Male sex and Breslow thickness are important risk factors for recurrence of localized melanoma in Korean populations

The diameter of cutaneous melanoma serves as a prognostic indicator for survival among acral-melanoma predominant East Asian patients

BACKGROUND

Tumor staging plays a pivotal role in melanoma management, where the depth of tumor invasion has been traditionally used as the cornerstone of staging. Paradoxically, the tumor diameter has not been integrated into the staging system. The aim of this study is to elucidate the clinical implications and prognostic value of tumor diameter in cutaneous melanoma, with a particular emphasis on the acral-melanoma predominant East Asian population, thus potentially enriching the clinical evaluation and treatment strategies for cutaneous melanoma.

METHODS

From January 1st, 2006 to December 31st, 2022, a total of 352 patients were diagnosed with melanoma in our center. Among them, there were 135 patients diagnosed as cutaneous melanoma who received complete surgical wide excision and regional lymph nodes assessment. The diameter of the tumor, the depth of tumor invasion, lymph node status and patient survival were all collected and analyzed.

RESULTS

The diameter of cutaneous melanoma had a weak positive correlation with tumor thickness (r = 0.26), however, it still had a significant predictive value for patients' overall survival (p = 0.005) and disease free survival (p = 0.023). As for lymph node metastasis prediction, the Breslow thickness had a better predictive value than tumor diameter (p = 0.002 vs. p = 0.565).

CONCLUSIONS

In this study, though with only weak positive correlation to tumor thickness, the tumor diameter of melanoma showed a statistically significant correlation with the patients' overall survival and disease free survival. However, the larger tumor diameter cannot be used as an indicator of high risk of lymph node metastasis.

Gender Differences in Prognosis After Primary Resection for Retroperitoneal Liposarcoma

BACKGROUND

Current evidence regarding gender difference in retroperitoneal liposarcoma (RLPS) is scarce, so we sought to investigate whether gender may affect prognosis after primary resection of RLPS.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify RLPS patients from January 1973 to December 2015. Multivariate cox proportional hazard analysis was adopted to generate adjusted hazard ratio (AHR) and 95% confidence intervals (CIs) of survival outcomes.

RESULTS

In total, 2108 RLPS patients, including 971 women and 1137 men, were identified, with a median follow-up of 45.0 (17.0-92.0) months. The 5-year and 10-year overall survival rates were 50.5% and 31.5% for men and 60.4% and 42.5% for women. The 5-year and 10-year disease-specific survival rates for men and women were 71.5%, 57.3% and 76.3%, 62.1%, respectively. We found men were associated with an increased risk of all-cause mortality (AHR 1.3, 95% CI 1.0-1.6, P = .017) but not disease-specific mortality (AHR 1.2, 95% CI .9-1.6, P = .246). The subgroup analyses revealed that men were associated with an increased risk of all-cause mortality in patients with low-grade tumors (AHR 1.8, 95% CI 1.3-2.5) or patients who received non-radical resection (AHR 1.6, 95% CI 1.2-2.1). In the subgroup of low-grade tumors, men were also associated with an increased risk of disease-specific mortality (AHR 2.0, 95% CI 1.2-3.3).

CONCLUSION

Men may have worse survival after primary resection of RLPS compared with women, especially in patients with low-grade tumors or patients who received non-radical resection. Gender-based disparities may deserve more attention in patients with RLPS.

Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis

BACKGROUND

Mohs micrographic surgery (MMS) is increasingly used to treat cutaneous melanoma. However, it is unclear whether intraoperative immunohistochemistry (IHC) improves surgical outcomes.

OBJECTIVE

To determine whether intraoperative IHC during MMS and staged excision is associated with a decreased risk of poor surgical outcomes.

MATERIALS AND METHODS

Search of 6 databases identified comparative and noncomparative studies that reported local recurrence after MMS or staged excision with or without IHC for melanoma. Random-effects meta-analysis was used to estimate pooled local recurrence rates, nodal recurrence, distant recurrence, and disease-specific mortality.

RESULTS

Overall, 57 studies representing 12,043 patients with cutaneous melanoma and 12,590 tumors met inclusion criteria. Combined MMS and staged excision with IHC was associated with decreased local recurrence in patients with invasive melanoma (0.3%, 95% CI: 0-0.6) versus hematoxylin and eosin alone (1.8%, 95% CI: 0.8%-2.8%) [p < .001]. Secondary outcomes including nodal recurrence, distant recurrence, and disease-specific mortality were not significantly different between these 2 groups. Study heterogeneity was moderately-high.

CONCLUSION

Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC. These findings suggest that the use of intraoperative IHC during MMS or staged excision should strongly be considered, particularly for invasive melanoma.Trial Registration PROSPERO Identifier: CRD42023435630.

Association of NRAS mutations and tertiary lymphoid structure formation with clinical outcomes of adjuvant PD-1 inhibitors for acral melanoma

OBJECTIVES

This study evaluates the efficacy of programmed death-1 (PD-1) inhibitors as adjuvant therapy for acral melanoma (AM) and the predictive value of genetic mutations and tertiary lymphoid structures (TLSs).

METHODS AND RESULTS

A single-center retrospective longitudinal cohort study was conducted between October 1, 2018, and September 31, 2022. Patients with stages II-III completely resected AM were treated with at least two doses of adjuvant PD-1 inhibitors. A total of 44 participants were included in the final analysis, of which 41 patients with stage III. The median follow-up time, median relapse-free survival (RFS), and median distance metastasis-free survival (DMFS) for all patients were 18.4 months, 21.6 months, and 30.6 months, respectively. 21 (47.7%) and 20 (45.5%) patients were intravenously administered pembrolizumab and toripalimab, respectively. There were no significant differences in RFS (24.4 months vs. 18.9 months, p = 0.432) or DMFS (30.6 months vs. not reached, p = 0.865) between the pembrolizumab and toripalimab groups, respectively. The median DMFS (41.1 months vs. 9.0 months, p < 0.001) in the wild-type NRAS group was significantly longer than that in the NRAS mutation group. Overall, different levels of TLSs infiltration did not significantly affect patient survival. Only three people discontinued treatment due to adverse events. No treatment-related death occurred during the study period.

CONCLUSION

Our study suggests that adjuvant toripalimab and pembrolizumab therapy have comparable efficacies in patients with AM and are both well tolerated. Adjuvant monotherapy with PD-1 inhibitors may not be appropriate for AM with NRAS mutations.

The utility of high-frequency 18 MHz ultrasonography for preoperative evaluation of acral melanoma thickness in Chinese patients

Background

Despite the increasing use of preoperative ultrasound evaluation for melanoma, there is limited research on the use of this technique for Acral Melanoma (AM).

Methods

This retrospective study analyzed the electronic medical records of patients who underwent preoperative evaluation for cutaneous melanoma maximum thickness using an 18 MHz probe and histopathological examination between December 2017 and March 2021 at the Department of Dermatology in Xiangya Hospital, Central South University.

Results

A total of 105 patients were included in the study. The mean tumor thickness was 3.9 mm (s.d., 2.3), with 63% of the specimens showing ulceration and 44 patients showing lymph node metastasis. The results showed a good correlation between the high-frequency ultrasonography (HFUS) and histopathological thickness measurements, with a Spearman's correlation coefficient of 0.83 [(95% CI 0.73-0.90) (P < 0.001)]. The positive predictive value (PPV) of sonography in identifying tumor thickness was also found to be high.

Conclusion

Our study suggests that high-frequency 18 MHz ultrasonography is an effective tool for the preoperative evaluation of AM thickness. The HFUS measurements correlated well with the histopathological thickness measurements, making it a valuable and reliable method for clinicians to assess the thickness of melanoma lesions preoperatively.

Patterns of Recurrence of Cutaneous Melanoma: A Literature Review

The incidence of melanoma has been dramatically increasing over the last decades. Melanoma is considered to have a high metastatic potential and it can progress via lymphatic vessels or through hematogenous metastasis. Different patterns of recurrence have been described, namely, local, satellite, and in transit metastasis (LCIT), lymphatic metastasis, and systemic metastasis. With a more advanced melanoma stage at diagnosis, there is a higher risk for systemic metastasis in comparison to LCIT; in contrast, early-stage melanoma tends to recur more frequently as LCIT and less commonly as systematic metastasis. The aim of this review was to summarize the patterns of recurrence of cuta-neous melanoma, giving the clinician a practical summary for diagnosis, prognosis, and surveillance. There is a knowledge gap of the common patterns of recurrence that needs to be addressed to better identify patients at high risk of disease recurrence and personalize surveillance strategies as well as patient counseling.

Clinical Outcomes and Prognostic Factors of Patients With Early Malignant Melanoma in One Latin American Country: Results of the Epidemiological Registry of Malignant Melanoma in Colombia Study

To describe the population with early malignant melanoma, we performed a cohort study on the basis of the Epidemiological Registry of Malignant Melanoma in Colombia-Asociacion Colombiana de Hematologia y Oncologia. From January 2011 until December 2021, 759 patients were included; the average age was 66 years, 57% were women, acral lentiginous histology was found in 27.8% of patients, and the median follow-up was 36.5 months. The prognostic factors for overall survival in our population are Eastern Cooperative Oncology Group 3-4 (hazard ratio [HR], 13.8), stage III (HR, 5.07), received radiotherapy (HR, 3.38), ulceration on histology (HR, 2.68), chronic sun exposure (HR, 2.3), low income (HR, 2.04), previous local surgery (HR, 0.27), and have received adjuvant treatment (HR, 0.41).

Risk of recurrence of nail unit melanoma after functional surgery versus amputation

BACKGROUND

Minimally invasive nail unit melanoma (NUM) can be treated with functional surgery (FS) instead of amputation.

OBJECTIVE

To determine risk factors associated with recurrence in NUM.

METHODS

We retrospectively reviewed patients with NUM between 2008 and 2022 at a tertiary referral center. Multivariable Cox regression models adjusted for male sex and Breslow thickness (BT) were generated. Receiver operating characteristic analysis was performed to determine optimal cut-off points of the BT for stratifying recurrence risk.

RESULTS

We evaluated 140 NUM cases (33 amputation and 107 FS). The mean BT values were 3.14 ± 2.62 mm (amputation) and 0.70 ± 1.36 mm (FS). Recurrence occurred in 10 (30.30%) patients with amputation and 23 (21.5%) with FS. Distant disease occurred in 10 (30.30%) patients with amputation and 8 (7.48%) with FS. Male sex, greater BT, amelanotic color, ulcers, and nodules were associated with greater risk for recurrence or distant disease. A BT of 0.8 mm was deemed the optimal cut-off for stratifying recurrence risk after surgery (odds ratio, 5.32; 95% CI, 2.04-13.85).

LIMITATIONS

Small sample.

CONCLUSION

FS can be considered for NUM with a BT < 0.8 mm, providing an amputation-sparing benefit. However, NUM with risk factors for recurrence requires patient counselling and close follow-ups.

Does sex matter? Analysis of sex-related differences in the diagnostic performance of a market-approved convolutional neural network for skin cancer detection

BACKGROUND

Advances in biomedical artificial intelligence may introduce or perpetuate sex and gender discriminations. Convolutional neural networks (CNN) have proven a dermatologist-level performance in image classification tasks but have not been assessed for sex and gender biases that may affect training data and diagnostic performance. In this study, we investigated sex-related imbalances in training data and diagnostic performance of a market-approved CNN for skin cancer classification (Moleanalyzer Pro®, Fotofinder Systems GmbH, Bad Birnbach, Germany).

METHODS

We screened open-access dermoscopic image repositories widely used for CNN training for distribution of sex. Moreover, the sex-related diagnostic performance of the market-approved CNN was tested in 1549 dermoscopic images stratified by sex (female n = 773; male n = 776).

RESULTS

Most open-access repositories showed a marked under-representation of images originating from female (40%) versus male (60%) patients. Despite these imbalances and well-known sex-related differences in skin anatomy or skin-directed behaviour, the tested CNN achieved a comparable sensitivity of 87.0% [80.9%-91.3%] versus 87.1% [81.1%-91.4%], specificity of 98.7% [97.4%-99.3%] versus 96.9% [95.2%-98.0%] and ROC-AUC of 0.984 [0.975-0.993] versus 0.979 [0.969-0.988] in dermoscopic images of female versus male origin, respectively. In the sample at hand, sex-related differences in ROC-AUCs were not statistically significant in the per-image analysis nor in an additional per-individual analysis (p ≥ 0.59).

CONCLUSION

Design and training of artificial intelligence algorithms for medical applications should generally acknowledge sex and gender dimensions. Despite sex-related imbalances in open-access training data, the diagnostic performance of the tested CNN showed no sex-related bias in the classification of skin lesions.

Characteristics, Prognosis, and Competing Risk Nomograms of Cutaneous Malignant Melanoma: Evidence for Pigmentary Disorders

PURPOSE

Cutaneous malignant melanoma (CMM) always presents as a complex disease process with poor prognosis. The objective of the present study was to explore the influence of solitary or multiple cancers on the prognosis of patients with CMM to better understand the landscape of CMM.

METHODS

We reviewed the records of CMM patients between 2004 and 2015 from the Surveillance, Epidemiology, and End Results Program. The cumulative incidence function was used to represent the probabilities of death. A novel causal inference method was leveraged to explore the risk difference to death between different types of CMM, and nomograms were built based on competing risk models.

RESULTS

The analysis cohort contained 165,043 patients with CMM as the first primary malignancy. Patients with recurrent CMM and multiple primary tumors had similar overall survival status (p = 0.064), while their demographics and cause-specific death demonstrated different characteristics than those of patients with solitary CMM (p < 0.001), whose mean survival times are 75.4 and 77.3 months and 66.2 months, respectively. Causal inference was further applied to unveil the risk difference of solitary and multiple tumors in subgroups, which was significantly different from the total population (p < 0.05), and vulnerable groups with high risk of death were identified. The established competing risk nomograms had a concordance index >0.6 on predicting the probabilities of death of CMM or other cancers individually across types of CMM.

CONCLUSION

Patients with different types of CMM had different prognostic characteristics and different risk of cause-specific death. The results of this study are of great significance in identifying the high risk of cause-specific death, enabling targeted intervention in the early period at both the population and individual levels.

Effect of changes in Breslow thickness between the initial punch biopsy results and final pathology reports in acral lentiginous melanoma patients

Acral lentiginous melanoma (ALM) is the most common subtype of cutaneous melanoma among Asians; punch biopsy is widely performed for its diagnosis. However, the pathologic parameters evaluated via punch biopsy may not be sufficient for predicting disease prognosis compared to the parameters evaluated via excisional biopsy. We investigated whether changes in Breslow thickness (BT) between initial punch biopsy results and final pathology reports can affect the prognosis of ALM. Pathologic parameters were recorded from specimens acquired through the initial punch biopsy and wide excision. Patients were classified into two groups based on a change in Breslow depth: the BT increased or decreased on comparing the samples from the initial punch biopsy and final wide excision. We compared clinical characteristics, and a Cox regression model was used to identify independent prognostic factors influencing melanoma-specific death (MSD). Changes in BT did not affect MSD (hazard ratio [HR]: 0.55, P = 0.447). In multivariate analysis, a higher BT (> 2 mm) (HR: 9.93, P = 0.046) and nodal metastasis (HR: 5.66, P = 0.041) were significantly associated with an increased MSD risk. The use of punch biopsy did not affect MSD despite the inaccuracy of BT measurement as long as ALM was accurately diagnosed.

Factors influencing locoregional recurrence and distant metastasis in Asian patients with cutaneous melanoma after surgery: A retrospective analysis in a tertiary hospital in Taiwan

BACKGROUND

The goal of this study was to investigate the prognostic factors for locoregional recurrence and metastasis in patients with cutaneous melanoma (CM) who underwent surgery, especially in the acral lentiginous melanoma (ALM) subtype.

METHODS

This study was a retrospective review of patients who underwent surgery for CM at Taipei Veterans General Hospital between 2000 and 2018. We investigated the risk factors for locoregional and distant metastases. The association between clinicopathological factors and locoregional recurrence and distant metastasis of the CM and ALM subtypes was analyzed. In addition, the outcomes between the ALM and non-ALM groups were compared.

RESULTS

A total of 161 patients were included in the analysis. The most common histological subtype was ALM. The overall locoregional recurrence rate of CM was 13.0% and the distant metastasis rate was 42.9%, whereas that of the ALM subtype was 12.5% and 45.5%, respectively. In patients with CM, male sex, tumor with lymphovascular invasion, and positive lymph node status were the prognostic factors for both locoregional recurrence and distant metastasis. Among the patients with ALM, positive lymph node status was significantly associated with both locoregional recurrence and distant metastasis.

CONCLUSION

In this cohort, factors influencing locoregional recurrence and distant metastasis were similar between the ALM and non-ALM groups. The above-recommended surgical margin did not show any benefit in either the CM or the ALM subtype. ALM can be handled using the same surgical strategy as CM in the Asian population.

Slow Mohs Micrographic Surgery for Acral Melanoma Treatment in Korean Patients

BACKGROUND

Obtaining conventional wide surgical margins is challenging in melanomas occurring at anatomically complex sites (e.g., hands and feet).

OBJECTIVE

We investigated the potential benefits of slow Mohs micrographic surgery (MMS) for acral melanomas.

MATERIALS AND METHODS

This single-center retrospective study investigated 210 patients who underwent slow MMS (n = 66) or wide local excision (WLE, n = 144) for melanomas during 2005 to 2015. Slow MMS was used for melanomas in anatomically complex locations and for high-risk lesions.

RESULTS

Acral melanoma (166/210) was the most common lesion observed in patients, in addition to head and neck (21/210) and trunk (23/210) melanomas. Slow MMS was more commonly performed for acral, and head and neck melanomas (32.5% and 52.4%, respectively) than for trunk melanomas (4.3%, p = .002). Local recurrence of acral melanomas occurred in 3.7% of patients after slow MMS and in 10.7% of patients after WLE. Multivariate analysis showed comparable prognostic outcomes between slow MMS and WLE used for acral melanomas. Compared with WLE, slow MMS resulted in a smaller postoperative defect after acral lesion excision (p < .001).

CONCLUSION

Slow MMS is an effective alternative to WLE for acral melanomas in anatomically complex sites, as evidenced by superior outcomes and maximum tissue conservation.