Malignant melanoma prognostic factors 1: use of photography

Melanomas detected with the aid of total cutaneous photography

BACKGROUND

Early detection of melanoma results in excision of thinner melanomas, which are associated with better prognosis. Total cutaneous photography provides a temporal comparison of lesions, which allows clinicians and patients to recognize new and subtly changing lesions.

OBJECTIVES

We examined the utility of total cutaneous photography in detecting melanoma, identified the reason for biopsy of suspicious lesions and determined who detected new melanomas, the physician on follow-up examination or the patient on self-examination.

PATIENTS/METHODS

The charts of the 576 patients in the total cutaneous photography database were reviewed. Twelve patients were identified who had melanoma diagnosed with photographic assistance. Baseline and prebiopsy photographs, dermatology clinic notes (115 patient visits) and pathology reports for each biopsied lesion were reviewed. Histological diagnosis, cause for biopsy, and whether the lesion was detected by the patient or physician, was recorded for each of the biopsied lesions. Also noted were all the lesions that concerned patients, the cause for concern, and whether these lesions were biopsied.

RESULTS

A total of 93 lesions were biopsied in these patients. Twenty-seven (35%) of 77 melanocytic lesions were histologically diagnosed as melanoma. The thickest melanoma found measured 1.1 mm, indicating a favourable prognosis in our patients. Seventy-four per cent of the melanomas were biopsied due to changes from baseline and 19% were biopsied because they were new lesions. The changes noted were subtle and the lesions that proved to be melanoma did not satisfy the classical clinical criteria for melanoma. Eight (30%) of the melanomas were identified by patients on skin self-examination. Twenty-six per cent of the lesions that concerned patients were not biopsied after evaluation by a physician.

CONCLUSIONS

We found that photographically assisted follow-up helped detect new and subtly changing melanomas, which did not satisfy the classical clinical features of melanoma. In addition, photographically assisted follow-up helped detect nonmelanoma skin cancers. Patient skin self-examination proved to be valuable, in that it complemented physician follow-up examination in detecting melanomas. Photographic follow-up was also valuable in avoiding unnecessary biopsy in suspicious, but stable lesions. Total cutaneous photography therefore may be an effective way to increase the sensitivity and specificity for detecting melanoma.

Malignant melanoma prognostic factors 7: elective lymph node dissection

Every prospective study published to date, whether randomized or nonrandomized, shows that the survival rate for patients with clinical stage I melanoma is the same, irrespective of whether they have an elective lymph node dissection (ELND). All the studies that purport to show a survival benefit from ELND have been based on retrospective data and are therefore subject to selection bias. Nevertheless, the data support the notion that there may be a small, select group of melanoma patients whose lives can be saved by ELND. This subgroup is made up of those patients who have epithelioid in small nests (ESN) melanomas. In the early stages of its evolution, this type of malignant melanoma metastasizes to regional lymph nodes and often does not have coexistent distant metastases. Other types of melanomas, when they metastasize, either bypass the lymph nodes or metastasize to the lymph node and simultaneously send distant metastases elsewhere, nullifying the anticipated benefit from an ELND. We encourage dermatologists, when they have a choice, to be supportive of those surgeons who have a choice, to be supportive of those surgeons who are actively participating in ongoing randomized trials designed to select patients who might benefit from ELND.

Prognostic classification of malignant melanoma by clinical criteria

In a retrospective study of 503 well-documented cases of primary malignant melanoma (stage I) clinical criteria were analysed for their prognostic relevance. The maximum elevation (in mm) of the tumour was found to be the most important single prognostic factor. There was a close association with tumour thickness, measured histologically by the method of Breslow (correlation coefficient = 0.73). A combination of elevation and three additional clinical criteria (site, nodule- or lesion-diameter, and surface defects such as erosion, ulceration or bleeding) allowed a further improvement in prognostic accuracy. This clinical classification into low-risk and high-risk melanomas was as effective as the use of tumour thickness measured histologically, and can therefore be used for the preoperative planning of treatment.