Dorothee Nashan

Malignant Melanoma S3-Guideline "Diagnosis, Therapy and Follow-up of Melanoma"

This first German evidence-based guideline for cutaneous melanoma was developed under the auspices of the German Dermatological Society (DDG) and the Dermatologic Cooperative Oncology Group (DeCOG) and funded by the German Guideline Program in Oncology. The recommendations are based on a systematic literature search, and on the consensus of 32 medical societies, working groups and patient representatives. This guideline contains recommendations concerning diagnosis, therapy and follow-up of melanoma. The diagnosis of primary melanoma based on clinical features and dermoscopic criteria. It is confirmed by histopathologic examination after complete excision with a small margin. For the staging of melanoma, the AJCC classification of 2009 is used. The definitive excision margins are 0.5 cm for in situ melanomas, 1 cm for melanomas with up to 2 mm tumor thickness and 2 cm for thicker melanomas, they are reached in a secondary excision. From 1 mm tumor thickness, sentinel lymph node biopsy is recommended. For stages II and III, adjuvant therapy with interferon-alpha should be considered after careful analysis of the benefits and possible risks. In the stage of locoregional metastasis surgical treatment with complete lymphadenectomy is the treatment of choice. In the presence of distant metastasis mutational screening should be performed for BRAF mutation, and eventually for CKIT and NRAS mutations. In the presence of mutations in case of inoperable metastases targeted therapies should be applied. Furthermore, in addition to standard chemotherapies, new immunotherapies such as the CTLA-4 antibody ipilimumab are available. Regular follow-up examinations are recommended for a period of 10 years, with an intensified schedule for the first three years.

A first prospective population-based analysis investigating the actual practice of melanoma diagnosis, treatment and follow-up

AIM OF THE STUDY To describe the current management of patients diagnosed with cutaneous melanoma and melanoma in situ in Germany and assess for adherence with the existing German guideline in a first prospective population-based analysis. METHODS Prospective and longitudinal population-based study using online questionnaires. Registration by practitioners and hospitals was open for all patients diagnosed with melanoma between April and June 2008 in Germany. For data analysis, patients with melanoma stages 0-III (AJCC 2002) were included. RESULTS Data from 1081 patients registered by 106 different centres were available for analysis. Male patients were significantly older than female patients (61.4 years versus 55.8years, p<0.0001) and presented with thicker primary tumours (1.62 mm [median 0.9 mm] versus 1.48 mm [median 0.8 mm], p=0.01). Excessive safety margin excisions were most often applied in melanoma in situ and in small centres. Insufficient excision margins (6.9%) were associated with head and neck localisation, geographical region and implementation of further staging procedures. Decision on sentinel lymph node biopsy complied with the German guideline in >85% of cases and was dependent on age and tumour localisation. Only 60% of patients received a complete lymph node dissection (CLND) after a positive SLNB, the rate of CLND was lowest in older patients. Adjuvant treatments were initiated in only 34% of patients formally qualifying for adjuvant treatment based on guideline recommendations. Approximately half of all staging procedures were done in no-risk/low-risk tumour patients. CONCLUSIONS Management of melanoma in Germany did not show great dependency on centre size, geographical area or treating physician but rather on patient and tumour characteristics. The low rate of adjuvant treatment initiations reflects the need of treatment options in this patient group. Excessive initial staging procedures generate significant costs.

Chronic urticaria, arthralgia, raised erythrocyte sedimentation rate and IgG paraproteinaemia: a variant of Schnitzler's syndrome?

Schnitzlers syndrome is a distinct disease entity characterized by the association of chronic urticaria, intermittent fever, arthralgia, elevated erythrocyte sedimentation rate and IgM macroglobulin‐aemia. We report a patient with the same symptoms, but a monoclonal IgG instead of IgM gammopathy. Histological examination of the urticarial lesions showed signs of mild leucocyto‐clastic vasculitis. Except for the different class of the monoclonal immunoglobulin, the clinical symptoms, laboratory findings and histology in this patient were identical with those in classical Schnitzlers syndrome. IgG and IgM paraproteins may be equivalent with regard to the putative pathophysiology of the disease process in Schnitzlers syndrome. We therefore suggest that the spectrum of Schnitzlers syndrome is expanded to include patients with chronic urticaria and monoclonal IgG gammopathy, as a closely related variant.

Short German guidelines: Cutaneous lymphomas

Journal compilation

Open label randomized study comparing 3 months vs. 6 months treatment of actinic keratoses with 3% diclofenac in 2.5% hyaluronic acid gel: a trial of the German Dermatologic Cooperative Oncology Group

Background Actinic keratoses (AK) are carcinomata in situ with the potential to develop into invasive carcinoma. Several studies have demonstrated that 3% diclofenac in 2.5% hyaluronic acid gel (HA) is effective and well tolerated in the treatment of AK. To date there are no large randomized multicentre trials with treatment durations longer than 90 days and histopathological control of treatment outcome.

Brief S2k guidelines--Cutaneous lymphomas.

Rudolf Stadler, Chalid Assaf, Claus-Detlev Klemke, Dorothee Nashan, Michael Weichenthal, Reinhard Dummer, Wolfram Sterry (1) Department of Dermatology, Johannes Wesling Klinikum, Minden, Germany (2) Department of Dermatology, HELIOS Klinikum, Krefeld, Germany (3) Department of Dermatology, Venereology, and Allergology, Mannheim University Hospital, Germany (4) Department of Dermatology, Dortmund Hospital, Germany (5) Department of Dermatology, Venereology, and Allergology, University Hospital Schleswig-Holstein (UKSH), Campus Kiel, Germany (6) Department of Dermatology, Zurich University Hospital, Switzerland (7) Department of Dermatology, Venereology, and Allergology, Charite – Universitatsmedizin Berlin, Germany

Skin Cancer: Epidemiology, Disease Burden, Pathophysiology, Diagnosis, and Therapeutic Approaches.

Skin cancer, including both melanoma and non-melanoma, is the most common type of malignancy in the Caucasian population. Firstly, we review the evidence for the observed increase in the incidence of skin cancer over recent decades, and investigate whether this is a true increase or an artefact of greater screening and over-diagnosis. Prevention strategies are also discussed. Secondly, we discuss the complexities and challenges encountered when diagnosing and developing treatment strategies for skin cancer. Key case studies are presented that highlight the practic challenges of choosing the most appropriate treatment for patients with skin cancer. Thirdly, we consider the potential risks and benefits of increased sun exposure. However, this is discussed in terms of the possibility that the avoidance of sun exposure in order to reduce the risk of skin cancer may be less important than the reduction in all-cause mortality as a result of the potential benefits of increased exposure to the sun. Finally, we consider common questions on human papillomavirus infection.

Significant Risk of a Second Melanoma in Patients with a History of Melanoma but No Further Predisposing Factors

It is a well-accepted fact that melanoma patients are prone to develop further melanomas. In a cohort of 535 melanoma patients, we determined the incidence of second melanomas, as well as risk factors known to be associated with melanoma development. A retrospective analysis of patients regularly consulting our melanoma care unit revealed second or even further melanomas in 5.6% (n = 30). When compared to the overall population, melanoma patients have at least a 30-fold increased risk for the development of a second melanoma. Twenty of these 30 patients revealed none of the known predisposing conditions for multiple melanomas.

Kutane Myiasis : ein Urlaubssouvenir

ZusammenfassungDie kutane Myiasis ist eine temporäre Infestation der Haut mit Fliegenlarven, die aufgrund des zunehmenden Fernreisetourismus in subtropische Gebiete auch vermehrt in Europa angetroffen wird. In Mittel- und Südamerika wird die kutane Myiasis meistens durch die Larven der Bot- oder Dasselfliege (Dermatobia hominis) verursacht. Moskitos oder andere blutsaugende Insekten übertragen die Larven der Dasselfliege durch Phoresis, einem einzigartigen Mechanismus der Eiablage. Im afrikanischen Raum lösen die Larven der Tumbufliege (Cordylobia anthropophaga) häufig die kutane Myiasis aus. In Kleidung oder Handtüchern abgelegte Eier der Tumbufliege führen dabei nach direktem Kontakt zur Infestation. Klinisch imponiert eine Furunkel-ähnliche Läsion, vereinzelt wird über spürbare Bewegungen in der Haut berichtet. Nach dem „Schlüpfen” der Larven erfolgt in der Regel eine spontane Heilung. Die Extraktion der Larven wird jedoch empfohlen, um stärker entzündliche Reaktionen und Sekundärinfektionen zu verhindern.SummaryCutaneous myiasis is a temporary infestation of the skin with fly larvae. Travelling to subtropical areas accounts for a higher risk and increasing incidence in Europeans. In Middle- and South America myiasis is mainly caused by the botfly (Dermatobia hominis). Blood-suckling arthropods, usually mosquitoes, transmit the larvae of the botfly via phoresis, a unique mechanism of egg deposition. In Africa cutaneous myiasis is mostly due to the tumbu fly (Cordylobia anthropophaga). Infection with the tumbu fly larvae occurs after direct contact with the eggs that are often deposited in clothes and towels. Clinically an abscess-like lesion develops. Creeping sensations of movement under the skin are occasionally described. Following hatching, spontaneous healing can normally be expected, although extraction of the larvae is recommended to prevent abscess formation and superinfection.

Morbus Still im Erwachsenenalter („adult onset Still’s disease”): Erkrankung mit einem charakteristischen Exanthem

ZusammenfassungDer Morbus Still ist ursprünglich für das Kindesalter als chronisch rheumatoide Arthritis mit initial systemischer Symptomatik definiert worden. In seltenen Fällen setzt die Erkrankung aber erst im Erwachsenenalter ein, man spricht dann vom Morbus Still mit Beginn im Erwachsenenalter („adult onset Still’s disease”). Die diagnostischen Kriterien beinhalten ein charakteristisches Exanthem, Gelenkbeschwerden, Fieberschübe und Leukozytose sowie Leberfunktionsstörungen, Halsschmerzen ohne nachweisbare Infektion, Vergrößerung von Lymphknoten oder Milz und fehlende Titer für Rheumafaktoren oder antinukleäre Antikörper. Wir berichten über zwei bereits länger erkrankte erwachsene Patienten, deren Hauterscheinungen uns zu der Diagnose Morbus Still führten. Das Exanthem des M. Still ist ein Symptom von hoher Sensitivität. Es äußert sich in roten, scharf begrenzten Makulae, die sehr flüchtig sind. Durch leichte Reibung können im Exanthemschub erythematöse KöbnerPhänomene ausgelöst werden, die, wie wir hier erstmals beschreiben, manchmal länger persistieren als das übrige Exanthem.SummaryStill’s disease was originally described as one form of rheumatoid arthritis in children beginning with fever and other systemic symptoms. In rare cases it may also begin in the adult and is then referred to as adult-onset Still’s disease. The diagnostic criteria include typical rash, arthralgias, bouts of fever, and leukocytosis, as well as lymphadenopathy or splenomegaly, liver dysfunctions, non-infectious angina, and absence of rheumatoid factor and antinuclear antibodies. We report two adult patients with longstanding disease whose exanthema guided us to the correct diagnosis. The rash is a finding with high sensitivity. It is characterized by red macules with distinct borders and is evanescent. During an acute flare of the rash, gentle friction induces erythematous, isomorphic (Koebner) phenomena, which, as we describe here for the first time, may persist longer than the remainder of the fleeting rash.