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array:24 [ "pii" => "S1578219015002632" "issn" => "15782190" "doi" => "10.1016/j.adengl.2015.10.003" "estado" => "S300" "fechaPublicacion" => "2015-12-01" "aid" => "1213" "copyright" => "Elsevier España, S.L.U. and AEDV" "copyrightAnyo" => "2015" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2015;106:846-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 692 "formatos" => array:3 [ "EPUB" => 48 "HTML" => 418 "PDF" => 226 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731015002847" "issn" => "00017310" "doi" => "10.1016/j.ad.2015.05.011" "estado" => "S300" "fechaPublicacion" => "2015-12-01" "aid" => "1213" "copyright" => "Elsevier España, S.L.U. y AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2015;106:846-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 476 "formatos" => array:3 [ "EPUB" => 2 "HTML" => 209 "PDF" => 265 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científico-clínica</span>" "titulo" => "¿Exploramos correctamente a los pacientes? ¿Qué nos está pasando?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "846" "paginaFinal" => "848" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Are We Examining Our Patients Properly and Can We Do a Better Job?" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 788 "Ancho" => 900 "Tamanyo" => 111356 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Imagen del tumor primario en el paciente con metástasis ganglionares de melanoma en la región inguinal izquierda. Se aprecia una lesión pigmentada oscura y queratósica de 1,5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm, con signo de Hutchinson, en el pulpejo del quinto dedo del pie izquierdo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Ivars, P. Redondo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Ivars" ] 1 => array:2 [ "nombre" => "P." 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"tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "846" "paginaFinal" => "848" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Ivars, P. Redondo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Ivars" "email" => array:2 [ 0 => "mivars@unav.es" 1 => "martaivars@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Redondo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Clínica Universidad de Navarra, Pamplona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Exploramos correctamente a los pacientes? ¿Qué nos está pasando?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 788 "Ancho" => 900 "Tamanyo" => 121487 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Image of the primary tumor in the patient with lymph node metastases in the left groin. A dark, kerotic pigmented lesion measuring 1.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm can be seen, with the Hutchinson sign, on the ball of the left little toe.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Melanoma remains a prominent health concern. It is one of the most frequent tumors in young adults.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> The incidence and associated mortality has increased in recent decades.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although metastatic melanoma can only be cured on limited occasions, new immunotherapy treatments<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5–7</span></a> (for example, high-dose IL-2, ipilimumab [anti-cytotoxic T-lymphocyte antigen 4], pembrolizumab, and nivolumab [anti-programmed cell death 1], etc.) and combination treatments for specific mutations<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8,9</span></a> (BRAF, mitogen-activated protein kinase [MEK], and c-KIT inhibitors) have increased survival for patients with stage <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span> disease. At times, melanoma is diagnosed in an advanced phase and a primary tumor is not detected despite exhaustive study. Metastatic melanoma from an unknown primary tumor is defined as the histologically confirmed presence of melanoma in a lymph node, organ, or other tissue without history or evidence of a primary skin, mucosal, or ocular lesion. These metastatic lesions are estimated to comprise 3.2% of all melanomas and they seem to have a better prognosis than those metastatic lesions of known origin.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the cases of 2 patients seen initially in tertiary hospitals with metastatic melanoma of unknown origin who sought a second opinion in our hospital.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Histories</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 67-year-old man was seen in his local hospital with swollen lymph nodes in his left groin. After histologic and immunohistochemical study of one of the swollen lymph nodes, metastatic melanoma of unknown origin was diagnosed. The patient was assessed by an oncologist and a dermatologist, who were unable to locate the primary melanoma. Given that immunotherapy treatment was contraindicated and the BRAF mutation was absent, he received 3 chemotherapy sessions for several months. We are awaiting a reduction in the inguinal mass before palliative lymphadenectomy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">By coincidence, in the same week, we assessed the second patient. He was 45 years old, and had a large and rapidly growing tumor in the left laterocervical region that prompted him to attend his reference hospital. Histologic and immunohistochemical study of the mass pointed to diagnosis of metastatic melanoma. The lesion was positive for the BRAF mutation. In the study of extension by computed tomography-positron emission tomography, lymph node metastases were also found at other sites. After multidisciplinary assessment by an oncologist, a dermatologist, an ear-nose-throat specialist, and a ophthalmologist, he was diagnosed with metastatic melanoma of unknown origin and prescribed treatment with a BRAF inhibitor (vemurafenib) and a MEK inhibitor (trametinib).</p><p id="par0030" class="elsevierStylePara elsevierViewall">After taking the medical history and the physical examination of the patients, the primary tumor was located in both patients: the first patient had a dark, keratotic pigmented lesion measuring 1.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm, with the Hutchinson sign, on the ball of the left big toe (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The second patient had a hyperpigmented lesion measuring 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>cm in diameter in the left parietal region, with a characteristic atypical dermoscopic pattern (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In both cases, the lesion was evident and was located on a region of the skin that should be examined given the site of the lymph node metastasis. Certain care in the examination was, however, required because the lesion was located on an area of the scalp covered by hair in one case and in the acral most part of the body in the other.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">We present 2 cases that may well reflect other avoidable situations in dermatology departments in our hospitals. Although this may appear a diagnostic omission and would have no bearing on the follow-up and therapeutic approach, prognosis does vary according to whether the primary tumor is known or unknown.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A detailed medical history and careful physical examination are the basis for diagnosis. A study in the United States concluded that the percentage of dermatologists who perform a complete examination of patients with risk factors for melanoma does not exceed 50%.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> Other studies highlight how a complete body examination can assist in early diagnosis of a high percentage of melanomas in patients who attend the clinic for another reason.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12–18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of the above, the physical examination of the patient in a melanoma unit should be protocolized and meticulous. First, the patient should be examined completely naked, with appropriate light sources, if possible with natural light. The whole body surface should be examined, without omitting the acral areas and those not readily accessible for some patients (retroauricular area, interdigital area, and soles of the feet, etc.). The mucosas (oral, genital, conjunctival, etc.) and appendages (nails and areas with hair follicles) should also be examined. When the patient has been diagnosed with metastatic melanoma of unknown primary tumor, an exhaustive examination of the area of skin drained by the affected lymph node should be undertaken.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Histories" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ivars M, Redondo P. ¿Exploramos correctamente a los pacientes? ¿Qué nos está pasando?. Actas Dermosifiliogr. 2015;106:846–848.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 788 "Ancho" => 900 "Tamanyo" => 121487 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Image of the primary tumor in the patient with lymph node metastases in the left groin. A dark, kerotic pigmented lesion measuring 1.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm can be seen, with the Hutchinson sign, on the ball of the left little toe.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1203 "Ancho" => 900 "Tamanyo" => 223334 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lymph node metastases in the left laterocervical region (gray arrow) and primary tumor (hyperpigmented lesion measuring 2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.5<span class="elsevierStyleHsp" style=""></span>cm in diameter with a characteristic atypical dermoscopic pattern) in the left parietal region (white arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cancer statistics, 2005" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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año/Mes | Html | Total | |
---|---|---|---|
2024 Noviembre | 5 | 7 | 12 |
2024 Octubre | 59 | 40 | 99 |
2024 Septiembre | 49 | 30 | 79 |
2024 Agosto | 83 | 54 | 137 |
2024 Julio | 73 | 29 | 102 |
2024 Junio | 76 | 19 | 95 |
2024 Mayo | 54 | 24 | 78 |
2024 Abril | 68 | 26 | 94 |
2024 Marzo | 59 | 26 | 85 |
2024 Febrero | 64 | 43 | 107 |
2024 Enero | 44 | 35 | 79 |
2023 Diciembre | 50 | 21 | 71 |
2023 Noviembre | 56 | 30 | 86 |
2023 Octubre | 56 | 26 | 82 |
2023 Septiembre | 59 | 26 | 85 |
2023 Agosto | 36 | 17 | 53 |
2023 Julio | 34 | 54 | 88 |
2023 Junio | 41 | 28 | 69 |
2023 Mayo | 51 | 26 | 77 |
2023 Abril | 33 | 28 | 61 |
2023 Marzo | 41 | 23 | 64 |
2023 Febrero | 39 | 17 | 56 |
2023 Enero | 29 | 28 | 57 |
2022 Diciembre | 44 | 36 | 80 |
2022 Noviembre | 36 | 24 | 60 |
2022 Octubre | 48 | 23 | 71 |
2022 Septiembre | 63 | 29 | 92 |
2022 Agosto | 41 | 34 | 75 |
2022 Julio | 22 | 34 | 56 |
2022 Junio | 30 | 35 | 65 |
2022 Mayo | 26 | 32 | 58 |
2022 Abril | 27 | 30 | 57 |
2022 Marzo | 32 | 40 | 72 |
2022 Febrero | 16 | 24 | 40 |
2022 Enero | 39 | 26 | 65 |
2021 Diciembre | 21 | 30 | 51 |
2021 Noviembre | 39 | 41 | 80 |
2021 Octubre | 37 | 55 | 92 |
2021 Septiembre | 35 | 36 | 71 |
2021 Agosto | 18 | 37 | 55 |
2021 Julio | 20 | 27 | 47 |
2021 Junio | 22 | 23 | 45 |
2021 Mayo | 31 | 26 | 57 |
2021 Abril | 54 | 36 | 90 |
2021 Marzo | 72 | 22 | 94 |
2021 Febrero | 36 | 18 | 54 |
2021 Enero | 32 | 17 | 49 |
2020 Diciembre | 28 | 13 | 41 |
2020 Noviembre | 22 | 21 | 43 |
2020 Octubre | 21 | 17 | 38 |
2020 Septiembre | 22 | 7 | 29 |
2020 Agosto | 27 | 22 | 49 |
2020 Julio | 24 | 15 | 39 |
2020 Junio | 48 | 27 | 75 |
2020 Mayo | 35 | 18 | 53 |
2020 Abril | 50 | 21 | 71 |
2020 Marzo | 63 | 22 | 85 |
2020 Febrero | 5 | 5 | 10 |
2020 Enero | 0 | 1 | 1 |
2019 Diciembre | 4 | 2 | 6 |
2019 Septiembre | 5 | 4 | 9 |
2019 Agosto | 4 | 4 | 8 |
2019 Julio | 0 | 2 | 2 |
2019 Junio | 0 | 2 | 2 |
2019 Mayo | 3 | 2 | 5 |
2019 Abril | 0 | 5 | 5 |
2019 Marzo | 2 | 4 | 6 |
2019 Febrero | 0 | 3 | 3 |
2018 Diciembre | 3 | 8 | 11 |
2018 Noviembre | 4 | 0 | 4 |
2018 Octubre | 7 | 0 | 7 |
2018 Septiembre | 6 | 0 | 6 |
2018 Febrero | 21 | 4 | 25 |
2018 Enero | 24 | 4 | 28 |
2017 Diciembre | 38 | 6 | 44 |
2017 Noviembre | 23 | 4 | 27 |
2017 Octubre | 19 | 7 | 26 |
2017 Septiembre | 26 | 6 | 32 |
2017 Agosto | 22 | 7 | 29 |
2017 Julio | 19 | 9 | 28 |
2017 Junio | 28 | 15 | 43 |
2017 Mayo | 18 | 6 | 24 |
2017 Abril | 24 | 9 | 33 |
2017 Marzo | 10 | 35 | 45 |
2017 Febrero | 18 | 10 | 28 |
2017 Enero | 9 | 6 | 15 |
2016 Diciembre | 26 | 12 | 38 |
2016 Noviembre | 26 | 15 | 41 |
2016 Octubre | 25 | 25 | 50 |
2016 Agosto | 0 | 1 | 1 |
2016 Julio | 0 | 1 | 1 |
2016 Junio | 1 | 1 | 2 |
2016 Mayo | 0 | 4 | 4 |
2016 Febrero | 0 | 1 | 1 |
2016 Enero | 0 | 1 | 1 |