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Orme SE, Moncrieff MD. A Review of Contemporary Guidelines and Evidence for Wide Local Excision in Primary Cutaneous Melanoma Management. Cancers (Basel) 2024; 16:895. [PMID: 38473257 DOI: 10.3390/cancers16050895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
Surgical wide local excision (WLE) remains the current standard of care for primary cutaneous melanoma. WLE is an elective procedure that aims to achieve locoregional disease control with minimal functional and cosmetic impairment. Despite several prospective randomised trials, the optimal extent of excision margin remains controversial, and this is reflected in the persistent lack of consensus in guidelines globally. Furthermore, there is now the added difficulty of interpreting existing trial data in the context of the evolving role of surgery in the management of melanoma, with our increased understanding of clinicopathologic and genomic prognostic markers leading to the often routine use of sentinel node biopsy (SNB) as a staging procedure, in addition to the development of adjuvant systemic therapies for high-risk disease. An ongoing trial, MelMarT-II, has been designed with the aim of achieving a definitive answer to guide this fundamental surgical decision.
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Affiliation(s)
- Sophie E Orme
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Marc D Moncrieff
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
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Khalid M, Sutterfield B, Minley K, Ottwell R, Abercrombie M, Heath C, Torgerson T, Hartwell M, Vassar M. The Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines Focused on the Management of Cutaneous Melanoma: Cross-Sectional Analysis. JMIR DERMATOLOGY 2023; 6:e43821. [PMID: 38060306 PMCID: PMC10739238 DOI: 10.2196/43821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/28/2023] [Accepted: 09/15/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) inform evidence-based decision-making in the clinical setting; however, systematic reviews (SRs) that inform these CPGs may vary in terms of reporting and methodological quality, which affects confidence in summary effect estimates. OBJECTIVE Our objective was to appraise the methodological and reporting quality of the SRs used in CPGs for cutaneous melanoma and evaluate differences in these outcomes between Cochrane and non-Cochrane reviews. METHODS We conducted a cross-sectional analysis by searching PubMed for cutaneous melanoma guidelines published between January 1, 2015, and May 21, 2021. Next, we extracted SRs composing these guidelines and appraised their reporting and methodological rigor using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklists. Lastly, we compared these outcomes between Cochrane and non-Cochrane SRs. All screening and data extraction occurred in a masked, duplicate fashion. RESULTS Of the SRs appraised, the mean completion rate was 66.5% (SD 12.29%) for the PRISMA checklist and 44.5% (SD 21.05%) for AMSTAR. The majority of SRs (19/50, 53%) were of critically low methodological quality, with no SRs being appraised as high quality. There was a statistically significant association (P<.001) between AMSTAR and PRISMA checklists. Cochrane SRs had higher PRISMA mean completion rates and higher methodological quality than non-Cochrane SRs. CONCLUSIONS SRs supporting CPGs focused on the management of cutaneous melanoma vary in reporting and methodological quality, with the majority of SRs being of low quality. Increasing adherence to PRISMA and AMSTAR checklists will likely increase the quality of SRs, thereby increasing the level of evidence supporting cutaneous melanoma CPGs.
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Affiliation(s)
- Mahnoor Khalid
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Bethany Sutterfield
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Kirstien Minley
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Ryan Ottwell
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - McKenna Abercrombie
- Dermatology Residency, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, United States
| | - Christopher Heath
- Dermatology Residency, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, United States
| | - Trevor Torgerson
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Micah Hartwell
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
| | - Matt Vassar
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, United States
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De Ravin E, Suresh N, Romeo D, Lu J, Shah M, Karakousis G, Moreira A, Rajasekaran K. Clinical Practice Guidelines on Sentinel Lymph Node Biopsy for Melanoma: A Systematic Review and Quality Appraisal Using the AGREE II Instrument. Ann Surg Oncol 2022; 29:8364-8372. [PMID: 36121581 DOI: 10.1245/s10434-022-12525-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/29/2022] [Indexed: 11/18/2022]
Abstract
Sentinel lymph node biopsy (SLNB) is a minimally invasive surgical procedure that is standard of care for the evaluation of clinically negative regional lymph nodes in patients with cutaneous melanoma. As the presence of metastases dictates patient prognosis and determines the need for further regional disease control or adjuvant therapy, SLNB is invaluable to clinical decision-making in patients presenting with melanoma. However, the indications for SLNB, specifically among patients with thin (<1 mm) or thick (>4 mm) melanomas, remain unclear. A number of clinical practice guidelines (CPGs) have been developed outlining recommendations for the role of lymph node biopsy in the management of melanoma. However, to date, their quality has not been critically appraised. Our objective was to systematically evaluate all available CPGs on this topic using the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Four total guidelines met the inclusion criteria and underwent appraisal. Only one CPG achieved a "high" quality rating, indicating scores of >60% in at least five of the six AGREE II domains. Across all CPGs, the lowest scoring domains were "Applicability" and "Stakeholder involvement," which had average scores of 41.2% and 48.3%, respectively. Based on the AGREE II instrument, the quality of existing CPGs for the indications of SLNB for melanoma is low. Future guidelines should be pilot tested to evaluate barriers to application and should utilize multidisciplinary guideline development teams that include patients and key stakeholders in addition to clinical experts from all relevant disciplines.
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Affiliation(s)
- Emma De Ravin
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Neeraj Suresh
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Dominic Romeo
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph Lu
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mitali Shah
- Drexel University College of Medicine, Drexel University, Philadelphia, PA, USA
| | - Giorgos Karakousis
- Department of Surgical Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, TX, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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4
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Park S, Yun SJ. Acral Melanocytic Neoplasms: A Comprehensive Review of Acral Nevus and Acral Melanoma in Asian Perspective. Dermatopathology (Basel) 2022; 9:292-303. [PMID: 35997352 PMCID: PMC9397077 DOI: 10.3390/dermatopathology9030035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Acral melanocytic neoplasms, including acral melanocytic nevus and acral melanoma, are common melanocytic lesions in Asian populations. Both lesions occur on the volar surface of the hands and feet, and on nail units. Acral melanocytic nevi occur on the arch area of the sole, whereas acral melanomas frequently occur on weight-bearing areas of the sole, and on the fingernails. Therefore, the development of acral melanoma may be associated with chronic pressure, physical stress, or trauma. Dermoscopy is a useful adjunctive diagnostic tool for differential diagnosis. Acral melanocytic nevus is characterized by a parallel furrow pattern, whereas acral melanoma has a parallel ridge pattern. Genetic alterations are also different between the two types of lesion. BRAF and NRAS mutations are common in acral melanocytic nevus, whereas acral melanoma shows lower rates of KIT, NF1, BRAF, and NRAS mutations and remarkable copy number variations in genes such as CCND1, CDK4, hTERT, PAK1, and GAB2. Sentinel lymph node biopsy is important for staging and prognosis. Contemporary treatments for melanoma include targeted therapy for mutations and immunotherapy, such as anti-PD1 inhibitors.
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Affiliation(s)
- Sanghyun Park
- Department of Dermatology, Chonnam National University Hwasun Hospital, Hwasun 58128, Korea
| | - Sook-Jung Yun
- Department of Dermatology, Chonnam National University Hwasun Hospital, Hwasun 58128, Korea
- Department of Dermatology, Chonnam National University Medical School, Gwangju 59626, Korea
- Correspondence:
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Sharib J, Slingluff CL, Beasley GM. Melanoma trials that defined surgical management: Overview of trials that established NCCN margin guidelines. J Surg Oncol 2022; 125:28-33. [PMID: 34897715 PMCID: PMC8682801 DOI: 10.1002/jso.26717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/06/2021] [Indexed: 01/03/2023]
Abstract
Since the observation that clearance of all visible and microscopic tumors from cutaneous melanoma is critical to prevent a recurrence, wide surgical margins have been central to surgical dogma. In the last several decades, more conservative margin widths have been vigorously studied by surgical investigators to lessen wound complications, the need for reconstruction, and healthcare costs. This review summarizes surgeon-led clinical trials that define current guidelines and highlights the challenges to initiate and perform trials today.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Craig L Slingluff
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
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Bozsányi S, Varga NN, Farkas K, Bánvölgyi A, Lőrincz K, Lihacova I, Lihachev A, Plorina EV, Bartha Á, Jobbágy A, Kuroli E, Paragh G, Holló P, Medvecz M, Kiss N, Wikonkál NM. Multispectral Imaging Algorithm Predicts Breslow Thickness of Melanoma. J Clin Med 2021; 11:jcm11010189. [PMID: 35011930 PMCID: PMC8745435 DOI: 10.3390/jcm11010189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/21/2021] [Accepted: 12/26/2021] [Indexed: 12/20/2022] Open
Abstract
Breslow thickness is a major prognostic factor for melanoma. It is based on histopathological evaluation, and thus it is not available to aid clinical decision making at the time of the initial melanoma diagnosis. In this work, we assessed the efficacy of multispectral imaging (MSI) to predict Breslow thickness and developed a classification algorithm to determine optimal safety margins of the melanoma excision. First, we excluded nevi from the analysis with a novel quantitative parameter. Parameter s’ could differentiate nevi from melanomas with a sensitivity of 89.60% and specificity of 88.11%. Following this step, we have categorized melanomas into three different subgroups based on Breslow thickness (≤1 mm, 1–2 mm and >2 mm) with a sensitivity of 78.00% and specificity of 89.00% and a substantial agreement (κ = 0.67; 95% CI, 0.58–0.76). We compared our results to the performance of dermatologists and dermatology residents who assessed dermoscopic and clinical images of these melanomas, and reached a sensitivity of 60.38% and specificity of 80.86% with a moderate agreement (κ = 0.41; 95% CI, 0.39–0.43). Based on our findings, this novel method may help predict the appropriate safety margins for curative melanoma excision.
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Affiliation(s)
- Szabolcs Bozsányi
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
- Selye János Doctoral College for Advanced Studies, Clinical Sciences Research Group, 1085 Budapest, Hungary
| | - Noémi Nóra Varga
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Klára Farkas
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - András Bánvölgyi
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Kende Lőrincz
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Ilze Lihacova
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, 1004 Riga, Latvia; (I.L.); (A.L.); (E.V.P.)
| | - Alexey Lihachev
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, 1004 Riga, Latvia; (I.L.); (A.L.); (E.V.P.)
| | - Emilija Vija Plorina
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, 1004 Riga, Latvia; (I.L.); (A.L.); (E.V.P.)
| | - Áron Bartha
- Department of Bioinformatics, Semmelweis University, 1085 Budapest, Hungary;
- 2nd Department of Pediatrics, Semmelweis University, 1085 Budapest, Hungary
| | - Antal Jobbágy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Enikő Kuroli
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, 1085 Budapest, Hungary
| | - György Paragh
- Department of Dermatology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA;
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA
| | - Péter Holló
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Márta Medvecz
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Norbert Kiss
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
| | - Norbert M. Wikonkál
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, 1085 Budapest, Hungary; (S.B.); (N.N.V.); (K.F.); (A.B.); (K.L.); (A.J.); (E.K.); (P.H.); (M.M.); (N.K.)
- Correspondence:
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Dash G, Pradhan S, Naik S. Unusual Morphological Presentation of Cutaneous Malignant Melanoma: A Rare Case Report. Indian Dermatol Online J 2021; 12:139-141. [PMID: 33768036 PMCID: PMC7982043 DOI: 10.4103/idoj.idoj_387_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/10/2020] [Accepted: 09/20/2020] [Indexed: 11/04/2022] Open
Abstract
Cutaneous malignant melanoma is a rapidly progressing skin tumor accounting for most deaths from skin malignancies. Four morphological variants (nodular, superficial spreading, lentigo maligna, and acral lentiginous) are described in the literature. Here we are reporting malignant melanoma in a 35-year-old male who presented with depigmented plaques with few hyperpigmented areas and extensive overlying scaling. The patient progressed to the nodular stage within 2 weeks and succumbed to death during chemotherapy. We are reporting such rare presentation of malignant melanoma to create awareness among dermatologists to avoid misdiagnosis and delayed treatment which can lead to rapid progression and fatal outcome.
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Affiliation(s)
- Gaurav Dash
- Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Swetalina Pradhan
- Department of Dermatology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Subhasini Naik
- Department of Pathology, Prolife Diagnostics, Bhubaneswar, Odisha, India
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Kim E, Obermeyer I, Rubin N, Khariwala SS. Prognostic significance of regression and mitotic rate in head and neck cutaneous melanoma. Laryngoscope Investig Otolaryngol 2020; 6:109-115. [PMID: 33614938 PMCID: PMC7883603 DOI: 10.1002/lio2.509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/17/2020] [Indexed: 12/28/2022] Open
Abstract
Importance While regression is a commonly reported microscopic feature of melanoma, its prognostic significance is unclear. Objective To examine the impact of regression on sentinel node status and the likelihood of recurrence in primary cutaneous melanoma of the head and neck. Design Retrospective analysis of 191 adults who underwent surgical management for primary cutaneous melanoma of the head and neck between May 2002 and March 2019. Setting Tertiary academic center. Participants Patients appropriate for the study were identified by the Academic Health Center Information Exchange using a list of current procedural terminology codes. One hundred and ninety‐one cases of invasive melanoma of the head and neck were included from 830 patients identified. Clinical features assessed for each patient included age, sex, location of primary lesion, date of diagnosis, and current disease status (alive with or without disease). Histologic features assessed were histological melanoma subtype (nodular vs non‐nodular), Breslow thickness, Clark level, presence/absence of ulceration, mitotic rate per square millimeter, and regression. If applicable, sentinel lymph node biopsy (SLNB) status, date of recurrence, interval treatments, and date of death related to melanoma were recorded. Exclusion criteria included melanoma outside the anatomic parameters of head and neck, ocular or choroidal melanoma, mucosal melanoma, metastatic melanoma to the head or neck with no known primary tumor, melanoma of the head or neck with no surgical intervention, and non‐melanoma skin cancers of the head and neck. Intervention/Exposure Surgery for cutaneous melanoma of the head and neck. Main Outcome(s) and Measure(s) The association between presence of regression and Breslow thickness, sentinel node status, and recurrence. Results Of the 191 patients identified, 30.9% were female and 69.1% were male with a mean age at diagnosis of 62.6 (range 20‐97) years. Mean Breslow thickness was 1.2 mm in those with regression and 2.0 mm in those without regression. In patients with regression, 17.6% had a positive sentinel node, and 13.0% experienced a recurrence. In patients without regression, 26.5% had a positive sentinel node, and 31.4% experienced a recurrence. When adjusted for other factors above, regression was not associated with positive sentinel node (odds ratio [OR] = 0.59, 95% confidence interval [CI] = 0.13‐2.00) or recurrence (OR = 0.33, CI = 0.07‐1.01). Mitotic rate >2 was associated with recurrence (OR = 2.71, CI = 1.11‐6.75, P = .03). Conclusions and Relevance Patients with presence of regression had thinner melanomas and trended toward decreased rates of sentinel node positivity and recurrence, suggesting regression may not be a negative prognostic indicator in patients with cutaneous melanoma of the head and neck.
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Affiliation(s)
- Elizabeth Kim
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA
| | - Isaac Obermeyer
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA
| | - Nathan Rubin
- Biostatistics Core, Masonic Cancer Center University of Minnesota Minneapolis Minnesota USA
| | - Samir S Khariwala
- Department of Otolaryngology-Head and Neck Surgery University of Minnesota Minneapolis Minnesota USA
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Babbush KM, Damanpour S. Melanoma Diagnosis and Treatment in the Elderly. CURRENT GERIATRICS REPORTS 2020. [DOI: 10.1007/s13670-020-00330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Response of human melanoma cell lines to interferon-beta gene transfer mediated by a modified adenoviral vector. Sci Rep 2020; 10:17893. [PMID: 33087767 PMCID: PMC7578831 DOI: 10.1038/s41598-020-74826-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/25/2020] [Indexed: 01/08/2023] Open
Abstract
Since melanomas often retain wild type p53, we developed an adenoviral vector, AdRGD-PG, which provides robust transduction and transgene expression in response to p53. Previously, this vector was used for interferon-β gene transfer in mouse models of melanoma, resulting in control of tumor progression, but limited cell killing. Here, the AdRGD-PG-hIFNβ vector encoding the human interferon-β cDNA (hIFNβ) was used to transduce human melanoma cell lines SK-MEL-05 and SK-MEL-147 (both wild type p53). In vitro, cell death was induced in more than 80% of the cells and correlated with elevated annexinV staining and caspase 3/7 activity. Treatment with hIFNβ promoted cell killing in neighboring, non-transduced cells, thus revealing a bystander effect. In situ gene therapy resulted in complete inhibition of tumor progression for SK-MEL-147 when using nude mice with no evidence of hepatotoxicity. However, the response in Nod-Scid mice was less robust. For SK-MEL-05, tumor inhibition was similar in nude and Nod-Scid mice and was less efficient than seen for SK-MEL-147, indicating both cell type and host specific responses. The AdRGD-PG-hIFNβ vector provides extensive killing of human melanoma cells in vitro and a potent anti-tumor effect in vivo. This study provides a critical advance in the development of our melanoma gene therapy approach.
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Lau KL, Bradish T, Rannan-Eliya S. 'Primum non nocere': how harmless is routine wide local excision for AJCC stage IA melanoma? Ann R Coll Surg Engl 2020; 102:483-487. [PMID: 32233852 PMCID: PMC7450430 DOI: 10.1308/rcsann.2020.0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Management of primary cutaneous malignant melanoma is with initial excision biopsy followed by a wide local excision to achieve locoregional control. For low-risk thin melanomas, the added survival benefit from the wide local excision is minimal. In this study, we investigated the morbidities of wide local excision and evaluated the current clinical practice in managing stage IA malignant melanoma. METHODS Patients with confirmed stage IA malignant melanoma who had undergone a wide local excision in the 2013/14 period were identified using a specialist cancer multidisciplinary team-held database. Primary pathology, surgical data and follow-up documentation were analysed. RESULTS A total of 231 cases were identified; 95% of patients (n = 220) had malignant melanoma excised completely at first excision biopsy, mean margin 2.8mm (range 0.5-8.0mm). Postoperative morbidities occurred in 25% of patients (n = 57), including 6.6% wound problems, 10.9% scarring problems, 10.0% psychological stress and 0.4% cosmetic concern. Wide local excision reconstructions were performed with primary closure in 82% of patients, split skin grafts in 4%, full-thickness skin grafts in 3% and flaps in 10%. Of the total, 44% of patients (n = 101) had further excisions and 17 received new low-risk melanoma diagnoses. CONCLUSIONS We demonstrated that 1cm wide local excision is associated with significant morbidity, which can affect patients' physical, psychological and social wellbeing. Since wide local excision does not give a survival advantage, and its margin is already frequently reduced in cosmetically sensitive areas, the need for a second full 1cm wide local excision procedure for thin melanoma should be re-evaluated, especially when 95% of our study cohort had their malignant melanoma completely excised by the initial biopsy alone.
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Affiliation(s)
- KL Lau
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - T Bradish
- Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, UK
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Li X, Cai Y. Risk stratification of cutaneous melanoma reveals carcinogen metabolism enrichment and immune inhibition in high-risk patients. Aging (Albany NY) 2020; 12:16457-16475. [PMID: 32858528 PMCID: PMC7485700 DOI: 10.18632/aging.103734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
Cutaneous melanoma (CM) is the most lethal form of skin cancer. Risk assessment should facilitate stratified surveillance and guide treatment selection. Here, based on the mRNA-seq data from 419 CM patients in the Cancer Genome Atlas (TCGA), we developed a prognostic 21-gene signature to distinguish the outcomes of high- and low-risk patients, which was further validated in two external cohorts. The signature achieved a higher C-index as compared with other known biomarkers and clinical characteristics in both the TCGA and validation cohorts. Notably, in high-risk patients the expression levels of three driver genes, BRAF, NRAS, and NF1 in the MAPK pathway, were lower but exhibited a stronger positive correlation as compared with low-risk patients. Moreover, the genes involved in nicotinamide adenine dinucleotide metabolism were negatively correlated with the expression of BRAF in the high-risk group. Function analysis revealed that the upregulated genes in the high-risk group were enriched in the cytochrome P450-mediated metabolism of chemical carcinogens. Furthermore, the low-risk group had high levels of gamma delta T cells infiltration, while regulatory T cells were accumulated in the high-risk group. The present study offers a promising new prognostic signature for CM, and provides insight into the mechanisms of melanoma progression.
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Affiliation(s)
- Xia Li
- Research Center for Biomedical Information Technology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, P.R. China
| | - Yunpeng Cai
- Research Center for Biomedical Information Technology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, P.R. China
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Scala J, Vojvodic A, Vojvodic P, Vlaskovic-Jovicevic T, Peric-Hajzler Z, Matovic D, Dimitrijevic S, Vojvodic J, Sijan G, Stepic N, Wollina U, Tirant M, Thuong NV, Fioranelli M, Lotti T. New Trends in Cutaneous Melanoma Surgery. Open Access Maced J Med Sci 2019; 7:3090-3092. [PMID: 31850129 PMCID: PMC6910799 DOI: 10.3889/oamjms.2019.828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/18/2022] Open
Abstract
The main surgical treatment for melanoma consists in wide surgical excision of the primary lesion and the sentinel node but in recent times management of melanoma is rapidly evolving with the introduction of new systemic therapies, like BRAF inhibitors, MEK inhibitors and antibodies anti-PD-1 that show good results in controlling even advanced stages of the disease. This review aims to present data for the optimal surgical management of patients with malignant melanoma.
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Affiliation(s)
| | - Aleksandra Vojvodic
- Department of Dermatology and Venereology, Military Medical Academy, Belgrade, Serbia
| | - Petar Vojvodic
- Clinic for Psychiatric Disorders "Dr. Laza Lazarevic", Belgrade, Serbia
| | | | | | | | | | - Jovana Vojvodic
- Clinic for Psychiatric Disorders "Dr. Laza Lazarevic", Belgrade, Serbia
| | - Goran Sijan
- Clinic for Plastic Surgery and Burns, Military Medical Academy, Belgrade, Serbia
| | - Nenad Stepic
- Chief of Clinic for Plastic Surgery and Burns, Military Medical Academy, Belgrade, Serbia
| | - Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Dresden, Germany
| | | | - Nguyen Van Thuong
- Vietnam National Hospital of Dermatology and Venereology, Hanoi, Vietnam
| | - Massimo Fioranelli
- Department of Nuclear Physics, Sub-nuclear and Radiation, G. Marconi University, Rome, Italy
| | - Torello Lotti
- Department of Dermatology, University of G. Marconi, Rome, Italy
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14
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[Surgical excision margins of 2 cm are sufficient for excision of cutaneous melanoma thicker than 2 mm]. Strahlenther Onkol 2019; 195:1039-1040. [PMID: 31463581 DOI: 10.1007/s00066-019-01509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Lee J, Nam S, Kim SJ. Role of 18F-Fluorodeoxyglucose Positron Emission Tomography or Positron Emission Tomography/Computed Tomography for the Detection of Recurrent Disease after Treatment of Malignant Melanoma. Oncology 2019; 97:286-293. [DOI: 10.1159/000501398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/06/2019] [Indexed: 11/19/2022]
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16
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Wright FC, Souter LH, Kellett S, Easson A, Murray C, Toye J, McCready D, Nessim C, Ghazarian D, Hong NJL, Johnson S, Goldstein DP, Petrella T. Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline. Curr Oncol 2019; 26:e541-e550. [PMID: 31548823 PMCID: PMC6726255 DOI: 10.3747/co.26.4885] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck. Methods Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017. Results Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection. Conclusions Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.
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Affiliation(s)
- F C Wright
- Odet te Regional Cancer Cent re, Toronto, ON
| | - L H Souter
- Program in Evidence-Based Care, Hamilton, ON
| | - S Kellett
- Program in Evidence-Based Care, Hamilton, ON
| | - A Easson
- Princess Margaret Hospital, Toronto, ON
| | - C Murray
- Women's College Hospital, Toronto, ON
| | - J Toye
- Royal Victoria Regional Health Centre, Barrie, ON
| | | | | | | | | | | | | | - T Petrella
- Odet te Regional Cancer Cent re, Toronto, ON
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17
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Cai W, Ding X, Li J, Li Z. Methylation analysis highlights novel prognostic criteria in human-metastasized melanoma. J Cell Biochem 2019; 120:11990-12001. [PMID: 30861178 DOI: 10.1002/jcb.28484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 01/24/2023]
Abstract
Melanoma accounts for 90% of the deaths associated with cutaneous neoplasms, and the 5-year survival rate of patients with the advanced stage is about 20%. Many mechanisms are involved in melanoma progression, but dynamic epigenetic changes are likely to be critical contributors, especially for DNA methylation. However, we know little about the methylation events involved in melanoma lymph node metastasis (LNM), a deficit that is of particular concern because it has a growing incidence and mortality. To identify DNA methylated-associated changes involved in the formation of metastatic melanoma, we explored the different methylated genes (DMGs) between primary and LNM melanoma by Illumina Human Methylation 450 K BeadArray GSE44661. By integrating DNA methylation and messenger RNA expression data from The Cancer Genome Atlas database, we identified these DNA methylation biomarkers. Pathway analysis highlighted these DMGs, which were closely related to the carcinogenesis of melanoma, such as cell cycle regulation and RNA transcription process. Furthermore, according to the univariate and multivariate Cox regression analysis, we constructed a four-DMG prognostic signature model, which could precisely predict the outcome of melanoma in a more exact way. In summary, this four-DMG based risk score model successfully predicts the survival of melanoma. It is independent of other clinical characteristics and is good for prognosis prediction.
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Affiliation(s)
- Weiyang Cai
- Department of Oncology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoxia Ding
- Department of Dermatology and Venereology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jingjing Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhiming Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Dinnes J, Ferrante di Ruffano L, Takwoingi Y, Cheung ST, Nathan P, Matin RN, Chuchu N, Chan SA, Durack A, Bayliss SE, Gulati A, Patel L, Davenport C, Godfrey K, Subesinghe M, Traill Z, Deeks JJ, Williams HC. Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma. Cochrane Database Syst Rev 2019; 7:CD012806. [PMID: 31260100 PMCID: PMC6601698 DOI: 10.1002/14651858.cd012806.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used. OBJECTIVES Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles. SELECTION CRITERIA We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity. MAIN RESULTS We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT. AUTHORS' CONCLUSIONS Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | | | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Seau Tak Cheung
- Dudley Hospitals Foundation Trust, Corbett HospitalDepartment of DermatologyWicarage RoadStourbridgeUKDY8 4JB
| | - Paul Nathan
- Mount Vernon HospitalMount Vernon Cancer CentreRickmansworth RoadNorthwoodUKHA6 2RN
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Sue Ann Chan
- City HospitalBirmingham Skin CentreDudley RdBirminghamUKB18 7QH
| | - Alana Durack
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation TrustDermatologyHills RoadCambridgeUKCB2 0QQ
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Abha Gulati
- Barts Health NHS TrustDepartment of DermatologyWhitechapelLondonUKE11BB
| | - Lopa Patel
- Royal Stoke HospitalPlastic SurgeryStoke‐on‐TrentStaffordshireUKST4 6QG
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Manil Subesinghe
- King's College LondonCancer Imaging, School of Biomedical Engineering & Imaging SciencesLondonUK
| | - Zoe Traill
- Oxford University Hospitals NHS TrustChurchill Hospital Radiology DepartmentOxfordUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Falk Delgado A, Zommorodi S, Falk Delgado A. Sentinel Lymph Node Biopsy and Complete Lymph Node Dissection for Melanoma. Curr Oncol Rep 2019; 21:54. [PMID: 31028497 PMCID: PMC6486528 DOI: 10.1007/s11912-019-0798-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose of Review The main surgical treatment for invasive malignant melanoma consists of wide surgical and examination of the sentinel node and in selected cases complete lymph node dissection. The aim of this review is to present data for the optimal surgical management of patients with malignant melanoma. Recent Findings A surgical excision margin of 1–2 cm is recommended for invasive melanoma depending on the thickness of the melanoma. Sentinel node biopsy may be considered for patients with at least T1b melanomas thickness 0.8 to 1.0 mm or less than 0.8 mm Breslow thickness with ulceration, classified as T1b lesion, per recent AJCC guidelines. Two randomized controlled trials have been published—DeCOG (German Dermatologic Cooperative Oncology Group Selective Lymphadenectomy) and MSLT-2 (Multicenter Selective Lymphadenectomy Trial) comparing the complete lymph node dissection (CLND) with observation after positive sentinel node biopsy. In the MSLT-2 study, the disease control rate was improved in the immediate CLND group compared with observation but there was no difference in 3-year melanoma specific survival (86% ± 1.3% and 86% ± 1.2%, respectively; p = 0.42). Isolated limb perfusion (ILP) or isolated limb infusion (ILI) with melphalan and actinomycin D is recommended for large and multiple in-transit metastases and satellite metastases in the extremities when local excision is considered ineffective or too extensive. Summary In light of new adjuvant treatment options and new indications for checkpoint inhibitors, and the lack of survival benefit after CLND, we can expect open surgery to decrease in melanoma disease.
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Affiliation(s)
- Alberto Falk Delgado
- Department of Plastic Surgery, Uppsala University, Ing 85, Akademiska Sjukhuset, 75185, Uppsala, Sweden.
| | - Sayid Zommorodi
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Falk Delgado
- Clinical neurosciences, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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20
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Ferrante di Ruffano L, Dinnes J, Deeks JJ, Chuchu N, Bayliss SE, Davenport C, Takwoingi Y, Godfrey K, O'Sullivan C, Matin RN, Tehrani H, Williams HC. Optical coherence tomography for diagnosing skin cancer in adults. Cochrane Database Syst Rev 2018; 12:CD013189. [PMID: 30521690 PMCID: PMC6516952 DOI: 10.1002/14651858.cd013189] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers, which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised, with potential to infiltrate and damage surrounding tissue. Anxiety around missing early cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Optical coherence tomography (OCT) is a microscopic imaging technique, which magnifies the surface of a skin lesion using near-infrared light. Used in conjunction with clinical or dermoscopic examination of suspected skin cancer, or both, OCT may offer additional diagnostic information compared to other technologies. OBJECTIVES To determine the diagnostic accuracy of OCT for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants, basal cell carcinoma (BCC), or cutaneous squamous cell carcinoma (cSCC) in adults. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA We included studies of any design evaluating OCT in adults with lesions suspicious for invasive melanoma and atypical intraepidermal melanocytic variants, BCC or cSCC, compared with a reference standard of histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standardised data extraction and quality assessment form (based on QUADAS-2). Our unit of analysis was lesions. Where possible, we estimated summary sensitivities and specificities using the bivariate hierarchical model. MAIN RESULTS We included five studies with 529 cutaneous lesions (282 malignant lesions) providing nine datasets for OCT, two for visual inspection alone, and two for visual inspection plus dermoscopy. Studies were of moderate to unclear quality, using data-driven thresholds for test positivity and giving poor accounts of reference standard interpretation and blinding. Studies may not have been representative of populations eligible for OCT in practice, for example due to high disease prevalence in study populations, and may not have reflected how OCT is used in practice, for example by using previously acquired OCT images.It was not possible to make summary statements regarding accuracy of detection of melanoma or of cSCC because of the paucity of studies, small sample sizes, and for melanoma differences in the OCT technologies used (high-definition versus conventional resolution OCT), and differences in the degree of testing performed prior to OCT (i.e. visual inspection alone or visual inspection plus dermoscopy).Pooled data from two studies using conventional swept-source OCT alongside visual inspection and dermoscopy for the detection of BCC estimated the sensitivity of OCT as 95% (95% confidence interval (CI) 91% to 97%) and specificity of 77% (95% CI 69% to 83%).When applied to a hypothetical population of 1000 lesions at the mean observed BCC prevalence of 60%, OCT would miss 31 BCCs (91 fewer than would be missed by visual inspection alone and 53 fewer than would be missed by visual inspection plus dermoscopy), and OCT would lead to 93 false-positive results for BCC (a reduction in unnecessary excisions of 159 compared to using visual inspection alone and of 87 compared to visual inspection plus dermoscopy). AUTHORS' CONCLUSIONS Insufficient data are available on the use of OCT for the detection of melanoma or cSCC. Initial data suggest conventional OCT may have a role for the diagnosis of BCC in clinically challenging lesions, with our meta-analysis showing a higher sensitivity and higher specificity when compared to visual inspection plus dermoscopy. However, the small number of studies and varying methodological quality means implications to guide practice cannot currently be drawn.Appropriately designed prospective comparative studies are required, given the paucity of data comparing OCT with dermoscopy and other similar diagnostic aids such as reflectance confocal microscopy.
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Affiliation(s)
| | - Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | | | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Hamid Tehrani
- Whiston HospitalDepartment of Plastic and Reconstructive SurgeryWarrington RoadLiverpoolUKL35 5DR
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Dinnes J, Deeks JJ, Saleh D, Chuchu N, Bayliss SE, Patel L, Davenport C, Takwoingi Y, Godfrey K, Matin RN, Patalay R, Williams HC. Reflectance confocal microscopy for diagnosing cutaneous melanoma in adults. Cochrane Database Syst Rev 2018; 12:CD013190. [PMID: 30521681 PMCID: PMC6492459 DOI: 10.1002/14651858.cd013190] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Early detection and treatment is key to improving survival; however, anxiety around missing early cases needs to be balanced against appropriate levels of referral and excision of benign lesions. Used in conjunction with clinical or dermoscopic suspicion of malignancy, or both, reflectance confocal microscopy (RCM) may reduce unnecessary excisions without missing melanoma cases. OBJECTIVES To determine the diagnostic accuracy of reflectance confocal microscopy for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with any lesion suspicious for melanoma and lesions that are difficult to diagnose, and to compare its accuracy with that of dermoscopy. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; and seven other databases. We studied reference lists and published systematic review articles. SELECTION CRITERIA Studies of any design that evaluated RCM alone, or RCM in comparison to dermoscopy, in adults with lesions suspicious for melanoma or atypical intraepidermal melanocytic variants, compared with a reference standard of either histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. To compare RCM with dermoscopy, we grouped studies by population (defined by difficulty of lesion diagnosis) and combined data using hierarchical summary receiver operating characteristic (SROC) methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of specificity at the point on the SROC curve with 90% sensitivity as this value lies within the estimates for the majority of analyses. We investigated the impact of using a purposely developed RCM algorithm and in-person test interpretation. MAIN RESULTS The search identified 18 publications reporting on 19 study cohorts with 2838 lesions (including 658 with melanoma), which provided 67 datasets for RCM and seven for dermoscopy. Studies were generally at high or unclear risk of bias across almost all domains and of high or unclear concern regarding applicability of the evidence. Selective participant recruitment, lack of blinding of the reference test to the RCM result, and differential verification were particularly problematic. Studies may not be representative of populations eligible for RCM, and test interpretation was often undertaken remotely from the patient and blinded to clinical information.Meta-analysis found RCM to be more accurate than dermoscopy in studies of participants with any lesion suspicious for melanoma and in participants with lesions that were more difficult to diagnose (equivocal lesion populations). Assuming a fixed sensitivity of 90% for both tests, specificities were 82% for RCM and 42% for dermoscopy for any lesion suspicious for melanoma (9 RCM datasets; 1452 lesions and 370 melanomas). For a hypothetical population of 1000 lesions at the median observed melanoma prevalence of 30%, this equated to a reduction in unnecessary excisions with RCM of 280 compared to dermoscopy, with 30 melanomas missed by both tests. For studies in equivocal lesions, specificities of 86% would be observed for RCM and 49% for dermoscopy (7 RCM datasets; 1177 lesions and 180 melanomas). At the median observed melanoma prevalence of 20%, this reduced unnecessary excisions by 296 with RCM compared with dermoscopy, with 20 melanomas missed by both tests. Across all populations, algorithms and thresholds assessed, the sensitivity and specificity of the Pellacani RCM score at a threshold of three or greater were estimated at 92% (95% confidence interval (CI) 87 to 95) for RCM and 72% (95% CI 62 to 81) for dermoscopy. AUTHORS' CONCLUSIONS RCM may have a potential role in clinical practice, particularly for the assessment of lesions that are difficult to diagnose using visual inspection and dermoscopy alone, where the evidence suggests that RCM may be both more sensitive and specific in comparison to dermoscopy. Given the paucity of data to allow comparison with dermoscopy, the results presented require further confirmation in prospective studies comparing RCM with dermoscopy in a real-world setting in a representative population.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Daniel Saleh
- Newcastle Hospitals NHS Trust, Royal Victoria InfirmaryNewcastle HospitalsNewcastleUK
- The University of Queensland, PA‐Southside Clinical UnitSchool of Clinical MedicineBrisbaneQueenslandAustralia
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Lopa Patel
- Royal Stoke HospitalPlastic SurgeryStoke‐on‐TrentStaffordshireUKST4 6QG
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Rakesh Patalay
- Guy's and St Thomas' NHS Foundation TrustDepartment of DermatologyDSLU, Cancer CentreGreat Maze PondLondonUKSE1 9RT
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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22
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Dinnes J, Deeks JJ, Grainge MJ, Chuchu N, Ferrante di Ruffano L, Matin RN, Thomson DR, Wong KY, Aldridge RB, Abbott R, Fawzy M, Bayliss SE, Takwoingi Y, Davenport C, Godfrey K, Walter FM, Williams HC. Visual inspection for diagnosing cutaneous melanoma in adults. Cochrane Database Syst Rev 2018; 12:CD013194. [PMID: 30521684 PMCID: PMC6492463 DOI: 10.1002/14651858.cd013194] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. History-taking and visual inspection of a suspicious lesion by a clinician is usually the first in a series of 'tests' to diagnose skin cancer. Establishing the accuracy of visual inspection alone is critical to understating the potential contribution of additional tests to assist in the diagnosis of melanoma. OBJECTIVES To determine the diagnostic accuracy of visual inspection for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with limited prior testing and in those referred for further evaluation of a suspicious lesion. Studies were separated according to whether the diagnosis was recorded face-to-face (in-person) or based on remote (image-based) assessment. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA Test accuracy studies of any design that evaluated visual inspection in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. We excluded studies reporting data for 'clinical diagnosis' where dermoscopy may or may not have been used. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. We investigated the impact of: in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; and observer expertise. MAIN RESULTS We included 49 publications reporting on a total of 51 study cohorts with 34,351 lesions (including 2499 cases), providing 134 datasets for visual inspection. Across almost all study quality domains, the majority of study reports provided insufficient information to allow us to judge the risk of bias, while in three of four domains that we assessed we scored concerns regarding applicability of study findings as 'high'. Selective participant recruitment, lack of detail regarding the threshold for deciding on a positive test result, and lack of detail on observer expertise were particularly problematic.Attempts to analyse studies by degree of prior testing were hampered by a lack of relevant information and by the restricted inclusion of lesions selected for biopsy or excision. Accuracy was generally much higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio of 8.54, 95% CI 2.89 to 25.3, P < 0.001). Meta-analysis of in-person evaluations that could be clearly placed on the clinical pathway showed a general trade-off between sensitivity and specificity, with the highest sensitivity (92.4%, 95% CI 26.2% to 99.8%) and lowest specificity (79.7%, 95% CI 73.7% to 84.7%) observed in participants with limited prior testing (n = 3 datasets). Summary sensitivities were lower for those referred for specialist assessment but with much higher specificities (e.g. sensitivity 76.7%, 95% CI 61.7% to 87.1%) and specificity 95.7%, 95% CI 89.7% to 98.3%) for lesions selected for excision, n = 8 datasets). These differences may be related to differences in the spectrum of included lesions, differences in the definition of a positive test result, or to variations in observer expertise. We did not find clear evidence that accuracy is improved by the use of any algorithm to assist diagnosis in all settings. Attempts to examine the effect of observer expertise in melanoma diagnosis were hindered due to poor reporting. AUTHORS' CONCLUSIONS Visual inspection is a fundamental component of the assessment of a suspicious skin lesion; however, the evidence suggests that melanomas will be missed if visual inspection is used on its own. The evidence to support its accuracy in the range of settings in which it is used is flawed and very poorly reported. Although published algorithms do not appear to improve accuracy, there is insufficient evidence to suggest that the 'no algorithm' approach should be preferred in all settings. Despite the volume of research evaluating visual inspection, further prospective evaluation of the potential added value of using established algorithms according to the prior testing or diagnostic difficulty of lesions may be warranted.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Matthew J Grainge
- School of MedicineDivision of Epidemiology and Public HealthUniversity of NottinghamNottinghamUKNG7 2UH
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | | | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | | | - Kai Yuen Wong
- Oxford University Hospitals NHS Foundation TrustDepartment of Plastic and Reconstructive SurgeryOxfordUK
| | - Roger Benjamin Aldridge
- NHS Lothian/University of EdinburghDepartment of Plastic Surgery25/6 India StreetEdinburghUKEH3 6HE
| | - Rachel Abbott
- University Hospital of WalesWelsh Institute of DermatologyHeath ParkCardiffUKCF14 4XW
| | - Monica Fawzy
- Norfolk and Norwich University Hospital NHS TrustDepartment of Plastic and Reconstructive SurgeryColney LaneNorwichUKNR4 7UY
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Fiona M Walter
- University of CambridgePublic Health & Primary CareStrangeways Research Laboratory, Worts CausewayCambridgeUKCB1 8RN
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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23
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Ferrante di Ruffano L, Dinnes J, Chuchu N, Bayliss SE, Takwoingi Y, Davenport C, Matin RN, O'Sullivan C, Roskell D, Deeks JJ, Williams HC. Exfoliative cytology for diagnosing basal cell carcinoma and other skin cancers in adults. Cochrane Database Syst Rev 2018; 12:CD013187. [PMID: 30521689 PMCID: PMC6517175 DOI: 10.1002/14651858.cd013187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early accurate detection of all skin cancer types is essential to guide appropriate management, reduce morbidity and improve survival. Basal cell carcinoma (BCC) is usually localised to the skin but has potential to infiltrate and damage surrounding tissue, while cutaneous squamous cell carcinoma (cSCC) and melanoma have a much higher potential to metastasise and ultimately lead to death. Exfoliative cytology is a non-invasive test that uses the Tzanck smear technique to identify disease by examining the structure of cells obtained from scraped samples. This simple procedure is a less invasive diagnostic test than a skin biopsy, and for BCC it has the potential to provide an immediate diagnosis that avoids an additional clinic visit to receive skin biopsy results. This may benefit patients scheduled for either Mohs micrographic surgery or non-surgical treatments such as radiotherapy. A cytology scrape can never give the same information as a skin biopsy, however, so it is important to better understand in which skin cancer situations it may be helpful. OBJECTIVES To determine the diagnostic accuracy of exfoliative cytology for detecting basal cell carcinoma (BCC) in adults, and to compare its accuracy with that of standard diagnostic practice (visual inspection with or without dermoscopy). Secondary objectives were: to determine the diagnostic accuracy of exfoliative cytology for detecting cSCC, invasive melanoma and atypical intraepidermal melanocytic variants, and any other skin cancer; and for each of these secondary conditions to compare the accuracy of exfoliative cytology with visual inspection with or without dermoscopy in direct test comparisons; and to determine the effect of observer experience. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We also studied the reference lists of published systematic review articles. SELECTION CRITERIA Studies evaluating exfoliative cytology in adults with lesions suspicious for BCC, cSCC or melanoma, compared with a reference standard of histological confirmation. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). Where possible we estimated summary sensitivities and specificities using the bivariate hierarchical model. MAIN RESULTS We synthesised the results of nine studies contributing a total of 1655 lesions to our analysis, including 1120 BCCs (14 datasets), 41 cSCCs (amongst 401 lesions in 2 datasets), and 10 melanomas (amongst 200 lesions in 1 dataset). Three of these datasets (one each for BCC, melanoma and any malignant condition) were derived from one study that also performed a direct comparison with dermoscopy. Studies were of moderate to poor quality, providing inadequate descriptions of participant selection, thresholds used to make cytological and histological diagnoses, and blinding. Reporting of participants' prior referral pathways was particularly poor, as were descriptions of the cytodiagnostic criteria used to make diagnoses. No studies evaluated the use of exfoliative cytology as a primary diagnostic test for detecting BCC or other skin cancers in lesions suspicious for skin cancer. Pooled data from seven studies using standard cytomorphological criteria (but various stain methods) to detect BCC in participants with a high clinical suspicion of BCC estimated the sensitivity and specificity of exfoliative cytology as 97.5% (95% CI 94.5% to 98.9%) and 90.1% (95% CI 81.1% to 95.1%). respectively. When applied to a hypothetical population of 1000 clinically suspected BCC lesions with a median observed BCC prevalence of 86%, exfoliative cytology would miss 21 BCCs and would lead to 14 false positive diagnoses of BCC. No false positive cases were histologically confirmed to be melanoma. Insufficient data are available to make summary statements regarding the accuracy of exfoliative cytology to detect melanoma or cSCC, or its accuracy compared to dermoscopy. AUTHORS' CONCLUSIONS The utility of exfoliative cytology for the primary diagnosis of skin cancer is unknown, as all included studies focused on the use of this technique for confirming strongly suspected clinical diagnoses. For the confirmation of BCC in lesions with a high clinical suspicion, there is evidence of high sensitivity and specificity. Since decisions to treat low-risk BCCs are unlikely in practice to require diagnostic confirmation given that clinical suspicion is already high, exfoliative cytology might be most useful for cases of BCC where the treatments being contemplated require a tissue diagnosis (e.g. radiotherapy). The small number of included studies, poor reporting and varying methodological quality prevent us from drawing strong conclusions to guide clinical practice. Despite insufficient data on the use of cytology for cSCC or melanoma, it is unlikely that cytology would be useful in these scenarios since preservation of the architecture of the whole lesion that would be available from a biopsy provides crucial diagnostic information. Given the paucity of good quality data, appropriately designed prospective comparative studies may be required to evaluate both the diagnostic value of exfoliative cytology by comparison to dermoscopy, and its confirmatory value in adequately reported populations with a high probability of BCC scheduled for further treatment requiring a tissue diagnosis.
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Affiliation(s)
| | - Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | | | - Derek Roskell
- Oxford University Hospitals NHS TrustDepartment of Cellular PathologyJohn Radcliffe HospitalHeadingtonOxfordUKOX3 9DU
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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24
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Ferrante di Ruffano L, Takwoingi Y, Dinnes J, Chuchu N, Bayliss SE, Davenport C, Matin RN, Godfrey K, O'Sullivan C, Gulati A, Chan SA, Durack A, O'Connell S, Gardiner MD, Bamber J, Deeks JJ, Williams HC. Computer-assisted diagnosis techniques (dermoscopy and spectroscopy-based) for diagnosing skin cancer in adults. Cochrane Database Syst Rev 2018; 12:CD013186. [PMID: 30521691 PMCID: PMC6517147 DOI: 10.1002/14651858.cd013186] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and cutaneous squamous cell carcinoma (cSCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Computer-assisted diagnosis (CAD) systems use artificial intelligence to analyse lesion data and arrive at a diagnosis of skin cancer. When used in unreferred settings ('primary care'), CAD may assist general practitioners (GPs) or other clinicians to more appropriately triage high-risk lesions to secondary care. Used alongside clinical and dermoscopic suspicion of malignancy, CAD may reduce unnecessary excisions without missing melanoma cases. OBJECTIVES To determine the accuracy of CAD systems for diagnosing cutaneous invasive melanoma and atypical intraepidermal melanocytic variants, BCC or cSCC in adults, and to compare its accuracy with that of dermoscopy. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA Studies of any design that evaluated CAD alone, or in comparison with dermoscopy, in adults with lesions suspicious for melanoma or BCC or cSCC, and compared with a reference standard of either histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities separately by type of CAD system, using the bivariate hierarchical model. We compared CAD with dermoscopy using (a) all available CAD data (indirect comparisons), and (b) studies providing paired data for both tests (direct comparisons). We tested the contribution of human decision-making to the accuracy of CAD diagnoses in a sensitivity analysis by removing studies that gave CAD results to clinicians to guide diagnostic decision-making. MAIN RESULTS We included 42 studies, 24 evaluating digital dermoscopy-based CAD systems (Derm-CAD) in 23 study cohorts with 9602 lesions (1220 melanomas, at least 83 BCCs, 9 cSCCs), providing 32 datasets for Derm-CAD and seven for dermoscopy. Eighteen studies evaluated spectroscopy-based CAD (Spectro-CAD) in 16 study cohorts with 6336 lesions (934 melanomas, 163 BCC, 49 cSCCs), providing 32 datasets for Spectro-CAD and six for dermoscopy. These consisted of 15 studies using multispectral imaging (MSI), two studies using electrical impedance spectroscopy (EIS) and one study using diffuse-reflectance spectroscopy. Studies were incompletely reported and at unclear to high risk of bias across all domains. Included studies inadequately address the review question, due to an abundance of low-quality studies, poor reporting, and recruitment of highly selected groups of participants.Across all CAD systems, we found considerable variation in the hardware and software technologies used, the types of classification algorithm employed, methods used to train the algorithms, and which lesion morphological features were extracted and analysed across all CAD systems, and even between studies evaluating CAD systems. Meta-analysis found CAD systems had high sensitivity for correct identification of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in highly selected populations, but with low and very variable specificity, particularly for Spectro-CAD systems. Pooled data from 22 studies estimated the sensitivity of Derm-CAD for the detection of melanoma as 90.1% (95% confidence interval (CI) 84.0% to 94.0%) and specificity as 74.3% (95% CI 63.6% to 82.7%). Pooled data from eight studies estimated the sensitivity of multispectral imaging CAD (MSI-CAD) as 92.9% (95% CI 83.7% to 97.1%) and specificity as 43.6% (95% CI 24.8% to 64.5%). When applied to a hypothetical population of 1000 lesions at the mean observed melanoma prevalence of 20%, Derm-CAD would miss 20 melanomas and would lead to 206 false-positive results for melanoma. MSI-CAD would miss 14 melanomas and would lead to 451 false diagnoses for melanoma. Preliminary findings suggest CAD systems are at least as sensitive as assessment of dermoscopic images for the diagnosis of invasive melanoma and atypical intraepidermal melanocytic variants. We are unable to make summary statements about the use of CAD in unreferred populations, or its accuracy in detecting keratinocyte cancers, or its use in any setting as a diagnostic aid, because of the paucity of studies. AUTHORS' CONCLUSIONS In highly selected patient populations all CAD types demonstrate high sensitivity, and could prove useful as a back-up for specialist diagnosis to assist in minimising the risk of missing melanomas. However, the evidence base is currently too poor to understand whether CAD system outputs translate to different clinical decision-making in practice. Insufficient data are available on the use of CAD in community settings, or for the detection of keratinocyte cancers. The evidence base for individual systems is too limited to draw conclusions on which might be preferred for practice. Prospective comparative studies are required that evaluate the use of already evaluated CAD systems as diagnostic aids, by comparison to face-to-face dermoscopy, and in participant populations that are representative of those in which the test would be used in practice.
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Affiliation(s)
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | | | - Abha Gulati
- Barts Health NHS TrustDepartment of DermatologyWhitechapelLondonUKE11BB
| | - Sue Ann Chan
- City HospitalBirmingham Skin CentreDudley RdBirminghamUKB18 7QH
| | - Alana Durack
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation TrustDermatologyHills RoadCambridgeUKCB2 0QQ
| | - Susan O'Connell
- Cardiff and Vale University Health BoardCEDAR Healthcare Technology Research CentreCardiff Medicentre, University Hospital of Wales, Heath Park CampusCardiffWalesUKCF144UJ
| | | | - Jeffrey Bamber
- Institute of Cancer Research and The Royal Marsden NHS Foundation TrustJoint Department of Physics15 Cotswold RoadSuttonUKSM2 5NG
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchEdgbaston CampusBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Dinnes J, Bamber J, Chuchu N, Bayliss SE, Takwoingi Y, Davenport C, Godfrey K, O'Sullivan C, Matin RN, Deeks JJ, Williams HC. High-frequency ultrasound for diagnosing skin cancer in adults. Cochrane Database Syst Rev 2018; 12:CD013188. [PMID: 30521683 PMCID: PMC6516989 DOI: 10.1002/14651858.cd013188] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Early, accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers with the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised, with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Ultrasound is a non-invasive imaging technique that relies on the measurement of sound wave reflections from the tissues of the body. At lower frequencies, the deeper structures of the body such as the internal organs can be visualised, while high-frequency ultrasound (HFUS) with transducer frequencies of 20 MHz or more has a much lower depth of tissue penetration but produces a higher resolution image of tissues and structures closer to the skin surface. Used in conjunction with clinical and/or dermoscopic examination of suspected skin cancer, HFUS may offer additional diagnostic information compared to other technologies. OBJECTIVES To assess the diagnostic accuracy of HFUS to assist in the diagnosis of a) cutaneous invasive melanoma and atypical intraepidermal melanocytic variants, b) cutaneous squamous cell carcinoma (cSCC), and c) basal cell carcinoma (BCC) in adults. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles. SELECTION CRITERIA Studies evaluating HFUS (20 MHz or more) in adults with lesions suspicious for melanoma, cSCC or BCC versus a reference standard of histological confirmation or clinical follow-up. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). Due to scarcity of data and the poor quality of studies, we did not undertake a meta-analysis for this review. For illustrative purposes, we plot estimates of sensitivity and specificity on coupled forest plots. MAIN RESULTS We included six studies, providing 29 datasets: 20 for diagnosis of melanoma (1125 lesions and 242 melanomas) and 9 for diagnosis of BCC (993 lesions and 119 BCCs). We did not identify any data relating to the diagnosis of cSCC.Studies were generally poorly reported, limiting judgements of methodological quality. Half the studies did not set out to establish test accuracy, and all should be considered preliminary evaluations of the potential usefulness of HFUS. There were particularly high concerns for applicability of findings due to selective study populations and data-driven thresholds for test positivity. Studies reporting qualitative assessments of HFUS images excluded up to 22% of lesions (including some melanomas) due to lack of visualisation in the test.Derived sensitivities for qualitative HFUS characteristics were at least 83% (95% CI 75% to 90%) for the detection of melanoma; the combination of three features (lesions appearing hypoechoic, homogenous and well defined) demonstrating 100% sensitivity in two studies (lower limits of the 95% CIs were 94% and 82%), with variable corresponding specificities of 33% (95% CI 20% to 48%) and 73% (95% CI 57% to 85%), respectively. Quantitative measurement of HFUS outputs in two studies enabled decision thresholds to be set to achieve 100% sensitivity; specificities were 93% (95% CI 77% to 99%) and 65% (95% CI 51% to 76%). It was not possible to make summary statements regarding HFUS accuracy for the diagnosis of BCC due to highly variable sensitivities and specificities. AUTHORS' CONCLUSIONS Insufficient data are available on the potential value of HFUS in the diagnosis of melanoma or BCC. Given the between-study heterogeneity, unclear to low methodological quality and limited volume of evidence, we cannot draw any implications for practice. The main value of the preliminary studies included may be in providing guidance on the possible components of new diagnostic rules for diagnosis of melanoma or BCC using HFUS that will require future evaluation. A prospective evaluation of HFUS added to visual inspection and dermoscopy alone in a standard healthcare setting, with a clearly defined and representative population of participants, would be required for a full and proper evaluation of accuracy.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jeffrey Bamber
- Institute of Cancer Research and The Royal Marsden NHS Foundation TrustJoint Department of Physics15 Cotswold RoadSuttonUKSM2 5NG
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | | | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Chuchu N, Dinnes J, Takwoingi Y, Matin RN, Bayliss SE, Davenport C, Moreau JF, Bassett O, Godfrey K, O'Sullivan C, Walter FM, Motley R, Deeks JJ, Williams HC. Teledermatology for diagnosing skin cancer in adults. Cochrane Database Syst Rev 2018; 12:CD013193. [PMID: 30521686 PMCID: PMC6517019 DOI: 10.1002/14651858.cd013193] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be 'store-and-forward' with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time. OBJECTIVES To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer (melanoma, BCC or cutaneous squamous cell carcinoma (cSCC)) in adults, and to compare its accuracy with that of in-person diagnosis. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration. MAIN RESULTS The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases (16 studies) and referral accuracy data for reported data for 1449 lesions and 270 'positive' cases as determined by the reference standard face-to-face decision (six studies). Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer (1588 lesions and 638 malignancies). For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%) (from four studies). Individual study estimates using dermoscopic images or a combination of photographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%) to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%) to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as 'atypical' or 'typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment (sensitivities of over 90%). For lesions considered of less concern when assessed face-to-face (e.g. for lesions not recommended for excision or referral), agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%) to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions. AUTHORS' CONCLUSIONS Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify 'possibly' malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.
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Affiliation(s)
- Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Jacqueline F Moreau
- University of Pittsburgh Medical CenterInternal MedicineDepartment of Medicine, Office of EducationUPMC Montefiore Hospital, N715PittsburghUSAPA, 15213
| | - Oliver Bassett
- Addenbrooke's HospitalPlastic SurgeryHills RoadCambridgeUKCB2 0QQ
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | | | - Fiona M Walter
- University of CambridgePublic Health & Primary CareStrangeways Research Laboratory, Worts CausewayCambridgeUKCB1 8RN
| | - Richard Motley
- University Hospital of WalesWelsh Institute of DermatologyHeath ParkCardiffUKCF14 4XW
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Dinnes J, Deeks JJ, Chuchu N, Ferrante di Ruffano L, Matin RN, Thomson DR, Wong KY, Aldridge RB, Abbott R, Fawzy M, Bayliss SE, Grainge MJ, Takwoingi Y, Davenport C, Godfrey K, Walter FM, Williams HC. Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults. Cochrane Database Syst Rev 2018; 12:CD011902. [PMID: 30521682 PMCID: PMC6517096 DOI: 10.1002/14651858.cd011902.pub2] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Although history-taking and visual inspection of a suspicious lesion by a clinician are usually the first in a series of 'tests' to diagnose skin cancer, dermoscopy has become an important tool to assist diagnosis by specialist clinicians and is increasingly used in primary care settings. Dermoscopy is a magnification technique using visible light that allows more detailed examination of the skin compared to examination by the naked eye alone. Establishing the additive value of dermoscopy over and above visual inspection alone across a range of observers and settings is critical to understanding its contribution for the diagnosis of melanoma and to future understanding of the potential role of the growing number of other high-resolution image analysis techniques. OBJECTIVES To determine the diagnostic accuracy of dermoscopy alone, or when added to visual inspection of a skin lesion, for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in-person), or based on remote (image-based), assessment. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: CENTRAL; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA Studies of any design that evaluated dermoscopy in adults with lesions suspicious for melanoma, compared with a reference standard of either histological confirmation or clinical follow-up. Data on the accuracy of visual inspection, to allow comparisons of tests, was included only if reported in the included studies of dermoscopy. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated accuracy using hierarchical summary receiver operating characteristic (SROC),methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely developed algorithm to assist diagnosis; observer expertise; and dermoscopy training. MAIN RESULTS We included a total of 104 study publications reporting on 103 study cohorts with 42,788 lesions (including 5700 cases), providing 354 datasets for dermoscopy. The risk of bias was mainly low for the index test and reference standard domains and mainly high or unclear for participant selection and participant flow. Concerns regarding the applicability of study findings were largely scored as 'high' concern in three of four domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The accuracy of dermoscopy for the detection of invasive melanoma or atypical intraepidermal melanocytic variants was reported in 86 datasets; 26 for evaluations conducted in person (dermoscopy added to visual inspection), and 60 for image-based evaluations (diagnosis based on interpretation of dermoscopic images). Analyses of studies by prior testing revealed no obvious effect on accuracy; analyses were hampered by the lack of studies in primary care, lack of relevant information and the restricted inclusion of lesions selected for biopsy or excision. Accuracy was higher for in-person diagnosis compared to image-based evaluations (relative diagnostic odds ratio (RDOR) 4.6, 95% confidence interval (CI) 2.4 to 9.0; P < 0.001).We compared accuracy for (a), in-person evaluations of dermoscopy (26 evaluations; 23,169 lesions and 1664 melanomas),versus visual inspection alone (13 evaluations; 6740 lesions and 459 melanomas), and for (b), image-based evaluations of dermoscopy (60 evaluations; 13,475 lesions and 2851 melanomas),versus image-based visual inspection (11 evaluations; 1740 lesions and 305 melanomas). For both comparisons, meta-analysis found dermoscopy to be more accurate than visual inspection alone, with RDORs of (a), 4.7 (95% CI 3.0 to 7.5; P < 0.001), and (b), 5.6 (95% CI 3.7 to 8.5; P < 0.001). For a), the predicted difference in sensitivity at a fixed specificity of 80% was 16% (95% CI 8% to 23%; 92% for dermoscopy + visual inspection versus 76% for visual inspection), and predicted difference in specificity at a fixed sensitivity of 80% was 20% (95% CI 7% to 33%; 95% for dermoscopy + visual inspection versus 75% for visual inspection). For b) the predicted differences in sensitivity was 34% (95% CI 24% to 46%; 81% for dermoscopy versus 47% for visual inspection), at a fixed specificity of 80%, and predicted difference in specificity was 40% (95% CI 27% to 57%; 82% for dermoscopy versus 42% for visual inspection), at a fixed sensitivity of 80%.Using the median prevalence of disease in each set of studies ((a), 12% for in-person and (b), 24% for image-based), for a hypothetical population of 1000 lesions, an increase in sensitivity of (a), 16% (in-person), and (b), 34% (image-based), from using dermoscopy at a fixed specificity of 80% equates to a reduction in the number of melanomas missed of (a), 19 and (b), 81 with (a), 176 and (b), 152 false positive results. An increase in specificity of (a), 20% (in-person), and (b), 40% (image-based), at a fixed sensitivity of 80% equates to a reduction in the number of unnecessary excisions from using dermoscopy of (a), 176 and (b), 304 with (a), 24 and (b), 48 melanomas missed.The use of a named or published algorithm to assist dermoscopy interpretation (as opposed to no reported algorithm or reported use of pattern analysis), had no significant impact on accuracy either for in-person (RDOR 1.4, 95% CI 0.34 to 5.6; P = 0.17), or image-based (RDOR 1.4, 95% CI 0.60 to 3.3; P = 0.22), evaluations. This result was supported by subgroup analysis according to algorithm used. We observed higher accuracy for observers reported as having high experience and for those classed as 'expert consultants' in comparison to those considered to have less experience in dermoscopy, particularly for image-based evaluations. Evidence for the effect of dermoscopy training on test accuracy was very limited but suggested associated improvements in sensitivity. AUTHORS' CONCLUSIONS Despite the observed limitations in the evidence base, dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants, particularly in referred populations and in the hands of experienced users. Data to support its use in primary care are limited, however, it may assist in triaging suspicious lesions for urgent referral when employed by suitably trained clinicians. Formal algorithms may be of most use for dermoscopy training purposes and for less expert observers, however reliable data comparing approaches using dermoscopy in person are lacking.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | | | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | | | - Kai Yuen Wong
- Oxford University Hospitals NHS Foundation TrustDepartment of Plastic and Reconstructive SurgeryOxfordUK
| | - Roger Benjamin Aldridge
- NHS Lothian/University of EdinburghDepartment of Plastic Surgery25/6 India StreetEdinburghUKEH3 6HE
| | - Rachel Abbott
- University Hospital of WalesWelsh Institute of DermatologyHeath ParkCardiffUKCF14 4XW
| | - Monica Fawzy
- Norfolk and Norwich University Hospital NHS TrustDepartment of Plastic and Reconstructive SurgeryColney LaneNorwichUKNR4 7UY
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Matthew J Grainge
- School of MedicineDivision of Epidemiology and Public HealthUniversity of NottinghamNottinghamUKNG7 2UH
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Fiona M Walter
- University of CambridgePublic Health & Primary CareStrangeways Research Laboratory, Worts CausewayCambridgeUKCB1 8RN
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Chuchu N, Takwoingi Y, Dinnes J, Matin RN, Bassett O, Moreau JF, Bayliss SE, Davenport C, Godfrey K, O'Connell S, Jain A, Walter FM, Deeks JJ, Williams HC. Smartphone applications for triaging adults with skin lesions that are suspicious for melanoma. Cochrane Database Syst Rev 2018; 12:CD013192. [PMID: 30521685 PMCID: PMC6517294 DOI: 10.1002/14651858.cd013192] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Melanoma accounts for a small proportion of all skin cancer cases but is responsible for most skin cancer-related deaths. Early detection and treatment can improve survival. Smartphone applications are readily accessible and potentially offer an instant risk assessment of the likelihood of malignancy so that the right people seek further medical attention from a clinician for more detailed assessment of the lesion. There is, however, a risk that melanomas will be missed and treatment delayed if the application reassures the user that their lesion is low risk. OBJECTIVES To assess the diagnostic accuracy of smartphone applications to rule out cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with concerns about suspicious skin lesions. SEARCH METHODS We undertook a comprehensive search of the following databases from inception to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles. SELECTION CRITERIA Studies of any design evaluating smartphone applications intended for use by individuals in a community setting who have lesions that might be suspicious for melanoma or atypical intraepidermal melanocytic variants versus a reference standard of histological confirmation or clinical follow-up and expert opinion. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). Due to scarcity of data and poor quality of studies, we did not perform a meta-analysis for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for each application under consideration. MAIN RESULTS This review reports on two cohorts of lesions published in two studies. Both studies were at high risk of bias from selective participant recruitment and high rates of non-evaluable images. Concerns about applicability of findings were high due to inclusion only of lesions already selected for excision in a dermatology clinic setting, and image acquisition by clinicians rather than by smartphone app users.We report data for five mobile phone applications and 332 suspicious skin lesions with 86 melanomas across the two studies. Across the four artificial intelligence-based applications that classified lesion images (photographs) as melanomas (one application) or as high risk or 'problematic' lesions (three applications) using a pre-programmed algorithm, sensitivities ranged from 7% (95% CI 2% to 16%) to 73% (95% CI 52% to 88%) and specificities from 37% (95% CI 29% to 46%) to 94% (95% CI 87% to 97%). The single application using store-and-forward review of lesion images by a dermatologist had a sensitivity of 98% (95% CI 90% to 100%) and specificity of 30% (95% CI 22% to 40%).The number of test failures (lesion images analysed by the applications but classed as 'unevaluable' and excluded by the study authors) ranged from 3 to 31 (or 2% to 18% of lesions analysed). The store-and-forward application had one of the highest rates of test failure (15%). At least one melanoma was classed as unevaluable in three of the four application evaluations. AUTHORS' CONCLUSIONS Smartphone applications using artificial intelligence-based analysis have not yet demonstrated sufficient promise in terms of accuracy, and they are associated with a high likelihood of missing melanomas. Applications based on store-and-forward images could have a potential role in the timely presentation of people with potentially malignant lesions by facilitating active self-management health practices and early engagement of those with suspicious skin lesions; however, they may incur a significant increase in resource and workload. Given the paucity of evidence and low methodological quality of existing studies, it is not possible to draw any implications for practice. Nevertheless, this is a rapidly advancing field, and new and better applications with robust reporting of studies could change these conclusions substantially.
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Affiliation(s)
- Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Oliver Bassett
- Addenbrooke's HospitalPlastic SurgeryHills RoadCambridgeUKCB2 0QQ
| | - Jacqueline F Moreau
- University of Pittsburgh Medical CenterInternal MedicineDepartment of Medicine, Office of EducationUPMC Montefiore Hospital, N715PittsburghUSAPA, 15213
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Susan O'Connell
- Cardiff and Vale University Health BoardCEDAR Healthcare Technology Research CentreCardiff Medicentre, University Hospital of Wales, Heath Park CampusCardiffWalesUKCF144UJ
| | - Abhilash Jain
- Imperial College Healthcare NHS trust, St Mary’s HospitalDepartment of Plastic and Reconstructive SurgeryLondonUKW2 1NY
| | - Fiona M Walter
- University of CambridgePublic Health & Primary CareStrangeways Research Laboratory, Worts CausewayCambridgeUKCB1 8RN
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
- University Hospitals Birmingham NHS Foundation Trust and University of BirminghamNIHR Birmingham Biomedical Research CentreBirminghamUK
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Seyed Jafari SM, Wiedmer C, Cazzaniga S, Frangež Ž, Shafighi M, Beltraminelli H, Weber B, Simon HU, Hunger RE. Correlation of Vascular Endothelial Growth Factor subtypes and their receptors with melanoma progression: A next-generation Tissue Microarray (ngTMA) automated analysis. PLoS One 2018; 13:e0207019. [PMID: 30408085 PMCID: PMC6224082 DOI: 10.1371/journal.pone.0207019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 10/22/2018] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Finding new markers to assess prognosis of melanoma without the necessity to perform a surgical interventions is an important goal in melanoma research. The current study aimed to assess the correlation of clinical course and prognosis of primary and metastatic melanoma with expression of VEGF family and their receptors. METHODS A ngTMA block was made from the randomly selected paraffin tissue blocks of the patients with melanocytic nevi, primary and metastatic melanoma. Then sections cut from ngTMA-block were immunohistochemically stained with proper antibodies. Expression of these proteins was investigated using automated image analysis and compared among the study groups. RESULTS We analyzed the tissue of 238 patients with following diagnoses: 101 (42.4%) with a diagnosis of nevus, 86 (36.1%) Malignant melanoma and 51 (21.4%) metastasis. Median follow-up time for the malignant lesions was 5.71 years. Among the tested antigen, VEGF-C (p = 0.016), VEGF-R2 (p<0.001) and VEGF-R3 (p = 0.002) were significantly higher expressed in the metastatic tissues. When these scores were assessed in multiple regression models, the only independent factor linked to patient's diagnosis was VEGF-R2 (p<0.001). In addition, groups of highly correlated variables (VEGF-C and VEGF-R3, VEGF-A and VEGF-R1) were found to form separate sub-clusters. On the other side, high values of VEGF-C were associated with both overall and disease-free survival with a statically significant HR of 2.76 (95% CI: 1.27, 5.98; p = 0.01) and 2.82 (95%CI: 1.62, 4.91; p<0.001), respectively. CONCLUSIONS This study shows that VEGF-C and VEGF-R2 might represent new prognostic marker in MM. However, further prospective studies are warranted to test their real efficacy as a prognostic marker.
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Affiliation(s)
- S. Morteza Seyed Jafari
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Christina Wiedmer
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simone Cazzaniga
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centro Studi GISED, Bergamo, Italy
| | - Živa Frangež
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Maziar Shafighi
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Helmut Beltraminelli
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Benedikt Weber
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | - Robert E. Hunger
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Wikstrom JD, Lundeberg L, Frohm-Nilsson M, Girnita A. Differences in cutaneous melanoma treatment and patient satisfaction. PLoS One 2018; 13:e0205517. [PMID: 30359387 PMCID: PMC6201885 DOI: 10.1371/journal.pone.0205517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/17/2018] [Indexed: 11/17/2022] Open
Abstract
Although clinical guidelines exist, the management of patients with cutaneous melanoma (CM) is a complex process that may vary between different care providers with potential dysfunctions ultimately mirrored in the overall patient satisfaction. The aim of the present study was to investigate the CM management as related to lead times, surgical quality and diagnosis communication with the hypothesis that the care may differ between providers and disparities may impact patient satisfaction. Medical records of 181 patients were retrospectively analyzed with parallel patient satisfaction evaluation by telephone interviews. Overall mean lead times from initial diagnosis until completion of all surgery and histopathology reports were 80-100 days and delays occurred at every step of the process. General practitioners performed excision biopsies faster however this was mitigated by slower histopathology processing. University level CM care showed less lag time between excision biopsy, wide local excision for thick melanomas and histopathology confirmation. University level care operated with twice the surgical margin as compared to general practitioners and non-university level specialists. Male patients had larger excision biopsy margins and significantly shorter lead times than female patients. Patient satisfaction rates were generally higher in the academic hospitals as compared to general practitioners and non-university dermatology clinics. Surprisingly, there was no correlation between lead times and patient satisfaction. Taken together, CM show substantial variation and caution should be practiced when using patient satisfaction as a quality indicator.
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Affiliation(s)
- Jakob D. Wikstrom
- Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lena Lundeberg
- Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Margareta Frohm-Nilsson
- Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ada Girnita
- Dermatology and Venereology Unit, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology and Pathology, Cancer Centre Karolinska, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Frerich B. [Treatment of cutaneous malignant melanoma in the head and neck region : An update]. HNO 2018; 66:857-873. [PMID: 30302496 DOI: 10.1007/s00106-018-0573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Major progress has been made in the treatment of malignant melanoma during recent years. On the one hand, reliable evidence-based recommendations regarding surgical resection as well as lymph node management have been established on the basis of results from randomized multicenter studies. On the other hand, the advent of targeted therapies has led to spectacular improvements in the treatment of metastasized melanomas. Knowledge concerning treatment algorithms and updates thereof is also essential for maxillofacial surgeons. The German S3 guideline on diagnosis and treatment of melanoma was published in 2013 and revised in 2016 and 2018. This article informs readers about these developments and addresses the items relevant for treatment of head and neck melanomas in particular.
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Affiliation(s)
- B Frerich
- Klinik und Poliklinik für Mund‑, Kiefer- und Plastische Gesichtschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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Moncrieff MD, Gyorki D, Saw R, Spillane AJ, Thompson JF, Peach H, Oudit D, Geh J, Dziewulski P, Wilson E, Matteucci P, Pritchard-Jones R, Olofsson Bagge R, Wright FC, Crampton N, Cassell O, Jallali N, Berger A, Kelly J, Hamilton S, Durrani A, Lo S, Paton E, Henderson MA. 1 Versus 2-cm Excision Margins for pT2-pT4 Primary Cutaneous Melanoma (MelMarT): A Feasibility Study. Ann Surg Oncol 2018; 25:2541-2549. [PMID: 29850955 PMCID: PMC6097739 DOI: 10.1245/s10434-018-6470-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is a lack of consensus regarding optimal surgical excision margins for primary cutaneous melanoma > 1 mm in Breslow thickness (BT). A narrower surgical margin is expected to be associated with lower morbidity, improved quality of life (QoL), and reduced cost. We report the results of a pilot international study (MelMarT) comparing a 1 versus 2-cm surgical margin for patients with primary melanoma > 1 mm in BT. METHODS This phase III, multicentre trial [NCT02385214] administered by the Australia & New Zealand Medical Trials Group (ANZMTG 03.12) randomised patients with a primary cutaneous melanoma > 1 mm in BT to a 1 versus 2-cm wide excision margin to be performed with sentinel lymph node biopsy. Surgical closure technique was at the discretion of the treating surgeon. Patients' QoL was measured (FACT-M questionnaire) at baseline, 3, 6, and 12 months after randomisation. RESULTS Between January 2015 and June 2016, 400 patients were randomised from 17 centres in 5 countries. A total of 377 patients were available for analysis. Primary melanomas were located on the trunk (56.9%), extremities (35.6%), and head and neck (7.4%). More patients in the 2-cm margin group required reconstruction (34.9 vs. 13.6%; p < 0.0001). There was an increased wound necrosis rate in the 2-cm arm (0.5 vs. 3.6%; p = 0.036). After 12 months' follow-up, no differences were noted in QoL between groups. DISCUSSION This pilot study demonstrates the feasibility of a large international RCT to provide a definitive answer to the optimal excision margin for patients with intermediate- to high-risk primary cutaneous melanoma.
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Affiliation(s)
| | - David Gyorki
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Robyn Saw
- Melanoma Institute Australia, Sydney, Australia
| | | | | | | | | | - Jenny Geh
- Guy's & St Thomas's NHS Trust, London, UK
| | | | | | | | | | | | | | - Nic Crampton
- Gold Coast Melanoma Clinic, Queensland, Australia
| | | | | | - Adam Berger
- Jefferson University Hospitals, Philadelphia, USA
| | - John Kelly
- The Alfred Hospital, Melbourne, Australia
| | | | | | - Serigne Lo
- Melanoma Institute Australia, Sydney, Australia.,Australia & New Zealand Melanoma Trials Group, North Sydney, Australia
| | - Elizabeth Paton
- Melanoma Institute Australia, Sydney, Australia.,Australia & New Zealand Melanoma Trials Group, North Sydney, Australia
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Nurdjaja V, Yozu M, Mathy JA. Essential Components of Melanoma Histopathological Reporting: The Surgical Oncologist's Perspective. J Skin Cancer 2018; 2018:9838410. [PMID: 29854464 PMCID: PMC5954935 DOI: 10.1155/2018/9838410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/10/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022] Open
Abstract
Histopathological reporting plays a critical role in guiding the surgical oncologist's management plan in treatment of primary cutaneous melanoma. The International Collaboration on Cancer Reporting (ICCR) espouses various components of structured histopathological reporting as "essential" or "recommended." From a surgical oncologist's perspective, we discuss the clinical relevance of each essential component, as well as prognostic and treatment implications with regard to treatment planning.
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Affiliation(s)
- Vinka Nurdjaja
- University of Auckland School of Medicine, Auckland, New Zealand
| | - Masato Yozu
- Histopathology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Jon A. Mathy
- University of Auckland School of Medicine, Auckland, New Zealand
- Plastic Surgery Unit, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
- New Zealand Melanoma Institute, Auckland, New Zealand
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Pasquali S, Hadjinicolaou AV, Chiarion Sileni V, Rossi CR, Mocellin S. Systemic treatments for metastatic cutaneous melanoma. Cochrane Database Syst Rev 2018; 2:CD011123. [PMID: 29405038 PMCID: PMC6491081 DOI: 10.1002/14651858.cd011123.pub2] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The prognosis of people with metastatic cutaneous melanoma, a skin cancer, is generally poor. Recently, new classes of drugs (e.g. immune checkpoint inhibitors and small-molecule targeted drugs) have significantly improved patient prognosis, which has drastically changed the landscape of melanoma therapeutic management. This is an update of a Cochrane Review published in 2000. OBJECTIVES To assess the beneficial and harmful effects of systemic treatments for metastatic cutaneous melanoma. SEARCH METHODS We searched the following databases up to October 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase and LILACS. We also searched five trials registers and the ASCO database in February 2017, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA We considered RCTs of systemic therapies for people with unresectable lymph node metastasis and distant metastatic cutaneous melanoma compared to any other treatment. We checked the reference lists of selected articles to identify further references to relevant trials. DATA COLLECTION AND ANALYSIS Two review authors extracted data, and a third review author independently verified extracted data. We implemented a network meta-analysis approach to make indirect comparisons and rank treatments according to their effectiveness (as measured by the impact on survival) and harm (as measured by occurrence of high-grade toxicity). The same two review authors independently assessed the risk of bias of eligible studies according to Cochrane standards and assessed evidence quality based on the GRADE criteria. MAIN RESULTS We included 122 RCTs (28,561 participants). Of these, 83 RCTs, encompassing 21 different comparisons, were included in meta-analyses. Included participants were men and women with a mean age of 57.5 years who were recruited from hospital settings. Twenty-nine studies included people whose cancer had spread to their brains. Interventions were categorised into five groups: conventional chemotherapy (including single agent and polychemotherapy), biochemotherapy (combining chemotherapy with cytokines such as interleukin-2 and interferon-alpha), immune checkpoint inhibitors (such as anti-CTLA4 and anti-PD1 monoclonal antibodies), small-molecule targeted drugs used for melanomas with specific gene changes (such as BRAF inhibitors and MEK inhibitors), and other agents (such as anti-angiogenic drugs). Most interventions were compared with chemotherapy. In many cases, trials were sponsored by pharmaceutical companies producing the tested drug: this was especially true for new classes of drugs, such as immune checkpoint inhibitors and small-molecule targeted drugs.When compared to single agent chemotherapy, the combination of multiple chemotherapeutic agents (polychemotherapy) did not translate into significantly better survival (overall survival: HR 0.99, 95% CI 0.85 to 1.16, 6 studies, 594 participants; high-quality evidence; progression-free survival: HR 1.07, 95% CI 0.91 to 1.25, 5 studies, 398 participants; high-quality evidence. Those who received combined treatment are probably burdened by higher toxicity rates (RR 1.97, 95% CI 1.44 to 2.71, 3 studies, 390 participants; moderate-quality evidence). (We defined toxicity as the occurrence of grade 3 (G3) or higher adverse events according to the World Health Organization scale.)Compared to chemotherapy, biochemotherapy (chemotherapy combined with both interferon-alpha and interleukin-2) improved progression-free survival (HR 0.90, 95% CI 0.83 to 0.99, 6 studies, 964 participants; high-quality evidence), but did not significantly improve overall survival (HR 0.94, 95% CI 0.84 to 1.06, 7 studies, 1317 participants; high-quality evidence). Biochemotherapy had higher toxicity rates (RR 1.35, 95% CI 1.14 to 1.61, 2 studies, 631 participants; high-quality evidence).With regard to immune checkpoint inhibitors, anti-CTLA4 monoclonal antibodies plus chemotherapy probably increased the chance of progression-free survival compared to chemotherapy alone (HR 0.76, 95% CI 0.63 to 0.92, 1 study, 502 participants; moderate-quality evidence), but may not significantly improve overall survival (HR 0.81, 95% CI 0.65 to 1.01, 2 studies, 1157 participants; low-quality evidence). Compared to chemotherapy alone, anti-CTLA4 monoclonal antibodies is likely to be associated with higher toxicity rates (RR 1.69, 95% CI 1.19 to 2.42, 2 studies, 1142 participants; moderate-quality evidence).Compared to chemotherapy, anti-PD1 monoclonal antibodies (immune checkpoint inhibitors) improved overall survival (HR 0.42, 95% CI 0.37 to 0.48, 1 study, 418 participants; high-quality evidence) and probably improved progression-free survival (HR 0.49, 95% CI 0.39 to 0.61, 2 studies, 957 participants; moderate-quality evidence). Anti-PD1 monoclonal antibodies may also result in less toxicity than chemotherapy (RR 0.55, 95% CI 0.31 to 0.97, 3 studies, 1360 participants; low-quality evidence).Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival (HR 0.63, 95% CI 0.60 to 0.66, 1 study, 764 participants; high-quality evidence) and progression-free survival (HR 0.54, 95% CI 0.50 to 0.60, 2 studies, 1465 participants; high-quality evidence). Anti-PD1 monoclonal antibodies may result in better toxicity outcomes than anti-CTLA4 monoclonal antibodies (RR 0.70, 95% CI 0.54 to 0.91, 2 studies, 1465 participants; low-quality evidence).Compared to anti-CTLA4 monoclonal antibodies alone, the combination of anti-CTLA4 plus anti-PD1 monoclonal antibodies was associated with better progression-free survival (HR 0.40, 95% CI 0.35 to 0.46, 2 studies, 738 participants; high-quality evidence). There may be no significant difference in toxicity outcomes (RR 1.57, 95% CI 0.85 to 2.92, 2 studies, 764 participants; low-quality evidence) (no data for overall survival were available).The class of small-molecule targeted drugs, BRAF inhibitors (which are active exclusively against BRAF-mutated melanoma), performed better than chemotherapy in terms of overall survival (HR 0.40, 95% CI 0.28 to 0.57, 2 studies, 925 participants; high-quality evidence) and progression-free survival (HR 0.27, 95% CI 0.21 to 0.34, 2 studies, 925 participants; high-quality evidence), and there may be no significant difference in toxicity (RR 1.27, 95% CI 0.48 to 3.33, 2 studies, 408 participants; low-quality evidence).Compared to chemotherapy, MEK inhibitors (which are active exclusively against BRAF-mutated melanoma) may not significantly improve overall survival (HR 0.85, 95% CI 0.58 to 1.25, 3 studies, 496 participants; low-quality evidence), but they probably lead to better progression-free survival (HR 0.58, 95% CI 0.42 to 0.80, 3 studies, 496 participants; moderate-quality evidence). However, MEK inhibitors probably have higher toxicity rates (RR 1.61, 95% CI 1.08 to 2.41, 1 study, 91 participants; moderate-quality evidence).Compared to BRAF inhibitors, the combination of BRAF plus MEK inhibitors was associated with better overall survival (HR 0.70, 95% CI 0.59 to 0.82, 4 studies, 1784 participants; high-quality evidence). BRAF plus MEK inhibitors was also probably better in terms of progression-free survival (HR 0.56, 95% CI 0.44 to 0.71, 4 studies, 1784 participants; moderate-quality evidence), and there appears likely to be no significant difference in toxicity (RR 1.01, 95% CI 0.85 to 1.20, 4 studies, 1774 participants; moderate-quality evidence).Compared to chemotherapy, the combination of chemotherapy plus anti-angiogenic drugs was probably associated with better overall survival (HR 0.60, 95% CI 0.45 to 0.81; moderate-quality evidence) and progression-free survival (HR 0.69, 95% CI 0.52 to 0.92; moderate-quality evidence). There may be no difference in terms of toxicity (RR 0.68, 95% CI 0.09 to 5.32; low-quality evidence). All results for this comparison were based on 324 participants from 2 studies.Network meta-analysis focused on chemotherapy as the common comparator and currently approved treatments for which high- to moderate-quality evidence of efficacy (as represented by treatment effect on progression-free survival) was available (based on the above results) for: biochemotherapy (with both interferon-alpha and interleukin-2); anti-CTLA4 monoclonal antibodies; anti-PD1 monoclonal antibodies; anti-CTLA4 plus anti-PD1 monoclonal antibodies; BRAF inhibitors; MEK inhibitors, and BRAF plus MEK inhibitors. Analysis (which included 19 RCTs and 7632 participants) generated 21 indirect comparisons.The best evidence (moderate-quality evidence) for progression-free survival was found for the following indirect comparisons:• both combinations of immune checkpoint inhibitors (HR 0.30, 95% CI 0.17 to 0.51) and small-molecule targeted drugs (HR 0.17, 95% CI 0.11 to 0.26) probably improved progression-free survival compared to chemotherapy;• both BRAF inhibitors (HR 0.40, 95% CI 0.23 to 0.68) and combinations of small-molecule targeted drugs (HR 0.22, 95% CI 0.12 to 0.39) were probably associated with better progression-free survival compared to anti-CTLA4 monoclonal antibodies;• biochemotherapy (HR 2.81, 95% CI 1.76 to 4.51) probably lead to worse progression-free survival compared to BRAF inhibitors;• the combination of small-molecule targeted drugs probably improved progression-free survival (HR 0.38, 95% CI 0.21 to 0.68) compared to anti-PD1 monoclonal antibodies;• both biochemotherapy (HR 5.05, 95% CI 3.01 to 8.45) and MEK inhibitors (HR 3.16, 95% CI 1.77 to 5.65) were probably associated with worse progression-free survival compared to the combination of small-molecule targeted drugs; and• biochemotherapy was probably associated with worse progression-free survival (HR 2.81, 95% CI 1.54 to 5.11) compared to the combination of immune checkpoint inhibitors.The best evidence (moderate-quality evidence) for toxicity was found for the following indirect comparisons:• combination of immune checkpoint inhibitors (RR 3.49, 95% CI 2.12 to 5.77) probably increased toxicity compared to chemotherapy;• combination of immune checkpoint inhibitors probably increased toxicity (RR 2.50, 95% CI 1.20 to 5.20) compared to BRAF inhibitors;• the combination of immune checkpoint inhibitors probably increased toxicity (RR 3.83, 95% CI 2.59 to 5.68) compared to anti-PD1 monoclonal antibodies; and• biochemotherapy was probably associated with lower toxicity (RR 0.41, 95% CI 0.24 to 0.71) compared to the combination of immune checkpoint inhibitors.Network meta-analysis-based ranking suggested that the combination of BRAF plus MEK inhibitors is the most effective strategy in terms of progression-free survival, whereas anti-PD1 monoclonal antibodies are associated with the lowest toxicity.Overall, the risk of bias of the included trials can be considered as limited. When considering the 122 trials included in this review and the seven types of bias we assessed, we performed 854 evaluations only seven of which (< 1%) assigned high risk to six trials. AUTHORS' CONCLUSIONS We found high-quality evidence that many treatments offer better efficacy than chemotherapy, especially recently implemented treatments, such as small-molecule targeted drugs, which are used to treat melanoma with specific gene mutations. Compared with chemotherapy, biochemotherapy (in this case, chemotherapy combined with both interferon-alpha and interleukin-2) and BRAF inhibitors improved progression-free survival; BRAF inhibitors (for BRAF-mutated melanoma) and anti-PD1 monoclonal antibodies improved overall survival. However, there was no difference between polychemotherapy and monochemotherapy in terms of achieving progression-free survival and overall survival. Biochemotherapy did not significantly improve overall survival and has higher toxicity rates compared with chemotherapy.There was some evidence that combined treatments worked better than single treatments: anti-PD1 monoclonal antibodies, alone or with anti-CTLA4, improved progression-free survival compared with anti-CTLA4 monoclonal antibodies alone. Anti-PD1 monoclonal antibodies performed better than anti-CTLA4 monoclonal antibodies in terms of overall survival, and a combination of BRAF plus MEK inhibitors was associated with better overall survival for BRAF-mutated melanoma, compared to BRAF inhibitors alone.The combination of BRAF plus MEK inhibitors (which can only be administered to people with BRAF-mutated melanoma) appeared to be the most effective treatment (based on results for progression-free survival), whereas anti-PD1 monoclonal antibodies appeared to be the least toxic, and most acceptable, treatment.Evidence quality was reduced due to imprecision, between-study heterogeneity, and substandard reporting of trials. Future research should ensure that those diminishing influences are addressed. Clinical areas of future investigation should include the longer-term effect of new therapeutic agents (i.e. immune checkpoint inhibitors and targeted therapies) on overall survival, as well as the combination of drugs used in melanoma treatment; research should also investigate the potential influence of biomarkers.
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Affiliation(s)
- Sandro Pasquali
- Sarcoma Service, Fondazione IRCCS 'Istituto Nazionale Tumori', Via G. Venezian 1, Milano, Italy, 20133
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Wu J, Du J, Fu X, Liu B, Cao H, Li T, Su T, Xu J, Tse AKW, Yu ZL. Iciartin, a novel FASN inhibitor, exerts anti-melanoma activities through IGF-1R/STAT3 signaling. Oncotarget 2018; 7:51251-51269. [PMID: 27323414 PMCID: PMC5239473 DOI: 10.18632/oncotarget.9984] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 05/25/2016] [Indexed: 01/07/2023] Open
Abstract
Icaritin (IT) is a flavonoid isolated from Herba Epimedii. In this study, we evaluated the anti-melanoma activities of IT, and determined its cytotoxic mechanism. We found that IT exerted cytotoxicity to melanoma cells. Furthermore, IT induced melanoma cell apoptosis, which was accompanied with PARP cleavage. Mechanistically, IT suppressed p-STAT3 (tyr705) level in parallel with increases of p-STAT3 (ser727), p-ERK and p-AKT. IT significantly inhibited STAT3 nuclear translocation and reduced the levels of STAT3 -targeted genes. IT also inhibited IGF-1-induced STAT3 activation through down-regulation of total IGF-1R level. No dramatic changes in IGF-1R mRNA levels were observed in IT-treated cells, suggesting that IT acted primarily at a post-transcriptional level. Using molecular docking analysis, IT was identified as a novel fatty acid synthase (FASN) inhibitor. We found that IT reduced the level of total IGF-1R via FASN inhibition. In summary, we reported that IT exerted anti-melanoma activities, and these effects were partially due to inhibition of FASN/IGF-1R/STAT3 signaling.
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Affiliation(s)
- Jinfeng Wu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong.,Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Juan Du
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Xiuqiong Fu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Bin Liu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong.,School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Huihui Cao
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Ting Li
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Tao Su
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Jinhua Xu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Anfernee Kai-Wing Tse
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Zhi-Ling Yu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong.,Institute of Integrated Bioinfomedicine and Translational Science, HKBU Shenzhen Research Institute and Continuing Education, Shenzhen, China
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Dinnes J, Saleh D, Newton-Bishop J, Cheung ST, Nathan P, Matin RN, Chuchu N, Bayliss SE, Takwoingi Y, Davenport C, Godfrey K, O'Sullivan C, Deeks JJ, Williams HC. Tests to assist in the staging of cutaneous melanoma: a generic protocol. Hippokratia 2017. [DOI: 10.1002/14651858.cd012806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jacqueline Dinnes
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Daniel Saleh
- Newcastle Hospitals NHS Trust, Royal Victoria Infirmary; Newcastle Hospitals; Newcastle UK
| | - Julia Newton-Bishop
- University of Leeds; Section of Epidemiology and Biostatistics; St James's Hospital Leeds UK LS9 7TF
| | - Seau Tak Cheung
- Dudley Hospitals Foundation Trust, Corbett Hospital; Department of Dermatology; Wicarage Road Stourbridge UK DY8 4JB
| | - Paul Nathan
- Mount Vernon Hospital; Mount Vernon Cancer Centre; Rickmansworth Road Northwood UK HA6 2RN
| | - Rubeta N Matin
- Churchill Hospital; Department of Dermatology; Old Road Headington Oxford UK OX3 7LJ
| | - Naomi Chuchu
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Susan E Bayliss
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Yemisi Takwoingi
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Clare Davenport
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Kathie Godfrey
- The University of Nottingham; c/o Cochrane Skin Group; Nottingham UK
| | | | - Jonathan J Deeks
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Hywel C Williams
- The University of Nottingham; Centre of Evidence Based Dermatology; Queen's Medical Centre Derby Road Nottingham UK NG7 2UH
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Liu J, Ding W, Ruan R, Zou L, Chen M, Wei P, Wen L. A Theoretical Study on Inhibition of Melanoma with Controlled and Targeted Delivery of siRNA via Skin Using SPACE-EGF. Ann Biomed Eng 2017; 45:1407-1419. [PMID: 28349327 DOI: 10.1007/s10439-017-1825-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/20/2017] [Indexed: 11/26/2022]
Abstract
Melanoma is a potentially lethal skin cancer with high mortality rate. Recently, the peptide-mediated transdermal delivery of small interference RNA (siRNA) emerges as a promising strategy to treat melanoma by inducing the apoptosis of tumor cells, but the related theoretical model describing the delivery of siRNA under the effect of SPACE-EGF, the growth inhibition of melanoma and the dynamic expanding of the bump on the skin due to the growth of melanoma has not been reported yet. In this article, a theoretical model is developed to describe the percutaneous siRNA delivery mediated by SPACE-EGF to melanoma and the growth inhibition of melanoma. The results present the spatial-temporal distribution of siRNA and the growth of melanoma under the inhibition of siRNA, which shows a good consistency with the experimental results. In addition, this model represents the uplift process of tumors on the skin surface. The model presented here is a useful tool to understand the whole process of the SPACE-EGF-mediated delivery of the siRNA to melanoma through skin, to predict the therapeutic effect, and to optimize the therapeutic strategy, providing valuable references for the treatment of melanoma.
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Affiliation(s)
- Juanjuan Liu
- Center for Biomedical Engineering, University of Science and Technology of China, Hefei, 230027, Anhui, China
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, 230027, Anhui, China
| | - Weiping Ding
- Center for Biomedical Engineering, University of Science and Technology of China, Hefei, 230027, Anhui, China.
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, 230027, Anhui, China.
| | - Renquan Ruan
- School of Life Sciences, University of Science and Technology of China, Hefei, 230027, Anhui, China
| | - Lili Zou
- Center for Biomedical Engineering, University of Science and Technology of China, Hefei, 230027, Anhui, China
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, 230027, Anhui, China
| | - Ming Chen
- School of Life Sciences, University of Science and Technology of China, Hefei, 230027, Anhui, China
- Department of Pharmacology, Anhui University of Chinese Medicine, Hefei, 230038, Anhui, China
| | - Pengfei Wei
- School of Life Sciences, University of Science and Technology of China, Hefei, 230027, Anhui, China
| | - Longping Wen
- School of Life Sciences, University of Science and Technology of China, Hefei, 230027, Anhui, China
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Head and neck melanoma (excluding ocular melanoma): United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology 2017; 130:S133-S141. [PMID: 27841141 PMCID: PMC4873897 DOI: 10.1017/s0022215116000852] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the United Kingdom. This paper provides consensus recommendations on the management of melanomas arising in the skin and mucosa of the head and neck region on the basis of current evidence.
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Haydu LE, Stollman JT, Scolyer RA, Spillane AJ, Quinn MJ, Saw RPM, Shannon KF, Stretch JR, Bonenkamp JJ, Thompson JF. Minimum Safe Pathologic Excision Margins for Primary Cutaneous Melanomas (1-2 mm in Thickness): Analysis of 2131 Patients Treated at a Single Center. Ann Surg Oncol 2016; 23:1071-81. [PMID: 25956574 DOI: 10.1245/s10434-015-4575-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Indexed: 12/16/2023]
Abstract
OBJECTIVE This study was designed to determine the minimum safe pathologic excision margin for primary cutaneous melanomas 1.01-2.00-mm thick (T2) and to identify prognostic factors that influence survival in these patients. BACKGROUND Several studies have shown previously that "narrow" clinical excision margins (1-2 cm in vivo) are as safe as "wide" excision margins (4-5 cm) for management of primary T2 melanomas. However, pathologic margins are likely to be a better predictor of recurrence than clinical margins. METHODS Clinicopathologic and follow-up data for 2131 T2 melanoma patients treated at Melanoma Institute Australia between January 1992 and May 2012 were analyzed. RESULTS Of the 2131 patients, those who had a pathologic excision margin of <8 mm (equivalent to 1 cm in vivo) had poorer prognosis in terms of disease-free survival compared with the 8-16-mm group (equivalent to 1-2 cm in vivo; P = 0.044). When comparing 8-mm with 16-mm pathologic margins, no differences were observed in any of the survival outcomes. Only the deep margin proved to be an independent predictor of local and in-transit recurrence-free survival (P = 0.003) in all excision margin categories. Pathologic excision margins <8 mm were associated with worse regional node recurrence-free survival and distant recurrence-free survival compared with margins ≥8 mm (P = 0.049 and P = 0.045; respectively). However, these results failed to translate into a statistically significant difference in melanoma-specific survival. CONCLUSIONS The results of this study suggest that if a peripheral/radial pathologic excision margin for a T2 primary cutaneous melanoma is <8 mm consideration should be given to performing a wider excision.
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Affiliation(s)
- Lauren E Haydu
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | - Richard A Scolyer
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Pathology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Quinn
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Kerwin F Shannon
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, North Sydney, NSW, Australia
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Johannes J Bonenkamp
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - John F Thompson
- Melanoma Institute Australia, North Sydney, NSW, Australia.
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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Sloot S, Speijers M, Bastiaannet E, Hoekstra H. Is there a relation between type of primary melanoma treatment and the development of intralymphatic metastasis? A review of the literature. Cancer Treat Rev 2016; 45:120-8. [DOI: 10.1016/j.ctrv.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/19/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
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Dinnes J, Matin RN, Moreau JF, Patel L, Chan SA, Chuchu N, Bayliss SE, Grainge M, Takwoingi Y, Davenport C, Walter FM, Fleming C, Schofield J, Shroff N, Godfrey K, O'Sullivan C, Deeks JJ, Williams HC. Tests to assist in the diagnosis of cutaneous melanoma in adults: a generic protocol. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011902] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jac Dinnes
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Rubeta N Matin
- Churchill Hospital; Department of Dermatology; Old Road Headington Oxford UK OX3 7LJ
| | - Jacqueline F Moreau
- University of Pittsburgh Medical Center; Internal Medicine; Department of Medicine, Office of Education UPMC Montefiore Hospital, N715 Pittsburgh USA PA, 15213
| | - Lopa Patel
- Royal Stoke Hospital; Plastic Surgery; Stoke-on-Trent Staffordshire UK ST4 6QG
| | - Sue Ann Chan
- NHS; Dermatology; 104 Times Square Avenue Brierley Hill Dudley UK DY5 1SX
| | - Naomi Chuchu
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Susan E Bayliss
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Matthew Grainge
- School of Community Health Sciences; Division of Epidemiology and Public Health; University of Nottingham Nottingham UK NG7 2UH
| | - Yemisi Takwoingi
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Clare Davenport
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Fiona M Walter
- University of Cambridge; Public Health & Primary Care; Strangeways Research Laboratory, Worts Causeway Cambridge UK CB1 8RN
| | - Colin Fleming
- NHS Tayside, Ninewells Hospital; Dermatology; Ninewells Drive Dundee UK DD1 9SY
| | - Julia Schofield
- United Lincolnshire Hospitals NHS Trust; Dermatology; Greetwell Street Lincoln UK LN2 5QY
| | - Neil Shroff
- Keyworth Medical Practice; Bunny Lane Keyworth Nottingham UK NG12 5JU
| | - Kathie Godfrey
- The University of Nottingham; c/o Cochrane Skin Group; Nottingham UK
| | | | - Jonathan J Deeks
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Birmingham UK B15 2TT
| | - Hywel C Williams
- The University of Nottingham; Centre of Evidence Based Dermatology; Queen's Medical Centre Derby Road Nottingham UK NG7 2UH
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Shirazi N, Jindal R, Singh S, Harsh M, Ahmad S. Pigmented Pre-malignant and Malignant Lesions of Skin with Special Reference to Atypical Presentations. J Clin Diagn Res 2015; 9:EC10-2. [PMID: 26393132 DOI: 10.7860/jcdr/2015/13245.6226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/22/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cutaneous melanocytic proliferations are diverse both morphologically as well as in their behavioural patterns. Both dermatologists and pathologists regularly encounter diagnostic dilemmas while interpreting such lesions. AIM To study all cutaneous premalignant and malignant lesions with respect to their clinical features and histopathological findings. MATERIALS AND METHODS A retrospective study was done in the Department of Pathology over a period of 10 years (2004-14) on all the clinically pigmented lesions that were biopsied or excised. Out of these only premalignant and malignant melanocytic lesions were analysed with respect to their important clinical and histologic features. Immunohistochemistry was carried out using HMB-45 and S-100 where indicated. RESULTS A total of 338 skin cancers were reported, out of these 27, 7.9% were cutaneous malignant melanoma. Premalignant lesions were 33. The mean age for premalignant lesions and melanomas was 43 years and 50.7 years respectively with a male predominance in both groups. The sole of foot/ankle was the most common site of involvement by melanoma (n=8,29.6%) while sun exposed sites like face and scalp were common sites for development of premalignant lesions like dysplastic nevi, lentigo simplex, pigmented seborrheic keratosis and Bowens disease. One case presented as post-traumatic scar tissue which turned out to be desmoplastic melanoma. One case of amelanotic melanoma presented as recurrent painful penile ulcers. Both cases were confirmed on Immunohistochemistry. CONCLUSION All pigmented lesions should be regarded as tumours of uncertain malignant potential and treated with complete excision if possible with long term follow up.
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Affiliation(s)
- Nadia Shirazi
- Associate Professor, Department of Pathology, Himalayan Institute of Medical Sciences , Jolly Grant, Dehradun, India
| | - Rashmi Jindal
- Assistant Professor, Department of Dermatology & Venereology, Himalayan Institute of Medical Sciences , Jolly Grant, Dehradun, India
| | - Sneha Singh
- Resident, Department of Pathology, Himalayan Institute of Medical Sciences , Jolly Grant, Dehradun, India
| | - Meena Harsh
- Professor, Department of Pathology, Himalayan Institute of Medical Sciences , Jolly Grant, Dehradun, India
| | - Sohaib Ahmad
- Professor, Department of Internal Medicine, Himalayan Institute of Medical Sciences , Jolly Grant, Dehradun, India
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Piscitelli P, Neglia C, Falco A, Rivezzi M, Agnello N, Argentiero A, Chitano G, Distante C, Della Rosa G, Vinci G, De Donno A, Distante A, Romanini A. Melanoma in the Italian Population and Regional Environmental Influences: A National Retrospective Survey on 2001-2008 Hospitalization Records. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:9102-18. [PMID: 26251915 PMCID: PMC4555267 DOI: 10.3390/ijerph120809102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To assess the burden of regional environmental factors influencing the incidence of Melanoma in the Italian population and overcome the problem of partial population coverage by local cancer registries and thematic archives. METHODS We analyzed the Italian national hospitalization records from 2001 to 2008 provided by the Ministry of Health, excluding hospital re-admissions of the same patients, in order to assess the occurrence of Melanoma over a 8-year period. Data were presented by age groups (absolute number of cases from 20 to ≥80 years old) and per Region (rates per 100,000 inhabitants) for each year. RESULTS The overall number of new hospitalizations due to malignant Melanoma increased by 16.8% from 2001 (n = 4846) to 2008 (n = 5823), with the rate per 100,000 inhabitants passing from 10.5 to almost 12.0 at a national level. The majority of new diagnoses of malignant Melanoma was observed in two age groups: 61-70 years old (from 979 in 2001 up to 2109 in 2008, corresponding to 15.1 and 18.1 new cases per 100,000 inhabitants, respectively) and 71-80 years old (from 954 in 2001 up to 1141 in 2008, corresponding to 19.5 and 21.8 new cases per 100,000 inhabitants, respectively). The number of hospitalizations due to Melanoma increased in all age groups with the only exception of the youngest patients aged 20-30 years old. The highest increases over the 8-year period were observed in people aged ≥81 years old (+34%), 61-70 years old (+20%) and surprisingly in the age group 31-40 years old (+17%). Southern Regions showed lower hospitalization rates compared to Northern Italy and Region Lazio. The highest increases between 2001 and 2008 were observed in Trentino/Alto Adige, Friuli Venezia Giulia, Valla d'Aosta and Veneto Region. CONCLUSIONS Hospitalizations due to malignant Melanoma in Italy seem to be influenced by environmental or population-related factors showing a decreasing incidence rate from the Northern to Southern Regions.
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Affiliation(s)
- Prisco Piscitelli
- Southern Italy Hospital Institute, IOS/Coleman Ltd., Naples 80100, Italy.
| | - Cosimo Neglia
- Euro Mediterranean Biomedical Scientific Institute, Brindisi 72100, Italy.
| | - Andrea Falco
- Southern Italy Hospital Institute, IOS/Coleman Ltd., Naples 80100, Italy.
| | - Matteo Rivezzi
- Southern Italy Hospital Institute, IOS/Coleman Ltd., Naples 80100, Italy.
| | - Nadia Agnello
- Euro Mediterranean Biomedical Scientific Institute, Brindisi 72100, Italy.
| | - Alberto Argentiero
- Euro Mediterranean Biomedical Scientific Institute, Brindisi 72100, Italy.
| | - Giovanna Chitano
- Euro Mediterranean Biomedical Scientific Institute, Brindisi 72100, Italy.
| | - Chiara Distante
- Euro Mediterranean Biomedical Scientific Institute, Brindisi 72100, Italy.
| | - Giulia Della Rosa
- Euro Mediterranean Biomedical Scientific Institute, Brindisi 72100, Italy.
| | - Giorgia Vinci
- Department of Medical Sciences, Federico II University, Naples 80132, Italy.
| | - Antonella De Donno
- Department of Science, Biotechnology and Environment (DISTEBA), University of Salento, Lecce 73100, Italy.
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Pföhler C, Vogt T, Müller CSL. [Malignant head and neck melanoma: Part 2: Therapy]. HNO 2015. [PMID: 26219523 DOI: 10.1007/s00106-015-0034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Resection margins of melanomas in the head and neck region often have to be adapted according anatomical circumstances. In the case of thicker primary tumors or after complete resection of locoregional lymph node metastases, adjuvant therapy with interferon-α can be performed; in some cases, adjuvant radiotherapy may also be indicated. In the case of inoperable lymph node or distant metastases, systemic treatment is required. Beside well-established mono- or polychemotherapy regimens, newer targeted therapies with BRAF inhibitors (vemurafenib, dabrafenib), mitogenic-activated protein kinase (MEK) inhibitors (trametinib, binimetinib, and cobimetinib), and kinase inhibitors (imatinib, sunitinib, nilotinib, dasatinib) are also available.
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Affiliation(s)
- C Pföhler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Kirrbergerstrasse, 66421, Homburg/Saar, Deutschland,
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Ye Y, Chao XJ, Wu JF, Cheng BCY, Su T, Fu XQ, Li T, Guo H, Tse AKW, Kwan HY, Du J, Chou GX, Yu ZL. ERK/GSK3β signaling is involved in atractylenolide I-induced apoptosis and cell cycle arrest in melanoma cells. Oncol Rep 2015; 34:1543-8. [PMID: 26151480 DOI: 10.3892/or.2015.4111] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/02/2015] [Indexed: 11/05/2022] Open
Abstract
Novel agents need to be developed to overcome the limitations of the current melanoma therapeutics. Atractylenolide I (AT-I) is a sesquiterpene compound isolated from atractylodis macrocephalae rhizoma. Previous findings demonstrated that AT-I exhibited cytotoxic action in melanoma cells. However, the molecular mechanisms of AT‑1's anti-melanoma properties remain to be elucidated. In the present study, the cell cycle-arrest and apoptosis-promoting effects as well as the ERK/GSK3β signaling-related mechanism of action of AT-I were examined. B16 melanoma cells were treated with various concentrations of AT-1 (50, 75 and 100 µM) for 48 or 72 h. Cell cycle and apoptosis were analyzed by flow cytometry. Protein expression levels were detected by western blot analysis. AT-I treatment induced G1 phase arrest, which was accompanied by increased p21 and decreased CDK2 protein expression levels. Apoptosis was observed after AT-I treatment for 72 h, which was accompanied by activated caspase‑3 and ‑8. AT-I treatment significantly decreased phospho-ERK, phospho-GSK3β, c-Jun and increased p53 protein expression levels. Lithium chloride (LiCl, 5 mM), a GSK3β inhibitor, treatment alone did not increase the apoptosis of B16 cells, while pretreatment with LiCl markedly reversed AT-I-induced apoptosis. Additionally, AT-I-induced G1 phase arrest was partially reversed by LiCl pretreatment. In conclusion, ERK/GSK3β signaling was involved in the apoptotic and G1 phase arrest effects of AT-I in melanoma cells.
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Affiliation(s)
- Yan Ye
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Xiao-Juan Chao
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Jin-Feng Wu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Brian Chi-Yan Cheng
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Tao Su
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Xiu-Qiong Fu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Ting Li
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Hui Guo
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Anfernee Kai-Wing Tse
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Hiu-Yee Kwan
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Juan Du
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
| | - Gui-Xin Chou
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Zhi-Ling Yu
- Center for Cancer and Inflammation Research, School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong, P.R. China
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Kyrgidis A, Tzellos T, Mocellin S, Apalla Z, Lallas A, Pilati P, Stratigos A. Sentinel lymph node biopsy followed by lymph node dissection for localised primary cutaneous melanoma. Cochrane Database Syst Rev 2015; 2015:CD010307. [PMID: 25978975 PMCID: PMC6461196 DOI: 10.1002/14651858.cd010307.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Melanoma is the leading cause of skin cancer-associated mortality. The vast majority of newly diagnosed melanomas are confined to the primary cutaneous site. Surgery represents the mainstay of melanoma treatment. Treatment strategies include wide excision of the primary tumour and sentinel lymph node biopsy (SLNB) to assess the status of the regional nodal basin(s). SLNB has become an important component of initial melanoma management providing accurate disease staging. OBJECTIVES To assess the effects and safety of SLNB followed by completion lymph node dissection (CLND) for the treatment of localised primary cutaneous melanoma. SEARCH METHODS We searched the following databases up to February 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2015, Issue 1), MEDLINE (from 1946), EMBASE (from 1974), and LILACS ((Latin American and Caribbean Health Science Information database, from 1982). We also searched the following from inception: African Index Medicus, IndMED of India, Index Medicus for the South-East Asia Region, and six trials registers. We checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We searched ISI Web of Science Conference Proceedings from inception to February 2015, and we scanned the abstracts of major dermatology and oncology conference proceedings up to 2015. SELECTION CRITERIA Two review authors independently assessed all RCTs comparing SLNB followed by CLND for the treatment of primary localised cutaneous melanoma for inclusion. Primary outcome measures were overall survival and rate of treatment complications and side effects. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and analysed data on survival and recurrence, assessed risk of bias, and collected adverse effect information from included trials. MAIN RESULTS We identified and included a single eligible trial comparing SLNB with observation and published in eight different reports (from 2005 to 2014) with 2001 participants. This did not report on our first primary outcome of overall survival. The study did report on the rate of treatment complications. Our secondary outcomes of disease-specific and disease-free survival, local recurrence and distant metastases were reported. There were 1347 participants in the intermediate-thickness melanoma group and 314 in the thick melanoma group.With regard to treatment complications, short-term surgical morbidity (30 days) in 1735 participants showed no difference between SLNB and observation (risk ratio [RR] 1.11; 95% confidence interval [CI] 0.9 to 1.37) for wide excision of the tumour site but favoured observation for complications related to the regional nodal basin (RR 14.36; 95% CI 6.74 to 30.59).The study did not report the actual 10-year melanoma-specific survival rate for all included participants. Instead, melanoma-specific survival rates for each group of participants: intermediate-thickness melanoma (defined as 1.2 to 3.5 mm) and thick melanomas (defined as 3.50 mm or more) was reported.In the intermediate-thickness melanoma group there was no statistically significant difference in disease-specific survival between study groups at 10 years (81.4 ± 1.5% versus 78.3 ± 2.0%, hazard ratio [HR] 0.84; 95% CI 0.65 to 1.09). In the thick melanoma group, again there was no statistically significant difference in disease-specific survival between study groups at 10 years (58.9.3 ± 4.1% versus 64.4 ± 4.6%, HR 1.12; 95% CI 0.77 to 1.64). Combining these groups there was some heterogeneity (I² = 34%) but the total HR was not statistically significant (HR 0.92; 95% CI 0.74 to 1.14). This study failed to show any difference for its stated primary outcome.The summary estimate for disease-free survival at 10 years favoured SLNB over observation in participants with intermediate-thickness and thick melanomas (HR 0.75; 95% CI 0.63 to 0.89).With regard to the rate of local and regional recurrence as the site of first recurrence, a benefit of SLNB uniformly existed in both groups of participants with intermediate-thickness and thick melanomas (RR 0.56; 95% CI 0.45 to 0.69). This is in contrast with a uniformly unfavourable effect of SLNB with regard to the rate of distant metastases as site of first recurrence, in both groups of participants with intermediate-thickness and thick melanomas (HR 1.33; 95% CI 1.03 to 1.72). AUTHORS' CONCLUSIONS We contacted the trial authors querying the lack of data on overall survival which was the primary outcome of their important study. They stated "there are numerous additional analyses that have yet to be reported for the trial". We expect that overall survival data will be available in a future update of this review.Disease-free survival and rate of local and regional recurrence favoured SLNB in both groups of participants with intermediate-thickness and thick melanomas but short-term surgical morbidity was higher in the SLNB group, especially with regard to complications in the nodal basin.The evidence for the outcomes of interest in this review is of low quality due to the risk of bias and imprecision of the estimated effects. Further research may have an important impact on our estimate of the effectiveness of SLNB in managing primary localised cutaneous melanoma. Currently this evidence is not sufficient to document a benefit of SLNB when compared to observation in individuals with primary localised cutaneous melanoma.
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Affiliation(s)
- Athanassios Kyrgidis
- Dessau Medical CenterDivision of Evidence Based DermatologyDessauGermany
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)Dermatology and Skin Cancer Unit, Arcispedale Santa Maria NuovaReggio EmiliaItaly
- Aristotle University of Thessaloniki1st Department of Otolaryngology, Head & Neck Surgery3 Papazoli St.ThessalonikiGreece54630
| | - Thrasivoulos Tzellos
- Faculty of Health Sciences, University Hospital of North NorwayDepartment of DermatologyHarstadTromsNorway
| | - Simone Mocellin
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyVia Giustiniani 2PadovaVenetoItaly35128
- IOV‐IRCCSIstituto Oncologico VenetoPadovaItaly35100
| | - Zoe Apalla
- Hospital of Skin and Venereal DiseasesState Clinic of Dermatology17, Omirou streetThessalonikiGreece55535
| | - Aimilios Lallas
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)Dermatology and Skin Cancer Unit, Arcispedale Santa Maria NuovaReggio EmiliaItaly
| | - Pierluigi Pilati
- University of PadovaMeta‐Analysis Unit, Department of Surgery, Oncology and Gastroenterologyvia Giustiniani 2PadovaItaly35128
| | - Alexander Stratigos
- Andreas Syggros HospitalDepartment of Dermatology, National and Kapodestrian University of Athens28 Voucourestiou StreetAthensGreece10671
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Rossi CR, Sommariva A. Melanoma. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Melanoma accounts for less than 2% of skin cancer cases but causes most skin cancer-related deaths. Surgery continues to be the cornerstone of treatment of melanoma and surgical principles are guided by data derived from clinical research. This article examines the evolution of surgical techniques for the diagnosis and treatment of primary and locally recurrent melanoma.
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Affiliation(s)
- Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA.
| | - Nandini Kulkarni
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Cary Hsu
- Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA; Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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49
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Tzellos T, Kyrgidis A, Mocellin S, Chan AW, Pilati P, Apalla Z. Interventions for melanoma in situ, including lentigo maligna. Cochrane Database Syst Rev 2014; 2014:CD010308. [PMID: 25526608 PMCID: PMC11005944 DOI: 10.1002/14651858.cd010308.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Malignant melanoma is a form of skin cancer associated with significant mortality once it has spread beyond the skin. Melanoma in situ (MIS) is the earliest histologically recognisable stage of malignant melanoma and represents a precursor of invasive melanoma. Lentigo maligna (LM) represents a subtype of pre-invasive intraepidermal melanoma associated specifically with chronic exposure to ultraviolet (UV) radiation. Over the past two decades, the incidence of MIS has increased significantly, even more than the invasive counterpart. There are several treatment options for MIS, but no consensus exists on the best therapeutic management of this condition. OBJECTIVES To assess the effects of all available interventions, surgical and non-surgical, for the treatment of melanoma in situ, including LM. SEARCH METHODS We searched the following databases up to November 2014: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 10), MEDLINE (from 1946), Embase (from 1974), LILACS (from 1982), African Index Medicus (from inception), IndeMED of India (from inception), and Index Medicus for the South-East Asia Region (IMSEAR) (from inception). We scanned the references of included and excluded studies for further references to relevant trials and searched five trials registries. We checked the abstracts of major dermatology and oncology conference proceedings, and we shared our lists of included and excluded studies with industry contacts and other experts in the field of melanoma to try to identify further relevant trials. SELECTION CRITERIA We included randomised controlled trials (RCT) on the management of MIS, including LM, that compared any intervention to placebo or active treatment. We included individuals, irrespective of age and sex, diagnosed with MIS, including LM, based on histological examination. DATA COLLECTION AND ANALYSIS Two authors independently evaluated possible studies for inclusion; extracted data from the included study using a standard data extraction form modified for our review; assessed risk of bias; and analysed data on efficacy, safety, and tolerability. They resolved any disagreements by discussion with a third author. We collected adverse effects information from included studies. MAIN RESULTS Our search identified only 1 study eligible for inclusion (and 1 ongoing study in active recruitment stage), which was a single centre, open label, parallel group, 2-arm RCT with 90 participants, who had 91 histologically proven LM lesions.Forty-four participants, with 44 LM lesions, were treated with imiquimod 5% cream 5 days per week plus tazarotene 0.1% gel 2 days/week for 3 months, and 46 participants, with 47 LM lesions, were treated with imiquimod 5% cream 5 days per week for 3 months. Two months after cessation of topical treatment, the initial tumour footprint was excised using 2 mm margins via a staged excision. This study was open label, and analysis was not intention-to-treat, leading to a high risk of incomplete outcome data.Our primary outcome 'Histological or clinical complete response' was measured at 5 months in 29/44 participants (66%) treated with imiquimod plus tazarotene (combination therapy) and 27/46 participants (59%) treated with imiquimod (monotherapy). The difference was not statistically significant (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.81 to 1.55, P value = 0.48).With regard to our secondary outcomes on recurrence and inflammation, after a mean follow up of 42 months, no local recurrences were observed among complete responders. Difference in overall inflammation score between the 2 groups was significant (mean difference (MD) 0.6, 95% CI 0.2 to 1, P value = 0.004), with the mean overall inflammation score being significantly higher in the combination group.The study authors did not clearly report on side-effects. Because of adverse effects, there was a dropout rate of 6/44 participants (13.7%) in the combination group compared with 1/46 (2.2%) in the imiquimod monotherapy group (due to excessive inflammation) before the cessation of topical treatment (first 3 months), but this was not statistically significant (RR 6.27, 95% CI 0.79 to 50.02, P value = 0.08). AUTHORS' CONCLUSIONS There is a lack of high-quality evidence for the treatment of MIS and LM.For the treatment of MIS, we found no RCTs of surgical interventions aiming to optimise margin control (square method, perimeter technique, 'slow Mohs', staged radial sections, staged "mapped" excisions, or Mohs micrographic surgery), which are the most widely used interventions recommended as first-line therapy. The use of non-surgical interventions in selected cases (patients with contraindications to surgical interventions) may be effective and may be considered preferable for experienced providers and under close and adequate follow up.For the treatment of LM, we found no RCTs of surgical interventions, which remain the most widely used and recommended available treatment. The use of non-surgical interventions, such as imiquimod, as monotherapy may be effective and may be considered in selected cases where surgical procedures are contraindicated and used preferentially by experienced providers under close and adequate follow up. The use of topical therapies, such as 5-fluorouracil and imiquimod, as neoadjuvant therapies warrants further investigation. There is insufficient evidence to support or refute the addition of tazarotene to imiquimod as adjuvant therapy; the current evidence suggests that it can increase topical inflammatory response and withdrawal of participants because of treatment-related side-effects.
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Affiliation(s)
- Thrasivoulos Tzellos
- Department of Dermatology, Faculty of Health Sciences, University Hospital of North Norway, Harstad, Troms, Norway. .
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50
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Schulz C, Häfner HM, Breuninger H, Leiter U. Local recurrence and survival in acral lentiginous melanoma comparing 3D histology and conventional histology. J Dtsch Dermatol Ges 2014. [DOI: 10.1111/ddg.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Claudia Schulz
- Department of Dermatology, University Hospital of Tübingen; Germany
| | | | | | - Ulrike Leiter
- Department of Dermatology, University Hospital of Tübingen; Germany
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