Prognosis and conditional nomogram of cervical spine fracture in patients with severe spinal cord injury: a multicenter retrospective study

INTRODUCTION

Cervical spine fractures with severe spinal cord injury (SCI) are common following cervical spine trauma and are associated with a high mortality rate. Understanding the mortality patterns of patients with cervical spine fractures and severe SCI can offer valuable evidence to surgeons and family members who are required to make critical healthcare decisions. The authors aimed to evaluate the instantaneous death risk and conditional survival (CS) of such patients and developed conditional nomograms to account for different periods of survivors and predict the survival rates.

METHODS

Their instantaneous death risks were calculated using the hazard function, and the Kaplan-Meier method was used to evaluate the survival rates. Cox regression was used to choose the variables for the construction of the nomograms. The area under the receiver operating characteristic curve and calibration plots were used to validate the performance of the nomograms.

RESULTS

The authors finally included 450 patients with cervical spine fractures and severe SCI using propensity score matching. The instantaneous death risk was the highest during the first 12 months after injury. Surgical treatment can help decrease the instantaneous death risk quickly, especially in early-term surgery. The 5-year CS increased constantly from 73.3% at baseline to 88.0% after 2 years of survival. Conditional nomograms were constructed at baseline and in those who survived for 6 and 12 months. The area under the receiver operating characteristic curve and calibration curves indicated that the nomograms had a good performance.

CONCLUSION

Their results improve our understanding of the instantaneous death risk of patients in different periods following injury. CS demonstrated the exact survival rate among medium-term and long-term survivors. Conditional nomograms are suitable for different survival periods in predicting the probability of survival. Conditional nomograms help in understanding the prognosis and improve the shared decision-making approaches.

Melanom

Das Melanom ist der gefährlichste Hautkrebs mit der höchsten Sterblichkeitsrate, der schon bei jungen Menschen auftreten kann und seit Jahrzehnten steigende Inzidenz verzeichnet (Jemal et al. 2007; Little et al. 2012). Jährlich erkranken weltweit etwa 137.000 Menschen am Melanom und 37.000 versterben an der Erkrankung (Boyle et al. 2004). Die Inzidenz liegt weltweit jährlich bei 2,3–2,6/100.000 Einwohner (Pisani et al. 2002). In Deutschland beträgt die Inzidenz 19,2/100.000 Einwohner und es verstarben 2711 Betroffene im Jahre 2010 (Statistisches Bundesamt).

Association between the use of surveillance PET/CT and the detection of potentially salvageable occult recurrences among patients with resected high-risk melanoma

The optimal surveillance for patients with resected high-risk melanoma is controversial. Select locoregional or oligometastatic recurrences can be cured with salvage resection. Data on the ability of PET/CT to detect such recurrences are sparse. We evaluated whether surveillance PET/CT in patients with resected stage III-IV melanoma led to detection of clinically occult recurrences amenable to curative-intent salvage treatment. We retrospectively identified 1429 melanoma patients who underwent PET/CT between January 2008 and October 2012 at Mayo Clinic (Rochester, Minnesota). A total of 1130 were excluded because of stage I-II, ocular or mucosal melanoma, incomplete resection, PET/CT not performed for surveillance or performed at a different institution, and records not available. A total of 299 patients were eligible. Overall, 162 (52%) patients developed recurrence [locoregional: 77 (48%), distant: 85 (52%)]. The first recurrence was clinically occult in 98 (60%) and clinically evident in 64 (40%). Clinically evident recurrences were more often superficial (skin, subcutaneous, or nodal) or in the brain, whereas clinically occult recurrences more often visceral. Overall, 90% of all recurrences were detected by 2.8 years. In all, 70% of patients with recurrence underwent curative-intent salvage treatment (locoregional: 94%, distant: 48%), with similar rates for clinically occult versus clinically evident recurrences (66 vs. 75%, P=0.240). Overall survival was superior among those who underwent curative-intent salvage treatment [5.9 vs. 1.2 years; hazard ratio=4.27, 95% confidence interval (CI)=2.68-6.80; P<0.001], despite 79% developing recurrence again. PET/CT had high sensitivity (88%, 95% CI=79.94-93.31%), specificity (90%, 95% CI=88.56-91.56%), and negative predictive value (99%, 95% CI=98.46-99.52%). However, the positive predictive value was only 37% (95% CI=31.32-43.68%). In patients with resected stage III-IV melanoma, surveillance PET/CT detected a large proportion of clinically occult recurrences amenable to curative-intent salvage treatment. Despite a high rate of second relapse, curative-intent salvage treatment was associated with superior overall survival. Even though PET/CT had high sensitivity, specificity, and negative predictive value, positive predictive value was poor, highlighting the need for histologic confirmation of PET/CT-detected abnormalities.

Emerging Biomarkers in Cutaneous Melanoma

Earlier identification of aggressive melanoma remains a goal in the field of melanoma research. With new targeted and immune therapies that have revolutionized the care of patients with melanoma, the ability to predict progression and monitor or predict response to therapy has become the new focus of research into biomarkers in melanoma. In this review, promising biomarkers are highlighted. These biomarkers have been used to diagnose melanoma as well as predict progression to advanced disease and response to therapy. The biomarkers take various forms, including protein expression at the level of tissue, genetic mutations of cancer cells, and detection of circulating DNA. First, a brief description is provided about the conventional tissue markers used to stage melanoma, including tumor depth. Next, protein biomarkers, which provide both diagnostic and prognostic information, are described. This is followed by a discussion of important genetic mutations, microRNA, and epigenetic modifications that can provide therapeutic and prognostic material. Finally, emerging serologic biomarkers are reviewed, including circulating melanoma cells and exosomes. Overall the goal is to identify biomarkers that aid in the earlier identification and improved treatment of aggressive melanoma.

Skin Examination Practices Among Melanoma Survivors and Their Children

Many professional organizations recommend skin self-examination (SSE) as a tool for early detection of malignancy among melanoma survivors, a growing population that is at increased risk for new or recurrent melanoma. This study examined the frequency and correlates of SSE use among melanoma survivors. Additionally, we assessed skin exam use among children of survivors, who are at elevated lifetime risk for the disease. The California Cancer Registry was used to identify melanoma survivors, who were contacted, screened for eligibility, and invited to participate in a survey. The survey, administered by mail, web, or telephone, assessed a broad range of topics related to melanoma prevention in high-risk families. The present study focuses on skin examination practices of survivors and their children and potential correlates of these practices. Among a sample of 316 melanoma survivors, fewer than one in five participants performed monthly skin self-exams, a lower rate than that observed in previous studies. Although greater family history of melanoma, use of skin protection strategies, and the perceived severity of melanom were associated with more frequent use of skin self-exams, these relationships disappeared in adjusted analyses. Participants reported unexpectedly frequent use of skin examinations for their children despite the lack of professional guidelines for this practice. Interventions are needed to improve skin self-examination practices among melanoma survivors and to counsel parents about optimal melanoma prevention strategies for their children.

Routine Computer Tomography Imaging for the Detection of Recurrences in High-Risk Melanoma Patients

BACKGROUND

The use of routine CT imaging for surveillance in asymptomatic patients with cutaneous melanoma is controversial. We report our experience using a surveillance strategy that included CT imaging for a cohort of patients with high-risk melanoma.

METHODS

A total of 466 patients with high-risk cutaneous melanoma enrolled in adjuvant immunotherapy trials were followed for tumor progression by physical examination, labs, and CT imaging as defined by protocol. Evaluations were obtained at least every 6 months for year 1, every 6 months for year 2, and then annually for the remainder of the 5-year study. Time to tumor progression, sites of recurrence, and the method of relapse detection were identified.

RESULTS

The patient cohort consisted of 115 stage II patients, 328 stage III patients, and 23 patients with resected stage IV melanoma. The medium time to progression for the 225 patients who developed tumor progression was 7 months. Tumor progression was detected by patients, physician examination or routine labs, or by CT imaging alone in 27, 14, and 59% of cases respectively. Melanoma recurrences were noted to be locoregional in 36% of cases and systemic in 64% of cases. Thirty percent of patients with locoregional relapse and 75% of patients with systemic relapse were detected solely by CT imaging.

CONCLUSIONS

CT imaging alone detected the majority of sites of disease progression in our patients with high-risk cutaneous melanoma. This disease was not heralded by symptoms, physical examination, or blood work. Although the benefit of the early detection of advanced melanoma is unknown, this experience is relevant because of the rapid development and availability of potentially curative immunotherapies.

Perinatal Considerations in Women With Previous Diagnosis of Cancer

As the average age that women have their first child increases and cancer therapies improve survival, obstetricians are more likely to care for pregnant women who have survived cancer. Managing these pregnancies can be challenging, as they may be associated with higher risks of maternal and neonatal morbidity and mortality. Different types of cancer require different types of intervention, including surgery, chemotherapy, radiation, or combinations of these. Prior cancer treatments therefore present different potential complications during pregnancy. Although for most women who survive cancer carrying a pregnancy does not seem to increase mortality rates, there are some associated neonatal morbidities. The most common perinatal complication associated with pregnancy after cancer is prematurity. Women who desire pregnancy after cancer survival should not be discouraged, but appropriate counseling and follow-up should be provided.

Performance of diagnostic tests in an intensive follow-up protocol for patients with American Joint Committee on Cancer (AJCC) stage IIB, IIC, and III localized primary melanoma: A prospective cohort study

BACKGROUND

There is no international consensus on optimal follow-up schedules and which supplementary tests should be used after resection of a primary melanoma.

OBJECTIVE

We sought to analyze the performance of the follow-up components and identify procedures that detect melanoma metastasis earlier.

METHODS

This was a prospective cohort from 290 consecutive patients given a diagnosis of stage IIB, IIC, and III melanoma. Patients were followed up with an intensive protocol based on imaging studies (computed tomography of the chest, abdomen, and pelvis, and brain magnetic resonance imaging), periodic laboratory tests, regular physical examinations, and patient self-examinations.

RESULTS

A total of 2382 clinical examinations and 3069 imaging tests were performed. The patients completed 899.8 person-years of follow-up, with a median of 2.5 years. In all, 115 recurrences in 290 patients were recorded, of which computed tomography detected 48.3%; brain magnetic resonance imaging, 7.6%; laboratory test, 2.5%; physician, 23.7%; and patient, 17.8%.

LIMITATIONS

Patients with stage III melanoma were not systematically classified into subgroups and overall survival was not evaluated.

CONCLUSION

We observed that this intensive monitoring is appropriate for early detection of recurrence in stage IIB, IIC, and III melanoma. Prompt diagnosis of metastasis and the recent development of new therapeutic targets may improve overall survival.

Retrospektive Analyse von Zufallsbefunden, die bei Patienten mit kutanem malignen Malignom durch (18) F-Fluordeoxyglucose-PET/CT erhoben wurden

HINTERGRUND UND ZIELE

Bei der (18) F-Fluordeoxyglucose-Positronenemissionstomographie/Computertomographie (FDG-PET/CT) ergeben sich häufig Zufallsbefunde. In der vorliegenden Studie konzentrierten wir uns auf mittels FDG-PET/CT erhaltene Zufallsbefunde bei Patienten mit kutanem Melanom und überprüften deren Relevanz hinsichtlich weiterer diagnostischer Maßnahmen und Interventionen.

PATIENTEN UND METHODEN

Die Krankenakten von 181 konsekutiven Melanom-Patienten wurden retrospektiv ausgewertet, um das Management von Zufallsbefunden zu dokumentieren. Der Schwerpunkt lag dabei auf den histologischen Befunden.

ERGEBNISSE

Bei 33 von 181 (18 %) Patienten lagen 39 relevante Zufallsbefunde vor, und zwar im Kolorektalbereich (n = 15 Patienten), in der Schilddrüse (n = 8), der Prostata (n = 2), dem Bewegungsapparat (n = 2), in Lymphknoten (n = 2), der Parotis (n = 1), den Mandeln (n = 1), den Nieren (n = 1) und der Gallenblase (n = 1). Bei 25 Patienten schlossen sich weitere diagnostische Verfahren an, wobei in 21 Fällen ein klinisches Korrelat nachgewiesen wurde. Bei 16 von 21 Patienten ergab sich eine Neoplasie, darunter fünf maligne Läsionen (vier Kolonkarzinome und ein Prostatakarzinom). Die Malignome wurden frühzeitig diagnostiziert und in der Mehrzahl der Fälle erfolgreich entfernt.

SCHLUSSFOLGERUNGEN

Der Einsatz der FDG-PET/CT als Routine-Diagnostik wird in den Leitlinien empfohlen und ist indiziert bei malignem Melanom ab Stadium IIC. In dieser Studie wurden auf effektive Weise ansonsten nicht erkannte Krebserkrankungen, insbesondere Kolonkarzinome, detektiert. In den meisten Fällen war eine frühe Intervention möglich. Zufallsbefunde durch FDG-PET/CT sollten, unter Berücksichtigung des Zustands und der Wünsche des Patienten, mit den geeigneten diagnostischen Maßnahmen abgeklärt werden.

The MELFO-Study: Prospective, Randomized, Clinical Trial for the Evaluation of a Stage-adjusted Reduced Follow-up Schedule in Cutaneous Melanoma Patients-Results after 1 Year

Background

Guidelines for evidence-based follow-up in melanoma patients are not available. This study examined whether a reduced follow-up schedule affects: patient-reported outcome measures, detection of recurrences, and follow-up costs.

Methods

This multicenter trial included 180 patients treated for AJCC stage IB-II cutaneous melanoma, who were randomized in a conventional follow-up schedule group (CSG, 4 visits first year, n = 93) or experimental follow-up schedule group (ESG, 1–3 visits first year, n = 87). Patients completed the State-Trait Anxiety Inventory, cancer worry scale, impact of events scale, and a health-related quality of life questionnaire (HRQoL, RAND-36). Physicians registered clinicopathologic features and the number of outpatient clinic visits.

Results

Sociodemographic and illness-related characteristics were equal in both groups. After 1-year follow-up, the ESG reported significantly less cancer-related stress response symptoms than the CSG (p = 0.01), and comparable anxiety, mental HRQoL, and cancer-related worry. Mean cancer-related worry and stress response symptoms decreased over time (p < 0.001), whereas mental HRQoL increased over time (p < 0.001) in all melanoma patients. Recurrence rate was 9 % in both groups, mostly patient-detected and not physician-detected (CSG 63 %, ESG 43 %, p = 0.45). Hospital costs of 1-year follow-up were reduced by 45 % in the ESG compared to the CSG.

Conclusions

This study shows that the stage-adjusted, reduced follow-up schedule did not negatively affect melanoma patients’ mental well-being and the detection of recurrences compared with conventional follow-up as dictated by the Dutch guideline, at 1 year after diagnosis. Additionally, reduced follow-up was associated with significant hospital cost reduction.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-016-5263-7) contains supplementary material, which is available to authorized users.

Melanoma: Clinical Presentations

The malignant cell in melanoma is the melanocyte. Because melanocytes are located in the basal layer of the epidermis, melanoma is most commonly seen on the skin. However, melanoma can also arise on mucosal surfaces such as the oral cavity, the upper gastrointestinal mucosa, the genital mucosa, as well as the uveal tract of the eye and leptomeninges. Melanomas tend to be pigmented but can also present as pink or red lesions. They can mimic benign or other malignant skin lesions. This chapter presents the spectrum of typical and less typical presentations of melanoma, as well as patterns of spread. It is divided into (1) cutaneous lesions; (2) patterns of regional spread, (3) non-cutaneous lesions; and (4) distant metastases.

Prospective evaluation of follow-up in melanoma patients in Germany - results of a multicentre and longitudinal study

BACKGROUND

Patient numbers requiring long-term melanoma surveillance are constantly rising. Surveillance is costly and guideline recommendations vary substantially.

METHODS

In this German nationwide study, information on surveillance and treatment of patients diagnosed with melanoma and melanoma in situ (MMis) between April and June 2008 was prospectively collected over four years. Additionally, patient self-report questionnaires were evaluated to assess anxiety, depression, health-related quality of life, socio-demographic information and use of disease specific health information sources at year 4 after primary diagnosis.

RESULTS

Complete data was available for 668 patients from 67 centres, of whom 96.0% were in regular melanoma surveillance. In year 3-4 of surveillance, only 55.6% of locoregionary metastases were detected during surveillance visits. Only 33.3% were self-detected by the patient even though 69.4% were documented as being clinically visible or palpable. Costs of 4year surveillance of 550 patients without tumour recurrence (stage I-IIC and MMis) accumulated to 228,155.75 €. Guideline-adherence for follow-up frequency, lymph node ultrasound, S100 serum level tests and diagnostic imaging recommendations was approximately 60% in year 3-4 of surveillance. Multivariate regression analysis showed that certain patient/tumour characteristics and regional differences were significantly associated with guideline deviations. The percentage of patients who exceeded published cut-off scores indicating clinically relevant symptoms of anxiety and depression were significantly increased. Patients frequently reported lack of psychosocial support and education but ascribed great importance to these.

CONCLUSIONS

We recommend further reduction of melanoma follow-up in low-risk melanoma patients and improvement of psycho-social support and patient education for all melanoma patients.

Follow-up in patients with low-risk cutaneous melanoma: is it worth it?

Follow-up examinations in melanoma aim to detect recurrences or secondary melanomas in an early phase of development. Follow-up guidelines that have been developed in many European countries, the USA and Australia show varying recommendations and are controversial, especially in patients with melanomas of 1.0 mm tumor thickness or less. This group contains 50-70% of all melanoma patients and the majority is unlikely to develop recurrences. On the other hand, within this entity, subgroups at higher risk for recurrences can be defined who require a more intense follow-up. This article discusses recommendations for the frequency, duration and costs of follow-up in low-risk melanoma patients. Patient preferences are addressed and a risk-adapted follow-up scheme is proposed.

Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies

OBJECTIVE

To guide resource utilization, we aimed to determine the impact of routine surveillance imaging for the detection of melanoma recurrences amenable to surgical resection with curative intent.

BACKGROUND

The National Comprehensive Cancer Network guidelines for melanoma surveillance are largely consensus based.

METHODS

Using single-institution, patient-level data (n = 1600), transition probabilities were calculated for a Markov model simulating the natural history of patients with stage I-III melanoma. As a base estimate, imaging was assumed to detect regional and distant recurrences of which 80% and 20% could be surgically treated with curative intent, respectively. Sensitivity analyses were conducted for all point estimates. For each disease stage, we calculated the number of surgically treatable regional or distant recurrence detected during 5 years per 10,000 patients undergoing computed tomography (CT) or positron emission tomography (PET)/CT scans at 6- or 12-month intervals. The associated positive and negative predictive values and life expectancy were also calculated and compared with clinical examination alone.

RESULTS

At 5-year follow-up, CT or PET/CT at 6-month intervals detected surgically treatable regional or distant recurrence in 6.4% of patients with stage I, 18.5% of stage II, and 33.1% of stage III disease; 12-month intervals decreased the rates to 3.0%, 7.9%, and 13.0%, respectively. The high false-positive rates of CT (20%) and PET/CT (9%) resulted in overall low positive predictive values. However, both CT and PET/CT effectively predicted absence of disease. Life-expectancy gains were minimal (≤ 2 months) for all groups.

CONCLUSIONS

The effectiveness of routine surveillance imaging for detecting treatable melanoma recurrences is limited. Even in patients with stage III disease, only minimal gains in life expectancy were achieved.

Exploring patterns of recurrent melanoma in Northeast Scotland to inform the introduction a digital self-examination intervention

BACKGROUND

Melanoma incidence is growing and more people require follow-up to detect recurrent melanoma quickly. Those detecting their own recurrent melanoma appear to have the best prognosis, so total skin self examination (TSSE) is advocated, but practice is suboptimal. A digital intervention to support TSSE has potential but it is not clear which patient groups could benefit most. The aim of this study was to explore cutaneous melanoma recurrence patterns between 1991 and 2012 in Northeast Scotland. The objectives were to: determine how recurrent melanomas were detected during the period; explore factors potentially predictive of mode of recurrence detection; identify groups least likely to detect their own recurrent melanoma and with most potential to benefit from digital TSSE support.

METHODS

Pathology records were used to identify those with a potential recurrent melanoma of any type (local, regional and distant). Following screening of potential cases available secondary care-held records were subsequently scrutinised. Data was collected on demographics and clinical characteristics of the initial and recurrent melanoma. Data were handled in Microsoft Excel and transported into SPSS 20.0 for statistical analysis. Factors predicting detection at interval or scheduled follow-up were explored using univariate techniques, with potentially influential factors combined in a multivariate binary logistic model to adjust for confounding.

RESULTS

149 potential recurrences were identified from the pathology database held at Aberdeen Royal Infirmary. Reliable data could be obtained on 94 cases of recurrent melanoma of all types. 30 recurrences (31.9%) were found by doctors at follow-up, and 64 (68.1%) in the interval between visits, usually by the patient themselves. Melanoma recurrences of all types occurring within one-year were significantly more likely to be found at follow-up visits, and this remained so following adjustment for other factors that could be used to target digital TSSE support.

CONCLUSIONS

A digital intervention should be offered to all newly diagnosed patients. This group could benefit most from optimal TSSE practice.

Intensity of follow-up after melanoma surgery

This contemporary review of melanoma surveillance strategies seeks to help practitioners examine and improve their surveillance protocols based on the currently available data. In general, there is no definitive benefit from increased screening or more aggressive use of interval imaging. Low-intensity surveillance strategies do not appear to adversely affect patient outcomes and should be the preferred approach compared with high-intensity strategies for most melanoma patients. All surveillance programs should emphasize education in order to maximize the effectiveness of patient-based detection of recurrent disease.

Multicohort model for prevalence estimation of advanced malignant melanoma in the USA: an increasing public health concern

The aim of the study was to estimate the current prevalence of advanced cutaneous malignant melanoma in 2010 in the USA and to project prevalence estimates to the year 2015. An excel-based, multicohort natural disease history model was developed. It used incidence, recurrence, all-cause mortality, and US population data from the up-to-date surveillance, epidemiology, and end results program, the US census, and the literature. The prevalence was stratified by tumor stage, sex, and age. The model estimated that there were 800 735 malignant melanoma cases (258 per 100 000 individuals) in the USA in 2010, of which 10.4% were in advanced stages including stage III (22 per 100 000 individuals) and stage IV (four per 100 000 individuals). Among these advanced cases, 58.8% were men. In total, 42.1% of patients with advanced malignant melanoma were 65 years of age and older. Of these elderly patients with an advanced stage of the disease, 65.7% were men. The total number of cases and number of advanced cases were projected to increase from 2010 to 2015 by 24.4 and 21.0%, respectively. There will be approximately one million malignant melanoma cases (306 per 100 000 individuals) in the USA in 2015. The prevalence of advanced malignant melanoma is expected to increase in the next few years. Advanced malignant melanoma disproportionately affects men and the elderly in the USA.

Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review

There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. There are significant intercountry and interspecialty variations in the surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.

Anaplastic Large Cell Lymphoma: A Potential Pitfall in the Differential Diagnosis of Melanoma

The diagnosis of metastatic melanoma can be complicated by absent characteristic cytology, melanin, or antigen expression in a suspect tumor, putting the pathologist at risk for incorrectly diagnosing recurrent melanoma while missing a second malignancy. We report a 69-year-old man with a history of acral melanoma, metastatic to inguinal nodes, presenting with an ipsilateral thigh nodule. Histology showed a proliferation of pleomorphic cells in the dermis and subcutis, suspicious for melanoma. S100, Melan-A, and HMB-45 immunohistochemistry were negative. However, microphthalmia-associated transcription factor and CD117 labeled the neoplasm, prompting consideration of a late metastatic melanoma with loss of antigen expression. Subsequent immunolabeling for CD4, CD43, and CD30 and clonal T-cell gene rearrangements enabled the correct diagnosis of cutaneous anaplastic large cell lymphoma. This case illustrates a pitfall in evaluating tumors in patients with known metastatic melanoma, and emphasizes the need for broad-spectrum immunohistochemistry in cases that are not clear-cut.

Serum microRNAs as biomarkers for recurrence in melanoma

BACKGROUND

Identification of melanoma patients at high risk for recurrence and monitoring for recurrence are critical for informed management decisions. We hypothesized that serum microRNAs (miRNAs) could provide prognostic information at the time of diagnosis unaccounted for by the current staging system and could be useful in detecting recurrence after resection.

METHODS

We screened 355 miRNAs in sera from 80 melanoma patients at primary diagnosis (discovery cohort) using a unique quantitative reverse transcription-PCR (qRT-PCR) panel. Cox proportional hazard models and Kaplan-Meier recurrence-free survival (RFS) curves were used to identify a miRNA signature with prognostic potential adjusting for stage. We then tested the miRNA signature in an independent cohort of 50 primary melanoma patients (validation cohort). Logistic regression analysis was performed to determine if the miRNA signature can determine risk of recurrence in both cohorts. Selected miRNAs were measured longitudinally in subsets of patients pre-/post-operatively and pre-/post-recurrence.

RESULTS

A signature of 5 miRNAs successfully classified melanoma patients into high and low recurrence risk groups with significant separation of RFS in both discovery and validation cohorts (p = 0.0036, p = 0.0093, respectively). Significant separation of RFS was maintained when a logistic model containing the same signature set was used to predict recurrence risk in both discovery and validation cohorts (p < 0.0001, p = 0.033, respectively). Longitudinal expression of 4 miRNAs in a subset of patients was dynamic, suggesting miRNAs can be associated with tumor burden.

CONCLUSION

Our data demonstrate that serum miRNAs can improve accuracy in identifying primary melanoma patients with high recurrence risk and in monitoring melanoma tumor burden over time.

Clinicopathologic features of incident and subsequent tumors in patients with multiple primary cutaneous melanomas

BACKGROUND

0.6-12.7% of patients with primary cutaneous melanoma will develop additional melanomas. Pathologic features of tumors in patients with multiple primary cutaneous melanomas have not been well described. In this large, international, multicenter, case-control study, we compared the clinicopathologic features of a subsequent melanoma with the preceding (usually the first) melanoma in patients with multiple primary cutaneous melanomas, and with those of melanomas in patients with single primary cutaneous melanomas.

METHODS

Multiple primary melanoma (cases) and single primary invasive melanoma (controls) patients from the Genes, Environment and Melanoma (GEM) study were included if their tumors were available for pathologic review and confirmed as melanoma. Clinicopathologic characteristics of invasive subsequent and first melanomas in cases and invasive single melanomas in controls were compared.

RESULTS

A total of 473 pairs comprising a subsequent and a first melanoma and 1,989 single melanomas were reviewed. Forward stepwise regression modeling in 395 pairs with complete data showed that, compared with first melanomas, subsequent melanomas were more commonly contiguous with a dysplastic nevus, more prevalent on the head/neck and legs than other sites, and thinner. Compared with single primary melanomas, subsequent melanomas were more likely to be associated with a contiguous dysplastic nevus, more prevalent on the head/neck and legs, and thinner. The same differences were observed when subsequent melanomas were compared with single melanomas. First melanomas were more likely than single melanomas to have associated solar elastosis and no observed mitoses.

CONCLUSIONS

Thinner subsequent than first melanomas suggest earlier diagnosis, perhaps due to closer clinical scrutiny. The association of subsequent melanomas with dysplastic nevi is consistent with the latter being risk factors or risk markers for melanoma.

Review of diagnostic imaging modalities for the surveillance of melanoma patients

As melanoma survival rates continue to increase, optimal surveillance strategies for recurrences are needed, as are effective imaging modalities. Therefore, we performed a meta-analysis to evaluate the current state of imaging modalities for surveillance of melanoma in the published medical literature to determine the sensitivity, specificity, and positive predictive values of ultrasonography, computed tomography (CT), positron emission tomography (PET), and CT-PET combined. Ultrasonography was found to be the most sensitive and specific for detecting lymph node metastases, and PET-CT was the most sensitive and specific for detecting distant metastases. In addition to identifying appropriate surveillance methods, future studies should focus on the most effective and cost-effective intervals for performing these tests. In addition, the results from the meta-analysis related to sensitivity and specificity of the tests should be made available to doctors in community practice.

Hazard rates for recurrent and secondary cutaneous melanoma: an analysis of 33,384 patients in the German Central Malignant Melanoma Registry

BACKGROUND

Knowledge about the risk for recurrence and secondary cutaneous melanoma (CM) is an important basis for patient counseling and planning of follow-up examinations.

OBJECTIVES

This study aimed to analyze stage- and time-dependent hazard rates (HR) and discusses current surveillance recommendations.

METHODS

Follow-up data of 33,384 patients with incident CM in stages I to III (American Joint Committee on Cancer 2002) were recorded by the German Central Malignant Melanoma Registry in 1976 through 2007. Survival was based on Kaplan-Meier estimates and HRs were calculated.

RESULTS

Recurrences were recorded in 4999 patients (stage I, 7.1%; stage II, 32.8%; and stage III, 51.0%). Ten-year recurrence-free survival was 78.9% (95% confidence interval 73.1-90.5); in stage I, 89.0%; stage II, 56.9%; and stage III, 36.0%. Whereas HR for recurrent CM showed a constantly low level less than or equal to 1:125 per year for stage IA, clearly higher HRs of greater than or equal to 1:40 were recorded in stage IB for the first 3 years and generally in stages II to III. Of all patients 2.3% developed secondary melanomas, with a consistently low HR of less than 1:220 per year.

LIMITATIONS

As German recommendations discontinued regular follow-up examinations after 10 years, no information can be given beyond this time point. Follow-up data of longer than 5 years were available in 41.4% of patients.

CONCLUSION

For patients at stage IA with thin melanoma and low HR for recurrent CM the need for surveillance remains questionable. For patients with higher HR greater than 1:40 per year, intensified surveillance strategies should be taken into account.

Plasma markers for identifying patients with metastatic melanoma

PURPOSE

With the rising incidence of melanoma, more patients are undergoing surveillance for disease recurrence. Our purpose was to study levels of proteins that might be secreted in the blood of patients with metastatic melanoma that can be used for monitoring these individuals.

METHODS

Genome-wide gene expression data were used to identify abundantly expressed genes in melanoma cells that encode for proteins likely to be present in the blood of cancer patients, based on high expression levels in tumors. ELISA assays were employed to measure proteins in plasma of 216 individuals; 108 metastatic melanoma patients and 108 age- and gender-matched patients with resected stage I/II disease split into equal-sized training and test cohorts.

RESULTS

Levels of seven markers, CEACAM (carcinoembryonic antigen-related cell adhesion molecule), ICAM-1 (intercellular adhesion molecule 1), osteopontin, MIA (melanoma inhibitory activity), GDF-15 (growth differentiation factor 15), TIMP-1 (tissue inhibitor of metalloproteinase 1), and S100B, were higher in patients with unresected stage IV disease than in patients with resected stage I/II disease. About 81% of the stage I/II patients in the training set had no marker elevation, whereas 69% of the stage IV patients had elevation of at least one marker (P < 0.0001). Receiver operating characteristic curves for the markers in combination in these two patient populations had an area under curve (AUC) of 0.79 in the training set and 0.8 in the test set. A CART (Classification and Regression Trees) model developed in the training set further improved the AUC in the test set to 0.898.

CONCLUSIONS

Plasma markers, particularly when assessed in combination, can be used to monitor patients for disease recurrence and can compliment currently used lactate dehydrogenase and imaging studies; prospective validation is warranted.

Risk factors associated with local and in-transit recurrence of cutaneous melanoma

BACKGROUND

Understanding the risk factors for local and in-transit recurrences (LR/ITR) may help facilitate methods of prevention, early detection, and treatment.

METHODS

A retrospective review of a prospectively collected database was performed on patients diagnosed with single-lesion cutaneous melanoma. Clinical and pathologic characteristics of the tumors were evaluated.

RESULTS

Of 225 patients, 10% had LR/ITR. Patients with LR/ITR were older (P = .0002), had thicker tumors (P = .018), and positive angiolymphatic invasion more frequently (P < .0001). An increased tumor mitotic rate (TMR) was more common in LR/ITRs (P = .051). On univariate logistic regression, age, thickness, TMR of 11/mm(2) or greater, and angiolymphatic invasion were all significant risk factors for LR/ITR. Multivariate logistic regression showed age, thickness, and angiolymphatic invasion were the only significant risk factors.

CONCLUSIONS

Older patients with thicker tumors and angiolymphatic invasion appear to be at higher risk for LR/ITR. Such patients warrant consideration of preventative strategies and should receive close clinical follow-up evaluation for early recurrence.

Melanoma

This chapter discusses the value of FDG-PET and combined FDG-PET/CT in staging and follow-up of melanoma patients. For melanoma patients, the presence or absence of regional lymph node metastases is one of the most important prognostic factors; the recent development of sentinel lymph node biopsy offers a highly sensitive staging method. FDG-PET has shown a limited sensitivity to detect microscopic lymph node metastases in this selected group of patients with stages I and II melanoma. However, for the detection of distant metastases, FDG-PET is frequently used. Although there is no consensus, some surgeons pursue surgical excision of metastatic disease if only one or a few sites of disease are apparent. Precise identification of the location and number of metastatic lesions could therefore be important for surgical planning. Even though patients with metastatic melanoma generally have a poor prognosis (5-year survival 3-16%), there is still a need for accurate staging. Firstly, to identify those patients who may benefit from a surgical procedure, while avoiding these potentially harmful surgical procedures for patients with multiple distant metastases. Secondly, accurate staging is important to improve the efficiency of clinical trials, and thirdly, to provide patients with detailed information about their prognosis. Taking the published literature together, and reasoning that FDG-PET/CT is the current standard in PET imaging, there may be a case for the combined PET/CT in the setting of metastatic melanoma. However, further research is needed as the benefit of the combined FDG-PET/CT vs. FDG-PET alone seems to be less than reported for other tumor entities, which may be due to the high avidity of melanoma for FDG, so that many of the metastases are detected with FDG-PET and the additional CT does not increase the sensitivity.

Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis

BACKGROUND

Meta-analyses were performed to examine the utility of ultrasonography, computed tomography (CT), positron emission tomography (PET), and a combination of both (PET-CT) for the staging and surveillance of melanoma patients.

METHOD

Patient-level data from 74 studies containing 10,528 patients (between January 1, 1990, and June, 30, 2009) were used to derive characteristics of the diagnostic tests used. Meta-analyses were conducted by use of Bayesian bivariate binomial models to estimate sensitivity and specificity. Diagnostic odds ratios [ie, true-positive results/false-negative results)/(false-positive results/true-negative results)] and their 95% credible intervals (CrIs) and positive predictive values were used as indicators of test performance.

RESULTS

Among the four imaging methods examined for the staging of regional lymph nodes, ultrasonography had the highest sensitivity (60%, 95% CrI = 33% to 83%), specificity (97%, 95% CrI = 88% to 99%), and diagnostic odds ratio (42, 95% CrI = 8.08 to 249.8). For staging of distant metastases, PET-CT had the highest sensitivity (80%, 95% CrI = 53% to 93%), specificity (87%, 95% CrI = 54% to 97%), and diagnostic odds ratio (25, 95% CrI = 3.58 to 198.7). Similar trends were observed for melanoma surveillance of lymph node involvement, with ultrasonography having the highest sensitivity (96%, 95% CrI = 85% to 99%), specificity (99%, 95% CrI = 95% to 100%), and diagnostic odds ratio (1675, 95% CrI = 226.6 to 15,920). For distant metastases, PET-CT had the highest sensitivity (86%, 95% CrI = 76% to 93%), specificity (91%, 95% CrI = 79% to 97%), and diagnostic odds ratio (67, 95% CrI = 20.42 to 229.7). Positive predictive values were likewise highest for ultrasonography in lymph node staging and for PET-CT in detecting distant metastases.

CONCLUSION

Among the compared modalities, ultrasonography was superior for detecting lymph node metastases, and PET-CT was superior for the detection of distant metastases in both the staging and surveillance of melanoma patients.

Detection of melanoma nodal metastases; differences in detection between elderly and younger patients do not affect survival

BACKGROUND

Melanoma lymph nodes metastases may be detected by patients or by physicians. Understanding the outcomes of self-detection or physician detection is essential for the design of follow-up studies. We evaluated the role of the method of detection in nodal disease in the prognosis of melanoma patients who underwent therapeutic lymph node dissection (TLND).

MATERIALS AND METHODS

All melanoma patients with palpable lymph nodes were included in a prospective database (n = 98), and the method of detection was recorded. Detection of lymph node metastases compared with pathological findings in the TLND was assessed by multivariate logistic regression. Disease-free survival (DFS) and disease-specific survival (DSS) were assessed by univariate and multivariate Cox proportional hazard analysis.

RESULTS

Nodal metastases were detected by physicians in 45% and by patients in 55% (P < 0.001). Age was significantly associated with method of detection. Patients ≤60 years detected 69% their lymph node metastases as opposed to 32% of patients >60 years (odds ratio [OR] 0.3; P = 0.007). However, this was not associated with prognostic findings in TLND, number of positive nodes, tumor size, or extranodal spread. Method of detection or age at the time of nodal metastases was not significantly associated with 2-year DFS or DSS.

CONCLUSIONS

45% of all lymph node metastases in stage I-II melanoma patients are physician detected. Younger patients detect their own lymph node metastases significantly more often than elderly patients. However, neither the method of detection nor age correlates with DSS. More frequent follow-up would not alter DFS and DSS significantly.

The influence of pregnancy on the recurrence of cutaneous malignant melanoma in women

Objective. The aim of this study was to determine whether pregnancy increases the recurrence risk of cutaneous malignant melanoma (CMM) in women with a history of stage I CMM. Methods. The electronic medical databases of Medline and Embase were explored. All 1084 obtained articles were screened on title and abstract using predetermined inclusion and exclusion criteria. A critical appraisal of relevance and validity was conducted on the remaining full text available articles. Results. Two studies were selected. Both studies revealed no significant difference in disease-free survival between women with stage I CMM and the control population. Conclusion. Pregnancy does not increase the recurrence risk of CMM in women with a history of stage I CMM.

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

BACKGROUND

There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.

METHODS

A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.

RESULTS

There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P<or=0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.

CONCLUSIONS

GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.

Outpatient Follow-up and Secondary Prevention for Melanoma Patients

Health care providers and their patients jointly participate in melanoma prevention, surveillance, diagnosis, and treatment. This paper reviews screening and follow-up strategies for patients who have been diagnosed with melanoma, based on current available evidence, and focuses on methods to assess disease recurrence and second primary occurrence. Secondary prevention, including the roles of behavioral modification and chemoprevention are also reviewed. The role of follow-up dermatologist consultation, with focused physical examinations complemented by dermatoscopy, reflectance confocal microscopy, and/or full-body mapping is discussed. Furthermore, we address the inclusion of routine imaging and laboratory assessment as components of follow-up and monitoring of advanced stage melanoma. The role of physicians in addressing the psychosocial stresses associated with a diagnosis of melanoma is reviewed.

Site and timing of first relapse in stage III melanoma patients: implications for follow-up guidelines

PURPOSE

Stage III melanoma is associated with a high risk of relapse and mortality. Nevertheless, follow-up guidelines have largely been empirical rather than evidence-based.

PATIENTS AND METHODS

Clinical records of stage III patients with no evidence of disease seen at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1992 and 2004, who ultimately relapsed, were reviewed retrospectively to evaluate date of first relapse, time to first relapse, method of first relapse detection, and survival. We also determined overall 5-year relapse-free survival (RFS) of all stage III patients seen at MSKCC during this period.

RESULTS

The overall 5-year RFS for stage IIIA, IIIB, and IIIIC patients was 63%, 32%, and 11%, respectively. Among relapsing patients, 340 had adequate follow-up to be evaluable for all parameters. Site of first relapse was local/in-transit (28%), regional nodal (21%), or systemic (51%). First relapses were detected by the patient or family, physician, or by screening radiologic tests in 47%, 21%, and 32% of patients, respectively. Multivariate analysis revealed that better overall survival was associated with younger age and first relapse being local/in-transit or nodal, asymptomatic, or resectable. For each substage, we estimated site-specific risk of first relapse.

CONCLUSION

Patients detected almost half of first relapses. Our data suggest that routine physical examinations beyond 3 years for stage IIIA, 2 years for stage IIIB, and 1 year for stage IIIC patients and radiologic imaging beyond 3 years for stages IIIA and IIIB and 2 years for stage IIIC patients would be expected to detect few first systemic relapses.

Sun protection and skin self-examination in melanoma survivors

OBJECTIVES

Patients diagnosed with melanoma are at risk for developing recurrent and second primary disease. Skin self-examination (SSE) and sun protection are standard clinical recommendations to minimize risk. In this study we examined performance of these behaviors in individuals with melanoma drawn from the general population.

METHODS

Potential participants (N=148) with a first primary melanoma diagnosed in 2000 were identified through a population-based cancer registry in New Jersey, USA. One hundred and fifteen individuals participated in a 30 min telephone interview concerning behavioral adherence with SSE and sun protection, self-efficacy for performing these behaviors, and perceived risk of developing another skin cancer. We utilized logistic regression to estimate potential associations of demographic, medical, and psychosocial factors with SSE and sun protection, respectively.

RESULTS

Seventeen percent of subjects reported performing comprehensive SSE at least once every two months and 23% engaged in regular sun protection. Utilization of SSE was related to the presence of moles (OR=4.2, 95% CI: 1.1-15) and higher SSE self-efficacy (OR=14.4, 95% CI: 1.9-112). Regular sun protection was related to older age (>60 years; OR=3.3, 95% CI: 1.3-8.7), being female (OR=2.8, 95% CI: 1.1-7.3), and higher sun protection self-efficacy (OR=5.0, 95% CI: 1.4-18). These factors remained significant in multivariate models.

CONCLUSION

In this group of primary melanoma survivors, the rates of SSE and sun protection are comparable to, but do not exceed, general population estimates. This study provides justification for further research to address barriers to prevention and control behaviors in melanoma survivors.

GP-led melanoma follow-up: the practical experience of GPs

OBJECTIVES

To explore how GP-led melanoma follow-up had actually worked from the perspective of GPs by exploring in detail the practical experience of GPs running the programme.

DESIGN

Semi-structured audio-taped telephone interviews with GPs delivering a GP-led follow-up programme for people with cutaneous malignant melanoma.

SUBJECTS

Seventeen GPs currently delivering structured GP-led routine follow-up for people with cutaneous melanoma.

RESULTS

GP-led melanoma follow-up worked well from the perspectives of GPs. The GPs felt that they were well equipped and supported in undertaking the follow-up consultations and recognized that they were freeing up hospital consultant time. They felt that patients appreciated the convenience of GP-led follow-up. The GPs felt that a robust recall system, initial training with regular refreshers and effective consultant backup were vital components of a successful long-term programme.

CONCLUSIONS

GP-led melanoma follow-up is feasible and, provided certain concerns can be addressed, GPs are willing to provide it.

Costs of the detection of metastases and follow-up examinations in cutaneous melanoma

At present, no universally accepted recommendations exist for cutaneous melanoma follow-up. Various surveillance strategies, some associated with significant cost, others of uncertain value, are routinely used. This study aimed to evaluate of the costs incurred for varied surveillance strategies practiced in Europe and the USA. One thousand nine hundred and sixty-nine cutaneous melanoma patients with stage I-III disease attending the Department of Dermatology, University of Tuebingen for follow-up between 1996 and 1998 participated in the study. Routine surveillance consisted of cutaneous examination, lymph node and abdomen sonography, chest radiograph (CR) and blood tests. The costs incurred were based upon the 2004 German official scale for medical reimbursement and the 2004 Medicare fee reimbursement schedule (USA). The total charges were based on the number of recurrences detected per stage. Recurrences were detected in 1.5% of patients with stage I, 18.0% in stage II, and 68.6% in stage III. Physical examination was the most effective method, detecting 50.0% of recurrences. Lymph node sonography was effective in stage II-III, detecting 13.2% of recurrences; CR and abdominal sonography, detecting 4.5 and 3.4% of recurrences, were deemed beneficial in stage III. Blood tests detected 1.4% of recurrences and were deemed to be ineffective. Computed tomography scans were valuable in clarifying ambiguous findings and helping to detect 22.5% of recurrences (1.9% in stage I, 1.9% in stage II, and 18.6% in stage III). A risk-adapted surveillance strategy for stage I-II including thorough history, physical examination and lymph node sonography but omitting CR, blood work and abdomen sonography, seems appropriate and cost effective.

Whole body positron emission tomography in follow-up of high risk melanoma

The aim of this study was to determine the clinical impact of whole body positron emission tomography (FDG PET) to detect clinically silent metastases in the follow-up of patients with high risk melanoma. FDG PET was performed to 30 asymptomatic melanoma patients (AJCC stage IIB-IIIC) 7-24 months after the primary surgery and sentinel node biopsy. FDG PET was able to detect six of seven recurrences, constituting 20% of all study patients. One patient presented with a negative FDG PET finding at the very first scanning, but was positive later in a repeated scan after manifestation of palpable mass in the axilla. The positive PET finding had an impact on treatment decisions in every case: three patients underwent surgical resection and four patients received chemotherapy or interferon. The mean follow-up time was 27 months (range, 12-48 months) and during that time the other 23 patients with true negative FDG PET were disease-free. One of the seven recurrences was in remission after surgical metastasectomy. In conclusion, whole body FDG PET is a valuable follow-up tool in high risk melanoma to diagnose recurrences and to select the patients, who are suitable for surgical metastasectomy.