Primary cutaneous melanoma. Identification of prognostic groups and estimation of individual prognosis for 5093 patients

Thorough skin examination for the early detection of melanoma

BACKGROUND

Melanoma is a major public health problem for which early detection may reduce mortality. Since melanoma is generally asymptomatic, this requires skin examination. We sought to evaluate the extent to which the general public has their skin examined by themselves, their partners, or health care providers and the frequency of these examinations.

METHODS

Random-digit-dial survey of adult Rhode Islanders.

RESULTS

Only 9% performed a thorough skin examination (TSE) at least once every few months, although over half of the sample reported conducting skin self-examination "deliberately and systematically." Participants were more likely to perform TSE if they were women and if their health care provider had asked them to examine their skin. Most participants reported that their health care provider never or rarely looked at the areas of their skin in which melanoma is most likely to arise.

CONCLUSIONS

The reported frequency of skin self-examination depends critically on the manner of inquiry. TSE by self or a partner is uncommon, and health care providers do not routinely examine the areas of the skin on which melanomas commonly arise.

Malignant Melanomas Treated By Plastic Surgeons in Hamilton, Ontario: A Retrospective Study of 80 Patients with Clinical and Histological Correlation

The present retrospective study was designed to analyze the clinical and survival data of 80 patients diagnosed between 1969 and 1987 with confirmed invasive malignant melanoma in Hamilton, Ontario and surrounding region. The age of peak incidence was 31 to 40 years of age for men and 51 to 60 years of age for women. The most frequent type of melanoma was superficial spreading. The most frequent sites were the upper back, ankle and leg. The six-year survival rate for all the patients was 63%. Patients below 50 years of age had a significantly better survival rate than patients above 50 years of age. Survival appears to be inversely proportional to tumour thickness. The findings in this study are similar to those of previous studies regarding clinical features and prognosis. Patient age, and tumour histology and thickness remain important prognostic factors in determining survival for invasive malignant melanoma.

Can immunohistochemical markers and mitotic rate improve prognostic precision in patients with primary melanoma?

BACKGROUND

In addition to tumor thickness, several other prognostic parameters have been identified in primary human melanomas. Some are available readily (localization, gender, age, and ulceration). Others must be evaluated with a moderate or even substantial amount of work (mitoses and immunohistochemical markers). This study was undertaken to determine whether this extra effort is justified because it actually improves the precision of prognostic statements.

METHODS

Immunohistologic markers were determined on frozen sections from 691 biopsies of human melanomas with the immunoperoxidase method. Univariate and multivariate Cox regression analyses were performed with metastases and with death as endpoints.

RESULTS

Fifteen parameters were related to disease free survival in univariate Cox regression analysis: tumor thickness, ulceration, localization, gender, age, mitoses, and the immunohistochemical markers very late antigen (VLA)-2, human leukocyte antigen (HLA)-ABC, HLA-DR, NKI-beteb, Mel 14, intercellular adhesion molecule (ICAM-1), K-1-2, G-7-E2, and H-2-4-7. Three of the easily available parameters exhibited independent significance in multivariate Cox regression analysis: tumor thickness, ulceration, and localization. If mitotic rate was included in this model, then it had independent prognostic significance but ulceration was no longer significant. However, the model that included tumor thickness, localization, and ulceration had a slightly higher overall chi-square test score, indicating a better performance compared with thickness, localization, and mitoses. The model that included tumor thickness, localization, and mitoses could not be improved by any of the immunohistochemical markers in this study.

CONCLUSIONS

Nine immunohistochemical markers with established prognostic significance for primary human melanoma were not found to improve a prognostic model that included tumor thickness, localization, and mitoses. If mitoses was replaced by ulceration, then the model performed slightly better, although ulceration was not significant in the presence of mitoses.

Accuracy of frozen section measurements for the determination of Breslow tumour thickness in primary malignant melanoma

AIMS

Microstaging of primary malignant melanoma (MM) and the width of surgical margins depend mainly on Breslow tumour thickness (BTT). The use of frozen section (FS) measurements of BTT has been doubted, and previous reports have shown conflicting results regarding the comparability to paraffin sections (PS). To look for significant differences of BTT due to freezing or paraffin embedding, we evaluated a larger series of melanocytic lesions as far as possible excluding other technical influences.

METHODS AND RESULTS

Paired 'mirror sections' of 112 melanocytic lesions (33 MM and 79 melanocytic naevi) were measured according to Breslow on single corresponding PS and FS of the same tumour specimen. Comparing measurements on FS and PS, we found very small differences of BTT on average and an almost equal distribution of BTT in the two sets of values with no statistically significant difference by applying the Wilcoxon signed rank test. Concerning the clinically most important 1 mm-threshold of BTT, 110 (98.2%) of the lesions gave equal measurements in FS and PS.

CONCLUSIONS

Frozen sections can be used for accurate measurements of Breslow tumour thickness. Consequently, intraoperative frozen section diagnosis of thick melanoma immediately followed by excision with wide surgical margins is possible in experienced centres.

Prognostic evaluation of cutaneous malignant melanoma: a clinicopathologic and immunohistochemical study

BACKGROUND AND OBJECTIVES

Depth of invasion and stage of the disease are established prognostic indicators in cutaneous malignant melanoma. The role of other parameters is still an open problem.

METHODS

In 93 consecutive patients with cutaneous malignant melanoma, the level of invasion, tumor thickness, ulceration, vascular invasion, lymphoplasmocytic infiltrates, and mitotic index were evaluated by histology. Expression of Ki-67 and PCNA proliferative antigens together with vimentin, S100, and HMB 45 proteins were assessed by immunohistochemistry.

RESULTS AND CONCLUSIONS

Disease-free and overall survival were correlated with tumor stage, tumor thickness, level of invasion, macroscopic pattern, ulceration, vascular invasion, expression of HMB 45, PCNA, and Ki-67/MIB1. Stage, HMB 45, and PCNA were independent prognostic factors for disease-free survival, whereas tumor stage, tumor thickness, and expression of both proliferative antigens influenced overall survival independently. The variables studied demonstrated reciprocal correlation; therefore, analysis of many prognostic parameters in malignant melanoma could be recommended.

Skin cancer of the head and neck

The incidence of skin cancers is increasing at a rate greater than any other cancer occurring in humans. In this era of managed care, patients with a suspicious skin lesion may first present to their primary care physician for evaluation. Therefore, it is important for the primary care physician to be able to distinguish between benign and malignant pigmented lesions, to know how to evaluate such a patient, and to appreciate the importance of appropriate interdisciplinary management of these patients.

Central nervous system metastases of cutaneous malignant melanoma--a population-based study

The objectives of this population-based study were to assess putative prognostic factors for central nervous system (CNS) metastases among patients with cutaneous malignant melanoma, to assess the cumulative risk of CNS metastases in different subsets of patients with recurrent disease, and to describe patient outcome. At a median follow-up of 11 years, 201/2516 patients with melanoma had developed CNS metastases, corresponding to a cumulative risk at 5 years of 7%. In 41 of these 201 patients the CNS metastases were recorded as the first site of recurrence. In a Cox's multivariate model, primary tumor thickness and ulceration in stage I patients were independent risk factors. The cumulative rates of incidence of CNS metastases 5 years after local or regional recurrence as first event were 5 and 42%, respectively. These results may help to form an individually based risk assessment, which might be of value for melanoma patients in certain occupations.

Malignant melanoma

The incidence of malignant melanoma is increasing at a rate greater than any other cancer occurring in humans. In this era of managed care, patients with a suspicious pigmented lesion may first present to their primary care physician for evaluation. Therefore it is mandatory that the primary care physician be capable of distinguishing between benign and malignant pigmented lesions, know how to evaluate such patients, and know when to refer patients with suspicious or malignant pigmented lesions. Surgical removal remains the mainstay of treatment for patients with melanoma. Thus, to increase the cure rate for melanoma, both the public and nondermatologists need to be educated regarding the prevention and early detection of melanoma. Only in this way can the diagnosis of melanoma be made early before deep invasion has occurred and the patient placed at risk for systemic spread. In recent years, the surgical management of melanoma has become more conservative and rational. Limb amputation, arbitrary 5-cm margins of excision, and elective lymph node dissections are no longer performed. The recommended margins of excision are now based on objective pathologic and clinical data and are more conservative, and the sentinel node biopsy is now used to determine which high-risk patients should undergo a formal lymph node dissection. Although encouraging results are being seen with immunotherapy protocols, to date the only adjunctive therapy shown to increase survival in patients at high risk for systemic spread is alpha-interferon. With this drug, the improved survival is modest at best; it is expensive and a minority of patients can tolerate it in the doses recommended. Although response rates of 20% are seen with chemotherapy in patients with disseminated disease, these responses are short-lived, and there is no associated increased survival. Except for lentigo maligna, radiation therapy, even when its delivery is modified, still is useful only as an adjunct to surgery or for palliation.

Laboratory tests and imaging studies in patients with cutaneous malignant melanoma

Laboratory tests and imaging studies are often ordered for asymptomatic patients with malignant melanomas (MMs) in an effort to detect subclinical metastatic disease. However, their sensitivity and specificity for detecting cryptic metastases are not well established. A review of the literature on laboratory tests and imaging studies for MM metastases was undertaken to address the usefulness of such investigations in asymptomatic patients with MM in AJCC (American Joint Committee on Cancer system of classification) stages I, II, and III. A review of the pertinent literature since 1966 was conducted through MEDLINE, Medica, and Cancerlit. Laboratory tests and imaging studies revealed occult MM metastases in only a small number of the thousands of reported patients with putative AJCC stage I, II, and III MM. However, for those diagnosed with limited metastases, surgical removal with or without immunotherapy, chemotherapy, or radiotherapy can lead to long-term remissions in some patients. For patients with asymptomatic AJCC stage I or II disease, chest roentgenograms (CXR) and blood lactic dehydrogenase (LDH) levels may be obtained at low cost and prove to be of benefit if metastases are identified. For patients with AJCC stage III disease, computed tomographic (CT) scans of the thorax, abdomen, and pelvis (especially when the primary cutaneous site of the melanoma is below the waist) may be considered for detecting metastatic MM. Other tests, such as magnetic resonance imaging (MRI) scans of the brain, may be ordered based on symptoms or physical findings. In the future, technologically improved techniques and newer methods may prove cost-effective for detecting treatable asymptomatic MM metastases. Furthermore, improvement in treatments will also influence the indications for the search for occult MM metastases. At this time there is a need for an international consensus conference on laboratory tests and imaging studies for occult melanoma metastases.

Classification trees. A possible method for iso-resource grouping in intensive care

Classification and grouping of clinical data into defined categories or hierarchies is difficult in intensive care practice. Diagnosis-related groups are used to categorise patients on the basis of diagnosis. However, this approach may not be applicable to intensive care where there is wide heterogeneity within diagnostic groups. Classification tree analysis uses selected independent variables to group patients according to a dependent variable in a way that reduces variation. In this study, the influence of three easily identified patient attributes on their length of intensive care unit stay was explored using classification analysis. Two thousand five hundred and forty-five critically ill patients from three hospitals were classified into groups so that the variation in length of stay within each group was minimised. In 23 out of 39 terminal groups, the interquartile range of the length of stay was < or = 3 days.

Prognostic value of MMP-2 immunoreactive protein (72 kD type IV collagenase) in primary skin melanoma

The penetration of the subepithelial basement membrane is the first critical step in the dissemination of melanoma. In vitro studies have suggested that the 72 kD type IV collagenase (MMP-2) may be important in melanoma invasion. It has recently been demonstrated that the expression of MMP-2 immunoreactive protein increased with increasing atypia in melanocytic tumours and was associated with later haematogenous metastases in melanoma. This paper investigates the value of MMP-2 as a possible prognostic marker in melanoma. The expression of MMP-2 immunoreactive protein was studied with immunoperoxidase staining in paraffin-embedded sections of 50 cases of primary skin melanoma by using specific, affinity purified antibodies. Positive immunostaining was quantified by counting the percentage of positive cancer cells and was compared with clinical patient characteristics and survival. Sixty-four per cent of the primary melanoma cases displayed positive cytoplasmic immunostaining for MMP-2 in tumour cells. Marked overexpression of MMP-2 protein (> or = 34 per cent of melanoma cells positive) correlated with the 5-year survival of the patients when compared with patients with lower MMP-2 positivity, 55 per cent vs. 85 per cent, respectively (P < 0.05). Male patients displayed positive staining more often than females (75 per cent vs. 54 per cent, respectively). There was no correlation between MMP-2 positivity and Clark level or Breslow classification. A distinct group with unfavourable prognosis was identified. The 10-year survival for MMP-2-positive male melanoma patients was 39 per cent as opposed to 79 per cent with the other melanoma patients (P < 0.05). In the hierarchic Cox regression model for survival, MMP-2 immunoreactive protein was found to be independent of Clark level and Breslow classification. Overexpression of MMP-2 protein indicated a 4.5-fold relative risk of dying from melanoma. It is concluded that MMP-2 immunoreactive protein in melanoma cells is an independent prognostic factor for survival. High MMP-2 expression in male melanoma patients indicates an unfavourable prognosis.

Prognosis in malignant melanoma

A uniform and practical classification and staging system for melanoma must exist and be widely adopted if useful comparisons between different treatment centers and databases are to be made. This article reviews the 1992 American Joint Committee on Cancer pTNM staging system. In this classification, localized disease without regional nodal involvement is defined as stage I or II, depending on the tumor thickness of the primary melanoma. Regional lymph node involvement and/or in-transit metastasis is defined as stage III, and systemic metastatic disease is defined as stage IV.

Mitotic rate and S-phase fraction as prognostic factors in stage I cutaneous malignant melanoma

Clinical data from 369 patients with clinical stage I cutaneous malignant melanoma treated in Kuopio University Hospital district between 1974 and 1989 with a mean follow-up of 6.4 years were analysed. Clinical parameters, histology, DNA index, S-phase fraction (SPF) and mitotic indices [mitotic activity index (MAI) and volume-corrected mitotic index (M/V index)] were correlated with the outcome of the disease to establish their value as predictors of stage I cutaneous malignant melanoma. In univariate survival analyses, bleeding, gender, tumour thickness, level of invasion according to Clark, TNM category, MAI, M/V index and SPF were the most significant predictors of recurrence-free (RFS) and overall survival. In Cox's multivariate analysis, tumour thickness (P = 0.0021), bleeding (P = 0.0106) and M/V index (P = 0.0058) predicted poor RFS in the 259 patients available for the analysis. Poor overall survival was predicted by MAI (P = 0.0002), bleeding (P = 0.004), SPF (P = 0.009) and male gender (P = 0.034). The present results indicate that mitotic activity index (MAI), volume-corrected mitotic index (M/V index) and S-phase fraction (SPF) are important prognostic factors in addition to the well-established Breslow thickness in stage I cutaneous malignant melanoma.

Skin melanoma in Italy: a population-based study on survival and prognostic factors

Survival and prognostic factors of invasive cutaneous melanoma patients diagnosed in the province of Florence, Italy, were studied using a regression analysis of relative survival rates. The case series consisted of 428 patients reported by the Tuscany Cancer Registry between 1985 and 1989. The effect of gender, age, anatomical site, histological type and microstaging parameters upon relative survival were evaluated using an extension of the Cox proportional hazard model. Five-year relative survival was 70%; 8-year relative survival, referring to a subset of patients, was 67%. In univariate analysis, the following variables were significantly associated with better prognosis: female gender, age younger than 60 years, superficial spreading melanoma (SSM) compared with nodular melanoma (NM), location on the limbs, a thinner lesion according to Breslow, a shallower Clark level. Females had a clear-cut prognostic advantage over males in each category of the variables considered above. After simultaneous adjustment for all other variables, three factors continued to show an independent prognostic effect: age, gender and microstaging parameters (Breslow thickness and Clark level, separately fitted in the model). In the multivariate analysis, the prognostic advantage of females over males was specifically seen for lesions located on the trunk and for both SSM and NM histotype.

Melanoma of the face: the safety of narrow excision margins

Recent studies have shown that narrower excision margins may be safe, but the optimal or minimum margin for melanoma is unknown. Wide margins of excision are possible on the trunk and limbs, but functional and cosmetic constraints often limit the extent of excision on the face. A collaborative study from two continents (Cape Town, South Africa and Northwood, England) investigated the outcome of different excision margins of 106 patients with stage I melanoma of the face. The margin of excision was measured from the records of the pathological specimen. Thirty patients had margins of less than 1 cm, 64 had margins of between 1 and 2 cm, and 12 had margins greater than 2 cm. Primary apposition or flap closure was possible in 85 patients. Seven patients developed local recurrences and these were not influenced by the excision margin. This study supports the contention that the primary treatment of cutaneous melanoma on the face should be histologically confirmed complete excision, and that this can be achieved with margins of excision less than 1 cm. Local recurrence is not related to the margin of excision or to tumour thickness.

Problems in defining cutoff points of continuous prognostic factors: example of tumor thickness in primary cutaneous melanoma

Continuous prognostic factors are often categorized by defining optimized cutoff points. One component of criticism of this approach is the problem of multiple testing that leads to an overestimation of the true prognostic impact of the variable. The present study focuses on another crucial point by investigating the dependence of optimized cutoff points on the observed distribution of the continuous variable. The continuous variable investigated was the vertical tumor thickness according to Breslow, which is known to be the most important prognostic factor in primary melanoma. Based on the data of 5093 patients, stratified random samples were drawn out of six artificially created distributions of tumor thickness. For each of these samples, Cox models were calculated to explore optimized cutoff points for tumor thickness together with other prognostic variables. The optimized cutoff points for tumour thickness varied considerably with the underlying distribution. Even in samples from the same distribution, the range of cutoff points was amazingly broad and, for some of the distributions, covered the whole region of possible values. The results of the present study demonstrate that optimized cutoff points are extremely data dependent and vary notably even if prerequisites are constant. Therefore, if the classification of a continuous prognostic factor is necessary, it should not be based on the results of one single study, but on consensus discussions including the findings of several investigations.

Staging and prognosis of melanoma

Prognosis and survival for patients diagnosed with melanoma depends on a number of interrelated factors, including histological, clinical, immunologic, and surgical parameters. Tumor thickness and depth of invasion is the most important prognostic factor, and helps to guide treatment and management plans. Besides tumor thickness, other histological criteria include melanoma growth phase (nodal v. vertical), host response, angiolymphatic invasion, mitotic rate, regression, satellitosis, and neurotropism. Important clinical prognostic factors include anatomic location of the melanoma and the patient's age and sex. Surgical factors to be examined involve excisional margin size, and elective lymph node dissection. Finally, the staging of patients with melanomas (nodal or visceral metastases) helps to define survival.

Laboratory tests and imaging studies in patients with cutaneous malignant melanomas: a survey of experienced physicians

BACKGROUND

The presence or absence of metastases is important in determining prognosis and treatment options for patients with malignant melanoma (MM). Laboratory tests and imaging studies are ordered for patients with MMs but without symptoms in an effort to detect occult metastases. However, which laboratory tests and imaging studies to order and how often to reorder them is not well established.

OBJECTIVE

Our purpose was to determine which tests and studies are ordered by physicians with major responsibilities for the care of patients with MM.

METHODS

Physicians were surveyed by questionnaire about the laboratory tests and imaging studies they ordered for MM stages 0, I, II, and III.

RESULTS

Of the 35 physicians queried, 30 (86%) responded to the survey. The majority of physicians order tests as follows: no tests for MM in situ; roentgenography of the chest with or without initial lactic acid dehydrogenase/liver function tests for stages I, II, and III and during follow-up for stages IB, II, and III (more frequently as the Breslow thickness increases); and baseline computed tomographic or magnetic resonance imaging scans of the chest, abdomen/pelvis, and brain for stage III.

CONCLUSION

Although the pattern of ordering examinations was similar for the majority of respondents, there was significant variability among experienced physicians in ordering laboratory tests and imaging studies in the search for occult metastases in patients with asymptomatic MM. The laboratory tests and imaging studies ordered and their frequency depend on the stage of the MM and sometimes on other risk factors.

Tamoxifen, 17beta-oestradiol and the calmodulin antagonist J8 inhibit human melanoma cell invasion through fibronectin

Invasion through stromal extracellular matrix (ECM) is part of the complex, multistep process of tumour cell invasion and metastasis. Our group has previously demonstrated that calcium and calmodulin are important in another step in the metastatic cascade - that of attachment of cells to ECM. Interestingly, the non-steroidal anti-oestrogen tamoxifen (which also has calmodulin antagonist activity), used in the treatment of breast cancer and now in metastatic cutaneous melanoma, can inhibit the attachment of normal and neoplastic cells to ECM. In this study, we investigated whether such drugs, known to inhibit cell attachment, could also subsequently reduce their invasion through a layer of human fibronectin. We examined the ability of the specific calmodulin antagonist J8, tamoxifen and its two major metabolites, N-desmethyltamoxifen (N-des) and 4-hydroxytamoxifen (4-OH), as well as the pure anti-oestrogen ICI 182,780 and 17beta-oestradiol to inhibit invasion of the human cutaneous melanoma cell line, A375-SM, uveal melanoma cells and uveal melanocytes. A375-SM cells and uveal melanoma cells showed a high level of invasion (15.2% and 33.7% respectively) compared with melanocytes (around 5%) under the experimental conditions used. Submicromolar concentrations of N-des, tamoxifen, J8 and 17beta-oestradiol significantly reduced the invasiveness of the A375-SM cell line. The uveal melanoma cells also showed similar inhibition, although at higher concentrations of these agents. 4-OH and ICI 182, 780 had little or no effect on invasion of A375-SM cells (these were not tested on uveal melanoma cells). All cells used in this study were found to be negative for type I nuclear oestrogen receptors, reinforcing the possibility that tamoxifen and 17beta-oestradiol can act via mechanisms unrelated to binding to classical oestrogen receptors to inhibit tumour cell invasion.

Endocrinology of melanoma

Melanoma has a better prognosis in women than in men, may be exacerbated by pregnancy, and has been to reported to respond to hormonal manipulations. Laboratory investigations have demonstrated that both animal and human melanomas may respond to changes in the hormonal milieu. Steroid hormone binding activity has been demonstrated in some human melanomas, but only a small percentage of melanomas respond to hormonal manipulation. Randomized trials suggest a possible role for tamoxifen in combination with chemotherapy for metastatic melanoma and for megestrol acetate as an adjuvant. Nevertheless, it appears that the use of steroid hormones in the management of melanoma is limited.

Dermatology

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