Cutaneous melanoma in Asian-Americans

Pathogenic mechanisms and etiologic aspects of Mycobacterium avium subspecies paratuberculosis as an infectious cause of cutaneous melanoma

Infectious etiologies have previously been proposed as causes of both melanoma and non-melanoma skin cancer. This exploratory overview explains and presents the evidence for the hypothesis that a microorganism excreted in infected ruminant animal feces, Mycobacterium avium subspecies paratuberculosis (MAP), is the cause of some cases of cutaneous melanoma (CM). Occupational, residential, and recreational contact with MAP-contaminated feces, soil, sand, and natural bodies of water may confer a higher rate of CM. Included in our hypothesis are possible reasons for the differing rates and locations of CM in persons with white versus nonwhite skin, why CM develops underneath nails and in vulvar skin, why canine melanoma is an excellent model for human melanoma, and why the Bacille Calmette-Guérin (BCG) vaccine has demonstrated efficacy in the prevention and treatment of CM. The pathogenic mechanisms and etiologic aspects of MAP, as a transmittable agent underlying CM risk, are carefully deliberated in this paper. Imbalances in gut and skin bacteria, genetic risk factors, and vaccine prevention/therapy are also discussed, while acknowledging that the evidence for a causal association between MAP exposure and CM remains circumstantial.

Comparison of full-thickness skin graft and punch grafting in the reconstruction of plantar defects

Acral melanoma commonly occurs on weight-bearing areas of the sole. Reconstruction of such areas presents a surgical challenge due to limited availability and mobility of local skin. Thus, we aimed to compare the scar outcome of full-thickness skin graft (FTSG) and punch grafting in the reconstruction of plantar defects after melanoma surgery. We retrospectively reviewed six patients who underwent both FTSG for nonweight-bearing areas and punch grafting for weight-bearing areas. We compared results of FTSG and punch grafting within the same patient. Photos of completely healed scars were graded using the Stony Brook Scar Evaluation Scale (SBSES). The averages of the FTSG scores and the punch graft scores, as measured by the SBSES, were statistically compared. Punch grafting yielded a better outcome than FTSG, according to the SBSES. The average of the punch grafting scars was 4.67, which was significantly greater (p = 0.004) than that of FTSG scar scores at 1.83. For weight-bearing areas, punch grafting should be considered as the first option of reconstruction, with FTSG as a second option for nonweight-bearing areas. Overall, this combined approach provides an effective and safe method for reconstruction of extensive plantar wounds.

Melanoma in skin of color: Part I. Epidemiology and clinical presentation

Although there is a higher incidence of melanoma among non-Hispanic White individuals, melanoma is diagnosed at more advanced stages and associated with worse survival rates among individuals with skin of color (SOC). The proportions of melanoma subtypes differ across racial groups, with acral lentiginous melanoma and mucosal melanoma representing higher proportions of melanoma diagnoses in individuals with SOC compared to White individuals. The recognition of distinct differences in anatomic locations and dermatoscopic patterns may facilitate the appropriate differentiation of physiologic from pathologic pigmentation. The first article of this continuing medical education series will focus on the epidemiology and clinical presentation of melanoma in individuals with SOC, with the aim of improving early diagnoses and clinical outcomes.

Skin Cancer in People of Color: A Systematic Review

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Racial Differences in the Prognosis and Survival of Cutaneous Melanoma From 1990 to 2020 in North America: A Systematic Review and Meta-Analysis

Background

Factors influencing the difference in the diagnosis and treatment of melanoma in racial minority groups are well-described in the literature and include atypical presentations and socioeconomic factors that impede access to care.

Objective

To characterize the differences in melanoma survival outcomes between non-Hispanic white patients and ethnic minority patients in North America.

Methods

We conducted searches of Embase via Ovid and MEDLINE via Ovid of studies published from 1989 to August 5, 2020. We included observational studies in North America which reported crude or effect estimate data on patient survival with cutaneous melanoma stratified by race.

Results

Forty-four studies met our inclusion criteria and were included in this systematic review. Pooled analysis revealed that black patients were at a significantly increased risk for overall mortality (HR 1.42, 95% CI, 1.25-1.60), as well as for melanoma-specific mortality (HR 1.27, 95% CI, 1.03-1.56). Pooled analyses using a representative study for each database yielded similar trends. Other ethnic minorities were also more likely report lower melanoma-specific survival compared to non-Hispanic white patients.

Conclusion

Our results support findings that melanoma patients of ethnic minorities, particularly black patients, experience worse health outcomes with regards to mortality. Overall survival and melanoma-specific survival are significantly decreased in black patients compared to non-Hispanic white patients. With the advent of more effective, contemporary treatments such as immunotherapy, our review identifies a gap in the literature investigating present-day or prospective data on melanoma outcomes, in order to characterize how current racial differences compare to findings from previous decades.

Acral lentiginous melanoma: Basic facts, biological characteristics and research perspectives of an understudied disease

Acral lentiginous melanoma is a histological subtype of cutaneous melanoma that occurs in the glabrous skin of the palms, soles and the nail unit. Although in some countries, particularly in Latin America, Africa and Asia, it represents the most frequently diagnosed subtype of the disease, it only represents a small proportion of melanoma cases in European-descent populations, which is partially why it has not been studied to the same extent as other forms of melanoma. As a result, its unique genomic drivers remain comparatively poorly explored, as well as its causes, with current evidence supporting a UV-independent path to tumorigenesis. In this review, we discuss current knowledge of the aetiology and diagnostic criteria of acral lentiginous melanoma, as well as its epidemiological and histopathological characteristics. We also describe what is known about the genomic landscape of this disease and review the available biological models to explore potential therapeutic targets.

Clinical Presentations of Melanoma in African Americans, Hispanics, and Asians

BACKGROUND

Skin cancer has traditionally been studied in Caucasian skin. Although it does occur with increased relative frequency in Caucasians, patients with skin of color suffer from elevated morbidity and mortality when diagnosed with skin cancer.

OBJECTIVE

To detail the unique demographic, clinical, and genetic features of melanoma in patients with skin of color, including Hispanic, African American, and Asian patients.

MATERIALS AND METHODS

A PubMed search was conducted spanning dates 1947 to June 2017. A total of 246 articles were screened, from which 69 were included in this review.

RESULTS

Relative to Caucasians, melanoma has unique demographic, clinical, and genetic features in African Americans, Hispanics, and Asians that include gender and subtype predominance.

CONCLUSION

Familiarization with these unique presentations of skin cancer in skin of color is imperative to accurate identification and treatment of cutaneous malignancies in these populations and ultimately to improved disease-related outcomes.

Characteristics of melanoma in Japan: a nationwide registry analysis 2011-2013

The distribution and incidence of melanoma vary among different races and ethnic groups. This study aimed to investigate the characteristics of cutaneous melanoma, mucosal melanoma, uveal melanoma, and melanoma of unknown primary (MUP) origin in a Japanese population. We studied these four types of melanoma in patients registered in Hospital Based Cancer Registries in Japan from 2011 to 2013. A total of 5566 patients with melanoma were identified. The distribution of sex, age, primary site, and clinical stage was analyzed. The number of patients, proportion in comparison with all melanoma cases, and crude incidence rate per 100 000 person-year of each melanoma type were 4481, 80.5%, and 1.24 in invasive cutaneous; 821, 14.8%, and 0.32 in mucosal; 163, 2.9%, and 0.064 in uveal; and 101, 1.8%, and 0.039 in MUP origin, respectively. Including the patients with in-situ cutaneous melanoma and stage unknown cutaneous melanoma, the crude incidence rate of cutaneous melanoma increased at 1.75. Almost half of the cutaneous melanomas were located in the lower limb. Cutaneous melanoma was the most common, but less frequent than that in western countries. Mucosal melanoma was quite rare, but its proportion and crude incidence rate were higher than those in western countries. Uveal melanoma was particularly rare, and its crude incidence rate was lower than that in western countries. MUP origin was also particularly rare, but it had almost the same incidence rate as that in other countries. Melanoma in Japan was heterogeneous among the four melanoma types and shares some attributes with that in western countries.

Other primary systemic cancers in patients with melanoma: Analysis of balanced acral and nonacral melanomas

BACKGROUND

Although other primary systemic cancers in patients with melanoma have been studied, there have been few focusing on acral melanomas.

OBJECTIVES

We assessed other primary systemic cancers in patients with acral and nonacral melanomas.

METHODS

We analyzed other primary cancers in 452 patients with melanoma from 1994 to 2013. Metachronous cancers were defined as those given a diagnosis more than 2 months after diagnosis of melanoma. The others were considered prechronous or synchronous cancers.

RESULTS

Among 51 cases of other primary cancers, gastrointestinal cancer (35.3%, n = 18/51) was the most common, followed by thyroid (17.6%), lung (11.8%), and breast (5.9%). Those were more prevalent in the acral melanoma group (12.8%, n = 31/243) compared with the nonacral melanoma group (9.6%, n = 20/209). Of 23 cases of metachronous cancer, the risk was the highest in bone marrow, followed by oral cavity, bladder, colon, lung, and thyroid. Among 28 cases of prechronous or synchronous cancers, gastrointestinal tract (35.7%, n = 10/28) was the most common site, followed by thyroid (17.9%), breast (10.7%), and lung (7.1%).

LIMITATIONS

The study is limited by a small number of patients.

CONCLUSION

Careful follow-up and imaging studies are necessary for early detection of other primary cancers and metastatic lesions in patients with melanoma.

Patient-reported frequency of acral surface inspection during skin examination in white and ethnic minority patients

BACKGROUND

Acral lentiginous melanomas compose a higher proportion of melanomas and have a higher mortality in ethnic minorities than in whites. Early detection by acral surface inspection during skin examinations may lead to improved acral lentiginous melanoma outcomes.

OBJECTIVE

This study compared patient-reported frequencies of acral skin examinations in ethnic and white populations.

METHODS

Written surveys were collected from 1040 dermatology clinic patients.

RESULTS

More whites reported performing self-skin examinations than ethnic minorities (P < .01), but there was no difference in the rates of hand (P = .7) or foot (P = .87) inspection during self-skin examination between whites and ethnic minorities. More whites (77.5%) than ethnic minorities (38.9%) reported having undergone a full-body skin examination (FBSE) from a health care provider (P < .01). During their most recent FBSE by a health care provider, more whites than ethnic minorities reported having their hands examined (P = .02), but there was no difference in reported hand inspection (P = .06) at any previous FBSE or foot inspection at any (P = .07) or the most recent (P = .59) FBSE between whites and ethnic minorities.

LIMITATIONS

Single-center study using a new unvalidated survey is a limitation.

CONCLUSION

Whites were found to more frequently report self-skin examination and FBSE than ethnic minorities, but significant differences in reported acral examinations were not detected.

Glutamate signaling in benign and malignant disorders: current status, future perspectives, and therapeutic implications

Glutamate, a nonessential amino acid, is the major excitatory neurotransmitter in the central nervous system. As such, glutamate has been shown to play a role in not only neural processes, such as learning and memory, but also in bioenergetics, biosynthetic and metabolic oncogenic pathways. Glutamate has been the target of intense investigation for its involvement not only in the pathogenesis of benign neurodegenerative diseases (NDDs) such as Parkinson's disease, Alzheimer's disease, schizophrenia, multiple sclerosis, and amyotropic lateral sclerosis (ALS), but also in carcinogenesis and progression of malignant diseases. In addition to its intracellular activities, glutamate in secreted form is a phylogenetically conserved cell signaling molecule. Glutamate binding activates multiple major receptor families including the metabotropic glutamate receptors (mGluRs) and ionotropic glutamate receptors (iGluRs), both of which have been implicated in various signaling pathways in cancer. Inhibition of extracellular glutamate release or glutamate receptor activation via competitive or non-competitive antagonists decreases growth, migration and invasion and induces apoptosis in breast cancer, melanoma, glioma and prostate cancer cells. In this review, we discuss the current state of glutamate signaling research as it relates to benign and malignant diseases. In addition, we provide a synopsis of clinical trials using glutamate antagonists for the treatment of NDD and malignant diseases. We conclude that in addition to its potential role as a metabolic biomarker, glutamate receptors and glutamate-initiated signaling pathways may provide novel therapeutic opportunities for cancer.

Risk factors for malignant melanoma in white and non-white/non-African American populations: the multiethnic cohort

It is unknown whether the established risk factors for malignant melanoma in whites influence malignant melanoma risk in non-whites. We examined the risk factors for melanoma among 39,325 whites and 101,229 non-whites/multiracials [Japanese American (47.5%), Latino American (34.8%), Native Hawaiian (2.1%), and multiracial (15.6%), excluding African Americans] in the Multiethnic Cohort study. With an average follow-up of 12.7 years, 581 invasive malignant melanoma (IMM) and 412 melanoma in situ (MIS) cases were identified, of which 107 IMM and 74 MIS were among non-whites/multiracials. The relative risks (RR) and 95% confidence intervals (CI) were estimated by Cox proportional hazards models using days from cohort entry as the underlying time variable. Among non-white/multiracial males, location of IMM tumors differed from those of white males (P < 0.001); and non-white/multiracial females were more likely to be diagnosed with later stage of disease (P < 0.001). After adjusting for potential confounders, age at cohort entry, male sex, higher education, and sunburn susceptibility phenotypes were associated with an increased risk of IMM in non-whites/multiracials (P < 0.05). The risk estimates for age at cohort entry and lighter hair and eye color were greater in non-whites/multiracials than in whites (P(heterogeneity) = 0.062, 0.016, and 0.005, respectively). For MIS risk, RRs between whites and non-whites/multiracials also differed for study location and education (P(heterogeneity) ≤ 0.015). In conclusion, similar to whites, age at cohort entry, male sex, and susceptibility to sunburn phenotypes may be predictive of malignant melanoma risk in non-white populations excluding African Americans.

Impact of socioeconomic status and sociodemographic factors on melanoma presentation among ethnic minorities

Minority melanoma patients have worse survival. In this study, we evaluated the impact of socioeconomic and demographic factors on minority melanoma patients presenting to two different New York City hospitals (one public and one private) managed by the same multidisciplinary team. Sociodemographic and clinicopathologic characteristics were retrieved for melanoma patients presenting to Bellevue Hospital Center (BHC), a public hospital, and the New York University Cancer Institute (NYUCI), a private cancer center. Socioeconomic data was obtained from the United States Census Bureau database. The Kruskal-Wallis and chi-square tests were used to evaluate the associations between race/ethnicity and continuous and categorical variables (e.g. income, stage at presentation), respectively. Minorities comprised 2% (27/1296) of melanoma patients at the NYUCI compared to 42% (50/119) at BHC. Those presenting to the NYUCI were more likely to have a higher median household income (P = 0.05), a higher educational level (P = 0.04), and an earlier stage at presentation (P = 0.02) than those at BHC. NYUCI patients were predominantly covered by commercial insurance (70%), whereas Medicaid (62%) was common among BHC patients. Only 19% of Hispanic patients at BHC chose English as their preferred language. Our data demonstrate that language and health care system factors affect melanoma presentation in minorities.

Cutaneous Spitzoid melanoma in a very young girl of Asian descent

Cutaneous melanoma is extremely uncommon in children. Further, Asian-Americans appear to be at decreased risk for cutaneous melanoma. The authors present the case of a prepubescent Asian girl who presents with the rare spitzoid variant of cutaneous melanoma. The patient is a 4-year-old girl of Chinese descent who presented with a red, raised nodule, which increased in size over a 3-month period. She underwent wide local excision with sentinel lymph node dissection. On histopathologic analysis, she was found to have Spitzoid melanoma of childhood/adolescence. Spitzoid melanoma in children is rare and incompletely understood. A recent systematic review was only able to identify 82 such cases published over a 57-year period. To our knowledge, this is the first report of Spitzoid melanoma in a paediatric age patient of Asian descent. While this clearly is an uncommon demographic, it seeks to highlight important differences in racial predilection for Spitzoid melanoma.

Coexistence of amelanotic melanoma and liposarcoma

An amelanotic malignant melanoma is characterized by little or no pigment. It is frequently misdiagnosed because it is a rare entity in general, and because of its unusual clinical features. Liposarcoma is one of the most common adult soft tissue sarcomas. We encountered a case of amelanotic melanoma with a concurrent liposarcoma. A 68-year-old man presented with a single, 1.5x1.5 cm round erythematous, eroded nodule on the left heel. A biopsy specimen showed atypical, pleomorphic tumor cells with little melanin pigment. The tumor cells were positive for S-100, HMB-45 and negative for cytokeratins. These findings were consistent with amelanotic melanoma. On positron emission tomography/computed tomography (PET/CT), a hypermetabolic lesion was found in the left buttock. This lesion was excised and diagnosed as a well-differentiated liposarcoma. An association between sarcomas and other primary malignancies has been reported. However, an association between melanoma and liposarcoma is rare.