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EARLY DIAGNOSIS OF MALIGNANT MELANOMA BY SURFACE MICROSCOPY
803
Drug takers report a most satisfactory and controllable effect from three capsules of temazepam, costing perhaps C7at a time when
street heroin, having diminished in both costs considerably more. The use of a
quantity,
quality
and
buprenorphine/
temazepam cocktail is becoming common. Drug takers now report severe withdrawal symptoms related specifically to temazepam, and at least two drug projects have noted a rise in the number of withdrawal seizures in these clients. Whatever the degree of hazard from temazepam abuse there are now grounds for concern. We would welcome comments from others who have knowledge of this type of drug abuse. We agree with Robertson et al that the vogue for intravenous drug taking shows little sign of passing and we must continue to look for ways to reduce harm. CAMERON STARK ROGER SYKES PATRICK MULLIN
Department of Psychiatry, Southern General Hospital, Glasgow G51 4TF
EARLY DIAGNOSIS OF MALIGNANT MELANOMA BY SURFACE MICROSCOPY
SiR,—Because of the increasing incidence of malignant melanoma and the problems in managing the advanced stage, early diagnosis is mandatory. Observation of pigmented lesions with a stereomicroscope after application of immersion oil to the skin surface (surface microscopy) has been introduced. We have systematically studied the surface microscopic features of 59 cases of naevocellular naevi and 40 cases of malignant melanoma with a Wild M 650 stereomicroscope. 16 surface microscopic criteria were computed for each case and evaluated by microcomputer. The surface microscopic data were correlated with histological features on serial step sections. 10 of the 16 criteria showed significant differences between benign and malignant lesions. The most discriminant features were changes in the pigment network, which largely correspond to the pattern of pigmented cells at the dermoepidermal junction.2 Malignant melanoma lesions were characterised by an unevenly distributed pigment network in 88 % of cases, by a broadened pigment network in 82%, by irregular extensions on the periphery in 76%, and so-called black dots corresponding to nests of melanocytes in the stratum corneum in 59%. The simultaneous evaluation3of all surface microscopic criteria resulted in correct classification of 93% of all lesions examined. Our observations illustrate the usefulness of surface microscopy as a non-invasive preoperative technique in the diagnosis of malignant melanoma. The method may be helpful in
screening programmes. HANS-PETER SOYER JOSEF SMOLLE HELMUT KERL
Department of Dermatology, University of Graz, A-8036 Graz, Austria Institute of Mathematics
University of Klagenfurt,
HARO STETTNER
Austria 1. MacKie RM. An aid to the
Br JDermatol 1971; 85:
preoperative assessment of pigmented lesions of the skin 232-38.
P, Pechlaner R. Differentiation of benign from malignant melanocytic lesions using incident light microscopy. In: Ackerman AB, ed. Pathology of malignant melanoma. New York: Masson Publishing, 1981: 301-12. 3. Fahrmeier L, Hamerle A. Multivariate statistische Verfahren. Berlin: W de Gruyter, 2. Fritsch
1984.
Treatment with 5-fluorouracil, vincristine, and lomustine was given March, 1984, to September, 1985. The patient has remained well. The patient was born and lived in Roseberg, Oregon, until the age ofl3 months; other residences included Webster Groves and St Louis, Missouri. In October, 1979, he moved to Times Beach, a town of 2000 residents on the Meramec River 25 miles west of St Louis. He moved from Times Beach in December, 1982, following a flood. He was probably exposed to 2,3,7,8-tetrachlorodibenxo-pdioxin (dioxin) because soils along many of the roadways in Times Beach were found in November, 1982, to be contaminated with dioxin at a level greater than 1 part per billion.2 This contamination occurred in the early 1970s when oil-containing waste products from a hexachlorophene production facility was sprayed on unpaved roads in Times Beach to control dust. Subsequently Times Beach residents were advised by the Centers for Disease Control to evacuate their homes. The maternal grandmother who had never lived in Times Beach but had helped clean up after the flood had been treated with irradiation for cancer of the uterus in 1975; in July, 1984, she was treated for carcinoma of the caecum and survived 9 months. The maternal grandfather had skin cancer and a maternal aunt had a tumour of unknown type affecting bones and bone marrow. The patient’s parents and a male and female sibling remain well. The annual incidence of colorectal carcinoma under the age of 20 is about 1 in 10 million.6 The population below 20 years of age in Times Beach between 1971 and 1983 numbered less than 1000, so even 1 case of colon carcinoma was unexpected (p < 0’0001, Poisson distribution, using as expected number 10 cases per 10 million in a 10 year period). The significance of colorectal carcinoma in two family members, one of whom was a resident of an area known to be contaminated with dioxin, cannot be assessed. The development of similar cancers in two individuals within a family suggests either that a common environmental exposure contributed to their disease or that there was familial aggregation of the cancer. However, in earlier patients with colon cancer on whom we have reported, we found no evidence of familial clustering.6 Risk assessment for contamination of soils with dioxin concluded that children would have greater potential, via direct soil contact, of exposure to dioxin by ingestion and skin absorption than individuals more than 15 years of age, and our patient’s history of residence in Times Beach for more than 3 years is sufficient reason for acknowledging potential exposure to dioxin.3,4 Many of our previous adolescent patients with colorectal cancer were exposed to herbicides and pesticidesand some had increased serum levels of pesticides.7 Although it is thought that long latent periods are required for development of carcinomas in adults after exposure to toxic chemicals, the latent period for colon cancer in children is not known. Dietary factors have not been implicated as contributing to the development of colorectal carcinoma in adolescents. Many of the former residents of Times Beach are still being followed up by the Missouri Dioxin Study Project of the Missouri Department of Health to determine their risk of developing cancer. St Jude Children’s Research Hospital, Memphis, Tennessee 38101, USA Cardinal Glennon Children’s St Louis, Missouri
CHARLES B. PRATT STEPHEN L. GEORGE
Hospital,
DENNIS O’CONNOR
Centers for Disease Control,
ADOLESCENT COLORECTAL CANCER AND DIOXIN EXPOSURE
SIR,-An 11-year-old boy noted blood in his stools in December, 1983, and was referred to the Cardinal Glennon Children’s Hospital in St Louis, Missouri. Barium enema demonstrated narrowing of the
sigmoid colon. At surgery, a tumour 4-5 cm in length almost encircled the bowel. The tumour was a mucinous adenocarcinoma, extending through the muscularis propria into the serosa, with normal proximal and distal resection margins; 1 of 20 resected lymph nodes was affected. Carcinoembryonic antigen level was less than 0-5 ng/ml on admission. When he was referred to St Jude Children’s Research Hospital in March, 1984, has vital signs, weight, haemogram, urinalysis, and blood chemistry were normal.
RICHARD E. HOFFMAN
Atlanta, Georgia 1. Mason
J. The ordeal
of a
poisoned town. Life 1983; 6: 58-64. Jefferson City Missouri
2. Missouri Dioxin Task Force. Final report.
Force,
Dioxin Task
1983.
3. Patterson DG Jr, Hoffman RE, Needham LL, et al 2,3,7,8-tetrachlorodibenzo-pdioxin levels m adipose tissue of exposed and control persons in Missouri: an interim report JAMA 1986; 256: 2683-86. 4. Kimbrough RD, Falk H, Stehr P, Fries G. Health implications of 2,3,7,8tetrachlorodibenzodioxin (TCDD) contamination of residential soil. J Tox Env Health 1984; 14: 47-93. 5. Garmon L. The buying of Times Beach: a town unfit for human beings. Sci News 1983, 123: 132,133. 6. Pratt CB, George SL. Epidemic colon cancer in children and adolescents? In. Correa P, Haensel W, eds Epidemiology of cancer of the digestive tract. The Hague
Martinus Nijhoff, 1982: 124-46. 7. Caldwell GC, Cannon SB, Pratt CB, Arthur RD. Serum pesticide levels colorectal carcinoma patients. Cancer 1981; 48: 774-78.
in
childhood
Drug takers report a most satisfactory and controllable effect from three capsules of temazepam, costing perhaps C7at a time when
street heroin, having diminished in both costs considerably more. The use of a
quantity,
quality
and
buprenorphine/
temazepam cocktail is becoming common. Drug takers now report severe withdrawal symptoms related specifically to temazepam, and at least two drug projects have noted a rise in the number of withdrawal seizures in these clients. Whatever the degree of hazard from temazepam abuse there are now grounds for concern. We would welcome comments from others who have knowledge of this type of drug abuse. We agree with Robertson et al that the vogue for intravenous drug taking shows little sign of passing and we must continue to look for ways to reduce harm. CAMERON STARK ROGER SYKES PATRICK MULLIN
Department of Psychiatry, Southern General Hospital, Glasgow G51 4TF
EARLY DIAGNOSIS OF MALIGNANT MELANOMA BY SURFACE MICROSCOPY
SiR,—Because of the increasing incidence of malignant melanoma and the problems in managing the advanced stage, early diagnosis is mandatory. Observation of pigmented lesions with a stereomicroscope after application of immersion oil to the skin surface (surface microscopy) has been introduced. We have systematically studied the surface microscopic features of 59 cases of naevocellular naevi and 40 cases of malignant melanoma with a Wild M 650 stereomicroscope. 16 surface microscopic criteria were computed for each case and evaluated by microcomputer. The surface microscopic data were correlated with histological features on serial step sections. 10 of the 16 criteria showed significant differences between benign and malignant lesions. The most discriminant features were changes in the pigment network, which largely correspond to the pattern of pigmented cells at the dermoepidermal junction.2 Malignant melanoma lesions were characterised by an unevenly distributed pigment network in 88 % of cases, by a broadened pigment network in 82%, by irregular extensions on the periphery in 76%, and so-called black dots corresponding to nests of melanocytes in the stratum corneum in 59%. The simultaneous evaluation3of all surface microscopic criteria resulted in correct classification of 93% of all lesions examined. Our observations illustrate the usefulness of surface microscopy as a non-invasive preoperative technique in the diagnosis of malignant melanoma. The method may be helpful in
screening programmes. HANS-PETER SOYER JOSEF SMOLLE HELMUT KERL
Department of Dermatology, University of Graz, A-8036 Graz, Austria Institute of Mathematics
University of Klagenfurt,
HARO STETTNER
Austria 1. MacKie RM. An aid to the
Br JDermatol 1971; 85:
preoperative assessment of pigmented lesions of the skin 232-38.
P, Pechlaner R. Differentiation of benign from malignant melanocytic lesions using incident light microscopy. In: Ackerman AB, ed. Pathology of malignant melanoma. New York: Masson Publishing, 1981: 301-12. 3. Fahrmeier L, Hamerle A. Multivariate statistische Verfahren. Berlin: W de Gruyter, 2. Fritsch
1984.
Treatment with 5-fluorouracil, vincristine, and lomustine was given March, 1984, to September, 1985. The patient has remained well. The patient was born and lived in Roseberg, Oregon, until the age ofl3 months; other residences included Webster Groves and St Louis, Missouri. In October, 1979, he moved to Times Beach, a town of 2000 residents on the Meramec River 25 miles west of St Louis. He moved from Times Beach in December, 1982, following a flood. He was probably exposed to 2,3,7,8-tetrachlorodibenxo-pdioxin (dioxin) because soils along many of the roadways in Times Beach were found in November, 1982, to be contaminated with dioxin at a level greater than 1 part per billion.2 This contamination occurred in the early 1970s when oil-containing waste products from a hexachlorophene production facility was sprayed on unpaved roads in Times Beach to control dust. Subsequently Times Beach residents were advised by the Centers for Disease Control to evacuate their homes. The maternal grandmother who had never lived in Times Beach but had helped clean up after the flood had been treated with irradiation for cancer of the uterus in 1975; in July, 1984, she was treated for carcinoma of the caecum and survived 9 months. The maternal grandfather had skin cancer and a maternal aunt had a tumour of unknown type affecting bones and bone marrow. The patient’s parents and a male and female sibling remain well. The annual incidence of colorectal carcinoma under the age of 20 is about 1 in 10 million.6 The population below 20 years of age in Times Beach between 1971 and 1983 numbered less than 1000, so even 1 case of colon carcinoma was unexpected (p < 0’0001, Poisson distribution, using as expected number 10 cases per 10 million in a 10 year period). The significance of colorectal carcinoma in two family members, one of whom was a resident of an area known to be contaminated with dioxin, cannot be assessed. The development of similar cancers in two individuals within a family suggests either that a common environmental exposure contributed to their disease or that there was familial aggregation of the cancer. However, in earlier patients with colon cancer on whom we have reported, we found no evidence of familial clustering.6 Risk assessment for contamination of soils with dioxin concluded that children would have greater potential, via direct soil contact, of exposure to dioxin by ingestion and skin absorption than individuals more than 15 years of age, and our patient’s history of residence in Times Beach for more than 3 years is sufficient reason for acknowledging potential exposure to dioxin.3,4 Many of our previous adolescent patients with colorectal cancer were exposed to herbicides and pesticidesand some had increased serum levels of pesticides.7 Although it is thought that long latent periods are required for development of carcinomas in adults after exposure to toxic chemicals, the latent period for colon cancer in children is not known. Dietary factors have not been implicated as contributing to the development of colorectal carcinoma in adolescents. Many of the former residents of Times Beach are still being followed up by the Missouri Dioxin Study Project of the Missouri Department of Health to determine their risk of developing cancer. St Jude Children’s Research Hospital, Memphis, Tennessee 38101, USA Cardinal Glennon Children’s St Louis, Missouri
CHARLES B. PRATT STEPHEN L. GEORGE
Hospital,
DENNIS O’CONNOR
Centers for Disease Control,
ADOLESCENT COLORECTAL CANCER AND DIOXIN EXPOSURE
SIR,-An 11-year-old boy noted blood in his stools in December, 1983, and was referred to the Cardinal Glennon Children’s Hospital in St Louis, Missouri. Barium enema demonstrated narrowing of the
sigmoid colon. At surgery, a tumour 4-5 cm in length almost encircled the bowel. The tumour was a mucinous adenocarcinoma, extending through the muscularis propria into the serosa, with normal proximal and distal resection margins; 1 of 20 resected lymph nodes was affected. Carcinoembryonic antigen level was less than 0-5 ng/ml on admission. When he was referred to St Jude Children’s Research Hospital in March, 1984, has vital signs, weight, haemogram, urinalysis, and blood chemistry were normal.
RICHARD E. HOFFMAN
Atlanta, Georgia 1. Mason
J. The ordeal
of a
poisoned town. Life 1983; 6: 58-64. Jefferson City Missouri
2. Missouri Dioxin Task Force. Final report.
Force,
Dioxin Task
1983.
3. Patterson DG Jr, Hoffman RE, Needham LL, et al 2,3,7,8-tetrachlorodibenzo-pdioxin levels m adipose tissue of exposed and control persons in Missouri: an interim report JAMA 1986; 256: 2683-86. 4. Kimbrough RD, Falk H, Stehr P, Fries G. Health implications of 2,3,7,8tetrachlorodibenzodioxin (TCDD) contamination of residential soil. J Tox Env Health 1984; 14: 47-93. 5. Garmon L. The buying of Times Beach: a town unfit for human beings. Sci News 1983, 123: 132,133. 6. Pratt CB, George SL. Epidemic colon cancer in children and adolescents? In. Correa P, Haensel W, eds Epidemiology of cancer of the digestive tract. The Hague
Martinus Nijhoff, 1982: 124-46. 7. Caldwell GC, Cannon SB, Pratt CB, Arthur RD. Serum pesticide levels colorectal carcinoma patients. Cancer 1981; 48: 774-78.
in
childhood