MD, PhD; Elizabeth Ward, PhD; Arch Dermatol. 2010;146(9):987-992. doi:10.1001/archdermatol.2010.220

Get Girls to Focus on Skin’s Appearance

Updated 3/2017 -- photos and all links removed as many no longer active. and it was easier than checking each one.

A study from Joel Hillhouse, Ph.D., of East Tennessee State University, Johnson City, and colleagues has just been published in the May issue of Archives of Dermatology looking at which health-based intervention worked best in reducing skin cancer risks.  They found that “Emphasizing the appearance-damaging effects of UV light, both indoor and outdoor, to young patients who are tanning is important no matter what their pathological tanning behavior status.”

I have used this tack on not just young girls, but middle aged women to try to get them to curtail their tanning habits.  This includes sun and tanning beds.

I have a patient I have known for many years now.  I got her to use sunscreen on her face and neck years ago, but had limited luck with decreasing her sun tanning until recently.  She noticed how much better her face and neck has aged verse her chest/cleavage.  She has also begun having multiple skin cancers removed by her dermatologist (so I guess neither of us had as much influence as we would have liked) from her back, arms, and legs.

This patient’s chest/cleavage skin looks at least 10 years older than her facial skin.  She has finally reduced her sun tanning, but the damage is done.

Damaging effects of tanning bed or sun tanning can led premature aging of the skin giving it a dry, wrinkled, leathery appearance; as well as increase skin cancers (melanomas and non-melanomas). (photo credit)

Tanning beds are not a safer way to get a tan.  Safe sun practices include:

• Plan your outdoor activities to avoid the sun's strongest rays. As a rule, avoid the sun between 10 a.m. and 4 p.m.
• Wear protective covering such as broad-brimmed hats, long pants, and long-sleeved shirts to reduce sun exposure.
• Wear sunglasses that provide 100 percent UV ray protection.
• When outdoors, always wear a broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or greater, which will block both UVA and UVB. Apply the sunscreen 30 minutes before sun exposure and reapply approximately every 1 1/2 to 2 hours.

REFERENCE

Effect of Seasonal Affective Disorder and Pathological Tanning Motives on Efficacy of an Appearance-Focused Intervention to Prevent Skin Cancer; Arch Dermatol. 2010;146[5]:485-491;  Joel Hillhouse, PhD; Rob Turrisi, PhD; Jerod Stapleton, BS; June Robinson, MD

President's Cancer Panel Report

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

While most of the news sources are reporting Cancers from Environment 'Grossly Underestimated' in response to the recently released the 240 page report from the President’s Cancer Panel, I want to focus on the small steps individuals can take to lessen their personal exposure to environmental carcinogens.

Collectively, these individual small actions can drastically reduce the number and levels of environmental contaminants.

• Children are most susceptible to damage from environmental carcinogens. As much as possible, parents and child care providers should choose foods, house and garden products, toys, medicines, and medical test that will minimize the child’s exposure to toxics.

Individuals and families can reduce chemical exposures by:

• Family exposure to numerous occupational chemical can be reduced by removing shoes before entering the home and washing work clothes separately from the other family laundry.
• Filter home tap or well water to decrease exposure to numerous known or suspected carcinogens and endocrine-disrupting chemicals.
• Store and carry water in stainless steel, glass, or BPA-free containers.
• Reduce expose to pesticides by choosing food grown without pesticides and washing produce to remove residues.
• Avoid or minimize consumption of processed, charred, and well-done meats to reduce expose to carcinogenic hydrocarbons.
• Properly dispose of pharmaceuticals, household chemicals, paints, and other materials to minimize drinking water and soil contamination.
• Reduce exposure to secondhand tobacco smoke in your home, car, and public places. If you smoke, then seek help to quit.
• Adults and children can reduce exposure to electromagnetic energy by wearing a headset when using a cell phone, texting instead of calling, and keeping the calls brief.
• Reduce exposure when possible from medical sources, but asking if the test is necessary. In addition, to help limit cumulative medical radiation exposure, consider creating a record of all imaging or nuclear medical tests received along with the estimated radiation dose of each test.
• Adults and children can avoid overexposure to ultraviolet light by wearing protective clothing and sunscreen when outdoors. Avoid exposure when the sunlight is most intense.

Source

National Cancer Institute --- Complete report available (pdf)

Skin Cancer

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

The entire March issue of Archives of Dermatology appears to be dedicated to skin cancer – non-melanoma and melanoma. 

Basal cell carcinoma (BCC) represents 65% to 75% of all skin cancers.  Most occur on sun-exposed parts of the face, ears, scalp, shoulders, and back.   Intense short-term UVB exposure is important in the formation of BCC.

Clinical features include pearly translucent flesh-colored papules or nodules with superficial telangiectasias (broken blood vessels). More active lesions may have rolled edges or ulcerated centers.

Squamous cell carcinoma (SSC) represent 30% to 65% of all cutaneous malignancies.  SCCs are most attributable to UVB exposure, long-term or accumulative exposure over years.

Clinical features include crusted papules and plaques that may become indurated, nodular, or ulcerated. SCC may arise in chronic wounds, scars, and leg ulcers.  Recurrent SCC development within 3 years is 18%, a 10-fold higher incidence compared with initial SCC diagnosis in the general population.

Malignant melanoma (MM) represents the most serious of all cutaneous malignancies.  It is estimated that approximately 65% to 90% are caused by UV exposure, predominantly UVA.  Roughly 10% of all melanoma cases are strictly hereditary.

The ABCD rule outlines the clinical presentation and warning signals of the most common type of melanoma.

• "A" is for asymmetry (one-half of the mole does not match the other half);
• "B" is for border irregularity (the edges are ragged, notched, or blurred);
• "C" is for color (the pigmentation is not uniform, with variable degrees of tan, brown, or black);
• "D" is for diameter greater than 6 mm (about the size of a pencil eraser).

Prevention Tips:

• Children should be taught the correct use of sunscreen.   Sunscreen should be applied to all exposed skin at least 20 minutes before going into the sun, even if it is cloudy outside, and needs to be reapplied every 2 to 3 hours or more frequently if swimming or exercising.   Use at least 1 oz per application, roughly equivalent to the volume of a shot glass.
• Select a product that contains the highest allowable percentage of zinc oxide (25%) and titanium dioxide (25%). Both do not undergo significant chemical change or photodegradation with exposure to UV light.  Avobenzone (3%) is the only truly effective UVA absorber available and offers the greatest photostability.
• Everyone needs to wear a hat and sunglasses with 99% to 100% UVA absorption.
  
• Exposure should be avoided between the hours of 10 AM and 4 PM when the sun is the strongest.  Sun-protective clothing and shade are helpful in avoiding exposure.
  
• There is no such thing as a safe tan.  This includes those gotten in tanning salons.
  

Recent News Stories

Non-Melanoma Skin Cancer Cases Jump:  Dr. Jennifer Ashton Discusses Most Common Cancer, Risk Factors, When to Go to the Doctor

Skin Cancer Epidemic?  -- Dr Sanjaya Gupta, CNN

 

Melanoma Related News:

A mother's inspirational skin cancer battle By Jane Elliott, Health reporter, BBC News

Katie’s Fight  -- the blog of the woman featured in the BBC story

Related blog posts:
Sun Protection (March 19, 2009)
Melanoma Review (February 25, 2008)
Skin Cancer—Melanoma (December 8, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)
Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)
Moles Should Not Be Treated by Lasers  (July 27, 2009)
Tanning Beds = High Cancer Risk (August 3, 2009)

REFERENCES
Incidence Estimate of Nonmelanoma Skin Cancer in the United States, 2006; Arch Dermatol. 2010;146(3):283-287; Howard W. Rogers; Martin A. Weinstock; Ashlynne R. Harris; Michael R. Hinckley; Steven R. Feldman; Alan B. Fleischer; Brett M. Coldiron
Increased Risk of Second Primary Cancers After a Diagnosis of Melanoma; Arch Dermatol. 2010;146(3):265-272.; Porcia T. Bradford; D. Michal Freedman; Alisa M. Goldstein; Margaret A. Tucker
Economic Burden of Melanoma in the Elderly Population: Population-Based Analysis of the Surveillance, Epidemiology, and End Results (SEER)–Medicare Data; Arch Dermatol. 2010;146(3):249-256; Anne M. Seidler; Michelle L. Pennie; Emir Veledar; Steven D. Culler; Suephy C. Chen

Cutaneous Metastatic Carcinoma – an Article Review

Updated 3/2017-- all links removed as many no longer active. and it was easier than checking each one.

Most of us will never see skin metastases from carcinoma in our clinical practices as they are relatively uncommon.  It is estimated that 2% to 9% of patients with internal malignancy may develop cutaneous metastasis.  Often these will herald the diagnosis of the internal malignancy. 

The short article in the Advances in Skin & Wound Care Journal on this topic is a review (full reference below) of the topic.  It comes out of the University of Calabar Teaching Hospital, Calabar, Nigeria.  The authors had six patients with histological diagnosis of cutaneous metastatic carcinoma between 2000 to 2006.   These patients were part of a wider study of cutaneous malignancy. The variables analyzed were age, sex, site of cutaneous metastasis, clinical presentation, site of primary tumor, and outcome. This was compared with total cutaneous and total malignancy.

Six cutaneous metastatic carcinomas during this period of study comprised 6.5% of total cutaneous cancer and accounted for 0.6% of total malignancy. The patients included 2 men and 4 women (male-female ratio = 1:2), and their ages ranged from 37 to 55 years (mean, 45.2 years). No patients with these lesions were in the first 3 decades of life, and the 6 patients who had these lesions were between the fourth and sixth decades.

The involved anatomic areas of the skin metastasis were chest (3), neck, anterior abdominal wall, and vulva.  The primary cancers were breast (ductal) in two of the chest lesions.  One of the chest lesion patients was lost to follow up prior to diagnosis of the primary. 

The patient with the neck skin lesion’s primary turned out to be nasopharyngeal carcinoma.  The patient with the anterior abdominal skin involvement primary was suspected to be gastrointestinal but he was lost to follow up during the evaluation.  The vulval skin lesion patient’s primary turned out to be choriocarcinoma of the uterus.

 

The second reference below gives a much fuller review of the topic and is referenced in the first article.

The breast, stomach, lung, uterus, large intestine, and kidneys are the most frequent organs to produce cutaneous metastases. Cancers that have the highest propensity to metastasize to the skin include melanoma (45% of cutaneous metastasis cases), breast (30%), nasal sinuses (20%), larynx (16%), and oral cavity (12%). Because breast cancer is so common, cutaneous metastasis of breast cancer is the most frequently encountered type of cutaneous metastasis in most clinical practices. Although some tumors are very common, they may not necessarily eventuate in metastasis in a manner that parallels their incidence in the overall population. For example, prostate cancer is very common, but cutaneous metastasis from prostate carcinoma is relatively uncommon……..

The mortality rate is high in patients with cutaneous metastases. The appearance of cutaneous metastases signals widespread metastatic disease, resulting in a poor prognosis. Patients often survive for a short period, depending on the type of carcinoma, but this is changing. Exciting advances in chemotherapy have greatly increased survival in recent years.

REFERENCE

Cutaneous Metastatic Carcinoma: Diagnostic and Therapeutic Values; Advances in Skin & Wound Care. 23(2):77-80, February 2010; Asuquo, Maurice E.; Umoh, Mark S.; Bassey, Ekpo E.

Metastatic carcinoma of the skin; eMedicine, August 14, 2008; Helm TN, Lee TC. (last accessed Feb 17, 2010)

Malignant Melanoma, "FDR's Deadly Secret"

Earlier today I wrote a short article which resulted in correspondence with one of the authors of the new book, 'FDR's Deadly Secret' by Steven Lomazow and Eric Fettmann.

Dr. Steven Lomazow sent me a copy of his Archives of Dermatology article with Dr. Bernard Ackerman, this photo, and a pdf of his book which I have spent the afternoon reading.

The article goes through a series of photos of FDR from his younger days to his older ones, showing the progression and changes. From the article:

The criteria currently touted for diagnosis of a slightly raised lesion of melanoma, a malignant neoplasm composed of abnormal melanocytes, are the "ABCDEs": Asymmetry, Border irregularity, Color variability, Diameter greater than 6 mm, and Elevation (or, for some proponents of the mnemonic, Enlarging or Evolving). The fully developed pigmented lesion above Roosevelt's left eyebrow admirably fulfills those criteria. But the ABCDEs also are encountered from time to time in a disparate variety of other pigmented lesions of the skin, among them being solar lentigo/seborrheic keratosis, melanocytic nevi of different kinds, and pigmented basal cell carcinoma.

The book is a “medical biography of Franklin D. Roosevelt. It presents a strong circumstantial case, backed by surviving medical records and analysis, that Roosevelt did indeed have cancer – melanoma, to be exact, originating in the pigmented lesion above the eye – that eventually spread to his brain and his abdomen. In other words, the cerebral hemorrhage that struck him down less than a month before V-E Day was not a “bolt out of the blue,” as his doctors contended, but the inevitable result of a deadly illness, compounded by catastrophic heart problems.”

Steven Lomazow and Eric Fettmann have done a great job with their book. I have enjoyed it immensely. Anyone who likes medical history will enjoy this book. Chapter 6 is entitled “The Brown Blob” and discusses the skin lesion seen in the photo above.

Back in FDR’s time, there were only two types of treatment for melanoma: surgery and radiation.

You may also like to check out Dr Lomazow’s blog: Magazine History: A Collector’s Blog.

For those of you who need to be educated regarding melanoma:

• Melanoma is the most serious form of skin cancer. If caught early, it is curable. If not, it becomes hard to treat and can be fatal.
• Melanoma accounts for less than 5% of all skin cancers, but accounts for the approximately 74% of all deaths from skin cancers.
• Melanoma metastasizes to the brain more than any other cancer. Of all the patients who die from melanoma, 90% will have brain metastases.
• Melanoma also metastasizes to the intestinal system more than any other tumor. Three cases in five metastasize to the small intestine.
• The American Cancer Society estimates that in 2009, there will be 8,650 fatalities in the U.S. The number of new cases of invasive melanoma is estimated at 68720. Overall, the lifetime risk of getting melanoma is about 1 in 50 for whites, 1 in 1,000 for blacks, 1 in 200 for Hispanics.

For many years, the early warning signs of melanoma have been identified by the acronym "ABCDE" (A stands for Asymmetry, B stands for Border, C for Color, D for Diameter and E for Evolving or changing was recently added.).

A new concept of the “ugly duckling” has been added to pick up the melanomas that don’t fit the ABCDE rule. This new method of sight detection for skin lesions is based on the concept that these melanomas look different -- ie, "the ugly duckling" -- compared to surrounding moles.

For early detection of melanoma, look for lesions that manifest the ABCDE's AND for lesions that look different compared to surrounding moles.

For more information on malignant melanoma:
National Cancer Institute
eMedicine
The Skin Cancer Foundation

REFERENCE

An Inquiry Into the Nature of the Pigmented Lesion Above Franklin Delano Roosevelt's Left Eyebrow; Arch Dermatol, Apr 2008; 144: 529 - 532; A. Bernard Ackerman; Steven Lomazow

Skin Cancer: More than Skin Deep – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

It’s winter so why think about skin cancer?   One of the major risk factors is UVA and UVB rays from sun exposure which is much more common in the summer.  Tanning beds never cease being used, regardless of season and may even be used more in the winter than summer.

There is never a wrong season to be reminded of the prevalence of skin cancer or the risk factors for skin cancer or ways to prevent skin cancer.

Having read this short article (full reference below) in the “throw away” December issue of the journal Advances in Skin & Wound Care it seemed a good time to again discuss skin cancer.  The article is a good overview of skin cancer which is the most common carcinoma in the United States.  The article quotes statistics from the American Cancer Society:

Statistics show that 1 in 5 Americans and 1  in 3 whites will develop skin cancer in their lifetime; 1 person dies of melanoma almost every hour.

The American Cancer Society (ACS) predicted an excess of 1.1 million new cases of cutaneous malignancy ending in 11,200 deaths in 2008.

The ACS predicted 62,480 new melanoma cases diagnosed in the United States in 2008, resulting in 8420 deaths.

The article gives a brief overview of skin changes seen with Actinic keratoses (AKs), basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM).

Actinic keratoses are precancerous or precursor lesions to 10% of SCCs.

Scaly lesions on sun-exposed skin that do not respond to moisturizers, itch, or bleed with minimal provocation need medical attention. The length of time for an AK to progress to an SCC can be as early as 24.6 months.

Basal cell carcinoma (BCC) represents 65% to 75% of all skin cancers.  Most occur on sun-exposed parts of the face, ears, scalp, shoulders, and back.   Intense short-term UVB exposure is important in the formation of BCC.

Clinical features include pearly translucent flesh-colored papules or nodules with superficial telangiectasias (broken blood vessels). More active lesions may have rolled edges or ulcerated centers.

Squamous cell carconoma (SSC) represent 30% to 65% of all cutaneous malignancies.  SCCs are most attributable to UVB exposure, long-term or accumulative exposure over years.

Clinical features include crusted papules and plaques that may become indurated, nodular, or ulcerated. SCC may arise in chronic wounds, scars, and leg ulcers.  Recurrent SCC development within 3 years is 18%, a 10-fold higher incidence compared with initial SCC diagnosis in the general population.

Malignant melanoma (MM) represents the most serious of all cutaneous malignancies.  It is estimated that approximately 65% to 90% are caused by UV exposure, predominantly UVA.  Roughly 10% of all melanoma cases are strictly hereditary.

The ABCD rule outlines the clinical presentation and warning signals of the most common type of melanoma.

"A" is for asymmetry (one-half of the mole does not match the other half);

"B" is for border irregularity (the edges are ragged, notched, or blurred);

"C" is for color (the pigmentation is not uniform, with variable degrees of tan, brown, or black);

"D" is for diameter greater than 6 mm (about the size of a pencil eraser).

Some clinicians now include "E" regarding evolution, elevation, or enlargement of a lesion

The article very briefly touches on management, but devotes more space to prevention and need for continued education of the public.

A key determinant of skin cancer in adulthood is the exposure to UV as a child. Sun protection messages should be linked with other health promotion messages targeting children

Prevention Tips:

• Children should be taught the correct use of sunscreen.
• Select a product that contains the highest allowable percentage of zinc oxide (25%) and titanium dioxide (25%). Both do not undergo significant chemical change or photodegradation with exposure to UV light. Avobenzone (3%) is the only truly effective UVA absorber available and offers the greatest photostability.
• Sunscreen should be applied to all exposed skin at least 20 minutes before going into the sun, even if it is cloudy outside, and needs to be reapplied every 2 to 3 hours or more frequently if swimming or exercising.
• Use at least 1 oz per application, roughly equivalent to the volume of a shot glass.
• Everyone needs to wear a hat and sunglasses with 99% to 100% UVA absorption.
• Patients should be instructed to avoid exposure between the hours of 10 AM and 4 PM when the sun is the strongest, wear sun-protective clothing, and seek shade whenever possible.
• There is no such thing as a safe tan.  This includes those gotten in tanning salons.

Related posts:
Sun Protection (March 19, 2009)
Melanoma Review (February 25, 2008)
Skin Cancer—Melanoma (December 8, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Skin Cancer -- Basal Cell Carcinoma  (December 3, 2008)
Skin Cancer – Squamous Cell Carcinoma  (December 4, 2008)
Moles Should Not Be Treated by Lasers  (July 27, 2009)
Tanning Beds = High Cancer Risk (August 3, 2009)

REFERENCES

Skin Cancer: More than Skin Deep; Advances in Skin & Wound Care. 22(12):574-580, December 2009.; doi: 10.1097/01.ASW.0000363470.25740.a2; Gordon, Randy M.

New Breast Cancer Screening Guidelines

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Yesterday,  the U.S. Preventive Services Task Force’s announced it’s new recommendations for Screening for Breast Cancer (November 2009).  The uproar has been loud and mostly against. 
The summary of the USPSTF’s recommendations:

• Recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
• Recommends biennial screening mammography for women aged 50 to 74 years.
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
• Recommends against teaching breast self-examination (BSE).
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
• Concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

If you recall some of the recent discussions regarding over-diagnosis  of breast cancers and the resulting harm done by the increased radiation, biopsies, and surgeries then it is easier to understand the task forces conclusions.  There has been an estimated 52% over-diagnosis of breast cancer in a populations of women who are offered organized mammography screening.  That amounts to one in three breast cancers being over diagnosed.

My personal feeling is that anyone with a family history of breast cancer should begin getting mammograms at 10 years earlier than the age when their mother was diagnosed with breast cancer.  There will always be “outliers” like the 10 year girl diagnosed with breast cancer. 

I do not agree with not teaching breast self-examination.  I think every woman/man should be familiar with their bodies.

Here are links to some of the responses to the USPSTF’s recommendations.  Some of the comments are as enlightening as the stories.

• Response of The American College of Obstetricians and Gynecologists to New Breast Cancer Screening Recommendations from the U.S. Preventive Services Task Force, November 16, 2009
• M. D. Anderson Maintains Mammogram Recommendations, November 16, 2009
• Will patients accept the new, evidence-based, breast cancer screening guidelines? by KevinMD, November 17, 2009
• Does number needed to treat help with rational decision-making? by Marya Zilberberg, November 17, 2009
• Panel Puts Off Mammography until Age 50; MedPageToday, November 16, 2009
• Mammography Screening: Are the New Guidelines Rationing by Dr Susan Love, November 16, 2009
• USA TODAY Forum: Breast cancer survivors sound off on new mammogram advice, moderated by @LizSzabo
• Susan G. Komen for the Cure® Recommends No Impediments to Breast Cancer Screening, November 16, 2009
• Breast Self-Examinations: What’s Wrong With Them? by Shirley S. Wang; Wall Street Journal Blog; November 16, 2009
• Breast-Screening Advice Is Upended by Shirley S. Wang, Wall Street Journal, November 17, 2009

Prevalence of Persistent Pain Following Breast Cancer Surgery – Article Review

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Rune Gärtner, MD, of the University of Copenhagen, and colleagues have done a population-based study on persistent pain following surgical treatment in breast cancer patients.  It was published in the Nov. 11 issue of the JAMA.  Their goal was to examine the prevalence, associated factors, and severity of chronic pain and sensory disturbances after surgery for breast cancer.  See the reference below.

Persistent pain following surgical treatment for breast cancer can be a significant problem for nearly half of all breast cancer survivors.  Younger women and those who have an axillary lymph node dissection are most at risk.

Persistent pain after breast cancer surgery  is often due to multiple mechanisms, including nerve damage related to surgical technique resulting in risk of intercostobrachial neuralgia, neuroma pain, or phantom breast pain.  

The researchers used a nationwide cross-sectional questionnaire study of 3754 women aged 18 to 70 years who received surgery and adjuvant therapy (if indicated) for primary breast cancer in Denmark between January 1, 2005, and December 31, 2006.  The study questionnaire was sent to the women between January and April 2008.  None reported a breast cancer recurrence or other malignancy since the initial treatment.

Findings

A total of 1543 patients (47%) reported pain in 1 or more areas, of which 201 (13%) reported severe pain (scores of 8-10 on the numeric rating scale of 0-10 scores), 595 (39%) reported moderate pain (scores of 4-7), and 733 (48%) reported light pain (scores of 1-3). Fourteen patients (1%) did not rate severity of pain. Among those patients reporting pain, the mean pain score in the 4 different areas varied between 3.5 and 4.0 (range, 0-10). Among women reporting severe pain, 77% experienced pain every day, whereas only 36% of women experiencing light pain had pain every day.

Of patients reporting pain, 306 (20%) had contacted a physician within the prior 3 months due to pain, 439 (28%) had taken analgesics due to pain in the surgical area, and 397 (26%) had received other treatments for pain (ie, physiotherapy, massage). A total of 1265 women (40%) reported pain in other parts of the body/nonsurgical areas (eg, low back pain, headache). Pain complaints in nonsurgical areas were associated with a higher incidence of chronic postoperative pain because 810 women (65%) had pain in the surgical regions, whereas 674 women (37%) without pain in the nonsurgical area had pain in the surgical area (P < .001)

The most common site of pain was the breast area (86%), followed by the axilla (63%), arm (57%), and side of the body (56%).

A total of 1265 women (40%) reported pain in other parts of the body/nonsurgical areas (eg, low back pain, headache). Pain complaints in nonsurgical areas were associated with a higher incidence of chronic postoperative pain because 810 women (65%) had pain in the surgical regions, whereas 674 women (37%) without pain in the nonsurgical area had pain in the surgical area.

Factors that predicted persistent pain were age younger than 40  (OR 3.62), axillary lymph node dissection (OR 1.77 versus sentinel lymph node dissection), and radiotherapy (OR 1.50 to 1.35).

Sensory disturbances  can include allodynia, aftersensations, burning, or sensory loss, and appear linked to chronic pain.

Conclusions

Based on the results of our study together with previously reported findings, chronic pain after breast cancer surgery and adjuvant therapy may predominantly be characterized as a neuropathic pain state and probably related to intraoperative injury of the intercostal-brachial nerve. In accordance with these findings, preliminary observations with nerve-sparing techniques may suggest such approaches to reduce the risk of developing a chronic neuropathic pain state. ………

So far, analgesic and other interventions with paravertebral blocks, topical capsaicin, gabapentin and local anesthetics, N-methyl-D-aspartate–receptor antagonists,  or glucocorticoids may suggest certain benefits, but large-scale studies including well-characterized relevant subpopulations are required before general recommendations can be made. …..

REFERENCES

Prevalence of and factors associated with persistent pain following breast cancer surgery; JAMA 2009; 302: 1985-92.; Gärtner R, et al

Evaluating patients with chronic pain after breast cancer surgery: The search for relief; JAMA 2009; 302: 2034-35.; Loftus LS, Laronga C