Malignant Melanoma Healed with Natural Therapies

How To Prevent Skin Cancer

How To Prevent Skin Cancer

Complete Guide to Preventing Skin Cancer. We all know enough to fear the name, just as we do the words tumor and malignant. But apart from that, most of us know very little at all about cancer, especially skin cancer in itself. If I were to ask you to tell me about skin cancer right now, what would you say? Apart from the fact that its a cancer on the skin, that is.

Get My Free Ebook

How I Survived Malignant Melanom

By The Time You've Finished Reading How I Survived Melanoma Skin Cancer Seven Survivors Tell Their Stories. You'll Feel Like A New Person, with A New, More Positive Outlook! You will learn: 1. How do I know if I have melanoma? What are the signs and symptoms? I wanted to know why the doctor was so concerned when she looked at that little mole on my forearm. What was it that looked so sinister? How worried should I be? Was the doctor over-reacting? 2. What tests will the doctor carry out to see if I have melanoma? Will they be able to tell me on the spot if there is a problem? Or will I have to wait for days, fretting about whats going on? 3. How curable is melanoma? If they do tell me its melanoma, what exactly does that mean? Is it a death sentence? Will they tell me You have 12 months to live. Get your life in order and prepare for the worst.? 4. What are the stages of the disease? The reading Id done said that there were different stages of melanoma. What are the symptoms of each stage? What are the survival rates of each stage? If I had a later stage melanoma, wouldnt I know about it? Wouldnt I actually feel like I was sick? 5. How quickly does the disease progress or spread? Should I have gone to the doctor sooner? Id noticed the mole changing over about 3 months. Was this delay critical? 6. How is melanoma normally treated? Would I have to go through chemotherapy and radiation treatment? If so, for how long? What are the odds of curing the disease using these treatments? How extensive is any surgery likely to be? How big will the scars be? 7. What are the common side effects of the treatments? Would I lose my hair? Would I become sterile? What else could I expect? 8. What alternative treatments are available? Id heard of people going on special macro-biotic diets. Id seen lots of herbal remedies on the internet. Which of these are proven and documented, and which ones are snake oil? Is it possible to combine alternative treatments with surgical other western treatments? How do I find a doctor that is open to using both alternative and western treatments? 9. What are the latest treatments being developed, and who is carrying out clinical trials of these new treatments?

How I Survived Malignant Melanom Summary


4.6 stars out of 11 votes

Contents: EBook
Author: Daryl Grant
Price: $39.00

My How I Survived Malignant Melanom Review

Highly Recommended

I usually find books written on this category hard to understand and full of jargon. But the writer was capable of presenting advanced techniques in an extremely easy to understand language.

Overall my first impression of this ebook is good. I think it was sincerely written and looks to be very helpful.

Download Now

Nail apparatus melanoma has a poorprognosis with up to 50 of patients dying within 5 years of the diagnosis

Subungual melanoma has a poor prognosis. The reported 5-year survival rates range from 35 to 50 . Most patients present with advanced subungual melanoma however, even early diagnosis is not a guarantee of a good prognosis. Women have a better prognosis than men. Factors contributing to a poor prognosis are delay in diagnosis and, as a result of this, inadequate treatment. The tumour may be mistaken for a traumatic dystrophy, and valuable time may be lost before the diagnosis is made. Treatment depends on the stage of the disease. Levels I and II melanomas may be adequately treated by wide local excision, and repair of the defect with graft or flap. Amputation is usually advised for melanoma at levels more advanced than II. When the thumb has to be amputated, pollicization of a finger may provide a functional replacement. There would appear to be no relationship between the prognosis and the extent of the amputation, although metacarpo metatarsophalangeal amputation is considered to be...

Nail apparatus melanoma

In the authors' experience ungual melanoma is dermoscopically characterized by a brown background and the presence of irregular lines. These lines are different in colour from one another, and their thickness varies dramatically from one to another, as does the inter-band spacing. In some areas the bands abruptly stop and in other areas their parallelism is disrupted (Figures 12.2, 12.3). Micro-Hutchinson's sign is rare and we have observed this feature in melanoma only. However, it is known from previous clinical studies that pigmentation of the cuticle is not completely specific to melanoma. In more advanced cases the pigmentation of periungual tissue appears irregular on dermoscopy (Figure 12.1). Blood spots may be found in melanoma, therefore their presence should not mislead the clinician to a diagnosis of subungual haemorrhage.

Malignant Melanoma and Nonepithelial Tumors 351 Malignant Melanoma

Penile Cancer Images

Primary malignant melanoma of the penis is a rare disease accounting for less than 1 of all penile cancers.23,96 Preferential location is in the glans (60-80 of all cases), followed by the penile shaft and foreskin.97 Melanomas of the distal penile urethra are even rarer but have been reported and tend to affect the fossa navicularis and infrequently the pendulous urethra or meatus urethralis.23,98,99 Grossly, they present as small, brown or black, often ulcerating, lesions and the clinical aspect is similar to that presented for cutaneous melanomas elsewhere. When affecting the distal urethra, tumors are typically polypoid. Histologically, malignant melanomas show a variegated picture with solid, nested, fusiform or mixed patterns of growth. Tumor cells are polygonal with ample and eosinophilic cytoplasm and marked nuclear atypia in most cases (Fig. 3.19a). Coarse brown intracytoplasmic pigment is usually seen but it may be inconspicuous or even absent (amelanotic melanoma). Presence...

Melanoma Clinical Summary

Melanoma is a potentially fatal cutaneous tumor derived from epidermal melanocytes. Any age can be affected but the peak incidence is 20- to 45-year old patients (much younger than basal cell or squamous cell carcinomas). The most significant risk factor is a primary relative with melanoma. Evaluation of any pigmented lesion should include the ABCDE rule (A for asymmetry, B for irregular borders, C for color variegation, D for diameter greater than 6 mm, and E for elevation or thickening). Any lesion with these characteristics is considered suspicious for melanoma.

Malignant Melanoma

Primary malignant melanoma of the CNS is not well characterized, and reports suggest an incidence of 1 or less compared with all melanomas.32 There are fewer than 250 primary melanomas reported in the literature.32,64,76 Peak incidence is in the fourth decade of life with a secondary peak in the first decade affecting both sexes equally. There is a strong association between primary melanoma and neurocutaneous melanosis, and such cases account for almost all melanomas in the pediatric These rare tumors are extremely aggressive lesions.3 The prominent distinction between a primary and a metastatic melanoma is location. Even though it may not always be possible to distinguish all melanomas as primary or metastatic, a typical metastatic melanoma is a parenchymal lesion, whereas primary melanoma is associated with the meninges. Primary malignant melanoma can occur anywhere in the CNS, including the pineal, posterior fossa and cerebellopontine angle, and spinal cord.3,6,61,76,77

Nail melanoma

Melanoma of the nail apparatus most commonly derives from the matrix, much less frequently from the nail bed or hyponychium. Matrix melanoma usually causes longitudinal melanonychia (see Chapter 5). Whether atypical melanocytic hyperplasia is already subungual in situ melanoma is not entirely clear. Large, atypical melanocytes in all layers of the matrix and nail bed epithelium, pycnotic melanocytes in the nail plate mirroring the pagetoid spread in the epithelium, and mitoses, are seen as proof of a malignant melanoma. Sometimes nail clippings reveal single intraungual pycnotic melanoma cells which retain their protein S-100 positivity. Most subungual melanomas are of acrolentiginous type however, those in the nail bed tend instead to be nodular melanomas. Even long-standing melanomas are often still very superficial. Invasive melanomas have therefore usually a decade-long history.

Skin Cancer

Identify the risk factors associated with skin cancer. 2. Describe the common signs and symptoms of skin cancer and identify the features of a mole that are suspicious for melanoma. 3. Identify the key features in the different stages of melanoma and their correlation with prognosis. 4. Explain the goals of therapy for the treatment of nonmelanoma and melanoma skin cancer. 5. Devise a plan of lifestyle modifications for the prevention of skin cancer. 6. Discuss the pros and cons of interferon-a therapy for melanoma, and formulate a monitoring plan for patients receiving interferon-a. 7. Discuss the pros and cons of interleukin-2 (IL-2) therapy for melanoma, and formulate a monitoring plan for patients receiving IL-2. 8. Discuss the different treatment options for melanoma with brain metastasis. 9. Discuss the role of temozolomide in the treatment of stage IV melanoma with or without CNS metastasis. 10. Discuss the different treatment options for nonmelanoma skin cancer. key concepts O...


Melanoma is the most lethal of the cutaneous malignancies, causing more than 77 of skin cancer deaths. In the United States, more than 62,000 new cases of invasive melanoma and almost 50,000 new cases of melanoma in situ were diagnosed in 2008. Melanoma arises from the pigment-producing cells (melanocytes) located predominantly in the skin, but it also found in the eyes, ears, GI tract, leptomeninges, and oral and genital mucous membranes. Early detection and treatment of melanoma are the best means of reducing mortality. The development of melanoma is not completely understood and is not as directly linked to chronic sun exposure as is BCC or SCC. Risk factors include fair complexion, red or blond hair, inability to tan or predisposed to burn, freckles, excessive childhood sun exposure, more than three blistering childhood sunburns, an increased number of moles (nevi) or dysplastic nevi, family history of melanoma, personal history of melanoma, immunosuppression, and older age. One...

Active Specific Immunotherapy Tumor Vaccines

Several very promising tumor vaccine strategies are in clinical trials for the treatment of melanoma (see Parmiani et al14 for a review of cancer vaccines and a summary of trial results) however, to date, vaccine strategies for glioma have met with minimal success, although new immunogene techniques hold promise.5

The Origins of Oncological Darwinism

Physical evidence for the existence of antioncogenes came from the study of several types of tumors, including Wilms tumor, hepatoblastoma, uveal melanoma and bladder cell carcinoma (Koufos, Hansen, Copeland, Jenkins, Lampkin and Cavenee 1986). The RB1 gene was found in 1986 by Friend and his colleagues, which maps to human chromosome 13q14 (Friend, Bernards, Rogelj, et al. 1986).

Staging of malignant disease

The TNM classification system is commonly used throughout the world for solid tumours, but other classification systems do exist. These include Dukes' staging system for colorectal cancer and Clark's classification for malignant melanoma. For haematological malignancies the TNM classifications are not appropriate because of the systemic nature of the diseases. O'Mary (2000) lists a number of classification systems for haematological malignancies, including the following

Historical perspective

At the incidence of lung cancer among British doctors. This study established a link between smoking and the development of small cell (oat cell) carcinoma of the lung. Further work undertaken by Doll and Hill has identified that the risk of dying from lung cancer is 32 times higher in heavy smokers compared with non-smokers (Horton-Taylor, 2001). A laboratory experiment, undertaken in 1915, proved for the first time that it was possible to develop cancer as a direct result of exposure to a chemical - coal tar. It was applied directly to the skin of a rabbit, resulting in the development of skin cancer (Yarbro, 2000a). In 1896 a German physicist, Roentgen, identified the use of radiation (X-rays) as a diagnostic tool. Further work looking at the use of radiation resulted in it being used as a new treatment for cancer by the close of the nineteenth century. However, within 7 years of Roentgen discovering the use of X-rays as a diagnostic tool, a causal link between exposure to...

Histological Classification of Penile Malignant Tumors

Malignant melanoma Basaloid and sarcomatoid carcinomas correspond to the most aggressive variants of all penile SCC. Basaloid carcinoma, which represents 4-10 of all penile carcinomas, is characterized by highly infiltrative neoplastic nests.9-11,13 Sarcomatoid carcinoma, which accounts for 1-3 of all penile SCC, is also a deeply infiltrative neoplasm which is often associated with necrosis and hemorrhage.9-11,14,15 Most of the tumor is composed of anaplastic spindle cells resembling those of different sarcoma variants. Tumors composed of an admixture of different subtypes of SCC represent up to one-quarter of all penile carcinomas.9,11 The most frequent combination corresponds to tumors in which warty and basaloid components are intermingled, followed by usual carcinomas mixed with other keratinizing SCC variants, especially a combination of verrucous and usual SCCs. Combinations of usual with either warty or basaloid carcinomas are less frequent. In rare occasions adenobasa-loid,...

Physical Examination

During the physical examination, inspect all pigmented lesions and be aware of the ''ABCD'' warning signs associated with malignant melanoma Asymmetry means that half the lesion appears different from the other half. Border irregularity describes a scalloped or poorly circumscribed contour. The color variation refers to shades of tan and brown, black, and sometimes white, red, or blue. A diameter larger than 6 mm, which is the size of a pencil eraser, is considered a danger sign for melanoma.

Pathologic Differential Diagnosis

Distinguishing pineal parenchymal neoplasms from normal pineal parenchyma or parenchyma incorporated in the wall of a pineal cyst is the principal issue in the differential diagnosis. Other small-blue-round-cell tumors, especially medulloblas-toma, is also a possibility, but the issue is easily resolved on clinical and radiological grounds. The histologic distinction, albeit more challenging, can also be made based on the presence of Flexner-Wintersteiner rosettes and absence of pale islands in a typical pineoblastoma. Differential diagnosis based on clinical features may be more challenging when confronted with a germ cell tumor, metastatic melanoma, pilocytic astro-cytoma, or a rare meningioma in the pineal region, yet the pathologic evaluation can readily differentiate such lesions from a PPT.

General Considerations

Oral cancer represents about 3 of all cancers. Cancer of the oral cavity and pharynx was responsible for 7550 deaths in 2007, killing approximately 1 person per hour, 24 hours per day. The rate of death from oral cancer is higher than those from cervical cancer Hodgkin's disease cancer of the brain, liver, testis, kidney, or ovary or malignant melanoma. One of the reasons for this high death rate is that the cancer is routinely discovered late in its development, with metastases to other areas or invasion deep into local structures. Oral cancer is also particularly dangerous because it has a high risk of producing second primary tumors. This means that patients who survive a first encounter with the disease have up to a 20 times higher risk for development of a second cancer. There is a 2 1 male-to-female incidence ratio and a 2 1 African-American-to-white death rate ratio. It is estimated that a man has a 1 72 lifetime risk for development of oral cancer. The American Cancer Society...

Separate Versus Comparative Evaluation

In the same vein, decision principles that are hard to apply in isolated evaluation may prove decisive in comparative settings, producing systematic fluctuations in attribute weights. Kahneman and Ritov (1994), for example, asked participants about their willingness to contribute to several environmental programs. One program was geared toward saving dolphins in the Mediterranean Sea another funded free medical checkups for farm workers at risk for skin cancer. When asked which program they would rather support, the vast majority chose the medical checkups for farm workers, presumably following the principle that human lives come before those of animals. However, when asked separately for the largest amount they would be willing to pay for each intervention, respondents, moved by the animals' vivid plight, were willing to pay more for the dolphins than for workers' checkups. In a similar application, potential jurors awarded comparable dollar amounts to plaintiffs who had suffered...

Neurocutaneous Melanosis And Diffuse Melanocytosis

Neurocutaneous melanosis was recognized in the latter half of the nineteenth century, and since its description, more than 100 cases have been reported.36 Peak incidence was reported to be in the fourth decade, affecting both sexes equally.26 Diffuse melanocytosis usually manifests in children and involves supratentorial and infratentorial leptomeninges. Symptomatic leptomeningeal melanosis with giant congenital nevi is more prevalent in the young.26,28,59 Thirty percent of patients with giant pigmented nevi were reported to eventually develop leptomeningeal melanoma. Because intracranial melanocytic lesions were diagnosed using various criteria, objective assessment of their incidence and epidemiologic characteristics has not been possible. This lesion is most commonly recorded as sporadic and was considered as an example of a genetic disorder's autosomal lethal genes surviving in a mosaic

Pathologic Features

Neurocutaneous melanosis characteristically involves a combination of multiple focally or diffuse pigmented congenital cutaneous nevi in addition to accumulation of melanotic cells in the meninges. These nevi usually exhibit histologic features of typical congenital nevi. In cases where neurocutaneous melanosis is associated with a melanocytic neoplasm, the lesion is typically a malignant melanoma but also can be a melanocytoma.17,27,36,37,52

Treatment and Outcome

Patients with diffuse melanocytosis have a poor outcome regardless of histologic malignancy.59 The prognosis for most patients is poor despite various treatment modalities including chemotherapy and surgery, and often these lesions are fatal within a few years.7,14,59 Patients with large congenital melano-cytic nevi are at increased risk for developing melanoma.2

Clinical Features

Primary melanoma of the CNS may occur either with localized intra-axial or extra-axial mass lesions or with meningeal spread, which carries a worse prognosis.32 Primary lep-tomeningeal melanoma typically occurs in the young and in the setting of leptomeningeal melanosis. Patients with large congenital melanocytic nevi are at increased risk for developing melanomas.12 The clinical presentation of primary malignant melanoma is variable and nonspecific and may include seizures, weakness, focal motor and sensory deficits, hydro-cephalus, psychiatric changes, and cranial nerve palsies depending on the tumor location. A rare melanoma in the cere-bellopontine angle can cause audiovestibular symptoms and facial nerve palsy.45 The primary melanomas are usually solitary masses in contrast to multiple, small masses typical of metastatic melanoma. The diagnosis is often challenging, and primary melanomas can be confused with many non-neoplas-tic and neoplastic lesions. The neoplasms in the...

Cytoskeleton Structure and Function

The loss of actin stress fibers has been associated with oncogenic transformation and increased metastatic potential. Abnormally low cellular levels of F-actin have been suggested as a marker of transformation in human bladder tumors.18 A disordered actin microfilament architecture has been associated with increased metastatic potential in several tumor models, including murine melanoma and fibrosarcoma models.1920 A loss of order in the actin microfilament architecture has also been observed as a late phenomenon in the progression of human colonic polyps to cancer.21 Mutated forms of actin have been shown to either increase or decrease metastatic potential. Transfection of a mutated form of P-actin with the substitution of a leucine for an arginine at position 28 reduces the metastatic potential of highly aggressive murine B16 melanoma cells.22 These cells developed organized actin stress fibers, were less motile in vitro, were less invasive in collagen gels, and produced fewer lung...

Cell Extracellular Matrix and Cell Cell Contacts

Melanoma, where the onset of integrin expression on the invasive front is closely correlated with vertical invasion and increased metastatic potential.32 Likewise, upregulation of the laminin-specific 06(34 integrin correlates with progression from a benign to malignant phenotype in several cell types, including those of thyroid origin.33 Transformed cells commonly express markedly diminished levels of a5P, fibronectin receptor but may exhibit increased levels of the a3p, integrin, which under certain conditions may also function as a fibronectin receptor.34 This observation corresponds with the finding that increased expression of the a5p, integrin receptor resulting from a transferred gene reduces cell migration.35 In some cells transformed by ras or tyrosine kinase oncogenes, there is diminished expression of the a5 integrin subunit (fibronectin receptor).343637 Our laboratory reported this type of derangement in cultured human FTC cells. Highly invasive clones of the FTC cell line...

Cytotoxic T Cell Antigen

Finally, the CTLA-4 tetrameric aptamer was evaluated in conjunction with dendritic cell-based vaccination strategies. The polypeptide component of telomerase (TERT) elicits modest protective tumor immunity against several tumors (Nair et al., 2000). In melanoma tumor-bearing mice, 50pmol injection of the CTLA-4 tetrameric aptamer enhanced the efficacy of immunotherapy engendered by TERTmRNA-transfected dendritic cells. Therefore, an aptamer also can act as an adjuvant to enhance the potency of vaccines (Santulli-Marotto et al., 2003).

Total Glansectomy and Split Skin Grafting

One study has reviewed three cases of penile verrucous carcinoma, angiosarcoma, and melanoma limited to the glans.46 All patients underwent glansectomy with clear resection margins. No local recurrences were reported at 12-48 months. Erections, sexual and urinary function had normalized shortly after the operation in all cases. Hatzichristou and colleagues reported seven cases of verrucous carcinoma treated with glansectomy.47 In this series, one patient required further surgery at 3 months for a local recurrence but all patients were alive and tumor free at 18-65 months.

Adjuvant Interferon Clinical Trials

Eastern Cooperative Oncology Group (ECOG) trial E1684, with 280 eligible patients with thick primary (> 4.00 mm) or node-positive melanoma who were randomly assigned after surgery to observation or post-operative adjuvant treatment with IFN-a2b for one year, demonstrated statistically-significant improvements in relapse-free and overall survival for patients randomised to the interferon arm. IFN-a2b therapy increased the median relapse-free survival by 9 months (1.72 years for IFN-a2b patients versus 0.98 years for observation patients) and produced a relative 42 improvement in the 5-year relapse-free survival rate (37 for IFN-a2b patients versus 26 for observation patients). In addition, IFN-a2b therapy significantly increased median overall survival by 1 year (3.82 years for IFN-a2b patients versus 2.78 years for observation patients) and produced a 24 relative improvement in the 5-year overall survival rate (46 for IFN-a2b patients versus 37 for observation patients).11 A...

Clinical Considerations

Statistically it is commonly known that, compared to overall survival, disease relapse is a less objective endpoint because it depends on the definition of relapse as well as the frequency and method of detection. Defining relapse is less of an issue in the adjuvant setting since patients enter the study with no detectable disease and thereafter any new disease found is considered a relapse. In a well-conducted clinical trial the interval and method of disease assessment are specified in the protocol and generally complied with by trialists, thereby rendering relapse-free survival a more reliable endpoint than in other situations. From the purely clinical viewpoint, patients have made clear that they are willing to accept even toxic adjuvant therapies that provide improvements in relapse-free survival, even if they do not result in any prolongation of overall survival. This observation has been directly validated in melanoma patients,16 and represents the perception that time spent...

Statistical Considerations

The tables indicate that when E1690 results became available, the study had 50 more patients than E1684, reflecting wider participation from the US Melanoma Intergroup. The patient enrollment periods were non-overlapping. Although the updated data for E1684 had longer follow-up at the time of E1690 publication, more events were analysed for E1690 from the larger sample size and the fact that few events occurred after 5 years. The main known patient characteristic difference was in the distribution of disease stage. There were more node-negative patients (26 vs. 11 ) and fewer recurrent disease patients (63 vs. 50 ) in E1690, representing a somewhat more favourable prognosis. It may be worth pointing out that, among those with nodal disease, there did not appear to be survival differences between newly diagnosed and recurrent disease patients. The more favourable relapse and survival experiences of the observation patients in E1690 compared to those in E1684 (5-year relapse-free...

Microsurgical Resection

Inclusion criteria for those studies were similar. Patients had to have single solid brain lesions, be older than 18 years, have had a tissue diagnosis of a primary cancer (within 5 years for Patchell et al), have a KPS score of at least 70 (or WHO QOL scale and RTOG Neurological Functional Scale of 2 or less), and their tumor in a resectable (noneloquent) location. Overall, approximately 20 to 25 of all patients with newly diagnosed solid tumor brain metastases satisfy these inclusion criteria. In both studies, favorable prognostic factors other than surgical resection included young age and absence of systemic disease. In the study by Patchell et al, a prolonged time from the diagnosis of the primary to the diagnosis of the brain metastasis (which favors breast cancer and melanoma primaries) was an additional favorable factor. In general, the local resection-cavity recurrence rate for surgical gross-total resection is approximately 10 if WBRT is added postoperatively but is 46 if...

Demographics Incidence of Brain Metastases

Among primary cancers, melanoma maintains the highest propensity to metastasize to the brain. The reported frequency of brain metastases in patients with melanoma varies widely and depends on the number of patients in the study, the methods used to collect the data, and the follow-up period. In our series of 6953 patients with melanoma, we primarily used clinical and radiographic criteria to establish the diagnosis of a brain metastasis and found that 10.7 of our patients had melanoma metastases to the brain.26 This rate is similar to those reported in other clinical studies, which have found incidence rates between 8.4 and 13.3 . The rate of brain metastases in autopsy studies has varied more widely, however. In these studies, a range between 17.5 and 75 has been reported in the literature. Overall, in our series of 6953 patients with melanoma, 99 , 87 , and 78 of patients were alive and free of brain metastases at 1, 5, and 10 years, respectively. One surprising feature is the...

Risk Factors for Brain Metastases

A number of factors have been identified that are present more often in patients with melanoma who develop cerebral metastases than in patients who do not develop cerebral metastases. In our series, independent factors associated with the development of brain metastases included being male a primary lesion located on a mucosal surface or in the head, neck, or trunk deep or ulcerated lesions acral lentiginous or nodular histologies and lymph node or visceral metastases, especially if the visceral metastases were to the lung or more than one organ site had metastatic lesions.26 A number of these factors have also been identified in other series. For example, all series find that males are more prevalent among those with cerebral metastases. This may reflect the fact that primary lesions that are more likely to be involved with brain metastases, such as those located in the head and neck or trunk area, are also more common in males. It also appears that primary lesions, at least in the...

Brain Metastases Symptoms and Signs

Patients with brain metastases may be asymptomatic or may have focal neurologic deficits, nonfocal symptoms or signs suggestive of increased intracranial pressure, seizures, or intracra-nial hemorrhage (Table 56-1). Before the widespread use of sensitive imaging studies, brain metastases from melanoma were rarely diagnosed in the absence of symptoms however, a small percentage of patients in most series reported were asymptomatic. In most series, the most common symptoms or signs for cerebral metastases from melanoma were focal neurologic ones. This was the case in 39 of our patients. These symptoms generally reflect the anatomic region of the brain affected, and metastases to the brain are generally distributed according to its overall mass, with no particular predilection to any given site.26 Nonfocal symptoms such as headache, nausea, or vomiting that are usually suggestive of increased intracra-nial pressure occurred in 36 of our patients. In our series intracerebral hemorrhage,...

Radiographic Appearance

Computed tomography (CT) scans of the brain may reveal melanoma metastases as lesions slightly hyperdense relative to normal brain on scans without contrast.8 These scans can also betray melanoma lesions by the presence of hemorrhage or edema. Melanoma metastases also typically enhance with iod-inated contrast. Typical melanoma metastases seen on magnetic resonance imaging (MRI) scans of the brain may display either melanotic or amelanotic patterns. Melanotic lesions are bright on T1-weighted images and dark on T2-weighted images, whereas amelanotic lesions are typically the reverse, although amelanotic lesions can be isointense on multiple sequences. More atypical patterns, which may be easily overlooked, include the very subtle military pattern (Figure 56-1) and periventricular patterns (Figure 56-2). In addition to the brain, TABLE 56-1 Demographics of Patients with Brain Metastases from Melanoma Source From Sampson JH, Carter JH, Jr, Friedman AH, et al Demographics, prognosis, and...

Role of Postoperative Radiation Therapy

The role of postoperative irradiation remains controversial. Although a prospective and randomized trial of postoperative radiation therapy after surgical treatment of a single metastasis to the brain has demonstrated that patients with a single metastasis to the brain who receive postoperative radiation therapy in addition to surgical resection have fewer recurrences and are less likely to die of neurologic causes, this study included only two patients with melanoma.21 No other prospective, randomized study has addressed this question in regard to melanoma metastases to the brain specifically. Although the majority of retrospective studies demonstrate enhanced survival,26,27 reduced rate of tumor recurrence in the brain,12 and better rates of neurologic improvement9,26,30 with postoperative adjuvant radiation therapy, several studies have suggested that postoperative radiation therapy may reduce survival17,24 or have no additional benefits.9 In our series, median survival time for...

Radiation Therapy and Radiosurgery for Brain Metastases

Malignant melanoma has historically been considered a radioresistant tumor. However, experiments with melanoma cells in culture have revealed radiation survival curves and other radiobiologic parameters that overlap those of other carcinoma cell lines. In addition, clinical studies have shown that when correct dose-fractionation schemes are used, melanoma responds appropriately to radiation therapy. The results of these and other studies have led to the conclusion that, in general, melanoma should not be considered a radioresistant tumor.11 Treatment of brain metastasis from melanoma, as with metastasis from most other primary tumors, results in a relatively unsatisfactory outcome for nearly all patients. In an attempt to determine prognostic classes in patients with brain metastasis, a recursive partitioning analysis (RPA) was performed on patients with brain metastasis.10 RPA is a statistical methodology designed to create a decision tree according to prognostic significance. This...

Systemic Therapy for Brain Metastases

Systemic treatment for melanoma that has metastasized to the brain is generally ineffective, and significant responses to systemic chemotherapy or immunotherapy have been reported only rarely. Response to systemic therapy is, in fact, so poor that most clinical studies even exclude patients with brain metastases. Chemotherapeutic options consist of dacarbazine, platinum analogs (cisplatin, carboplatin), nitrosoureas (car-mustine, lomustine, semustine, and particularly, fotemustine), tamoxifen, temozolomide, and vinblastine. Potentially useful biologic agents include the interferons, interleukin 2, and thalidomide. However, even advanced therapeutic combinations that produce objective extracerebral tumor responses in the majority of patients are generally thwarted by relapse within the central nervous system. Overall, no drug combination, even when delivered directly into the internal carotid artery, produces consistent response rates of more than 30 . Direct intracerebral delivery of...

Degradation of Complement Proteins with Proteases

Demonstrated that such proteases can also cleave complement components and, thus, inhibit complement activation (Ollert et al., 1990 Jean et al., 1995, 1996). Best studied is the degradation of C3, a key protein in the complement cascade, by tumor proteases. Human melanoma cells contain a C3-cleaving serine protease, p65, that rapidly degrades surface deposited C3b and is mostly expressed on the surface of melanoma cell lines resistant to complement-mediated lysis (Ollert et al., 1990). Blocking studies revealed that p65 contributed to resistance of melanoma cells to human complement. A C3-cleaving cysteine protease related to procathepsin-L, p39, was also identified on the membrane and in conditioned medium of murine melanoma cells (Jean et al., 1995). Inhibition of p39 with specific antibodies caused increased susceptibility of murine melanoma cells to complement lysis. A human cystein protease, antigenically related to murine p39 and to human procathepsin-L, was purified from a...

Histopathologic Studies

Immunoperoxidase staining is based on the detection of tissue-, organ-, or tumor-specific antigens using monoclonal or polyclonal antibodies. These antibodies can unequivocally confirm the diagnosis of important treatable subgroups such as lymphoma, melanoma, neuroendocrine tumors, and others. Many antibodies are available for this type of analysis (Table 60-4). The choice of antibody for a particular specimen is based on the results of the initial light microscopy examination and clinical information. For example, if lymphoma is suspected, then it is imperative to first perform immunohistochemistry using an antibody to common leukocyte antigen (CLA), which is highly specific for lymphoma. Immunohistochemistry can be costly and time consuming. Therefore specific antibody tests that are based on all available clinical information should be done sequentially rather than in a shotgun approach. For example, in the case of undifferentiated adenocarcinoma, the pattern of cytokeratin-7 and...

Patients Outcome And Adjuvant Treatment Of Systemic Disease

Melanoma and adjunctive radiation therapy and chemotherapy.1,19 Patients with squamous cell carcinoma in a high- or mid-cervical lymph node appear to benefit from surgical treatment and specific adjuvant therapies.1,19 Patients with other specific tumor histologies such as melanoma, lymphoma, prostate, germ cell tumor, or sarcoma should undergo treatment according to established guidelines.

Intervention Strategies

As demonstrated in numerous experiments, anti-mCRP blocking antibodies, which usually are poor activators of complement on their own, successfully enhance the susceptibility of tumor cells to complement-mediated lysis. For example, neutralisation of CD55 in Burkitt lymphoma cells (Kuraya et al., 1992), leukemia cells (Zhong et al., 1995 Jurianz et al., 2001 Golay et al., 2001), melanoma cells (Cheung et al., 1988) and breast cancer cells (Jurianz et al., 1999 Donin et al., 2003) increased their sensitivity to complement. In contrast, anti-CD55 mAb had no effect on killing of renal carcinoma cells (Gorter et al., 1996). Despite the expression of significant levels of CD55, blocking of this mCRP was not sufficient to sensitise prostate and ovarian carcinoma cells to complement-mediated lysis (Donin et al., 2003). The effect of blocking CD46 with neutralising mAb in augmenting cytotoxicity is often poor as shown for erythroleukemic cells (K562) and cervix carcinoma cell lines (Jurianz et...

Pathology And Epidemiology

The histologic characteristics of different types of primary and secondary spinal tumors are similar to those of intracranial tumors. Intramedullary tumors are rare, accounting for only 5 to 10 of all spinal tumors. In contrast, the benign encapsulated tumors such as meningiomas and schwannomas constitute between 55 and 65 of all primary spinal tumors. As a rule, intramedullary tumors are more common in children, and extramedullary tumors are more common in adults. The leading primary sites of metastatic tumors to the spine in order of frequency are lung, breast, and prostate45 however, several other systemic sites of spinal metastasis have been reported, including gastrointestinal tract, lymphoma, melanoma, kidney, sarcoma, and thyroid.8'9,14'20'23'32,54

Toxicity of inorganic arsenic compounds

Inorganic arsenic is a known human carcinogen which acts via a genotoxic mechanism. It is assumed, therefore, that there is no threshold for such effects and that risk management measures should ensure that exposures are prevented whenever possible or otherwise kept as low as reasonably practicable (see Box 14.1 for more on the concept ofALARP). There is sufficient evidence that chronic exposure to inorganic arsenic in drinking water causes non-melanoma skin cancers and an increased risk of bladder and lung cancers in humans.

Drug Delivery Based on Blood Brain Barrier Disruption

It has been shown that the barrier opening for high molecular weight compounds is of shorter duration than that for small molecules (37). When the degree of barrier opening is measured with methods that are suitable for a regional evaluation (autoradiography in animal studies, positron emission tomography in man), there is a characteristic difference in the degree of barrier opening in the tumor versus normal brain. This opening was consistently found to be more pronounced for the normal BBB (38, 39). While the nonspecific opening of the BBB to plasma proteins has a potential to elicit neuropathological changes, osmotic disruption has been tested as a strategy for the brain delivery of macromolecular drugs such as monoclonal antibodies, nanopar-ticles, and viruses. Quantitative uptake studies after hyperosmolar BBB opening in animals and humans were performed with radiolabeled monoclonal antibodies and their antigen binding fragments against various tumor antigens (40-42). In normal...

Macrophage Recruitment at the Tumor Site

By the constitutive expression of chemokines belonging to the inducible realm (Mantovani 1999). The molecular mechanisms accounting for the constitutive expression of chemokines by cancer cells have been defined only for CXCL1 and involve NF-kB activation by NF-KB-inducing kinase (Yang and Richmond 2001). CCL2 is probably the most frequently found CC chemokine in tumors. Most human carcinomas produce CCL2 and its levels of expression correlate with the increased infiltration of macrophages (Mantovani, et al. 2002 Conti and Rollins 2004 Balkwill, et al. 2005). Interestingly, CCL2 production has also been detected in TAMs, indicating the existence of an amplification loop for their recruitment (Ueno, et al. 2000 Mantovani, et al. 2002). Other CC chemokines related to CCL2, such as CCL7 and CCL8, are also produced by tumors and shown to recruit monocytes (Van Damme, et al. 1992). Along with the supposed pro-tumoral role of TAM, the local production of chemokines and the extent of TAM...

Surgical Techniques of Lymphadenectomy 981 Inguinal Lymphaden ectomy

Transected and the muscle together with its overlying fascia is sutured to the inferior margin of the inguinal ligament. Excellent coverage of the femoral vessels is achieved with no long-term sequelae. The saphenous vein can also be spared, if possible, in order to minimize postoperative lymphedema. After performing the dissection, the skin edges are carefully inspected any area with doubtful viability should be excised. There are no comparative studies on the use of antibiotics but it seems reasonable to give prophylactic antibiotics at the time of surgery, as this type of surgery should be considered a contaminated procedure, because of coexisting inflammatory reactions within the lymph nodes. Along with the general recommendations for prophylactic antibiotics, the authors' group gives one dose at the start of anesthesia. Prior to closing the wound, suction drains are inserted in order to prevent lymphocele formation and also increase the chance of primary wound healing....

Metastatic and Other Miscellaneous Tumors

True metastatic tumors involving peripheral nerves are most commonly seen in patients with breast (24 ) and pulmonary carcinoma (19 ). They may also be seen in the clinical setting of lymphoma, bladder cancer, and melanoma.61 Breast and pulmonary carcinomas often affect the brachial plexus through direct invasion and infiltration of peripheral nerves.73 Apical pulmonary tumors, characteristic of Pancoast's syndrome, often involve the lower spinal nerve roots and trunks of the brachial plexus.74,133 Other tumors such as pelvic tumors often infiltrate the lumbar and sacral plexus, whereas head and neck tumors often invade the cranial nerves.6 Definitive diagnosis of these carcinomas requires multiple biopsy samples. Invasion by carcinomas can appear as a mass on CT or MRI. These tumors can cause severe neuropathic pain that often precedes weakness or sensory loss. Metastatic tumors involving the brachial plexus or other peripheral nerve elements are often approached surgically with the...

Melanocytic naevus of the nail organ

Naevi may be located at any site in or around the nail organ, and may pose considerable differential diagnostic problems when they cause longitudinal melanonychia. This sign may be due to a focus of functionally active melanocytes (as in ethnic pigmentation), to an accumulation of active melanocytes (as in the Laugier-Hunziker-Baran syndrome), or to a common lentigo, junctional melanocytic naevus, compound naevus or malignant melanoma. Most naevi are of the junctional type. A few barely visible cells or large numbers of distinctly pigmented melanocytes may be seen singly or in clusters within the basal and suprabasal matrix epithelium. Mitoses are absent. A few melanophages may occur in the upper papillary. The nail plate contains intracellular fine melanin granules. Despite clinically obvious pigmentation, pigment visualization under the microscope often requires staining with the Fontana-Masson argentaffin reaction. Suprabasal location of melanocytes is common in the matrix and nail...

Radiotherapy as a Treatment of the Primary Tumor 12321 EBRT

By using external megavoltage radiation beams a relatively homogeneous dose is delivered to the target region. Tissue equivalent bolus is often required to provide sufficient dose build-up to the surface of the lesion. Normal tissues can be spared by using fractionated treatment schedules. Although superficial radiotherapy for CIS has been described using a fractionation scheme similar to that for skin cancer (3540 Gy 10 fractions over 2 weeks), EBRT is more appropriate in locally advanced cases. In order to avoid radiation damage to the adjacent skin, the penis is housed in a wax or Perspex cylindrical block (approximately 10 x 10 cm) which maintains the penis in a suitable upright position. The most commonly utilized fractionation scheme consists of 2-Gy daily fractions for a total dose of 60-66 Gy using two opposed beams over a 6 week period. During the treatment period, penile edema may develop and therefore the cylindrical blocks have to be upsized.

Patient Encounter 2

An a-half-life of 6 minutes and a terminal half-life of 21 minutes. Carmustine has shown clinical activity in the treatment of lymphoma, melanoma, and brain tumors. Side effects include myelosuppression, severe nausea and vomiting, and pulmonary fibrosis with long-term therapy. Lomustine is an orally available nitrosurea alkylating agent. Lomustine is converted rapidly to the cis- and trans-4-hydroxy metabolites the range of half-lives of these two metabolites is 2 to 4 hours.26 Lomustine has shown clinical activity in the treatment of non-Hodgkin's lymphoma and melanoma. Side effects are similar to those of carmustine. Patients should receive only enough drug for one cycle at a time to prevent confusion and accidental overdose. While the exact mechanism of action remains unclear, dacarbazine appears to inhibit DNA, RNA, and protein synthesis. Dacarbazine disappears rapidly from the plasma, with a terminal half-life of about 40 minutes. Dacarbazine has shown clinical benefit in the...

Meningeal and Ventricular Metastases

Unlike intracerebral metastases reflective of a variety of histological origins, metastases to the subarachnoid space, ventricular system, and choroid plexus are most commonly of adenocarcinoma (usually of breast, lung, or gastrointestinal), melanoma, or lymphoma origin (,.T bIe 4.7.-5.). Although days to years may pass before the meninges are invaded, the diagnosis of leptomeningeal involvement is most commonly made 6 months to 3 years after the primary tumor is discovered. Prognosis and Future Perspectives. Although a percentage of patients with leukemia, lymphoma, and breast cancer respond to some treatment, the prognosis for patients with non-small cell lung cancer, melanoma, and other adenocarcinomas is extremely poor. Future trends are likely to concentrate on treatment utilizing slow-release chemotherapy agents.

The Characteristics Of The Enzyme

The enzymes which catalyze the oxidation of polyphenols are known as polyphenol oxidases and are widespread in the animal kingdom (45). They are also abundant in some species of mushrooms. Animal melanomas are rich in tyrosinase, an enzyme capable of transforming tyrosine into dopa, and then dopa into dopaquinone at the initial stages of melanin synthesis. Studies on in vitro melanogenesis using mushroom polyphenol oxidase have been considered as valid for mammalian melanogenesis, although the enzymes isolated from different sources show qualitative differences, e.g., the mammalian tyrosinase is more specific for L-dopa and L-tyrosine and does not significantly oxidize catechol (46,47). The methods of extraction and purification of the enzyme from mushrooms (48), Neurospora crassa (49), and hamster melanoma (50) have been reported.

Location And Tumor Histology

The point of origin of olfactory neuroblastoma appears to be the upper portion of the nasal septum. This tumor commonly has an intracranial component, whereas neuroendocrine carcinoma rarely penetrates the cranium. Neuroblastomas occur at the skull base, usually as metastatic lesions to the orbit in infants, but occasionally occur as a primary tumor at any age of childhood. These tumors arise from autonomic neurons or neuronal precursors. Neurofibromas and schwannomas usually arise from the branches of the fifth nerve. They may also be plexiform, involving the orbit, face, or deep tissues of the skull base. These can occur in patients with neurofibromatosis or as isolated tumors. Gliomas of the optic nerve within the orbit occur as sporadic tumors but are often associated with neuro-fibromatosis type 1. Primary melanoma can occur from mucosal and sinus tissues, and metastatic lesions from the eye can seed to the skull base. Primitive neuroectodermal tumors (PNETs), whose cell of...

Neurooncology Imaging

Tive embolization may be of value in limiting blood loss. This has been used for large angiofibromas, giant cell tumors of bone, chemodectomas, and metastatic melanoma. Embolization depends on the distribution of the feeding vessels. If these are from the external carotid artery, extensive and safe emboliza-tion is possible and helpful. It is the most superior portion of the tumor that is likely to be fed by the internal carotid and the least able to be embolized.

Neurological Applications in Diagnosis and Treatment

The most common plain film finding is pedicle destruction, even though, in adults, the initial site of involvement is typically the vertebral body. Pathological compression fractures, multiple lytic vertebral body lesions, and paraspinous soft tissue masses are other common expressions of metastatic neoplasms. A discriminating eye can sometimes detect an indistinct posterior vertebral body margin, a clue to epidural metastatic disease. MRI, however, is a highly sensitive imaging study that can portray epidural and paraspinous soft tissue involvement as well as cord compression. Breast, lung, and prostate cancer are commonly associated with epidural spinal cord compression. Other common adult metastatic primary lesions include renal cell carcinoma, melanoma, lymphoma, multiple myeloma, and sarcoma.

Effects of laundering on UV protection

The preceding discussion outlines the need for UV protective textiles and the complexities associated with making a textile impervious to ultraviolet radiation. What is not certain, however, is the magnitude of the market for UV textiles. According to most industry experts, people have been led to believe over many decades that sunscreen lotions are an equivalent alternative to covering up with clothing. Thus currently the market is limited to audiences that are very aware of the risks of skin cancer due to UV exposure. It is apparent that campaigns to increase public awareness of the harmful risks of UV exposure and education regarding the beneficial effects of UV textiles have to be mounted to develop the UV textiles market. Nevertheless, there is guarded optimism among manufacturers that the need for UV protective fabrics will grow as people live longer lives and are more active outdoors. However, in the immediate future the most promising market for UV protective textiles appears...

Choice of Neck Dissection

Sentinel lymph node dissection is now used to assess the status of lymph nodes in patients with breast cancer and melanoma and has changed the surgical management. Intraoperative lymphatic mapping has also been investigated in thyroid cancer.7678 The technique has been carried out with a vital dye technique and or a radiotracer technique. The sentinel node dissection seems feasible, although the false-negative rate is difficult to establish since not all patients undergo a central and modified neck dissection. As mentioned previously, the influence of occult lymph node metastases on prognosis of papillary cancer is the most questionable. Therefore, the usefulness in papillary cancer is limited because most surgeons would agree that systematic surgical resection of lymph nodes should be limited to therapeutic dissection in patients with enlarged lymph nodes. Sentinel lymph node studies might be helpful in patients with medullary cancer and small primary tumors since surgeons advocate a...

The Search for More Smart Drugs

Somewhat encouraging responses to the weaker Bayer drug against kidney tumors, or when it is combined with carpet-bombing chemotherapy, possibly against malignant melanoma, often an intractable malignancy that usually originates in the skin but may arise anywhere in the body. Scientists at Dana-Farber and elsewhere have clearly established a central role of raf in the growth of melanomas. More experience of better raf inhibitors is needed, but the results already provide proof that understanding the pathways that cancer cells adopt to ensure their survival and administering a drug to block that pathway will target the tumor at its very engine, in which resistance will be less likely to arise.

Metastases to the Thyroid

Semiotic Triangle Meaning

The true incidence of metastases to the thyroid gland has not been clearly established. Autopsy studies have reported an incidence ranging from 2 to 25 .156159 In the study by Mortensen and colleagues, 4 of patients with metastatic neoplasms had secondary tumors of the thyroid gland.159 Silverberg and Vidone157 found the incidence to be much higher. In their study, they meticulously examined the thyroid and found the incidence of metastatic disease to the thyroid to be 24 in patients dying from metastatic cancer. This study suggested that the incidence of microscopic disease in the thyroid is greater the more diligently it is looked for. Shimaoka and coworkers156 studied the occurrence of thyroid metastases for a given primary neoplasm. In their autopsy study of patients who died of metastatic cancer, they found that metastases to the thyroid occurred in 39 of melanoma patients, 21 of breast cancer patients, 12 of

Carcinomatous Meningitis

Breast cancer is one of the most common cancer types leading to leptomeningeal involvement, along with melanoma, lymphoma, and lung cancer. The frequency of leptomeningeal disease in clinical series of breast cancer patients is 2 to 5 , with similar rates of 3 to 6 seen at autopsy. Lobular carcinoma has a predilection to spread to the subarachnoid space, as compared with ductal disease (16 versus 0.3 in one study).35 Patients with solid tumor metastatic brain disease can develop carcinomatous meningitis, and this will occur in up to one third of symptomatic cases. Clinical symptoms of carcino-matous meningitis include symptoms from hydrocephalus and raised intracranial pressure (headache, nausea, vomiting, somnolence, memory problems, other alterations in mental status), cranial neuropathy (diplopia and auditory symptoms most common), back pain, radiculopathy, or cauda equina syndrome.

A 9substituted camptothecins

9-Aminocamptothecin (9-AC) is a semisynthetic CPT derivative which showed outstanding preclinical activity against a wide spectrum of tumor types, including those of breast, colon, lung, prostate, and melanoma (255). In clinical trials, the drug has been very extensively studied using two different formulations based on the use of dimethylacetamide polyethylene glycol 400 or a colloidal dispersion preparation, which enhances solubility and stability. Clinical Phase I investigations have been conducted using a variety of i.v. administration schedules, including a 30-min infusion given daily for 5 days every 3 weeks (256), and more prolonged infusion schedules using 24-h (257), 72-h (258-261), 120-h (262), or 7-day continuous dosing repeated every 4 weeks (263). In addition, trials have evaluated the usefulness of delivering the agent intraperitoneally (264) or orally (265-267). Phase I clinical evaluation of 9-NC has been focused on oral administration in a daily-times-five per week...

Epidemiology and etiology

With regard to increased cancer risk, although there is ongoing controversy, some studies are showing an increased risk of lymphoma, with one study demonstrating a significantly increased risk of cutaneous T-cell lymphoma (relative risk of 10.75) or Hodgkin's lymphoma (relative risk of 3.18) in patients with severe disease.6 Some psoriatic treatments with a known lymphoma risk may be confounding factors. Increased cancer risk may be limited to subpopulations Caucasian with more than 250 PUVA (psoralens + UVA) treatments have a 14-fold greater risk of cutaneous squamous cell carcinoma than those with fewer treatments. However, the risk of melanoma and nonmelanoma skin cancer appears to be equivalent to the general population.6

The Larynx Early Stage Disease

Cancer Larynx Disease Pathophysiology

Has decreased in several countries, including the United States, and is thought to be due to an increased incidence in women. Age at diagnosis ranges from the second to tenth decade, with the seventh the most common. Over 90 percent of all laryn-geal cancers are squamous cell carcinoma, which will be the primary focus of this chapter. Other histologic types include lymphoma, spindle-cell carcinoma, neuroendocrine carcinoma, minor salivary gland carcinomas, mucosal melanoma, and various sarcomas. Metastatic lesions and direct extension of thyroid carcinoma are other rare possibilities.

Arkansas Cancer Research Center Neuro Oncology Program Strategy

Metastatic Brain Tumours

What follows is a description of our current treatment philosophy and priority ranking in the Neuro-Oncology Program at the Arkansas Cancer Research Center. A breakdown of our case distribution for each treatment modality over the past 3.5 years according to tumor number and the tumor location relative to eloquent brain is given in Figure 55-6. All patients with breast cancer and solid brain tumor metastases receive WBRT at our institution. A single brain metastasis as the only evidence of residual disease (isolated metastasis) is extremely rare with breast cancer, as compared with the situation with non-small cell lung cancer, melanoma, or renal cell carcinoma. We reserve additional measures to maximize local control, such as surgical resection or SRS, in an effort to increase life expectancy for patients with a KPS score of 70 or greater who have controlled or controllable disease (defined as a reasonable chance of at least a 6-month life expectancy if the CNS disease were not...

Yamamoto Cranioacupuncture Paris

Sialadenitis Pathology

Margins and round or ovoid architecture but without a fatty hilum. Late in the disease, mass can mimic infected or inflammatory nodes with heterogenous borders, enhancement, and necrosis. Late in the disease with extranodal spread the margins blur and are ill-defined. Contrast enhancement is heterogenous. Similar findings are seen on MRI with T1 showing low to intermediate signal pre-contrast and homogenous to heterogenous signal post-contrast depending on intranodal versus extranodal disease. PET with FDG is abnormal in infectious, inflammatory, and neoplastic etiology and is not typically helpful within the parotid, but can aid in localizing the site of the primary lesion as well as other sites of metastases. This can be significant since the incidence of clinically occult neck disease is high in skin cancer metastatic to the parotid gland (Bron, Traynor, and McNeil et al. 2003). Local failure was highest with metastatic squamous cell carcinoma and distant metastases were higher in...

Acquired longitudinal melanonychia after puberty in a whiteskinned individual requires urgent biopsy

Approximately 2-3 of melanomas in whites, and 15-20 in blacks are located in the nail unit. However, malignant melanoma is rare in black people thus the number of nail melanomas does not significantly differ between these population groups. Most white patients have a fair complexion, light hair, and blue or hazel eyes. There is no sex predominance, although some reports show variable female or male predominance. The mean age at onset is 55-60 years. Most tumours are found in the thumbs or great toes. Melanoma of the nail region is often asymptomatic. Many patients only notice a pigmented lesion after trauma to the area only approximately two-thirds seek medical advice because of the appearance of the lesion pain or discomfort is rare, and nail deformity, spontaneous ulceration, sudden change in colour, bleeding or tumour mass breaking through the nail are even more infrequent. It is useful to remember that a pigmented subungual lesion is more likely to be malignant than benign. If the...

Diagnostic Procedures

The cytologic features of thyroid nodules. A, Colloid nodule B, Hashimoto's thyroiditis C, papillary carcinoma D, follicular neoplasm E, anaplastic carcinoma F, secondary deposit melanoma. FIGURE 9-6. The cytologic features of thyroid nodules. A, Colloid nodule B, Hashimoto's thyroiditis C, papillary carcinoma D, follicular neoplasm E, anaplastic carcinoma F, secondary deposit melanoma.

Cancer of the Nasal Cavity and Paranasal Sinuses

Cancers of the nasal cavity and paranasal sinuses are rare, comprising less than 1 percent of all human malignancies and only 3 percent of those arising in the head and neck.1 Sinonasal malignancies occur twice as often in males as in females, and are most often diagnosed in patients 50 to 70 years of age.2 The majority of these tumors are squamous cell carcinoma, although a wide variety of other malignancies including sarcoma, adenoid cystic carcinoma, lymphoma, melanoma, and olfactory neuroblastoma may occur at this site.3-4

BRM other agents Can also consider BRM earlier even as first line bul costly

Phototherapy for Psoriasis Phototherapy or photochemotherapy is used for patients with moderate to severe psoriasis, generally when topical therapies alone are inadequate. Photochemotherapy is the concurrent use of phototherapy together with topical agents16,18 or systemic drugs.1,18 Phototherapy of psoriasis involves the use of either ultraviolet A (UVA) or UVB. UVA is a longer wavelength, and therapy with UVA is always combined with psoralens (e.g., methoxsalen or trioxsalen), which are used as photosensitizers to increase efficacy. There may be an increased risk of skin cancers after prolonged use of phototherapy and risks are greater with PUVA than UVB.10,18 In particular, long-term PUVA treatments in Caucasians is associated with an increased risk of squamous cell carcinoma and possibly malignant melanoma.6 There is a bath PUVA and an oral PUVA. Bath PUVA therapies involve soaking in a bath of psoralens liquid for 15 minutes prior to UVA treatment. Oral PUVA involves taking an...

Minimally Invasive Staging Techniques

Dslnb Penile Cancer

Sentinel node biopsy for penile cancer was first reported by Cabanas in 1977.58 This was based on lymphangiograms of the penis and the lymph node medial to the superficial epigastric vein was identified as being the first echelon lymph node or so called sentinel node. It was assumed that a negative sentinel node was indicative for absence of further lymphatic spread and therefore no lymphadenectomy was indicated. Sentinel node surgery consisted of identification and removal of this lymph node with completion lymphadenectomy only in those with a tumor-positive lymph node. However, this initial static procedure, based on anatomic landmarks only, did not take into account individual drainage patterns. Several false-negative results were reported, and the technique was largely abandoned. The sentinel node procedure was revived by Morton et al. in 1992, by using patent blue-V or isosulfan blue dye as a tracer enabling individual lymphatic mapping.59 This technique with the addition of a...

Traumatic disorders of the nail

Histological examination is essential to rule out amelanotic melanoma. These are numerous (Figures 9.5-9.8). Trauma-induced Beau's line accompanied by pyogenic granuloma of the proximal nail folds of the affected fingers from trauma on the palm and the arm has been reported. Delayed effects of major trauma include permanent damage of the nail matrix, sometimes with unequal growth of different sections of the nail plate. Damage to the matrix may result in a split extending along the entire length of the nail, or a longitudinal prominent ridge, and may even result in ectopic nail due to the altered position of the matrix following the trauma, Trauma to the proximal nail fold may be responsible for the formation of pterygium. Longitudinal melanonychia following acute trauma is rare in white individuals. Hook nail is observed when the nail bed is shortened after distal section of the bony phalanx. Any traumatic force to the distal phalanx can result in...

Intraparenchymal Metastases

Virtually all systemic cancers have the capacity for brain metastasis. The most common sources of metastases to the brain are tumors of the lung, breast, kidney, and gastrointestinal tract (colon and cecum) and malignant melanoma, reflecting the frequent occurrence of these primary malignancies (,X bJe,47z2. ). The predilection of melanoma to spread to the brain is emphasized because its histological pattern is different from other metastases. Other sources that are relatively Melanoma Wide variability in the interval between the appearance of the primary cancer and that of the cerebral metastasis is observed. In many instances, the cerebral metastasis represents the first manifestation of a malignant neoplasm, usually of lung or melanoma origin. Slow-growing neoplasms of breast, ovarian, or uterine origin can result in cerebral metastasis up to 15 years after the diagnosis of the primary tumor. The average interval between the diagnosis of the primary...

Malignant Epithelial Tumors with Clear Cell Features 3461 Clear Cell Carcinoma

Penile Cancer

In secondary EMPD an underlying tumor is found, mainly from the genitourinary or lower gastrointestinal tract. Morphologically it is similar to primary EMPD and efforts should be aimed to identify, if present, the associated internal malignancy. Immunohistochemistry is crucial in achieving this. Paget cells in primary EMPD are usually positive for CK7, MUC-1, and MUC-5AC and negative for MUC-2, MUC-6, and CK20.737881 They are also positive for glandular markers such as CAM 5.2, EMA, CEA and GCDFP-15 (Fig. 3.18b).73 Conversely, Paget cells in secondary EMPD, which probably originates from the epidermo-tropic dissemination of the underlying tumor 3,78 are usually positive for specific tissue markers such as PSA (prostate), uroplakin-III (urothelium), and CDX-2 (colon-rectum). They are also positive for MUC-2 and negative for GCDFP-15.73,78 The differential diagnoses of EMPD include conditions in which clear cells are present within the epidermis (clear cell papulosis, pagetoid...

Normal and Pathological Findings see Xables262 263 and 264

Its breakdown to bilirubin and other pigments. Oxyhemoglobin is red but becomes pink or yellow when diluted. The concentration of oxyhemoglobin is maximal within the first 36 hours and disappears by 14 days. Bilirubin is yellow and is first detected in the CSF 10 hours after subarachnoid bleeding. Its concentration is maximal at 2 days and may persist for up to a month. Other causes for coloration of CSF include an elevated systemic bilirubin from liver disease a brownish or gray coloration in the presence of CNS melanoma and a greenish tinge related to leukemic meningeal infiltration.

Ancyclostoma Brazillienses Force Out Of The Skin

Digital Sclerosis

Figure 20-79 shows a subungual presentation of malignant melanoma of the hallux. Determine the cause of all subungual pigmented lesions. Unusual pigmentation under the nail, especially if of long duration, should always be regarded with suspicion. Subungual melanomas represent approximately 20 of melanomas in dark-skinned and Asian populations, in comparison with about 2 of cutaneous melanomas in white populations. Ultraviolet radiation exposure seems to be an important risk factor for cutaneous melanoma however, because ultraviolet radiation is unlikely to penetrate the nail plate, it does not appear to be a risk factor for subungual melanomas. There is a considerable predominance of subungual melanoma localized on the thumb (58 of all affected fingers) and the hallux (86 of all affected toes).

The immune surveillance theory

Have better survival than those with few infiltrated immune cells, suggesting that such immune cells are responsible for the improved survival in these patients (Ropponen et al., 1997 Naito et al., 1998 Nakano et al., 2001 Nakayama et al., 2002 Ohno et al., 2002). Second, as described above, the incidence of cancer is higher in older people and in the neonatal period when immune responses are less efficient. Third, the incidence of cancer is much higher in immunodeficient people (e.g. AIDS patients) than in those with a normal immune system. About 40 of HIV-infected individuals develop some form of cancer such as Kaposi's sarcoma (a malignant tumour of the blood vessels in the skin), or lymphoma (a malignant tumour of the lymphatic system) (Scadden, 2003). In addition, the incidence of certain types of cancer (e.g. skin cancers, lymphoma) is increased by four- to 500-fold in patients who have received organ transplants, whose immune systems have been downregulated with...

From Speculations to Reality and Beyond Some Implications of a Darwinian View of Cancer Progression

More recently, Rudolph Jaenisch and his group demonstrated by using nuclear transplantation that an oocyte's microenvironment can re-establish development pluripotency of malignant cancer cells. The nuclei of murine leukemia, lymphoma and breast cancer cells can support normal preimplantation development to the blastocyst stage, but fail to produce embryonic stem cells. A blastocyst cloned from a RAS-inducible melanoma nucleus develops into ES cells with the potential to differentiate into multiple types in vivo. These findings are in some way paradigmatic for studying the tumorigenic effect of a given cancer genome in the context of the whole animal, and demonstrate that the malignant phenotype of at least some cancer cells can be reversed to a pluripotent state despite the presence of irreversible genetic alterations and allow apparently normal differentiation. It is now important to define the epigenetic factors that influence the malignant pheno-type to help establish therapeutic...

Textiles for UV protection

The past decade has witnessed an alarming increase in the incidence of skin cancer worldwide. A primary reason for the increased incidence of skin cancers is attributed to stratospheric ozone depletion. Because ozone is a very effective UV-absorber each one percent decrease in ozone concentration is predicted to increase the rate of skin cancer by two percent to five percent. It is estimated by the United States Environmental Protection Agency that ozone depletion will lead to between three and fifteen million new cases of skin cancer in the United States by the year 2075.1 Other reasons for the skin cancer epidemic can be traced to lifestyle changes such as excessive exposure to sunlight during leisure activities. These activities include playing outdoors and swimming in the case of children, and golfing and fishing in the case of adults. In the case of agricultural and other outdoor workers, exposure to the sun is an occupational hazard as they have no choice about the duration of...

General protection requirements and applications

Chapter 13 covers textiles for protection of human skin from ultraviolet light, and is the contribution of Dr Ajoy Sarkar of Colorado State University, USA. The last decade of the 20th century saw the incidence of skin cancer increase throughout the world. This is attributed to the depletion of atmospheric ozone by various agents, including halogenated (CFC) compounds. This has been compounded by excessive exposure of skin to sunlight during human leisure activities. Because ozone is a very effective UV absorber, every 1 decrease in ozone concentration gives rise to an increase in skin cancer by 2 to 5 Doctor Sarkar explains the problem, describes test methods and details the textile solutions to defeat this recent phenomenon.

Treatments Independent of Differentiated Thyroid Function

Hyperthyroidism Nis

Suicide gene therapy is the transduction of chemosensitization genes that can transform a nontoxic form of a drug (prodrug) into a toxic substance. A classic example of this therapy is transduction of the herpes simplex virus thymidine kinase (HSV-rfc) gene with nucleoside analogs, such as acyclovir or ganciclovir. It is, however, difficult to transfect all of the target cells. A bystander effect is therefore an important aspect of suicide gene therapy.88 With a bystander effect, this strategy has been evaluated for possible treatment of localized tumors. Suicide gene therapy is currently in clinical trials for several human cancers including melanoma, glioblastoma, and breast cancer.8991

Angiogenesis and Lymphangiogenesis in Tumors Insights from Intravital Microscopy

Acute Liver Damage Animal Model

As another example, a human melanoma cell line yields a collagen-rich tumor when grown subcutaneously and a collagen-poor tumor in the cranial window (Fig. 4C,D) (Pluen et al. 2001). In concert with our previous finding that collagen can hinder the diffusion of macro-molecules in tumors (Netti et al. 2000), we found that the diffusion of macromolecules in this melanoma was lower in the subcutaneous implant compared to the cranial implant (Pluen et al. 2001). Figure 4. Effect of the host-tumor interaction on vascular permeability (A,B) and extracellular matrix production (CD). A human glioma is leaky when grown in the subcutaneous space (A) and not leaky when grown in the cranium (B). (Adapted from Yuan et al. 1994, Online permission pending.) A human melanoma xenograft has an abundance of collagen when grown in the sc space (C) and a paucity of collagen when grown in the cranium (D). (Reprinted from Pluen et al. 2001.) (Green) Lissamine green dye (red) collagen (blue) cell nucleus....

How common is prostate cancer

There are more than 100 different types of cancer. In the United States, a man has a 50 chance of developing some type of cancer in his lifetime. In American men, (excluding skin cancer) prostate cancer is the most common cancer. Prostate cancer accounts for about 33 (234,460) of cases of cancer (Table 2). More than 75 of the cases of prostate cancer are diagnosed in men older than 65 years. Based on cases diagnosed between 1995 and 2001, it is estimated that 91 of the new cases of prostate cancer are expected to be diagnosed at local or regional stages (see staging of prostate cancer), for which 5-year survival is nearly 100 . It is estimated that prostate cancer will be the cause of death in 9 of men, 27,350 prostate cancer related deaths. In the United States, deaths from prostate cancer have decreased significantly by 4.1 per year from 1994 to 2004. Most notably, the death rate for African American men in the United States has decreased by 6 .

What is the role of chemotherapy in the treatment of a metastatic spinal lesion

Chemotherapy is used in patients with documented spinal metastases, patients at risk of developing spinal metastases, and patients with spinal lesions not amenable to surgical excision. The response to chemotherapy is determined by the tumor type. Tumors that are highly sensitive to chemotherapy include small-cell carcinoma of the lung, Ewing's sarcoma, thyroid carcinoma, breast carcinoma, lymphoma, germ cell tumors, and neuroblastoma. Tumors that are relatively resistant to chemotherapy include adenocarcinoma of the lung and GI tract, squamous cell carcinoma of the lung, metastatic melanoma, and renal cell carcinoma.

Large Number Of Different Skin Diseases

Have an impact in terms of physical disability or even mortality, are rare or very rare. They include, among others, autoimmune bullous diseases, such as pemphigus, severe pustular and erythrodermic psoriasis, generalised eczematous reactions, and such malignant tumours as malignant melanoma and lymphoma. The disease frequency may show variations according to age, sex and geographic area. Eczema is common at any age while acne is decidedly more frequent among male adolescents. Skin tumours are particularly frequent in aged white populations. Infestations and infections such as scabies, pyoderma and dermato-phytosis predominate in developing countries and some urban pockets of developed countries. In many cases, skin diseases are minor health problems, which may be trivialised in comparison with other more serious medical conditions. However, as mentioned above, skin manifestations are visible and may cause more distress to the public than more serious medical problems. The issue is...

Periimplant Soft Tissue Optimization

Gay Dripping Precum

It is valuable to detect the gingival hyperpigmenta-tion, because it can be detrimental to the overall treatment result. Oral pigmentation is most commonly physiologic in nature however, nonphysiologic pigmentations may be encountered. Physiologic pigmentation results primarily from melanin produced by melanocytes present with the stratum basale of the oral epithelium and is typically more generalized than its nonphysiologic counterparts. The etiology of these pigmentations may be hereditary, due to pregnancy, or medication-induced. Nonphysiologic pigmentations may be pathologic or nonpathologic. Examples of localized pathologic pigmented lesions include hemangiomas, Kaposi's sarcoma, and melanoma, among others. Pathologic pigmented lesions may also be generalized when associated with systemic conditions

Melanin In The Photoprotection Of Skin

In biological systems, superoxide and H2O2 are formed in small quantities during normal processes and both species produce harmful effects in tissues. While the cell-defense mechanisms are adequate to remove these active oxygen species under normal conditions, with exposure to UV light, their concentration increases (247) and thus the function of melanin as an in situ quencher is important for the protection of skin. However, with continuous exposure to UV radiation, melanin itself may become energetically overloaded into a toxic state (248) augmenting the radiative damage to cells (12). There exists evidence of phaeomelanin's role in sunlight-induced skin cancer (249).

Etiology of Minor Salivary Gland Tumors

Risk factors for salivary gland tumors have been studied extensively. Carcinoma of the major salivary glands, for example, has identified a relationship with prior radiation therapy and previous skin cancer (Spitz, Tilley, and Batsakis et al. 1984). Another study reported 31 patients who had both a newly diagnosed salivary gland tumor and a history of radiation therapy to the head and neck region (Katz and Preston-Martin 1984). Radiation therapy had been administered with a range of 11-66 years prior to the development of the salivary gland tumors. No course of radiation therapy was administered for a malignant condition, but rather for acne, hypertrophied tonsils, keloids, and other benign conditions. As such, it is reasonable to assume that a low dose of radiation therapy was administered. Only 3 cases of minor salivary gland tumors were identified among these 31 cases, including 2 adenoid cystic carcinomas and 1 muco-epidermoid carcinoma. One of the tumors was located in the palate...

Peripheral Nerve Metastases

Cancer can affect peripheral nerves either by compression or direct invasion. Direct invasion occurs either from hematogenous spread of tumor to peripheral nerves or dorsal root ganglia or by direct extension to nerve from surrounding structures. Typically, head and neck malignancies, melanoma, lung and breast cancer, and

Neural Compression And Invasion

The cervical, brachial, and lumbar plexuses are vulnerable to compression from metastatic tumors. The brachial plexus is quite vulnerable to metastatic breast cancer, metastatic melanoma, and superior sulcus lung tumors.1 Lumbar plexus compression can result from cervical, rectal, or metastatic cancer.

Nonpharmacologic Therapy

Radiation is not standard therapy for the treatment of skin cancer however, there are circumstances in which radiation may be preferred. Older patients or patients who are poor candidates for surgery may be offered radiation as an option. 8 Radiation offers good cosmetic results, but it requires multiple visits over the course of several months, making it inconvenient for patients.19 In the treatment of NMSC, radiation

Epidemiology Distribution and Geography

Palm gathered data via correspondence with medical missionaries worldwide and concluded that the main etiologic factor in rickets is the lack of sunlight. It was much later before scientists linked the variable pigmentation in the races of men with the regulation of vitamin D synthesis (Loomis 1967). The processes of pigmentation and keratinization of the outer layer of the skin (stratum corneum) directly affect the amount of solar ultraviolet radiation reaching the deeper stratum granulosum, where vitamin D is synthesized. White or depigmented skin of the northern latitudes allows maximum ultraviolet penetration. Black or heavily pigmented skin and Oriental or keratinized skin minimize UV penetration in southern latitudes to maintain vitamin D synthesis within physiological limits. The skin pigmentation or keratinization also plays a role in preventing sun-induced skin cancer, a greater problem among light-skinned groups who move to sunnier climates.

Occupational and Environmental History

Many occupational diseases have been well described over the years malignant meso-thelioma in workers exposed to asbestos cancer of the bladder in workers exposed to aniline dye malignant neoplasms of the nasal cavities in woodworkers pneumoconiosis in coal miners silicosis in sandblasters and quarry workers leukemia in those exposed to benzene hepatic angiosarcoma in workers exposed to vinyl chloride byssinosis in cotton industry workers skin cancer in those chronically exposed to the sun, such as sailors ornithosis in bird breeders toxic hepatitis in solvent users and workers in the plastics industry and chronic bronchitis in individuals exposed to industrial dusts. It has been shown that there is an association between sterility in men and women and exposure to certain pesticides and an association between dementia and exposure to certain solvents.

Inspect the External Ear Structures

Inspect the external ear for deformities, nodules, inflammation, or lesions. The presence of tophi is a highly specific but nonsensitive sign of gout. Tophi are deposits of uric acid crystals. They appear as hard nodules in the helix or antihelix. In rare cases, a white discharge may be seen in association with them. A ''cauliflower ear'' is a pinna that is gnarled as a result of repeated trauma. Figure 11-11 shows a squamous cell carcinoma and a malignant melanoma of one lobule.

Paraneoplastic Retinal Degeneration or Cancer Associated Retinopathy

The outer retinal layers with relative preservation of the other retinal layers occurs. This syndrome is usually associated with small cell lung cancer but is also observed with other tumors, including melanoma and cervical cancer. The distinctive clinical triad consists of photosensitivity, ring scotomatous visual field loss, and attenuated caliber of retinal arterioles. U

Genetic screening of cancer

So far, the only major familial cancer screened for is familial breast and ovarian cancer caused by the genes BRCA-l and BRCA-2. Some cancer centres now offer screening for BRCA-1 and BRCA-2 mutations in families with multiple cases of these tumours. If mutations are found it is estimated that a woman has up to an 85 lifetime risk of developing breast cancer and a 60 risk of developing ovarian cancer (Armstrong et al., 2000). If BRCA mutations are detected, intensive monitoring can be used to pick up developing tumours at an early stage. For the most high-risk cases preventive measures such as prophylatic mastectomy, or taking drugs that reduce the chances of these cancers (such as tamoxifen), can be considered. Unfortunately BRCA-1 and BRCA-2 mutation-associated familial cases account for only around 15-20 of familial cancers, so possibly there are many genetic risk factors yet to be discovered (Balmain, 2001). Genes that confer strong susceptibility to other familial cancers may...

Relationship With Specific Systemic Cancers

These studies, the abdominal and pelvic organs are typically the second most common primary site. This difference may be a result of the earlier diagnosis of primary breast cancer, which tends to metastasize at an advanced stage of the disease. Other primary tumor sites that become manifest include the skin and upper aerodigestive tract (e.g., melanoma, squamous cell carcinoma, adenocarcinoma), thyroid gland, hematologic system, and reproductive organs.

What are the indications for radiation therapy as the primary form of treatment for metastatic spinal lesions

Radiation therapy plays a role in the treatment of malignancies by promoting reossification of the vertebral body and reducing tumor load. Pain relief has been reported in up to 80 of patients receiving radiation. Use of a spinal orthosis for 3 months following radiation therapy is recommended to prevent development of spinal fracture and instability. Tumors that are sensitive to radiation therapy include lung, breast, and prostate cancer, as well as lymphoma and myeloma. Radioresistant tumors include GI adenocarcinoma, metastatic melanoma, thyroid carcinoma, and renal cell carcinoma. Potential indications for radiation therapy as the primary form of treatment for metastatic spinal lesions include radiosensitive tumors with stable or slowly progressive neurologic symptoms, spinal canal compromise secondary to soft tissue tumor lesions, and patients who are not candidates for surgery due to medical comorbidities.

For which common disorders can a PET scan provide useful diagnostic information

PET scans are most commonly used in the evaluation of cancer for diagnosis, staging, and assessment of treatment effectiveness. Utility in head and neck tumors, colorectal tumors, melanoma, lymphoma, multiple myeloma, lung cancer, and metastatic breast cancer have been reported. The role of PET scans in the diagnosis of spinal infections is evolving.

Squamous Cell Carcinoma

After basal cell carcinoma, squamous cell carcinoma (SCC) is the next most common type of skin cancer accounting for 20 percent of all cutaneous malignancies and occurring in approximately 40 people per 100,000 population annually.49,63,64 Well over 90 percent of cutaneous squamous cell carcinomas arise in the head and neck and most commonly involve the ears and upper face.49,64 Like basal cell carcinoma, these lesions have been associated with chronic exposure to UVB radiation.53 There is a significant increase in the rate of development of squa-mous cell carcinomas in immunosuppressed patients including patients undergoing medical immunosup-pression for organ transplantation, as well as patients with lymphoma and acquired immunodeficiency syndrome.65-68 Although an increasing proportion of squamous cell carcinoma is seen with age, age is felt to be a coexistent rather than independent variable with respect to causation.

Fractionation Equivalence

The ratio a p represents the dosage at which the two components of cell killing are equal. For acutely responding tissues and radio-responsive tumors (eg, lymphomas), this ratio is estimated to be between 800 to 2,000 cGy. For late responding tissues and poorly responsive tumors (eg, melanoma), this ratio is estimated to be between 200 to 500 cGy. Clinically the a p ratio gives the fractionation sensitivity of tissues.

Case 8 Mustarde Advancement Rotation Cheek Flap

A patient with a Hutchinson's melanotic freckle (lentigo maligna or in situ melanoma) presenting on the skin of the cheek in the right infraorbital region is shown in Figure 4-12A. The superior margin of the surgical defect and the Mustarde flap are kept as close to the tarsal margin as possible, depending on the location of the lesion and the surgical defect. In this particular patient, the medial border of the defect was aligned to the nasolabial skin crease. The extent of surgical resection depends on the surface dimension, depth, and histology of the primary tumor.