The Burden of Thin Melanomas in Tuscany, Italy, 1985-2017: Age- and Sex-Specific Temporal Trends in Incidence and Mortality

A steady increase in the incidence and mortality burden correlated to thin melanomas (≤1 mm) has been reported in recent years in some international studies, but there is currently a paucity of data from the Mediterranean area. We aimed to describe the epidemiological characteristics of thin melanoma in Tuscany, Central Italy. A total of 6002 first cutaneous invasive melanomas occurring from 1985 to 2017 were selected for analysis; data were retrieved from the local population-based cancer registry. The standardized incidence rate was 15.0 per 100,000 in the population, higher among men than women (16.5 vs. 14.1). Incidence rates tended to increase over time across all age group-specific population strata, with annual percent changes moderately higher among men (+8.0%) than women (+6.9%), especially among the elderly. Among both sexes and in each age group, the trend toward increasing incidence rates was particularly strong for thin melanomas. Survival was better among women than men across all categories of thickness. Approximately 15% of deaths occurred among patients with thin lesions, with no major temporal changes in recent years. This study contributes to an improved understanding of melanoma epidemiology in Tuscany and underscores the need for primary prevention strategies tackling the growing burden of thin melanomas.

Optically Guided High-Frequency Ultrasound Shows Superior Efficacy for Preoperative Estimation of Breslow Thickness in Comparison with Multispectral Imaging: A Single-Center Prospective Validation Study

Melanoma is the most aggressive form of skin cancer that is known for its metastatic potential and has an increasing incidence worldwide. Breslow thickness, which determines the staging and surgical margin of the tumor, is unavailable at initial diagnosis. Novel imaging techniques for assessing Breslow thickness lack comparative data. This study evaluates optically guided high-frequency ultrasound (OG-HFUS) and multispectral imaging (MSI) for preoperative estimation of Breslow thickness and staging. We enrolled 101 patients with histologically confirmed primary melanoma and categorized them based on tumor thickness. Optically guided 33 MHz HFUS and MSI were utilized for the assessment. Our MSI-based algorithm categorized melanomas into three subgroups with a sensitivity of 62.6%, specificity of 81.3%, and fair agreement (κ = 0.440, CI: 0.298-0.583). In contrast, OG-HFUS demonstrated a sensitivity of 91.8%, specificity of 96.0%, and almost perfect agreement (κ = 0.858, CI: 0.763-0.952). OG-HFUS performed better than MSI in estimating Breslow thickness, emphasizing its potential as a valuable tool for melanoma diagnosis and patient management. OG-HFUS holds promise for enhancing preoperative staging and treatment decision-making in melanoma.

Melanoma and subcutaneous adipose tissue: Role of peritumoral adipokines in disease characterization and prognosis

In the last decades, the concept of adipose organ has emerged, giving adipose tissue an active endocrine and immunologic function through the secretion of multiple cytokines and chemokines that seem to be implicated in the development and progression of several cancer, including cutaneous melanoma. In this pilot experimental study, we analyzed the expression in the peritumor subcutaneous adipose tissue of the most significant adipokines involved in the processes of carcinogenesis and metastasis in a population of melanoma patients and in two control groups composed of melanocytic nevi and epidermoid cysts, respectively. We correlated the results obtained with the main disease prognostic factors observing a statistically significant increase in the expression of PAI1, LEP, CXCL1, NAMPT, and TNF-α at the level of the peritumor tissue of the melanoma samples compared to the control groups and a correlation of the same with the histopathological prognostic factor of melanoma. Our preliminary study shows that the overexpression of PAI1, LEP, CXCL1, NAMPT, and TNF-α may contribute to the growth and to the local aggressiveness of cutaneous melanoma. It opens the hypothesis of a direct oncogenic role of subcutaneous adipose tissue and adipokines in the tumorigenesis of melanoma.

Invasive Cutaneous Melanoma: Evaluating the Prognostic Significance of Some Parameters Associated with Lymph Node Metastases

Background and Objectives: This study aimed to assess the clinical-pathological profile of patients with invasive cutaneous melanomas and to identify the parameters with a prognostic role in the lymph nodal spread of this malignant tumor. Materials and Methods: We performed a retrospective study on patients with invasive cutaneous melanomas who underwent surgery in the "Pius Brînzeu" County Clinical Emergency Hospital from Timișoara, Romania, and were evaluated for the status of loco-regional lymph nodes. We selected and analyzed some parameters searching for their relationship with lymph node metastases. Results: We identified 79 patients with invasive cutaneous melanomas (29 men and 50 women, mean age 59.36 years). A percentage of 58.3% of melanomas had Breslow tumor thickness >2 mm; 69.6% of melanomas showed a Clark level IV-V. Tumor ulceration was present in 59.5% of melanomas. A mitotic rate of ≥5 mitoses/mm² was observed in 48.1% of melanomas. Tumor-infiltrating lymphocytes (TILs), non-brisk, were present in 59.5% of cases and 22.8% of patients had satellite/in-transit metastasis (SINTM). Tumor regression was identified in 44.3% of cases. Lymph nodes metastases were found in 43.1% of patients. Statistical analysis showed that lymph node metastases were more frequent in melanomas with Breslow thickness >2 mm (p = 0.0002), high Clark level (p = 0.0026), mitotic rate >5 mitoses/mm² (p = 0.0044), ulceration (p = 0.0107), lymphovascular invasion (p = 0.0182), SINTM (p = 0.0302), and non-brisk TILs (p = 0.0302). Conclusions: The Breslow thickness >2 mm, high Clark level, high mitotic rate and ulceration are the most important prognostic factors for lymph nodal spread in cutaneous melanomas. However, some melanomas without these clinical-pathological features can have an unexpected, aggressive evolution, which entails the necessity of close and prolonged clinical follow-up of patients, including those with lesions considered without risk.

The Importance of Immunohistochemistry in the Evaluation of Tumor Depth of Primary Cutaneous Melanoma

Primary cutaneous melanoma (PCM) is the most aggressive skin malignancy, with an increasing incidence and significant mortality. Tumoral invasion, expressed as Breslow thickness, is routinely assessed on hematoxylin and eosin (HE), although this stain may sometimes underestimate the tumoral depth. The aim of this study was to compare the efficiency of the immunohistochemical (IHC) markers S-100, SOX10, Melan-A, and HMB-45 with HE for the evaluation of the Breslow thickness and staging of PCM. This retrospective study included 46 cases of PCM diagnosed between 2015 and 2022; for each case, the Breslow thickness using HE, S-100, SOX10, Melan-A, and HMB-45 was measured and the appropriate T category was recorded. The highest values of the Breslow thickness were observed for S-100. However, S-100, SOX10, and Melan-A provided statistically significant higher values of the Breslow thickness compared to HE, but no difference was noted between HMB-45 and HE. S-100 was most frequently involved in increasing the T category (26.1%), the majority of cases being upstaged from T1a to T1b. The IHC markers S-100, SOX10, and Melan-A contributed to better evaluation of the melanoma invasion, especially in thin melanomas, but their impact on staging and consecutive treatment remains to be confirmed by future studies.

Risk of recurrence of nail unit melanoma after functional surgery versus amputation

BACKGROUND

Minimally invasive nail unit melanoma (NUM) can be treated with functional surgery (FS) instead of amputation.

OBJECTIVE

To determine risk factors associated with recurrence in NUM.

METHODS

We retrospectively reviewed patients with NUM between 2008 and 2022 at a tertiary referral center. Multivariable Cox regression models adjusted for male sex and Breslow thickness (BT) were generated. Receiver operating characteristic analysis was performed to determine optimal cut-off points of the BT for stratifying recurrence risk.

RESULTS

We evaluated 140 NUM cases (33 amputation and 107 FS). The mean BT values were 3.14 ± 2.62 mm (amputation) and 0.70 ± 1.36 mm (FS). Recurrence occurred in 10 (30.30%) patients with amputation and 23 (21.5%) with FS. Distant disease occurred in 10 (30.30%) patients with amputation and 8 (7.48%) with FS. Male sex, greater BT, amelanotic color, ulcers, and nodules were associated with greater risk for recurrence or distant disease. A BT of 0.8 mm was deemed the optimal cut-off for stratifying recurrence risk after surgery (odds ratio, 5.32; 95% CI, 2.04-13.85).

LIMITATIONS

Small sample.

CONCLUSION

FS can be considered for NUM with a BT < 0.8 mm, providing an amputation-sparing benefit. However, NUM with risk factors for recurrence requires patient counselling and close follow-ups.

Ultra-High Frequency Ultrasound in Melanoma Management: A New Combined Ultrasonographic-Histopathological Approach

OBJECTIVES

The main aim of this study is to evaluate the correspondence between the ultrasonographic thickness and the Breslow thickness in melanoma using ultra-high frequency ultrasound and the intra- and inter-operator repeatability in the ultrasonographic measurements of melanoma depth. Moreover, we propose a new protocol based on a combined ultrasonographic-histopathological approach.

METHODS

We analyzed 27 melanomas in a population consisted of 27 patients (mean age 57.6 years, 51.8% males), who came at the Department of Dermatology (University of Pisa, Pisa, Italy) from April 2016 to March 2018 and had an ultrasonographic examination of a suspected lesion before the surgical removal using ultra-high frequency ultrasound (Vevo®MD, Fujifilm, Visualsonics, Toronto, Canada; 70 MHz probe). B-mode images were analyzed by two skilled and blinded operators, and the maximum depth of the lesions was measured using a dedicated graphical user interface developed in Matlab R2016b (MathWorks Inc., Natick, MA), to obtain repetitive measurements.

RESULTS

All melanomas appeared as band-like or oval/fusiform shaped hypoechoic inhomogeneous lesions. We observed an excellent agreement between the Breslow thickness of melanomas and the ultrasonographic thickness, as well as a reduced intra- and inter-operator variability in the ultrasonographic measurements of melanoma depth.

CONCLUSIONS

We propose a ultrasonographic-histopathological protocol which may help clinicians to reduce the diagnostic delay, improve prognosis and survival rates, perform a surgical excision with negative margins, and reduce the variability in the assessment of Breslow thickness.

Impact of the COVID-19 Pandemic on Melanoma Diagnosis: Increased Breslow Thickness in Primary Melanomas-A Single Center Experience

Early melanoma diagnosis plays a key role in ensuring best prognosis with good survival rates. The ongoing global COVID-19 pandemic has greatly impacted global and national healthcare systems, thus making it a real challenge. The aim of this study was to evaluate the impact of the pandemic on diagnostic delay in melanoma patients in Serbia. In this retrospective study, we included patients treated at the university hospital in Serbia's capitol over a period of five years and three months. We compared the prepandemic (01/JAN/17-14/MAR/20) and pandemic periods (15/MAR/20-31/MAR/22) by evaluating patient demographic data, melanoma subtype, Breslow thickness, Clark level, ulceration status, mitotic index rate and pT staging. We observed a significant reduction in the number of diagnosed patients (86.3 vs. 13.7%; p = 0.036), with melanomas having an increased median Breslow thickness (1.80 vs. 3.00; p = 0.010), a higher percentage of Clark IV-V level lesions (44.0% vs. 63.0%; p = 0.009), an increase in median mitotic index rate (2 vs. 5; p < 0.001) and a trend of increase in lesions thicker than 2 mm (37.8% vs. 53.7%; p = 0.026). We believe that this study can be a useful scenario guide for future similar events, highlighting the importance of preventive measures and timely diagnosis for the best patient outcomes.

Preoperative Ultrasound-Guided Incisional Biopsy Enhances the Pathological Accuracy of Incisional Biopsy of Cutaneous Melanoma: A Prospective Clinical Trial in Chinese Patients

OBJECTIVES

To assess the feasibility of preoperative ultrasound (US)-guided incisional biopsy through a prospective controlled clinical trial.

METHODS

This was a prospective, double-arm, single-center study of Chinese patients. Thirty patients were enrolled in the study. Fourteen patients received incisional biopsies for which the choice of biopsy area relied on a clinical evaluation, and 16 patients received incisional biopsies for which the choice of biopsy area relied on a US-guided evaluation. The following procedure was used in the US-guided incisional biopsy group: 1) clinical and dermoscopic evaluation of skin lesions; 2) US examination; 3) incisional biopsy; 4) surgical excision; and 5) histopathological examination. The same procedure was used in the non-US-guided group except without US examination.

RESULTS

In the non-US-guided group, the mean tumor thicknesses obtained from incisional biopsy and postoperative histopathological examination were 2.1 and 4.1 mm, respectively. Seven melanomas were underestimated by incisional biopsy, resulting in margins narrower than currently recommended. In the US-guided group, the mean tumor thicknesses obtained from US, incisional biopsy, and postoperative histopathological examination were 3.4, 2.9, and 2.7 mm, respectively. In only 3 melanomas was the tumor thickness of the incisional biopsy less than that of the postoperative histopathological examination, demonstrating that US-guided biopsy obtains the maximum thickness area.

CONCLUSIONS

Preoperative US-guided incisional biopsy can enhance the pathological accuracy of incisional biopsy, which may allow us to better perform surgical excision with safe peripheral surgical margins.

Malignant Melanoma in Lagos, Nigeria: Elucidating Histopathologic Prognostic Factors

BACKGROUND

Malignant melanoma (MM) is the most lethal of all cutaneous malignancies, accounting for about 79% of skin cancer related deaths. In blacks, it is associated with greater morbidity and mortality compared to Caucasians. Breslow thickness and ulceration status are two of the most important histopathologic prognostic factors in MM. No study on MM in Nigeria has however examined these factors.

METHODS

Formalin-fixed paraffin-embedded (FFPE) tissue blocks and corresponding Haematoxylin and Eosin (H&E) stained slides of all confirmed cases of MM from January 2005 to December 2014 in the AMP Department of Lagos University Teaching Hospital (LUTH) were retrieved.

RESULTS

Fifty-two MM cases were histologically diagnosed in LUTH during the study period which represented 1.0% of total solid malignancies. Forty-three of these occurred in the skin accounting for 19.7% of all skin malignancies and making MM the 3rd commonest skin malignancy after squamous cell carcinoma (SCC) and kaposi sarcoma (KS). Eighty eight percent (88%) of the tumour were in Clark's stage IV and V while 84% had Breslow thickness >4mm. Ulceration was present in 67%. The Clark's level and Breslow thickness were correlated with the ulceration status of the tumour. There is significant correlation between the Breslow thickness and ulceration with p-value < 0.05 while there is no significant association between the Clark's level and ulceration.

CONCLUSION

MM constituted a significant proportion of skin malignancy in LUTH and majority of the cases present at an advanced stage. Breslow thickness and ulceration statuses of the tumour are important histopathologic parameters that should be reported in all MM biopsies.

The impact of the COVID-19 pandemic on melanoma diagnoses

Introduction

We investigated whether governmental measures and lockdowns during the COVID-19 pandemic had an impact on the number and histopathologic stages of melanoma.

Methods

The number and thickness (Breslow) of all diagnosed melanomas per day, month, or period at the 'Institute for Pathology in the Centre' in 2019 and 2020 were compared. For 2020, we defined four time periods: Period 1: 1 January-15 March; Period 2: 16 March-15 May (Lockdown 1); Period 3: 16 May-2 November; Period 4: 3 November-7 December (Lockdown 2).

Results

We found similar melanoma numbers in 2019 (577) and 2020 (608). The mean number of diagnoses per day during Lockdown 1 (Period 2) was significantly lower (0.87 melanomas/day; p = 0.005) when compared to the respective time periods in 2019 and to the other three periods in 2020 (Period 1: 1.65 melanomas/day, Period 3: 1.77 melanomas/day, and Period 4: 2.49 melanomas/day). Tumour thickness in July 2020 (1.9 mm) was significantly higher (p = 0.02) than in July 2019 (1.1 mm).

Discussion

The significant lower number of histopathologic diagnoses of melanoma during 'Lockdown 1' may be explained by postponed or missed patient consultations. This assumption is supported by the demonstration of a higher tumour thickness in July and August 2020, compared to 2019.

Effects of COVID-19 Lockdown on Melanoma Diagnosis in Switzerland: Increased Tumor Thickness in Elderly Females and Shift towards Stage IV Melanoma during Lockdown

At the early stages of the COVID-19 outbreak in 2020, Switzerland was among the countries with the highest number of SARS-CoV2-infections per capita in the world. Lockdowns had a remarkable impact on primary care access and resulted in postponed cancer screenings. The aim of this study was to investigate the effects of the COVID-19 lockdown on the diagnosis of melanomas and stage of melanomas at diagnosis. In this retrospective, exploratory cohort study, 1240 patients with a new diagnosis of melanoma were analyzed at five tertiary care hospitals in German-speaking Switzerland over a period of two years and three months. We compared the pre-lockdown (01/FEB/19-15/MAR/20, n = 655) with the lockdown (16/MAR/20-22/JUN/20, n = 148) and post-lockdown period (23/JUN/20-30/APR/21, n = 437) by evaluating patients' demographics and prognostic features using Breslow thickness, ulceration, subtype, and stages. We observed a short-term, two-week rise in melanoma diagnoses after the major lift of social lockdown restrictions. The difference of mean Breslow thicknesses was significantly greater in older females during the lockdown compared to the pre-lockdown (1.9 ± 1.3 mm, p = 0.03) and post-lockdown period (1.9 ± 1.3 mm, p = 0.048). Thickness increase was driven by nodular melanomas (2.9 ± 1.3 mm, p = 0.0021; resp. 2.6 ± 1.3 mm, p = 0.008). A proportional rise of advanced melanomas was observed during lockdown (p = 0.047). The findings provide clinically relevant insights into lockdown-related gender- and age-dependent effects on melanoma diagnosis. Our data highlight a stable course in new melanomas with a lower-than-expected increase in the post-lockdown period. The lockdown period led to a greater thickness in elderly women driven by nodular melanomas and a proportional shift towards stage IV melanoma. We intend to raise awareness for individual cancer care in future pandemic management strategies.

Classification and Staging of Melanoma in the Head and Neck

The rates of melanoma continue to rise, with recent estimates have shown that 18% to 22% of new melanoma cases occur within the head and neck in the United States each year. The mainstay of treatment of nonmetastatic primary melanomas of the head and neck includes the surgical resection and management of regional disease as indicated. Thorough knowledge of the classification and staging of melanoma is paramount to evaluate prognosis, determine the appropriate surgical intervention, and assess eligibility for adjuvant therapy and clinic trials. The traditional clinicopathologic classification of melanoma is based on morphologic aspects of the growth phase and distinguishes 4 of the most common subtypes as defined by the World Health Organization: superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. The data used to derive the AJCC TNM Categories are based on superficial spreading melanoma and nodular subtypes. Melanoma is diagnosed histopathologically following initial biopsy that will assist with classifying the tumor to guide treatment. Classification is based on tumor thickness and ulceration (T stage, Breslow Staging), Regional Lymph Node Involvement (N Stage), and presence of metastasis (M Stage). Tumor thickness (Breslow thickness) and ulceration are 2 independent prognostic factors that have been shown to be the strongest predictors of survival and outcome. Clark level of invasion and mitotic rate are no longer incorporated into the current AJCC staging system, but still have shown to be important prognostic factors for cutaneous melanoma. For patients with metastatic (Stage IV) disease Lactate Dehydrogenase remains an independent predictor of survival. The Maxillofacial surgeon must remain up to date on the most current management strategies in this patient population. Classification systems and staging provide the foundation for clinical decision making and prognostication for the Maxillofacial surgeon when caring for these patients.

Predictive Values of Pathological and Clinical Risk Factors for Positivity of Sentinel Lymph Node Biopsy in Thin Melanoma: A Systematic Review and Meta-Analysis

Background

The indications for sentinel lymph node biopsy (SLNB) for thin melanoma are still unclear. This meta-analysis aims to determine the positive rate of SLNB in thin melanoma and to summarize the predictive value of different high-risk features for positive results of SLNB.

Methods

Four databases were searched for literature on SLNB performed in patients with thin melanoma published between January 2000 and December 2020. The overall positive rate and positive rate of each high-risk feature were calculated and obtained with 95% confidence intervals (CIs). Both unadjusted odds ratios (ORs) and adjusted ORs (AORs) of high-risk features were analyzed. Pooled effects were estimated using random-effects model meta-analyses.

Results

Sixty-six studies reporting 38,844 patients with thin melanoma who underwent SLNB met the inclusion criteria. The pooled positive rate of SLNB was 5.1% [95% confidence interval (CI) 4.9%-5.3%]. Features significantly predicted a positive result of SLNB were thickness≥0.8 mm [AOR 1.94 (95%CI 1.28-2.95); positive rate 7.0% (95%CI 6.0-8.0%)]; ulceration [AOR 3.09 (95%CI 1.75-5.44); positive rate 4.2% (95%CI 1.8-7.2%)]; mitosis rate >0/mm2 [AOR 1.63 (95%CI 1.13-2.36); positive rate 7.7% (95%CI 6.3-9.1%)]; microsatellites [OR 3.8 (95%CI 1.38-10.47); positive rate 16.6% (95%CI 2.4-36.6%)]; and vertical growth phase [OR 2.76 (95%CI 1.72-4.43); positive rate 8.1% (95%CI 6.3-10.1%)].

Conclusions

The overall positive rate of SLNB in thin melanoma was 5.1%. The strongest predictor for SLN positivity identified was microsatellites on unadjusted analysis and ulceration on adjusted analysis. Breslow thickness ≥0.8 mm and mitosis rate >0/mm² both predict SLN positivity in adjusted analysis and increase the positive rate to 7.0% and 7.7%. We suggest patients with thin melanoma with the above high-risk features should be considered for giving an SLNB.

Multispectral Imaging Algorithm Predicts Breslow Thickness of Melanoma

Breslow thickness is a major prognostic factor for melanoma. It is based on histopathological evaluation, and thus it is not available to aid clinical decision making at the time of the initial melanoma diagnosis. In this work, we assessed the efficacy of multispectral imaging (MSI) to predict Breslow thickness and developed a classification algorithm to determine optimal safety margins of the melanoma excision. First, we excluded nevi from the analysis with a novel quantitative parameter. Parameter s’ could differentiate nevi from melanomas with a sensitivity of 89.60% and specificity of 88.11%. Following this step, we have categorized melanomas into three different subgroups based on Breslow thickness (≤1 mm, 1–2 mm and >2 mm) with a sensitivity of 78.00% and specificity of 89.00% and a substantial agreement (κ = 0.67; 95% CI, 0.58–0.76). We compared our results to the performance of dermatologists and dermatology residents who assessed dermoscopic and clinical images of these melanomas, and reached a sensitivity of 60.38% and specificity of 80.86% with a moderate agreement (κ = 0.41; 95% CI, 0.39–0.43). Based on our findings, this novel method may help predict the appropriate safety margins for curative melanoma excision.

Association of Melanoma-Risk Variants with Primary Melanoma Tumor Prognostic Characteristics and Melanoma-Specific Survival in the GEM Study

Genome-wide association studies (GWAS) and candidate pathway studies have identified low-penetrant genetic variants associated with cutaneous melanoma. We investigated the association of melanoma-risk variants with primary melanoma tumor prognostic characteristics and melanoma-specific survival. The Genes, Environment, and Melanoma Study enrolled 3285 European origin participants with incident invasive primary melanoma. For each of 47 melanoma-risk single nucleotide polymorphisms (SNPs), we used linear and logistic regression modeling to estimate, respectively, the per allele mean changes in log of Breslow thickness and odds ratios for presence of ulceration, mitoses, and tumor-infiltrating lymphocytes (TILs). We also used Cox proportional hazards regression modeling to estimate the per allele hazard ratios for melanoma-specific survival. Passing the false discovery threshold (p = 0.0026) were associations of IRF4 rs12203592 and CCND1 rs1485993 with log of Breslow thickness, and association of TERT rs2242652 with presence of mitoses. IRF4 rs12203592 also had nominal associations (p < 0.05) with presence of mitoses and melanoma-specific survival, as well as a borderline association (p = 0.07) with ulceration. CCND1 rs1485993 also had a borderline association with presence of mitoses (p = 0.06). MX2 rs45430 had nominal associations with log of Breslow thickness, presence of mitoses, and melanoma-specific survival. Our study indicates that further research investigating the associations of these genetic variants with underlying biologic pathways related to tumor progression is warranted.

ROR2 has a protective role in melanoma by inhibiting Akt activity, cell-cycle progression, and proliferation

BACKGROUND

Receptor tyrosine kinase-like orphan receptor 2 (ROR2) is a Wnt5a receptor aberrantly expressed in cancer that was shown to either suppress or promote carcinogenesis in different tumor types. Our goal was to study the role of ROR2 in melanoma.

METHODS

Gain and loss-of-function strategies were applied to study the biological function of ROR2 in melanoma. Proliferation assays, flow cytometry, and western blotting were used to evaluate cell proliferation and changes in expression levels of cell-cycle and proliferation markers. The role of ROR2 in tumor growth was assessed in xenotransplantation experiments followed by immunohistochemistry analysis of the tumors. The role of ROR2 in melanoma patients was assessed by analysis of clinical data from the Leeds Melanoma Cohort.

RESULTS

Unlike previous findings describing ROR2 as an oncogene in melanoma, we describe that ROR2 prevents tumor growth by inhibiting cell-cycle progression and the proliferation of melanoma cells. The effect of ROR2 is mediated by inhibition of Akt phosphorylation and activity which, in turn, regulates the expression, phosphorylation, and localization of major cell-cycle regulators including cyclins (A, B, D, and E), CDK1, CDK4, RB, p21, and p27. Xenotransplantation experiments demonstrated that ROR2 also reduces proliferation in vivo, resulting in inhibition of tumor growth. In agreement with these findings, a higher ROR2 level favors thin and non-ulcerated primary melanomas with reduced mitotic rate and better prognosis.

CONCLUSION

We conclude that the expression of ROR2 slows down the growth of primary tumors and contributes to prolonging melanoma survival. Our results demonstrate that ROR2 has a far more complex role than originally described.

Clinical Study on the Increased Incidence of Nodular Melanoma Cases Compared to Superficial Melanoma

Our study group was comprised of 67 patients with melanoma, admitted and operated in our clinic between 2010-2018. Only the patients with melanoma localized on the head, torso and upper limb were selected for our study. We attempted to establish a link between the clinical appearance, presence or absence of ulceration, presence or absence of regional lymphadenopathy or distant metastases, surgical technique, histopathological type, Clark level and Breslow depth, disease stage (TNM), adjuvant therapies and survival rates at 1, 3, 5 and 10 years.

Body Mass Index and Melanoma Prognosis

Introduction

Obesity has been suggested as a risk factor in the progression of malignancies, including melanoma. Most studies defined obesity using body mass index (BMI), although the index is considered an imperfect measure of body composition.

Objective

The aim of this article is to examine whether BMI can impact on the prognosis of cutaneous melanoma, regardless of anti-tumor therapy. The relationship between BMI and specific prognostic factors in melanoma patients has been reviewed.

Methods

Literature search was conducted on PubMed using the terms "melanoma" and "body mass index" or "obesity". We selected articles, published up to 30 November 2020, examining the prognostic aspects of melanoma. Articles evaluating the risk and incidence of melanoma were excluded as well as studies regarding morbidity and complications following surgical procedures, or those performed in metastatic melanoma patients treated with anti-tumor therapies.

Results

Mixed results have emerged from studies assessing the clinical outcomes in melanoma patients in relation to BMI. More consistent data seem to support the relationship between BMI and Breslow thickness.

Conclusions

Studies that focus specifically on the link between obesity and melanoma prognosis are limited; further research is needed to deepen our knowledge on this link.

Association between melanoma thickness and clinical and demographic characteristics

The large-scale implementation of primary and secondary skin cancer prevention strategies in recent decades has led to an increase in the diagnosis of thin melanomas and a decrease in the mean thickness of tumours diagnosed. The number of newly diagnosed thick melanomas, however, has remained stable. To investigate associations between melanoma thickness, clinical presentation and demographic and phenotypic characteristics. The study is based on a cross-sectional study of 1,459 patients with melanoma from a dermatology department at a tertiary hospital in Spain between 2000 and 2017. We analysed associations between median Breslow thickness and demographic, phenotypic, and clinical characteristics, including the method of melanoma detection. Age ≥ 70 years (regression coefficient [RC] =  1.2, 95% CI: 1.1-1.3; p  <  0.001), male sex (RC  =  0.9, 95% CI: 0.8-0.9; p  <  0.001), symptom-based detection (RC  =  1.3, 95% CI: 1.1-1.4; p  <  0.001), and a history of sunburn at the melanoma site (RC  =  0.9, 95% CI: 0.8-0.9; p  =  0.04) were all associated with thicker tumours. Melanomas on the lower extremities, by contrast, were significantly thinner (RC  =  0.9, 95% CI: 0.8-0.9; p = 0.04). Thick melanomas occur preferentially in older men and show changes such as bleeding or an increase in volume or colour. This information should be incorporated into health training and education programs to design better prevention strategies and minimize diagnostic delays.

Characteristics of 637 melanomas documented by 27 general practitioners on the Skin Cancer Audit Research Database

BACKGROUND AND OBJECTIVE

Most melanomas (including melanomas in situ), in Australasia, are treated by general practitioners (GPs). Previously undescribed, the characteristics of a series of melanomas treated by multiple GPs are examined.

PATIENTS AND METHODS

Six hundred and thirty-seven melanomas treated by 27 Australasian GPs during 2013 and documented on the Skin Cancer Audit Research Database (SCARD) were analysed by anatomical site, subtype, Breslow thickness, diameter, associated naevi and linked adverse outcomes.

RESULTS

Most melanomas (59.7%) were on males, mean age at diagnosis being 62.7 years (range 18-96). Most (65.0%) were in situ, with a high incidence of lentiginous melanoma (LM) (38.8%) and 32% were naevus associated. Most LM (86.4%) were in situ, compared to 55% of superficial spreading melanoma (SSM) (P < 0.0001). There was male predominance on the head, neck and trunk and female predominance on extremities. There was no significant association between Breslow thickness and diameter, with small melanomas as likely to be thick as large melanomas, and melanomas ≤3 mm diameter, on average, more likely to be invasive than larger melanomas. There was a positive correlation between age and both melanoma diameter and Breslow thickness. Seven cases progressed to melanoma-specific death: Five nodular melanoma (NM) and two SSM, one of which was thin (Breslow thickness 0.5 mm).

CONCLUSIONS

A large series of melanomas treated by Australasian GPs were predominantly in situ, with a high proportion of LM subtype. With implications for GP training, NM linked to death was over-represented and there was a novel finding that older patients had larger diameter melanomas.

Can Dermoscopy Be Used to Predict if a Melanoma Is In Situ or Invasive?

Background

The preoperative prediction of whether melanomas are invasive or in situ can influence initial management.

Objectives

This study evaluated the accuracy rate, interobserver concordance, sensitivity and specificity in determining if a melanoma is invasive or in situ, as well as the ability to predict invasive melanoma thickness based on clinical and dermoscopic images.

Methods

In this retrospective, single-center investigation, 7 dermatologists independently reviewed clinical and dermoscopic images of melanomas to predict if they were invasive or in situ and, if invasive, their Breslow thickness. Fleiss' and Cohen's kappa (κ) were used for interobserver concordance and agreement with histopathological diagnosis.

Results

We included 184 melanomas (110 invasive and 74 in situ). Diagnostic accuracy ranged from 67.4% to 76.1%. Accuracy rates for in situ and invasive melanomas were 57.5% (95% confidence interval [CI], 53.1%-61.8%) and 81.7% (95% CI, 78.8%-84.4%), respectively. Interobserver concordance was moderate (κ = 0.47; 95% CI, 0.44-0.51). Sensitivity for predicting invasiveness ranged from 63.6% to 91.8% for 7 observers, while specificity was 32.4%-82.4%. For all correctly predicted invasive melanomas, agreement between predictions and correct thickness over or under 1.0 mm was moderate (κ = 0.52; 95% CI, 0.45-0.58). All invasive melanomas incorrectly predicted by any observer as in situ had a thickness <1.0 mm. All 32 melanomas >1.0 mm were correctly predicted to be invasive by all observers.

Conclusions

Accuracy rates for predicting thick melanomas were excellent, melanomas inaccurately predicted as in situ were all thin, and interobserver concordance for predicting in situ or invasive melanomas was moderate. Preoperative dermoscopy of suspected melanomas is recommended for choosing appropriate surgical margins.

Features associated with melanoma metastasis in Latvia

Cutaneous melanoma (CM) is the most aggressive form of skin cancer, exhibits an increasing incidence worldwide and has a high potential to develop metastasis. The current study aimed to identify a set of parameters that may aid in predicting the probability and timing of the onset of CM metastasis. A retrospective analysis was performed using the archive data of 2,026 patients with CM that were treated at the Riga East University Hospital Latvian Oncology Centre, which is the largest oncological hospital in the country, between 1998 and 2015. A case-control study design was employed, where patients with metastasis (n=278) were used as the cases and patients without metastasis were used as the controls. The present study examined the associations between metastasis and potential risk factors and constructed multivariate models of features that predicted metastasis using stepwise regression. Time until metastasis was analyzed using negative binomial regression models. The results of the present study indicated an increase in the number of melanomas that developed metastases during 1998–2015. Tumor Breslow thickness was demonstrated to be significantly larger in patients with metastasis compared with those without (P=0.012). The presence of ulceration significantly increased the risk of metastases [odds ratio (OR), 1.66; 95% CI, 1.07-2.59; P=0.033]. The absence of pigment in melanoma tissues was indicated to lead to a greater likelihood of metastasis (OR, 2.14; 95% CI, 1.10-4.19; P=0.035). Shorter times from diagnosis until the onset of metastases were observed in older patients (incident rate ratio (IRR), 6.85; 95% CI, 2.43-19.30; P=2.78×10⁻⁴), and a borderline significant association was observed in those with ulcerated tumors (IRR, 1.33; 95% CI, 0.98-1.80; P=0.064). Therefore, the main features associated with the development of melanoma metastasis in Latvia were indicated to be tumor ulceration, absence of pigment and Breslow thickness.

A brief synopsis on scalp melanoma

Melanoma constitutes one of the most sinister and troublesome malignancies encountered by humanity. Generally, the diagnosis of advanced melanoma connotes a grave prognosis, prompting a sense of looming threat of death, however, the early-stage detected disease responds well to robust treatment resulting in reasonable survivorship. Scalp melanomas are even more troublesome, because they typically exhibit more aggressive biologic behavior and are often diagnosed at a late stage. This review tries to comprehensively highlight the various diagnostic, therapeutic, and outcome aspects of scalp melanomas. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Immunohistochemical Staining in the Assessment of Melanoma Tumor Thickness

Vertical tumor thickness has great influence in the prognosis and staging of melanoma. The aim of this study was determination of the differences between melanoma tumor thickness in conventional hematoxylin and eosin (H&E) and immunohistochemical techniques. Thirty-six biopsy specimens were included in our study. For each sample, four adjacent tissue sections were stained with H&E, in addition S-100, Melan- A and HMB-45 staining was performed on the next serial sections. The mean thickness of tumor invasion was 2.16, 2.38, 2.22 and 2.29 mm in H&E, S-100, HMB45 and Melan-A sections evaluation, respectively. The mean difference of the Breslow thickness between H&E and S-100 and also, between H&E and Melan-A stained slides were statistically significant (p˂0.05) while no difference was found in the tumor thickness of the H&E and HMB45 staining evaluation (p = 0.278). Greater tumor thickness was observed in 25 lesions (69.4%) with S-100, 20 lesions (55.5%) with Melan-A and 17 (47.2%) lesions in HMB-45 rather than H&E staining. Conclusively, it appears that H&E staining cannot prove the actual size of melanoma invasion in some cases and immunohistochemical examination can be a complementary method in this situations. Of the melanoma associated immunomarkers, the combination of S-100 and Melan-A staining may suffice to measure depth of tumor invasion.

Serum Total 25-Hydroxyvitamin D Levels in Patients With Cutaneous Malignant Melanoma: A Case-Control Study in a Low-Risk Southern European Population

Background

Recent data have shown an inverse association between serum 25-hydroxyvitamin D concentration and incidence of several cancers, including cutaneous malignant melanoma (CMM). In addition, lower serum 25-hydroxyvitamin D levels have been associated with thicker or higher stage melanomas and worse survival in observational studies.

Materials and Methods

Ninety-nine patients diagnosed with primary CMM and 97 matched healthy controls entered the study. Demographic characteristics, risk factors for CMM, and clinical and histological characteristics were recorded for patients with primary CMM. Total serum 25-hydroxyvitamin D levels of melanoma patients measured by fully automated chemiluminescent vitamin D total immunoassay (Elecsys vitamin D total, Roche) at the time of diagnosis were compared with those of healthy controls. In addition, we tested the association of serum total 25-hydroxyvitamin D levels at melanoma diagnosis with known risk and prognostic factors for CMM.

Results

Of the melanoma patients, 49 (49.49%) had deficient serum total 25-hydroxyvitamin D levels (<20 ng/mL), 23 (23.23%) had insufficient levels (21-29 ng/mL), and 27 (27.27%) had adequate levels (>30 ng/mL). The median serum total 25-hydroxyvitamin D levels were significantly lower in melanoma patients (20.62 ng/mL) compared with healthy controls (24.71 ng/mL), but statistical significance was not reached (chi-square test, P = 0.051) No statistically significant association was found between serum total 25-hydroxyvitamin D levels and demographic characteristics; risk factors for CMM; prognostic factors, such as Breslow thickness and ulceration; as well as clinical characteristics, such as melanoma stage, clinical type, and location.

Conclusions

Lower serum 25-hydroxyvitamin D levels were found in our Greek cohort of melanoma patients compared with healthy controls, without reaching, however, statistical significance; these levels were not statistically associated with established risk and prognostic factors for CMM.

Malignant Melanoma Cells and Hair Follicles

OBJECTIVES

The extension of atypical melanocytes to the hair follicle, also termed melanoma folliculotropism, is poorly evaluated and its role is contradictory. We performed an observational study focusing on anatomical areas rich in follicles, such as the head and neck region.

METHODS

Primary head and neck melanomas diagnosed in the Melanoma Unit, Policlinic Sant'Orsola-Malpighi, University of Bologna were analyzed. Folliculotropism was evaluated with a quantitative and morphologic parameter. Statistical analyses were performed correlating patients' prognosis with folliculotropism and other clinical and histopathologic factors.

RESULTS

The study was carried out on a sample of 62 patients. The diffuse distribution (atypical melanocytes present in more than three contiguous follicular units) correlated with scalp localization, nodular subtype, higher Breslow thickness, and a poorer prognosis.

CONCLUSIONS

We believe that folliculotropism should be further investigated and reported by pathologists during the histologic diagnosis of melanoma.

Cutaneous nevi and risk of melanoma death in women and men: A prospective study

BACKGROUND

It was unclear whether an increased number of common nevi (moles) predicts melanoma death.

OBJECTIVE

We prospectively examined the association between number of common nevi and risk of melanoma death.

METHODS

Our study used data from the Nurses' Health Study (n = 77,288 women) and Health Professionals Follow-up Study (n = 32,455 men). In 1986, participants were asked about the number of moles they had with a ≥3-mm diameter on the upper extremity, and we stratified their answers into 3 categories (none, 1-2, or ≥3) on the basis of data distribution.

RESULTS

During follow-up (1986-2012), 2452 melanoma cases were pathologically confirmed; among these, we identified 196 deaths due to melanoma. Increased number of nevi was associated with melanoma death; the hazard ratio (HR) for ≥3 nevi compared with no nevi was 2.49 (95% confidence interval [CI] 1.50-4.12) for women and 3.97 (95% CI 2.54-6.22) for men. Among melanoma cases, increased number of nevi was associated with melanoma death in men (≥3 nevi, HR 1.89, 95% CI 1.17-3.05) but not in women. Similarly, the number of nevi was positively associated with Breslow thickness in men only (Ptrend = .01).

LIMITATIONS

This is an epidemiologic study without examination into mechanisms.

CONCLUSION

Increased number of cutaneous nevi was significantly associated with melanoma death. High nevus count might serve as an independent prognostic factor to predict the risk of melanoma death particularly among male melanoma patients.

Time to reconsider the role of sentinel lymph node biopsy in melanoma

The Multicenter Selective Lymphadenectomy Trials indicate that there are no overall or melanoma-specific survival advantages to performing sentinel lymph node biopsy (SLNB) followed by immediate completion lymph node dissection compared with wide excision and observation for patients with positive sentinel nodes. These results make SLNB solely a staging procedure. The role of SLNB in the management of patients with melanoma deserves reappraisal. The potential marginal benefit of SLNB beyond the clinical and pathologic features of the melanoma has not been well studied. The use of sentinel lymph node status alone to accept and stratify patients into trials or to receive adjuvant treatment is not rational.

Metastases risk in thin cutaneous melanoma: prognostic value of clinical-pathologic characteristics and mutation profile

Background

A high percentage of patients with thin melanoma (TM), defined as lesions with Breslow thickness ≤1 mm, presents excellent long-term survival, however, some patients develop metastases. Existing prognostic factors cannot reliably differentiate TM patients at risk for metastases.

Objective

We aimed at characterizing the clinical-pathologic and mutation profile of metastatic and not-metastatic TM in order to distinguish lesions at risk of metastases.

Methods

Clinical-pathologic characteristics were recorded for the TM cases analyzed. We used a Next Generation Sequencing (NGS) multi-gene panel to characterize TM for multiple somatic mutations.

Results

A statistically significant association emerged between the presence of metastases and Breslow thickness ≥0.6 mm (p=0.003). None of TM with lymph-node involvement had Breslow thickness <0.6 mm. Somatic mutations were identified in 19 of 21 TM analyzed (90.5%). No mutations were observed in two not-metastatic cases with the lowest Breslow thickness (≤0.4 mm), whereas mutations in more than one gene were detected in one metastatic case with the highest Breslow thickness (1.00 mm).

Conclusion

Our study indicates Breslow thickness ≥0.6 mm as a valid prognostic factor to distinguish TM at risk for metastases.

Melanoma staging: Varying precision and terminal digit clustering in Breslow thickness data is evident in a population-based study

BACKGROUND

Errors in Breslow thickness reporting can give misclassification of T category, an important classifier in melanoma staging.

OBJECTIVE

We sought to investigate precision (number of digits) and terminal digit clustering in Breslow thickness and potential consequences for T category.

METHODS

All first primary and morphologically verified invasive melanomas in Norway between 2008 and 2015 were included. A smoothing model was fitted to estimate the underlying Breslow thickness distribution without digit clustering.

RESULTS

Thickness was reported for 13,057 (97.5%) patients; the median was 1.0 mm (range, 0.09-85). It was reported as whole numbers (15.6%), to 1 decimal (78.2%) and 2 decimal places (6.2%)-thin tumors with more precision than thick tumors. Terminal digit clustering was found with marked peaks in the observed frequency distribution for terminal digits 0 and 5, and with drops around these peaks. Terminal digit clustering increased proportions of patients classified with T1 and T4 tumors and decreased proportions classified with T2 and T3.

LIMITATIONS

Breslow thickness was not reported in 2.5% of cases.

CONCLUSIONS

The Norwegian recommendation of measurement to the nearest 0.1 mm was not followed. Terminal digit clustering was marked, with consequences for T category. Pathologists, clinicians, and epidemiologists should know that clustering of thickness data around T category cut points can impact melanoma staging with consequent effect on patient management and prognosis.

A comprehensive genome-wide analysis of melanoma Breslow thickness identifies interaction between CDC42 and SCIN genetic variants

Breslow thickness (BT) is a major prognostic factor of cutaneous melanoma (CM), the most fatal skin cancer. The genetic component of BT has only been explored by candidate gene studies with inconsistent results. Our objective was to uncover the genetic factors underlying BT using an hypothesis-free genome-wide approach. Our analysis strategy integrated a genome-wide association study (GWAS) of single nucleotide polymorphisms (SNPs) for BT followed by pathway analysis of GWAS outcomes using the gene-set enrichment analysis (GSEA) method and epistasis analysis within BT-associated pathways. This strategy was applied to two large CM datasets with Hapmap3-imputed SNP data: the French MELARISK study for discovery (966 cases) and the MD Anderson Cancer Center study (1,546 cases) for replication. While no marginal effect of individual SNPs was revealed through GWAS, three pathways, defined by gene ontology (GO) categories were significantly enriched in genes associated with BT (false discovery rate ≤5% in both studies): hormone activity, cytokine activity and myeloid cell differentiation. Epistasis analysis, within each significant GO, identified a statistically significant interaction between CDC42 and SCIN SNPs (pmeta-int =2.2 × 10(-6) , which met the overall multiple-testing corrected threshold of 2.5 × 10(-6) ). These two SNPs (and proxies) are strongly associated with CDC42 and SCIN gene expression levels and map to regulatory elements in skin cells. This interaction has important biological relevance since CDC42 and SCIN proteins have opposite effects in actin cytoskeleton organization and dynamics, a key mechanism underlying melanoma cell migration and invasion.

Sentinel node biopsy in patients with primary cutaneous melanoma of any thickness: A cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of the sentinel node biopsy with lymphadenectomy for nodal metastases (SNB) in patients with primary cutaneous melanoma (CM) of different Breslow thickness (intermediate, thick, thin).

METHODS

Decision tree models were constructed to compare two different strategies of management of patients with CM, wide excision of the primary lesion and SNB and wide excision only (WE). Tree models were created for every Breslow thickness over 1-, 5- and 10-year time horizons. Mean and total direct healthcare costs, life years saved (LYSs), quality-adjusted life years (QALYs), cost effectiveness ratio (CER), and incremental cost effectiveness ratio (ICER) were estimated. Every model was considered as a base case, and its results tested with sensitivity analyses.

RESULTS

Base case analyses showed that the best results were obtained for intermediate CM over 10-year time horizon. In this case, ICER for SNB was 130,508€/QALY, well over the threshold of acceptance (30,000€/QALY). In patients with intermediate CM over 1 and 5 years, and for those with thick and thin CM at any time horizon, negative ICER values were estimated since SNB was proved to be more expensive and less effective than WE. Sensitivity analyses confirmed the robustness of our results.

CONCLUSIONS

SNB caused no improvement in health outcomes in terms of LYSs and QALYs in patients with thick and thin CM, and only a slight benefit in those with intermediate CM. WE was more cost-effective compared with SNB for any CM thickness over any time horizon up to 10 years.

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.

Breslow thickness and (18)F-FDG PET-CT result in initial staging of cutaneous melanoma: Can a cut-off point be established?

AIM

To establish a Breslow Thickness (BT) cut-off point for indication of PET-CT of cutaneous melanoma in early stages and evaluate its prognostic value.

MATERIAL AND METHODS

Retrospective analysis of 347 PET-CT studies with diagnosis of melanoma, of which 108 were performed for initial staging. Thirty-one patients were excluded, and a final sample of 77 patients remained. A ROC curve analysis was performed to establish an optimal cut-off point. A survival analysis was performed, considering death assignable to melanoma as the main event, for the evaluation of its prognostic value.

RESULTS

Forty-seven (61.04%) of all 77 patients selected were men, and 11 (14.29%) had a positive PET-CT result. Mean age was 65.17±15.00 years. The median BT in patients with a negative PET-CT result was 2.75 mm (IQR 1.83-4.50) and in the positive group 6.25 mm (IQR 5.40-7.50) (P=.0013). In the ROC curve analysis (AUC 0.804, SE 0.054), an optimal value of 5 mm BT with the following values was obtained: sensitivity 90.91%, specificity 78.79%, negative predictive value (NPV) 98.1%, positive predictive value (PPV) 41.7%, diagnostic OR 37.1, and accuracy 80.52%. Mean follow-up was 18.66±14,35 months, detecting 2/53 (3.77%) deaths in the BT<5 mm group, and 7/24 (29.17%) in the BT≥5 mm group. Survival curves between both groups were significantly different (P=.0013).

CONCLUSIONS

A 5 mm cut-off point correctly distinguishes those patients with positive PET-CT from those with negative results in the early stages of cutaneous melanoma; therefore it could be included in initial staging of this subgroup of patients.

Increasing time trends of thin melanomas in The Netherlands: What are the explanations of recent accelerations?

BACKGROUND

A disproportional increase in in situ or thin melanomas may point at underlying causes such as increased melanoma awareness, as well as 'overdiagnosis' of melanoma in diagnostically equivocal small lesions.

OBJECTIVES

The purposes of this study were to estimate trends in melanoma incidence by sex, Breslow thickness (thin melanomas subdivided into four subgroups: <0.25 mm, 0.25-0.49 mm, 0.50-0.74 mm, and 0.75-1.0 mm), age and location, and to compare these with trends in subgroups of thicker melanomas.

METHODS

Data on all histologically confirmed in situ and invasive melanomas diagnosed between 1994 and 2010 were retrieved from the Netherlands Cancer Registry. Trends in European standardised rates (ESRs) were assessed using joinpoint analysis, and expressed as estimated annual percentage change (EAPC).

RESULTS

Between 1994 and 2010, 34,156 persons were diagnosed with an in situ or thin melanoma. The ESR of in situ melanomas doubled for males and females with a recent steeper rise in incidence (EAPC 12% (95% confidence interval [CI]: 8.1-16) and 13% (95% CI: 5.9-20), respectively). ESR for thin melanomas amongst males approximately doubled with a steep, but non-significant acceleration compared to other thickness categories since 2006 for <0.25 mm melanomas (EAPC 26% (95% CI: 2.1-35)). For female patients with thin melanomas the ESRs increased almost two-fold, except for <0.25 mm melanomas.

CONCLUSIONS

The incidence rates of in situ, thin and thick melanomas increased similarly between 1994 and 2010. Recently steep increases were found for in situ melanomas and thin melanomas in men. Explanations are 'overdiagnosis' in conjunction with increased ultraviolet exposure (natural and artificial) and therefore a 'true' increase, increased awareness, early detection, diagnostic drift and changed market forces in the Dutch health care system.

Excision versus incision biopsy in the management of malignant melanoma

INTRODUCTION

The incidence of melanoma has increased over the last decade. The Breslow thickness is one of the most important histological parameters. The gold standard for histological diagnosis is an excision biopsy. Incisional, punch or shave biopsies are not recommended as they are often incomplete and can result in false negatives.

OBJECTIVE

To assess the validity of incision versus excision biopsies in the prediction of Breslow thickness in the histopathological analysis of malignant melanoma.

METHODS

A retrospective review of histopathological records was conducted for all patients undergoing incision biopsy for malignant melanoma. The Breslow thicknesses of the incisional biopsies were matched to the later corresponding excisional biopsies. The demographical data, site of melanoma and histological subtype were also examined.

RESULTS

Sixty patients between 1st January 2005 and 31st December 2013 were identified. The most common area biopsied was the upper and lower limbs - 50%. The Breslow thickness and Clark's level were found to be significantly increased in excision versus incision biopsy specimens. Nine patients had differing mitotic rates which were all higher in the excision biopsy samples.

CONCLUSION

Our data supports the UK national guidelines on the management of malignant melanoma in that incisional biopsies are not indicated in the diagnostic pathway of malignant melanoma.

Are we seeing the effects of public awareness campaigns? A 10-year analysis of Breslow thickness at presentation of malignant melanoma in the South West of England

INTRODUCTION

The last 20 years has seen a marked improvement in skin cancer awareness campaigns. We sought to establish whether this has affected the presenting Breslow thickness of malignant melanoma in the South West.

METHOD

This is a retrospective study looking at the first presentation of melanomas from 2003 to 2011. Data was accessed using the local online melanoma database.

RESULTS

A total of 2001 new melanomas presented from 2003 to 2012 (Male:Female = 1:1.062). The average yearly number of melanomas was 200.1 (range = 138-312). The mean age was 62.5 years (range 12-99). Data was analysed using a Chi² test. For 0-1 mm melanomas, there is a significant difference in the observed versus expected values over the 10 years (p = 0.0018). There is an increasing proportion of 0-1 mm (thin) melanomas presenting year on year, with a positive linear trend. This is very statistically significant (p < 0.0001). The 1-2 mm melanomas are decreasing in proportion with a negative linear trend (p = 0.0013). The 2-4 mm are also decreasing in proportion (p = 0.0253). There is no significant change in the thick >4 mm melanomas (p = 0.1456).

CONCLUSION

The proportion of thin 0-1 mm melanomas presenting in South West England has significantly increased from 2003 to 2012. There is no significant change in the thick >4 mm melanomas. This may be a result of increased public awareness due to effective public health campaigns which has significant prognostic and financial implications.