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Summary Erectile dysfunction varied by country, affecting between 20 to 40% of men aged 60 and 69 and more than 50% of men aged over 75. Our objective was to evaluate the habits of urologists in 2018 and also evaluate the need for additional, objective tools to aid physicians when providing care. A questionnaire was sent from the French Urology Association to 1158 physicians between November and December 2018. In all, 177 urologists (15.28%) took part in the study. Only 22% of urologists regularly used a questionnaire, such as the IIEF-5. When faced with erection problems, 56.5% of them did not carry out systematic cardiology evaluations. More than half of urologists requested fasting glucose, lipid and total testosterone levels. Twenty-seven percent did not carry out additional tests. First line treatment included a phosphodiesterase 5 inhibitor in 81% of cases. Two thirds of urologists (78%) rated themselves as being correctly trained in the area of erectile dysfunction. However, only 49% systematically inquired about erection problems when faced with benign prostatic hyperplasia and 65% thought that erectile dysfunction was not treated optimally. Despite existing recommendations, only half of urologists carry out a cardiac evaluation when a finding of erectile dysfunction is made. One third of urologists do not request additional testing. Greater training, along with the use of an objective diagnostic tool could help urologists to optimise the care they provide for patients suffering from erectile dysfunction, allowing them to keep working within current guidelines. Level of evidence 3.

Aims To assess the impact of sacral neuromodulation (SNM) on pregnancy and vice-versa, by identifying women who had received SNM for lower-urinary tract symptoms (LUTS) and had become pregnant. Methods A cross-sectional descriptive study was carried out based on responses to an on-line questionnaire sent to practitioners listed on the InterStim enCaptureTM National Registry. Questions were related to pre-pregnancy health and SNM efficacy, deactivation of the device, its impact on LUTS, childbirth, the infant, its reactivation and postpartum effectiveness. Results Twenty-seven pregnancies were recorded among 21 women. Six women had had a pregnancy prior to implantation, two of whom had had a c-section. A total of 18.5% of women had the device disabled prior to conception. The others had their device disabled during the first trimester and did not reactivate it before delivery. Complications were reported in 25.9% of pregnancies: six women had urinary infections, including three of the four treated for chronic retention of urine (CRU), and 1 woman had pain at the stimulation site. There were 24 live births (including one premature birth and four c-sections), one spontaneous miscarriage and two voluntary interruptions of pregnancy. No neonatal disorders have been reported. Effectiveness of sacral neuromodulation decreased in 20% in postpartum. Conclusions In 27 pregnancies established during SNM for LUTS, 18.5% of patients deactivated their case before pregnancy and the others switched it off during the first trimester. Three-quarters of women with CRU had urinary infection. No adverse effects on fetuses were found. SNM effectiveness deteriorated in 20% cases after childbirth.

Resume Introduction Les troubles vesicosphincteriens (TVS) sont frequents au cours de la maladie de Parkinson (MP) et des autres syndromes parkinsoniens (SP). Ils sont responsables d’une morbidite et mortalite significative et alterent de maniere notable la qualite de vie des patients. La prise en charge therapeutique de ces TVS exige de savoir distinguer la MP des autres SP et de connaitre leur epidemiologie et physiopathologie. Objectif Proposer une strategie diagnostique et therapeutique des TVS chez les patients presentant un SP. Methode Etude de la litterature a partir de la base de donnee Pubmed en utilisant les mots cles suivants, Parkinson's disease, multiple system atrophy, lower urinary tract disorders, neurogenic bladder , overactive bladder , obstruction, anticholinergics, dopamine, prostate surgery . Resultats Parfois revelateurs de la maladie neurologique, les TVS au cours des SP posent un probleme diagnostique car ils surviennent a un âge ou diverses pathologies urogynecologiques peuvent etre intriquees avec le dysfonctionnement vesical neurogene. Le diagnostic differentiel entre MP et atrophie multisystematisee, important a connaitre par l’urologue, repose sur l’analyse semiologique clinique, la reponse au traitement dopaminergique et l’evolution clinique mais aussi sur les donnees des explorations urodynamiques. La prise en charge therapeutique de ces TVS est rendue complexe par la difficulte d’utilisation de certains traitements pharmacologiques et par les risques d’aggravation apres traitement chirurgical inapproprie. L’arsenal therapeutique comprend l’utilisation prudente des anticholinergiques, la stimulation tibiale posterieure, la stimulation profonde sous-thalamique, les injections intradetrusoriennes de toxine botulique a faibles doses et hors autorisation de mise sur le marche. La decision d’une chirurgie prostatique doit etre prise avec prudence apres avoir prouve l’obstruction sous-vesicale. Conclusion Lors de l’analyse des TVS au cours de SP, l’urologue doit savoir remettre en question le diagnostic initial de MP idiopathique. Les traitements, visant a reduire la morbi-mortalite des TVS et a ameliorer la qualite de vie des patients souffrant de ces maladies degeneratives, ne seront proposes qu’apres concertation pluridisciplinaire neuro-urologique. La decision d’une chirurgie prostatique doit etre prise avec prudence apres avoir prouve l’obstruction sous-vesicale.

The surgical care pathway of neurologic patients has two aims: preventing urinary morbidity and mortality and improving their quality of life. It requires taking into account the specificities of disabilities in domains of body functions: circulatory, ventilation and digestive physiology, motor functions, sensory functions, mental functions, and skin fragility which are responsible of dependencies in this heterogeneous group of patients. This management is necessarily multidisciplinary to be optimal and through specific clinical care pathway, providing guidance to the surgical procedure: preparation of the surgery, its realization, and post-operative rehabilitation. The indication for surgery must be coordinated and validated in neuro-urology multidisciplinary staff. Preoperative stay in a physical and rehabilitation medicine center may be useful to ensure a complete assessment and anticipate problems related to surgery. The patient will be hospitalized in the urology department in a single room suited to their disabilities and handicaps. The chronic treatments should be not modified if possible. The lack of sensitivity does not dispense anesthesia to prevent autonomic hyperreflexia, the most severe complication after high complete spinal cord injury. The laparoscopy and sub-peritoneal surgery, the early removal nasogastric tube and early refeeding make it possible to early resumption of intestinal transit. In many cases, the patients should be transferred to a physical and rehabilitation medicine during post-operative period where the nursing care will be most suitable. A quickly adapted rehabilitation must be able to reduce loss of function and physical dependence.

Interstitial cystitis is the first cause of bladder pain. In case of failure of the usual treatments, several other modalities have been proposed. These therapeutic modalities are posterior sacral root neuromodulation, posterior tibial nerve stimulation, vanilloid agent intravesical instillation, intradetrusor botulinum toxin injections and surgery. A certain efficiency of each of these treatments in the interstitial cystitis has been reported. However, the evaluation of these treatments is limited and the level of evidence is too low to propose these treatments in routine.

In France, the prevalence of urinary incontinence is about 44%. Obesity, defined by a Body Mass Index (BMI) above 30kg/m(2), is well established as a risk factor of stress urinary incontinence. Odds ratio (OR) varies between 1.7 and 2.4. Urge or mixed incontinence also occurs in obesity. Urinary incontinence epidemiology is not well-known in obese women. Weight loss, obtained by a weight reduction diet program or bariatric surgery, improves urinary symptoms of stress, urge or mixed incontinence. Functional outcome of urge incontinence surgery is not influenced by obesity. Typically, functional outcome and morbidity of tension-free vaginal tape are not influenced by BMI variations.

The management of some neurological patients can require urinary diversion. Continent cystostomy is one of the treatment options proposed in young patients, usually for cosmetic reasons. In this article, the authors describe the main techniques used in this particular indication and then review the literature to define the results of the various techniques used, as well as the modalities of follow-up in these patients in view of the potential complications.

Multiple sclerosis (MS) is a neurological disease characterized by multiple demyelinating lesions disseminated throughout the central nervous system (nerve conduction block). The management of these patients requires a perfect knowledge of the natural history of the disease. In this article, the authors review the literature to identify the most frequent voiding disorders observed in this disease and then study the diagnostic and therapeutic modalities and the optimal modalities of follow-up in these patients, in view of the risk of various urological complications.

Background Many factors have been identified as important determinants that increase the risk of malignant melanoma (MM) developing. Patients with classic atypical mole syndrome (CAMS) have multiple such factors and are known to be at high risk for MMs developing. Objective We sought to evaluate the risk for newly diagnosed MMs developing in patients with CAMS and in a heterogeneous group of patients at high risk (ie, those with high-risk non-CAMS [HRNCAMS]) who had 1 or more risk factors: personal history of nonmelanoma skin cancers; family history of melanoma; biopsy specimen–confirmed dysplastic nevi; and meeting 1 or 2 of the 3 CAMS criteria. We also aimed to report our experience treating these patients at high risk with annual total cutaneous examination, total cutaneous photography, and dermoscopy. Methods Consecutive medical records from a private dermatology practice were reviewed. A total of 258 patients were selected who fulfilled the criteria of having: (1) total cutaneous photography as an aid for follow-up; (2) total cutaneous examination at least once per year; (3) at least 6 months of clinical follow-up; and (4) no personal history of melanomas. A total of 160 patients with CAMS and 98 with HRNCAMS were included in this study. The 10-year risk for MM developing in these 2 cohorts was computed using the Kaplan-Meier method. Results In the CAMS cohort, 28 new MMs developed in 19 patients resulting in a cumulative 10-year risk of 14% (95% confidence interval: 7-20). In the HRNCAMS cohort, 10 new MMs developed in 9 patients, and the cumulative 10-year risk was 10% (95% confidence interval: 2-17). The difference between the 2 groups was not statistically significant ( P = .91). The MMs diagnosed in both cohorts were either in situ or less than 1 mm in Breslow thickness. There were no MM metastases or MM-related deaths in either cohort during a mean follow-up period of 120 months for the CAMS and 98 months for the HRNCAMS group. Conclusion Both the patients with CAMS and HRNCAMS were at very high risk for MMs developing. The combination of total cutaneous photography, total cutaneous examination, and dermoscopy were used in treating our patients. No MM 1 mm or greater in thickness developed during follow-up in either group.

Background: Opinions concerning the significance of dysplastic nevi and their management vary among dermatologists. Objective: The purpose of this study was to assess how fellows of the American Academy of Dermatology (AAD) perceive and manage dysplastic nevi. Methods: Questionnaires were sent to 1216 fellows of the AAD; 456 questionnaires were returned. Results: Almost all respondents (98%) accept the dysplastic nevus, or atypical mole, as an entity. Seventy-five percent of respondents perform follow-up total cutaneous examinations on all their patients with dysplastic nevi, and another 22% on some of them; 86% usually intend to do total removals when they perform biopsies of dysplastic nevi; 75% use margins of 2 mm or less when removing dysplastic nevi; 49% order baseline total-cutaneous photographs of some or all of their patients with multiple dysplastic nevi, although only 12% do so routinely; 67% prefer to re-excise dysplastic nevi when margins are positive, some using histologic atypia as a criterion; 60% recommend an ophthalmologic examination for at least some of their patients with many dysplastic nevi, although only 3% do so routinely; 12% always recommend cutaneous examinations of blood relatives of their patients with dysplastic nevi and another 81% recommend such examinations for at least some of their patients with dysplastic nevi; 23% use dermoscopy; 99% recommend self-examination; almost 100% recommend sunscreen use and 93%, sun avoidance. Conclusion: Most respondents, in agreement with the literature, accept the concept that patients with dysplastic nevi are at increased risk for melanoma and that methods for prevention and early detection of melanomas are appropriate for these patients. (J Am Acad Dermatol 2002;46:674-82.)

The incidence and mortality rates of melanoma have risen for many decades in the United States. Increased exposure to ultraviolet (UV) radiation is generally considered to be responsible. Sunburns, a measure of excess sun exposure, have been identified as a risk factor for the development of melanoma. Because sunburns are primarily due to UVB (280-320 nm) radiation, UVB has been implicated as a potential contributing factor to the pathogenesis of melanoma. The adverse role of UVA (320-400 nm) in this regard is less well studied, and currently there is a great deal of controversy regarding the relationship between UVA exposure and the development of melanoma. This article reviews evidence in the English-language literature that surrounds the controversy concerning a possible role for UVA in the origin of melanoma. Our search found that UVA causes DNA damage via photosensitized reactions that result in the production of oxygen radical species. UVA can induce mutations in various cultured cell lines. Furthermore, in two animal models, the hybrid Xiphophorus fish and the opossum (Mondelphis domestica), melanomas and melanoma precursors can be induced with UVA. UVA radiation has been reported to produce immunosuppression in laboratory animals and in humans. Some epidemiologic studies have reported an increase in melanomas in users of sunbeds and sunscreens and in patients exposed to psoralen and UVA (PUVA) therapy. There is basic scientific evidence of the harmful effects of UVA on DNA, cells and animals. Collectively, these data suggest a potential role for UVA in the pathogenesis of melanoma. To date evidence from epidemiologic studies and clinical observations are inconclusive but seem to be consistent with this hypothesis. Additional research on the possible role of UVA in the pathogenesis of melanoma is required.

B large congenital melanocytic nevus (LCMN), defined herein as a nevus present at birth that is predicted to be at least 20 cm in greatest diameter in adulthood, occurs infrequently. Approximately one in 20,000 infants, amounting to 200 newborns per year in the United States, is born with a LCMN. In addition, one in 500,000 newborns, translating to 10 infants, is born each year with very large LCMN of the garment or bathing-trunks type. 1 The implications for the affected infant are significant. Beside cosmetic disfigurement, a LCMN increases an individual's risk for developing malignant melanoma (MM), and may be associated with neurocutaneous melanocytosis (NCM). 2"5 There are many definitions for what constitutes a LCMN (Table 1). 6-13 As mentioned above, we elect to define LCMN based on the predicted maximum diameter of the nevus in adulthood: at least 20 cm. Congenital melanocytic nevi (CMN) generally enlarge in proportion to the growth of the skin coveting the involved area of the body. 14 Figure 1 depicts the graphs we use to predict the adult diameter of an infant's or child's CMN. 15 Clinically, LCMN can be light brown, dark brown, black, blue, or exhibit a combination of colors. The surface may be macular, papular, mamillated, hyperkeratotic, rugose, and/or nodular. The nevus may be hypertrichotic. 16 With time, LCMN may get darker or lighter, and rarely, completely disappear.5,! 6,17 LCMN can sometimes be associated with anomalies such as NCM, neurofibromatosis type I, occult spinal dysraphism, and/or the tethered cord syndromeJ 8 NCM may affect over 10% of patients with LCMN. 15 It is a s2cndrome with a poor prognosis for survival. According to one definition, NCM is characterized by the presence of an LCMN, or multiple (three or more) smallto medium-size CMN, accompanied by a benign and/or malignant melanocytic proliferation in the leptomeningesJ 9 Of the patients with central ner

BACKGROUND Thickness is known to be an important survival prognosticator for cutaneous melanoma, but controversy exists as to whether Clark level of invasion retains prognostic significance once thickness has been accounted for. A recent proposal to eliminate Clark level from the staging system for melanoma of the American Joint Committee on Cancer (AJCC) prompted the authors to investigate whether level adds useful prognostic information to Breslow thickness. They used the data base of the New York University Melanoma Cooperative Group (NYU-MCG) Registry. METHODS The analysis was based on 919 patients with AJCC Stage I or II melanomas diagnosed between 1972 and 1982 and followed for an average of 10.9 years. Melanoma thicknesses were divided into 4 categories (≤0.75, 0.76–1.50, 1.51–4.00, and >4.00 mm). Patients were cross-classified according to tumor thickness and Clark level (II–V). For each combination of thickness and level, the Kaplan–Meier survival curve and 10-year survival proportion were computed, using death from melanoma as the outcome. The impact of Clark level on survival was evaluated for each of the thickness categories. The Cox proportional hazards model was used to assess the simultaneous effect of thickness and level on survival while controlling for other important prognostic factors, i.e., age, tumor location, and presence or absence of ulceration. RESULTS Level of invasion was a significant predictor of death from melanoma in each of the four thickness categories. Likewise, in the Cox analyses, level was a significant prognostic variable, even after thickness was included in the model and regardless of whether thickness was treated as a categoric or a continuous variable. CONCLUSIONS These results confirm that both tumor thickness and level of invasion are important independent prognostic factors in AJCC Stage I and II melanomas. The authors recommend that Clark levels be kept as criteria in the AJCC staging system and be included in pathology reports. [See editorial on pages 491–6, this issue.] Cancer 2000;88:589–95. © 2000 American Cancer Society.

The authors report the case of a 44-year-old man in whom a poorly differentiated primary carcinoma of the head of the epididymis was discovered incidentally. Due to the rarity of this diagnosis, a comprehensive assessment was performed looking for a primary tumour, but without success. Despite early surgical resection, the patient developed lymph-node metastases. This exceptional tumour showed low sensitivity to chemotherapy. Malignant tumours of the epididymis are exceptional and require investigations to detect a primary tumour. Treatment is based on surgical resection, ideally via an inguinal incision, combined with chemotherapy adapted to the histological type.

Complete necrosis of the penis and scrotum due to strangulation of the external genitalia is unusually encountered in urologic emergencies. Urological conservative management is recommended. Delayed presentation is a major source of complications. We report the case of a psychotic patient, who was transferred from the emergency department in a context of complete necrosis of the external genitalia. This patient's history included chronic psychotic disorder and positive HIV serology, but he refused to take either neuroleptic or antiretroviral therapy. Complete amputation of the penis and bilateral orchidectomy were performed. We report the first six months of medical management.

Ten percent of patients with kidney cancer have associated vena cava thrombus, which is associated with a high operative morbidity. Up to now, no medical treatment has allowed regression of vena cava tumour thrombus. The authors report the case of a 62-year-old patient with left kidney cancer associated with vena cava tumour thrombus. After surgical resection, the patient relapsed in the form of vena cava thrombus associated with right renal vein thrombus, responsible for renal insufficiency requiring dialysis. Sorafenib therapy allowed regression of the vena cava thrombus, suspension of haemodialysis and local disease control with a follow-up of one year. This case report justifies a review of the place of anti-angiogenic therapy in the treatment of kidney cancer.

Background: One of the most difficult problems in the in vivo diagnosis of cutaneous tumors is the differentiation clinically between early malignant melanoma (MM) and atypical (dysplastic) melanocytic nevi (AMNs) because these lesions share clinical features. High-quality digital imaging systems and store-and-forward technology have the potential for use in a teledermatology system with which experts would be able to immediately transmit their diagnostic opinions concerning these challenging lesions. Objective: The main purpose of this study was to determine if the clinical and dermoscopic diagnoses and the dermoscopic features of AMN and early MM are unaltered after telephonic transmission of their digitized images. Methods: Conventional and dermoscopic photographic transparencies of 22 AMNs and 9 early MMs, viewed on rearview projectors and then scanned, compressed, transmitted (Internet) and viewed on color monitors, were evaluated. Results: The concordance in the diagnosis of AMN and of early MM by all four observers, both clinically and dermoscopically, when comparing rearview-projected conventional transparency slides to transmitted, compressed, digitized images, was high. For most specific dermoscopic features, the concordance was good, although less so for the presence or absence of some dermoscopic features, namely ‘dots’, ‘blue/gray’ color and ‘red’ color. Conclusion: The results reported support the conclusion that Internet transmission of digitized images of MMs and AMNs retains sufficient informativeness for diagnostic purposes. This study is a step in the creation of an international teledermoscopy network for pigmented cutaneous lesions.

BACKGROUND Recently, the Pigmented Lesion Group at the University of Pennsylvania described a 4-variable model for predicting 10-year survival for patients with primary cutaneous melanoma. The variables are tumor thickness, anatomic site of the lesion, age, and gender. The objective of the current study was to test the validity of this model, employing the large data base of the New York University Melanoma Cooperative Group. METHODS The predicted probabilities of 10-year survival for 780 patients with primary cutaneous melanoma were determined by multivariate logistic regression, using the 4 variables. RESULTS The overall 10-year survival rate of the current study group was 78.4%. Of the four variables, tumor thickness, anatomic site of the lesion, and age were found to be independent predictors of survival. Although survival was better for women, gender was not a statistically significant factor in predicting 10-year survival when entered into the multivariate logistic regression model. In the current study, the probability of 10-year survival of patients with melanomas < 0.76 mm ranged from 93-99%, depending on the age and primary site. Age and site had more impact on the prognosis of intermediate and thick melanomas than on thin melanomas. Thus, for melanomas 0.76-1.69 mm, 1.70-3.60 mm, and thicker than 3.60 mm, the probabilities of survival ranged from 70-94%, 39-82%, and 23-68%, respectively. CONCLUSIONS The wider ranges in survival rates for thicker melanomas, depending on the other variables, emphasize the importance of including variables in addition to tumor thickness in a prognostic model. Using a large data base from a medical center, the current study supports the prognostic multivariate model of the Pigmented Lesions Group of the University of Pennsylvania; however, the authors of the current study did not find gender to be statistically significant in this multivariate model. Cancer 1997; 80:1426-31. © 1997 American Cancer Society.

Background: A substantial proportion of malignant melanomas arise in preexisting melanocytic nevi. However, the clinical and dermoscopic features of such combination lesions have not been well defined in the literature. Objective: To determine the ability to recognize in thin malignant melanomas the presence or absence of melanocytic nevi based on clinical and/or dermoscopic observations. Methods: Thirty malignant melanomas, less than 1 mm in Breslow thickness, were studied clinically, dermoscopically, and histologically for the presence or absence of features of a melanocytic nevus. Results: The ability to recognize melanocytic nevi within thin malignant melanomas was poor by clinical and dermoscopic examinations, with 30% false negatives and 23% false positives. Conclusion: One cannot depend on clinical and/or dermoscopic observations to rule out a melanocytic nevus within a thin malignant melanoma. Histopathologic study of a small portion of a combined melanocytic neoplasm could lead to the mistaken conclusion that the lesion is entirely a melanocytic nevus or entirely a malignant melanoma. Therefore, when feasible, lesions suspected of being malignant melanomas should be totally excised and step-sectioned throughout.

BACKGROUND/AIMS Atypical melanocytic nevi (AMN) share some or all of the clinical features of malignant melanoma (MM). The clinical sensitivity for diagnosing MM by physicians experienced in evaluating pigmented lesions is reported to range from 73% to 89%. This study attempted to determine whether clinical sensitivity can be increased by dermoscopy (epilumnescence microscopy, dermatoscopy). METHODS A total of 72 melanocytic neoplasms were histologically diagnosed as either AMN or early MM (

The classic atypical-mole syndrome (CAMS) and/or a history of malignant melanoma (MM) increases the risk for multiple melanomas. Case notes of 118 CAMS and 173 control patients, each with a history of MM, were reviewed for the occurrence of second primary MMs. The mean (+/-SD) age at diagnosis of the first MM was 38.8 +/- 12.8 and 48.9 +/- 14.7 years (P < 0.001) for CAMS cases and controls, respectively. Thirty-two of 118 CAMS and 18 of 173 controls developed second primary MMs, for a cumulative 10-year life-table risk of 35.5% and 17.0%, respectively (P < 0.0001). The mean number of months from the time of diagnosis of the first to the second MM was 33.9 +/- 41.8 and 58.6 +/- 57.3 months for the CAMS and controls, respectively (P = 0.08). In both cohorts the second MMs were significantly thinner, compared with the first MMs. The relative risk (RR) for developing second MMs for CAMS patients was 3.2. The RR for the CAMS cohort compared with a matched population from the United States Statistics, Epidemiology. End Results data base was 337, and for the controls, the RR was 84. All patients with MMs are at significant risk for developing multiple MMs: the risk is greater for patients with CAMS. Periodic total cutaneous examinations are indicated for life in an attempt to identify new MMs when they are thin.

Background: The incidence of malignant melanoma (MM) has rapidly increased during the past five decades. Relatively little information is available on whether the role of the dermatologist has increased concomitantly in the surgical management of this cancer. Objective: Our purpose was to learn how members of the American Academy of Dermatology (AAD) treat patients with lesions highly suspected as being MM and how the management of these patients may have changed over the past decade. This, the first of a two-part series, concerns biopsies. Methods: The data for the study were collected by means of a questionnaire that was sent to all members of the AAD practicing in the United State ( N = 7412). Results: A total of 2991 valid questionnaires were returned, a response rate of 40%. The majority of respondents (89% in 1982; 90% in 1992) stated that they performed the biopsies of pigmented lesions suspected of being MMs. Excisional biopsy was the preferred technique (58% in 1982; 68% in 1992). The type of biopsy and who performed the initial biopsy of a suspected MM were associated with the following factors: (1) the number of years in practice, (2) the type of practice, and (3) whether the dermatologist subsequently performed the definitive surgery for the MM. Regional variations in biopsy practices were also noted. Conclusion: Most AAD dermatologists who responded to the questionnaire perform the biopsies of lesions highly suspected of being MM. During the last decade an increasing proportion of dermatologists are performing excisional biopsies rather than other types of biopsies for such lesions.

Background. This study was designed to determine the risk of developing malignant melanoma (MM) in patients with a history of basal cell and/or squamous cell skin cancer (BCC/SCC) and to determine whether surveillance efforts can be directed toward these patients for the detection of early MMs. Methods. The study cohort was followed by annual total cutaneous examination (TCE). Controls consisted of individuals from the United States population matched for age, sex, and length of follow-up. The anatomic locations of the study cohorts'newly diagnosed MMs were plotted on an anatomic chart. The setting was a private dermatology practice. Two hundred, ninety consecutive white patients with a history of BCC/SCC but with no personal or family history of MM were followed by annual TCEs. The main outcome measures were the relative risk of developing MM and their prognosis. Results. Ten of the 290 patients developed an MM within an average of 109 months of follow-up (range, 317 years). All MMs were less than 0.70 mm in Breslow thickness and 80% occurred on usually clothed cutaneous sites. The expected number of MMs in the control population was 0.59 (P=0.006), resulting in a relative risk of 17. Conclusion. Patients with BCC/SCC skin cancer are at substantial increased risk for developing MM. Regular and life-long surveillance TCE is an inexpensive and effective method for detecting curable MMs in such patients

Skin cancers are the most common cancers in humans. The American Cancer Society estimates that in the United States more than 700,000 new skin cancers are diagnosed annually. Although the majority of nonmelanoma skin cancers occur on visibly exposed anatomic areas, most malignant melanomas occur on body sites obscured by clothing. The high mortality associated with advanced melanomas emphasizes the importance of performing regular total cutaneous examinations in all patients to detect early, easily curable lesions. A number of techniques aid in these examinations: (1) physical and psychologic preparation of the patient; (2) appropriate lighting and a suitable examination table; (3) when indicated, use of Wood's light, dermoscopy, and photography. In addition, any suspicious lesion should be biopsied promptly either in parte or in toto. Lastly, the patient should be educated about the signs and symptoms of skin cancer, the role of sunlight in causing skin cancer, and the need for sun avoidance and/or protection. By heightening public awareness of the high incidence of cancers of the skin and by emphasizing the need for routine examination of the entire cutaneous surface, most cutaneous malignancies can be diagnosed early when they can be cured by simple surgical procedures.

UnlabelledWe have analyzed pharmacokinetic data for glycerol phenylbutyrate (also GT4P or HPN-100) and sodium phenylbutyrate with respect to possible dosing biomarkers in patients with urea cycle disorders (UCD).Study designThese analyses are based on over 3000 urine and plasma data points from 54 adult and 11 pediatric UCD patients (ages 6-17) who participated in three clinical studies comparing ammonia control and pharmacokinetics during steady state treatment with glycerol phenylbutyrate or sodium phenylbutyrate. All patients received phenylbutyric acid equivalent doses of glycerol phenylbutyrate or sodium phenylbutyrate in a cross over fashion and underwent 24-hour blood samples and urine sampling for phenylbutyric acid, phenylacetic acid and phenylacetylglutamine.ResultsPatients received phenylbutyric acid equivalent doses of glycerol phenylbutyrate ranging from 1.5 to 31.8 g/day and of sodium phenylbutyrate ranging from 1.3 to 31.7 g/day. Plasma metabolite levels varied widely, with average fluctuation indices ranging from 1979% to 5690% for phenylbutyric acid, 843% to 3931% for phenylacetic acid, and 881% to 1434% for phenylacetylglutamine. Mean percent recovery of phenylbutyric acid as urinary phenylacetylglutamine was 66.4 and 69.0 for pediatric patients and 68.7 and 71.4 for adult patients on glycerol phenylbutyrate and sodium phenylbutyrate, respectively. The correlation with dose was strongest for urinary phenylacetylglutamine excretion, either as morning spot urine (r = 0.730, p < 0.001) or as total 24-hour excretion (r = 0.791 p

The objective of follow-up examinations of patients who have had Stage I invasive malignant melanoma is the early detection of local recurrences, metastases, and new primary melanomas. Model schedules for follow-up intervals were developed based on a survey of eight physicians. These melanoma experts agree that regular follow-up examinations are indicated and that the time intervals between examination vary according to the thicknesses of the melanomas. The patient follow-up schedule derived is: for melanomas up to 0.75-mm thick, every 6 months for years 1 and 2, and annually for years 3, 4, and 5; for melanomas 0.76-1.50 mm thick, every 3 months for years 1 and 2, semi-annually for years 3, 4, and 5; and for melanomas > 1.50 mm thick, every 3 months for years 1, 2, and 3, and semi-annually for years 4 and 5. After the fifth year, the recommendation is to examine all patients annually for life because of the continued risk for recurrences and new primary melanomas. For those individuals at especially high risk for developing multiple primary melanomas more frequent examinations may be appropriate.

Background: There is an increased risk of new basal cell carcinomas (BCCs) developing in a person who has had a BCC. Objective: This study attempts to define the magnitude of this increased risk. Methods: The charts of 260 white patients with a histologically proven BCC were reviewed for the occurrence of new BCCs. The cumulative 5-year incidence (modified life-table method) for new BCCs developing in these patients was compared with the 5-year incidence in the general white population of the United States. Results: Of the 260 patients, new BCCs developed in 137 within an average of 38.3 months, a 5-year cumulative rate of one or more new BCCs of 45.2%. The yearly risk for new BCCs developing in the study population remained high during the 5-year interval. In the general white population of the United States, the maximal 5-year incidence was calculated to be 5% (p Conclusion: Patients with a history of BCC require life-long follow-up because of the high probability of new BCCs developing.

Background: The risk for the development of malignant melanoma has been reported to be higher in persons with more formal education than in individuals with less. Objective: To study whether those with more formal education are indeed at more risk for malignant melanoma than those with less formal education. Methods: This case-control study explores the relation between education and melanoma risk by analyzing data collected by the American Cancer Society. A total of 1.2 million people were surveyed for a history of cancer and followed up for 6 years for the development of any cancer. In total, 2780 white persons had a history of malignant melanoma or developed malignant melanoma during the study period. The controls were age-, sex-, and geographically matched white persons selected from the remaining people enrolled. Results: Both men and women were shown to have a statistically significant increase in the relative risk for malignant melanoma with increasing education level ( p p = 0.001, respectively). This relation was more striking in men when the relative risk with 95% confidence interval was calculated by sex for each education level. Conclusion: Americans with more formal education are at greater risk for malignant melanoma than those with less education.

The use of computers in the workplace is now commonplace. Correspondingly, injuries associated with computer use have increased. However, little research has been done investigating whether these injuries are associated with the software being used. One reason is the difficulty in measuring muscle strain (a predictor of muscle related injuries). Here we present preliminary results of study on the relationship between objective and subjective measures of muscle strain during computer use. As users completed sets of tasks using MSWord®, SEMG muscle activity was recorded for the muscles associated with using a keyboard and mouse. After each task set, users completed surveys asking the level of strain they experienced during the tasks. Correlations between the measures suggest that subjective measures can provide reliable information regarding the muscle strain associated with software use. These easily obtained subjective measurements could assist in producing software interaction designs that are better for users.

International audience; OBJECTIVE: Mapping of transrectal ultrasonographic (TRUS) prostate biopsies is of fundamental importance for either diagnostic purposes or the management and treatment of prostate cancer, but the localization of the cores seems inaccurate. Our objective was to evaluate the capacities of an operator to plan transrectal prostate biopsies under 2-dimensional TRUS guidance using a registration algorithm to represent the localization of biopsies in a reference 3-dimensional ultrasonographic volume. METHODS: Thirty-two patients underwent a series of 12 prostate biopsies under local anesthesia performed by 1 operator using a TRUS probe combined with specific third-party software to verify that the biopsies were indeed conducted within the planned targets. RESULTS: The operator reached 71% of the planned targets with substantial variability that depended on their localization (100% success rate for targets in the middle and right parasagittal parts versus 53% for targets in the left lateral base). Feedback from this system after each series of biopsies enabled the operator to significantly improve his dexterity over the course of time (first 16 patients: median score, 7 of 10 and cumulated median biopsy length in targets of 90 mm; last 16 patients, median score, 9 of 10 and a cumulated median length of 121 mm; P = .046). CONCLUSIONS: In addition to being a useful tool to improve the distribution of prostate biopsies, the potential of this system is above all the preparation of a detailed "map" of each patient showing biopsy zones without substantial changes in routine clinical practices.

The clinical features of 100 dysplastic nevi were tabulated. Although certain characteristics were present in most or all of these melanocytic nevi, there was a marked heterogeneity of other clinical features. The preponderant type of large (≥, 8 mm) melanocytic nevus in patients with classic dysplastic nevi is a papule or plaque with the following characteristics: multicoloration (various shades of tans, browns, reds, or black); slightly raised height for its broad diameter; mamillated surface; and lack of hypertrichosis. An atlas illustrates some of the clinical varieties of melanocytic nevi in this syndrome.

This is the second article in a series that reviews the experience in the Skin and Cancer Unit, from 1955 through 1982, with the treatment of basal cell carcinomas (BCCs). This report deals with 2314 previously untreated (primary) BCCs removed by curettage-electrodesiccation. Multivariate analysis showed that increasing lesion diameter (P less than .001), high-risk anatomic sites (nose, paranasal, nasal-labial groove, ear, chin, mandibular, peri-oral, and peri-ocular areas) (P less than .001), middle-risk anatomical sites (scalp, forehead, pre- and post-auricular, and malar areas) (P less than .001), and time-span treated (1955 to 1963) (P = .012) were independent risk factors for high recurrence rates. The patient's age, sex, and lesion duration before treatment did not affect the recurrence rates. In order to best illustrate our current experience with BCCs, the last time-span (1973 to 1982) was examined in detail. For the low-risk sites (neck, trunk, and four extremities), BCCs of all diameters responded well to curettage-electrodesiccation with an overall 5-year recurrence rate of 3.3% (SE = 1.5%) determined by the modified life-table method. In the middle-risk sites BCCs less than 10 mm in diameter had a recurrence rate of 5.3% (SE = 2.7%). Finally, in the high-risk sites, lesions less than 6 mm in diameter had a recurrence rate of 4.5% (SE = 2.6%). Thus, BCCs less than 6 mm in diameter, regardless of anatomic site, as well as selected larger BCCs depending on their anatomic site, are effectively treated by currettage-electrodesiccation.

This is a study of factors associated with late recurrence (i.e. 10 or more years after definitive surgery) of cutaneous malignant melanoma (MM). Four factors were evaluated: Breslow thickness, site of the primary MM, age of the patient at initial treatment for MM, and gender. These factors were compared between two groups: (1) Stage I cases in the New York University Melanoma Cooperative Group (NYU-MCG) database that had 'early recurrence' (less than 10 years) of MM, and (2) cases in the literature with late recurrence of MM plus five new cases reported here. Compared to the group of patients with 'early recurrence' of MM, the group of patients who had late recurrence of MM were found more likely to have thinner primary melanomas (p less than 0.001), to be younger (p less than 0.001), to be female (p = 0.001), and, for females, to have the MM located on an extremity (p = 0.017). Because late recurrence does occur and because the risk of developing a new primary MM is increased in MM patients, any patient who has had a MM should be followed for life.

Background: There is no consensus concerning management of Spitz nevi. Objective: This study was carried out to ascertain how dermatologists manage Spitz nevi. Methods: A questionnaire was sent to 997 fellows of the American Academy of Dermatology, 284 pediatric dermatologists, and 27 directors of pigmented-lesion clinics. The results are based on the 381 questionnaires returned. Results: The vast majority of responding dermatologists (93%) recommend biopsies of suspected Spitz nevi. Of this group, 43% recommend total biopsies and 55% recommend partial biopsies; 2% would recommend either total or partial biopsies, depending on the clinical situation. Sixty-nine percent of physicians would completely excise a lesion that was histologically diagnosed as an incompletely removed Spitz nevus. Seventy percent of general dermatologists and 80% of pediatric dermatologists would recommend excision with a 1- to 2-mm margin of normal-appearing skin around a Spitz nevus. Nine percent of general dermatologists would recommend margins of 4 mm or more; however, all pediatric dermatologists surveyed would recommend margins less than 4 mm. Physicians were less likely to monitor patients whose Spitz nevi were completely removed. Three fourths (74%) of respondents believe Spitz nevi are entirely benign, 4% believe they are precursors to melanoma, and 22% are not sure. Seven percent of general dermatologists and 4% of pediatric dermatologists have seen metastatic melanomas arise at sites of lesions initially diagnosed histologically as Spitz nevi; 40% of pigmented-lesion clinic directors have seen such lesions. Conclusions: We believe that the lack of consensus, both in our survey and in the medical literature, reflects to some extent the lack of certainty in the histologic differentiation of Spitz nevi from melanomas and that concern about melanoma influences management. At the pigmented-lesion clinic of the New York University Skin and Cancer Unit, because of this concern about melanoma, it is usually recommended that Spitz nevi be completely excised. (J Am Acad Dermatol 2002;47:224-30.)

Objective. To determine the risk for developing malignant melanoma and neurocutaneous melanocytosis (NCM) in patients with large congenital melanocytic nevi. Design. Follow-up data suitable for calculations were available on 160 patients in the New York University Registry of Large Congenital Melanocytic Nevi who had been free of known melanomas or NCM when entered into the Registry. The cumulative 5-year life-table risks for developing melanoma and NCM were calculated. The relative risk for developing melanoma, using a control general population reference group, was determined. Results. The 160 patients (median age at entry: 14 months) were followed prospectively for an average of 5.5 years. Three extracutaneous melanomas developed: 2 were in the central nervous system (CNS) and 1 was retroperitoneal. The 5-year cumulative life-table risk for developing melanoma was 2.3% (95% confidence interval [CI]: .8–6.6) and the relative risk was 101 (95% CI: 21–296). No melanoma occurred within a large congenital melanocytic nevus. Four patients developed manifest NCM, 2 with CNS melanomas. The 5-year cumulative life-table risk for developing NCM was 2.5% (95% CI: .8–7.2). Ten patients were excluded from the calculations because of preexisting disease on entry into the Registry: 5 with manifest NCM and 5 with melanomas (3 in large congenital melanocytic nevi, 1 in nonnevus skin, and 1 unknown primary). Conclusions. Patients with large congenital melanocytic nevi are at increased risk for developing melanomas. There is also a significant increased risk for developing NCM. The high incidence of CNS involvement may influence decisions concerning treatment of the large congenital melanocytic nevi.

Background: The risk of the occurrence of malignant melanoma (MM) in medium-sized (1.5 to 19.9 cm in diameter) congenital melanocytic nevi (CMN) is the subject of controversy. Universally accepted recommendations regarding the management of such lesions have not been made. Objective: Our purpose was to assess the risk of MM arising in medium-sized CMN. Methods: The study included 230 medium-sized CMN in 227 patients, first seen in a private dermatology practice from 1955 to 1996, who were followed up for MM arising within their CMNs. Criteria for entry into the study included (1) a clinically diagnosed medium-sized CMN, (2) minimum follow-up period of 1 year, and (3) a photograph of the lesion in the patient's medical record. Results: No MM occurred in a medium-sized CMN during an average follow-up of 6.7 years (median, 5.8 years) to an average age of 25.5 years (median, 19.1 years). Conclusion: The results of this short-term follow-up study do not support the view that there is a clinically significantly increased risk for MM arising in banal-appearingmedium-sized CMN or that prophylactic excision of all such lesions is mandatory. Life-long medical observation seems a reasonable alternative for many medium-sized CMN. (J Am Acad Dermatol 1998;39:428-33.)

Laboratory tests and imaging studies are often ordered for asymptomatic patients with malignant melanomas (MMs) in an effort to detect subclinical metastatic disease. However, their sensitivity and specificity for detecting cryptic metastases are not well established. A review of the literature on laboratory tests and imaging studies for MM metastases was undertaken to address the usefulness of such investigations in asymptomatic patients with MM in AJCC (American Joint Committee on Cancer system of classification) stages I, II, and III. A review of the pertinent literature since 1966 was conducted through MEDLINE, Medica, and Cancerlit. Laboratory tests and imaging studies revealed occult MM metastases in only a small number of the thousands of reported patients with putative AJCC stage I, II, and III MM. However, for those diagnosed with limited metastases, surgical removal with or without immunotherapy, chemotherapy, or radiotherapy can lead to long-term remissions in some patients. For patients with asymptomatic AJCC stage I or II disease, chest roentgenograms (CXR) and blood lactic dehydrogenase (LDH) levels may be obtained at low cost and prove to be of benefit if metastases are identified. For patients with AJCC stage III disease, computed tomographic (CT) scans of the thorax, abdomen, and pelvis (especially when the primary cutaneous site of the melanoma is below the waist) may be considered for detecting metastatic MM. Other tests, such as magnetic resonance imaging (MRI) scans of the brain, may be ordered based on symptoms or physical findings. In the future, technologically improved techniques and newer methods may prove cost-effective for detecting treatable asymptomatic MM metastases. Furthermore, improvement in treatments will also influence the indications for the search for occult MM metastases. At this time there is a need for an international consensus conference on laboratory tests and imaging studies for occult melanoma metastases.

Background: Patients with large congenital melanocytic nevi (LCMN) are at greater risk for the development of malignant melanoma (MM) than are persons in the general population. Objective: Our purpose was to identify the clinical features of LCMN in those patients in whom MMs actually developed. Methods: The records of 117 patients in the New York University Registry of LCMN and the reports of 172 cases of LCMN in the world literature were studied. Results: Of the 289 cases of LCMN studied, 34 patients (12%) had primary cutaneous MMs within their nevi; in two additional patients, MMs developed at cutaneous sites other than within their nevi. All patients in whom MM developed within LCMN had nevi in axial locations; however, 91 % of the LCMN were axial. No MM was found that had arisen in any of the 26 LCMN confined to the extremities. In addition, no MM was found that had arisen in thousands of satellite nevi. Conclusion: When MM develops within an LCMN, it generally does so in those LCMN in an axial location. The absence of cases of MM arising in LCMN confined to the extremities suggests that such nevi represent lower risk lesions, but the number of extremity nevi analyzed was too small to allow definitive conclusions. A striking finding was the absence of MMs arising in satellite nevi.

Background: Patients with a large congenital melanocytic nevus (LCMN) may have associated leptomeningeal melanocytosis with or without central nervous system (CNS) melanomas. These patients are considered to have neurocutaneous melanosis, a disorder that, when symptomatic or otherwise manifest neurologically, carries a poor prognosis even in the absence of malignancy. Objective: Our purpose was to identify typical clinical features in patients who have manifest CNS melanosis in association with LCMN. Methods: The records of 117 patients with LCMN in the New York University Registry of LCMN and the reports of 172 cases of LCMN in the world literature were included for features that might signal a high risk for the development of manifest CNS involvement. Results: Of the 289 patients with LCMN, 33 had manifest CNS melanosis. In all 33 in whom symptomatic neurocutaneous melanosis was diagnosed, the LCMNs were present in a posterior axial location on the head, neck, back, and/or buttocks. "Satellite" nevi were known to be present in 31 of the 33 patients. Conclusion: Patients with LCMN in a posterior axial location, especially when associated with "satellite" melanocytic nevi, are at greater risk for the development of manifest neurocutaneous melanosis than patients with LCMN limited to the extremities or those who are lacking satellite nevi.

The incidence of malignant melanoma is increasing faster than that of any other cancer. It is important to identify subsets of the population at high risk of its development so that they can be observed more closely to identify early melanomas when they are curable. It has been reported worldwide that persons with the atypical mole (dysplastic nevus) syndrome are such a subset at increased risk. A risk gradient for the development of melanoma exists and varies from persons with one or two atypical moles and no family history of melanoma at one end of the spectrum to persons with the familial atypical multiple-mole melanoma syndrome at the other. Guidelines for the management of atypical mole syndrome are presented.

This is the fourth report in a series that reviews the experience in the Skin and Cancer Unit, from 1955 through 1982, with the treatment of basal cell carcinomas (BCCs). It concerns 862 primary (previously untreated) BCCs irradiated by a "standardized" x-ray therapy schedule. The overall 5-year recurrence rate for these lesions, as determined by the modified life-table method, was 7.4%. This rate was not significantly different from that experienced with 211 recurrent (previously treated) BCCs with a re-recurrence rate of 9.5% (P = .552). For the primary BCCs, multivariate analysis showed that increasing BCC diameter was the only independent risk factor for high recurrence rates (P = .003). The patient's age or sex, the duration of the BCC, the anatomic site of the BCC, or time-span treated (1955-1963, 1964-1972, 1973-1982) did not significantly affect the recurrence rate. Additional analysis showed that BCCs on the head less than 10 mm in diameter had a 5-year recurrence rate of 4.4% whereas those 10 mm or greater in diameter had a rate of 9.5%. Lastly, the proportion of recurrence-free treatment sites with a good or excellent long-term cosmetic outcome after x-ray therapy (63%) was lower than previous reports in this series with curettage-electrodesiccation (91%) and surgical excision (84%). Thus, if the long-term cosmetic outcome after treatment is not an overriding concern to the patient, x-ray therapy is an effective modality for many primary and recurrent BCCs.

This is the first article in a series reviewing the extensive experience of the Oncology Section of the Skin and Cancer Unit, from 1955 through 1982, with 5755 basal cell carcinomas (BCCs) treated by curettage-electrodesiccation, surgical excision, or x-ray therapy. Recurrence rates were calculated by three methods for each of the treatment modalities: 1) by the raw recurrence rate method; 2) by the "strict" 5-year recurrence rate method; and 3) by modification of the life-table method. Our analyses show that the last method best approximates the true recurrence rate. Primary (previously untreated) BCCs had a 5-year recurrence rate of 10.6% (standard error 0.6%), and previously treated BCCs had a rate of 15.4% (standard error 1.3%) (P = .0002). The greatest risk for recurrence of treated primary BCCs occurred 1 to 4 years after therapy. It is concluded that recurrence rates of primary BCCs should be reported separately from those of previously treated BCCs and that the modified life-table method is best suited to calculate 5-year recurrence rates.

A total of 357 white patients who had melanocytic nevi that fulfilled the clinical criteria for the "classic" atypical-mole (dysplastic-nevus) syndrome (100 or more melanocytic nevi; one or more melanocytic nevi 8 mm or larger in diameter; and, one or more melanocytic nevi with atypical features) were followed for the development of cutaneous malignant melanomas. Seventeen patients (4.8%) developed malignant melanomas during an average follow-up period of 49 months. One patient developed two malignant melanomas. Eight of the malignant melanomas detected were in situ and ten were invasive melanomas (less than 0.86 mm in Breslow thickness), implying an excellent prognosis. The number of malignant melanomas detected in these patients exceeded significantly the number expected to occur in age- and sex-matched white controls. All groups were shown to have an increased risk for the development of malignant melanomas. Total-body photographs were helpful in detecting changes in size, shape, and color that led to the diagnosis of malignant melanoma. These data support the concept that patients with this readily regionalized clinical presentation of classic atypical-mole syndrome are at an increased risk for malignant melanomas and, therefore, should be examined regularly.

In order to determine the prevalence of key features concerning nevocytic nevi (NN) in 150 consecutive Caucasian patients with dysplastic nevi (DN), total-body photographs were reviewed that revealed the following: 74% had greater than or equal to 100 NN, 73% had NN 8 mm or more in diameter, and 81% had atypical NN. The patients were then divided into two subsets, those with a personal and/or family history of malignant melanoma (MM) and those without, to see if the proportion of these three features differed in these two groups. There were no statistically significant differences between the MM-history-positive and MM-history-negative subsets.

A case of a possible primary carcinoid tumor of the skin in a 40-year-old man is presented. The neoplasm was diagnosed as consistent with carcinoid tumor on the basis of conventional light microscopy, immunohistochemical studies, and electron microscopy. Workup revealed no evidence of carcinoid tumor elsewhere. Metastases to the skin from internal carcinoid tumors are uncommon, but presumed primary carcinoid tumors that arise in the skin are extremely rare; only three cases have been found in the English-language literature.

Several case-control studies have shown that the risk for development of a malignant melanoma (MM) isproportionalto the number ofmelanocytic neviborneby a person.1-3 Accordingto Hollyet al.,4 the risk of MM increases with the number of nevi: relative risksare 1.6(p =0.43) for 11 to 25 melanocytic nevi, 4.4 (p = 0.01) for 26 to 50 nevi, 5.4 (P =0.008) for 51 to 100nevi, and 9.8 (p = 0.001) for 1 to 5 dysplastic nevi and 6.3 (p =0.003) for 6 or more dysplastic nevi. The anatomic distribution of melanocytic nevi, favoring sun-exposed rather than sun-protected areas of the skin, implies their solar induction(i.e., solar nevogenesis).5-12 An increased numberof melanocytic nevi is seen in geographic regions of higher insolation.l3, 14 In addition, the number of nevi is increasedin immunosuppressed patientsl5,16 and UV irradiation causes cutaneous immunosuppression.l" Melanocytic nevi are congenital or acquired. Most of the latter appearduring the first20 years of life. Acquired nevi, which are far more common than congenital nevi, can be subdivided into those induced bysun exposure (i.e., solarnevogenesis) and those lesscommonmelanocytic nevi that are not related to sun exposure.l ''

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)

• 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)

This report verifies the ability of a Prognostic Index (PI) to accurately predict 5-year survival rates for 879 Stage I cutaneous malignant melanoma (MM) patients seen at New York University Medical Center. The PI used in this study was first reported from Munich, West Germany, and is calculated from standard histologic sections by multiplying the MM thickness in millimeters (Breslow method) by the number of MM mitoses per square millimeter. A PI value of less than 19 versus greater than or equal to 19 was found to be a significant and independent prognostic variable for Stage I MM when compared with seven other predictive variables (including Breslow thickness). These PI intervals identified a subgroup of patients with MM of intermediate thicknesses (1.50-3.49 mm) whose significantly worse survival would not have been anticipated if prognosis were determined by Breslow thickness alone. For example, patients with MM 1.50 to 2.49 mm thick have a 5-year survival rate of 84.1% determined by Breslow thickness alone; however, among these patients exists a subgroup with PI greater than or equal to 19 whose survival rate is only 57.6%. This study verifies the additive usefulness of the PI in predicting survival rates of patients with Stage I cutaneous MM.