Prospective follow-up for malignant melanoma in patients with atypical-mole (dysplastic-nevus) syndrome

Recurrent driver mutations in benign tumors

The understanding of the molecular pathogenesis of benign tumors may bring essential information to clarify the process of tumorigenesis, and ultimately improve the understanding of events such as malignant transformation. The definition of benign neoplasia is not always straightforward and herein the issues surrounding this concept are discussed. Benign neoplasms share all cancer hallmarks with malignancies, except for metastatic potential. Recently, next-generation sequencing has provided unprecedented opportunities to unravel the genetic basis of benign neoplasms and, so far, we have learned that benign neoplasms are indeed characterized by the presence of genetic mutations, including genes rearrangements. Driver mutations in advanced cancer are those that confer growth advantage, and which have been positively selected during cancer evolution. Herein, some discussion will be brought about this concept in the context of cancer prevention, involving precursor lesions and benign neoplasms. When considering early detection and cancer prevention, a driver mutation should not only be advantageous (i.e., confer survival advantage), but predisposing (i.e., promoting a cancer phenotype). By including the benign counterparts of malignant neoplasms in tumor biology studies, it is possible to evaluate the risk posed by a given mutation and to differentiate advantageous from predisposing mutations, further refining the concept of driver mutations. Therefore, the study of benign neoplasms should be encouraged because it provides valuable information on tumorigenesis central for understanding the progression from initiation to malignant transformation.

The paradox of cancer genes in non-malignant conditions: implications for precision medicine

Next-generation sequencing has enabled patient selection for targeted drugs, some of which have shown remarkable efficacy in cancers that have the cognate molecular signatures. Intriguingly, rapidly emerging data indicate that altered genes representing oncogenic drivers can also be found in sporadic non-malignant conditions, some of which have negligible and/or low potential for transformation to cancer. For instance, activating KRAS mutations are discerned in endometriosis and in brain arteriovenous malformations, inactivating TP53 tumor suppressor mutations in rheumatoid arthritis synovium, and AKT, MAPK, and AMPK pathway gene alterations in the brains of Alzheimer's disease patients. Furthermore, these types of alterations may also characterize hereditary conditions that result in diverse disabilities and that are associated with a range of lifetime susceptibility to the development of cancer, varying from near universal to no elevated risk. Very recently, the repurposing of targeted cancer drugs for non-malignant conditions that are associated with these genomic alterations has yielded therapeutic successes. For instance, the phenotypic manifestations of CLOVES syndrome, which is characterized by tissue overgrowth and complex vascular anomalies that result from the activation of PIK3CA mutations, can be ameliorated by the PIK3CA inhibitor alpelisib, which was developed and approved for breast cancer. In this review, we discuss the profound implications of finding molecular alterations in non-malignant conditions that are indistinguishable from those driving cancers, with respect to our understanding of the genomic basis of medicine, the potential confounding effects in early cancer detection that relies on sensitive blood tests for oncogenic mutations, and the possibility of reverse repurposing drugs that are used in oncology in order to ameliorate non-malignant illnesses and/or to prevent the emergence of cancer.

A Self-Reported Study Toward Melanoma Knowledge, Protective Behavior and Personal Risk Among Nursing Faculty Students at AAB University of Kosovo

Introduction

In nowadays, melanoma is one of the major problems of public health all over the world. In Kosovo, the incidence of melanoma has shown irregular tendency with significant increases and decreases in the last five years.

Aim

The aim of this paper was to detect the knowledge level of nursing students in Kosovo's University (AAB University) regarding melanoma and its risk factors; to evaluate their knowledge about the protection and prevention methods of melanoma as one of the main topics of dermatology and major problems of public health worldwide nowadays. Of a great importance, it was to evaluate the necessity of establishing a dermatology course in nursing curricula in Kosovo universities, as nurses have a key role in educating and promoting health in the population.

Methods

The training was conducted through slides, photos, videos and a questionnaire was used to collect the data before and after training. Data analysis was run through SPSS program version 20.0. Data were expressed through mean values and standard deviations. T-test, Anova and regression analysis were performed to test the relationship between the protective behaviors, knowledge, personal risk and level of concern.

Results

Results indicated a low level of knowledge and a fairly poor protective behavior among the participants.

Conclusion

On-going training and enrichment of school curricula emerged as an intervention to increase the awareness of the students toward potential risks of melanoma and ultimate change in the protective behavior.

A prospective observational study of pigmented naevi changes in psoriasis patients on biologic therapy

BACKGROUND/OBJECTIVES

Patients on biologic therapy are thought to be at increased risk of developing non-melanoma skin cancers and melanomas. It is unknown whether biologic therapy alters the natural history of melanocytic naevi. Therefore, a prospective observational study was conducted to determine whether psoriasis patients on biologic therapy develop changes in naevi.

METHODS

Clinical and dermoscopic assessment of all melanocytic naevi was performed in 45 psoriasis patients on biologic therapy versus a control cohort of 43 subjects, using sequential digital dermoscopic imaging and total body photography. The mean follow-up period was 1.5 years.

RESULTS

The study and control patients had comparable age, gender, previous and family history of non-melanoma skin cancers and melanomas, as well as previous sun exposure and total number of naevi. The number of naevi with major dermoscopic changes was 3% in the study and 1.9% in the control group, with an adjusted incidence rate ratio of 1.45 (95% confidence interval 0.90-2.33; P = 0.125). The rate of minor changes was 15.9% in the study group versus 19.4% in the control (adjusted incidence rate ratio 0.77, 95% confidence interval 0.57-1.08; P = 0.14). There were six new dysplastic naevi in 4/45 biologic patients and four in 4/43 controls; however, the difference was not significant (relative risk 0.96, 95% confidence interval -0.12 to 0.12; P = 0.95). There were no melanomas in either group.

CONCLUSION

Over a mean follow-up period of 1.5 years there was no evidence of significantly different changes in naevi or development of new dysplastic naevi in psoriasis patients on biologic treatment compared to controls.

The Conundrum of Genetic "Drivers" in Benign Conditions

Advances in deep genomic sequencing have identified a spectrum of cancer-specific passenger and driver aberrations. Clones with driver anomalies are believed to be positively selected during carcinogenesis. Accumulating evidence, however, shows that genomic alterations, such as those in BRAF, RAS, EGFR, HER2, FGFR3, PIK3CA, TP53, CDKN2A, and NF1/2, all of which are considered hallmark drivers of specific cancers, can also be identified in benign and premalignant conditions, occasionally at frequencies higher than in their malignant counterparts. Targeting these genomic drivers can produce dramatic responses in advanced cancer, but the effects on their benign counterparts are less clear. This benign-malignant phenomenon is well illustrated in studies of BRAF V600E mutations, which are paradoxically more frequent in benign nevi (∼80%) than in dysplastic nevi (∼60%) or melanoma (∼40%-45%). Similarly, human epidermal growth factor receptor 2 is more commonly overexpressed in ductal carcinoma in situ (∼27%-56%) when compared with invasive breast cancer (∼11%-20%). FGFR3 mutations in bladder cancer also decrease with tumor grade (low-grade tumors, ∼61%; high-grade, ∼11%). “Driver” mutations also occur in nonmalignant settings: TP53 mutations in synovial tissue from rheumatoid arthritis and FGFR3 mutations in seborrheic keratosis. The latter observations suggest that the oncogenicity of these alterations may be tissue context–dependent. The conversion of benign conditions to premalignant disease may involve other genetic events and/or epigenetic reprogramming. Putative driver mutations can also be germline and associated with increased cancer risk (eg, germline RAS or TP53 alterations), but germline FGFR3 or NF2 abnormalities do not predispose to malignancy. We discuss the enigma of genetic “drivers” in benign and premalignant conditions and the implications for prevention strategies and theories of tumorigenesis.

Dysplastic nevi

Dysplastic nevi have been a subject of much debate since their original description in 1978. Although some question the biological potential of dysplastic nevi themselves, several studies have shown that their presence confers substantial risk for melanoma. In addition to predisposing patients to melanoma, dysplastic nevi have been shown to harbor genetic mutations, indicating their position on a continuum between banal nevi and melanomas. Dysplastic nevi are also clinically relevant as mimickers of melanoma, and can be challenging diagnostically. This article reviews the history, epidemiology, biology and genetics, clinical features, histopathologic features, and management guidelines for patients with these lesions.

Melanoma survival in the United States, 1992 to 2005

BACKGROUND

Population-based data on melanoma survival are important for understanding the impact of demographic and clinical factors on prognosis.

OBJECTIVE

We describe melanoma survival by age, sex, race/ethnicity, stage, depth, histology, and site.

METHODS

Using Surveillance, Epidemiology, and End Results data, we calculated unadjusted cause-specific survival up to 10 years from diagnosis for 68,495 first primary cases of melanoma diagnosed from 1992 to 2005. Cox multivariate analysis was performed for 5-year survival. Data from 1992 to 2001 were divided into 3 time periods to compare stage distribution and differences in stage-specific 5-year survival over time.

RESULTS

Melanomas that had metastasized (distant stage) or were thicker than 4.00 mm had a poor prognosis (5-year survival: 15.7% and 56.6%). The 5-year survival for men was 86.8% and for persons given the diagnosis at age 65 years or older was 83.2%, varying by stage at diagnosis. Scalp/neck melanoma had lower 5-year survival (82.6%) than other anatomic sites; unspecified/overlapping lesions had the least favorable prognosis (41.5%). Nodular and acral lentiginous melanomas had the poorest 5-year survival among histologic subtypes (69.4% and 81.2%, respectively). Survival differences by race/ethnicity were observed in the unadjusted survival, but nonsignificant in the multivariate analysis. Overall 5-year melanoma survival increased from 87.7% to 90.1% for melanomas diagnosed in 1992 through 1995 compared with 1999 through 2001, and this change was not clearly associated with a shift toward localized diagnosis.

LIMITATIONS

Prognostic factors included in revised melanoma staging guidelines were not available for all study years and were not examined.

CONCLUSIONS

Poorer survival from melanoma was observed among those given the diagnosis at late stage and older age. Improvements in survival over time have been minimal. Although newly available therapies may impact survival, prevention and early detection are relevant to melanoma-specific survival.

Comparative analysis of total body and dermatoscopic photographic monitoring of nevi in similar patient populations at risk for cutaneous melanoma

BACKGROUND

Our previous experience monitoring nevi in high-risk patients using serial digital epiluminescence microscopy (DELM) photography achieved low biopsy rates but was limited by melanomas presenting as new lesions or arising from nevi that had not been photographed.

OBJECTIVE

To determine whether biopsy rates, efficiency of melanoma detection, and melanoma origin (de novo vs nevus derived) differed in a similar patient population monitored using total body (TB) photography.

METHODS

One thousand seventy-six patients (including 187 from a prior cohort) underwent TB photography and were monitored using photographs obtained at the initial visit. Risk factors and median monitoring periods for these patients were comparable with those of patients previously monitored using DELM photography.

RESULTS

Two hundred seventy-five biopsies were performed in 467 patients on follow-up visits. Of 12 melanomas detected on follow-up, five were invasive, five presented as changing lesions and two as new lesions, nine arose de novo, and the remainder were nevus derived.

CONCLUSIONS

In our experience with both approaches, monitoring patients at risk for melanoma using TB photography was associated with lower biopsy rates and lower nevus-to-melanoma ratios than using DELM and facilitated detection of new and changing lesions. In both cohorts, the majority of melanomas detected on follow-up arose de novo.

Current and emerging technologies in melanoma diagnosis: the state of the art

Relative to other specialties, dermatologists have been slow to adopt advanced technologic diagnostic aids. Most skin disease can be diagnosed by simple visual inspection, and the skin is readily accessible for a diagnostic biopsy. Diagnostic aids, such as total body photography and dermoscopy, improve the clinician's ability to diagnose melanoma beyond unaided visual inspection, however, and are now considered mainstream methods for early detection. Emerging technologies such as in vivo reflectance confocal microscopy are currently being investigated to determine their utility for noninvasive diagnosis of melanoma. This review summarizes the currently available cutaneous imaging devices and new frontiers in noninvasive diagnosis of skin disease. We anticipate that multimodal systems that combine different imaging technologies will further improve our ability to detect, at the bedside, melanoma at an earlier stage.

The value of screening in melanoma

The incidence of cutaneous melanoma has increased substantially in most white populations during the past several decades. Despite improvements in the early recognition of melanoma and the use of novel diagnostic techniques that enhance our diagnostic capabilities, disease-related mortality remains a significant public health issue. In the absence of effective treatment approaches for advanced disease, the best means for reducing deaths by melanoma are screening as well as professional and public education. The role of population-or community-based screening remains controversial, but evidence from self-selected screening campaigns, health care professional surveillance, and specialized pigmented lesions clinics underscores the value of screening and early detection programs, particularly in high-risk groups. Annual screening campaigns coupled with intense media promotion have become commonplace in many countries, and despite their low yield of melanoma detection, the dissemination of educational material and information to the public during these events is important in increasing public awareness. Future directions should include using screening campaigns to target middle-aged and older men and persons of lower socioeconomic status, who suffer most from the burden of the disease and its associated mortality. On a worldwide scale, comprehensive educational and screening campaigns should be implemented or intensified in underserved areas and geographic regions with lower survival rates, such as Eastern European countries. A better understanding of the biology of the disease, already occurring with notable strides, will help us to define better those individuals who will benefit most from screening and early detection efforts. Technologic advances and new diagnostic modalities will afford a more reliable and vigilant surveillance of high-risk individuals, whereas the wide use of the Internet will enhance the distribution of relevant information to the public with the ultimate goal of achieving a better control of melanoma.

The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic

BACKGROUND

Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes.

OBJECTIVE

We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi.

METHODS

A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts.

RESULTS

The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (-0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (-1.209, P < .0001), increasing provider experience (-0.047, P = .029), and increased number of biopsies before the initial PLC (-0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC.

LIMITATIONS

This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period.

CONCLUSION

Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma

BACKGROUND

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention.

OBJECTIVE

Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas.

METHODS

A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients.

RESULTS

Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27).

LIMITATIONS

Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations.

CONCLUSIONS

The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

Screening for Cutaneous Melanoma

Current data do not support widespread population-based screening for melanoma. While the incidence of melanoma is high, the overall mortality is low, and thus any potential benefit of screening the general population is hard to demonstrate. No randomized controlled trial showing reduction in mortality has ever been completed and, given the expense and time necessary for such a trial, probably will never be completed. The idea of skin screening remains appealing for this common, visible malignancy which is eminently treatable when detected early. Efforts should be focused on populations at particularly high risk of developing melanoma and on those at high risk of death from melanoma once diagnosed. Persons in kindreds of familial melanoma, and persons who have atypical mole syndrome, those who have a prior diagnosis of melanoma, or those who have diagnosed atypical nevi are all reasonable candidates for routine screening, based on lower-level evidence in the absence of randomized clinical trials targeting these groups. Programs targeting persons of low socioeconomic status and targeting white men over the age of 50 could address groups known to beat especially high risk of melanoma mortality.

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.

Surveillance of patients at high risk for cutaneous malignant melanoma using digital dermoscopy

BACKGROUND

Dermoscopy has improved the sensitivity and specificity of clinical diagnosis of melanoma from 60% to over 90%. However, in order not to miss melanoma a certain percentage of suspicious but benign lesions has to be excised.

OBJECTIVES

To evaluate the dermoscopic changes and the rates of excision in benign melanocytic naevi and cutaneous malignant melanoma in long-term follow-up of high-risk patients using digital dermoscopy.

METHODS

Digital dermoscopic images of 2015 atypical melanocytic naevi in 196 high-risk patients were analysed retrospectively. Among others, the following data were collected for each naevus: changes in surface area, overall architecture, dermoscopic patterns and distribution of pigmentation. All tumours suspicious for melanoma or showing asymmetrical changes were excised.

RESULTS

During a median follow-up time of 25 months 128 (6.4%) of all naevi showed changes in size or architecture. Eighty-six per cent of all changes in patients who attended more than one visit were observed at the first follow-up visit. Thirty-three lesions showing changes were excised and two melanomas in situ and 31 melanocytic naevi were diagnosed.

CONCLUSIONS

Follow-up examinations using digital dermoscopy revealed unchanged morphology in the large majority of melanocytic naevi. Excisions were only performed in cases of asymmetrical growth, asymmetrical changes of pigmentation, or development of dermoscopic features indicative of melanoma. The ratio of 33 lesions excised in order to identify two melanomas in situ seems reasonable and may be further reduced in future.

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.

Detection of melanomas in patients followed up with total cutaneous examinations, total cutaneous photography, and dermoscopy

BACKGROUND

Many factors have been identified as important determinants that increase the risk of malignant melanoma (MM) developing. Patients with classic atypical mole syndrome (CAMS) have multiple such factors and are known to be at high risk for MMs developing.

OBJECTIVE

We sought to evaluate the risk for newly diagnosed MMs developing in patients with CAMS and in a heterogeneous group of patients at high risk (ie, those with high-risk non-CAMS [HRNCAMS]) who had 1 or more risk factors: personal history of nonmelanoma skin cancers; family history of melanoma; biopsy specimen-confirmed dysplastic nevi; and meeting 1 or 2 of the 3 CAMS criteria. We also aimed to report our experience treating these patients at high risk with annual total cutaneous examination, total cutaneous photography, and dermoscopy.

METHODS

Consecutive medical records from a private dermatology practice were reviewed. A total of 258 patients were selected who fulfilled the criteria of having: (1) total cutaneous photography as an aid for follow-up; (2) total cutaneous examination at least once per year; (3) at least 6 months of clinical follow-up; and (4) no personal history of melanomas. A total of 160 patients with CAMS and 98 with HRNCAMS were included in this study. The 10-year risk for MM developing in these 2 cohorts was computed using the Kaplan-Meier method.

RESULTS

In the CAMS cohort, 28 new MMs developed in 19 patients resulting in a cumulative 10-year risk of 14% (95% confidence interval: 7-20). In the HRNCAMS cohort, 10 new MMs developed in 9 patients, and the cumulative 10-year risk was 10% (95% confidence interval: 2-17). The difference between the 2 groups was not statistically significant (P=.91). The MMs diagnosed in both cohorts were either in situ or less than 1 mm in Breslow thickness. There were no MM metastases or MM-related deaths in either cohort during a mean follow-up period of 120 months for the CAMS and 98 months for the HRNCAMS group.

CONCLUSION

Both the patients with CAMS and HRNCAMS were at very high risk for MMs developing. The combination of total cutaneous photography, total cutaneous examination, and dermoscopy were used in treating our patients. No MM 1 mm or greater in thickness developed during follow-up in either group.

Adoption of new technologies for early detection of melanoma in dermatologic practice

The identification and diagnosis of early melanoma will reduce unnecessary operations and may be important in reducing mortality from melanoma and impacting cost savings to the health system. New technologies are being developed and used at some specialized centers to facilitate the detection and diagnosis of early melanoma for patients at high risk. These technologies include but are not limited to digital photography, dermoscopy, computerized image analysis systems, and confocal scanning laser microscopy. To most effectively implement these novel approaches, it is important to identify the key factors that influence the adoption or diffusion of new medical technologies. We propose patient-, physician-, and health care system-related factors that influence the diffusion of new technologies for the early detection of skin cancer. Studies involving physicians and patients in a variety of clinical settings need to be conducted to achieve a greater understanding of the barriers to the adoption of these new technologic tools that are intended to aid in skin cancer screening.

Standardized positioning of patients (poses) for whole body cutaneous photography

Whole body photography (WBP) has been used for decades by some specialized pigmented lesion clinics as an aid to early melanoma detection in high-risk persons. The recent advent of digital imaging systems for acquiring and archiving whole body skin images has resulted in greater dissemination of this technique. This in turn has led to the recent establishment of a Category III Current Procedural Terminology code for WBP. Here we present a proposed set of standardized body poses for WBP on the basis of the extant literature and the experience of a panel of experts in the field. The proposed poses were developed with consideration of patient comfort and technical efficiency. The poses were optimized to comply with a predetermined set of desirable technical parameters as assessed in a series of 20 consecutive patients. The resulting set of poses is presented as a first step toward the increased standardization of dermatologic WBP.

Acquired melanocytic nevi as risk factor for melanoma development. A comprehensive review of epidemiological data

Acquired melanocytic nevi (MN) in Caucasian populations are important markers for the risk of melanoma development. The total number of MN on the whole body is the most important independent risk factor for melanoma and the risk of melanoma development increases almost linearly with rising numbers of MN. Additionally, the presence of atypical MN and of actinic lentigines are likewise independent risk factors for melanoma. Atypical mole syndrome should be defined by the presence of many acquired MN and a threshold number of atypical MN. Acquired MN develops mainly during childhood and adolescence in the first two decades of life. The number of acquired nevi seems to be related to hereditary factors and nevus-prone families exist. The amount of sun exposure is the most important environmental risk factor for nevus development, particularly in early childhood. Interestingly, sunburns may play a role in nevus development, but seem not to be required, and even moderate sun exposure promotes the process. Therefore, preventive measures for nevus and melanoma development should target young children and adolescents.

Early melanoma detection: nonuniform dermoscopic features and growth

BACKGROUND

Dermoscopy alone is not sufficient to detect all early melanomas. Total body photos reveal growth of melanomas but also reveal growth of melanocytic nevi.

OBJECTIVE

We set out to determine whether a simplified algorithm on the basis of nonuniform dermoscopic features combined with growth noted from baseline total body photos targeted the early melanocytic neoplasms most likely to be malignant.

METHODS

Lesions removed during follow-up of patients with total body photographs were reviewed and 169 melanocytic lesions were identified for which both gross clinical and dermoscopic photos were available. The images were evaluated separately by 3 academic dermatologists, without knowledge of the given pathologic diagnosis, for uniformity (consistent gradient of features from center to edge) and change (specifically, that which could indicate melanoma growth in normal skin or within a nevus).

RESULTS

Using a minimum of 2 out of 3 agreement for uniformity and change, 12 of 16 melanomas (including all 5 superficially invasive tumors) were graded as nonuniform and changed. The 4 melanomas not included in this category were in situ. The predicted odds of melanoma for lesions scored as both nonuniform and changed was 4.06 (P >.0195). If 3 out of 3 agreement was used, the odds ratio increased to 6 (P >.0010).

CONCLUSION

An algorithm on the basis of dermoscopic nonuniformity and change suggestive of growth as determined by total body photography segregates melanocytic neoplasms most likely to be malignant.

Total body skin imaging as an aid to melanoma detection

Total body skin imaging (TBSI) is being increasingly used as an aid to melanoma detection in high-risk individuals. In this article, we review the rationale, techniques, advantages, and potential pitfalls of TBSI as an aid to melanoma detection. We highlight the technical and clinical considerations relevant to implementation of TBSI in clinical practice.

Computer-aided melanoma diagnosis

This article presents a snapshot of fast-moving research into the application of digital imaging technology to in vivo computer-aided diagnosis of early melanoma. It is written from the perspective of a researcher with a keen interest in bringing this technology to physicians' offices. The primary emphasis is on reviewing the existing literature, supplemented by unpublished material relating to a particular system and as yet unpublished research studies.

Use of and beliefs about baseline photography in the management of patients with pigmented lesions: a survey of dermatology residency programmes in the United States

Medical photography is often used in dermatology to aid in the clinical surveillance of patients with pigmented lesions. This study aimed to assess the utilization, logistics, rationale and beliefs about the usefulness of baseline photography in patients with pigmented lesions by physicians in dermatology residency programmes, and to compare current utilization to that reported in the last decade. Questionnaires were mailed to directors of all accredited dermatology residency programmes in the United States (n = 105). Eighty-three physicians responded to the questionnaire (79%). Utilization of total body and individual lesion photography was reported by 63% and 75% of the respondents, respectively; 16% of the respondents did not use any method of photography. Reasons for using photography included the following beliefs: that it helps detect early melanoma, it results in fewer biopsies, and it reduces patient anxiety. Financial and logistical constraints were reasons why some programmes were not utilizing photography. Thus baseline photography is currently used in a majority of academic dermatology programmes as an aid in the early detection of melanoma.

The genetics of hereditary melanoma and nevi. 1998 update

Although the first English-language report of melanoma in 1820 contained a description of a melanoma-prone family, it was 1983 before formal genetic analysis suggested an autosomal dominant mode of inheritance for both melanoma and the then newly described melanoma precursor, dysplastic nevi (DN). Subsequent genetic studies have assumed this model to be correct, although when viewed in aggregate, the data are inconsistent. The first proposed melanoma gene (CMM1) was mapped to chromosome 1p36. This gene assignment has not been confirmed. A second melanoma gene, designated CMM2, has been mapped to chromosome 9p21. This gene assignment has been confirmed, and the cell cycle regulator CDKN2A has been proposed as the candidate gene. Germline mutations in this gene have been identified in about 20% of melanoma-prone families that have been studied to date. Pancreatic cancer occurs excessively in melanoma families with germline mutations in CDKN2A. Germline mutations in the cyclin-dependent kinase gene CDK4 (chromosome 12q14) have been described in three melanoma families. This finding represents a third melanoma gene but one that accounts for only a tiny fraction of all hereditary melanoma. Recently, a familial melanoma-astrocytoma syndrome has been reported. Large germline deletions of 9p21 occur in these families, with the p19 gene implicated in its pathogenesis. At present, clinical predictive genetic testing for mutations in the CDKN2A gene is available commercially, but its use has been limited by uncertainty as to how test results would affect the management of melanoma-prone family members. Currently, management recommendations include monthly skin self-examination, clinical skin examination once or twice yearly, a low threshold for simple excision of changing pigmented lesions, moderation of sun exposure, and appropriate use of sunscreens. A heritable determinant for total nevus number has been suggested by twin studies. Other data suggest the presence of a major gene responsible for "total nevus density" in melanoma-prone families. Approximately 55% of the mole phenotype in multiplex melanoma families was explained by this proposed gene. An autosomal dominant mode of inheritance has been proposed for DN, and data exist to suggest that DN may be a pleiotropic manifestation of the 1p36 familial melanoma gene. However, there clearly are melanoma-prone families that do not express the dysplastic nevus trait, and some of the families linked to CDKN2A also present with dysplastic nevi. Several studies have shown a surprisingly high prevalence of DN on the skin of family members of probands with DN. In light of the extensive evidence documenting that persons with DN (both sporadic and familial) have an increased prospective risk of melanoma, these family studies suggest that relatives of persons with DN should be examined for both DN and melanoma. Genetic determinants play a major role in the pathogenesis of normal nevi, DN, and melanoma. Identifying the molecular basis of these genetic events promises to enhance melanoma risk-reduction strategies and, ultimately, reduce melanoma-associated mortality.

Multiple primary melanoma

BACKGROUND

Incidence rates of cutaneous malignant melanoma (CMM) have been increasing for decades among Caucasian populations worldwide. Multiple factors identify persons at increased risk of CMM, including those with a family history of melanoma and those with atypical moles. Approximately 6-12% of melanomas are familial and approximately 12% of patients with familial melanoma have multiple primary melanomas.

OBJECTIVE

To report a case of a patient with atypical moles and with 17 multiple primary melanomas. To review the literature on multiple primary melanomas as well as to review the genetics and treatment of melanoma.

CONCLUSION

Patients with numerous atypical moles and a family or personal history of melanoma are at greatest risk for developing CMM. Patients from this population tend to develop CMM approximately 10 years earlier than the general population and have an increased risk for developing multiple primary melanomas. Since genetic tests capable of detecting individuals with an inherited susceptibility to CMM are not available, it is important to identify those patients with an increased risk and monitor them closely with regular total-body examinations.

Multiple primary melanomas

BACKGROUND

The diagnosis of primary melanoma increases the risk of additional primary melanomas.

OBJECTIVE

We characterize the subgroup of patients with multiple melanomas.

METHODS

We reviewed the melanoma database.

RESULTS

Sixty patients with multiple primary melanomas were identified. Twelve (20%) experienced melanomas in the same regional location, 43 (72%) in different locations, and 5 (8%) in both the same and different locations (> 2 melanomas). Eighteen (30%) were diagnosed concurrently with multiple melanomas, 38 (63%) subsequently, and 4 (7%) concurrently and subsequently (>2 melanomas). Forty-two percent of subsequent melanomas occurred within 3 years of the initial lesion diagnosis, 9 (17%) between 3 and 7 years, and 22 (42%) after more than 7 years. Subsequent melanomas were thinner in 70% of cases (P = .05). The mean age at first melanoma diagnosis was 38 and 59 years, respectively, for those with and without dysplastic nevi (P < .001).

CONCLUSION

In patients with multiple melanomas, subsequent melanomas often occur in different regional locations several years after diagnosis of the initial lesion.

Effectiveness of a skin cancer control educational intervention for internal medicine housestaff and attending physicians

OBJECTIVES

To evaluate the effects of a brief educational program on beliefs, knowledge, and behaviors related to skin cancer control among internal medicine housestaff and attending physicians.

DESIGN

Randomised controlled trial.

SETTING

Urban academic general medicine practice.

PARTICIPANTS

Internal medicine housestaff and attending physicians with continuity clinics at the practice site.

INTERVENTION

Two 1-hour educational seminars on skin cancer control conducted jointly by a general internist and a dermatologist.

MEASUREMENTS AND MAIN RESULTS

Self-reported attitudes and beliefs about skin cancer control, ability to identify and make treatment decisions on 18 skin lesions, and knowledge of skin cancer risk factors were measured by a questionnaire before and after the teaching intervention. Exit surveys of patients at moderate to high risk of skin cancer were conducted 1 month before and 1 month after the intervention to measure physician skin cancer control practices reported by patients. Eighty-two physicians completed baseline questionnaires and were enrolled in the study, 46 in the intervention group and 36 in the control group. Twenty-five physicians attended both sessions, 11 attended one, and 10 attended neither. Postintervention, the percentage of physicians feeling adequately trained increased from 35% to 47% in the control group (p = .34) and from 37% to 57% in the intervention group (p = .06). Intervention physicians had an absolute mean improvement in their risk factor identification score of 6.7%, while control physicians' mean score was unchanged (p = .06). Intervention and control physicians had similar increases in their postintervention lesion identification and management scores. Postintervention, the mean proportion of patients per physician stating they were advised to watch their moles increased more among intervention physicians than control physicians (absolute difference of 19% vs -8%, p = .04). Other changes in behavior were not significant.

CONCLUSIONS

Although we observed a few modest intervention effects, overall this brief skin cancer education intervention did not significantly affect primary care physicians' skin cancer control attitudes, beliefs, knowledge, or behaviors. A more intensive intervention with greater participation may be necessary to show a stronger impact on attitudes and knowledge about skin cancer control among primary care physicians.

Genetics of cutaneous melanoma and nevi

To provide a state-of-the-art summary of currently available data about the genetics of cutaneous melanoma and nevi, we reviewed the pertinent literature and outlined the important findings on genetic analyses. Although the first English-language report of melanoma in 1820 contained a description of a melanoma-prone family, seminal studies by investigators at the National Cancer Institute and the University of Pennsylvania identified dysplastic nevi (DN) as an important melanoma precursor, suggested an autosomal dominant mode of inheritance for both melanoma and DN, and proposed that a melanoma-susceptibility gene (CMM1) was located on chromosome 1p36. This gene assignment has not yet been confirmed by independent investigators. A second melanoma gene, designated CMM2, has been mapped to chromosome 9p21. This gene assignment has been confirmed independently, and the cell cycle regulator p16INK4a has been proposed as a candidate gene; germline mutations in this gene have been identified in about half of melanoma-prone families. Germline mutations in the cyclin-dependent kinase gene CDK4 (chromosome 12q14) have recently been described in two melanoma kindreds; this finding likely represents a third melanoma gene. A heritable determinant for total nevus number has been suggested, as has the presence of a major gene responsible for total nevus density in melanoma-prone families. An autosomal dominant mode of inheritance for DN has been proposed, and evidence suggests that DN may be a pleiotropic manifestation of the 1p36 familial melanoma gene. Several studies have shown a surprisingly high prevalence of DN on the skin of family members of probands with DN. In light of the extensive evidence documenting that persons with DN (both sporadic and familial) have an increased prospective risk for melanoma, these family studies suggest that relatives of persons with DN should be examined for DN and for melanoma. Overall, genetic determinants have a major role in the pathogenesis of normal nevi, DN, and melanoma. Elucidating the molecular basis of these genetic events promises to enhance melanoma risk reduction strategies and thereby reduce melanoma-associated mortality.

Sun exposure, sunscreens, and skin cancer prevention: a year-round concern

OBJECTIVE

To review the role of sunlight in skin aging and skin cancer formation, and to provide guidelines on the use of sunscreens to minimize the adverse effects of sun damage.

DATA SOURCES

A MEDLINE search of applicable articles on ultraviolet (UV) radiation, melanoma, sunscreens, and skin cancer, evaluating both human and animal studies. Published and unpublished original research as well as clinical experience were also used.

DATA SYNTHESIS

The interaction of UV radiation and skin type plays a central role in melanoma formation. Mortality from melanoma is highest in geographic locations near the equator, where UV intensity is greatest. The incidence of melanomas in light-complected individuals (skin types I-III) is several times higher than those with darker skin types (types IV-VI), even in similar geographic regions. The UVB portion of the spectrum appears to be primarily responsible for skin cancer formation and photoaging, while short wave UVA rays play a significant contributing role. Regular sunscreen use has been shown to reduce the formation of precancerous actinic keratoses (AK) lesions by 36%. A dose-response relationship has also been found between the amount of sunscreen used and AK formation.

CONCLUSIONS

Sunscreens have now been shown to reduce the carcinogenic effects of sunlight in humans. Patients should be advised of the long-term consequences of sun exposure and the benefits of regular sunscreen use.

Current therapy for cutaneous melanoma

We review the current therapy for melanoma. The diagnosis, prognostic variables, staging, treatment, and follow-up guidelines for cutaneous melanoma are reviewed from the earliest to the most advanced stages. New guidelines for margins are discussed. A new, evolving, innovative radiographic technique, positron emission tomography using 2-fluorine-18-fluoro-2-deoxy-D-glucose, may be useful to identify subclinical nodal and visceral disease. Recent advances with respect to tumor vaccines, gene therapy, immunotherapy, and interleukin 2 as well as current concepts regarding lymph node dissection are discussed.

Atypical mole syndrome: risk factor for cutaneous malignant melanoma and implications for management

The incidence of malignant melanoma is increasing faster than that of any other cancer. It is important to identify subsets of the population at high risk of its development so that they can be observed more closely to identify early melanomas when they are curable. It has been reported worldwide that persons with the atypical mole (dysplastic nevus) syndrome are such a subset at increased risk. A risk gradient for the development of melanoma exists and varies from persons with one or two atypical moles and no family history of melanoma at one end of the spectrum to persons with the familial atypical multiple-mole melanoma syndrome at the other. Guidelines for the management of atypical mole syndrome are presented.

Risk of developing cutaneous malignant melanoma in atypical-mole syndrome: New York University experience and literature review

The presence of atypical moles (AM) is considered to be a marker for an increased risk of developing cutaneous malignant melanoma (MM). The extent to which individuals with the atypical-mole syndrome (AMS) are at risk for developing MM is unknown. We present a review of the world literature and of our experience at New York University. We conclude that the presence of AMS in Caucasians significantly increases the risk of developing MM, regardless of geographic location. A further increase in MM risk is noted if there is a personal and/or family history of MM.

p53 and PCNA expression in malignant melanomas of the head and neck

Mutation in the p53 tumor suppressor gene is the most common genetic alteration in human cancer. As in mutant p53 the protein is stabilised and the half-life is extended, it becomes detectable by immunohistological staining. p53 immunoreactivity thus seems to be a potential biomarker for the assessment of the oncogenic potential of malignant melanomas. In 103 tissue sections of primary and metastatic malignant melanomas of the head and neck detectable levels of p53 were only found in 3 of the primary tumors and in none of the metastases. At the same time the proliferation status of the malignant melanoma lesions was determined using the cell cycle specific antibody PCNA. 55 primary and metastatic tumors were stained with a PCNA-MAb to determine the proliferation activity of the tumors. The results of our immunohistochemical investigation suggest that immunoreactivity of p53 cannot be used to determine the malignant potential of melanomas in the head and neck. PCNA staining showed that the majority of the tumors and metastases were proliferating rapidly.

Melanocytic nevi in Turner syndrome

One morphologic feature of Turner syndrome is increased numbers of melanocytic nevi; however, little attention has been given to their characterization. The development of a melanoma in one of our patients with Turner syndrome prompted this study. We prospectively examined 10 patients with the disease, confirmed by karyotype. All patients underwent full body skin examination noting the number, size, distribution, and degree of clinical atypia of melanocytic nevi. Representative and unusual lesions were photographed. An average of 115 nevi were seen, with the majority measuring 1 to 5 mm. Most were located on the back and extremities. Clinical atypia was uncommon. Our patients had larger numbers of benign-appearing nevi than the general population. Large numbers of melanocytic nevi is a risk factor for melanoma, suggesting that these patients have an increase in one risk factor. Longitudinal studies are indicated to clarify this issue; nevertheless, we recommend periodic skin examinations and the regular use of sunscreens for individuals with Turner syndrome.

Recalling basal cell carcinoma patients. A regional survey

BACKGROUND

Patients with a basal cell carcinoma (BCC) are at increased risk for developing further BCCs, and long-term follow-up has been recommended to detect new cancers at an earlier, more easily treatable stage. The majority of BCCs are treated by dermatologists in their offices; we do not know to what extent they perform long-term follow up on their patients.

OBJECTIVE

To determine how practicing dermatologists follow up their BCC patients.

METHODS

A mailed questionnaire survey of 166 practicing members of a regional dermatologic society (the San Francisco Dermatological Society), to which 142 (85%) replied.

RESULTS

Two thirds of the respondents recalled BCC patients for screening examinations; of these, 58% followed up non-responders. Recall efforts were hampered by inefficient, unwieldy, and time-consuming techniques.

CONCLUSION

Practicing dermatologists are motivated to recall BCC patients for examination, but guidelines and techniques for effective and efficient computerized recalling of skin cancer patients are needed. It is suggested that the American Academy of Dermatology set up a task force to develop guidelines and criteria for effective recall software.

Current topics of immunohistochemistry as applied to skin tumors

Suppressor oncogene p53 is expressed more frequently in the nodular portion than the superficial spreading portion of the same melanoma. PCNA expression follows the same pattern but it is strongly expressed already in the superficial spreading portion. CD34 is found to label dermatofibrosarcoma protuberans. There is the mixture of negative strands but the immunostains are predominantly positive in the three cases studied. Neurogenic tumors are reactive but the intensity of staining is only moderate. Fibrous histiocytoma, dermatofibroma and other fibrohistiocytic tumors are non-reactive. CD34 is expressed in the outer root sheath of hair follicle below the sebaceous gland level. A case of piloepidermal cyst is CD34 positive. CD34 is expressed in vascular endothelial cells; not only hemangiomas but also lymphangiosarcoma is CD34 positive. A case of indeterminate cell histiocytosis following scabies and superficial variant of clear cell sarcoma are discussed as examples of new entities.

Syndromes associated with melanocytic nevi

Melanocytic nevi have been reported in association with several congenital syndromes. This review describes the clinical and cutaneous manifestations of six syndromes associated with congenital melanocytic nevi, two associated with acquired nevi, and six associated with melanocytic nevi in which insufficient evidence exists to classify them as congenital or acquired. It is important to recognize these associations to evaluate and counsel patients with melanocytic nevi. Early recognition will also facilitate timely intervention.

A cohort study of melanoma in patients with dysplastic nevi

A historical cohort of 153 patients with dysplastic nevi was studied for the development of melanoma. Each subject had a minimum follow-up of 5 years, with an average study follow-up of 94 months. Eleven new melanomas developed in 11 patients between 11 and 143 months (average 61 months) into the study period. Age-adjusted melanoma incidence in the cohort was 692/100,000 person years. Development of melanoma was strongly correlated with prior personal and/or family history of melanoma. Even among the 89 patients with no personal or family history of melanoma, the age-adjusted incidence of melanoma was an alarming 154/100,000 person years. Within this small, non-randomly ascertained cohort no association could be discerned between melanoma incidence and total number of banal or dysplastic nevi. These findings support the public health significance of the recognition of dysplastic nevi and confirm the importance of family history in evaluating melanoma risk associated with dysplastic nevi.

Risk of melanoma and other cancers in melanoma-prone families

We evaluated the risk of developing melanoma over time in members of 23 melanoma-prone families. All 23 families had dysplastic nevi as well as melanoma. Forty-seven melanomas occurred prospectively, all in family members with dysplastic nevi. The prospective melanomas were markedly thinner than the melanomas diagnosed prior to or at the time of the subject's entry into the study. The cumulative risk of melanoma by age 50 years among people with dysplastic nevi was 48.9% +/- 4.2%. Overall, the relative risk of a prospective melanoma among family members with previous melanoma was 229 (95% confidence interval 110-422). The risk varied by time interval and was 362 in the first 5 years, decreasing to 120 after 5 years. The risk of developing melanoma was 85 times increased (95% confidence interval 41-156) in family members with dysplastic nevi and also declined over time in this group. There was no significant excess of cancers other than melanoma. Close surveillance of these high-risk families has led to diagnosis of melanoma at an earlier developmental stage, which should result in a decrease in mortality over time.