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Huber R, Lee J, Borretta L, Tessier-Cloutier B, Lum A, Yip S, Horst BA. TERT promoter mutations in atypical melanocytic lesions: A series of seven cases with adverse melanoma-specific outcome. Hum Pathol 2024; 144:34-39. [PMID: 38224873 DOI: 10.1016/j.humpath.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/17/2024]
Abstract
The majority of melanocytic proliferations can be readily categorized as benign or malignant based on histologic assessment under the microscope by a trained dermatopathologist. However, a subset of lesions, termed Atypical Melanocytic Proliferations (AMPs), are histologically ambiguous, leading to possible diagnostic error and suboptimal treatment. Mutations in the promoter region of the catalytic subunit of telomerase, telomerase reverse transcriptase (TERT), are commonly found in melanomas but are rare in melanocytic nevi. In this study, we aimed to determine the prevalence of hot spot TERT promoter (TERT-p) mutations in AMPs with adverse melanoma-specific outcome. Studies were approved by respective institutional review boards. Using a multi-center database, we identified seven cases of melanocytic proliferations with a clinical follow-up period of at least 4 years, which were initially diagnosed as AMPs, and which recurred either as melanoma at site of prior biopsy or as metastatic melanoma. Sequencing of the TERT-p region showed hotspot mutations in three cases (43 %), suggesting that TERT-p mutations are enriched and could aid in the identification of AMPs with adverse outcome. In comparison with existing ancillary techniques for prognostication of AMPs, TERT-p mutation analysis may have advantages in terms of cost effectiveness and turnaround time, and is a promising diagnostic parameter with potential widespread utility.
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Affiliation(s)
- Reed Huber
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, V5Z 1M9, Canada
| | - Jonathan Lee
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, V5Z 1M9, Canada
| | - Lisa Borretta
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
| | | | - Amy Lum
- Molecular Oncology, BC Cancer Agency, Vancouver, BC, V5Z 1L3, Canada
| | - Stephen Yip
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, V5Z 1M9, Canada
| | - Basil A Horst
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, BC, V5Z 1M9, Canada.
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Boutko A, Asadbeigi S, Roth A, Lampley N, Olivares S, Dittmann D, Dittmann D, Jennings L, Gerami P. TERT Promoter Mutational Analysis as an Ancillary Diagnostic Tool for Diagnostically Challenging Melanocytic Neoplasms. Am J Dermatopathol 2023; 45:289-299. [PMID: 36898007 DOI: 10.1097/dad.0000000000002366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/14/2022] [Indexed: 03/12/2023]
Abstract
ABSTRACT Telomerase reverse transcriptase promoter mutations (TPMs) have been shown to be common in melanoma and uncommon in benign nevi. To assess the use of TPMs as an ancillary diagnostic tool, we report the concordance of the TPM status with the final diagnosis in clinical cases with distinct differential diagnostic scenarios: dysplastic nevus versus melanoma, atypical Spitz nevus versus melanoma, atypical deep penetrating nevus (DPN) versus melanoma, and atypical blue nevus versus malignant blue nevus. In a control cohort, we found a positive TPM in 51/70 (73%) of the total melanomas with the highest frequency in vertical growth phase melanoma cases. Conversely, only 2/35 (6%) dysplastic nevi in our control cases were TPM-positive and b were severely atypical dysplastic nevi. Our clinical cohort of 257 cases had a positive TPM in 24% of cases diagnosed as melanoma and in 1% of cases with a benign diagnosis. The overall concordance of the TPM status with the final diagnosis was 86%. The TPM status had the greatest concordance (95%) with the final diagnosis in the atypical DPN versus melanoma group, with the rest of the groups ranging between 50% and 88%. Overall, our results suggest that TPMs are most useful in the differential diagnosis of atypical DPN versus melanoma. It also has some value in the differential diagnosis of atypical Spitz tumor versus melanoma and dysplastic nevus versus melanoma, whereas in our cohort, it did not contribute meaningfully to differentiating malignant blue nevus and atypical blue nevus.
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Affiliation(s)
- Anastasiya Boutko
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
| | - Sepideh Asadbeigi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
| | - Andrew Roth
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
| | - Nathaniel Lampley
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
| | - Shantel Olivares
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
| | - David Dittmann
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
| | - David Dittmann
- Department of Molecular Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Lawrence Jennings
- Department of Molecular Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Pedram Gerami
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL; and
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Maher NG, Scolyer RA, Colebatch AJ. Biology and genetics of acquired and congenital melanocytic naevi. Pathology 2023; 55:169-177. [PMID: 36635156 DOI: 10.1016/j.pathol.2022.12.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022]
Abstract
Acquired and congenital melanocytic naevi are common benign neoplasms. Understanding their biology and genetics will help clinicians and pathologists correctly diagnose melanocytic tumours, and generate insights into naevus aetiology and melanomagenesis. Genomic data from published studies analysing acquired and congenital melanocytic naevi, including oncogenic driver mutations, common melanoma associated mutations, copy number aberrations, somatic mutation signature patterns, methylation profile, and single nucleotide polymorphisms, were reviewed. Correlation of genomic changes to dermoscopic features, particular anatomic sites and total body naevus counts, was also performed. This review also highlights current scientific theories and evidence concerning naevi growth arrest. Acquired and congenital melanocytic naevi show simple genomes, typically characterised by mutually exclusive single oncogenic driver mutations in either BRAF or NRAS genes. Genomic differences exist between acquired and congenital naevi, common and dysplastic naevi, and by dermoscopic features. Acquired naevi show a higher rate of BRAF hotspot mutations and a lower rate of NRAS hotspot mutations compared to congenital naevi. Dysplastic naevi show upregulation of follicular keratinocyte-related genes compared to common naevi. Anatomical locations and DNA signatures of naevi implicates ultraviolet radiation and non-ultraviolet radiation pathways in naevogenesis. DNA driver point mutations in acquired and congenital melanocytic naevi have been well characterised. Future research is required to better understand transcriptional and epigenetic changes in naevi, as well as those regulating naevus growth arrest and cell environment signalling.
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Affiliation(s)
- Nigel G Maher
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia.
| | - Andrew J Colebatch
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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4
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Andea AA. Molecular testing in melanoma for the surgical pathologist. Pathology 2023; 55:245-257. [PMID: 36653236 DOI: 10.1016/j.pathol.2022.12.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
The diagnostic work-up of melanocytic tumours has undergone significant changes in the last years following the exponential growth of molecular assays. For the practising pathologist it is often difficult to sort through the multitude of different tests that are currently available for clinical use. The molecular tests used in melanocytic pathology can be broadly divided into four categories: (1) tests that predict response to systemic therapy in melanoma; (2) tests that predict prognosis in melanoma; (3) tests useful in determining the type or class of melanocytic tumour; and (4) tests useful in the differential diagnosis of naevus versus melanoma (primarily used as an aid in the diagnosis of histologically ambiguous melanocytic lesions). This review will present an updated synopsis of major molecular ancillary tests used in clinical practice.
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Affiliation(s)
- Aleodor A Andea
- Departments of Pathology and Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
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TERT Promoter Mutations and Telomerase in Melanoma. JOURNAL OF ONCOLOGY 2022; 2022:6300329. [PMID: 35903534 PMCID: PMC9325578 DOI: 10.1155/2022/6300329] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022]
Abstract
Malignant melanoma is an extremely malignant tumor with a high mortality rate and an increasing incidence with a high mutation load. The frequency of mutations in the TERT promoter exceeds the frequency of any known noncoding mutations in melanoma. A growing number of recent studies suggest that the most common mutations in the TERT promoter (ATG start site −124C>T and −146C>T) are associated with increased TERT mRNA expression, telomerase activity, telomere length, and poor prognosis. Recently, it has been shown that TERT promoter mutations are more correlated with the occurrence, development, invasion, and metastasis of melanoma, as well as emerging approaches such as the therapeutic potential of chemical inhibition of TERT promoter mutations, direct telomerase inhibitors, combined targeted therapy, and immunotherapies. In this review, we describe the latest advances in the role of TERT promoter mutations and telomerase in promoting the occurrence, development, and poor prognosis of melanoma and discuss the clinical significance of the TERT promoter and telomerase in the treatment of melanoma.
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Andea AA. Molecular testing for melanocytic tumors: a practical update. Histopathology 2021; 80:150-165. [DOI: 10.1111/his.14570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Aleodor A Andea
- Departments of Pathology and Dermatology Michigan Medicine University of Michigan Ann Arbor MI USA
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Rachakonda S, Hoheisel JD, Kumar R. Occurrence, functionality and abundance of the TERT promoter mutations. Int J Cancer 2021; 149:1852-1862. [PMID: 34313327 DOI: 10.1002/ijc.33750] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/14/2021] [Accepted: 07/16/2021] [Indexed: 12/18/2022]
Abstract
Telomere shortening at chromosomal ends due to the constraints of the DNA replication process acts as a tumor suppressor by restricting the replicative potential in primary cells. Cancers evade that limitation primarily through the reactivation of telomerase via different mechanisms. Mutations within the promoter of the telomerase reverse transcriptase (TERT) gene represent a definite mechanism for the ribonucleic enzyme regeneration predominantly in cancers that arise from tissues with low rates of self-renewal. The promoter mutations cause a moderate increase in TERT transcription and consequent telomerase upregulation to the levels sufficient to delay replicative senescence but not prevent bulk telomere shortening and genomic instability. Since the discovery, a staggering number of studies have resolved the discrete aspects, effects and clinical relevance of the TERT promoter mutations. The promoter mutations link transcription of TERT with oncogenic pathways, associate with markers of poor outcome and define patients with reduced survivals in several cancers. In this review, we discuss the occurrence and impact of the promoter mutations and highlight the mechanism of TERT activation. We further deliberate on the foundational question of the abundance of the TERT promoter mutations and a general dearth of functional mutations within noncoding sequences, as evident from pan-cancer analysis of the whole-genomes. We posit that the favorable genomic constellation within the TERT promoter may be less than a common occurrence in other noncoding functional elements. Besides, the evolutionary constraints limit the functional fraction within the human genome, hence the lack of abundant mutations outside the coding sequences.
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Affiliation(s)
| | - Jörg D Hoheisel
- Division of Functional Genome Analysis, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rajiv Kumar
- Division of Functional Genome Analysis, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Molecular Biology of Cancer, Institute of Experimental Medicine of the Czech Academy of Sciences, Prague, Czech Republic
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Chang GA, Wiggins JM, Corless BC, Syeda MM, Tadepalli JS, Blake S, Fleming N, Darvishian F, Pavlick A, Berman R, Shapiro R, Shao Y, Karlin-Neumann G, Spittle C, Osman I, Polsky D. TERT, BRAF, and NRAS Mutational Heterogeneity between Paired Primary and Metastatic Melanoma Tumors. J Invest Dermatol 2020; 140:1609-1618.e7. [PMID: 32087194 PMCID: PMC7387168 DOI: 10.1016/j.jid.2020.01.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/06/2019] [Accepted: 01/06/2020] [Indexed: 11/26/2022]
Abstract
Mutational heterogeneity can contribute to therapeutic resistance in solid cancers. In melanoma, the frequencies of intertumoral and intratumoral heterogeneity are controversial. We examined mutational heterogeneity within individual patients with melanoma using multiplatform analysis of commonly mutated driver and nonpassenger genes. We analyzed paired primary and metastatic tumors from 60 patients and multiple metastatic tumors from 39 patients whose primary tumors were unavailable (n = 271 tumors). We used a combination of multiplex SNaPshot assays, Sanger sequencing, mutation-specific PCR, or droplet digital PCR to determine the presence of BRAFV600, NRASQ61, TERT-124C>T, and TERT-146C>T mutations. Mutations were detected in BRAF (39%), NRAS (21%), and/or TERT (78%). Thirteen patients had TERTmutant discordant tumors; seven of these had a single tumor with both TERT-124C>T and TERT-146C>T mutations present at different allele frequencies. Two patients had both BRAF and NRAS mutations; one had different tumors and the other had a single tumor with both mutations. One patient with a BRAFmutant primary lacked mutant BRAF in at least one of their metastases. Overall, we identified mutational heterogeneity in 18 of 99 patients (18%). These results suggest that some primary melanomas may be composed of subclones with differing mutational profiles. Such heterogeneity may be relevant to treatment responses and survival outcomes.
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Affiliation(s)
- Gregory A Chang
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; St. Georges University School of Medicine, Grenada, West Indies
| | - Jennifer M Wiggins
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Broderick C Corless
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Weill Cornell Medicine Graduate School of Medical Sciences, New York, USA
| | - Mahrukh M Syeda
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Jyothirmayee S Tadepalli
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Shria Blake
- MolecularMD Corporation, Portland, Oregon, USA
| | - Nathaniel Fleming
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Farbod Darvishian
- The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Department of Pathology, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Anna Pavlick
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Division of Medical Oncology, Department of Medicine, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Russell Berman
- The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Department of Surgery, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Richard Shapiro
- The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Department of Surgery, New York University School of Medicine, NYU Langone Health, New York, USA
| | - Yongzhao Shao
- The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Department of Population Health, New York University School of Medicine, NYU Langone Health, New York, USA
| | | | | | - Iman Osman
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA; Division of Medical Oncology, Department of Medicine, New York University School of Medicine, NYU Langone Health, New York, USA
| | - David Polsky
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NYU Langone Health, New York, USA; The Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, NYU Langone Health, New York, USA.
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Motaparthi K, Kim J, Andea AA, Missall TA, Novoa RA, Vidal CI, Fung MA, Emanuel PO. TERT and TERT promoter in melanocytic neoplasms: Current concepts in pathogenesis, diagnosis, and prognosis. J Cutan Pathol 2020; 47:710-719. [PMID: 32202662 DOI: 10.1111/cup.13691] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Located on chromosome locus 5p15.33, telomerase reverse transcriptase (TERT or hTERT) encodes the catalytic subunit of telomerase which permits lengthening and preservation of telomeres following mitosis. Mutations in TERT promoter (TERT-p) upregulate expression of TERT, allowing survival of malignant cells and tumor progression in wide variety of malignancies including melanoma. The objective of this review is to examine the roles of TERT and TERT-p in the pathogenesis, diagnosis, and prognostication of cutaneous melanoma. METHODS All studies of TERT or TERT-p in cutaneous melanocytic neoplasms with the following inclusion criteria were reviewed: publication date between 2010 and 2019, English language, and series of ≥3 cases were reviewed for evidence supporting the role of TERT in pathogenesis, diagnosis, and prognosis. Studies with <3 cases or focused primarily on mucosal or uveal melanocytic tumors were excluded. RESULTS AND CONCLUSION TERT-p mutations are frequent in chronic and non-chronic sun damage melanoma and correlate with adverse prognosis, inform pathogenesis, and may provide diagnostic support. While TERT-p mutations are uncommon in acral melanoma, TERT copy number gains and gene amplification predict reduced survival. Among atypical spitzoid neoplasms, TERT-p mutations identify biologically aggressive tumors and support the diagnosis of spitzoid melanoma. TERT-p methylation may have prognostic value in pediatric conventional melanoma and drive tumorigenesis in melanoma arising within congenital nevi. Finally, TERT-p mutations may aid in the differentiation of recurrent nevi from recurrent melanoma.
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Affiliation(s)
- Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Jinah Kim
- Palo Alto Medical Foundation, Palo Alto, California
| | - Aleodor A Andea
- Department of Dermatology, University of Michigan Medical Center, Ann Arbor, Michigan
- Department of Pathology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Tricia A Missall
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Claudia I Vidal
- Dermatology Center of Southern Indiana, Bloomington, Indiana
| | - Maxwell A Fung
- Department of Dermatology, University of California, Davis, California
| | - Patrick O Emanuel
- Laboratorio Recavarren Emanuel, Clínica Ricardo Palma, Lima, Peru
- IGENZ Molecular Laboratory, Auckland, New Zealand
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10
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Heymann WR. Promoting TERT promoter mutations for prognostication in cutaneous oncology. J Am Acad Dermatol 2018; 80:606-607. [PMID: 30584893 DOI: 10.1016/j.jaad.2018.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Warren R Heymann
- Division of Dermatology, Cooper Medical School of Rowan University, Marlton, New Jersey.
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