Gender-related differences in outcome for melanoma patients

BRAF mutations in advanced cancers: clinical characteristics and outcomes

Background

Oncogenic BRAF mutations have been found in diverse malignancies and activate RAF/MEK/ERK signaling, a critical pathway of tumorigenesis. We examined the clinical characteristics and outcomes of patients with mutant (mut) BRAF advanced cancer referred to phase 1 clinic.

Methods

We reviewed the records of 80 consecutive patients with mutBRAF advanced malignancies and 149 with wild-type (wt) BRAF (matched by tumor type) referred to the Clinical Center for Targeted Therapy and analyzed their outcome.

Results

Of 80 patients with mutBRAF advanced cancer, 56 had melanoma, 10 colorectal, 11 papillary thyroid, 2 ovarian and 1 esophageal cancer. Mutations in codon 600 were found in 77 patients (62, V600E; 13, V600K; 1, V600R; 1, unreported). Multivariate analysis showed less soft tissue (Odds ratio (OR) = 0.39, 95%CI: 0.20–0.77, P = 0.007), lung (OR = 0.38, 95%CI: 0.19–0.73, p = 0.004) and retroperitoneal metastases (OR = 0.34, 95%CI: 0.13–0.86, p = 0.024) and more brain metastases (OR = 2.05, 95%CI: 1.02–4.11, P = 0.043) in patients with mutBRAF versus wtBRAF. Comparing to the corresponding wtBRAF, mutBRAF melanoma patients had insignificant trend to longer median survival from diagnosis (131 vs. 78 months, p = 0.14), while mutBRAF colorectal cancer patients had an insignificant trend to shorter median survival from diagnosis (48 vs. 53 months, p = 0.22). In melanoma, V600K mutations in comparison to other BRAF mutations were associated with more frequent brain (75% vs. 36.3%, p = 0.02) and lung metastases (91.6% vs. 47.7%, p = 0.007), and shorter time from diagnosis to metastasis and to death (19 vs. 53 months, p = 0.046 and 78 vs. 322 months, p = 0.024 respectively). Treatment with RAF/MEK targeting agents (Hazard ratio (HR) = 0.16, 95%CI: 0.03–0.89, p = 0.037) and any decrease in tumor size after referral (HR = 0.07, 95%CI: 0.015–0.35, p = 0.001) correlated with longer survival in mutBRAF patients.

Conclusions

BRAF appears to be a druggable mutation that also defines subgroups of patients with phenotypic overlap, albeit with differences that correlate with histology or site of mutation.

Estrogens, estrogen receptors and melanoma

The skin is the largest nonreproductive target tissue on which estrogen plays many beneficial and protective roles. Although neither exogenous hormones nor pregnancy represent significant risk factors for melanoma, epidemiological data suggest a higher survival rate in women with metastatic disease versus men and in premenopausal versus postmenopausal patients. Despite the fact that hyperestrogenic signaling has long been implicated in the initiation and progression of several tumors, the role of estrogens in malignant melanoma is still unclear. The cellular effects of estrogens are mediated by two subtypes of estrogen receptors (ERs). Estrogen receptor β (ERβ), the predominant ER in the skin, antagonizes the proliferative action mediated by estrogen receptor α. According to recent immunohistochemical studies, ERβ protein expression decreases progressively with increased Breslow thickness and results in more invasive melanomas; thus, ERβ immunophenotype may distinguish melanomas linked to poor prognosis from those with a favorable course and lead to melanoma unresponsiveness to both estrogen and anti-estrogen treatment. Therefore, if future large-scale immunohistochemical and molecular studies point towards ERβ as an important factor in malignant melanoma progression, they will open up novel and targeted prognostic and therapeutic perspectives.

Incomplete sentinel node biopsy is not clearly related to survival or regional recurrence in cutaneous melanoma patients

BACKGROUND

In melanoma patients, we define incomplete sentinel node biopsy (I-SNB) as when fewer lymph nodes are removed during sentinel node biopsy (SNB) than identified on preoperative lymphoscintigraphy (LS). This study quantifies the frequency of I-SNB and evaluates any correlation with patient outcomes.

METHODS

Evaluation of a prospective database of consecutive patients having LS and negative SNB from 1996 to 2006. Additional LS information was obtained from a nuclear medicine database. All statistical analyses were performed using the IBM SPSS Statistic 19.0 software package.

RESULTS

I-SNB occurred in 20% of the cohort (n = 2007). For axillary (n = 895), groin (n = 569), and neck/axial patients (n = 334) I-SNB occurred in 12%, 26%, and 28% of cases, respectively (P < .001). On univariate analysis, there was a significant association between I-SNB and worse disease-free survival (DFS), P = .007 and trend toward worse melanoma-specific survival (MSS), P = .056. I-SNB was not associated with worse regional recurrence-free survival (RRFS), P = .144. There was no relationship between I-SNB and worse DFS, RRFS, or MSS on multivariate analysis. Sentinel node region (axilla better than groin and neck/axial) had a significant association with RRFS (P = .039) on univariate analysis and DFS on univariate (P = .009) and multivariate analysis. Significantly worse outcomes for MSS, DFS, and RRFS were seen with male gender, increasing age, high mitotic count, ulceration, and increasing Breslow thickness.

CONCLUSION

This study demonstrates no statistically significant relationship between I-SNB and patient outcomes when adjusting for known prognostic factors. These data do not exclude the possibility that I-SNB may have a weak association with worse outcomes.

Lymphovascular Invasion as a Prognostic Factor in Melanoma

The prognostic significance of lymphovascular invasion (LVI) in melanoma remains controversial. Clinicopathologic data from a prospective trial of patients with melanoma were analyzed with respect to LVI. Disease-free survival and overall survival (OS) were evaluated by Kaplan-Meier (KM) analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive sentinel nodes (SLN) and survival. A total of 2183 patients were included in this analysis; 171 (7.8%) had LVI. Median follow-up was 68 months. Factors associated with LVI included tumor thickness, ulceration, and histologic subtype ( P < 0.05). LVI was associated with a greater risk of SLN metastasis ( P < 0.05). By KM analysis, LVI was associated with worse OS ( P = 0.0009). On multivariate analysis, age, gender, thickness, ulceration, anatomic location, and SLN status were predictors of OS; however, LVI was not an independent predictor of OS. Among patients with regression, the 5-year OS rate was 49.4 per cent for patients with LVI versus 81.1 per cent for those with no LVI ( P < 0.0001). LVI is associated with a greater risk of SLN metastasis. Although LVI is not an independent predictor of OS in general, it is a powerful predictor of worse OS among patients who have evidence of regression of the primary tumor.

Malignant melanoma: gender patterns in care seeking for suspect marks

AIMS AND OBJECTIVES

Gender patterns in self-detection of melanoma are not sufficiently highlighted in the literature. The aim of the study was to identify specific patterns in the decision-making process to seek care for suspect melanoma, as narrated by women and men.

BACKGROUND

Females have a more favourable prognosis than males and also a higher level of perceived susceptibility and a higher level of knowledge about melanoma. Women are, furthermore, more prone to participate in screening.

METHOD

Thirty patients (15 women and 15 men) with a mean age of 55.5 years and diagnosed with malignant melanoma were interviewed about their decisions to seek care for suspect skin marks. The interviews were transcribed and analysed with qualitative content analysis.

RESULTS

Care-seeking behaviour for suspect melanoma was influenced by gender constructions. Men seldom or never acknowledged interest in attention to bodily changes, but when they became aware of changes, they often took a quick decision and sought an expert's assessment. Men were compliant with wives' and relatives' advice about seeking care. All women reported that they paid attention to bodily changes, but they often delayed care seeking, due to family responsibilities and emotional struggles. The women also attempted self-care remedies, such as applying ointment, before seeking professional care.

CONCLUSIONS

There are gender-specific patterns that may influence decision making in the care-seeking process. Such patterns are important to identify, since health care professionals must take these factors into account in communicating with men and women.

RELEVANCE TO CLINICAL PRACTICE

Nurses and in particular those working in telephone counselling, are often at the frontlines, deciding who can have access to health services. They are ideally placed to tackle the issue of gender constructions in the development of effective health care services.

Association of socioeconomic status with Breslow thickness and disease-free and overall survival in stage I-II primary cutaneous melanoma

OBJECTIVE

To investigate the influence of socioeconomic status (SES) on Breslow thickness, disease-free survival, and overall survival in patients with stage I-II primary cutaneous melanoma (PCM).

PATIENTS AND METHODS

The study consists of all consecutive patients who were diagnosed as having PCM and were treated and followed up at our hospital between November 1, 1998, and July 31, 2009. Pathologic and sociodemographic characteristics of the patients were obtained. We categorized SES into 3 levels: low (manual employees and skilled/unskilled workers, including farmers, with primary education level), middle (nonmanual employees and clerks with middle education level), and high (professionals, executives, administrators, and entrepreneurs with tertiary education).

RESULTS

A total of 1443 consecutive patients were evaluated. In a multivariate logistic regression analysis, sex (female vs male: odds ratio [OR], 1.37; 95% confidence interval [CI], 1.08-1.75), SES (high vs middle: OR, 1.27; 95% CI, 0.96-1.69; high vs low: OR, 1.73; 95% CI, 1.26-2.38), age (<60 vs ≥60 years: OR, 1.35; 95% CI, 1.03-1.78), and family context (single vs living with relatives: OR, 1.37; 95% CI, 0.97-1.94) were the strongest correlates of Breslow thickness. Compared with high SES, the risk of melanoma-related death, adjusted for age and sex, was 7 times higher (hazard ratio, 7.44; 95% CI, 3.27-16.93) and almost 2 times higher (hazard ratio, 1.88; 95% CI, 1.04-3.39) in patients with low SES living alone or living with relatives, respectively.

CONCLUSION

In patients with PCM, low SES is associated with thicker melanoma and a poorer clinical outcome.

Trends in the survival of patients diagnosed with malignant melanoma of the skin in the Nordic countries 1964-2003 followed up to the end of 2006

A previous Nordic study showed a marked and steady increase in the age-adjusted 5-year relative survival of skin melanoma patients diagnosed during the period 1958 through 1987. Males had considerably poorer survival than females.

MATERIAL AND METHODS

Using the NORDCAN database, we studied relative survival and excess mortality of patients diagnosed with melanoma of the skin in the Nordic countries 1964-2003 followed up to the end of 2006. These were contrasted with concomitant trends in incidence and mortality.

RESULTS

The overall incidence of melanoma almost quadrupled, but there was considerable variation in the trends in the five countries. Mortality was low but doubled during the study period. Survival ratios increased steadily to between 80% and 90% for patients diagnosed in 1999-2003. Swedish patients had consistently higher survival, whereas Danish patients had the highest excess death rates the first three months after diagnosis up until 1990, but thereafter, rates reached a similar low level to that observed in the other Nordic countries. The survival of Nordic women is still higher than that of men, but the difference has diminished, while the mortality rates among men are becoming increasingly higher relative to those for women among individuals 50 years and older. In younger individuals, mortality rates are similar in the two sexes, and declining.

CONCLUSIONS

Nordic patient survival following melanoma diagnosis is generally high and has been steadily increasing in the last decades. Differences in incidence between the five countries are more pronounced than the differences in survival. The strong upward trends in incidence and survival may mainly be the result of extensive changes in sunbathing habits or other UV exposure and, more recently, of an increasing awareness by the medical community and the public concerning early detection of melanoma of the skin.

Sentinel node positive melanoma patients: prediction and prognostic significance of nonsentinel node metastases and development of a survival tree model

BACKGROUND

Completion lymph node dissection (CLND) following positive sentinel node biopsy (SNB) for melanoma detects additional nonsentinel node (NSN) metastases in approximately 20% of cases. This study aimed to establish whether NSN status can be predicted, to determine its effect on survival, and to develop survival tree models for the sentinel node (SN) positive population.

MATERIALS AND METHODS

Sydney Melanoma Unit (SMU) patients with at least 1 positive SN, meeting inclusion criteria and treated between October 1992 and June 2005, were identified from the Unit database. Survival characteristics, potential predictors of survival, and NSN status were assessed using the Kaplan-Meier method, Cox regression model, and logistic regression analyses, respectively. Classification tree analysis was performed to identify groups with distinctly different survival characteristics.

RESULTS

A total of 323 SN-positive melanoma patients met the inclusion criteria. On multivariate analysis, age, gender, primary tumor thickness, mitotic rate, number of positive NSNs, or total number of positive nodes were statistically significant predictors of survival. NSN metastasis, found at CLND in 19% of patients, was only predicted to a statistically significant degree by ulceration. Multivariate analyses demonstrated that survival was more closely related to number of positive NSNs than total number of positive nodes. Classification tree analysis revealed 4 prognostically distinct survival groups.

CONCLUSIONS

Patients with NSN metastases could not be reliably identified prior to CLND. Prognosis following CLND was more closely related to number of positive NSNs than total number of positive nodes. Classification tree analysis defined distinctly different survival groups more accurately than use of single-factor analysis.

Reactive oxygen species and melanoma: an explanation for gender differences in survival?

Epidemiological research consistently shows a female advantage in melanoma survival. So far, no definite candidate for the explanation of this phenomenon has emerged. We propose that gender differences in oxidative stress caused by radical oxygen species (ROS) underlie these survival differences. It is known that males express lower amounts of anti-oxidant enzymes, resulting in more oxidative stress than females. The primary melanoma environment is characterized by high ROS levels, from exogenous sources as well as ROS production within melanoma cells themselves. ROS are known to be able to promote metastasis through a wide variety of mechanisms. We hypothesize that the higher levels of ROS in men enhance selection of ROS-resistance in melanoma cells. Subsequently, ROS can stimulate the metastatic potential of melanoma cells. In addition, due to the lower anti-oxidant defenses in men, ROS produced by melanoma cells cause more damage to healthy tissues surrounding the tumor, further stimulating metastasis. Therefore, ROS may explain the observed differences between males and females in melanoma survival.

Metastatic-promoting effects of LPS: sexual dimorphism and mediation by catecholamines and prostaglandins

Inflammation is implicated in several medical conditions that are sexually dimorphic, including depression, cardiovascular diseases, autoimmunity, and presumably cancer progression. Here we studied the effects of the proinflammatory agent, LPS, on MADB106 lung tumor retention (LTR), and sought to elucidate underlying mechanisms and sexual dimorphism. F344 male and female rats were administered with LPS (0.001-1mg/kg i.v.) simultaneously with tumor cell inoculation, and treated with a beta-blocker (nadolol, 0.2-0.3mg/kg s.c.), a COX inhibitor (indomethacin, 4mg/kg s.c.) or both drugs. To study the role of NK cells, numbers and cytotoxicity of marginating-pulmonary NK cells were studied, and selective in vivo NK-depletion was employed. Serum levels of corticosterone, IL-6, and TNF-alpha were also assessed. The findings indicated that LPS increased LTR in both sexes, but 10-fold higher doses were needed in females to reach the increase evident in males. Additionally, nadolol and indomethacin reduced the effects of LPS, more so in males. In vivo NK-depletion and ex vivo NK activity studies suggested that LPS affected LTR through both NK-independent and NK-dependent mechanisms, the latter mediated through prostaglandin release in males. Corticosterone, IL-6, and TNF-alpha responses to LPS were sexually dimorphic, but were not associated with LPS or drugs' impacts on LTR. Overall, our findings demonstrate sexual dimorphism in LPS-induced elevated susceptibility to MADB106 experimental metastasis, and in potential humoral underlying mechanisms. Further studies are needed to elucidate additional immunological and non-immunological mediators of these dimorphisms, as well as to assess their involvement in other sexually dimorphic pathologies that are associated with inflammation.

Acral lentiginous melanoma: incidence and survival patterns in the United States, 1986-2005

OBJECTIVE

To examine incidence and survival patterns of acral lentiginous melanoma (ALM) in the United States.

DESIGN

Population-based registry study. We used the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute to evaluate data from 17 population-based cancer registries from 1986 to 2005.

PARTICIPANTS

A total 1413 subjects with histologically confirmed cases of ALM. Main Outcome Measure Incidence and survival patterns of patients with ALM.

RESULTS

The age-adjusted incidence rate of ALM overall was 1.8 per million person-years. The proportion of ALM among all melanoma subtypes was greatest in blacks (36%). Acral lentiginous melanoma had 5- and 10-year melanoma-specific survival rates of 80.3% and 67.5%, respectively, which were less than those for all cutaneous malignant melanomas overall (91.3% and 87.5%, respectively; P < .001). The ALM 5- and 10-year melanoma-specific survival rates were highest in non-Hispanic whites (82.6% and 69.4%), intermediate in blacks (77.2% and 71.5%), and lowest in Hispanic whites (72.8% and 57.3%) and Asian/Pacific Islanders (70.2% and 54.1%). Acral lentiginous melanoma thickness and stage correlated with survival according to sex and in the different racial groups.

CONCLUSIONS

Population-based data showed that ALM is a rare melanoma subtype, although its proportion among all melanomas is higher in people of color. It is associated with a worse prognosis than cutaneous malignant melanoma overall. Hispanic whites and Asian/Pacific Islanders have worse survival rates than other groups, and factors such as increased tumor thickness and more advanced stage at presentation are the most likely explanations.

Tissue biomarkers for prognosis in cutaneous melanoma: a systematic review and meta-analysis

In the clinical management of early-stage cutaneous melanoma, it is critical to determine which patients are cured by surgery alone and which should be treated with adjuvant therapy. To assist in this decision, many groups have made an effort to use molecular information. However, although there are hundreds of studies that have sought to assess the potential prognostic value of molecular markers in predicting the course of cutaneous melanoma, at this time, no molecular method to improve risk stratification is part of recommended clinical practice. To help understand this disconnect, we conducted a systematic review and meta-analysis of the published literature that reported immunohistochemistry-based protein biomarkers of melanoma outcome. Three parallel search strategies were applied to the PubMed database through January 15, 2008, to identify cohort studies that reported associations between immunohistochemical expression and survival outcomes in melanoma that conformed to the REMARK criteria. Of the 102 cohort studies, we identified only 37 manuscripts, collectively describing 87 assays on 62 distinct proteins, which met all inclusion criteria. Promising markers that emerged included melanoma cell adhesion molecule (MCAM)/MUC18 (all-cause mortality [ACM] hazard ratio [HR] = 16.34; 95% confidence interval [CI] = 3.80 to 70.28), matrix metalloproteinase-2 (melanoma-specific mortality [MSM] HR = 2.6; 95% CI = 1.32 to 5.07), Ki-67 (combined ACM HR = 2.66; 95% CI = 1.41 to 5.01), proliferating cell nuclear antigen (ACM HR = 2.27; 95% CI = 1.56 to 3.31), and p16/INK4A (ACM HR = 0.29; 95% CI = 0.10 to 0.83, MSM HR = 0.4; 95% CI = 0.24 to 0.67). We further noted incomplete adherence to the REMARK guidelines: 14 of 27 cohort studies that failed to adequately report their methods and nine studies that failed to either perform multivariable analyses or report their risk estimates were published since 2005.

Solitary dermal melanoma: beginning or end of the metastatic process?

BACKGROUND

Solitary dermal melanoma (SDM) is confined to the dermal and/or subcutaneous tissue without an epidermal component. It is unclear whether this lesion is a subtype of primary melanoma or distant cutaneous metastasis from an unknown primary. We evaluated our large experience to determine the prognosis and optimal management of SDM.

METHODS

Our melanoma referral center's database of prospectively acquired records was used for identification and clinicopathologic analysis of patients presenting with SDM between 1971 and 2005.

RESULTS

Of 12,817 database patients seen during a 34-year period, 101 (0.8%) had SDM. Of 92 patients free of distant metastasis on initial presentation, 55 (60%) were observed and 37 (40%) underwent surgical nodal staging: regional metastases were identified in 7 (19%). Nodal recurrence occurred in 1 of 30 patients (3.3%) with histopathology-negative nodes compared with 13 of 55 patients (24%) who underwent nodal observation instead of nodal staging. Thus, 21 of 92 patients (23%) had nodal metastasis identified during surgical nodal staging or postoperative nodal observation. At a median follow-up of 68 months, estimated 5-year overall survival rate was 73% for 71 patients with localized disease versus 67% for 21 patients with regional disease (P=0.25) versus 22% for 9 patients with distant disease (P=0.009, regional versus distant disease).

CONCLUSIONS

SDM resembles intermediate-thickness primary cutaneous melanoma with respect to prognostic characteristics and clinical evolution, but its rate of distant metastasis justifies radiographic staging and its high rate of regional node metastasis justifies wide excision and sentinel node biopsy.

Factors influencing time between biopsy and definitive surgery for malignant melanoma: do they impact clinical outcome?

BACKGROUND

Whether time between biopsy and surgery for malignant melanoma affects clinical outcomes is sparsely defined. This study evaluated factors influencing surgical interval and surgical interval effect on outcomes.

METHODS

We performed a review of a prospective 10-year, single-institution database.

RESULTS

There were 473 patients treated for 478 malignant melanomas. The mean surgical interval was 30.5 days. The mean thickness was 2.1 mm; 46% of patients had a surgical interval of more than 28 days whereas 8% had a surgical interval of more than 56 days. Residual melanoma was found at excision in 170 (36%) patients. Age, sex, and referral source significantly affected surgical interval, however, lesion thickness, sentinel lymph node status, ulceration, and residual melanoma at excision did not. In univariate Cox models, neither a surgical interval of 28 or less nor less than 56 days showed better overall survival (OS) or disease-free survival (DFS). In multivariate Cox models of OS and DFS including lesion thickness, sentinel lymph node status, ulceration, and residual melanoma at excision, neither a surgical interval of 28 days or fewer nor a surgical interval of 56 days or fewer significantly affected outcomes.

CONCLUSIONS

Age, sex, referral source, and lesion thickness were associated with surgical interval. Immediate surgery for malignant melanoma does not significantly impact OS or DFS.

Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

AIM

To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS).

MATERIALS AND METHODS

Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan-Meier were performed.

RESULTS

Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness (p<0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR=5.6, p<0.001), positive SN (RR=5.0, p<0.001) and male sex (RR=2.9, p=0.001). The presence of a metastatic SN (RR=8.4, p<0.001), male sex (RR=6.1, p<0.001), Breslow thickness (RR=3.2, p=0.013) and ulceration (RR=2.6, p=0.015) were significantly associated with a poorer DSS.

CONCLUSION

SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure.

Gender differences in skin: a review of the literature

BACKGROUND

There has been increasing interest in studying gender differences in skin to learn more about disease pathogenesis and to discover more effective treatments. Recent advances have been made in our understanding of these differences in skin histology, physiology, and immunology, and they have implications for diseases such as acne, eczema, alopecia, skin cancer, wound healing, and rheumatologic diseases with skin manifestations.

OBJECTIVE

This article reviews advances in our understanding of gender differences in skin.

METHODS

Using the PubMed database, broad searches for topics, with search terms such as gender differences in skin and sex differences in skin, as well as targeted searches for gender differences in specific dermatologic diseases, such as gender differences in melanoma, were performed. Additional articles were identified from cited references. Articles reporting gender differences in the following areas were reviewed: acne, skin cancer, wound healing, immunology, hair/alopecia, histology and skin physiology, disease-specific gender differences, and psychological responses to disease burden.

RESULTS

A recurring theme encountered in many of the articles reviewed referred to a delicate balance between normal and pathogenic conditions. This theme is highlighted by the complex interplay between estrogens and androgens in men and women, and how changes and adaptations with aging affect the disease process. Sex steroids modulate epidermal and dermal thickness as well as immune system function, and changes in these hormonal levels with aging and/or disease processes alter skin surface pH, quality of wound healing, and propensity to develop autoimmune disease, thereby significantly influencing potential for infection and other disease states. Gender differences in alopecia, acne, and skin cancers also distinguish hormonal interactions as a major target for which more research is needed to translate current findings to clinically significant diagnostic and therapeutic applications.

CONCLUSIONS

The published findings on gender differences in skin yielded many advances in our understanding of cancer, immunology, psychology, skin histology, and specific dermatologic diseases. These advances will enable us to learn more about disease pathogenesis, with the goal of offering better treatments. Although gender differences can help us to individually tailor clinical management of disease processes, it is important to remember that a patient's sex should not radically alter diagnostic or therapeutic efforts until clinically significant differences between males and females arise from these findings. Because many of the results reviewed did not originate from randomized controlled clinical trials, it is difficult to generalize the data to the general population. However, the pressing need for additional research in these areas becomes exceedingly clear, and there is already a strong foundation on which to base future investigations.

Estrogen receptor beta expression in nevi during pregnancy

Estrogen levels increase during pregnancy and clinical evidence has long suggested that melanocytes are estrogen-responsive. We hypothesized that nevi from pregnant patients would exhibit increased expression of estrogen receptor beta (ERbeta) and thus enhanced potential to respond to altered estrogen levels. Normal, dysplastic and congenital nevi (n = 212) were collected from pregnant and non-pregnant women ranging from 18 to 45 years of age. Immunohistochemical staining was performed on these nevi using antibodies specifically directed against estrogen receptor alpha (ERalpha) and ERbeta. ERalpha was not observed in any lesions; thus, ERbeta was the predominant estrogen receptor in melanocytic cells from all types of nevi. Enhanced positivity for ERbeta in normal nevi during pregnancy was noted, compared with non-pregnant controls including nevocytes residing in both the epidermal and dermal micro-environments (P = 0.005 and P = 0.001 respectively). Nevi with increasingly melanocytic atypia showed increased ERbeta in nevocytes nested within the epidermis. No additional increase in ERbeta in atypical nevi was observed during pregnancy. For normal and congenital nevi, regardless of pregnancy status, dermally associated nevocytes tended to have greater ERbeta immunoreactivity. Significant decreases in ERbeta immunoreactivity were observed in congenital nevi from pregnant women compared with normal and dysplastic nevi from pregnant women. Our data suggest that nevi possess the capacity to be estrogen-responsive. Factors such as pregnancy and degree of atypia are associated with enhanced ERbeta with the exception of congenital nevi where the melanocytes were unique in their response to pregnancy.

Superior survival of females among 10,538 Dutch melanoma patients is independent of Breslow thickness, histologic type and tumor site

BACKGROUND

Worldwide, female melanoma patients have superior survival compared with males, which is usually ascribed to earlier detection among women and/or a more favorable site distribution. We studied gender difference in melanoma survival in a large population-based setting after adjusting for tumor-related variables and offer clues for further research.

PATIENTS AND METHODS

A total of 10,538 patients diagnosed with melanoma from 1993 to 2004 in The Netherlands were included. Multivariate analyses were carried out to estimate adjusted relative excess risk (RER) of dying for men compared with women, adjusted for the patient and tumor characteristics.

RESULTS

Univariate relative survival analyses showed a RER of dying of 2.70 [95% confidence interval (CI) 2.38-3.06] for men compared with women. After adjusting for time period of diagnosis, region, age, Breslow thickness, histologic subtype, body site, nodal and metastatic status, a significant excess mortality risk was still present for males (RER 1.87, 95% CI 1.65-2.10). Among patients with advanced disease and in those < 45 or > or = 60, the adjusted risk estimates were similar.

CONCLUSIONS

The superior survival of women compared with men persisted after adjusting for multiple confounding variables indicating that factors other than stage at diagnosis and body site reduce mortality risk in female melanoma patients.

The evolution of the management of regional lymph nodes in melanoma

The last two decades have seen sweeping changes in the surgical approach to melanoma. Traditionally, patients without evidence of nodal metastases were considered for elective lymph node dissection. This approach placed many patients at risk of morbidity while many derived no benefit. As investigators gained a deeper understanding of melanoma and lymphatic biology, newer methods of managing regional lymph nodes were sought. The advent of sentinel node biopsy has radically changed the approach to melanoma.

Successful treatment of metastatic malignant melanoma with Viscum album extract (Iscador M)

BACKGROUND

Recent study results demonstrate possible clinical benefit from adjuvant treatment with a standardized mistletoe (Viscum album) extract in patients with malignant melanoma.

PATIENT AND METHOD

We present a male patient, currently 68 years of age, with one malignant melanoma at the upper part of the right arm since 1992, and another nodular melanoma at the left shoulder, first diagnosed in 1999. After discovery of the second melanoma and surgical resection, the patient was exclusively treated with standardized mistletoe extract (Iscador, (R)M; Weleda AG, CH-Arlesheim, Switzerland). COURSE OF THERAPY AND RESULTS: In June 1992, histologic analysis confirmed the presence of stage IA superficially spreading malignant melanoma with low infiltration of the papillary dermis in a skin excision sample from the upper part of the right arm. In November 1999, another melanoma was surgically removed at the patient's right shoulder. In this case, the histologic examination revealed nodular melanoma, stage IIA (pT3, pN0, M0). Therapy with mistletoe extract was introduced shortly afterwards as the sole adjuvant treatment. During the course of the mistletoe therapy, axillary removal of 8 lymph nodes became necessary, 3 of which proved to be metastatic. First signs of a defined solitary liver metastasis in an area next to segments IV and V were detected during an abdominal ultrasound examination in September 2001. This finding was confirmed by further sonographic examinations. The solitary liver metastasis was not resected, nor was classical antitumor treatment (chemotherapy or radiotherapy) initiated. The patient continued subcutaneous treatment with Iscador M after dose adaptation to 2 mg twice weekly (0.2 mL of a 10-mg vial); the treatment is still ongoing to the present. By June 2002, complete remission of the liver metastasis was diagnosed by liver ultrasound examination. There has been no local relapse so far, and the patient has been in stable condition ever since. No further metastases were discovered so far (as of May 2006).

CONCLUSIONS

The use of low-dose Iscador as the sole postoperative modality for the adjuvant treatment of metastatic melanoma was extremely effective and very well tolerated in this patient. It achieved complete response and absence of all complaints.

Melanoma incidence and mortality in Scotland 1979-2003

We studied 12,450 cases of invasive melanoma diagnosed in Scotland in 1979-2003, by thickness, pathological type, and body site at ages under 40, 40-59, and 60 years and over. Melanoma incidence trebled in males from 3.57 to 10.93/10(5) per year, and increased 2.3-fold in females from 5.60 to 12.96/10(5) per year. The rate of increase fell in each successive 5-year period. The greatest increase was in males aged 60 years and over at diagnosis. Significant incidence increases were seen in melanomas < 1 mm in all three age groups, but those > 4 mm only increased significantly at ages 60 years and over. All histological types increased significantly at ages 60 years and over, and in this age group the greatest increase was seen on the head and neck. Five-year disease-free survival improved steadily. Survival figures for 1994-1998 ranged from 93.6% for males and 95.8% for females with tumours < 1 mm, to 52.4 and 48.3%, respectively, for those with tumours > 4 mm. Over the 25 years, melanoma mortality doubled in males from 1.1 to 2.4/10(5) per year, but was unchanged in females at 1.5/10(5) per year. Public education on melanoma is required both for primary prevention and earlier diagnosis, particularly for older males.

Up-to-date survival estimates and historical trends of cutaneous malignant melanoma in the south-east of The Netherlands

BACKGROUND

We present survival outcomes of patients registered in the Dutch population-based Eindhoven Cancer Registry (ECR).

PATIENTS AND METHODS

Data on patients diagnosed with a melanoma between 1980 and 2002 were obtained from the ECR. Data on vital status up to 1 January 2005 were obtained, up-to-date survival rates were calculated using period analysis. Multivariate analyses were carried out using Cox proportional hazards model.

RESULTS

Ten-year crude survival rates were 82% for women and 60% for men (P < 0.05). Thin melanomas (Breslow thickness <or= 2.0 mm) had 5-year crude survival rates >74%, for melanomas >4.0 mm these rates were <65% (P < 0.05). In the early 1980s, 5-year relative survival rates were 84% and 62% for young (<60 years) women and men, and 66% and 69%, respectively, for the elderly (aged 60+). In the period 2000-2002, these rates had improved to >90% for females and to >72% for males. Multivariate analyses showed increased hazard ratios with increasing age and Breslow thickness, being male, having a melanoma on the trunk or unknown sites and having a nodular melanoma.

CONCLUSIONS

Despite the absence of improvements in treatment options for melanoma, survival improved significantly, except for elderly males.

Sentinel Node Mapping for Melanoma: Results of Trials and Current Applications

The value of sentinel node (SN) biopsy as a staging procedure and as a guide to prognosis with patients who have melanoma is now clearly established. As well, there is recent clinical trial evidence suggesting a survival benefit for patients found to be SN positive who have an immediate complete lymph node dissection (CLND), compared with those with nodal disease not treated by CLND until it becomes clinically apparent. Clinical trials are ongoing to determine whether CLND is necessary in all patients who are found to be SN positive.