Multiple primary melanomas

Multiple Primary Melanoma Associated with CDKN2A Mutation-Case Report and Review of the Literature

The CDKN2A gene remains understudied in melanoma compared to BRAF alterations. Inactivation of this tumor suppressor gene through homozygous deletions in the 9p21 chromosomal region leads to cellular proliferation and disrupts pro-apoptotic pathways. Genetic changes in CDKN2A are linked to multiple primary melanomas (MPM), with patients diagnosed with melanoma facing an elevated risk of developing additional primaries. We present the rare case of a 72-year-old Caucasian woman with nine metastasizing melanomas across diverse anatomical sites, posing a diagnostic challenge. Initial diagnosis in 2022 revealed ulcerated superficial spreading melanomas, progressing to intradermal and papillary dermal populations with neurotropism and angiotropism by early 2023. Lymph node metastases were identified, classifying the condition as pT3b N3b. Subsequent assessments in April 2023 revealed clinically suspicious melanocytic lesions diagnosed as intradermal and traumatized junctional nevi. In late 2023, cutaneous pigmented lesions and subcutaneous metastases were confirmed as nodular nevoid low-CSD multiple melanomas. Fluorescence in situ hybridization testing revealed homozygous CDKN2A deletion, necessitating close multidisciplinary collaboration for an optimized care plan for effective monitoring and intervention in this intricate clinical scenario. In summary, this case report highlights the diagnostic challenges of MPM in a single patient. Stressing the importance of immuno-histochemistry and CDKN2A genetic testing, our findings underscore the crucial role of these tools in accurately distinguishing malignant melanocytic proliferations from nevi and characterizing MPM cases.

Incidence and Factors Associated With Second Primary Invasive Melanoma in Norway

Importance

Patients diagnosed with a primary melanoma are at high risk of subsequent melanomas. Understanding the risk of second primary invasive melanoma and associated factors is crucial to optimize patient follow-up.

Objective

To assess the incidence rate of second primary invasive melanoma and time between the first and second primary invasive melanoma in the Norwegian population.

Design, Setting, and Participants

This population-based cohort study included data from deidentified records of all invasive melanomas diagnosed in Norway in 2008 to 2020, obtained from the Cancer Registry of Norway. Data were from adults aged 18 years or older diagnosed with a first primary melanoma. Data analysis was performed from March to August 2023.

Main Outcomes and Measures

The main outcome was the incidence rate of second primary invasive melanoma at least 30 days after the first. Accelerated failure time models were fitted to examine potential associations with patient and tumor characteristics. Median time between first and second primary melanomas and 95% CIs were calculated. The likelihood of, and median interval for, second primary melanomas on the same or different site as the first primary were calculated.

Results

A total of 19 196 individuals aged 18 years or older were diagnosed with a first primary melanoma. The mean (SD) age at diagnosis of the first primary melanoma was 62 (16) years (range, 18-104 years), and 9763 (51%) were female. The incidence rate in the year following diagnosis was 16.8 (95% CI, 14.9-18.7) per 1000 person-years, which decreased to 7.3 (95% CI, 6.0-8.6) during the second year and stabilized thereafter. Median time between first and second primaries decreased with advancing age and was 37 months (95% CI, 8-49) in patients younger than 40 years, 18 (95% CI, 13-24) in patients aged 50 to 59 years, and 11 (95% CI, 7-18) in patients aged 80 years or older. The second primary was on the same site as their first primary for 47% (359 patients), and on a different site for 53% (407 patients). The median interval until second melanoma on the same site as the initial melanoma was 12 (95% CI, 7-19) months in men and 22 (95% CI, 11-35) months in women.

Conclusions and Relevance

Older age and male sex were associated with an increased risk, suggesting that increased surveillance intensity may be considered for men, especially those older than 50 years, for at least 3 years after their initial diagnosis, regardless of the characteristics of their first invasive melanoma.

Association of multiple primary melanomas with malignancy risk: A population-based analysis of entries from the Surveillance, Epidemiology, and End Results program database during 1973-2014

BACKGROUND

Genetic and environmental risk factors have been associated with the development of multiple primary melanomas (MPMs). We hypothesized that individuals with MPMs might have an increased incidence of internal malignancies.

OBJECTIVE

To identify the risk for subsequent malignancies in MPM patients.

METHODS

Multiple primary standardized incidence ratios were analyzed for individuals with ≥1, ≥2 and ≥3 primary melanomas (PMs) recorded in the Surveillance, Epidemiology, and End Results database during 1973-2014.

RESULTS

We identified 223,799 individuals with ≥1 PM, 19,709 with ≥2 PMs, and 3,995 with ≥3 PMs. Risks of subsequent internal malignancy increased with number of PMs, with observed:expected ratios of 0.99, 1.14, and 1.23 (P < .05) for patients with ≥1 PM, ≥2 PMs, and ≥3 PMs, respectively. Internal malignancy was higher in younger MPM patients and those with superficial spreading melanoma. The most common malignancies among MPM patients included breast, prostate, thyroid, soft tissue, brain, kidney, non-Hodgkin lymphoma, and chronic lymphocytic leukemia. Risk for subsequent cutaneous melanoma increased with observed:expected ratios of 8.09, 22.52, 41.03 (P < .05) for patients with ≥1 PM, ≥2 PMs, and ≥3 PMs, respectively.

LIMITATIONS

Surveillance, Epidemiology, and End Results records limited information about pigmentation phenotypes, histology, and treatments.

CONCLUSION

Patients with MPMs have an increased risk for subsequent internal and cutaneous malignancies and might benefit from tight adherence to age-specific cancer screening.

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.

Multiple primary melanomas: Our experience

Patients with melanoma have an increased risk of having other neoplasms, and particularly other melanomas and non-melanoma skin cancers. The study aimed to describe multiple primary melanomas in a large medical university centre from Romania (Cluj-Napoca) from 2004 to 2020. Out of 699 patients with melanoma included in the study, 26 (3.71%) developed multiple tumours. The 26 patients developed a total of 59 melanomas, corresponding to a mean of 2.3 melanomas per patient. The site and histological subtype of the first and second melanomas were not consistent. The proportion of subsequent melanomas that were in situ (51.5%) or thin melanomas (<1 mm, 24.2%) was higher compared with first melanomas (7.7%, respectively 11.5%). The median and mean time to diagnosis was 2.75 months, respectively, 28.09 months. In total, 76.92% of second melanomas were detected within three years, but we were able to document a subsequent melanoma more than ten years after the first diagnosis. The study highlights the importance of follow-up in patients diagnosed with melanoma, not only in the first years after the primary diagnoses but for the entire life.

Differences in Risk Factors for Melanoma in Young and Middle-aged Higher-risk Patients

BACKGROUND/AIM

Differences in risk factors for melanoma between young adults (18-39 years) and middle-aged (40-60 years) are not well documented. In this study, we aimed to determine differences in risk factors and characteristics of melanoma between these groups.

PATIENTS AND METHODS

This retrospective study is a review on 330 patients, including 250 middle-aged and 80 young adults, during the period 2006-2016 in the Tampere university hospital, in Finland.

RESULTS

Forty-one per cent of middle-aged and 47% of young adults were defined as higher-risk patients. High nevus count was the most common host risk factor in both groups. Young were more likely to have a family history of melanoma. Middle-aged had more often excessive intermittent sun exposure and a history of sunburn. Host risk characteristics were less commonly associated with thicker melanomas.

CONCLUSION

A high number of patients have host risk factors for melanoma. Several differences exist in risk factors and characteristics of melanomas between young adults and middle-aged patients.

Risk factors for the development of a second melanoma in patients with cutaneous melanoma

BACKGROUND

Cutaneous melanoma patients have an increased risk of developing other neoplasms, especially cutaneous neoplasms and other melanomas. Identifying factors associated with an increased risk might be useful in the development of melanoma guidelines.

OBJECTIVES

To identify risk factors related to the development of a second primary melanoma in a series of patients diagnosed with sporadic melanoma and to establish the estimated incidence rate.

METHODS

A longitudinal study based on prospective follow-up information of patients diagnosed with sporadic cutaneous melanoma at our centre from 2000 to 2015 was performed. Cumulative incidence was estimated based on competing risk models, and the association of characteristics with the risk of a second melanoma was performed by Cox proportional hazard models.

RESULTS

Out of 1447 patients included in the study, after a median follow-up of 61 months, 55 patients (3.8%) developed a second melanoma. Fair hair colour, more than 100 common melanocytic nevi and the presence of more than 50 cherry angiomas were independently associated with the development of a second melanoma. The site and the histological subtype of the first and second melanomas were not consistent. The second melanomas were thinner than the first ones.

CONCLUSIONS

Fair-haired and multiple-nevi patients might benefit from more intensive prevention measures. The finding of cherry angiomas as a risk factor suggests that these lesions could be markers of skin sun damage in the setting of certain degree of genetic susceptibility.

Prioritization and comprehensive analysis of genes associated with melanoma

Melanoma is a malignant tumor derived from melanocytes, which occurs mostly in the skin. A major challenge in cancer research is the biological interpretation of the complexity of cancer somatic mutation profiles. The aim of the present study was to obtain a comprehensive understanding of the formation and development of melanoma and to identify its associated genes. In the present study, a pipeline was proposed for investigating key genes associated with melanoma based on the Online Mendelian Inheritance in Man and Search Tool for the Retrieval of Interacting Genes/Proteins databases through a random walk model. Additionally, functional enrichment analysis was performed for key genes associated with melanoma. This identified a total of 17 biological processes and 30 pathways which may be associated with melanoma. In addition, melanoma-specific network analysis followed by Kaplan-Meier analysis along with log-rank tests identified tyrosinase, hedgehog acyltransferase, BRCA1-associated protein 1 and melanocyte inducing transcription factor as potential therapeutic targets for melanoma. In conclusion, the present study increased the knowledge of melanoma progression and may be helpful for improving its prognosis.

Risk Factors of Subsequent Primary Melanomas in Austria

Importance

Information on risk factors of subsequent melanomas would be helpful to identify patients at risk after the diagnosis of their first melanomas.

Objective

To determine risk factors of subsequent melanomas.

Design, Setting, and Participants

In this retrospective case-control study, 1648 participants with histologically verified cutaneous melanoma diagnosed from January 1, 1968, though March 16, 2015, were recruited from a tertiary referral center as part of the Molecular Markers of Melanoma study. CDKN2A was sequenced in 514 and MC1R in 953 participants. Data were analyzed from March 7, 2008, through March 25, 2015.

Main Outcomes and Measures

Phenotypic traits and internal and external risk factors for the development of a second, third, or fourth melanoma.

Results

In total, 1648 patients (53.6% men; mean [SD] age, 54 [15] years) were enrolled, including 1349 with single and 299 with multiple primary melanoma. Mean (SD) age at recruitment was 57 (15) years for the single-melanoma and 62 (14) years for the multiple-melanoma groups. From the internal risk factors, family history (odds ratio [OR], 1.76; 95% CI, 1.22-2.55; P = .006), CDKN2A high-risk mutations (OR, 4.03; 95% CI, 1.28-12.70; P = .02), and high numbers of nevi as a phenotypic risk factor (ORs, 2.23 [95% CI, 1.56-3.28, P < .001] for 20-30 smaller nevi and 2.56 [95% CI, 1.50-4.36; P = .003] for 20-30 larger nevi) were significantly associated with the risk of developing a subsequent primary melanoma using multivariate logistic regression analysis. Nonmelanoma skin cancer (OR, 2.57; 95% CI, 1.84-3.58; P < .001) and signs of actinic skin damage, particularly on the back (ORs, 1.91 [95% CI, 1.12-3.25; P = .04] for freckling and 1.92 [95% CI, 1.29-3.08; P = .007] for solar lentigines), additionally increased risk of a subsequent melanoma. All those factors were also associated with an earlier development of the second melanoma. Patients with 3 melanomas developed their second melanoma earlier than patients with only 2 melanomas (mean [SD] age, 55 [15] years for those with 2 primary melanomas; 52 [15] years for those with 3 primary melanomas). Time spent outdoors, solarium use, outdoor occupation, and hair color had no significant associations in these models.

Conclusions and Relevance

According to the results of this study, internal factors (family history and genetic variants), number of nevi, and actinic damage on the back are more relevant for the development of subsequent melanomas than skin phototype or hair color. Patients with many nevi were younger at the time of the diagnosis of their first melanoma. This finding could help to identify persons at increased risk of developing multiple primary melanomas.

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.

Clinicopathological characteristics of cutaneous malignant melanoma in patients at a tertiary hospital in Macaronesia. Survival as a function of locoregional prognostic factors per the American Joint Committee on Cancer

BACKGROUND

Despite suffering high ultraviolet radiation levels, few data on malignant melanoma (MM) in Macaronesia are available.

METHODS

Observational study of cutaneous MM cases diagnosed during a period of 12 years at a tertiary hospital in Canary Islands.

RESULTS

A total of 532 patients (female/male = 1.4) with an average age of 56 years were included; 5% developed more than one MM, and 7% reported family history of MM. Phototype II (43%), dark eyes (41%), and dark hair (41%) predominated. There was a lower frequency of light-colored hair and eyes in those born in the Canary Islands. The most frequent locations of MM were on the back for men (37%) and on the lower extremities for women (35%). Among the infiltrating tumors (83%), the (median) thickness was 1.07 mm (women, 0.90 mm; men, 1.21 mm). Anatomopathological ulceration (AU) and a mitotic rate ≥1 mitosis/mm² (HMR) were recorded in 27% of patients. Patients with regional disease constituted 12% of the population. The most common stage was IA (34%). Melanoma-specific survival (MSSV) decreased significantly with thickness, presence of AU, HMR, and sentinel lymph node disease. These four variables were independent prognostic factors. The five-year MSSV varied between 100% (stage IA) and 39% (stage IIIC).

CONCLUSIONS

The characteristics of the patients were similar to those published in datasets from continental Europe, although the pigmentary features were darker in those originating from Macaronesia. The prognostic parameters described in the 7th edition of the American Joint Committee on Cancer (AJCC) independently predict MSSV in our patients.

Early detection of cutaneous melanoma by sequential digital dermatoscopy (SDD)

The early diagnosis and excision of cutaneous melanoma is essential for an improved prognosis of the disease. Besides the investigation of pigmented lesions with the unaided eye and conventional dermatoscopy, long-term sequential digital dermatoscopy has been shown to improve the sensitivity of melanoma detection, especially in high-risk patients. In addition to the static clinical and dermatoscopic assessment, the sequential digital dermatoscopy strategy helps to detect changes over time. This review summarizes the latest developments in the field of sequential digital dermatoscopy, describes current strategies for the selection of patients and lesions to monitor, and suggests objective criteria that should lead to an excisional biopsy.

Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care

BACKGROUND

Melanoma is the fastest growing tumor of the skin, which disproportionately affects younger and middle-aged adults. As melanomas are visible, recognizable, and highly curable while in early stages, early diagnosis is one of the most effective measures to decrease melanoma-related mortality. Skin self-examination results in earlier detection and removal of the melanoma. Due to the elevated risk of survivors for developing subsequent melanomas, monthly self-exams are strongly recommended as part of follow-up care. Yet, only a minority of high-risk individuals practices systematic and regular self-exams. This can be improved through patient education. However, dermatological education is effective only in about 50% of the cases and little is known about those who do not respond. In the current literature, psychosocial variables like distress, coping with cancer, as well as partner and physician support are widely neglected in relation to the practice of skin self-examination, despite the fact that they have been shown to be essential for other health behaviors and for adherence to medical advice. Moreover, the current body of knowledge is compromised by the inconsistent conceptualization of SSE. The main objective of the current project is to examine psychosocial predictors of skin self-examination using on a rigorous and clinically sound methodology.

METHODS/DESIGN

The longitudinal, mixed-method study examines key psychosocial variables related to the acquisition and to the long-term maintenance of skin self-examination in 200 patients with melanoma. Practice of self-exam behaviors is assessed at 3 and 12 months after receiving an educational intervention designed based on best-practice standards. Examined predictors of skin self-exam behaviors include biological sex, perceived self-exam efficacy, distress, partner and physician support, and coping strategies. Qualitative analyses of semi-structured interviews will complement and enlighten the quantitative findings.

DISCUSSION

The identification of short and long-term predictors of skin self-examination and an increased understanding of barriers will allow health care professionals to better address patient difficulties in adhering to this life-saving health behavior. Furthermore, the findings will enable the development and evaluation of evidence-based, comprehensive intervention strategies. Ultimately, these findings could impact a wide range of outreach programs and secondary prevention initiatives for other populations with increased melanoma risk.

Multiple primary melanomas: do they look the same?

BACKGROUND

A series of studies has investigated epidemiological, clinical and genetic characteristics of patients with multiple primary melanoma (MPM). However, comparison of the clinical and dermoscopic features of MPM within a given individual has been described only in case reports.

OBJECTIVES

To describe the dermoscopic features of MPM for each given patient, and to evaluate the characteristics eventually associated with similar or dissimilar appearance.

METHODS

From the databases of three skin-lesion clinics in the U.S.A., Italy and Spain we collected the dermoscopic images of melanomas in patients diagnosed with MPM.

RESULTS

Among 58 patients with MPM, we found that 53% of patients had dermoscopically similar melanomas and 47% of patients had dermoscopically different melanomas. In older patients 59% of melanomas were dermoscopically similar vs. 47% in younger patients (P=0·377). Similar thickness was associated with the occurrence of dermoscopically similar melanomas (19/30 cases, 63%; P=0·039). Most (65%) of the synchronous lesions were similar, compared with 36% of nonsynchronous lesions (P=0·029), and most (69%) of the melanomas on sun-damaged skin were similar, vs. 37% of melanomas on nonsun-damaged skin (P=0·015; odds ratio 3·88, 95% confidence interval 1·11-13·98). The percentage of dermoscopically different melanomas was higher in patients with a family history of melanoma (67% vs. 48%).

CONCLUSIONS

MPMs in a given patient have almost the same chance of looking dermoscopically similar or different. However, a subset of elderly patients with sun-damaged skin may present multiple, similar, thin melanomas characterized by pigment-network and regression structures.

Melanoma prevention: are we doing enough? A Canadian perspective

Melanoma is the most dangerous form of skin cancer, and its incidence is increasing significantly among Canadians. In parallel with the rising incidence and morbidity, the financial burden caused by this disease will continue to increase dramatically for the government and for individuals alike. More concerted effort to raise awareness of melanoma in Canada is therefore needed.Risk factors-such as family history, childhood sunburn exposure, and age-play a significant role in an individual's likelihood to develop melanoma. Ultraviolet radiation exposure is the most modifiable variable in melanoma causation. It is therefore important for the general public, in particular the country's youth, to understand the consequences of lifestyle choices-especially tanning bed use and "sun worshipping." Many of these issues are not being addressed fully at either the national or the provincial level, with Canadian efforts trailing those of other nations facing similar challenges. Canada also has workforce issues, with an inadequate distribution and number of physicians who can detect and treat melanoma at an early curative stage. With proper education and public awareness, melanoma prevention can be an achievable goal in Canada.

Histopathological characteristics of subsequent melanomas in patients with multiple primary melanomas

BACKGROUND

Multiple primary melanomas (MPM) occur in up to 20% of melanoma patients, and subsequent tumours seem to have a favourable histopathological pattern.

OBJECTIVE

A prospectively collected cohort of 194 patients with MPM was retrospectively reviewed to investigate clinical and histopathological features of first and subsequent melanomas.

METHODS

Patients with MPM who were diagnosed at our Department (1985-2011) and who attended at least a follow-up control yearly were identified.

RESULTS

The number of nevi was <10, 10-50 and >50 in 8.7%, 41% and 50.3% of patients respectively. Histopathological dysplastic nevi have been diagnosed in 105 patients. During a median follow-up of 58 months, 159 (81.9%), 24 (12.3%), 7 (3.6%) and 4 (2%) patients developed 2, 3, 4 and ≥ 5 melanomas, respectively. The median time to second primary melanoma was 45 months. The second primary melanoma was diagnosed within 1-year and after 5-year from the first melanoma in 36.6% and 17.3% of patients respectively. First and second primary melanomas were in situ in 41 (21%) and 104 (54%) patients respectively (P < 0.001). Among patients with ≥ 2 invasive melanomas (N = 80), median tumour thickness and ulceration of first and second primaries were 0.91 and 0.44 mm (P <0.001), and 32% and 7.7% (P = 0.001) respectively.

CONCLUSIONS

Subsequent melanomas occurred within 1-year from the appearance of the first melanoma in 36% of patients with MPM, while a late melanoma diagnosis was detected in 17% of cases. Second primary melanoma had favourable histopathological features. Our findings support long-term skin surveillance to detect subsequent melanomas at an early stage.

Single versus multiple primary melanomas: old questions and new answers

BACKGROUND

In patients with multiple primary melanomas (MPM), mean tumor thickness tends to decrease from the first melanoma to the second melanoma, and prognosis may be improved compared with the prognosis for patients who have a single primary melanoma (SPM). In this study, the authors compared the clinicopathologic features of patients with MPM and SPM to better characterize the differences between these 2 groups and to determine whether or not there is an inherent difference in tumor aggression.

METHODS

In total, 788 patients with melanoma who were enrolled prospectively in the Interdisciplinary Melanoma Cooperative Group database from 2002 to 2008 were studied. Patients with SPM and with MPM were compared with regard to clinical and primary melanoma characteristics.

RESULTS

Of 788 patients with melanoma, 61 patients (7.7%) had 2 or more primary melanomas. The incidence of developing a second primary melanoma 1 year and 5 years after initial melanoma diagnosis was 4.1% and 8.7%, respectively, and most of the risk accumulated within the first year. The incidence of MPM was greater in patients aged ≥60 years than in those aged ≤60 years. The absence or presence of mitosis and other tumor characteristics did not differ significantly between patients with SPM and patients with MPM (P = .61).

CONCLUSIONS

No difference was observed in the presence or absence of mitoses, a marker of tumor proliferation, in SPM and MPM. Because it has been demonstrated that the presence of mitosis is a powerful prognostic marker, the current findings suggested that the tumors behave similarly in patients with SPM and patients with MPM. The authors concluded that differences in tumor thickness and prognosis between SPM and MPM more likely are caused by factors other than tumor biology, such as increased surveillance.

Clinicopathologic features of incident and subsequent tumors in patients with multiple primary cutaneous melanomas

BACKGROUND

0.6-12.7% of patients with primary cutaneous melanoma will develop additional melanomas. Pathologic features of tumors in patients with multiple primary cutaneous melanomas have not been well described. In this large, international, multicenter, case-control study, we compared the clinicopathologic features of a subsequent melanoma with the preceding (usually the first) melanoma in patients with multiple primary cutaneous melanomas, and with those of melanomas in patients with single primary cutaneous melanomas.

METHODS

Multiple primary melanoma (cases) and single primary invasive melanoma (controls) patients from the Genes, Environment and Melanoma (GEM) study were included if their tumors were available for pathologic review and confirmed as melanoma. Clinicopathologic characteristics of invasive subsequent and first melanomas in cases and invasive single melanomas in controls were compared.

RESULTS

A total of 473 pairs comprising a subsequent and a first melanoma and 1,989 single melanomas were reviewed. Forward stepwise regression modeling in 395 pairs with complete data showed that, compared with first melanomas, subsequent melanomas were more commonly contiguous with a dysplastic nevus, more prevalent on the head/neck and legs than other sites, and thinner. Compared with single primary melanomas, subsequent melanomas were more likely to be associated with a contiguous dysplastic nevus, more prevalent on the head/neck and legs, and thinner. The same differences were observed when subsequent melanomas were compared with single melanomas. First melanomas were more likely than single melanomas to have associated solar elastosis and no observed mitoses.

CONCLUSIONS

Thinner subsequent than first melanomas suggest earlier diagnosis, perhaps due to closer clinical scrutiny. The association of subsequent melanomas with dysplastic nevi is consistent with the latter being risk factors or risk markers for melanoma.

Clinical and prognostic reports from 270 patients with multiple primary melanomas: a 34-year single-institution study

BACKGROUND

Development of more than one primary melanoma in a sole patient is frequent, accounting for 1.2-8.2% of melanoma patients in most recent series.

OBJECTIVE AND METHODS

Clinical, histological and epidemiological characteristics of 270 multiple primary melanomas patients were reviewed.

RESULTS

Two-hundred and seven patients (76.7%) had two melanomas, whereas in the remaining 63 the number of primary ranged from three to eight; on the whole, 639 multiple primary melanomas were identified. Synchronous melanomas developed more frequently in patients with three or more lesions; median age was significantly lower in the group of patients with more than three melanomas than in the others. Mean Breslow's thickness significantly decreases (P<0.001) from the first (1.77±1.76 mm) to subsequent primaries (0.85±1.25 mm for the second and 0.66±0.48 mm for the third melanoma). Percentage of 'in situ' melanomas was 5.6% as first diagnosis, but increased to 24.8% for the second melanoma; number of nodular melanomas was significantly lower for succeeding diagnosis. AJCC stage at diagnosis showed a statistical prognostic significance, whereas outcome and survival did not depend on the number of primary lesions. Multivariate analysis confirmed the prognostic role of Breslow's thickness, ulceration, gender and patient age, and the better prognosis of patients with multiple melanomas, respect to those with single primary melanoma.

CONCLUSIONS

Skin examination and long-term follow-up are mandatory for patients affected by melanoma, with the intent to promptly diagnose not only a disease progression but also possible new primary melanomas.

Different aspects of self-reported quality of life in 450 german melanoma survivors

The present study was aimed at assessing quality of life (QoL) in a total of 450 melanoma patients who filled out the EORTC QLQ-C30 (Q1; 15 months post diagnosis) as part of the OVIS Study. Follow-up questionnaires (Q2) were administered two years after Q1. The analyses presented herein were based on the following assumptions: QoL of melanoma patients is worse than that of a German reference population. Further, both tumor location and tumor stage have an influence on self-reported QoL, with patients with tumors located on face, head, neck, and advanced tumor stage (T3/T4) reporting the worst QoL levels. Finally, patients' QoL improves over time based on the theory of disease adaptation. In contrast to the above assumptions, with the exception of global health/QoL scores, differences between OVIS and the reference population were below the minimal clinical important difference of ten points. Furthermore, no clinically meaningful differences were found between patients after stratifying our data by tumor location and tumor stage. Finally, no clinically relevant changes were seen between Q1 and Q2 across all scales of the EORTC QLQ-C30. However, when data were stratified by patients with stable disease versus those with progression, clinically relevant differences were found between Q1 and Q2 predominantly in women in the latter group regarding emotional function, insomnia, dyspnoea, and fatigue. The lack of clinically meaningful differences across strata (tumor location; tumor stage), time, and patients compared to a reference population is surprising. However, it is possible that the instrument used, a generic QoL instrument, is generally not sensitive enough to detect differences in melanoma patients. Our findings may further be explained by the fact that all patients included in our sample had been diagnosed well before Q1, i.e., main illness adaptation processes may have occurred before study entry.

Risk factors in a cohort of patients with multiple primary melanoma

BACKGROUND

There are various known familial and environmental risk factors that influence the risk for melanoma. This study sought to define the risk factors for multiple primary melanoma.

METHODS

A telephone survey of patients with multiple primary melanomas was conducted from a private practice in south-east Queensland, in order to examine various risk factors in this cohort.

RESULTS

Our findings of high rates of family history of melanoma (37%), and of dysplastic naevi (42%) support the influence of genotype in this high-risk group. A family history of multiple primary melanomas, seen in 17% of our patients, is a risk factor not previously reported in similar cohort studies. Sixty-eight per cent of patients had an equal or lesser degree of invasive malignancy in subsequent melanomas. Most multiple primary melanoma patients in this group (86.6%) were conducting self skin examination at least once per month. With regards to sun-protective behaviour, 85% reported regular sunscreen use and 92% reported regular use of sun-protective clothing; however, fewer had done this in childhood.

CONCLUSIONS

Enhanced knowledge of the genetic and environmental risk factors for multiple primary melanomas can assist clinicians in assessing risk and planning surveillance of patients.

Clinical and therapeutic impact of 18F-FDG PET/CT whole-body acquisition including lower limbs in patients with malignant melanoma

OBJECTIVES

To assess the added benefit of scanning lower limbs in addition to the usual whole-body positron emission tomography/computed tomography (PET/CT) scan in patients with no known or suspected primary or metastatic melanoma involving the lower limbs.

MATERIALS AND METHODS

This is a retrospective study of 122 consecutive patients [174 2-[¹⁸F]-fluoro-2-deoxy-D-glucose (FDG) PET/CT] who underwent FDG PET/CT for staging of melanoma at different time points in the course of the disease from October 2005 to February 2009 at the Brest University Hospital. Reports of whole-body PET/CT scans including lower limbs were reviewed. PET/CT abnormalities on the lower extremities were tabulated by location and correlated with pathology, other imaging studies and at least a 6-month clinical follow-up. The usefulness of lower limbs acquisition in clinical management was evaluated according to imagery findings.

RESULTS

Among the 174 consecutive PET/CT scans performed in 122 patients, 33 scans in 28 patients highlighted abnormal FDG uptakes considered as equivocal or suggestive of malignancy in the lower limbs. In 28 cases, uptakes were located at once in the lower limbs and in the rest of the body (lung, liver, mediastinal and sub-diaphragmatic lymph nodes, adrenal glands, bone) corresponding to disseminated disease. In five cases, PET/CT uptakes were located only in lower limbs; each pathological uptake corresponded to benign lesions. Lower limbs findings never impacted clinical and therapeutic decision.

CONCLUSION

Lower limbs additional PET/CT acquisition seems to offer poor additional benefit with none unexpected lesion detected and routine skull base to upper thigh images might be sufficient for this subset of patients.

Gesundheitsverhalten von Hautkrebspatienten während der Melanomnachsorge

Zusammenfassung. Das maligne Melanom ist die häufigste Krebserkrankung im mittleren Erwachsenenalter. Es zeichnet sich durch besonders hohe Heilungschancen in frühen Krankheitsstadien und Therapieresistenz metastasierter Melanome aus. Zudem ist das Melanom einer der wenigen soliden Tumore, die sich – beobachtbar für den Fachmann aber auch für den medizinischen Laien – an der Hautoberfläche entwickeln. Die Überlebenswahrscheinlichkeit wird primär durch das Melanomstadium zum Zeitpunkt der Diagnose bestimmt. Die frühzeitige Behandlung von Krankheitsprogression ist von entscheidender Bedeutung für die Dauer und Qualität der verbleibenden Lebenszeit. Dementsprechend fokussieren Interventionen zur Senkung melanombedingter Morbidität und Mortalität auf die frühestmögliche Entdeckung der Melanome und der Krankheitsprogression. Regelmäßige Hautselbstuntersuchungen als sekundäre und tertiäre Präventionsmaßnahme stellen ein hocheffektives Komplement zu ärztlicher Vor- und Nachsorge dar, da die Mehrzahl der Melanome sowie die Krankheitsprogression von Patienten, deren Familie und Freunden selbst entdeckt werden. Eine wichtige Fragestellung stellt daher das auf die Melanomerkrankung bezogene Selbstuntersuchungsverhalten und Möglichkeiten seiner Optimierung dar. Psychoonkologische Forschung hat bisher darauf fokussiert, Handlungsergebniserwartung und Selbstwirksamkeitserwartung durch dermatologische Patientenschulung zu erhöhen. Die vorliegende Studie untersucht psychosoziales Belastungserleben und Krankheitsbewältigung in ihrer Bedeutung für das Selbstuntersuchungsverhalten in einer Stichprobe von 164 Patienten in der Melanomnachsorge. Mehr als 70% der Patienten gaben an, nicht von ihrem Arzt zur Selbstuntersuchung angeleitet worden zu sein. Angeleitete Patienten maßen der Selbstuntersuchung höhere Bedeutung bei und praktizierten diese häufiger, obwohl sie sich dadurch unangenehm an die Krebserkrankung erinnert fühlten. Nichtinstruierte Patienten zeigen ein weniger funktionales Verhaltensmuster: Die Selbstuntersuchungshäufigkeit wurde u.a. durch erlebte Selbstunsicherheit, mangelnde ärztliche Unterstützung und berufliche/finanzielle Probleme bestimmt, während das objektive Rückfallrisiko keine Rolle spielte. Auf Basis dieser sowie weiterer psychoonkologischer Befunde und gesundheitspsychologischer Paradigmen wird ein integratives Modell für die dringend notwendige Forschung und evidenzbasierte Praxis der individuellen Gesundheitsfürsorge bei Personen mit erhöhtem Melanomrisiko vorgeschlagen.

Defining the patient at high risk for melanoma

In this practical review, we aim to help clinicians identify patients who are at significant risk of developing malignant melanoma. Universal screening is challenging, thus it is important to effectively single out patients who have a high risk of developing the disease. We provide a summary of pertinent questions to review when taking the patient's history, point out the phenotypic features to note during skin examination, and suggest risk stratification as a means to plan initial and long-term surveillance strategy. We mention personal and family history of melanoma as prime risk factors for melanoma, yet the review also focuses on the patient who has no history of melanoma, either in himself or his family, and the proper ways to evaluate his likelihood of developing the disease.

Second Primary Melanomas: Incidence and Outcome

The objective of this study was to determine the incidence of multiple primary melanomas (MPM) and other cancers types among patients with melanoma. Factors associated with development of MPM were assessed in a post hoc analysis of the database from a multi-institutional prospective randomized trial of patients with melanoma aged 18 to 70 years with Breslow thickness 1 mm or greater. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis. Forty-eight (1.9%) of 2506 patients with melanoma developed additional primary melanomas. Median follow-up was 66 months. Except in one patient, the subsequent melanomas were thinner (median, 0.32 mm vs 1.50 mm; P < 0.0001). Compared with patients without MPM, patients with MPM were more likely to be older (median age, 54.5 vs 51.0 years; P = 0.048), to have superficially spreading melanomas (SSM) ( P = 0.025), to have negative sentinel lymph nodes ( P = 0.021), or to lack lymphovascular invasion (LVI) ( P = 0.008) with the initial tumor. On multivariate analysis, age ( P = 0.028), LVI ( P = 0.010), and SSM subtype of the original melanoma ( P = 0.024) were associated with MPM. Patients with MPM and patients with single primary melanoma had similar DFS (5-year DFS 88.7 vs 81.3%, P = 0.380), but patients with MPM had better OS (5-year OS 95.3 vs 80.0%, P = 0.005). Nonmelanoma malignancies occurred in 152 patients (6.1%). Ongoing surveillance of patients with melanoma is important given that a significant number will develop additional melanoma and nonmelanoma tumors. With close follow-up, second primary melanomas are usually detected at an early stage.

A systematic review of health-related quality of life in cutaneous melanoma

Melanoma can be considered an emerging chronic disease that may considerably affect patients’ lives. The authors systematically reviewed the available literature on health-related quality of life (HRQOL) and melanoma. Of reviews and the selected studies, reference lists were hand-searched. The quality of the eligible studies was appraised based on 14 previously published criteria. Of the 158 abstracts, 44 articles were appraised, resulting in 13 selected studies written in English (published between 2001 and 2008). Most studies assessed patients from specialised centres with varying, but relatively advanced, disease stages. The most commonly used instruments were the SF-36 and EORTC QLQ-C30. Recently, a melanoma-specific HRQOL questionnaire [FACT-Melanoma (FACT-M)] was introduced for clinical trial purposes. It showed that approximately one-third of melanoma patients experienced considerable levels of distress, mostly at the time of diagnosis and following treatment. Systemic therapies affected HRQOL negatively in the short term, but to a lesser extent in the long term. Health status and patients’ psychological characteristics are associated with higher levels of HRQOL impairment. The authors found that the impact of melanoma on patients’ HRQOL is comparable to that of other cancers. Accurately assessing HRQOL impairment in melanoma patients is pivotal, as it may affect disease management, including therapy and additional counselling, future preventive behaviour and perhaps even prognosis.

Two cutaneous malignant melanomas at the same anatomic site: a case report with molecular evaluation

Patients who have had malignant melanoma are at an increased risk of developing a second primary melanoma compared with the general population risk of developing a first melanoma. Many of these second primary melanomas occur at a similar anatomic site as the first lesion. Determining whether a second lesion is indeed a separate primary vs. a metastasis or locoregional recurrence can be very difficult histologically. We report the case of a patient who developed a second melanoma, 2 years after the initial diagnosis, within 3 cm of the site of the original lesion. Because of distinct histomorphologic features, the second lesion was favored to be a separate primary. However, because of the nearly identical anatomic location, molecular testing for loss of heterozygosity and BRAF mutation was performed to help further make this distinction. The first lesion was found to have loss of heterozygosity and a BRAF mutation that were not present in the second lesion. While these tests cannot elucidate the true molecular origin of these lesions, they provide a useful clinical tool to assess whether a second lesion should be treated as a recurrence or as a separate lesion with unique biologic potential.

Detection of second primary cutaneous melanomas

AIMS

There have been few studies investigating the value of follow-up in the detection of second primary melanomas (SPMs) and there is scant information on the role of self-surveillance by the patient. The aim of this study was to assess the frequency of patient detection of both first primary melanomas (FPMs) and SPMs.

PATIENTS AND METHODS

Patients were interviewed to determine who detected their FPM and SPM (in situ or invasive). The associations between clinical and pathological factors and the person who identified the FPM and SPM were examined using multivariate analysis.

RESULTS

One hundred and twelve patients with a recently diagnosed SPM were treated at the Sydney Melanoma Unit (July 2001 to March 2003). Patients detected 59% of the FPMs as compared with 46% of the SPMs. Female gender, greater Breslow tumour thickness and younger age were significant predictors for a patient-detected FPM (Odds Ratio: 4.9 (Confidence Interval 1.5-16.0), 3.2 (1.65-6.04), and 0.9 (0.9-1.0), respectively). Greater tumour thickness and ready visibility of the lesion to the patient were predicting factors for patient detection of a SPM (Odds Ratio: 1.9 (Confidence Interval 1.1-3.3) and 3.6 (1.4-9.1), respectively).

CONCLUSIONS

A history of melanoma does not increase the ability of patients to detect new or thinner primary melanomas themselves. Therefore, patients may benefit from regular clinical review by clinicians, who play an important role in the detection of new melanomas.

The importance of self-examination in the earliest diagnosis of multiple primary cutaneous melanomas: a report of 47 cases

BACKGROUND

Development of more than one primary melanoma in a patient is a relatively uncommon but well-recognized phenomenon. Its frequency has ranged from 1.2% to 8.2% in several series. This subgroup of patients with multiple primary lesions has not been characterized sufficiently. We report the experience of the Melanoma Unit of University Hospital Spedali Civili of Brescia, Italy.

METHOD

Study subjects were drawn from 1240 patients with histologically confirmed melanoma, including melanoma in situ. From this group, multiple melanomas developed in 47 patients (3.79%). Every one of our patients has been taught to perform self-examination of the skin to detect suspicious pigmented lesions.

RESULTS

Of the 47 patients described in this study, 38 had two primary melanomas, 7 had three melanomas and 2 had 5 and 10 melanomas, respectively. Mean age at first diagnosis was 46.2 years. The majority of subsequent melanomas (74.5%) were removed within 5 years of the initial operation. Synchronous lesions were found in 10 patients. In male patients, the lesion appeared most frequently on the trunk; in female patients, melanoma appeared mostly on the lower extremities. The second primary melanomas developed in the same anatomic region from the first in 53.2% of our patients. The proportion of in situ to invasive melanomas was greater for the second melanomas compared with the first melanomas. Regarding invasive melanomas, the mean thickness of the first melanomas was 1.31 mm compared with 0.66 mm for the second ones. Dividing patients into two groups, of more and less than 50, it is highlighted that in older patients synchronous lesions appear more frequently (36.4% vs. 8.0%); the median time interval between sequential melanomas is longer (84 vs. 63.7 months); and the ratio between the primary and secondary melanoma mean thickness is lower (1.21 : 1.08 vs. 1.43 : 0.63 mm).

CONCLUSIONS

The study confirms that second primary melanoma is usually thinner than the first lesion, and it is more common in the same region of the body as the initial melanoma. The highest risk for a second melanoma is during the first 5 years, but a much longer time interval of 28 years is possible. Continued medical follow-up with complete skin examinations seems prudent, but it is very important to promote self-skin evaluation in patients to detect not only metastases but also subsequent primary melanomas in their earliest phases.

Patient education and regular surveillance results in earlier diagnosis of second primary melanoma

BACKGROUND

As the incidence of cutaneous melanoma continues to rise, more individuals will be at risk for developing second primary melanomas. We hypothesize that patient education and follow-up surveillance will lead to the early detection of subsequent primary melanomas as demonstrated by a decrease in Breslow thickness at diagnosis.

METHODS

A computer-based investigation was performed to identify patients who had developed a second primary melanoma following treatment of in situ and American Joint Commission on Cancer (AJCC) Stage I or II melanoma. Patients are routinely educated on the increased risk of developing a second primary lesion and characteristic clinical features of melanoma. Patient surveillance was performed on a regular basis. Differences in Breslow thickness between the initial and subsequent primary melanomas were analyzed by a paired t-test.

RESULTS

Among 877 individuals identified in the Mount Sinai School of Medicine Department of Dermatopathology database with in situ or AJCC Stage I or II melanoma, 111 developed a second primary melanoma. The mean thickness was 0.239 +/- 0.661 mm for the initial melanoma and 0.1135 +/- 0.319 mm for the subsequent melanoma. By paired t-test, the difference in tumor thickness was statistically significant (P = 0.019).

CONCLUSIONS

Upon analysis of our data, subsequent primary cutaneous melanomas were found to be significantly thinner than initial primary melanomas at the time of diagnosis. This suggests that earlier diagnosis may be the result of patient education and careful follow up. Counselling on the risk of developing a second primary melanoma, education regarding clinical characteristics of melanoma, and routine lifelong follow up should be provided to all patients diagnosed with a cutaneous melanoma.

Ambient UV, personal sun exposure and risk of multiple primary melanomas

OBJECTIVE

Sun exposure is the main cause of melanoma in populations of European origin. No previous study has examined the effect of sun exposure on risk of multiple primary melanomas compared with people who have one melanoma.

METHODS

We identified and enrolled 2,023 people with a first primary melanoma (controls) and 1,125 with multiple primary melanomas (cases) in seven centers in four countries, recorded their residential history to assign ambient UV and interviewed them about their sun exposure.

RESULTS

Risk of multiple primary melanomas increased significantly (P<0.05) to OR=2.10 for the highest exposure quarter of ambient UV irradiance at birth and 10 years of age, to OR=1.38 for lifetime recreational sun exposure, to OR=1.85 for beach and waterside activities, to OR=1.57 for vacations in a sunnier climate, to OR=1.50 for sunburns. Occupational sun exposure did not increase risk (OR=1.03 for highest exposure). Recreational exposure at any age increased risk and appeared to add to risk from ambient UV in early life.

CONCLUSIONS

People who have had a melanoma can expect to reduce their risk of a further melanoma by reducing recreational sun exposure whatever their age. The same is probably true for a person who has never had a melanoma.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma

BACKGROUND

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention.

OBJECTIVE

Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas.

METHODS

A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients.

RESULTS

Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27).

LIMITATIONS

Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations.

CONCLUSIONS

The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

Follow-up in patients with localised primary cutaneous melanoma

Follow-up services for patients with localised cutaneous melanoma are widely discussed but there is no international consensus. Our aim was to discuss frequency and duration of follow-up, type of health professional involved, optimum intensity of routine investigation, and patients' satisfaction with follow-up. Searches of the published work were directed at publications between January, 1985, and February, 2004 on recurrences, subsequent primary melanoma, routine tests, and patients' satisfaction. In a selection of 72 articles, 2142 (6.6%) recurrences were reported, 62% of which were detected by the patients themselves. 2.6% of patients developed a subsequent primary melanoma. Most investigators do not support high-intensity routine follow-up investigations. Of the various follow-up investigations requested by physicians, only medical history and physical examination seem to be cost effective. Lymph-node sonography seems to be a promising method for detection, although survival benefit remains to be proven. Patients were found to be anxious about follow-up visits, although other research showed that provision of information to patients was much appreciated. Published work on the follow-up of patients with cutaneous melanoma has mainly been retrospective and descriptive. Recommendations can be given with only a low grade of evidence. For meaningful guidelines to be developed, prospective, high-quality methodological research is needed.

Role of the CDKN2A Locus in Patients With Multiple Primary Melanomas

Purpose

We have studied a consecutive case series of patients with multiple primary melanoma (MPM) for the involvement of the melanoma susceptibility loci CDKN2A and CDK4.

Patients and Methods

One hundred four MPM patients (81 patients with two primary melanomas, 14 with three, five with four, one with five, two with six, and one with seven) were included.

Results

Seven different CDKN2A germline mutations were identified in 17 patients (16.3%). In total, we identified 15 CDKN2A exon 2, one exon 1α missense mutation, and one exon 1β frameshift mutation. The age of onset was significantly lower and the number of primary melanomas higher in patients with mutations. CDKN2A mutations were more frequent in patients with familial history of melanoma (35.5%) compared with patients without (8.2%), with a relative risk (RR) of 4.32 (95% CI, 1.76 to 10.64; P = .001), and in patients with more than two melanomas (39.1%) compared with patients with only two melanomas (10%) with an RR of 3.29 (95% CI, 1.7 to 6.3; P = .002). The A148T polymorphism was more frequent in patients with MPMs than in the control population (P = .05). A variant of uncertain significance, A127S, was also detected in one patient. No CDK4 mutations were identified, suggesting that it has a low impact in susceptibility to MPM.

Conclusion

MPM patients are good candidates for CDKN2A mutational screening. These patients and some of their siblings should be included in a program of specific follow-up with total body photography and digital dermoscopy, which will result in the early detection of melanoma in this subset of high-risk patients and improve phenotypic characterization.

Results of a surveillance programme for patients at high risk of malignant melanoma using digital and conventional dermoscopy

Patients with a high number of atypical naevi and a personal and/or family history of melanoma are at high risk of malignant melanoma. The objective of this study was to design a special documentation and surveillance programme using epiluminescence microscopy (ELM) and digital epiluminescence microscopy (DELM) to improve the surveillance of these patients. High-risk patients (n=212) were categorized by the number and phenotype of their naevi and their personal and family history of melanoma. Then patients were screened by the unaided eye, conventional photography, ELM and, in selected cases of atypia, DELM. Median follow-up was 18 months, and 2939 pigmented lesions were followed by DELM. Examination on the first visit identified 17 cutaneous melanomas. During the following observation period, another 17 melanomas were identified. Fifteen of these follow-up melanomas were exclusively identified based upon DELM. In these cases, subtle lesional changes occurred over time, and ELM diagnostic algorithms for differentiating benign melanocytic lesions from melanoma did not score a suspicion of melanoma. All melanomas, either pre-existing or developing during follow-up, were identified in an early, curable phase of tumour growth. We conclude that DELM follow-up for patients at high risk allows the early detection of melanomas that have not yet acquired melanoma-typical ELM features.

Multiple primary melanoma revisited

BACKGROUND

Incidence of cutaneous melanoma continues to increase in the Caucasian population worldwide. Approximately 5% of melanoma patients develop additional primary melanoma. This rate is significantly higher than the estimated lifetime risk of an individual for developing the disease (1.4%). These features suggest that a genetic predisposition may underlie multiple primary melanomas (MPMs). Prior studies had identified CDKN2A mutations in a few MPM individuals. The objectives of this study were to determine the frequency of family history of melanoma in MPM cases, to characterize other clinical features including history of other cancer, and to determine the association with functional CDKN2A mutations.

METHODS

This study used a case series design. All living patients who had been seen in the Pigmented Lesion Clinic at the University of Pennsylvania and who had more than one primary invasive malignant melanoma or an invasive primary followed by an in situ melanoma were eligible for participation.

RESULTS

Individuals with MPM frequently had a family history of melanoma, dysplastic nevi (DN), and/or another cancer including basal cell carcinoma (BCC), and squamous cell carcinoma breast cancer, and a personal history of DN, and basal cell carcinoma. Germline mutations in CDKN2A gene were identified in 8 of 96 MPM cases (8.3%, 95% confidence interval, 6.7-9.9%).

CONCLUSIONS

These data indicate that the presence of MPM is associated with a modest incidence of a family history of melanoma, DN, or BCC and a small association with CDKN2A mutations. Therefore, in addition to the MPM index case, other family members can benefit from screening and regular surveillance for melanoma, DN, and BCC.