Malignant melanoma in children: its management and prognosis

A Scoping Review and Population Study Regarding Prevalence and Histopathology of Juvenile Vulvar Melanocytic Lesions. A Recommendation

Cases of vulvar melanocytic lesions in juveniles are rarely reported. We analyze the evidence regarding vulvar melanocytic lesions in juveniles with or without vulvar lichen sclerosus to help decision making by clinicians and pathologists. A scoping review on vulvar melanocytic lesions with or without vulvar lichen sclerosus, including malignant vulvar melanomas, in females up to age 18 years was performed. In addition, the histopathology records of the cohort of all such lesions in The Netherlands from 1991 through 2020 were investigated, and a structured analysis of tissue samples of the subset of cases with lichen sclerosus was performed. The literature study performed confirms that vulvar melanomas in juveniles are extremely rare and that published case reports are often disputed. In The Netherlands, there are no cases of malignant vulvar melanomas up to age 18 years recorded from 1991 through 2020. Atypical histopathological features are often found in biopsies of vulvar nevi in juveniles, especially with concomitant lichen sclerosus, confirming earlier case studies in the literature. We conclude that even with atypical findings, vulvar melanocytic lesions in juveniles have a benign course. To avoid unnecessary and possibly mutilating procedures, we advise referral to an expert center and adaption of existing guidelines for vulvar melanocytic lesions in juveniles.

Congenital uveal malignant melanoma- A rare case report

Purpose

To report a rare case of congenital uveal malignant melanoma from Indian subcontinent in an infant with multiple cutaneous naevi and no distant metastasis.

Observation

An 8 month old male child presented with proptosis and black discoloration in the right eye since birth. Enucleation of the right eye was performed and specimen sent for histopathology and immunohistochemical analysis. Results were strongly suggestive of a malignant melanoma of uvea. No metastasis was found on MRI scan of brain, chest and abdomen. Patient is on close follow up and will be subjected to metastasis workup every 6 months.

Conclusion and importance

This entity of congenital uveal malignant melanoma is rather rare with very few reported cases across the globe and needs further understanding of its correct line of treatment.

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.

An 18-year Study of Malignant Melanoma in Childhood and Adolescence

Malignant melanoma is rare in childhood and adolescence. Diagnostic uncertainty and misdiagnosis often lead to delayed treatment.

Pediatric Melanoma: A 35-year Population-based Review

Background:

Melanoma is a rare neoplasm in the pediatric population. Recent publications suggest a possible increase in incidence over the past few decades. The purpose of this study was to analyze trends in pediatric patients diagnosed with malignant melanoma in British Columbia (BC) in the past 35 years.

Methods:

A retrospective review was performed. All patients in BC diagnosed with melanoma before 18 years of age from 1979 to 2014 were included. Patient demographics, melanoma description, treatment details, and survival data were collected.

Results:

Seventy-eight subjects were identified for the study. Patients were equally distributed by sex. Sixty-one (78%) of the subjects were diagnosed in the postpubertal age (≥12 years old). The most common sites of occurrence were the extremities (n = 33) and the trunk (n = 27), with the location on the trunk showing the highest mortality rate (22%). All patients were surgically treated and some had additional chemotherapy (12) and/or radiotherapy (12). Fatal outcome was recorded in 12 of the 78 subjects, 10 of whom had postpubertal diagnosis. The average time from date of diagnosis to date of death was 9.3 years.

Conclusions:

The incidence of melanoma in the pediatric population remains exceedingly rare: less than 2.5 per million children younger than 18 years. The diagnosis is rarely made before puberty; the incidence is equal in males and females and has not changed over a 35-year time period in BC. Our study shows 85% survival with the majority of patients having had surgical excision only.

Giant congenital melanocytic nevus: report from 30 years of experience in a single department

Giant congenital melanocytic nevi (GCMN) occur in 1:20,000 livebirths and are associated with increased risk of malignant transformation. The treatment of GCMN from 1981 to 2010 in a tertiary referral center was reviewed evaluating the modalities used, cosmetic results, associated complications, and malignant transformation. Of 35 patients, 25 underwent surgery. Curettage was most frequently used (64%) followed by excision and tissue expansion (20%). Six percent of the patients treated with curettage, and 78% of the patients who received excision surgery required more than 1 planned procedure, and 25% versus 44% required unplanned additional surgery, respectively. Complications were noted in 25% and 67% of the patients, respectively. Cosmetic result was satisfying in 76% of patients without difference between the groups. No malignant transformation was found during a mean follow-up of 11 years. Curettage is a gentle alternative to excision with a lower complication rate and good cosmetic outcome.

Cutaneous melanoma in 1-year-old child: an insight on infantile melanoma

In the past, malignant melanoma (MM) is a diagnosis of unheard in children, but nowadays MM is a very rare malignancy in children. Its diagnosis requires careful interpretation of the pathological diagnostic criteria with clinical correlation of the findings. In this study, the authors are presenting a pigmented lesion in a 12-month-old girl, which was present since her birth with increase in size and shape. The authors discussed the difficulty that confronted them in making a diagnosis of MM and the differential diagnosis.

Management of melanomas in children and young adults

Melanoma is rare in children and young adults. The incidence is rising yearly in this population. The clinical features of the disease in the pediatric population have been well documented through single-institution experiences and population-based analyses. Still, our understanding of the etiologic factors in the majority of children remains unclear, and diagnosis of melanoma remains challenging in certain cases. Because of its rarity, the staging, management and treatment of melanoma in this population is adopted from adult guidelines. In this review, we provide information on the epidemiology, clinical presentation, staging, prognosis and management of melanoma in children and young adults.

Melanoma in children

CONTEXT

Cutaneous melanoma in childhood (CMC) is rare; therefore, its prognostic factors and biologic behavior, and the effectiveness of adjuvant techniques for CMC remain mostly unknown.

OBJECTIVE

To review the most useful, evidence-based practice criteria for establishing the diagnosis of CMC, for which universally accepted criteria are lacking, in order to facilitate the interpretation and comparison of the results from different institutions, and to perform systematic reviews and meta-analysis.

DATA SOURCES

A comprehensive review of the most relevant previous single-institution series reported in the literature since 1990, including our cumulative experience of 137 cases of primary cutaneous and mucosal melanoma in patients younger than 18 years. Special characteristics of melanoma in children are discussed, regarding clinical settings and risk factors, helpful histologic features, and immunohistochemical patterns for diagnosis and prognosis.

CONCLUSIONS

Careful analysis of histologic features as well as the additional information provided by immunohistochemistry should allow for a correct diagnosis in most cases of melanoma in children. Although it seems that pediatric patients with melanoma have higher survival probability than adults, still a number of children will develop metastasis and die of their disease, particularly when melanoma is diagnosed after puberty. Until further studies more accurately determine the prognosis, a prudent approach to CMC diagnosis and therapy seems to follow the same principles as those established for adult melanoma.

Infantile melanoma--a triple threat: diagnosis and management

Cases of infantile melanoma are very rare, and only a few have been presented in the literature. Pediatric melanoma can present to the clinician as a "triple threat" of delayed diagnosis resulting in thick lesions at risk for metastasis, histologic uncertainty of diagnosis, and a lack of data guiding regional node management and adjuvant therapy. Melanoma in childhood is an uncommon condition, and it is even more atypical in infants. There is evidence however that it is increasing in frequency. We present 2 cases of infantile melanoma diagnosed before age 1 and multidisciplinary management performed at our institution. One child was diagnosed with melanoma arising within a congenital melanocytic nevus, and the other presented with melanoma from a de novo acquired scalp lesion. The ambiguity surrounding correct pathologic diagnosis of melanoma in this age group, and the tendency for late diagnosis with thicker lesions presents special staging and treatment challenges to the team of specialists involved in the care of these children.

Evaluation of 39 cases of pediatric cutaneous head and neck melanoma

BACKGROUND

Studies examining head and neck (H&N) melanoma in the pediatric population are scarce.

OBJECTIVE

The goal of this study is to describe pediatric H&N melanoma with the intent of increasing understanding of the course of disease.

METHODS

The Duke Melanoma Database and Duke Tumor Registry Database were searched for patients with a diagnosis of melanoma occurring on the H&N before age 18 years, with exclusion of ocular/mucosal/aerodigestive melanomas.

RESULTS

Queries yielded 39 Caucasian pediatric patients, 24 (61.5%) of them male. The mean age at diagnosis was 14.2 years (15 years, median). The primary sites were represented as follows: cutaneous auricular (1/39, 2.6%), facial (15/39, 38.5%), and scalp/neck (23/39, 59%). The follow-up time ranged from 2 months to 23 years with a median of 9.9 years (95% confidence interval: 6.2-13 years). At the time of follow-up, there were 12 (12/39, 30.8%) melanoma-associated deaths. The anatomic distribution of primary melanoma for these 12 patients follows: 4 (33.3%) facial and 8 (66.7%) scalp/neck. Histologic data revealed 24 (61.5%) tumors classified as superficial spreading melanoma with nodular melanoma (12.8%) a distant second. The mean Breslow depth for patients with melanoma-related mortality was 2.4 mm, compared with 1.8 mm for those who were alive at last follow-up.

LIMITATIONS

Small sample size limited this study.

CONCLUSION

This study found that the majority (59%) of H&N melanomas presented as scalp or neck lesions with a predilection for adolescents and boys. Those who experienced melanoma-related mortality had thicker lesions. Superficial spreading melanoma was the most common subtype.

Prognostic factors for melanoma in children and adolescents: a clinicopathologic, single-center study of 137 Patients

BACKGROUND

Cutaneous melanoma in childhood is rare; therefore, its prognostic factors and biologic behavior and the effectiveness of adjuvant diagnostic techniques in this group remain mostly unknown.

METHODS

The authors conducted a retrospective, observational study on the prognostic significance of clinical and pathologic findings from 137 cutaneous and mucosal melanomas in patients aged <18 years that were reviewed by the pathology department of a large cancer center during the period from 1992 to 2006.

RESULTS

Univariate analysis indicated that there was a significantly greater risk of metastases for patients who had previous nonmelanocytic malignancies, nodular histologic type, fusiform or spitzoid cytology, high Breslow thickness, vertical growth phase, high dermal mitotic activity, ulceration, and vascular invasion. Adjacent nevus and radial growth phase were associated with a better prognosis. Twelve patients (10.3%) died during follow-up. Decreased overall survival was related significantly to age >10 years, previous nonmelanocytic malignancy, high Breslow thickness, high Clark level, and the presence of metastases at diagnosis. All patients who died were aged ≥ 11 years, and 8 of those patients had metastases at diagnosis. In multivariate analysis, higher Breslow thickness predicted an increased risk of metastases, whereas age >10 years and the presence of metastases at diagnosis were associated with decreased survival.

CONCLUSIONS

Similar to adults, the detection of metastases at diagnosis in children with melanoma was 1 of the main factors that influenced overall survival. Melanomas that were detected in children aged <11 years appeared to have a less aggressive behavior than those detected in adults.

Increased detection of metastatic melanoma in pediatric sentinel lymph node biopsies using RT-PCR on paraffin-embedded tissue

Sentinel lymph node (SLN) biopsy has become integral in the staging of patients with melanoma, and entails detailed histologic examination with immunohistochemistry. Reverse transcriptase-polymerase chain reaction (RT-PCR) for tyrosinase transcripts has been used to increase sensitivity but requires a dedicated piece of tissue that does not undergo histologic examination. We developed a nested RT-PCR assay for tyrosinase applicable on paraffin-embedded tissue and applied this to a series of SLNs from pediatric patients with melanoma. Thirty-six SLNs from 4 females and 4 males were included in the study. Eight lymph nodes with reactive changes were included as controls. SLNs were examined histologically and immunohistochemically for S100, tyrosinase, and MART1. Seven patients had between 1 and 4 morphologically-positive SLNs and one patient had negative SLNs (HISTO+; 12/36, 33%). Three lymph nodes were excluded from molecular analysis owing to inadequate RNA, and 29 of the remaining 33 nodes were positive (MOL+; 88%). All patients had at least 1 SLN positive by RT-PCR. Twelve were HISTO+/MOL+; 17 were HISTO-/MOL+; and 4 were HISTO-/MOL-. All control lymph nodes were negative for tyrosinase transcripts. The application of RT-PCR for tyrosinase to paraffin-embedded tissue significantly increased the number of positive SLNs and upstaged one patient from negative to positive. The prognostic implications of such findings require further investigation, especially in the pediatric age group. Nonetheless, this technique provides a useful tool to determine the clinical significance of RT-PCR positivity in melanoma SLNs.

Childhood melanoma

Pediatric melanoma is rare but increasing in incidence. Because early diagnosis and treatment improves prognosis, clinicians need to include it as a possible diagnosis when evaluating a pigmented lesion in a pediatric patient. Some risk factors for melanoma include xeroderma pigmentosum, giant congenital melanocytic nevi, dysplastic nevus syndrome, atypical nevi, many acquired melanocytic nevi, family history of melanoma, and immunosuppression. Definitive treatment is with surgical excision. Adjuvant therapies such as chemotherapy, immunotherapy, and radiation therapy can be used in advanced cases.

An 18-year experience in the management of congenital nevomelanocytic nevi

BACKGROUND

Children with giant congenital nevomelanocytic nevi (CNN) are referred to our pediatric burn center for the surgical management of this disfiguring and potentially malignant skin disorder. Use of tissue expanders has contributed significantly in limiting donor site morbidity associated with treatment of giant CNN. Cultured skin substitutes (CSS) have also shown promise as an alternative wound coverage. With recent controversy regarding the effectiveness of excision in preventing melanoma risk, we wished to review our surgical management of giant CNN and to determine the incidence of malignancy in these patients.

METHODS

A retrospective chart review of patients with giant CNN was performed from 1985 to 2003. Charts were reviewed for age, sex, percentage total body surface area (TBSA) involved, age at initiation and completion of treatment, surgical treatment, complications, histopathology, and length of follow-up.

RESULTS

Of the 40 patients treated at our facility, the mean extent of skin involvement was 10% TBSA (range: 0.5%-75%). The mean age at initial operation was 5.1 years, and the majority of surgical interventions were completed within a mean of 1.3 years. Twenty-two patients (55%) required more than 1 surgical procedure. Excision and split-thickness skin grafting was the most common surgical procedure (n = 22) followed by excision with primary closure (n = 18). Ten patients were treated with tissue expansion, while 4 received cultured skin replacements. One patient died of extracutaneous melanoma during the course of surgical treatment. Three patients demonstrated histopathologic evidence of cytoatypia but remained clinically free of malignancy during a mean follow-up of 11 years.

CONCLUSIONS

Giant CNN are both important cosmetic and medical problems. With an associated lifetime risk of melanoma in 4%-10% of patients, excision of CNN is recommended despite the fact that 50% of melanomas arise extracutaneously. Depending on the extent of body surface area involvement, wound closure can be obtained with conventional split- or full-thickness skin grafts, tissue expansion, and/or cultured autologous cultured skin substitutes. The latter 2 modalities provide improved cosmetic results, with minimal donor site morbidity.

Melanoma in the young: Differences and similarities with adult melanoma

BACKGROUND

Melanoma in the first 2 decades of life is rare and is less well characterized than melanoma in adults. Previously published comparisons of melanoma of the young (age <or=20 years) and in adults have been biased by the observation that primary melanomas of the young are significantly thicker on average than adult melanomas. In this study, the use of an adult control group that was matched for tumor thickness adjusted for this bias and allowed for a comparison of the biology of pediatric melanoma and adult melanoma.

METHODS

The authors identified young patients with melanoma who were treated at their institution between 1971 and 2002, and matched each patient by thickness and year of diagnosis to 2 adult control patients with melanoma. The study group of 73 young patients with melanoma (aged <or=20 years) was compared with to 146 adult case-matched control patients for clinical presentation, treatment, and clinically relevant outcome parameters, including disease-free and cause-specific survival. A subset of pediatric patients aged <or=13 years also was analyzed against case-matched adult controls.

RESULTS

The demographics and clinical presentation of the 2 groups were similar. Of the young patients with melanoma who underwent pathologic staging of clinically negative lymph nodes by either elective lymph node dissection or lymphatic mapping/sentinel lymph node biopsy, 11 of 25 patients (44%) had positive lymph nodes compared with 11 of 46 patients (23.9%) among the adults. The overall incidence of positive lymph nodes was 17.8% in young melanoma patients and 9.6% in thickness-matched adult control patients. Nonetheless, 10-year cause-specific survival was similar between young melanoma patients and adult melanoma patients (89.4% and 79.3%, respectively). No significant differences were observed comparing young patients with melanoma aged <13 years versus age >13 years.

CONCLUSIONS

Melanoma of the young had some important differences and similarities relative to adult melanoma. Lymph node metastases were more prevalent in young patients with melanoma compared with adult (thickness-matched) control patients; however, the 5- and 10-year survival rates were similar.

Adolescent melanoma: Risk factors and long term survival

AIMS

To report the adolescent melanomas with focus on differences in clinical characteristics, prognostic factors, disease free (DFS) and overall survival (OS) in comparison with adults.

METHODS

A single institution retrospective study in which 49 adolescent patients were compared to an adult group of 972 patients. The 10-year DFS, 10-year OS and prognostic factors were calculated for both groups.

RESULTS

The median age for the adolescent patients was 17 (range 12-19) years and 49 (range 20-93) years for the adult patients. Median follow-up time was 92 (range 4-366) months. Adolescent patients presented more often with locally advanced melanoma (p<0.01). The median Breslow thickness was 1.6 vs 2.0mm for the adults (p=0.075). Increasing age, ulceration, Breslow thickness, tumour location, male gender and stage at diagnosis were calculated to be negative prognostic factors for the adult group. In the adolescent group, only the stage at diagnosis was a significant negative predictor. The 10-year DFS and OS for the adolescent patients and adult group were not significantly different regarding AJCC stages I-III.

CONCLUSION

Although adolescent patients presented more often with locally advanced disease, there are no significant differences in the 10-year DFS and OS between adolescent and adult patients. In our series, we could not confirm the prognostic factors found in the adult group for the adolescent patients, except for the stage at diagnosis.

Childhood melanoma: update and treatment

Childhood melanoma is a rare but potentially fatal disease that is important to include in the differential diagnosis of any pigmented lesion in a child. The best prognosis is achieved with early diagnosis and definitive surgical excision. Adjuvant chemotherapy and immunotherapy are options for those with more advanced tumors. Melanoma in children must be treated as aggressively as in adults because childhood melanoma may be equally devastating.

Malignant melanoma in childhood and adolescence: Report of 13 cases

We reviewed all cases of malignant melanoma in children younger than 17 years of age who were evaluated at Sainte Justine Hospital, a tertiary care pediatric center, between 1980 and 2002. The medical records and histologic features of all cases were reviewed. Thirteen cases were identified, 4 boys and 9 girls. Fifty-three percent of patients were prepubescent. None of the patients had a predisposing condition (eg, giant congenital nevi, dysplastic nevus syndrome, or xeroderma pigmentosum). One patient had had chemoradiotherapy previously for an undifferentiated pleuropulmonary malignant tumor (blastoma) and another patient had Down syndrome. The most frequent reason for initial consultation was a recent increase in size of the lesion. Three patients had pyogenic granuloma-like lesions. Eighty-five percent of the observed melanomas were nodular in type. Tumor thickness ranged from 0 to 6 mm with a median and mean thickness of 2.8 and 3.2 mm, respectively. The overall 5-year survival rate was 58.8%. Lack of awareness and delay in diagnosis may lead to a higher incidence of thick and intermediate melanoma in children. Because it appears that the majority of melanomas in childhood and adolescence occur de novo, clinicians should consider this condition in the differential diagnosis of any suspect lesion in children and adolescents even without an identified predisposing factor.

Survival in sentinel lymph node-positive pediatric melanoma

BACKGROUND

Sentinel lymph node (SLN) status is the strongest predictor of survival in adult melanoma. However, the prognostic value of SLN status in children and adolescents with melanoma is unknown.

METHODS

Records of 327 patients aged 12 to 86 years undergoing SLN biopsy for melanoma or other melanocytic lesions were reviewed. A literature search identified additional patients younger than 21 years undergoing SLN biopsy for the same indications and these patients were combined with our series for meta-analysis.

RESULTS

Sentinel lymph node metastases were found in 8 (40%) of 20 patients aged 12 to 20 years compared with 55 (18%) of 307 adults (P < .05). Median follow-up was 35 and 17 months for the groups, respectively. Sentinel lymph node-positive pediatric patients did not recur, whereas 14 (25%) adults recurred within this period. Of the 55 adults, 5 (9.1%) have died of disease. Of the combined SLN-positive children and adolescents from the literature (total n = 25), only a single (4%) child recurred at 6 months. The difference in survival for adult and pediatric patients was significant.

CONCLUSION

Pediatric patients have a higher incidence of SLN metastases than adults yet have a lower incidence of recurrence. Sentinel lymph node status does not predict early recurrence in pediatric patients with melanoma or atypical Spitz nevi.

High-risk surgically resected pediatric melanoma and adjuvant interferon therapy

BACKGROUND

Pediatric patients with high-risk surgically resected melanoma are at risk for relapse, yet little is known about these young patients and how they tolerate high-dose interferon therapy.

PROCEDURE

We reviewed medical records of patients (< or =18 years) with high-risk melanoma referred to the University of Michigan Pediatric Hematology-Oncology service between January 1989 and July 2003.

RESULTS

Fourteen patients were identified with high-risk resected melanoma. The median age at diagnosis was 8.5 years. The median time to establish diagnosis was 9 months. Primary lesions were diagnosed as unequivocal melanoma, atypical epithelioid melanocytic proliferations, or atypical Spitz tumor with indeterminate malignant potential. Twelve patients had a positive sentinel lymph node (SLN) biopsy or a palpable regional lymph node and underwent regional lymph node dissection (LND). Two patients with unequivocal melanoma with Breslow depth >4 mm had negative SLN biopsies. Twelve patients received adjuvant high-dose interferon. The following toxicities were observed: constitutional symptoms, gastrointestinal symptoms, depression or neuropsychiatric symptoms, myelosuppression, elevated AST or ALT, hypothyroidism, and hypertension. Grade 3 or 4 toxicities were uncommon with exception of neutropenia, resulting in modification of therapy in one patient. All patients are alive and free of disease at follow-up (median 24.5 months).

CONCLUSIONS

Invasive melanoma can occur in very young children. Despite early signs of malignancy, there is often a delay in diagnosis. Histologically, diagnosis may be difficult because of overlap with Spitz nevi. Pediatric patients tolerated adjuvant high-dose interferon well and may be less likely than adults to require therapy modification secondary to toxicities.

Does melanoma behave differently in younger children than in adults? A retrospective study of 33 cases of childhood melanoma from a single institution

OBJECTIVE

To ascertain whether childhood melanoma presents any peculiar clinical features or differences in prognosis with respect to adults, we retrospectively analyzed the data from 33 patients who were up to 14 years of age and treated for cutaneous melanoma at the Istituto Nazionale Tumori, Milan, over a 25-year period.

METHODS

Primary lesions were amelanotic in half of the cases and raised in 73%. Lower extremities were the most common primary sites. Histologically, 9 cases were classified as nodular type, and median thickness was 2.5 mm. Nine children had nodal involvement at diagnosis, 2 in-transit metastases, and 1 distant spread. Surgery was the mainstay of treatment; 9 patients underwent lymph node dissection, 3 received chemotherapy, and 2 received radiotherapy.

RESULTS

With a median follow-up of 122 months, 5-year event-free survival and overall survival were 60% and 70%, respectively. Age seemed to correlate with survival, event-free survival being 90% in children under 10 and 47% in older patients, although the initial microstaging seemed worse in the former.

CONCLUSION

By comparison with adult cases, childhood melanoma can have a higher percentage of atypical clinical features (amelanotic and raised lesions), nodular histotype, and thick lesions. Although we have no data to support any suggestion of biological differences between young children and adolescents or adults, our findings give the impression that melanoma behaves differently in the younger age group.

The feasibility of adjuvant interferon ?-2b in children with high-risk melanoma

BACKGROUND

It has been shown that induction high-dose interferon alpha-2b (IFN-alpha-2b) followed by maintenance therapy improves recurrence-free survival in adults with high-risk, resected melanoma. In this study, the feasibility and toxicity of this regimen were evaluated in newly diagnosed pediatric patients with Stage III melanoma involving regional lymph nodes.

METHODS

Fifteen patients age <or=18 years with newly diagnosed Stage III melanoma were enrolled on an institutional protocol. Patients were treated with wide local excision, sentinel lymph node biopsy, lymph node dissection, and adjuvant biotherapy, consisting of induction therapy with 20 million IU/m2 per day IFN-alpha-2b intravenously 5 times per week for 4 weeks followed by maintenance therapy with IFN-alpha-2b 10 million IU/m2 per day subcutaneously 3 times per week for 48 weeks. Patients were monitored for toxicity and tumor recurrence.

RESULTS

All patients completed induction therapy, and nine patients completed maintenance therapy. Three patients currently are receiving maintenance, 2 patients developed recurrent disease on maintenance therapy, and 1 patient stopped maintenance therapy 5 weeks early. During induction therapy, Grade 3-4 toxicities included 14 episodes of neutropenia in 11 patients, 3 episodes of leukopenia in 2 patients, and 6 episodes of liver transaminase elevations in 5 patients. Dose modifications were required in four patients. During maintenance therapy, Grade 3-4 toxicities included 23 episodes of neutropenia in 10 patients and 2 episodes of liver transaminase elevations in 2 patients. Three patients required dose modifications. All toxicities were reversible with interruption or dose modification of therapy, and no patients were taken off study due to toxicity.

CONCLUSIONS

High dose IFN-alpha-2b for 4 weeks followed by a lower dose maintenance phase for 48 weeks was feasible in children with Stage III melanoma and was associated with tolerable toxicity.

Sentinel lymph node biopsy for melanoma and other melanocytic tumors in adolescents

BACKGROUND/PURPOSE

Melanoma is rare, accounting for only 1% of all pediatric malignancies. The management of pediatric melanoma is controversial but largely parallels that of an adult occurrence. Sentinel lymph node biopsy (SLNBX) has become a standard of care for adults with melanoma, but the role of this procedure in the staging of pediatric patients remains to be established. The goal of this study was to determine outcomes and complications of children and adolescent patients undergoing SLNBX at the authors' institution.

METHODS

A retrospective review of patients younger than 21 years (N = 20) undergoing SLNBX for melanoma or other melanocytic skin lesions at the University of Colorado Health Science Center between 1996 and 2003 was conducted.

RESULTS

Sentinel lymph node biopsy was successful in all 20 patients, and 8 patients (40%) were found to have metastases within the sentinel node. As in adults, the sentinel node status correlates with primary tumor depth. No complications occurred in patients undergoing SLNBX, but 4 clinically significant complications (57%) occurred in the 7 patients undergoing a completion lymph node dissection. At 33 months median follow-up, all patients were disease free.

CONCLUSIONS

Sentinel lymph node biopsy can be successfully and safely performed in pediatric patients for melanoma and atypical nevi. However, the prognostic information and therapeutic implications of SLNBX results for children and adolescents remain unclear. Completion lymph node dissection for microscopic disease is a morbid procedure with uncertain benefit to pediatric or adult patients with a positive SLNBX result. Long-term follow-up data are needed before SLNBX can become a standard of care in pediatric melanoma or as a diagnostic tool to distinguish the atypical Spitz nevus from melanoma.

Melanoma in children and adolescents

Childhood and adolescent melanoma is rare, accounting for only 1.3% for all cases of cancer in patients under the age of 20 years. However, in 15-19 year olds, melanoma accounts for up to 7% of all cancers. Review of reported cases in this age group reveals that predisposing 'paediatric' conditions such as a giant congenital melanocytic naevi or xeroderma pigmentosum are rarely present. Furthermore, inactivating germ-line mutations of the gene CDKN2A have only been reported in 1.5% of cases of early onset melanoma. Epidemiological studies suggest that interactions between solar exposure, development of naevi, pigmentary traits, and a family history of melanoma are the main determinants of melanoma development during the first 20 years of life. As yet, there are no available staging or treatment strategies for this group of patients so treatment recommendations are based on the adult experience. To improve our understanding of the natural history of melanoma and to identify the most appropriate therapies for young patients with this disease, practising physicians are encouraged to enroll their patients, especially those with advanced stage disease, in cooperative group trials which incorporate newer staging systems and promising therapies.

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

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

Sentinel lymph node biopsy in children and adolescents with malignant melanoma

BACKGROUND/PURPOSE

Sentinel lymph node biopsy (SLNB) provides valuable staging information for adult patients presenting with clinically localized cutaneous melanoma. There are little data pertaining to the use of SLNB in the pediatric melanoma population. The objective of this study is to investigate the use of SLNB in the pediatric population, focusing on its diagnostic and therapeutic implications.

METHODS

Retrospective identification was made of patients 18 years or younger who underwent sentinel lymph node biopsy for clinically localized melanoma at Indiana University Medical Center between 1994 and 2001. Patient demographics, primary tumor thickness, location of primary tumor, presence of tumor ulceration, number of lymph nodes removed, pathology of examined nodes, and number of lymph nodes involved with tumor were recorded. Disease status and dates of last clinical contact were determined.

RESULTS

Twelve patients, 18 years or younger, were identified. Mean age of the study population was 14.1 years (range, 4 to 18). Mean tumor thickness was 1.65 mm (range, 0.36 to 4.7 mm). Three patients (25%) had positive sentinel lymph node biopsies. All 3 patients underwent completion lymph node dissection (CLND). One patient had micrometastatic disease detected on CLND; he had recurrence 6.1 months later and died 7.5 months after his SLND/CLND. At a median follow-up of 11.7 months, the remaining 11 patients had not experienced recurrence. There were no complications related to the SLNB procedure.

CONCLUSIONS

The minimally invasive surgical approach and limited complications associated with SLNB make this procedure a useful aid in assisting the physician in making therapeutic decisions in the pediatric melanoma patient.

Melanomas in prepubescent children: review comprehensively, critique historically, criteria diagnostically, and course biologically

Our series was comprised of 11 children age 10 years or younger (6 were younger than age 5) with primary cutaneous melanoma. All of the melanomas occurred de novo and all metastasized; one child died. In no instance was melanoma a clinical consideration, and in none did the histopathologist who first "signed out" the case make a diagnosis of melanoma. Despite the inability of clinicians and pathologists to diagnose correctly, with repeatability, melanomas that develop in children yet to be pubescent, those neoplasms, nonetheless, are melanomas and, therefore, criteria employed currently for diagnosis of melanoma, especially clinically, must be refined in order that they be applicable equally to melanomas in pre- and postpubescents. The vaunted ABCDs (Asymmetry, Border irregular, Color variability, Diameter >6.0mm) surely do not work for melanomas that appear in children who are prepubescent. Additionally, melanomas that occur in these children have distinctly different architectural and cytopathological features from those that arise in postpubescents, often being confused as they are by conventional microscopy with a Spitz's nevus. As a rule, melanomas in prepubescent children grow much more rapidly then those in adults but, like them, have the capability to disseminate widely and cause death.

Cutaneous melanoma in childhood and adolescence: an analysis of 36 patients

Analysis of data of 6931 patients with cutaneous melanoma seen at the Department of Dermatology and Allergology at the Ludwig-Maximilians-University of Munich between 1977 and 1998 identified 36 patients in whom cutaneous melanomas developed during childhood or adolescence (age <18 years). Clinical courses of all patients and histopathologic characteristics of the lesions were reviewed. Seventeen patients were boys and 19 patients were girls. The median ages of the boys and girls were 15 and 16 years, respectively (range, 2-17 years). Thirty-one patients presented with nonmetastatic primary melanomas and 5 patients presented with metastatic melanoma. Forty-seven percent of the primary lesions were associated with a nevus (22% with congenital nevi and 25% with acquired nevi). Tumor thickness ranged from 0.24 to 7.0 mm, with a median of 1.29 mm (mean, 1.67 mm). All patients with primary melanomas received surgical therapy; patients with metastatic disease received chemotherapy, radiation therapy, or both. Relative 5-year survival was 87.5% for the group of patients younger than 18 years. Similar to experience in adult patients, survival strongly correlated with tumor thickness and clinical stage at the time of diagnosis. The data emphasize that a high index of suspicion for cutaneous melanoma is needed by clinicians assessing melanocytic lesions in children and adolescents for early diagnosis. Reduction of the melanoma mortality rate in children and adolescents will be achieved through identification of patients at increased risk.

Pediatric skin tumors

This article summarizes several malignant childhood neoplasms and benign tumors that can mimic malignancies. Because malignant skin tumors are rare in children, parents and physicians often are not sufficiently suspicious to ensure that an early diagnosis can be made. Many malignant skin tumors have features that suggest a vascular or hemangioma-like lesion. Because hemangiomas occur in 10% of infants, it is often considered prudent to adopt a wait-and-see attitude; however, if the lesion is too firm to be a hemangioma or its growth pattern does not follow that of a typical hemangioma, additional options should be considered. To manage childhood skin malignancies, one needs expert consultation, early biopsy, and correct histopathologic interpretation.

Sentinel lymph node biopsy for melanoma in young children

Lymphoscintigraphy and sentinel lymph node biopsy techniques can be applied successfully to young children with melanoma to detect nodal disease. The authors describe their methods of lymphoscintigraphy and sentinel node biopsy and its application in 2 young children with malignant melanoma of the head and neck.

Childhood melanoma survival

BACKGROUND

Melanoma in childhood is uncommon. Some believe that melanoma among children is associated with a better prognosis than among adults.

METHODS

The authors reviewed their institutional experience with melanoma in 40 patients younger than 18 years treated between 1950 and 1984. All slides were reviewed by a single dermatopathologist who was blinded to clinical outcomes. Long term follow-up was available for all but three patients.

RESULTS

There were 26 girls and 14 boys. The median age at diagnosis was 15 years (range, 3-17 years). Eleven patients (28%) were younger than 12 years. Fifteen patients (38%) had melanoma arise in a congenital nevus (2 had bathing trunk nevi. The most common site was the extremity (n = 23), followed by the trunk (n = 10) and the head and neck (n = 7). Seventeen patients (43%) initially were considered to have benign lesions, and 23 patients (57%) were diagnosed correctly with melanoma at initial presentation. Only 21 of 37 evaluable patients (57%) were alive at last follow-up with a median follow-up of 18 years (range, 2-48 years). Fifteen patients (41%) died of their disease, with a median survival of 12 months (range, 6-60 months). One patient died of breast carcinoma 14 years after treatment for melanoma. Disease free survival was 57% at 5 and 10 years. Of the 15 patients who died of disease, 12 were female (P = 0.09) and 10 had melanoma arising in a congenital nevus (P < 0.05). Five-year overall survival was 78% for patients who presented with localized disease (n = 23) and 30% for patients who presented with regional metastasis (n = 16, P < 0.001). There were no survivors among those who presented with systemic disease (n = 1).

CONCLUSIONS

Children with melanoma are at significant risk of dying of their disease. Survival is similar to that seen among adults and depends on stage at presentation. The survival advantage observed for adult females is not seen among children.

Brain metastases in children with melanoma

BACKGROUND

Brain metastases complicate the course of malignant melanoma in at least 20% of adult cases. These events are commonly preceded by metastases to other sites. Due to the rarity of malignant melanoma in children, little is known about the incidence, clinical features, and outcome of children with melanoma who develop brain metastases.

METHODS

The authors reviewed the records of 44 children with malignant melanoma treated at St. Jude Children's Research Hospital over a 33-year period. Eight (18%) developed brain metastases during the course of their disease. The authors reviewed the clinical and radiologic features of six of these cases, for whom complete clinical information and imaging studies were available.

RESULTS

The median age at diagnosis of malignant melanoma was 15 years (range, 11-21 years). Brain metastases developed a median of 20 months (range, 0-50 months) after diagnosis and were preceded by metastases to other organs in 5 patients. In most cases, lesions were supratentorial and multiple. Most showed radiologic signs of intralesional hemorrhage. All patients received whole brain radiotherapy, and one had surgical resection. Three patients received chemotherapy. Five patients died a median of 5 months (range, 2-10 months) after diagnosis of brain involvement. One patient, who had a single brain metastasis at diagnosis, is alive more than 34 months later.

CONCLUSIONS

Brain metastases develop in a significant proportion of children with malignant melanoma and are associated with a poor outcome. The incidence, features, and outcome in children do not appear to differ from those in adults.

Cutaneous malignant melanoma in the young

Between the years 1967 and 1993, 3246 patients were diagnosed with malignant melanoma at Frenchay Hospital, Bristol. This paper reports 47 patients, 21 years of age or under, including 10 preadolescent cases under 14 years of age. It represents a further follow-up of a cohort originally published from this centre in 1986 in addition to 18 new cases. Most (89%) of the lesions occurred on the trunk and extremities, with females showing a predominance of lesions on the lower limbs. 83% of the melanomas were of the superficial spreading type: 72% invaded to Clark level III and IV. Thickness ranged from 0.29 mm to 50.00 mm (median 1.20 mm). Ulceration was present in 17% of cases and 32% of melanomas arose within a pre-existing small congenital melanocytic naevus. Overall 5-year survival was 81%, with a mean follow-up of 8.5 years. Ulceration and tumour thickness of greater than 1.5 mm were associated with a poor prognosis.

Malignant melanoma in children: imaging spectrum

OBJECTIVE

The objective of this study was to investigate the role of diagnostic imaging in detecting unsuspected metastatic disease in children with malignant melanoma. This has not been well studied previously.

MATERIALS AND METHODS

We correlated imaging findings of 33 children diagnosed with melanoma with the level of invasion and clinical stage of disease.

RESULTS

Clinically undetectable metastases were identified in eight patients (25 %), four of whom had multiple metastases. All eight patients had deep lesions (Clark's level IV or V) or unknown primary sites of disease.

CONCLUSION

Children with thick melanomas and those with unknown site of primary tumors are at increased risk of having clinically unsuspected metastases and should undergo CT of the chest, abdomen, and local-regional nodal basins at diagnosis to determine disease extent.

Malignant melanocytic lesions of unknown primary site in children and adolescents

BACKGROUND

Metastatic melanoma with an unidentified primary site represents 4% of all newly diagnosed cases of malignant melanoma in adults. Little is known of the incidence and clinicopathologic features of this clinical entity in the pediatric population.

METHODS

We reviewed all previously diagnosed cases of malignant melanoma in children and adolescents (< 21 years) who were treated at our institution and identified three patients who presented with metastatic melanocytic lesions with an unidentified primary site.

RESULTS

This clinical presentation accounted for 9% of all malignant melanocytic lesions treated at our center over a 20-year period. The clinicopathologic features were similar to those seen in adults. Two patients died of progressive disease within two years of presentation; the third is alive and disease-free 18 years post-diagnosis.

CONCLUSIONS

Although uncommon in the pediatric population, malignant melanoma should be considered in the differential diagnosis of poorly differentiated disseminated malignancy that involves lymph nodes or viscera with no identifiable primary tumor.

Malignant melanoma in children

BACKGROUND

Cutaneous melanoma is an uncommon malignancy in children and for this reason, there is little information available regarding the timing and patterns of recurrence in children with this disease. This study reviews the experience at a single institution (Duke University Melanoma Clinic) in treating children with malignant melanoma.

METHODS

Eighty-five patients < or = 18 years of age with malignant melanoma have been treated. All but three patients were over the age of 10; 73% of them were > 14. As for adults, treatment consisted of wide local excision of all primary lesions with primary closure or split-thickness skin graft, as needed. In addition, 22 patients underwent dissection of regional lymph nodes. Patients whose tumors had aggressive pathologic characteristics were treated with an adjuvant immunotherapy protocol. Patients with recurrence at distant sites were offered combination chemotherapy.

RESULTS

Patients and pathologic characteristics of sex, race, primary site, histologic type, tumor thickness, and Clark level were similar to those observed in adults. Actuarial survival rates (79% versus 77% at 5 years) of the pediatric and adult Stage I melanoma patients were also not significantly different. Children had a greater incidence of recurrence after initial treatment, although recurrence tended to happen after a longer disease-free interval than for adults. Half of the 79 children who were first seen with Stage I disease have suffered a relapse, but more than one-third were disease free for > or = 5 years after initial treatment. Of the 18 patients who were disease free for > or = 7 years, 12 (67%) ultimately had recurrent disease, including five patients who had recurrences > 13 years after initial diagnosis.

CONCLUSIONS

The early age at which malignant melanoma may occur and the significant potential for very late recurrence mandate that pediatricians and other primary care physicians consider the diagnosis of melanoma even in young patients with new skin lesions and that patients treated for melanoma be carefully followed for a lifetime.

Cutaneous malignant melanoma in teenagers

Of 57 reviewed cases of malignant melanoma in teenagers, 51 had a minimum follow-up of 5 years. The histological and some clinical features of the 51 cases were compared for diagnostic and prognostic significance with those of 19 Spitz naevi and 10 other benign naevi using the SPSS-X computer program. The overall crude survival was 71% (males 64%, females 81%). Five patients with regional metastases survived more than 5 years, three of these more than 10 years. The main statistically significant features associated with a poor prognosis were Breslow thickness, diameter of ulcer, abnormal mitoses, pushing dermal borders and marginal (deep) mitoses. In comparison with Spitz naevi, features favouring malignancy were Breslow thickness, fine dusty cytoplasmic melanin pigment, marginal or abnormal mitoses, epithelioid intra-epidermal melanocytes below parakeratosis, dermal nests larger than junctional nests and the mitotic rate in the papillary dermis. Features favouring a benign lesion were diffuse maturation, spindle cells, spindle nuclei and Kamino bodies, especially if numerous or clustered. In comparison with the atypical benign naevi, significant features favouring malignancy were marginal or abnormal mitoses, single cell epidermal invasion below parakeratosis, large nuclei and irregular nuclei.

Prepubertal melanoma in a medium-sized congenital naevus

A case of malignant melanoma in a medium-sized congenital naevus in a prepubertal girl is presented. Risk factors for developing melanoma during childhood include giant congenital naevi, dysplastic naevus syndrome and xeroderma pigmentosum. The lifetime risk of melanoma associated with giant congenital naevi has been estimated to be 4%-20%; the risk associated with small and medium-sized congenital naevi however remains controversial. In the latter lesions, malignant transformation is considered an almost exclusively postpubertal phenomenon, in contrast to giant congenital naevi where it often occurs prior to puberty. In our patient, malignant transformation in a medium-sized congenital naevus occurred before puberty. We suggest that the true incidence of malignant transformation within these lesions and the time at which it occurs, should be documented by prospective studies and that not only the giant congenital naevi but also the smaller congenital naevi should be considered for prophylactic excision in early childhood.