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Background and Design: Patients with large congenital melanocytic nevi have been described to have an increased risk for the development of malignant melanoma (MM). Ninety-two patients with large congenital melanocytic nevi were followed up prospectively for the development of MM. Matched individuals from the general population served as control subjects. Results: Ninety-two patients (median age, 3 years) were followed up prospectively for an average of 5.4 years. In three patients (3%), MM developed in extracutaneous sites. The cumulative 5-year life-table risk for the development of MM was calculated to be 4.5% (95% confidence interval, 0% to 9.3%). In individuals in the general US population, matched for age, sex, and length of follow-up to the 92 study patients, 0.013 would be expected to develop MM. The standardized morbidity ratio (adjusted relative risk) was calculated to be 239, which was highly significant (P Conclusions: Patients with large congenital melanocytic nevi are at a significantly increased risk for the development of MM and should be kept under continuous surveillance for the development of cutaneous as well as noncutaneous primary MM. (Arch Dermatol. 1996;132:170-175)

Background and Design: There is an increased risk of developing cutaneous malignant melanomas (MMs) in patients with classic atypical-mole syndrome (AMS). This study compares the incidence of newly diagnosed MMs in patients with classic AMS (cases) with the incidence of newly diagnosed MMs developing in a population without classic AMS (control patients). The charts of 287 white patients with AMS and 831 white patients without AMS were reviewed for the occurrence of newly diagnosed invasive MMs during follow-up. Both cases and control patients were followed up regularly by total-body cutaneous examinations. The cumulative 10-year risk for developing newly diagnosed invasive MMs was calculated (life-table method) for each cohort. Results: Of the 287 AMS cases, 10 developed a newly diagnosed invasive MM, resulting in a 10-year cumulative risk of 10.7%. Of the 831 control patients, two developed a newly diagnosed invasive MM, resulting in a 10-year cumulative risk of 0.62%. Conclusion: Patients with classic AMS, regardless of the presence of a personal and/or family history of MM, are at significantly increased risk of developing invasive MMs compared with control patients. (Arch Dermatol. 1994;130:993-998)

• The computerized database (1955 through 1982) of the Oncology Section of the Skin and Cancer Unit of New York (NY) University Medical Center includes data on 13 878 lesions. Of these lesions, 214 were diagnosed clinically and histologically as malignant melanoma (MM). An additional 51 lesions, diagnosed clinically as other than MMs, were found histologically to be MM. Seventy-nine lesions were clinically diagnosed as MM but were found histologically to be other entities. An analysis of the clinical diagnostic accuracy showed some improvement over the three periods studied (1955 through 1963, 1964 through 1973, and 1974 through 1982). Although the diagnostic accuracy for the best period (1974 through 1982) was only 64%, the diagnosis of MM was made in 84.5% of the histologically proved cases of MM, reflecting a high degree of sensitivity. ( Arch Dermatol . 1990;126:763-766)

• In a clinicohistopathologic study of 557 patients with primary cutaneous malignant melanoma, there were fewer metastases and/or deaths from melanoma when histologic evidence of a coexisting acquired melanocytic nevus was found. A total of 130 patients with melanocytic nevus and 427 cases of melanoma without histologic evidence of a nevus (denovo) were studied. Clinical follow-up evaluation for evidence of metastases and/or death was obtained. Only ten of the patients (7.7%) with nevus-associated melanoma had metastases and/or death v 78 (18.3%) with de novo melanoma. When stratified by lesion thickness, the logrank test for survival revealed a statistically significant difference between the two groups. An overall favorable outcome seen in patients with malignant melanomas associated with acquired melanocytic nevi was found, therefore, to be independent of lesion thickness as well as six other variables reported to be related to the biologic behavior of malignant melanoma. Thus, the presence of nevus cells in a specimen of malignant melanoma portends a better prognosis and may have important implications in the biology of this neoplasm. ( Arch Dermatol 1983;119:455-462)

In Reply.— We thank Dr Epstein for his comments concerning our article entitled "Curettage-Electrodesiccation Treatment of Basal-Cell Carcinomas." We join Dr Epstein in hoping that our statistical methods will be found useful by others. We did not think that our paper would be interpreted as suggesting that the technique of simple elliptical excision should be abandoned by dermatologists. As a matter of fact, we are presently studying the results of simple surgical excision by the same means that we used to study curettage-electrodesiccation. Surgical excision is both taught and used at the Skin and Cancer Unit. Because of the "speed and simplicity" of the curettage-electrodesiccation procedure, it is used more frequently at the Skin and Cancer Unit than the technique of excision or any other method. But these are only two reasons for use of curettage-electrodesiccation. Other reasons have recently been reviewed. 1 Also, the advantages and disadvantages of the

Eight patients received superficial x-ray therapy for morphea-type basal cell carcinomas. Seven lesions did not recur. One recurrence adjacent to an irradiated field was observed; it was considered to be a geographic miss and has led us to include a wider field (10 mm) of normal-appearing skin beyond the clinical perimeter of the tumor when the lesion is ill-defined. The cosmetic results after treatment were poorer than anticipated for this schedule of radiation therapy, based on our extensive experience with other types of basal cell carcinomas. To obtain the best long-term results we believe that, where technically feasible Mohs surgery and conventional surgical excision with histologic verification of free margins are the treatments of choice for morphea-type basal cell carcinomas. However, our experience indicates that morphea-type basal-cell carcinomas can be cured with radiation therapy; therefore, x-rays have a place in the armamentarium of therapeutic modalities for this tumor if surgery is not feasible or if it is refused by the patient.

Cure rates after treatment of basal cell carcinomas with curettage-electrodesiccation were compared among three groups: group A, 597 lesions treated in the Skin and Cancer Unit in 1958 to 1962; group B, 91 lesions treated in the Skin and Cancer Unit in 1970; and group C, 210 lesions treated in private practice in 1962 to 1973. The following were the five-year cumulative recurrence rates: group A, 18.8%; group B, 9.6%; and group C, 5.7%. In all three groups, there were high recurrence rates for tumors treated on the nose, paranasal areas, and forehead. Few complications occurred after curettage-electrodesiccation with the exception of hypertrophic scars. The cosmetic results following curettage-electrodesication improved with time. Curettage-electrodesiccation, when performed by experienced physicians, is a very useful modality for the treatment of basal cell carcinomas, with cure rates of over 90%, satisfactory cosmetic results, and few significant complications.

• The diagnostic accuracy and index of suspicion concerning malignant melanoma were calculated based on review of 5,538 histologically examined lesions (of which 99 were melanomas) that were recorded in the Oncology Section of the Skin and Cancer Unit from 1955 to 1967. The diagnostic accuracy of the physicians in the Section was determined to be 64.4%. Thus, in almost one of every three melanomas an error in clinical diagnosis was made. This "batting average" is, however, better than those of previously published reports. The index of suspicion in relation to malignant melanoma in our series was 96%. Thus, the physicians in the Oncology Section demonstrated an appropriate awareness of this tumor. However, coupled with a diagnostic accuracy of 64%, a problem nevertheless exists in the diagnosis of this serious cutaneous cancer. Our study emphasizes the importance of having histologic verification prior to definitive radical surgery on patients with malignant melanoma. ( Arch Dermatol 111:1291-1292, 1975)

The Miescher technique of x-radiation was employed to treat eight melanotic freckles. Five lesions responded well; the sixth also responded, but an underlying unrecognized malignant melanoma continued to grow, eventually metastasizing. The seventh lesion, repeatedly subjected to electrodesiccation prior to radiation, failed to respond; the eighth recurred three years after treatment. Modification of grenz-ray machines for the Miescher technique is described. This is accomplished by placing a thin filter of cellulose acetate in the grenz-ray beam to filter out softest radiations. The Miescher technique is reserved for lesions confined to the dermoepidermal junction, that is, to the precancerous phase. It is not indicated when dermal invasion, ie, malignant melanoma, has supervened. Further experience and long-term follow-up studies are needed to establish the place of x-radiation in management of this precancer.

• Hazard-rate analysis provides a unique means of assessing prognosis in patients with malignant disease. The hazard rate is the probability of a patient dying within a particular unit of time after definitive therapy. Hazardrate analysis was performed on a series of 719 consecutive patients with clinical stage I cutaneous malignant melanoma (MM). The peak hazard rate for death from metastatic MM occurred during the 48th month of followup. Thereafter, the hazard rate declined and approached zero by the 120th month. When the patients were stratified by the thickness of their primary MM, thicker lesions reached their peak hazard-rate month earlier than thinner lesions. We conclude that after 120-month survival, the risk of dying from MM is virtually zero. However, since rare late deaths from MM occur, lifetime follow-up is recommended. ( Arch Dermatol 1986;122:999-1002)

To the Editor.— I read with interest theArchivesarticle by Carr and Rau (1981;117:814-815) entitled "Dermatitis at vein graft site in coronary artery bypass patients." The authors expressed the hope that their report would lead to recognition of other cases of this disorder, and to an elucidation of its specific cause. I have seen such a case in New York, and would like to report it here, although I do not know the specific cause of this dermatitis. Report of a Case.— A 58-year-old white man consulted me concerning a pruritic dermatitis of two months' duration situated on the medial aspect of his left leg. Four months previous to his visit, he had undergone a triple coronary bypass operation; the vascular grafts were taken from the left saphenous vein. The patient had an eczematous dermatitis, measuring several centimeters in diameter, on and around the lower part of the healed

The simultaneous occurrence of urticarial dermographism in monozygotic twins is reported. Studies suggested successful passive tranfer with sera. A simple device for estimating the pressures necessary to induce whealing is described. Preliminary results indicate that persons who urticate at a pressure of 32 gm/sq mm or less are clinically symptomatic. Hydroxyzine treatment was effective.

Digital fibrokeratomas are benign acquired lesions. They are firm, more or less hyperkeratotic projections arising out of a collarette of slightly raised skin. Clinically, they resemble rudimentary supernumerary digits. Microscopically, a fibrokeratoma is composed of a core of normal appearing connective tissue covered with an acanthotic epidermis which produces a dense enveloping hyperkeratosis.

Light eyes are uncommon in patients with solidly pigmented black or dark brown basal-cell carcinomas. All eye colors are found in patients with malignant melanoma. A solidly pigmented black or dark brown malignant lesion, in a patient with blue, gray, or green eyes, is more likely to be a melanoma than a basal-cell carcinoma.