Thick melanoma: the problem continues

The anatomic distribution of cutaneous melanoma: A detailed study of 5141 lesions

BACKGROUND/OBJECTIVES

There is evidence that cutaneous melanomas at different anatomic sites present with distinctive clinicopathologic features. We examined the anatomic distribution of cutaneous melanoma and its variation by patient characteristics, subtype and Breslow thickness, using high-resolution anatomic site data.

METHODS

A cross-sectional study was performed of all primary cutaneous melanoma cases managed at a tertiary referral centre, analysing prospectively collected clinical data across 50 anatomic subsites.

RESULTS

The study included 5141 in situ or invasive melanomas; most were invasive (76.2%), and the median Breslow thickness of invasive lesions was 1.0 mm. Superficial spreading (57.2%), lentigo maligna (20.8%) and nodular (12.2%) were the most common histopathological subtypes. Sun-exposed sites such as the female nose and cheek, the male ear, as well as the upper back in both sexes had the highest incidence of melanoma per unit area. When compared to the posterior forearm, the scalp, ear, preauricular, perioral, subungual and plantar sites had thicker invasive melanomas (each P < 0.05). The peri-auricular, ear and cheek had the highest incidence of nodular melanoma per unit area. There were subtype-, age- and sex-specific differences in melanoma anatomic distribution.

CONCLUSION

Melanoma most commonly arises in sun-exposed facial areas, as well as the upper back. Increased thickness is found for melanoma in acral and many head and neck sites. Nodular melanoma is more likely to occur in head and neck sites including the peri-auricular area, ear and cheek. Clinicians should carefully assess these sites during skin examinations.

Thick melanoma in Tuscany

BACKGROUND

The epidemiologic trends of cutaneous melanoma are similar in several countries with a Western-type lifestyle, where there is a progressively increasing incidence and a low but not decreasing mortality - even increasing in selected cases, especially in the older age groups. Also in Tuscany there is a steady rise in the incidence with prevalence of in situ and invasive thin melanomas, with also an increase of thick melanomas. It is necessary to reduce the frequency of thick melanomas to reduce specific mortality. The objective of the current survey has been to compare, in the Tuscany population, by a case-case study, thin and thick melanoma cases, trying to find out those personal and tumor characteristics which may help to customize preventive interventions.

METHODS

The study included nine centers involved in the melanoma diagnosis. A consecutive series of incident invasive melanomas diagnosed in a period of about 18 months (July 2010 to December 2011) was collected and matched according in a ratio of one thick melanoma (cutoff thickness: 1 mm) every two thin melanomas. The investigators filled in a questionnaire on patients' self-reported sun exposure, way of melanoma detection, awareness and performance of self-skin examination, as well as propensity to prevention in general.

RESULTS

The results of this survey confirm that older age and the lower education level are associated with a later detection. The habit of performing skin self-examination is crucial in the early diagnosis of thick melanoma. The results of this survey seem to suggest that population aged over 50 years, with few total and few atypical nevi, and limited sun exposure and burning are at higher risk of late diagnosis. It can be assumed that part of the population is not effectively reached by prevention campaigns because they do not recognize themselves as being at risk for skin cancers.

CONCLUSIONS

In order to achieve a higher rate of early diagnosis of skin melanoma, a new strategy must be implemented. It could be useful to rethink educational campaigns - which seem to unintentionally leave out subjects more at risk for melanoma - and to renew the active involvement of the general practitioners.

Trends in the diagnosis and clinical features of melanoma in situ (MIS) in US men and women: A prospective, observational study

BACKGROUND

The incidence of melanoma in situ (MIS) is increasing, but little is known about its clinical and epidemiologic features.

OBJECTIVE

We sought to determine trends in diagnosis and clinical features of MIS.

METHODS

Incident cases of melanoma were collected prospectively from the Nurses' Health Study (1976-2010) and Health Professionals Follow-up Study (1986-2010).

RESULTS

MIS incidence increased from 2 to 42 per 100,000 person-year among women, and from 11 to 73 per 100,000 person-year among men, exceeding the rate of increase of invasive melanomas. Melanoma mortality initially increased during the follow-up period then plateaued. Men were more likely than women to develop in situ melanomas on the upper half of the body (P < .001). Invasive melanomas were diagnosed at a younger age than MIS (P < .001), and were more likely to be found on the lower extremities than MIS (P < .001).

LIMITATIONS

This is a strictly descriptive study without examination into mechanisms.

CONCLUSION

We found epidemiologic and clinical differences for in situ and invasive melanomas, which support further examination into the variations in etiologic pathways. The lack of improvement in mortality despite the increase in detection of in situ relative to invasive lesions further highlights the need to improve invasive melanoma-specific clinical screening features.

Priorities and challenges for skin cancer prevention in Europe: an expert survey

The incidence, mortality, and survival rates of melanoma vary significantly across Europe, likely related to persistent inequalities between European countries in the areas of skin cancer early detection, case registration, and prevention. To enhance the planning of prevention strategies for skin cancer in Europe, we solicited the direct opinion of European experts in the field of dermato-oncology on the main obstacles, needs, and priorities for the reduction of the skin cancer burden on this continent. We surveyed European dermatologists with leading positions in European and international organizations active in skin cancer prevention by means of written, single-choice and multiple-choice questionnaires. Fifty-two dermatologists from 32 European countries completed the survey (response rate 80%). Fewer respondents in Eastern Europe compared with Western Europe reported the presence of governmental (12 vs. 46%) or nongovernmental (35 vs. 65%) initiatives for skin cancer prevention. Most respondents in Eastern (73%) and Western Europe (69%) reported the existence of national cancer registries, but the confidence in the accuracy of melanoma registration was low. Public and professional education for early detection were top priorities for skin cancer campaigns across Europe and the perceived obstacles were similar in both regions: the lack of a national program of public education, insufficient public authority initiatives, and insufficient training of physicians on skin cancer. Our survey highlighted several areas requiring intervention for skin cancer prevention and found that the main issues and obstacles appear to be similar across Europe, creating the premise for coordinated, pan-European action.

Melanoma characteristics at diagnosis from the Spanish National Cutaneous Melanoma Registry: 15 years of experience

BACKGROUND AND OBJECTIVES

The Spanish National Cutaneous Melanoma Registry (Registro Nacional de Melanoma Cutáneo [RNMC]) was created in 1997 to record the characteristics of melanoma at diagnosis. In this article, we describe the characteristics of these tumors at diagnosis.

PATIENTS AND METHODS

This was a cross-sectional observational study of prevalent and incident cases of melanoma for which initial biopsy results were available in the population-based RNMC.

RESULTS

The RNMC contains information on 14,039 patients. We analyzed the characteristics of 13,628 melanomas diagnosed between 1997 and 2011. In total, 56.5% of the patients studied were women and 43.5% were men. The mean age of the group was 57 years (95% CI, 56.4-57 years) while median age was 58 years. The most common tumor site was the trunk (37.1%), followed by the lower limbs (27.3%). The most frequent clinical-pathologic subtype was superficial spreading melanoma (n=7481, 62.6%), followed by nodular melanoma (n=2014, 16.8%). Localized disease was observed in 86.2% of cases (n=10,382), regional metastasis in 9.9% (n=1188), and distant metastasis in 3.9% (n=479). Independently of age at diagnosis, men had thicker tumors, more ulceration, higher lactate dehydrogenase levels, and a higher rate of metastasis than women (P<.001).

CONCLUSIONS

Based on our findings, melanoma prevention campaigns should primarily target men over 50 years old because they tend to develop thicker tumors and therefore have a worse prognosis.

Meta-analysis of digital dermoscopy follow-up of melanocytic skin lesions: a study on behalf of the International Dermoscopy Society

It has been demonstrated that dermoscopic monitoring of melanocytic lesions allows for the recognition of melanoma in early stages while minimizing the excision of benign lesions. However, it is still pending to determine the real impact of digital follow-up in the clinical management of pigmented lesions. To assess the evidence of follow-up of melanocytic skin lesions with digital dermoscopy in the management of individuals at risk for melanoma by performing a meta-analysis. Medline database was screened, no limits in terms of date or language were applied. Original studies were selected when the following criteria were met: performed in clinical setting with clinical and dermoscopic evaluation made by physicians, data regarding population characteristics included, follow-up strategy used described. Fourteen of 145 retrieved references were retained. Included studies account for a total of 5787 patients (mean 445 per study) and 52,739 lesions monitored (mean per study 4057; range 272-11,396) with a mean of 12 lesions monitored per patient; a total of 4388 lesions (8.3%) were excised. The mean length of follow-up was 30 months. A mean of <1 lesion was excised per patient along the surveillance period. The number needed to monitor (NNM) ranged from 31 to 1008 (mean: 348) among eligible studies. For every additional month of monitoring, 1additional melanoma was detected. Using digital dermoscopy follow-up, the proportion of in situ melanoma and thin melanomas are higher than expected in general population. Chances to detect a melanoma during surveillance increase as the length of follow-up extends.

Melanoma epidemiology, prognosis and trends in Latvia

BACKGROUND

Melanoma incidence and mortality rates are increasing worldwide within the white population. Clinical and histological factors have been usually used for the prognosis and assessment of the risk for melanoma.

OBJECTIVES

The aim of the study was to describe the clinical and histopathological features of the cutaneous melanoma (CM) in the Latvian population, to test the association between melanoma features and patient survival, and to assess the time trends for melanoma incidence.

METHODS

We undertook a descriptive, retrospective analysis of archive data of 984 melanoma patients treated at the largest oncological hospital of Latvia, Riga East University Hospital Latvian Oncology Centre (LOC), between 1998 and 2008. Cox proportional hazards model was used to analyse patient survival and autoregressive models were applied to detect trends in melanoma incidence over time for various categories of melanoma.

RESULTS

The study showed a significant ascending trend in melanoma incidence in Latvia during the time period from 1998 to 2008 (ß = 1.83, 95% CI = 1.15-2.91, P = 0.011). Nodular melanoma was the most common tumour subtype with a frequency of 39.2%. Ulceration was present in 45.2% of melanomas. The mean Breslow thickness was 6.0 mm (6.8 mm) and no significant decline in median Breslow thickness was observed during the study period (P = 0.609). A better overall prognosis was detected for females in comparison with males (HR = 1.49; 95% CI = 1.22-1.81; P < 0.001).

CONCLUSIONS

There is a steady increase in melanoma incidence in Latvia with the majority of melanomas diagnosed at late stages with poor prognosis for survival.

Melanoma incidence and mortality in Europe: new estimates, persistent disparities

BACKGROUND

Melanoma incidence and mortality in Europe are high but there are significant gaps in the epidemiological information available across the continent.

OBJECTIVES

With the aim of enhancing the planning of educational programmes for reducing the melanoma burden in Europe, we analysed the most recent incidence and mortality data for Europe with a new focus on the regional disparities of melanoma reporting.

METHODS

GLOBOCAN 2008, the standard set of worldwide estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer for 2008, was used to provide the estimated age-standardized rates (world standard population) of melanoma incidence and mortality in European countries and regions.

RESULTS

The estimated age-standardized incidence of melanoma (measured per 100 000 person-years) varies widely from 19·2 in Switzerland to 2·2 in Greece. The incidence rate of 4·3 of Central and Eastern Europe (CEE) is less than half of that of Western Europe. Melanoma mortality rates of 1·5 are similar in CEE and Western Europe, although rates vary with a high of 3·2 in Norway and a low of 0·9 in Greece. Over 20 000 deaths from melanoma were estimated in Europe in 2008, with CEE having the largest share (35·5%) among the four geographical European regions. Population-based data are lacking for significant parts of CEE, which must rely on estimates.

CONCLUSIONS

The most recent estimates of melanoma incidence and mortality in Europe reveal sharp differences between European countries, possibly related to missed opportunities for early diagnosis and incomplete reporting of melanoma in Eastern Europe.

Superficial spreading and nodular melanoma are distinct biological entities: a challenge to the linear progression model

The classification of melanoma subtypes into prognostically relevant and therapeutically insightful categories has been a challenge since the first description of melanoma in the 1800s. One limitation has been the assumption that the two most common histological subtypes of melanoma, superficial spreading and nodular, evolve according to a linear model of progression, as malignant melanocytes spread radially and then invade vertically. However, recent clinical, pathological, and molecular data indicate that these two histological subtypes might evolve as distinct entities. Here, we review the published data that support distinct molecular characterization of superficial spreading and nodular melanoma, the clinical significance of this distinction including prognostic relevance and the therapeutic implications.

Melanoma of the feet: misdiagnosed and misunderstood

Acral lentiginous melanoma of the foot is a relatively rare but often very aggressive variant of melanoma. More commonly identified in patients with darker skin, diagnosis of the lesions is often delayed because the area is not routinely examined by patients or primary care physicians. In addition, these lesions often mimic other entities, including vascular lesions and infections. Greater awareness of this entity and performing appropriate biopsies will result in more timely diagnoses and improved survival.

Melanoma thickness trends in the United States, 1988-2006

Over the past two decades, numerous efforts have been initiated to improve screening and early detection of melanoma both in the United States and worldwide. It is commonly believed that these efforts have contributed to the stabilization of melanoma mortality, and that the proportion of thick melanoma with unfavorable prognosis is on the decline. Data obtained from 17 population-based cancer registries of the Surveillance Epidemiology and End Result (SEER) program of the National Cancer Institute for 1988-2006 were used to examine trends in melanoma tumor thickness. For malignant melanoma cases with recorded thickness, the proportionate distribution among four thickness categories (<or=1, 1.01-2, 2.01-4, and >4 mm) remained relatively stable over the 19-year study period, however, for melanomas resulting in death, the proportion of thick tumors increased. The most substantial change occurred in the proportion of melanoma in situ, which nearly doubled from 1988 to 2006. Surveillance and early detection efforts in the United States have not resulted in a substantial reduction in the proportion of tumors with prognostically unfavorable thickness. Continued improvement and new methods of screening, especially among demographics with higher incidence of thick tumors, is necessary.