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Marghoob AA, Changchien L, DeFazio J, Dessio WC, Malvehy J, Zalaudek I, Halpern AC, Scope A. The most common challenges in melanoma diagnosis and how to avoid them. Australas J Dermatol 2009; 50:1-13; quiz 14-5. [DOI: 10.1111/j.1440-0960.2008.00496_1.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tran KT, Wright NA, Cockerell CJ. Biopsy of the pigmented lesion—When and how. J Am Acad Dermatol 2008; 59:852-71. [DOI: 10.1016/j.jaad.2008.05.027] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 05/16/2008] [Accepted: 05/27/2008] [Indexed: 11/28/2022]
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Abstract
Cancer stem cells (CSC) have been identified in hematological malignancies and several solid cancers. Similar to physiological stem cells, CSC are capable of self-renewal and differentiation and have the potential for indefinite proliferation, a function through which they may cause tumor growth. Although conventional anti-cancer treatments might eradicate most malignant cells in a tumor, they are potentially ineffective against chemoresistant CSC, which may ultimately be responsible for recurrence and progression. Human malignant melanoma is a highly aggressive and drug-resistant cancer. Detection of tumor heterogeneity, undifferentiated molecular signatures, and increased tumorigenicity of melanoma subsets with embryonic-like differentiation plasticity strongly suggest the presence and involvement of malignant melanoma stem cells (MMSC) in the initiation and propagation of this malignancy. Here, we review these findings in the context of functional properties ascribed to melanocyte stem cells and CSC in other cancers. We discuss the association of deregulated signaling pathways, genomic instability, and vasculogenic mimicry phenomena observed in melanoma subpopulations in light of the CSC concept. We propose that a subset of MMSC may be responsible for melanoma therapy-resistance, tumor invasiveness, and neoplastic progression and that targeted abrogation of a MMSC compartment could therefore ultimately lead to stable remissions and perhaps cures of metastatic melanoma.
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Affiliation(s)
- Tobias Schatton
- Transplantation Research Center, Children's Hospital Boston & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Risser J, Pressley Z, Veledar E, Washington C, Chen SC. The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic. J Am Acad Dermatol 2007; 57:428-34. [PMID: 17624623 DOI: 10.1016/j.jaad.2007.02.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 02/20/2007] [Accepted: 02/25/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes. OBJECTIVE We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi. METHODS A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts. RESULTS The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (-0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (-1.209, P < .0001), increasing provider experience (-0.047, P = .029), and increased number of biopsies before the initial PLC (-0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC. LIMITATIONS This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period. CONCLUSION Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.
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Affiliation(s)
- Jessica Risser
- Department of Dermatology, Emory University, Atlanta, GA 30322, USA
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Abstract
PURPOSE OF REVIEW Early diagnosis has the greatest potential for short-term impact on melanoma mortality. We highlight recent trends in early melanoma detection and address the related challenges and opportunities. RECENT FINDINGS Significant strides have been made in the early diagnosis of melanoma. Success has been achieved through improved awareness of early signs of melanoma and identification of high-risk cohorts. Detection pressure, however, may also be resulting in the diagnosis of indolent disease, leading to unnecessary morbidity and cost. A looming imbalance of supply and demand for melanoma detection services is anticipated with the aging of the baby boom generation. Prioritization of other preventive services and a growing emphasis on cosmetic dermatology are anticipated to exacerbate this imbalance. While a paucity of hard data have precluded adoption of formal screening recommendations for melanoma, general consensus supports opportunistic screening and identification of high-risk individuals who may benefit from specialized surveillance with dermoscopy and whole-body photography. Research is needed to distinguish biologically indolent and aggressive melanoma, to develop and test evolving technologies to aid diagnosis, and to assess the utility of specific public health strategies for melanoma detection. SUMMARY Significant strides have been made in early melanoma detection, but multiple challenges remain.
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Affiliation(s)
- Allan C Halpern
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Wang SQ, Halpern AC. Management of Cutaneous Melanoma: A Public Health and Individual Patient Care Perspective. ACTA ACUST UNITED AC 2007; 23:81-98. [DOI: 10.1016/j.yadr.2007.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Melanoma is a major public health problem. There will be a projected 60,000 cases of invasive melanoma diagnosed in 2005, and that number is increasing each year. Fortunately, the prognosis is improving as well, but we still have approximately 8000 deaths per year related to this tumor. To reduce this number of deaths, we need to look at the skin--inspect--and see--recognize potential early melanomas when we look at them. Most of the population does not see a dermatologist regularly, and there are many barriers to general clinicians inspecting the skin, including inadequacy of dermatologic skills. Patients are ultimately responsible for their own skin, but only a small proportion of people actually perform thorough skin self-examination on a recommended monthly basis. There are various tools used by some dermatologists to facilitate early detection, including total body and lesional photography and epiluminescence microscopy (dermoscopy) of lesions. A basic skin cancer triage algorithm has been developed and tested in primary care, with promising results for improving practice. The general population also needs better guidance on early melanoma detection. Hence, instead of relying on the "ABCDs" for a morphologic diagnosis, the message of "a new or changing skin lesion" is being promoted to facilitate early diagnosis of thin, curable tumors. Together, patients and clinicians can improve early detection to reduce melanoma-related mortality.
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Affiliation(s)
- Martin A Weinstock
- Dermatoepidemiology Unit, V A Medical Center-111D, 830 Chalkstone Avenue, Providence, RI 02908, USA.
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Haenssle HA, Krueger U, Vente C, Thoms KM, Bertsch HP, Zutt M, Rosenberger A, Neumann C, Emmert S. Results from an observational trial: digital epiluminescence microscopy follow-up of atypical nevi increases the sensitivity and the chance of success of conventional dermoscopy in detecting melanoma. J Invest Dermatol 2006; 126:980-5. [PMID: 16514414 DOI: 10.1038/sj.jid.5700119] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We analyzed the value of digital epiluminescence microscopy (DELM) for the long-term follow-up of atypical nevi. Patients (n=530) were prospectively categorized into defined melanoma risk groups and followed by clinical and epiluminescence microscopy (ELM) examinations. Atypical nevi (n=7001) were additionally followed by DELM. During follow-up (median 32.2 months), we detected 53 melanomas among 637 excised lesions (8.3% overall chance of success). The chance of success for melanoma detection among lesions suspicious by ELM criteria was increased to 17% when additional DELM-documented changes were present. Moreover, 18 of the 53 melanomas were exclusively identified by DELM-documented changes, indicating that DELM increased the sensitivity of the ELM analysis by identifying additional melanomas. However, for lesions exclusively excised due to DELM changes, the chance of success was lower than for ELM (5.2 vs 11.8%). Excisions due to mere DELM changes detected 66.7% of melanomas in familial atypical mole and multiple melanoma (FAMMM) and 32.5% of melanomas in atypical mole syndrome (AMS) patients. We conclude that DELM is a valuable tool for the long-term follow-up of atypical nevi, especially in the high-risk groups of FAMMM and AMS patients. Randomized controlled trials are needed to validate the data from this clinical trial.
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Affiliation(s)
- Holger A Haenssle
- Department of Dermatology, Georg-August-University Goettingen, Von Siebold Strasse 3, D-37075 Goettingen, Germany.
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Moreno D, Ferrándiz L, Pérez-Bernal AM, Ríos JJ, Carrasco R, Camacho F. [Evaluation of a screening system for patients with pigmented lesions using store-and-forward teleconsultation]. ACTAS DERMO-SIFILIOGRAFICAS 2006; 96:222-30. [PMID: 16476372 DOI: 10.1016/s0001-7310(05)73074-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Pigmented lesion clinics (PLC's) were developed as a quick referral system for patients with pigmented lesions. However, the most appropriate method of selecting patients who need to be seen in these units is not clearly defined. Teledermatology is a tool whose usefulness as a patient selection system for PLC's needs to be evaluated. OBJECTIVE To evaluate teleconsultation as a screening system for patients with pigmented lesions in terms of efficacy, accuracy and satisfaction. METHOD Teleconsultations received at a PLC over a period of 12 weeks were evaluated. Teleconsultation patients reported changes in a pigmented lesion, a lesion that had recently appeared, multiple lesions, symptomatic lesions or concern about a nevus. We calculated the time intervals in sending the teleconsultation report and in patients being seen at the "physical" PLC consultation, the intraobserver, interobserver and pathologist kappa coefficients, as well as the degree of satisfaction of patients and Primary Care (PC) physicians. RESULTS 219 teleconsultations were evaluated, 49.3 % of which were referred to the "physical" consultation. The most frequent reason for the teleconsultation was concern about a nevus (37.0 %). The teleconsultations received responses in an average time of 43.9 hours, and patients were seen at the "physical" consultation within 2 weeks. The intraobserver agreement was kappa = 0.93 (95 % CI 0.87-0.98); interobserver agreement, kappa = 0.91 (95 % CI 0.87-0.96); and the agreement between the teledermatologist and the pathologist, kappa = 0.79 (95 % CI 0.70-0.89). 86 % of the patients and 91 % of the Primary Care physicians said that they were "very satisfied" with the implementation of this new system. CONCLUSIONS Teleconsultation is an accurate screening system for patients with pigmented lesions. With this methodology, waiting times for patients with malignant lesions or those suspected of malignancy can be shortened at the same time as the PLC's excess workload is decreased. However, more experience is needed to establish the true usefulness of this filtering system in the early diagnosis of melanoma.
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Affiliation(s)
- David Moreno
- Unidad de Lesiones Pigmentadas y Teledermatología, Departamento de Dermatología, Hospital Universitario Virgen Macarena, Avda. Dr. Fedriani 3, 41071 Seville, Spain.
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Fisher NM, Schaffer JV, Berwick M, Bolognia JL. Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma. J Am Acad Dermatol 2006; 53:393-406. [PMID: 16112344 DOI: 10.1016/j.jaad.2005.03.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Revised: 02/27/2005] [Accepted: 03/04/2005] [Indexed: 12/01/2022]
Abstract
BACKGROUND Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention. OBJECTIVE Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas. METHODS A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients. RESULTS Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27). LIMITATIONS Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations. CONCLUSIONS The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.
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Affiliation(s)
- Nina M Fisher
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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63
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Weinstock MA. Progress and Prospects on Melanoma: The Way Forward for Early Detection and Reduced Mortality. Clin Cancer Res 2006; 12:2297s-2300s. [PMID: 16609048 DOI: 10.1158/1078-0432.ccr-05-2559] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The public health problem of melanoma is difficult. Recent decades have seen substantial efforts directed at primary prevention, yet the incidence of melanoma continues to increase. Substantial efforts have been devoted to improving treatment, yet melanoma retains a poor prognosis if simple surgical excision is not curative. Early detection has made remarkable progress, however. Five-year relative survival has increased from approximately 80% in 1975 to greater than 90% in 1996. Even so, almost 8,000 Americans are projected to succumb to melanoma in 2005. Because most of these fatal melanomas are visible on the skin surface at a curable phase in their evolution, more can and must be done. To improve the early detection practices of clinicians, we have developed an eight-step Basic Skin Cancer Triage algorithm, which forms the core of a curriculum that we have shown can result in improved skills, attitudes, and practices. We are now in the process of attempting to test a Web-based version of that curriculum in a randomized trial. Skin self-examination also has tremendous potential for contributing to early detection of melanoma. We have tested an intervention to encourage thorough skin self-examination in a randomized trial and found it effective in increasing the performance of this procedure, on increase that is sustained for at least a year, while resulting in only short-term increases in surgical procedures on the skin. Early detection has not yet reached its full potential effect on the public health problem of melanoma and is poised to further reduce melanoma mortality.
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Affiliation(s)
- Martin A Weinstock
- Dermatoepidemiology Unit, Veterans Affairs Medical Center and Department of Dermatology, Rhode Island Hospital and Brown University, Providence, Rhode Island 02908, USA.
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Seidenari S, Longo C, Giusti F, Pellacani G. Clinical selection of melanocytic lesions for dermoscopy decreases the identification of suspicious lesions in comparison with dermoscopy without clinical preselection. Br J Dermatol 2006; 154:873-9. [PMID: 16634889 DOI: 10.1111/j.1365-2133.2006.07165.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In most cases dermoscopy is performed only on lesions selected by clinical inspection which present worrying clinical features or appear to deviate from the patient's average type of naevus. Thus, possible early malignant melanomas (MMs) or MM precursors, lacking typical clinical characteristics, may elude the dermoscopic examination. OBJECTIVES To perform a comparison between two different approaches to the patient's examination, one based on a clinical preselection of lesions to be examined by dermoscopy, and the other consisting of the dermoscopic scrutiny of all melanocytic lesions with a diameter>or=2 mm (total dermoscopy). METHODS Sixty-three consecutive patients with MM, undergoing periodic dermoscopic examinations of their naevi, were enrolled in the study. The patients first underwent an assessment of the entire skin with the unaided eye for the identification of lesions for dermoscopy. Subsequently, the patients underwent dermoscopic examination of all melanocytic lesions. Images of naevi identified by clinical examination or by total dermoscopy as having dermoscopic aspects characteristic of a suspicious lesion, i.e. necessitating either surgical excision or follow-up examinations, were separately recorded, classified and described employing the ABCD rule of dermoscopy and the seven-point checklist. RESULTS Five hundred and fifty-one lesions were chosen by clinical inspection for subsequent dermoscopic examination; among these, 117 were considered for excision or follow-up. Ninety-two further lesions were identified for excision or follow-up by employing only total dermoscopy. Dermoscopy scores of lesions selected by clinical inspection plus dermoscopy were similar to those identified by dermoscopy alone. In the former group, 13 lesions showed either an ABCD or a seven-point score corresponding to a suspicious lesion, whereas eight such lesions were identified only by total dermoscopy. Thus, by clinical selection plus dermoscopy we were able to identify only 62% of dermoscopically suspicious lesions. CONCLUSIONS Clinical selection of melanocytic lesions for dermoscopic examination is associated with the 'loss' of a conspicuous number of lesions which deserve surgical excision or follow-up examinations. Total dermoscopy, enabling the detection of suspicious lesions, together with storage, retrieval and sequential comparison of their images, could enhance MM diagnosis by follow-up, in comparison with clinical preselection for dermoscopy.
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Affiliation(s)
- S Seidenari
- Department of Dermatology, University of Modena and Reggio Emilia, Via del Pozzo 71, 41100 Modena, Italy.
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65
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Abstract
Melanocytic nevi, which are benign tumors of melanocytes, may have occasional cosmetic significance but, for the most part, they are important only in relation to melanoma. Nevi are the most important simulants of melanoma, both clinically and histologically, and can usually be reliably distinguished from melanomas using published criteria. Some lesions are characterized by greater degrees of atypia and may be more difficult to diagnose. Dysplastic nevi are among the most important simulants of melanoma. Nevi may also be important as potential precursors of melanoma; however, most nevi are stable and will not progress to malignancy. Nevi are vastly more common than melanomas and the rate of progression of individual lesions is very low. Therefore, nevi are not as a rule managed by wholesale excision to prevent melanoma. Nevi are also important as risk markers, identifying individuals at greater risk of developing melanoma in the future. Dysplastic nevi and, to a lesser extent, common acquired and congenital nevi are among the most important melanoma risk markers. Nevi of special sites have been identified as nevi that may show atypical features suggestive of a dysplastic nevus or of a melanoma. However, they are not risk markers and they are not malignancies. Nevi of genital skin, acral skin, and flexural skin are among the most important 'nevi of special sites'. It is important, in considering the differential diagnosis of a lesion in a special site, to avoid overcalling such a lesion as a melanoma or a dysplastic nevus because this could lead to excessive treatment. Conversely, it is important to avoid undercalling a lesion that is a dysplastic nevus or a melanoma as a nevus of special sites, because in this circumstance a patient could lose the opportunity either for surveillance to recognize a developing melanoma at an early, curable stage, or for definitive treatment of an established malignancy. In this monograph, dysplastic nevi and nevi of special sites are compared and contrasted in relation to melanoma.
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Affiliation(s)
- David E Elder
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, PA 19104, USA.
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Grichnik JM, Burch JA, Schulteis RD, Shan S, Liu J, Darrow TL, Vervaert CE, Seigler HF. Melanoma, a Tumor Based on a Mutant Stem Cell? J Invest Dermatol 2006; 126:142-53. [PMID: 16417230 DOI: 10.1038/sj.jid.5700017] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stem cells play a critical role in normal tissue maintenance, and mutations in these stem cells may give rise to cancer. We hypothesize that melanoma develops from a mutated stem cell and therefore residual stem cell characteristics should be able to be identified in melanoma cell lines. We studied three metastatic melanoma cell lines that exhibited multiple morphologic forms in culture and demonstrated the capacity to pigment. We used the ability to efflux Hoechst 33342 dye, a technique known to enrich for stem cells in many tissues, to segregate cell populations. The cells with the greatest ability to efflux the dye were (1) small in size, (2) had the capacity to give rise to larger cell forms, and (3) had the greatest ability to expand in culture. The small cells were found to have a decreased proliferative rate and were less melanized. Large dendritic cells that appeared to be nonproliferative were identified in cultures. Treatment with cytosine beta-D-arabinofuranoside hydrochloride (Ara-C) expanded the large cell population but the residual proliferative capacity, both in vitro and in vivo, remained concentrated in the smaller cell fraction. Antigenic staining patterns were variable and heterogeneous. Nestin (a neural stem cell marker) and gp100 (premelanosomal marker) favored the smaller cell population, while nerve growth factor receptor often labeled larger cells. Morphologic and antigenic heterogeneity remained intact after clonal purification. These findings are consistent with the behavior expected for a tumor based on stem cell biology; this finding has diagnostic and therapeutic implications for melanocytic neoplasias.
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Affiliation(s)
- James M Grichnik
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Rhodes AR. Cutaneous melanoma and intervention strategies to reduce tumor-related mortality: what we know, what we don't know, and what we think we know that isn't so. Dermatol Ther 2006; 19:50-69. [PMID: 16405570 DOI: 10.1111/j.1529-8019.2005.00056.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The care of patients who have cutaneous melanoma (CM) has undergone a dramatic change during the past five decades. In an increasing majority of cases, CM is being discovered in a premetastatic phase of tumor progression. Most patients are being treated in the ambulatory setting with a minimum of inconvenience and economic cost, and modest re-excision margins have largely replaced the mutilating surgical exonerations that were once standard only four decades ago. Histopathologic assessment of the primary tumor is the most widely used staging procedure to determine who is most likely to develop metastatic disease. For patients who develop distant metastases, there is no therapy currently available, based on large-scale randomized trials, that will prolong patient survival. Therefore, establishing an early diagnosis in a premetastatic phase of tumor development must be the overriding goal of any intervention strategy that seeks to reduce CM-related mortality. Unfortunately, as a result of public messages that emphasize the role of ultraviolet radiation (UVR) exposure in tumor development, most general physicians and lay people believe that most if not all cases of CM are the direct result of UVR exposure. In fact, we do not know the case fraction of CM directly attributable to UVR, and the unintended consequences of current messages directly linking UVR exposure and CM development may be thwarting the primary intervention goal of reducing tumor-related mortality. More likely to have an immediate positive impact on CM-related mortality are public messages that encourage skin awareness and self-examination by patients, total skin screening examinations by physicians during routine care, and periodic lifetime surveillance of patients determined to have a high CM risk based on identifiable historic and phenotypic traits.
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Affiliation(s)
- Arthur R Rhodes
- Department of Dermatology, University Medical Center, Rush University, 707 South Wood Street, Annex #220, Chicago, IL 60612, USA.
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Armour K, Mann S, Lee S. Dysplastic naevi: to shave, or not to shave? A retrospective study of the use of the shave biopsy technique in the initial management of dysplastic naevi. Australas J Dermatol 2005; 46:70-5. [PMID: 15842396 DOI: 10.1111/j.1440-0960.2005.00144.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of dysplastic naevi is a controversial subject. This study sought to assess the usefulness of the shave biopsy technique in the initial management of dysplastic naevi, and to demonstrate the advantages over the punch biopsy technique. We report a retrospective observational study of histopathology specimens examined in one histopathology practice over a 14-month period. Patients who had a clinical diagnosis of 'dysplastic naevus', which had initially been biopsied using either a shave or punch biopsy, and then followed up with a full-thickness elliptical excision, were included in the study. Histopathological concordance between the shave and punch biopsy specimens and their respective follow-up elliptical excisions was compared. We found that 21 of 22 (95.5%) shave biopsies were concordant with their respective excision specimens, and that 29 of 41 (70.7%) punch biopsies were concordant with their respective elliptical excision specimens. Of the shave biopsy specimens reviewed, 66% showed that the dysplastic naevi were completely excised with the initial biopsy, compared with 21.2% of the punch biopsy specimens. These findings confirm that shave biopsies provide accurate diagnostic information in the assessment of dysplastic naevi. Shave biopsies enable the entire lesion to be submitted for histopathological assessment, improving the chances of an accurate diagnosis.
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Affiliation(s)
- Katherine Armour
- Department of Dermatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Thomas NE, Groben P. Invasive superficial spreading melanomas arising from clinically normal skin. J Am Acad Dermatol 2005; 51:466-70. [PMID: 15337995 DOI: 10.1016/j.jaad.2004.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We provide documentation of the onset of 3 invasive superficial spreading melanomas arising from clinically normal skin and correlation with histologic lack of nevus association. Clinical, dermoscopic, and pathologic features of these "de novo" melanomas, which became invasive while small in diameter and had few clinical criteria for diagnosis, are reported.
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Affiliation(s)
- Nancy E Thomas
- Department of Dermatology, University of North Carolina at Chapel Hill, NC 27599, USA.
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Affiliation(s)
- Martin A Weinstock
- Dermatoepidemiology Unit, V A Medical Center Providence, Rhode Island, USA
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Gandini S, Sera F, Cattaruzza MS, Pasquini P, Abeni D, Boyle P, Melchi CF. Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi. Eur J Cancer 2005; 41:28-44. [PMID: 15617989 DOI: 10.1016/j.ejca.2004.10.015] [Citation(s) in RCA: 498] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2004] [Revised: 09/20/2004] [Accepted: 10/14/2004] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sara Gandini
- Department of Epidemiology and Biostatistics, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy.
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72
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Jacyk WK. Precursors of Melanoma. S Afr Fam Pract (2004) 2004. [DOI: 10.1080/20786204.2004.10873135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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73
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Dixon AJ, Dixon BF. Ultraviolet radiation from welding and possible risk of skin and ocular malignancy. Med J Aust 2004; 181:155-7. [PMID: 15287834 DOI: 10.5694/j.1326-5377.2004.tb06207.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2003] [Accepted: 05/18/2004] [Indexed: 11/17/2022]
Abstract
Arc welding produces the full spectrum of ultraviolet radiation (UVR). It is possible that welders are at greater risk of developing skin cancer than the general population, but there is a dearth of well designed studies in this area. The only major study of the relationship between arc welding and skin cancer risk did not reveal an increased incidence of skin cancer in welders. As the welders examined were all well protected and the length-of-exposure period was limited, the findings cannot be generalised to all welders. Studies have demonstrated that welding increases the risk of ocular melanoma. Just as we urge the public to protect themselves from UVR, we need to consider similar advice for arc welders.
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Affiliation(s)
- Anthony J Dixon
- Geelong Skin Cancer Clinic, 66 Roslyn Road, Belmont, Victoria 3216, Australia.
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74
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Jacyk WK. Precursors of Melanoma. S Afr Fam Pract (2004) 2004. [DOI: 10.1080/20786204.2004.10873105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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75
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Abstract
BACKGROUND Early detection of melanoma results in excision of thinner melanomas, which are associated with better prognosis. Total cutaneous photography provides a temporal comparison of lesions, which allows clinicians and patients to recognize new and subtly changing lesions. OBJECTIVES We examined the utility of total cutaneous photography in detecting melanoma, identified the reason for biopsy of suspicious lesions and determined who detected new melanomas, the physician on follow-up examination or the patient on self-examination. PATIENTS/METHODS The charts of the 576 patients in the total cutaneous photography database were reviewed. Twelve patients were identified who had melanoma diagnosed with photographic assistance. Baseline and prebiopsy photographs, dermatology clinic notes (115 patient visits) and pathology reports for each biopsied lesion were reviewed. Histological diagnosis, cause for biopsy, and whether the lesion was detected by the patient or physician, was recorded for each of the biopsied lesions. Also noted were all the lesions that concerned patients, the cause for concern, and whether these lesions were biopsied. RESULTS A total of 93 lesions were biopsied in these patients. Twenty-seven (35%) of 77 melanocytic lesions were histologically diagnosed as melanoma. The thickest melanoma found measured 1.1 mm, indicating a favourable prognosis in our patients. Seventy-four per cent of the melanomas were biopsied due to changes from baseline and 19% were biopsied because they were new lesions. The changes noted were subtle and the lesions that proved to be melanoma did not satisfy the classical clinical criteria for melanoma. Eight (30%) of the melanomas were identified by patients on skin self-examination. Twenty-six per cent of the lesions that concerned patients were not biopsied after evaluation by a physician. CONCLUSIONS We found that photographically assisted follow-up helped detect new and subtly changing melanomas, which did not satisfy the classical clinical features of melanoma. In addition, photographically assisted follow-up helped detect nonmelanoma skin cancers. Patient skin self-examination proved to be valuable, in that it complemented physician follow-up examination in detecting melanomas. Photographic follow-up was also valuable in avoiding unnecessary biopsy in suspicious, but stable lesions. Total cutaneous photography therefore may be an effective way to increase the sensitivity and specificity for detecting melanoma.
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Affiliation(s)
- N E Feit
- Department of Dermatology, Memorial Sloan-Kettering Cancer Center, 160 East 53rd St, New York, NY 10022, USA
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76
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Casanova Seuma JM, Ribera Pibernat M. [Melanoma]. Aten Primaria 2004; 33:335-46. [PMID: 15087080 PMCID: PMC7676023 DOI: 10.1016/s0212-6567(04)70803-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- J M Casanova Seuma
- Servei de Dermatologia, Hospital Universitari Arnau de Vilanova, Facultat de Medicina, Universitat de Lleida, Lleida, España.
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77
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Haenssle HA, Vente C, Bertsch HP, Rupprecht R, Abuzahra F, Junghans V, Ellinghaus B, Emmert S, Hallermann C, Rosenberger A, Neumann C. Results of a surveillance programme for patients at high risk of malignant melanoma using digital and conventional dermoscopy. Eur J Cancer Prev 2004; 13:133-8. [PMID: 15100580 DOI: 10.1097/00008469-200404000-00007] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with a high number of atypical naevi and a personal and/or family history of melanoma are at high risk of malignant melanoma. The objective of this study was to design a special documentation and surveillance programme using epiluminescence microscopy (ELM) and digital epiluminescence microscopy (DELM) to improve the surveillance of these patients. High-risk patients (n=212) were categorized by the number and phenotype of their naevi and their personal and family history of melanoma. Then patients were screened by the unaided eye, conventional photography, ELM and, in selected cases of atypia, DELM. Median follow-up was 18 months, and 2939 pigmented lesions were followed by DELM. Examination on the first visit identified 17 cutaneous melanomas. During the following observation period, another 17 melanomas were identified. Fifteen of these follow-up melanomas were exclusively identified based upon DELM. In these cases, subtle lesional changes occurred over time, and ELM diagnostic algorithms for differentiating benign melanocytic lesions from melanoma did not score a suspicion of melanoma. All melanomas, either pre-existing or developing during follow-up, were identified in an early, curable phase of tumour growth. We conclude that DELM follow-up for patients at high risk allows the early detection of melanomas that have not yet acquired melanoma-typical ELM features.
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Affiliation(s)
- H A Haenssle
- Department of Dermatology and Venerology, Georg-August-University Goettingen, Von-Siebold-Strasse 3, D-37075 Goettingen, Germany.
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78
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Marghoob AA, Swindle LD, Moricz CZM, Sanchez Negron FA, Slue B, Halpern AC, Kopf AW. Instruments and new technologies for the in vivo diagnosis of melanoma. J Am Acad Dermatol 2003; 49:777-97; quiz 798-9. [PMID: 14576657 DOI: 10.1016/s0190-9622(03)02470-8] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The principal objective of screening individuals at risk for melanoma is detection of cutaneous melanoma during the curable stages of its early evolution. Unaided visual inspection of the skin is often suboptimal at diagnosing melanoma. Improving the diagnostic accuracy for melanoma remains an area of active research. These research efforts have focused on both the detection of early melanoma and the in-depth evaluation of suspicious pigmented lesions for the presence or absence of melanoma. Numerous instruments are under investigation to determine their usefulness in imaging and ascertaining a correct in vivo diagnosis of melanoma. It is anticipated that some of these tools, alone or in combination, will improve our ability to differentiate, in vivo, melanoma from its simulators. Ultimately, these advances may prevent unnecessary biopsies (increased specificity) while increasing the sensitivity for diagnosing melanoma. This article reviews the current instruments and new technologies for the in vivo diagnosis of melanoma. Learning objective At the conclusion of this learning activity, participants should be acquainted with the instruments designed to facilitate the early detection of melanoma. They should also be familiar with the basic technology behind these instruments and should recognize the potential benefits and limitations inherent in each.
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79
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Oliveria SA, Sachs D, Belasco KT, Halpern AC. Adoption of new technologies for early detection of melanoma in dermatologic practice. J Am Acad Dermatol 2003; 49:955-9. [PMID: 14576692 DOI: 10.1016/s0190-9622(03)02464-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The identification and diagnosis of early melanoma will reduce unnecessary operations and may be important in reducing mortality from melanoma and impacting cost savings to the health system. New technologies are being developed and used at some specialized centers to facilitate the detection and diagnosis of early melanoma for patients at high risk. These technologies include but are not limited to digital photography, dermoscopy, computerized image analysis systems, and confocal scanning laser microscopy. To most effectively implement these novel approaches, it is important to identify the key factors that influence the adoption or diffusion of new medical technologies. We propose patient-, physician-, and health care system-related factors that influence the diffusion of new technologies for the early detection of skin cancer. Studies involving physicians and patients in a variety of clinical settings need to be conducted to achieve a greater understanding of the barriers to the adoption of these new technologic tools that are intended to aid in skin cancer screening.
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Affiliation(s)
- Susan A Oliveria
- Memorial Sloan-Kettering Cancer Center, New York, NY 10022, USA.
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80
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Halpern AC, Marghoob AA, Bialoglow TW, Witmer W, Slue W. Standardized positioning of patients (poses) for whole body cutaneous photography. J Am Acad Dermatol 2003; 49:593-8. [PMID: 14512902 DOI: 10.1067/s0190-9622(03)02125-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Whole body photography (WBP) has been used for decades by some specialized pigmented lesion clinics as an aid to early melanoma detection in high-risk persons. The recent advent of digital imaging systems for acquiring and archiving whole body skin images has resulted in greater dissemination of this technique. This in turn has led to the recent establishment of a Category III Current Procedural Terminology code for WBP. Here we present a proposed set of standardized body poses for WBP on the basis of the extant literature and the experience of a panel of experts in the field. The proposed poses were developed with consideration of patient comfort and technical efficiency. The poses were optimized to comply with a predetermined set of desirable technical parameters as assessed in a series of 20 consecutive patients. The resulting set of poses is presented as a first step toward the increased standardization of dermatologic WBP.
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Affiliation(s)
- Allan C Halpern
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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81
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English DR, Burton RC, del Mar CB, Donovan RJ, Ireland PD, Emery G. Evaluation of aid to diagnosis of pigmented skin lesions in general practice: controlled trial randomised by practice. BMJ 2003; 327:375. [PMID: 12919990 PMCID: PMC175808 DOI: 10.1136/bmj.327.7411.375] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine whether an aid to the diagnosis of pigmented skin lesions reduces the ratio of benign lesions to melanomas excised in general practice. DESIGN Controlled trial randomised by practice. SETTING General practices in Perth, Western Australia. PARTICIPANTS 468 general practitioners in 223 practices. INTERVENTIONS Intervention practices were given an algorithm and instant camera to assist with the diagnosis of pigmented skin lesions. All practices were given national guidelines on managing melanoma. MAIN OUTCOME MEASURES Ratio of benign pigmented lesions to melanomas excised. Analyses conducted with and without inclusion of seborrhoeic keratoses. RESULTS At baseline the ratios of benign to malignant lesions were lower in the intervention group than in the control group. During the trial period the ratios were higher in the intervention group (19:1 v 17:1 without seborrhoeic keratoses and 29:1 v 26:1 with seborrhoeic keratoses). After adjustment for patients' age, sex, and socioeconomic status, the ratio was 1.02 times higher (95% confidence interval 0.68 to 1.51, P = 0.94) in the intervention group when seborrhoeic keratoses were not included and 1.03 times higher (0.71 to 1.50, P = 0.88) when seborrhoeic keratoses were included. General practitioners in the intervention group were less likely than those in the control group to excise the most recent pigmented skin lesion they managed (22% v 48%, P < 0.001) and to refer the patient to a specialist (16% v 27%, P = 0.06). CONCLUSIONS Provision of the algorithm and camera did not decrease the ratio of benign pigmented skin lesions to melanomas excised by general practitioners.
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82
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Abstract
Melanoma incidence rates are rising rapidly, particularly in older men. Older men are also more likely to have thick melanomas, which confer high mortality and morbidity. The reasons for the rate of increase are not known; increasing sun and UV exposure, however, is the major hypothesized explanation. In the past several years, two major susceptibility genes for melanoma, CDKN2A and CDK4, have been identified, but the two genes together account for a minority of familial melanoma. Other high-risk susceptibility genes are being sought actively. Genetic epidemiologic studies suggest that penetrance of each of the two identified genes is altered by other factors, either genetic or environmental. Epidemiologic studies have also identified other major host factors important in the development of melanoma. In European, North American, and Australian populations, the presence of clinically identified dysplastic nevi confers greatly increased risk of melanoma. A new measure of sun exposure, based on individual residential history, confers substantially increased risk of melanoma. Recent surveys of sun behavior in the US reveal extensive sunburning and use of tanning beds in adolescents and adults. Sun protective behaviors are not as prevalent as in Australia, where population rates of melanoma are stabilizing.
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Affiliation(s)
- Margaret A Tucker
- Genetic Epidemiology Branch, DCEG, NCI, Executive Plaza South 7122, 6120 Executive Blvd, Rockville, MD 20892-7236, USA.
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83
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Lucas CR, Sanders LL, Murray JC, Myers SA, Hall RP, Grichnik JM. Early melanoma detection: nonuniform dermoscopic features and growth. J Am Acad Dermatol 2003; 48:663-71. [PMID: 12734494 DOI: 10.1067/mjd.2003.283] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dermoscopy alone is not sufficient to detect all early melanomas. Total body photos reveal growth of melanomas but also reveal growth of melanocytic nevi. OBJECTIVE We set out to determine whether a simplified algorithm on the basis of nonuniform dermoscopic features combined with growth noted from baseline total body photos targeted the early melanocytic neoplasms most likely to be malignant. METHODS Lesions removed during follow-up of patients with total body photographs were reviewed and 169 melanocytic lesions were identified for which both gross clinical and dermoscopic photos were available. The images were evaluated separately by 3 academic dermatologists, without knowledge of the given pathologic diagnosis, for uniformity (consistent gradient of features from center to edge) and change (specifically, that which could indicate melanoma growth in normal skin or within a nevus). RESULTS Using a minimum of 2 out of 3 agreement for uniformity and change, 12 of 16 melanomas (including all 5 superficially invasive tumors) were graded as nonuniform and changed. The 4 melanomas not included in this category were in situ. The predicted odds of melanoma for lesions scored as both nonuniform and changed was 4.06 (P >.0195). If 3 out of 3 agreement was used, the odds ratio increased to 6 (P >.0010). CONCLUSION An algorithm on the basis of dermoscopic nonuniformity and change suggestive of growth as determined by total body photography segregates melanocytic neoplasms most likely to be malignant.
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Affiliation(s)
- Chere R Lucas
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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84
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Abstract
Although numerous second-generation isoprenylation inhibitors are proposed or under investigation for the treatment and/or prevention of cancer (eg, R115777, SCH 66336, L-778,123, BMS-214662), the chemotherapeutic and chemopreventive potential of commonly prescribed first-generation isoprenylation inhibitors, the statins, and other classes of lipid-lowering medications, the fibrates, has yet to be seriously explored. Two lipid-lowering medications, lovastatin and gemfibrozil, have been associated with a decreased incidence of melanoma in large, prospective, randomized, double-blind, placebo-controlled clinical cardiology trials. This article reviews melanoma biology and the clinical evidence for the use of lipid-lowering medications for melanoma chemoprevention and/or adjuvant chemotherapy.
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Affiliation(s)
- Robert P Dellavalle
- Department of Dermatology, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA.
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85
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Halpern AC. Total body skin imaging as an aid to melanoma detection. SEMINARS IN CUTANEOUS MEDICINE AND SURGERY 2003; 22:2-8. [PMID: 12773009 DOI: 10.1053/sder.2003.50000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Total body skin imaging (TBSI) is being increasingly used as an aid to melanoma detection in high-risk individuals. In this article, we review the rationale, techniques, advantages, and potential pitfalls of TBSI as an aid to melanoma detection. We highlight the technical and clinical considerations relevant to implementation of TBSI in clinical practice.
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Affiliation(s)
- Allan C Halpern
- Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
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86
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Abstract
Since the discovery of X-rays, the use of imaging technology has continued to play an important role in medicine. Technological advancements have led to the development of various imaging modalities, most of which have been used to image organs deep within the human body. More recently, attention has focused on the application of imaging technology for evaluation of the skin. A variety of techniques are currently being used to examine the skin and these include specialized photography, surface microscopy, ultrasound, laser Doppler perfusion imaging, confocal microscopy, and magnetic resonance imaging. These modalities can provide information that can assist in the management of skin problems. Although many of these techniques are still undergoing research, they are showing promise as useful clinical tools in dermatology.
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87
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Abstract
There are few areas in dermatology that provoke as much controversy as dysplastic nevus. Over the past decade, there have been significant strides made in terms of understanding the biology and etiology of the lesion. Distinct and reliable clinical and histologic features have been delineated. In this article, the management of patients with dysplastic nevi and the role for dermoscopy, photographic surveillance, genetic mapping and counseling, chemoprevention, and nevi removal are discussed.
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Affiliation(s)
- Thomas G Salopek
- Division of Dermatology and Cutaneous Sciences, University of Alberta, 2-125 Clinical Sciences Building, Edmonton, Alberta, Canada, T6G 2G3.
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88
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Tucker MA, Fraser MC, Goldstein AM, Struewing JP, King MA, Crawford JT, Chiazze EA, Zametkin DP, Fontaine LS, Clark WH. A natural history of melanomas and dysplastic nevi: an atlas of lesions in melanoma-prone families. Cancer 2002; 94:3192-209. [PMID: 12115352 DOI: 10.1002/cncr.10605] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Few long-term clinical and histologic data for melanocytic lesions have been available based on the mutation status of families at an increased risk of melanoma. In the current study, the authors describe the clinical and histologic features of dysplastic nevi and melanoma over time in families at an increased risk of melanoma with differing germline mutations in CDKN2A, CDK4, or not yet identified genes. METHODS Thirty-three families with > 2 living members with invasive melanoma were evaluated clinically and followed prospectively for up to 25 years. All the participants were evaluated by the same study team at the Clinical Center of the National Institutes of Health or in local clinics. After informed consent was obtained, family members (n = 844) were examined and photographed. Blood was obtained for genetic studies; genotyping for CDKN2A and CDK4 was performed. Sequential photographs of melanocytic lesions were taken as part of the clinical evaluations. When melanocytic lesions were removed, the histology was reviewed. Representative photographs and photomicrographs were selected for six classes of lesions and three mutation groups. RESULTS All the families were found to have members with dysplastic nevi and melanoma; 17 had mutations in CDKN2A, 2 had mutations in CDK4, and 14 had no mutations in either gene identified. The majority of dysplastic nevi either remain stable or regress; few change in a manner that should cause concern for melanoma. With careful surveillance, melanomas can be found early. CONCLUSIONS The melanomas and dysplastic nevi that were found to occur in the study families did not appear to vary by the type of mutation identified in the families.
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Affiliation(s)
- Margaret A Tucker
- Genetic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland 20892-7236, USA.
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89
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Tripp JM, Kopf AW, Marghoob AA, Bart RS. Management of dysplastic nevi: a survey of fellows of the American Academy of Dermatology. J Am Acad Dermatol 2002; 46:674-82. [PMID: 12004306 DOI: 10.1067/mjd.2002.121029] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Opinions concerning the significance of dysplastic nevi and their management vary among dermatologists. OBJECTIVE The purpose of this study was to assess how fellows of the American Academy of Dermatology (AAD) perceive and manage dysplastic nevi. METHODS Questionnaires were sent to 1216 fellows of the AAD; 456 questionnaires were returned. RESULTS Almost all respondents (98%) accept the dysplastic nevus, or atypical mole, as an entity. Seventy-five percent of respondents perform follow-up total cutaneous examinations on all their patients with dysplastic nevi, and another 22% on some of them; 86% usually intend to do total removals when they perform biopsies of dysplastic nevi; 75% use margins of 2 mm or less when removing dysplastic nevi; 49% order baseline total-cutaneous photographs of some or all of their patients with multiple dysplastic nevi, although only 12% do so routinely; 67% prefer to re-excise dysplastic nevi when margins are positive, some using histologic atypia as a criterion; 60% recommend an ophthalmologic examination for at least some of their patients with many dysplastic nevi, although only 3% do so routinely; 12% always recommend cutaneous examinations of blood relatives of their patients with dysplastic nevi and another 81% recommend such examinations for at least some of their patients with dysplastic nevi; 23% use dermoscopy; 99% recommend self-examination; almost 100% recommend sunscreen use and 93%, sun avoidance. CONCLUSION Most respondents, in agreement with the literature, accept the concept that patients with dysplastic nevi are at increased risk for melanoma and that methods for prevention and early detection of melanomas are appropriate for these patients.
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Affiliation(s)
- Jackie M Tripp
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York 10016, USA
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90
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Malvehy J, Puig S. Follow-up of melanocytic skin lesions with digital total-body photography and digital dermoscopy: a two-step method. Clin Dermatol 2002; 20:297-304. [PMID: 12074871 DOI: 10.1016/s0738-081x(02)00220-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Josep Malvehy
- Dermatology Department, Melanoma Unit, Hospital Clinic, Barcelona, Spain.
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91
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Nehal KS, Oliveria SA, Marghoob AA, Christos PJ, Dusza S, Tromberg JS, Halpern AC. Use of and beliefs about baseline photography in the management of patients with pigmented lesions: a survey of dermatology residency programmes in the United States. Melanoma Res 2002; 12:161-7. [PMID: 11930113 DOI: 10.1097/00008390-200204000-00009] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Medical photography is often used in dermatology to aid in the clinical surveillance of patients with pigmented lesions. This study aimed to assess the utilization, logistics, rationale and beliefs about the usefulness of baseline photography in patients with pigmented lesions by physicians in dermatology residency programmes, and to compare current utilization to that reported in the last decade. Questionnaires were mailed to directors of all accredited dermatology residency programmes in the United States (n = 105). Eighty-three physicians responded to the questionnaire (79%). Utilization of total body and individual lesion photography was reported by 63% and 75% of the respondents, respectively; 16% of the respondents did not use any method of photography. Reasons for using photography included the following beliefs: that it helps detect early melanoma, it results in fewer biopsies, and it reduces patient anxiety. Financial and logistical constraints were reasons why some programmes were not utilizing photography. Thus baseline photography is currently used in a majority of academic dermatology programmes as an aid in the early detection of melanoma.
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Affiliation(s)
- K S Nehal
- Dermatology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA.
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92
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Kanzler MH, Mraz-Gernhard S. Primary cutaneous malignant melanoma and its precursor lesions: diagnostic and therapeutic overview. J Am Acad Dermatol 2001; 45:260-76. [PMID: 11464189 DOI: 10.1067/mjd.2001.116239] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During the past few decades, scientific data relating to melanoma have flourished. New information regarding acquired nevi, dysplastic nevi (atypical nevi), and congenital nevi has given us a better understanding of these precursor lesions and their relationships to malignant melanoma. The roles of laboratory testing, photography, and newer diagnostic tools (eg, epiluminescence) to evaluate patients for melanoma or precursor lesions have fallen under close scrutiny. Traditional surgical therapeutic interventions continue to be replaced by less aggressive protocols based on prospective randomized studies. Many new interventions such as sentinel lymph node procedures are currently being evaluated at research/referral centers around the world. We present clinicians with an evidence-based summary of the current literature with regard to primary cutaneous melanoma, its diagnosis, precursor lesions, and therapy.
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Affiliation(s)
- M H Kanzler
- Division of Dermatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA.
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93
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Ajekigbe L, Baguley P. Synchronous Multiple Primary Malignant Melanoma in a Patient with Atypical Mole Syndrome. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2000. [DOI: 10.1177/229255030000800606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multiple primary malignant melanoma developing in people with atypical mole syndrome is well documented but rare. Synchronous occurrence of such melanomas is even rarer. The present case report, while not unique, provides an excellent opportunity to remind clinicians of presentation and management of atypical mole syndrome, while emphasizing the higher risk of developing malignant melanoma.
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Affiliation(s)
- Lo Ajekigbe
- Middlesbrough General Hospital, Middlesbrough, United Kingdom
| | - Pe Baguley
- Middlesbrough General Hospital, Middlesbrough, United Kingdom
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Hanrahan PF, Menzies SW, D'Este CA, Plummer T, Hersey P. Participation of older males in a study on photography as an aid to early detection of melanoma. Aust N Z J Public Health 2000; 24:615-8. [PMID: 11215011 DOI: 10.1111/j.1467-842x.2000.tb00527.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the acceptability of photography as an aid to skin examinations in men over 50 years of age. METHODS A randomised trial of men selected from the electoral roll. All participants were photographed, but only half received their photographs. Skin examinations by GPs at years one and two. RESULTS 55% of men consented to have photographs taken and 51% did so. 86% of respondents had risk factors for melanoma (compared to 68% of non-responders) and 47% had two or more risk factors (compared to 23% of non-responders). At year one, 91% of participants remaining in study regions had been examined. Photographs were lost by only six participants. CONCLUSIONS Men over 50 years of age respond to personalised health messages about melanoma and respondents include a high proportion of males with risk factors for melanoma. IMPLICATIONS These initial results suggest that photography may be a logistically acceptable approach for assisting in the early detection of melanoma.
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Affiliation(s)
- P F Hanrahan
- Oncology & Immunology Unit, Newcastle Mater Misericordiae Hospital, New South Wales
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96
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Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of melanocytic skin lesions with digital epiluminescence microscopy: patterns of modifications observed in early melanoma, atypical nevi, and common nevi. J Am Acad Dermatol 2000; 43:467-76. [PMID: 10954658 DOI: 10.1067/mjd.2000.107504] [Citation(s) in RCA: 190] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Digital epiluminescence microscopy (DELM) has been reported to be a useful technique for the follow-up of melanocytic nevi. One of the promises of this technique is to identify modifications over time that indicate impending or incipient malignancy and to facilitate surveillance of melanocytic skin lesions, particularly in patients with multiple clinically atypical nevi. OBJECTIVE Our purpose was to report on patterns of modifications over time observed in benign melanocytic skin lesions and melanoma. METHODS A total of 1862 sequentially recorded DELM images of melanocytic lesions from 202 patients (mean age, 36.1 years; 54.0% female patients) with multiple clinically atypical nevi were included in the analysis. The median follow-up interval was 12. 6 months. Melanocytic lesions with substantial modifications over time (enlargement, changes in shape, regression, color changes or appearance of ELM structures known to be associated with melanoma) were excised and referred to histopathologic examination. RESULTS A total of 75 melanocytic skin lesions (4.0%) from 52 patients (mean age, 33.3 years; 63.5% female patients) showed substantial modifications over time and were excised and referred to histopathologic examination. Eight changing lesions were histologically diagnosed as early melanomas. These lesions frequently showed focal enlargement associated with a change in shape as well as appearance of ELM structures that are known to be associated with melanoma. In contrast, the majority of benign changing lesions (common and atypical nevi) showed symmetric enlargement without substantial structural ELM changes. Six of the 8 patients in whom melanoma developed were unaware of the fact that the lesion had changed over time. CONCLUSION We demonstrate that follow-up of melanocytic lesions with DELM helps to identify patterns of morphologic modifications typical for early melanoma. DELM may therefore serve as a useful tool to improve the surveillance of patients with multiple atypical nevi.
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Affiliation(s)
- H Kittler
- Department of Dermatology, Division of General Dermatology, University of Vienna Medical School, Austria.
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97
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Abstract
Although the first English-language report of melanoma in 1820 contained a description of a melanoma-prone family, it was 1983 before formal genetic analysis suggested an autosomal dominant mode of inheritance for both melanoma and the then newly described melanoma precursor, dysplastic nevi (DN). Subsequent genetic studies have assumed this model to be correct, although when viewed in aggregate, the data are inconsistent. The first proposed melanoma gene (CMM1) was mapped to chromosome 1p36. This gene assignment has not been confirmed. A second melanoma gene, designated CMM2, has been mapped to chromosome 9p21. This gene assignment has been confirmed, and the cell cycle regulator CDKN2A has been proposed as the candidate gene. Germline mutations in this gene have been identified in about 20% of melanoma-prone families that have been studied to date. Pancreatic cancer occurs excessively in melanoma families with germline mutations in CDKN2A. Germline mutations in the cyclin-dependent kinase gene CDK4 (chromosome 12q14) have been described in three melanoma families. This finding represents a third melanoma gene but one that accounts for only a tiny fraction of all hereditary melanoma. Recently, a familial melanoma-astrocytoma syndrome has been reported. Large germline deletions of 9p21 occur in these families, with the p19 gene implicated in its pathogenesis. At present, clinical predictive genetic testing for mutations in the CDKN2A gene is available commercially, but its use has been limited by uncertainty as to how test results would affect the management of melanoma-prone family members. Currently, management recommendations include monthly skin self-examination, clinical skin examination once or twice yearly, a low threshold for simple excision of changing pigmented lesions, moderation of sun exposure, and appropriate use of sunscreens. A heritable determinant for total nevus number has been suggested by twin studies. Other data suggest the presence of a major gene responsible for "total nevus density" in melanoma-prone families. Approximately 55% of the mole phenotype in multiplex melanoma families was explained by this proposed gene. An autosomal dominant mode of inheritance has been proposed for DN, and data exist to suggest that DN may be a pleiotropic manifestation of the 1p36 familial melanoma gene. However, there clearly are melanoma-prone families that do not express the dysplastic nevus trait, and some of the families linked to CDKN2A also present with dysplastic nevi. Several studies have shown a surprisingly high prevalence of DN on the skin of family members of probands with DN. In light of the extensive evidence documenting that persons with DN (both sporadic and familial) have an increased prospective risk of melanoma, these family studies suggest that relatives of persons with DN should be examined for both DN and melanoma. Genetic determinants play a major role in the pathogenesis of normal nevi, DN, and melanoma. Identifying the molecular basis of these genetic events promises to enhance melanoma risk-reduction strategies and, ultimately, reduce melanoma-associated mortality.
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Affiliation(s)
- M H Greene
- Division of Hematology/Oncology, Mayo Clinic Scottsdale, Arizona, USA
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98
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Kefford RF, Newton Bishop JA, Bergman W, Tucker MA. Counseling and DNA testing for individuals perceived to be genetically predisposed to melanoma: A consensus statement of the Melanoma Genetics Consortium. J Clin Oncol 1999; 17:3245-51. [PMID: 10506626 DOI: 10.1200/jco.1999.17.10.3245] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- R F Kefford
- Westmead Institute for Cancer Research, University of Sydney, Westmead Hospital, New South Wales, Australia.
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100
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Richert SM, D'Amico F, Rhodes AR. Cutaneous melanoma: patient surveillance and tumor progression. J Am Acad Dermatol 1998; 39:571-7. [PMID: 9777764 DOI: 10.1016/s0190-9622(98)70006-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The goal of surveillance examinations (SVE) in patients at high risk for cutaneous melanoma (CM) is to diagnose premetastatic tumors. OBJECTIVE We attempted to determine whether SVE before CM diagnosis influences the histopathologic features of tumor progression. METHODS A retrospective review was conducted of consecutive patients who presented with an intact primary CM during a 36 month period (1991 to 1994) in a university dermatology ambulatory setting. RESULTS Thirty-nine intact CMs were diagnosed in 34 patients. Compared with 23 CMs in as many patients presenting at the first encounter, 16 CMs diagnosed in 11 patients during SVE had a smaller mean tumor diameter (P = .007) and tumor thickness (P = .002) and were more likely anatomic level I or II (P = .003) with microscopic thickness less than 0.76 mm (P = .01) and less than 0.50 mm (P = .002). CONCLUSION Primary CMs are more likely to be smaller and thinner when diagnosed during SVE than at first encounter, features that are likely to have a positive impact on CM mortality.
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Affiliation(s)
- S M Richert
- Department of Dermatology, University of Pittsburgh School of Medicine, PA, USA
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