Pathologic Reporting and Special Diagnostic Techniques for Melanoma

Evaluation of Melanoma Features and Their Relationship with Nodal Disease: The Importance of the Pathological Report

Background

The pathological features of melanoma biopsies can provide significant prognostic information that can help the surgeon evaluate the risk of nodal disease. The aim of this study was to attempt to determine the relationship between pathological features of primary melanoma and nodal disease, by sentinel node biopsy (SNB) and complete node dissection (CND).

Methods

A retrospective analysis was completed of patients who underwent SNB at AC Camargo Cancer Center, Sao Paulo, Brazil, between 2000 and 2010.

Results

A total of 697 patients were evaluated. By univariate analysis, it was found that histology, Clark level, Breslow depth, mitotic index, ulceration, regression, lymphatic and perineural invasion and satellitosis were significantly associated with SNB positivity. In the multivariate analysis, it was found that Breslow depth, mitotic index, ulceration, regression, lymphatic invasion and satellitosis were significant factors. In patients with a positive SNB, the primary tumor site, Clark level and Breslow depth greater than 2 mm were significantly related to non-sentinel node (NSN) positivity by univariate analysis. By multivariate analysis, Breslow depth greater than 2 mm was the only primary tumor feature that was significantly related (p = 0.038).

Conclusions

The indication of SNB should not be based solely on Breslow depth and ulceration or mitotic index. A complete evaluation of the pathological report should improve the identification of high-risk patients.

Cost-effectiveness of a FISH assay for the diagnosis of melanoma in the USA

OBJECTIVE

The authors evaluated the cost-effectiveness of a FISH assay in melanoma diagnosis in the USA.

METHOD

A model was developed simulating the addition of FISH to the diagnosis of suspected melanoma. A decision analytic module simulated diagnosis using microscopic assessment alone versus addition of FISH (sensitivity: 92%; specificity: 94%). The authors simulated a clinical setting in which an initial excisional biopsy microscopic assessment (sensitivity: 73%; specificity: 78%) was followed by dermatopathologist assessment (sensitivity: 89%; specificity: 79%) for inconclusive results. Diagnostic strategies 1 and 2 added FISH to the initial and dermatopathologist assessments, respectively. A Markov outcomes module simulated patients' remaining lifetime, including treatment.

RESULTS

In diagnostic strategies 1 and 2, the cost per quality-adjusted life year gained was US$14,930 and 43,925, respectively, versus no FISH. Cost per misdiagnosis avoided was US$3292 and 3759, respectively. Sensitivity and specificity without FISH were both ≥88%; however, addition of FISH exceeded US$100,000/quality-adjusted life year.

CONCLUSION

In specific clinical settings, FISH could be cost effective for melanoma diagnosis.

Sentinel lymph node molecular ultrastaging in patients with melanoma: a systematic review and meta-analysis of prognosis

PURPOSE

Molecular biology-based ultrastaging of cancer is already part of the standard management of patients with hematologic malignancies, whereas the evidence for solid tumors is much more debated. Polymerase chain reaction (PCR) -based detection of melanoma cells in sentinel lymph nodes (SLN) of patients with melanoma represents an appealing prognostic tool. However, no consensus exists on the clinical implementation of this prognostic indicator for the management of these patients.

METHODS

Twenty-two studies enrolling 4,019 patients who underwent SLN biopsy for clinical stage I to II cutaneous melanoma were reviewed. Correlation of PCR status with TNM stage, disease recurrence rates, and survival was assessed by means of association statistics and formal meta-analysis, respectively.

RESULTS

PCR status correlated with both TNM stage (stage I to II v III; PCR positivity, 95.1% v 46.6%; P < .0001) and disease recurrence (PCR positive v negative; relapse rate, 16.8% v 8.7%; P < .0001). PCR positivity was also associated with worse overall (hazard ratio [HR], 5.08; 95% CI, 1.83 to 14.08; P = .002) and disease-free (HR, 3.41; 95% CI, 1.86 to 6.24; P < .0001) survival. Statistical heterogeneity was significant, underscoring the variability among overall effect estimates across studies; metaregression and subgroup analysis did not identify clear-cut sources of heterogeneity, although some study design variables were suggested as potential causes.

CONCLUSION

PCR status of SLN appears to have a clinically valuable prognostic power in patients with melanoma. Although the heterogeneity of the studies so far published warrants caution to avoid overestimating the favorable results of pooled data, our findings strongly support additional investigation in this field.