Archive for May, 2011
See this recent article about the accuracy and safety of shave biopsies for evaluation of melanoma.
So shave biopsies are not so bad after all. Email if you want a copy of the article.
BACKGROUND: Shave biopsy of cutaneous lesions is simple, efficient, and commonly used clinically. However, this technique has been criticized for its potential to hamper accurate diagnosis and microstaging of melanoma, thereby complicating treatment decision-making.
STUDY DESIGN: We retrospectively analyzed a consecutive series of patients referred to the University of Florida Shands Cancer Center or to the Moffitt Cancer Center for treatment of primary cutaneous melanoma, initially diagnosed on shave biopsy to have Breslow depth2 mm, to determine the accuracy of shave biopsy in T-staging and the potential impact on definitive surgical treatment and outcomes.
RESULTS: Six hundred patients undergoing shave biopsy were diagnosed with melanoma from extremity (42%), trunk (37%), and head or neck (21%). Mean ( SEM) Breslow thickness was 0.73 0.02 mm; 6.2% of lesions were ulcerated. At the time of wide excision, residual melanoma was found in 133 (22%), resulting inT-stage upstaging for 18 patients (3%). Recommendations for additional wide excision or sentinel lymph node biopsy changed in 12 of 600 (2%) and 8 of 600 patients (1.3%), respectively. Locoregional recurrence occurred in 10 (1.7%) patients and distant recurrence in 4 (0.7%) patients.
CONCLUSIONS: These data challenge the surgical dogma that full-thickness excisional biopsy of suspicious cutaneous lesions is the only method that can lead to accurate diagnosis.Data obtained on shave biopsy of melanoma are reliable and accurate in the overwhelming majority of cases (97%). The use of shave biopsy does not complicate or compromise management of the overwhelming majority of patients with malignant melanoma. ( J Am Coll Surg 2011;212:454–462. © 2011 by the American College of Surgeons)
This is a great video on the importance on melanoma diagnosis, particularly in younger people.
In 2005, a group of dermatologists published a study showing that frequent tanners experience a loss of control over their tanning schedule, displaying a pattern of addiction similar to smokers and alcoholics. 
Biochemical evidence indicates that tanning addicts are addicted to an opioid release experienced during tanning. When frequent tanners took an endorphin blocker in a 2006 study, they experienced severe withdrawal symptoms, while infrequent tanners experienced no withdrawal symptoms under the same conditions. 
Tanorexia is the term often used to describe a condition in which a person participates in excessive outdoor sun tanning or excessive use of other skin tanning methods (such as tanning beds) to achieve a darkerskin complexion because they perceive themselves as unacceptably pale. The syndrome is different than tanning addiction, although both may fit into the same syndrome and can be considered a subset of tanning addiction.
Although the term “tanorexia” has been commonly used by the media and several doctors to describe the syndrome, both the word and syndrome have not been widely accepted by the medical community, and is considered a slang by many. The term was coined after the medical condition anorexia nervosa, a disorder characterized by low body weight and body image distortion with an obsessive fear of gaining weight. It can be likened to the common practice of adding the suffix “-oholic” (from the term alcoholic) to the end of any action or food someone enjoys extensively and often (e.g. “choc-aholic,” “golf-oholic,” “shop-aholic,” etc.).
Serious cases of tanorexia can be considered dangerous because many of the more popular methods of tanning (such as those mentioned above) require prolonged exposure to UV radiation, which is known to be a cause of many negative side effects, including skin cancer.
Extreme instances may be an indication of body dysmorphic disorder (BDD),  a mental disorder in which one is extremely critical of his or her physique or self-image to an obsessive and compulsive degree. As it is with anorexia, a person with BDD is said to show signs of a characteristic called distorted body image. In layman’s terms, anorexia sufferers commonly believe they are overweight, many times claiming they see themselves as “fat,” when in reality, they are nutritionally underweight and physically much thinner than the average person. In the same way, a sufferer of “tanorexia” may believe him or herself to have a much lighter–even a pale–complexion when he or she is actually quite dark-skinned.
Neither tanning addiction nor tanorexia are covered under the latest edition of the DSM-IV, though they are most likely versions of similar problems already on record. To that end, a 2005 article in The Archives of Dermatology presents a case for UV light tanning addiction to be viewed as a type of substance abuse disorder.
Symptoms of Tanning Addiction
Although the syndrome has not been officially described by the medical community, it may include the following reported symptoms: intense anxiety if a session of tanning is missed, competition among peers to see which can get the darkest tan, and chronic frustration about the color of one’s skin, with the affected person being convinced his or her complexion is constantly lighter than it actually is. Notable figures known to have suffered from tanorexia are Christine Swanson and the cast of the MTV reality show Jersey Shore.
- ^ Medical News Today, Tanning addiction exists, study. August 16, 2005, accessed December 30, 2007.
- ^ M. Warthan, T. Uchida, R. Wagner, Jr. UV Light Tanning as a Type of Substance-Related Disorder. Archives of Dermatology, August 2005; vol 141: pp 963-966.
- ^ M. Kaur, A. Liguori, W. Lang, S. Rapp, A. Fleischer, Jr., S. Feldman. Induction of withdrawal-like symptoms in a small randomized, controlled trial of opioid blockade in frequent tanners. Journal of the American Academy of Dermatology, 54(4): p. 709-711, 2006
- ^ Hunter-Yates J, Dufresne RG, Phillips KA (May 2007). “Tanning in body dysmorphic disorder”. J. Am. Acad. Dermatol. 56 (5 Suppl): S107–9. doi:10.1016/j.jaad.2006.05.025. PMID 17434030.
- ^ Warthan MM, Uchida T, Wagner RF (August 2005). “UV light tanning as a type of substance-related disorder”. Arch Dermatol 141 (8): 963–6. doi:10.1001/archderm.141.8.963. PMID 16103324.
Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Many patients treated for vitamin D deficiency fail to achieve an adequate serum level of 25-hydroxyvitamin D [25(OH)D] despite high doses of ergo- or cholecalciferol. The objective of this study was to determine whether administration of vitamin D supplement with the largest meal of the day would improve absorption and increase serum levels of 25(OH)D. This was a prospective cohort study in an ambulatory tertiary-care referral center. Patients seen at the Cleveland Clinic Foundation Bone Clinic for the treatment of vitamin D deficiency who were not responding to treatment make up the study group. Subjects were instructed to take their usual vitamin D supplement with the largest meal of the day. The main outcome measure was the serum 259(OH)D level after 2 to 3 months. Seventeen patients were analyzed. The mean age (+/-SD) and sex (F/M) ratio were 64.5 +/- 11.0 years and 13 females and 4 males, respectively. The dose of 25(OH)D ranged from 1000 to 50,000 IU daily. The mean baseline serum 25(OH)D level (+/-SD) was 30.5 +/- 4.7 ng/mL (range 21.6 to 38.8 ng/mL). The mean serum 25(OH)D level after diet modification (+/-SD) was 47.2 +/- 10.9 ng/mL (range 34.7 to 74.0 ng/mL, p < .01). Overall, the average serum 25(OH)D level increased by 56.7% +/- 36.7%. A subgroup analysis based on the weekly dose of vitamin D was performed, and a similar trend was observed.Thus it is concluded that taking vitamin D with the largest meal improves absorption and results in about a 50% increase in serum levels of 25(OH)D levels achieved. Similar increases were observed in a wide range of vitamin D doses taken for a variety of medical conditions.
Copyright 2010 American Society for Bone and Mineral Research.
Have a look at this abstract which is the importance of mitotic rate (and lack of importance of Clark level)
Prognostic Significance of Mitotic Rate in Localized Primary Cutaneous Melanoma: An Analysis of Patients in the Multi-Institutional American Joint Committee on Cancer Melanoma Staging Database.
Melanoma Institute Australia; and the University of Sydney, Sydney, New South Wales, Australia; University of Pennsylvania, Philadelphia, PA; Memorial Sloan-Kettering Cancer Center, New York, NY; The University of Texas MD Anderson Cancer Center, Houston, TX; University of Michigan, Ann Arbor, MI; John Hopkins Medical Institutions, Baltimore, MD; and University of Alabama at Birmingham, Birmingham, AL.
PURPOSE The aim of this study was to assess the independent prognostic value of primary tumor mitotic rate compared with other clinical and pathologic features of stages I and II melanoma. METHODS From the American Joint Committee on Cancer (AJCC) melanoma staging database, information was extracted for 13,296 patients with stages I and II disease who had mitotic rate data available. Results Survival times declined as mitotic rate increased. Ten-year survival ranged from 93% for patients whose tumors had 0 mitosis/mm(2) to 48% for those with ≥ 20/mm(2) (P < .001). Mean number of mitoses/mm(2) increased as the primary melanomas became thicker (1.0 for melanomas ≤ 1 mm, 3.5 for 1.01 to 2.0 mm, 7.3 for 3.01 to 4.0 mm, and 9.6 for > 8 mm). Ulceration was also associated with a higher mitotic rate; 59% of ulcerated melanomas had ≥ 5 mitoses/mm(2) compared with 16% of nonulcerated melanomas (P < .001). In a multivariate analysis of 10,233 patients, the independent predictive factors for survival in order of statistical significance were as follows: tumor thickness (χ(2) = 104.9; P < .001), mitotic rate (χ(2) = 67.0; P < .001), patient age (χ(2) = 48.2; P < .001), ulceration (χ(2) = 46.4; P < .001), anatomic site (χ(2) = 34.6; P < .001), and patient sex (χ(2) = 33.9; P < .001). Clark level of invasion was not an independent predictor of survival (χ(2) = 3.2; P = .37). CONCLUSION A high mitotic rate in a primary melanoma is associated with a lower survival probability. Among the independent predictors of melanoma-specific survival, mitotic rate was the strongest prognostic factor after tumor thickness.