Real Life Clinical Management and Survival in Advanced Cutaneous Melanoma: The Italian Clinical National Melanoma Registry Experience

Background

Cutaneous melanoma (CM) is one of the most aggressive types of skin cancer. Currently, innovative approaches such as target therapies and immunotherapies have been introduced in clinical practice. Data of clinical trials and real life studies that evaluate the outcomes of these therapeutic associations are necessary to establish their clinical utility. The aim of this study is to investigate the types of oncological treatments employed in the real-life clinical management of patients with advanced CM in several Italian centers, which are part of the Clinical National Melanoma Registry (CNMR).

Methods

Melanoma-specific survival and overall survival were calculated. Multivariate Cox regression models were used to estimate the hazard ratios adjusting for confounders and other prognostic factors.

Results

The median follow-up time was 36 months (range 1.2-185.1). 787 CM were included in the analysis with completed information about therapies. All types of immunotherapy showed a significant improved survival compared with all other therapies (p=0.001). 75% was the highest reduction of death reached by anti-PD-1 (HR=0.25), globally immunotherapy was significantly associated with improved survival, either for anti-CTLA4 monotherapy or combined with anti-PD-1 (HR=0.47 and 0.26, respectively) and BRAFI+MEKI (HR=0.62).

Conclusions

The nivolumab/pembrolizumab in combination of ipilimumab and the addition of ant-MEK to the BRAFi can be considered the best therapies to improve survival in a real-world-population. The CNMR can complement clinical registries with the intent of improving cancer management and standardizing cancer treatment.

The surgical treatment of non-metastatic melanoma in a Clinical National Melanoma Registry Study Group (CNMR): a retrospective cohort quality improvement study to reduce the morbidity rates

Background

Reproducible, high-quality surgery is a key point in the management of cancer patients. Quality indicators for surgical treatment of melanoma has been presented with benchmarks but data on morbidity are still limited. This study presents the quality indicators on morbidity after surgical treatment for non-metastatic skin melanoma in an Italian registry.

Methods

Data were extracted from the Central National Melanoma Registry (CNMR) promoted by the Italian Melanoma Intergroup (IMI). All surgical procedures (WE, SNLB or LFND) for non-metastatic skin melanoma between January 2011 and February 2017 were evaluated for inclusion in the study. Only centers with adequate completeness of information (> 80%) were included in the study. Short-term complications (wound infection, dehiscence, skin graft failure and seroma) were investigated.

Results

Wound infection rate was 1.1% (0.4 to 2.7%) in WE, 1.3% (0.7 to 2.5%) in SLNB and 4.1% (2.1 to 8.0%) in LFND. Wound dehiscence rate was 2.0% (0.8 to 5.1%) in WE, 0.9% (0.2 to 3.0%) in SLNB and 2.8% (0.9 to 8.6%) in LFND. Seroma rate was 4.2% (1.5 to 11.1%) in SLNB and 15.1% (4.6 to 39.9%) in LFND. Unreliable information was found on skin graft failure.

Conclusions

Our findings contribute to available literature in setting up the recommended standards for melanoma centers, thus improving the quality of surgery offered to patients. A consensus on the core issues around surgical morbidity is needed to provide practical guidance on morbidity prevention and management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07705-4.

Diaminodiphenylmethane Sensitization in north-eastern Italy from 1996 to 2012

BACKGROUND

4,4'-Diaminodiphenylmethane (DDM) is an aromatic amine used as a hardener, insulator and anticorrosive. Exposure implies risk of being sensitized and developing contact dermatitis.

OBJECTIVE

The aim of this study was to determine the occurrence of contact sensitization to DDM among patients with contact dermatitis and the role of occupational exposure.

PATIENTS AND METHODS

From 1996 to 2012, 24 056 consecutive patients with suspected allergic contact dermatitis were patch tested in north-eastern Italy. Individual characteristics were collected through a standardized questionnaire in eight departments of dermatology and occupational medicine.

RESULTS

The overall prevalence of DDM sensitization was 2.5% (n = 599) with a decreasing trend in considered years. Trieste area had the higher prevalence of sensitization (3.2%). Mechanics and chemical industry workers had a significant higher risk of being sensitized to DDM.

CONCLUSION

DDM sensitization is decreasing in years and is associated with some occupational exposures.

Sun exposure and melanoma prognostic factors

Previous studies have reported an association between sun exposure and the increased survival of patients with cutaneous melanoma (CM). The present study analyzed the association between ultraviolet (UV) light exposure and various prognostic factors in the Italian Clinical National Melanoma Registry. Clinical and sociodemographic features were collected, as well as information concerning sunbed exposure and holidays with sun exposure. Analyses were performed to investigate the association between exposure to UV and melanoma prognostic factors. Between December 2010 and December 2013, information was obtained on 2,738 melanoma patients from 38 geographically representative Italian sites. A total of 49% of the patients were >55 years old, 51% were men, 50% lived in the north of Italy and 57% possessed a high level of education (at least high school). A total of 8 patients had a family history of melanoma and 56% had a fair phenotype (Fitzpatrick skin type I or II). Of the total patients, 29% had been diagnosed with melanoma by a dermatologist; 29% of patients presented with a very thick melanoma (Breslow thickness, >2 mm) and 25% with an ulcerated melanoma. In total, 1% of patients had distant metastases and 13% exhibited lymph node involvement. Holidays with sun exposure 5 years prior to CM diagnosis were significantly associated with positive prognostic factors, including lower Breslow thickness (P<0.001) and absence of ulceration (P=0.009), following multiple adjustments for factors such as sociodemographic status, speciality of doctor performing the diagnosis and season of diagnosis. Sunbed exposure and sun exposure during peak hours of sunlight were not significantly associated with Breslow thickness and ulceration. Holidays with sun exposure were associated with favorable CM prognostic factors, whereas no association was identified between sunbed use and sun exposure during peak hours of sunlight with favorable CM prognostic factors. However, the results of the present study do not prove a direct causal effect of sun exposure on melanoma prognosis, as additional confounding factors, including vitamin D serum levels, may have a role.

Healthcare workers and skin sensitization: north-eastern Italian database

BACKGROUND

Working in healthcare is regarded as a risk factor for occupational skin disease. Workers are exposed to disinfectants, soaps, detergents and latex and need to wash their hands frequently and thoroughly.

AIMS

To investigate the association between healthcare work and patch test reactions to various potential sensitizers in a population of contact dermatitis patients in various dermatology and occupational medicine units in north-eastern Italy.

METHODS

Patients with suspected allergic dermatitis underwent patch testing. Odds ratios (ORs) and 95% confidence intervals (CIs), adjusted by age and sex, were calculated for healthcare workers (HCWs), using white-collar workers as control group.

RESULTS

HCWs represented 14% of the sample of 19088 patients (68% women, 32% men). Among HCWs, both sexes had a higher risk of developing hand/forearm dermatitis (females: OR 2.1, 95% CI 1.8-2.5; males: OR 1.6, 95% CI 1.3-2.1). HCWs had an increased risk of sensitization to formaldehyde (OR 1.65; 95% CI 1.2-2.3) and to p-phenylenediamine (OR 1.6; CI 1.1-2.3).

CONCLUSIONS

Our study suggests a significant association between healthcare work, hand/forearm dermatitis and sensitization to formaldehyde and p-phenylenediamine.

Differences in clinicopathological features and distribution of risk factors in Italian melanoma patients

BACKGROUND

No studies are available in the literature on the distribution of different melanoma features and risk factors in the Italian geographical areas.

OBJECTIVE

To identify the differences in clinical-pathological features of melanoma, the distribution of risk factors and sun exposure in various Italian macro-areas.

METHODS

Multicentric-observational study involving 1,472 melanoma cases (713 north, 345 centre, 414 south) from 26 referral centres belonging to the Italian Multidisciplinary Group for Melanoma.

RESULTS

Melanoma patients in northern regions are younger, with thinner melanoma, multiple primaries, lower-intermediate phototype and higher counts of naevi with respect to southern patients; detection of a primary was mostly connected with a physician examination, while relatives were more involved in the south. Northern patients reported a more frequent use of sunbeds and occurrence of sunburns before melanoma despite sunscreen use and a lower sun exposure during the central hours of the day.

CONCLUSIONS

The understanding of differences in risk factors distribution could represent the basis for tailored prevention programmes.

Occupational sensitization to epoxy resins in Northeastern Italy (1996-2010)

BACKGROUND

One of the main health concerns of epoxy resins is their role as skin sensitizer. This sensitization is not uncommon, because the prevalence ranges around 1-12% of the general population.

OBJECTIVES

Perform a cross sectional study in a patch test population from Northeastern Italy to investigate the prevalence of epoxy resins sensitization among patients with suspected contact dermatitis. Subsequently, relate findings to patients' occupation and evaluate time trend of prevalence.

METHODS

The final study database included 19 088 consecutive patients, tested from 1996 to 2010 in Northeastern Italy.

RESULTS

The overall prevalence of epoxy resins sensitization was 0·89%. Dermatitis most frequently involved hands (40·25%). In both sexes, we find a significant correlation in mechanics, woodworkers, and chemical industry workers; and in males only, among farmers and fishers, construction workers, and unemployed. We found significant increase of sensitization in construction workers in the analyzed period.

CONCLUSIONS

The overall prevalence of sensitization to epoxy resins in Northeastern Italy is in line with other European countries, but we found an increased risk of sensitization in some professions and an increasing trend of prevalence in construction workers. Better preventive actions are strongly advised in higher risk professions, with particular attentions towards building sector.

In situ malignant melanoma on nevus spilus in an elderly patient

Nevus spilus is the term usually given to a pigmented skin lesion, congenital or acquired, that may occur anywhere on the body, consisting of a large light tan patch with numerous superimposed darker scattered maculae or papulae that are flat or slightly raised. For a long time, nevus spilus was believed to be a benign lesion. However, in 1957 Perkinson reported a melanoma appearing on nevus spilus for the first time. Since then other reports about melanomas developing on nevus spilus have been published, sometimes with a fatal outcome. We describe the case of an 80-year-old male patient with a congenital nevus just above his left knee. The lesion had remained unchanged over time, but some months before his checkup the patient noticed a darker area in the lesion that had continued to enlarge. The lesion was removed and histological examination revealed an in situ malignant melanoma. Although nevus spilus is not normally considered a precursor of melanoma, the potentiality of malignant transformation requires regular monitoring, and careful checkups are recommended and justified.

Concurrent sensitization to metals and occupation

BACKGROUND

Cosensitization to nickel, cobalt and chromium occurs in the general population and in some occupational groups.

OBJECTIVES

To estimate the isolated and concurrent occurrence of nickel, cobalt and chromium contact sensitization and their association with individual and occupational risk factors.

PATIENTS/METHODS

Twelve thousand four hundred and ninety-two patients were patch tested with the European baseline series between 1997 and 2004 in north-eastern Italy. The associations between patch test results and patient characteristics and occupations were investigated by means of multinomial logistic regression analysis.

RESULTS

Of the patients, 34.7% (4334 patients) had one or more positive patch test reactions to metals. As compared with those with negative reactions to all three metals, nickel sensitization was significantly higher in females than in males, not only as monosensitization, but also as cosensitization with cobalt, with chromium, or with both metals. Building and related trades workers showed positive reactions to chromium + nickel [odds ratio (OR) 1.99; 95% confidence interval (CI) 1.05-3.76) and chromium + cobalt (OR 2.61; 95% CI 1.46-4.67]. Cleaning workers showed a high prevalence of nickel, chromium, nickel + chromium and nickel + cobalt + chromium cosensitization (ORs 1.29, 1.66, 2.11, and 1.79, respectively). An excess risk for cosensitization to all three metals was found in textile and leather workers (OR 2.19; 95% CI 1.10-4.33), and in bartenders (OR 2.10; 95% CI 1.03-4.26).

CONCLUSIONS

Some occupational groups are more likely to develop nickel, cobalt and chromium cosensitization.

p-Phenylenediamine sensitization and occupation

BACKGROUND

p-Phenylenediamine (PPD) is an extreme delayed-type skin sensitizer, and is relevant in both occupational and non-occupational exposures.

OBJECTIVES

To estimate the prevalence of PPD sensitization in a population of consecutive patients with suspected allergic contact dermatitis who attended units of dermatology or occupational medicine in north-eastern Italy and to investigate the association between their PPD sensitization and occupation.

PATIENTS/MATERIALS/METHODS

A total of 14,464 patients (67.6% women and 32.4% men) with suspected allergic dermatitis underwent patch testing. The associations between patch test results and occupations were studied by multivariate logistic regression analysis.

RESULTS

In both sexes, PPD sensitization was significantly associated with hairdressing and beauty occupation [women, odds ratio (OR) 6.58, 95% confidence interval (CI) 3.76-11.50; men, OR 22.3, 95% CI 4.18-119]. In the female group, PPD sensitization was also significantly higher in professional drivers (OR 5.31, 95% CI 1.76-16.1), barmaids (OR 1.89, 95% CI 1.04-3.44), and cleaners (OR 1.82, 95% CI 1.24-2.68). In the male group, PPD sensitization was significantly higher in bakers and waiters (OR 13.0, 95% CI 1.38-123), household workers (OR 8.46, 95% CI 1.68-42.8), and printers (OR 5.68, 95% CI 1.50-21.5).

CONCLUSIONS

Our study showed that workers in several occupations may be at higher risk of developing sensitization to PPD. It is of importance to reduce possible exposure to PPD-crossreacting substances in these occupations.

Nevus Spilus and Melanoma: Case Report and Review of the Literature

Background:

Nevus spilus is characterized by a pigmented patch with scattered flat or maculopapular speckles. Nevus spilus was first described by Burkley in 1842. Since then, this lesion has been widely debated in the literature, particularly for the possible occurrence of melanoma within the lesion.

Objective:

We describe the case of a 65-year-old female presenting with a nodular achromic melanoma that occurred within a nevus spilus on the left thigh.

Conclusion:

Our observation is consistent with the idea that this entity in some circumstances may have the ability to evolve into a malignant melanoma.

Baseline factors influencing decisions on digital follow-up of melanocytic lesions in daily practice: An Italian multicenter survey

BACKGROUND

Guidelines for optimized use of digital follow-up of melanocytic lesions are not yet available, and little is known about inclusion criteria adopted in clinical practice.

OBJECTIVE

Our purpose was to describe the frequency of digital follow-up adoption in melanoma screening, the characteristics of patients and lesions selected, and the predictors of duration of the intervals of digital follow-up.

METHODS

Baseline characteristics of patients and lesions selected for digital follow-up in 12 Italian pigmented lesion clinics were examined. Predictors of a short follow-up interval (<or=3 months) compared with a 6-month interval were investigated by means of logistic regression analysis.

RESULTS

Out of 2116 subjects consecutively examined, 409 were submitted to digital follow-up (19.3%), with 1.6 mean lesions found per patient (range, 1-9; median, 1). According to an a posteriori analysis, 15.2% of the lesions were diagnostically equivocal and 7.8% of lesions had a total dermoscopy score (TDS) suggestive of malignancy. However, large differences in the TDS were found among the participating centers. Determinants of a short follow-up interval, adopted in 40.8% of patients, were the personal history of melanoma (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.09-5.99) and the presence of atypical nevi (at least one atypical nevus (OR 4.54, 95% CI 2.45-8.42). Unexpectedly, the dermoscopic atypia of the lesion (TDS >4.75) was associated only with a marginal effect on the scheduled duration of follow-up interval (OR 1.34, 95% CI 0.97-1.86). These findings were confirmed by a multivariate analysis.

LIMITATIONS

The adoption of different digital dermoscopy systems in the participating centers may have limited the reliability of the TDS assigned by a central group to dermoscopy images.

CONCLUSIONS

Practicing dermatologists who use digital epiluminescence microscopy in screening for melanoma decided to submit at least one melanocytic lesion to digital follow-up for approximately 1 patient for every 5 examined. This implies costs and time spent that need to be evaluated together with the benefits of this procedure from a large-scale perspective. The lack of well-defined guidelines for inclusion and exclusion criteria may hamper optimized use of digital follow-up in daily practice.

Allergic contact sensitivity in elderly patients

BACKGROUND AND AIMS

Aging has been shown to be correlated with the rate and type of contact sensitization, but only a few studies have evaluated patch test reactivity in elderly subjects with an adequately large population.

METHODS

The response patterns to patch testing in 1444 elderly subjects (>65 years) with suspected allergic contact dermatitis were studied, and the results compared with a control group of individuals with suspected allergic contact dermatitis, aged between 20 and 40 years.

RESULTS

The prevalence of the positive patch test to at least one hapten was significantly lower in the group of elderly patients compared with adult patients (40.7 vs 47.8%, p<0.0001). However, some allergens, i.e., primin, diaminodiphenylmethane, neomycin, lanolin alcohols, paraben mix, Euxyl K400 and quinoline mix, showed an increased sensitization rate in elderly patients compared with adult patients. These allergens are now less frequently employed in the workplace, or are substances particularly used in the formulation of topical treatment of age-related diseases, i.e., leg ulcer and xerosis. It was also found that the intensity of positive patch test reactions was significantly lower in elderly patients compared with younger subjects, with higher proportions of weak (+) positive reactions. Moreover, elderly patients showed a dynamic pattern of increasing intensity of patch test reactions at the second reading after 3 days compared with the first reading after 2 days more frequently than younger patients (60 vs 53%, p<0.0001).

CONCLUSIONS

These findings suggest an age-dependent decline of overall positive patch test reactions, but a higher sensitization rate to some allergens frequently used in the composition of topical treatments. The development of an allergic response in elderly patients was found to be delayed, and this may require an additional reading after 7 days and the interpretation of even weak reactions as valid positive patch test reactions.

Diaminodiphenylmethane (DDM): frequency of sensitization, clinical relevance and concomitant positive reactions

Diaminodiphenylmethane (DDM) is an aromatic diamine used in the manufacture of rubber, plastics, diisocyanates, dyes and adhesives. It may cross-react with para-(amino)compounds. Allergic patch test reactions to DDM are relatively frequent, but their relevance is often difficult to detect. We report our experience in 6809 patients (4589 female, 2220 male, mean age 39.9+/-17.8 years) with suspected contact dermatitis patch tested during the period 1997-1999 by the North-East Italy Contact Dermatitis Group (NEICDG). A positive patch test to DDM was detected in 132 (1.9%) patients (88 female, 44 male, mean age 49.5+/-16.2 years). Eczema was mostly localized on the hands. The relevance was detected in 31 patients. A logistic regression analysis showed an association with patient's age (odds ratio 5.4 for age 30-59 years), absence of atopic diseases (odds ratio 3.1) and presence of leg ulcer (odds ratio 5). We found a highly significant correlation (p<0.001) between sensitivity to DDM and to para-phenylenediamine, Disperse Yellow 3, cobalt chloride, fragrance mix, benzocaine, paraben mix and primin. Positive patch test results to DDM were relatively frequent. The difficulty in detecting the relevance of these sensitizations may be related to the surprisingly high frequency of concomitant positive reactions to other allergens.