Melanoma in pediatric, adolescent, and young adult patients

Development and validation of prognostic nomogram in pediatric melanoma: a population-based study

The aim of the study is to use the Surveillance, Epidemiology, and End Results (SEER) database to develop a useful clinical nomogram that uses prognosis prediction for pediatric melanoma patients. We obtained clinical information on pediatric melanoma patients from the SEER database between 2000 and 2018. Each patient was split into a training cohort or a validation cohort at random. Results between various subgroups were compared using Kaplan-Meier analyses. We created a nomogram to calculate the probability of survival for pediatric patients with melanoma. The performance of nomograms was assessed using calibration and discrimination. To assess the clinical use of this newly created model, decision curve analysis was also performed. In this study, a total of 890 eligible patients were chosen at random and allocated to 70% of training cohorts ( n  = 623) and 30% of validation cohorts ( n  = 267). After applying the chosen various components to create a nomogram, validated indexes showed that the nomogram had a strong capacity for discrimination. The training set's and validation set's C-index values were 0.817 and 0.832, respectively. The calibration plots demonstrated a strong correlation between the observation and the forecast. The model has a good clinical net benefit for pediatric melanoma patients, according to the clinical decision curve. In conclusion, we created an effective survival prediction model for pediatric melanoma. This nomogram is accurate and useful for clinical decision-making. Still, more external confirmation is required.

What's new in pediatric melanoma: An update from the APSA cancer committee

BACKGROUND/PURPOSE

Melanoma is the most common skin cancer in children and often presents in an atypical fashion when compared to adults. The purpose of this review is to present an update on the epidemiology, surgical and medical management and prevention strategies in pediatric melanoma.

METHODS

A comprehensive review of the current literature on the epidemiology, surgical and medical management and prevention of adult and pediatric melanoma was performed by the authors and the results of this review are summarized in the manuscript.

RESULTS

Most recently, the incidence of melanoma in children has been declining, possibly owing to increased awareness and sun exposure prevention. The mainstay of therapy is surgical resection, often with sentinel lymph node biopsy. A positive sentinel node has prognostic value; however, completion node dissection is no longer recommended in the absence of clinically or radiographically positive nodes. Those with advanced disease also receive adjuvant systemic therapy using increasingly targeted immunologic therapies.

CONCLUSIONS

Sentinel lymph node positive patients no longer require completion lymph node dissection and instead may be followed by ultrasound. However, it is important to note that children have been excluded from most melanoma clinical trials to date, and therefore, recommendations for management are based on existing pediatric retrospective data and extrapolation from adult studies.

LEVEL OF EVIDENCE

IV.

National Burden of Hospitalization Due to Cutaneous Melanoma in Adolescents and Young Adults

OBJECTIVES

Although adolescents and young adults (AYA) suffer disproportionately from cutaneous melanoma (CM), little is known regarding the burden of CM leading to hospitalization in AYA. The objective of this study was to elucidate sociodemographic/hospitalization characteristics of AYA CM inpatients, determine which factors lead to the greater length of stay (LOS) and cost of care for AYA CM inpatients, and evaluate trends in the prevalence, LOS, and cost of care for AYA CM hospitalizations.

MATERIALS AND METHODS

A retrospective cohort study of nationally representative data from the 2009 to 2015 National Inpatient Sample. Multivariable survey-weighted logistic regression models were used to determine sociodemographic factors associated with AYA CM hospitalization. Multivariable survey-weighted linear regression models were used to determine characteristics associated with the greater cost of care and LOS in AYA CM inpatients.

RESULTS

A total of 8986 AYA CM inpatients were included in this study. The prevalence of AYA CM hospitalizations is decreasing over time while the cost of care is increasing. On average, AYA CM hospitalizations were 3.3 days long and cost $38,018.40. Controlling for all covariates, male sex, older age, non-Hispanic white race, higher income, private insurance, and elective admissions were associated with AYA hospitalization due to CM (P<0.0001). Male sex was associated with longer LOS (P=0.007) and cost of care (P=0.01) among AYA hospitalized for CM.

CONCLUSIONS

Despite a decreasing prevalence of CM hospitalizations in AYA inpatients, the economic burden of these hospitalizations is increasing. Substantial sex-based differences exist in the inpatient burden of AYA CM. Further research is required to elucidate the causes of these differences and prevent AYA hospitalization due to CM.

Melanoma in children, adolescents and young adults: anatomo-clinical features and prognostic study on 426 cases

PURPOSE

This study was conducted to determine the difference in anatomo-pathological and prognostic features of cutaneous melanoma in children, adolescents and young adults.

METHODS

This is a retrospective review on 383 young patients ≤ 39 years of age with cutaneous melanoma, in a period from 2006 to 2016 in Area Vasta Nord Ovest, Tuscany, Italy. We subdivided patients in three groups (children ≤ 14 years, adolescents 15-21 years, young adults 22-39 years). We correlated all the anatomo-pathological parameters with age groups.

RESULTS

We identified a total of 426 cases of cutaneous melanoma on an overall total of 383 patients. Mean age at diagnosis for all the patients ≤ 39 years of age was 31.2 years: in group A was 11.2 years, in group B 19.2 years and in group C 32.5 years. Incidence, in the subjects between 0 and 14 years, is 14 cases per million inhabitants, between 15 and 21 years of 145, and between 22 and 39 years of 394. Global incidence was 1.6 case per million for group A, 8.9 cases per million for group B, 105 cases per million for group C. No statistically significative correlation could be described for clinical parameters and age groups.

CONCLUSIONS

Incidence of melanoma in our casuistry results as the highest in the world. These data open new study for this kind of cancer.

Pediatric melanoma and aggressive Spitz tumors: a retrospective diagnostic, exposure and outcome analysis

BACKGROUND

The diagnosis and management of pediatric melanomas is challenging given the presence of both melanomas and histologically aggressive Spitz tumors of undetermined biological significance (S-UBS) in this age group. Study objectives were to examine: factors leading to diagnostic delays, therapy side effects and patient outcomes in these diagnostic groups.

METHODS

A retrospective case review was performed using The University of Michigan's pediatric oncology database over a 13-year timespan. Patients referred to our clinic for consideration of interferon therapy due to a diagnosis of a stage III melanoma or aggressive appearing S-UBS with significant lymph node involvement were included.

RESULTS

We found two major causes of diagnosis delay: patients with amelanotic lesions misdiagnosed as having a wart and cases reviewed by non-expert pathologists upfront. The side effects from interferon therapy requiring dose adjustments included neutropenia, thrombocytopenia and mood disturbances. There was wide variability in surveillance scan utilization, therefore leading to variability in patient radiation exposure. Unlike melanoma patients, none of the S-UBS patients experienced disease progression or death.

CONCLUSIONS

This study highlights the challenges with the initial clinical diagnosis and pathological sub-categorization of the pediatric S-UBS/melanoma spectrum of skin lesions and emphasizes the role of expert pathology review upfront. Further, education at the primary care level could improve accurate and timely diagnoses. Earlier diagnosis could spare patients from more extensive interventions, metastatic spread or adverse outcomes in this patient population. This study is limited due to its retrospective, single-institution perspective.

Paediatric melanoma

Paediatric melanoma, although rare, is the most common skin cancer in children. Our current knowledge on paediatric melanoma incidence trends is expanding, as several studies have addressed this issue with conflicting results. Known risk factors for paediatric melanoma include family history of melanoma, a previous history of malignancy, large congenital nevi, numerous melanocytic nevi, sunburns, increased UV exposure and a sun-sensitive phenotype. In younger children, melanoma more often presents with atypical features, such as a changing, amelanotic or uniformly coloured, often bleeding lesion, not fulfilling in most cases the conventional ABCDE criteria. The major differential diagnoses are melanocytic nevi, proliferative nodules in congenital nevi and atypical Spitz tumours. Moreover, in the younger age group non-Caucasian children are over-represented, tumours tend to be thicker and lymph nodes are often involved. Despite the frequent diagnosis at an advanced stage, the overall survival is fair in paediatric melanoma. Specific guidelines for management of melanoma in children do not exist, and most often the disease is treated similarly to melanoma in adults.

Pediatric melanoma: incidence, treatment, and prognosis

The purpose of this review is to outline recent advancements in diagnosis, treatment, and prevention of pediatric melanoma. Despite the recent decline in incidence, it continues to be the deadliest form of skin cancer in children and adolescents. Pediatric melanoma presents differently from adult melanoma; thus, the traditional asymmetry, border irregularity, color variegation, diameter >6 mm, and evolution (ABCDE) criteria have been modified to include features unique to pediatric melanoma (amelanotic, bleeding/bump, color uniformity, de novo/any diameter, evolution of mole). Surgical and medical management of pediatric melanoma continues to derive guidelines from adult melanoma treatment. However, more drug trials are being conducted to determine the specific impact of drug combinations on pediatric patients. Alongside medical and surgical treatment, prevention is a central component of battling the incidence, as ultraviolet (UV)-related mutations play a central role in the vast majority of pediatric melanoma cases. Aggressive prevention measures targeting sun safety and tanning bed usage have shown positive sun-safety behavior trends, as well as the potential to decrease melanomas that manifest later in life. As research into the field of pediatric melanoma continues to expand, a prevention paradigm needs to continue on a community-wide level.

Do the European Medicines Agency Decisions Hurt Pediatric Melanoma Patients?

PURPOSE

US pediatric legislation was introduced in 1997 and was followed by European Union pediatric legislation that, since 2007, requires a European Medicines Agency (EMA)-approved pediatric investigation plan (PIP) for registration of new medicines unless they are PIP exempted. In 2008, the EMA decided that enough adolescent patients with melanoma existed and removed melanoma from the list of PIP-exempted diseases (class waiver list). We examined the logic and the results of this decision.

METHODS

We analyzed the EMA class waiver decision, the melanoma PIP decisions, the wording of the European Union pediatric legislation, and melanoma trials listed in www.clinicaltrials.gov and www.clinicaltrialsregister.eu that recruit adults and minors or only minors.

FINDINGS

There are 12 melanoma PIP decisions. Two apparently PIP-triggered melanoma trials were terminated in 2016 because of slow recruitment, and 4 are ongoing. Numerous non-PIP-driven trials are recruiting both adults and minors with melanoma worldwide, thus competing with PIP-triggered melanoma trials.

IMPLICATIONS

Revoking the melanoma class waiver was not based on science but on flawed logic. It resulted in PIP-demanded pediatric trials that do not make medical sense, fail to recruit adequately, and prevent participants from more promising off-label treatment or treatment in clinically, scientifically, and ethically superior non-PIP-triggered studies. Institutional review boards and ethics committees should consult both www.clinicaltrials.gov and www.clinicaltrialsregister.eu for competing trials in the same population and reject or withdraw approval for questionable trials. A major revision or replacement of the European Union pediatric legislation is needed to prevent children from being enrolled in unnecessary, unfeasible, or scientifically invalid trials.

Pediatric melanoma

Childhood melanoma is a rare pediatric malignancy, with fewer than 500 new diagnoses annually. The incidence is increasing, particularly in the adolescent population. This review highlights the epidemiology, clinical presentation, and histopathologic challenges of pediatric melanoma. Surgical resection remains the cornerstone for localized and regionally advanced disease. Adjuvant therapies, including current options and potential novel therapeutics for this unique population will be discussed.

Economic independence in survivors of cancer diagnosed at a young age: A Norwegian national cohort study

BACKGROUND

The impact of cancer on socioeconomic outcomes is attracting attention as the number of survivors of cancer in young age continues to rise. This study examines economic independence in a national cohort of survivors of cancer at a young age in Norway.

METHODS

Through the linkage of several national registries, the study cohort comprised 1,212,013 individuals born in Norway during 1965 through 1985, of which 5440 had received a cancer diagnosis before age 25 years. Follow-up was through 2007, and the main outcomes were receipt of governmental financial assistance, employment, income, and occupation. Analytic methods included Cox proportional hazard regression, log-binomial regression, and quantile regression models.

RESULTS

Individuals in the cancer survivor group had an increased probability of receiving governmental financial assistance (men: hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.3-1.5; women: HR, 1.5; 95% CI, 1.3-1.6) and of not being employed (men: HR, 1.4; 95% CI, 1.2-1.7; women: HR, 1.4; 95% CI, 1.2-1.6) compared with those in the noncancer group. Income discrepancies were particularly pronounced for survivors of central nervous system tumors. There was no difference in representation in higher skilled occupations.

CONCLUSIONS

Survivors of cancer at a young age in Norway had an increased risk of being economically dependent and unemployed. This was evident in several tumor groups and was most pronounced in female survivors. There were only small differences in income or representation in higher skilled occupations for most employed survivors compared with the noncancer group. The current results are important for understanding the impact of a cancer diagnosis at a young age on subsequent job market outcomes. Cancer 2016;122:3873-3882. © 2016 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

Dermatologic Concerns of the Lower Extremity in the Pediatric Patient

As the largest organ in the body, skin can prove the most daunting to diagnose and manage due to the large number of conditions and their uncanny ability to have similar qualities visually. Skin can reflect current trauma or infections or can be a harbinger of an underlying systemic disorder. With knowledge of the most common pediatric skin conditions, it is possible for practitioners to start a child on a basic treatment regimen and then refer to an appropriate specialist for more complex or rare disorders. This article covers the most common skin conditions seen on the lower extremity in the pediatric population.

Meta-Analysis of the Safety and Efficacy of Interferon Combined With Dacarbazine Versus Dacarbazine Alone in Cutaneous Malignant Melanoma

The aim of this study was to compare the efficacy and safety of interferon (IFN) combined with dacarbazine (DTIC) (experimental group) versus DTIC alone (control group) in cutaneous malignant melanoma. After searching all available databases, eligible articles were identified and subjected to quality assessment. Meta-analysis was performed using RevMan 5.3; combined relative risk (RR) and 95% confidence intervals (95% CIs) were calculated for survival rates, response rates, and adverse events. Eight randomized controlled trials published between 1990 and 2014 involving 795 patients were included in the meta-analysis. Compared with DTIC alone, IFN combined with DTIC significantly increased the overall response rate (RR = 1.59, 95% CI 1.21-2.08, P = 0.0008),the complete response rate (RR = 3.30, 95% CI 1.89-5.76, P < 0.0001), 2-year survival (RR = 1.59, 95% CI 0.99-2.54, P = 0.050) grade ≥3 hematologic toxicity (RR = 2.30, 95% CI 1.32-4.02, P = 0.003), neurotoxicity (RR = 18.15, 95% CI 5.34-61.74, P < 0.00001), and flu-like symptoms (RR = 6.31, 95% CI 1.95-20.39, P = 0.002). The partial response rate, grade ≥3 nausea and vomiting, treatment-related, and 1- and 3-year survival were not significantly different between IFN combined with DTIC and DTIC alone. IFN combined with DTIC may moderately improve the complete response rate, but increases the incidence of adverse events and has no significant effect on 1- and 3-year survival in cutaneous malignant melanoma.

Biologic and clinical characteristics of adolescent and young adult cancers: Acute lymphoblastic leukemia, colorectal cancer, breast cancer, melanoma, and sarcoma

Adolescent and young adult (AYA) patients with cancer have not attained the same improvements in overall survival as either younger children or older adults. One possible reason for this disparity may be that the AYA cancers exhibit unique biologic characteristics, resulting in differences in clinical and treatment resistance behaviors. This report from the biologic component of the jointly sponsored National Cancer Institute and LiveStrong Foundation workshop entitled "Next Steps in Adolescent and Young Adult Oncology" summarizes the current status of biologic and translational research progress for 5 AYA cancers; colorectal cancer breast cancer, acute lymphoblastic leukemia, melanoma, and sarcoma. Conclusions from this meeting included the need for basic biologic, genomic, and model development for AYA cancers as well as translational research studies to elucidate any fundamental differences between pediatric, AYA, and adult cancers. The biologic questions for future research are whether there are mutational or signaling pathway differences (for example, between adult and AYA colorectal cancer) that can be clinically exploited to develop novel therapies for treating AYA cancers and to develop companion diagnostics.

Incidence of Melanoma in Children: A Population-Based Study in Olmsted County, Minnesota

BACKGROUND

The incidence of melanoma has been rising in the United States, with conflicting evidence regarding trends in children.

METHODS

We identified patients 0 to 17 years old with a diagnosis of melanoma from January 1, 1970, through December 31, 2010, in Olmsted County, Minnesota. Information on survival and demographic characteristics was abstracted, and estimates of true incidence were calculated.

RESULTS

The estimated true incidence of melanoma in children from 1970 to 2010 was found to be 0.62 per 100,000 girls and 0.45 per 100,000 boys. The incidence of melanoma in this population did not increase with time after adjusting for age and sex. Only one case of metastatic disease (lymph node) was identified. Girls were more commonly affected and the mean age of disease onset was 14 years. Five of the seven melanomas in this population arose in association with a nevus, and none involved the trunk. Overall and disease-specific survival rates were not calculated because all patients studied were alive at the last follow-up.

CONCLUSION

The estimated true incidence rates of pediatric melanoma from our population-based study in Olmsted County, Minnesota, appear stable. This finding is in contrast to our prior research showing rapidly increasing incidence rates of melanoma in young and middle-aged adults from the same population.

Adolescent and young adult patients with cancer: a milieu of unique features

Adolescent and young adult (AYA) patients with cancer are a unique category of patients who, depending on age at time of diagnosis, might receive treatment from oncologists specializing either in the treatment of children or adults. In the USA, AYA oncology generally encompasses patients 15-39 years of age. AYA patients with cancer typically present with diseases that span the spectrum from 'paediatric' cancers (such as acute lymphoblastic leukaemia [ALL] and brain tumours) to 'adult' tumours (such as breast cancer and melanoma), as well as cancers that are largely unique to their age group (such as testicular cancer and bone tumours). Research indicates that outcomes of AYA patients with cancer are influenced not only by the treatment provided, but also by factors related to 'host' biology. In addition to the potential biological and cancer-specific differences between AYAs and other patients with cancer, AYA patients also often have disparate access to clinical trials and suffer from a lack of age-appropriate psychosocial support services and health services, which might influence survival as well as overall quality of life. In this Review, these issues are discussed, with a focus on two types of AYA cancer--ALL and melanoma--highlighting findings arising from the use of emerging technologies, such as whole-genome sequencing.

Non-pigmented melanoma with nodal metastases masquerading as pyogenic granuloma in a 1-year old

Malignant melanomas are the most common skin cancer in the pediatric population. Melanoma incidence is extremely low in infants, and metastatic disease is even less common. We present the case of an 11-month-old girl who presented with a non-pigmented lesion that progressed to an ulcerated lesion. Pathology was found to be Spitzoid melanoma of 7.6-mm thickness. Micrometastases were found on examination of the sentinel lymph node. The family chose expectant observation following the excision procedure. A pediatric melanoma registry may be helpful in developing future analyses of incidence in survival in this specialized population.

Melanoma incidence rises for children and adolescents: an epidemiologic review of pediatric melanoma in the United States

BACKGROUND/PURPOSE

This study was conducted to determine the influence of age on disease presentation and evaluate the change in pediatric melanoma incidence between 1998 and 2007.

METHODS

We performed a retrospective review of all children ≤18 years with cutaneous melanoma who were included in the 2007 National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2007.

RESULTS

We identified a total of 1447 patients with cutaneous melanoma. The overall average annual melanoma incidence was 5.4 per 1 million children and adolescents in the U.S., which increased throughout the study period. Most patients (89%) were at least 10 years of age (average age 15 years). Melanoma in situ (21%), thin (<1 mm) lesions (37%), stage I disease (46%), and superficial spreading histology (25%) were common at presentation. Only 1% of patients presented with distant metastases. Preadolescents younger than age 10 were ethnically more diverse and more likely to present with non-truncal primaries and advanced disease (P<.01) compared to adolescents.

CONCLUSIONS

The incidence of pediatric melanoma in the U.S. is increasing. There are significant differences between children and adolescents which suggest age-based inherent differences in the biology of the disease may exist.

The unique clinical characteristics of melanoma diagnosed in children

BACKGROUND

Studies have demonstrated a higher rate of nodal metastases in melanoma of childhood, but there is controversy about the overall prognosis relative to adults. We describe a large single-institution experience with pediatric melanoma and assess prognostic characteristics.

METHODS

Retrospective review identified 126 patients diagnosed with melanoma at <21 years of age and referred for treatment from 1986 to 2011. Atypical lesions were excluded. Clinicopathologic characteristics were correlated with sentinel lymph node (SLN) status and outcomes.

RESULTS

SLN biopsy was positive in 18 of 62 cases (29 %). Increasing Breslow thickness correlated with a positive SLN (p < 0.05). After a median follow-up of 5 years, there were 27 recurrences and 20 deaths. Positive SLN patients had significantly worse recurrence-free survival (RFS, p < 0.05) and significantly worse melanoma-specific survival (MSS, p = 0.05) compared with negative SLN patients. The 5-year RFS and MSS for positive SLN patients were 59.5 and 77.8 %, compared with 93.7 and 96.8 % for negative SLN patients. Recurrences and melanoma-related deaths were often seen beyond 5 years. No deaths have occurred in patients <12 years, but 9.1 % of patients 12-17 years and 17.2 % of patients 18-20 years died from melanoma (p = 0.291).

CONCLUSIONS

Children with melanoma have higher rates of SLN metastases (29 %) than adults with comparable melanomas. Despite the higher incidence of nodal metastases, survival is equal to or better than what is reported for adults. However, long-term follow-up is necessary in this population since recurrences and deaths are often seen beyond 5 years.

Microrna profiling analysis of differences between the melanoma of young adults and older adults

BACKGROUND

This study represents the first attempt to perform a profiling analysis of the intergenerational differences in the microRNAs (miRNAs) of primary cutaneous melanocytic neoplasms in young adult and older age groups. The data emphasize the importance of these master regulators in the transcriptional machinery of melanocytic neoplasms and suggest that differential levels of expressions of these miRs may contribute to differences in phenotypic and pathologic presentation of melanocytic neoplasms at different ages.

METHODS

An exploratory miRNA analysis of 666 miRs by low density microRNA arrays was conducted on formalin fixed and paraffin embedded tissues (FFPE) from 10 older adults and 10 young adults including conventional melanoma and melanocytic neoplasms of uncertain biological significance. Age-matched benign melanocytic nevi were used as controls.

RESULTS

Primary melanoma in patients greater than 60 years old was characterized by the increased expression of miRs regulating TLR-MyD88-NF-kappaB pathway (hsa-miR-199a), RAS/RAB22A pathway (hsa-miR-204); growth differentiation and migration (hsa-miR337), epithelial mesenchymal transition (EMT) (let-7b, hsa-miR-10b/10b*), invasion and metastasis (hsa-miR-10b/10b*), hsa-miR-30a/e*, hsa-miR-29c*; cellular matrix components (hsa-miR-29c*); invasion-cytokinesis (hsa-miR-99b*) compared to melanoma of younger patients. MiR-211 was dramatically downregulated compared to nevi controls, decreased with increasing age and was among the miRs linked to metastatic processes. Melanoma in young adult patients had increased expression of hsa-miR-449a and decreased expression of hsa-miR-146b, hsa-miR-214*. MiR-30a* in clinical stages I-II adult and pediatric melanoma could predict classification of melanoma tissue in the two extremes of age groups. Although the number of cases is small, positive lymph node status in the two age groups was characterized by the statistically significant expression of hsa-miR-30a* and hsa-miR-204 (F-test, p-value < 0.001).

CONCLUSIONS

Our findings, although preliminary, support the notion that the differential biology of melanoma at the extremes of age is driven, in part, by deregulation of microRNA expression and by fine tuning of miRs that are already known to regulate cell cycle, inflammation, Epithelial-Mesenchymal Transition (EMT)/stroma and more specifically genes known to be altered in melanoma. Our analysis reveals that miR expression differences create unique patterns of frequently affected biological processes that clearly distinguish old age from young age melanomas. This is a novel characterization of the miRnomes of melanocytic neoplasms at two extremes of age and identifies potential diagnostic and clinico-pathologic biomarkers that may serve as novel miR-based targeted modalities in melanoma diagnosis and treatment.