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Sun J, Karasaki KM, Farma JM. The Use of Gene Expression Profiling and Biomarkers in Melanoma Diagnosis and Predicting Recurrence: Implications for Surveillance and Treatment. Cancers (Basel) 2024; 16:583. [PMID: 38339333 PMCID: PMC10854922 DOI: 10.3390/cancers16030583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Cutaneous melanoma is becoming more prevalent in the United States and has the highest mortality among cutaneous malignancies. The majority of melanomas are diagnosed at an early stage and, as such, survival is generally favorable. However, there remains prognostic uncertainty among subsets of early- and intermediate-stage melanoma patients, some of whom go on to develop advanced disease while others remain disease-free. Melanoma gene expression profiling (GEP) has evolved with the notion to help bridge this gap and identify higher- or lower-risk patients to better tailor treatment and surveillance protocols. These tests seek to prognosticate melanomas independently of established AJCC 8 cancer staging and clinicopathologic features (sex, age, primary tumor location, thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and/or SLNB status). While there is a significant opportunity to improve the accuracy of melanoma prognostication and diagnosis, it is equally important to understand the current landscape of molecular profiling for melanoma treatment. Society guidelines currently do not recommend molecular testing outside of clinical trials for melanoma clinical decision making, citing insufficient high-quality evidence guiding indications for the testing and interpretation of results. The goal of this chapter is to review the available literature for GEP testing for melanoma diagnosis and prognostication and understand their place in current treatment paradigms.
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Affiliation(s)
- James Sun
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19002, USA;
| | | | - Jeffrey M. Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19002, USA;
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2
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Hosler GA, Murphy KM. Ancillary testing for melanoma: current trends and practical considerations. Hum Pathol 2023; 140:5-21. [PMID: 37179030 DOI: 10.1016/j.humpath.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
The diagnosis of melanocytic lesions is aided by ancillary testing, but clinical inspection with the histomorphological assessment on biopsy remains sufficient in most cases. Immunohistochemistry and molecular studies have proven useful for diminishing the pool of histomorphologically borderline lesions, and sequential testing may further improve overall diagnostic performance, but these assays should be used in a stepwise fashion if at all. Ancillary tests vary based on their technology, performance, and practical considerations, including but not limited to the specific diagnostic question, cost, and turn-around time, which impact test selection. This review examines currently used ancillary tests for the purpose of characterizing melanocytic lesions. Both scientific and practical considerations are discussed.
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Affiliation(s)
- Gregory A Hosler
- ProPath, Dallas, TX, 75247, USA; University of Texas Southwestern, Departments of Dermatology and Pathology, Dallas, TX, 75390, USA.
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3
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Massi D, Szumera-Ciećkiewicz A, Alos L, Simi S, Ugolini F, Palmieri G, Stanganelli I, Cook MG, Mandalà M. Impact of second opinion pathology review in the diagnosis and management of atypical melanocytic lesions: A prospective study of the Italian Melanoma Intergroup (IMI) and EORTC Melanoma Group. Eur J Cancer 2023; 189:112921. [PMID: 37280145 DOI: 10.1016/j.ejca.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND The clinical value of an expert pathological review in patients with an atypical melanocytic lesion diagnosis remains unclear. Herein, we evaluate its impact in a prospective clinical study. METHODS Patients with newly diagnosed or suspected atypical melanocytic proliferations and challenging skin tumours were reviewed prospectively by a specialised dermatopathologist through the nationwide 'Second Opinion Platform' of the Italian Melanoma Intergroup (IMI) network. The primary aim was the rate of major discrepancies that impacted patient management. Major discrepancies in diagnosis between referral and specialised review were blindly re-analysed by a panel of European Organisation for Research and Treatment (EORTC) Melanoma pathologists. RESULTS The samples submitted to central review included 254 lesions from 230 patients. The most frequent referral diagnoses were atypical melanocytic nevi of different subtypes (74/254, 29.2%), invasive melanomas (61/254, 24.0%), atypical melanocytic proliferations (37/254, 14.6%), AST (21/254, 8.3%) and in situ melanomas (17/254, 6.7%). There was disagreement between referral diagnosis and expert review in 90/254 cases (35.4%). Most importantly, 60/90 (66.7%) were major discordances with a change to the patient's clinical management. Among the 90 discordant cases, the most frequent new diagnosis occurred in World Health Organisation (WHO) Pathway I, followed by WHO Pathway IV (64/90 and 12/90, respectively). In total, 51/60 cases with major discrepancies were blindly re-evaluated by EORTC Melanoma pathologists with a final interobserver agreement in 90% of cases. CONCLUSION The study highlights that a second opinion for atypical melanocytic lesions affects clinical management in a minor, but still significant, proportion of cases. A central expert review supports pathologists and clinicians to limit the risk of both over- and under-treatment.
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Affiliation(s)
- Daniela Massi
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Anna Szumera-Ciećkiewicz
- Maria Sklodowska-Curie National Research Institute of Oncology, Department of Pathology, Warsaw, Poland
| | - Llucia Alos
- Department of Pathology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sara Simi
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Filippo Ugolini
- Section of Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giuseppe Palmieri
- Immuno-Oncology & Targeted Cancer Biotherapies, Unit of Cancer Genetics, University of Sassari IRGB-CNR, Sassari, Italy
| | - Ignazio Stanganelli
- Skin Cancer Unit, IRCCS Scientific Institute of Romagna for the Study of Cancer, IRCCS IRST, Meldola, Italy; Dermatology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Martin G Cook
- Unit of Pathology, Royal Surrey County Hospital, Guildford, UK
| | - Mario Mandalà
- University of Perugia, Unit of Medical Oncology, Santa Maria della Misericordia Hospital, Perugia, Italy
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4
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Battistella M, Balme B, Jullie ML, Zimmermann U, Carlotti A, Crinquette M, Frouin E, Macagno N, Ortonne N, Lamant L, de la Fouchardiere A, Aubriot-lorton MH, Durand L, Josselin N, Franck F, Chatelain D, Lemasson G, Algros MP, Durlach A, Machet MC, Courville P, Osio A, Seris A, Mortier L, Jouary T, Cribier B. Impact of expert pathology review in skin adnexal carcinoma diagnosis: Analysis of 2573 patients from the French CARADERM network. Eur J Cancer 2022; 163:211-221. [DOI: 10.1016/j.ejca.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/19/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022]
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Fidanzi C, Manzo Margiotta F, Spinelli C, Janowska A, Dini V, Oranges T, Romanelli M, Morganti R, Viacava P, D'Erme AM, Bagnoni G. Risk factors in pediatric melanoma: a retrospective study of 39 cases. Melanoma Res 2021; 31:555-560. [PMID: 34570022 DOI: 10.1097/cmr.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pediatric melanoma is a rare form of the tumor whose epidemiology is widely increasing thanks to the improvement of dermoscopic and anatomopathologic diagnostic techniques. Although it is a tumor of considerable interest in adults, little has been described about the pediatric field. The objective of our study was then to identify the possible risk factors for the development of melanoma in the pediatric population. We performed a retrospective study conducted in the Melanoma and Skin Cancer Unit and Unit of Dermatology (Livorno, Italy). We analyzed a population of 38 children under 21 years with a diagnosis of melanoma. This population was compared with a control population of 114 children followed up in our dermatologic clinic. From our combined univariate-multivariate statistics analysis, the number of nevi [regression coefficient (RC) of 1.04 and odds ratio (OR) of 2.8 confidence interval (Cl, 1.2-6.6)], and family history of melanoma [RC of 1.99 and OR of 7.3 (Cl, 2.3-22.7)] emerged as possible risk factors for the development of melanoma. The identification of these elements would allow the physician to carry out a more targeted preliminary assessment of the patient, potentially decisive in cases of diagnostic doubt of the lesion. Our study also lays the foundations for identifying those children who, despite not having received a diagnosis of melanoma on histologic examination, should be considered as patients susceptible to a focused follow-up, because of the presence of the risk factors that emerged from our research.
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Affiliation(s)
- Cristian Fidanzi
- Unit of Dermatology, Department of Medical and Oncological Area, University of Pisa
| | - Flavia Manzo Margiotta
- Unit of Dermatology, Department of Medical and Oncological Area, University of Pisa
- Institute of Life Sciences, Scuola Superiore Sant'Anna
| | - Claudio Spinelli
- Pediatric, Adolescent and Young Adults Surgery Division, Department of Surgical, Medical, Pathological, Molecular and Critical Area, University of Pisa, Pisa
| | - Agata Janowska
- Unit of Dermatology, Department of Medical and Oncological Area, University of Pisa
| | - Valentina Dini
- Unit of Dermatology, Department of Medical and Oncological Area, University of Pisa
| | - Teresa Oranges
- Unit of Dermatology, Department of Medical and Oncological Area, University of Pisa
- Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Florence
| | - Marco Romanelli
- Unit of Dermatology, Department of Medical and Oncological Area, University of Pisa
| | - Riccardo Morganti
- Statistical Support to Clinical Trials Department, University of Pisa, Pisa
| | - Paolo Viacava
- Clinical Pathology Departmental Area, Services Department, Operative Union Of Pathological Anatomy, Livorno Hospital
| | - Angelo M D'Erme
- Melanoma and Skin Cancer Unit AVNO (Area Vasta Nord Ovest) and Unit of Dermatology, Specialist Surgery Area, Department Of General Surgery, Livorno Hospital, Livorno, Italy
| | - Giovanni Bagnoni
- Melanoma and Skin Cancer Unit AVNO (Area Vasta Nord Ovest) and Unit of Dermatology, Specialist Surgery Area, Department Of General Surgery, Livorno Hospital, Livorno, Italy
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Katz I, O’Brien B, Clark S, Thompson CT, Schapiro B, Azzi A, Lilleyman A, Boyle T, Espartero LJL, Yamada M, Prow TW. Assessment of a Diagnostic Classification System for Management of Lesions to Exclude Melanoma. JAMA Netw Open 2021; 4:e2134614. [PMID: 34889949 PMCID: PMC8665368 DOI: 10.1001/jamanetworkopen.2021.34614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
Importance The proposed MOLEM (Management of Lesion to Exclude Melanoma) schema is more clinically relevant than Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MATH-Dx) for the management classification of melanocytic and nonmelanocytic lesions excised to exclude melanoma. A more standardized way of establishing diagnostic criteria will be crucial in the training of artificial intelligence (AI) algorithms. Objective To examine pathologists' variability, reliability, and confidence in reporting melanocytic and nonmelanocytic lesions excised to exclude melanoma using the MOLEM schema in a population of higher-risk patients. Design, Setting, and Participants This cohort study enrolled higher-risk patients referred to a primary care skin clinic in New South Wales, Australia, between April 2019 and December 2019. Baseline demographic characteristics including age, sex, and related clinical details (eg, history of melanoma) were collected. Patients with lesions suspicious for melanoma assessed by a primary care physician underwent clinical evaluation, dermoscopy imaging, and subsequent excision biopsy of the suspected lesion(s). A total of 217 lesions removed and prepared by conventional histologic method and stained with hematoxylin-eosin were reviewed by up to 9 independent pathologists for diagnosis using the MOLEM reporting schema. Pathologists evaluating for MOLEM schema were masked to the original histopathologic diagnosis. Main Outcomes and Measures Characteristics of the lesions were described and the concordance of cases per MOLEM class was assessed. Interrater agreement and the agreement between pathologists' ratings and the majority MOLEM diagnosis were calculated by Gwet AC1 with quadratic weighting applied. The diagnostic confidence of pathologists was then assessed. Results A total of 197 patients were included in the study (102 [51.8%] male; 95 [48.2%] female); mean (SD) age was 64.2 (15.8) years (range, 24-93 years). Overall, 217 index lesions were assessed with a total of 1516 histological diagnoses. Of 1516 diagnoses, 677 (44.7%) were classified as MOLEM class I; 120 (7.9%) as MOLEM class II; 564 (37.2%) as MOLEM class III; 114 (7.5%) as MOLEM class IV; and 55 (3.6%) as MOLEM class V. Concordance rates per MOLEM class were 88.6% (class I), 50.8% (class II), 76.2% (class III), 77.2% (class IV), and 74.2% (class V). The quadratic weighted interrater agreement was 91.3%, with a Gwet AC1 coefficient of 0.76 (95% CI, 0.72-0.81). The quadratic weighted agreement between pathologists' ratings and majority MOLEM was 94.7%, with a Gwet AC1 coefficient of 0.86 (95% CI, 0.84-0.88). The confidence in diagnosis data showed a relatively high level of confidence (between 1.0 and 1.5) when diagnosing classes I (mean [SD], 1.3 [0.3]), IV (1.3 [0.3]) and V (1.1 [0.1]); while classes II (1.8 [0.2]) and III (1.5 [0.4]) were diagnosed with a lower level of pathologist confidence (≥1.5). The quadratic weighted interrater confidence rating agreement was 95.2%, with a Gwet AC1 coefficient of 0.92 (95% CI, 0.90-0.94) for the 1314 confidence ratings collected. The confidence agreement for each MOLEM class was 95.0% (class I), 93.5% (class II), 95.3% (class III), 96.5% (class IV), and 97.5% (class V). Conclusions and Relevance The proposed MOLEM schema better reflects clinical practice than the MPATH-Dx schema in lesions excised to exclude melanoma by combining diagnoses with similar prognostic outcomes for melanocytic and nonmelanocytic lesions into standardized classification categories. Pathologists' level of confidence appeared to follow the MOLEM schema diagnostic concordance trend, ie, atypical naevi and melanoma in situ diagnoses were the least agreed upon and the most challenging for pathologists to confidently diagnose.
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Affiliation(s)
- Ian Katz
- Southern Sun Pathology, Sydney, New South Wales, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Blake O’Brien
- Sullivan Nicolaides Pathology, Brisbane, Queensland, Australia
| | - Simon Clark
- Douglass Hanly Moir Pathology, Sydney, New South Wales, Australia
| | | | | | - Anthony Azzi
- Newcastle Skin Check, Charlestown, New South Wales, Australia
| | | | - Terry Boyle
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Lore Jane L. Espartero
- Future Industries Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Miko Yamada
- Future Industries Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Tarl W. Prow
- Future Industries Institute, University of South Australia, Adelaide, South Australia, Australia
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7
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Bollard SM, Casalou C, Potter SM. Gene expression profiling in melanoma: A view from the clinic. Cancer Treat Res Commun 2021; 29:100447. [PMID: 34450405 DOI: 10.1016/j.ctarc.2021.100447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 06/13/2023]
Abstract
The treatment of Melanoma, one of the most aggressive human malignancies, has been revolutionised by the advent of novel targeted and immuno-therapies. However, methods utilised to detect early presentations, and to stratify risk for patients diagnosed with invasive melanoma in the clinical setting are lagging. The primary prognostic indicator is restricted to Breslow Thickness, or depth the tumour invades into the dermis. Gene Expression Profiling (GEP), the analysis of molecular gene signatures of an individual tumour, has been implemented with great success in other malignancies, such as breast and prostate cancer. In the setting of melanoma, commercial GEP panels are becoming available, offering patients a personalised approach, though yet to enter widespread clinical use. This short perspective seeks to describe how GEP is currently employed in practice, and its current clinical impact. We also suggest the potential roles for GEP in meeting the key clinical challenges faced by clinicians in melanoma treatment, such as decisions around adjuvant therapy, sentinel lymph node biopsy (SLNB) and surgical resection , thus highlighting areas for future potential research.
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Affiliation(s)
- S M Bollard
- School of Medicine & UCD Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland; Department of Plastic & Reconstructive Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland; Mater Melanoma Research Group, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - C Casalou
- Charles Institute of Dermatology, University College Dublin, Belfield, Dublin 4, Ireland
| | - S M Potter
- School of Medicine & UCD Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland; Department of Plastic & Reconstructive Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland; Mater Melanoma Research Group, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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8
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Laar RV, King S, McCoy R, Saad M, Fereday S, Winship I, Uzzell C, Landgren A. Translation of a circulating miRNA signature of melanoma into a solid tissue assay to improve diagnostic accuracy and precision. Biomark Med 2021; 15:1111-1122. [PMID: 34184547 DOI: 10.2217/bmm-2021-0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Successful treatment of cutaneous melanoma depends on early and accurate diagnosis of clinically suspicious melanocytic skin lesions. Multiple international studies have described the challenge of providing accurate and reproducible histopathological assessments of melanocytic lesions, highlighting the need for new diagnostic tools including disease-specific biomarkers. Previously, a 38-miRNA signature (MEL38) was identified in melanoma patient plasma and validated as a novel biomarker. In this study, MEL38 expression in solid tissue biopsies representing the benign nevi to metastatic melanoma spectrum is examined. Patients & methods: Nanostring digital gene expression assessment of the MEL38 signature was performed on 308 formalin-fixed paraffin-embedded biopsies of nevi, melanoma in situ and invasive melanoma. Genomic data were interrogated using hierarchical clustering, univariate and multivariate statistical approaches. Classification scores computed from the MEL38 signature were analyzed for their association with demographic data and histopathology results, including MPATH-DX class, AJCC disease stage and tissue subtype. Results: The MEL38 score can stratify higher-risk melanomas (MPATH-Dx class V or more advanced) from lower-risk skin lesions (class I-IV) with an area under the curve of 0.97 (p < 0.001). The genomic score ranges from 0 to 10 and is positively correlated with melanoma progression, with an intraclass correlation coefficient of 0.85 with stage 0-IV disease. Using an optimized classification threshold of ≥2.7 accurately identifies higher-risk melanomas with 89% sensitivity and 94% specificity. Multivariate analysis showed the score to be a significant predictor of malignancy, independent of technical and clinical covariates. Application of the MEL38 signature to Spitz nevi reveals an intrasubtype profile, with elements in common to both nevi and melanoma. Conclusion: Melanoma-specific circulating miRNAs maintain their association with malignancy when measured in the hypothesized tissue of origin. The MEL38 signature is an accurate and reproducible metric of melanoma status, based on changes in miRNA expression that occur as the disease develops and spreads. Inclusion of the MEL38 score into routine practice would provide physicians with previously unavailable, personalized genomic information about their patient's skin lesions. Combining molecular biomarker data with conventional histopathology data may improve diagnostic accuracy, healthcare resource utilization and patient outcomes.
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Affiliation(s)
- Ryan Van Laar
- Geneseq Biosciences, 555 St Kilda Road, Melbourne, Victoria, 3004, Australia
| | - Samuel King
- Australian Clinical Labs, 1868 Dandenong Road, Clayton, Victoria, 3168, Australia
| | - Richard McCoy
- Australian Clinical Labs, 1868 Dandenong Road, Clayton, Victoria, 3168, Australia
| | - Mirette Saad
- Australian Clinical Labs, 1868 Dandenong Road, Clayton, Victoria, 3168, Australia
| | - Sian Fereday
- Geneseq Biosciences, 555 St Kilda Road, Melbourne, Victoria, 3004, Australia
| | - Ingrid Winship
- Geneseq Biosciences, 555 St Kilda Road, Melbourne, Victoria, 3004, Australia
| | - Catherine Uzzell
- Australian Clinical Labs, 1868 Dandenong Road, Clayton, Victoria, 3168, Australia
| | - Anthony Landgren
- Australian Clinical Labs, 1868 Dandenong Road, Clayton, Victoria, 3168, Australia
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9
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Ronen S, Al-Rohil RN, Keiser E, Jour G, Nagarajan P, Tetzlaff MT, Curry JL, Ivan D, Middleton LP, Torres-Cabala CA, Gershenwald JE, Aung PP, Prieto VG. Discordance in Diagnosis of Melanocytic Lesions and Its Impact on Clinical Management. Arch Pathol Lab Med 2021; 145:1505-1515. [PMID: 33577643 DOI: 10.5858/arpa.2020-0620-oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Accurate diagnosis of melanocytic lesions is fundamental for appropriate clinical management. OBJECTIVE.— To evaluate the degree of discordance, if any, between histopathologic diagnoses of melanocytic lesions at referring institutions and at a tertiary referral cancer center and the potential impact of such discordance on clinical management. DESIGN.— We retrospectively identified all patients referred to our comprehensive cancer center for evaluation of a melanocytic lesion from January 2010 to January 2011. For each patient, the histopathologic diagnosis from the referring institution was compared with the histopathologic diagnosis from a dermatopathologist at our center. Discordances were classified as major if they resulted in a change in clinical management and minor if they did not. RESULTS.— A total of 1521 cases were included. The concordance rates were 72.2% (52 of 72) for dysplastic nevus, 75.0% (15 of 20) for all other types of nevi, 91.1% (143 of 157) for melanoma in situ, 96.1% (758 of 789) for invasive melanoma, and 99.6% (478 of 480) for metastatic melanoma. Major discordances were found in 20.2% of cases (307 of 1521), and minor discordances were found in 48.8% of cases (742 of 1521). Compared with the guideline-based treatment recommendation based on the referring-institution diagnosis, the guideline-based treatment recommendation based on the cancer center diagnosis was more extensive in 5.9% (89 of 1521) of patients and less extensive in 5.0% (76 of 1521) of patients. CONCLUSIONS.— Our findings underscore the importance of secondary histopathologic review of melanocytic lesions by expert dermatopathologists because significant changes in the diagnosis, tumor classification, and/or staging may be identified; thus, resulting in critical changes in recommendations for clinical management.
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Affiliation(s)
- Shira Ronen
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto).,Ronen, Al-Rohil, and Keiser contributed equally to this work.,Ronen's current affiliation is the Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rami N Al-Rohil
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto).,Ronen, Al-Rohil, and Keiser contributed equally to this work.,Al-Rohil's current affiliation is the Department of Pathology, Duke University Hospital, Durham, North Carolina
| | - Elizabeth Keiser
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto).,Ronen, Al-Rohil, and Keiser contributed equally to this work
| | - George Jour
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto).,Jour's current affiliation is the Department of Pathology, New York University, New York City
| | - Priyadharsini Nagarajan
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto)
| | - Michael T Tetzlaff
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto)
| | - Jonathan L Curry
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto)
| | - Doina Ivan
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto)
| | - Lavinia P Middleton
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto)
| | - Carlos A Torres-Cabala
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto)
| | - Jeffrey E Gershenwald
- Surgical Oncology and Cancer Biology (Gershenwald), The University of Texas MD Anderson Cancer Center, Houston
| | - Phyu P Aung
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto).,Aung and Prieto contributed equally to this work
| | - Victor G Prieto
- From the Departments of Pathology (Ronen, Al-Rohil, Keiser, Jour, Nagarajan, Tetzlaff, Curry, Ivan, Middleton, Torres-Cabala, Aung, Prieto).,Aung and Prieto contributed equally to this work
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10
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Hawryluk EB, Moustafa D, Bartenstein D, Brahmbhatt M, Cordoro K, Gardner L, Gauthier A, Grossman D, Gupta D, Hunt RD, Jen M, Kao PC, Kruse LL, Lawley LP, London WB, Mansour D, O'Haver JA, Phung T, Pope E, Price HN, Rogers T, Shah SD, Wolner Z, Huang J, Marghoob AA. A retrospective multicenter study of fatal pediatric melanoma. J Am Acad Dermatol 2020; 83:1274-1281. [DOI: 10.1016/j.jaad.2020.06.1010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
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11
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Kutzner H, Jutzi TB, Krahl D, Krieghoff‐Henning EI, Heppt MV, Hekler A, Schmitt M, Maron RCR, Fröhling S, Kalle C, Brinker TJ. Überdiagnose von Melanomen – Ursachen, Konsequenzen und Lösungsansätze. J Dtsch Dermatol Ges 2020; 18:1236-1244. [DOI: 10.1111/ddg.14233_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Tanja B. Jutzi
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Dieter Krahl
- Privates Labor für Dermatohistopathologie Mönchhofstraße 52 Heidelberg
| | - Eva I. Krieghoff‐Henning
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | | | - Achim Hekler
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Max Schmitt
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Roman C. R. Maron
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Stefan Fröhling
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Christof Kalle
- Berlin Institute of Health (BIH) und Charité – Universitätsmedizin Berlin
| | - Titus J. Brinker
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
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12
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Kutzner H, Jutzi TB, Krahl D, Krieghoff-Henning EI, Heppt MV, Hekler A, Schmitt M, Maron RCR, Fröhling S, von Kalle C, Brinker TJ. Overdiagnosis of melanoma - causes, consequences and solutions. J Dtsch Dermatol Ges 2020; 18:1236-1243. [PMID: 32841508 DOI: 10.1111/ddg.14233] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/13/2020] [Indexed: 12/14/2022]
Abstract
Malignant melanoma is the skin tumor that causes most deaths in Germany. At an early stage, melanoma is well treatable, so early detection is essential. However, the skin cancer screening program in Germany has been criticized because although melanomas have been diagnosed more frequently since introduction of the program, the mortality from malignant melanoma has not decreased. This indicates that the observed increase in melanoma diagnoses be due to overdiagnosis, i.e. to the detection of lesions that would never have created serious health problems for the patients. One of the reasons is the challenging distinction between some benign and malignant lesions. In addition, there may be lesions that are biologically equivocal, and other lesions that are classified as malignant according to current criteria, but that grow so slowly that they would never have posed a threat to patient's life. So far, these "indolent" melanomas cannot be identified reliably due to a lack of biomarkers. Moreover, the likelihood that an in-situ melanoma will progress to an invasive tumor still cannot be determined with any certainty. When benign lesions are diagnosed as melanoma, the consequences are unnecessary psychological and physical stress for the affected patients and incurred therapy costs. Vice versa, underdiagnoses in the sense of overlooked melanomas can adversely affect patients' prognoses and may necessitate more intense therapies. Novel diagnostic options could reduce the number of over- and underdiagnoses and contribute to more objective diagnoses in borderline cases. One strategy that has yielded promising results in pilot studies is the use of artificial intelligence-based diagnostic tools. However, these applications still await translation into clinical and pathological routine.
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Affiliation(s)
| | - Tanja B Jutzi
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dieter Krahl
- Private Laboratory for Dermatohistopathology, Mönchhofstraße 52, Heidelberg, Germany
| | - Eva I Krieghoff-Henning
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Markus V Heppt
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Achim Hekler
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Max Schmitt
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Roman C R Maron
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Fröhling
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christof von Kalle
- Berlin Institute of Health (BIH) and Charité-University Medical Center Berlin, Berlin, Germany
| | - Titus J Brinker
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
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13
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Clarke LE, Mabey B, Flake Ii DD, Meek S, Cassarino DS, Duncan LM, High WA, Napekoski KM, Prieto VG, Tetzlaff MT, Vitale P, Elder DE. Clinical validity of a gene expression signature in diagnostically uncertain neoplasms. Per Med 2020; 17:361-371. [PMID: 32915688 DOI: 10.2217/pme-2020-0048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Aim: Evaluate the accuracy of a 23-gene expression signature in differentiating benign nevi from melanoma by comparing test results with clinical outcomes. Materials & methods: Seven dermatopathologists blinded to gene expression test results and clinical outcomes examined 181 lesions to identify diagnostically uncertain cases. Participants independently recorded diagnoses and responses to questions quantifying diagnostic certainty. Test accuracy was determined through comparison with clinical outcomes (sensitivity and percent negative agreement). Results: Overall, 125 cases fulfilled criteria for diagnostic uncertainty (69.1%; 95% CI: 61.8-75.7%). Test sensitivity and percent negative agreement in these cases were 90.4% (95% CI: 79.0-96.8%) and 95.5% (95% CI: 87.3-99.1%), respectively. Conclusion: The 23-gene expression signature has high diagnostic accuracy in diagnostically uncertain cases when evaluated against clinical outcomes.
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Affiliation(s)
- Loren E Clarke
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Brent Mabey
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Darl D Flake Ii
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Stephanie Meek
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - David S Cassarino
- Kaiser Permanente, Los Angeles Medical Center Bldg., Los Angeles, CA 90027, USA
| | - Lyn M Duncan
- Pathology Associates, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Whitney A High
- Department of Dermatology, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | - Victor G Prieto
- Departments of Pathology & Translational & Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michael T Tetzlaff
- Departments of Pathology & Translational & Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Patricia Vitale
- Departments of Dermatology and Pathology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - David E Elder
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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14
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Zarabi SK, Azzato EM, Tu ZJ, Ni Y, Billings SD, Arbesman J, Funchain P, Gastman B, Farkas DH, Ko JS. Targeted next generation sequencing (NGS) to classify melanocytic neoplasms. J Cutan Pathol 2020; 47:691-704. [PMID: 32291779 DOI: 10.1111/cup.13695] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/12/2020] [Accepted: 03/10/2020] [Indexed: 12/18/2022]
Abstract
This study piloted a pan-solid-tumor next generation sequence (NGS)-based laboratory developed test as a diagnostic aid in melanocytic tumors. 31 cases (4 "epithelioid" nevi, 5 blue nevi variants, 7 Spitz tumors [3 benign and 4 malignant] and 15 melanomas) were evaluated. All tumors [median diameter 7 mm (range 4-15 mm); median thickness 2.25 mm (range 0.25-12 mm)] yielded satisfactory results. The number of small nucleotide variants/tumor was significantly different between melanoma (median 18/tumor, range 4-71) and all other lesions (median 8/tumor, range 3-17) (P < 0.004) and malignant (median 16/tumor, range 4-71) vs benign lesions (median 7/tumor, range 3-14) (P = 0.01). BRAF, MET, NTRK1, and ROS fusions only occurred in benign Spitz tumors; EML4 fusion, BRAF, MAP2K1 and TERT mutations occurred in malignant Spitz tumors and/or melanoma. Amplifications and NRAS and NF1 mutations only occurred in melanoma. Most melanomas contained >1 pathogenic alteration. Developed NGS-based criteria correctly classified all malignant lesions in this series. 10/12 cases showed concordance with FISH; consensus diagnosis agreed with NGS classification in FISH-non-concordant cases. This pilot study suggests that NGS may be an effective diagnostic adjunct comparable to FISH, but further studies with larger numbers of cases are needed.
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Affiliation(s)
- Samaneh K Zarabi
- Department of Pathology, Stony Brook University Hospital, New York, New York, USA
| | - Elizabeth M Azzato
- Molecular Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Zheng Jin Tu
- Molecular Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ying Ni
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven D Billings
- Dermatopathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Josh Arbesman
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pauline Funchain
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Gastman
- Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel H Farkas
- Molecular Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer S Ko
- Dermatopathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Incorporation of dermoscopy improves inter-observer agreement among dermatopathologists in histologic assessment of melanocytic neoplasms. Arch Dermatol Res 2020; 313:101-108. [PMID: 32338293 DOI: 10.1007/s00403-020-02079-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/27/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
Abstract
Histopathologic assessment of melanocytic neoplasms is the current gold standard of diagnosis. However, there are well recognized limitations including inter-observer diagnostic discordance. This study aimed to determine if integrating dermoscopy with histopathology of melanocytic neoplasms impacts diagnosis and improves inter-observer agreement. We conducted a prospective cohort study in a pigmented lesion clinic. Consecutive melanocytic lesions were identified for biopsy based on atypical gross or dermoscopic features. Standardized immunohistochemistry and levels were ordered on each specimen. The cases were randomized. Three dermatopathologists blinded to the clinical impression assessed each lesion. The cases were then re-randomized and re-assessed with addition of gross clinical and dermoscopic images. Inter-rater reliability (IRR) using Fleiss' kappa statistic revealed an increase from 0.447 without to 0.496 with dermoscopy amongst all dermatopathologists. The kappa increased from 0.495 before to 0.511 with dermoscopy in separating high-grade atypia or melanoma from moderate atypia or less. In 16 of 136 cases, at least 2 of 3 dermatopathologists favored a diagnosis of melanoma only after dermoscopy. In total, the consensus grade of atypia changed in 24.3% (33/ 136) of cases thereby representing changes to excisional margins and patient follow up. This study is limited by the cohort size. Dermoscopy significantly impacts diagnosis and improves identification of early melanomas in high risk populations and improves inter-observer agreement.
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16
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Internal Pathology Review of Invasive Melanoma: An Academic Institution Experience. J Surg Res 2020; 250:97-101. [PMID: 32044512 DOI: 10.1016/j.jss.2019.12.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/15/2019] [Accepted: 12/29/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Prior studies of internal pathology review (IPR) for melanoma have shown that changes in the pathology analysis are common. How these changes impact clinical management of melanoma or how the margin status reports may modify has not been evaluated. Our goal was to determine what changes to staging and surgical management occurred after IPR of newly diagnosed melanomas and to determine how the final surgical pathology report may correlate with the IPR. METHODS A retrospective study was conducted from 2014 to 2016 of newly diagnosed invasive melanomas referred to a single National Comprehensive Cancer Network tertiary care center. RESULTS A total of 370 cases met inclusion criteria. The most common feature changed after internal review was mitotic rate, in 155 (41.7%) patients, followed by Breslow depth in 99 (26.9%) patients. Tumor staging was changed in 45 (12.2%) patients. The most common change was a T1a lesion being upgraded to a T1b lesion. These tumor staging changes lead to 38 (10.3%) overall staging differences. A biopsy's deep margin status was changed in 27 (7.3%) patients. Outside hospital reports lacked information about deep margin status in 71 (19.2%) of specimens. Based on the National Comprehensive Cancer Network guidelines, 22 (5.9%) patients had changes in their sentinel lymph node biopsy recommendations and one of these patients had a positive node found on pathology. Of those patients who had changes in the T-stage, 16 (4.3%) of them also had changes in the recommended wide local excision radial margin. CONCLUSIONS IPR of invasive melanoma leads to both changes in staging and the surgical management of melanoma and should remain an important component of care of melanoma patients at a tertiary referral center.
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17
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Lowenstein EJ, Sidlow R, Ko CJ. Visual perception, cognition, and error in dermatologic diagnosis: Diagnosis and error. J Am Acad Dermatol 2019; 81:1237-1245. [DOI: 10.1016/j.jaad.2018.12.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/18/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
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18
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Imaging Mass Spectrometry–Based Lipidomic Approach to Classification of Architectural Features in Nevi. J Invest Dermatol 2019; 139:2055-2058.e7. [DOI: 10.1016/j.jid.2019.01.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 11/23/2022]
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19
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Ko JS, Clarke LE, Minca EC, Brown K, Flake DD, Billings SD. Correlation of melanoma gene expression score with clinical outcomes on a series of melanocytic lesions. Hum Pathol 2019; 86:213-221. [DOI: 10.1016/j.humpath.2018.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/30/2018] [Accepted: 12/07/2018] [Indexed: 01/06/2023]
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20
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21
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Elston DM, Luo Y, Echols K, Rensch G, Metcalf J. Changes in melanoma diagnosis after presurgical tertiary care center review. J Am Acad Dermatol 2018; 85:480-481. [PMID: 29753056 DOI: 10.1016/j.jaad.2018.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Dirk M Elston
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina.
| | - Ying Luo
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Kathryn Echols
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Gage Rensch
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - John Metcalf
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina
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22
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Pathologists' Use of Second Opinions in Interpretation of Melanocytic Cutaneous Lesions: Policies, Practices, and Perceptions. Dermatol Surg 2018; 44:177-185. [PMID: 28858936 DOI: 10.1097/dss.0000000000001256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Research examining the role of second opinions in pathology for diagnosis of melanocytic lesions is limited. OBJECTIVE To assess current laboratory policies, clinical use of second opinions, and pathologists' perceptions of second opinions for melanocytic lesions. MATERIALS AND METHODS Cross-sectional data collected from 207 pathologists in 10 US states who diagnose melanocytic lesions. The web-based survey ascertained pathologists' professional information, laboratory second opinion policy, use of second opinions, and perceptions of second opinion value for melanocytic lesions. RESULTS Laboratory policies required second opinions for 31% of pathologists and most commonly required for melanoma in situ (26%) and invasive melanoma (30%). In practice, most pathologists reported requesting second opinions for melanocytic tumors of uncertain malignant potential (85%) and atypical Spitzoid lesions (88%). Most pathologists perceived that second opinions increased interpretive accuracy (78%) and protected them from malpractice lawsuits (62%). CONCLUSION Use of second opinions in clinical practice is greater than that required by laboratory policies, especially for melanocytic tumors of uncertain malignant potential and atypical Spitzoid lesions. Quality of care in surgical interventions for atypical melanocytic proliferations critically depends on the accuracy of diagnosis in pathology reporting. Future research should examine the extent to which second opinions improve accuracy of melanocytic lesion diagnosis.
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23
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24
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Leachman SA, Mengden Koon S, Korcheva VB, White KP. Assessing Genetic Expression Profiles in Melanoma Diagnosis. Dermatol Clin 2017; 35:537-544. [PMID: 28886810 DOI: 10.1016/j.det.2017.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Most melanocytic tumors can be characterized as a benign nevus or a melanoma by a trained pathologist using traditional histopathological methods. However, a minority demonstrates ambiguous features and continues to be a diagnostic challenge. Genetic expression profiling (GEP) assays have been developed in an effort to resolve this dilemma. These assays measure mRNA levels of specified genes using reverse transcription quantitative polymerase chain reaction technology. The development of GEP assays, methodology, challenges associated with GEP validation and testing, and the suitability of a currently available GEP test for clinical use are reviewed.
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Affiliation(s)
- Sancy A Leachman
- Melanoma and Skin Cancer Program, Department of Dermatology, OHSU Knight Cancer Institute, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA.
| | - Stephanie Mengden Koon
- Department of Dermatology, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA
| | - Veselina B Korcheva
- Department of Dermatology, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA
| | - Kevin P White
- Department of Dermatology, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA
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25
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Histopathologic features of melanoma in difficult-to-diagnose lesions: A case-control study. J Am Acad Dermatol 2017; 77:543-548.e1. [DOI: 10.1016/j.jaad.2017.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 11/21/2022]
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26
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Clarke LE, Flake DD, Busam K, Cockerell C, Helm K, McNiff J, Reed J, Tschen J, Kim J, Barnhill R, Elenitsas R, Prieto VG, Nelson J, Kimbrell H, Kolquist KA, Brown KL, Warf MB, Roa BB, Wenstrup RJ. An independent validation of a gene expression signature to differentiate malignant melanoma from benign melanocytic nevi. Cancer 2017; 123:617-628. [PMID: 27768230 PMCID: PMC5324582 DOI: 10.1002/cncr.30385] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 08/22/2016] [Accepted: 09/19/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recently, a 23-gene signature was developed to produce a melanoma diagnostic score capable of differentiating malignant and benign melanocytic lesions. The primary objective of this study was to independently assess the ability of the gene signature to differentiate melanoma from benign nevi in clinically relevant lesions. METHODS A set of 1400 melanocytic lesions was selected from samples prospectively submitted for gene expression testing at a clinical laboratory. Each sample was tested and subjected to an independent histopathologic evaluation by 3 experienced dermatopathologists. A primary diagnosis (benign or malignant) was assigned to each sample, and diagnostic concordance among the 3 dermatopathologists was required for inclusion in analyses. The sensitivity and specificity of the score in differentiating benign and malignant melanocytic lesions were calculated to assess the association between the score and the pathologic diagnosis. RESULTS The gene expression signature differentiated benign nevi from malignant melanoma with a sensitivity of 91.5% and a specificity of 92.5%. CONCLUSIONS These results reflect the performance of the gene signature in a diverse array of samples encountered in routine clinical practice. Cancer 2017;123:617-628. © 2016 American Cancer Society.
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Affiliation(s)
| | | | - Klaus Busam
- Memorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Clay Cockerell
- The University of Texas Southwestern Medical CenterDallasTexas
| | - Klaus Helm
- Penn State Hershey DermatologyHersheyPennsylvania
| | | | - Jon Reed
- CellNetix Pathology and Laboratories LLCSeattleWashington
| | | | - Jinah Kim
- Department of PathologyStanford School of MedicineStanfordCalifornia
| | - Raymond Barnhill
- Department of PathologyUniversity of California Los AngelesLos AngelesCalifornia
| | - Rosalie Elenitsas
- Department of DermatologyUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Victor G. Prieto
- Department of PathologyThe University of Texas MD Anderson Cancer CenterHoustonTexas
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Cockerell C, Tschen J, Billings SD, Evans B, Brown K, Rock C, Clarke LE. The influence of a gene-expression signature on the treatment of diagnostically challenging melanocytic lesions. Per Med 2017; 14:123-130. [PMID: 28757886 PMCID: PMC5480781 DOI: 10.2217/pme-2016-0097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/03/2017] [Indexed: 11/21/2022]
Abstract
AIM The effect of a gene-expression-based test on treatment of melanocytic neoplasms by dermatologists was evaluated. PATIENTS & METHODS Pathologists submitted diagnostically challenging melanocytic neoplasms to a clinical laboratory for testing accompanied by pretest surveys documenting the intended treatment recommendations. The actual treatment rendered by dermatologists was then documented after testing. Changes between the pretest recommendations and actual treatment were analyzed. RESULTS In 71.4% (55/77) of cases, there was a change from pretest recommendations to actual treatment. The majority of changes were consistent with the test result. There was an 80.5% (33/41) reduction in the number of biopsy site re-excisions performed for cases with a benign test result. CONCLUSION The actual treatment of diagnostically challenging melanocytic neoplasms is influenced by the test.
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Affiliation(s)
- Clay Cockerell
- Cockerell Dermatopathology & University of Texas Southwestern Medical Center, 2110 Research Row #100, Dallas, TX 75235, USA.,Cockerell Dermatopathology & University of Texas Southwestern Medical Center, 2110 Research Row #100, Dallas, TX 75235, USA
| | - Jaime Tschen
- St Joseph Medical Center, 6909 Greenbriar Drive, Houston, TX 77030, USA.,St Joseph Medical Center, 6909 Greenbriar Drive, Houston, TX 77030, USA
| | - Steven D Billings
- Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44106, USA.,Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44106, USA
| | - Brent Evans
- Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA.,Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Krystal Brown
- Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA.,Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Colleen Rock
- Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA.,Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
| | - Loren E Clarke
- Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA.,Myriad Genetic Laboratories, Inc., 320 Wakara Way, Salt Lake City, UT 84108, USA
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28
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Minca EC, Billings SD, Elson P, Tetzlaff MT, Andea AA, Ko JS. Significance of epidermal mitoses in challenging melanocytic proliferations. J Cutan Pathol 2016; 44:135-143. [PMID: 27862191 DOI: 10.1111/cup.12855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/26/2016] [Accepted: 11/02/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Accurate diagnosis of melanoma remains histologically challenging. Dermal mitoses support malignancy, but are only occasionally seen in melanomas. As melanomagenesis is thought to begin at the dermal-epidermal junction, we investigated the significance of epidermal melanocytic mitoses (EMM) in a spectrum of lesions with molecular characterization. METHODS Epidermal mitoses density (EMD) was evaluated in 46 straightforward lesions (24 benign and 22 malignant) and 30 challenging lesions with expert interpretation, fluorescence in situ hybridization and myPath-score characterization (12 favor-benign, 9 favor-malignant and 9 ambiguous). EMD was correlated with clinicopathologic parameters and myPath. RESULTS In straightforward cases, 25% nevi and 77% melanomas had EM. Median EMD was significantly lower in nevi vs. melanomas (0/mm vs. 0.04/mm, p = 0.001). EMD (0.01/mm-cutoff) had 77% sensitivity, 79% specificity discriminating melanomas from nevi. In challenging cases, 17% favor-benign, 67% favor-malignant and 78% ambiguous lesions had EM. EMD (0.01/mm-cutoff) had 67% sensitivity, 82% specificity on 21 non-ambiguous lesions, similar to myPath. EMD was less accurate in Spitzoid lesions, which have high EMD and dermal mitoses. CONCLUSION While EMD is not an adequate single criterion in diagnosing melanoma, our results validate its discriminatory potential, suggesting that EM should prompt closer investigation for malignancy. Expanded studies with clinical follow up are warranted to further assess the EM utility in classifying melanocytic lesions.
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Affiliation(s)
- Eugen C Minca
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA.,Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
| | - Steven D Billings
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA.,Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
| | - Paul Elson
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA.,Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael T Tetzlaff
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.,Department of Pathology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Aleodor A Andea
- Department of Pathology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA.,Department of Pathology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Jennifer S Ko
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA.,Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
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Patrawala S, Maley A, Greskovich C, Stuart L, Parker D, Swerlick R, Stoff B. Discordance of histopathologic parameters in cutaneous melanoma: Clinical implications. J Am Acad Dermatol 2016; 74:75-80. [PMID: 26514601 DOI: 10.1016/j.jaad.2015.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/27/2015] [Accepted: 09/06/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Histopathologic analysis remains the gold standard for the diagnosis of melanoma, however previous studies have shown a substantial rate of interobserver variability in the evaluation of melanocytic lesions. OBJECTIVE We sought to evaluate discordance in the histopathological diagnosis and microstaging parameters of melanoma and subsequent impact on clinical management. METHODS This was a retrospective review of 588 cases of cutaneous melanoma and melanoma in situ from January 2009 to December 2014 that were referred to Emory University Hospital, Atlanta, GA, for treatment. Per institutional policy, all outside melanoma biopsy specimens were reviewed internally. Outside and institutional reports were compared. RESULTS Disagreement between outside and internal reports resulted in a change in American Joint Committee on Cancer pathologic stage in 114/588 (19%) cases, resulting in a change in management based on National Comprehensive Cancer Network guidelines in 105/588 (18%) cases. LIMITATIONS Given the retrospective nature of data collection and the bias of a tertiary care referral center, cases in this study may not be representative of all melanoma diagnoses. CONCLUSION These findings confirm consistent subjectivity in the histopathologic interpretation of melanoma. This study emphasizes that a review of the primary biopsy specimen may lead to significant changes in tumor classification, resulting in meaningful changes in clinical management.
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Affiliation(s)
- Samit Patrawala
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander Maley
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Caitlin Greskovich
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Lauren Stuart
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Douglas Parker
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Robert Swerlick
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Benjamin Stoff
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia.
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Cassarino DS, Lewine N, Cole D, Wade B, Gustavsen G. Budget impact analysis of a novel gene expression assay for the diagnosis of malignant melanoma. J Med Econ 2014; 17:782-91. [PMID: 25170544 DOI: 10.3111/13696998.2014.950421] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Traditional pathology techniques alone can be insufficient to reliably distinguish between malignant melanoma, dysplastic nevi, and benign nevi in biopsies of suspicious pigmented lesions. Numerous studies have shown high rates of ambiguity when assessing such samples. A novel gene expression assay has been developed to objectively differentiate malignant melanoma from benign nevi. OBJECTIVE The purpose of this study was to quantify the economic impact of the gene expression assay on a US commercial health plan. METHODS The clinical paradigm of care was modeled for a hypothetical cohort of patients with suspicious pigmented lesions that are difficult-to-diagnose. Costs were assigned to each unit of care provided based on 2013 Medicare fee-for-service rates. Patients were followed for 10 years and were modeled to progress according to the natural history of their disease. The total cost of care was calculated for two scenarios: a Reference Scenario, representing current clinical practice, and a Test Scenario, in which each lesion was tested with the gene expression assay and diagnosed. Total cost of care was compared between the two scenarios to determine overall budget impact. Sensitivity analyses were performed to test the robustness of the model. RESULTS The gene expression assay reduces costs by $1268 per patient tested over 10 years, a decrease of 8.3%, after accounting for the cost of the assay. For a health plan with 10 million members, this would translate to over $8 million in savings. The largest portion of this saving comes from reducing the number of missed melanomas, which would otherwise progress to advanced disease. In sensitivity analyses, no single model input changed within a reasonable range of values caused the model to show that the assay was not cost-saving. CONCLUSION In addition to improving the diagnosis of melanoma, this gene expression assay would likely reduce costs for health plans that choose to cover it.
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Affiliation(s)
- David S Cassarino
- Department of Pathology, Southern California Permanente Medical Group , Los Angeles, CA , USA
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31
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Dandekar M, Lowe L, Fullen DR, Johnson TM, Sabel MS, Wong SL, Patel RM. Discordance in Histopathologic Evaluation of Melanoma Sentinel Lymph Node Biopsy with Clinical Follow-Up: Results from a Prospectively Collected Database. Ann Surg Oncol 2014; 21:3406-11. [DOI: 10.1245/s10434-014-3773-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Indexed: 11/18/2022]
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Abstract
Although pediatric melanoma is a rare disease, diagnosis and management of pigmented lesions in the pediatric population, particularly dysplastic nevi and Spitz nevi, can be challenging. In this article, we provide an overview of pigmented lesions in children, including melanoma and management of melanoma risk factors and melanocytic nevi in the pediatric population. Congenital melanocytic nevi, Spitz nevi, dysplastic and acquired nevi, and changes over time are reviewed. We discuss considerations for excision and management of pigmented lesions in children.
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Affiliation(s)
- Elena B Hawryluk
- Dermatology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Marilyn G Liang
- Dermatology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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33
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Diagnostic role of chromosomal instability in melanoma. J Skin Cancer 2012; 2012:914267. [PMID: 23125934 PMCID: PMC3483783 DOI: 10.1155/2012/914267] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/20/2012] [Accepted: 09/21/2012] [Indexed: 02/03/2023] Open
Abstract
Early diagnosis gives melanoma patients the best chance for long term survival. However discrimination of an early melanoma from an unusual/atypical benign nevus can represent a significant challenge. There are no current pathological markers to definitively define malignant potential in these indeterminate lesions. Thus, there is a need for improved diagnostic tools. Chromosomal instability (CIN) is a hallmark of cancer and is markedly prevalent in melanoma. Advances in genomics have opened the door for the development of molecular tools to better segregate benign and malignant lesions. This paper focuses on CIN in melanoma and the role of current diagnostic approaches.
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