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Pediatric melanoma: An opportunity for psychosocial research
892 Letters
J AM ACAD DERMATOL MAY 2010
Supported by the Shiraz University of Medical Sciences. Conflicts of interest: None declared. Correspondence to: Farideh Jowkar, MD, Department of Dermatology, Shahid Faghihi Hospital, PO Box 71345-1558, Shiraz, Iran. E-mail: [email protected] REFERENCES 1. Alrajhi AA, Ibrahim EA, De Vol EB, Khairat M, Faris RM, Maguire JH. Fluconazole for the treatment of cutaneous leishmaniasis caused by Leishmania major. N Engl J Med 2002;346:891-5.
CASE Pediatric melanoma: An opportunity for psychosocial research To the Editor: A 5-year-old girl with melanoma of the leg underwent local excision and sentinel node biopsy with two nodes positive and no additional disease on complete nodal dissection. At 8 years of age, she complained of abdominal pain and made statements such as ‘‘it feels like cancer is in my legs.’’ Concurrently, she drew unusual pictures at school. As part of her evaluation she was referred to the department of pediatric psychology. Psychological issues identified included somatic expression of anxiety, active worries about disease recurrence and death, and separation concerns at bedtime. Sessions focused on relaxation strategies to address anxiety, educational reframing of melanoma recurrence fears, and play therapy to address early medical experiences. Her complaints completely resolved after five sessions. This case supports the benefit of psychosocial intervention and illustrates that young melanoma survivors’ needs may be different as they age.1 There are no data specific to the pediatric melanoma population to guide the clinician in identifying which patients may be at risk for short- or long-term adjustment disorders. The National Comprehensive Cancer Network guidelines recommend referral for psychosocial treatment based on distress.2 As many as 25% to 30% of children with cancer and their families may have significant difficulties with coping and adjustment.3 Many children undergoing cancer treatment have psychosocial intervention and support available. Children with melanoma likely experience similar stress responses to children with other cancers and should also be studied and offered intervention.
2. Reithinger R, Dujardin JC, Louzir H, Primez C, Alexander B, Brooker S. Cutaneous leishmaniasis. Lancet Infect Dis 2007;7:581-96. 3. Evans AT, Croft SL, Peters W, Neal RA. Antilesihmanial effects of clofazimine and other antimycobacterial agents. Ann Trop Med Parasitol 1989;83:447-54. 4. Datta G, Bera T. The effect of clofazimine, niclosamide and amphotericin B, on electron transport of Leishmania donovani promastigotes. Indian J Med Res 2000;112:15-20. 5. Torres Idavoy D, Montalvo Alvarez AM, Finlay CM. Effects of clofazimine on Leishmania promastigotes [in Spanish]. Rev Cubana Med Trop 1987;39:33-8. 6. Knablo AL Jr, Davis LS. Miscellaneous systemic drugs. In: Wolverton SE, editor. Comprehensive dermatologic drug therapy. 2nd ed, China: Saunders Elsevier; 2007. pp. 475-7. doi:10.1016/j.jaad.2009.07.011
LETTERS Evaluating and understanding the psychosocial impact of pediatric melanoma requires identifying and examining stressors that are unique to this group.1,3 An atypical presentation and reluctance to diagnose melanoma in children may delay early detection.4 Once diagnosed, parental guilt because of the delay in detection may affect the parentechild relationship. Because melanoma is uncommon in childhood, children with melanoma may experience isolation because they lack a specific cohort and support group.4 Posttreatment surveillance in melanoma is unlike other childhood cancers, where monitoring for recurrence is dependent more on blood and imaging tests. In addition to physician examinations, both the patient and parents perform skin examinations to monitor for recurrence and new lesions. This may lead to hypervigilance, increased physician visits, and more biopsies. Children may be reassured they are disease-free after physician visits, yet the frequent and ongoing surveillance is a continuous reminder of concern. Sun precaution measures also serve as a constant reminder. Patients are encouraged to limit sun exposure, use protective clothing, and apply sunscreen to reduce the risk of new lesions. Dependent on compliance, this may lead to guilt, depression, and/or anxiety. This lifelong recommendation to minimize sun exposure and use sun protection may limit athletic and social activities and career choice, and impact both peer relationships and self-esteem. Psychological issues may persist or begin years after diagnosis and treatment of cancer in children, including melanoma.1,3 There is a paucity of research on psychosocial adjustment of children with
Letters 893
J AM ACAD DERMATOL VOLUME 62, NUMBER 5
melanoma, and there are unique stressors in this group. An opportunity exists to study methods to assess psychosocial issues in pediatric melanoma patients and how best to integrate psychosocial intervention into their care. Jennifer L. Schwartz, MD,a Eileen Mollen, PhD,b Mathew W. Ludgate, MBChB,a Michelle B. Riba, MD,c and Timothy M. Johnson, MDa Departments of Dermatology,a Pediatrics and Communicable Diseases,b and Psychiatry,c University of Michigan Medical School and Comprehensive Cancer Center, Ann Arbor, Michigan Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jennifer L. Schwartz, MD, Department of Dermatology, University of Michigan Health System, 1910 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0314 E-mail: [email protected] REFERENCES 1. Zebrack BJ, Zeltzer LK. Quality of life issues and cancer survivorship. Curr Probl Cancer 2003;27:198-211. 2. National Comprehensive Cancer Network Web site. Guidelines in oncology: distress management, version 1.2008. Available at: http://www.nccn.org/professionals/physician_gls/PDF/distress. pdf. Accessed December 6, 2008. 3. Patenaude AF, Kupst MJ. Psychosocial functioning in pediatric cancer. J Pediatr Psychol 2005;30:9-27. 4. Lange JR, Palis BE, Chang DC, Soong SJ, Balch CM. Melanoma in children and teenagers: an analysis of patients from the National Cancer Data Base. J Clin Oncol 2007;25:1363-8. doi:10.1016/j.jaad.2009.07.017
Pitfalls in the dermoscopic diagnosis of amelanotic melanoma To the Editor: Vascular patterns observed during dermoscopy can increase the index of suspicion for the diagnosis of amelanotic melanoma.1 A 55-year-old man presented with enlarged palpable lymph nodes localized to the left axilla that had developed 2 months earlier. An ultrasound-guided core needle biopsy was performed, leading to a diagnosis of epithelioid cell neoplasia consistent with metastatic melanoma. The physical examination revealed a pink symmetrical nodule on the back, firm on palpation, featuring whitish-yellow areas (Fig 1, A) that had appeared and grown rapidly over the course of a few months. The dermoscopic image (Fig 1, B) revealed a polymorphous vascular pattern characterized by
Fig 1. A, A 4-mm thick nodular malignant melanoma on the back of a 55-year-old man. Note the pink symmetrical nodule, associated with some whitish-yellow areas and a dotted trace of pigment B, The dermoscopic image of the same melanoma revealed a polymorphous vascular pattern characterized by milky red/pink areas (blue arrows), more than one shade of pink, linear irregularly sized vessels (black arrows), ranging from very subtle and coiled to large and aneurismatic, and large, slightly blurred arborizing vessels ( green arrows). In addition, large and irregularly round, whitish-yellow areas, suggesting milialike structures (red arrows), ovoid areas of depigmentation (star), and a small globule-like pigmented structure ( yellow arrow) can be seen within the diffuse pinkish pigmentation. (Original magnifications: A, 310; B, 320.)
milky red/pink areas, more than one shade of pink, linear irregular vessels, arborizing vessels, and large and irregularly round, whitish-yellow areas resembling milia-like structures. The amelanotic skin lesion was excised together with a complete axillary lymph node dissection. The histopathologic examination revealed a nodular malignant melanoma, Clark level IV, Breslow thickness 4 mm, with large, confluent dermal nodules of amelanotic melanoma cells with a limited junctional component, having a mitotic index of 10 mitotic figures per mm2 and central, well defined necrotic areas inside the nodules (Fig 2). Two of the 26 lymph nodes showed metastatic melanoma. There was neoplastic extension to the perinodal fatty tissue with a cellular morphology similar to the primary tumor, along with the presence of necrotic microareas.
J AM ACAD DERMATOL MAY 2010
Supported by the Shiraz University of Medical Sciences. Conflicts of interest: None declared. Correspondence to: Farideh Jowkar, MD, Department of Dermatology, Shahid Faghihi Hospital, PO Box 71345-1558, Shiraz, Iran. E-mail: [email protected] REFERENCES 1. Alrajhi AA, Ibrahim EA, De Vol EB, Khairat M, Faris RM, Maguire JH. Fluconazole for the treatment of cutaneous leishmaniasis caused by Leishmania major. N Engl J Med 2002;346:891-5.
CASE Pediatric melanoma: An opportunity for psychosocial research To the Editor: A 5-year-old girl with melanoma of the leg underwent local excision and sentinel node biopsy with two nodes positive and no additional disease on complete nodal dissection. At 8 years of age, she complained of abdominal pain and made statements such as ‘‘it feels like cancer is in my legs.’’ Concurrently, she drew unusual pictures at school. As part of her evaluation she was referred to the department of pediatric psychology. Psychological issues identified included somatic expression of anxiety, active worries about disease recurrence and death, and separation concerns at bedtime. Sessions focused on relaxation strategies to address anxiety, educational reframing of melanoma recurrence fears, and play therapy to address early medical experiences. Her complaints completely resolved after five sessions. This case supports the benefit of psychosocial intervention and illustrates that young melanoma survivors’ needs may be different as they age.1 There are no data specific to the pediatric melanoma population to guide the clinician in identifying which patients may be at risk for short- or long-term adjustment disorders. The National Comprehensive Cancer Network guidelines recommend referral for psychosocial treatment based on distress.2 As many as 25% to 30% of children with cancer and their families may have significant difficulties with coping and adjustment.3 Many children undergoing cancer treatment have psychosocial intervention and support available. Children with melanoma likely experience similar stress responses to children with other cancers and should also be studied and offered intervention.
2. Reithinger R, Dujardin JC, Louzir H, Primez C, Alexander B, Brooker S. Cutaneous leishmaniasis. Lancet Infect Dis 2007;7:581-96. 3. Evans AT, Croft SL, Peters W, Neal RA. Antilesihmanial effects of clofazimine and other antimycobacterial agents. Ann Trop Med Parasitol 1989;83:447-54. 4. Datta G, Bera T. The effect of clofazimine, niclosamide and amphotericin B, on electron transport of Leishmania donovani promastigotes. Indian J Med Res 2000;112:15-20. 5. Torres Idavoy D, Montalvo Alvarez AM, Finlay CM. Effects of clofazimine on Leishmania promastigotes [in Spanish]. Rev Cubana Med Trop 1987;39:33-8. 6. Knablo AL Jr, Davis LS. Miscellaneous systemic drugs. In: Wolverton SE, editor. Comprehensive dermatologic drug therapy. 2nd ed, China: Saunders Elsevier; 2007. pp. 475-7. doi:10.1016/j.jaad.2009.07.011
LETTERS Evaluating and understanding the psychosocial impact of pediatric melanoma requires identifying and examining stressors that are unique to this group.1,3 An atypical presentation and reluctance to diagnose melanoma in children may delay early detection.4 Once diagnosed, parental guilt because of the delay in detection may affect the parentechild relationship. Because melanoma is uncommon in childhood, children with melanoma may experience isolation because they lack a specific cohort and support group.4 Posttreatment surveillance in melanoma is unlike other childhood cancers, where monitoring for recurrence is dependent more on blood and imaging tests. In addition to physician examinations, both the patient and parents perform skin examinations to monitor for recurrence and new lesions. This may lead to hypervigilance, increased physician visits, and more biopsies. Children may be reassured they are disease-free after physician visits, yet the frequent and ongoing surveillance is a continuous reminder of concern. Sun precaution measures also serve as a constant reminder. Patients are encouraged to limit sun exposure, use protective clothing, and apply sunscreen to reduce the risk of new lesions. Dependent on compliance, this may lead to guilt, depression, and/or anxiety. This lifelong recommendation to minimize sun exposure and use sun protection may limit athletic and social activities and career choice, and impact both peer relationships and self-esteem. Psychological issues may persist or begin years after diagnosis and treatment of cancer in children, including melanoma.1,3 There is a paucity of research on psychosocial adjustment of children with
Letters 893
J AM ACAD DERMATOL VOLUME 62, NUMBER 5
melanoma, and there are unique stressors in this group. An opportunity exists to study methods to assess psychosocial issues in pediatric melanoma patients and how best to integrate psychosocial intervention into their care. Jennifer L. Schwartz, MD,a Eileen Mollen, PhD,b Mathew W. Ludgate, MBChB,a Michelle B. Riba, MD,c and Timothy M. Johnson, MDa Departments of Dermatology,a Pediatrics and Communicable Diseases,b and Psychiatry,c University of Michigan Medical School and Comprehensive Cancer Center, Ann Arbor, Michigan Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jennifer L. Schwartz, MD, Department of Dermatology, University of Michigan Health System, 1910 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0314 E-mail: [email protected] REFERENCES 1. Zebrack BJ, Zeltzer LK. Quality of life issues and cancer survivorship. Curr Probl Cancer 2003;27:198-211. 2. National Comprehensive Cancer Network Web site. Guidelines in oncology: distress management, version 1.2008. Available at: http://www.nccn.org/professionals/physician_gls/PDF/distress. pdf. Accessed December 6, 2008. 3. Patenaude AF, Kupst MJ. Psychosocial functioning in pediatric cancer. J Pediatr Psychol 2005;30:9-27. 4. Lange JR, Palis BE, Chang DC, Soong SJ, Balch CM. Melanoma in children and teenagers: an analysis of patients from the National Cancer Data Base. J Clin Oncol 2007;25:1363-8. doi:10.1016/j.jaad.2009.07.017
Pitfalls in the dermoscopic diagnosis of amelanotic melanoma To the Editor: Vascular patterns observed during dermoscopy can increase the index of suspicion for the diagnosis of amelanotic melanoma.1 A 55-year-old man presented with enlarged palpable lymph nodes localized to the left axilla that had developed 2 months earlier. An ultrasound-guided core needle biopsy was performed, leading to a diagnosis of epithelioid cell neoplasia consistent with metastatic melanoma. The physical examination revealed a pink symmetrical nodule on the back, firm on palpation, featuring whitish-yellow areas (Fig 1, A) that had appeared and grown rapidly over the course of a few months. The dermoscopic image (Fig 1, B) revealed a polymorphous vascular pattern characterized by
Fig 1. A, A 4-mm thick nodular malignant melanoma on the back of a 55-year-old man. Note the pink symmetrical nodule, associated with some whitish-yellow areas and a dotted trace of pigment B, The dermoscopic image of the same melanoma revealed a polymorphous vascular pattern characterized by milky red/pink areas (blue arrows), more than one shade of pink, linear irregularly sized vessels (black arrows), ranging from very subtle and coiled to large and aneurismatic, and large, slightly blurred arborizing vessels ( green arrows). In addition, large and irregularly round, whitish-yellow areas, suggesting milialike structures (red arrows), ovoid areas of depigmentation (star), and a small globule-like pigmented structure ( yellow arrow) can be seen within the diffuse pinkish pigmentation. (Original magnifications: A, 310; B, 320.)
milky red/pink areas, more than one shade of pink, linear irregular vessels, arborizing vessels, and large and irregularly round, whitish-yellow areas resembling milia-like structures. The amelanotic skin lesion was excised together with a complete axillary lymph node dissection. The histopathologic examination revealed a nodular malignant melanoma, Clark level IV, Breslow thickness 4 mm, with large, confluent dermal nodules of amelanotic melanoma cells with a limited junctional component, having a mitotic index of 10 mitotic figures per mm2 and central, well defined necrotic areas inside the nodules (Fig 2). Two of the 26 lymph nodes showed metastatic melanoma. There was neoplastic extension to the perinodal fatty tissue with a cellular morphology similar to the primary tumor, along with the presence of necrotic microareas.