Melanoma in the very elderly, management in patients 85years of age and over

Clinical-histological characteristics and therapeutic management of primary cutaneous melanoma in elderly patients

BACKGROUND

Life expectancy is rising in developed countries. The impact of age on melanoma characteristics is unclear, but it seems that melanomas in the elderly have distinct features affecting management and outcomes.

OBJECTIVES

To compare clinical and histopathological melanoma characteristics and management in elderly and younger patients.

METHODS

A retrospective population-based study analyzed melanomas observed between 2007 and 2022 was made in the southern Seville health area (Spain). Patients were divided into two age groups: <65 and ≥65. Data were collected from clinical histories.

RESULTS

Among 431 primary cutaneous melanomas, 33% were in patients ≥65-years. Elderly patients had more head and neck melanomas (37.8% vs. 14.9%; p < 0.001), larger lesions (1.3 vs. 0.9 cm; p < 0.001), more ulcerated melanomas (17.8% vs. 8.8%; p < 0.012), and higher Breslow thickness (1.03 vs. 0.65 mm; p < 0.01) than younger patients. No differences were found in the number of mitoses or histopathological invasions. Stage 0 and more advanced stages (II/III/IV) were observed more frequently in ≥65-years (29.3% vs. 23% and 27.1% vs. 15.7%, p < 0.001 respectively). Fewer wide excisions (28.4% vs. 5.6%, p < 0.001), sentinel lymph node biopsy (17.6% vs. 2.4%, p < 0.001), and adjuvant therapy (11.9% vs. 2.1%, p < 0.001) were performed in patients ≥65-years.

STUDY LIMITATIONS

The study was retrospective, primarily covering the last 10-years, with older data missing. Key risk factors like the number of nevi and family history of melanoma were not collected.

CONCLUSIONS

Melanomas in the elderly were diagnosed more frequently at initial and advanced stages despite having worse prognostic characteristics compared melanomas occurring in younger people.

Management of Melanoma in Elderly Patients over 80 Years

Melanoma is a malignant tumour with a poorer prognosis in stage III and IV patients. Development of effective therapies for the treatment of advanced melanoma has led to an improvement in survival. Furthermore, the French population is ageing, and treatment of melanoma in this population has several specific limitations. This descriptive, retrospective, single-centre study collected data on the diagnostic and therapeutic management of patients with melanoma of Breslow ≥ 1 mm or of unknown primary and metastatic spread, at Limoges University Hospital, between 2018 and 2022, and compared the results obtained between 2 groups: under 80 and over 80 years of age; 344 patients were included. The extension work-up was more frequently complete and the sentinel lymph node technique more frequently performed in patients under 80. Wide excision was more frequently in accordance with guidelines in patients over 80. Adjuvant or first-line metastatic treat-ment was more frequently instituted in patients under 80, but no difference was found as regards the second and third lines, the frequency of adverse events, and the reason for stopping treatment. Our study supports similar management of elderly and young subjects, given the safety profile and efficacy of treatments.

The Utility of Sentinel Lymph Node Biopsy in Elderly Patients with Melanoma

BACKGROUND

Sentinel lymph node biopsy (SLNB) is performed less often for older patients with melanoma. We investigated the association of SLNB and melanoma-specific survival (MSS) in the elderly.

METHODS

We retrospectively reviewed the Surveillance, Epidemiology, and End Results (SEER: 2010-2019) for patients ≥ 70 years with cT2-4N0M0 melanoma. We used multivariable Cox proportional hazard models to evaluate the impact of SLNB performance and SLN status on MSS at increasing age cutoffs. In addition, we evaluated the association of different factors with SLNB performance using multivariable logistic regression.

RESULTS

We identified 11,548 patients. Sentinel lymph node biopsy occurred in 6754 (58.5%) patients, 1050 (15.5%) of whom had a positive SLN. On adjusted SEER analysis, a negative SLN was independently associated with improved MSS (overall hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.63-0.67) for patients up to 87 years old. Positive SLNB was independently associated with inferior MSS (HR 1.71, 95% CI 1.93-1.98). Increasing age groups were significantly associated with decreased SLNB performance.

CONCLUSIONS

Sentinel lymph node biopsy is associated with cancer-specific survival and adds prognostic information for elderly patients with melanoma. Sentinel lymph node biopsy performance should not be eliminated in elderly patients based on age alone, unless justified by poor performance status, patient preference, or other surgical contraindications. Decreased SLNB performance with increasing age in our cohort may indicate a missed therapeutic opportunity in the care of elderly patients with melanoma.

Malignant melanoma in the hand: current evidence and recommendations

Malignant melanoma is the leading cause of death from skin cancer. In spite of significant advances in the management of melanoma with the advent of sentinel lymph node biopsy (SLNB) and adjuvant oncological therapies, the death rate continues to increase worldwide. Melanoma in the hand poses additional diagnostic and management challenges. Consequently, these tend to present at a later stage and are associated with a poorer prognosis. It is imperative that hand surgeons treat any pigmented hand lesion with suspicion to ensure rapid diagnosis and treatment. This article outlines the presentation of melanoma, and how to investigate suspicious pigmented lesions of the hand and digits. It guides hand surgeons in their approach to melanoma of the hand, outlining the multidisciplinary team approach as well as current standard surgical and reconstructive options to optimize outcomes.

Cutaneous melanoma in older patients

BACKGROUND

In industrialized countries, the aging population is steadily rising. The incidence of cutaneous malignant melanoma (CMM) is highest in old people. This study focuses on the clinicopathological profile of CMM and indicators of diagnostic-therapeutic performance in older patients.

METHODS

This retrospective population-based cohort study included 1,368 incident CMM, as recorded in 2017 by the Regional Veneto Cancer Registry (Northeast Italy). Older subjects were defined as ≥ 80, old as 65-79, and adults as < 65 years of age. The strength of association between pairs of variables was tested by Cramer's-V. Using age groups as the dependent variable, ordered logistic regression was fitted using the clinicopathological CMM profiles as covariates. In each of the three age-groups, the indicators of clinical performance were computed using the Clopper-Pearson exact method.

RESULTS

Compared to patients aged younger than 80 years (1,187), CMM in older patients (181; 13.2%) featured different CMM topography, a higher prevalence of ulcers (43.3% versus 12.7%; p < 0.001), a higher Breslow index (p < 0.001), a lower prevalence of tumor-infiltrating lymphocytes (64.4% versus 76.5%, p < 0.01), and a more advanced pTNM stage at clinical presentation (p < 0.001). Elderly patients with a positive sentinel-lymph node less frequently underwent sentinel- lymph node biopsy and lymphadenectomy (60.0% versus 94.2%, and 44.4% versus 85.5%, respectively; p < 0.001).

CONCLUSIONS

In older CMM patients, the clinicopathological presentation of CMM shows a distinctive profile. The present results provide critical information to optimize secondary prevention strategies and refine diagnostic-therapeutic procedures tailored to older patients.

The impact of prognostic factors and comorbidities on survival in older adults with stage I - III cutaneous melanoma in Southwest Finland: A register study

INTRODUCTION

Despite being diagnosed with thicker and more often ulcerated melanomas, cancer-specific survival (CSS) is not necessarily inferior in older adults with melanoma compared to younger patients.

MATERIALS AND METHODS

Our aim was to evaluate the impact of baseline melanoma-specific prognostic factors and comorbidities on recurrence-free survival (RFS), CSS, and overall survival (OS) in patients aged 70-79 (n = 474) and ≥ 80 years (n = 286) with resected stage I - III cutaneous melanoma in Southwest Finland between January 1, 2000 and December 31, 2020. Patients were restaged according to the 8th edition of TNM classification, and comorbidities were assessed using the Charlson Comorbidity Index (CCI).

RESULTS

Patients aged ≥80 years had thicker and more commonly ulcerated melanomas: 43.0%, 40.9%, and 16.1% of patients aged ≥80 and 56.5%, 25.3%, and 18.1% of patients aged 70-79 years were diagnosed with stage I, II, and III melanoma, respectively. Multiple comorbidities (CCI ≥2) were more common and sentinel lymph node biopsy less frequently performed in patients aged ≥80 years. RFS and CSS were similar in patients aged 70-79 years and ≥ 80 years: median RFS 13.8 years vs not reached, with the hazard ratio of melanoma recurrence or death from melanoma 1.25 (95% confidence interval [CI]: 0.91-1.71); median CSS was not reached, with the hazard ratio of death from melanoma 1.12 (95%CI: 0.81-1.75). The proportion of patients who were alive with melanoma recurrence or had died from melanoma was similar in both age groups. In multivariable analysis, higher pathological stage was the only independent risk factor for short RFS regardless of age group, sex, CCI, and tumor ulceration. Higher stage and male sex were associated with short CSS. Age ≥ 80 years, stage III disease, and CCI ≥ 2 were associated with short OS and female sex with long OS in multivariable analysis.

DISCUSSION

Pathological stage was the most influential factor determining RFS and CSS in older adults with resected stage I - III melanoma. Concerning OS, age ≥ 80 years, stage III disease, and multiple comorbidities had a significant negative impact.

Risk of Cardiovascular Disease Death in Older Malignant Melanoma Patients: A Population-Based Study

Noncancer deaths account for a large proportion of deaths in patients with malignant melanoma (MM), but the risk of cardiovascular disease (CVD) death in older MM patients remains unclear. This study aimed to estimate the risk of CVD death in older MM patients. Data on older MM patients were obtained in the Surveillance, Epidemiology, and End Results database. Risk of CVD death was calculated by standardized mortality rates (SMRs), cumulative mortality and proportion of different causes of death. MM patients had a higher risk of CVD death than general populations (SMR = 1.98; 95% CI 1.93−2.03, p < 0.001). CVD death was more common in MM patients who were diagnosed at age 85 or older, had a localized stage, were white, had surgical treatment, had a primary head/neck/upper limb site and had a low-grade and superficial spreading/lentigo malignant pathologic type. Cumulative CVD mortality was more common than primary cancer in all older age groups, male or female, and patients with localized-stage disease. Other than primary cancer, CVD was the main cause of death in older patients diagnosed with MM. Our findings highlight CVD death is an important competing event of deaths in older MM patients, and more attention should be paid to reducing CVD death to improve survival.

Cutaneous melanoma survival rates of the elderly are not worse than those of the young, yet they have some specific differences

Introduction

The incidence of cutaneous melanoma among the elderly has increased significantly. Unfavorable survival rates are associated with insufficient patient managements and poor prognostic features in the elderly. We aimed to compare elderly (≥75 years) and younger (<75 years) patients with cutaneous melanoma to determine the differences and the prognostic significance of age.

Materials and Methods

The retrospective data of 117 elderly and 232 younger patients with cutaneous melanoma were compared.

Results

The median age of the elderly patients was 78 years (75-104), and 51.3% of the patients were female. Of the patients, 14.5% were in the metastatic stages. Clinicopathologic factors such as extremity melanomas (P = 0.01), Clark levels IV-V (P = 0.04), ulceration (P = 0.009), and neurotropism (P = 0.03) were significantly more common in elderly patients. However, BRAF mutation was significantly more common in younger patients (P = 0.003). Overall survival (OS) and recurrence-free survival (RFS) rates of both the groups were similar. Lymph node involvement (P < 0.005), distant metastasis (P < 0.005), and relapse of disease (P = 0.02) were associated with poor OS in elderly patients. Tumor-infiltrating lymphocytes was associated with prolonged RFS (P = 0.05), while extremity melanomas (P = 0.01), lymphovascular invasion (P = 0.006), and lymph node involvement (P < 0.005) had negative impact on RFS.

Conclusions

Although elderly patients with cutaneous melanoma had different clinicopathologic features in our series, their survival rates are similar to those of younger patients, which shows that age alone is inadequate to determine the prognosis. Disease stage and a comprehensive geriatric assessment might assist to determine appropriate management.

Conjunctival Melanoma: Outcomes Based on Age at Presentation in 629 Patients at a Single Ocular Oncology Center

PURPOSE

To investigate the clinical features and outcomes for conjunctival melanoma based on patient age.

METHODS

A retrospective review of patients with conjunctival melanoma managed at a single tertiary referral center from April 18, 1974, to September 9, 2019. Clinical features and outcomes were compared by patient age category at presentation (young ≤45 years, middle-aged 46-69 years, and older ≥70 years), with Kaplan-Meier and Cox proportional hazard analysis [hazard ratio (95% confidence interval)].

RESULTS

There were 629 patients categorized as young in 130 (21%), middle-aged in 278 (44%), and older in 221 (35%). A comparison by age category (young vs. middle-aged vs. older) revealed that older patients had melanoma with greater number of affected quadrants (1.7 vs. 1.8 vs. 2.0, P = 0.001) and clock hours (3.9 vs. 4.2 vs. 5.2, P = 0.001). All patients were treated with surgical excision, with no difference in requirement for additional medical or radiation therapy. By 10-year Kaplan-Meier outcomes, older patients had more frequent visual acuity loss ≥3 lines (11% vs. 28% vs. 64%, P < 0.001) and local tumor recurrence (38% vs. 46% vs. 70%, P < 0.001). Hazard ratio for the oldest age group (age ≥70) revealed a 7.76-fold (3.33-18.09) increased risk for visual acuity loss (P < 0.001), and a 2.08-fold (1.32-3.28) increased risk of local tumor recurrence (P = 0.002). There was no difference by age in risk for enucleation, exenteration, locoregional lymph node involvement, distant systemic metastasis, or death.

CONCLUSIONS

Older patients with conjunctival melanoma present with more extensive disease and have increased risk for visual acuity loss and local tumor recurrence.

Focused Ultrasound Surveillance of Lymph Nodes Following Lymphoscintigraphy Without Sentinel Node Biopsy: A Useful and Safe Strategy in Elderly or Frail Melanoma Patients

BACKGROUND

Sentinel node (SN) biopsy (SNB) has become standard of care in clinically localized melanoma patients. Although it is minimally invasive, advanced age and/or comorbidities may render SNB inadvisable in some patients. Focused ultrasound follow-up of SNs identified by preoperative lymphoscintigraphy may be an alternative in these patients. This study examines the outcomes in patients managed in this way at a major melanoma treatment center.

METHODS

All patients with clinically localized cutaneous melanoma who underwent lymphoscintigraphy and in whom SNB was intentionally not performed due to advanced age and/or comorbidities were included.

RESULTS

Between 2000 and 2009, 160 patients (5.2% of the total) underwent lymphoscintigraphy without SNB because of advanced age and/or comorbidities. Compared with the 2945 patients who had a SNB, the 160 patients were older, had thicker melanomas that were more often located in the head and neck region, and had more SNs in more nodal regions. Of the 160 patients, 150 (94%) were followed with ultrasound examination of their SNs at each follow-up visit; this identified 33% of the nodal recurrences before they became clinically apparent. Compared with SN-positive patients who were treated by completion lymph node dissection, observed patients who developed nodal recurrence had more involved nodes when a delayed lymphadenectomy was performed. Melanoma-specific survival, recurrence-free survival, and distant recurrence-free survival rates were similar, while regional lymph node-free survival was worse.

CONCLUSIONS

Lymphoscintigraphy with focused ultrasound follow-up of SNs is a reasonable management alternative to SNB in patients who are elderly and/or have substantial comorbidities.

Cutaneous Melanoma in the Elderly: Review of a Growing Problem

Cutaneous melanoma (CM) causes more deaths than any other skin tumor, and incidence and mortality rates have risen in recent years, especially in patients of advanced age. There are differences in the biological behavior of CM tumors in the elderly as well as differential management of the disease, evidently influenced by such factors as limited life expectancy, the high incidence of concomitant conditions in older patients, and issues of quality of life unrelated to CM itself. We review relevant current literature on the epidemiology, etiology, pathogenesis, and immunology of CM as well as research on the clinical features, prevention, and management of these tumors in the elderly.

Histopathologic variables differentially affect melanoma survival by age at diagnosis

We evaluated clinical, phenotypic, behavioral, and histopathologic variables in relationship to melanoma-specific survival by age at diagnosis among 650 population-based melanoma patients in Connecticut, with 20 years of follow-up. Only one variable, skin awareness, was significantly associated with melanoma mortality in both groups. The variables that differed between the age-groups were anatomic site, Breslow thickness, histologic subtype, mitoses, tumor-infiltrating lymphocytes (TILs), and solar elastosis. Head and neck melanoma, Breslow thickness, nodular melanoma, and solar elastosis were all significantly more likely to be associated with mortality among the older subjects; among the younger subjects, the presence of mitoses was associated with an increased probability of dying and TILs were associated with a reduced risk of mortality.