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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Melanoma remains a prominent health concern&#46; It is one of the most frequent tumors in young adults&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> The incidence and associated mortality has increased in recent decades&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although metastatic melanoma can only be cured on limited occasions&#44; new immunotherapy treatments<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#8211;7</span></a> &#40;for example&#44; high-dose IL-2&#44; ipilimumab &#91;anti-cytotoxic T-lymphocyte antigen 4&#93;&#44; pembrolizumab&#44; and nivolumab &#91;anti-programmed cell death 1&#93;&#44; etc&#46;&#41; and combination treatments for specific mutations<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#44;9</span></a> &#40;BRAF&#44; mitogen-activated protein kinase &#91;MEK&#93;&#44; and c-KIT inhibitors&#41; have increased survival for patients with stage <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span> disease&#46; At times&#44; melanoma is diagnosed in an advanced phase and a primary tumor is not detected despite exhaustive study&#46; Metastatic melanoma from an unknown primary tumor is defined as the histologically confirmed presence of melanoma in a lymph node&#44; organ&#44; or other tissue without history or evidence of a primary skin&#44; mucosal&#44; or ocular lesion&#46; These metastatic lesions are estimated to comprise 3&#46;2&#37; of all melanomas and they seem to have a better prognosis than those metastatic lesions of known origin&#46;<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&#46;</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&#46; After histologic and immunohistochemical study of one of the swollen lymph nodes&#44; metastatic melanoma of unknown origin was diagnosed&#46; The patient was assessed by an oncologist and a dermatologist&#44; who were unable to locate the primary melanoma&#46; Given that immunotherapy treatment was contraindicated and the BRAF mutation was absent&#44; he received 3 chemotherapy sessions for several months&#46; We are awaiting a reduction in the inguinal mass before palliative lymphadenectomy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">By coincidence&#44; in the same week&#44; we assessed the second patient&#46; He was 45 years old&#44; and had a large and rapidly growing tumor in the left laterocervical region that prompted him to attend his reference hospital&#46; Histologic and immunohistochemical study of the mass pointed to diagnosis of metastatic melanoma&#46; The lesion was positive for the BRAF mutation&#46; In the study of extension by computed tomography-positron emission tomography&#44; lymph node metastases were also found at other sites&#46; After multidisciplinary assessment by an oncologist&#44; a dermatologist&#44; an ear-nose-throat specialist&#44; and a ophthalmologist&#44; he was diagnosed with metastatic melanoma of unknown origin and prescribed treatment with a BRAF inhibitor &#40;vemurafenib&#41; and a MEK inhibitor &#40;trametinib&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">After taking the medical history and the physical examination of the patients&#44; the primary tumor was located in both patients&#58; the first patient had a dark&#44; keratotic pigmented lesion measuring 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm&#44; with the Hutchinson sign&#44; on the ball of the left big toe &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The second patient had a hyperpigmented lesion measuring 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter in the left parietal region&#44; with a characteristic atypical dermoscopic pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In both cases&#44; 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&#46; Certain care in the examination was&#44; however&#44; 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&#46;</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&#46; Although this may appear a diagnostic omission and would have no bearing on the follow-up and therapeutic approach&#44; prognosis does vary according to whether the primary tumor is known or unknown&#46;<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&#46; 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&#37;&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12&#8211;18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of the above&#44; the physical examination of the patient in a melanoma unit should be protocolized and meticulous&#46; First&#44; the patient should be examined completely naked&#44; with appropriate light sources&#44; if possible with natural light&#46; The whole body surface should be examined&#44; without omitting the acral areas and those not readily accessible for some patients &#40;retroauricular area&#44; 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Case and Research Letters
Are We Examining Our Patients Properly and Can We Do a Better Job?
¿Exploramos correctamente a los pacientes? ¿Qué nos está pasando?
M. Ivars
Autor para correspondencia
, P. Redondo
Departamento de Dermatología, Clínica Universidad de Navarra, Pamplona, Spain
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mitogen-activated protein kinase &#91;MEK&#93;&#44; and c-KIT inhibitors&#41; have increased survival for patients with stage <span class="elsevierStyleSmallCaps">iii</span> and <span class="elsevierStyleSmallCaps">iv</span> disease&#46; At times&#44; melanoma is diagnosed in an advanced phase and a primary tumor is not detected despite exhaustive study&#46; Metastatic melanoma from an unknown primary tumor is defined as the histologically confirmed presence of melanoma in a lymph node&#44; organ&#44; or other tissue without history or evidence of a primary skin&#44; mucosal&#44; or ocular lesion&#46; These metastatic lesions are estimated to comprise 3&#46;2&#37; of all melanomas and they seem to have a better prognosis than those metastatic lesions of known origin&#46;<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&#46;</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&#46; After histologic and immunohistochemical study of one of the swollen lymph nodes&#44; metastatic melanoma of unknown origin was diagnosed&#46; The patient was assessed by an oncologist and a dermatologist&#44; who were unable to locate the primary melanoma&#46; Given that immunotherapy treatment was contraindicated and the BRAF mutation was absent&#44; he received 3 chemotherapy sessions for several months&#46; We are awaiting a reduction in the inguinal mass before palliative lymphadenectomy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">By coincidence&#44; in the same week&#44; we assessed the second patient&#46; He was 45 years old&#44; and had a large and rapidly growing tumor in the left laterocervical region that prompted him to attend his reference hospital&#46; Histologic and immunohistochemical study of the mass pointed to diagnosis of metastatic melanoma&#46; The lesion was positive for the BRAF mutation&#46; In the study of extension by computed tomography-positron emission tomography&#44; lymph node metastases were also found at other sites&#46; After multidisciplinary assessment by an oncologist&#44; a dermatologist&#44; an ear-nose-throat specialist&#44; and a ophthalmologist&#44; he was diagnosed with metastatic melanoma of unknown origin and prescribed treatment with a BRAF inhibitor &#40;vemurafenib&#41; and a MEK inhibitor &#40;trametinib&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">After taking the medical history and the physical examination of the patients&#44; the primary tumor was located in both patients&#58; the first patient had a dark&#44; keratotic pigmented lesion measuring 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm&#44; with the Hutchinson sign&#44; on the ball of the left big toe &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The second patient had a hyperpigmented lesion measuring 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter in the left parietal region&#44; with a characteristic atypical dermoscopic pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In both cases&#44; 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&#46; Certain care in the examination was&#44; however&#44; 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&#46;</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&#46; Although this may appear a diagnostic omission and would have no bearing on the follow-up and therapeutic approach&#44; prognosis does vary according to whether the primary tumor is known or unknown&#46;<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&#46; 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&#37;&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12&#8211;18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of the above&#44; the physical examination of the patient in a melanoma unit should be protocolized and meticulous&#46; First&#44; the patient should be examined completely naked&#44; with appropriate light sources&#44; if possible with natural light&#46; The whole body surface should be examined&#44; without omitting the acral areas and those not readily accessible for some patients &#40;retroauricular area&#44; interdigital area&#44; and soles of the feet&#44; etc&#46;&#41;&#46; The mucosas &#40;oral&#44; genital&#44; conjunctival&#44; etc&#46;&#41; and appendages &#40;nails and areas with hair follicles&#41; should also be examined&#46; When the patient has been diagnosed with metastatic melanoma of unknown primary tumor&#44; an exhaustive examination of the area of skin drained by the affected lymph node should be undertaken&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ivars M&#44; Redondo P&#46; &#191;Exploramos correctamente a los pacientes&#63; &#191;Qu&#233; nos est&#225; pasando&#63;&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;846&#8211;848&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Image of the primary tumor in the patient with lymph node metastases in the left groin&#46; A dark&#44; kerotic pigmented lesion measuring 1&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm can be seen&#44; with the Hutchinson sign&#44; on the ball of the left little toe&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lymph node metastases in the left laterocervical region &#40;gray arrow&#41; and primary tumor &#40;hyperpigmented lesion measuring 2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter with a characteristic atypical dermoscopic pattern&#41; in the left parietal region &#40;white arrows&#41;&#46;</p>"
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