Ten-Year Survival after Multiple Invasive Melanomas Is Worse than after a Single Melanoma: a Population-Based Study

The Skin Molecular Ecosystem Holds the Key to Nevogenesis and Melanomagenesis

Early detection of melanoma is critical to good patient outcomes, but we still know little about the mechanisms of early melanoma development. Normal epidermis has many of the sequence variants and genetic architecture disruptions found in both benign nevi, melanomas, and other skin cancers, yet continues to behave more or less normally. One hypothesis is that many melanocytes in this context are "tumor competent" but are regulated by the microenvironment provided by the surrounding keratinocytes to inhibit progress to nevi or melanoma. There is evidence of accumulating disorder in several measures of the genomic and epigenomic landscape from normal skin through nevi to melanoma that may be key to promoting nevogenesis and melanomagenesis.

Potential risk factors, clinicopathological features and determinants of survival for multiple primary melanoma patients compared to single primary melanoma: a large single-center Italian study

Melanoma patients have a high risk of developing subsequent primary melanomas, a condition known as multiple primary melanoma (MPM). We aimed to compare risk factors of patients with MPM and single primary melanoma (SPM). Primary MPM and SPM consecutively treated at the National Cancer Institute in Milan, Italy, from 1978 to 2021 were retrospectively investigated. Demographic and clinicopathological characteristics were analyzed. Multivariate hazard ratios and mortality were estimated using Cox proportional hazards regression models. Overall, 9122 patients with SPM and 944 with MPM were included. A total of 1437 and 85 deaths occurred in SPM and MPM group, respectively. Of these, 1315 (14.4%) within SPM patients and 60 (6.4%) in MPM group were melanoma-specific deaths (MSDs). Males had a higher risk for MPM (hazard ratio = 1.29), while age was not associated with MPM (hazard ratio = 0.98). The risk of MPM decreased by about 50% for Breslow thickness >1 mm, and by about 45 and 75% in presence of mitoses and ulceration, respectively. The multivariate hazard ratio of death for MPM compared to SPM patients was 0.85 (95% confidence interval, CI: 0.67-1.06), while considering MSD the corresponding hazard ratio was 0.93 (95% CI: 0.71-1.22). Melanoma patients should receive regular follow-up with complete skin examination to detect early subsequent primary melanoma. Patients with more advanced primary have decreased risk of MPM, while males have higher risk. Our study reported no significant difference in mortality between SPM and MPM, but the issue is still open for discussion and further studies.

A practical nomogram and risk stratification system predicting the cancer-specific survival for patients aged >50 with advanced melanoma

Objective

To investigate risk factors for advanced melanoma over 50 years of age and to develop and validate a new line chart and classification system.

Methods

The SEER database was screened for patients diagnosed with advanced melanoma from 2010 to 2019 and Cox regression analysis was applied to select variables affecting patient prognosis. The area under curve (AUC), relative operating characteristic curve (ROC), Consistency index (C-index), decision curve analysis (DCA), and survival calibration curves were used to verify the accuracy and utility of the model and to compare it with traditional AJCC tumor staging. The Kaplan-Meier curve was applied to compare the risk stratification between the model and traditional AJCC tumor staging.

Results

A total of 5166 patients were included in the study. Surgery, age, gender, tumor thickness, ulceration, the number of primary melanomas, M stage and N stage were the independent prognostic factors of CSS in patients with advanced melanoma (P<0.05). The predictive nomogram model was constructed and validated. The C-index values obtained from the training and validation cohorts were 0.732 (95%CI: 0.717-0.742) and 0.741 (95%CI: 0.732-0.751). Based on the observation and analysis results of the ROC curve, survival calibration curve, NRI, and IDI, the constructed prognosis model can accurately predict the prognosis of advanced melanoma and performs well in internal verification. The DCA curve verifies the practicability of the model. Compared with the traditional AJCC staging, the risk stratification in the model has a better identification ability for patients in different risk groups.

Conclusion

The nomogram of advanced melanoma and the new classification system were successfully established and verified, which can provide a practical tool for individualized clinical management of patients.

Melanoma-specific survival before and after inclusion in a familial melanoma dermatologic surveillance program in CDKN2A mutation carriers and non-carriers

BACKGROUND

Inherited mutations in the CDKN2A gene are among the strongest known risk factors for cutaneous melanoma. Further, previous studies have reported inferior melanoma-specific survival in CDKN2A mutation carriers.

OBJECTIVES

Here, the melanoma-specific survival was studied, depending on CDKN2A carrier status and if the melanomas had been diagnosed before or after families were included in a surveillance program.

METHODS

Melanoma-prone families participating in this study were identified through a nationwide preventive program starting in 1987. Information on melanoma tumours and deaths was obtained through the Swedish Cancer Registry and Cause of Death Registry. Kaplan-Meier and Cox proportional hazards regression models were used to assess melanoma-specific survival in four defined cohorts, CDKN2A mutation (MUT) carriers with first invasive melanoma before or after inclusion [MUT-pre (n = 53) and MUT-post (n = 43)] and likewise in CDKN2A wild type (WT) cases [WT-pre (n = 255) and WT-post (n = 122)].

RESULTS

The MUT-pre and MUT-post cases were diagnosed with their first invasive melanoma at a significantly younger ages (38 and 42 years, respectively) than the WT-pre and WT-post cases (48 and 57 years, respectively). The melanomas in the MUT-pre had significantly higher T stage compared with MUT-post (p = 0.006), whereas no such difference was seen comparing WT-pre with WT-post (p = 0.849). MUT-pre had compared with WT-pre, significantly worse melanoma-specific survival, unadjusted (HR 2.33, 95% CI 1.33-4.08, p = 0.003) adjusted (HR 2.70, 95% CI 1.46-5.00, p = 0.001). However, the MUT-post cases had compared with the WT-post cases, no significant survival differences.

CONCLUSION

This study is the first to address the impact on survival from introducing a dermatologic surveillance program to familial melanoma cases with or without CDKN2A mutations. The CDKN2A-mut carriers appeared to have a clear benefit with less advanced melanomas diagnosed and better melanoma-specific survival after inclusion. Among the CDKN2A-wt cases, the effect of the inclusion on the studied outcomes was less evident.

Clinical Features and Survival of Multiple Primary Melanoma: A Belgian Single Center Cohort

INTRODUCTION

It remains unclear whether multiple primary melanoma (MPM) patients have a worse survival prognosis compared with single primary melanoma (SPM) patients.

OBJECTIVES

To investigate the demographics, histological features, and survival of MPM versus SPM patients.

METHODS

Cox regression analyses compared survival between SPM and MPM patients. Furthermore, demographics and histological features of the MPM cohort were compared with the SPM patients retrieved from dermatopathology files between 2000 and 2019.

RESULTS

Out of 3853 melanoma patients, 95 MPM patients were retrieved: 81 with two primary melanomas (85.2%) and 14.8% with three or more. Mean Breslow of the first melanoma was 0.84 mm [minimum (min): 0 mm, maximum (max): 16 mm, standard deviation (SD) 1.77] versus 0.37 mm (second MPM) (min: 0 mm, max: 2.5 mm, SD 0.50) and 0.33 mm (third MPM) (min: 0 mm, max: 0.6 mm, SD 0.22). The mean Breslow for the second MPM was significantly higher for men than women (0.59 mm versus 0.27 mm). First and second melanoma in MPM patients developed on preexisting melanocytic nevi in 13% and 12%, respectively. In contrast with the mean age of primary melanoma in Belgium for women (58.2 years) and men (63.3 years), MPM patients developed their first melanoma earlier, at 44.8 years and 54.6 years, respectively. The mean distribution of anatomical localization of primary and secondary melanoma was highly similar in women, whereas in men a shift towards lower extremities was observed (19% versus 28%). The thicker the primary melanoma was, the sooner the second appeared. Follow-up (2-4/year) versus (1/year) yielded a mean Breslow of 0.29 mm and 0.55 mm, respectively. Cox regression analysis with time-varying covariate revealed a tendency for a worse prognosis in 5-year survival rates, but this was not statistically significant (p = 0.09). Patient phenotypes were not available on the histological reports.

CONCLUSION

A closer follow-up regimen of MPM versus SPM patients is probably justified.

Predictors of subsequent primary melanoma: a case-control study

Patients with history of malignant melanoma (MM) are at risk of developing subsequent primary MM (SPM). Predictors of SPM may be helpful to identify patients at higher risk. The objective of the study is to investigate the phenotypic traits, indirect actinic exposure features and pathological variables associated with the risk of development of SPM. A ten-year retrospective case-control study was undertaken involving patients following MM excision who underwent regular video-dermoscopic examination at 4-6-month intervals for the first 5 years, followed by annual dermoscopic examination for the following five years. Patients with only one primary cutaneous MM were compared with those who developed at least one SPM. A total of 577 patients were included, 309 (53.6%) men and 268 (46.5%) women (mean age, 55 ± 15 years), comprising 450 patients with single melanoma and 127 with at least one SPM. The median time span to the SPM was 30 (IQR 12-53) months. Compared to the first melanoma, SPM were thinner, mean Breslow 0.56 ± 0.64 mm vs 1.37 ± 1.83 mm (p < 0.001); in situ MM prevalence 12% vs 36% (p < 0.001). 36 % of the patients with SPM developed it in the anatomical site of the previous melanoma. At multivariate analysis, having numerous naevi (i.e. 10-50 nevi) OR = 2.88 (95% CI 1.32-6.28, previous dysplastic naevi excisions OR = 2.51 (95% CI 1.53-4.12), solar lentigo OR = 2.68 (95% CI 1.67-4.31) and actinic keratosis OR = 3.09 (95% CI 1.64-4.31) were associated with an increased risk of SPM. These features may identify persons at increased risk of developing SPM.

Synchronous primary cutaneous melanomas: a descriptive study of their clinical features, histology, genetic background of the patients and clinical outcomes

BACKGROUND

Around 0.5% cutaneous melanoma (CM) patients will present with synchronous melanomas when first seen. Moreover, 26%-40% of patients with multiple primary melanomas present with synchronous lesions.

OBJECTIVES

To assess the prevalence, clinical and histopathological characteristics, germline mutations and outcome in patients with synchronous melanoma.

METHODS

Clinical and histopathological data from 4703 melanoma patients were included. Clinical, histological and genetic mutational status information was analyzed. Kaplan-Meier curves were used to investigate survival outcomes.

RESULTS

A total of 144 patients (3.06%) presented simultaneously with 2 or more primary melanomas. During follow-up, 25.7% of patients with synchronous melanoma developed a new primary melanoma compared to 8.6% of patients diagnosed with single melanoma (p < 0.001). Germinal CDKN2A mutations were identified in 10.7% of patients with synchronous melanomas and genetic variants in MC1R in 72%. No significant differences in all survival outcomes between patients with synchronous melanomas and single melanomas were found.

CONCLUSION

Synchronous melanomas are more frequent than previously reported and are more frequent in older patients compared to single melanomas. Moreover, these patients have a higher risk of developing a new primary melanoma during follow-up and have higher rates of germline susceptibility variants. Nevertheless, these findings were not associated with worse outcomes.

Poorer survival outcomes in patients with multiple versus single primary melanoma

BACKGROUND

Given equivocal results related to overall survival (OS) for patients with multiple primary melanomas (MPMs) compared with those with single primary melanomas (SPMs) in previous reports, the authors sought to determine whether OS differs between these 2 cohorts in their center using their UPCI-96-99 database. Secondary aims were to assess the differences in recurrence-free survival (RFS). In a subset of patients, transcriptomic profiling of peripheral blood mononuclear cells (PBMCs) was performed to assess disease-associated genes of interest.

METHODS

This retrospective case-controlled study included patients with MPMs and age-, sex-, and stage-matched controls with SPMs at a 1:1 ratio. Cox regression models were used to evaluate the effect of the presence of MPMs on death and recurrence. NanoString PanCancer Immune Profiling was used to assess peripheral blood immune status in patients.

RESULTS

In total, 320 patients were evaluated. The mean patient age was 47 years; 43.8% were male. Patients with MPMs had worse RFS and OS (P = .023 and P = .0019, respectively). The presence of MPMs was associated with an increased risk of death (hazard ratio [HR], 4.52, P = .0006), and increased risk of disease recurrence (HR, 2.17; P = .004) after adjusting for age, sex, and stage. The degree of tumor-infiltrating lymphocytes (TILs) was different between the first melanoma of MPMs and SPMs. Expression of CXCL6 and FOXJ1 was increased in PBMCs isolated from patients with MPMs.

CONCLUSIONS

Patients with MPMs had worse RFS and OS compared with patients with SPMs. Immunologic differences were also observed, including TIL content and expression of CXCL6/FOXJ1 in PBMCs of patients with MPMs, which warrant further investigation.

Characteristics, treatment and outcomes of 589 melanoma patients documented by 27 general practitioners on the Skin Cancer Audit Research Database

BACKGROUND AND OBJECTIVE

General practitioners manage more melanomas than dermatologists or surgeons in Australia. Previously undescribed, the management and outcomes of melanoma patients treated by multiple Australasian general practitioners are examined.

METHODS

The characteristics, management and outcomes of 589 melanoma patients, managed by 27 Australasian general practitioners and documented on the Skin Cancer Audit Research Database (SCARD), were analysed.

RESULTS

Most patients (58.9%) were males with mean age at diagnosis of 62.7 years (range 18-96), and most melanomas were in situ or thin-invasive. Patients aged under 40 years had fewer melanomas, but a higher proportion (the majority) were invasive, compared with older patients (P < 0.0001). Most (55.9%) melanomas were diagnosed following elliptical excision biopsy, the rate of unintended involved margins being eightfold higher for shave biopsies. Wide re-excision was performed by the treating general practitioner for most (74.9%) melanomas, with thick melanomas preferentially referred to surgeons. The average Breslow thickness of invasive melanomas re-excised by general practitioners was 0.67 mm compared with 1.99 mm for those referred to other specialists (P < 0.0001). Of 205 patients with invasive melanoma, 14 progressed to metastatic disease, 50% of these being associated with nodular melanoma. Nine patients progressed to melanoma-specific death. The 5-year survival rate for patients with invasive melanoma was 95.2% (95% CI: 91.2-98.5%).

CONCLUSIONS

Diagnostic and therapeutic management of a series of melanoma patients by Australasian general practitioners were closely aligned with current guidelines and 5-year survival with respect to invasive melanoma was at least as favourable as national population-based metrics.

Melanoma: Staging and Follow-Up

Cancer staging is the process determining to which extent a cancer has spread and where it is located in the body. A thorough staging is of utmost importance, not only because it provides the most accurate prognostic estimation, but also because several crucial decisions, such as the treatment choice and the follow-up strategy, vary according to the tumor's stage. The current staging system for melanoma is based on the 8^th edition of TNM classification issued by the American Joint Committee on Cancer (AJCC) in 2017. It includes a clinical and a pathological staging, both consisting of 5 stages (0-IV). The stage of a melanoma is determined by several factors, among which the Breslow thickness, the pathological presence or absence of ulceration in the primary tumor, the presence and the number of tumor-involved regional lymph nodes, the presence or absence of in-transit, satellite and/or microsatellite metastases, and the presence of distant metastases. Following melanoma diagnosis, an accurate medical workup, in line with the stage and the physical examination, should be performed. A continuous patient monitoring is fundamental to detect a potential relapse or a second primary melanoma and should be lifelong. However, there is still no universally adopted follow-up strategy program and different follow-up schemes have been suggested. Future prospective studies are needed to evaluate different follow-up protocols according to the adopted therapy, as novel recent therapies (targeted and immunotherapies) are being increasingly used. Key MessagesProper staging is of utmost importance because it provides accurate prognostic estimation. Several crucial decisions, such as the treatment choice and the follow up strategy, are based on the tumor stage.Physical examination during staging procedure and follow-up visits are important to avoid unnecessary imaging and laboratory tests that could increase the patients' anxiety. A personalized approach taking into consideration the patient's risk factors, is strongly recommended.Melanoma patients should be kept under surveillance lifelong due to an increased risk of developing a second primary melanoma and the risk of recurrence. Higher intensity follow-up strategies during the first 5 years are recommended due to higher rates of regional or distant relapse.

Identification of death risk factors of primary melanoma based on the competing risk model

OBJECTIVE

To preliminarily explore death risk factors in primary melanoma patients.

METHOD

Competing risk model analysis was used using a large sample public cohort and Cox proportional hazard model was compared.

RESULT

In the competing risk model analysis, age, gender, ethnicity, stage, site, TMN stage and metastases were the independent risk factors of single primary melanoma (SPM) death. T stage had a particularly important impact on SPM death. T2 stage had a 3.212 times greater risk of interest event than T1 stage [hazard ratio (HR)=3.212, 95%CI: 2.994-3.446], T3 stage was 5.747 times greater than that T1 stage (HR=5.747, 95%CI: 5.337-6.187) and T4 stage had a 7.086 times than T1 stage (HR=7.086, 95%CI: 6.514-7.708). Gender, ethnicity, stage, site, T stage and brain and liver metastases were the independent risk factors of multiple primary melanoma (MPM) death. When some groups had a very high death rate or the reference group had a very low death rate in competing events, the results of Cox proportional hazard model may not be as accurate as the results obtained by fine-Gray regression model.

CONCLUSION

Early diagnosis and therapy, and prevention of tumor progression and metastases of primary melanoma patients are important measures to improve its prognosis and survival.

Synchronous and metachronous malignant melanomas arising in a human immunodeficiency virus-positive patient after the commencement of highly active antiretroviral therapy treatment: a case report

BACKGROUND

We present an unusual case of a patient who developed four melanomas within a few months of diagnosis with human immunodeficiency virus and commencement of highly active antiretroviral therapy therapy. The patient had no previous history of melanoma, and previous skin checks were normal.

CASE PRESENTATION

A 50-year-old Caucasian male drainlayer with Fitzpatrick type 2 skin presented for a routine skin examination. He had been diagnosed with human immunodeficiency virus 4 months earlier and commenced on highly active antiretroviral therapy therapy. He was found to have three melanomas (melanoma in situ stage) on excision biopsies, and when he presented for wider excisions of these sites a few weeks later, another new melanoma in situ was found. He had no other medical history of note, and no symptoms to report. He is being followed up 3-monthly.

CONCLUSIONS

This case of a human immunodeficiency virus-positive person presenting with four cutaneous melanomas-occurring in both synchronous and metachronous fashion within a 4-month period-is being presented both for its uniqueness and also to highlight the increased need for close skin surveillance in human immunodeficiency virus-positive patients.

Multiple Primary Melanoma Incidence Trends Over Five Decades: A Nationwide Population-Based Study

BACKGROUND

Over the past decades, many regions have experienced a steady increase in the incidence of cutaneous melanoma. Here, we report on incidence trends for subsequent primary melanoma.

METHODS

In this nationwide population-based study, patients diagnosed with a first primary cutaneous melanoma reported to the Swedish Cancer Registry were followed for up to 10 years for a diagnosis of subsequent primary melanoma. Patients were grouped with patients diagnosed with first melanoma in the same decade (1960s, 1970s, 1980s, 1990s, and 2000s, respectively). Frequencies, incidence rates (IRs), standardized incidence ratios (SIRs), and 95% confidence intervals (CIs) for second melanomas were calculated. All tests of statistical significance were 2-sided.

RESULTS

Of patients with melanoma, 54 884 were included and 2469 were diagnosed, within 10 years, with subsequent melanomas. Over the 5 decades, there was a statistically significant steady increase in the frequency, IR, and SIR for second primary melanoma. For example, in the 1960s cohort, less than 1% (IR = 1.0, 95% CI = 0.5 to 1.7, and IR = 1.1, 95% CI = 0.5 to 1.9 per 1000 person-years in women and men, respectively) had second primary melanoma, and this rose to 6.4% (IR = 7.5, 95% CI = 6.8 to 8.3, per 1000 person-years) in the women and 7.9% (IR = 10.3, 95% CI = 9.3 to 11.2, per 1000 person-years) in the men in the 2000s cohort. This rise was seen independent of age, sex, invasiveness, or site of the melanoma. Further, in patients diagnosed with a second melanoma, the frequency of those having more than 2 melanomas increased statistically significantly and was 0.0% in the 1960s and rose to 18.0% in the 2000s (P < .001).

CONCLUSIONS

This is the first study to evaluate and report on a rising trend for subsequent primary melanoma. Additional primary melanomas worsen the patients' survival, and precautions are needed to turn this steep upgoing trend.

Association of Indoor Tanning Regulations With Health and Economic Outcomes in North America and Europe

Importance

UV radiation emissions from indoor tanning devices are carcinogenic. Regulatory actions may be associated with reduced exposure of UV radiation at a population level.

Objective

To estimate the long-term health and economic consequences of banning indoor tanning devices or prohibiting their use by minors only in North America and Europe compared with ongoing current levels of use.

Design, Setting, and Participants

This economic analysis modeled data for individuals 12 to 35 years old in North America and Europe, who commonly engage in indoor tanning. A Markov cohort model was used with outcomes projected during the cohort's remaining life-years. Models were populated by extracting data from high-quality systematic reviews and meta-analyses, epidemiologic reports, and cancer registrations.

Main Outcomes and Measures

Main outcomes were numbers of melanomas and deaths from melanoma, numbers of keratinocyte carcinomas, life-years, and health care and productivity costs. Extensive sensitivity analyses were performed to assess the stability of results.

Results

In an estimated population of 110 932 523 in the United States and Canada and 141 970 492 in Europe, for the next generation of youths and young adults during their remaining lifespans, regulatory actions that ban indoor tanning devices could be expected to gain 423 000 life-years, avert 240 000 melanomas (-8.2%), and avert 7.3 million keratinocyte carcinomas (-7.8%) in North America and gain 460 000 life-years, avert 204 000 melanomas (-4.9%), and avert 2.4 million keratinocyte carcinomas (-4.4%) in Europe compared with ongoing current levels of use. Economic cost savings of US $31.1 billion in North America and €21.1 billion (US $15.9 billion) in Europe could occur. Skin cancers averted and cost savings after prohibiting indoor tanning by minors may be associated with one-third of the corresponding benefits of a total ban.

Conclusions and Relevance

Banning indoor tanning may be associated with reduced skin cancer burden and health care costs. Corresponding gains from prohibiting indoor tanning by minors only may be smaller.

Germline variants are associated with increased primary melanoma tumor thickness at diagnosis

Germline genetic variants have been identified, which predispose individuals and families to develop melanoma.

Tumor thickness is the strongest predictor of outcome for clinically localized primary melanoma patients. We sought to determine whether there is a heritable genetic contribution to variation in tumor thickness. If confirmed, this will justify the search for specific genetic variants influencing tumor thickness.

To address this, we estimated the proportion of variation in tumor thickness attributable to genome-wide genetic variation (variant-based heritability) using unrelated patients with measured primary cutaneous melanoma thickness. As a secondary analysis, we conducted a genome-wide association study (GWAS) of tumor thickness.

The analyses utilized 10 604 individuals with primary cutaneous melanoma drawn from nine GWAS datasets from eight cohorts recruited from the general population, primary care and melanoma treatment centers. Following quality control and filtering to unrelated individuals with study phenotypes, 8125 patients were used in the primary analysis to test whether tumor thickness is heritable. An expanded set of 8505 individuals (47.6% female) were analyzed for the secondary GWAS meta-analysis. Analyses were adjusted for participant age, sex, cohort and ancestry.

We found that 26.6% (SE 11.9%, P = 0.0128) of variation in tumor thickness is attributable to genome-wide genetic variation. While requiring replication, a chromosome 11 locus was associated (P < 5 × 10⁻⁸) with tumor thickness. Our work indicates that sufficiently large datasets will enable the discovery of genetic variants associated with greater tumor thickness, and this will lead to the identification of host biological processes influencing melanoma growth and invasion.

Clinical and Histologic Features of Multiple Primary Melanoma in a Series of 31 Patients

BACKGROUND

We reviewed all cases of multiple primary melanoma diagnosed at our department over a 32-year period (1987-2019) to better characterize this subgroup of patients and develop a tailored protocol to offer them closer follow-up.

METHODS

Retrospective, observational, descriptive study of patients diagnosed with multiple primary melanoma at a tertiary care hospital between January 1987 and March 2019. We collected clinical, epidemiologic, and histologic characteristics of primary and subsequent melanomas and performed a descriptive analysis.

RESULTS

Thirty-one patients (15 men and 16 women) with a median age of 67years (range, 36-85years) were included. Second primary melanomas were diagnosed after a median of 2years (range, 0-4years). The median number of melanomas per patient was 2 (range, 2-6). Twenty-three of the 31 patients, 25 had 2 primary melanomas (80%), 4 had 3 melanomas (13%), and 2 patients each had 5 and 6 primary melanomas. Subsequent melanomas were less invasive than the initial primary melanomas. Median Breslow thickness was 1mm (range, 0.67-4mm) for the first primary melanoma and 0.5mm (range, 0.32-2.42mm) for subsequent melanomas.

CONCLUSIONS

Subsequent melanomas are thinner than primary melanomas. We observed an increase in the number of cases of multiple primary melanoma diagnosed in the last 2years of our study. Our findings highlight the importance of close, long-term follow-up of patients.

Long-term deaths from melanoma according to tumor thickness at diagnosis

There is little long-term follow-up information about how the number of melanoma deaths and case fatality vary over time according to the measured thickness of melanoma at diagnosis. This population-based longitudinal cohort study examines patterns and trends in case fatality among 44,531 people in Queensland (Australia) diagnosed with a single invasive melanoma (International Classification of Diseases for Oncology, third revision [ICD-O-3], C44, Morphology 872-879) between 1987 and 2011, including 11,883 diagnosed between 1987 and 1996, with up to 20 years follow-up (to December 2016). The 20-year case fatality increased by thickness, with the percentage of melanoma deaths within 20 years of diagnosis being up to 4.8% for melanomas with measured thickness <0.80 mm, 10.6% for tumors 0.8 to <1.0 mm and generally more than 30% for melanomas measuring 3 mm and more. For melanomas <1.0 mm, most deaths occurred between 5 and 20 years after diagnosis, whereas for thicker melanomas the reverse was true with most deaths occurring within the first 5 years. Five-year case fatality decreased over successive calendar time periods for melanomas <1.0 mm, but not for melanomas ≥1.0 mm. These findings demonstrate that the time course for fatal melanomas varies markedly according to tumor thickness at diagnosis. Improved understanding of the patient factors and characteristics of melanomas, in addition to tumor thickness, which increase the likelihood of progression, is needed to guide clinical diagnosis, communication with patients and ongoing surveillance pathways of patients with potentially fatal lesions.

Prevention versus early detection for long-term control of melanoma and keratinocyte carcinomas: a cost-effectiveness modelling study

OBJECTIVE

To compare the long-term economic impact of melanoma prevention by sun protection, with the corresponding impact of early detection of melanoma to decrease melanoma deaths.

DESIGN

Cost-effectiveness analysis using Markov cohort model. Data were primarily from two population-based randomised controlled trials, epidemiological and costing reports, and included flow-on effects for keratinocyte cancers (previously non-melanoma skin cancers) and actinic keratoses.

SETTING

Queensland, Australia.

PARTICIPANTS

Men and women with a mean age 50 years modelled for 30 years.

INTERVENTIONS

Daily sunscreen use (prevention) compared with annual clinical skin examinations (early detection) and comparing these in turn with the status quo.

PRIMARY AND SECONDARY OUTCOMES

Costs, counts of melanoma, melanoma deaths, keratinocyte cancers, life years and quality-adjusted life years.

RESULTS

Per 100 000 individuals, for early detection, primary prevention and without intervention, there were 2446, 1364 and 2419 new melanomas, 556, 341 and 567 melanoma deaths, 64 452, 47 682 and 64 659 keratinocyte cancers and £493.5, £386.4 and £406.1 million in economic costs, respectively. There were small differences between prevention and early detection in life years saved (0.09%) and quality-adjusted life years gained (0.10%).

CONCLUSIONS

Compared with early detection of melanoma, systematic sunscreen use at a population level will prevent substantial numbers of new skin tumours, melanoma deaths and save healthcare costs. Primary prevention through daily use of sunscreen is a priority for investment in the control of melanoma.

Second Primary Cancers in Melanoma Patients Critically Shorten Survival

Background

Survival in malignant cutaneous melanoma has improved but increasing survival will result in an increased likelihood of the occurrence of second primary cancers (SPCs). SPCs may adversely interfere with survival. We quantified survival in patients with different types of SPCs, in comparison to known poor prognostic indicators of metastatic disease.

Methods

Data for melanoma and any SPCs were obtained from the Swedish Cancer Registry for years 2003 through 2015, including clinical TNM classification. SPCs were grouped into three ‘prognostic groups’ based on 5-year relative survival of these cancers as first primary cancer. Kaplan-Meier survival curves were generated and hazard ratios were estimated using Cox regression, adjusted for a number of variables and treating diagnosis of SPC as a time-dependent variable.

Results

The total number of first melanoma patients was 28,716 followed by 3,202 (11.1%) SPCs, 1/3 of which had a second melanoma while 2/3 had other SPCs. Among men diagnosed at age over 70 years, who survived at least 10 years, 31.4% had SPC. HRs (95% CI) for survival increased systematically from the reference rate of 1.00 (no SPC) to 1.59 (1.35–1.87) with SPC of good prognosis (78.6% of SPCs) to 3.49 (2.58–4.72) of moderate prognosis (12.0%) and to 7.93 (5.50–11.44) of poor prognosis (9.4%). In patients without SPC, the HRs increased to 2.62 (2.02–3.39) with any nodal metastases and to 5.88 (4.57–7.57) with any distant metastases compared to patients without local or distant metastases.

Conclusion

The data showed that SPCs are an increasingly common negative prognostic factor for melanoma. Future attempts to improve melanoma survival need to target SPCs.

Melanoma: clinical-pathological and molecular analysis in patients of Ibague city, Colombia

This study aimed to establish the clinicopathological characteristics of patients with melanoma and its association with BRAF gene mutations. The pathology reports and paraffin-embedded tumor samples from 47 women and 30 men with melanoma, with an average age of diagnosis of 60 years, were reviewed at the Hospital Federico Lleras Acosta of Ibague, between 2010 and 2016. The presence of V600E mutation at the exon 15 of BRAF gene, was analyzed in these tumoral samples by Sanger sequencing and visual inspection of the electropherograms. We also studied the clinicopathological variables with X2, t-Student and the Kaplan Meier index. Most of the lesions were located in the lower limbs (46.6%). The most frequent subtype was Acral Lentiginous Melanoma (41.8%). Most lesions were of poor prognosis: Breslow depth greater than 4.1 mm (52.7%), ulceration (61.4%) and medium or high mitotic rate (> 30 %). The V600E mutation was identified in five patients with large, deep and ulcerated tumors, four of them had less than four years of survival. In conclusion, there was a higher frequency of melanoma in women, V600E BRAF mutation was present in patients with advanced disease (high Breslow index) and, the probability of five-year survival was less than 40%.

Thick melanomas without lymph node metastases: A forgotten group with poor prognosis

INTRODUCTION

Although adjuvant therapy is available for melanoma patients with sentinel lymph node (SLN) metastases (pN+), this is not the case for thick melanomas without SLN involvement (pN-).

OBJECTIVES

We assessed overall and relative survival (OS, RS) in patients with >4.0 mm Breslow thickness (BT) pN- and pN + melanomas and ≤4.0  mm pN+ patients.

MATERIALS AND METHODS

Clinicopathological data were retrieved from a cohort of >4.0 mm thick and/or pN + melanoma patients in The Netherlands from 2000 to 2014. OS and RS was compared using Kaplan-Meier-curves. A Cox-regression-model was developed to assess determinants of OS in >4.0 mm pN- patients.

RESULTS

In 54 645 patients, 3940 (7.2%) had >4.0 mm thick melanomas. SLN biopsy was performed in 1150 (29.2%) patients. Five-year OS was 70.5% for >4.0 mm pN- and 48.1% for >4.0  mm pN+ patients (p < 0.001), with a decreasing trend in OS for every mm BT. Five-year OS in 1877 ≤ 4.0  mm pN+ patients was 71.5%, which was not different from >4.0 mm pN- (p = 0.24). Higher age, higher BT category, ulceration and male gender were significantly associated with poor survival in >4.0 mm pN- patients.

CONCLUSIONS

Thick pN- melanomas have a poor prognosis, comparable to that of less thick pN + melanomas, which is not accounted for in current guidelines. We encourage including these high-risk patients in adjuvant trials.

Comparison of Survival Between Patients With Single vs Multiple Primary Cutaneous Melanomas

Importance

Melanoma is one of the most rapidly increasing forms of cancer worldwide. Most studies about survival among patients with melanoma consider only the primary tumor and disregard the potential effect of multiple primary tumors. A better understanding of the prognosis of patients with multiple primary melanoma is important for patient counselling and follow-up strategies.

Objective

To describe the epidemiologic features of multiple primary melanoma in patients from the Netherlands.

Design, Setting, and Participants

This retrospective, population-based cohort study included adults with histologically proven, primary, invasive cutaneous melanoma in the Netherlands between January 1, 2000, and December 31, 2014, with a median follow-up of 75.1 months, using data from PALGA, the Dutch Nationwide Network and Registry of Histopathology and Cytopathology. Follow-up data were retrieved from the Netherlands Cancer Registry. Statistical analysis was performed from August 1, 2018, to September 3, 2018.

Main Outcomes and Measures

A multivariable Cox model with a time-varying covariate was performed to assess overall survival between patients with a single primary melanoma vs those with multiple primary melanomas. Secondary outcomes included incidence of multiple primary melanoma, differences in Breslow thickness, and time between first and second multiple primary melanoma.

Results

Of the 56 929 study patients, 31 916 (56.1%) were female, with a mean (SD) age of 56.4 (16.2) years. A total of 54 645 single primary melanomas and 4967 multiple primary melanomas in 2284 patients were included. The median Breslow thickness decreased from 0.90 mm (interquartile range, 0.55-1.70 mm) for the first melanoma to 0.65 mm (interquartile range, 0.45-1.10 mm) for the second melanoma (P < .001). For their second melanoma, 370 patients (16.2%) had a higher T stage, 1112 (48.7%) had the same T stage, and 802 (35.1%) had a lower T stage. In addition, 841 of 2284 second melanomas (36.8%) in patients with multiple primary melanomas were found during the first year of follow-up, whereas 624 of 2284 (27.3%) were found after 5 years of follow-up. These proportions did not vary when stratified for melanoma stage. Worse overall survival was seen among patients with multiple primary melanomas compared with patients with a single primary melanoma (hazard ratio, 1.31; 95% CI, 1.20-1.42; P < .001).

Conclusions and Relevance

A significant decrease in Breslow thickness between the first and second multiple primary melanoma was found, and overall survival among patients with multiple primary melanomas was significantly worse than that among patients with a single primary melanoma. These findings suggest that more strict follow-up strategies may be warranted for patients with multiple primary melanomas.

Immunomodulatory germline variation associated with the development of multiple primary melanoma (MPM)

Multiple primary melanoma (MPM) has been associated with a higher 10-year mortality risk compared to patients with single primary melanoma (SPM). Given that 3–8% of patients with SPM develop additional primary melanomas, new markers predictive of MPM risk are needed. Based on the evidence that the immune system may regulate melanoma progression, we explored whether germline genetic variants controlling the expression of 41 immunomodulatory genes modulate the risk of MPM compared to patients with SPM or healthy controls. By genotyping these 41 variants in 977 melanoma patients, we found that rs2071304, linked to the expression of SPI1, was strongly associated with MPM risk reduction (OR = 0.60; 95% CI = 0.45–0.81; p = 0.0007) when compared to patients with SPM. Furthermore, we showed that rs6695772, a variant affecting expression of BATF3, is also associated with MPM-specific survival (HR = 3.42; 95% CI = 1.57–7.42; p = 0.0019). These findings provide evidence that the genetic variation in immunomodulatory pathways may contribute to the development of secondary primary melanomas and also associates with MPM survival. The study suggests that inherited host immunity may play an important role in MPM development.

A 10-year retrospective study of melanoma stage at diagnosis in the academic emergency hospital of Sibiu county

Melanoma is considered to be the most aggressive skin cancer, with an increasing incidence worldwide. An accurate staging of melanoma is crucial in describing the cancer status, estimating prognosis and deciding the optimal treatment solution. In the present study, melanoma staging highlights the importance of early detection, most of the patients having been diagnosed with advanced stages of this skin cancer. A retrospective study was conducted among 117 patients of the Academic Emergency County Hospital of Sibiu, diagnosed with melanoma between 2007 and 2016. The staging of the patients with melanoma was made using the American Joint Committee on Cancer (AJCC) 7th edition, and reconsidered in the light of the AJCC 8th edition. The results showed that the majority of the cases had distant metastases, 40.17% were diagnosed with stage IV melanoma. 25.65% of the patients were diagnosed with stage III melanoma, having a regional disease. The rest of the cases had localized melanoma (stages I and II, 30.76%), while only 3.42% of them were diagnosed with melanoma in situ, the melanoma type with the greatest chances of survival. Analyzing the Breslow index, it was observed that the most common tumor thickness was 2.1 to 4 mm (34.19%). In conclusion, as the incidence of melanoma increases in Romania, further efforts are needed to improve the early detection of melanoma. There are hopes that with the correct and early diagnosis of melanoma, the mortality rate of this neoplasm will decrease in the future.

Outcomes and Risk Factors in Patients with Multiple Primary Melanomas

The incidence and patient survival rates of melanoma have increased over the last several decades, with a growing population of patients who develop multiple primary melanomas (MPMs). To determine risk factors for developing MPMs and compare the survival of patients with MPMs to those with single primary melanomas, a prospective, multidisciplinary database of patients with melanoma at a single tertiary care institution was retrospectively reviewed. From 1985 to 2013, 6,963 patients with single primary melanomas and 305 patients with MPMs were identified. Mean follow-up was 8.3 ± 6.3 years for patients with single primary melanomas and 8.8 ± 5.9 years for patients with MPMs. Risk of developing multiple melanomas increased with age at diagnosis of first melanoma (hazard ratio [HR] = 1.20 for a 10-year increase in age, 95% confidence interval [CI] = 1.11-1.29, P < 0.001), male sex (HR = 1.44, 95% CI = 1.12-1.84, P = 0.005), and white race (HR = 3.07, 95% CI = 1.45-6.51). Patients with invasive MPMs had increased risk of melanoma-specific death both before (HR = 1.47, 95% CI = 1.0-2.2) and after adjusting for age, sex, site, race, family history of melanoma, personal history of other cancer, and Surveillance, Epidemiology, and End Results Program (SEER) stage (HR = 1.44, 95% CI = 0.95-2.2); however, this result did not reach statistical significance.

Similar survival of patients with multiple versus single primary melanomas based on Utah Surveillance, Epidemiology, and End Results data (1973-2011)

BACKGROUND

Survival data are mixed comparing patients with multiple primary melanomas (MPM) to those with single primary melanomas (SPM).

OBJECTIVES

We compared MPM versus SPM patient survival using a matching method that avoids potential biases associated with other analytic approaches.

METHODS

Records of 14,138 individuals obtained from the Surveillance, Epidemiology, and End Results registry of all melanomas diagnosed or treated in Utah between 1973 and 2011 were reviewed. A single matched control patient was selected randomly from the SPM cohort for each MPM patient, with the restriction that they survived at least as long as the interval between the first and second diagnoses for the matched MPM patient.

RESULTS

Survival curves (n = 887 for both MPM and SPM groups) without covariates showed a significant survival disadvantage for MPM patients (chi-squared 39.29, P < .001). However, a multivariate Cox proportional hazards model showed no significant survival difference (hazard ratio 1.07, P = .55). Restricting the multivariate analysis to invasive melanomas also showed no significant survival difference (hazard ratio 0.99, P = .96).

LIMITATIONS

Breslow depth, ulceration status, and specific cause of death were not available for all patients.

CONCLUSIONS

Patients with MPM had similar survival times as patients with SPM.

Concordance of somatic mutational profile in multiple primary melanomas

This study aimed to determine the frequency and concordance of BRAF and NRAS mutation in tumours arising in patients with multiple primary melanoma (MPM). Patients with MPM managed at one of three tertiary referral centres in Melbourne, Australia, from 2010 to 2015 were included. Incident and subsequent melanomas underwent mutation testing. Cohen's kappa (κ) coefficient assessed agreement between incident and subsequent primary melanomas for both BRAF and NRAS mutation status (mutant versus wild-type). Mutation testing of at least two primary tumours from 64 patients was conducted. There was poor agreement for both BRAF and NRAS mutation status between incident and subsequent melanomas (κ = 0.10, 95% CI -0.10 to 0.42; κ = 0.06, 95% CI -0.10 to 0.57, respectively). In view of the low concordance in BRAF mutation status between incident and subsequent melanomas, mutational analysis of metastatic tissue, rather than of a primary melanoma, in patients with MPM should be used to guide targeted therapy.

Reduced disease-specific survival following a diagnosis of multiple primary cutaneous malignant melanomas-a nationwide, population-based study

Outcome data comparing patients with multiple primary invasive cutaneous malignant melanomas (MPMs) to single primary invasive cutaneous malignant melanomas (SPMs) show conflicting results. We have analyzed differences in disease-specific survival between these patients in a nationwide population-based setting. From the Swedish Melanoma Register, 27,235 patients were identified with a first invasive cutaneous malignant melanoma (CMM) between 1990 and 2007, followed-up through 2013. Of these, 700 patients developed MPMs. Cox proportional hazard regression was used for adjusted cause-specific hazard ratios (HRs). An interval of ≤5 years between CMM diagnoses was significantly correlated to a decreased CMM-specific survival in Stage I-II MPM- vs. SPM-patients (HR 1.32; 95% CI 1.04-1.67; p = 0.02). MPM-patients with longer time interval between diagnoses experienced similar risk of CMM-death as SPM-patients. The risk of CMM-death increased by almost 50% above the expected outcome according to stage of the index CMM by the diagnosis of a second CMM (HR 1.48; 95% CI 1.19-1.85; p < 0.001). MPM vs. SPM-patients had a worse outcome (HR 1.38; 95% CI 1.05-1.83; p = 0.001). This emphasizes the importance of prevention efforts in SPM-patients to decrease the risk of subsequent CMMs and has implications for more vigilant follow-up in MPM-patients.

Cancer risks and survival in patients with multiple primary melanomas: Association with family history of melanoma and germline CDKN2A mutation status

BACKGROUND

Worse outcomes have been noted in patients with multiple primary melanomas (MPMs) than in patients with single primary melanomas.

OBJECTIVE

We investigated how family history of melanoma and germline CDKN2A mutation status of MPM patients affects risks of developing subsequent melanomas and other cancers and survival outcomes.

METHODS

Comprehensive data on cancer diagnoses and deaths of MPM patients, their first-degree relatives, and matched controls were obtained through Swedish national health care and population registries.

RESULTS

Familial MPM cases with germline CDKN2A mutations were youngest at the diagnosis of their second melanoma (median age 42 years) and had among the MPM cohorts the highest relative risks (RR) compared to controls of developing >2 melanomas (RR 238.4, 95% CI 74.8-759.9). CDKN2A mutated MPM cases and their first-degree relatives were the only cohorts with increased risks of nonskin cancers compared to controls (RR 3.6, 95% CI 1.9-147.1 and RR 3.2, 95% CI 1.9-5.6, respectively). In addition, CDKN2A mutated MPM cases had worse survival compared with both cases with familial (HR 3.0, 95% CI 1.3-8.1) and sporadic wild-type MPM (HR 2.63, 95% CI 1.3-5.4).

LIMITATIONS

Our study examined outcomes in subgroups of MPM patients, which affected the sample size of the study groups.

CONCLUSION

This study demonstrates that CDKN2A mutation status and family history of melanoma significantly affects outcomes of MPM patients.

Utility and Limitations of Large Population-Based Data for Skin Cancer Outcomes

Large population-based studies are useful for determining cancer outcomes, but interpreting their findings requires understanding their limitations. Youlden et al. highlight the utility of using a large dataset for studying melanoma survival, whereas Gimotty et al. point out the limitations of such datasets in miscoding thickness, a key prognostic variable. Awareness of limitations of population-based registry data can help to inform their interpretations and clinical implications.