Abstract: Melanoma is widely known as the most lethal skin cancer. Specific tumor-related mortality can be significantly reduced if diagnosis and treatment are properly performed during initial phases of the disease. The current search for biomarkers in early-stage melanomas is a high-priority challenge for physicians and researchers. We aimed to assess the immunoexpression of BRAFV600E and KIT in a case series consisting of 44 early-stage melanomas. Formalin-fixed paraffin-embedded samples were systematically evaluated using a semi-quantitative method based on scores of percentage and intensity for immunostained tumor cells. We observed significant concordance between BRAFV600E and KIT immunoexpression in thin invasive melanomas. Our findings corroborate previous evidence showing abnormal expression of proteins associated with MAPK intracellular signaling pathway in early-stage melanomas.

A fêmea da pulga Tunga penetrans é responsável pela dermatose ectoparasitária denominada Tungíase. Relatamos o caso clínico de um adolescente branco de 12 anos de idade, o qual procurou atendimento em consultório dermatológico devido à lesão dolorosa na planta e cujo exame dermatoscópico sem contato com a pele permitiu visualizar o movimento do parasita dentro da pele. O diagnóstico da tungíase é clínico, porém pode ser auxiliado pelo exame dermatoscópico in vivoe ex vivoda lesão.

The female flea Tunga penetrans is responsible for a cutaneous parasitosis known as Tungiasis. We report the clinical case of a 12 year-old Caucasian boy who sought treatment in a dermatological private office due to a painful lesion in the plantar area and whose dermoscopic examination, without skin contact, allowed the visualization of parasite's movement inside the skin. The diagnosis of tungiasis is clinical, but it can be aided by in vivoand ex vivodermoscopic examination of the lesion.

O tricoadenoma é um tumor cutâneo benigno, assintomático, raro e de crescimento lento. Existem poucos casos relatados na literatura e identificamos apenas um descrito na região palpebral. Apresentamos o caso de uma paciente portadora de tricoadenoma no canto externo da pálpebra inferior direita, tratada com excisão cirúrgica associada a blefaroplastia.

Trichoadenoma is a benign cutaneous tumor that is asymptomatic, rare, and slow growing. There are few cases reported in the literature, and we could only identify one description of trichoadenoma occurring in the eyelid area. We describe the case of a patient with trichoadenoma in the outer corner of the lower eyelid that we treated with surgical excision associated with blepharoplasty.

Merkel cell carcinoma is a very rare and aggressive neoplasm. Due to its rarity, therapeutic guidelines are not well established, especially for regionally advanced disease. Articles in English, French, Italian, Portuguese, and Spanish from the last 20 years were identified in MEDLINE and reviewed. The key word "Merkel" was used for the search, relevant articles were selected, and their references were examined. The most important articles related to epidemiology, genesis and treatment were reviewed. The incidence of Merkel cell carcinoma is increasing due to the advancing age of the population, higher rates of sun exposure and an increasing number of immunocompromised individuals. With regard to etiology, the recently described Merkel Cell polyomavirus is thought to play a role. Either local or regional surgical intervention remains the standard of care, but adjuvant radiotherapy or radiotherapy as a primary treatment have been discussed as reasonable therapeutic options. An update on this rare neoplasia is essential because of its increasing incidence and changing treatment options.

Atypical Mole Syndrome is the most important phenotypic risk factor for developing cutaneous melanoma, a malignancy that accounts for about 80% of deaths from skin cancer. Because the diagnosis of melanoma at an early stage is of great prognostic relevance, the identification of Atypical Mole Syndrome carriers is essential, as well as the creation of recommended preventative measures that must be taken by these patients.

CONTEXTO E OBJETIVO: Melanoma de vulva é uma doença rara. Descrevemos a experiência de uma instituição e revisamos a literatura. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo no Departamento de Ginecologia do Hospital do Câncer A. C. Camargo. MÉTODOS: De Janeiro de 1987 a Dezembro de 2006, foram revisados aspectos clínico-patológicos, tratamento cirúrgico e acompanhamento de 11 pacientes com melanoma de vulva. RESULTADOS: Lesão vulvar, prurido, dor e sangramento foram sintomas iniciais. A idade mediana foi 64,8 anos. A mediana da profundidade de invasão foi 3.08 mm. O estadiamento variou de IB a IIIC (American Joint Committee on Cancer, 2002). Todas as pacientes foram submetidas a vulvectomia. Duas pacientes não foram submetidas a linfadenectomia eletiva primária. A linfadenectomia inguinal bilateral foi realizada em cinco pacientes e uma foi submetida à linfadenectomia inguinal unilateral. A pesquisa do linfonodo sentinela foi realizada em três casos. Cinco tiveram recidiva locorregional. A sobrevida prolongada esteve relacionada com a ausência de comprometimento linfonodal. O tempo mediano de acompanhamento foi de 56 meses. A sobrevida mediana livre de doença foi de 15 meses e a sobrevida mediana global de 29 meses. CONCLUSÕES: O prognóstico das pacientes com melanoma de vulva geralmente é ruim, com tendência a recorrência regional e à distância. A profundidade de invasão e envolvimento linfonodal são os principais fatores prognósticos. Na maioria dos casos a ressecção da lesão com margens adequadas pode substituir a vulvectomia. A linfadenectomia inguino-femoral eletiva ainda é o procedimento padrão para estadiamento linfonodal. Pesquisa do linfonodo sentinela é factível e deve ser realizada por equipe multidisciplinar com experiência no método.

CONTEXT AND OBJECTIVE: Vulvar melanoma is a rare disease. We describe the experience of a single institution and review the literature. DESIGN AND SETTING: Retrospective study at the Department of Gynecology, Hospital do Cancer A. C. Camargo. METHODS: Eleven patients with vulvar melanoma attended between January 1987 and December 2006 were reviewed regarding clinicopathological characteristics, surgical therapy and follow-up. RESULTS: The initial symptoms were vulvar lesions, pruritus, pain and bleeding. The median age was 64.8 years. The median depth of invasion was 3.08 mm. The staging ranged from IB to IIIC (American Joint Committee on Cancer, 2002). All the patients underwent vulvectomy. Two patients did not undergo primary elective lymphadenectomy. Bilateral inguinal lymphadenectomy was performed on five patients, and one had unilateral inguinal lymphadenectomy. Sentinel lymph node investigation was performed on three patients. Five patients had locoregional recurrence. Prolonged survival was only achieved in the absence of lymph node involvement. The median follow-up was 56 months. The median disease-free survival was 15 months and the median overall survival was 29 months. CONCLUSIONS: The prognosis for patients with vulvar melanoma is generally poor, with a high tendency towards regional and distant recurrence. Depth of invasion and lymph node involvement are the most important prognostic factors. In most cases, resection of the lesion with adequate margins may replace vulvectomy. Elective inguinal femoral lymphadenectomy remains the standard lymph node staging procedure. Sentinel lymph node investigation is feasible and should be performed by a multidisciplinary team with experience of this method.

BACKGROUND: Primary cutaneous melanoma still constitutes the main cause of skin cancer death in developed countries, and its incidence in recent years has been increasing in a steady, worrisome manner. OBJECTIVES: This study evaluated the clinical, epidemiological and demographic aspects of this disease, and correlated them with patient prognosis. METHODS: Using epidemiologic and clinical data, we analyzed 84 patients with mild to severe primary cutaneous melanoma treated between 1990 and 2007. Slides containing surgical specimens were analyzed, and new slides were made from archived paraffin sections when necessary. RESULTS: The melanoma incidence was higher in areas of sun exposure, with lesions commonly observed in the trunk for males, and lower limbs for females. In addition to Breslow's thickness and ulceration (p = 0.043 and p < 0.001, respectively), the mitotic rate per mm² also correlated with worse patient outcome (p = 0.0007). The sum of ulceration (0 when absent or 1 when present), the Breslow index (1 when <1 mm, 2 when >1 mm and <4 mm, 3 when >4 mm) and the mitotic index (0 when absent or 1 when >1 per mm²) allowed the establishment of a prognostic score: if the sum was equal to or over three, nearly all (91.7%) patients had systemic disease. The 5-year survival was approximately seventy percent. CONCLUSION: Because American Join Committee of Cancer Staging will update the classification of malignant tumors (TNM) staging in the near future, and introduce mitosis as a prognostic factor, our results show the importance of such a feature. Additional studies are necessary to confirm the importance of a prognostic score as proposed herein.

Os principais méritos da biópsia de linfonodo sentinela em pacientes com melanoma cutâneo residem na possibilidade de serem evitadas linfadenectomias radicais desnecessárias e de permitir a correta identificação da cadeia de drenagem linfática, principalmente quando o tumor se localiza em áreas de drenagem ambígua. Atualmente já foi incorporada como fator prognóstico, sendo importante dado para o correto estadiamento do paciente. No presente relato são apresentados dois casos em que a utilização desta técnica foi extremamente útil, sobretudo por ter identificado a presença de drenagem linfática para duas cadeias linfáticas distintas. é importante que o dermatologista esteja consciente da correta indicação da técnica, para poder orientar da melhor forma possível seus pacientes.

The main merits of sentinel lymph node biopsy in patients with cutaneous melanoma reside in the possibility of avoiding unnecessary radical nodectomies and of allowing a correct identification of the lymphatic draning basin, specially when the tumor is located in areas of ambiguous drainage. It is currently incorporated as a prognostic factor, being important for correct staging of the patient. This paper reports two cases in which the use of this technique was extremely useful, above all for having identified the presence of lymphatic drainage for two distinct basins. It is important for dermatologists to be aware of the correct indication of such technique, in order to guide patients in the best possible manner.

CONTEXTO E OBJETIVO: Estudos recentes têm indicado que áreas de vitiligo contêm melanócitos inativos ou dormentes. A síntese de melanina está relacionada com a presença de tirosinase é indicadora de estado metabólico ativo. O escopo deste artigo é comparar repigmentação, distribuição epidérmica de melanócitos e detecção do RNAm de tirosinase através da reação de polimerase em cadeia por transcriptase reversa, em amostras de tecido de vitiligo, antes e após curetagem, seguido ou não por uma nova técnica de enxerto autólogo de pele. TIPO DE ESTUDO E LOCAL: Prospectivo, na Disciplina de Dermatologia da Faculdade de Medicina do ABC, Santo André. MÉTODOS: Duas áreas de vitiligo foram curetadas. Uma foi subseqüentemente enxertada com pele autóloga sacral normal, enquanto a outra não recebeu nenhum enxerto. As áreas curetadas foram examinadas após 30 dias, para avaliar o grau de repigmentação. A porcentagem de melanócitos e a presença de RNAm de tirosinase de pele normal e de pele de vitiligo (antes e após curetagem apenas e antes e após curetagem seguida de enxertia) foram comparadas. RESULTADOS: Repigmentação completa foi observada em todas as áreas enxertadas, enquanto as áreas de vitiligo apenas curetadas apresentaram repigmentação parcial. A porcentagem de melanócitos nas áreas enxertadas excederam as áreas de vitiligo não tratados (p = 0.01) e as áreas tratadas com curetagem simples (p = 0,015). RNAm de tirosinase foi negativo em 93.75% das áreas não tratadas de vitiligo. Após tratamento (somente curetagem ou curetagem seguida de enxerto), todas as lesões tornaram-se positivas para RNAm de tirosinase. CONCLUSÃO: Melanócitos metabolicamente inativos ou dormentes estão provavelmente presentes dentro das áreas de vitiligo, e podem ser ativados por estímulos endógenos ou exógenos.

CONTEXT AND OBJECTIVE: Recent studies have indicated that vitiligo areas contain inactive or dormant melanocytes. Melanin synthesis is related to tyrosinase presence and indicative of active metabolic state. The aim of this study was to compare repigmentation, epidermal melanocyte distribution and tyrosinase mRNA detection through reverse transcriptase polymerase chain reaction, in tissue samples of vitiligo, before and after curettage, with or without subsequent autologous skin graft using a new method. DESIGN AND SETTING: Prospective, in the Department of Dermatology, Faculdade de Medicina do ABC, Santo André. METHODS: Two vitiligo areas were curetted. One subsequently received grafted normal sacral autologous skin, whereas the other had no further treatment. The curetted areas were examined after 30 days, to evaluate the degree of repigmentation. The melanocyte percentages and tyrosinase mRNA presence in normal skin and vitiligo areas, before and after curettage and grafting, were compared. RESULTS: Complete repigmentation was seen in all grafted areas, whereas non-grafted curetted vitiligo presented partial repigmentation. The melanocyte percentage in grafted areas was greater than in non-treated vitiligo skin (p = 0.01) and skin with curettage alone (p = 0.015). Tyrosinase mRNA was negative in 93.75% of non-treated vitiligo areas. After treatment (curettage alone or curettage and grafting), all lesions became positive for tyrosinase mRNA. CONCLUSION: Metabolically inactive or dormant melanocytes are probably present within vitiligo areas, and may be activated by exogenous or endogenous stimuli.

Os efeitos da rejeição e da imunossupressão com ciclosporina A em retalhos epigástricos utilizados como transplantes cutâneos alógenos microcirúrgicos, foram estudados em 58 ratos, distribuídos em três grupos: Wistar-Furth isogênicos doadores e receptores; e Brown-Norway doadores e Wistar-Furth receptores, imunossuprimidos com cicloporina A(10mg/kg/dia). Biópsias dos retalhos e da pele normal contralateral utilizadas como contrôle foram colhidas no terceiro, sétimo, 15º e 30º dias pós transplante. As biópsias foram preparadas em historesina, e coradas em azul de toluidina, para avaliação do infiltrado inflamatório local, permitindo estudo quantitativo dos linfócitos infiltrantes nos retalhos. O modelo revelou-se eficiente, obtendo-se sobrevivência dos transplantes por 30 dias, de 83,3% entre animais isogênicos, e de 60% nos alogênicos sob ação da ciclosporina A. Em ratos alogênicos não imunossuprimidos houve 100% de rejeição dos retalhos, até o nono dia pós-operatório. Nos transplantes desses animais, verificou-se aumento significativo do número de linfócitos infiltrantes no terceiro dia, quando comparados aos ratos isogênicos. A linfocitose observada antecedeu os achados macroscópicos da rejeição, verificados apenas no quinto ou sexto dias.

The rejection of allotransplantation of epigastric microsurgical flaps and the effect of immunosuppression have been studied in 58 rats. Three sets of experiments were planned: (1) Wistar Furth isogenic donors and receptors (control set); (2) Brown Norway donors and Wistar Furth receptors (rejection set); and (3) Brown Norway donors and Wistar Furth immunosuppressed receptors (cyclosporin A set). Cyclosporin A (10 mg/kg/d) treated rats had a transplantation survival rate of up to 30 days: 83.3% among isogenic animals and 60% among allogeneic. There was 100% rejection by the 9th day after the transplantation in allogeneic non-immunosuppressed rats. Biopsies embedded with historesin were taken from the flap and normal contralateral skin (used as control) on the 3rd, 7th, 15th, and 30th days after the surgery. A quantitative study of infiltrating lymphocytes in the flaps, with and without cyclosporin A, was done by evaluating the local inflammatory infiltrate. A significant increase in the number of lymphocytes among the rejection and immunosuppressed groups was seen, as compared to the isogenic set. Local lymphocytosis in allogeneic non-immunosuppressed transplantations reached its highest level on the 3rd day after surgery, before gross findings of rejection, which could only be seen by naked eye on the 5th or 6th day. Therefore, we conclude that cyclosporin A is effective in preserving allogenic transplantation in rats. Biopsies of transplanted areas may contribute to earlier diagnosis of the need for immunosuppressive therapy.