Inefficacy of extracorporeal photochemotherapy in the treatment of B-cell chronic lymphocytic leukemia: preliminary results

Because extracorporeal photopheresis has been shown to be clinically effective in Sezary syndrome, a disease characterized by a circulating malignant clone, we initiated a pilot study of its use in B-cell chronic lymphocytic leukemia (B-CLL) to see if it could be similarly effective. We treated three patients with Rai stage III and IV B-CLL with photopheresis (3 consecutive days a week every 3 weeks) and followed serial clinical and immunologic parameters. While we noted no major toxicity, there was neither clinical response to treatment nor marked improvement in white counts or mitogen assays. We conclude that photopheresis was not effective in inducing remission in this pilot study of advanced stage B-CLL patients.

Who discovers melanoma? Patterns from a population-based survey

BACKGROUND

Melanoma is external and potentially detectable by many persons but little is known about who first discovers these lesions. An understanding of discovery patterns can shape future public and professional education programs.

OBJECTIVE

Our purpose was to assess patterns of melanoma discovery and to determine the patients' role in finding their own lesions.

METHODS

With a written, mailed questionnaire, we conducted a population-based statewide survey of 216 incident cases of melanoma in Massachusetts.

RESULTS

Approximately half (53%) of melanomas were self-discovered, whereas the remainder were detected by medical providers (26%), family members (17%), and others (3%). Nearly one third of persons said they could not see their own lesions easily. Compared with men, women were more likely to discover their own lesions (66% vs 42%, p = 0.001) and those on their spouses (23% vs 2%, p less than 0.001).

CONCLUSION

Improving early detection and reducing mortality of melanoma will require both public and professional education programs, with particular emphasis on targeting men at highest risk of this disease.

Practices and beliefs concerning screening family members of patients with melanoma. Results of a survey of New England dermatologists

BACKGROUND

First-degree relatives of patients with melanoma are roughly two to eight times more likely than the general public to be diagnosed with melanoma. Several organizations recommend regular screening for these and other persons at high risk for melanoma. However, there are no data as to how frequently such persons receive skin cancer examinations.

OBJECTIVE

Our purpose was to determine the current screening recommendations and practices of dermatologists regarding family screening for melanoma.

METHODS

With a one-page questionnaire, we surveyed dermatologists attending a 1989 meeting of the New England Dermatological Society.

RESULTS

Seventy-three dermatologists completed the questionnaire. Most dermatologists (70%) reported that they encouraged screening of family members of patients with melanoma but also reported that family members infrequently appeared for skin examinations.

CONCLUSION

Although most dermatologists encouraged screening of first degree relatives of melanoma patients, there appears to be infrequent acceptance by the patient of these recommendations. Recording family screening in the patients' charts, reminders to patients, and distributing literature on familial melanoma may increase acceptance by the patient of these recommendations.

Use of health services before the diagnosis of melanoma: implications for early detection and screening

OBJECTIVE

To determine whether persons with melanoma were integrated into the health care system prior to diagnosis.

DESIGN

Population-based survey by mailed questionnaire.

PATIENTS/PARTICIPANTS

216 persons with malignant melanoma diagnosed in Massachusetts in 1986.

MAIN RESULTS

Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported physician skin examinations.

CONCLUSIONS

Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However, most of these persons neither received skin examinations nor examined their own skin during that time. While additional study is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate melanoma screening into routine care.

Epidemiology of cutaneous melanoma. An update

Dramatic increases in melanoma incidence and more moderate increases in the death rate have been observed. Although paradoxes exist, most, but not all, melanomas appear to be related in some way to solar exposure and genetic factors. No other exogenous factor has been strongly implicated.

Can screening for melanoma and skin cancer save lives?

Although screening for melanoma and skin cancer is theoretically appealing, too few data exist to evaluate its effectiveness. The rising incidence and mortality rates of melanoma and the continued incurability of metastatic disease underscore the desperate need for effective screening. The extraordinary incidence of NMSC is a public health problem, but the value of screening for NMSC has not been established. The AAD screening program offers an opportunity to obtain critical data. Further research must make our screenings more effective and efficient. We need rigorous design and evaluation of all screening efforts. In the absence of a randomized controlled trial, other design measures, with careful tracking of incidence and mortality, are critical to assessing whether screening for melanoma and skin cancer can reduce morbidity and save lives.

Systematic underreporting of cutaneous malignant melanoma in Massachusetts. Possible implications for national incidence figures

An independent tabulation of incidence of cutaneous malignant melanoma in Massachusetts indicates that 12% and perhaps as many as 19% of new cases of cutaneous malignant melanoma in Massachusetts are not recorded in the Massachusetts Cancer Registry, significantly more than the expected 5% (p = 0.0001). The increasing number of nonhospital medical settings in which melanomas can be diagnosed and/or treated appears to account for this discrepancy. We suspect that these findings in Massachusetts also apply to cancer reporting systems in other regions of the United States. We suggest that the true incidence of cutaneous malignant melanoma in Massachusetts, and perhaps in the United States, may be significantly higher than reported.

Who is being screened for melanoma/skin cancer? Characteristics of persons screened in Massachusetts

We conducted a survey of persons who voluntarily attended melanoma/skin cancer screenings in Massachusetts in 1987. Of 1219 persons asked to fill out a questionnaire, 1116 (92%) completed it. Our study demonstrates that persons attending the melanoma/skin cancer screening program were, for the most part, at risk for the disease and appropriately selected themselves to be screened. Most were women, well educated (with college or advanced degrees), and white. More than 86% had at least one risk factor for melanoma/skin cancer whereas 78% had at least two risk factors. Future studies are necessary to determine whether our experience can be verified. Additional efforts should try to attract those who are at risk but perhaps are less willing to attend screening programs--men and those of lower socioeconomic status. These efforts can help target screening to those at highest risk and maximize the yield of these public health efforts.

Advances in screening protocols for the detection of early bladder cancer

Bladder cancer screening faces several obstacles, including low yield, numerous false-positive results, and the absence of a single effective screening test. We present a model of a screening program that (1) targets an occupational cohort exposed to a putative carcinogen, to increase the detection of disease, (2) uses four screening tests in parallel to maximize case detection, and (3) defines a diagnostic protocol that minimizes the number of invasive procedures by utilizing both flexible and rigid cystoscopy. In a hypothetical cohort of 1000 men aged 45 to 74 years potentially exposed to a bladder carcinogen, the model would find eight of the nine detectable cancers, with a sensitivity of 89% and a specificity of 78%. In addition, the model allows the sensitivities, specificities, and predictive values of the individual screening tests to be compared and evaluated in a single cohort.

Years of potential life lost: another indicator of the impact of cutaneous malignant melanoma on society

Years of potential life lost (YPLL) is an indicator of premature mortality that complements traditional incidence and mortality rates and that facilitates comparisons among different cancers. We calculated YPLL from cutaneous melanoma and 11 other cancers routinely recorded and tracked by Surveillance, Epidemiology and End Results (SEER). YPLL from cutaneous melanoma ranked eighth for persons younger than 65 years of age and fourth for those 20 to 49 years of age. An average of 17.1 YPLL per death were due to melanoma, one of the highest rates for adult-onset cancers. The results of our study, the first to apply YPLL to cutaneous melanoma, emphasize the disproportionate impact of this cancer on young and middle-aged adults and reemphasize the importance of this cancer as a public health priority.

Use of health services before diagnosis of head and neck cancer among Boston residents

One hundred thirty incident cases of head and neck cancer in Boston between September 1, 1985, and March 31, 1988, provided interview or medical record review data on the use of health services in the 24 months preceding the diagnosis of cancer. One hundred twenty-four subjects were able to recall whether and how often they visited health care sites in this period, reporting a median number of 10.5 visits; 94% recalled at least one visit. Eighty-nine medical record reviews indicated a median of seven visits. For the most part, these visits were to providers whom subjects considered their regular source of care--sources that provided care in a broad range of locations. These data support a strategy of integrating screening for head and neck cancers into existing health care services.

Sézary syndrome: diagnosis, prognosis, and critical review of treatment options

Sézary syndrome is a form of leukemia-lymphoma characterized clinically by erythroderma, pruritus, adenopathy, and circulating atypical cells with cerebriform nuclei. Histologically, atypical lymphocytes in the dermis and Pautrier's microabscesses are often present in skin biopsy specimens. Immunologic findings that support a diagnosis of Sézary syndrome include a predominance of CD4+ lymphocytes in both skin biopsy specimens and peripheral blood. Cytogenetic studies that demonstrate aneuploidy and DNA probe analysis that shows gene rearrangement for the beta-subunit of the T cell receptor are the latest, most sensitive, and specific methods for identifying the clonal nature of the disease. Various staging systems are used. We review the various treatments for Sézary syndrome, including the newer, biologically based investigational therapies, (e.g., antithymocyte globulin, monoclonal antibodies and other immunostimulants, retinoids, cyclosporine, interferon, and extracorporeal photopheresis). Extracorporeal photopheresis and some chemotherapeutic agents appear to produce the best results in terms of response and remission duration with minimal toxicity. However, more multicenter controlled clinical trials are needed to determine the most effective single or combined therapeutic regimen.

Evaluation of melanoma/skin cancer screening in Massachusetts. Preliminary results

Although screening for melanoma/skin cancer is theoretically of value, few data are available to evaluate its effectiveness or the value of a visual exam by a dermatologist as a cancer screening tool. From the 2560 persons screened for melanoma/skin cancer in Massachusetts in 1986 and 1987, the authors followed the positive screenees to determine their final diagnosis. The authors obtained information on 85% of these persons, and found nine malignant melanomas, 91 non-melanoma skin cancers, 39 dysplastic nevi, and three congenital nevi. The sensitivity of the visual exam by a dermatologist was 89% to 97% and the predictive value positive was 35% to 75% for skin cancer. The authors conclude that the yield of screening is equivalent to that of other major cancer screening efforts and that the sensitivity and predictive value of the visual examination by the dermatologist is appropriate for a cancer screening tool.

Nonsecretory multiple myeloma in a 26-year-old man with acquired immunodeficiency syndrome, presenting with multiple extramedullary plasmacytomas and osteolytic bone disease

High grade B-cell lymphoma and leukemia have been well described in patients with the acquired immunodeficiency syndrome (AIDS). Malignant transformation of more differentiated lymphoid cells has not been well described in these patients. We report a 26-year-old man with AIDS-associated multiple myeloma, who had a highly unusual presentation and clinical course. A review of the literature indicates that monoclonal gammopathy in patients seropositive for the human immunodeficiency virus (HIV) is common. Multiple myeloma and extramedullary plasmacytomas, diseases that are extraordinarily rare in young persons, are now being reported in patients with AIDS and should be added to the list of neoplastic diseases now associated with HIV infection.

Malignant melanoma: early detection and treatment

The primary care physician has a critical role in the early detection and cure of malignant melanoma. We present an overview of melanoma epidemiology, offer guidelines for recognition of melanoma and its precursors, review prognosis and staging, and describe the latest developments in surgical and medical treatment.

Screening for melanoma/skin cancer: theoretic and practical considerations

There is increasing national interest concerning strategies for the early detection of melanoma/skin cancer. Screening has been implemented on a national scale in an effort to decrease morbidity and mortality from this disease; however, many crucial questions about the proper methods and ultimate value of screening remain unanswered. In this review we apply the scientific principles of cancer screening to dermatology, address the theoretic and practical challenges of cancer screening in terms of melanoma/skin cancer, analyze existing data on skin cancer screening, and identify issues that require future research.

Malignant melanoma and pigmented lesions: a review

We have described the epidemiology and clinical characteristics of malignant melanoma and its precursors in the hope that this discussion will help physicians to recognize suspicious pigmented lesions earlier, thus helping to decrease avoidable cancer deaths from melanoma.

Malignant fibrous histiocytoma arising from discoid lupus erythematosus

While the association of discoid lupus erythematosus (DLE) and subsequent squamous cell carcinoma is well known, there are no reports in the English-language literature concerning the association of DLE and soft-tissue sarcoma. We describe a patient with DLE and malignant fibrous histiocytoma.

Ocular abnormalities associated with cutaneous melanoma and vitiligolike leukoderma

Several varieties of ocular pathology are associated with acquired cutaneous hypomelanosis (leukoderma; vitiligo). Our current study was undertaken to investigate the relationship between ophthalmologic disorders and a specific depigmentary phenomenon, the vitiligolike leukoderma of cutaneous melanoma. Over the past 14 years, eight patients with cutaneous melanoma and widespread areas of hypopigmentation were identified at the Pigmented Lesion Clinic of the Massachusetts General Hospital. The seven patients who underwent ophthalmologic examination had pigment-related ocular abnormalities. Among these were inflammations of the uveal tract in three patients, heterochromia in two, halo nevi of the choroid in one, and hypopigmentation and/or atrophy of the retinal pigment epithelium or choroid in four. Our findings demonstrate that ocular disease may be a component in a syndrome consisting also of cutaneous melanoma and vitiligolike leukoderma and suggest the need for complete ophthalmologic examinations in patients with melanoma and leukoderma.

Prognosis of clinical stage I melanoma patients with positive elective regional node dissection

We tested 12 clinical and histologic variables to see which ones best predicted death from melanoma in 66 patients with positive elective regional node dissections (clinical stage I, pathologic stage II [CSI, PSII]). Despite the presence of lymph node metastases, not all patients had poor prognoses. Patients with tumors less than or equal to 3.5 mm and a percentage of positive nodes less than or equal to 20% had a 7-year survival rate of 66%. Within this low-risk group the subset with primary lesions on the trunk or extremities (except hands and feet) had a 7-year survival rate of 76%. This compares with poor 7-year survivals of 29% and 30% observed in other defined high-risk groups. Our results confirm and extend earlier observations concerning the prognoses of CSI, PSII melanoma patients and are relevant to any ongoing and future studies concerning elective regional node dissection (ERND) or adjuvant therapy trials in melanoma.

Influence of estrogen administration on tumor characteristics and survival in women with cutaneous melanoma

A prospective study on 289 women with clinical stage I cutaneous melanoma was done to determine the relationship between estrogen administration, tumor characteristics, and survival. Eighty-two women took oral contraceptives (OC) and 44 took menopausal estrogens (MPE) prior to the diagnosis of melanoma. Users of OC presented with thinner primary tumors than nonusers of OC (P less than .01). A similar trend was observed in users of MPE. Women who used OC in the year prior to the diagnosis of melanoma had statistically thinner tumors than those who had discontinued use of OC more than 1 year prior to diagnosis (P less than .025). A statistically significant preponderance of truncal lesions was observed among users of OC (P less than .01). Other tumor characteristics were unaltered by estrogen administration. Duration of use and time in relation to diagnosis of melanoma did not affect survival. Women who took hormones had slightly better 5- and 9-year survival rates than nonusers. These results suggest that prior estrogen use and, particularly, use of OC in women developing melanoma have no deleterious effect.

Epidemiology of cutaneous melanoma

Although intermittent intense solar exposure and genetic traits such as fair skin continue to be associated with the risk of developing cutaneous melanoma, these factors fail to account for much of the incidence. Suggestive evidence has increased speculation that viral agents, radiation, hormones, chemicals in the workplace, and dietary factors play some etiologic role.

Adjuvant therapy of cutaneous malignant melanoma: a critical review

The emergence of revised definitions for the high-risk patient with cutaneous malignant melanoma prompts us to re-examine the current status of adjuvant therapy in this disease. We wish to address the question, "once a cutaneous melanoma is surgically removed and the patient is currently free of disease but at high risk for metastases, what can be done to prevent recurrence"?

Prognosis in Stage 1 malignant melanoma: seven-year follow-up study of splenic radiocolloid uptake as predictor of death

In an earlier study we found that patients with clinical Stage 1 and 2 cutaneous malignant melanoma and increased splenic radiocolloid uptake had more frequent recurrence at 24 mo, compared with melanoma patients having normal liver-spleen scintigrams. This report, an 80-mo follow-up study, gives further information on 119 clinical Stage 1 patients. Fifteen of 35 patients with increased splenic uptake (42.9%) died from melanoma as opposed to only 16 of 84 (19.1%) with normal liver-spleen images (p less than 0.01). Multivariate analysis showed that augmented splenic uptake of technetium-99m sulfur colloid is a marker for adverse prognosis in patients with malignant melanoma but does not appear to be an independent variable in predicting death. In clinical Stage 1 patients, increased splenic uptake correlated significantly with pathologic stage (positive elective node biopsy) as well as thickness and mitotic rate in patients with thicker lesions. It may be that patients with thicker, pathologically aggressive tumors have an increased splenic blood flow and/or enhanced immune and reticuloendothelial response (as manifested by abnormal liver-spleen scintigram). If so, the enhanced immune response does not appear to contribute to overall survival.

Lentigo maligna melanoma has no better prognosis than other types of melanoma

We studied 48 patients with lentigo maligna melanoma (LMM) and compared the clinical stage I patients with non-LMM melanoma patients (matched by site and thickness) to see if prognosis differed. There was no significant difference in mortality from melanoma between the two groups (P = .68) after a mean follow-up time of five years (67.5 months for LMM, 60.5 months for non-LMM). In addition, a Cox multivariate analysis of the entire matched group showed that only thickness was significantly associated with death from melanoma (P = .0007) while histology (LMM v non-LMM) did not make a significant contribution (P = .61). Our data suggest that after accounting for primary tumor thickness and site, LMM and non-LMM have the same prognosis and biologic behavior, in contrast to the widely held belief that LMM has a better prognosis than other forms of melanoma.

Cigarette smoking and malignant melanoma. Prognostic implications

Heavy cigarette smoking (current smoking with greater than 15-pack-year smoking history), along with 13 other variables, were tested for their ability to predict death in 196 patients with clinical Stage I melanoma. A stepwise proportional hazards general linear model (Cox multivariate analysis) showed that although heavy cigarette smoking as a single variable is an adverse prognostic marker (P = 0.0065), it has only suggestive prognostic significance once thickness factors are taken into account (P = 0.0747). People who stopped smoking had the same survival as nonsmokers. Clinical Stage I patients with melanoma who were heavy smokers presented with thicker lesions than their nonsmoking counterparts (P = 0.037). Although cigarette smoking may play a role in the biologic behavior of melanoma by mediating an effect on thickness, it need not be considered as an independent stratification criterion when analyzing results of melanoma prognosis or treatment.

Late recurrence (beyond ten years) of cutaneous malignant melanoma. Report of two cases and a review of the literature

Two patients experienced a recurrence of cutaneous malignant melanoma more than ten years after initial diagnosis, treatment, and presumed cure. A review of the literature shows that delayed metastases (more than ten years) have been clearly documented in only seven previous patients with cutaneous malignant melanoma. With the rising incidence of cutaneous malignant melanoma, physicians may begin to see more cases of late recurrence in patients with a history of presumably cured disease. Although uncommon, late recurrence has important implications in the long-term management of all patients with malignant melanoma.