Predictors of germline status for hereditary melanoma: 5 years of multi-gene panel testing within the Italian Melanoma Intergroup

BACKGROUND

The incidence of cutaneous melanoma is increasing in Italy, in parallel with the implementation of gene panels. Therefore, a revision of national genetic assessment criteria for hereditary melanoma may be needed. The aim of this study was to identify predictors of susceptibility variants in the largest prospective cohort of Italian high-risk melanoma cases studied to date.

MATERIALS AND METHODS

From 25 Italian centers, we recruited 1044 family members and germline sequenced 940 cutaneous melanoma index cases through a shared gene panel, which included the following genes: CDKN2A, CDK4, BAP1, POT1, ACD, TERF2IP, MITF and ATM. We assessed detection rate according to familial status, region of origin, number of melanomas and presence and type of non-melanoma tumors.

RESULTS

The overall detection rate was 9.47% (5.53% analyzing CDKN2A alone), ranging from 5.14% in sporadic multiple melanoma cases (spoMPM) with two cutaneous melanomas to 13.9% in familial cases with at least three affected members. Three or more cutaneous melanomas in spoMPM cases, pancreatic cancer and region of origin predicted germline status [odds ratio (OR) = 3.23, 3.15, 2.43, P < 0.05]. Conversely, age > 60 years was a negative independent predictor (OR = 0.13, P = 0.008), and was the age category with the lowest detection rate, especially for CDKN2A. Detection rate was 19% when cutaneous melanoma and pancreatic cancer clustered together.

CONCLUSIONS

Gene panel doubled the detection rate given by CDKN2A alone. National genetic testing criteria may need a revision, especially regarding age cut-off (60) in the absence of strong family history, pancreatic cancer and/or a high number of cutaneous melanomas.

Anogenital lichen sclerosus et atrophicus lesions in a case series of cancer patients on immunotherapy

Lichenoid reactions are one of the most frequently observed toxicities with anticancer agents and, recently, a rapid emergence of immunotherapies in oncology has hastened the need to better characterize their unique toxicity profiles, particularly for less common skin toxicities, including anogenital lichen sclerosus et atrophicus (LSA). This case series describes four patients with advanced cancer (one melanoma, two lung cancers, and one kidney tumor) developing LSA lesions while receiving an immunotherapy. Medical records from 2017 to 2020 were retrospectively reviewed. Two patients received pembrolizumab, anti-programmed cell death-1 (PD-1), one nivolumab, anti-programmed cell death-1 (PD-1), and one ipilimumab, an immune checkpoint inhibitor. LSA emerged after a median of 3 months (range, 2-4 months) from starting immunotherapy. All LSA cases were grade 2. Three cases occurred on the penis and one case on the anus. All patients improved after a specific treatment for LSA, and no LSA-related antineoplastic treatment interruption/life-threatening condition were reported. To date, this is the first case series of LSA lesions associated with immunotherapy. Early LSA recognition and management is helpful in cancer patients on immunotherapy allowing a long survival and treatment response.

Melanoma in children and adolescents: analysis of susceptibility genes in 123 Italian patients

BACKGROUND

A polygenic inheritance involving high, medium and low penetrance genes has been suggested for melanoma susceptibility in adults, but genetic information is scarce for paediatric patients.

OBJECTIVE

We aim to analyse the major high and intermediate melanoma risk genes, CDKN2A, CDK4, POT1, MITF and MC1R, in a large multicentre cohort of Italian children and adolescents in order to explore the genetic context of paediatric melanoma and to reveal potential differences in heritability between children and adolescents.

METHODS

One-hundred-twenty-three patients (<21 years) from nine Italian centres were analysed for the CDKN2A, CDK4, POT1, MITF, and MC1R melanoma predisposing genes. The rate of gene variants was compared between sporadic, familial and multiple melanoma patients and between children and adolescents, and their association with clinico-pathological characteristics was evaluated.

RESULTS

Most patients carried MC1R variants (67%), while CDKN2A pathogenic variants were found in 9% of the cases, the MITF E318K in 2% of patients and none carried CDK4 or the POT1 S270N pathogenic variant. Sporadic melanoma patients significantly differed from familial and multiple cases for the young age at diagnosis, infrequent red hair colour, low number of nevi, low frequency of CDKN2A pathogenic variants and of the MC1R R160W variant. Melanoma in children (≤12 years) had more frequently spitzoid histotype, were located on the head/neck and upper limbs and had higher Breslow thickness. The MC1R V92M variant was more common in children than in adolescents. CDKN2A common polymorphisms and MC1R variants were associated with a high number of nevi.

CONCLUSION

Our results confirm the scarce involvement of the major high-risk susceptibility genes in paediatric melanoma and suggest the implication of MC1R gene variants especially in the children population.

The association between pesticide use and cutaneous melanoma: a systematic review and meta-analysis

BACKGROUND

The incidence of cutaneous melanoma (CM), the deadliest form of skin cancer, has gradually increased in the last decades among populations of European origin. Epidemiological studies suggested that farmers and agricultural workers are at an increased risk of CM because they were exposed to pesticides. However, little is known about the relationship between pesticides and CM.

OBJECTIVES

To investigate the association between exposure to pesticides and CM by systematically reviewing the literature. Secondary aim was to determine the categories of pesticides mainly involved in CM development.

METHODS

A systematic review of the literature was performed up to September 2018 using MEDLINE, Embase and Web of Science. Studies assessing CM risk in licensed pesticide applicators were considered. Strict criteria were established to select independent studies and risk estimates; random effect models, taking into account heterogeneity, were applied. A pooled risk estimate for CM was calculated for the use of each type of pesticide and type of exposure. Between-study and estimate heterogeneity was assessed and publication bias investigated.

RESULTS

A total of nine studies (two case-controls and seven cohorts) comprising 184 389 unique subjects were included. The summary relative risks for the categories 'herbicides - ever exposure', 'insecticides - ever exposure', 'any pesticide - ever exposure' and 'any pesticide - high exposure' resulted 1.85 [95% confidence interval (CI): 1.01, 3.36], 1.57 (95% CI: 0.58, 4.25), 1.31 (95% CI: 0.85, 2.04) and 2.17 (95% CI: 0.45, 10.36), respectively. Herbicides and insecticides had no between-study heterogeneity (I2  = 0%), while a significant heterogeneity (I2  > 50%) was detected for the high exposure to any pesticide. No indication for publication bias was found.

CONCLUSIONS

Individuals exposed to herbicides are at an increased risk of CM. Future properly designed observational studies are required to confirm this finding.

Morphological classification of melanoma metastasis with reflectance confocal microscopy

BACKGROUND

Cutaneous malignant melanoma metastases differential diagnosis is challenging, as clinical and dermoscopic features can simulate primary melanoma or other benign or malignant skin neoplasms, and in-vivo reflectance confocal microscopy could assist. Our aim was to identify specific reflectance confocal microscopy features for cutaneous malignant melanoma metastases, and epidermal and dermal involvement.

METHODS

A retrospective, multicentre observational study of lesions with proven cutaneous malignant melanoma metastases diagnosis between January 2005 and December 2016. Lesions were retrospectively assessed according to morphological features observed at reflectance confocal microscopy. Potential homogeneous subgroups of epidermal or dermal involvement were investigated with cluster analysis.

RESULTS

Cutaneous malignant melanoma metastases (51 lesions in 29 patients) exhibited different frequencies of features according to metastasis dermoscopy patterns. Lesions classified at dermoscopy with nevus-like globular and non-globular patterns were more likely to be epidermotropic, showing characteristics of epidermal and dermal involvement at reflectance confocal microscopy. Other dermoscopy pattern classifications were more likely to be dermotropic, showing characteristics od dermal involvement at reflectance confocal microscopy. Distinguishing features at reflectance confocal microscopy included irregular (78%) and altered (63%) epidermis, pagetoid infiltration (51%), disarranged junctional architecture (63%), non-edged papillae (76%), dense and sparse, and cerebriform nests in the upper dermis (74%), and vascularity (51%). Cluster analysis identified three groups, which were retrospectively correlated with histopathological diagnoses of dermotropic and epidermotropic diagnoses (P < 0.001). The third cluster represents lesions with deep dermis morphological changes, which were too deep for evaluation with reflectance confocal microscopy.

CONCLUSIONS

Specific reflectance confocal microscopy features of cutaneous malignant melanoma metastases for correct diagnosis, and subtype diagnosis, seem achievable in most cases where morphological alterations are located above the deep dermis.

Evaluation of the agreement between TNM 7th and 8th in a population-based series of cutaneous melanoma

BACKGROUND

The 8th edition of TNM has introduced new rules for staging cutaneous melanoma.

OBJECTIVE

To compare TNM 7th and 8th editions in defining pathological stages of melanoma.

METHODS

A population-based series of 1847 skin melanoma from Romagna cancer registry (Italy) incident during 2003-2012 has been used to measure the agreement (with Cohen's kappa) between TNM 8th and 7th editions in defining melanoma stage. Disease-specific survival has been computed for each stage according to TNM 7th and 8th.

RESULTS

The agreement between the two TNM editions was quite good when considered on average (kappa = 70.7%), moderate for stage I (61.5%), nearly perfect for stage II (95.0%), but extremely poor for stage III (8.1%). The overall melanoma-specific observed survival was 90.8% at 5 year and 88.9% at 10 year with a strong prognostic effect of stage.

CONCLUSION

TNM 8th edition introduces several changes which do not seem really helpful in addressing the care of stage I melanoma and may complicate the definition and comparability of stage III.

Analysis of Breslow Tumor Thickness Distribution of Skin Melanoma in the Italian Region of Romagna, 1986–1991

Aims and Background

In southern European countries, the availability of epidemiologic data on cutaneous malignant melanoma is limited. A descriptive analysis was performed on melanoma cases diagnosed in the Italian region of Romagna (population 600,000), 1986-91.

Methods

The main end point was the proportion of cases less than 1.5 mm thick by sex, age, and site.

Results

A total of 297 incident cases was evaluated. The average annual age-standardized (World) incidence rates were 6.2 (95% CI 5.2–7.2) per 100,000 females and 4.5 (95% CI 3.6–5.3) per 100,000 males. Females presented with significantly thinner melanomas than males. The proportion of cases less than 1.5 mm thick decreased significantly with increasing age in both sexes, with the most pronounced decrease (approximately from 2/3 to 1/3) being observed above 60 years for females and above 40 for males. Comparing sexes by 10-year age groups, a significant F:M advantage in thickness distribution was found only at age 40–49 and 50–59 years. Among females under 60, melanomas of the legs and those of the trunk showed no difference in thickness distribution, in both sexes, incidence appeared to increase progressively with age. No apparent elevation in incidence rates was observed in the age groups with the highest frequency of thin melanomas.

Conclusions

The major implication of these data is that in public education programs specific messages should be aimed at those subgroups that show the poorest levels of self-surveillance.

Accuracy of Epiluminescence Microscopy among Practical Dermatologists: A Study from the Emilia-Romagna Region of Italy

AIMS AND BACKGROUND

The accuracy of epiluminescence microscopy (ELM) for pigmented skin lesions (PSLs) is still unclear. The large scale utilization of the technique is generally discouraged. The present study was aimed at comparing the accuracy of ELM with that of clinical examination alone in a group of 20 practical dermatologists.

METHODS AND STUDY DESIGN

Thirty digital clinical images of benign and malignant PSLs and their digital ELM counterparts were used. A set of cumulative accuracy measures reported in the combined clinical/ELM diagnosis was compared with that reported in the clinical diagnosis alone.

RESULTS

The proportion of nonmelanocytic lesions (NMLs), melanocytic nevi, and melanomas correctly identified, the predictive value of such diagnoses, and the proportion of melanomas detected by referral for biopsy (irrespective of the diagnosis reported) increased significantly. The cases referred for biopsy despite a "benign" impression decreased significantly among NMLs.

CONCLUSIONS

The observed tendency towards a greater accuracy suggests that even in the routine dermatology practice ELM has the potential to improve the clinical examination of PSLs.

Pigmented nodular melanoma: the predictive value of dermoscopic features using multivariate analysis

BACKGROUND

Nodular melanoma (NM), representing 10-30% of all melanomas, plays a major role in global mortality related to melanoma. Nonetheless, the literature on dermoscopy of NM is scanty.

OBJECTIVES

To assess odds ratios (ORs) to quantify dermoscopic features of pigmented NM vs. pigmented superficial spreading melanoma (SSM), and pigmented nodular nonmelanocytic and benign melanocytic lesions.

METHODS

To assess the presence or absence of global patterns and dermoscopic criteria, digitized images of 457 pigmented skin lesions from patients with a histopathological diagnosis of NM (n = 75), SSM (n = 93), and nodular nonmelanocytic and benign melanocytic lesions (n = 289; namely, 39 basal cell carcinomas, 85 seborrhoeic keratoses, 81 blue naevi, and 84 compound/dermal naevi) were retrospectively collected and blindly evaluated by three observers.

RESULTS

Multivariate analysis showed that ulceration (OR 4.07), homogeneous disorganized pattern (OR 10.76), and homogeneous blue pigmented structureless areas (OR 2.37) were significantly independent prognostic factors for NM vs. SSM. Multivariate analysis of dermoscopic features of NM vs. nonmelanocytic and benign melanocytic lesions showed that the positive correlating features leading to a significantly increased risk of NM were asymmetric pigmentation (OR 6.70), blue-black pigmented areas (OR 7.15), homogeneous disorganized pattern (OR 9.62), a combination of polymorphous vessels and milky-red globules/areas (OR 23.65), and polymorphous vessels combined with homogeneous red areas (OR 33.88).

CONCLUSIONS

Dermoscopy may be helpful in improving the recognition of pigmented NM by revealing asymmetric pigmentation, blue-black pigmented areas, homogeneous disorganized pattern and abnormal vascular structures, including polymorphous vessels, milky-red globules/areas and homogeneous red areas.

Morphological features of naevoid melanoma: results of a multicentre study of the International Dermoscopy Society

BACKGROUND

Naevoid melanoma (NeM), a rare variant of melanoma, can be difficult to detect as its clinical and histopathological morphology can simulate a naevus.

OBJECTIVES

To describe the clinical and dermoscopic features associated with NeM.

METHODS

Lesions with a histopathological diagnosis of NeM were collected via an e-mail request sent to all members of the International Dermoscopy Society. All lesions were histopathologically reviewed and only lesions fulfilling a set of predefined histopathological criteria were included in the study and analysed for their clinical and dermoscopic features.

RESULTS

Twenty-seven of 58 cases (47%) fulfilled the predefined histopathological criteria for NeM and were included in the study. Clinically, 16 of the 27 NeMs presented as a nodular lesion (59%), eight (30%) as plaque type and three (11%) as papular. Analysis of the global dermoscopic pattern identified three types of NeM. The first were naevus-like tumours (n = 13, 48%), typified by a papillomatous surface resembling a dermal naevus. In these lesions local dermoscopic features included irregular dots/globules (46%), multiple milia-like cysts (38%) and atypical vascular structures (46%). The second type were amelanotic tumours (n = 8, 30%), typified by an atypical vascular pattern (75%). The third type consisted of tumours displaying a multicomponent pattern (n = 4, 15%), characterized by classical local melanoma-specific criteria. Two lesions (7%) were classified as mixed-pattern tumours as they did not manifest any of the aforementioned patterns.

CONCLUSIONS

While NeMs may be clinically difficult to differentiate from naevi, any papillomatous lesion displaying dermoscopically atypical vessels and/or irregular dots/globules should prompt consideration for the possible diagnosis of NeM.

Integration of reflectance confocal microscopy in sequential dermoscopy follow-up improves melanoma detection accuracy

BACKGROUND

Successful treatment of melanoma depends on early diagnosis, but its varied clinical presentation means that no single noninvasive method or criterion can provide reliable detection in all cases.

OBJECTIVES

To determine whether combining sequential dermoscopy imaging with reflectance confocal microscopy (RCM) can improve melanoma detection and reduce the burden of unnecessary excisions.

METHODS

We conducted a retrospective study with median follow-up of 25 months. We included equivocal pigmented lesions that lacked clear dermoscopy criteria for melanoma at baseline but were excised subsequently because of changes during digital monitoring. RCM imaging was performed before excision. Main melanoma dermoscopy features, seven-point checklist score at baseline, and changes in structure and/or colour, and development of new melanoma-specific criteria at follow-up (scored as major, moderate or minor) were considered. Main melanoma RCM criteria were evaluated and diagnosis was made. Histopathological diagnosis was the reference standard for defining parameter frequency and diagnostic accuracy.

RESULTS

Seventy lesions were included. Major changes were more frequently correlated with melanoma diagnosis, although one-third (four of 12) of melanomas showed moderate or minor changes. Cytological atypia and architectural disarrangement on RCM were correlated with melanoma diagnosis. A correct melanoma diagnosis was achieved with RCM in almost all cases (11 of 12, 92%). Referring for excision only those lesions with RCM-positive features and/or presenting major changes at digital dermoscopy follow-up, theoretically 27 of 58 naevi could be saved from surgery.

CONCLUSIONS

Integration of RCM in the clinical and instrumental strategy for managing difficult pigmented lesions provided additional diagnostic information useful in the decision-making process.

CDKN2A mutations could influence the dermoscopic pattern of presentation of multiple primary melanoma: a clinical dermoscopic genetic study

BACKGROUND

Patients who develop cutaneous melanoma are at increased risk of developing a second primary melanoma. There are many aetiological reasons by which the risk of a second melanoma increases. Among others, genetic factors may contribute to modulating this risk. The risk of identifying a CDKN2A germline mutation increases with the number of primary melanomas and with the presence of familial history of melanoma. Patients with melanoma are especially encouraged to have regular follow-up visits with their dermatologist to perform clinical and dermatoscopic examination. In particular, dermoscopy could be very useful in multiple primary melanoma (MPM) patients.

OBJECTIVES

To analyse the clinical and dermatoscopic features of multiple melanomas, focusing on those features that are more frequently found in the same patient to recognize them earlier and understand whether they appear with the similar peculiar dermatoscopic features, especially in CDKN2A carriers.

METHODS

Medical records of MPM patients were selected from a database including 1065 patients with histopathologically proven melanoma diagnosis, all treated at the dermatology clinic of the University of Florence from 2000 to 2013. Pictures of melanoma were independently and blindly administered to three dermatologist experts in dermoscopy to evaluate the presence or absence of ABCD criteria for each clinical image, and the main pattern for the dermoscopic images. The results were then analyzed and crossed to rate the clinical and dermoscopic features of MPM.

RESULTS

Seventy five (7.0%) of 1065 patients included in our database were found to carry an MPM disease. Among them, we selected 12 (16%) patients with three or more MPMs. The presence of the CDKN2A melanoma susceptibility gene was observed in 4/12 (33.33%) patients; two patients presented the C500G and c.5 + 1delG polymorphisms in the CDKN2A gene. In CDKN2A carriers, each patient showed a similar and specific dermatoscopic pattern in their lesions.

CONCLUSIONS

Even being aware of the limitations of this study, according to hereditary characters and their modes of transmissions, we could speculate that for each patient with a CDKN2A germline mutation, it is possible to find the same kind of dermoscopical pattern among their melanocytic tumours.

Melanoma detection in Italian pigmented lesion clinics

AIM

Accuracy in melanoma detection is important to recognize early curable melanomas and to minimize the unnecessary excision of benign lesions. The aim of this paper was to evaluate melanoma screening accuracy of Italian pigmented lesion clinics in terms of number needed to excise (NNE), melanoma thickness, and number of melanomas diagnosed during patient follow-up.

METHODS

Information on all skin tumors excised in 2011 were extracted from the databases of the participating centers. Information whether the lesion was excised at the baseline examination or during patient follow-up was recorded, as well as the overall number of patients examined in each center in 2011.

RESULTS

After e-mail solicitation, 22 of 40 centers agreed to participate. A total of 8229 excised lesions were collected. The overall number of examined patients was 86.564, thus 9.5% of screened patients had a lesion removed. Of the excised lesions, 866 were diagnosed as melanoma (1% of examined patients) and 5311 (88.9%) were melanocytic nevi. Three NNE were calculated giving values of 7.9 excised lesions to find 1 melanoma, 7.1 melanocytic lesions to find 1 melanoma, and 3.7 lesions to find 1 skin malignancy. The median melanoma thickness was 0.6 mm, with only 15.1% of melanomas ≥ 1 mm of thickness. Melanomas detected over time were 96 (11.1%; mean thickness, 0.3 mm), with 15.6% of lesions excised after short-term follow-up and 84.4% after long-term follow-up.

CONCLUSION

The NNE values comparable to those achieved in specialized clinical settings and the high number of early melanomas diagnosed at the baseline examination or during patient follow-up indicate a high level of accuracy in melanoma screening achieved by Italian pigmented lesion clinics.

Dermoscopy of acral melanoma: a multicenter study on behalf of the international dermoscopy society

BACKGROUND

Most studies on dermoscopy of acral lesions were conducted in Asian populations. In this study, we analyzed these features in a predominantly Caucasian population.

OBJECTIVE

Estimate the prevalence of dermoscopic features in acral lesions, and assess their level of agreement between observers.

METHODS

In this retrospective multicenter study, 167 acral lesions (66 melanomas) were evaluated for 13 dermoscopic patterns by 26 physicians, via a secured Internet platform.

RESULTS

Parallel furrow pattern, bizarre pattern, and diffuse pigmentation with variable shades of brown had the highest prevalence. The agreement for lesion patterns between physicians was variable. Agreement was dependent on the level of diagnostic difficulty.

CONCLUSION

Lesions with a diameter >1 cm were more likely to be melanoma. We found as well that a benign pattern can be seen in parts of melanomas. For this reason one should evaluate an acral lesion for the presence of malignant patterns first.

Dermoscopy of scalp tumours: a multi-centre study conducted by the international dermoscopy society

BACKGROUND

Little is known about the dermoscopic features of scalp tumours. Objective  To determine the dermoscopic features of scalp tumours.

METHODS

Retrospective analysis of dermoscopic images of histopathologically diagnosed scalp tumours from International Dermoscopy Society members.

RESULTS

A total of 323 tumours of the scalp from 315 patients (mean age: 52 years; range 3-88 years) were analysed. Scalp nevi were significantly associated with young age (<30 years) and exhibited a globular or network pattern with central or perifollicular hypopigmentation. Melanoma and non-melanoma skin cancer were associated with male gender, androgenetic alopecia, age >65 years and sun damage. Atypical network and regression were predictive for thin (≤1 mm) melanomas, whereas advanced melanomas (tumour thickness > 1 mm) revealed blue white veil, unspecific patterns and irregular black blotches or dots.

CONCLUSIONS

The data collected provide a new knowledge regarding the clinical and dermoscopy features of pigmented scalp tumours.

Melanoma epidemic across the millennium: time trends of cutaneous melanoma in Emilia-Romagna (Italy) from 1997 to 2004

BACKGROUND

After a rapid increase in malignant melanoma (MM) incidence in the last decades, trends of the melanoma epidemic in the recent years seemed not homogeneous.

OBJECTIVE

This study aimed at the monitoring of some epidemiological data referring to melanoma in a region of the Northern Italy during the past 8-year period.

METHODS

All cases of melanoma, including also in situ lesions, diagnosed in Emilia-Romagna and San Marino State, with the exclusion of Cesena province, from 1997 to 2004 were recorded and the incidence of melanoma, adjusted for the European standard population by the direct method, was calculated.

RESULTS

Mean standardized incidence was 9.7 for invasive MMs and 11.9, considering also in situ ones, showing an ascending trend with an increment of 3.3 new incident cases in 2004 compared with 1997. No differences in age distribution, gender and site were reported. Concerning tumour thickness, although a general ascending trend in all subtypes, only thin melanoma incidence significantly increased over the study period.

CONCLUSIONS

Contrary to data from Northern European countries, melanoma incidence still showed an ascending trend in the Italian population of Emilia Romagna.

Dermoscopy for early detection of facial lentigo maligna

Up until now, only lesions selected on the basis of their clinical atypia or which appear equivocal on naked eye examination have been shown to benefit from the use of dermoscopy. In our experience, dermoscopic evaluation of lesions located on the face may require a different approach, as a histopathological diagnosis of malignancy is not uncommon in clinically trivial lesions (i.e. lesions lacking the ABCD criteria for clinical suspicion). Moreover, at this site dermoscopy reveals specific criteria according to the particular histological architecture shown by sun-damaged skin. We report four cases of lentigo maligna (LM) of the face whose identification depended on dermoscopic examination which was performed routinely on all facial lesions, as the lesions did not show ABCD clinical criteria for malignancy. In our experience, the identification of early signs of malignancy by dermoscopy may indicate the excision of LM at an early phase, before the lesion is associated with the ABCD signs of melanoma. Dermatologists should avoid the mistake of immediately excluding a diagnosis of malignancy when examining an ABCD-negative pigmented skin lesion of the face.

Diagnosis of melanoma in the elderly and surgical implications

The diagnosis of primary melanoma is mainly related to the precocity on which a patient is referred to the specialist, but in elderly patients this may present some peculiar characteristics, one is anatomical, a typical melanoma of the face, the lentigo maligna melanoma and the second is attitudinal, the fact that elderly patients often do not refer a changing cutaneous lesion to a doctor until becoming symptomatic. The therapeutic approach has to be discussed with an anaesthesiologist if the procedure has to be conducted under general anaesthesia or with a cardiologist if under local anaesthesia. Once there are no contraindications medically, a similar oncological approach should be proposed without any reduction in radicality due to the elderly age.

Self-detected cutaneous melanomas in Italian patients

Self-detection of suspicious pigmented skin lesion combined with rapid referral to dermatologic centres is the key strategy in the fight against melanoma. The investigation of factors associated with pattern of detection of melanoma (self- vs. nonself-detection) may be useful to refine educational strategies for the future. We investigated the frequency of melanoma self-detection in a Mediterranean population at intermediate melanoma risk. A multicentric survey identified 816 consecutive cases of cutaneous melanoma in the period January to December 2001 in 11 Italian clinical centres belonging to the Italian Multidisciplinary Group on Melanoma. All patients filled a standardized questionnaire and were clinically examined by expert dermatologists. Self-detected melanomas were 40.6%, while the remaining lesions were detected by a dermatologist (18.5%), the family physician (15.2%), other specialists (5%), the spouse (12.5%), a friend or someone else (8.2%). Variables associated with self-detected melanomas were female sex, young age, absence of atypical nevi, knowledge of the ABCD rule, habit of performing skin self-examination. Self-detected melanomas did not differ from nonself-detected tumours in term of lesion thickness; however, patients with self-detected melanomas waited a longer period before having a diagnostic confirmation (patient's delay) (> 3 months: odds ratio, 3.89; 95% confidence interval, 2.74-5.53). In order to reduce the patients' delays, educational messages should adequately stress the need for a prompt referral to a physician once a suspicious pigmented lesion is self-detected.

Amelanotic/hypomelanotic melanoma: clinical and dermoscopic features

BACKGROUND

Amelanotic malignant melanoma is a subtype of cutaneous melanoma with little or no pigment on visual inspection. It may mimic benign and malignant variants of both melanocytic and nonmelanocytic lesions.

OBJECTIVES

To evaluate whether dermoscopy is also a useful technique for the diagnosis of amelanotic/hypomelanotic melanoma (AHM).

METHODS

We conducted a retrospective clinical study of 151 amelanotic/hypomelanotic skin lesions from 151 patients with a mean age of 47 years (+/- 17.5 SD). Digitized images of amelanotic/hypomelanotic skin lesions were converted to JPEG format and sent by e-mail from the five participating centres. Lesions included 55 amelanotic/hypomelanotic nonmelanocytic lesions (AHNML), 52 amelanotic/hypomelanotic benign melanocytic lesions (AHBML), and 44 AHM, 10 (23%) of which were nonpigmented, truly amelanotic melanomas (AM). The 44 AHM lesions were divided into thin melanomas (TnM) </= 1 mm (29 cases) and thick melanomas (TkM) > 1 mm (15 cases), according to the Breslow index. Five clinical features (elevation, ulceration, shape, borders and colour) as well as 10 dermoscopic criteria (pigment network, pigmentation, streaks, dots/globules, blue-whitish veil, regression structures, hypopigmentation, leaf-like areas, multiple grey-bluish globules, central white patch) and eight vascular patterns (comma, arborizing, hairpin, dotted, linear irregular, dotted and linear irregular vessels, and milky-red areas) were evaluated in order to achieve clinical and dermoscopic diagnoses. Statistical analyses were performed with the chi2-test and Fisher's exact test, when appropriate.

RESULTS

The most frequent and significant clinical features for TnM and TkM were asymmetry and ulceration (the latter only for TkM) compared with AHBML. Irregular dots/globules (62% vs. 35%; P </= 0.03), regression structures (48% vs. 27%; P </= 0.03), irregular pigmentation (41% vs. 11%; P </= 0.03) and blue-whitish veil (10% vs. 0%; P </= 0.03) were the most relevant dermoscopic criteria for TnM in comparison with AHBML. TkM differed significantly from AHBML in frequency of occurrence of irregular pigmentation (87% vs. 11%; P </= 0.03), irregular dots/globules (73% vs. 35%; P </= 0.03), regression structures (67% vs. 27%; P </= 0.03), blue-whitish veil (27% vs. 0%; P </= 0.03) and hypopigmentation (13% vs. 55%; P </= 0.03). Linear irregular vessels and the combination of dotted and linear irregular vessels associated with TnM and TkM were not found in our cases of AHBML and were only rarely seen in AHNML (3.6% and 1.8%, respectively). Moreover, TkM differed significantly from AHBML and TnM in frequency of occurrence of milky-red areas (93% vs. 17%; P </= 0.03 and 93% vs. 31%; P </= 0.01, respectively). The dermoscopic diagnosis of melanoma had a higher sensitivity and specificity than the clinical diagnosis (89% and 96% vs. 65% and 88%, respectively). With the limitation of the small number of cases, vascular patterns were the only dermoscopic criteria for 'truly' AM. In the 10 cases of 'truly' AM, we found milky-red areas in more than half of the cases (six of 10), dotted vessels in four, hairpin vessels in two, linear irregular vessels in two, dotted and linear irregular vessels in two.

CONCLUSIONS

Because dermoscopy uses criteria reflecting pigmentation (irregular pigmentation and irregular dots/globules) and vascular patterns, it is a useful technique not only for pigmented melanoma but also for hypomelanotic melanoma. In 'truly' AM, vascular patterns alone may not be sufficient to diagnose melanoma. A combined approach with the clinical information should help in the detection of 'truly' AM.

Epidemiology of digital epiluminescence microscopy features of acquired melanocytic naevi

This study addressed the independent association of past and recent sun exposure indicators and other host factors with the prevalence of major digital epiluminescence microscopy (D-ELM) features such as the pigment network (PN), brown globules (BGs), and pigment dots (PDs) in acquired melanocytic naevi. In a consecutive series of 189 patients (median age 28 years; range 10-73 years) with one or more naevi as diagnosed on D-ELM, we evaluated 35 solitary lesions and one naevus randomly selected from each of the 154 patients with multiple lesions. D-ELM images were classified for the presence or absence of PN, BGs and PDs on two blind readings. Data analysis was based on multiple logistic regression. Patient age was positively associated with PN and inversely associated with BGs. The probability of PN increased with more than 110 days since last exposure to the sun, whereas a rapid decrease for BGs and PDs was observed after approximately 1 month. PDs were significantly more likely among lesions with 6-10 h/day of recent exposure. Sex, total lifetime hours of exposure, sunbed use, skin type and colour of hair exerted no effect. In conclusion, major D-ELM features appeared to differ in their relationship with sun exposure indicators.

Epiluminescence microscopy features of melanoma in relation to tumor thickness. Current concepts and clinical examples

Based on current information, the expression of ELM features as a function of tumor thickness seems to be consistent not only with the definition of main ELM features but also with the model of histogenesis of the disease. The published data and observations, however, are insufficient. The relationship between tumor thickness and the ELM picture needs to be the subject of further research.

Epiluminescence microscopy versus clinical evaluation of pigmented skin lesions: effects of Operator's training on reproducibility and accuracy. Dermatology and Venereology Society of the Canton of Ticino

BACKGROUND

An acceptable level of reliability is a prerequisite for the introduction of epiluminescence microscopy (ELM) into the diagnosis of pigmented skin lesions.

OBJECTIVE

To assess the effects of a training program on the reproducibility and accuracy of ELM as compared to clinical evaluation.

METHODS

Before and after the program, 48 clinical images and their ELM counterparts were independently evaluated by seven participants. Reproducibility was measured by the kappa index, accuracy by the rate of exact diagnoses (RED) assuming histology as a reference.

RESULTS

We observed (i) no effect of training on clinical reproducibility, (II) an improved reproducibility of ELM diagnoses of non-melanocytic lesions (NML) and melanomas but not of melanocytic nevi (MN), (iii) a greater increase in the clinical RED of NML and melanomas compared with MN and (iv) a similar though more pronounced increase in the RED on ELM.

CONCLUSIONS

The effects of training were greater for ELM as compared to clinical diagnosis, and for NML and melanomas as compared to MN.

A cancer-registry-assisted evaluation of the accuracy of digital epiluminescence microscopy associated with clinical examination of pigmented skin lesions

BACKGROUND

The accuracy of digital epiluminescence microscopy (D-ELM) as an adjunct to clinical examination for the diagnosis of pigmented skin lesions (PSLs) has seldom been evaluated.

OBJECTIVE

To compare the accuracy of the combined clinical/D-ELM (C/D-ELM) examination with that of the clinical examination alone.

METHODS

A total of 3,372 PSLs from 1,556 consecutive patients referred to a skin cancer clinic underwent clinical examination and a combined C/D-ELM examination. The reference diagnosis was established using the histology report of known surgical excisions plus a cancer-registry-based follow-up (duration 18 months) of benign C/D-ELM diagnoses. The two diagnostic approaches were compared for sensitivity, predictive value and false-positive rate.

RESULTS

The series included 55 melanomas and 43 basal cell carcinomas. About 50% of malignant misdiagnosed cases were identified solely through the cancer registry. The C/D-ELM diagnosis showed a greater sensitivity for melanoma <0.76 mm thick (83 vs. 46% for clinical examination alone; ratio, 1.82) and basal cell carcinoma (79 vs. 49%; ratio, 1. 62), a greater predictive value for melanoma (81 vs. 53%; ratio, 1. 53) and a reduced total false-positive rate (0.3 vs. 0.9%; ratio, 0. 31).

CONCLUSION

D-ELM showed a potential to improve the clinical diagnosis of PSL.

Diagnosis of pigmented skin lesions by epiluminescence microscopy: determinants of accuracy improvement in a nationwide training programme for practical dermatologists

BACKGROUND

The poor accuracy of the clinical examination of pigmented skin lesions (PSLs) is a major limitation of secondary prevention strategies for cutaneous melanoma (CMM). In the last few years, the epiluminescence microscopy (ELM) technique has been used increasingly as an adjunct to clinical examination in the dermatology practice. Although the question of training has emerged as a priority, the diffusion, the effects, and the correlates of educational programmes in ELM have seldom been studied.

METHODS

Thirty ELM images of PSLs (11 CMMs, 14 melanocytic nevi (MN), and 5 nonmelanocytic lesions (NMLs) each matched with the corresponding clinical or plain photographic image were independently diagnosed before and after a one-day workshop by 83 Italian dermatologists participating in a nationwide educational programme on ELM. The original histology diagnosis was assumed as a gold standard. The overall effect of training on a set of accuracy measures by PSL type was evaluated. The association of the professional sector (public/private), number of years of general experience in dermatology (1-10/>10), average weekly number of PSLs seen (< or =10/11-20/>20), routine use of ELM (no/yes), and area of residence (northern/southern Italy) with the mean number of PSLs correctly diagnosed before and after training was evaluated with the general factorial analysis of variance. The factors associated with improvement between the two tests were evaluated with the analysis of variance for repeated measures.

RESULTS

Compared with pretraining data, the average percentage of exact diagnosis increased significantly for all PSLs (CMMs, 72% vs 55%; MN, 68% vs 64%; NMLs, 67% vs 58%; total lesions combined, 69% vs 60%). Baseline as well as final accuracy were independent from the professional sector and the years of experience but were greater among those subjects who reported >20 PSLs per week compared with the reference group (< or =10 PSLs). The routine use of ELM was associated with a slight advantage in pretraining accuracy. The area of residence was the strongest determinant of baseline as well as final accuracy. The effect of training was independent from all factors studied with the exception of the area of residence with a 13% increase in the frequency of exact diagnosis in northern Italy (from 66-79%) and 6% in southern Italy (from 55-61%).

CONCLUSIONS

Though insufficient in absolute terms, a measurable increase in ELM accuracy can be achieved even with intense training sessions of short duration. Medical education to ELM in southern Italy should be a priority.

Critical effects of intense sun exposure on the expression of epiluminescence microscopy features of acquired melanocytic nevi

BACKGROUND

Current knowledge of the histologic counterparts of epiluminescence microscopy (ELM) features in pigmented skin lesions is limited. As a particular aspect of this problem, the transient effects of intense sun exposure on the morphological characteristics of melanocytic nevi may influence the expression of ELM features as well as the demonstration of stable and consistent histologic correlates.

OBSERVATIONS

Forty melanocytic nevi from 11 subjects living in Northern Italy were examined by digital ELM before and after 5 to 13 days of sun exposure at latitudes of 5 degrees north to 3 degrees south. A number of multifaceted changes were observed. In particular, 3 lesions showed the expression of some structures compatible with radial streaming, pseudopods, and gray-blue areas. These features are considered to have often severe histologic correlates. In a third image, obtained 5 to 6 weeks later, they showed partial or total regression. Another case showed a massive regression of the pigment network as a result of a progressive inflammatory reaction with marked asymmetry in the distribution of pigmentation.

CONCLUSIONS

Digital ELM has the potential to detect subtle changes in the structure of nevi after intense sun exposure. The transient observation of certain ELM features often associated with severe histologic substrates casts doubts on the ability of ELM to characterize sun-exposed nevi by a single examination.

Correlation between the histopathology and the epiluminescence microscopy features of malignant blue nevus

BACKGROUND

The validation of epiluminescence microscopy (ELM) for the diagnosis of pigmented skin lesions is conditional on the demonstration of consistent histologic correlates of the ELM patterns. The ELM characteristics of malignant blue nevus (MBN) have never been reported previously.

OBJECTIVE

To evaluate the histologic counterparts of the ELM features of a case of MBN.

METHODS

Comparison between the histologic characteristics observed in step-sections of the lesion and the structures observed in a digital ELM image.

RESULTS

On ELM, the lesion showed a diffuse whitish-blue veil, round black blotches, a collection of dark colored punctate spots, and fragmented bluish reticular-like formations in the periphery. At histologic examination, the black blotches and the spots appeared to correlate with areas of intense focal necrosis in the papillary and reticular dermis, and the reticular-like structures were demonstrated to correspond to the presence of free melanin and melanophages in the papillary dermis.

CONCLUSION

In this case of MBN, blotches and spots seen on ELM correlated with intense necrosis in the papillary and reticular dermis, and reticular-like formations were the counterparts of free melanin and melanophages in the papillary dermis.

Seasonal prevalence of digital epiluminescence microscopy patterns in acquired melanocytic nevi

BACKGROUND

Available information of the effect of sun exposure on the biologic activity and morphologic characteristics of nevi is based on a few cross-sectional studies. According to these, nevi excised in summer show a higher mitotic count, a greater extent of the junctional component, and more frequent regression and inflammation.

OBJECTIVE

Our goals were to obtain data on the seasonal prevalence of digital epiluminescence microscopy (D-ELM) patterns in acquired melanocytic nevi (AMN) and to test the reliability of D-ELM as a substitute for histology in prospective studies of the morphologic response of AMN to sun exposure.

METHODS

Two independent series of AMN located on intermittently sun-exposed body sites and undergoing D-ELM in winter (n=121) and in summer (n=116) were compared for the prevalence of major ELM patterns.

RESULTS

Cases in the summer series showed a greater frequency of a broad and prominent pigment network; black dots with varied size, irregular distribution, and peripheral location; and peripheral depigmentation.

CONCLUSION

On the basis of known histologic correlates of D-ELM features, our findings were consistent with studies of seasonal histologic changes in AMN. D-ELM may be a useful tool in the prospective evaluation of effects of sun exposure on AMN morphology.

Intraobserver agreement in interpretation of digital epiluminescence microscopy

BACKGROUND

Although a major problem with the classification of epiluminescence microscopy (ELM) findings is the lack of standard definitions, reproducibility of the criteria proposed has never been investigated.

OBJECTIVES

Our purposes were (1) to perform a review of four major published classifications to obtain a set of apparently well-defined ELM variables and descriptors and (2) to evaluate the ability of one of us to report consistently ELM findings in melanocytic lesions according to these criteria.

METHODS

Intraobserver agreement (with a set of 44 selected descriptors) between two readings of 150 digital ELM images was evaluated with the kappa (kappa) statistic. Subgroups of descriptors were compared for kappa value distribution.

RESULTS

The median kappa value for the whole series of descriptors was 0.66. Median kappa did not vary significantly among the four classification systems (kappa = 0.61 to 0.67). Agreement was significantly better as to the presence or absence of ELM findings (kappa range, 0.39 to 1.00; median kappa, 0.77) compared with agreement as to their distribution (kappa range, 0.10 to 0.79; median kappa, 0.47; p = 0.0007) and their width, thickness, and size (kappa range, 0.06 to 0.83; median kappa, 0.39; p = 0.0075).

CONCLUSION

Although nothing can be inferred from a single study, descriptors associated with low intraobserver agreement are likely to be inadequately defined.