Skin melanoma in Italy: a population-based study on survival and prognostic factors

Incidence and Survival Rates of Cutaneous Melanoma in South Korea Using Nationwide Health Insurance Claims Data

PURPOSE

Melanoma incidence is rising worldwide along with the associated personal and socioeconomic health expenditures. We investigated the incidence and survival-rate patterns of melanoma in South Korea using nationwide data.

MATERIALS AND METHODS

This retrospective cohort study included patients with melanoma between 2004 and 2017, based on National Health Insurance (NHI) claims data in South Korea. The incidence, prevalence, and survival rate were analyzed along with baseline demographic characteristics. We collected solar irradiation dose (SID) and healthcare ranking score (HRS) according to the administrative district from the Korea Meteorological Administration and Korea Health Promotion Institute. The incidence and survival rates were assessed using Pearson's correlation, the Kaplan-Meier estimation, multiple linear regression, and multiple logistic regression methods.

RESULTS

Twenty-five thousand, five hundred ninety-one patients with melanoma were diagnosed during the study period. The age-standardized incidence of melanoma steadily increased from 2004 to 2017 from 2.6 to 3.0/100,000/yr. The incidence of melanoma increased with significantly higher income (p < 0.05). The prevalence followed a similar pattern as the incidence. According to multivariate analysis, HRS significantly influenced the incidence of melanoma in high sun-exposed sites (p < 0.001). There was no significant change in annual mortality. Women had a higher 5-year survival rate than men (78.4% vs. 72.8%). Mortality by the administrative district was highly correlated with HRS.

CONCLUSION

The incidence of melanoma is increasing in South Korea. A low HRS is associated with both higher incidence and mortality. The findings of this study could be utilized as a guideline for treating melanoma patients.

Prognosis for Cutaneous Melanoma by Clinical and Pathological Profile: A Population-Based Study

Introduction

Among white people, the incidence of cutaneous malignant melanoma (CMM) has been increasing steadily for several decades. Meanwhile, there has also been a significant improvement in 5-year survival among patients with melanoma. This population-based cohort study investigates the five-year melanoma-specific survival (MSS) for all melanoma cases recorded in 2015 in the Veneto Tumor Registry (North-Est Italian Region), taking both demographic and clinical-pathological variables into consideration.

Methods

The cumulative melanoma-specific survival probabilities were calculated with the Kaplan-Meier method, applying different sociodemographic and clinical-pathological variables. Cox’s proportional hazards model was fitted to the data to assess the association between independent variables and MSS, and also overall survival (OS), calculating the hazard ratios (HR) relative to a reference condition, and adjusting for sex, age, site of tumor, histotype, melanoma ulceration, mitotic count, tumor-infiltrating lymphocytes (TIL), and stage at diagnosis.

Results

Compared with stage I melanoma, the risk of death was increased for stage II (HR 3.31, 95% CI: 0.94-11.76, p=0.064), almost ten times higher for stage III (HR 10.51, 95% CI: 3.16-35.02, p<0.001), and more than a hundred times higher for stage IV (HR 117.17, 95% CI: 25.30-542.62, p<0.001). Among the other variables included in the model, the presence of mitoses and histological subtype emerged as independent risk factors for death.

Conclusions

The multivariable analysis disclosed that older age, tumor site, histotype, mitotic count, and tumor stage were independently associated with a higher risk of death. Data on survival by clinical and morphological characteristics could be useful in modelling, planning, and managing the most appropriate treatment and follow-up for patients with CMM.

Prognostic significance of drainage to pelvic nodes at sentinel lymph node mapping in patients with extremity melanoma

Patients undergoing sentinel lymph node (SLN) mapping for lower extremity melanoma may have drainage to pelvic nodes (DPN) in addition to superficial inguinal nodes. These nodes are not sampled routinely at SLN biopsy. Factors predicting DPN and its prognostic significance were assessed in a large cohort of patients undergoing an SLN biopsy. Three hundred and twenty five patients with single primary melanomas of the lower extremity or buttocks who underwent SLN mapping were identified from our prospective melanoma database (December 1995-October 2008). Associations of clinical and pathologic factors with DPN and time to melanoma recurrence (TTR) were analyzed by logistic and Cox regression, respectively. DPN was common, occurring in 23% of cases. Increased Breslow's thickness (P=0.007) and age (P=0.01) were associated with DPN by multivariate analysis. Patients with DPN were not more likely to have a positive SLN; however, SLN- patients with DPN showed a shorter TTR (P=0.02) in a multivariable model including thickness and ulceration. With age included in the model, DPN remained marginally associated with TTR in this group (P=0.08). The pelvic recurrence rates observed were similar in recurrent patients with DPN compared with those without DPN (39% in both groups). In conclusion, DPN occurs in almost one-quarter of patients with lower extremity melanoma and is marginally associated with a shorter TTR in SLN- patients.

Modifying effect of gender on the prognostic value of clinicopathological factors and Ki67 expression in melanoma: a population-based cohort study

Background

Malignant melanoma is the most deadly form of skin cancer. Female sex is known to have a protective effect on incidence, tumour characteristics, and mortality from melanoma. However, the potentially modifying effect of sex on the prognostic significance of clinicopathological and investigative factors is generally not taken into consideration in biomarker studies. In this study, we compared the sex-specific distribution and prognostic value of established tumour characteristics and Ki67 expression in 255 cases of incident primary melanoma in a prospective, population-based cohort study.

Methods

The study included 255 incident cases of melanoma, 132 females and 123 males, in the Malmö Diet and Cancer Study. Tumours from 226 (88.6%) cases had been assembled in tissue microarrays. Clinicopathological factors and immunohistochemical Ki67 expression were assessed and correlated with disease-free survival (DFS) and overall survival (OS) using Kaplan-Meier analysis, log rank test and univariable and multivariable Cox regression analyses, stratified for gender. Effect of gender on melanoma-specific survival (MSS) after first recurrence was also analysed.

Results

Women were significantly younger at diagnosis than men (p = 0.012). The most common tumour sites were the legs in women (37.5%) and the dorsal trunk in men (37.8%). Kaplan-Meier analysis revealed that tumour location had no prognostic impact in women, but in men, location to the frontal trunk was significantly associated with a reduced DFS compared with all other locations combined and location to the dorsal trunk was significantly associated with a prolonged OS. High Ki67 expression was significantly associated with a reduced DFS and OS in men but not in women, also when adjusted for other factors. In men, but not in women, ulceration was an independent prognostic factor for both DFS and OS. MSS after first local, regional or distant recurrence was significantly shorter for men than for women.

Conclusions

The results from this study demonstrate that the prognostic value of tumour location, Ki67 expression and ulceration in melanoma differs according to gender. These findings need to be validated in future studies, as they may help improve prognostication in patients with melanoma. Moreover, our findings demonstrate that sex-stratified analyses add valuable information to biomarker studies.

Histological ulceration as a prognostic factor in cutaneous melanoma: a study of 423 cases in Spain

INTRODUCTION

Histological ulceration in cutaneous melanoma carries a high risk of metastasis and has a poor prognosis. However, some epidemiological and survival studies of patients with cutaneous melanoma do not consider histological ulceration as one of the main prognostic factors.

MATERIALS AND METHODS

Epidemiological, clinical, histological and survival characteristics of all patients diagnosed with cutaneous melanoma over a 10-year period (1994- 2003) were retrospectively analysed.

RESULTS

Ulcerated melanoma was observed in 77 of 423 patients (18.2%). Ulceration was significantly associated with male sex, deeper tumour thickness, positive sentinel lymph node biopsy and metastasis (p<0.001). Histological ulceration indicates a high relative risk (RR) of death from melanoma (RR 9.41; 95% CI 4.52-19.59) and a significant risk of metastasis (RR 5.72; 95% CI 3.56-9.19) (p<0.001).

CONCLUSIONS

Histological ulceration is associated with lower overall survival and disease-free survival in patients with cutaneous melanoma. Presence of ulceration must be included in the clinical history of patients with melanoma to ensure a careful diagnostic work-up and follow-up.

Melanoma prognostic factors found in the dermatopathology report

Significant prognostic information is available in a routine melanoma dermatopathology report. Features that are enumerated in the pathology report and that portend a potentially poorer prognosis are older age, site (acral, head, neck), male sex, increasing Breslow tumor thickness, increasing Clark's level, ulceration, increasing number of mitoses, vertical growth phase, regression, absence of a host inflammatory response, increased tumor vascularity, angiotropism, vascular invasion, neurotropism, marked atypia, and satellite metastasis.

Distribution of clinical-pathological types of cutaneous melanomas and mortality rate in the region of Passo Fundo, RS, Brazil

OBJECTIVE

To describe the characteristics of all cases of primary cutaneous melanoma during the period 1995-2001, registered at pathology departments in the region of Passo Fundo.

METHODS

The sample studied consisted of 229 primary cutaneous melanoma lesions, identified by anatomopathological reports, in 218 patients. The variables evaluated were: sex, age, anatomical site, histological type, level of invasion and tumor thickness. The rate of incidence, mortality and survival curve were calculated.

RESULTS

The most frequent tumor site was in the back of men (49.5%) and in the lower limbs of women (33.1%). The most frequent clinical-pathological type for both sexes was the superficial expansive type (superficial spreading) at 61.6%. The level of invasion was higher in men, using Clark level III (30.3%), than in women. In women the most frequent level of invasion was Clark level II (33.1%). Of the total number of lesions, 198 (47.2%) were </= 1 mm thick, and 23.2% of the men had thicker lesions (> 4 mm) than the women. The incidence was 5.67 per 100,000 patients-year during this period and the mortality rate was 2.16 per 100,000 patients-year.

CONCLUSIONS

In the sample studied the most common sites were in the back of men and in the legs of women. The predominant type clinical-pathological was superficial spreading.

Epidemiología y supervivencia del melanoma cutáneo en España: estudio de 552 casos (1994-2003)

Studies on epidemiology and survival of patients diagnosed of cutaneous melanoma in our country are few. We described epidemiological, clinical, histopathologic and survival characteristics of patients diagnosed of cutaneous melanoma at Hospital Gregorio Marañón of Madrid during ten years (1994-2003). The incidence of melanoma has doubled in the last decade. An important proportion of melanomas continues to be diagnosed in advanced stages (III-IV; 14.5%). The following factors were associated with a poor global survival: Tumor thickness, ulceration, nodular type, masculine gender and age older than 65.

Bronzeamento e risco de melanoma cutâneo: revisão da literatura

Estudos epidemiológicos sugerem a relação entre comportamentos relacionados ao bronzeamento e risco elevado de melanoma. Nesse sentido, realizou-se revisão sobre essa temática que abrangeu o período correspondente aos anos de 1977 a 1998. Foram pesquisadas as bases de dados Medline e Embase (Excerpta Medica). A análise mostrou que entre os jovens, apesar do conhecimento sobre os riscos da exposição excessiva à radiação ultravioleta e sobre as práticas visando à proteção da pele, prevalece o hábito de expor-se intencionalmente ao sol. Esse hábito é alimentado por crenças e atitudes em relação ao bronzeado e estimulado por influência do grupo e de pessoas consideradas "referências". As práticas mais freqüentemente adotadas para bronzear a pele apresentam risco elevado para o desenvolvimento de melanoma. Conclui-se que a forma mais eficaz de prevenir o melanoma é divulgar nos meios de comunicação que a pele bronzeada não é saudável, pois foi danificada pela radiação ultravioleta solar; e iniciar campanhas com ações efetivas para mudar comportamentos, naquilo que os motiva e os alimenta.

Prognosis for patients with thin cutaneous melanoma: long-term survival data from New South Wales Central Cancer Registry and the Sydney Melanoma Unit

BACKGROUND

Estimates of long-term survival for patients with thin (< or = 1 mm) primary cutaneous melanomas vary widely. Two separate methods were used to study the survival of patients with melanoma from New South Wales (NSW), Australia, and from the Sydney Melanoma Unit (SMU).

METHODS

The NSW Central Cancer Registry (NSWCCR) provided data on all patients who were diagnosed with cutaneous melanomas that measured < or = 1 mm thick between 1983 and 1998, inclusive. Patients with metastases at the time of diagnosis were not included, leaving 18,088 patients for analysis. The SMU data base was analyzed to extract data for all patients with thin melanomas who met the same criteria from 1979 to 1998, inclusive. All patients who had their primary tumors treated definitively elsewhere were excluded, leaving 2746 patients for analysis. Ten-year Kaplan-Meier survival rates were calculated, and significant differences were determined using log-rank analysis. Prognostic factors were evaluated with Cox proportional hazards analysis.

RESULTS

The NSWCCR analysis revealed a 10-year survival rate of 96.4%. The 10-year survival rate for patients at SMU was 92.7%. Among the patients at SMU who died, the median time to recurrence was 49.8 months, and the median time to death was 65.9 months. The 10-year survival for patients at SMU who had lesions that measured < or = 0.75 mm was 96.9% compared with 84.3% for patients who had lesions that measured 0.76-1.0 mm. For patients who had ulcerated melanomas measuring < or = 1 mm thick, the 10-year survival rate was 83%, compared with 92.3% for patients who had nonulcerated melanomas.

CONCLUSIONS

The results of the current study confirmed the excellent survival rate for patients with thin melanomas. Higher-risk subsets of patients who may warrant consideration for aggressive investigation and treatment are identifiable.

Cutaneous melanoma in the Florentine area, Italy: incidence, survival and mortality between 1985 and 1994

In recent decades, the increase in incidence of melanoma (MM) and the consequent mortality pointed to the concept of a 'melanoma epidemic'. More recently, the mortality has been slowly declining in many countries. This study is aimed at evaluating the incidence, mortality and survival in the Florentine area of Italy, using registry-based information. Between 1985 and 1994, 997 cases were notified with a survival of 713 patients (1985-92) and 316 deaths. Age-adjusted incidence, mortality rates and 95% confidence interval were calculated by period, gender and Breslow thickness. The relative survival rates were calculated and the effects of prognostic factors were evaluated using multivariate analysis. The incidence of MM increased during this period. This result referred only to 'thin melanomas', while the incidence rate for melanomas thicker than 1.00 mm remained unchanged both in young and old individuals. The mortality rate remained stable. The 5-year survival rate increased between 1985 and 1992. The inclusion of Breslow thickness in the multivariate model caused a reduction of the period effect. In conclusion, a changing pattern of MM epidemiology is being observed, with increase of 'thin' forms and a tendency for mortality to decline. The increasing awareness of population about MM prevention may partially explain these findings.

Time trends in cancer incidence and mortality in central Italy

Time trends in cancer incidence and mortality represent an essential tool for monitoring the changes in population lifestyle and in the environmental risks and the effectiveness of the health system on cancer control in a specific area. During 1985-1997 82 506 malignant tumours were diagnosed in the Tuscany Cancer Registry, central Italy (about 1 200 000 inhabitants) and 54 979 cancer deaths registered in the period 1985-1999 by the Regional Mortality Registry were analysed. A statistically significant decrease in incidence was evidenced for stomach and gallbladder in both sexes, and for oesophagus, larynx and lung among males. Significant increases were documented for melanomas of the skin, kidney and non-Hodgkin's lymphoma in both sexes for colon, prostate and Kaposi's sarcoma among males and for breast, thyroid and multiple myeloma among females. Mortality decreased significantly for stomach and thyroid in both sexes and for oral cavity and pharynx, oesophagus, rectum, larynx, lung, bone, prostate, testis and Hodgkin's disease among males and colon, gallbladder and breast among females. Mortality increased for soft tissue, brain and multiple myeloma. In conclusion, most of these data can be explained as the effect of the modifications that occurred in smoking habits between the sexes and as the consequence of the primary and secondary prevention activities that are ongoing in the area.

Population-based study of cutaneous malignant melanoma in the Granada province (Spain), 1985-1992

Cutaneous melanoma has received substantial attention during the last years because of the increase in its incidence which has been registered in many countries. This paper aims at describing the incidence and characteristics of all new cutaneous malignant melanoma cases during 1985-1992 reported to the Granada Cancer Registry (Spain) in the context of Mediterranean populations. A population-based study with 247 cutaneous melanoma cases was carried out. The variables used were: sex, age, anatomic site, hystological type, level of invasion and tumour thickness. The Age-Standardised incidence Rate per World population (ASRW) was 2.9 for males and 3.7 for females in the whole period. An increasing incidence trend for both males and females was found. The ASRW in 1985-1987, 1988-1990 and 1991-1992 was respectively 2.2, 2.9 and 3.2 for males and 3, 3.4, 4.7 for females. The most frequent location was trunk for males (36%) and lower extremities for females (44%). The most frequent hystological type for both males and females was superficial spreading melanoma. Seventy-six percent of males and 60% of females were diagnosed Clark's level III or over. Average tumour thickness was 3.3 mm for males and 2.4 mm for females. The results of this study can be a guidance for the setting up of health policies which would contribute to the prevention of the disease and to an improvement in care. Because of the increase in incidence rates and the high percentage of cases which were diagnosed at advanced stages, it is advised that prevention campaigns are addressed to the Granada population.

Skin melanoma in Saarland: incidence, survival and mortality 1970-1996

Over the past few decades, the incidence of cutaneous malignant melanoma has been rising in both sexes in almost all developed countries, notably those with fair-skinned populations. Detailed population-based time trend analyses of skin melanoma incidence and survival in Germany accounting for stage have not been published until now. We analysed skin melanoma data from the population-based Saarland Cancer Registry in Germany from 1970 to 1996. Incidence rates were age-standardized. We estimated 5-year disease-specific survival rates and evaluated the effects of sex, age, calendar period and staging on the prognosis in Cox's proportional hazards models. From 1970-1972 to 1994-1996, melanoma incidence increased 170% from 2.4 to 6.5 per 100 000 person-years among men and 150% from 2.4 to 6.0 per 100 000 person-years among women. Mortality rates peaked in 1988-1990. After 1988-1990, mortality rates declined among women and remained roughly constant among men. The increase in the incidence of localized melanoma and T1-T2 melanoma respectively is driving the overall incidence trend. The improvement of survival over time is most likely due to earlier detection of skin melanoma. In the 1990s, about 30% of all newly diagnosed skin melanoma had stage T3 or T4, implying that further improvement in survival by earlier detection is feasible.

Using a continuous transformation of the Breslow thickness for prognosis in cutaneous melanoma

Although the Breslow thickness provides the most important histologic information for prognosis in cutaneous melanoma, controversies and uncertainty remain about how best to use thickness. It is unclear whether cut points should be used, or, if they are used, which are optimal. We studied new data collected from more than 1,000 patients followed up for a relatively long period. From Cox proportional hazards models of survival we learned that more cut points provide more prognostic information than using, for example, just 1 cut point at 1.7 mm. Nevertheless, a continuous transformation provides an effective alternative that captures the information that thickness provides, and it avoids the pitfalls of using multiple cut points. In a multivariate model, this transformation provided strong prognostic information, and the result produced a prognostic score for cutaneous melanoma. This score provides a practical way that Cox model results can be used, and we believe it consolidates the prognostic information provided by traditional histologic and clinical variables. When newer prognostic variables are introduced, we suggest that they be used with this continuous transformation of thickness rather than with cut points in thickness.

Expression of Melan-A/MART-1 antigen as a prognostic factor in primary cutaneous melanoma

In this study we assessed the expression of the Melan-A/MART-1 antigen by immunohistochemistry using monoclonal antibody A103 in 73 primary cutaneous melanomas and its correlation with tumor staging and patient survival. Melan-A/MART-1 was expressed in 90% of primary tumors, with loss of expression increasing with Breslow thickness. Kaplan-Meier analysis demonstrated a significantly reduced disease-free interval and overall survival rate for patients not expressing this antigen. The poor prognosis of such patients was even worse for those presenting with a primary melanoma and a Breslow thickness of > or = 1 mm. Thus, Melan-A/MART-1 is not only a useful and specific additional marker for the diagnosis of primary cutaneous melanoma, but it may also help refine the prognosis of patients with malignant melanoma.