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De Giorgi V, Silvestri F, Cecchi G, Venturi F, Zuccaro B, Perillo G, Cosso F, Maio V, Simi S, Antonini P, Pillozzi S, Antonuzzo L, Massi D, Doni L. Dermoscopy as a Tool for Identifying Potentially Metastatic Thin Melanoma: A Clinical-Dermoscopic and Histopathological Case-Control Study. Cancers (Basel) 2024; 16:1394. [PMID: 38611072 PMCID: PMC11010964 DOI: 10.3390/cancers16071394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Despite being early-stage tumors, thin cutaneous melanomas contribute significantly to mortality and have a rising incidence. A retrospective case-control study was performed to identify clinical-dermoscopic and histopathological variables linked to local and distant metastases in melanomas ≤0.8 mm. Data from 1 January 2000 to 22 June 2022 were analyzed from two Italian skin cancer referral centers. Sixteen patients with ≤0.8 mm melanomas developing metastases were studied compared to controls without metastases over 5 years. Statistical analysis involved Pearson's chi-squared test or Fisher's exact test. Of the 1396 cases, 1.1% progressed. The median diagnosis age was 49 (range 28-83), with 56.3% men and 43.7% women. The torso was the primary tumor site (43.7%). Clinically, lesions were pigmented (>10 mm diameter: 73.3%, ≥3 colors: 80%). Dermoscopically, the common features were white patches (73.3%), atypical vascular patterns (66.5%), blue-gray areas (60%) and absent pigment networks (60%). Histopathologically, all cases had adverse features like regression (87.4%), dermal mitoses (50%), a vertical growth phase (62.5%) and ulceration (12.5%). These findings were statistically significant compared to controls (p < 0.05). In ≤0.8 mm melanomas, specific clinical-dermoscopic traits might indicate higher metastatic potential when paired with adverse histopathological features.
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Affiliation(s)
- Vincenzo De Giorgi
- Section of Dermatology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (F.S.); (G.C.); (F.V.); (B.Z.); (G.P.)
- Cancer Research “Attilia Pofferi” Foundation, 51100 Pistoia, Italy
| | - Flavia Silvestri
- Section of Dermatology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (F.S.); (G.C.); (F.V.); (B.Z.); (G.P.)
| | - Giovanni Cecchi
- Section of Dermatology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (F.S.); (G.C.); (F.V.); (B.Z.); (G.P.)
| | - Federico Venturi
- Section of Dermatology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (F.S.); (G.C.); (F.V.); (B.Z.); (G.P.)
| | - Biancamaria Zuccaro
- Section of Dermatology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (F.S.); (G.C.); (F.V.); (B.Z.); (G.P.)
| | - Gabriella Perillo
- Section of Dermatology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (F.S.); (G.C.); (F.V.); (B.Z.); (G.P.)
| | - Federica Cosso
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (F.C.); (S.P.); (L.A.); (L.D.)
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
| | - Vincenza Maio
- Section of Pathology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (V.M.); (S.S.); (P.A.); (D.M.)
| | - Sara Simi
- Section of Pathology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (V.M.); (S.S.); (P.A.); (D.M.)
| | - Pietro Antonini
- Section of Pathology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (V.M.); (S.S.); (P.A.); (D.M.)
- Section of Pathology, Department of Diagnostic and Public Health, University of Verona, 37129 Verona, Italy
| | - Serena Pillozzi
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (F.C.); (S.P.); (L.A.); (L.D.)
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
| | - Lorenzo Antonuzzo
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (F.C.); (S.P.); (L.A.); (L.D.)
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
| | - Daniela Massi
- Section of Pathology, Department of Health Sciences, University of Florence, 50121 Florence, Italy; (V.M.); (S.S.); (P.A.); (D.M.)
| | - Laura Doni
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (F.C.); (S.P.); (L.A.); (L.D.)
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Kakish H, Sun J, Zheng DX, Ahmed FA, Elshami M, Loftus AW, Ocuin LM, Ammori JB, Hoehn RS, Bordeaux JS, Rothermel LD. Predictors of sentinel lymph node metastasis in very thin invasive melanomas. Br J Dermatol 2023; 189:419-426. [PMID: 37290803 DOI: 10.1093/bjd/ljad195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/04/2023] [Accepted: 06/04/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Melanomas < 0.8 mm in Breslow depth have less than a 5% risk for nodal positivity. Nonetheless, nodal positivity is prognostic for this group. Early identification of nodal positivity may improve the outcomes for these patients. OBJECTIVES To determine the degree to which ulceration and other high-risk features predict sentinel lymph node (SLN) positivity for very thin melanomas. METHODS The National Cancer Database was reviewed from 2012 to 2018 for patients with melanoma with Breslow thickness < 0.8 mm. Data were analysed from 7 July 2022 through to 25 February 2023. Patients were excluded if data regarding their ulceration status or SLN biopsy (SLNB) performance were unknown. We analysed patient, tumour and health system factors for their effect on SLN positivity. Data were analysed using χ2 tests and logistic regressions. Overall survival (OS) was compared by Kaplan-Meier analyses. RESULTS Positive nodal metastases were seen in 876 (5.0%) patients who underwent SLNB (17 692). Factors significantly associated with nodal positivity on multivariable analysis include lymphovascular invasion [odds ratio (OR) 4.5, P < 0.001], ulceration (OR 2.6, P < 0.001), mitoses (OR 2.1, P < 0.001) and nodular subtype (OR 2.1, P < 0.001). Five-year OS was 75% and 92% for patients with positive and negative SLN, respectively. CONCLUSIONS Nodal positivity has prognostic significance for very thin melanomas. In our cohort, the rate of nodal positivity was 5% overall in these patients who underwent SLNB. Specific tumour factors (e.g. lymphovascular invasion, ulceration, mitoses, nodular subtype) were associated with higher rates of SLN metastases and should be used to guide clinicians in choosing which patients will benefit from SLNB.
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Affiliation(s)
- Hanna Kakish
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - James Sun
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - David X Zheng
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Fasih Ali Ahmed
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - Alexander W Loftus
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
| | - Jeremy S Bordeaux
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, USA
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Young JN, Griffith‐Bauer K, Hill E, Latour E, Samatham R, Leachman S. The benefit of early-stage diagnosis: A registry-based survey evaluating the quality of life in patients with melanoma. SKIN HEALTH AND DISEASE 2023; 3:e237. [PMID: 37538330 PMCID: PMC10395626 DOI: 10.1002/ski2.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 08/05/2023]
Abstract
Background The morbidity associated with advanced stage melanoma is an important consideration in the dialog surrounding early detection and overdiagnosis. Few studies have stratified melanoma patient quality of life (QoL) by stage at diagnosis. Objective We sought to investigate if melanoma stage is independently associated with changes in QoL within a large, community-based melanoma registry. Secondarily, we investigated whether demographic factors such as age, geographic location or level of education are associated with changes in QoL in the same population. Methods 1108 melanoma patients were surveyed over a three-month period using the QoL in Adult Cancer Survivors Survey, consisting of 47 items on a 7-point frequency scale. Data were analysed using both descriptive statistical models and adjusted multivariate logistic regression. Results There were 677 respondents generating a 61% response rate. Overall, higher stage at diagnosis correlated with the largest decreases in QoL as it pertained to both general (p = 0.001) and Cancer-Specific stressors (p < 0.001). Education level (p = 0.020), age (p < 0.001), rural area code designation (p = 0.020) and family history of melanoma (p = 0.017) were also independently associated with changes in QoL. Conclusion Earlier stage at melanoma diagnosis is associated with better QoL and thus represents a crucial intervention in patient care. Given our findings and the growing body of evidence surrounding morbidity in late-stage melanoma, it is essential that QoL be included in assessing the benefits of early detection.
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Affiliation(s)
- Jade N. Young
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
| | - Kelly Griffith‐Bauer
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
- The PolyclinicSeattleWashingtonUSA
| | - Emma Hill
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
| | - Emile Latour
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
- Biostatistics Shared ResourceKnight Cancer InstituteOregon Health and Science UniversityPortlandOregonUSA
| | - Ravikant Samatham
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
| | - Sancy Leachman
- Department of DermatologyOregon Health and Science UniversityPortlandOregonUSA
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Sentinel lymph node biopsy in patients with T1a cutaneous malignant melanoma: A multicenter cohort study. J Am Acad Dermatol 2023; 88:52-59. [PMID: 36184008 DOI: 10.1016/j.jaad.2022.09.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/15/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy is not routinely recommended for T1a cutaneous melanoma due to the overall low risk of positivity. Prognostic factors for positive sentinel lymph node (SLN+) in this population are poorly characterized. OBJECTIVE To determine factors associated with SLN+ in patients with T1a melanoma. METHODS Patients with pathologic T1a (<0.80 mm, nonulcerated) cutaneous melanoma from 5 high-volume melanoma centers from 2001 to 2020 who underwent wide local excision with sentinel lymph node biopsy were included in the study. Patient and tumor characteristics associated with SLN+ were analyzed by univariate and multivariable logistic regression analyses. Age was dichotomized into ≤42 (25% quartile cutoff) and >42 years. RESULTS Of the 965 patients identified, the overall SLN+ was 4.4% (N = 43). Factors associated with SLN+ were age ≤42 years (7.5% vs 3.7%; odds ratio [OR], 2.14; P = .03), head/neck primary tumor location (9.2% vs 4%; OR, 2.75; P = .04), lymphovascular invasion (21.4% vs 4.2%; OR, 5.64; P = .01), and ≥2 mitoses/mm2 (8.2% vs 3.4%; OR, 2.31; P = .03). Patients <42 years with ≥2 mitoses/mm2 (N = 38) had a SLN+ rate of 18.4%. LIMITATIONS Retrospective study. CONCLUSION SLN+ is low in patients with T1a melanomas, but younger age, lymphovascular invasion, mitogenicity, and head/neck primary site appear to confer a higher risk of SLN+.
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The importance of mitosis ≥2 in selecting patients with T1 cutaneous melanomas for sentinel lymph node biopsy. Melanoma Res 2022; 32:469-476. [DOI: 10.1097/cmr.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Huang H, Fu Z, Ji J, Huang J, Long X. Predictive Values of Pathological and Clinical Risk Factors for Positivity of Sentinel Lymph Node Biopsy in Thin Melanoma: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:817510. [PMID: 35155254 PMCID: PMC8829564 DOI: 10.3389/fonc.2022.817510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background The indications for sentinel lymph node biopsy (SLNB) for thin melanoma are still unclear. This meta-analysis aims to determine the positive rate of SLNB in thin melanoma and to summarize the predictive value of different high-risk features for positive results of SLNB. Methods Four databases were searched for literature on SLNB performed in patients with thin melanoma published between January 2000 and December 2020. The overall positive rate and positive rate of each high-risk feature were calculated and obtained with 95% confidence intervals (CIs). Both unadjusted odds ratios (ORs) and adjusted ORs (AORs) of high-risk features were analyzed. Pooled effects were estimated using random-effects model meta-analyses. Results Sixty-six studies reporting 38,844 patients with thin melanoma who underwent SLNB met the inclusion criteria. The pooled positive rate of SLNB was 5.1% [95% confidence interval (CI) 4.9%-5.3%]. Features significantly predicted a positive result of SLNB were thickness≥0.8 mm [AOR 1.94 (95%CI 1.28-2.95); positive rate 7.0% (95%CI 6.0-8.0%)]; ulceration [AOR 3.09 (95%CI 1.75-5.44); positive rate 4.2% (95%CI 1.8-7.2%)]; mitosis rate >0/mm2 [AOR 1.63 (95%CI 1.13-2.36); positive rate 7.7% (95%CI 6.3-9.1%)]; microsatellites [OR 3.8 (95%CI 1.38-10.47); positive rate 16.6% (95%CI 2.4-36.6%)]; and vertical growth phase [OR 2.76 (95%CI 1.72-4.43); positive rate 8.1% (95%CI 6.3-10.1%)]. Conclusions The overall positive rate of SLNB in thin melanoma was 5.1%. The strongest predictor for SLN positivity identified was microsatellites on unadjusted analysis and ulceration on adjusted analysis. Breslow thickness ≥0.8 mm and mitosis rate >0/mm2 both predict SLN positivity in adjusted analysis and increase the positive rate to 7.0% and 7.7%. We suggest patients with thin melanoma with the above high-risk features should be considered for giving an SLNB.
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Affiliation(s)
- Hanzi Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ziyao Fu
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Ji
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiuzuo Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Muzumdar S, Lin G, Kerr P, Grant-Kels JM. Evidence concerning the accusation that melanoma is overdiagnosed. J Am Acad Dermatol 2021; 85:841-846. [PMID: 34116095 DOI: 10.1016/j.jaad.2021.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Melanoma is one of the most commonly diagnosed malignancies in the United States and is responsible for the majority of deaths from skin cancer. OBJECTIVE Since the 1970s, the incidence of melanoma has risen appreciably while melanoma-specific mortality has remained stable. This has raised a debate about potential overdiagnosis of melanoma. Herein, we review temporal trends in melanoma incidence and mortality and explore factors that may contribute to observed trends, including an aging population in the United States, ultraviolet exposure, increased numbers of biopsies by dermatologists and physician extenders, skin cancer screenings, histopathology criteria, and historic underdiagnosis. Additionally, we discuss melanoma overdiagnosis and the extent to which it may contribute to current trends. METHODS The literature was reviewed. RESULTS Several factors may contribute to an increased incidence of melanoma, including an aging population, ultraviolet exposure, increased skin biopsies, skin cancer screenings, histopathologic criteria, historic underdiagnosis, and current overdiagnosis. LIMITATIONS Further studies are required to determine exactly which tumors are being overdiagnosed, and how to improve patient outcomes with adjustment to physician's practice. CONCLUSION The rise in the incidence of melanoma observed since the 1970s is likely multifactorial.
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Affiliation(s)
- Sonal Muzumdar
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Gloria Lin
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Philip Kerr
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut; University of Florida Dermatology Department, Gainesville, Florida.
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Prognostic significance of acral lentiginous histologic type in T1 melanoma. Mod Pathol 2021; 34:572-583. [PMID: 32759976 DOI: 10.1038/s41379-020-0641-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023]
Abstract
Acral lentiginous melanoma (ALM) is a rare type of cutaneous melanoma with a poor prognosis. It is unclear whether the poor outcome of ALM is due to its inherent disease characteristics or advanced stage at initial diagnosis. To address this question, we retrospectively analyzed the clinicopathologic factors of 828 thin (T1; Breslow thickness ≤1.0 mm) melanomas [129 (15.6%) ALMs and 699 (84.4%) non-ALMs] and their nodal and distance metastases and local recurrence rates and determined their relationship with the disease-specific (DSS), overall (OS), and recurrence-free survivals (RFS) at the pathologic stages T1, T1a, and T1b with a median follow-up time of 84.5 months. With the exception of OS at T1b stage, ALM patients showed significantly lower 5- and 10-year DSS, OS, and RFS rates at every pathologic stage when compared with non-ALM. In multivariable analysis, ALM histologic type, SLN positivity, age, and the use of systemic therapy were detected as independent poor prognostic factors associated with significantly lower survival rates. ALM histologic type was associated with lower DSS and OS rates at T1 and T1a stages and lower RFS rates at T1b stage. SLN positivity was associated with lower DSS, OS, and RFS rates at T1, T1a, and T1b stages. Age was associated with lower OS rates at T1 and T1b stages. Whereas the use of systemic therapy was associated with lower DSS rates at T1a stage and RFS rates at T1b stage. In addition, the ALM group showed significantly older median age patients and higher rates of female sex, Hispanic ethnicity, nevoid cytology, non-brisk tumor-infiltrating lymphocytes, nodal metastasis, and local recurrence at every pathologic stage of thin melanoma. Our findings suggest that ALM is inherently more aggressive than other types of cutaneous melanoma. This information may be useful for prognostic stratification of patients with thin melanomas, especially to help guide the clinical decision-making for SLN biopsy and patients entering clinical trials.
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Eggermont AMM, Bellomo D, Arias-Mejias SM, Quattrocchi E, Sominidi-Damodaran S, Bridges AG, Lehman JS, Hieken TJ, Jakub JW, Murphree DH, Pittelkow MR, Sluzevich JC, Cappel MA, Bagaria SP, Perniciaro C, Tjien-Fooh FJ, Rentroia-Pacheco B, Wever R, van Vliet MH, Dwarkasing J, Meves A. Identification of stage I/IIA melanoma patients at high risk for disease relapse using a clinicopathologic and gene expression model. Eur J Cancer 2020; 140:11-18. [PMID: 33032086 PMCID: PMC7655519 DOI: 10.1016/j.ejca.2020.08.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/09/2020] [Accepted: 08/16/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Patients with stage I/IIA cutaneous melanoma (CM) are currently not eligible for adjuvant therapies despite uncertainty in relapse risk. Here, we studied the ability of a recently developed model which combines clinicopathologic and gene expression variables (CP-GEP) to identify stage I/IIA melanoma patients who have a high risk for disease relapse. PATIENTS AND METHODS Archival specimens from a cohort of 837 consecutive primary CMs were used for assessing the prognostic performance of CP-GEP. The CP-GEP model combines Breslow thickness and patient age, with the expression of eight genes in the primary tumour. Our specific patient group, represented by 580 stage I/IIA patients, was stratified based on their risk of relapse: CP-GEP High Risk and CP-GEP Low Risk. The main clinical end-point of this study was five-year relapse-free survival (RFS). RESULTS Within the stage I/IIA melanoma group, CP-GEP identified a high-risk patient group (47% of total stage I/IIA patients) which had a considerably worse five-year RFS than the low-risk patient group; 74% (95% confidence interval [CI]: 67%-80%) versus 89% (95% CI: 84%-93%); hazard ratio [HR] = 2.98 (95% CI: 1.78-4.98); P < 0.0001. Of patients in the high-risk group, those who relapsed were most likely to do so within the first 3 years. CONCLUSION The CP-GEP model can be used to identify stage I/IIA patients who have a high risk for disease relapse. These patients may benefit from adjuvant therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Mark A Cappel
- Mayo Clinic, Jacksonville, FL, USA; Gulf Coast Dermatopathology Laboratory, Tampa, FL, USA
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Kutzner H, Jutzi TB, Krahl D, Krieghoff‐Henning EI, Heppt MV, Hekler A, Schmitt M, Maron RCR, Fröhling S, Kalle C, Brinker TJ. Überdiagnose von Melanomen – Ursachen, Konsequenzen und Lösungsansätze. J Dtsch Dermatol Ges 2020; 18:1236-1244. [DOI: 10.1111/ddg.14233_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/13/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Tanja B. Jutzi
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Dieter Krahl
- Privates Labor für Dermatohistopathologie Mönchhofstraße 52 Heidelberg
| | - Eva I. Krieghoff‐Henning
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | | | - Achim Hekler
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Max Schmitt
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Roman C. R. Maron
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Stefan Fröhling
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
| | - Christof Kalle
- Berlin Institute of Health (BIH) und Charité – Universitätsmedizin Berlin
| | - Titus J. Brinker
- Nachwuchsgruppe Digitale Biomarker für die Onkologie (DBO), Nationales Centrum für Tumorerkrankungen (NCT) Deutsches Krebsforschungszentrum (DKFZ) Heidelberg
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Aiken TJ, Stahl CC, Schwartz PB, Barrett J, Acher AW, Lemaster D, Leverson G, Weber S, Neuman H, Abbott DE. Sentinel lymph node biopsy is associated with increased cost in higher risk thin melanoma. J Surg Oncol 2020; 123:104-109. [PMID: 32939750 DOI: 10.1002/jso.26225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION National Comprehensive Cancer Network guidelines recommend that sentinel lymph node biopsy (SLNB) be discussed with patients with thin melanoma at higher risk for lymph node metastasis (T1b or T1a with positive deep margins, lymphovascular invasion, or high mitotic index). We examined the association between SLNB and resource utilization in this cohort. METHODS We conducted a retrospective cohort study of patients that underwent wide local excision for higher risk thin melanomas from 2009 to 2018 at a tertiary care center. Patients who underwent SLNB were compared to those who did not undergo SLNB with regard to resource utilization, including total hospital cost. RESULTS A total of 70 patients were included in the analysis and 50 patients (71.4%) underwent SLNB. SLNB was associated with increased hospital costs ($6700 vs. $3767; p < .01) and increased operative time (68.5 vs. 36.0 min; p < .01). This cost difference persisted in multivariable regression (p < .01). Of patients who underwent successful SLN mapping, 3 out of 49 patients had a positive SLN (6.1%). The cost to identify a single positive sentinel lymph node (SLN) was $47,906. CONCLUSION In patients with a higher risk of thin melanoma, SLNB is associated with increased cost despite a low likelihood of SLN positivity. These data better inform patient-provider discussions as the role of SLNB in thin melanoma evolves.
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Affiliation(s)
- Taylor J Aiken
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Christopher C Stahl
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Patrick B Schwartz
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - James Barrett
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Alexandra W Acher
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Deborah Lemaster
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Heather Neuman
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
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12
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Kutzner H, Jutzi TB, Krahl D, Krieghoff-Henning EI, Heppt MV, Hekler A, Schmitt M, Maron RCR, Fröhling S, von Kalle C, Brinker TJ. Overdiagnosis of melanoma - causes, consequences and solutions. J Dtsch Dermatol Ges 2020; 18:1236-1243. [PMID: 32841508 DOI: 10.1111/ddg.14233] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/13/2020] [Indexed: 12/14/2022]
Abstract
Malignant melanoma is the skin tumor that causes most deaths in Germany. At an early stage, melanoma is well treatable, so early detection is essential. However, the skin cancer screening program in Germany has been criticized because although melanomas have been diagnosed more frequently since introduction of the program, the mortality from malignant melanoma has not decreased. This indicates that the observed increase in melanoma diagnoses be due to overdiagnosis, i.e. to the detection of lesions that would never have created serious health problems for the patients. One of the reasons is the challenging distinction between some benign and malignant lesions. In addition, there may be lesions that are biologically equivocal, and other lesions that are classified as malignant according to current criteria, but that grow so slowly that they would never have posed a threat to patient's life. So far, these "indolent" melanomas cannot be identified reliably due to a lack of biomarkers. Moreover, the likelihood that an in-situ melanoma will progress to an invasive tumor still cannot be determined with any certainty. When benign lesions are diagnosed as melanoma, the consequences are unnecessary psychological and physical stress for the affected patients and incurred therapy costs. Vice versa, underdiagnoses in the sense of overlooked melanomas can adversely affect patients' prognoses and may necessitate more intense therapies. Novel diagnostic options could reduce the number of over- and underdiagnoses and contribute to more objective diagnoses in borderline cases. One strategy that has yielded promising results in pilot studies is the use of artificial intelligence-based diagnostic tools. However, these applications still await translation into clinical and pathological routine.
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Affiliation(s)
| | - Tanja B Jutzi
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Dieter Krahl
- Private Laboratory for Dermatohistopathology, Mönchhofstraße 52, Heidelberg, Germany
| | - Eva I Krieghoff-Henning
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Markus V Heppt
- Department of Dermatology, University Hospital Erlangen, Erlangen, Germany
| | - Achim Hekler
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Max Schmitt
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Roman C R Maron
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Fröhling
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christof von Kalle
- Berlin Institute of Health (BIH) and Charité-University Medical Center Berlin, Berlin, Germany
| | - Titus J Brinker
- Digital Biomarkers for Oncology group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Heidelberg, Germany
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13
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Kocsis A, Karsko L, Kurgyis Z, Besenyi Z, Pavics L, Dosa-Racz E, Kis E, Baltas E, Ocsai H, Varga E, Bende B, Varga A, Mohos G, Korom I, Varga J, Kemeny L, Nemeth IB, Olah J. Is it Necessary to Perform Sentinel Lymph Node Biopsy in Thin Melanoma? A Retrospective Single Center Analysis. Pathol Oncol Res 2020; 26:1861-1868. [PMID: 31792874 PMCID: PMC7297827 DOI: 10.1007/s12253-019-00769-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/21/2019] [Indexed: 01/09/2023]
Abstract
Sentinel lymph node biopsy (SLNB) is a standard procedure for regional lymph node staging and still has the most important prognostic value for the outcome of patients with thin melanoma. In addition to ulceration, SLNB had to be considered even for a single mitotic figure in thin (<1 mm) melanoma according to AJCC7th guideline, therefore, a retrospective review was conducted involving 403 pT1 melanoma patients. Among them, 152 patients suffered from pT1b ulcerated or mitotic rate ≥ 1/ mm2 melanomas according to the AJCC7th staging system. SLNB was performed in 78 cases, of which nine (11.5%) showed SLN positivity. From them, interestingly, we found a relatively high positive sentinel rate (6/78-8%) in the case of thin primary melanomas ˂0.8 mm. Moreover, the presence of regression increased the probability of sentinel positivity by 5.796 fold. After reassessing pT stage based on the new AJCC8th, 37 pT1b cases were reordered into pT1a category. There was no significant relation between other characteristics examined (age, gender, Breslow, Clark level, and mitosis index) and sentinel node positivity. Based on our data, we suggest that mitotic rate alone is not a sufficiently powerful predictor of SLN status in thin melanomas. If strict histopathological definition criteria are applied, regression might be an additional adverse feature that aids in identifying T1 patients most likely to be SLN-positive. After reassessing of pT1b cases according to AJCC8th regression proved to be independent prognostic factor on sentinel lymph node positivity. Our results propose that sentinel lymph node biopsy might also be considered at patients with regressive thin (˂0.8 mm) melanomas.
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Affiliation(s)
- A Kocsis
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - L Karsko
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - Zs Kurgyis
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - Zs Besenyi
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - L Pavics
- Department of Nuclear Medicine, University of Szeged, Szeged, Hungary
| | - E Dosa-Racz
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - E Kis
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - E Baltas
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - H Ocsai
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - E Varga
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - B Bende
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - A Varga
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - G Mohos
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - I Korom
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - J Varga
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - L Kemeny
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - I B Nemeth
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary.
| | - J Olah
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
- Department of Oncology, Faculty of General Medicine, University of Szeged, Szeged, Hungary
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14
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Bellomo D, Arias-Mejias SM, Ramana C, Heim JB, Quattrocchi E, Sominidi-Damodaran S, Bridges AG, Lehman JS, Hieken TJ, Jakub JW, Pittelkow MR, DiCaudo DJ, Pockaj BA, Sluzevich JC, Cappel MA, Bagaria SP, Perniciaro C, Tjien-Fooh FJ, van Vliet MH, Dwarkasing J, Meves A. Model Combining Tumor Molecular and Clinicopathologic Risk Factors Predicts Sentinel Lymph Node Metastasis in Primary Cutaneous Melanoma. JCO Precis Oncol 2020; 4:319-334. [PMID: 32405608 PMCID: PMC7220172 DOI: 10.1200/po.19.00206] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/01/2023] Open
Abstract
PURPOSE More than 80% of patients who undergo sentinel lymph node (SLN) biopsy have no nodal metastasis. Here we describe a model that combines clinicopathologic and molecular variables to identify patients with thin and intermediate thickness melanomas who may forgo the SLN biopsy procedure due to their low risk of nodal metastasis. PATIENTS AND METHODS Genes with functional roles in melanoma metastasis were discovered by analysis of next generation sequencing data and case control studies. We then used PCR to quantify gene expression in diagnostic biopsy tissue across a prospectively designed archival cohort of 754 consecutive thin and intermediate thickness primary cutaneous melanomas. Outcome of interest was SLN biopsy metastasis within 90 days of melanoma diagnosis. A penalized maximum likelihood estimation algorithm was used to train logistic regression models in a repeated cross validation scheme to predict the presence of SLN metastasis from molecular, clinical and histologic variables. RESULTS Expression of genes with roles in epithelial-to-mesenchymal transition (glia derived nexin, growth differentiation factor 15, integrin β3, interleukin 8, lysyl oxidase homolog 4, TGFβ receptor type 1 and tissue-type plasminogen activator) and melanosome function (melanoma antigen recognized by T cells 1) were associated with SLN metastasis. The predictive ability of a model that only considered clinicopathologic or gene expression variables was outperformed by a model which included molecular variables in combination with the clinicopathologic predictors Breslow thickness and patient age; AUC, 0.82; 95% CI, 0.78-0.86; SLN biopsy reduction rate of 42% at a negative predictive value of 96%. CONCLUSION A combined model including clinicopathologic and gene expression variables improved the identification of melanoma patients who may forgo the SLN biopsy procedure due to their low risk of nodal metastasis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mark A. Cappel
- Mayo Clinic, Jacksonville, FL
- Gulf Coast Dermatopathology Laboratory, Tampa, FL
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15
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Isom C, Wheless L, Hooks MA, Kauffmann RM. Early Melanoma Nodal Positivity and Biopsy Rates Before and After Implementation of the 7th Edition of the AJCC Cancer Staging Manual. JAMA Dermatol 2020; 155:572-577. [PMID: 30840034 DOI: 10.1001/jamadermatol.2018.5902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance There has been a continued increase in the incidence of newly diagnosed melanomas, most of which are T1 melanomas. The associations between changes in tumor staging, implemented with the 7th edition of the AJCC Cancer Staging Manual (AJCC 7), and sentinel lymph node biopsy rates and nodal positivity rates remain to be seen. Objective To evaluate the change that the implementation of the AJCC 7 had on staging criteria and the distribution of thin melanomas requiring nodal surgery and nodal positivity rates. Design, Setting, and Participants Retrospective cross-sectional study from 2004 through 2013 of all adults (≥18 years) diagnosed with a T1 (Breslow depth ≤1.0 mm) melanoma using The National Cancer Database that captures 70% of all newly diagnosed cancers from accredited Commission on Cancer organizations, including both academic and community settings. Data were analyzed in May 2017. Exposures Patients were grouped together based on year of diagnosis, before and after 2009. Main Outcomes and Measures To determine the sentinel lymph node biopsy rate before and after the implementation of the AJCC 7. Results A total of 141 280 patients met inclusion criteria. Of 86 846 patients diagnosed from 2004 through 2009, 53.7% (49 644) were male and had a mean (SD) age of 57.7 (16.4) years. Of 54 434 patients diagnosed from 2010 through 2013, 54.3% (31 086) were male and had a mean (SD) age of 59.5 (15.9) years. After 2010, there was a 3.8% decrease in the number of nodal surgeries performed (32 485 of 86 846 patients [37.6%] vs 18 379 of 54 434 patients [33.8%]; P < .001). The nodal positivity rate decreased 1.0% from (9.8% [3166 of 86 846] to 8.8% [1618 of 54 434]) (P < .001). An increase in the proportion of T1b melanomas being evaluated, from 48.8% to 62.2%, was seen (P < .001). Of T1b melanomas that underwent nodal evaluation from 2004 through 2009, 74.0% had Clark level IV (invasion of the reticular dermis) or Clark level V (invasion of the deep, subcutaneous tissue) and 9.5% were ulcerated. From 2010 through 2013, of the T1b melanomas undergoing nodal evaluation, 82.6% had an elevated mitotic rate only, 3.7% were ulcerated, and 13.7% had both ulceration and an elevated mitotic rate. Conclusions and Relevance It appears that after the institution of AJCC 7, there was an overall decrease in the number of T1 melanomas undergoing nodal biopsy without a clinically relevant change in sentinel lymph node positivity, with an increase in the number of T1b melanomas undergoing nodal evaluation.
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Affiliation(s)
- Chelsea Isom
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lee Wheless
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary A Hooks
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rondi M Kauffmann
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Abstract
In this article we provide a critical review of the evidence available for surgical management of the nodal basin in melanoma, with an aim to ensure an understanding of risks and benefits for all lymph node surgery offered to patients, and alternatives to surgical management where appropriate.
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Affiliation(s)
- Rogeh Habashi
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada
| | - Valerie Francescutti
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada.
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17
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Should Sentinel Lymph Node Biopsy Be Performed for All T1b Melanomas in the New 8th Edition American Joint Committee on Cancer Staging System? J Am Coll Surg 2019; 228:466-472. [DOI: 10.1016/j.jamcollsurg.2018.12.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/17/2018] [Indexed: 11/21/2022]
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18
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dos Santos FDM, da Silva FC, Pedron J, Furian RD, Fortes C, Bonamigo RR. Association between tumor-infiltrating lymphocytes and sentinel lymph node positivity in thin melanoma. An Bras Dermatol 2019; 94:47-51. [PMID: 30726463 PMCID: PMC6360962 DOI: 10.1590/abd1806-4841.20197414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/13/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sentinel lymph node biopsy in thin invasive primary cutaneous melanoma (up to 1mm thick) is a controversial subject. The presence of tumor-infiltrating lymphocytes could be a factor to be considered in the decision to perform this procedure. OBJECTIVE To evaluate the association between the presence of tumor-infiltrating lymphocytes and lymph node metastases caused by thin primary cutaneous melanoma. METHODS Cross-sectional study with 137 records of thin invasive primary cutaneous melanoma submitted to sentinel lymph node biopsy from 2003 to 2015. The clinical variables considered were age, sex and topography of the lesion. The histopathological variables assessed were: tumor-infiltrating lymphocytes, melanoma subtype, Breslow thickness, Clark levels, number of mitoses per mm2, ulceration, regression and satellitosis. Univariate analyzes and logistic regression tests were performed as well the odds ratio and statistical relevance was considered when p <0.05. RESULTS Among the 137 cases of thin primary cutaneous melanoma submitted to sentinel lymph node biopsy, 10 (7.3%) had metastatic involvement. Ulceration on histopathology was positively associated with the presence of metastatic lymph node, with odds ratio =12.8 (2.77-59.4 95% CI, p=0.001). The presence of moderate/marked tumor-infiltrating lymphocytes was shown to be a protective factor for the presence of metastatic lymph node, with OR=0.20 (0.05-0.72 95% CI, p=0.014). The other variables - clinical and histopathological - were not associated with the outcome. STUDY LIMITATIONS The relatively small number of positive sentinel lymph node biopsy may explain such an expressive association of ulceration with metastatization. CONCLUSIONS In patients with thin invasive primary cutaneous melanoma, few or absent tumor-infiltrating lymphocytes, as well as ulceration, represent independent risk factors for lymph node metastasis.
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Affiliation(s)
| | - Felipe Correa da Silva
- Discipline of Pathology, Faculdade de Medicina da Universidade
Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS),
Brazil
| | - Julia Pedron
- Discipline of Pathology, Faculdade de Medicina da Universidade
Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS),
Brazil
| | | | - Cristina Fortes
- Department of Epidemiology, Istituto Dermopatico dell’Immacolata,
Rome, Italy
| | - Renan Rangel Bonamigo
- Service of Dermatology, Hospital de Clínicas de Porto
Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil
- Pathology Post-Graduate Program, Universidade Federal de
Ciências da Saúde de Porto Alegre, Porto Alegre (RS), Brazil
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19
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Chiaravalloti AJ, Jinna S, Kerr PE, Whalen J, Grant-Kels JM. A deep look into thin melanomas: What's new for the clinician and the impact on the patient. Int J Womens Dermatol 2018; 4:119-121. [PMID: 30175212 PMCID: PMC6116825 DOI: 10.1016/j.ijwd.2018.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 01/31/2018] [Indexed: 11/29/2022] Open
Abstract
Melanoma incidence and mortality are on the rise and although most new cases of melanoma are thin, a significant percentage of these patients still experience disease progression. The American Joint Committee on Cancer publishes staging criteria for melanoma, which were recently updated to the 8th edition. The most significant revision from the 7th edition affects the T1b classification, which now includes melanomas with a Breslow depth of 0.8 mm to 1.0 mm. The second major revision eliminates mitoses as a criterion to upstage a thin melanoma to T1b. Although mitotic figures have been established as an independent prognostic factor, they do not have a significant correlation with sentinel lymph node (SLN) biopsy positivity. SLN status remains the most important independent prognostic factor in thin melanomas. Nonetheless, the identification of patients who are at the highest risk for having a positive SLN test result remains difficult. Importantly, a positive SLN test result has high positive predictive value, but a negative one has very low negative predictive value. Since there is no proven survival benefit in performing an SLN biopsy in T1 disease, dermatologists need to have a personalized discussion with patients with thin melanomas to review expected risks and benefits before undertaking this procedure.
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Affiliation(s)
- A J Chiaravalloti
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - S Jinna
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - P E Kerr
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - J Whalen
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - J M Grant-Kels
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
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20
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Nurdjaja V, Yozu M, Mathy JA. Essential Components of Melanoma Histopathological Reporting: The Surgical Oncologist's Perspective. J Skin Cancer 2018; 2018:9838410. [PMID: 29854464 PMCID: PMC5954935 DOI: 10.1155/2018/9838410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/10/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022] Open
Abstract
Histopathological reporting plays a critical role in guiding the surgical oncologist's management plan in treatment of primary cutaneous melanoma. The International Collaboration on Cancer Reporting (ICCR) espouses various components of structured histopathological reporting as "essential" or "recommended." From a surgical oncologist's perspective, we discuss the clinical relevance of each essential component, as well as prognostic and treatment implications with regard to treatment planning.
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Affiliation(s)
- Vinka Nurdjaja
- University of Auckland School of Medicine, Auckland, New Zealand
| | - Masato Yozu
- Histopathology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Jon A. Mathy
- University of Auckland School of Medicine, Auckland, New Zealand
- Plastic Surgery Unit, Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
- New Zealand Melanoma Institute, Auckland, New Zealand
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21
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Impact of National Comprehensive Cancer Network Guidelines on Case Selection and Outcomes for Sentinel Lymph Node Biopsy in Thin Melanoma. Dermatol Surg 2018; 44:493-501. [DOI: 10.1097/dss.0000000000001369] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Chang JM, Kosiorek HE, Dueck AC, Leong SPL, Vetto JT, White RL, Avisar E, Sondak VK, Messina JL, Zager JS, Garberoglio C, Kashani-Sabet M, Pockaj BA. Stratifying SLN incidence in intermediate thickness melanoma patients. Am J Surg 2017; 215:699-706. [PMID: 29502857 DOI: 10.1016/j.amjsurg.2017.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/08/2017] [Accepted: 12/11/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Guidelines for melanoma recommend sentinel lymph node biopsy (SLNB) in patients with melanomas ≥1 mm thickness. Recent single institution studies have found tumors <1.5 mm a low-risk group for positive SLNB. METHODS A retrospective review of the Sentinel Lymph Node Working Group multicenter database identified patients with intermediate thickness melanoma (1.01-4.00 mm) who had SLNB, and assessed predictors for positive SLNB. RESULTS 3460 patients were analyzed, 584 (17%) had a positive SLNB. Univariate factors associated with a positive SLNB included age <60 (p < .001), tumor on the trunk/lower extremity (p < .001), Breslow depth ≥2 mm (p < .001), ulceration (p < .001), mitotic rate ≥1/mm2 (p = .01), and microsatellitosis (p < .001). Multivariate analysis revealed age, location, and Breslow depth as significant predictors. Patients ≥75 with lesions 1.01-1.49 mm on the head/neck/upper extremity and 1.5-1.99 mm without high-risk features had <5% risk of SLN positivity. CONCLUSIONS Intermediate thickness melanoma has significant heterogeneity of SLNB positivity. Low-risk subgroups can be found among older patients in the absence of high-risk features.
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Affiliation(s)
- James M Chang
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | | | - Amylou C Dueck
- Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Stanley P L Leong
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - John T Vetto
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Richard L White
- Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Eli Avisar
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vernon K Sondak
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Jane L Messina
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Carlos Garberoglio
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
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23
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Puza CJ, Warren WS, Mosca PJ. The changing landscape of dermatology practice: melanoma and pump-probe laser microscopy. Lasers Med Sci 2017; 32:1935-1939. [PMID: 28890988 DOI: 10.1007/s10103-017-2319-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/28/2017] [Indexed: 12/28/2022]
Abstract
To present current melanoma diagnosis, staging, prognosis, and treatment algorithms and how recent advances in laser pump-probe microscopy will fill in the gaps in our clinical understanding. Expert opinion and significantly cited articles identified in SCOPUS were used in conjunction with a pubmed database search on Melanoma practice guidelines from the last 10 years. Significant advances in melanoma treatment have been made over the last decade. However, proper treatment algorithm and prognostic information per melanoma stage remain controversial. The next step for providers will involve the identification of patient population(s) that can benefit from recent advances. One method of identifying potential patients is through new laser imaging techniques. Pump-probe laser microscopy has been shown to correctly identify nevi from melanoma and furthermore stratify melanoma by aggressiveness. The recent development of effective adjuvant therapies for melanoma is promising and should be utilized on appropriate patient populations that can potentially be identified using pump-probe laser microscopy.
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Affiliation(s)
| | | | - Paul J Mosca
- Duke University, Department of Surgery, Durham, NC, USA
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24
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Verstijnen J, Damude S, Hoekstra HJ, Kruijff S, Ten Tije AJ, Louwman WJ, Bastiaannet E, Stuiver MM. Practice variation in Sentinel Lymph Node Biopsy for melanoma patients in different geographical regions in the Netherlands. Surg Oncol 2017; 26:431-437. [PMID: 29113662 DOI: 10.1016/j.suronc.2017.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the lack of solid evidence for treatment benefit of Sentinel Lymph Node Biopsy (SLNB) as part of loco-regional surgical treatment of non-distant metastatic melanoma, there might be variation in surgical treatment strategies in the Netherlands. The objective of the current study was to assess differences in the performance of SLNB, in geographical regions in the Netherlands, of non-distant metastatic melanoma patients (American Joint Committee on Cancer (AJCC) stage I-III). MATERIALS AND METHODS A total of 28 550 melanoma patients, diagnosed between 2005 and 2013, were included in this population based retrospective study. Data were retrieved from the Netherlands Cancer Registry (NCR). Treatment strategies in 8 regions of the Netherlands were compared according to stage, excluding patients with distant metastasis (AJCC stage IV). RESULTS Throughout the Netherlands, there was substantial practice variation across the regions. The performance of SLNB in patients with clinically unsuspected lymph nodes and Breslow thickness >1.0 mm was significantly different between the regions. In a post hoc analysis, we observed that patients aged over 60 years, female patients and patients with a melanoma located in head and neck have lower odds to receive a SLNB. CONCLUSION There is considerable loco-regional practice variation which cannot completely be explained by the patient and tumor characteristics, in the surgical treatment of non-distant metastatic melanoma patients in the Netherlands. Although national guidelines recommend considering SLNB in all patients with a melanoma thicker than 1 mm, only half of the patients received a SLNB. Future research should assess whether this practice variation leads to unwanted variations in clinical outcome.
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Affiliation(s)
- J Verstijnen
- Department of Medical Oncology, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - S Damude
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - H J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - S Kruijff
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - A J Ten Tije
- Department of Medical Oncology, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands; Department of Medical Oncology, VU Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - W J Louwman
- Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, 3511 DT Utrecht, The Netherlands.
| | - E Bastiaannet
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; Department of Gerontology & Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - M M Stuiver
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Oude Ophuis CMC, Louwman MWJ, Grünhagen DJ, Verhoef K, van Akkooi ACJ. Implementation of the 7th edition AJCC staging system: Effects on staging and survival for pT1 melanoma. A Dutch population based study. Int J Cancer 2017; 140:1802-1808. [PMID: 28109000 DOI: 10.1002/ijc.30607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/19/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022]
Abstract
In the 7th edition of the AJCC staging system, the mitotic rate criterion replaced Clark level to increase correct classification of high-risk thin melanoma patients (pT1B). Additionally, sentinel node biopsy (SNB) was recommended for nodal staging of pT1B melanomas. The aim of this article was to evaluate the effects on pT1 substaging and clinical implications in the national pT1 melanoma population. All pT1 melanomas diagnosed in the Netherlands between 2003 and 2014 were selected from the Netherlands Cancer Registry (IKNL). Patients were stratified by cohort according to AJCC edition: (1) 2003-2009 (6th ) and (2) 2010-2014 (7th ). Relative survival was calculated to estimate melanoma-specific survival. A total of 29.546 pT1 melanoma patients were included. The pT1b proportion increased from 10.1% in Cohort 1 to 21.5% in Cohort 2. The proportion of performed SNBs per cohort increased: for pT1b melanomas alone from 4.5% to 13.0%. SNB positivity rate decreased from 10.5% to 8.8% for the entire pT1 population, and for pT1b melanomas from 11.3% to 8.6%. At 5 years, the relative survival rate was similar for pT1a and pT1b in both cohorts, namely, pT1a 100% vs pT1b 97% (Cohort 1), and pT1a 100% vs pT1b 98% (Cohort 2). The 7th edition of the AJCC staging system has caused an increased number of patients to undergo SNB, without an increase in SNB positivity rate. Survival between pT1 subgroups remains similar. The mitotic rate criterion for pT1b classification and the recommendation to perform SNB for pT1b melanomas should be reconsidered.
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Affiliation(s)
- Charlotte M C Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Marieke W J Louwman
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Postbus 19079, 3501 DB, Utrecht, The Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Kees Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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26
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Gimotty PA, Shore R, Lozon NL, Whitlock J, He S, Vigneau FD, Dickie L, Elder DE, Xu X, Schwartz AG, Guerry D. Miscoding of Melanoma Thickness in SEER: Research and Clinical Implications. J Invest Dermatol 2016; 136:2168-2172. [PMID: 27354265 PMCID: PMC5077675 DOI: 10.1016/j.jid.2016.05.121] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/05/2016] [Accepted: 05/17/2016] [Indexed: 12/23/2022]
Abstract
Melanoma-related deaths and metastases among patients with thin (≤1 mm) and ultrathin (≤0.25 mm) melanomas have been reported. These observations might reflect adverse biology and/or errors in administrative data. Cumulative melanoma-related death rates for thickness groups of patients with thin melanomas were compared among five cohorts including the Surveillance, Epidemiology, and End Results (SEER) registry. Thickness in one SEER region was reexamined in pathology reports. The 5-year cumulative melanoma-related death rate of patients with ultrathin melanomas was higher in SEER (2.8%) compared with other registries (0.6-0.9%). The rates across the 16 SEER regions were 0.25% to 8.4%. In SEER, 21% of thin melanomas were ultrathin; in other registries, they comprised 5.8-15%. A reexamination of thickness in one SEER site revealed that 114 of 447 ultrathin melanomas had errors; after correction, only 17 of the 114 remained ultrathin. The majority of errors were related to decimal point placement. The 86 thin melanomas reclassified to >1.00 mm included 96% of the original ultrathin-associated deaths and 100% of the original positive lymph nodes. Significant miscoding of thickness that is concentrated in ultrathin lesions is present in SEER and results in mischaracterization of patient outcomes. When using administrative data, validation of results can identify critical data issues.
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Affiliation(s)
- Phyllis A Gimotty
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Ronald Shore
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Nancy L Lozon
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Jeanne Whitlock
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Sidan He
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Fawn D Vigneau
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Lois Dickie
- Division of Cancer Control and Population Science, National Cancer Institute, Rockville, Maryland, USA
| | - David E Elder
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Xiaowei Xu
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ann G Schwartz
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - DuPont Guerry
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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27
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Caldarella A, Fancelli L, Manneschi G, Chiarugi A, Nardini P, Crocetti E. How staging of thin melanoma is changed after the introduction of TNM 7th edition: a population-based analysis. J Cancer Res Clin Oncol 2016; 142:73-6. [PMID: 26113451 DOI: 10.1007/s00432-015-2007-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/14/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In 2009, the American Joint Committee on Cancer (AJCC) incorporated the tumor mitotic rate in the melanoma pathological TNM staging system. To investigate the effect of this change on the pT1 substaging of primary cutaneous melanomas, we reclassified the cases collected by a cancer registry according to the 6th and the 7th editions of AJCC melanoma staging. METHODS Patients with pathological T1 melanoma diagnosed in the period 2000-2008 were selected from Tuscan Cancer Registry. The histological reports were reviewed and pT1 melanomas classified according to both the 6th and the 7th editions of the AJCC staging system. The shift of melanomas between pT1 substages was analyzed. RESULTS Among the 242 pT1 melanomas collected in the study period and with mitotic index available, there were 202 (83 % of all pT1) and 175 (72 %) pT1a, according to the 6th and the 7th editions of the AJCC melanoma staging, respectively. When the 7th edition was used, 20 % of all pT1a melanomas shifted to pT1b, and 32 % of all pT1b melanomas shifted to pT1a. A poor level agreement between the two TNM staging systems, measured by the Cohen's kappa coefficient, was found (K = 0.37). CONCLUSIONS The addition of mitotic activity to the pathological staging resulted in an increase in pT1b proportion and in a change in the classification of some cases. This modification could influence the clinical approach, with a different use of the sentinel lymph node biopsy, and underlines the role of mitosis evaluation in the management of thin melanoma patients.
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Affiliation(s)
- A Caldarella
- Cancer Prevention and Research Institute, Via Cosimo il Vecchio n. 2, 50141, Florence, Italy.
| | - L Fancelli
- Dermatology Section, Department of Surgery and Translational Medicine, School of Medicine, Florence, Italy
| | - G Manneschi
- Cancer Prevention and Research Institute, Via Cosimo il Vecchio n. 2, 50141, Florence, Italy
| | - A Chiarugi
- Screening and Cancer Prevention, Melanoma Prevention Service, Cancer Prevention and Research Institute, Florence, Italy
| | - P Nardini
- Screening and Cancer Prevention, Melanoma Prevention Service, Cancer Prevention and Research Institute, Florence, Italy
| | - E Crocetti
- Cancer Prevention and Research Institute, Via Cosimo il Vecchio n. 2, 50141, Florence, Italy
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