Skin cancer. Melanoma and other specific nonmelanoma skin cancers

Synergistic inhibitory actions of resveratrol, epigallocatechin-3-gallate, and diallyl trisulfide against skin cancer cell line A431 through mitochondrial caspase dependent pathway: a combinational drug approach

The harmful effect of chemotherapeutic side effects has paid a way to discover a novel with curative way for skin cancer treatment. Skin cancer prevention is more viable with the use of combination of bioactive agents than using of single bioactive compounds. Present work was demonstrated to evaluate the interaction of Resveratrol (Res), Epigallocatechin-3-gallate (EGCG), and diallyl trisulfide (DATS) with each other as a binary combination on A431 cells. Nuclear fragmentation analysis of combination of bioactive agents using DAPI analysis, detection of apoptosis, analysis of cell cycle, ROS assay, antimigration assays, and western blotting were implemented to study the combination of bioactive compounds on A431 cell line. Among the selected combination EGCG + DATS had a synergetic effect reducing cellular migration, increased intercellular reactive oxygen species generation, condensation, cell phagocytosis induced by phosphatidylserine externalization, rise in sub-G1 DNA content, and S-phase were cell cycle arrest. The combinations EGCG + DATS induced apoptotic proteins in A431 cells by upregulation of proapoptotic Bax and Bad proteins, a downmodulation of anti-apoptotic proteins Bcl2 and caspases (caspase-3, and -9) activity got triggered by intrinsic pathway. The combination of EGCG + DATS showed good anticancer potential against A431 skin cancer cell line via the mitochondrial caspase dependent pathway with very strong synergism. This finding will help to produce a novel combination/chemoprevention using dietary bioactive agents (EGCG + DATS) for the treatment of skin cancer after clinical trial.

Skin Cancer in People of Color: A Systematic Review

BACKGROUND

People of African, Asian, Hispanic or Latino, Pacific Islander, and Native Indian descent are considered people of color by the Skin of Color Society (SOCS).

OBJECTIVES

In this study, we assess incidence, risk factors, clinical characteristics, histopathology, treatment, and survival for skin malignancies in people of color as defined by the SOCS, by systematically reviewing the literature.

METHODS

An electronic literature search of the PubMed, EMBASE, and MEDLINE databases was performed. Articles published from 1 January 1990 through 12 December 2020 were included in the search.

RESULTS

We identified 2666 publications potentially meeting the study criteria. Titles and abstracts of these studies were reviewed and 2353 were excluded. The full text of 313 articles were evaluated and 251 were included in this review.

CONCLUSION

Differences in incidence, patterns, treatment, and survival exist among people of color for cutaneous malignancies. Further research and initiatives are needed to account for and mitigate these differences.

The 2018 World Health Organization Classification of Cutaneous, Mucosal, and Uveal Melanoma: Detailed Analysis of 9 Distinct Subtypes Defined by Their Evolutionary Pathway

CONTEXT.—

There have been major advances in the understanding of melanoma since the last revision of the World Health Organization (WHO) classification in 2006.

OBJECTIVE.—

To discuss development of the 9 distinct types of melanoma and distinguishing them by their epidemiology, clinical and histologic morphology, and genomic characteristics. Each melanoma subtype is placed at the end of an evolutionary pathway that is rooted in its respective precursor, wherever appropriate and feasible, based on currently known data. Each precursor has a variable risk of progression culminating in its fully evolved, invasive melanoma.

DATA SOURCES.—

This review is based on the "Melanocytic Tumours" section of the 4th edition of the WHO Classification of Skin Tumours, published in 2018.

CONCLUSIONS.—

Melanomas were divided into those etiologically related to sun exposure and those that are not, as determined by their mutational signatures, anatomic site, and epidemiology. Melanomas on the sun-exposed skin were further divided by the histopathologic degree of cumulative solar damage (CSD) of the surrounding skin, into low and high CSD, on the basis of degree of associated solar elastosis. Low-CSD melanomas include superficial spreading melanomas and high-CSD melanomas incorporate lentigo maligna and desmoplastic melanomas. The "nonsolar" category includes acral melanomas, some melanomas in congenital nevi, melanomas in blue nevi, Spitz melanomas, mucosal melanomas, and uveal melanomas. The general term melanocytoma is proposed to encompass "intermediate" tumors that have an increased (though still low) probability of disease progression to melanoma.

Clinical and Biological Characterization of Skin Pigmentation Diversity and Its Consequences on UV Impact

Skin color diversity is the most variable and noticeable phenotypic trait in humans resulting from constitutive pigmentation variability. This paper will review the characterization of skin pigmentation diversity with a focus on the most recent data on the genetic basis of skin pigmentation, and the various methodologies for skin color assessment. Then, melanocyte activity and amount, type and distribution of melanins, which are the main drivers for skin pigmentation, are described. Paracrine regulators of melanocyte microenvironment are also discussed. Skin response to sun exposure is also highly dependent on color diversity. Thus, sensitivity to solar wavelengths is examined in terms of acute effects such as sunburn/erythema or induced-pigmentation but also long-term consequences such as skin cancers, photoageing and pigmentary disorders. More pronounced sun-sensitivity in lighter or darker skin types depending on the detrimental effects and involved wavelengths is reviewed.

Density-based parallel skin lesion border detection with webCL

Background

Dermoscopy is a highly effective and noninvasive imaging technique used in diagnosis of melanoma and other pigmented skin lesions. Many aspects of the lesion under consideration are defined in relation to the lesion border. This makes border detection one of the most important steps in dermoscopic image analysis. In current practice, dermatologists often delineate borders through a hand drawn representation based upon visual inspection. Due to the subjective nature of this technique, intra- and inter-observer variations are common. Because of this, the automated assessment of lesion borders in dermoscopic images has become an important area of study.

Methods

Fast density based skin lesion border detection method has been implemented in parallel with a new parallel technology called WebCL. WebCL utilizes client side computing capabilities to use available hardware resources such as multi cores and GPUs. Developed WebCL-parallel density based skin lesion border detection method runs efficiently from internet browsers.

Results

Previous research indicates that one of the highest accuracy rates can be achieved using density based clustering techniques for skin lesion border detection. While these algorithms do have unfavorable time complexities, this effect could be mitigated when implemented in parallel. In this study, density based clustering technique for skin lesion border detection is parallelized and redesigned to run very efficiently on the heterogeneous platforms (e.g. tablets, SmartPhones, multi-core CPUs, GPUs, and fully-integrated Accelerated Processing Units) by transforming the technique into a series of independent concurrent operations. Heterogeneous computing is adopted to support accessibility, portability and multi-device use in the clinical settings. For this, we used WebCL, an emerging technology that enables a HTML5 Web browser to execute code in parallel for heterogeneous platforms. We depicted WebCL and our parallel algorithm design. In addition, we tested parallel code on 100 dermoscopy images and showed the execution speedups with respect to the serial version. Results indicate that parallel (WebCL) version and serial version of density based lesion border detection methods generate the same accuracy rates for 100 dermoscopy images, in which mean of border error is 6.94%, mean of recall is 76.66%, and mean of precision is 99.29% respectively. Moreover, WebCL version's speedup factor for 100 dermoscopy images' lesion border detection averages around ~491.2.

Conclusions

When large amount of high resolution dermoscopy images considered in a usual clinical setting along with the critical importance of early detection and diagnosis of melanoma before metastasis, the importance of fast processing dermoscopy images become obvious. In this paper, we introduce WebCL and the use of it for biomedical image processing applications. WebCL is a javascript binding of OpenCL, which takes advantage of GPU computing from a web browser. Therefore, WebCL parallel version of density based skin lesion border detection introduced in this study can supplement expert dermatologist, and aid them in early diagnosis of skin lesions. While WebCL is currently an emerging technology, a full adoption of WebCL into the HTML5 standard would allow for this implementation to run on a very large set of hardware and software systems. WebCL takes full advantage of parallel computational resources including multi-cores and GPUs on a local machine, and allows for compiled code to run directly from the Web Browser.

Chemical analysis of constitutive pigmentation of human epidermis reveals constant eumelanin to pheomelanin ratio

The skin constitutive pigmentation is given by the amount of melanin pigment, its relative composition (eu/pheomelanin) and distribution within the epidermis, and is largely responsible for the sensitivity to UV exposure. Nevertheless, a precise knowledge of melanins in human skin is lacking. We characterized the melanin content of human breast skin samples with variable pigmentations rigorously classified through the Individual Typology Angle (ITA) by image analysis, spectrophotometry after solubilization with Soluene-350 and high-performance liquid chromatography (HPLC) after chemical degradation. ITA and total melanin content were found correlated, ITA and PTCA (degradation product of DHICA melanin), and TTCA (degradation product of benzothiazole-type pheomelanin) as well but not 4-AHP (degradation product of benzothiazine-type pheomelanin). Results revealed that human epidermis comprises approximately 74% of eumelanin and 26% pheomelanin, regardless of the degree of pigmentation. They also confirm the low content of photoprotective eumelanin among lighter skins thereby explaining the higher sensitivity toward UV exposure.

Melanoma risk perception and prevention behavior among African-Americans: the minority melanoma paradox

Introduction

Melanoma is the most deadly type of skin cancer with 75% of all skin cancer deaths within the US attributed to it. Risk factors for melanoma include ultraviolet exposure, genetic predisposition, and phenotypic characteristics (eg, fair skin and blond hair). Whites have a 27-fold higher incidence of melanoma than African-Americans (AA), but the 5-year survival is 17.8% lower for AA than Whites. It is reported continuously that AA have more advanced melanomas at diagnosis, and overall lower survival rates. This minority melanoma paradox is not well understood or studied.

Objective

To explore further, the possible explanations for the difference in melanoma severity and survival in AA within the US.

Methods

Qualitative review of the literature.

Results

Lack of minority-targeted public education campaigns, low self-risk perception, low self-skin examinations, intrinsic virulence, vitamin D differences, and physician mistrust may play a role in the melanoma survival disparity among AA.

Conclusion

Increases in public awareness of melanoma risk among AA through physician and media-guided education, higher index of suspicion among individuals and physicians, and policy changes can help to improve early detection and close the melanoma disparity gap in the future.

Cumulative ultraviolet radiation flux in adulthood and risk of incident skin cancers in women

BACKGROUND

Solar ultraviolet (UV) exposure estimated based on residential history has been used as a sun exposure indicator in previous case-control and descriptive studies. However, the associations of cumulative UV exposure based on residential history with different skin cancers, including melanoma, squamous cell carcinoma (SCC), and basal cell carcinoma (BCC), have not been evaluated simultaneously in prospective studies.

METHODS

We conducted a cohort study among 108,578 women in the Nurses' Health Study (1976-2006) to evaluate the relative risks of skin cancers with cumulative UV flux based on residential history in adulthood.

RESULTS

Risk of SCC and BCC was significantly lower for women in lower quintiles vs the highest quintile of cumulative UV flux (both P for trend <0.0001). The association between cumulative UV flux and risk of melanoma did not reach statistical significance. However, risk of melanoma appeared to be lower among women in lower quintiles vs the highest quintile of cumulative UV flux in lag analyses with 2-10 years between exposure and outcome. The multivariable-adjusted hazard ratios per 200 × 10(-4) Robertson-Berger units increase in cumulative UV flux were 0.979 (95% confidence interval (CI): 0.933, 1.028) for melanoma, 1.072 (95% CI: 1.041, 1.103) for SCC, and 1.043 (95% CI: 1.034, 1.052) for BCC.

CONCLUSIONS

Associations with cumulative UV exposure in adulthood among women differed for melanoma, SCC, and BCC, suggesting a potential variable role of UV radiation in adulthood in the carcinogenesis of the three major skin cancers.

5-Year Review of a Unique Multidisciplinary Nonmelanoma Skin Cancer Clinic

Background:

A multidisciplinary nonmelanoma skin cancer (NMSC) clinic is held weekly at our center, where all new patients are jointly assessed by dermatology/dermatopathology, radiation oncology, and plastic surgery. A new patient database was established in 2004. The purpose of this study was to provide a preliminary report on the patients seen in the NMSC clinic and the treatment recommendations rendered.

Methods:

The new patient database was reviewed from January 2004 to December 2008, and patient demographics, tumor characteristics, and treatment recommendations were extracted. Cochran-Mantel-Harnszel (CMH) testing and chi-square analysis were used to detect any associations or relationships between variables within the database. A p value of less than .05 was considered significant.

Results:

During the 5-year study period, 2,146 new patients were seen in the NMSC clinic. The majority of patients presented with basal cell carcinoma (64%) or squamous cell carcinoma (22%), with a median tumor size of 1 to 2 cm (range 0 to #x003E; 9 cm). Tumors were located in the head and neck region (80%), extremities (14%), and torso (6%). Previous treatment included biopsy only (62%), surgery (20%), electrodesiccation and curettage (11%), topical imiquimod (3%), and radiotherapy (1%). Treatment recommendations included surgery (55%) (with either simple excision [31%] or excision with margin control under frozen-section guidance [24%]), radiotherapy (19%), topical imiquimod (10%), observation (7%), and electrodesiccation and curettage (4%).

Conclusions:

The NMSC clinic at our center sees a high volume of patients who benefit from the multidisciplinary assessment provided. Treatment recommendations were based on patient and disease characteristics as well as patient preference.

Primary cutaneous malignancies in sub-Saharan Africa

Cutaneous malignancies are the most common malignancies in Whites; traditionally considered rare among Blacks, their occurrence in sub-Saharan Africa is yet to be fully characterized.Data on specimens submitted between 1992 and April 2008 on all histologically proven primary cutaneous malignancies were collected from the Pathology Department, including patient age, sex, anatomic site of malignancy, and histologic diagnosis. There were 1900 patients with primary cutaneous malignancies, aged between 8 months and 110 years, with a mean age of 49 years. There were 14 different types of malignancies found, with squamous cell carcinoma representing 45% of the total. A number of the rarer types have not been reported previously, from this region.Cutaneous malignancies in Africa present a number of management challenges including the following: difficulties in early diagnosis in the dark skin, late presentation, access to treatment, and the ability to pay for the appropriate treatment. The current human immunodeficiency virus/acquired immune deficiency syndrome scourge on the continent may lead a significant increase in cutaneous malignancies, posing even bigger challenges.

Burden of malignancy after a primary skin cancer: recurrence, multiple skin cancers and second primary cancers

The current paper summarizes relevant recent research on the high risk of recurrence, multiple skin cancers and second primary cancers in the growing number of people with a history of skin cancer; the ultimate purpose is to better assess the burden of malignancy following skin cancer. A number of challenges exist in identifying and tracking both melanoma and non-melanoma skin cancer (NMSC) cases. Most jurisdictions do not routinely track NMSC cases and, even if they do, it is customary to only include the first diagnosis. There are variable rules for counting multiple melanoma cancers, and recurrences are not considered for either major type of skin cancer. Applying insights from recent studies of this issue to Canadian cancer statistics would increase reported diagnoses of NMSC by about 26% and melanoma by 10% in this country. This approach to a fuller assessment of the burden of skin cancers has been called a "diagnosis-based incidence approach" as compared with a "patient-based incidence approach". A further issue that is not usually taken into account when assessing the burden of skin cancers is the 20% to 30% elevated risk of noncutaneous second primary cancers following a primary skin tumour. In summary, individuals with skin cancer are subject to a high risk of recurrence, multiple skin cancers and second primary cancers. This burden should be a special concern in the large and growing pool of individuals with a history of skin cancer, as well as among prevention planners.

Nevi of Special Sites

Melanocytic nevi can have a wide range of histologic appearances. Within the spectrum of nevi, there exists a group that presents in certain anatomic locations with histologically worrisome features but nonetheless benign behavior. This group of nevi has been broadly categorized as nevi of special sites. The anatomic locations affected by this group include the embryonic milkline (breast, axillae, umbilicus, genitalia), flexural areas, acral surfaces, ear, and scalp. Nevi in these locations may be mistaken for melanomas because of their histologic appearance, resulting in inappropriate overtreatment of patients. In this article, the authors review the histologic features of these special site nevi and discuss the criteria that help distinguish them from melanoma.

Melanoma in Hispanic and Black Americans

Background

Although age-adjusted incidence rates (per 100,000) for melanoma are lower among Hispanics and blacks (4.5 and 1.0, respectively) compared with white non-Hispanics (21.6), melanomas among minority populations in the United States are more likely to metastasize and have poorer outcomes.

Methods

A review of the literature was conducted on melanomas affecting Hispanic and black Americans.

Results

Because of the low index of suspicion in both the medical community and these ethnic populations, diagnosis is often delayed, resulting in advanced presentation and a poorer prognosis.

Conclusions

More comprehensive medical training, expanded public educational campaigns, and increased awareness among patients of all skin types to perform self skin checks are recommended. Further studies elucidating the etiology and risk factors for melanoma among minority populations are warranted.

Detailed site distribution of melanoma and sunlight exposure: aetiological patterns from a Swiss series

BACKGROUND

The relation between detailed cutaneous distribution of melanoma and indicators of sun exposure patterns has scantily been explored in moderately sun-sensitive populations.

PATIENTS AND METHODS

The precise site of 1658 primary malignant melanoma, registered from 1995 to 2002, in Switzerland were retrieved and clinically validated. Relative melanoma density (RMD) was computed by the ratio of observed to expected number of melanoma allowing for body site surface areas, and further adjusted for site-specific melanocyte density.

RESULTS

Sites of highest risks were the face, shoulder and upper arm for both sexes, the back for men, and leg for women. Major features of this series were: (i) an unexpectedly high RMD for the face in women (5.6 versus 3.7 in men), (ii) the absence of a male predominance for melanoma on the ears and (iii) for the upper limbs, a steady gradient of increasing melanoma density with increasing proximity to the trunk, regardless of sex. Age and sex patterns of RMD parallelled general indicators of sun exposure and behaviour, except for the hand (RMD = 0.2).

CONCLUSION

RMD increased with (cumulative) site sun exposure, but a few notable exceptions support the impact of intermittent exposure in melanoma risk.

Multiple Primary Acral Melanomas in African-Americans: A Case Series and Review of the Literature

BACKGROUND

Although melanoma accounts for only 4% to 5% of all skin cancers in the United States, it causes most skin cancer-related deaths. We describe a unique group of African-American patients with multiple primary acral lentiginous melanomas (ALMs).

OBJECTIVE

The purpose of this study was to review the case histories and management of a cohort of patients in the Mohs practice of our dermatologic surgeon with multiple primary ALM.

METHODS

This is a case series of patients with multiple ALM identified by chart review from 2000 to 2005. A thorough review of the literature was performed.

RESULTS

Four patients, all African-American, were identified with multiple ALM. All patients were managed with excision or Mohs micrographic surgery utilizing permanent sections. None of the patients with ALM had melanomas at nonacral sites or other types of skin cancer. Several had acral melanosis. Information in the literature on patients with multiple primary acral melanomas was insufficient.

CONCLUSION

Patients with multiple acral melanomas have not, to our knowledge, been reported thus far. It can be extrapolated from current literature, however, that appropriate management of these patients, including staging work and surgical intervention, is to be determined by the individual characteristics of the melanoma and the patient's concomitant risk factors, if any.

Relationship between skin response to ultraviolet exposure and skin color type

Sun exposure is responsible for detrimental damage ranging from sunburn to photoaging and skin cancer. This damage is likely to be influenced by constitutive pigmentation. The relationship between ultraviolet (UV) sensitivity and skin color type was analyzed on 42 ex vivo skin samples objectively classified from light to dark skin, based on their values of individual typology angle (ITA) determined by colorimetric parameters. The biologically efficient dose (BED) was determined for each sample by quantifying sunburn cells after exposure to increasing doses of UV solar-simulated radiation. Typical UV-induced biologic markers, other than erythema, such as DNA damage, apoptosis and p53 accumulation, were analyzed. A statistically significant correlation was found between ITA and BED and, ITA and DNA damage. Interestingly, DNA lesions were distributed throughout the whole epidermal layers and the uppermost dermal cells in light, intermediate and tanned skin while they were restricted to suprabasal epidermal layers in brown or dark skin. Our data support, at the cellular level, the relationship between UV sensitivity and skin color type. They emphasize the impact of DNA damage accumulation in basal layer in relation to the prevalence of skin cancer.

Skin cancer in skin of color

Skin cancer is less common in persons with skin of color than in light-skinned Caucasians but is often associated with greater morbidity and mortality. Thus, it is crucial that physicians become familiar with skin cancer in persons of color so as to maximize the likelihood of early detection of these tumors. In dark-skinned ethnic groups, squamous cell carcinoma is most common; squamous cell carcinoma and melanoma usually occur on nonsun-exposed sites; and ultraviolet radiation is not an important etiologic factor for skin cancer with the exception of basal cell carcinoma. Races of intermediate pigmentation, such as Hispanics and Asians, share epidemiologic and clinical features of dark-skinned ethnic groups and Caucasians. Skin cancers pose a significant risk in skin of color and clinicians should focus on preventive measures in these groups such as regular skin exams, self-examination, public education, and screening programs.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the epidemiology and unique clinical features of skin cancer in skin of color and be aware of strategies to prevent skin cancer in skin of color.

Role of Sun Exposure in Melanoma

BACKGROUND

Malignant melanoma is the third most common skin cancer in the United States. It is commonly thought that sun exposure is causative in these tumors. Recently, however, the significance of the role of sun exposure in melanoma has come into question. Some have suggested that other factors, such as genetics, play a larger role, and that sun protection may even be harmful.

OBJECTIVE AND METHODS

To investigate the role of sun exposure in melanoma etiology. An extensive review of basic science and clinical literature on this subject was conducted.

RESULTS

Although exceptions exist, sun exposure likely plays a large role in most melanomas. The pattern of this exposure, however, is not fully known, and controversy exists, especially in the use of sunscreens. Sun exposure may interact with genetic factors to cause melanomas, and sun protective measures appear to be prudent.

CONCLUSIONS

The cause of melanoma is probably variable and multifactorial. Sun exposure may play a primary or supporting role in most melanoma tumors.

Precursors to melanoma and their mimics: nevi of special sites

Melanocytic nevi, which are benign tumors of melanocytes, may have occasional cosmetic significance but, for the most part, they are important only in relation to melanoma. Nevi are the most important simulants of melanoma, both clinically and histologically, and can usually be reliably distinguished from melanomas using published criteria. Some lesions are characterized by greater degrees of atypia and may be more difficult to diagnose. Dysplastic nevi are among the most important simulants of melanoma. Nevi may also be important as potential precursors of melanoma; however, most nevi are stable and will not progress to malignancy. Nevi are vastly more common than melanomas and the rate of progression of individual lesions is very low. Therefore, nevi are not as a rule managed by wholesale excision to prevent melanoma. Nevi are also important as risk markers, identifying individuals at greater risk of developing melanoma in the future. Dysplastic nevi and, to a lesser extent, common acquired and congenital nevi are among the most important melanoma risk markers. Nevi of special sites have been identified as nevi that may show atypical features suggestive of a dysplastic nevus or of a melanoma. However, they are not risk markers and they are not malignancies. Nevi of genital skin, acral skin, and flexural skin are among the most important 'nevi of special sites'. It is important, in considering the differential diagnosis of a lesion in a special site, to avoid overcalling such a lesion as a melanoma or a dysplastic nevus because this could lead to excessive treatment. Conversely, it is important to avoid undercalling a lesion that is a dysplastic nevus or a melanoma as a nevus of special sites, because in this circumstance a patient could lose the opportunity either for surveillance to recognize a developing melanoma at an early, curable stage, or for definitive treatment of an established malignancy. In this monograph, dysplastic nevi and nevi of special sites are compared and contrasted in relation to melanoma.

Primary malignant melanoma of the vulva--an aggressive tumor for modeling the genesis of non-UV light-associated melanomas

Malignant melanomas appear in such sun-shielded areas as the vulva, challenging conventional knowledge that they are associated with UV radiation. Based on 1442 patients with vulvar melanomas the tumors' epidemiology, clinical manifestations, histopathology, molecular genetics, treatment strategies, and prognosis were surveyed. Despite their sun-shielded location and rare incidence, vulvar melanomas were, on average, more dense than melanomas on the body surface and nearly the density of melanomas in chronically sun-exposed skin of the head and neck. Vulvar melanomas differed markedly from cutaneous melanomas, as evidenced by histopathological lesions and molecular genetics. Most melanomas were located on the glabrous skin as opposed to the hairy skin within the vulva and differed significantly in biological properties. The prognosis for the patients was poor, and in the 11 largest studies of surgical strategies, none offered a significant survival advantage. Tumor thickness and ulceration were usually significant predictors of (poor) prognosis in multivariate analyses along with macroscopic amelanosis, angioinvasion or DNA non-diploidy in some reports. Clear-cut biological differences between vulvar and cutaneous melanomas and between melanomas within different vulvar sites provide new paths for extensive research on melanomagenesis and for potential therapies. Additionally, studies of vulvar and other extracutaneous melanomas should characterize subgroups of cutaneous melanomas and identify their cause(s), which are apparently not linked to UV radiation.

The small leucine-rich proteoglycan lumican inhibits melanoma progression

Lumican is a member of the small leucine-rich proteoglycan (SLRP) family. It contributes to the organisation of the collagen network and plays an important role in cell migration and tissue repair. The present study aimed to determine the influence of lumican expression on adhesion, anchorage-dependent and -independent growth, migration, in vitro invasion and in vivo melanoma growth. For that purpose, B16F1 mouse melanoma cells were stably transfected with an expression plasmid containing the complete lumican cDNA. Lumican expression by tumor cells did not change the proliferative activity of mouse melanoma cells in monolayer culture and did not influence either cell adhesion to extracellular matrix gel or type I collagen or cell spreading on these substrates. In contrast, lumican-transfected cells were characterized by a strong reduction of their anchorage-independent proliferation in agarose gel and capacity to invade extracellular matrix gel. After subcutaneous injections of transfected B16F1 cells in syngenic mice, lumican expression significantly decreased subcutaneous tumor formation in vivo, with a concomitant decrease of cyclin D1 expression. Lumican induced and/or increased the apoptosis of B16F1 cells. The results suggest that lumican is involved in the control of melanoma growth and invasion and may be considered, like decorin, as an anti-tumor factor from the extracellular matrix.

Conjunctival melanoma: is it increasing in the United States?

PURPOSE

While the incidence of cutaneous melanoma has been found to have increased over time, the evidence for conjunctival melanoma is not as clear. We applied a large cancer registry database to determine whether any changes had occurred in the incidence of conjunctival melanoma.

DESIGN

Descriptive epidemiologic analysis.

METHOD

Using population-based registry data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI), we identified 206 newly diagnosed patients with conjunctival melanoma from 1973 to 1999. For analysis purposes, we calculated age-adjusted incidence rates and described temporal changes, using joinpoint regression model.

RESULTS

Overall estimated biannual percent change (EBAPC) was 5.5 (95% confidence interval [CI] = 2.3, 8.8; P <.001). The significant elevated trend was observed for white men (EBAPC = 11.2; 95% CI = 6.3, 16.3; P <.001) but not for white women (EBAPC = 0.3; 95% CI = -4.1, 4.9; P >.05). In white men, the incidence rate increased 295% within the 27 years. Our analysis also showed a significant upward trend in the age group aged 60 years or more (EBAPC = 7.6; 95% CI = 3.9, 11.3; P <.001). Incidence tended to rise in the group aged 40 to 59 years, but it was not statistically significant (EBAPC = 4.4; 95% CI = -2.3, 11.6; P =.1536).

CONCLUSIONS

Substantial temporal changes in the incidence of conjunctival melanoma have occurred in the United States in recent years. The changing incidence patterns coincide with those seen in cutaneous melanoma, suggesting a possible link to a sunlight-related etiology.

Cancer incidence in adolescents and young adults in the United States, 1992-1997

PURPOSE

To examine cancer incidence patterns among adolescents and young adults in the United States.

METHODS

Cancer incidence data from 26 population-based central cancer registries for 1992-1997 were used. Individual cancers were grouped into specific diagnostic groups and subgroups using an integrated classification scheme. The integrated scheme was developed for this study and was based on the most commonly used schemes in population-based epidemiologic studies: Surveillance, Epidemiology, and End Results Program's site groups, International Classification of Childhood Cancer, and International Agency for Research on Cancer's Histological Groups for Comparative Studies. Percent distributions and age-specific incidence rates per million population were computed for adolescents (aged 15-19 years) and young adults (aged 20-24 years) by gender.

RESULTS

The data for 26,010 cancer cases were examined. Among 15-19-year-olds, the five most common cancers were Hodgkin's disease, leukemia, cancer in the brain and other nervous system, bone cancer, and non-Hodgkin's disease. Among 20-24-year-olds, the five most common cancers were Hodgkin's disease, testicular cancer, thyroid cancer, melanoma of the skin, and leukemia. The proportions and rates of the histologic subtypes for most of the common cancers changed with advancing age. For example, among 15-19-year-olds, acute lymphocytic leukemia accounted for approximately 60% of leukemias in males and 50% in females. Among 20-24-year-olds, however, the corresponding percentages of acute lymphocytic leukemia were 37% in males and 31% in females. For ovarian cancer, the germ cell tumor was the most common subtype (54.6% of all ovarian cancers) among 15-19-year-olds. In contrast, ovarian carcinoma was the predominant subtype (70.4%) among 20-24-year-olds. For both age groups, the incidence rates of nodular Hodgkin's disease, melanoma of the skin, and thyroid cancer were significantly greater in females than in males.

CONCLUSIONS

Cancer incidence patterns among adolescents and young adults are distinctive. In these age groups, a transition from predominantly pediatric histologic subtypes to adult subtypes was observed for Hodgkin's disease, leukemia, ovarian cancer, and soft tissue sarcoma. Gender differences were found for Hodgkin's disease, melanoma of the skin, and thyroid cancer.

Controversies in acral lentiginous melanoma

BACKGROUND

Acral lentiginous melanoma (ALM) is a subtype of melanoma initially described only two and half decades ago, but well-recognized by dermatologists today. However, several areas of controversy surround this entity.

OBJECTIVE

The primary aims of this article are to review the literature, highlight recent advances, and review some of the ongoing controversies in ALM.

METHODS

A review of the English language literature was performed.

RESULTS

Controversy continues to surround ALM, particularly in regard to diagnostic histologic and clinical criteria. This leads to difficulties when reviewing studies that evaluate the epidemiology, etiology, and prognosis of ALM.

CONCLUSION

Progress in understanding ALM requires the development of standardized diagnostic criteria.

Malignant melanoma

CONTEXT

The rapidly developing fields of melanoma research are revolutionizing the current concepts on melanoma etiology and pathogenesis and are introducing newer diagnostic techniques and potential therapeutic approaches.

OBJECTIVES

To present the most current concepts on the etiology and pathogenesis of melanoma and to introduce the recent diagnostic techniques and the potential therapeutic approaches.

METHODS

Data sources were reports on melanoma published in the English language literature and observations made using specimens available at Harvard University, Johns Hopkins Medical Center, Albany Medical College, Loyola University Medical Center, and University of Tennessee Health Science Center.

RESULTS

Studies on melanoma containing chromosomal or genetic evaluation were selected for further analysis. Current clinical and pathologic categories with the reported genetic abnormalities were related to the latest information on pigment biology. The data extracted were used to develop a conceptual framework on the pathogenesis of melanoma; the generated model was then evaluated and used to suggest potential therapeutic approaches.

CONCLUSIONS

(1) Melanoma is not genetically homogeneous, and the existing differences between the pathologic categories, particularly in areas such as type of growth phase (radial vs vertical growth), total vertical dimension, ulceration of primary tumor, and metastatic process, have profound prognostic and therapeutic implications. (2) Chromosomal aberrations and gene mutations are found in sporadic and familial melanomas; among the most important are those affecting the 9p21, which contains the p16 locus, a site known to be critical for normal progression of the cell cycle. Aberrant p16 expression is associated with more aggressive behavior. (3) Melanoma cells possess a remarkable repertoire of biosynthetic capacities represented by the production of hormones, growth factors, and their receptors that may sustain and accelerate tumor development and progression. For example, expression of the tumoral products alpha-melanocyte-stimulating hormone and adrenocorticotropic hormone is regulated in vitro by ultraviolet light, a known carcinogen. (4) Melanomas differ from other tumors in their intrinsic capability to express melanogenic enzymes with the corresponding structural proteins to actually synthesize melanin. Melanogenesis-related proteins are rapidly entering the clinical arena, being used not only as diagnostic markers, but also as potential targets for melanoma therapy.

c-MYC and nodular malignant melanoma. A case report

BACKGROUND

The incidence of skin cancer has been rising since the 1950s. About 75% of skin cancer-associated deaths are caused by malignant melanoma. Nodular malignant melanoma accounts for 20% of melanocytic malignant tumors and is associated with a relatively poor prognosis. Extensive research has been undertaken, but a molecular marker that can predict a more aggressive course of melanoma still has not been found.

METHODS

The authors applied cytogenetic and molecular genetic techniques to a case of nodular malignant melanoma. They used comparative genomic hybridization (CGH) to identify chromosomal regions affected by genomic changes and interphase fluorescence in situ hybridization (FISH) on touch preparations of the tissue to elucidate the CGH findings further. To investigate the functionality of the affected c-MYC gene, the authors detected its transcript via reverse transcription and polymerase chain reaction.

RESULTS

CGH revealed a copy number gain in the 6p and 8q24-8qter region. FISH with c-MYC and centromere eight specific probes revealed that the tumor, in contrast to unaffected skin, was characterized by a gain in copy numbers of the c-MYC gene. The c-MYC gene transcript was detected at higher levels in the tumor than in the tissue taken from the safety margin.

CONCLUSIONS

The WAF1 gene located on chromosome 6p, which in this case had a copy number gain, might be involved in melanoma pathogenesis. The authors suggest that the c-MYC gene plays an important role in melanoma development and progression. The c-MYC gene seems to be affected by gaining functional copies, leading to a change in the normally regulated gene-dose effect.

Incidence and survival for cancer in children and young adults in the North of England, 1968-1995: a report from the Northern Region Young Persons' Malignant Disease Registry

The Northern Region Young Persons' Malignant Disease Registry records information on young people under 25 years old diagnosed with cancer in the Northern Region of England. Incidence and survival rates were calculated for children and young adults diagnosed with cancer between 1968 and 1995. There were 2099 (M:F 1.28:1) children (age 0-14 years) and 2217 (M:F 1.23:1) young adults (15-24 years) diagnosed with a first cancer between 1968 and 1995. The age-standardized rate (ASR) for childhood cancer was 121 per million 0 to 14 year-olds per year. For young adults the ASR was 175 per million 15 to 24 year-olds, per year. Incidence of childhood cancer increased over time at a rate of 12 extra cases per million children, per decade (P < 0.001). In young adults incidence rates increased by 16 extra cases per million 15 to 24 year-olds, per decade (P < 0.001). For childhood cancer 5-year survival was 42% for those diagnosed 1968-1977, 57% for 1978-1987 and 71% (95% CI 67-75) for 1988-1995. Survival for young adults over the three periods was 45%, 62% and 73% (95% CI 70-78) respectively. The cumulative risk of developing cancer before the age of 25 is 1 in 285. Over the 28-year period there were significant improvements in survival and modest increases in incidence in both children and young adults.

Overview of skin cancer detection and prevention for the primary care physician

The incidence of both melanoma and nonmelanoma skin cancer is increasing, and an accurate and timely diagnosis is important to reduce the morbidity and mortality associated with these malignancies. Clinical features and examination techniques are discussed, and the need to recognize important secondary tumor characteristics, which supplement the primary diagnosis, is reviewed. Recent evidence on etiologic factors and their importance are addressed to highlight the role of primary prevention. Pediatricians, family physicians, and all primary care physicians are encouraged to promote skin cancer awareness among children and their parents.

A survey of hospital management practices for vulvar melanoma

BACKGROUND

Vulvar melanoma is a very rare form of cancer. The purpose of this study was to describe practice patterns for the management of vulvar melanoma.

STUDY DESIGN

The National Cancer Data Base was reviewed from 1985 through 1994 for patient reports submitted with a diagnosis of vulvar melanoma.

RESULTS

Five hundred sixty-nine patients with vulvar melanoma were identified. A substantial number of patients were older; during the latter period of this study (1990 to 1994), 50% were 70 years old or older. Surgery was used in more than 90% of patients with stages 0 to III. Local excision was used mainly in early-stage (0 and I) disease. Adjuvant therapy was used infrequently. Lymph node evaluation was performed in more than half of the patients, with greater frequency for patients who had advanced disease. The overall 5-year relative survival rate was 62%. If the lymph nodes contained metastases, survival was poor. Patients with recurrent disease also had poor survival.

CONCLUSIONS

Surgery remains the mainstay of therapy for vulvar melanoma. The use of excision and radical operations remained constant during the 10 years of the study.

Melanoma in Kauai, Hawaii, 1981-1990: the significance of in situ melanoma and the incidence trend

BACKGROUND

The incidence of melanoma has often been portrayed as reaching 'epidemic' proportions. The reality of such an epidemic is, however, not clearly established due to the methods of data collection and interpretation. The population-based incidence data and incidence trend of melanoma from the Island of Kauai, Hawaii provide an illustration of this 'epidemic'.

METHODS

We used medical records housed at the dermatology clinic and pathology laboratory in Kauai to: identify residents of Kauai who had their first melanoma during the years 1981-1990; and to measure the 10-year population-based incidence of melanoma.

RESULTS

In Caucasians: A total of 53 Caucasian residents (29 men and 24 women), were identified with an initial episode of melanoma (MM) during the 10-year period. The average annual standardized incidence rate per 100,000 Kauai Caucasian residents was 36. Whereas the incidence of in-situ MM increased during the 10-year period, the incidence of invasive MM did not. The average patient age was 55 years. The trunk and the limbs were the most common anatomic sites of MM. In men, one third of MM occur on the back. In women, one third develop on the leg/thigh. Three patients (6%) had metastasis and eventually died of MM. Thirteen patients (25%) had other skin cancers such as basal cell carcinoma and squamous cell carcinoma at some time. In Filipinos, Japanese and Hawaiians: Three Filipinos (all women), two Japanese (one man and one woman) and one Hawaiian (man) had melanoma. The standardized incidence rates, to the U.S.A. Caucasian population, were 3.1, 0.8 and 2.1 per 100,000 residents, respectively.

CONCLUSIONS

The melanoma incidence in Kauai is one of the highest rates documented in the U.S.A. However, a decreased incidence of invasive melanoma during the 10-year period was unexpected. The finding of nonmelanoma skin cancer in these patients supports a common etiology among these skin cancers.

Large datasets: common uses and caveats

BACKGROUND

Increasingly, large collections of pre-existing data are being used to analyze the occurrence, burden, and health care resources directed to the management of various skin diseases.

OBJECTIVE

This article discusses a number of different types of large datasets along with their common uses. Various concerns about the use of this information are also discussed.

CONCLUSION

Although large datasets provide significant statistical power with readily available data, there are significant concerns, particularly regarding data quality and statistical analysis. Readers need to be aware of how an investigator has addressed these issues. Furthermore, the profession needs to be cognizant of very legitimate public concerns regarding confidentiality of personal information.

Multiple primary melanomas

BACKGROUND

The diagnosis of primary melanoma increases the risk of additional primary melanomas.

OBJECTIVE

We characterize the subgroup of patients with multiple melanomas.

METHODS

We reviewed the melanoma database.

RESULTS

Sixty patients with multiple primary melanomas were identified. Twelve (20%) experienced melanomas in the same regional location, 43 (72%) in different locations, and 5 (8%) in both the same and different locations (> 2 melanomas). Eighteen (30%) were diagnosed concurrently with multiple melanomas, 38 (63%) subsequently, and 4 (7%) concurrently and subsequently (>2 melanomas). Forty-two percent of subsequent melanomas occurred within 3 years of the initial lesion diagnosis, 9 (17%) between 3 and 7 years, and 22 (42%) after more than 7 years. Subsequent melanomas were thinner in 70% of cases (P = .05). The mean age at first melanoma diagnosis was 38 and 59 years, respectively, for those with and without dysplastic nevi (P < .001).

CONCLUSION

In patients with multiple melanomas, subsequent melanomas often occur in different regional locations several years after diagnosis of the initial lesion.

Conjunctival melanoma in the black population

Melanoma of the conjunctiva is a rare, unilateral malignancy primarily affecting middle-aged whites; the annual average age-adjusted incidence rate is 0.012 per 100,000 population. Although conjunctival melanoma in the black population is extremely rare, cases have been reported. Melanoma of skin in blacks has a predilection for nonsun-exposed, nonpigmented sites such as mucous membranes, palms, and soles. Primary acquired melanosis may lead to the development of melanoma even in blacks. Primary acquired melanosis in the black population may be difficult to differentiate from racial melanosis clinically and histopathologically. Early diagnosis through awareness and education can help improve the survival of black patients with conjunctival melanoma.