Pigmentary traits, modalities of sun reaction, history of sunburns, and melanocytic nevi as risk factors for cutaneous malignant melanoma in the Italian population: results of a collaborative case-control study

Cutaneous malignant melanoma in women. Phenotypic characteristics, sun exposure, and hormonal factors: a case-control study from Italy

PURPOSE

We examined the role of personal host characteristics in relation to cutaneous malignant melanoma (CMM) among women, with a particular focus on hormonal and reproductive factors.

METHODS

A case-control study conducted in Italy between 1992 and 1994, including 316 women with incident, histologically confirmed CMM and 308 controls, admitted to the same network of hospitals as cases for acute, non-dermatological, and non-neoplastic conditions.

RESULTS

CMM was significantly associated with body mass index (kg/m(2)) (odds ratio [OR]=1.96 for > or =27 compared with < 23) and body surface area (m(2)) (OR=1.68 for > or =1.71 compared with < 1.59), eye color (OR=1.74 for green/hazel compared with brown), solar lentigines (OR=1.47), and number of melanocytic nevi (OR=3.39 for total number of nevi > or =16 compared with < 5). Age at first (OR=2.69 for > or =27 compared with < 23 years) and last birth (OR=2.13 for > or =31 compared with < 27 years) were associated with the risk of CMM, whereas other reproductive, menstrual, and hormonal factors, including menopause, number of live-births and abortions, use of oral contraceptives, and hormone replacement therapy were not significantly associated.

CONCLUSIONS

Our results confirm findings from previous studies on the role of major recognized risk factors for CMM, and add further evidence of an absence of a consistent association between hormonal and reproductive factors and CMM risk.

Meta-analysis of risk factors for cutaneous melanoma: III. Family history, actinic damage and phenotypic factors

A systematic meta-analysis of observational studies of melanoma and family history, actinic damage and phenotypic factors was conducted as part of a comprehensive meta-analysis of all major risk factors for melanoma. Following a systematic literature search, relative risks were extracted from 60 studies published before September 2002. Fixed and random effects models were used to obtain pooled estimates for family history (RR = 1.74, 1.41-2.14), skin type (I vs. IV: RR = 2.09, 1.67-2.58), high density of freckles (RR = 2.10, 1.80-2.45), skin colour (Fair vs. Dark: RR = 2.06, 1.68-2.52), eye colour (Blue vs. Dark: RR = 1.47, 1.28-1.69) and hair colour (Red vs. Dark: RR = 3.64, 2.56-5.37), pre-malignant and skin cancer lesions (RR = 4.28, 2.80-6.55) and actinic damage indicators (RR = 2.02, 1.24-3.29). Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated reliability of results and publication bias. Latitude and adjustment for phenotype were two study characteristics that significantly influenced the estimates.

Sun Exposure, Phenotypic Characteristics, and Cutaneous Malignant Melanoma. An Analysis According to Different Clinico-Pathological Variants and Anatomic Locations (Italy)

OBJECTIVE

The aim of the study was to examine the relation between sun exposure and other selected risk factors and the development of different clinico-pathological variants of cutaneous malignant melanoma (CMM) at different body locations.

METHODS

We analysed data from a case-control study conducted in Italy between 1992 and 1994 on 542 cases of CMM and 538 hospital controls. Clinico-pathological variants included 391 superficial spreading (SSM), 72 nodular (NM) and 39 lentigo maligna (LMM) melanomas.

RESULTS

The risk of SSM increased for a high education level (odds ratio, OR = 1.5, 95% confidence interval, CI, 1.0-2.2), sunburn episodes before age 15 (OR = 1.8, 95% CI, 1.1-2.8), light eye colour (OR = 1.6, 95% CI, 1.1-2.4) and solar lentigines (OR = 1.4, 95% CI, 1.0-1.8). The ORs for total number of nevi >30 were 4.4 (95% CI, 2.9-6.7) for SSM, 5.7 (95% CI, 2.6-12.5) for NM and 2.2 (95% CI, 0.5-9.4) for LMM. The risk of CMM located on the trunk seemed to be higher for a high education level (OR = 1.6, 95% CI, 1.0-2.6) and propensity to sunburn (OR = 1.6, 95% CI, 0.8-3.2). The ORs for sunburn episodes, eye and skin colour, and solar lentigines tended to be higher for CMM located on the face/neck and on the upper limbs than the trunk. Total number of nevi was strongly associated with all anatomic locations.

CONCLUSIONS

Total number of nevi was the major risk factor associated with all melanoma variants and locations. A higher level of education and sunburn episodes in early childhood appeared to be more strongly related to SSM than to other variants.

Screening for Cutaneous Melanoma

Current data do not support widespread population-based screening for melanoma. While the incidence of melanoma is high, the overall mortality is low, and thus any potential benefit of screening the general population is hard to demonstrate. No randomized controlled trial showing reduction in mortality has ever been completed and, given the expense and time necessary for such a trial, probably will never be completed. The idea of skin screening remains appealing for this common, visible malignancy which is eminently treatable when detected early. Efforts should be focused on populations at particularly high risk of developing melanoma and on those at high risk of death from melanoma once diagnosed. Persons in kindreds of familial melanoma, and persons who have atypical mole syndrome, those who have a prior diagnosis of melanoma, or those who have diagnosed atypical nevi are all reasonable candidates for routine screening, based on lower-level evidence in the absence of randomized clinical trials targeting these groups. Programs targeting persons of low socioeconomic status and targeting white men over the age of 50 could address groups known to beat especially high risk of melanoma mortality.

Sun Protection in Renal Transplant Recipients: Urgent Need for Education

BACKGROUND

Renal transplant recipients (RTR) are considered as a high-risk group of skin cancer development.

OBJECTIVE

The aim of the present studywas to find out the knowledge about the harmfulness of sunlight and the methods of sun protection among RTR.

MATERIAL AND METHODS

151 RTR (91 males and 60 females) were surveyed using a specially designed questionnaire.

RESULTS

The knowledge about the danger of sunlight exposure among RTR appeared to be very unsatisfactory. Only 40.4% of patients knew that the development of skin cancer is connected with the exposure to sunlight. Moreover, only 68.2% of investigated individuals considered RTR as a high-risk group of skin cancer development. Although 74.8% of patients were informed about the necessity of sun protection, only 11.3% could explain what the number of the SPF (sun protection factor) means. Females significantly more often knew that RTR are especially predisposed to the development of skin cancers (p = 0.0001) and significantly more frequently could explain what the SPF number means (p = 0.006). 72.8% of RTR (females significantly more often, p = 0.02) made efforts to avoid sunlight irradiation. However, only 5.3% of the examined patients routinely used creams with SPF (females significantly more often, p < 0.0001). More than a half of the patients (62.3%) did not apply any sun protection.

CONCLUSIONS

The present study revealed the urgent necessity of education concerning the harmfulness of sunlight and the methods of sun protection among RTR. Moreover, it is postulated that every patient should be routinely examined by a dermatologist in a dedicated transplant patient clinic.

Presence of high-risk mucosal human papillomavirus genotypes in primary melanoma and in acquired dysplastic melanocytic naevi

BACKGROUND

Some studies have shown that cutaneous and mucosal melanoma biopsy specimens harbour human papillomavirus (HPV), suggesting that this virus may play a role in development and progression of the tumour.

OBJECTIVES

To investigate the presence of HPV DNA and the prevalence of different high-risk mucosal HPV genotypes in primary melanoma (PM) and in acquired dysplastic melanocytic naevi (ADMN).

METHODS

Fifty-one PMs from 18 men and 33 women (median age 55.5 years), 33 ADMN from 15 men and 18 women (median age 35.1 years) and 20 control skin samples from nine men and 11 women (median age 43.5 years) were studied. All diagnoses were made after histological analysis. HPV DNA analysis was made using two different polymerase chain reaction-enzyme-linked immunosorbent assay (PCR-ELISA) methods, namely MY-PCR and GP-PCR.

RESULTS

Using GP-PCR, mucosal HPVs were detected in 14 PMs (27%; P = 0.0166) and eight ADMN (24%; P = 0.0367), while with MY-PCR, mucosal HPVs were found in 11 PMs (22%; P = 0.04) and five ADMN (15%; P not significant). All control skin samples were negative for mucosal HPVs with both DNA amplification procedures.

CONCLUSIONS

Using our PCR-ELISA methods, the detection of mucosal high-risk HPV genotypes in 24% of precursor lesions (ADMN) and in 27% of PMs adds to the body of evidence indicating a colocalization of mucosal HPV and tumoral melanocytic pathologies.

Case-control study to identify melanoma risk factors in the Belgian population: the significance of clinical examination

BACKGROUND

Although numerous studies have evaluated risk factors associated with cutaneous malignant melanoma (CMM), no such study has been carried out in Belgium.

OBJECTIVES

To identify individuals who are at high risk of developing malignant melanoma in Belgium, which could enhance the efficacy of screening interventions and avoid unnecessary skin inspections. STUDY DESIGN/SETTING/SUBJECTS: We prospectively included patients who were diagnosed with invasive malignant melanoma between 1998 and 2001 at the Department of Dermatology in a case-control study. Controls were selected from the outpatient dermatology clinic. Participants were interviewed and clinically examined by a dermatologist. We asked questions concerning most known risk factors associated with malignant melanoma such as phenotypical and skin characteristics, and environmental and lifestyle exposures. To adjust for confounding variables and to estimate odds ratios (ORs) and 95% confidence intervals (CIs), a multivariate model was used.

RESULTS

Although sunburn in childhood and substantial occupational solar exposure were modestly, but significantly, associated with malignant melanoma risk, clinical examination yielded several stronger risk factors. In a multivariate model, which adjusted for age, gender and skin phototype, phenotypical characteristics such as skin, hair and eye colour were significantly associated with the development of malignant melanoma. In the multivariate model, people with three or more atypical naevi were at more than 10-fold risk of developing a malignant melanoma (> or = 3 atypical naevi; adjusted OR = 11.40, 95% CI = 4.79-17.53) compared to those without an atypical naevus. The presence of one or more palpable naevi on the upper extremities or having solar lentigines increased the odds of developing malignant melanoma at least twofold.

CONCLUSIONS

In Belgium, risk factors associated with malignant melanoma appear to be in accordance with previous studies. To assess peoples' risk profile, clinical skin examination is likely to yield the most important sporadic malignant melanoma risk factors. Therefore, focusing screening campaigns on individuals with predefined findings on skin self-examination may increase its efficacy.

Melanoma of the head and neck

Staging of cutaneous melanoma has changed in recent years with an increased emphasis upon thickness and ulceration on prognosis of early stage disease. Cutaneous melanoma of the head and neck is treated with complete surgical resection in early stage disease. Resection margins are determined by the size, depth, and presence of satellite lesions. Evaluation for regional and distant metastatic disease is necessary in all cases of advanced stage disease. Sentinel lymph node biopsy and possible parotidectomy and neck dissection should be considered in head and neck cutaneous melanomas greater than 1 mm in thickness or with ulceration. Adjuvant therapy may be indicated in advanced primary, nodal, and metastatic disease. Mucosal melanoma of the head and neck remains a difficult disease to treat, with high locoregional recurrence rates and poor prognosis despite aggressive therapy.

Dermatoepidemiology

Dermatoepidemiology is an important emerging discipline in dermatology. This article reviews clinical and analytic epidemiology pertinent to reading, interpreting, and critically examining the literature, and presents an overview of evidence-based dermatology as a starting point for further study.

Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure

A systematic revision of the literature was conducted in order to undertake a comprehensive meta-analysis of all published observational studies on melanoma. An extensive analysis of the inconsistencies and variability in the estimates was performed to provide some clues about its Epidemiology. Following a systematic literature search, relative risks (RRs) for sun exposure were extracted from 57 studies published before September 2002. Intermittent sun exposure and sunburn history were shown to play considerable roles as risk factors for melanoma, whereas a high occupational sun exposure seemed to be inversely associated to melanoma. The country of study and adjustment of the estimates adjuste for phenotype and photo-type were significantly associated with the variability of the intermittent sun exposure estimates (P = 0.024, 0.003 and 0.030, respectively). For chronic sun exposure, inclusion of controls with dermatological diseases and latitude resulted in significantly different data (P = 0.05 and 0.031, respectively). Latitude was also shown to be important (P = 0.031) for a history of sunburn; studies conducted at higher latitudes presented higher risks for a history of sunburns. Role of country, inclusion of controls with dermatological diseases and other study features seemed to suggest that "well conducted" studies supported the intermittent sun exposure hypothesis: a positive association for intermittent sun exposure and an inverse association with a high continuous pattern of sun exposure.

Constitutional and environmental risk factors for cutaneous melanoma in an Italian population. A case-control study

The aim of this study was to determine the relative risk for cutaneous melanoma associated with phenotypic and environmental variables in a population in central Italy and to assess how the combination of the different risk factors contributes to the overall risk for melanoma. We performed a case-control study of 100 patients with sporadic cutaneous melanoma and 200 controls matched for sex, age, ethnicity and residential area. Individuals were interviewed concerning pigmentary traits and sun exposure, and underwent a total body skin examination. Logistic regression models were used to evaluate the association between cutaneous melanoma and constitutional and environmental variables. The strongest risk factors were prolonged recreational sun exposure (odds ratio [OR] 5.010, 95% confidence interval [CI] 2.110-11.891), the presence of clinically atypical naevi (OR 4.916, 95% CI 2.496-9.995) and the presence of >50 common melanocytic naevi (OR 4.684, 95% CI 2.442-9.231). In addition, occupational sun exposure (OR 2.573, 95% CI 1.399-4.732), light brown hair (OR 2.336, 95% CI 1.328-4.138), high density of solar lentigos and/or actinic keratoses (OR 1.824, 95% CI 1.0-3.510) and type II, fair skin (OR 1.815, 95% CI 1.031-3.193) and blue eyes (OR 1.757, 95% CI 1.0-3.477) were each significantly associated with cutaneous melanoma risk. The combination of individual strong risk factors was associated with up to a 46-fold increase in the risk for cutaneous melanoma. Selected pigmentary traits, sun exposure and melanocytic naevi, individually and in combination, are important risk factors for cutaneous melanoma in an Italian population.

Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi

A systematic meta-analysis of observational studies of melanoma and one of the most important risk factors, the number of naevi, was conducted in order to clarify aspects of the aetiology of this disease. Following a systematic literature search, relative risks (RRs) were extracted from 46 studies published before September 2002. Dose-response random effects models were used to obtain pooled estimates. Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated the reliability of the results and any publication bias. Number of common naevi was confirmed an important risk factor with a substantially increased risk associated with the presence of 101-120 naevi compared with <15 (pooled Relative Risk (RR) = 6.89; 95% Confidential Interval (CI): 4.63, 10.25) as was the number of atypical naevi (RR = 6.36 95%; CI: 3.80, 10.33; for 5 versus 0). The type of study and source of cases and controls were two study characteristics that significantly influenced the estimates. Case-control studies, in particular when the hospital was the source for cases or controls, appeared to present much lower and more precise estimates than cohort studies.

Risk of melanoma and vitamin A, coffee and alcohol: a case–control study from Italy

Limited information is available on the association between the risk of cutaneous malignant melanoma (CMM) and dietary factors. The issue was investigated using data from a case-control study conducted in Italy between 1992 and 1994, including 542 patients with incident, histologically confirmed CMM and 538 controls, admitted to the same hospitals as cases for non-dermatologic and non-neoplastic diseases. We found a significant inverse association between vitamin A intake and CMM risk. The multivariate odds ratio, after allowance for phenotypic characteristics and history of sunburns, for the highest, compared with the lowest, quartile of intake was 0.71 (95% confidence interval (CI) 0.50-1.02) for beta-carotene, 0.57 (95% CI 0.39-0.83) for retinol, and 0.51 (95% CI 0.35-0.74) for total vitamin A. We found no appreciable association of CMM risk with selected food items, including fish, meat, vegetables, fruit, dairy products, wholemeal bread, alcohol, coffee and tea drinking. Consumption of tea appeared to have a protective effect on CMM risk. The relations with measures of dietary vitamin A are, however, moderate compared with the associations between phenotypic characteristics, sun exposure and number of naevi and CMM risk.

Epidemiological differences for cutaneous melanoma in a relatively dark-skinned caucasian population with chronic sun exposure

The aim of this study was to reveal differences in the epidemiology and to identify significant risk factors for cutaneous melanoma (CM) in a relatively dark-skinned, chronically sun-exposed Caucasian population. This group is considered to have a low risk for this tumour. One hundred and ten newly diagnosed patients with primary CM and 110 age- and gender-matched controls, all of Cretan origin, were interviewed and underwent a complete skin examination. Solar keratoses odds ratio (OR) 6.2 and lentigines (OR 2.2), common and atypical naevi (OR 5.4 and 3.0, respectively), blonde or red hair colour (OR 3.1), skin phototypes I/II (OR 1.8), as well as total sun exposure (weeks per year) (OR 1.03), were all significantly associated with CM risk in a multivariate logistic regression analysis. In the relatively dark-skinned Cretan population, sun exposure indices represent the most important risk markers for CM which contrasts with data from fair-skinned Caucasian populations where melanocytic naevi are the main risk factors.

Mortality from cutaneous malignant melanoma in Europe. Has the epidemic levelled off?

Trends of mortality from cutaneous malignant melanoma (CMM) between 1960 and 1999 in several European countries and the European Union (EU) as a whole have been reviewed, using death certification data for skin cancer available from the World Health Organization. Separate analyses were performed for young (i.e., age 20-44 years) and middle-aged (i.e., age 45-64 years) adults, among whom around 80-90% of skin cancer deaths are attributable to CMM. After steady rises between 1960 and 1990, skin cancer rates among young adults have tended to decline since the mid-1990s in several European countries, with a fall of 14% in men and of 11% in women in the EU as a whole. In middle-aged adults, the trends were less favourable, although mortality started to level off since the mid-1990s. Thus, our data provide further evidence of an improvement of CMM mortality trends in recent years in several European countries. The particularly favourable trends in young people suggest that a further decline in mortality from CMM in Europe is likely to occur within the next few years.

Number of acquired melanocytic nevi in patients with melanoma and control subjects in Japan: Nevus count is a significant risk factor for nonacral melanoma but not for acral melanoma

BACKGROUND

Epidemiologic studies have suggested that number of acquired melanocytic nevi is a risk factor for melanoma development in Japanese as it is in white populations. However, there are only a few population-based studies on acquired nevi in Asian populations, and no epidemiologic study on relationship between number of acquired nevi and melanoma in Japanese populations has been reported.

OBJECTIVE

The purpose of this study was to assess number, size, and distribution of acquired melanocytic nevi in a Japanese population. Particular attention was paid to evaluation of relationship between number of acquired nevi and development of nonacral or acral malignant melanoma.

METHODS

In all, 82 patients with malignant melanoma and 600 control subjects were included in this study. All participants were Japanese. The number of acquired melanocytic nevi, 2 mm or larger in diameter, on the whole body except the scalp and genital areas was counted by experienced dermatologists. The participants were divided into 5 age categories (0-19, 20-39, 40-59, 60-79, and >80 years old) for the statistical analyses. This categorization adjusted the age and sex distribution between patients with melanomas and control subjects in 40- to 59-, 60- to 79-, and over 80-year-old groups.

RESULTS

In the control Japanese population, the number of acquired melanocytic nevi on the whole body increased with age in 0- to 19-year-old age group and reached the highest number, 6.7 +/- 8.1/person, in 20- to 39-year-old group. In patients with nonacral melanoma, the number of acquired nevi on the whole body in 40- to 59- and 60- to 79-year-old groups was significantly higher than that of the corresponding control group. In contrast, the rate of individuals who had acquired nevi on soles, palms, and nail apparatus was not significantly different between acral melanoma group and the control group in 40- to 59- and 60- to 79-year-old groups.

CONCLUSION

This study has revealed that a large number of acquired melanocytic nevi is a risk factor for the development of nonacral melanoma in Japanese and white populations. However, acquired nevi on soles, palms, and nail apparatus do not seem to be a risk factor for acral melanoma in Japanese populations.

Cancer mortality in Europe, 1995-1999, and an overview of trends since 1960

Mortality data, abstracted from the World Health Organization database, are presented in tabular form for 26 cancer sites or groups of sites, plus total cancer mortality, in 36 European countries during the period 1995-1999. Trends in mortality are also given in graphic form for 23 major countries plus the European Union as a whole over the period 1960-1999. In the European Union, total cancer mortality declined by 7% for both sexes over the last 5 years considered. The fall since the late 1980s was 10% in both sexes, corresponding to the avoidance of over 90000 deaths per year, as compared to the rates of the late 1980s. For the first time, over the last few years, some leveling of mortality was reported also in the Russian Federation, the Czech Republic, Poland, Hungary and other Eastern European countries, although cancer rates in those areas remain exceedingly high. The overall favorable pattern of cancer mortality over recent years is largely driven by the decline of tobacco-related cancer mortality in men. However, important components of the trends are also the persistence of substantial falls in gastric cancer, mainly in Russia and Eastern Europe, the recent decline in intestinal cancer in both sexes and of breast cancer in women, together with the long-term falls in uterine (cervical) cancer, leukemias, Hodgkin's disease and other neoplasms amenable to advancements in diagnosis and treatment. Female lung cancer mortality has been declining in the Russian Federation, but is still rising in other areas of the continent. Thus, urgent intervention is needed to bring under control the tobacco-related lung cancer epidemic in European women before it reaches the high level observed in North America. Supplementary material for this article can be found on the International Journal of Cancer website at http://www.interscience.wiley.com/jpages/0020-7136/suppmat/index.html

BRAF mutations are common somatic events in melanocytic nevi

We determined mutations in the BRAF, N-ras, and CDKN2A genes in 27 histologically diverse melanocytic nevi and corresponding surrounding tissues from 17 individuals. Mutations in the BRAF and N-ras gene were found in 22 nevi (81%) from 16 individuals (94%). The predominant BRAF mutation T1799A (V600E) was detected in 18 nevi; 1 nevus had a novel A1781G (D594V) mutation in the same gene and 3 nevi had mutations in codon 61 of the N-ras gene. In 4 individuals both nevi carried a BRAF mutation, whereas in 2 other individuals 1 nevus showed a BRAF mutation and the second nevus had an N-ras mutation. In 2 individuals normal skin distant from nevi showed a BRAF mutation. No mutations were detected in the CDKN2A gene. The mutations in the BRAF and N-ras genes, in this study, were not associated with histologic type, location, skin type, size, or numbers of nevi. Our results suggest that mutations in the BRAF gene and to some extent in the N-ras gene represent early somatic events that occur in melanocytic nevi. We hypothesize the dual effect of solar ultraviolet irradiation on melanoma, through mutagenesis and by increasing the number of melanocytic nevi, many of which carry a BRAF or N-ras mutation.

Improving Sun Protection Behaviour in Children: Study Design and Baseline Results of a Randomized Trial in Italian Elementary Schools

OBJECTIVE

To evaluate, in the context of a randomized study, the 'Sole Si Sole No GISED' project, the effectiveness of an educational intervention to improve sun protection behaviour in schoolchildren.

METHODS

A large number of primary schools (classes II and III) in Italy were randomized to an educational intervention or control group: The intervention was conducted by trained teachers using ad hoc developed materials. Attitudes toward sun exposure and behaviour while in the sun were assessed at baseline and 1 year after concluding the educational intervention. In a subgroup of children, melanocytic naevi were counted on the upper limbs at the same intervals. The pilot phase of the study was started in 2001.

RESULTS

During the pilot phase, a total of 4,233 children was recruited. Of these, 2,116 were randomized to the active intervention and 2,117 to the control group. No difference for any of the study variables was documented between the 2 groups at baseline. About 20% of the children reported intense sun exposure during the year preceding the study. About 88% of the children reported adequate modalities of sun protection. Sunscreens were commonly used. A total of 508 children (12%) reported a history of sunburns in the year preceding the start of the study. Melanocytic naevi were counted in a total of 1,503 children (852 in the experimental and 651 in the control group). No differences in terms of skin, hair and eye colours were documented between the experimental and the control groups. The mean naevus count at baseline was 9.6 (median 7) in the experimental group and 10.1 (median 8) in the control group.

CONCLUSION

About 50% of the total expected number of children was recruited during the pilot phase of the study. Randomization proved to be an excellent modality to select 2 samples similar for all the important study variables examined. A history of sunburns was reported less frequently than expected. The 'Sole Si Sole No GISED programme' is one of the few examples of a controlled evaluation of the effectiveness of an educational intervention in Italy.

Malignant melanoma

In the European Community cutaneous melanoma accounts for 1 and 1.8% of cancers occurring in men and women, respectively. The incidence rate is increasing faster than that of any other tumour. Sun exposure, patient's phenotype, family history, and history of a previous melanoma are the major risk factors. The change over a period of months is the main sign of a skin lesion turned into a melanoma. The ABCDE scheme for early detection of melanoma is commonly accepted. A new staging classification will be published in the next AJCC/UICC Cancer Staging System Manual in 2002. The clinical course of melanoma is determined by its dissemination and depends on thickness, ulceration, localisation, gender and histology of the primary tumour. Tumour stage at diagnosis remains the major prognostic factor. Surgery is the standard treatment option for operable local-regional disease. Sentinel node biopsy represents a promising experimental approach in the clinical detection and early treatment of occult lymph node involvement. For metastatic inoperable patients systemic chemotherapy can be attempted, while radiation therapy has to be considered as palliative treatment. No studies concerning frequency of follow-up are currently available, but common procedures may be performed.

Acquired melanocytic nevi as risk factor for melanoma development. A comprehensive review of epidemiological data

Acquired melanocytic nevi (MN) in Caucasian populations are important markers for the risk of melanoma development. The total number of MN on the whole body is the most important independent risk factor for melanoma and the risk of melanoma development increases almost linearly with rising numbers of MN. Additionally, the presence of atypical MN and of actinic lentigines are likewise independent risk factors for melanoma. Atypical mole syndrome should be defined by the presence of many acquired MN and a threshold number of atypical MN. Acquired MN develops mainly during childhood and adolescence in the first two decades of life. The number of acquired nevi seems to be related to hereditary factors and nevus-prone families exist. The amount of sun exposure is the most important environmental risk factor for nevus development, particularly in early childhood. Interestingly, sunburns may play a role in nevus development, but seem not to be required, and even moderate sun exposure promotes the process. Therefore, preventive measures for nevus and melanoma development should target young children and adolescents.

Numerous, small, darkly pigmented melanocytic nevi: the cheetah phenotype

BACKGROUND

The presence of multiple atypical nevi or numerous melanocytic nevi increases the risk for the development of cutaneous melanoma.

OBJECTIVE

We sought to describe a distinct clinical phenotype characterized by numerous (>100), small (< or =4 mm), darkly pigmented melanocytic nevi that are uniform in color.

METHODS

Biopsy specimens from 6 patients (3 men and 3 women; age range, 44 to 81 years) with this clinical phenotype were reviewed and compared with a database of melanocytic lesions analyzed by the Yale Dermatopathology Laboratory (YDL) in the year 2000.

RESULTS

Of the 6 patients, 4 had multiple primary melanomas develop (n = 2-4), ranging from in situ to 1.0 mm in depth. The other 2 patients each had 1 nevus with severe cytologic atypia. When compared with the YDL database, our patients were more likely to have the following pigmented lesions: junctional melanocytic nevi, junctional lentiginous nevi, junctional nevi with cytologic atypia, and simple lentigines (P <.001).

CONCLUSIONS

The longitudinal evaluation of patients with this phenotype can be challenging because similar-appearing pigmented lesions (small and uniformly dark-brown to black) had a range of histologic diagnoses from simple lentigo to junctional lentiginous nevus to thin melanoma.

Moderate sun exposure and nevus counts in parents are associated with development of melanocytic nevi in childhood: a risk factor study in 1,812 kindergarten children

BACKGROUND

Melanocytic nevi have been identified as the most important risk factor for cutaneous melanoma. Sun exposure, sunburns, and light pigmentation have been found to be associated with their development in childhood. To the authors' knowledge, nevus proneness of parents and the exact type of ultraviolet (UV) exposure have not yet been investigated in this context. The authors' objective was to determine independent risk factors and their impact for nevus development in childhood.

METHODS

The current study was conducted by two university departments of dermatology in 49 public nursery schools in Stuttgart, Germany and in 38 public nursery schools in Bochum, Germany. The cross-sectional study included 1,812 children aged 2-7 years and their parents. Total body nevus counts in children, assessment of pigmentary features, and nevus counts on the arms of parents were performed. Parents underwent a standardized interview concerning national origin and lifestyle features, as well as habits and magnitude of sun exposure of children. Analysis was performed by multivariate linear regression analysis and by multiple logistic regression analysis.

RESULTS

The number of nevi was found to steadily increase with age from a median of 3 at age 2 years to 19 at age 7 years (P < 0.0001). High numbers of nevi in children were associated with the number of weeks on sunny holidays, outdoor activities at home, skin type, facial freckling, ethnicity of parents, and the number of nevi on the arms of parents. Previously experienced sunburns failed significance (P = 0.0620).

CONCLUSIONS

The authors found a strong association between nevus development in children and the number of parental moles, which most likely points to an inherited factor. Moderate sun exposure such as outdoor activities during a German summer without sunburns seemed to be sufficient for induction of melanocytic nevi. The authors believe that these findings will have direct impact on concepts for preventive strategies.

The density of melanocytic nevi correlates with constitutional variables and history of sunburns: a prevalence study among Italian schoolchildren

In several studies from northern Europe, north America and Australia, melanocytic nevi are correlated with pigmentary traits and with intense sun exposure in a way similar to malignant melanoma. However, it is unclear if these data can be extrapolated to populations in other geographic locations and with different prevalent phenotypes. Our study was conducted among schoolchildren aged 13-14 years in 16 Italian cities. The parents of 3,127 children of a total of 3,160 (99%) consented to our study. A structured questionnaire was used to collect information about sun exposure and lifetime history of sunburns. Children were also examined by trained dermatologists to assess pigmentary traits and to make a count of melanocytic nevi. The median nevus density was higher among boys than girls. Areas that are usually chronically exposed to the sun exhibited a higher density of nevi compared to intermittently and rarely exposed areas. A higher density of nevi was found in children with lighter skin, blond hair and blue eyes. Red-haired children had a remarkably lower nevus density compared to the other color categories. The density of nevi increased with an increased number of reported episodes of sunburns. The results concerning nevi >/=6 mm in diameter paralleled those obtained for the total nevus density. However, at variance with total nevus density, a significant relation was also observed between larger nevi and freckling. Our study confirms that, in Italian schoolchildren, there is a relation between pigmentary traits, history of sunburns and the density of melanocytic nevi. Melanocytic nevi and malignant melanoma share a similar risk factor profile.

Melanoma detection rate and concordance between self-skin examination and clinical evaluation in patients attending a pigmented lesion clinic in Italy

BACKGROUND

The early diagnosis of melanoma is based on the collaboration between dermatologists and family doctors, who filter subjects to be referred to a pigmented lesion clinic (PLC). Following growing media coverage, there is increasing concern in the general population about the risk of the 'changing mole', resulting in a progressively increased workload in PLCs.

AIM AND METHODS

We investigated the causes of referral to a PLC in a series of 193 attendees seen consecutively at the PLC of the University of Florence. Because the number of naevi is the major risk factor for melanoma in Mediterranean populations, the concordance between self-counting of naevi and the clinical evaluation of a PLC dermatologist in order to classify high-risk individuals was also investigated.

RESULTS

Detection of a clinically suspicious lesion at dermatological examination occurred in 13 of 193 subjects referred by general practitioners (6.7%), with three melanomas confirmed histologically (overall detection rate: three of 193, 1.6%). The positive predictive value of the 'presence of a suspicious lesion', the cause of referral in 39.9% of subjects, was 9.1% when based on the gold standard criterion represented by the clinical detection of a suspicious lesion by the dermatologist and 3.8% based on the histological diagnosis of melanoma; the negative predictive value was 94.8% (100% when based on the histological diagnosis of melanoma), suggesting that the clinical detection of a suspicious lesion in subjects with different causes of referral (such as risk factors for melanoma, or the need to be reassured about moles) is unlikely. There was poor agreement between self-evaluation based on the presence of multiple naevi and the dermatological examination (gold standard) for both common and atypical naevi. The highest concordance (kappa = 0.32, 95% confidence interval 0.20-0.43) was associated with a dichotomized count of naevi as up to 50 or more than 50 naevi.

CONCLUSIONS

In order to reduce the PLC workload, the filtering role of the family doctor needs to be improved, so that only subjects with a specific suspicious lesion are referred to the PLC. The self-assessment of melanoma risk based on the presence of multiple naevi was not reliable.

Ultraviolet photoproduct levels in melanocytic nevi and surrounding epidermis in human skin in situ

Melanocytic nevi are localized benign proliferations of melanocytes. The number of nevi has been shown to be the major risk marker for the development of cutaneous melanoma. This study compares the induction of photoproducts in nevi and in surrounding skin after exposure to solar-simulating radiation. Cyclobutane pyrimidine dimers (TT=T and TT=C) and 6-4 photoproducts (TT-T and TT-C) were measured in 20 nevi and 20 surrounding skin samples obtained from 14 subjects, using a 32P-postlabeling method. The amount of all four types of photoproducts in nevi was found to be 3-5-fold lower than that in surrounding skin, and the difference was statistically significant (paired t test, p < 0.01). In nevi, the photoproduct level was significantly associated with the color of nevi (the lowest level in the darkest color of nevi; r = -0.86, p < 0.01 for TT=T; r = -0.68, p < 0.01 for TT=C). Our findings suggest that the magnitude of the DNA damage is not a sole risk marker for the development of cutaneous melanoma.

Combined risk factors for melanoma in a Mediterranean population

A case-control study of non-familial melanoma including 183 incident cases and 179 controls was conducted in North-Eastern Italy to identify important risk factors and determine how combination of these affects risk in a Mediterranean population. Presence of dysplastic nevi (OR = 4.2, 95% CI = 2.4-7.4), low propensity to tan (OR = 2.4, 95% CI = 1.1-5.0), light eye (OR = 2.4, 95% CI = 1.1-5.2), and light skin colour (OR = 4.1, 95% CI = 1.4-12.1) were significantly associated with melanoma risk after adjustment for age, gender and pigmentation characteristics. A chart which identifies melanoma risk associated with combinations of these factors is presented; it can be used to identify subjects who would most benefit from preventive measures in Mediterranean populations. According to the combination of these factors, a relative risk range from 1 to 98.5 was found. Light skin colour, high number of sunburns with blistering, and low propensity to tan were significantly associated with melanoma thickness, possibly indicating that individuals with these characteristics underestimate their risk and seek attention when their lesion is already advanced.

Basic fibroblast growth factor and ultraviolet B transform melanocytes in human skin

Ultraviolet (UV) light is an epidemiological risk factor for melanoma, but its specific contribution to melanoma induction is not known. The first critical step of melanoma development, ie, the uncontrolled proliferation of melanocytes, may be induced by a combination of UV damage and an imbalance of growth factor production by cells in the immediate area of the melanocyte. Among several candidates, basic fibroblast growth factor (bFGF) is the major autocrine growth factor in melanoma and associated with tumor progression. Overexpression of bFGF via adenoviral gene transfer in human skin xenografted to severe combined immunodeficiency mice led to black-pigmented macules within 3 weeks of treatment. Immunofluorescence analysis demonstrated pathological hyperpigmentation, proliferation and hyperplasia of activated melanocytes, but no malignant transformation. Similar changes were observed in skin reconstructs. When bFGF was combined with UVB, pigmented lesions with hyperplastic melanocytic cells were detected, including a lesion with high-grade atypia resembling lentiginous forms of malignant melanoma. Donor-matched control grafts revealed no melanocytic changes. bFGF was overexpressed in dermal fibroblasts demonstrating the co-carcinogenic influence of paracrine-acting growth factors by cells of the microenvironment. This is the first report suggesting that an imbalance of physiological growth factor production in the skin may cause melanoma in combination with UVB.

Update on genetic events in the pathogenesis of melanoma

Melanoma is the most common fatal malignancy among young adults, and its incidence and mortality continue to increase at an alarming rate. Epidemiologic studies have clearly demonstrated roles for genetic predisposition and sun exposure in melanoma development. In the past few years, substantial information has been added to the body of evidence suggesting that inherited and somatic genetic events contribute to the pathogenesis of melanoma. This review focuses on recent advances in the understanding of the genetic events, particularly aberration of cell cycle control and transcriptional control mechanisms, implicated in the pathogenesis of melanoma.