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Yu Y, Hosseini N, Dodington D, Wood K, Ghazarian D, Kamil ZS. The combined diagnostic value of 5-hmC and PRAME immunohistochemistry in melanocytic neoplasms. Pathol Res Pract 2025; 270:155993. [PMID: 40328178 DOI: 10.1016/j.prp.2025.155993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2025] [Revised: 04/23/2025] [Accepted: 04/25/2025] [Indexed: 05/08/2025]
Abstract
The diagnosis of melanocytic neoplasms, particularly those with borderline morphologic features, remains a challenging area in dermatopathology. 5-hydroxymethylcytosine (5-hmC) and PRAME (PReferentially expressed Antigen in MElanoma) are recent immunohistochemical markers which have been shown to be valuable in distinguishing benign from malignant melanocytic neoplasms. A retrospective cohort of 144 benign, borderline (Spitz nevi, atypical Spitz tumors and dysplastic nevi) and malignant melanocytic tumors at our institution were analyzed for 5-hmC and PRAME expression by immunohistochemistry. Compared to benign nevi, melanoma cases had higher PRAME expression (p < 0.0001) and lower 5-hmC (p < 0.0001) expression. In receiver operator curve analysis, 5-hmC and PRAME were good discriminators between benign and malignant neoplasms; the area under the curve (AUC) was 0.91 for 5-hmC (p < 0.0001) and 0.94 for PRAME (p < 0.001). Subgroup analysis showed that 5-hmC expression was significantly different between dysplastic nevi and melanoma. The combination of PRAME and 5-hmC significantly improved the predictive ability of these markers (AUC 0.97, p < 0.001). Having both PRAME expression of 4 + (> 75 % lesional cells positive) and 5-hmC of < 0.2 was highly specific for malignancy (98 %) with a sensitivity of 61 %. Utilizing 5-hmC and PRAME in conjunction improves their diagnostic value in distinguishing benign from malignant melanocytic neoplasms.
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Affiliation(s)
- Yanhong Yu
- University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada.
| | | | - David Dodington
- University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada
| | - Kimberly Wood
- University of Saskatchewan, Regina Pasqua Hospital, Regina, SK, Canada
| | - Danny Ghazarian
- University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada
| | - Zaid Saeed Kamil
- University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada
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2
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Vavrukh P, LeBlanc RE, Yan S. Diagnostic Utility of Preferentially Expressed Antigen in Melanoma (PRAME) and p16 Immunohistochemistry in Distinguishing Genital Melanomas From Benign Melanocytic Proliferations. Am J Dermatopathol 2025; 47:462-467. [PMID: 40314660 DOI: 10.1097/dad.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2025]
Abstract
ABSTRACT Preferentially expressed antigen in melanoma (PRAME) expression is valuable for distinguishing malignant from benign melanocytic proliferations, and p16 has also been shown to aid in this distinction. However, data on the utility of these two immunohistochemistry stains in genital melanocytic lesions are limited. We retrospectively analyzed 56 genital melanocytic lesions, including 41 benign lesions and 15 melanomas (6 in situ and 9 invasive) with PRAME and p16 immunohistochemistry. All melanomas exhibited extensive PRAME positivity: 93.3% (14 of 15) had a 4+ score (>75% positive cells) and 1 had a 3+ score (51%-75% positive cells). In contrast, 87.8% (36 of 41) of benign lesions were PRAME negative, and none scored higher than 2+ (26%-50% positive cells). Using a 4+ cutoff, PRAME demonstrated a sensitivity of 93.3% and specificity of 100%. Lowering the cutoff to 3+ increased sensitivity to 100%. Complete or partial loss of p16 was observed in 60.0% (9 of 15) of melanomas but not in any benign lesions (0 of 41), resulting in a sensitivity of 60.0% and specificity of 100%. Our findings indicate that PRAME immunohistochemistry is highly sensitive and specific for genital melanoma. Loss of p16 expression, although not sensitive, is highly specific for genital melanomas and is, therefore, useful in challenging genital melanocytic lesions.
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MESH Headings
- Humans
- Melanoma/diagnosis
- Melanoma/pathology
- Melanoma/metabolism
- Immunohistochemistry
- Cyclin-Dependent Kinase Inhibitor p16/analysis
- Diagnosis, Differential
- Retrospective Studies
- Biomarkers, Tumor/analysis
- Female
- Male
- Antigens, Neoplasm/analysis
- Antigens, Neoplasm/biosynthesis
- Middle Aged
- Aged
- Skin Neoplasms/diagnosis
- Skin Neoplasms/pathology
- Adult
- Aged, 80 and over
- Genital Neoplasms, Female/diagnosis
- Genital Neoplasms, Female/pathology
- Genital Neoplasms, Female/metabolism
- Predictive Value of Tests
- Genital Neoplasms, Male/diagnosis
- Genital Neoplasms, Male/pathology
- Sensitivity and Specificity
- Young Adult
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Affiliation(s)
- Petro Vavrukh
- Department of Pathology, Cooperman Barnabas Medical Center, Livingston, NJ; and
| | - Robert E LeBlanc
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Shaofeng Yan
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Perrin C, Coutts M, Dadone-Montaudié B. Subungual melanoma: molecular analysis of 31 cases from early stage to invasive melanoma. Histopathology 2025; 86:214-225. [PMID: 39138795 DOI: 10.1111/his.15297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/08/2024] [Accepted: 07/20/2024] [Indexed: 08/15/2024]
Abstract
AIMS The distinction between the benign subungual melanocytic lesions and an early lesion of subungual melanoma (SUM) remains a diagnostic challenge. We evaluated the routine diagnostic utility of array Comparative Genomic Hybridization (aCGH) to detect whole-genome copy number variations (CNV) as well as targeted next-generation sequencing (NGS) in SUM. METHODS AND RESULTS This retrospective study included 20 cases of in situ SUM and 11 cases of invasive SUM. Analysis by aCGH detected common oncogene amplifications in all but one case of invasive SUM (n = 10) and in all cases of in situ SUM with a melanocyte count (MC) >45/mm (n = 4 true positive) and the average number of CNV was 8.5. Thirteen remaining cases of in situ SUM gave false negative results (n = 13), owing to a lack of sufficient melanocytes to analyse (median MC of 35.35; range: 10.16-39.5). Molecular analysis failed in four cases (three in situ SUM and one invasive SUM) due to insufficient amounts of DNA. Across the whole cohort, the sensitivity of aCGH was 52%, but when adjusting the cutoff to MC >45/mm, the sensitivity was 93%. Targeted NGS was less informative than aCGH analyses in our series of SUM. CONCLUSION To distinguish malignant from benign lesions, especially in situ SUM versus atypical lentiginous melanocytic proliferations, aCGH analysis should be performed when the MC is above 45 melanocytes per linear millimetre. This pangenomic method can detect oncogene amplifications, as well as a number of CNV >3, which strongly support the diagnosis of malignancy.
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Affiliation(s)
- Christophe Perrin
- Laboratoire Central d'Anatomie Pathologique, Nice University Hospital, Nice, France
| | - Michael Coutts
- Department of Cellular Pathology, Maidstone Hospital, Kent, UK
| | - Bérengère Dadone-Montaudié
- Institute for Research on Cancer and Aging of Nice (IRCAN) CNRS UMR 7284/INSERM U1081, University of Cote d'Azur (UCA), Nice University Hospital, Nice, France
- Department of Pathology and Molecular Oncology, Laboratoire d'Oncologie Moléculaire, Nice University Hospital, Nice, France
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Jin A, Haynes D, Rodriguez O, Park JH, Jellinek N, Rubin AI. A Review of the Histopathology of Nail Unit Tumors Including Selection of the Optimal Surgical Sampling. Skin Appendage Disord 2024; 10:443-458. [PMID: 39659653 PMCID: PMC11627548 DOI: 10.1159/000539383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/11/2024] [Indexed: 12/12/2024] Open
Abstract
Background A wide variety of tumors can affect the nail unit, with some commonly mistaken as inflammatory or infectious diseases. Obtaining an optimal sample for histopathologic evaluation requires understanding of nail unit anatomy as well as the histopathology of the suspected nail tumor. Summary This review discusses clinical and histopathologic features of a subset of benign and malignant nail tumors, including subungual melanoma, nail unit squamous cell carcinoma in situ, nail unit squamous cell carcinoma, onychomatricoma, onychopapilloma, onychocytic matricoma, and onychocytic carcinoma. Optimal surgical sampling techniques for each lesion are presented. Key Messages In summary, the clinical and histopathologic features of several common and rare nail unit tumors and the optimal sampling techniques for each lesion are presented in this manuscript. Knowledge of the clinical and histopathologic features of these tumors informs the surgical approach to them and will produce the best patient outcomes.
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Affiliation(s)
- Annie Jin
- Department of Dermatology, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Dylan Haynes
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Olaf Rodriguez
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ji Hye Park
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nathaniel Jellinek
- Dermatology Professionals, Inc, APDerm, East Greenwich, RI, USA
- Department of Dermatology, The Warren Alpert Medical School at Brown University, Providence, RI, USA
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Adam I. Rubin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Bui CM, Vuong HG, Le MK, D'Angelo J, Mannava K, Smoller BR. Clinical implication of PRAME immunohistochemistry in differentiating melanoma in situ and dysplastic nevus in non-acral nevus-associated melanoma in situ: An institutional experience and meta-analysis. J Cutan Pathol 2024; 51:783-789. [PMID: 39031706 DOI: 10.1111/cup.14671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/27/2024] [Accepted: 06/03/2024] [Indexed: 07/22/2024]
Abstract
INTRODUCTION PReferentially expressed Antigen in MElanoma (PRAME) has shown utility in differentiating benign from malignant melanocytic neoplasms. In this study, we investigated the clinical significance of PRAME expression in dysplastic nevi (DN) and nevus-associated melanoma in situ (MIS). METHODS We included 172 DN and 38 nevus-associated MIS from our institutional archive. PRAME positive expression was defined as nuclear staining in at least 75% of melanocytes. In addition, relevant studies from PubMed and Web of Science were incorporated into a meta-analysis using the random-effects model to assess PRAME expression in MIS and DN. RESULTS Our institutional data revealed that 71.1% of nevus-associated MIS cases exhibited positive PRAME expression in the MIS components, whereas all DN components were negative for PRAME. 5.7% of cases diagnosed as DN in our cohort demonstrated diffuse positivity for PRAME. Notably, MIS associated with DN displaying epidermal and dermal components displayed a higher likelihood of PRAME positivity compared to those arising on a background of DN with solely epidermal (junctional) components (84% vs. 46%, p = 0.024). The meta-analysis indicated that the pooled PRAME positivity in MIS and DN was 54.5% and 1.9%, respectively. CONCLUSION PRAME is a valuable immunohistochemical marker for differentiating MIS from DN, particularly in the context of nevus-associated MIS.
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Affiliation(s)
- Chau M Bui
- Department of Pathology, University of Rochester Medical Center, Rochester, New York, USA
| | - Huy Gia Vuong
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Minh-Khang Le
- Department of Pathology, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Josephine D'Angelo
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York, USA
| | - Kathleen Mannava
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York, USA
| | - Bruce R Smoller
- Department of Pathology, University of Rochester Medical Center, Rochester, New York, USA
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Daruish M, Karunaratne S, Duffy-Gadd P, Hansford S, Taibjee S. Utility of PRAME Immunohistochemistry in the Detection of Subtle Melanoma Microsatellites. Am J Dermatopathol 2024; 46:668-671. [PMID: 39141754 DOI: 10.1097/dad.0000000000002817] [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: 08/16/2024]
Abstract
ABSTRACT Microsatellitosis is well established as a prognostic factor in malignant melanoma. Its identification leads to subsequent upstaging with implications for further management. We describe 6 cases in which immunohistochemical staining for PReferentially expressed Antigen in MElanoma facilitated detection of small foci of micrometastasis on scanning magnification, which may be potentially missed in routine sections.
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Affiliation(s)
- Maged Daruish
- Department of Cellular Pathology, Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom ; and
- Poundbury Cancer Institute, Dorchester, United Kingdom
| | - Sanwadana Karunaratne
- Department of Cellular Pathology, Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom ; and
| | - Paula Duffy-Gadd
- Department of Cellular Pathology, Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom ; and
| | - Samantha Hansford
- Department of Cellular Pathology, Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom ; and
| | - Saleem Taibjee
- Department of Cellular Pathology, Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom ; and
- Poundbury Cancer Institute, Dorchester, United Kingdom
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Zboraș I, Ungureanu L, Șenilă S, Petrushev B, Zamfir P, Crișan D, Zaharie FA, Vesa ȘC, Cosgarea R. PRAME Immunohistochemistry in Thin Melanomas Compared to Melanocytic Nevi. Diagnostics (Basel) 2024; 14:2015. [PMID: 39335694 PMCID: PMC11431529 DOI: 10.3390/diagnostics14182015] [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: 08/21/2024] [Revised: 09/06/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024] Open
Abstract
PRAME (PReferentially expressed Antigen in Melanoma) immunohistochemistry has proven helpful in distinguishing malignant from benign melanocytic tumors. We studied PRAME IHC expression in 46 thin melanomas and 39 melanocytic nevi, mostly dysplastic nevi. Twenty-six percent (26.09%) of the melanomas showed diffuse PRAME staining in over 76% of the tumor cells (4+), and 34.78% of the melanomas showed PRAME expression in over 51% of the tumor cells (3+ or 4+), while 8% were entirely negative for PRAME. No melanocytic nevi were PRAME 4+ or 3+. More than half of the nevi (64%) were entirely negative for PRAME staining, and 36% of the nevi showed staining expression in 1-25% (1+) or 26-50% of the cells (2+). No nevi were stained with a color intensity of 3, while 16.67% of the melanomas were stained with this color intensity. Most nevi (78.57%) were stained with an intensity of 1. With a lower positivity threshold, sensitivity increases with still reasonable specificity. The best accuracy was obtained for the 2+ positivity threshold. In conclusion, PRAME staining helps distinguish thin melanomas from dysplastic nevi. However, the threshold of positivity should be lowered in order not to miss thin melanomas.
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Affiliation(s)
- Iulia Zboraș
- Department of Dermatology, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Loredana Ungureanu
- Department of Dermatology, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Simona Șenilă
- Department of Dermatology, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Bobe Petrushev
- Department of Pathology, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Paula Zamfir
- Department of Pathology, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Doinița Crișan
- Department of Pathology, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Flaviu Andrei Zaharie
- Faculty of Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Ștefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
| | - Rodica Cosgarea
- Department of Dermatology, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
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Cassalia F, Danese A, Tudurachi I, Federico S, Zambello A, Guidotti A, Franceschin L, Bolzon A, Naldi L, Belloni Fortina A. PRAME Updated: Diagnostic, Prognostic, and Therapeutic Role in Skin Cancer. Int J Mol Sci 2024; 25:1582. [PMID: 38338862 PMCID: PMC10855739 DOI: 10.3390/ijms25031582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Preferentially Expressed Antigen in Melanoma (PRAME), a member of the cancer/testis antigen family, is central to the field of skin cancer diagnostics and therapeutics. As a nuclear receptor and transcriptional regulator, PRAME plays a critical role in inhibiting retinoic acid signalling, which is essential for cell differentiation and proliferation. Its aberrant overexpression in various malignancies, particularly cutaneous melanoma, is associated with more aggressive tumour phenotypes, positioning PRAME as both a diagnostic and prognostic marker. In melanoma, PRAME is typically highly expressed, in contrast to its weak or absent expression in benign nevi, thereby improving the accuracy of differential diagnoses. The diagnostic value of PRAME extends to various lesions. It is significantly expressed in uveal melanoma, correlating to an increased risk of metastasis. In acral melanomas, especially those with histopathological ambiguity, PRAME helps to improve diagnostic accuracy. However, its expression in spitzoid and ungual melanocytic lesions is inconsistent and requires a comprehensive approach for an accurate assessment. In soft tissue sarcomas, PRAME may be particularly helpful in differentiating melanoma from clear cell sarcoma, an important distinction due to their similar histological appearance but different treatment approaches and prognosis, or in detecting dedifferentiated and undifferentiated melanomas. In non-melanoma skin cancers such as basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma, the variable expression of PRAME can lead to diagnostic complexity. Despite these challenges, the potential of PRAME as a therapeutic target in melanoma is significant. Emerging immunotherapies, including T-cell-based therapies and vaccines targeting PRAME, are being investigated to exploit its cancer-specific expression. Ongoing research into the molecular role and mechanism of action of PRAME in skin cancer continues to open new avenues in both diagnostics and therapeutics, with the potential to transform the management of melanoma and related skin cancers.
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Affiliation(s)
- Fortunato Cassalia
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
| | - Andrea Danese
- Dermatology Unit, Department of Integrated Medical and General Activity, University of Verona, 37100 Verona, Italy;
| | - Ina Tudurachi
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
| | - Serena Federico
- Dermatology Unit, University of Magna Graecia, 88100 Catanzaro, Italy;
| | - Anna Zambello
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
| | - Alessia Guidotti
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
| | - Ludovica Franceschin
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
| | - Anna Bolzon
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
| | - Luigi Naldi
- Department of Dermatology, Ospedale San Bortolo, 36100 Vicenza, Italy;
- Centro Studi Gruppo Italiano Studi Epidemiologici in Dermatologia (GISED), 24121 Bergamo, Italy
| | - Anna Belloni Fortina
- Dermatology Unit, Department of Medicine (DIMED), University of Padua, 35121 Padua, Italy; (I.T.); (A.Z.); (A.G.); (L.F.); (A.B.); (A.B.F.)
- Pediatric Dermatology Department of Women’s and Child’s Health (SDB), University of Padua, 35121 Padua, Italy
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Turner N, Ko CJ, McNiff JM, Galan A. Pitfalls of PRAME Immunohistochemistry in a Large Series of Melanocytic and Nonmelanocytic Lesions With Literature Review. Am J Dermatopathol 2024; 46:21-30. [PMID: 37982498 DOI: 10.1097/dad.0000000000002584] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
ABSTRACT Preferentially expressed antigen in melanoma (PRAME) immunohistochemistry is currently used to facilitate distinction of benign and malignant melanocytic proliferations. We hypothesized that evaluation of 1 institution's experience with PRAME labeling in a large number of consecutive cases might elucidate additional strengths and potential pitfalls and reveal base rates of positivity versus negativity in 1 academic practice. Pathology reports for all specimens on which PRAME labeling was performed at our institution between January 2021 and May 2022 were retrieved from our database. Eighty percent of conventional malignant melanomas were labeled diffusely positive with PRAME; there were no significant differences in mean age, sex, site, Breslow depth, ulceration status, or American Joint Committee on Cancer pathological tumor stage when comparing diffusely PRAME-positive malignant melanomas with those that lack diffuse labeling. Although no banal melanocytic nevi were labeled with PRAME, 13% of dysplastic nevi were diffusely PRAME positive, with junctional proliferations, severe atypia, male gender, and older age being associated with PRAME positivity. As some but not all ambiguous melanocytic lesions in which malignancy could not be excluded based on morphology alone were diffusely PRAME positive, PRAME's accuracy in predicting malignancy remains unclear to the authors; further study is needed to assess the precision to which PRAME immunohistochemistry can separate benign borderline lesions from their malignant counterparts. Among nonmelanocytic lesions, some poorly differentiated tumors, including atypical fibroxanthomas, can be PRAME positive. This series underscores the importance of clinicopathologic correlation and shows that diffuse PRAME positivity is highest in conventional malignant melanomas (∼80%, or 8 of 10 lesions), is seen in about half of challenging borderline lesions at our institution, and can be observed in lesions diagnosed as dysplastic nevi by our group (∼10% or 1 in 10 lesions), as well as in rare poorly differentiated malignancies.
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Affiliation(s)
- Noel Turner
- Department of Dermatology, Yale University, New Haven, CT; and
| | - Christine J Ko
- Department of Dermatology, Yale University, New Haven, CT; and
- Department of Pathology, Yale University, New Haven, CT
| | - Jennifer M McNiff
- Department of Dermatology, Yale University, New Haven, CT; and
- Department of Pathology, Yale University, New Haven, CT
| | - Anjela Galan
- Department of Dermatology, Yale University, New Haven, CT; and
- Department of Pathology, Yale University, New Haven, CT
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Wakefield C, O'Keefe L, Heffron CCBB. Refining the application of PRAME-a useful marker in high CSD and acral melanoma subtypes. Virchows Arch 2023; 483:847-854. [PMID: 37723345 DOI: 10.1007/s00428-023-03648-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/14/2023] [Accepted: 09/10/2023] [Indexed: 09/20/2023]
Abstract
Pathologic discordance affecting patient management may approach 20% in melanocytic cases following specialist review. The diagnostic utility of PRAME has been highlighted in several studies but interpretative challenges exist including its use in severely dysplastic compound nevi showing progression to melanoma in situ, nevoid melanoma, and coexisting nevi with melanoma. We examine the PRAME status of a broad spectrum of melanocytic lesions including challenging, dysplastic nevi with severe atypia from a large Irish patient cohort. Retrospective review of the dermatopathology database was conducted to evaluate the PRAME staining characteristics of two hundred and twenty-one melanocytic lesions using a commercially available PRAME antibody (EPR20330). The proportion of nuclear labeling and intensity of staining was recorded. The sensitivity and specificity of PRAME for in situ and malignant melanocytic lesions was 77% and 100%, respectively. Virtually all of our melanoma in situ from high-cumulative sun damaged (CSD) skin (22/23) and all acral lentiginous melanoma (5/5) were PRAME positive while 80% (8/10) of our lentigo maligna melanoma showed diffuse expression. None of our benign subgroup showed diffuse immunoexpression (0/82), including thirty-seven moderate or severely dysplastic nevi. In all cases of melanoma in situ arising in association with a dysplastic compound nevus (0/10), no immunoexpression was observed in the nevic component while in five cases of melanoma in situ with coexistent, intradermal nevus immunostaining was confined to the in situ component. A total of 100% (2/2) of desmoplastic melanomas and 50% (4/8) of nodular melanomas were PRAME positive. PRAME is a sensitive and highly specific immunostain in the diagnosis of in situ and invasive melanoma and we emphasize its application in the evaluation of high CSD and acral melanoma subtypes as well as in challenging threshold cases.
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Affiliation(s)
- Craig Wakefield
- Department of Pathology, Cork University Hospital, Wilton, Cork, Ireland.
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Laura O'Keefe
- Department of Pathology, Cork University Hospital, Wilton, Cork, Ireland
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Abstract
ABSTRACT Preferentially expressed antigen in melanoma (PRAME) is a tumor-associated antigen first identified in a melanoma patient and found to be expressed in most melanomas as well as in variable levels in other malignant neoplasms of epithelial, mesenchymal, or hematolymphoid lineage. Detection of PRAME expression in formalin-fixed paraffin-embedded tissue is possible by immunohistochemistry (IHC) with commercially available monoclonal antibodies. In situ and invasive melanoma frequently show a diffuse pattern of nuclear PRAME immunoreactivity which contrasts with the infrequent and typically nondiffuse staining seen in nevi. In many challenging melanocytic tumors, results of PRAME IHC and other ancillary tests correlate well, but not always: The tests are not interchangeable. Most metastatic melanomas are positive for PRAME, whereas nodal nevi are not. Numerous studies on PRAME IHC have become available in the past few years with results supporting the value of PRAME IHC as an ancillary tool in the evaluation of melanocytic lesions and providing insights into limitations in sensitivity and specificity as well as possible pitfalls that need to be kept in mind by practicing pathologists.
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Affiliation(s)
- Cecilia Lezcano
- Pathologist, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Achim A Jungbluth
- Pathologist, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Klaus J Busam
- Pathologist, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Godse R, Rodriguez O, Ayoade KO, Rubin AI. Update on nail unit histopathology. Hum Pathol 2023; 140:214-232. [PMID: 36921726 DOI: 10.1016/j.humpath.2023.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
Histopathologic evaluation of the nail unit is an essential component in the diagnosis of nail unit disorders. This review highlights recent updates in nail unit histopathology and discusses literature covering a wide range of nail disorders including melanoma/melanocytic lesions, squamous cell carcinoma, onychomatricoma, onychopapilloma, onychomycosis, lichen planus, and other inflammatory conditions. Herein we also discuss recent literature on nail clipping histopathology, a useful and noninvasive diagnostic tool that continues to grow in popularity and importance to both dermatologists and dermatopathologists.
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Affiliation(s)
- Rama Godse
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Olaf Rodriguez
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine Omueti Ayoade
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Adam I Rubin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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13
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Arasu A, Howard A, Tan CG, Prakash S, Kern JS. Clinical and dermoscopic features of nail unit melanoma in an Australian nail clinic cohort. Australas J Dermatol 2023; 64:417-422. [PMID: 37102442 DOI: 10.1111/ajd.14057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/02/2023] [Indexed: 04/28/2023]
Abstract
Nail unit melanoma carries diagnostic challenges conferring with its poor prognosis. This audit aims to characterise both clinical and dermoscopic features of nail unit malignant lesions and compare them with biopsied benign lesions. It focuses on informing future practice by aiding in the stratification and recognition of malignant diagnostic patterns in the Australian context.
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Affiliation(s)
- Alexis Arasu
- Department of Dermatology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Anne Howard
- Department of Dermatology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Skin Health Institute, Carlton, Victoria, Australia
| | - Chin-Guan Tan
- Melbourne Pathology (Sonic Healthcare), Collingwood, Victoria, Australia
| | - Saurabh Prakash
- Melbourne Pathology (Sonic Healthcare), Collingwood, Victoria, Australia
| | - Johannes S Kern
- Department of Dermatology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Skin Health Institute, Carlton, Victoria, Australia
- Faculty of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Dermatology, Alfred Health, Melbourne, Victoria, Australia
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14
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Conway J, Bellet JS, Rubin AI, Lipner SR. Adult and Pediatric Nail Unit Melanoma: Epidemiology, Diagnosis, and Treatment. Cells 2023; 12:cells12060964. [PMID: 36980308 PMCID: PMC10047828 DOI: 10.3390/cells12060964] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Nail unit melanoma (NUM) is an uncommon form of melanoma and is often diagnosed at later stages. Approximately two-thirds of NUMs are present clinically as longitudinal melanonychia, but longitudinal melanonychia has a broad differential diagnosis. Clinical examination and dermoscopy are valuable for identifying nail findings concerning malignancy, but a biopsy with histopathology is necessary to confirm a diagnosis of NUM. Surgical treatment options for NUM include en bloc excision, digit amputation, and Mohs micrographic surgery. Newer treatments for advanced NUM include targeted and immune systemic therapies. NUM in pediatric patients is extremely rare and diagnosis is challenging since both qualitative and quantitative parameters have only been studied in adults. There is currently no consensus on management in children; for less concerning melanonychia, some physicians recommend close follow-up. However, some dermatologists argue that the "wait and see" approach can cause delayed diagnosis. This article serves to enhance the familiarity of NUM by highlighting its etiology, clinical presentations, diagnosis, and treatment options in both adults and children.
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Affiliation(s)
- Jade Conway
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Jane S Bellet
- Department of Dermatology and Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA
| | - Adam I Rubin
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
- Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY 10021, USA
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Kunc M, Żemierowska N, Skowronek F, Biernat W. Diagnostic test accuracy meta-analysis of PRAME in distinguishing primary cutaneous melanomas from benign melanocytic lesions. Histopathology 2023. [PMID: 36942814 DOI: 10.1111/his.14904] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/23/2023]
Abstract
PRAME is a novel immunohistochemical marker that aids the diagnosis of melanocytic lesions. Diffuse PRAME positivity suggests melanoma, whereas benign naevi are negative or only weakly positive. However, the factual diagnostic accuracy of PRAME is not well established. Moreover, some studies have suggested that the threshold of 3+/50% positive cells may be more useful in practice than the most widely used cut-off (4+/75% of positive cells). Hence, we performed a systematic review and diagnostic accuracy meta-analysis to evaluate sensitivity, specificity, likelihood ratios and optimal threshold for PRAME in distinguishing benign melanocytic proliferations from melanomas. Twenty-six studies were enrolled into the meta-analysis. A total of 2915 melanocytic lesions were analysed. The optimal threshold for PRAME positivity was estimated at 3.11, which translates into 3+ in practice. Sensitivity and specificity calculated from SROC at the 3+ threshold were 0.735 (0.631-0.818) and 0.915 (0.834-0.958), respectively, compared to 0.679 (0.559-0.957) and 0.957 (0.908-0.981) at the 4+ cut-off. In subgroup analysis, the spitzoid subgroup was characterised by the lowest sensitivity and diagnostic odds ratio of PRAME. Our findings indicate that PRAME immunohistochemistry may serve as an ancillary marker to support the diagnosis of melanoma. Nevertheless, the accuracy of PRAME may be lower in spitzoid neoplasms. Our meta-analysis suggests that the 3+/50% threshold might be more useful in practice than the 4+/75% cut-off, as it shows higher sensitivity with retained satisfactory specificity.
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Affiliation(s)
- Michał Kunc
- Department of Pathomorphology, Medical University of Gdańsk, Gdańsk
| | - Natalia Żemierowska
- Student Scientific Circle of Pathomorphology, Medical University of Gdańsk, Gdańsk, Poland
- University Clinical Hospital in Białystok, Białystok, Poland
| | - Filip Skowronek
- Student Scientific Circle, Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Wojciech Biernat
- Department of Pathomorphology, Medical University of Gdańsk, Gdańsk
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Muacevic A, Adler JR, Herrera Ortiz AF, Dussan Tovar CA, Saldarriaga Santamaría S, Cifuentes Burbano J, García N, Rodríguez Díaz MC, Sierra Molina SM, Jiménez Calfat G. Incipient Melanonychia: Benign Finding or Occult Malignancy? A Case Report of Subungual Melanoma. Cureus 2023; 15:e34292. [PMID: 36721707 PMCID: PMC9883383 DOI: 10.7759/cureus.34292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
Subungual melanomas are rare neoplasms that tend to debut as longitudinal melanonychia. They are primarily found in patients over 60 years of age and are usually diagnosed late, representing a diagnostic challenge. We present a case report of a 59-year-old female Hispanic patient who initially presented with melanonychia and was eventually diagnosed with subungual melanoma in situ. She was surgically treated and, after three months, remained healthy. Relevant risk factors, clinical and onychoscopic findings, diagnostic criteria, and treatment options are also discussed. Since many benign entities present similarly, high clinical suspicion is critical for diagnosing this entity.
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Rothrock AT, Torres-Cabala CA, Milton DR, Cho WC, Nagarajan P, Vanderbeck K, Curry JL, Ivan D, Prieto VG, Aung PP. Diagnostic utility of PRAME expression by immunohistochemistry in subungual and non-subungual acral melanocytic lesions. J Cutan Pathol 2022; 49:859-867. [PMID: 35794643 DOI: 10.1111/cup.14290] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The immunohistochemical (IHC) marker PReferentially expressed Antigen in MElanoma (PRAME) has shown promise in the diagnosis of melanocytic lesions. A few studies have investigated PRAME IHC expression in acral melanomas, but PRAME expression in subungual melanomas is largely unknown. We evaluated the utility of PRAME IHC expression in distinguishing subungual melanomas (SUM) and non-subungual acral melanomas (AM) from acral nevi (AN). METHODS Twenty-two SUM, 20 AM, and 14 AN were identified. IHC studies were performed using an anti-PRAME antibody. The percentage of lesional cells with PRAME expression was recorded and categorized as follows: 0%, 0; 1%-25%, 1+; 26%-50%, 2+; 51%-75%, 3+; and >75%, 4+. Patient demographics and other relevant clinicopathologic parameters were recorded. RESULTS Diffuse (4+) PRAME IHC expression was identified in 55% (12/22) SUM and 70% (14/20) AM, respectively. Any PRAME expression (1+ to 4+) was identified in 73% (16/22) SUMs and 95% (19/20) AM, respectively. One of 14 (7%) AN exhibited PRAME expression; interestingly, the pattern of expression was diffuse. CONCLUSIONS In our study, PRAME IHC expression was useful in identifying AM, including SUM. However, there are exceptions of PRAME-negative melanomas and PRAME-positive nevi.
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Affiliation(s)
- Aimi T Rothrock
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos A Torres-Cabala
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Denái R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Woo Cheal Cho
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Priyadharsini Nagarajan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kaitlin Vanderbeck
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jonathan L Curry
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Doina Ivan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Victor G Prieto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Phyu P Aung
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Shojiguchi N, Takai S, Arai E. Hyperplastic melanocytes with chromosomal aberrations in surrounding skin of subungual melanoma: fluorescence in situ hybridization analysis using whole-slide digital imaging. Histopathology 2022; 81:808-817. [PMID: 36094779 DOI: 10.1111/his.14793] [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: 06/08/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022]
Abstract
AIMS Subungual melanoma (SUM) is increasingly being treated with conservative surgery. Consequently, the evaluation of resection margins has increased in importance. However, in several cases it is difficult to distinguish the in-situ lesion of SUM from hyperplastic melanocytes in surrounding skin. We examined whether PReferentially expressed Antigen in MElanoma (PRAME) immunohistochemistry and fluorescence in situ hybridization (FISH) labeling of CCND1 (11q13), RREB1 (6p25), MYB (6q23), and centromere 6 (CEP6) genes differentiated SUM from hyperplastic melanocytes. METHODS AND RESULTS We reviewed specimens of 36 SUM cases and compared PRAME immunostains of invasive melanoma, melanoma in situ, and hyperplastic melanocytes. PRAME-positive cases accounted for 90.5% of invasive melanoma, 88.9% of in situ melanoma, and 59.4% of hyperplastic melanocyte specimens. While invasive and in situ melanomas in more than half of examined cases were diffusely positive, this was found for only 9.4% of hyperplastic melanocyte cases. Four-colored FISH using whole-slide digital imaging was used to analyze positive detection rates and changes in chromosomal aberrations. The FISH positive detection rate was 100% in invasive melanomas, 94.7% in melanomas in situ, and 66.7% in hyperplastic melanocytes. The number of RREB1 (6p25) signals per cell was significantly amplified following tumor progression. CONCLUSION Hyperplastic melanocytes in the surrounding skin of SUM, considered morphologically non-neoplastic, showed chromosomal aberrations similar to those in melanoma. Such cells are also thought similar to the field cells of acral melanomas. Thus, whole-slide digital imaging is a technique that allows the evaluation of individual melanocyte lesions by FISH.
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Affiliation(s)
- Naoko Shojiguchi
- Department of Pathology, Saitama Medical University International Medical Center
| | - Sayaka Takai
- Department of Dermatology, Saitama Medical University
| | - Eiichi Arai
- Department of Pathology, Saitama Medical University International Medical Center
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