Primary cutaneous malignant melanoma and its precursor lesions: diagnostic and therapeutic overview

Is Raman Spectroscopy of Fingernails a Promising Tool for Diagnosing Systemic and Dermatological Diseases in Adult and Pediatric Populations?

Background: Raman spectroscopy is a well-known tool used in criminology, molecular biology, and histology. It is also applied to diagnose bone mineral disorders by taking advantage of the similarity of the structure of keratin and bone collagen. Raman spectroscopy can also be used in dermatology and diabetology. The purpose of the present review is to critically evaluate the available research about the use of Raman spectroscopy in the mentioned areas of medicine. Methodology: PubMed was searched for peer-reviewed articles on the subject of use of Raman spectroscopy in bone mineral disorders, dermatology, and diabetes mellitus. Results: Nail keratin and bone collagen are related structural proteins that require disulfide bond for structural stability. Therefore, Raman spectroscopy of keratin may have potential as a diagnostic tool for screening bone quality and distinguishing patients at risk of fracture for reasons different from low bone mineral density (BMD) in the adult women population. Raman spectroscopy can also investigate the changes in keratin's structure in nails affected by onychomycosis and distinguish between healthy and onychomycosis nail samples. It could also reduce the need for nail biopsy by distinguishing between dermatophytic and non-dermatophytic agents of onychomycosis. Additionally, Raman spectroscopy could expedite the diagnostic process in psoriasis (by assessing the secondary structure of keratin) and in diabetes mellitus (by examining the protein glycation level). Conclusions: In adult populations, Raman spectroscopy is a promising and safe method for assessing the structure of fingernails. However, data are scarce in the pediatric population; therefore, more studies are required in children.

Advances in melanoma: epidemiology, diagnosis, and prognosis

Unraveling the multidimensional complexities of melanoma has required concerted efforts by dedicated community of researchers and clinicians battling against this deadly form of skin cancer. Remarkable advances have been made in the realm of epidemiology, classification, diagnosis, and therapy of melanoma. The treatment of advanced melanomas has entered the golden era as targeted personalized therapies have emerged that have significantly altered the mortality rate. A paradigm shift in the approach to melanoma classification, diagnosis, prognosis, and staging is underway, fueled by discoveries of genetic alterations in melanocytic neoplasms. A morphologic clinicopathologic classification of melanoma is expected to be replaced by a more precise molecular based one. As validated, convenient, and cost-effective molecular-based tests emerge, molecular diagnostics will play a greater role in the clinical and histologic diagnosis of melanoma. Artificial intelligence augmented clinical and histologic diagnosis of melanoma is expected to make the process more streamlined and efficient. A more accurate model of prognosis and staging of melanoma is emerging based on molecular understanding melanoma. This contribution summarizes the recent advances in melanoma epidemiology, classification, diagnosis, and prognosis.

Nanoparticle-Based Combination Therapy for Melanoma

Melanoma is a cutaneous carcinoma, and its incidence is rapidly increasing with every year. The treatment options for melanoma have been comprehensively studied. Conventional treatment methods (e.g., radiotherapy, chemotherapy and photodynamic therapy) with surgical removal inevitably cause serious complications; moreover, resistance is common. Nanoparticles (NPs) combined with conventional methods are new and promising options to treat melanoma, and many combinations have been achieving good success. Due to their physical and biological features, NPs can help target intended melanoma cells more efficiently with less damage. This creates new hope for a better treatment strategy for melanoma with minimum damage and maximum efficacy.

Finding reduced Raman spectroscopy fingerprint of skin samples for melanoma diagnosis through machine learning

Early-stage detection of cutaneous melanoma can vastly increase the chances of cure. Excision biopsy followed by histological examination is considered the gold standard for diagnosing the disease, but requires long high-cost processing time, and may be biased, as it involves qualitative assessment by a professional. In this paper, we present a new machine learning approach using raw data for skin Raman spectra as input. The approach is highly efficient for classifying benign versus malignant skin lesions (AUC 0.98, 95% CI 0.97-0.99). Furthermore, we present a high-performance model (AUC 0.97, 95% CI 0.95-0.98) using a miniaturized spectral range (896-1039 cm^-1), thus demonstrating that only a single fragment of the biological fingerprint Raman region is needed for producing an accurate diagnosis. These findings could favor the future development of a cheaper and dedicated Raman spectrometer for fast and accurate cancer diagnosis.

Dermatologic Follow-up and Assessment of Suspicious Lesions

As our knowledge and understanding of melanoma evolve, melanoma surveillance guidelines will reflect these findings. Currently, there is no consensus across international guidelines for melanoma follow-up. However, it is accepted that more aggressive surveillance is recommended for more advanced disease. When examining high-risk individuals, a systematic approach should be followed. Future considerations include the use of noninvasive imaging techniques, 'liquid biopsies,' and artificial intelligence to enhance detection of melanomas.

Expression levels of FBXW7 and MDM2 E3 ubiquitin ligases and their c-Myc and p53 substrates in patients with dysplastic nevi or melanoma

E3 ubiquitin ligases are of interest as drug targets due to their involvement in the regulation of the functions and interactions of several proteins. Various E3 ligase complexes are considered oncogenes or tumor suppressors associated with the development of melanoma. These proteins regulate the functions of various signaling pathways and proteins, such as p53 and Notch. The aim of the present study was to determine the expression levels of F-box and WD repeat domain-containing 7 (FBXW7), c-Myc, MDM2 and p53 proteins in samples from patients with dysplastic nevi or melanoma, and to evaluate their association with clinicopathological parameters and prognosis of the disease. Paraffin blocks with postoperative material from 100 patients diagnosed with dysplastic moles or melanoma were used in the present study. Tissue microarrays and immunohistochemistry were used to examine FBXW7, c-Myc, MDM2 and p53 protein expression. The results revealed that there was significantly lower FBXW7 expression in advanced melanoma compared with dysplastic nevus, melanoma in situ and stage pT1 melanoma (P<0.001). Additionally, there was a statistically significant association between the expression levels of FBXW7 and the morphological type of the tumor (P<0.001). In addition, there was a strong positive association between FBXW7 expression and the changes in c-Myc expression (P<0.02), and a strong trend was observed between decreased FBXW7 expression and a higher risk of death in patients, with the major factor in patient mortality being the stages of melanoma. Additionally, p53 expression was associated with the depth of melanoma invasion and the morphological type of the tumor. In summary, FBXW7 expression exhibited the highest statistically significant prognostic value and associations with advanced melanoma. As the majority of FBXW7 substrates are oncoproteins, their degradation by FBXW7 may highlight these proteins as potential targets for the treatment of melanoma.

Morphologic characteristics of nevi associated with melanoma: a clinical, dermatoscopic and histopathologic analysis

Background

The aim of this retrospective study was to determine the frequency of nevus-associated melanomas and to better characterize the preexisting nevus from a histopathologic, clinical and dermatoscopic point of view.

Methods

We reviewed the histopathologic slides of a consecutive series of 357 melanomas and corresponding clinical and dermatoscopic images, if available.

Results

We found that 31 (8.7%) melanomas were associated with a preexisting nevus, 284 (79.5%) melanomas developed de novo, and in 42 (11.8%) a preexisting nevus could not be excluded, although the alternative explanation that the entire lesion represented a melanoma was also possible. The preexisting nevus was a "superficial" or "superficial and deep" congenital nevus in 27 cases (87%) and a Clark nevus in 4 cases (13%). Clinical or dermatoscopic images were available in 149 (41.7%) cases. The preexisting nevus, if visible, looked inconspicuous clinically or dermatoscopically. The median invasion thickness of nevus-associated melanoma was not significantly different from "de novo" melanomas but the frequency of in situ melanomas was higher in the "de novo" group (40.1% versus 16.1%). Patients with melanoma in association with a nevus were significantly younger (mean age=55 years, SD: 16 years) than patients with "de novo" melanomas (mean age=68 years SD: 15 years, p<0.001). When controlled for age and invasion thickness overall, survival did not differ significantly between patients with nevus-associated melanomas and patients with de novo melanomas.

Conclusions

From a histomorphologic point of view, the majority of melanomas arise de novo. If melanomas develop in a preexisting nevus, they usually occur in association with a "superficial" or "superficial and deep" congenital nevus.

Altered Expression of the Dna Mismatch Repair Proteins Hmlh1 and Hmsh2 in Cutaneous Dysplastic Nevi and Malignant Melanoma

Molecular alterations in the mismatch repair system suggest that this mechanism may be important in the evolution of cutaneous melanoma. Our current study evaluated the expression of two mismatch repair proteins, hMLH1 and hMSH2, in dysplastic nevi (DN) and cutaneous melanoma (CM). Immunohistochemical staining of these proteins was performed on 55 CM and 30 DN specimens. The staining results were divided into three groups: negative, partially positive and strongly positive. Normal adjacent skin cells served as an internal control for positive immunostaining. Altered immunoreactivity of one of the proteins was found in four (13.4%) DN and seven (12.7%) CM. Lack of staining for hMLH1 was observed in two (6.7%) cases of DN and five (9.1%) cases of CM; staining for hMSH2 was absent in two (6.7%) of the DN and two (3.6%) of the CM specimens. Partially positive staining was found in 33.3% and 53.3% for hMLH1 and hMSH2, respectively, in DN, and in 54.5% and 69.1%, respectively, in CMM. Our study shows that complete or partial loss of MMR protein expression occurs in a subset of both DN and CM and may represent a distinct pathway in the development of some DN and CM.

From melanocytes to melanomas

Melanomas on sun-exposed skin are heterogeneous tumours, which can be subtyped on the basis of their cumulative levels of exposure to ultraviolet (UV) radiation. A melanocytic neoplasm can also be staged by how far it has progressed, ranging from a benign neoplasm, such as a naevus, to a malignant neoplasm, such as a metastatic melanoma. Each subtype of melanoma can evolve through distinct evolutionary trajectories, passing through (or sometimes skipping over) various stages of transformation. This Review delineates several of the more common progression trajectories that occur in the patient setting and proposes models for tumour evolution that integrate genetic, histopathological, clinical and biological insights from the melanoma literature.

Malignant Melanoma and Acquired Dermal Melanocytosis on Congenital Nevus Spilus

We reported a case of malignant melanoma and acquired dermal melanocytosis that appeared on congenital nevus spilus; this is the first report from Japan. An 85-year-old woman had had a nevus spilus on the right lower leg since birth. A black-brown nodule developed on the nevus three years before treatment. Blue-gray patches were found within the nevus on inspection. Histopathological analysis of these lesions revealed superficial spreading melanoma and acquired dermal melanocytosis, respectively. There have been 19 previous case reports of malignant melanoma on nevus spilus, and there have only been 4 cases of dermal melanocytosis (plaque-type blue nevus) on nevus spilus. We reviewed the reported cases in the literature and discussed the risk factors of nevus spilus.

A lesion suspected of melanoma by dermoscopy: we must trust this diagnostic tool

BACKGROUND

The incidence of cutaneous melanoma is increasing worldwide and early diagnosis is essential since the prognosis is poor in advanced stages of disease. Dermoscopy emerged as an additional and important diagnostic procedure for the early diagnosis of cutaneous melanoma.

MAIN OBSERVATION

We report a case of a 52-year-old man, who developed a pigmented lesion in the right pretibial region. Dermoscopy highly suggestive of melanoma. The initial histopathological evaluation suggested a benign lesion. Since dermoscopy was very suspicious, a more extensive histopathological study of the excised skin fragment was performed. This led to a change of diagnosis to a melanoma with partial regression.

CONCLUSIONS

The present case shows that occasionally dermoscopy may be more informative for diagnosis of melanoma than an initial histopathology result.

Skin cancers of the hand and upper extremity

Skin cancers represent the most common primary malignancies of the hand. They typically present as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. The most common malignancy is squamous cell carcinoma, followed by basal cell carcinoma and melanoma. The key to successful treatment is early and accurate diagnosis and treatment. Unlike open biopsies, which are indicated for deep soft tissue and bone lesions, biopsies for skin cancer can be performed under local anesthesia in the office setting in the form of shave or punch biopsies. A number of nonsurgical treatment options are available for treatment. However, when surgical excision is indicated, appropriate margin resections are dictated by the grade and stage of the malignancy.

Introduction to skin cancer

The incidence of skin cancer has been increasing throughout the United States and much of the world. Although the mortality rate of nonmelanoma skin cancer is low, that type of skin cancer accounts for considerable morbidity, including cosmetic and functional impairment. Melanoma, although less common, is a life-threatening malignancy if not detected and treated early. Skin cancer also significantly contributes to the rising costs of health care in the United States. Prevention, early diagnosis, and treatment are critical in helping to reduce the incidence, morbidity, and mortality associated with skin cancer. This article provides an introduction to skin cancer, including the changing incidence, clinical presentation, and summary of treatment and prognosis.

Protein expression of carcinoembryonic antigen cell adhesion molecules in benign and malignant melanocytic skin lesions

Dysregulation of cell adhesion molecules is associated with progression of malignant melanoma. Immunohistologic study of benign nevi (BN), dysplastic nevi (DN), and primary superficial spreading melanoma (SSM) was performed for carcinoembryonic antigen (CEA) and CEA cell adhesion molecule-1 (CEACAM1) using monoclonal antibodies. We investigated BN (n = 42), DN (n = 22), thin SSM (n = 21), and thick SSM (n = 21). CEA expression in melanomas and DN was significantly increased compared with BN. CEA expression in thick SSM was significantly higher than in DN. Compared with BN, expression of CEACAM1 in melanomas was significantly increased. CEACAM1 expression in thick SSM was significantly increased compared with DN and thin SSM. Our data support the findings of previous studies indicating that cell adhesion molecules of the CEA family may have a role in the development and progression of cutaneous melanoma and potentially serve as prognostic markers.

[The prevalence of melanocytic naevi among teenagers]

Malignant melanoma is an increasing public health problem worldwide; accordingly, identification of the constitutional and environmental factors which contribute to the development of the disease, and hence identification of the individuals at high risk of melanoma, are indispensable steps in all primary prevention efforts.

AIM

The objective of the present study was to assess the prevalence of different pigmented lesions among schoolchildren, and to investigate their relationship with phenotypic pigmentary characteristics, sun exposure and other factors.

METHODS

A cross-sectional study was performed in two secondary schools in Szeged, Hungary. A total of 1320 schoolchildren, aged 14 to 18 years, underwent a whole-body skin examination. A standardized questionnaire was used to collect data on phenotypic, sun exposure and other variables.

RESULTS

Between 1-10 common melanocytic naevi were found in 27% of the participants, and naevi numbers were in the range between 10-100 in 67%. 5.4% of them had more than 100 common melanocytic naevi. The prevalence of clinically atypical naevi was 24.3%. Congenital naevi were detected in 6.2% of the schoolchildren. A statistically significant association was found between the number of pigmented lesions and gender, hair colour, eye colour, skin phototype, the history of severe painful sunburns, and the family history of a large number of melanocytic naevi.

CONCLUSIONS

Our study population displayed a markedly high prevalence of clinically atypical melanocytic naevi. Moreover, a considerable proportion of the investigated individuals had multiple common melanocytic naevi. Since the presence of large number of melanocytic naevi is a strong predictor for future melanoma development, health educational programmes on melanoma prevention should be aimed at young age groups.

The role of observation in the management of atypical nevi

OBJECTIVE

The definition and management of the atypical nevus remains a controversial issue. Some believe that atypical nevi are common variants of benign melanocytic nevi while others believe they are lesions intermediate between benign melanocytic nevi and melanoma. Therefore, the question of whether or not partially removed atypical nevi should be re-excised with clear margins in order to prevent their evolution into melanoma remains unanswered. Although studies have shown that most atypical nevi will never progress into melanoma, re-excision, when biopsy margins are positive, is commonly practiced. We argue that re-excision in such cases is not necessary.

METHODS

Our cohort study includes 55 previously biopsied atypical nevi that were not re-excised and which were followed for at least 5 years with a mean follow up time of 6.12 years.

RESULTS

The experimental group included 26 atypical nevi whose biopsy revealed at least one involved margin. The control group included 29 atypical nevi whose biopsy revealed clear margins. No melanomas were observed to arise in association with a pre-existing atypical nevus in either the experimental or control group during the follow-up period.

CONCLUSIONS

The results of our study support observation as a safe alternative to re-excision for incompletely removed atypical nevi. A large prospective study with longer follow up would be necessary to better answer the question of how often atypical nevi evolve into melanoma and over what time period this occurs.

RAS and RAF mutations in banal melanocytic aggregates contiguous with primary cutaneous melanoma: clues to melanomagenesis

BACKGROUND

Distinguishing banal melanocytic aggregates contiguous with malignant melanoma can be a histological challenge but is essential because of the potential for a spurious Breslow measurement.

OBJECTIVES

Our aim was to ascertain whether the histological distinction between the two relates to differences in the prevalence of mutations in genes significant in melanomagenesis.

METHODS

Mutations in BRAF codon 600, NRAS1 codons 12/13, NRAS2 codons 60/61 and KRAS codons 12/13 were ascertained in 18 cases of primary cutaneous malignant melanoma contiguous with banal melanocytic aggregates using laser capture microdissection.

RESULTS

Overall, 12 of 18 cases (67%) exhibited a mutation in at least one gene. BRAF V600E appeared to be the most commonly mutated gene in both the melanocytic aggregate (seven of 18, 39%) and the melanoma (four of 18, 22%). Both populations demonstrated a similar BRAF genomic profile in 11 of 18 cases (61%) (two BRAF V600E, nine BRAF-WT), a similar KRAS genomic profile in 14 of 18 cases (78%) (one KRAS G12V, 13 KRAS-WT) and a similar NRAS2 genomic profile in 14 of 18 cases (all WT). Of interest, we noted a relatively high prevalence of KRAS mutations (five of 18, 28%). The frequency of KRAS mutations in the melanocytic aggregate (five of 18, 28%) was second to BRAF V600E, while in melanoma, the frequency was also second to BRAF V600E but equalled that of NRAS2 (1 of 18, 6%). No NRAS1 mutations were observed. BRAF and RAS mutations appeared to be mutually exclusive with only three of 18 cases (17%) demonstrating a mutation in both genes (melanocytic aggregate only).

CONCLUSIONS

Our findings hint towards the interpretation of banal melanocytic aggregates serving as precursor lesions.

The prevalence of melanocytic naevi among schoolchildren in South Hungary

BACKGROUND

Malignant melanoma is an increasing public health problem worldwide; accordingly, identification of the constitutional and environmental factors which contribute to the development of the disease, and hence identification of the individuals at high risk of melanoma, is an indispensable step in all primary prevention efforts.

OBJECTIVES

This paper aims to assess the prevalence of different pigmented lesions among schoolchildren and to investigate their relationship with phenotypic pigmentary characteristics, sun exposure and other factors.

PATIENTS/METHODS

A cross-sectional study was performed in two secondary schools in Szeged, Hungary. A total of 1320 schoolchildren, aged 14 to 18 years, underwent a whole-body skin examination. A standardized questionnaire was used to collect data on phenotypic, sun exposure and other variables.

RESULTS

One to 10 common melanocytic naevi were found in 27% of the participants, and the naevus numbers were in the range of 10-100 in 67%; 5.4% of them had more than 100 common melanocytic naevi. The prevalence of clinically atypical naevi was 24.3%. Statistically significant associations were found between the number of pigmented lesions and gender, hair colour, eye colour, skin phototype, a history of severe painful sunburns and a family history of a large number of melanocytic naevi.

CONCLUSION

Our study population displayed a markedly high prevalence of clinically atypical melanocytic naevi. Moreover, a considerable proportion of the investigated individuals had multiple common melanocytic naevi. Since the presence of a large number of melanocytic naevi is a strong predictor for future melanoma development, health educational programmes on melanoma prevention should be aimed at young age groups.

Soft Tissue Tumors of the Hand. 2. Malignant

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (previous article) and malignant tumors (this article) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.

A Primer of Mohs Micrographic Surgery: Uncommon Indications

Mohs micrographic surgery has been used for the treatment of tumors other than basal and squamous cell carcinomas. Parameters to be considered when deciding on a treatment include location, size, growth pattern, and recurrence rates. It is important to consider that sometimes the high-risk nature of the tumor is more significant than the need for tissue sparing. Modifications to the Mohs micrographic surgery technique may be used to ensure diagnostic accuracy and confirm complete removal of the lesion (e.g., immunohistochemical staining and paraffin-embedded sections).

Current surgical management of melanoma

The surgical management of melanoma has changed dramatically over the last few decades. Through the development and conduction of well-designed, prospective, randomized trials, we have been able to refine the way that we surgically manage patients with melanoma. Indeed, many important issues have been addressed through such trials: the proper surgical margins for the primary melanoma, utility of the elective lymph node dissection and the role for selective lymphadenectomy, to name a few. This review will also discuss what we have learned from past clinical trials and address several issues with regards to where we are going in the future.

Clinical presentations of cutaneous melanoma

Cutaneous melanoma is responsible for the majority of skin cancer deaths. Early and accurate detection are the most important means to improve patient survival. This article reviews the common clinical presentations of head and neck cutaneous melanoma, and discusses lesions that might be clinically mistaken for melanoma.

Melanoma inhibitor of apoptosis protein is expressed differentially in melanoma and melanocytic naevus, but similarly in primary and metastatic melanomas

BACKGROUND

Malignant melanoma is highly resistant to current treatments. The inhibitor of apoptosis protein (IAP) family member, melanoma IAP (ML-IAP), is overexpressed in some melanoma cell lines, rendering them resistant to apoptotic signals. Targeting ML-IAP is a promising approach to treating melanoma. However, the status of ML-IAP expression in human melanoma tissues and the difference in expression between melanoma and melanocytic naevus are not known.

AIMS

To investigate these issues.

METHODS

ML-IAP expression in 48 archived patient samples (34 melanomas and 14 dermal naevi) was assessed by immunohistochemistry and by in situ hybridisation and reverse transcription polymerase chain reaction (RT-PCR) assays developed for the study.

RESULTS

Expression of ML-IAP was detected in 47.6-70.6% (10 of 21 to 24 of 34) of the melanomas, varying with detection methods. The expression rate in melanoma was much higher than that in melanocytic naevus (10.0-21.4%; one of 10 to three of 14). No significant difference was seen between primary and secondary melanomas. ML-IAP expression rates assessed by the three methods were in agreement.

CONCLUSIONS

The ML-IAP expression rate in archived melanoma tissues is around 50-70%, with no difference between primary and secondary melanomas. A small number of dermal naevi ( approximately 20%) also expressed ML-IAP.

Congenital melanocytic nevi needing treatment

Patients presenting with congenital melanocytic nevi (CMN) need individualized treatment based upon nevus size, thickness, location, risk for developing melanoma, and psychological characteristics of the patient and family. The present authors review CMN types and prognoses, as well as absolute and relative indications for treatment. Risks and benefits of several treatment options are discussed, including surgical options, such as excision, chemical peels, dermabrasion and curettage, and laser therapy. The main focus of treatment is, in all cases, to address the concern for developing melanoma, at the same time optimizing the aesthetic and functional outcomes.

Management of nevi in transplant patients

Immunosuppression is known to be an independent risk factor for melanoma. As allograft-sparing therapies have improved in the past two decades and transplant recipients have longer survival rates, the numbers of patients at increased risk for cutaneous malignancies, including melanoma, have dramatically grown. For a majority of transplant recipients, the first opportunity for skin cancer screening and patient education does not begin prior to transplantation, nor does it involve a dermatologist. Dermatologists detect thinner melanomas when compared to those detected by other physicians, including other specialists. A dermatology consultation for assessment of individual risk and a baseline physical examination should be done as part of a pretransplant evaluation for every patient. The authors review the known risk factors for cutaneous melanoma and melanocytic nevi in both immunocompetent and immunosuppressed populations and current methods of examination and management of pigmented lesions, including brief discussions of a multidisciplinary approach, and when to consider decreasing or stopping immunosuppressive therapy.

Cutaneous melanoma: methods of biopsy and definitive surgical excision

The proper method of biopsy and definitive surgical excision of cutaneous melanoma is vital for optimal patient outcome. Clearly, the present authors' understanding of the pathophysiology of cutaneous melanoma continues to change at a rapid pace. Indeed, as the present authors' research efforts begin to expose some of the mysteries of melanoma, so do they begin to better understand the intricacies of this dreaded cancer. This article will highlight methods of biopsy for melanoma and the management of the primary tumor. The present authors review current recommendations for excision margins for the primary tumor, usefulness of lymphoscintigraphy, timing of definitive surgical excision, and issues unique for head and neck melanoma.

Presence of high-risk mucosal human papillomavirus genotypes in primary melanoma and in acquired dysplastic melanocytic naevi

BACKGROUND

Some studies have shown that cutaneous and mucosal melanoma biopsy specimens harbour human papillomavirus (HPV), suggesting that this virus may play a role in development and progression of the tumour.

OBJECTIVES

To investigate the presence of HPV DNA and the prevalence of different high-risk mucosal HPV genotypes in primary melanoma (PM) and in acquired dysplastic melanocytic naevi (ADMN).

METHODS

Fifty-one PMs from 18 men and 33 women (median age 55.5 years), 33 ADMN from 15 men and 18 women (median age 35.1 years) and 20 control skin samples from nine men and 11 women (median age 43.5 years) were studied. All diagnoses were made after histological analysis. HPV DNA analysis was made using two different polymerase chain reaction-enzyme-linked immunosorbent assay (PCR-ELISA) methods, namely MY-PCR and GP-PCR.

RESULTS

Using GP-PCR, mucosal HPVs were detected in 14 PMs (27%; P = 0.0166) and eight ADMN (24%; P = 0.0367), while with MY-PCR, mucosal HPVs were found in 11 PMs (22%; P = 0.04) and five ADMN (15%; P not significant). All control skin samples were negative for mucosal HPVs with both DNA amplification procedures.

CONCLUSIONS

Using our PCR-ELISA methods, the detection of mucosal high-risk HPV genotypes in 24% of precursor lesions (ADMN) and in 27% of PMs adds to the body of evidence indicating a colocalization of mucosal HPV and tumoral melanocytic pathologies.

Malignant melanoma in a candidate for heart transplantation

A superficial spreading melanoma (Breslow thickness 0.4 mm) was diagnosed in a 65-year-old candidate for heart transplantation due to refractory end stage heart failure. After extensive review of the literature (USA and Europe), no clear guidelines about the management of candidates for transplantation with a previous diagnosis of melanoma were found. As this patient had a 5-year probability of survival higher than 95% and heart transplantation was necessary for saving his life, the final decision was to perform the transplantation. Unfortunately, the patient died of heart failure before a suitable heart became available. This case stresses the need for early and continuous dermatological evaluation of all candidates for solid organ transplantation. Clear guidelines for screening of skin cancer before transplantation are needed.

Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi

A systematic meta-analysis of observational studies of melanoma and one of the most important risk factors, the number of naevi, was conducted in order to clarify aspects of the aetiology of this disease. Following a systematic literature search, relative risks (RRs) were extracted from 46 studies published before September 2002. Dose-response random effects models were used to obtain pooled estimates. Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated the reliability of the results and any publication bias. Number of common naevi was confirmed an important risk factor with a substantially increased risk associated with the presence of 101-120 naevi compared with <15 (pooled Relative Risk (RR) = 6.89; 95% Confidential Interval (CI): 4.63, 10.25) as was the number of atypical naevi (RR = 6.36 95%; CI: 3.80, 10.33; for 5 versus 0). The type of study and source of cases and controls were two study characteristics that significantly influenced the estimates. Case-control studies, in particular when the hospital was the source for cases or controls, appeared to present much lower and more precise estimates than cohort studies.

Myths and misconceptions: the risk of melanoma in small congenital nevi

A 2-year-old boy presents with a 4 x 3-cm, darkly pigmented nevus on his back. His mother states that this lesion has been present since birth. Both parents noticed that the nevus has become slightly larger but deny any other changes in its appearance. The boy is otherwise healthy. He has no allergies and does not take any medication. There is no family history of skin disease or cutaneous malignancy. The parents are concerned about the melanoma risk in their child's congenital nevus.

Melanoma Diagnosis by Raman Spectroscopy and Neural Networks: Structure Alterations in Proteins and Lipids in Intact Cancer Tissue

Melanoma is the most aggressive skin cancer. The specificity and sensitivity of clinical diagnosis varies from around 40% to 80%. Here, we investigated whether the chemical changes in the melanoma tissue detected by Raman spectroscopy and neural networks can be used for diagnostic purposes. Near-infrared Fourier transform Raman spectra were obtained from samples of melanoma (n=22) and other skin tumors that can be clinically confused with melanoma: pigmented nevi (n=41), basal cell carcinoma (n=48), seborrheic keratoses (n=23), and normal skin (n=89). A sensitivity analysis of spectral frequencies used by a neural network was performed to determine the importance of the individual components in the Raman spectra. Visual inspection of the Raman spectra suggested that melanoma could be differentiated from pigmented nevi, basal cell carcinoma, seborrheic keratoses, and normal skin due to the decrease in the intensity of the amide I protein band around 1660 cm-1. Moreover, melanoma and basal cell carcinoma showed an increase in the intensity of the lipid-specific band peaks around 1310 cm-1 and 1330 cm-1, respectively. Band alterations used in the visual inspection were also independently identified by a neural network for melanoma diagnosis. The sensitivity and specificity for diagnosis of melanoma achieved by neural network analysis of Raman spectra were 85% and 99%, respectively. We propose that neural network analysis of near-infrared Fourier transform Raman spectra could provide a novel method for rapid, automated skin cancer diagnosis on unstained skin samples.

[The dysplastic nevus. Separate entity, melanoma precursor or diagnostic dilemma?]

Today, 20 years after Clark and Elder postulated their tumor progression model of melanocytic lesions from common nevi to melanoma, there are still controversies surrounding this subject. Despite modem molecular biological developments, a consensus about the question, if the dysplastic nevus should be considered as a separate entity, melanoma precursor or just represent a diagnostic dilemma, still seems to be impossible. In addition, since the term melanocytic dysplasia is not precisely defined with regard to all diagnostic methods (clinical morphology, dermatoscopy, dermatopathology, molecular biology), there is considerable confusion. The question remains if a quite arbitrary classification of melanocytic lesions such as dysplastic nevus is useful at all. In daily practice, dermatologists should be aware of the fact that each suspicious melanocytic lesion could represent an early malignant neoplasia, regardless whether it is formally named dysplastic nevus or initial malignant melanoma. We conclude that solid dermatological experience plus novel tools of documentation represent the key factor to minimize patients' risk.

Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice

OBJECTIVES

To determine whether an aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice.

DESIGN

Controlled trial randomised by practice.

SETTING

General practices in Perth, Western Australia.

PARTICIPANTS

468 general practitioners in 223 practices.

INTERVENTIONS

Intervention practices were given an algorithm and instant camera to assist with the diagnosis of pigmented skin lesions. All practices were given national guidelines on managing melanoma.

MAIN OUTCOME MEASURES

Ratio of benign pigmented lesions to melanomas excised. Analyses conducted with and without inclusion of seborrhoeic keratoses.

RESULTS

At baseline the ratios of benign to malignant lesions were lower in the intervention group than in the control group. During the trial period the ratios were higher in the intervention group (19:1 v 17:1 without seborrhoeic keratoses and 29:1 v 26:1 with seborrhoeic keratoses). After adjustment for patients' age, sex, and socioeconomic status, the ratio was 1.02 times higher (95% confidence interval 0.68 to 1.51, P = 0.94) in the intervention group when seborrhoeic keratoses were not included and 1.03 times higher (0.71 to 1.50, P = 0.88) when seborrhoeic keratoses were included. General practitioners in the intervention group were less likely than those in the control group to excise the most recent pigmented skin lesion they managed (22% v 48%, P < 0.001) and to refer the patient to a specialist (16% v 27%, P = 0.06).

CONCLUSIONS

Provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners.

[Marking the route of lymphatic spread of melanoma and sentinel lymph node biopsy]

<zakljucak> Biopsija limfnih zlezda strazara je postupak koji, uz relativno nizak morbiditet, daje precizne podatke o stanju regionalnog limfonodalnog basena bolesnika sa melanomom koze. Stanje regionalnih limfnih zlezda je kljucni prognosticki parametar, veoma bitan za planiranje daljeg lecenja. Za uspesnu identifikaciju i histopatolosku obradu SLN neophodna je saradnja hirurga, nuklearnog radiologa i histopatologa. Dijagnostikovanjem okultnih metastaza u regionalnim limfnim zlezdama identifikuju se bolesnici kojima treba uciniti kompletnu limfonododisekciju, kao i oni koji mogu imati koristi od primene adjuvantne antitumorske terapije. Uvodjenjem ovog postupka dilema izvodjenja ili ne ELND vise ne postoji. Tehnicki i kadrovski zahtevi medjutim, jos uvek je ne svrstavaju u rutinske standardne postupke u lecenju melanoma. Pronalazenje mikrometastaza u regionalnim limfnim zlezdama menja stadijum bolesti u kome je bolesnik do tada bio (migracija stadijuma, Will Rogers fenomen). Novim klasifikacionim sistemom definise se klinicki i patoloski stadijum bolesti (14, 114). Ukoliko su regionalni limfonodusi ispitivani klinickim i/ili radioloskim postupcima, moze se govoriti o klinickom stadijumu bolesti. Za odredjivanje patoloskog stadijuma neophodna je histoloska evaluacija limfnih zlezda dobijenih bilo selektivnom bilo elektivnom limfadenektomijom. SLNB se smatra jednim od najvecih napredaka u terapiji melanoma u zadnjoj deceniji XX veka (4, 111). Ocekuje se da ce postati standard u lecenju bolesnika sa klinicki negativnim limfnim zlezdama (99, 111, 112), posebno sa usvajanjem novog sistema za odredjivanje stadijuma koze (14, 114, 115).

Epidemiology of melanoma and nonmelanoma skin cancer

OBJECTIVES

To describe the epidemiology of melanoma and nonmelanoma skin cancers.

DATA SOURCES

Review and research articles, book chapters, and Surveillance, Epidemiology, and End Results (SEER) data.

CONCLUSIONS

In 2002, an estimated 1.3 million Americans were diagnosed with skin cancer. Of these, 53,000 individuals were diagnosed with melanoma, the most common fatal form of skin cancer, and more than 7,000 Americans died of melanoma. Nonmelanoma skin cancer has the highest incidence of all cancers and the rise in the rate of cutaneous melanoma exceeds all other preventable cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can act as case-finders and as advocates and educators for prevention of overexposure to ultraviolet radiation. Nurses should ascertain possible inherited risk and monitor patients for additional primary skin cancers.

Risk assessment and early detection of skin cancers

OBJECTIVES

To describe a systematic method for skin cancer assessment, applying current standard practices for integration into nursing practice. To provide the fundamentals of performing a skin cancer assessment for the nonmelanoma skin cancers, basal cell carcinoma, and squamous cell carcinomas, and melanoma. Included in this discussion are risk profile calculations, mechanics of skin cancer assessment, descriptions of suspicious lesions, patient management, and follow-up.

DATA SOURCES

Textbooks, research, review of the literature, and clinical experience.

CONCLUSIONS

Skin cancer assessment is a skill that nurses can learn and implement into practice.

IMPLICATIONS FOR NURSING PRACTICE

Knowledge and practice of good skin cancer assessment skills enhances nursing competence and positively influences patient outcomes.

Nevo melanocítico congênito

O nevo melanocitico congênito está presente em aproximadamente 1% dos recém nascidos. As lesões classificadas como pequenas e medias são relativamente comuns, ao passo que o nevo gigante, maior que 20 cm no maior diâmetro, é uma condição mais rara cuja a incidência esta estimada em 1 para cada 20 mil nascimentos. As lesões melanociticas congênitas pequenas e médias têm um risco de degeneração maligna baixo, raramente ocorrendo na infância. Por outro lado, estima-se um risco entre 5 a 12 % de um melanoma se desenvolver a partir ou relacionado com um nevo gigante, e de regra, metade dos casos ocorrem antes dos 3 anos de idade. Alem da possibilidade de degeneração maligna, o acometimento neurológico e as implicações psicológicas devido ao aspecto estético são dois aspectos importantes relacionados com as lesões gigantes, influindo também na decisão e na abordagem terapêutica.