Faculty Bibliography

Meningeal carcinomatosis is the tumoral invasion of the leptomeninges. It is caused by the spread of malignant cells throughout the subarachnoid space, which produces signs and symptoms due to multifocal involvement. Cranial nerve symptoms are the most common focal findings. The diagnosis is usually made by imaging and/or cytology. Head and neck cancers are the cause of approximately 2% of all cases of meningeal carcinomatosis; in very rare cases, they are caused by a nasopharyngeal carcinoma. We report a case of meningeal carcinomatosis that was caused by a recurrence of undifferentiated nasopharyngeal carcinoma. The patient, a 60-year-old woman, experienced no focal neurologic symptoms and exhibited no radiologic evidence of meningeal involvement. We also review the literature on meningeal carcinomatosis secondary to nasopharyngeal carcinoma.

Disseminated superficial actinic porokeratosis, which was described in 1966, is characterized by small, atrophic patches with distinctive keratin rims that occur on sun-exposed areas of the extremities, shoulders, and back. The diagnosis is based on the histopathologic finding of a cornoid lamella, absence of a granular layer, and often a thin epidermis. It is associated with exposure to ultraviolet radiation. Gene studies suggest a pathway defect in which several mutations in keratinocyte proliferation and differentiation lead to development of porokeratosis.

BACKGROUND: Experimental evidences have shown that tumor necrosis factor (TNF)-alpha may play a role in the pathogenesis of nonsegmental vitiligo, and successful cases of vitiligo treated with TNF-alpha inhibitors have been recently reported. MATERIALS AND METHODS: Two cases of refractory generalized vitiligo, which showed high tissue levels of TNF-alpha, were commenced anti-TNF-alpha antibody etanercept 50 mg weekly. A retrospective study, considering chart review and immunohistochemical staining for TNF-alpha, was then carried out on eight additional patients affected by untreated vitiligo. RESULTS: Etanercept achieved improvement of vitiligo in two patients at 6-month follow-up. Five out of eight specimens showed a strong cytoplasmic staining for TNF-alpha. Considering all 10 cases, patients with a strong TNF-alpha staining were characterized by a higher vitiligo disease activity score than patients with a weak staining. DISCUSSION: These findings, albeit limited in significance by the low number of cases and the retrospective nature of the study, confirm a probable role of TNF-alpha in the pathogenesis of vitiligo. The intensity of TNF-alpha staining in vitiligo lesions may be worth to be further studied as a biomarker for potentially successful anti-TNF-alpha treatment of nonsegmental vitiligo in cases refractory to conventional treatment.

BACKGROUND: Chronic venous insufficiency (CVI) ulcers represent a major medical problem worldwide. Current theories concerning the pathogenesis of CVI ulcers focus on abnormalities in the blood vascular system. Other abnormalities, such as chronic leg edema, may also play pathogenic roles in CVI ulcer development and further understanding of such alterations may lead to better treatments. OBJECTIVE: To gain insight into lymphatic abnormalities occurring in CVI, we compared dermal lymphatics in histologic sections from CVI ulcers and normal controls. METHODS: We compared global and architectural features of dermal lymphatics in D2-40-stained histologic sections from CVI ulcer tissue and from normal controls. D2-40 recognizes podoplanin, a transmembrane glycoprotein that is constitutively expressed in lymphatic endothelial cells, allowing us to distinguish dermal blood vessels from lymphatic vessels. RESULTS: Our analyses reveal that CVI ulcer specimens have more dermal lymphatic vessels per unit area than controls (5.71 vs 4.08 per mm(2), respectively; P = .0281); a higher percentage of lymphatic vessels with collapsed lumina compared with controls (30.5% vs 8.1%, respectively; P < .0001); and a higher percentage of competent lymphatic vessels displaying open inter-endothelial junctions compared with controls (5.7% vs 2.9%, respectively; P < .0369). LIMITATIONS: Our study is limited by its retrospective nature and relatively small sample size. CONCLUSIONS: Lymphatic vessels in CVI ulcer specimens display global and architectural differences compared with lymphatic vessels in control specimens. These findings further implicate lymphatic dysfunction in the pathogenesis of CVI ulcers and allow for the formulation of a hypothesis concerning lymphatic changes that may be tested in future studies.

BACKGROUND: Upper arm skin laxity is an important area of cosmetic concern. Recent studies using a noninvasive infrared device has demonstrated its efficacy in tightening skin in various body regions. The use of this device in upper arm loose skin has not been investigated. OBJECTIVES: To determine the safety and efficacy of an infrared device to treat upper arm laxity in aged skin. PATIENTS AND METHODS: Twenty women with mild to very loose aged upper arm skin underwent two treatments with an infrared device 1 month apart. Nineteen patients completed the study with a 3-month follow-up. Outcome measures included investigator and participant evaluations of skin laxity improvement, blinded photographic assessments of skin tightening, and differences in circumferences and spectrophotometric analysis of collagen content in the treated arms. Two patients participated in histological evaluations. RESULTS: The patient and investigator clinical assessments showed minimal improvement in skin laxity. There was a statistically significant decrease in arm circumference. Blinded photographic assessments and spectrophotometric analysis revealed no statistical improvement in skin laxity. The immediate post-treatment histological evaluations showed architectural disarray of dermal collagen and elastin. CONCLUSION: An infrared device is safe, well tolerated, and minimally effective in treating aged upper arm skin laxity.

OBJECTIVE: We sought to evaluate differences in the stage at diagnosis and the survival of breast cancer patients enrolled in two different Medicare healthcare delivery systems: fee for service (FFS) and health maintenance organizations (HMO). METHODS: We used a linkage of two national databases, the Medicare database from the Centers for Medicare and Medicaid Services (CMS), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program database, to evaluate differences in demographic data, stage at diagnosis, and survival in patients with breast cancers over the period 1985-2001. RESULTS: Medicare patients enrolled in HMOs were diagnosed at an earlier stage of diagnosis than FFS patients. HMO patients diagnosed with breast cancer had improved survival, and these differences remained even after controlling for potential confounders. Specifically, breast cancer patients enrolled in HMOs had 9% increased probability of survival (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.93) than their counterparts enrolled in FFS. These findings persisted even when patients had a cancer diagnosis before their breast cancer. CONCLUSIONS: Improved survival among breast cancer patients in HMOs compared with FFS is likely due to a combination of factors, including but not limited to earlier stage at the time of diagnosis.

OBJECTIVE: To compare melanoma trends within Florida with national melanoma trends from 1992 through 2004. An analysis of state and national melanoma trends is critical for the identification of high-risk regions of the country. DESIGN: Data from the Florida Cancer Data System (FCDS) and Surveillance, Epidemiology, and End Results (SEER) were evaluated to determine age-adjusted and race/ethnicity- and sex-specific invasive cutaneous melanoma incidence trends for 1992 through 2004 using joinpoint regression analysis. Standardized incidence rate ratios (SIRRs) were computed to compare Florida with the United States. PATIENTS: A population of 109 633 patients with invasive melanoma was evaluated: 73 206 (66.8%) from SEER and 36 427 (33.2%) from FCDS. MAIN OUTCOME MEASURES: Melanoma incidence and change in melanoma rates over time. RESULTS: The incidence of melanoma among male Hispanic patients residing in Florida was 20% higher than that of their male counterparts in the SEER catchment areas (SIRR, 1.2; 95% confidence interval [CI], 1.1-1.4). Conversely, the incidence of melanoma among female Hispanic patients residing in Florida was significantly lower than that in SEER (SIRR, 0.7; 95% CI, 0.7-0.8). Differences in melanoma incidence were identified in female non-Hispanic black (NHB) patients in Florida who had a 60% significantly higher incidence of melanoma compared with female NHB patients in SEER (SIRR, 1.6; 95% CI, 1.3-2.0). CONCLUSION: These findings suggest an emerging public health concern in race/ethnic subgroups that were previously understudied.

BACKGROUND: Hispanics are given the diagnosis of melanoma at later stages and have reduced survival. OBJECTIVE: We sought to evaluate the effect of Hispanic ethnicity and different health care delivery systems (fee-for-service [FFS] and health maintenance organizations) on melanoma stage at diagnosis and survival. METHODS: We studied a retrospective cohort of 40,633 patients, with at least 3 years of follow-up, who were given the diagnosis of incident melanoma from 1991 to 2002 and were 65 years or older using data from the Surveillance, Epidemiology, and End Results-Medicare linked database. The analytic sample consisted of 39,962 non-Hispanic whites (NHW) and 671 Hispanics. Logistic regression models examined the roles of the health care delivery system and race/ethnicity in stage at diagnosis and survival. RESULTS: For FFS patients, Hispanics were more likely to be given a diagnosis at an advanced stage (distant vs earlier stages [odds ratio {OR} = 2.07; 95% confidence interval CI = 1.36-3.16]; regional vs earlier stages [OR = 2.31; 95% CI = 1.75-3.03]) compared with NHW. Among Hispanic patients, those enrolled in health maintenance organizations were less likely to be given a diagnosis at later stage (regional vs earlier stages [OR = 0.50; 95% CI = 0.31-0.81]) than FFS patients; however, the earlier stage at diagnosis did not improve survival. For patients with a previous cancer before their melanoma diagnoses, NHW enrolled in health maintenance organizations from 1991 to 2002 were given a diagnosis at earlier stages compared with NHW FFS patients (OR = 0.72; 95% CI = 0.52-0.99); this was not found among Hispanics. LIMITATIONS: These results reflect findings in a Medicare-aged population and it is not clear if they are generalizable to younger patients. CONCLUSIONS: Differences in melanoma outcomes among different ethnic groups are, in part, dependent on the health care setting in which patients are enrolled.