Malignant melanoma in Italy: risks associated with common and clinically atypical melanocytic nevi

Melanocytic lesion in children and adolescents: an Italian observational study

Malignant melanoma is a rare neoplasm in the pediatric age group. One of the main risks factors is represented by the presence of a high number of melanocytic nevi. Sun exposure in pediatric age represents a predictor of melanocytic nevi number in the adult age and there is a direct correlation between the presence of melanocytic moles in early childhood and the development of many nevi in adults, suggesting that a high number of nevi in childhood should be considered as a predictor of melanoma development during adult life. The predominance of dermoscopic types of melanocytic nevi varies according to the individual’s age and depends on endogenous or exogenous signaling, suggesting different pathways of nevogenesis. We evaluated the total amount of melanocytic nevi of pediatric patients and their prevalent dermoscopic pattern. We investigated the reasons for dermatological examination, pointing out the role of older parents’ populations in the decision to refer to a dermatological consultant. We performed a prospective observational study on 295 pediatric outpatients consecutively enrolled from July 2018 to July 2019. Descriptive and inferential statistical analyses were performed using logistic and linear regression. 49% of children were characterized by less than 10 nevi, 45% of children by a number of nevi between 10 and 30, whilst 17 patients (5%) had a number of nevi between 30 and 50. The most prevalent dermoscopic pattern was the globular one. An older parenting age was correlated with an autonomous reason for referral and a later first visit. Our data agreed with previous suggestions demonstrating a strong influence of latitude, sun exposure and ethnic background in the development of the number of nevi. To our knowledge, this is the first study, which evaluated the reasons for dermatological examination and the role of older parents’ populations in the decision to refer to a dermatological consultant

Assessing Scientific Data: The Case-Control Study as it Applies to Dermatology Part 1: The Case-Control Method

Background:

Epidemiology is integral to medical research. To keep abreast of medical advances related to the specialty, dermatologists need a sound understanding of epidemiologic principles.

Objective:

The purpose of this article is to introduce the case-control study design in the context of dermatology. Topics covered include subject selection, exposure assessment, and data analysis.

Conclusions:

The case-control design is applicable to dermatology research. This method is especially relevant for rare diseases or those with a long latency period.

Pigmented naevi and sun protection behaviour among primary and secondary school students in an Eastern Hungarian city

BACKGROUND

The most important risk factors for malignant melanoma are skin type I or II, large number of atypical naevi and a history of sunburn in childhood and adolescence.

METHODS

A cross-sectional study was performed to assess skin type, number of pigmented lesions and sun protection behaviour in 1157 12- to 19-year-old Hungarian students at 20 primary and secondary schools in Debrecen, Hungary. After receiving dermatological training, 18 school doctors examined the students' skin. A questionnaire was completed by the students with the assistance of their parents about sun protection, sunburns and the use of sunbed. Data from 612 questionnaires were evaluated.

RESULTS

Based on the doctors' evaluation, most of the pupils were classified as having skin type II and majority of them had 5-20 naevi, particularly on the trunk. Based on the student's response, 5.2% purposely sunbathed daily, 10.1% did not use any form of sun protection, 32.2% wore sun-protective clothing and 65.7% applied sunscreen generally. 6.9% used sunbed, and 74.0% previously experienced serious sunburn at least once. Indoor tanning statistically correlated with the number of melanocytic naevi.

CONCLUSION

A high prevalence of sunburn was reported by the students and some of them did not apply any sun protection methods but used sunbed at a critical age for developing melanoma at a later time. These data highlight the importance of educating children and parents about appropriate sun protection.

Melanoma density and relationship with the distribution of melanocytic naevi in an Italian population: a GIPMe study--the Italian multidisciplinary group on melanoma

The most frequent site for melanoma is the back in men and the lower limbs in women, where intermittent sun exposure has been reported to be an environmental agent, although studies on age-specific incidence have suggested that melanoma in chronically sun-exposed areas, such as the face, increases with age. To identify the preferential development of melanoma in chronically or intermittently sun-exposed areas and the relationship between body site distribution and parameters such as sex, age, distribution of melanocytic naevi, atypical naevi and actinic keratoses, a prospective epidemiological multicentre study was carried out on all the consecutive melanoma cases diagnosed in a 2-year period from 27 Italian GIPMe centres (GIPMe: the Italian Multidisciplinary Group on Melanoma). Both the relative density of melanoma (RDM), defined as the ratio between observed and expected melanoma for a specific body site, and the average nevi density were identified. The most common melanoma site was the back, a factor that was not affected by either age or sex, even if men had higher density values. Statistically significant higher RDM values were observed in women aged more than 50 years for leg lesions and in the anterior thighs for young women (<50 years), whereas the lowest values were observed in the posterior thighs in women of any age. Facial RDM was statistically significantly higher than expected in both male and female patients more than 50 years of age. Melanoma was associated with a significantly higher atypical naevi density only for the back, chest and thighs. Indeed, facial melanoma was related to the presence of more than four actinic keratoses and not naevi density. To the best of our knowledge, the RDM method was applied for the first time together with naevus density calculation to obtain these data, which strongly substantiate the 'divergent pathway' hypothesis for the development of melanoma, but not find a direct correlation between melanoma and nevi for each anatomical site.

Epidemiological and genetic factors underlying melanoma development in Italy

Among human cancers, melanoma remains one of the malignancies with an ever-growing incidence in white populations. Recent advances in biological and immunological therapeutic approaches as well as increased efforts for secondary prevention are contributing to improve the survival rates. It is likely that a significant fall in mortality rates for melanoma will be achieved by further increase of the early detection through a more accurate selection of the higher-risk individuals (i.e., carriers of predisposing genetic alterations). A similar scenario occurs in Italy. In the present review, we have considered data on incidence, survival and mortality rates of melanoma in Italian population, including evaluation of the main risk factors and genetic mutations underlying disease susceptibility.

Melanoma: A new strategy to reduce morbidity and mortality

BACKGROUND

Public awareness campaigns could address risk factors for melanoma to reinforce their sun protection message. The objective of this study is to prioritise risk factors associated with malignant melanoma (MM) to improve public awareness.

METHOD

DESIGN

A cross-sectional study with retrospective data analysis from 2004 to 2010.

SETTING

Western Australian Melanoma Advisory Service (WAMAS), a tertiary referral multidisciplinary organisation providing MM management advice. WAMAS data files were analysed with histologically confirmed cutaneous MM. Forty- seven patients had two or more melanomas, but the patient file was counted only once. Six MM data files with missing or incomplete information were excluded.

MAIN OUTCOME MEASURES

The number of naevi, blood relatives with MM, and previous sunburns were the primary variables collected.

RESULTS

The results showed that 70.9 per cent (268/378) had previous sunburn; 40.2 per cent (152/378) had multiple naevi; and 22.5 per cent (85/378) had a positive family history. In the 110 MM data files not associated with sunburn, multiple naevi and a positive family history represented 34.5 per cent (38/110) and 20.0 per cent (22/110), respectively.

CONCLUSION

The results confirm the findings of previous studies that multiple naevi and a positive family history are important risk factors associated with MM. We suggest that MM can be detected earlier and its mortality decreased by focusing on these high-risk groups who are not targeted by current public awareness campaigns.

Multicenter case-control study of risk factors for cutaneous melanoma in Valencia, Spain

INTRODUCTION

It is important to identify subgroups within the general population that have an elevated risk of developing cutaneous melanoma because preventive and early-detection measures are useful in this setting. The findings of most studies that have evaluated risk factors for cutaneous melanoma are of limited application in Spain because the populations studied have different pigmentary traits and are subject to different environmental factors.

OBJECTIVE

To identify the phenotypic characteristics and amount of exposure to sunlight that constitute risk factors for cutaneous melanoma in the population of the Autonomous Community of Valencia, Spain.

METHODS

We performed a multicenter observational case-control study. In total, the study included 242 patients with melanoma undergoing treatment in 5 hospitals and 173 controls enrolled from among the companions of the patients between January 2007 and June 2008. The information was collected by means of a standardized, validated questionnaire. The odds ratio (OR) was calculated for each variable and adjusted using a multiple logistic regression model.

RESULTS

The risk factors found to be statistically significant were skin phototypes I and II, blond or red hair, light eye color, abundant melanocytic nevi, and a personal history of actinic keratosis or nonmelanoma skin cancer. After the multivariate analysis, only blond or red hair (OR=1.9), multiple melanocytic nevi (OR=3.1), skin phototypes i and ii (OR=2.1), and a personal history of actinic keratosis (OR=3.5) or nonmelanoma skin cancer (OR=8.1) maintained significance in the model as independent predictive variables for melanoma.

CONCLUSIONS

Our study supports the importance of certain factors that indicate genetic predisposition (hair color and skin phototype) and environmental factors associated with exposure to sunlight. Patients with multiple acquired melanocytic nevi and patients with markers of chronic skin sun damage (actinic keratosis and nonmelanoma cancer) presented a significant increase in risk.

Factors associated with the prevalence of atypical nevus in a Mediterranean pigmented skin lesion clinic

Atypical melanocytic nevi constitute central risk factor and are precursor lesions for cutaneous melanoma. Data regarding factors associated with their prevalence are mainly derived from fair-skinned populations, whereas little is known regarding their epidemiological associations in darker-skinned, chronically sun-exposed populations. The aim of this study was to identify risk factors for the occurrence of at least one atypical nevus on Crete, the southernmost island of Greece. This hospital-based case-control study included 143 patients and 189 controls with at least one atypical nevus presented at the pigmented skin lesion clinic of the University of Crete. All participants were interviewed and underwent complete skin examination by the same two experienced dermatologists. Multivariate logistic regression analysis was used to adjust for potential confounders. In the multivariate analysis, common melanocytic nevi [odds ratio (OR): of 2.2, 7.5, and 58.9 for the presence of 11-25, 26-100, and >100 common nevi, respectively] and recreational sun exposure (OR: 4.4) increased significantly the risk of the presence of atypical nevus. A decreased risk for atypical nevi was related to an increasing age (OR: 0.96/age), and professional sun exposure (OR: 0.5). Intermittent, recreational sun exposure is mainly associated with the prevalence of atypical nevi in our sample and this effect does not depend on skin phototype. Promotion of sun protection, especially in patients with high numbers of common nevi, might serve as a measure to prevent the development of atypical nevi.

Parents' attitudes related to melanocytic nevus count in children

Sun exposure, fair phototype, and a high common melanocytic nevus (MN) count have been identified as the most important risk factors for melanoma. MN are mainly acquired during childhood, and their relationship to sun exposure, sunburn, and light skin complexion is well documented. The purpose of this study was to investigate how the sun protection attitudes of parents and their offspring affect MN development in children. We designed a cross-sectional study in 828 9-year-old school children. Trained nurses counted the MN on each child's back and arms, depending on their size. Questionnaires filled by children and parents provided information about sun exposure, attitude towards the sun, and sun-protection behaviors. Multivariate analysis showed that the childhood MN count was linked to fair phenotype--fair skin: rate ratio (RR)=3.80, 95% confidence interval (CI)=2.25-6.41; blue/green eyes: RR=1.2, 95% CI=1.11-1.34; blond hair: RR=1.25, 95% CI=1.10-1.41; history of sunburn: RR=1.13, 95% CI=1.03-1.23, seaside sun exposure--RR=1.14, 95% CI=1.01-1.28, and to their parents' behaviors during exposure to the sun--increase in the number of MN when parents used sunscreen: RR=1.23, 95% CI=1.08-1.40; decrease in MN count when parents wore a tee-shirt: RR=0.86, 95% CI=0.79-0.93. In conclusion, fair phenotype and sun exposure are known major risk factors for MN. Parents' behaviors influence their children and appeared in our analysis as another determinant predictor of MN count, being protective against (wearing a tee-shirt when exposed to sun) or increasing the risk (sunscreen use, reflecting higher sun exposure) for childhood MN development.

Tanning and increased nevus development in very-light-skinned children without red hair

OBJECTIVE

To examine the relationship between tanning and nevus development in very-light-skinned children.

DESIGN

Prospective cohort nested within a randomized controlled trial. Skin examinations in 3 consecutive years (2004, 2005, and 2006) included full-body counts of nevi, skin color and tanning measurement using colorimetry, and hair and eye color evaluation by comparison with charts. Telephone interviews of parents provided sun exposure, sun protection, and sunburn history.

SETTING

Large managed-care organization and private pediatric offices in the Denver, Colorado, metropolitan area.

PARTICIPANTS

A total of 131 very-light-skinned white children without red hair and 444 darker-skinned white children without red hair born in Colorado in 1998.

MAIN OUTCOME MEASURES

Full-body nevus counts at ages 6 to 8 years.

RESULTS

Among very-light-skinned white children, geometric mean numbers of nevi for minimally tanned children were 14.8 at age 6 years; 18.8 at age 7 years; and 22.3 at age 8 years. Mean numbers of nevi for tanned children were 21.2 at age 6 years; 27.9 at age 7 years; and 31.9 at age 8 years. Differences in nevus counts between untanned and tanned children were statistically significant at all ages (P < .05 for all comparisons). The relationship between tanning and number of nevi was independent of the child's hair and eye color, parent-reported sun exposure, and skin phototype. Among darker-skinned white children, there was no relationship between tanning and nevi.

CONCLUSIONS

Very-light-skinned children who tan (based on objective measurement) develop more nevi than children who do not tan. These results suggest that light-skinned children who develop tans may be increasing their risk for developing melanoma later in life.

[The prevalence of melanocytic naevi among teenagers]

Malignant melanoma is an increasing public health problem worldwide; accordingly, identification of the constitutional and environmental factors which contribute to the development of the disease, and hence identification of the individuals at high risk of melanoma, are indispensable steps in all primary prevention efforts.

AIM

The objective of the present study was to assess the prevalence of different pigmented lesions among schoolchildren, and to investigate their relationship with phenotypic pigmentary characteristics, sun exposure and other factors.

METHODS

A cross-sectional study was performed in two secondary schools in Szeged, Hungary. A total of 1320 schoolchildren, aged 14 to 18 years, underwent a whole-body skin examination. A standardized questionnaire was used to collect data on phenotypic, sun exposure and other variables.

RESULTS

Between 1-10 common melanocytic naevi were found in 27% of the participants, and naevi numbers were in the range between 10-100 in 67%. 5.4% of them had more than 100 common melanocytic naevi. The prevalence of clinically atypical naevi was 24.3%. Congenital naevi were detected in 6.2% of the schoolchildren. A statistically significant association was found between the number of pigmented lesions and gender, hair colour, eye colour, skin phototype, the history of severe painful sunburns, and the family history of a large number of melanocytic naevi.

CONCLUSIONS

Our study population displayed a markedly high prevalence of clinically atypical melanocytic naevi. Moreover, a considerable proportion of the investigated individuals had multiple common melanocytic naevi. Since the presence of large number of melanocytic naevi is a strong predictor for future melanoma development, health educational programmes on melanoma prevention should be aimed at young age groups.

Vacations to waterside locations result in nevus development in Colorado children

Nevi are a main risk factor for malignant melanoma, and most nevi develop in childhood. This study examined the relationship between vacations and nevi in 681 White children born in 1998 who were lifetime residents of Colorado. Vacation histories were assessed through telephone interviews of parents, whereas nevus and phenotypic characteristics were assessed through skin exams at age 7. Multiple linear and logistic regression were used to assess the influence of vacations on counts of nevi <2 mm in size and the presence of any nevi > or = 2 mm after controlling for other variables. Each waterside vacation > or = 1 year before the exam at age 7 was found to be associated with a 5% increase in nevi <2 mm. Waterside vacations <1 year before the skin exam were not related to nevus count (<2 mm); regardless of timeframe, waterside vacations were not related to the presence of nevi > or = 2 mm. UV dose received on waterside vacations, number of days spent on waterside vacations, and nonwaterside vacations were not significantly related to nevi <2 or > or = 2 mm. These results suggest that there is a lag of at least 1 year in the development of new nevi after vacation sun exposure. It appears that a threshold dose of UV exposure is received quickly on each waterside vacation. Parents of young children should exercise caution in selection of vacation locations to reduce melanoma risk.

Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis

PURPOSE

Sunburns are an important risk factor for melanoma and those occurring in childhood are often cited as posing the greatest risk. We conducted a meta-analysis to quantify the magnitude of association for melanoma and sunburns during childhood, adolescence, adulthood and over a lifetime.

METHODS

After reviewing over 1300 article titles and evaluating 270 articles in detail, we pooled odds ratios from 51 independent study populations for "ever" sunburned and risk of cutaneous melanoma. Among these, 26 studies reported results from dose-response analyses. Dose-response analyses were examined using both fixed-effects models and Bayesian random-effects models.

RESULTS

An increased risk of melanoma was seen with increasing number of sunburns for all time-periods (childhood, adolescence, adulthood, and lifetime). In an attempt to understand how risk between life-periods compares, we also report these same linear models on a scale of five sunburns per decade for each life-period. The magnitude of risk for five sunburns per decade is highest for adult and lifetime sunburns.

CONCLUSIONS

Overall, these results show an increased risk of melanoma with increasing number of sunburns during all life-periods, not just childhood. Prevention efforts should focus on reducing sunburns during all life-periods.

The prevalence of melanocytic naevi among schoolchildren in South Hungary

BACKGROUND

Malignant melanoma is an increasing public health problem worldwide; accordingly, identification of the constitutional and environmental factors which contribute to the development of the disease, and hence identification of the individuals at high risk of melanoma, is an indispensable step in all primary prevention efforts.

OBJECTIVES

This paper aims to assess the prevalence of different pigmented lesions among schoolchildren and to investigate their relationship with phenotypic pigmentary characteristics, sun exposure and other factors.

PATIENTS/METHODS

A cross-sectional study was performed in two secondary schools in Szeged, Hungary. A total of 1320 schoolchildren, aged 14 to 18 years, underwent a whole-body skin examination. A standardized questionnaire was used to collect data on phenotypic, sun exposure and other variables.

RESULTS

One to 10 common melanocytic naevi were found in 27% of the participants, and the naevus numbers were in the range of 10-100 in 67%; 5.4% of them had more than 100 common melanocytic naevi. The prevalence of clinically atypical naevi was 24.3%. Statistically significant associations were found between the number of pigmented lesions and gender, hair colour, eye colour, skin phototype, a history of severe painful sunburns and a family history of a large number of melanocytic naevi.

CONCLUSION

Our study population displayed a markedly high prevalence of clinically atypical melanocytic naevi. Moreover, a considerable proportion of the investigated individuals had multiple common melanocytic naevi. Since the presence of a large number of melanocytic naevi is a strong predictor for future melanoma development, health educational programmes on melanoma prevention should be aimed at young age groups.

Pigmentary disorders in the Mediterranean area

The Mediterranean area represents the area of land that borders the Mediterranean basin. It is composed of several countries that share many geographic and racial characteristics. Although Mediterraneans seem to share common skin type and are subjected to similar enviromental factors, they still represent a genetic and socioeconomic diversity. True prevalence of pigmentary disorders in this area depends on large epidemiologic studies, including countries that are not available. This article, however, highlights and classifies the most important developmental (heritable-genetic) and acquired pigmentary disorders seen and reported in this important area of the world.

Melanocytic nevi in 2783 children and adolescents in Turkey

This study investigated the numbers of melanocytic nevi in Turkish children and adolescents. The research was conducted on 2783 subjects (age range, 7-14 yrs) at three elementary schools in Malatya, Turkey (latitude 38 degrees N). Numbers of melanocytic nevi per subject were counted using a standard international protocol. Comparisons were made with subjects categorized according to age, sex and skin type. The mean melanocytic nevus count was 1.07 +/- 2.37. A significant positive correlation was found between nevus count and age (p < 0.001). The mean count for boys was significantly higher than that for girls (p < 0.001). Subjects with skin type II had a higher mean melanocytic nevus count than the other three groups. This is the first study related to numbers of melanocytic nevi in Turkey. The findings reveal that Turkish children and adolescents have few melanocytic nevi compared to those elsewhere in the world. In line with previous reports on other populations, analysis showed that older age, skin type II, and male sex are associated with higher melanocytic nevus counts. The results underline the importance of ethnic background in melanocytic nevus development.

Predictors of skin self-examination in subjects attending a pigmented lesion clinic in Italy

BACKGROUND

Skin self-examination (SSE) is associated with thinner melanomas in both North American and Italian patients. The knowledge of conditions associated with SSE may help in refining educational strategies for the prevention of melanoma.

OBJECTIVE

The aim of the study was to investigate the frequency of SSE and the factors associated with SSE in subjects followed at a specialized pigmented lesion clinic (PLC) in Italy.

PATIENTS/METHODS

A series of 299 consecutive subjects who visited the Florence PLC was investigated by means of a self-administered questionnaire regarding SSE habits. The statistical association between SSE and selected variables was examined by univariate and multivariate analyses.

RESULTS

In the univariate analysis, variables significantly associated with SSE were: green/blue eyes, phototype I/II, the presence of large numbers of common acquired and atypical melanocytic naevi, sunscreen use, having had a previous PLC examination, and having received a leaflet explaining SSE. SSE was less frequent in women using sunbeds and more frequent in those performing breast self-examination. Using the multivariate model, which included all the variables associated with SSE in the previous analysis, we found that, among males, the only variable significantly associated with SSE was the report of having received a leaflet explaining SSE [odds ratio (OR) 3.02, 95% confidence interval (CI) 1.24-7.38]. Among females, having had a previous consultation at a PLC was significantly associated with SSE (OR 4.84, 95%CI 1.57-14.93); this might be because of the explanation and advice about skin cancer prevention customarily provided as a part of the PLC consultation at our department.

CONCLUSION

Educational tools, including a leaflet explaining SSE and counselling given within previous PLC visits, seem to play a crucial role in promoting SSE habits in subjects followed at a specialized PLC consultation.

The incidence of cutaneous melanoma on Crete, Greece

BACKGROUND

For Greece, no data regarding the incidence of cutaneous melanoma (CM) have been reported. In this report, we present epidemiologic data for CM on Crete, an island in southern Greece, during the years 1999-2002. We attempt a comparison with corresponding data reported for the Italian population.

METHODS

One hundred and two CM patients of Cretan origin with primary CM first diagnosed between the years 1999-2002 were interviewed and underwent complete skin examination by the same two experienced dermatologists. Crude and/or age-standardized incidence rates were calculated for Crete as a whole, as well as for each one of the four prefectures of the island.

RESULTS

The age-standardized incidence rate according to the Greek population was 4.6 per 100,000 person-years for men and 4.7 per 100,000 person-years for women. The crude incidence rates did not differ significantly between the four prefectures. Significant differences between Cretan and Italian CM patients were found in terms of gender, age at diagnosis, anatomic site and histogenetic type of CM, hair color, skin reaction to sun exposure, history of sunburn before the age of 15 years, presence of solar lentigines, and total common nevus count.

CONCLUSIONS

The incidence of CM on Crete is higher than that estimated for the whole of Greece and comparable with the incidence reported for other southern European countries.

Cutaneous malignant melanoma in women. Phenotypic characteristics, sun exposure, and hormonal factors: a case-control study from Italy

PURPOSE

We examined the role of personal host characteristics in relation to cutaneous malignant melanoma (CMM) among women, with a particular focus on hormonal and reproductive factors.

METHODS

A case-control study conducted in Italy between 1992 and 1994, including 316 women with incident, histologically confirmed CMM and 308 controls, admitted to the same network of hospitals as cases for acute, non-dermatological, and non-neoplastic conditions.

RESULTS

CMM was significantly associated with body mass index (kg/m(2)) (odds ratio [OR]=1.96 for > or =27 compared with < 23) and body surface area (m(2)) (OR=1.68 for > or =1.71 compared with < 1.59), eye color (OR=1.74 for green/hazel compared with brown), solar lentigines (OR=1.47), and number of melanocytic nevi (OR=3.39 for total number of nevi > or =16 compared with < 5). Age at first (OR=2.69 for > or =27 compared with < 23 years) and last birth (OR=2.13 for > or =31 compared with < 27 years) were associated with the risk of CMM, whereas other reproductive, menstrual, and hormonal factors, including menopause, number of live-births and abortions, use of oral contraceptives, and hormone replacement therapy were not significantly associated.

CONCLUSIONS

Our results confirm findings from previous studies on the role of major recognized risk factors for CMM, and add further evidence of an absence of a consistent association between hormonal and reproductive factors and CMM risk.

Constitutional and environmental risk factors for cutaneous melanoma in an Italian population. A case-control study

The aim of this study was to determine the relative risk for cutaneous melanoma associated with phenotypic and environmental variables in a population in central Italy and to assess how the combination of the different risk factors contributes to the overall risk for melanoma. We performed a case-control study of 100 patients with sporadic cutaneous melanoma and 200 controls matched for sex, age, ethnicity and residential area. Individuals were interviewed concerning pigmentary traits and sun exposure, and underwent a total body skin examination. Logistic regression models were used to evaluate the association between cutaneous melanoma and constitutional and environmental variables. The strongest risk factors were prolonged recreational sun exposure (odds ratio [OR] 5.010, 95% confidence interval [CI] 2.110-11.891), the presence of clinically atypical naevi (OR 4.916, 95% CI 2.496-9.995) and the presence of >50 common melanocytic naevi (OR 4.684, 95% CI 2.442-9.231). In addition, occupational sun exposure (OR 2.573, 95% CI 1.399-4.732), light brown hair (OR 2.336, 95% CI 1.328-4.138), high density of solar lentigos and/or actinic keratoses (OR 1.824, 95% CI 1.0-3.510) and type II, fair skin (OR 1.815, 95% CI 1.031-3.193) and blue eyes (OR 1.757, 95% CI 1.0-3.477) were each significantly associated with cutaneous melanoma risk. The combination of individual strong risk factors was associated with up to a 46-fold increase in the risk for cutaneous melanoma. Selected pigmentary traits, sun exposure and melanocytic naevi, individually and in combination, are important risk factors for cutaneous melanoma in an Italian population.

Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi

A systematic meta-analysis of observational studies of melanoma and one of the most important risk factors, the number of naevi, was conducted in order to clarify aspects of the aetiology of this disease. Following a systematic literature search, relative risks (RRs) were extracted from 46 studies published before September 2002. Dose-response random effects models were used to obtain pooled estimates. Sub-group analysis and meta-regression were carried out to explore sources of between-study variation and bias. Sensitivity analyses investigated the reliability of the results and any publication bias. Number of common naevi was confirmed an important risk factor with a substantially increased risk associated with the presence of 101-120 naevi compared with <15 (pooled Relative Risk (RR) = 6.89; 95% Confidential Interval (CI): 4.63, 10.25) as was the number of atypical naevi (RR = 6.36 95%; CI: 3.80, 10.33; for 5 versus 0). The type of study and source of cases and controls were two study characteristics that significantly influenced the estimates. Case-control studies, in particular when the hospital was the source for cases or controls, appeared to present much lower and more precise estimates than cohort studies.

Epidemiological differences for cutaneous melanoma in a relatively dark-skinned caucasian population with chronic sun exposure

The aim of this study was to reveal differences in the epidemiology and to identify significant risk factors for cutaneous melanoma (CM) in a relatively dark-skinned, chronically sun-exposed Caucasian population. This group is considered to have a low risk for this tumour. One hundred and ten newly diagnosed patients with primary CM and 110 age- and gender-matched controls, all of Cretan origin, were interviewed and underwent a complete skin examination. Solar keratoses odds ratio (OR) 6.2 and lentigines (OR 2.2), common and atypical naevi (OR 5.4 and 3.0, respectively), blonde or red hair colour (OR 3.1), skin phototypes I/II (OR 1.8), as well as total sun exposure (weeks per year) (OR 1.03), were all significantly associated with CM risk in a multivariate logistic regression analysis. In the relatively dark-skinned Cretan population, sun exposure indices represent the most important risk markers for CM which contrasts with data from fair-skinned Caucasian populations where melanocytic naevi are the main risk factors.

Self-detected cutaneous melanomas in Italian patients

Self-detection of suspicious pigmented skin lesion combined with rapid referral to dermatologic centres is the key strategy in the fight against melanoma. The investigation of factors associated with pattern of detection of melanoma (self- vs. nonself-detection) may be useful to refine educational strategies for the future. We investigated the frequency of melanoma self-detection in a Mediterranean population at intermediate melanoma risk. A multicentric survey identified 816 consecutive cases of cutaneous melanoma in the period January to December 2001 in 11 Italian clinical centres belonging to the Italian Multidisciplinary Group on Melanoma. All patients filled a standardized questionnaire and were clinically examined by expert dermatologists. Self-detected melanomas were 40.6%, while the remaining lesions were detected by a dermatologist (18.5%), the family physician (15.2%), other specialists (5%), the spouse (12.5%), a friend or someone else (8.2%). Variables associated with self-detected melanomas were female sex, young age, absence of atypical nevi, knowledge of the ABCD rule, habit of performing skin self-examination. Self-detected melanomas did not differ from nonself-detected tumours in term of lesion thickness; however, patients with self-detected melanomas waited a longer period before having a diagnostic confirmation (patient's delay) (> 3 months: odds ratio, 3.89; 95% confidence interval, 2.74-5.53). In order to reduce the patients' delays, educational messages should adequately stress the need for a prompt referral to a physician once a suspicious pigmented lesion is self-detected.

Number of acquired melanocytic nevi in patients with melanoma and control subjects in Japan: Nevus count is a significant risk factor for nonacral melanoma but not for acral melanoma

BACKGROUND

Epidemiologic studies have suggested that number of acquired melanocytic nevi is a risk factor for melanoma development in Japanese as it is in white populations. However, there are only a few population-based studies on acquired nevi in Asian populations, and no epidemiologic study on relationship between number of acquired nevi and melanoma in Japanese populations has been reported.

OBJECTIVE

The purpose of this study was to assess number, size, and distribution of acquired melanocytic nevi in a Japanese population. Particular attention was paid to evaluation of relationship between number of acquired nevi and development of nonacral or acral malignant melanoma.

METHODS

In all, 82 patients with malignant melanoma and 600 control subjects were included in this study. All participants were Japanese. The number of acquired melanocytic nevi, 2 mm or larger in diameter, on the whole body except the scalp and genital areas was counted by experienced dermatologists. The participants were divided into 5 age categories (0-19, 20-39, 40-59, 60-79, and >80 years old) for the statistical analyses. This categorization adjusted the age and sex distribution between patients with melanomas and control subjects in 40- to 59-, 60- to 79-, and over 80-year-old groups.

RESULTS

In the control Japanese population, the number of acquired melanocytic nevi on the whole body increased with age in 0- to 19-year-old age group and reached the highest number, 6.7 +/- 8.1/person, in 20- to 39-year-old group. In patients with nonacral melanoma, the number of acquired nevi on the whole body in 40- to 59- and 60- to 79-year-old groups was significantly higher than that of the corresponding control group. In contrast, the rate of individuals who had acquired nevi on soles, palms, and nail apparatus was not significantly different between acral melanoma group and the control group in 40- to 59- and 60- to 79-year-old groups.

CONCLUSION

This study has revealed that a large number of acquired melanocytic nevi is a risk factor for the development of nonacral melanoma in Japanese and white populations. However, acquired nevi on soles, palms, and nail apparatus do not seem to be a risk factor for acral melanoma in Japanese populations.

Acquired melanocytic nevi as risk factor for melanoma development. A comprehensive review of epidemiological data

Acquired melanocytic nevi (MN) in Caucasian populations are important markers for the risk of melanoma development. The total number of MN on the whole body is the most important independent risk factor for melanoma and the risk of melanoma development increases almost linearly with rising numbers of MN. Additionally, the presence of atypical MN and of actinic lentigines are likewise independent risk factors for melanoma. Atypical mole syndrome should be defined by the presence of many acquired MN and a threshold number of atypical MN. Acquired MN develops mainly during childhood and adolescence in the first two decades of life. The number of acquired nevi seems to be related to hereditary factors and nevus-prone families exist. The amount of sun exposure is the most important environmental risk factor for nevus development, particularly in early childhood. Interestingly, sunburns may play a role in nevus development, but seem not to be required, and even moderate sun exposure promotes the process. Therefore, preventive measures for nevus and melanoma development should target young children and adolescents.

Relationship between cause of referral and diagnostic outcome in pigmented lesion clinics: a multicentre survey of the Italian Multidisciplinary Group on Melanoma (GIPMe)

Pigmented lesion clinics (PLCs) are permanent units to which subjects presenting with suspicious pigmented skin lesions can be rapidly referred and which can provide a prompt response to an individual's concern about melanoma. However, little is known about the melanoma detection rate in these clinics, in particular with regard to intermediate risk populations. We report a survey involving more than 1000 subjects consecutively referred by family doctors to six Italian PLCs. Using a histological diagnosis of melanoma as the endpoint, the pooled melanoma detection rate at these PLCs was 1.5% (one melanoma for diagnosed every 64 subjects examined), and the ratio between the number of melanomas and benign lesions excised for diagnostic verification was 1: 5.8 (16 melanomas and 93 benign lesions). Almost all the melanomas (15 out of 16) were detected in subjects who had requested referral for a specific doubtful lesion (group A) or for the presence of melanoma risk factors (previous melanoma, large number of common and atypical naevi, family history of melanoma) (group B). Only one melanoma was detected amongst the 418 subjects seeking consultation for concern about their moles (group C) (P = 0.004). The positive and negative predictive values of the referral groups A and B combined were 2.5% and 99.7%, respectively. Since the probability of detecting a melanoma in subjects referred only for reassurance about their moles, which nevertheless represented 43% of the subjects examined, is very low, an optimized role for PLCs in melanoma prevention would be to limit consultation to subjects who present for examination of a specific lesion or who have one or more risk factors for melanoma.

Sunburn, sunscreens, and phenotypes: some risk factors for cutaneous melanoma in southern Brazil

BACKGROUND

The risk factors for cutaneous malignant melanoma have been studied in populations from numerous countries around the world. There are no published studies on the risk factors for this malignancy in Brazil, the largest country in South America.

METHODS

A case-control study of all melanoma patients attending a university hospital in Porto Alegre, Brazil, was conducted over a 3-year period from 1995 to 1998. Phototype, hair and eye color, solar habits, history of sunburn, use of sunscreens, and the number of nevi were evaluated through a questionnaire and full body skin examination. Bivariate analysis and a logistic regression model were used to evaluate the data.

RESULTS

One hundred and three malignant melanoma patients and 206 matched controls were enrolled in the study. The female to male ratio was 2 : 1. Light phototypes were more prone to the development of cutaneous melanoma. Although stronger in the bivariate analysis, in the logistic regression model, phototypes I or II and ephelides emerged only as moderate risk factors; light eye color and light hair color were not independently significant, with adjusted odds ratios (OR) close to zero. Commonly acquired nevi (CAN) showed a significant and strong effect in the bivariate analysis only when the "30 or more" category was compared to baseline. In the logistic regression model, the presence of a large number of CAN showed an association with increased levels of risk, although these findings did not reach classical significance. Dysplastic or atypical nevi seemed to contribute more strongly, although still with a moderate excess of relative risk. When the use of sunscreens was compared to no use at all, it appeared to show progressive protection as the solar protection factor (SPF) increased. Only SPF15 or greater (SPF15+) showed strong and significant protection when compared to baseline. Physical measures offered a weaker level of protection. Nevertheless, there was a significant increase in the risk of melanoma for those with a large number of sunburn episodes. It was found that 30 or more alleged episodes of sunburn showed a very strong OR of 11.4 (95% confidence interval, 2.6-50.5), the most significant in the study.

CONCLUSIONS

Phototypes I and II, freckles, a large number of acquired nevi, dysplastic nevi, and inadequate photoprotection appeared as risk factors with moderate strength for cutaneous malignant melanoma in the studied population. The color of the eyes and hair showed a very weak statistical significance as a risk factor. Sunscreens showed progressive significance corresponding to an increase in SPF, the best scores in statistical protection being achieved in users of sunscreens with SPF15 or greater. Frequent sunburn episodes appeared as the most important risk factor associated with malignant melanoma in this sample of the white population in southern Brazil.

DNA repair, dysplastic nevi, and sunlight sensitivity in the development of cutaneous malignant melanoma

BACKGROUND

Exposure to UV radiation is associated with cutaneous malignant melanoma (CMM). In mammalian cells, UV radiation induces DNA damage that can be repaired by the nucleotide excision repair system. We designed this case-control study to determine whether DNA repair capacity (DRC) is associated with the risk of CMM and to identify risk factors that may interact biologically with DRC in the development of melanoma.

METHODS

Global DRC was measured in lymphocytes with the host-cell reactivation assay. Data were analyzed by use of multiple regression models. All statistical tests were two-sided.

RESULTS

DRC could be determined for 132 case patients with incident melanoma and for 145 age- and sex-matched control subjects. No statistically significant association between melanoma risk and DRC by itself was found (odds ratio [OR] = 1.0; 95% confidence interval [CI] = 0.6 to 1.7, adjusted for age, sex, lymphocyte viability, and sample storage time). DRC, however, strongly influenced CMM risk in individuals with a low tanning ability or dysplastic nevi. Individuals with a low tanning ability and a low DRC had a higher risk for CMM (OR = 8.6; 95% CI = 2.7 to 27.5) than individuals with a higher tanning ability and a high DRC. Likewise, individuals with dysplastic nevi and a low DRC had a higher relative risk (OR = 6.7; 95% CI = 2.4 to 18.6) than those lacking dysplastic nevi and having a high DRC. Subjects with dysplastic nevi and a high DRC had an intermediate risk. A likelihood-ratio test gave statistically significant interactions between DRC and tanning response (P =.001) and between DRC and dysplastic nevus status (P =.04), which were independently associated with CMM risk.

CONCLUSIONS

DRC may modify the risk for melanoma in the presence of other strong risk factors, such as a low tanning ability and the presence of dysplastic nevi. The occurrence of melanoma in subjects without these risk factors appears to be independent of DRC.

Combined risk factors for melanoma in a Mediterranean population

A case-control study of non-familial melanoma including 183 incident cases and 179 controls was conducted in North-Eastern Italy to identify important risk factors and determine how combination of these affects risk in a Mediterranean population. Presence of dysplastic nevi (OR = 4.2, 95% CI = 2.4-7.4), low propensity to tan (OR = 2.4, 95% CI = 1.1-5.0), light eye (OR = 2.4, 95% CI = 1.1-5.2), and light skin colour (OR = 4.1, 95% CI = 1.4-12.1) were significantly associated with melanoma risk after adjustment for age, gender and pigmentation characteristics. A chart which identifies melanoma risk associated with combinations of these factors is presented; it can be used to identify subjects who would most benefit from preventive measures in Mediterranean populations. According to the combination of these factors, a relative risk range from 1 to 98.5 was found. Light skin colour, high number of sunburns with blistering, and low propensity to tan were significantly associated with melanoma thickness, possibly indicating that individuals with these characteristics underestimate their risk and seek attention when their lesion is already advanced.

Do larger people have more naevi? Naevus frequency versus naevus density

BACKGROUND

It is unclear which of the number or the density of naevi on the skin is the more appropriate measure of risk of melanoma. Furthermore, the relationship between the number of naevi and their density in an individual has not been explored. Thus, for example, it is unknown if larger people tend to have more naevi by virtue of having a larger skin area, or if the density of naevi is similar in people of different body sizes. In this study, we explored the relationship between the number and the density of naevi in a sample of adolescents.

SUBJECTS AND METHODS

A sample survey of naevi in 472 grade 9 secondary school students (aged 14-15 years) was conducted in Tasmania, Australia during 1992, and a subset of these individuals was followed up in 1997. Counts of naevi of various sizes were taken on the arm, leg, and back. Naevus density was estimated by using an algorithm to estimate body surface area from the height and weight of an individual. More general relationships of the naevus counts to height and weight were also explored. Finally, we considered whether the relationship between naevus density and the anthropometric variables could be confounded by exposure to ultraviolet radiation.

RESULTS

The mean number of naevi was very similar in the two samples. Naevus density was slightly lower in the 1997 sample, mainly because of increasing body size in the cohort. The numbers of naevi were only weakly related to height and weight in males, and there was essentially no relationship in females. Regression analysis showed significant relationships of weight to the back naevus counts in males in 1992 and 1997, and to the arm naevus count in males in 1997; otherwise, none of the regression coefficients for height and weight were statistically significant. This picture did not change following adjustment for potentially confounding variables indicating time spent outdoors or in the sun. Furthermore, there was no evidence that time spent in the sun was related to the body mass index.

CONCLUSIONS

It appears that the number and density of naevi in an individual are unrelated. Accordingly, with the present state of knowledge concerning the risk of melanoma, both the number and density of naevi should be considered as equally valid in future studies as markers of the risk of melanoma, and in studies on the natural history of naevi. If the disease mechanism is systemic, and not related to particular naevi, naevus density might form the better marker of risk. However, if the disease mechanism is related to effects on particular naevi, then the risk would vary in proportion to the number of naevi.

The role of pattern analysis and the ABCD rule of dermoscopy in the detection of histological atypia in melanocytic naevi

BACKGROUND

Clinical features of melanocytic naevi correlate poorly with the presence, histopathologically, of architectural disorder and cytological atypia, making the detection of histological atypia by means of macroscopic appearance unreliable.

OBJECTIVES

The aim of this study was to investigate the diagnostic effectiveness of dermoscopy in the non-invasive detection of histological atypia in naevi.

METHODS

Observers blinded for histological diagnosis classified a series of 168 melanocytic naevi as common or atypical on the basis of their clinical features and on their dermoscopic profile. The diagnostic performance of both methods compared with the true (histopathological) diagnosis was assessed.

RESULTS

Dermoscopy using pattern analysis showed better results than clinical examination in the non-invasive detection of naevi with architectural disorder with or without cytological atypia (diagnostic accuracy 45% vs. 28%). A statistically significant difference in the frequency of dermoscopic parameters between atypical and common naevi was found for atypical pigment network (39% vs. 17%, P = 0.001) and dermoscopic regression structures (13% vs. 2%, P = 0.008). Dermoscopic features, which best predicted histological atypia in naevi, were regression structures (white scar-like areas or peppering), irregular vascular pattern and grey-blue areas (positive predictive values 83%, 83% and 73%, respectively). In contrast, no statistically significant difference in the mean values of the ABCD score between common and atypical naevi was found. The best diagnostic performance of dermoscopy by means of the ABCD rule (cut-off point of 4.0 of total dermoscopy score) was not dissimilar to that of clinical diagnosis (diagnostic accuracy 30%).

CONCLUSIONS

Dermoscopy by means of pattern analysis enhances the diagnostic accuracy of dermatologists in the prediction of histological atypia in melanocytic naevi as compared with clinical examination alone.

Pigmentary traits, modalities of sun reaction, history of sunburns, and melanocytic nevi as risk factors for cutaneous malignant melanoma in the Italian population: results of a collaborative case-control study

BACKGROUND

To the authors' knowledge, limited data are available from Mediterranean populations concerning risk factors for malignant melanoma. A few Italian case-control studies have produced conflicting results regarding the association between malignant melanoma and pigmentary traits, sunburns, and melanocytic nevi.

METHODS

A case-control study was conducted within the framework of the Italian Group for Epidemiologic Research in Dermatology (GISED). Twenty-seven centers in the north and south of Italy participated. A total of 542 cases and 538 controls were entered onto the study. A standardized questionnaire was administered to cases and controls. Cases and controls also were examined by trained dermatologists who were required to count the number of melanocytic nevi (those measuring > or = 2 mm and > 6 mm in greatest dimension, separately) and to make judgments regarding pigmentary traits.

RESULTS

In the multivariate analysis, eye and skin color, propensity to sunburn, history of sunburns before age 15 years, and solar lentigines all were associated with malignant melanoma. In addition, the risk of melanoma increased with the number of melanocytic nevi > or = 2 mm. Nevi > 6 mm in greatest dimension had effects on risk that appeared to be independent from the effects of smaller nevi (2-6 mm).

CONCLUSIONS

The results of the current study largely are similar to those obtained in northern European countries, the U.S., and Australia and provide further evidence of the importance of selected pigmentary traits, sun exposure, and the number of melanocytic nevi in the risk of cutaneous malignant melanoma.

Cutaneous melanoma histologically associated with a nevus and melanoma de novo have a different profile of risk: results from a case-control study

BACKGROUND

Histopathologic association between melanocytic nevus and melanoma has been reported in approximately 10% to more than 50% of melanoma cases. Whether melanomas in contiguity with a nevus have a different natural history and pathogenesis from melanomas without a nevus is still to be determined.

OBJECTIVE

The present study was undertaken to clarify whether melanocytic nevus-associated melanomas (MN[+]) have a different risk factor profile from cases without histopathologic evidence of melanocytic nevus association (MN[-]).

METHODS

The study population consisted of 131 invasive melanoma cases with a thickness of 4.00 mm or less and 174 control cases without melanomas. The whole series was evaluated for the following risk factors: phenotypic traits; the number of common, atypical, and congenital nevus-like nevi; and freckling and history of sunburns. Melanoma cases were revised for the presence of associated melanocytic nevi. The analysis of risk factors was performed by a case-control approach comparing cases, classified by histologic association with nevus, to the group of controls. Possible differences in risk factor distribution between MN(+) cases and MN(-) cases were evaluated with a polychotomous logistic regression model and a likelihood ratio test for heterogeneity.

RESULTS

Histopathologic association between melanocytic nevus and melanoma was found in 27 cases (20.6%). Phenotypic traits were shown to be more powerful predictors of risk for MN(-) than for MN(+) cases (blond/red hair; odds ratio, 7.4 and 1.2, respectively; likelihood ratio test for heterogeneity, 4.13; P < .05). Conversely, history of frequent sunburn was a risk factor only in MN(+) cases (more than 5 sunburns; odds ratio, 6.7; 95% confidence interval, 1.3-33.7), but not in MN(-) cases (odds ratio, 1.2; 95% confidence interval, 0.3-4.0; likelihood ratio test for heterogeneity, 4.2; P < .05). Where melanocytic nevi are concerned, an increased number of common nevi was a predictor of melanoma risk in both MN(+) and MN(-) cases, but with a different magnitude of risk, higher for MN(+) cases (number of common nevi, 10-30; odds ratio, 14.4 and 4.7, respectively; likelihood ratio test for heterogeneity, 3.7; P = .055).

CONCLUSION

This study showed that, although MN(+) and MN(-) melanomas share many risk factors, there is a different strength of association between the 2 groups. The effect of a history of sunburn as a predictor of risk was found only for nevus-associated melanomas, suggesting a possible role of sunburns in the neoplastic transformation of nevi.

Pigmentary traits, nevi and skin phototypes in a youth population of Central Italy

Five thousand eight hundred and thirty-seven healthy young men, aged 18-19, from two distinct regions of Central Italy, Abruzzo and Marche, have been investigated during the military medical examination to evaluate pigmentary traits and skin phototypes. They were examined over the entire body except the scalp and ano-genital area for pigmented lesions, which included common acquired melanocytic nevi (MN), clinically atypical nevi and solar lentigines. Eye and hair color were also recorded. Information was gathered by self-questionnaire, personal interview and clinical skin examination performed by two independent dermatologists. For sunlight susceptibility and sun exposure, each subject was classified from I to IV skin phototype according to the classification of sun-reactive skin types as proposed by Fitzpatrick. Almost half of the entire population (44.5%) had affirmed that they tanned easily and rarely burned (phototype IV), 10.3% had skin phototype I or II, 11.2% had more than 40 common MN, and 37.2% had atypical nevi with a diameter > or = 5 mm. The common MN and atypical nevi count had a significant association with skin phototype. Subjects with phototype I or II, and solar lentigo had significantly higher nevus counts than individuals without these characteristics.

Sun exposure and large numbers of common and atypical melanocytic naevi: an analytical study in a southern European population

The study analysed the relationship between high counts of common naevi and numbers of atypical naevi (AN) in sites differing in exposure to the sun. A series of 90 subjects with 100 or more common naevi (cases) and 92 controls was investigated by means of a case-control study. A striking association between high numbers of common naevi and prevalence of AN (whole body) was found. The adjustment for phenotype and phototype did not obscure this association. Similar findings were obtained after exclusion of subjects with familiarity for melanoma. Cases had more AN than controls in all the body sites, except for the buttocks, where sun exposure can be considered minimal or absent: in this site, an excess of common naevi but not of AN was found. The present study suggests that subjects with high common naevi counts show a higher prevalence of AN independently of their complexion, sunburn history and family history of melanoma. Phenotypic expression of AN seems to be enhanced by direct sun exposure.

Counts of common and atypical melanocytic nevi in Korean young men: assessment of their risks and correlations with associated factors

Two hundred and thirty-five Korean young men were examined for the count of melanocytic nevi (MN). The mean count of common MN of at least 2 mm diameter was 16.1. Three subjects had more than 50 common MN and another four had clinically atypical MN. We determined skin phototype by interview with questionnaires in the same persons as proposed by Fitzpatrick. All subjects were classified with respect to skin phototype and the number of previous sunburns. The correlations between common MN and the skin phototype or the number of previous sunburns were statistically analyzed. The skin phototype showed the correlation with the number of common MN, which means if skin phototype of any subject belongs to type I, he could to be predicted to have many more common MN than subjects with darker phototypes, like type VI. The correlation between number of previous sunburns and number of common MN was not statistically significant. This study shows persons at moderate risk of cutaneous melanoma (CM) do exist and skin phototype is associated with the prevalence of common MN in Koreans.