Category: Interesting Cases

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Melanoma treated in early stages has good prognosis.

Now that the summer is fast approaching, we should revisit the topic of skin cancer. Today, we will discuss melanoma, next week we will visit non-melanoma skin cancers and in the third week we will discuss appropriate use of sunscreen.

In early stages, surgical removal of melanoma is usually successful. Once the melanoma has spread then the prognosis is grim. Recently, FDA has approved certain drugs to be used in late stage melanoma. But these drugs do not cure the cancer and the side-effects are many. The current prognosis for survival in metastatic melanoma is nine months or less, with 9,000 people dying in the U.S. each year.

For Canadian males, the rate for melanoma has tripled since the late 1960s. For Canadian females, the rates have varied over the years but still show a gradual increase. The death rate from melanoma continues to rise about two percent annually. Approximately, two per cent of melanomas occur in patients under the age of 20 years, and about 0.4 per cent of melanomas occur in pre-pubertal children.

Melanoma arises from cells called melanocytes. These cells contain melanin (melas = black) – a principal pigment responsible for the color of human skin, hair, and eyes. Melanin also acts as a filter to decrease the harmful effects of ultraviolet rays to the dermis.

When the skin is exposed to ultraviolet radiation, there is immediate increase in the number of melanocytes and production of melanin pigment. This results in tanning. The amount of melanin produced is genetically determined. That is why some people burn easily without tanning.

The risk of skin cancer is increased in individuals who spend too much time outdoors; children who have had episodic sunburn, and if there is a family or personal history of skin cancer (especially melanoma). Males are affected more than females.

Melanoma is usually found on the backs or chest in men and lower legs in women. These areas are most exposed to sunlight. Melanoma can also occur in eyes, mouth or internal organs although these areas are not directly exposed to sun.

Examples of melanoma on the abdominal wall skin:
Abdominal wall skin melanoma.
Abdominal wall skin melanoma.

There are four different types of melanomas:
-superficial spreading melanoma: most common, looks like a spreading mole
-nodular melanoma: 10 per cent of cases, looks like a dome rising from a mole
-lentigo maligna: less common, looks like an irregular stain in older Caucasians, not related to moles
-acral lentiginous melanoma: found in all skin types in the sole of the feet, palms of the hands, undersides of the fingers or finger nails or toe nails

Prevention is better than cure. We should avoid sunburn and generally reduce exposure to ultraviolet radiation by staying out of the midday sun, wearing protective clothing, and seeking shade and applying sunscreen.

Now, that cannot be too difficult!

Example of recurrent melanoma:
Example of recurrent melanoma.

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Enlarged lymph glands should not be ignored.

Enlarged Lymph Glands in the Neck Due to Cancer of the Tongue
Enlarged Lymph Glands in the Neck Due to Cancer of the Tongue

During the flu season it is not uncommon to find people complaining of enlarged glands in the neck. The glands are usually enlarged due to viral infection. There is a reason why we are born with hundreds of lymph glands in our body. So, let us find out why normally we cannot feel them but in disease we can find them.

The lymph glands are also known as lymph nodes. A lymph node acts as a filter and is part of the lymphatic system. Tissues in the body release fluid called lymph. Lymph is transported through the lymphatic system, is filtered through the lymph nodes and the filtered fluid is then transported to the blood to maintain fluid balance.

Lymph nodes contain lymphocytes which destroy bacteria and viruses. When the body is fighting infection the lymph nodes produce more lymphocytes. The activity in the lymph node is increased and the node gets enlarged.

Our body has approximately 500-600 lymph nodes. They are found in the underarms, groin, neck, chest, and abdomen. They vary in size from few millimeters to couple of centimeters. Normally, they are not palpable on physical examination unless they enlarge due to infection or tumour.

Enlarged lymph nodes due to viral infection are “reactive” in nature and are usually small, firm and non-tender and they may not go away for weeks to months. Enlarged nodes due to bacterial infection are usually tender and more than a centimeter large. The most common site is the neck. These nodes get enlarged due to infection in the mouth, throat or the scalp. This may be associated with fever.

There are many other causes of lymph node enlargement such as: eczema, mono, tuberculosis, cat scratch disease, cancer (Hodgkin’s disease, non-Hodgkin’s disease, leukemia or metastatic cancer from other site).

A good history and physical examination is important in a patient presenting with persistent enlarged lymph node. This may give us a clue regarding the origin of the problem. Clinically, we may find that there is more than one area of enlarged nodes. The liver and spleen may be enlarged as well as they are part of the lymphatic system.

Patient is initially treated with 10 days of antibiotics. If the node does not respond to antibiotics then further investigations should be done to check for other causes of enlargement.

Blood tests, ultrasound and chest x-ray may give us more information. Finally, CAT scan, fine needle aspiration biopsy or open biopsy will be required to get to the bottom of the problem.

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Anal (Genital) Warts

Anal Warts

This is the most common sexually transmitted disease. It is estimated that one per cent of adults who are sexually active have warts in the genital or anal area. In the U.S. alone, one million people will develop genital warts each year. Of these, 25 per cent will have recurrent warts. And that is frustrating for the patient and the doctor.

Genital warts are also called condylomata acuminate or venereal warts. The warts are benign and are caused by human papillomavirus (HPV). There are at least 60 types of HPV. Genotypes six and 11 are found in over 90 per cent of cases of genital warts and genotypes 16 and 18 cause cervical cancers.

The virus is transferred from person to person or from contact with something someone has touched. In women, genital warts can grow on the outside or inside of the vagina, on the cervix, in the urethra or around the anus. In men, warts can grow on the tip or shaft of the penis, on the scrotum, in the urethra or around the anus.

How do you get genital warts?

Most, but not all, genital warts are sexually transmitted. Generally speaking warts are more common amongst people whose immune system is poor. But most people who get warts are healthy and well.

How do you know you have genital warts?

Most people with genital warts have no symptoms. By the time a person is infected and by the time the warts appear may be many months or years. The good news is most of those who get infected never develop warts.

The warts are soft fleshy lumps on or near sex organs or anus. Some people have itching or burning. Warts may be hidden in the vagina or anus.

What are the implications of the disease for patients?

The lesions are benign but they do cause psychosocial distress and may affect relationships as the warts are disfiguring and can be transmitted sexually. Genital warts also increase the incidence of cancer in the genital and anal area. Practicing safe sex is important. It is advisable to use barrier protection with new sexual partners. Condoms can reduce the risk of getting genital warts but warts can spread from areas not covered by a condom. Patients who are in stable relationship may not need barrier protection because the partner is already exposed to infection by the time patient sees a doctor.

How do we manage warts?

No specific treatment is appropriate for all patients and a person will need more than one treatment to clear the warts.

Most treatment plans will achieve clearance of virus within one to six months. In 20-30 per cent of patients new warts will occur over months or even years. Patients can treat themselves with podophyllotoxin (0.5 per cent solution or 0.15 per cent cream) and imiquimod (5 per cent cream). Imiquimod is expensive and podophyllotoxin takes longer to cure the condition.

Physicians can treat warts in the office by using trichloroacetic acid or by physical removal using cryosurgery (liquid nitrogen), electrosurgery and excision or laser treatment. In my surgical practice I use electrosurgery and/or excision.

The US Food and Drug Administration (FDA) has approved a new indication for a quadrivalent recombinant vaccine (Gardasil, Merck & Company, Inc) for the prevention of genital warts caused by human papillomavirus (HPV) types 6 and 11 in boys and men aged nine through 26 years. Since the vaccine does not cover all the viruses, about 30 percent of cervical cancers and 10 percent of genital warts will not be prevented by the current vaccines.

The HPV vaccine will not have an impact on an existing infection or any consequences of infection, such as anal and genital warts and cancerous or pre-cancerous changes that you may already have. It is very important to practice safe sex with your partner.

Examining Anal Warts

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Fingers and Toes Sensitive to Cold can Lead to Ulcers and Gangrene

Raynaud's Phenomenon

There are many individuals whose hands and feet are very sensitive to cold or emotions resulting in blanching, pain and numbness of the fingers and toes. The condition is episodic and is known as Raynaud’s phenomenon. In severe cases this can progress to local ulcers and gangrene. This condition can also cause nails to become brittle with longitudinal ridges.

Primary or idiopathic Raynaud’s phenomenon (Raynaud’s disease) occurs without an underlying disease. In this situation the blood vessels of the fingers and toes are excessively sensitive to cold or emotional stimuli without any good reason. Raynaud’s disease accounts for 60 per cent of cases.

Secondary Raynaud’s phenomenon (Raynaud’s syndrome) occurs in association with an underlying disease. Most patients with scleroderma and about 30 per cent of patients with systemic lupus erythematosus have secondary Raynaud phenomenon. There are many other medical conditions which can cause Raynaud’s syndrome. Forty per cent of cases are secondary to other medical conditions.

The condition was first described in 1862 by Maurice Raynaud (1834-1881), a physician and professor in Paris. The onset is typically between the ages of 20 and 40 years, and it is more common in women than men.

In a general population it is difficult to estimate how many people suffer from this condition. But people who live in cool damp climates seem to have higher incidence (20-25 per cent). About 40 to 90 per cent of chainsaw operators and miners using vibrating equipment have Raynaud’s syndrome. Food workers who work in cold areas have about 50 per cent incidence of this disease. Raynaud’s has also occurred in breastfeeding mothers, causing nipples to turn white and become extremely painful. This may cause painful breast feeding.

In 2002, the New England Journal of Medicine described a case of a 54-year-old man who had an acute primary episode of Raynaud’s disease involving only the ring finger after surfing for 80 minutes in water that was 21°C. The episode persisted for 40 minutes. Medical evaluation subsequently revealed no disorder known to cause secondary Raynaud’s phenomenon.

Most patients with Raynaud’s syndrome have only mild symptoms, which respond well to simple conservative treatment, including wearing of warm clothes and gloves. Avoid cold environment and stress. Do not smoke. Avoid blood vessel constricting agents.

About 10 per cent of patients have sufficiently severe and frequent episodes to require drug therapy. Vasodilators are most frequently used. Many medications have been studied including vasodilators, platelet inhibitors, serotonin antagonists and fibrinolytics.

Here are some examples: sustained-release nifedipine (Adalat) reduces attack rate compared to placebo, losartan (Cozaar) 50 mg/day may be more effective than nifedipine 40 mg/day, sildenafil (Viagra) 50 mg twice daily reduces frequency of Raynaud attacks and topical nitroglycerin may be effective for treatment of Raynaud’s phenomenon.

Recently, another erectile dysfunction drug tadalafil (Cialis) 20 mg has been tried. Compared to Viagra, Cialis has a longer half-life of 17.5 hours. The conclusion was that Cialis, in combination with other vasodilators, help reduce the severity of attacks but also helps heal digital ulcers.

Surgical treatment in the form of sympathectomy (division of autonomic nervous system) causes dramatic improvement in occasional patient but can be unpredictable and disappointing.

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