Risk factors for the development of primary cutaneous malignant melanoma

Cutaneous melanoma in Latin America: a population-based descriptive study

Cutaneous melanoma incidences vary between geographic regions and are a health concern for Caucasians and for all ethnic populations. In Latin America, data from population-based cancer registries of cutaneous melanoma incidence rates have rarely been reported. We searched the Cancer Incidence in Five Continents volume IX (CI5-IX) database for cutaneous melanoma and select cases by topography (C43) from 11 population-based cancer registries in Latin America. Between 1998 and 2002, a total of 4,465 cutaneous melanoma cases were reported in Latin America. The average age-standardized incidence rates (per 100,000 persons-year) was 4.6 (male) and 4.3 (female). This study presents an overview of cutaneous melanoma incidence in Latin America, highlighting the need to enhance coverage of population-based cancer registries in Latin America, to allow for a better understanding of this neoplasm in the region. Thus it can help in implementing primary prevention programs for the whole Latino population. At this point in time, early detection messages should target young women and older men in Latin America.

New insights into pigmentary pathways and skin cancer

The ability of cells to respond to and to mitigate environmental stress is crucial for their survival. Constitutive and facultative pigmentation have evolved in order for human skin to contend with high levels of terrestrial ultraviolet radiation (UVR). When this melanin 'shield' is compromised, individuals are exposed to increased skin cancer risk. The purpose of this review is to discuss new insights into the genetic basis of phenotypic risk factors for skin cancer, their connection to pigmentation and tanning, the precise molecular connections linking UVR to the tanning response, and potential methods of modulating pigmentation that avoid genotoxic damage. Highly translational implications of this research include a scientific basis on which to counsel patients regarding the carcinogenicity of UVR exposure related to tanning and potential new tanning agents that may actually protect against skin cancer by circumventing the need for UVR exposure.

Malignant melanoma in the 21st century: the emerging molecular landscape

Malignant melanoma presents a substantial clinical challenge. Current diagnostic methods are limited in their ability to diagnose early disease and accurately predict individual risk of disease progression and outcome. The lack of adequate approaches to properly define disease subgroups precludes rational treatment design and selection. Better tools are urgently needed to provide more accurate and personalized melanoma patient management. Recent progress in the understanding of the molecular aberrations that underlie melanoma oncogenesis will likely advance the diagnosis, prognosis, and treatment of melanoma. The emerging pattern of molecular complexity in melanoma tumors mirrors the clinical diversity of the disease and highlights the notion that melanoma, like other cancers, is not a single disease but a heterogeneous group of disorders that arise from complex molecular changes. Understanding of molecular aberrations involving important cellular processes, such as cellular signaling networks, cell cycle regulation, and cell death, will be essential for better diagnosis, accurate assessment of prognosis, and rational design of effective therapeutics. Defining an individual patient's unique tumor characteristics may lead to personalized prediction of outcomes and selection of therapy. We review the emerging molecular landscape of melanoma and its implications for better management of patients with melanoma.

Multiple Primary Acral Melanomas in African-Americans: A Case Series and Review of the Literature

BACKGROUND

Although melanoma accounts for only 4% to 5% of all skin cancers in the United States, it causes most skin cancer-related deaths. We describe a unique group of African-American patients with multiple primary acral lentiginous melanomas (ALMs).

OBJECTIVE

The purpose of this study was to review the case histories and management of a cohort of patients in the Mohs practice of our dermatologic surgeon with multiple primary ALM.

METHODS

This is a case series of patients with multiple ALM identified by chart review from 2000 to 2005. A thorough review of the literature was performed.

RESULTS

Four patients, all African-American, were identified with multiple ALM. All patients were managed with excision or Mohs micrographic surgery utilizing permanent sections. None of the patients with ALM had melanomas at nonacral sites or other types of skin cancer. Several had acral melanosis. Information in the literature on patients with multiple primary acral melanomas was insufficient.

CONCLUSION

Patients with multiple acral melanomas have not, to our knowledge, been reported thus far. It can be extrapolated from current literature, however, that appropriate management of these patients, including staging work and surgical intervention, is to be determined by the individual characteristics of the melanoma and the patient's concomitant risk factors, if any.

[Evaluation of a screening system for patients with pigmented lesions using store-and-forward teleconsultation]

INTRODUCTION

Pigmented lesion clinics (PLC's) were developed as a quick referral system for patients with pigmented lesions. However, the most appropriate method of selecting patients who need to be seen in these units is not clearly defined. Teledermatology is a tool whose usefulness as a patient selection system for PLC's needs to be evaluated.

OBJECTIVE

To evaluate teleconsultation as a screening system for patients with pigmented lesions in terms of efficacy, accuracy and satisfaction.

METHOD

Teleconsultations received at a PLC over a period of 12 weeks were evaluated. Teleconsultation patients reported changes in a pigmented lesion, a lesion that had recently appeared, multiple lesions, symptomatic lesions or concern about a nevus. We calculated the time intervals in sending the teleconsultation report and in patients being seen at the "physical" PLC consultation, the intraobserver, interobserver and pathologist kappa coefficients, as well as the degree of satisfaction of patients and Primary Care (PC) physicians.

RESULTS

219 teleconsultations were evaluated, 49.3 % of which were referred to the "physical" consultation. The most frequent reason for the teleconsultation was concern about a nevus (37.0 %). The teleconsultations received responses in an average time of 43.9 hours, and patients were seen at the "physical" consultation within 2 weeks. The intraobserver agreement was kappa = 0.93 (95 % CI 0.87-0.98); interobserver agreement, kappa = 0.91 (95 % CI 0.87-0.96); and the agreement between the teledermatologist and the pathologist, kappa = 0.79 (95 % CI 0.70-0.89). 86 % of the patients and 91 % of the Primary Care physicians said that they were "very satisfied" with the implementation of this new system.

CONCLUSIONS

Teleconsultation is an accurate screening system for patients with pigmented lesions. With this methodology, waiting times for patients with malignant lesions or those suspected of malignancy can be shortened at the same time as the PLC's excess workload is decreased. However, more experience is needed to establish the true usefulness of this filtering system in the early diagnosis of melanoma.

Teledermatoscopy as a triage system for pigmented lesions: a pilot study

BACKGROUND

Skin-cancer screening should rely on simple, low-cost and high-sensitivity diagnostic procedures.

AIMS

To compare diagnosis and management options after the evaluation of clinical and dermatoscopic teleconsultations with a store-and-forward teledermatology screening system for pigmented lesions.

METHODS

Kappa values between telediagnoses and the gold standard (histological examination) were assessed. Referral rates, diagnostic confidence level (DCL), sensitivity and specificity were evaluated in both approaches. Picture quality and time and cost investments were also measured. In total, 61 teleconsultations were evaluated.

RESULTS

Sensitivity of the clinical and dermatoscopic teleconsultations was 1 for both, whereas specificities were 0.65 and 0.78, respectively (P < 0.05). DCL was higher for the dermatoscopic teleconsultations (4.75 vs. 4.14, P < 0.05). Agreement between the clinical and dermatoscopic teleconsultation was kappa = 0.89 (95% CI 0.81-0.97). Agreement with the gold standard was 0.91 (95% CI 0.82-1.00) for the clinical teleconsultation and 0.94 (95% CI 0.88-1.00) for teledermatoscopy (P > 0.05). Teledermatoscopy increased the economic investment of a teledermatology facility by 2.4 times. The GP spent 1.5 times longer on dermatoscopic teleconsultations.

CONCLUSIONS

Teledermatoscopy has improved the DCL, specificity and referral rates of a teledermatology-based screening system for pigmented lesions. A more detailed economic analysis remains to be performed before recommending teledermatoscopy as a routine screening procedure in pigmented-lesion clinics.

Family physician visits and early recognition of melanoma

BACKGROUND

Malignant melanoma is a deadly skin cancer with a rapidly-increasing incidence, mortality and public health burden. Thin melanomas are easily treated with good prognosis, while the thicker lesions have relatively poor survival. To broaden strategies for early recognition of melanoma, we investigated the relationship between primary care service and melanoma thickness at diagnosis.

METHODS

All 714 patients diagnosed with a primary malignant melanoma between January 1995 and December 1999 in Nova Scotia were included in the present study and linked to provincial physician billing databases to reveal the patients' use of family physician services prior to the diagnosis of melanoma. We examined the importance of physician use of services for tumour thickness using logistic regression while adjusting for potential confounders. Tumour thickness was dichotomized to thin and thick using 0.75 mm as a cutoff.

RESULTS

Patients who regularly visited their family physician (2 to 5 times during a two-year interval prior to diagnosis) were 66% (95% CI, 31-84) less likely to be diagnosed with thick melanoma as compared to patients who consulted their family physician less or not at all. Progression to thick tumours could have been reduced by 11.70% (95% CI, -1.33-25.77) if all patients had consulted their family physician at least once a year.

DISCUSSION

Increased awareness of the need for regular medical check-ups could reduce the public health burden of melanoma.

Having children with different men and subsequent cancer risk. A nationwide study in Denmark

The more men by whom a woman has children, the more diverse will be the foetal antigens of paternal origin introduced into her bloodstream, and we investigated whether this has an impact on subsequent cancer risks. By using population registries we identified 64 704 women who had children with at least two different partners from 1973 to 1996 in Denmark. We compared their cancer incidence with that of women who during the same time period had at least two births with no indication of partner change, adjusting for age, parity, socioeconomic factors and residence. The overall cancer incidence was more than 50% higher in women with two or more partners. Women having children with multiple partners had a higher incidence of cancer of the cervix and corpus uteri, a lower incidence of melanoma but a similar incidence of breast and ovarian cancer. Uncontrolled differences in lifestyle factors may explain the higher cancer risk associated with having multiple partners. The strong protective effect for melanoma was unexpected and deserves further study.

Cutaneous malignant melanoma in association with mycosis fungoides

We retrospectively analyzed the first 461 cases entered into our cutaneous lymphoma database and found 285 cases of mycosis fungoides. We also identified 6 cases of malignant melanoma, all of which were found in patients with mycosis fungoides. The crude rate of melanoma in the general population in England, United Kingdom, in 1998 was 8.8/100,000 in men and 11.4/100,000 in women. The incidence of melanoma found in our cohort of patients with mycosis fungoides was far higher, and in 4 of the 6 patients cannot be explained on the basis of prior therapy. The reason for this association is unclear, but this report emphasizes the risk of second malignancies for patients with cutaneous T-cell lymphoma and melanoma.