NCOA3: A molecular prognostic marker for melanoma

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Background: Nuclear receptor coactivator-3 (NCOA3, also known as AIB1 or SRC-3), a member of the steroid receptor coactivator 1 family, has been shown to be amplified in human breast cancer. We recently identified NCOA3 as differentially expressed in metastatic melanomas by gene expression profiling, suggesting its role as a possible molecular prognostic factor. In this study, we assessed the prognostic significance of NCOA3 expression in a large melanoma patient cohort using tissue micro-arrays (TMAs). Methods: We used a commercially available antibody against NCOA3 to perform immunohistochemical analysis of NCOA3 expression in TMAs containing primary melanoma specimens from 353 patients seen at the UCSF Melanoma Center. Cases included clinicopathologic information (e.g., age, sex, tumor location, tumor thickness, Clark level and ulceration), as well as sentinel lymph node (SLN) status, and information regarding relapse-free (RFS) and disease-specific (DSS) survival. NCOA3 expression was assessed on a 4-point scale (0–3) by an observer blinded to patient outcomes. Results: High NCOA3 expression was significantly predictive of SLN metastasis by univariate logistic regression (p=0.015), and associated with a higher mean positive SLN count (p=0.03, Le test). Kaplan-Meier analysis demonstrated a significant association between increased NCOA3 expression and reduced RFS as well as DSS (p=0.024, and p=0.031 by log-rank test, respectively). Multivariate step-wise logistic regression analysis of 12 factors revealed NCOA3 expression, along with tumor thickness, age, vascular involvement, and Clark level to be independent predictors of SLN status. Multivariate Cox regression analysis showed the independent impact of NCOA3 expression on RFS and DSS with the inclusion of the AJCC factors tumor thickness, ulceration, Clark level, tumor location, patient age and sex. Conclusions: These results reveal NCOA3 to be a novel, independent marker of melanoma outcome, with a significant impact on SLN metastasis, RFS and DSS.

No significant financial relationships to disclose.

Vascular involvement in the prognosis of primary cutaneous melanoma

OBJECTIVE

To examine the role of vascular invasion as a prognostic factor in melanoma.

DESIGN

Retrospective survival analysis.

SETTING

Academic medical center.

PATIENTS

A total of 526 patients with primary cutaneous melanoma from the University of California, San Francisco, Melanoma Center database with 2 years of follow-up or documented relapse.

MAIN OUTCOME MEASURES

(1) Presence of vascular involvement defined as vascular invasion with tumor cells within blood or lymphatic vessels; or uncertain vascular invasion, with melanoma cells immediately adjacent to the endothelium. (2) Percentage with metastasis or death and relapse-free and overall survival.

RESULTS

The presence of either type of vascular involvement significantly increased the risk of relapse and death and reduced the survival associated with melanoma. The impact of vascular involvement on these outcomes was similar to that of ulceration. In a multivariate analysis, vascular involvement was the second most important factor (after tumor thickness) in the primary tumor in predicting survival.

CONCLUSIONS

Vascular involvement is an important independent predictor of metastasis and survival in melanoma. The phenomenon of uncertain vascular invasion describes an earlier step than definite vascular invasion in tumor progression.

Micrometastasis to in-transit lymph nodes from extremity and truncal malignant melanoma

BACKGROUND

The sentinel lymph node (SLN) is the first lymph node in the regional nodal basin to receive metastatic cells. In-transit nodes are found between the primary melanoma site and regional nodal basins. To date, this is one of the first reports on micrometastasis to in-transit nodes.

METHODS

Retrospective database and medical records were reviewed from October 21, 1993, to November 19. 1999. At the UCSF Melanoma Center, patients with tumor thickness > 1 mm or < 1 mm with high-risk features are managed with preoperative lymphoscintigraphy, selective SLN dissection, and wide local excision.

RESULTS

Thirty (5%) out of 557 extremity and truncal melanoma patients had in-transit SLNs. Three patients had positive in-transit SLNs and negative SLNs in the regional nodal basin. Two patients had positive in-transit and regional SLNs. Three patients had negative in-transit SLNs but positive regional SLNs. The remaining 22 patients were negative for in-transit and regional SLNs.

CONCLUSIONS

In-transit SLNs may harbor micrometastasis. About 10% of the time, micrometastasis may involve the in-transit and not the regional SLN. Therefore, both in-transit and regional SLNs should be harvested.

Evaluation of sentinel lymph node status in spindle cell melanomas

BACKGROUND

The propensity for spindle cell melanoma to metastasize to the lymph node is relatively low despite its relative thick depth. To date, there are no published reports on the sentinel lymph node (SLN) status in patients diagnosed with spindle cell melanoma and desmoplastic malignant melanoma (DMM).

OBJECTIVE

Our purpose was to report our experience on the SLN status in spindle cell melanoma and DMM.

METHODS

We undertook a retrospective database and medical record review from Oct 21, 1993 to Sept 29, 1999. At the University of California at San Francisco Melanoma Center, patients with tumor thickness greater than 1 mm or less than 1 mm with high-risk features are managed with preoperative lymphoscintigraphy, selective SLN dissection, and wide excision.

RESULTS

Of 29 patients diagnosed with spindle cell melanoma and DMM, 28 had negative SLNs and are free of disease except for one patient who experienced splenic, bony, and brain metastases. The mean follow-up in this population was 16.5 and 11 months, respectively.

CONCLUSION

Our preliminary findings show that SLNs from patients diagnosed with spindle cell melanoma and DMM only rarely harbor micrometastasis despite their relative thickness. A larger number of cases from multicenter databases may further define the true biology of SLNs in this melanoma variant.

Fine needle aspiration in the diagnosis of metastatic melanoma

BACKGROUND

Fine needle aspiration is an accurate technique to diagnose metastatic melanoma. Few reports exist in the literature describing its usefulness in many patients with melanoma confirmed by open biopsy.

OBJECTIVE

The purpose of this study was to determine the utility and predictive value of fine needle aspiration in patients with malignant melanoma who presented with lesions suspected to be metastatic.

METHODS

We retrospectively reviewed 99 cases of fine needle aspiration and the corresponding histologic findings obtained by open biopsy in 82 patients.

RESULTS

Of the 99 cases, 86 were positive for melanoma, 12 were negative, and one was indeterminate. The positive predictive value of fine needle aspiration was 99%. One patient had a false-positive diagnosis.

CONCLUSION

Fine needle aspiration is a rapid, accurate, and minimally invasive procedure that is useful in the diagnosis of metastatic melanoma. Patients with a positive aspirate of palpable regional nodes can proceed directly to surgery, bypassing the need for an open biopsy.

Outpatient combination chemoimmunotherapy for patients with metastatic melanoma. Results of a phase I/II trial

BACKGROUND

Few studies have examined the feasibility, safety, and efficacy of an outpatient biochemotherapy regimen of low dose, subcutaneously administered interleukin-2 (IL-2) for patients with metastatic (Stage IV) melanoma.

METHODS

Nineteen patients were treated with intravenous cisplatin and dacarbazine (DTIC), oral tamoxifen, and subcutaneous IL-2 and interferon-alpha-2b (IFN). Eligibility requirements included bidimensionally measurable metastatic melanoma, a Karnofsky performance score of 60 or higher, absence of significant cardiac or pulmonary dysfunction, no prior DTIC or cisplatin chemotherapy, and no evidence of central nervous system involvement. Patients were given a minimum of 2 6-week cycles. Treatment was continued in the absence of progressive disease, and patients were monitored for response at two-cycle intervals.

RESULTS

Of the 19 patients, 1 (5%) achieved a complete response; 6 (32%) a partial response; 3 (16%) stable disease; and 9 (47%) progressive disease, for an overall response proportion of 37% (95% confidence interval, 16-61%). The median survival of the treated cohort was 10.6 months. The mean time to disease progression for patients with stable disease or better was 8.4 months, with a mean response duration of 5.1 months. The most common toxicities noted were constitutional symptoms, weight loss, nausea, neutropenia, and fatigue. The 19 patients received a total of 59 cycles of treatment, and IL-2, IFN, or both were held in 14 of these cycles secondary to Grade 3 or 4 toxicities. In addition, six patients required dose reduction of IL-2 and/or IFN.

CONCLUSIONS

Chemoimmunotherapy consisting of cisplatin, DTIC, and tamoxifen combined with subcutaneous IL-2 and IFN can be safely administered in an outpatient setting. The described regimen yields moderate activity in metastatic melanoma, and efforts to improve its efficacy merit further examination.

Recombinant human granulocyte macrophage-colony stimulating factor (rhGM-CSF) and autologous melanoma vaccine mediate tumor regression in patients with metastatic melanoma

In mice, significant immunoprotection was achieved using B16 melanoma cells transfected with granulocyte-macrophage colony-stimulating factor (GM-CSF) as vaccines (Dranoff G, Jaffee E, Lazenby A, et al. Vaccination with irradiated tumor cells engineered to secrete murine granulocyte-macrophage colony-stimulating factor stimulates potent, specific, and long-lasting anti-tumor immunity. Proc Natl Acad Sci USA 1993;90:3539-43). The aim of this study is to test the hypothesis that recombinant human GM-CSF (rhGM-CSF) injected with autologous melanoma vaccine may result in tumor rejection in melanoma patients. Twenty stage IV melanoma patients were treated as outpatients with multiple cycles of autologous melanoma vaccine and bacillus Calmette-Guérin (BCG) plus rhGM-CSF injection in the vaccine sites. Two patients (10%) showed a complete response, with one patient showing resolution of subcutaneous, hepatic, and splenic metastases. In the second patient, buccal, subcutaneous, pulmonary, paraaortic, hepatic, splenic, and retroperitoneal metastases regressed completely. Two patients (10%) showed partial response, with regression of a paraaortic metastasis in one patient. In the second patient, there was shrinkage (> 75%) of a large hepatic lesion. One patient has been rendered free of disease after resection of a single pulmonary metastatic nodule. Three patients (15%) had stable disease during treatment but subsequently developed progression of disease. In 12 patients (60%), the disease progressed. Side effects were minimal. In a separate pilot study, 15 stage IV melanoma patients were also treated with autologous melanoma vaccine with BCG but not with rhGM-CSF; none responded. The fact that four patients showed objective responses to active specific immunotherapy with rhGM-CSF demonstrates that melanoma patients bearing a significant tumor burden may respond specifically to their autologous melanoma.

Prediction of sentinel lymph node micrometastasis by histological features in primary cutaneous malignant melanoma

OBJECTIVE

To develop a prognostic model, based on clinical and pathological data, to estimate the probability of micrometastasis in the sentinel lymph node in patients with malignant melanoma.

DESIGN

Retrospective analytical study.

SETTING

University medical center.

PATIENTS

Two hundred fifteen patients with American Joint Committee on Cancer stages I and II cutaneous malignant melanoma underwent sentinel lymph node biopsy.

MEASUREMENTS

Presence of microscopic melanoma in the sentinel lymph node(s). Clinical attributes recorded included age, sex, and location of the primary melanoma. Pathological attributes recorded before lymph node evaluation included ulceration, microsatellites, angiolymphatic invasion, mitotic rate, tumor infiltrating lymphocytes, and regression.

RESULTS

Forty-six patients (21.4%) overall had a positive sentinel lymph node. Patients with tumor thickness ranging from 3.0 to 3.9 mm had the highest incidence (50%) of nodal involvement, followed by those with tumors 4.0 to 4.9 mm thick (41%). Patients with melanomas measuring greater than 4.9 mm thick and those between 1.0 and 2.9 mm had a similar rate of nodal involvement (16%-17%). Clinical characteristics had minimal correlation with nodal status in multivariate analysis. The total number of histological high-risk features was significantly correlated with sentinel lymph node involvement. Important pathological risk factors included ulceration, high mitotic rate, angiolymphatic invasion, and microsatellites. Patients with tumor thickness greater than 1.0 mm but lacking these features had a 14% risk of occult metastases.

CONCLUSION

Among patients with clinically node-negative primary melanoma, the presence of 1 or more high-risk histological features significantly increases the incidence of microscopic nodal involvement and can be used to predict the likelihood of a positive sentinel lymph node biopsy.

Pigmented lesion pathology: the specimen and its report. A personal and probably biased approach

The author outlines general principles and pitfalls in the pathologic interpretation of pigmented skin lesions, then focuses on issues related specifically to gross tissue specimens and to the histologic report. He concludes that definitive therapy for melanoma should not be based on partial biopsies, that frozen sections are not indicated, and that the pathologist should report all of the relevant histologic attributes whenever possible.

Optimal selective sentinel lymph node dissection in primary malignant melanoma

OBJECTIVE

To determine the optimal approach of selective sentinel lymph node (SLN) dissection in primary malignant melanoma.

DESIGN

Consecutive patient study. Prior to selective SLN dissection and wide local excision of the primary melanoma biopsy site, technetium Tc 99m sulfur colloid was injected intradermally around the primary melanoma or biopsy site to mark the SLN. Isosulfan blue (Lymphazurin, Hirsch Industries Inc, Richmond, Va) was injected at the primary biopsy site immediately before the surgical procedure.

SETTING

Teaching hospital tertiary care referral center.

MAIN OUTCOME MEASURES

Successful identification of SLNs being defined as positive for microscopic metastatic melanoma by blue dye staining, radioisotope uptake, or both.

RESULTS

Selective intraoperative mapping by gamma probe and visualization of blue dye-stained SLN(s) resulted in a 98% (160/163) successful identification rate. Thirty patients (18.4%) had microscopic metastatic melanoma of the SLN(s), 22 of whom had subsequently completed lymphadenectomy. In 4 (18.2%) of these 22 patients, further microscopic metastatic disease was found in 1 of 8 nodes, 1 of 8 nodes, 1 of 28 nodes, and 1 of 9 nodes. No notable complications were encountered. Five recurrent cases from patients with SLNs without microscopic metastatic melanoma (3.8%) and 2 from patients with SLNs with microscopic metastatic melanoma (6%) were found during a median follow-up period of 463 days. A second primary melanoma developed in 2 patients; neither had no local recurrence.

CONCLUSIONS

Sequential combination of preoperative lymphoscintigraphy and intraoperative mapping is a reliable way to identify regional SLN. The frequency of microscopic metastatic melanoma of the SLN(s) is 18.4%. Gamma-probe--guided resection minimizes the extent of lymph node dissection. Further follow-up is needed to assess the outcome of this group of patients for regional and systemic recurrences.

Clinically recognized dysplastic nevi. A central risk factor for cutaneous melanoma

OBJECTIVE

To investigate the relationship of number and type of nevi to the development of melanoma.

DESIGN

Case-control study.

SETTING

Outpatient clinics in referral hospitals.

PATIENTS

Cases were 716 consecutive patients with newly diagnosed melanoma identified at 2 melanoma centers between January 1, 1991, and December 31, 1992. Stratified random sampling of patients from outpatient clinics was used to identify 1014 participating controls of the same age, sex, race, and geographic distribution as the melanoma cases. All study subjects underwent an interview, a complete skin examination, photography of the most atypical nevi, and, if the patient was willing, a biopsy of the most atypical nevus.

MAIN OUTCOME MEASURES

Number and type of nevi on the entire body were systematically reported. All diagnoses of clinically dysplastic nevi were confirmed by expert examiners.

RESULTS

Risk for melanoma was strongly related to number of small nevi, large nondysplastic nevi, and clinically dysplastic nevi. In the absence of dysplastic nevi, increased numbers of small nevi were associated with an approximately 2-fold risk, and increased numbers of both small and large nondysplastic nevi were associated with a 4-fold risk. One clinically dysplastic nevus was associated with a 2-fold risk (95% confidence interval, 1.4-3.6), while 10 or more conferred a 12-fold increased risk (95% confidence interval, 4.4-31). Congenital nevi were not associated with increased risk of melanoma.

CONCLUSIONS

Although nondysplastic nevi confer a small risk, clinically dysplastic nevi confer substantial risk for melanoma. On the basis of nevus number and type, clinicians can identify a population at high risk of this epidemic cancer for screening and intervention.

The multidisciplinary melanoma center

The evolution of the multidisciplinary melanoma clinics from 1965 to the present is reviewed. The University of California Melanoma Center database is presented as a model of actual visualization of the data in the care of individual melanoma patients. The basis of the ideal melanoma multidisciplinary center is given with common attributes that could be shared among all clinics, thus establishing a national network of such clinics.

Unusual variants of melanoma: fact or fiction?

Evidence is reviewed separating unusual variants of melanoma from the large group of superficial spreading and nodular (SSM/NOD) histogenetic types. These include (1) the relationship of moles to melanoma of the SSM/ NOD types not found in melanoma arising in lentigo maligna (LMM), desmoplastic neurotrophic melanoma (DNM), mucosal lentiginous melanoma (MLM), or acral lentiginous melanoma (ALM); (2) the strong sunlight association in lentigo maligna (LM) and LMM not always present in SSM/NOD and not likely at all in acral or mucosal lesions (ALM, MLM); (3) epidemiological differences of age, race, and prognosis among the various subtypes; and (4) analogies to neoplasms in other organ systems. These data justify the following conclusions: (1) Variants of melanoma exist as in other neoplasms. (2) They are of epidemiological and therapeutic importance. (3) Until further data are available or networked, data base analysis should use microstage measurements in the common forms of SSM and NOD only, and approach the unusual variants separately and cautiously.

Cutaneous melanoma in women: anatomic distribution in relation to sun exposure and phenotype

An analysis of the relationship between the anatomic site of cutaneous melanoma, sun exposure, and phenotype was conducted in 355 women with histologically confirmed superficial-spreading melanoma and in 935 control subjects. The most frequent site for superficial-spreading melanoma was the leg. However, when major sun-related and phenotype risk factors were examined by site, risk ratios were lowest for melanomas that occurred on the leg. A history of frequent sunburns during elementary or high school, increased number of self-assessed large nevi, and blond hair were more strongly associated with melanoma sites other than the leg. Tumors on the trunk were more likely than tumors at other sites to be associated with histological evidence of a preexisting nevus. Results of this work indicate that associations between melanoma phenotypic factors may differ by anatomic site.

Nevus counting as a risk factor for melanoma: comparison of self-count with count by physician

BACKGROUND

The number of total body nevi is a major risk marker for malignant melanoma. No previous study has evaluated the accuracy of whole body large nevus (> or = 5 mm) self-counts.

OBJECTIVE

Our purpose was to evaluate the accuracy of large nevus self-counts by sex, age, educational level, body site, family history of skin cancer, and nevus characteristics.

METHODS

Self-counting of large nevi by 125 patients was compared with physician counting, with attention to nevus characteristics.

RESULTS

Overall, 79% of the self-counts agreed to within +/- 3 nevi of the physician's count. Analysis of variance revealed that the presence of nonpigmented or flat nevi significantly increased the chance of subject undercount, as did male sex.

CONCLUSION

Self-counts of large nevi are comparable to physician's counts and may be useful for melanoma screening.

Risk factors for melanoma incidence in prospective follow-up. The importance of atypical (dysplastic) nevi

BACKGROUND AND DESIGN

Assessment of melanoma risk factors can help identify individuals at greatest risk for melanoma. Previous studies were retrospective case-control or prospective without control groups. A prospective group of 3889 employees without previous melanoma or family history of multiple melanoma at the Lawrence Livermore (Calif) National Laboratory were examined as part of a melanoma screening program. Their subsequent incidence of melanoma in relationship to potential melanoma risk factors, which were recorded at the first examination, was determined.

RESULTS

Nine invasive melanomas developed after initial examination among the studied population over an 8-year period with an average follow-up of 5 years. The presence of an easily recognized pattern of definite clinically atypical (dysplastic) nevi was present in 7% of employees and was associated with a cumulative melanoma risk of 1.9%. It was the strongest risk factor, with a relative risk of 47 compared with the 0.04% cumulative melanoma risk in the 64% of employees with no atypical (dysplastic) moles (chi 2 for equal risk, P = 7 x 10(-8). Significant, but less marked associations with melanoma risk were found for the total number of moles and for a history of many moles in other family members, with a maximal relative risk of 11.6 and 10.4, respectively.

CONCLUSION

A small subgroup of the population with easily recognizable definite atypical (dysplastic) nevi have a marked increased risk of melanoma. Smaller significant melanoma risks were found for a total number of moles and a family history of many moles.

Inter-observer variability among pathologists' evaluation of malignant melanoma: effects upon an analytic study

This study examined whether inter-observer variability in rating tumor characteristics affected results of an investigation of surveillance bias and malignant melanoma at the Lawrence Livermore National Laboratory. The 20 cases from the Laboratory and their 36 non-Laboratory controls belonged to the same pre-paid health plan and were diagnosed with melanoma between 1970 and 1984. Tumors were independently and then jointly rated by three dermatopathologists blind to the subjects' Laboratory status. The mean difference between the reviewers and the consensus reading for tumor thickness was small, ranging from -0.06 mm (95% confidence interval [CI]--0.12, 0.00) to 0.00 mm (95% CI--0.07, 0.07). Agreement was much lower for histologic type (kappa = 0.48, 95% CI 0.37, 0.58). Because the inter-observer variability, the study's hypothesis was rejected by analyses based on data from the consensus reading and two reviewers, but not on data from the third reviewer. These findings suggest that epidemiologists using data subject to inter-observer variability may want to employ consensus instead of individual ratings.

A multiobserver, population-based analysis of histologic dysplasia in melanocytic nevi

BACKGROUND

Nevi that are clinically atypical and histologically dysplastic have been associated with increased melanoma risk. There are few reproducibility studies or population-based studies of nevus histology.

OBJECTIVE

Our purpose was to quantify concordance in histologic diagnosis of melanocytic lesions among a diverse group of pathologists, to assess intraobserver concordance by comparing readings of the same slide as well as of adjacent recuts from the same block, to correlate histology with nevus appearance and melanoma risk, and to estimate the range of prevalence of histologic dysplasia.

METHODS

Histologic slides were prepared from 149 tissue blocks of pigmented lesions from melanoma cases, relatives, and controls. Six dermatopathologists independently evaluated the lesions for histologic dysplasia, without prior agreement on criteria.

RESULTS

According to kappa statistics, intraobserver reproducibility was substantial, and interobserver concordance was fair, despite differences in criteria. The estimated prevalences of histologic dysplasia for the six pathologists ranged from 7% to 32%. Histologic dysplasia was correlated with nevus size for most observers, confounding the observed correlation between nevus appearance and histology.

CONCLUSION

Although experienced dermatopathologists use different diagnostic criteria for histologic dysplasia, their usage is consistent. Histologic changes ascribed to melanocytic dysplasia are prevalent in the white population for all pathologists. The term nevus with histologic dysplasia should be used in preference to dysplastic nevus.

Melanoma risk factors and atypical moles

Despite important advances in the treatment of melanoma, the prognosis for advanced disease remains discouraging. This fact, in combination with a worldwide epidemic of melanoma among persons of white skin type, has focused attention on identifying melanoma in its early, surgically curable stages. Attention has also been directed toward pinpointing which persons are at increased risk for melanoma to reduce risk where possible and to aid early diagnosis. Essentially all epidemiologic studies have identified an increased number of melanocytic nevi as an important risk factor in the development of melanoma, but controversy has arisen concerning the risk associated with certain types of nevi, particularly "dysplastic" nevi. We review melanoma risk factors and examine the relationship between melanocytic nevi and melanoma to clarify for primary care physicians what is "known" (non-controversial) and what is "unknown" (controversial). We propose a working definition of an atypical mole phenotype and outline an approach to managing high-risk patients.

The pathology of melanoma as a basis for prognostic models: the UCSF experience

A patient survival model is proposed which allows visualization of a data base, and which includes only routine and commonly recorded attributes in most melanoma clinics. It is proposed that a network of such data be collected for meta-analysis (MELNET), which could make stratification within the individual subsets more significant by virtue of the large numbers. Such a network could then be fully tested in various melanoma clinics for clinical usefulness.

Familial and cutaneous features of dysplastic nevi: a case-control study

BACKGROUND

Although dysplastic nevi are an important risk factor for melanoma, little is understood about the epidemiology of these nevi. To further characterize some of the correlates of dysplastic nevi, we reexamined patients from one of the original prevalence reports and their first-degree relatives.

OBJECTIVE

Our purpose was to characterize the prevalence and correlates of dysplastic nevi.

METHODS

We studied 25 persons originally diagnosed with dysplastic nevi in 1980 and 1981, 28 controls stratified by age, sex, race, and date of initial examination, and all willing first-degree relatives of both patients (n = 78) and control subjects (n = 76). Each study subject underwent a full skin examination and biopsy of nevi suspected of being dysplastic nevi, if willing.

RESULTS

Eighty percent of the case kindreds were multiplex (2 members or more affected) for dysplastic nevi; the relative risk of having dysplastic nevi was 7.2 (95% confidence interval 2.1 to 24) if one or more relatives had dysplastic nevi. Three of the cases (12%) in multiplex families also had a first-degree relative with melanoma. Cases and relatives with dysplastic nevi of both patients and control subjects tended to have increased numbers of nevi. The risk of having dysplastic nevi rose 99-fold in persons with more than five nevi 4 mm or larger and/or scars on their back (p < 0.001).

CONCLUSION

These data support the hypothesis that family members of unselected persons with dysplastic nevi are likely to have dysplastic nevi and may be at increased risk of melanoma.

Melanocytic nevi in histologic association with primary cutaneous melanoma of superficial spreading and nodular types: effect of tumor thickness

The histologic presence of benign dermal nevus cells in contiguity with primary cutaneous melanoma, as a distinct population separate from malignant melanocytes, was evaluated in a large referral data base. The melanomas were limited to superficial spreading melanoma (SSM) and nodular melanoma (NM). Overall, dermal melanocytic nevi were found associated with 1126 of 1954 primary SSM/NM (57.6%). When the melanomas were stratified by tumor thickness, an inverse relationship between the presence of benign nevus cells and tumor thickness was found: 64.9% of tumors less than 0.76 mm and 64.5% of those between 0.76 and 1.69 mm were associated with dermal nevi, whereas in the thickness range 1.70-3.60 mm, there were 45.6% associated nevi, and in melanomas greater than 3.60 mm, there were only 32.0% noted to have nevus cells. When melanomas were separated by nevus type, it was found that 41% were associated with an acquired pattern nevus, 38% with congenital pattern nevus, and 21% with dysplastic nevus. It may be concluded that 1) the histologic presence of nevus cells is a common event in SSM/NM; 2) the association of melanocytic nevus and melanoma is more easily demonstrated in thinner tumors; and 3) acquired pattern nevi, congenital pattern nevi, and dysplastic nevi are all potential precursors of melanoma.

The inheritance pattern of dysplastic naevi in families of dysplastic naevus patients

Dysplastic naevi (DN) are the major precursor lesions of malignant melanoma, yet the presumed mode of inheritance or genetic aetiology of DN remains controversial. The inheritance pattern of DN in families from a randomly selected population of 26 dysplastic naevus patients was investigated by estimating the segregation ratio in families ascertained through an offspring with DN (incomplete ascertainment). For families ascertained through a parent with DN (complete ascertainment) the transmission pattern was examined by comparing the observed number of affected offspring to the expected number using a chi 2 goodness-of-fit test. Results from the chi 2 tests and the estimated segregation ratio of 0.52 (95% confidence interval: 0.31, 0.73) suggest that the inheritance pattern for dysplastic naevi in these families is consistent with autosomal dominant transmission, although the present study was limited because of a small sample size. The findings, therefore, need to be confirmed by a much larger study that is able to test more rigorously specific genetic hypotheses.

Surveillance bias and the excess risk of malignant melanoma among employees of the Lawrence Livermore National Laboratory

To assess the role of surveillance bias in the observed three-fold excess of cutaneous malignant melanoma (CMM) at the Lawrence Livermore National Laboratory (LLNL) in California, we examined the thickness of CMMs among all 20 laboratory employees who were members of a large prepaid health plan and whose CMM was diagnosed from 1970 through 1984. For comparison, we reviewed slides of 36 other members of the same health plan matched (usually 2:1) to the laboratory case by age, sex, facility, and year of diagnosis. Three expert dermatopathologists read the slides using a multiheaded microscope to reach a consensus; they were blind to the laboratory employment status of the subjects. We found that from 1970 to 1976, before there was widespread publicity about the excess incidence of CMM at LLNL, lesion thickness was greater for non-LLNL employees (mean difference = 1.5 mm; 95% confidence interval 0.1-2.9). From 1977 through 1984, however, there was no appreciable difference [mean difference = -0.3 mm; 95% confidence limits (CL) = -1.4, 0.9]. Dropping the matching to adjust for histologic type of melanoma as well as gender, year, and age at diagnosis yielded substantially the same results. These data are compatible with an effect of surveillance bias up to around 1976, but in this health plan population, they do not support a role for surveillance bias in the continuing excess incidence observed since that time.

Early diagnosis of cutaneous malignant melanoma at Lawrence Livermore National Laboratory

The Lawrence Livermore (Calif) National Laboratory (LLNL) has observed a threefold increase in incidence of cutaneous malignant melanoma (CMM) since 1972. A consultant pathologist reviewed 49 of 50 cases of CMM diagnosed from 1969 to 1984 and reclassified 4 cases; this did not significantly affect the elevated rate. A comparison of the thicknesses of CMM at LLNL from 1976 to 1984 with those from a nearby community histopathology laboratory showed that 74% of the LLNL cases were Clark level I or II, compared with 40% of the comparison laboratory cases. A matched-pair comparison controlling for age, sex, and year of diagnosis showed the LLNL cases were thinner in 58% of the pairs. The median thickness of CMMs at LLNL decreased faster than those from the comparison laboratory.

Clinical diagnosis of dysplastic melanocytic nevi. A clinicopathologic correlation

A prospective, community practice-based, clinicopathologic correlation was undertaken in 165 melanocytic nevi excised from a group of forty-three patients, each patient having previously had at least one clinically suspected and histologically confirmed dysplastic melanocytic nevus. Eighty-two percent of seventy-two lesions with histologic evidence of mild dysplasia had been diagnosed correctly as such clinically. The accuracy of clinical diagnosis of moderate dysplasia was low (20%); however, all cases of severe dysplasia with or without in situ melanoma were diagnosed correctly. In 75% of all cases in which dysplasia of any degree was diagnosed clinically, histologic evidence of dysplasia was found. In order to investigate further the clinical features of these nevi, 175 color enlargements of histologically confirmed dysplastic melanocytic nevi were examined. The following clinical features were found to be most common: ill-defined border (90%), irregularly distributed pigmentation (84%), maximum diameter greater than 5.0 mm (72%), erythema (64%), and accentuated skin markings (63%). Increasing darkness and confluence of pigmentation in these dysplastic melanocytic nevi correlated with increasing severity of dysplasia. We conclude that careful clinical examination of individual melanocytic nevi will separate severe dysplasia with or without in situ melanoma from low-grade (mild or moderate) dysplasia in a high percentage of nevi from patients with the dysplastic nevus syndrome. Clinical examination will yield a diagnosis of dysplasia in approximately 75% of nevi from such patients in whom histologic evidence of dysplasia is present. Clinical examination constitutes a practical and sufficiently reliable method for the assessment of melanocytic nevi in patients with the dysplastic nevus syndrome.

Age distribution and histologic patterns of dysplastic nevi

A total of 676 dysplastic moles collected from 487 patients over a 1-year period were reviewed together with demographic data. The associated nevus in 642 cases (95%) had a superficial, or "acquired," pattern within the papillary dermis, in comparison with the nevus in the remaining 34 cases (5%), which showed a deep, or "congenital," pattern. The dysplasia was graded in severity as mild, moderate, or severe (on a scale of 1 to 3). When patients with mild to severe dysplastic melanocytic nevi were compared with those patients showing atypical intraepidermal melanocytic hyperplasia (also called in situ malignant melanoma) or early invasive malignant melanoma associated with dysplasia, a progression of ages was noted. The average ages in the five diagnostic groups were as follows: 34.8 years, mild dysplasia (group 1); 35.1 years, moderate dysplasia (group 2); 41.5 years, severe dysplasia (group 3); 44.4 years, in situ malignant melanoma (group 4), and 46.9 years, early invasive malignant melanoma (group 5). Statistical analysis revealed that the two younger groups differed significantly in age from the three older groups. Men and women had an equal proportion of acquired and congenital pattern nevi, but men were older in each category and had more severe dysplasia, a greater tendency toward truncal lesions, and more regressive changes. Biopsy of trunk lesions was done in 275 cases (80%), of extremity lesions in 60 cases (17%), and in head and neck sites in 9 cases (3%).(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency and duration of patient follow-up after treatment of a primary malignant melanoma

To develop guidelines for the follow-up of patients with primary cutaneous melanoma (clinical Stage I), we studied 295 patients who had presented with a primary melanoma and who subsequently developed evidence of metastatic disease in the course of follow-up. Cox multivariate analysis was used to assess the influence of five variables in predicting the interval of time from the diagnosis of melanoma to the first clinical or laboratory evidence of metastatic disease (disease-free interval). The variables studied were tumor thickness, patient sex, patient age, elective lymph node dissection, and primary tumor location. Tumor thickness was found to be the major predictor of disease-free interval, which shortened progressively with increasing tumor thickness. Men had a shorter mean disease-free interval than women, although this effect did not reach statistical significance at the 0.05 level. Patient age, tumor location, and elective lymph node dissection were found not to be predictors of disease-free interval. The risk of recurrence of melanoma was tabulated, by year, for four intervals of tumor thickness. The increase in risk of recurrence associated with increases in tumor thickness above 1.5 mm was shown to occur predominantly in the early years following diagnosis-particularly in the first year. On the basis of our findings, we have suggested regimens of follow-up for melanoma.

Limited Wegener's granulomatosis. Report of a case with oral, renal, and skin involvement

Limited Wegener's granulomatosis is a form of the disease in which only one or two organ systems are involved. A rare case is reported in which the initial symptoms were in the skin and the lip, complicated by skin lesions exhibiting features of a clinical variant of lupus erythematosus.

Regression in malignant melanoma. A histologic feature without independent prognostic significance

A total of 844 cutaneous malignant melanomas were examined prospectively for the presence or absence of histologic regression within the primary tumor. Cases were then stratified into three groups according to tumor thickness and survival was compared between substrata with and without regression in each group. The distribution of other major prognostic variables within these substrata was assessed and their influence as potential confounding variables considered. No statistically significant effect of regression on survival was found in any of the three thickness strata. These results do not confirm the finding of an earlier study, which suggested that regression may be a poor prognostic sign when found in association with thin malignant melanomas. Regression was almost invariably associated with the radial growth phase of melanomas. Regression was more common in male than in female patients, and was more frequent in association with truncal than extremity or head and neck melanomas.

Thin level IV malignant melanoma. A subset in which level is the major prognostic indicator

A small proportion of "thin" malignant melanomas will metastasize and cause death. To assess the role of discordance between the major indicators of tumor depth (thickness and level) as a possible explanation for this phenomenon, prognosis by level has been examined in 255 cases, with tumors ranging in thickness from 0.6 to 1.1 mm. This is the range of thickness at which levels II, III, and IV overlap. The 5-year survival rate of patients with level IV tumors in this thickness range (59.35%) was poor (p less than 0.0001), relative to that of patients with level II (96.8%) and III (94.49%) lesions in the same range of tumor thickness. The distributions of other major prognostic indicators, among the groups of patients with tumors at each level, were examined to assess the possible contribution of factors other than level to the differences in survival between the three groups. These differences in survival could not be attributed to differing distributions of tumor thickness, tumor location, or patient sex. Of six prognostic variables, examined by Cox multivariate regression analysis, for tumors of thickness 0.6 to 1.1 mm, only level was found to have independent prognostic significance (p = 0.0025). The thin level IV melanoma appears to be an important exception to the rule that this melanomas are associated with an excellent prognosis. In this, as well as in other studies, after accounting for the effect on prognosis of tumor thickness, level has been shown to be a prognostic indicator with independent significance. The continued use of level as a prognostic indicator, in addition to thickness, is recommended.

Diagnosis and management of premalignant melanocytic proliferations

The histopathology of melanocytic proliferations in human skin can be defined in a way which allows a rational approach to their management. Early and/or premalignant lesions such as melanocytic hypertrophy, hyperplasia, dysplasia, and atypical hyperplasias are correlated with clinical lesions such as lentigo, compound nevoid lentigo, changes in nevi during pregnancy, and unusual moles seen in patients with the dysplastic nevus syndrome. Clinical management of such lesions may be determined from the pathological process. Hypertrophic and hyperplastic lesions need not be re-excised, although partially removed moles showing junctional hyperplasia may recur clinically. The mildly and moderately dysplastic nevus need only be narrowly removed. Severe dysplasia and melanoma in situ may recur locally as invasive melanoma, and consideration for conservative reexcision is warranted. Dysplastic nevi should be considered to be markers of patients who may develop melanoma. Patients with dysplastic nevi or a family history of unusual moles or melanoma should have continued follow-up, preferably with standardized clinical photographs.

Differential diagnosis of Kaposi's sarcoma

The biopsies of all lesions clinically thought to be suspicious for Kaposi's sarcoma (KS) were reviewed over a 15-month period. A diagnosis of KS was made in 40 of 106 biopsies (38%). The cases in which a diagnosis other than KS was made included dermatofibroma, hemangioma, and scar. This second group comprised 59 of 106 cases (56%). A third group included some lesions that had an atypical vascular proliferation, but in which the changes were insufficient for a definite diagnosis of KS. The presence of abnormally shaped vessels, especially those classified as irregular, was the best single criterion to diagnose KS in its early stages. In later stages, the neoplasm assumes a nodular configuration with typical, slitlike vascular channels. At the periphery of such nodules dilated, irregularly shaped vessels similar to those of the early lesions are often seen. The histologic features which help in the diagnosis of KS from other histologic entities are reviewed.

The relationship of psychosocial factors to prognostic indicators in cutaneous malignant melanoma

This study investigated the relationship between prognosis (estimated by histopathologic indicators) in cutaneous malignant melanoma and a comprehensive set of physical risk, demographic, psychosocial, and situational variables. These variables were derived from the medical examination, the pathology report, psychosocial self-report measures, and an hour-long videotaped interview with 59 patients from two melanoma clinics in San Francisco. Variables significantly correlated with tumor thickness were: darker skin/hair/eye coloring, longer patient delay in seeking medical attention, two correlated dimensions within an operationally defined 'Type C' constellation of characteristics, two character style measures, and less previous knowledge of melanoma and understanding of its treatment. Of these variables, delay was the most significant in a hierarchical multiple regression analysis in which tumor thickness was the dependent variable. Associations between tumor thickness and psychosocial measures of Type C were considerably stronger and more significant for subjects less than age 55, suggesting that the role of behavioral and psychosocial factors in the course of malignant melanoma is more potent for younger than for older subjects.

Factors related to patient delay in seeking medical attention for cutaneous malignant melanoma

This study investigated the relationship between patient delay in seeking medical attention and prognostic indicators, tumor characteristics, and demographic and behavioral factors in 106 patients with cutaneous malignant melanoma. Patients with less readily apparent lesions, particularly on the back, had longer delays in seeking treatment, as might be expected. The prognostically unfavorable nodular melanomas were detected more frequently by patients themselves than they were found during visits to physicians for unrelated problems. In terms of behavioral variables, patients with less knowledge of melanoma or its appropriate treatment had significantly longer delays. Patients who minimized the seriousness of their condition were more likely to seek treatment sooner, perhaps because this reduced fear and anxiety about the disease or its treatment. For superficial spreading melanoma, delay was significantly and positively correlated with Clark's level of invasion, and also with tumor thickness when only noncoincidentally diagnosed patients were included; whereas for the nodular type, delay was significantly and positively associated with tumor thickness, whether the patient was coincidentally diagnosed or not. The significance of these findings for early detection, and hence improved prognosis of malignant melanoma, is discussed.

The frequency of local recurrence and microsatellites as a guide to reexcision margins for cutaneous malignant melanoma

A retrospective study was undertaken of local, regional, and distant recurrences in 346 patients with primary melanomas of tumor thickness less than 1.0 mm that were excised with margins of normal skin varying between 0.1 cm and 5.0 cm or more. Prospective histopathologic examination of 284 melanomas for the presence of microsatellites was also performed and their effect upon the frequency of local recurrence was studied. Margins of excision did not influence the frequency of local, regional, or distant metastases. Four recurrences of in situ superficial spreading melanoma occurred, however, when very narrow margins of excision (0.5 cm or less) were employed. Microsatellites were uncommon with tumors less than 3.0 mm in thickness (2.8% of all tumors of less than 3.0 mm in thickness, taken together), but relatively frequent in association with thicker tumors (37%). Melanomas with microsatellites were associated with a greater frequency of local clinical metastasis than those without (14% vs. 3%). Removal of more than 1.0 cm of normal skin around a melanoma of less than 1.0 mm in thickness does not further reduce rates of recurrence of any type. The use of margins of 0.5 cm or less for melanomas with a radial growth phase does appear to result in an increased frequency of local recurrence of the primary melanoma with an epidermal in situ component. These recurrences can be prevented by the removal of 1.0 cm of normal skin around such a melanoma. Microsatellites constitute a risk factor for local recurrence, but are a relatively uncommon phenomenon at tumor thickness less than 3.0 mm.

Giant congenital melanocytic nevus: quantification of nevus debulking after split-thickness excision

Although giant congenital melanocytic nevi (CMN) may undergo malignant transformation, their complete surgical removal is commonly difficult to achieve and may require sacrifice of normal skin. We treated a patient with CMN by a combination of full-thickness excision and primary closure of the central atypical portion and split-thickness excision of the remainder. Histometric analysis of the tissues obtained at surgery indicated that the split-thickness procedure removed approximately 70% of the cellular nevus content from that area. Total debulking by the combined procedure was calculated to be approximately 80%. If the risk of malignant degeneration is proportional to the number of melanocytes present, the debulking procedure described may provide a useful alternative for the management of some giant CMN. The cosmetic result is satisfactory and the significant lightening in color and removal of nodular irregularities may facilitate prospective follow-up of the residual lesion.

Pigmented spindle cell nevus. Clinical and histologic review of 90 cases

A clinical and histologic review of 90 patients with melanocytic lesions termed pigmented spindle cell nevi (PSCN) is reported. The lesions are small in surface diameter, sharply confined both clinically and histologically, and often occur on the proximal extremities of young adults. They are generally of recent onset, moderately to heavily pigmented, and made up of nests of spindled cells confined to the epidermis and papillary dermis. There were 30 male and 60 female patients. Their average age was 25.3 years (ranging from 2.5 to 56 years). Lesions were located on the extremities in 61 cases (67%). Follow-up was possible in 38 cases seen more than 6 months after histologic diagnosis and ranged up to 40 months (average 14 months). No local recurrence or distant spread was found. The importance of recognizing this lesion lies in differentiating it from malignant melanoma. Conservative but complete excision has resulted in no recorded instances of local recurrence or distant spread.

Malignant eccrine poroma. Case report and review of the literature

A case of malignant eccrine poroma with lymph node metastases is described. The patient had a nodular growth of the right thigh 2 years before its first excision. Local recurrence in the scar occurred in 6 months, and by 8 months a right groin lymph node was involved. Subsequent skin nodules of the right thigh occurred over the next 12 months, associated with recurrent lymphedema of the leg. During several follow-up visits, associated malignancies were found including villous adenoma of the ascending colon and renal cell carcinoma of the right kidney, both typical histologically and unrelated to the cutaneous tumor. Subsequently, left inguinal lymph node disease histologically identical to the skin tumor was found. Clinical and histologic findings were similar to the 31 previous cases reviewed. Electron microscopic examination confirmed the presence of a ductal structure consistent with eccrine duct and a crystalline membrane-bound granule which may represent a specific marker for this rare tumor. The histologic features of this tumor are important to separate from other differential diagnostic possibilities which may have a quite different prognosis.

Malignant melanoma of the skin. I. The association of tumor depth and type, and patient sex, age, and site with survival

The occurrence and behavior of cutaneous melanomas in a group of 1123 patients studied prospectively, is described in terms of histologic type, tumor thickness and levels of invasion, the patients' sex and age, and the anatomic location of the primary tumors. Associations amongst these attributes, and with survival, are also examined. The characteristics of the patients in this study (who on average are somewhat younger, and have better prognoses and survivals than those reported by most other groups) are compared with data obtained (primarily over the past decade) in other geographical areas, and with different patient populations. Evidence is presented that sex, tumor location, and age (in the case of males) are also predictive of survival.