Diagnosis and Management of Melanoma of the Scalp: A Review of the Literature

Characteristics of patients with melanoma with non‑melanoma skin cancer comorbidity: Practical implications based on a retrospective study

The co-occurrence of melanoma and non-melanoma skin cancer (NMSC) can lead to increased morbidity. However, there has been limited research into the dermoscopic characteristics of melanomas and clinical factors during co-occurrence. A total of 264 patients with melanoma, including 63 with NMSC comorbidity, were enrolled in the present study to retrospectively analyse the coexistence of melanoma morphology, as determined by dermoscopic examination, pathological report, tumour location and clinically manifested risk factors. The frequency of solar lentiginosis (SL) was compared between 264 patients with melanoma and 233 patients with NMSC without melanoma. In 83.4% of cases, skin cancer occurred before or concomitantly with the melanoma. The leading indicators of comorbidity were age (median 70 years; P<0.0001) and SL on the trunk and arms (P<0.0001). Melanomas in patients with NMSC comorbidity were significantly more frequently located on the head and neck [P<0.001; Bonferroni adjusted P-value (P-adj.)<0.01], then on the trunk, but less frequently occurred on the lower limbs (P<0.05). The dermoscopic multicomponent asymmetric pattern was the predominant pattern in both groups. The most characteristic pattern in the NMSC group was facial melanoma (P<0.005; P-adj.<0.05); the spitzoid pattern (P<0.001; P-adj.<0.01) was rare. Dermoscopic regression was more common (P<0.001) in the NMSC group. Regression and the number of nevi were independent of age. Differences in the incidence of SL were evaluated based on the presence of melanoma (P<0.01) and in patients without melanoma based on the presence of squamous cell carcinoma (SCC; P<0.01), multiple basal cell carcinoma (P<0.0001) and multiple SCC (P<0.005). Patients with melanoma were 10 years younger on average compared with patients with NMSC (P<0.0001). The differentiation factors identified in the present study may improve the precision of dermoscopic examinations and potentially lead to modifications in the diagnostic workflow for patients with multiple NMSCs with comorbid melanoma.

Factors associated with the likelihood of being diagnosed with stage I melanoma in Germany: a multicenter study on 12 648 patients from the ADOReg skin cancer registry

BACKGROUND

The aim of the present study was to evaluate the factors associated with a higher or lower likelihood of being early diagnosed with melanoma at stage I in Germany.

METHODS

This retrospective cross-sectional study utilizes data from the German skin cancer registry (Arbeitsgemeinschaft Dermatologische Onkologie Registry) and included 12 648 patients with a first melanoma diagnosis in 80 hospitals between 1 January 2018 and 30 November 2024. Multivariable logistic regression analyses were conducted to assess the associations between demographic and clinical variables and the likelihood of being early diagnosed with stage I melanoma.

RESULTS

This study included 4138 patients with stage I and 8510 patients with stages II-IV melanoma. Factors including older age [adjusted odds ratio (aOR): 0.61] for age group 71-80 years and 0.54 for age group > 80 years, compared to the age group 18-40 year, male sex (aOR: 0.73), Celtic (aOR: 0.66), mixed (aOR: 0.58), and Mediterranean (aOR: 0.31) skin types, melanomas located on the gluteal region (aOR: 0.35), scalp and neck (aOR: 0.44), lower limb (aOR: 0.51), upper limb (aOR: 0.67), and back (aOR: 0.72) and being single (aOR: 0.81) were negatively associated with an early diagnosis of stage I melanoma. Finally, a positive association was observed between a family history of skin cancer and the likelihood of being diagnosed with stage I melanoma (aOR: 1.50).

CONCLUSION

This study provides important insights into the demographic and clinical factors associated with early-stage melanoma diagnosis in Germany and underscores the importance of targeted interventions aimed at increasing melanoma awareness.

High-Frequency and Ultra-High-Frequency Ultrasound in Dermatologic Diseases and Aesthetic Medicine

Dermatologic ultrasonography applications are rapidly growing in all skin fields. Thanks to very high spatial resolution, high-frequency and ultra-high-frequency ultrasound can evaluate smaller structures, allowing us to improve diagnosis accuracy and disease activity. Moreover, they can guide treatment, such as drug injection, and assess therapy efficacy and complications. In this narrative review, we evaluated high-frequency ultrasound and ultra-high-frequency ultrasound in infections, inflammatory dermatoses, metabolic and genetic disorders, specific cutaneous structure skin disorders, vascular and external-agent-associated disorders, neoplastic diseases, and aesthetics.

The Carcinogenesis of the Human Scalp: An Immunometabolic-Centered View

The human scalp is a common site of skin cancer in humans, with nonmelanoma skin cancer being exceedingly common. In this review, two dermatologists with extensive experience in cutaneous oncology will discuss unique features of the epidemiology of cancer of the scalp. Clinical observations on these common skin cancers lead to insight into the pathogenesis and potential prevention and treatment of cutaneous scalp neoplasia. Our hypothesis is that the presence of hair protects against the development of skin cancer but not by serving as a physical shield but rather by providing continuous IL-17-biased immunosurveillance. The loss of hair allows for a release from immunosurveillance, resulting in the expansion of neoplastic cells towards skin cancer. Both hair follicles and metabolic changes in stroma allow for permissiveness for tumor promotion.

Rapidly progressing scalp melanoma in an elderly patient

A rapidly progressing scalp melanoma incorrectly diagnosed and managed as a 'chronic wound', lead to delayed referral to dermatologist and correct diagnosis. This case highlights the importance of early diagnosis of scalp melanoma and of frailty screening in elderly patients.

Clinical and Dermoscopic Insights Into Scalp Nevi in Chinese Children

BACKGROUND

The presence of scalp nevi in children frequently causes apprehension, leading physicians and parents to consider unnecessary biopsies or excisions of scalp nevi in children. There are limited data on the dermoscopic characteristics of scalp nevi in Chinese children.

OBJECTIVE

The aim of this study was to comprehensively analyze the clinical and dermoscopic features of scalp nevi in this specific population of Chinese pediatric patients, with a focus on a single pediatric dermatologic surgery practice.

METHODS

This retrospective cohort study investigated patients who underwent surgical excision of scalp nevi. All patients underwent dermoscopy with photographic documentation.

RESULTS

Seventy-two scalp nevi in 56 Chinese children were included. Notably, no melanoma cases were detected. The parietal region (35, 48.6%) was the most frequently affected anatomical site. Clinical asymmetry was more prevalent in nevi with a diameter exceeding 6 mm ( p < .05). The predominant dermoscopic pattern observed was the globular pattern (50, 69.4%) while an intriguing rarity of a reverse-eclipse pattern (1, 1.4%).

CONCLUSION

This study revealed that scalp nevi in Chinese children usually did not exhibit concerning behavior. Increasing awareness of the clinical characteristics, dermoscopic features, and the natural progression of scalp nevi in children can potentially help reduce unnecessary surgical interventions.

Reflectance confocal microscopy versus dermoscopy for the diagnosis of cutaneous melanoma: a head-to-head comparative meta-analysis

This meta-analysis aimed to evaluate the comparative diagnostic performance of reflectance confocal microscopy (RCM) and dermoscopy in detecting cutaneous melanoma patients. An extensive search was conducted in the PubMed and Embase databases to identify available publications up to December 2023. Studies were included if they evaluated the diagnostic performance of RCM and dermoscopy in patients with cutaneous melanoma. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool. A total of 14 articles involving 2013 patients were included in the meta-analysis. The overall sensitivity of RCM was 0.94 [95% confidence interval (CI), 0.87-0.98], while the overall sensitivity of dermoscopy was 0.84 (95% CI, 0.71-0.95). These results suggested that RCM has a similar level of sensitivity compared with dermoscopy ( P  = 0.15). In contrast, the overall specificity of RCM was 0.76 (95% CI, 0.67-0.85), while the overall specificity of dermoscopy was 0.47 (95% CI, 0.31-0.63). The results indicated that RCM appears to have a higher specificity in comparison to dermoscopy ( P  < 0.01). Our meta-analysis indicates that RCM demonstrates superior specificity and similar sensitivity to dermoscopy in detecting cutaneous melanoma patients. The high heterogeneity, however, may impact the evidence of the current study, further larger sample prospective research is required to confirm these findings.

Preliminary Experience in Ultra-High Frequency Ultrasound Assessment of Cutaneous Primary Lymphomas: An Innovative Classification

BACKGROUND

Primary cutaneous lymphoma (PCL) is a rare form of extranodal non-Hodgkin's lymphoma characterized by malignant lymphocytes confined to the skin. Accurate diagnosis and staging are crucial for optimal management, yet radiological literature on imaging PCL remains limited. This study aims to delineate the imaging characteristics of PCLs using high and ultra-high frequency ultrasound (UHFUS) and proposes a classification system based on ultrasound findings.

METHODS

A cohort of 88 individuals with suspected PCL underwent high-resolution ultrasound (HRUS) and color Doppler examination of lesions. Lesions were categorized based on sonographic appearance, and subsequent histopathological assessment confirmed the diagnosis.

RESULTS

Ultrasound imaging revealed distinct patterns for primary cutaneous T-cell lymphomas (PCTCL) and primary cutaneous B-cell lymphomas (PCBCL), with characteristic features such as hypoechoic nodules, pseudonodular lesions, and dermal infiltration. Histopathological analysis confirmed the ultrasound findings, supporting the proposed classification system.

CONCLUSIONS

Ultrasonography, particularly UHFUS, offers valuable insights into the imaging characteristics of primary cutaneous lymphomas, aiding the accurate diagnosis and assessment of treatment response. The proposed classification system based on ultrasound findings enhances the diagnostic approach to PCLs, and paves the way for improved patient care and management strategies.

Complete lymph node dissection in cutaneous melanoma patients with positive sentinel lymph node: Outcome and predictors in a retrospective cohort study over 16 years

BACKGROUND

In melanoma treatment, complete lymph node dissection (CLND) has been considered the therapeutic gold standard in patients with positive sentinel lymph node biopsy (SLNB). This long-held approach was revised in 2017, with recent evidence questioning the therapeutic benefit of CLND in malignant melanoma (MM) therapy. In this study, we aimed to fill this knowledge gap by retrospectively analyzing the impact of CLND on MM patients' survival.

METHODS

We retrospectively analyzed the multi-center population-based Clinical Cancer Registry at the Tumor Center Regensburg (TUDOK) database (2004-2020) to identify patients who had been diagnosed with SLN-positive MM and underwent (non)invasive management thereof. Patient cohorts were subdivided according to the treatment received (CLND and waiving CLND). Primary outcomes included overall survival (OS), recurrence-free survival (RFS), and cumulative recurrence rate.

RESULTS

We identified 1143 MM patients, of whom 126 (11.0%) had positive SLN status. CLND was waived in the majority of SLN-positive MM cases (n = 71; 56.3%), with 55 (43.7%) patients undergoing CLND. Univariable and multivariable Cox regression revealed no significant advantage for CLND patients compared to non-CLND patients in OS (HR=0.970, p = 0.915 and HR=1.295, p = 0.479, respectively), RFS (HR=1.050, p = 0.849 and HR=1.220, p = 0.544, respectively), and cumulative recurrence rate (HR=1.234, p = 0.441 and HR=1.220, p = 0.544), respectively).

CONCLUSION

We found that CLND had no significant impact on patient survival and MM recurrence rate, thus corroborating the validity of current clinical guidelines.

The Importance of In Vivo Reflectance Confocal Microscopy in a Case of Desmoplastic Melanoma

Desmoplastic melanoma accounts for 5% of all cases of melanoma, but its diagnosis can be difficult due to its frequent clinical presentation with amelanotic lesions. Histologically, spindled melanocytes surrounded by a collagenous stroma are observed. Compared with other types of melanoma, the desmoplastic types presents greater local aggression, and is more prone to local recurrence, but has a lower risk of lymph node metastasis. Early detection, accurate staging, and proper surgical management are the main factors associated with higher survival rates in melanoma patients. Reflectance confocal microscopy (RCM) has proven to be a valuable imaging tool in the diagnosis of skin neoplasms, being useful for orientating practitioners towards the diagnosis of melanoma and indicating the necessity of performing a diagnostic biopsy. We present the case of 52-year-old woman, who presented to the dermatology department with an irregular, dark-colored plaque in the right deltoid region. Dermoscopy showed asymmetry with an atypical network and some areas of regression. RCM revealed pagetoid cells in the upper epidermis, cell atypia, non-edged papillae, dermal inflammation, and nucleated cells in the dermis, which are highly suggestive of melanoma. A biopsy was also performed. A histopathology exam confirmed the diagnosis of superficially spreading melanoma with a desmoplastic component, and revealed a Breslow index of 0.9 mm, Clark level IV, an absence of mitoses, angiolymphatic invasion and regression, and complete excision. The CT and PET-CT scans were negative. A biopsy of the axillary sentinel lymph node was conducted, with a negative result obtained, establishing the IB stage of the disease. The patient will remain under follow-up to look for a recurrence or a new primary melanoma.

Extensive Scalp Melanoma in an Elderly Female: A Case Report and Literature Review

Scalp melanoma is a rare and aggressive form of skin cancer. Its occurrence in the elderly population poses unique challenges due to factors such as delayed diagnosis and comorbidities. We present a case of extensive scalp melanoma in an elderly female to highlight the clinical presentation, diagnostic process, treatment modalities, and outcomes. Biopsy and histopathological analysis showed the presence of dysplastic nevi arising in pigmented melanocytic nevi, with uncertain pagetoid spread of atypical melanocytes. The management involved complete excision with safety margins and immunotherapy based on melanoma guidelines. This case underscores the importance of early detection and tailored treatment strategies in managing melanoma in elderly patients.

Sentinel Lymph Node Biopsy in Malignant Melanoma of the Head and Neck: A Single Center Experience

Purpose: This study evaluated the characteristics of patients with head and neck (H&N) melanoma who underwent sentinel lymph node biopsy (SNLB) and assessed the clinical course of patients categorizing subjects according to SLNB status and melanoma location (scalp area vs. non-scalp areas). Methods: Patients undergoing SLNB for melanoma of H&N from 2015 to 2021 were prospectively characterized according to sentinel lymph node (SLN) status. SPECT/CT had been previously performed. Patients were followed until the first adverse event to evaluate progression-free survival. Results: 93 patients were enrolled. SLNB was negative in 75 patients. The median Breslow index was higher for patients with positive SLNB compared with patients with negative SLNB. In addition, the Breslow index was higher for melanoma of the scalp compared with non-scalp melanoma. The median follow-up was 24.8 months. Progression occurred at the systemic level in the 62.5% of cases. There was a significant association between positive SLNB and progression (p-value < 0.01) of disease, with lower progression-free survival for patients with melanoma of the scalp compared with those with melanoma at other anatomic sites (p-value: 0.15). Conclusions: Scalp melanomas are more aggressive than other types of H&N melanomas. Sentinel lymph node status is the strongest prognostic criterion for recurrence.

Melanoma of the Scalp and Neck: A Population-Based Analysis of Survival and Treatment Patterns

Introduction: Melanoma is an aggressive skin cancer. Large demographic and clinic-pathologic studies are required to identify variations of tumour behavior. The aim of our study was to offer updated epidemiologic data on the scalp and neck melanoma with an overall survival analysis. Method: The SEER database was searched for all scalp and neck melanoma in adult patients between 2000 and 2019. Demographic and clinic-pathologic variables were described. Their impact on overall survival was assessed with the log-rank test after Kaplan−Meier model. A multivariable cox-regression was conducted to identify predictors of decreased survival. A p-value of <0.005 was considered statistically significant. Results: 20,728 Melanomas of the scalp and neck were identified. Mean age was 62.5 years. Gender ratio was 76.3% males. 79% of the tumours were localized at diagnosis. Increasing age, male gender, tumour ulceration, high mitotic rate or nodular subtype were independent prognostic factors of decreased overall survival. Surgery with less than 1 cm margin is associated with the best overall survival in this cohort. No significant difference in OS was seen between less than 1 cm and 1 to 2 cm margins. Conclusion: Knowledge of negative prognostic factors might help identify subgroups at risk and adapt their oncologic treatment.

A cross-sectional study of clinical, dermoscopic, histopathological, and molecular patterns of scalp melanoma in patients with or without androgenetic alopecia

Scalp melanoma (SM) has a worse prognosis than melanoma in other locations likely because of late diagnosis due to hair coverage, difficulties in interpreting dermoscopy findings, and its unique molecular profile. We aimed to describe the clinical, histopathological, molecular, and dermoscopic patterns of SM and its relation to androgenetic alopecia/elastosis at the tumor site. Through a retrospective cross-sectional study, we identified all SM diagnosed at the A.C.Camargo Cancer Center between 2008 and 2018. In all, 48 SM were analyzed: 45.8% of which exhibited moderate/severe androgenetic alopecia and 54.1% exhibited elastosis. Androgenetic alopecia/elastosis at the site of the SM was associated with older age (p < 0.001), chronic sun damage (p < 0.001), lentigo maligna subtype (p = 0.029), and photodamaged dermoscopic pattern (p < 0.001). Additionally, 41 cases were evaluated with a 14-gene panel: 53.7% displayed mutations and 46.3% were wild-type. BRAF mutations were most common (77%), with BRAF V600K being more frequent (50%) than BRAF V600E (31.2%). The NF1 gene was evaluated in 40 samples, of which 20% exhibited mutations. SM presents differently in areas covered by hair compared to in areas with androgenetic alopecia. Patients without alopecia may have higher Breslow thickness due to late diagnosis because of hair concealment. The high frequency of detrimental mutations can also explain the poor prognosis of SM.