Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system

Reassessing the role of lymphatic mapping and sentinel lymphadenectomy in the management of cutaneous malignant melanoma

Lymphatic mapping and sentinel lymphadenectomy was developed as a minimally invasive technique to provide regional lymph node staging information for patients at high risk for metastatic melanoma, but without clinically palpable disease. Only patients who demonstrate micrometastases undergo complete regional lymphadenectomy, sparing approximately 80% of patients the expense and morbidity of an elective lymph node dissection. This technique has been widely accepted as the preferred method to determine the pathologic status of the regional lymph nodes and the staging information gained is incorporated into the latest version of the American Joint Committee on Cancer staging system for cutaneous melanoma. Still, there is much controversy as to the use of this technique as a staging procedure and its overall therapeutic benefit in the treatment of patients with melanoma. Currently ongoing clinical trials will determine if lymphatic mapping and sentinel lymphadenectomy directly influences overall survival for patients with malignant melanoma. We review the latest technical aspects of this procedure and discuss the controversies surrounding its use.

Prediction of disease outcome in melanoma patients by molecular analysis of paraffin-embedded sentinel lymph nodes

PURPOSE

A significant number of patients who develop recurrence after a histopathologically negative sentinel lymph node (SLN) biopsy will demonstrate occult metastases on re-evaluation of the SLNs with serial sectioning and immunohistochemistry. Reverse transcriptase polymerase chain reaction (RT-PCR) has been evaluated to improve disease staging and avoid false-negative findings in fresh or frozen-section SLNs. The purpose of this study was to develop a multimarker RT-PCR assay for assessing melanoma patients' archived paraffin-embedded (PE) SLNs.

PATIENTS AND METHODS

Archived PE histopathologically positive (n = 37) and negative (n = 40) SLNs from patients with primary melanoma were analyzed using a semiquantitative multimarker RT-PCR assay.

RESULTS

Marker expression in histopathologically positive and negative SLNs were as follows: 89%, 92%, 35%, and 43% (positive) and 40%, 33%, 5%, and 13% (negative) for tyrosinase, melanoma antigen recognized by T cells-1, tyrosinase-related protein-1, and tyrosinase-related protein-2, respectively. Twenty-five percent of histopathologically negative SLN patients were upstaged using at least two markers. Of these, 80% developed a recurrence. Furthermore, at a median follow-up of 55 months, patients with histopathologically negative SLNs who expressed zero or one marker had a significantly improved disease-free (P <.002) and overall (P <.03) survival versus those expressing two or more markers.

CONCLUSION

These findings demonstrate the feasibility of a multimarker RT-PCR assay for evaluating archived PE SLNs. More significantly, identification of molecular risk factors can be detected in histopathologically negative SLNs for distinguishing early-stage melanoma patients with a worse prognosis.

Cost-effectiveness of sentinel lymph node biopsy in thin melanomas

BACKGROUND

Consideration of sentinel lymph node biopsy (SLNB) is recommended for thin melanomas with poor prognostic features; however, few metastases are identified. The purpose of this study was to assess the cost effectiveness of SLNB in this population.

METHODS

The prospective melanoma database was reviewed to identify patients with melanomas <1.2 mm thick who had undergone SLNB. Physician and hospital charges were collected from the appropriate billing department.

RESULTS

A total of 138 patients were identified over an 8-year period (1994-2002). Two patients with positive SLNs were identified (1.4%), one with a melanoma <1 mm thick. Patient charges for SLNB ranged from $10,096 to $15,223 US dollars, compared with $1000 to $1740 US dollars for wide excision as an outpatient. Using these charges, the cost to identify a single positive SLN would be between $696,600 and $1,051,100 US dollars. The cost for wide excision would be between $69,000 and $120,100 US dollars. Assuming that all patients with a positive SLN would die of melanoma, the cost per life saved would be $627,000 to $931,000 US dollars.

CONCLUSIONS

The cost of performing SLNB in this population is great and only a small number will have disease identified that will alter treatment. These data call into question the appropriateness of SLNB for thin melanomas.

The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population

Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors' study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.

Prognosis for patients with thin cutaneous melanoma: long-term survival data from New South Wales Central Cancer Registry and the Sydney Melanoma Unit

BACKGROUND

Estimates of long-term survival for patients with thin (< or = 1 mm) primary cutaneous melanomas vary widely. Two separate methods were used to study the survival of patients with melanoma from New South Wales (NSW), Australia, and from the Sydney Melanoma Unit (SMU).

METHODS

The NSW Central Cancer Registry (NSWCCR) provided data on all patients who were diagnosed with cutaneous melanomas that measured < or = 1 mm thick between 1983 and 1998, inclusive. Patients with metastases at the time of diagnosis were not included, leaving 18,088 patients for analysis. The SMU data base was analyzed to extract data for all patients with thin melanomas who met the same criteria from 1979 to 1998, inclusive. All patients who had their primary tumors treated definitively elsewhere were excluded, leaving 2746 patients for analysis. Ten-year Kaplan-Meier survival rates were calculated, and significant differences were determined using log-rank analysis. Prognostic factors were evaluated with Cox proportional hazards analysis.

RESULTS

The NSWCCR analysis revealed a 10-year survival rate of 96.4%. The 10-year survival rate for patients at SMU was 92.7%. Among the patients at SMU who died, the median time to recurrence was 49.8 months, and the median time to death was 65.9 months. The 10-year survival for patients at SMU who had lesions that measured < or = 0.75 mm was 96.9% compared with 84.3% for patients who had lesions that measured 0.76-1.0 mm. For patients who had ulcerated melanomas measuring < or = 1 mm thick, the 10-year survival rate was 83%, compared with 92.3% for patients who had nonulcerated melanomas.

CONCLUSIONS

The results of the current study confirmed the excellent survival rate for patients with thin melanomas. Higher-risk subsets of patients who may warrant consideration for aggressive investigation and treatment are identifiable.

Lymph node status and survival in cutaneous malignant melanoma--sentinel lymph node biopsy impact

AIM

The survival benefit of sentinel lymph node biopsy (SLB) with lymphadenectomy for microscopic melanoma metastases to regional lymph nodes (SLND) is uncertain. The aim of the study was to analyse the factors influencing clinical outcome (overall survival (OS) and disease free survival (DFS)) of patients undergone lymph node dissection (LND) as result of positive sentinel lymph node disease (SLND) or as consequence of clinically detected metastases (CLND).

PATIENTS AND METHODS

This was a single-institution retrospective analysis of survival data of 350 consecutive, prospectively collected, melanoma patients who underwent radical LND in 1995-2001. One hundred and forty-five patients underwent SLND and 205 underwent CLND.

RESULTS

The median OS and DFS times of the entire group of melanoma patients, computed from the date of primary lesion excision, were 46.3 months and 26.5 months (5-year OS ratio 41.8% and 5-year DFS ratio 31.5%). The factors which correlated with poor OS by multivariate analysis were: primary tumour Breslow thickness >4 mm (p=0.001), extracapsular extension of lymph node metastases (p=0.004), male sex (p=0.001) and metastases to more than one regional lymph node (p=0.04). The negative factors for DFS were: nodal extracapsular invasion (p=0.00002) and primary tumour Breslow thickness >4 mm (p=0.004). There were no significant differences in OS and DFS between SLND and CLND groups, when calculated from the date of primary tumour excision. However, if OS and DFS were estimated from the date of LND, the SLND group demonstrated significantly better survival in comparison with CLND.

CONCLUSION

The study demonstrates no survival benefit from SLB with subsequent radical regional LND in malignant melanoma patients with lymph node metastases.

Interobserver reproducibility of ulceration assessment in primary cutaneous melanomas

In the recently revised melanoma staging system proposed by the American Joint Committee on Cancer (AJCC), ulceration assessment by the pathologist is a pivotal parameter. Patients upstaged because of ulceration might be included in adjuvant trials conducted in AJCC stage II melanoma patients. Therefore, accuracy based on interobserver reproducibility for melanoma ulceration assessment is crucial for proper clinical management. In some cases, it is extremely difficult, even for an experienced pathologist, to distinguish between trauma-induced ulceration, artifact and tumoral ulceration. Whether this difficulty may be resolved by the use of a more precise definition of ulceration has not been evaluated. Therefore, we have proposed a refined definition of melanoma ulceration and we tested whether this definition might improve the interobserver interpretative reproducibility of ulceration in primary cutaneous melanomas. The results of this study support the need for a more precise definition of melanoma ulceration that rules out biopsy trauma or processing artifact and could be incorporated into a standardised pathology worksheet for reporting primary melanomas.

Differential expression of vascular endothelial growth factor-A isoforms at different stages of melanoma progression

Vascular endothelial growth factor-A (VEGF-A) is an important mediator of angiogenesis in normal and neoplastic tissues. Total VEGF-A levels have been associated with melanoma progression, but the relative contributions of each isoform is unknown. To determine whether differences in the production of any or all of the major VEGF-A isoforms are related to stage of progression, we compared message levels for the three major isoforms of VEGF in melanoma specimens from different stages of progression.Primary melanomas (N = 18), primary recurrences (N = 5), regional dermal metastases (N = 11), nodal metastases (N = 12), normal lymph nodes (N = 18), and distant metastases (N = 9) were prospectively collected. Samples from the horizontal and vertical growth phases of primary tumors were also collected from five additional patients. Message levels for the three major VEGF-A isoforms were measured using real-time quantitative reverse-transcriptase polymerase chain reaction and normalized to beta-actin mRNA levels. There was a marked increase in the expression of all three VEGF-A isoforms from the vertical growth phase tissue as compared with the horizontal growth phase tissue. Primary tumors, local recurrences, regional dermal metastases, nodal metastases, and distant metastases all produced more VEGF(121) and VEGF(165) than negative nodes. Nodal metastases produced the highest level of these two isoforms, higher even than distant metastases. There was no significant difference in VEGF(189) message among the groups. Melanomas in the vertical growth phase produce more VEGF-A (all isoforms) than in the horizontal growth phase. Nodal metastases produce the highest levels of VEGF(121) and VEGF(165), but not VEGF(189) as compared with other stages of progression. These data suggest that the soluble forms of VEGF-A might be an important factor in melanoma metastasis to regional lymph nodes.

Epidermal hyperplasia overlying human melanoma correlates with tumour depth and angiogenesis

The aim of this study was to determine whether epidermal hyperplasia overlying cutaneous human melanoma is associated with increased tumour angiogenesis, tumour growth and the potential for metastasis. Forty-two surgical specimens of cutaneous human melanoma of different depths, each containing epidermis present in the tumour-free margin, were analysed by immunohistochemistry for the expression of the pro-angiogenic molecules basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) and the anti-angiogenic molecule interferon-beta (IFN-beta). The epidermis overlying intermediate and thick (1.0-10.0 mm), but not thin (0.5-1.0 mm), melanoma specimens was hyperplastic. Although the expression level of bFGF, VEGF and IL-8 in the epidermis directly overlying the tumour was similar to that in the distant epidermis, the expression of IFN-beta was significantly decreased in keratinocytes overlying intermediate and thick, but not thin, melanomas. The microvessel density was also increased in intermediate and thick specimens. Human melanoma cells were injected subcutaneously into nude mice. The resulting tumours were used to determine the association between overlying epidermal hyperplasia and neoplastic angiogenesis. Similar to human autochthonous melanomas, epidermal hyperplasia was found only over lesions produced by metastatic cells. Although there was no change in the expression of the pro-angiogenic molecules, the expression of IFN-beta was significantly decreased in the hyperplastic epidermis. Conditioned medium collected from cultures of the metastatic cell line induced in vitro proliferation of mouse keratinocytes, whereas conditioned medium collected from cultures of the non-metastatic cell line did not. Collectively, the data demonstrate that metastatic melanoma cells induce keratinocyte proliferation, leading to decreased expression of the negative regulator of angiogenesis, IFN-beta, and hence to increased angiogenesis.

The genetics of malignant melanoma: lessons from mouse and man

Therapeutic resistance and proclivity for metastasis are hallmarks of malignant melanoma. Genetic, epidemiological and genomic investigations are uncovering the spectrum of stereotypical mutations that are associated with melanoma and how these mutations relate to risk factors such as ultraviolet exposure. The ability to validate the pathogenetic relevance of these mutations in the mouse, coupled with advances in rational drug design, has generated optimism for the development of effective prevention programmes, diagnostic measures and targeted therapeutics in the near future.

Insights into the mechanisms of lymph node metastasis

The mechanisms by which malignant tumors leave the primary tumor site, invade lymphatics, and metastasize to regional lymph nodes (RLNs) are complex and interrelated. Although the phenomenon of lymph node metastasis has been recognized for over 200 years, the exact mechanisms have only recently been the subject of intense interest and sophisticated experimentation. Sentinel lymph node biopsy has rapidly entered the clinical mainstream for melanoma and breast carcinoma, and this technique has provided confirmation of the orderly anatomic progression of tumor cells from primary site to the RLNs through lymphatic capillaries and trunks. Exciting studies involving the pathophysiology of interstitial fluid pressure in tumors and the peritumoral extracellular matrix have focused on lymphatic flow and tumor microenvironment and microcirculation. Molecular techniques have led to the definition of unique markers found on lymphatic endothelial cells. These markers have enabled scientists to identify peritumoral and intratumoral lymphatics and to visualize the ingrowth of tumor cells into the lumena of lymphatic capillaries. Tumor-secreted cytokines, such as vascular endothelial growth factors (VEGF)-C and -D, bind to VEGF receptors on lymphatic endothelial cells and induce proliferation and growth of new lymphatic capillaries; this process is similar to the well-known mechanism of angiogenesis, which results from the proliferation of new blood vessel capillaries. Lymphangiogenesis is associated with an increased incidence of RLN metastasis, and it is possible that this step is essential to the metastatic process. Directional movement toward lymphatics and lymph nodes appears to follow a chemokine gradient, and it is likely that some tumor cells that express certain types of chemokine receptors are more likely to metastasize to the RLNs. In contrast, tumor cells that do not express specific receptors that are responsive to lymphatic chemokines may not metastasize. New knowledge regarding the molecules involved in these processes should enable improvements in prognostic and possibly therapeutic approaches to the management of malignant tumors.

Phase I study of intranodal delivery of a plasmid DNA vaccine for patients with Stage IV melanoma

BACKGROUND

Based on the likelihood of transfecting large numbers of local antigen-presenting cells, a Phase I study in patients with Stage IV melanoma was conducted to determine the practicality, toxicity of, and immune responses to repeated infusions into a groin lymph node of escalating doses of a DNA plasmid encoding tyrosinase epitopes.

METHODS

Cohorts of 8 patients each received 200 microg, 400 microg, or 800 microg of DNA intranodally by pump over 96 hours every 14 days for 4 cycles. Blood was collected for immunologic assays and to measure plasmid in serum prior to treatment, 4 weeks later, and 8 weeks later. Scans and X-rays were performed at baseline and after 8 weeks.

RESULTS

Treatment was tolerated well, with only five patients demonstrating Grade 1-2 toxicity. Vaccine delivery by 96-hour infusions of plasmid into a groin lymph node resulted in only 1 episode of catheter leakage in 107 cannulations. Detection of plasmid in serum was rare and transient in two patients. Immune responses by peptide-tetramer assay to tyrosinase 207-216 were detected in 11 of 26 patients. No clinical responses were seen. Survival of the heavily pretreated patients on this trial was unexpectedly long, with 16 of 26 patients alive at a median follow-up of 12 months.

CONCLUSIONS

Infusion of a DNA plasmid vaccine into a groin lymph node was practical and well tolerated. Immune responses to a novel tyrosinase epitope were noted. Overall survival in this trial of heavily pretreated patients was unexpectedly long, with 16 of 26 patients alive after a follow-up of 12 months, favoring immune responders.

Malignant melanoma

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

Surgical treatment of splenic metastases in patients with melanoma

BACKGROUND

Surgery is rarely undertaken for metastatic melanoma in the spleen. To identify indications for surgical treatment, results after splenectomy for metastatic melanoma were analyzed.

STUDY DESIGN

A retrospective study in which all patients at the Sydney Melanoma Unit recorded as having splenic metastases between January 1990 and May 2001 were identified. For those who underwent surgery, indications for splenectomy, operative complications, and outcomes were documented.

RESULTS

Splenectomy was performed in 15 patients, and 98 patients were treated conservatively. Indications for surgery were rupture of the spleen (n = 1), discomfort or pain (n = 7), and the spleen as an apparently solitary site of metastasis (n = 7). All seven symptomatic patients were free of pain after recovery from surgery. Postoperative morbidity occurred in two patients (14%) but there was no mortality. Median overall survival after splenectomy was 11 months, with a survival of 23 months for the subgroup of patients treated for a solitary lesion. Two patients who underwent splenectomy were disease free after more than 2 years of followup. Median overall survival of the conservatively treated patients was 4 months, which was statistically shorter than median survival of the patients who underwent splenectomy (p = 0.02).

CONCLUSIONS

Splenectomy can provide good palliation for symptomatic patients with melanoma metastases in the spleen. A selected group of patients with solitary splenic metastases can achieve longterm disease-free survival after splenectomy.

The amount of metastatic melanoma in a sentinel lymph node: does it have prognostic significance?

BACKGROUND

The amount of metastatic disease in the sentinel lymph node (SLN) is examined as a prognostic factor in malignant melanoma.

METHODS

SLN mapping was performed on 592 patients with stage I and II malignant melanoma from March 1, 1994, through December 31, 1999. One hundred four patients were found to have 134 sentinel SLNs containing metastatic melanoma. The slides were reviewed, and the size of the metastatic melanoma in each SLN was measured. The size of the metastatic deposit was defined as macrometastasis (>2 mm), micrometastasis (< or =2 mm), a cluster of cells (10-30 grouped cells) in the subcapsular space or interfollicular zone, or isolated melanoma cells (1 to > or =20 individual cells) in subcapsular sinuses.

RESULTS

The number of metastases in each SLN was isolated melanoma cells, n = 5 (3.7%); cluster of cells, n = 35 (26.1%); < or =2 mm, n = 45 (33.6%); and >2 mm, n = 49 (36.7%). Seventy-nine patients (76%) had a single positive SLN. The size of the largest nodal metastasis was used to stratify patients with multiple positive SLNs. The overall 3-year survival for patients with SLN micrometastases was 90%, versus 58% for patients with SLN macrometastases (P =.004).

CONCLUSIONS

The amount of metastatic melanoma in an SLN is an independent predictor of survival. Patients with SLN metastatic deposits >2 mm in diameter have significantly decreased survival.

Body site of cutaneous malignant melanoma--a study on patients with hereditary and multiple sporadic tumours

Individuals with an increased risk of developing cutaneous malignant melanoma (CMM) include members of kindreds with hereditary cutaneous malignant melanoma (HCMM) and patients who have already been treated for a CMM. Some of these patients develop multiple primary cutaneous malignant melanomas (MCMMs). Ultraviolet radiation is the main instigator of CMM. There are indications that patients in these high-risk groups react differently to sunlight than patients who develop a single sporadic CMM. The objectives of this study were to analyse tumour site in patients with HCMM and sporadic MCMM. Data on 2517 patients with 2608 CMMs from a population-based regional cancer registry were used. The new computer program EssDoll was used for the analyses of primary tumour sites. This software is able to analyse any chosen body area(s) with reference to the number of tumours arising there. When the site of the first and second tumours in patients with sporadic MCMM were analysed in a skin 'field division', there was a significant concordance with respect to site (P < 0.0001). In patients with MCMM, the second primary tumour was significantly thinner than the first (P = 0.001). Primary tumour sites in patients with HCMM were compared with those in patients with a single sporadic CMM. In HCMM we found significantly fewer tumours in the head and neck area and more on the trunk. These differences remained significant in two different body area models, even when stratified for age (P < 0.05). In conclusion, a site-concordance was noted for sporadic MCMM. This may be the result of a 'field effect'. Our results indicate that intermittent ultraviolet exposure may be of relatively greater importance than chronic exposure in HCMM.

Isolated limb perfusion with melphalan in the treatment of malignant melanoma of the extremities: a systematic review of randomised controlled trials

Isolated limb perfusion is a surgical procedure for delivering a high dose of chemotherapeutic or immunochemotherapeutic agent to a localised area, thus avoiding the severity of side-effects caused by systemic administration. This technique is generally used for treatment of patients with tumours of the limbs and extremities. We have done a systematic review of randomised controlled trials assessing the effectiveness of this treatment in patients with melanoma of the extremities. Four trials of 1038 patients met our inclusion criteria and were analysed. Although our analysis confirmed the reported increase in survival in two of the trials, neither had sufficient power to detect significant benefit for perfusion. Results from the trials showed that prophylactic perfusion has an equivocal effect on survival in patients with limb melanoma. Therefore, current evidence suggests that prophylactic isolated limb perfusion cannot be recommended as a routine adjunct to standard surgery in patients with high-risk primary limb melanoma, but only as a treatment for local disease control if other forms of locoregional therapy are not available.

Close monitoring and lifetime follow-up is optimal for patients with a history of melanoma

Malignant melanoma, a potentially lethal form of skin cancer, is becoming more common each year in the United States and worldwide. The cure rate, however, is also increasing due to better education, earlier detection, and more effective treatment. Thus, there are more melanoma survivors who are at risk for recurrence of melanoma and also a second primary. Because there are few prospective screening and surveillance results in the medical literature, recommendations for follow-up of melanoma survivors have been based on the natural history of the disease, physical examinations, laboratory tests, and radiologic evaluations.

Revised American Joint Committee on Cancer staging criteria accurately predict sentinel lymph node positivity in clinically node-negative melanoma patients

BACKGROUND

The American Joint Committee on Cancer (AJCC) has recently modified staging criteria for primary melanoma patients and recommends sentinel lymph node (SLN) biopsy in many because microscopic nodal metastasis represents the most important factor predicting survival. The purpose of this study was to correlate the incidence of SLN metastasis with revised AJCC staging.

METHODS

The records of 1375 melanoma patients undergoing SLN biopsy were reviewed. Univariate and multivariate analyses were performed to identify predictors of a positive SLN. Patients were stratified by using revised AJCC criteria to determine whether such groups also predicted positive SLNs.

RESULTS

A positive SLN was found in 16.9% of patients. By multivariate analysis, tumor thickness (relative risk [RR], 3.4) and ulceration (RR, 2.2) were dominant independent predictors of SLN metastases; age < or =50 years (RR, 1.8) and axial tumor location (RR, 1.5) were also significant. When patients were stratified by AJCC staging criteria, a significant increase in SLN metastases between successive stages was demonstrated.

CONCLUSIONS

Stratification of patients by using AJCC classification reveals an increasing risk of SLN metastases with successive stage groups. Given the significant association of SLN status and survival, the ability of the revised AJCC staging system to predict survival is likely due to its ability to predict the risk of occult nodal disease.

Sentinel lymph node mapping for thick (>or=4-mm) melanoma: should we be doing it?

BACKGROUND

Thick (>or=4-mm) primary melanomas are believed to be associated with a high incidence of occult distant metastases. The use of sentinel lymph node (SLN) mapping and biopsy in the treatment lesions has been questioned.

METHODS

A retrospective review of a computerized database identified 114 patients who underwent successful SLN mapping and biopsy from January 1, 1994, to December 31, 1999. Records were reviewed for clinicopathologic features of the patients and their tumors. Survival curves were constructed from Kaplan-Meier estimates and analyzed with log-rank tests and Cox proportional hazards modeling.

RESULTS

There were 75 men and 39 women with a mean age of 57 years (range, 24-85 years). The primary tumor sites were head and neck (n = 29; 25.4%), trunk (n = 44; 38.6%), and extremities (n = 41; 36%). Tumor thickness ranged from 4 to 17 mm (median, 5.2 mm; mean, 6.3 mm). Ulceration was present in 40 (35.1%) tumors. Thirty-seven patients (32.5%) had a positive SLN biopsy, and 18 of these patients (48.6%) had a single tumor-positive lymph node after dissection. The mean follow-up was 37.8 months. The overall 3-year survival for SLN-negative patients was 82%, versus 57% for SLN-positive patients (P =.006). Lymph node status and tumor ulceration were independent predictors of overall survival in multivariate Cox regression analysis.

CONCLUSIONS

The pathologic status of the SLN in patients with thick melanomas is a strong independent prognostic factor for survival, and SLN mapping should be routinely performed.

Melanoma chemoprevention: a role for statins or fibrates?

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.

Adjuvant immunization of HLA-A2-positive melanoma patients with a modified gp100 peptide induces peptide-specific CD8+ T-cell responses

PURPOSE

To measure the CD8+ T-cell response to a melanoma peptide vaccine and to compare an every-2-weeks with an every-3-weeks vaccination schedule.

PATIENTS AND METHODS

Thirty HLA-A2-positive patients with resected stage I to III melanoma were randomly assigned to receive vaccinations every 2 weeks (13 vaccines) or every 3 weeks (nine vaccines) for 6 months. The synthetic, modified gp100 peptide, g209-2M, and a control peptide, HPV16 E7, were mixed in incomplete Freund's adjuvant and injected subcutaneously. Peripheral blood mononuclear cells obtained before and after vaccination by leukapheresis were analyzed using a fluorescence-based HLA/peptide-tetramer binding assay and cytokine flow cytometry.

RESULTS

Vaccination induced an increase in peptide-specific T cells in 28 of 29 patients. The median frequency of CD8+ T cells specific for the g209-2M peptide increased markedly from 0.02% before to 0.34% after vaccination (P <.0001). Eight patients (28%) exhibited peptide-specific CD8+ T-cell frequencies greater than 1%, including two patients with frequencies of 4.96% and 8.86%, respectively. Interferon alfa-2b-treated patients also had significant increases in tetramer-binding cells (P <.0001). No difference was observed between the every-2-weeks and the every-3-weeks vaccination schedules (P =.59).

CONCLUSION

Flow cytometric analysis of HLA/peptide-tetramer binding cells was a reliable means of quantifying the CD8+ T-cell response to peptide immunization. This assay may be suitable for use in future trials to optimize different vaccination strategies. Concurrent interferon treatment did not inhibit the development of a peptide-specific immune response and vaccination every 2 weeks, and every 3 weeks produced similar results.

The Sydney Melanoma Unit--a multidisciplinary melanoma treatment center

The undoubted success of the SMU as a specialist multidisciplinary melanoma treatment center has clearly been the result of many factors. Perhaps chief among these was the vision and commitment that led Dr. Milton to establish it in the first place, and the sharing of that vision and commitment by those who were associated with him and by those who joined the SMU later. Another vitally important element, however, has been the continuing sense of unity and purpose fostered by the weekly SMU clinical meetings, which are truly multidisciplinary, in which all staff are encouraged to participate, and at which the desirability of adherence to agreed, evidence-based treatment guidelines is emphasized. A further influential factor has been the SMU's strong commitment to clinical and basic research as a concomitant of high quality clinical care, with stimulation, encouragement, and advice provided at its monthly multidisciplinary research meetings, where all current and proposed clinical and laboratory studies are discussed. As a result of these activities, despite an ever-increasing number of people working within it, the SMU has been able to present to referring doctors, to patients, and to the community a unified commitment to the best possible patient care and to high quality clinical and laboratory research. These groups have responded by recognizing the SMU as the major referral center for melanoma in Australia, as evidenced by the steadily increasing number of patients referred to it for treatment each year. Melanoma is a more pressing health problem in Australia than elsewhere, because it is the third most common cancer in women (after breast cancer and colorectal cancer), and the fourth most common cancer in men (after prostate cancer, colorectal cancer, and lung cancer). Nevertheless the experiences of the SMU as a large multidisciplinary melanoma treatment center are likely to have relevance and application in other countries, where the incidence of melanoma is lower but continues to rise, and may within a few years approach rates currently recorded in Australia.

Clinical outcome of stage I/II melanoma patients after selective sentinel lymph node dissection: long-term follow-up results

PURPOSE

Although sentinel lymph node (SLN) status is part of the new American Joint Committee on Cancer staging system, there is no final proof that the SLN procedure in melanoma patients influences outcome of disease. This study investigated the accuracy of the SLN procedure and clinical outcome in melanoma patients after at least 60 months of follow-up.

PATIENTS AND METHODS

Between 1993 and 1996, 209 patients with stage I/II cutaneous melanoma underwent selective SLN dissection by the triple technique. If the SLN contained metastatic disease, a completion lymphadenectomy was performed. Survival analyses were performed using the Kaplan-Meier approach. Factors associated with survival were analyzed using the Cox proportional hazards regression model.

RESULTS

The success rate was 99.5%. Median follow-up was 72 months. Forty patients (19%) had a positive SLN. The false-negative rate was 9%. Five-year overall survival was 87% for the entire group and 92% and 67% for SLN-negative and SLN-positive patients (P <.0001), respectively. All patients with a positive SLN and a Breslow thickness < or = 1.00 mm survived, and SLN-positive patients with a Breslow thickness less than 2.00 mm tend to have a better prognosis compared with SLN-negative patients with a Breslow thickness greater than 2.00 mm. SLN status (P =.002), Breslow thickness (P =.002), and lymphatic invasion (P =.0009) were all found to be independent prognostic factors for overall survival.

CONCLUSION

With a success rate of 99.5% and a false-negative rate of 9% after long-term follow-up, the triple-technique SLN procedure is a reliable and accurate method. Survival data seem promising, although a therapeutic effect is still questionable. As shown in this study, not all SLN-positive patients have a poor prognosis.

Tumor mitotic rate is a more powerful prognostic indicator than ulceration in patients with primary cutaneous melanoma: an analysis of 3661 patients from a single center

BACKGROUND

The current study was performed to determine whether tumor mitotic rate (TMR) is a useful, independent prognostic factor in patients with localized cutaneous melanoma.

METHODS

From the Sydney Melanoma Unit database, 3661 patients with complete clinical information and details of primary tumor thickness, ulcerative state, and TMR were studied. TMR was expressed as mitoses per mm(2) in the dermal part of the tumor in which most mitoses were seen, as recommended in the 1982 revision of the 1972 Sydney classification of malignant melanoma. To determine which was the more prognostically useful method of grouping TMR, two separate methods (A and B) were used. Factors predicting melanoma-specific survival were analyzed using the Cox proportional hazards regression model.

RESULTS

Patients with a TMR of 0 mitoses/mm(2) had a significantly better survival than those with 1 mitosis/mm(2) (P < 0.0001) but no significant survival differences were recorded for the stepwise increases from 1-2, 2-3, 3-4, and 4-5/mm(2). Tumor thickness, ulceration, and TMR were closely correlated, whether TMR was grouped using Method A (0, 1-4, 5-10, and >/= 11 mitoses/mm(2)) or Method B (0-1, 2-4, and >/= 5 mitoses/mm(2)). However, Cox regression analysis indicated that the TMR was a highly significant independent prognostic factor, particularly when grouped according to Method A, in which it was second only to tumor thickness as the most powerful predictor of survival (P < 0.0001).

CONCLUSIONS

TMR is an important independent predictor of survival for melanoma patients. If confirmed by studies from other centers, it has the potential to further improve the accuracy of melanoma staging, as well as to define more rigidly the risk categories for patients entering clinical trials.

Prognostic value of circulating melanoma cells detected by reverse transcriptase-polymerase chain reaction

PURPOSE

Factors that are predictive of prognosis in patients who are diagnosed with malignant melanoma (MM) are widely awaited. Detection of circulating melanoma cells (CMCs) by reverse transcriptase-polymerase chain reaction (RT-PCR) has recently been postulated as a possible negative prognostic factor. Two main questions were addressed: first, whether the presence of CMCs, defined as the patient being positive for any of the three markers, had a prognostic role; and second, what the predictive value of each individual marker was.

PATIENTS AND METHODS

A consecutive series of 200 melanoma patients observed between January 1997 and December 1997, with stage of disease ranging from I to IV, was analyzed by semiquantitative RT-PCR. Tyrosinase, p97, and MelanA/MART1 were used as markers to CMCs on baseline peripheral blood samples. Progression-free survival (PFS) was used as a unique end point and was described by the product limit method. Multivariable analysis was applied to verify whether the auspicated prognostic value of these markers was independent of the stage of disease, and a subgroup analysis was performed that excluded patients with stage IV disease.

RESULTS

Overall, 32% (64 of 200) of patients progressed, and a median PFS of 52 months in the whole series was observed. The presence of CMCs and the markers individually or combined was predictive of prognosis in the univariate analysis but did not provide additional prognostic information to the stage of disease in multivariable models. In the subgroup analysis of stage (ie, I-III subgroup), similar results were observed.

CONCLUSION

Detection of CMCs in peripheral blood samples at the time of MM diagnosis by semiquantitative RT-PCR does not add any significant predictive value to the stage of disease. Thus, this approach should not be used in clinical practice, and further studies are required to determine its usefulness.

Malignant melanoma in an 8-year-old Caribbean girl: diagnostic criteria and utility of sentinel lymph node biopsy

The incidence of malignant melanoma (MM) is continuing to rise, although childhood MM remains rare. We describe an 8-year-old Afro-Caribbean girl who developed a non pigmented lesion on the tip of her left thumb, which persisted despite treatment in primary care with cryotherapy. At biopsy she was found to have an acquired acral MM. She underwent amputation of the distal phalanx of her thumb, together with positive sentinel lymph node (SLN) biopsy and subsequent axillary lymph node clearance and adjuvant chemotherapy. MMs are very rare in this age and skin-type group, therefore requiring strict diagnostic criteria. These criteria include the distinction from MM mimics, especially Spitz tumours, and an appropriate use of staging techniques such as SLN biopsy to influence management.

Malignant melanoma: current state of primary and adjuvant treatment

Metastatic malignant melanoma remains a highly lethal disease with an incidence that continues to rise. Management of melanoma includes definitive local, regional and distant control. There is substantial prospective and retrospective data to base the extent of both primary as well as adjuvant therapy. The results of these trials have on occasion been at odds. A critical assessment of the available information pertaining to the adjuvant treatment of cutaneous melanoma is needed. This review provides a critical assessment of the current data that is available to guide both primary resection as well as adjuvant therapy. To date, current trials have shown little promise with nonspecific immunostimulants and cytotoxic chemotherapy. In contrast, dose interferon-alpha2b has been shown to improve relapse-free survival and likely improves melanoma-specific survival as well. Based on the available data, interferon-alpha2b remains the adjuvant therapy of choice for high-risk patients treated outside clinical trials, and the appropriate control arm for clinical trials evaluating new or modified adjuvant regimens.

Margins of excision for cutaneous melanoma of the eyelid skin: the Collaborative Eyelid Skin Melanoma Group Report

PURPOSE

To evaluate the practice patterns among surgeons who treat melanomas of the eyelid skin with respect to margins of excision and to look for possible correlation between margins of excision and the incidence of local and regional recurrence and distant metastasis.

METHODS

A retrospective survey of the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the European Society of Ophthalmic Plastic and Reconstructive Surgery yielded 44 cases. The patients' age, sex, date of diagnosis, histologic classification of melanoma, Breslow thickness, Clark level, location of melanoma, size of margins of excision, and findings of local or regional recurrence or distant metastasis were recorded in each case. Patients were stratified on the basis of margins of excision: </=5 mm; >5 mm but <10 mm; and >/=10 mm. Patients were also stratified by Breslow thickness. A Cox regression model was used to evaluate the predictive value of each factor for recurrence. Main outcome measures were the incidences of local and regional recurrence and distant metastasis as a function of margins of excision and Breslow thickness.

RESULTS

The majority of patients for whom reliable information was available had excision margins of </=5 mm. The Breslow thickness of most of the tumors was </=1 mm. Eleven patients (25%) had local recurrence. Five patients (11%) had regional lymph node metastasis. All patients with regional nodal metastasis were men. Distant metastasis developed in 3 patients (7%)-2 men and 1 woman. The follow-up times ranged from 10 to 108 months (mean, 34 months; median, 21 months). The incidence of local recurrence was higher among patients with melanomas at least 2 mm thick and margins of excision </=5 mm than among patients with melanomas at least 2 mm thick but with margins >/=10 mm, but this difference was not statistically significant because very few patients had melanomas at least 2 mm thick. Breslow thickness was the only statistically significant predictor of local, regional, and distant metastasis. Margins of excision did not have a statistically significant effect on local, regional, or distant recurrence.

CONCLUSIONS

Breslow thickness is an important prognostic indicator for eyelid skin melanomas. A 5-mm margin of excision may be adequate for thin melanomas of the periocular skin, but because of the small number of patients in this series who had >5-mm margins, a definitive comparison of outcome with larger margins of excision cannot be made. For melanomas >/=2 mm, wider margins of excision may be prudent, and careful surveillance for local and regional recurrence is indicated.

The new melanoma staging system

The new melanoma staging system from The American Joint Committee on Cancer (AJCC) is described. This major revision includes new criteria for staging the primary tumor (T), metastatic nodes (N) and distant metastases (M) as well as stage groupings. These criteria more accurately reflect those prognostic features of the primary and metastatic melanoma that correlate with survival outcome. Physicians managing melanoma should use this staging system in their clinical practice and in the conduct of melanoma clinical trials.

Current management of melanoma: benefits of surgical staging and adjuvant therapy

Issues regarding appropriate management of stage I to III melanoma are addressed. Accurate surgical staging is critical to identifying patients who can benefit from therapeutic lymph node dissection and adjuvant therapy. Patients with primary tumors > or = 1 mm thick are appropriate candidates for sentinel lymph node biopsy, and node-positive patients benefit from therapeutic lymphadenectomy. Although the overall survival benefit of high-dose interferon has been questioned, the weight of evidence supports the use of adjuvant therapy in patients with stage IIB and III disease.

Adjuvant immunotherapy with tumor infiltrating lymphocytes and interleukin-2 in patients with resected stage III and IV melanoma

Adoptive immunotherapy with tumor infiltrating lymphocytes (TIL) and interleukin (IL)-2 is reasonably effective in the treatment of patients with advanced melanoma. However, theoretically it should be of greater benefit as adjuvant therapy, especially in high-risk stages (resected stages III and IV). In a preliminary study, 25 patients (aged 23-72 years) with stage III-IV melanoma who underwent resection of metachronous metastases were reinfused with TIL cultivated and expanded in vitro with IL-2 from surgically removed metastases. IL-2 (starting dose 12 x 10 IU/m ) was co-administered as a continuous infusion according to West's scheme. A total of 8/22 (36.3%) evaluable patients were disease-free (DF) at a median follow-up of 5 years. DF survival (DFS) and overall survival (OS) rates were 44% and 37%, respectively, at 2 years, and 52% and 45% at 3 years. The CNS was the only site of disease recurrence in 57% of patients who relapsed. DF patients received a higher median dose of IL-2 than those who progressed (total dose 110 x 10 versus 86 x 10 IU/m, respectively). The progressive reduction in IL-2 dosage allowed all patients to complete treatment without permanent grade 4 toxicity. Analysis of tumor immunosuppression factors in lymphocytes inside the tumor (TCR zeta and epsilon chains, p56, FAS, and FAS-ligand) confirmed that the immunologic potential of TIL, depressed at the time of metastasectomy, was significantly restored after in vitro culture with IL-2. Adoptive immunotherapy with TIL and IL-2 could improve DFS and OS, although further work is required to determine its role in the treatment of patients with high-risk melanoma.

Surgical treatment of malignant melanoma

The surgical management of melanoma has evolved over the last 100 years. when early concepts of lymphatic permeation of the tumors and metastases led surgeons to perform radical operative procedures. Wide excision of primary melanoma is now performed with 1- to 2-cm radial margins, significantly reducing the need for complex plastic closures, skin grafts. and hospital admissions. Although elective lymph node dissection remains controversial as a therapeutic procedure, the development of SL has improved the staging of the regional lymph nodes and diminished the morbidity of lymph node dissection. The role of SL for routine care of melanoma patients remains unknown. Metastasectomy, which is the surgical resection of distant metastases with tumor-free surgical margins, has not been popular for AJCC stage IV patients with multiple metastases, because surgery is considered a local therapy and therefore of little value for management of disseminated disease. Nevertheless, the many reports of long-term survival after resection of distant melanoma metastases to diverse soft tissue and organ sites clearly indicate that this form of cytoreductive surgery can be extremely successful in carefully selected patients. Unlike chemotherapy, complete surgical metastasectomy can rapidly render a patient disease-free with only a short period of postoperative morbidity. Most patients fully recover from the surgical procedure within 6 weeks, returning to most or all activities. The ability to select patients for surgery is based on the development of more sophisticated imaging techniques, which allow better preoperative differentiation of patients with single versus multiple metastases and improve the surgeon's ability to identify and resect multiple metastatic sites. The overall data suggest that patients whose metastases can be completely resected will experience improved overall survival and occasional long-term cure regardless of the metastatic organ site and number of metastases. We believe that increased understanding of the biology of the primary and metastases, dramatic improvement in the accuracy of staging metastatic disease, and better techniques of surgical resection provide the best chance for long-term palliation or cure of melanoma. Cytoreductive surgery should be considered a form of immunotherapy. The long-term clinical benefit of this therapy depends on the patient's immune response to, the surgical reduction in tumor burden: an immune response that controls subclinical micrometastases should optimize postoperative survival.

Diagnosis and management of stage I/II melanoma

OBJECTIVES

To describe the clinical features and histologic subtypes of cutaneous melanoma; to review the diagnosis, clinical, and pathologic staging of melanoma and the associated prognostic factors; and to review the treatment and management of AJCC stage I and II melanoma.

DATA SOURCES

Scientific and review articles, textbooks, and clinical practice.

CONCLUSIONS

Management of melanoma depends on accurate diagnosis, staging, and interpretation of prognostic factors. The treatment of choice for stage I and II melanoma is surgery, ranging from simple excision to lymph node dissection.

IMPLICATIONS FOR NURSING PRACTICE

Familiarity with the clinical features of melanoma assists nurses in the screening and early detection of melanoma. Knowledge of AJCC staging guides education regarding treatment and lifelong surveillance.

Prognostic factors in primary cutaneous melanoma

Tumor thickness has historically been the single most important factor in risk assessment for stage I and II melanoma patients. However, it is possible to more accurately determine a patient's prognosis by also using other known prognostic indicators, such as ulceration, vascular invasion, and angiogenesis. A probabilistic approach to risk assessment has implications for the appropriate selection of treatment modalities, such as sentinel lymph node biopsy and re-excision margins. Each patient's risk for recurrence also has implications for which follow-up protocol would be most appropriate for the patient. Finally, those risk factors that repeatedly demonstrate an independent impact on prognosis should be used as stratification factors in adjuvant therapy trials.

Sentinel node detection in malignant melanoma patients: radiation safety considerations

BACKGROUND

The surgical management of malignant melanoma necessitates correct sentinel lymph node localization. The highest reported sensitivities are those of lymphoscintigraphy and intraoperative gamma-probe detection combined with a vital blue dye technique.

OBJECTIVE

Control of the radiation doses experienced by surgical personnel untrained in the use of unsealed radioactive materials.

METHODS

Sentinel lymph nodes were localized, and biopsies were performed in 25 patients with malignant melanoma. Radiation doses during surgery were determined with energy-compensated silicon pin diode detectors and LiF thermoluminescent ring dosimeters.

RESULTS

In 21 cases (24%), the measured doses were less than 1 microSv, but in 4 operations (16%), 1 to 4.5 microSv was received. The equivalent dose rate was generally less than 1 microSv/h. The finger-absorbed doses for the surgeon and the assistant surgeon were (mean+/-SD) 159+/-23 and 48+/-17 microGy per intervention, respectively.

CONCLUSION

Personal dosimetric survey and limitation of the number of surgical interventions do not appear to be essential.

Patterns of recurrence in patients with melanoma and histologically negative but RT-PCR-positive sentinel lymph nodes

BACKGROUND

We studied the patterns of recurrence of patients with only reverse transcriptase-polymerase chain reaction (RT-PCR) evidence of regional nodal spread to see whether or not proposed treatment interventions are likely to be effective.

STUDY DESIGN

One hundred seventy-five patients who underwent selective lymphadenectomy for clinical stage I and II melanomas were included in this analysis. We preserved a portion of each sentinel lymph node (SLN) in liquid nitrogen in the operating room and performed RT-PCR on the specimens to detect the melanoma/melanocyte-specific marker tyrosinase. We then compared the pattern of recurrence (regional dermal metastases, regional nodal recurrence, or distant metastatic spread) of the patients with histologically positive SLNs to that of patients who had histologically negative SLNs.

RESULTS

The mean followup time of the 175 patients was 33.83 months (SD = 15.94, median = 34.17, maximum = 62.95, minimum = 6.21). Thirty-four patients had at least one histologically positive SLN, and 17 of these patients had a recurrence (50%). Of the 141 patients that had histologically negative SLNs, 73 had SLNs that were also negative for tyrosinase by RT-PCR, and none of these patients had a recurrence. Of the 68 patients that had histologically negative but RT-PCR-positive SLNs, 14 had a recurrence (20.6%).

CONCLUSIONS

Because the pattern of recurrence of patients with only RT-PCR evidence of melanoma in SLNs was identical to that in patients who had histologically evident melanoma in the SLN and underwent subsequent completion lymphadenectomy, we conclude that completion lymphadenectomy might be ineffective in decreasing the recurrence rate of patients with only RT-PCR evidence of melanoma in SLNs.

Automated melanoma detection: multispectral imaging and neural network approach for classification

Our aim in the present research is to investigate the diagnostic performance of artificial neural networks (ANNs) applied to multispectral images of cutaneous pigmented skin lesions as well as to compare this approach to a standard traditional linear classification method, such as discriminant function analysis. This study involves a series of 534 patients with 573 cutaneous pigmented lesions (132 melanomas and 441 nonmelanoma lesions). Each lesion was analyzed by a telespectrophotometric system (TS) in vivo, before surgery. The system is able to acquire a set of 17 images at selected wavelengths from 400 to 1040 nm. For each wavelength, five lesion descriptors were extracted, related to the criteria of the ABCD (for asymmetry, border, color, and dimension) clinical guide for melanoma diagnosis. These variables were first reduced in dimension by the use of factor analysis techniques and then used as input data in an ANN. Multivariate discriminant analysis (MDA) was also performed on the same dataset. The whole dataset was split into two independent groups: i.e., train (the first 400 cases, 95 melanomas) and verification set (last 173 cases, 37 melanomas). Factor analysis was able to summarize the data structure into ten variables, accounting for at least 90% of the original parameters variance. After proper training, the ANN was able to classify the population with 80% sensitivity, 72% specificity, and 78% sensitivity, 76% specificity for the train and validation set, respectively. Following ROC analysis, area under curve (AUC) was 0.852 (train) and 0.847 (verify). Sensitivity and specificity values obtained by the standard discriminant analysis classifier resulted in a figure of 80% sensitivity, 60% specificity and 76% sensitivity, 57% specificity for the train and validation set, respectively. AUC for MDA was 0.810 and 0.764 for the train and verify set, respectively. Classification results were significantly different between the two methods both for diagnostic scores and model stability, which was worse for MDA.