Risk factors for developing cutaneous melanoma and criteria for identifying persons at risk: multicenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society

Inter-Rater Agreement in Assessing Risk of Bias in Melanoma Prediction Studies Using the Prediction Model Risk of Bias Assessment Tool (PROBAST): Results from a Controlled Experiment on the Effect of Specific Rater Training

Assessing the risk of bias (ROB) of studies is an important part of the conduct of systematic reviews and meta-analyses in clinical medicine. Among the many existing ROB tools, the Prediction Model Risk of Bias Assessment Tool (PROBAST) is a rather new instrument specifically designed to assess the ROB of prediction studies. In our study we analyzed the inter-rater reliability (IRR) of PROBAST and the effect of specialized training on the IRR. Six raters independently assessed the risk of bias (ROB) of all melanoma risk prediction studies published until 2021 (n = 42) using the PROBAST instrument. The raters evaluated the ROB of the first 20 studies without any guidance other than the published PROBAST literature. The remaining 22 studies were assessed after receiving customized training and guidance. Gwet's AC₁ was used as the primary measure to quantify the pairwise and multi-rater IRR. Depending on the PROBAST domain, results before training showed a slight to moderate IRR (multi-rater AC₁ ranging from 0.071 to 0.535). After training, the multi-rater AC₁ ranged from 0.294 to 0.780 with a significant improvement for the overall ROB rating and two of the four domains. The largest net gain was achieved in the overall ROB rating (difference in multi-rater AC₁: 0.405, 95%-CI 0.149-0.630). In conclusion, without targeted guidance, the IRR of PROBAST is low, questioning its use as an appropriate ROB instrument for prediction studies. Intensive training and guidance manuals with context-specific decision rules are needed to correctly apply and interpret the PROBAST instrument and to ensure consistency of ROB ratings.

Using the Prediction Model Risk of Bias Assessment Tool (PROBAST) to Evaluate Melanoma Prediction Studies

Simple Summary

The rising incidence of cutaneous melanoma over recent decades, combined with a general interest in cancer risk prediction, has led to a high number of published melanoma risk prediction models. The aim of our work was to assess the validity of these models in order to discuss the current state of knowledge about how to predict incident cutaneous melanoma. To assess the risk of bias, we used a standardized procedure based on PROBAST (Prediction model Risk Of Bias ASsessment Tool). Only one of the 42 studies identified was rated as having a low risk of bias. However, it was encouraging to observe a recent reduction of problematic statistical methods used in the analyses. Nevertheless, the evidence base of high-quality studies that can be used to draw conclusions on the prediction of incident cutaneous melanoma is currently much weaker than the high number of studies on this topic would suggest.

Abstract

Rising incidences of cutaneous melanoma have fueled the development of statistical models that predict individual melanoma risk. Our aim was to assess the validity of published prediction models for incident cutaneous melanoma using a standardized procedure based on PROBAST (Prediction model Risk Of Bias ASsessment Tool). We included studies that were identified by a recent systematic review and updated the literature search to ensure that our PROBAST rating included all relevant studies. Six reviewers assessed the risk of bias (ROB) for each study using the published “PROBAST Assessment Form” that consists of four domains and an overall ROB rating. We further examined a temporal effect regarding changes in overall and domain-specific ROB rating distributions. Altogether, 42 studies were assessed, of which the vast majority (n = 34; 81%) was rated as having high ROB. Only one study was judged as having low ROB. The main reasons for high ROB ratings were the use of hospital controls in case-control studies and the omission of any validation of prediction models. However, our temporal analysis results showed a significant reduction in the number of studies with high ROB for the domain “analysis”. Nevertheless, the evidence base of high-quality studies that can be used to draw conclusions on the prediction of incident cutaneous melanoma is currently much weaker than the high number of studies on this topic would suggest.

Reporting Quality of Studies Developing and Validating Melanoma Prediction Models: An Assessment Based on the TRIPOD Statement

Transparent and accurate reporting is essential to evaluate the validity and applicability of risk prediction models. Our aim was to evaluate the reporting quality of studies developing and validating risk prediction models for melanoma according to the TRIPOD (Transparent Reporting of a multivariate prediction model for Individual Prognosis Or Diagnosis) checklist. We included studies that were identified by a recent systematic review and updated the literature search to ensure that our TRIPOD rating included all relevant studies. Six reviewers assessed compliance with all 37 TRIPOD components for each study using the published “TRIPOD Adherence Assessment Form”. We further examined a potential temporal effect of the reporting quality. Altogether 42 studies were assessed including 35 studies reporting the development of a prediction model and seven studies reporting both development and validation. The median adherence to TRIPOD was 57% (range 29% to 78%). Study components that were least likely to be fully reported were related to model specification, title and abstract. Although the reporting quality has slightly increased over the past 35 years, there is still much room for improvement. Adherence to reporting guidelines such as TRIPOD in the publication of study results must be adopted as a matter of course to achieve a sufficient level of reporting quality necessary to foster the use of the prediction models in applications.

Sun Protective Behaviors and Attitudes of Runners

Sun exposure is a risk factor for skin cancer. Knowledge and behaviors around sun exposure protective measures are poorly described in athletes including runners. Our primary objective was to describe sun exposure behaviors and knowledge in a population of runners. A cross-sectional online survey was administered to 697 runners to measure the frequency of seven sun protective behaviors: sunscreen use on the face or body; wearing a hat, sunglasses, or long sleeves; running in shade; and avoidance of midday running. Between 54% and 84% of runners reported that they engaged in these behaviors at least sometimes, but only 7% to 45% reported frequent use. Of 525 runners who gave a primary reason for not using sunscreen regularly, 49.0% cited forgetfulness; 17.3% cited discomfort; and only a small percentage cited maintaining a tan (6.1%) or optimizing vitamin D (5.1%). Of 689 runners who responded to a question about what factor most influences their overall sun exposure habits, 39.2% cited fear of skin cancer, 28.7% cited comfort level, and 15.8% cited fear of skin aging. In addition to the seven individual behaviors, we also asked runners how frequently they took precautions to protect against the sun overall. We explored associations between participant characteristics and the overall use of sun protection using ordinal logistic regression. Overall, sun protection was used more frequently in runners who were female, older, or had a history of skin cancer. Runners appear to recognize the importance of sun protection and the potential consequences of not using it, but report forgetfulness and discomfort as the biggest barriers to consistent use. Interventions using habit-formation strategies and self-regulation training may prove to be most useful in closing this gap between knowledge and practice.

Dermatologic Follow-up and Assessment of Suspicious Lesions

As our knowledge and understanding of melanoma evolve, melanoma surveillance guidelines will reflect these findings. Currently, there is no consensus across international guidelines for melanoma follow-up. However, it is accepted that more aggressive surveillance is recommended for more advanced disease. When examining high-risk individuals, a systematic approach should be followed. Future considerations include the use of noninvasive imaging techniques, 'liquid biopsies,' and artificial intelligence to enhance detection of melanomas.

Current concepts of ectopic nodal inclusions with special emphasis on nodal nevi

Nodal inclusions of ectopic tissue within lymph nodes are seen comparatively often in dermatopathology and general pathology. Glandular and nonglandular epithelium, as well as melanocytic nevi can be observed within lymph nodes and represent mostly incidental findings without any relevance. The main challenge in reporting these morphologic features is to differentiate such benign inclusions from metastatic settlements of distinct organ tumors. As sentinel node biopsy and lymph node dissection have become standard procedure in clinical oncology and have an immense clinical impact, the correct evaluation of these nodal inclusions is indispensable to avoid undertreatment or overtreatment of patients. In addition, the genesis of these inclusions has not yet been satisfactorily clarified. Two concepts have been laid out: the theory of benign metastases and the migration arrest theory. However, neither theory has so far been able to answer the following questions: Why do we find more nodal nevi in patients with melanoma who had a sentinel node biopsy than in patients without melanoma, and why do we not find nodal nevi in deep visceral lymph nodes? We present a comprehensive review of the current knowledge on nodal inclusions, proposing a concept for the pathogenesis of nodal nevi, to answer these questions.

Risk Prediction Models for Melanoma: A Systematic Review on the Heterogeneity in Model Development and Validation

The rising incidence of cutaneous melanoma over the past few decades has prompted substantial efforts to develop risk prediction models identifying people at high risk of developing melanoma to facilitate targeted screening programs. We review these models, regarding study characteristics, differences in risk factor selection and assessment, evaluation, and validation methods. Our systematic literature search revealed 40 studies comprising 46 different risk prediction models eligible for the review. Altogether, 35 different risk factors were part of the models with nevi being the most common one (n = 35, 78%); little consistency in other risk factors was observed. Results of an internal validation were reported for less than half of the studies (n = 18, 45%), and only 6 performed external validation. In terms of model performance, 29 studies assessed the discriminative ability of their models; other performance measures, e.g., regarding calibration or clinical usefulness, were rarely reported. Due to the substantial heterogeneity in risk factor selection and assessment as well as methodologic aspects of model development, direct comparisons between models are hardly possible. Uniform methodologic standards for the development and validation of risk prediction models for melanoma and reporting standards for the accompanying publications are necessary and need to be obligatory for that reason.

Ultraviolet Radiation Exposure, Risk, and Protection in Military and Outdoor Athletes

Overexposure to ultraviolet radiation (UVR) from the sun is associated with deleterious health effects including, but not limited to, increased risk of skin cancers. Military personnel and those who participate in outdoor exercise or sports represent two potential populations at elevated risk of negative health consequences of UVR exposure due to large amounts of time spent outdoors, often in harsh UVR environments. Despite exposure to high and/or frequent doses of UVR in recreational and tactical athletes, adequate sun-protection practices are often disregarded or not well understood by many within these at-risk populations, resulting in heightened risk of negative UVR effects. The focus of this review is to examine the available literature regarding UVR exposure, risk of adverse health effects of UVR exposure, and sun protection practices in outdoor exercisers, athletes, and military personnel.

Future reduction of cutaneous malignant melanoma due to improved sun protection habits and decreased common melanocytic nevi density among Swedish children?: A follow-up from 2002 to 2012

We have previously demonstrated significant improvements in sun protection regimens and significantly fewer common melanocytic nevi (CMN) among 7-year-old children in southern Sweden when comparing year 2007 with 2002. The aim of this study was to investigate whether the observed decreasing trend also can be observed at age 10 and, in addition, to compare the CMN density change between 7 and 10 years of age during two periods of time. Two open cohorts were used, cohort I with schoolchildren investigated in 2002 at age 7 and in 2005 at age 10 and cohort II with schoolchildren investigated in 2009 at age 7 and in 2012 at age 10. A significant decrease in CMN density (number/m² BSA) at age 10 from 2005 to 2012 was observed: 15.9 (14.7-17.2) and 11.4 (10.1-12.7), respectively. The density growth rate from 7 to 10 years was 2.8 (2.1-3.5) between 2002 and 2005 and decreased significantly to 0.9 (0.2-1.5) between 2009 and 2012. Significant increases were observed for 'often use of sunscreen', 'often staying in shade' and 'often staying indoors' from cohort I to cohort II: 65 vs 80%, 7.6 vs 13% and 7.3 vs 19%, respectively. The decrease in number of CMN among 10-year-old children confirms a current trend in Sweden. If this persists, a future reduction of cutaneous malignant melanoma incidence in Sweden might be anticipated. The results also indicate that CMN count could be used as an indicator of ultraviolet exposure.

Macroenvironment-gene-microenvironment interactions in ultraviolet radiation-induced melanomagenesis

Cutaneous malignant melanoma is one of the few major cancers that continue to exhibit a positive rate of increase in the developed world. A wealth of epidemiological data has undisputedly implicated ultraviolet radiation (UVR) from sunlight and artificial sources as the major risk factor for melanomagenesis. However, the molecular mechanisms of this cause-and-effect relationship remain murky and understudied. Recent efforts on multiple fronts have brought unprecedented expansion of our knowledge base on this subject and it is now clear that melanoma is caused by a complex interaction between genetic predisposition and environmental exposure, primarily to UVR. Here we provide an overview of the effects of the macroenvironment (UVR) on the skin microenvironment and melanocyte-specific intrinsic (mostly genetic) landscape, which conspire to produce one of the deadliest malignancies.

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.

Melanoma - role of the environment and genetics

Melanoma rates have increased in populations that are mainly European. The main etiologic factor is ultraviolet radiation, from the sun as well as artificial tanning devices. Host factors such as skin color, number of nevi, hair and eye color and tanning ability are critical factors in modifying an individual's response to the sun. Genetic factors interact with host factors and environmental factors to increase risk. This review summarizes our current knowledge of environment and genetics on melanoma risk and on gene-environment interaction.

Various Dermatoses What the Patients with Cutaneous Melanoma Had Anxiety for the Recurrence during Postoperative Surveillance

BACKGROUND

The incidence and mortality rates associated with cutaneous melanoma (CM) have steadily increased over the last 20 years. Even with successful treatment, melanoma patients usually experience substantial anxiety regarding the development of terrible recurrence. To date, few studies have investigated various dermatoses what the patients with CM had anxiety for the recurrence during postoperative surveillance (Dw).

OBJECTIVE

To describe various Dw and to evaluate the risk of subsequent malignant skin disease in patients with CM.

METHODS

We performed a prospective study between August 2002 and August 2015.

RESULTS

Fifty-six patients presented with a total of 68 Dw. Among them, melanocytic nevus was the most common (n=27), followed by seborrheic keratosis (n=9) and CM recurrence (n=7). Approximately 5.6% of the lesions were diagnosed as malignant skin diseases. This was a single-center study, so the prevalence of malignant skin diseases following primary melanoma may not represent that of all patients with CM.

CONCLUSION

The results of this study can be referred by dermatologists dealing with melanoma especially when CM patients have too excessive or unrealistic anxiety for melanoma recurrence during postoperative surveillance of CM. However, the importance of postoperative surveillance must still be emphasized because of real risk of melanoma recurrence and other malignant skin.

Genetic analysis of melanocortin 1 receptor red hair color variants in a Russian population of Eastern Siberia

The melanocortin 1 receptor is a G_s protein-coupled receptor implicated in melanogenesis regulation. The receptor gene is highly polymorphic, which accounts for the association of several of its single-nucleotide polymorphisms (SNPs) with an increased risk of melanoma. The present study aimed to evaluate the distribution of melanocortin 1 receptor gene variants R151C, R160W, and D294H within the Russian population of Eastern Siberia and its association with melanoma development. Melanoma patients (n=95) admitted to Krasnoyarsk Territorial Oncological Center and healthy controls (n=334) were enrolled in the study. A clinical examination of patients was performed to evaluate the phenotypic features of melanoma patients. SNPs were analyzed by real-time PCR. Clinical examination indicated a more frequent occurrence of fair skin type, blue eyes, blonde and red hair, and more frequent localization of freckles on the neck, trunk, and extremities in the melanoma group of patients. The R151C melanocortin 1 receptor gene variant was found in 18% of melanoma patients and associated with an increased likelihood of melanoma development (odds ratio=6.4; 95% confidence interval: 2.8–14.3; P=0.0001). The two remaining variant alleles of the melanocortin 1 receptor gene occurred with low frequency both in controls and in the melanoma group. The R160W SNP was identified neither in controls nor in melanoma patients. The D294H heterozygous variant was observed in 0.3% of individuals in the control group and in 1.1% of the patients in the melanoma group. Such an asymmetric distribution of the melanocortin 1 receptor within red hair color genotypes in the population under study compared with other populations may be because of Russian genetic homogeneity. Carriers of the mutant R151C allele should exercise caution in terms of exposure to the sun to avoid the risk of melanoma development.

Assessing Scientific Data: The Case-Control Study as it Applies to Dermatology Part 1: The Case-Control Method

Background:

Epidemiology is integral to medical research. To keep abreast of medical advances related to the specialty, dermatologists need a sound understanding of epidemiologic principles.

Objective:

The purpose of this article is to introduce the case-control study design in the context of dermatology. Topics covered include subject selection, exposure assessment, and data analysis.

Conclusions:

The case-control design is applicable to dermatology research. This method is especially relevant for rare diseases or those with a long latency period.

Association of nevus count with prevention attitudes and behaviors before melanoma diagnosis

Although melanoma risk factors are commonly known to healthcare professionals, the extent to which the at-risk public is either aware of these factors or perceives their risk accordingly has rarely been studied. We sought to investigate whether the presence of known melanoma risk factors, such as high total nevus and atypical nevus counts, was associated with increased prevention attitudes and behaviors, such as skin self-examinations and physician skin examinations. This was a retrospective study of 566 individuals recently diagnosed with melanoma in two large academic centers. Most prevention attitudes and behaviors did not vary on the basis of total nevi or atypical nevi counts. However, younger patients (<60 years) with many total nevi (>50) were more likely than those with fewer nevi (<20) to believe that they were at-risk for melanoma (42 vs. 23%; P<0.05), and more likely to state that they had been instructed on the signs of melanoma (36 vs. 21%; P<0.05). Patient and health provider recognition of the impact of nevus count on melanoma risk presents a unique and mostly untapped opportunity for earlier detection.

[Malignant head and neck melanoma : Part 1: Diagnosis and histological particularities]

About 15% of all cutaneous melanomas develop in the head and neck region. Mucosal melanomas are rare and represent only 1% of all melanomas, however, most frequently, these are located in the nose, the paranasal sinuses and the oral cavity. Visual diagnosis and reflected-light microscopy are relevant for the evaluation of melanoma-suspect lesions. Histological investigation of resected tumors need special skills of the histopathologist and includes in case of high-risk tumors investigations of mutations in the tumor tissue concerning NRAS, BRAF and KIT. The risk of lymphatic or hematogeneous spread rises with increasing tumor thickness and the presence of further prognostic risk factors such as ulceration of the primary tumor or the presence of mitoses within the tumor.

Melanoma: Clinical Presentations

The malignant cell in melanoma is the melanocyte. Because melanocytes are located in the basal layer of the epidermis, melanoma is most commonly seen on the skin. However, melanoma can also arise on mucosal surfaces such as the oral cavity, the upper gastrointestinal mucosa, the genital mucosa, as well as the uveal tract of the eye and leptomeninges. Melanomas tend to be pigmented but can also present as pink or red lesions. They can mimic benign or other malignant skin lesions. This chapter presents the spectrum of typical and less typical presentations of melanoma, as well as patterns of spread. It is divided into (1) cutaneous lesions; (2) patterns of regional spread, (3) non-cutaneous lesions; and (4) distant metastases.

Zebrafish Melanoma

Melanoma skin cancer is a potentially deadly disease in humans and has remained extremely difficult to treat once it has metastasized. In just the last 10 years, a number of models of melanoma have been developed in the zebrafish that are biologically faithful to the human disease and have already yielded important insights into the fundamental biology of melanoma and offered new potential avenues for treatment. With the diversity and breadth of the molecular genetic tools available in the zebrafish, these melanoma models will continue to be refined and expanded upon to keep pace with the rapidly evolving field of melanoma biology.

Distinct melanoma types based on reflectance confocal microscopy

Distinct melanoma types exist in relation to patient characteristics, tumor morphology, histopathologic aspects and genetic background. A new diagnostic imaging tool, reflectance confocal microscopy (RCM), allows in vivo analysis of a given lesion with nearly histologic resolution while offering a dynamic view of the tissue in its 'natural' environment. The aim of this study was to analyse cell morphology of consecutive melanomas as they appear on RCM and to correlate morphology with tumor and patient characteristics. One hundred melanomas were visualized by RCM before excision. Clinical data, confocal features and histologic criteria were analysed. Four types of melanomas were identified as follows: (i) Melanomas with a predominantly dendritic cell population ('dendritic-cell melanomas') typically were thin by Breslow index; (ii) Melanomas typified by roundish melanocytes were smaller in size than dendritic cell MMs, but thicker by Breslow index, and predominantly occurred in patients with a high nevus count; (iii) Melanomas characterized by dermal nesting proliferation usually were thick by Breslow index at the time of diagnosis, although frequently smaller in size compared with the other types; and (iv) combined type melanomas may represent an evolution of dendritic cell and/or round cell types. Integration of confocal microscopy with clinical and histologic aspects may help in identifying and managing distinct tumors.

Black light visualized solar lentigines on the shoulders and upper back are associated with objectively measured UVR exposure and cutaneous malignant melanoma

Previous studies on the association of solar lentigines with ultraviolet radiation (UVR) exposure have been based on retrospective questionnaires about UVR exposure. We aimed to investigate the association between solar lentigines and UVR exposure in healthy individuals using objective measurements, and to investigate the association between solar lentigines and cutaneous malignant melanoma (CMM). Forty-eight patients with CMM and 48 controls that matched the patients individually by age, sex, constitutive skin type and occupation participated. Solar lentigines on the shoulders and upper back were counted and graded into 3 categories using black light photographs to show sun damage. Current UVR exposure in healthy controls was assessed by personal electronic UVR dosimeters that measured time-related UVR and by corresponding exposure diaries during a summer season. Sunburn history was assessed by interviews. Among controls, the number of solar lentigines was positively associated with daily hours spent outdoors between noon and 3 pm on holidays (P = 0.027), days at the beach (P = 0.048) and reported number of life sunburns (P < 0.001). Compared with matched controls CMM patients had a higher number of solar lentigines (P = 0.044). There was a positive association between CMM and higher solar lentigines grade; Category III versus Category I (P = 0.002) and Category II versus Category I (P = 0.014). Our findings indicate that solar lentigines in healthy individuals are associated with number of life sunburns, as well as time spent outdoors around noon on holidays and beach trips during a summer season, most likely reflecting past UVR exposure, and that solar lentigines are a risk factor for CMM.

Independent validation of six melanoma risk prediction models

Identifying people at high risk of melanoma is important for targeted prevention activities and surveillance. Several tools have been developed to classify melanoma risk, but few have been independently validated. We assessed the discriminatory performance of six melanoma prediction tools by applying them to individuals from two independent data sets, one comprising 762 melanoma cases and the second a population-based sample of 42,116 people without melanoma. We compared the model predictions with actual melanoma status to measure sensitivity and specificity. The performance of the models was variable with sensitivity ranging from 97.7 to 10.5% and specificity from 99.6 to 1.3%. The ability of all the models to discriminate between cases and controls, however, was generally high. The model developed by MacKie et al. (1989) had higher sensitivity and specificity for men (0.89 and 0.88) than women (0.79 and 0.72). The tool developed by Cho et al. (2005) was highly specific (men, 0.92; women, 0.99) but considerably less sensitive (men, 0.64; women, 0.37). Other models were either highly specific but lacked sensitivity or had low to very low specificity and higher sensitivity. Poor performance was partly attributable to the use of non-standardized assessment items and various differing interpretations of what constitutes "high risk".

Predicting melanoma risk: theory, practice and future challenges

The incidence of melanoma continues to rise in most fair-skinned populations. Strategies to curb the toll from melanoma include targeting the patients who are at highest risk with the aim of either preventing the onset of cancer or intervening early in order to improve survival. The challenge has been to synthesize the available information on risk factors into prediction tools with clinical utility, such that 'high-risk' patients can be identified with accuracy. While a number of risk prediction tools for melanoma have been developed, few have undergone rigorous evaluation of their performance in order to assess calibration or discrimination, and even fewer have been validated in independent populations. Future research should assess the validity of existing tools and seek to integrate the increasing volumes of data being generated by genomic studies.

Nevus-associated melanomas: clinicopathologic features

OBJECTIVES

The clinical significance of nevus-associated melanoma compared with de novo melanomas remains controversial. It has been suggested that nevus-associated melanomas have a higher Breslow thickness and therefore worse prognosis. Over a 10-year period, this study evaluated the incidence of nevus-associated melanoma and its prognostic significance related to clinicopathologic features.

METHODS

Cross-sectional study from 1995 through 2004 in a dermatopathology referral center. With available data, we evaluated sex, primary location, histologic subtype, Breslow thickness, Clark level, presence of ulceration, associated lesion, and histologic subtype of the associated lesion.

RESULTS

Of 135,653 pathologic records from skin biopsy specimens over a 10-year period, 1,190 melanoma records were selected. Nevus-associated melanomas corresponded to 390 (32.8%) melanomas, with thin melanomas having a nevus 1.52 times the association observed with thick melanomas (>1.01 mm; 95% confidence interval, 1.16-1.99; P < .001). Superficial spreading melanoma was the most frequent, while no lentigo maligna melanoma was associated with nevi. The median Breslow thickness of nevus-associated melanomas was lower than that of de novo melanomas.

CONCLUSIONS

Nevus-associated melanomas, which represent one-third of the melanomas in southeast Brazil, are associated with intermittent sun exposure, superficial spreading melanomas, and lower Breslow thickness. This is one of the largest series describing nevus-associated melanomas in Latin America.

The first skin cancer screening day at the Italian parliament: a Euromelanoma initiative

BACKGROUND

The effort to decrease incidence/mortality of skin cancer should target not only the general public but also politicians and decision makers, to create a proper health policy. We report the results of the first Skin Cancer Screening Day at the Italian Parliament, organized to draw politicians' attention on skin cancer.

METHODS

A questionnaire was used to collect data on participants' characteristics and suspected skin cancers.

RESULTS

We screened 70 members of parliament (61.4% males, median age 54 years). Overall skin cancer suspicion rate was 14.5%. Suspicion rate, detection rate, and positive predictive values for melanoma were respectively 1.6, 1.6, and 100%, and for basal cell carcinoma 6.5, 1.6, and 25%. Highly educated, <54-year-old females reported sun-seeking behaviors.

CONCLUSIONS

The considerable suspicion rate produced by this screening is justified by the particular demographics of the study population. Italian members of parliament display sun-seeking behaviors similar to those previously described in the general public. Increasing politicians' attention on skin cancer is vital for sufficient resources to be allocated to prevention strategies. Expert medical groups and politicians should cooperate to create a proper, integrated policy on skin cancer.

Identifying risk factors using a skin cancer screening program

BACKGROUND

The incidence of melanoma and nonmelanoma skin cancer continues to increase. To detect lesions at an earlier phase in their progression, skin cancer screening programs have been advocated by some. However, the effectiveness of skin cancer screening and the ideal population that these screenings should target have yet to be firmly established. This study details the relationship of a group of well-known risk factors with presumptive diagnoses in a large series of individuals self-referred for free skin cancer screening.

METHODS

Data obtained during 2007 to 2010 from a descriptive cross-sectional study skin cancer screening program are presented. Participant history was recorded using standardized medical history forms prior to skin examination. Screeners conducted a skin examination varying from whole-body to limited areas (per participant preference) and recorded diagnoses. Diagnoses were assigned to the nonmelanoma cancer (NMC) or suspicious pigmented lesion group for analysis.

RESULTS

A presumptive diagnosis of NMC was associated with male sex, age ≥ 50 years, personal history of skin cancer, lower skin phototype, increased sunscreen use, and increased chronic sun exposure (all P values ≤ .0001). After controlling for skin phototype, increased sunscreen use was not associated with a presumptive diagnosis of NMC (P = .96). Presumptive diagnosis of a suspicious pigmented lesion was associated with a reported history of "changing mole" (P < .0001) and negatively associated with age ≥ 50 years (P < .0001) and a personal history of skin cancer (P = .0119).

CONCLUSIONS

Several known risk factors for nonmelanoma skin cancer correlated with a presumptive diagnosis of NMC. The yield of presumptive atypical pigmented lesions was increased in participants aged < 50 years, supporting the notion that this population may benefit from screening.

Risk prediction models for melanoma: a systematic review

Melanoma incidence is increasing rapidly worldwide among white-skinned populations. Earlier diagnosis is the principal factor that can improve prognosis. Defining high-risk populations using risk prediction models may help targeted screening and early detection approaches. In this systematic review, we searched Medline, EMBASE, and the Cochrane Library for primary research studies reporting or validating models to predict risk of developing cutaneous melanoma. A total of 4,141 articles were identified from the literature search and six through citation searching. Twenty-five risk models were included. Between them, the models considered 144 possible risk factors, including 18 measures of number of nevi and 26 of sun/UV exposure. Those most frequently included in final risk models were number of nevi, presence of freckles, history of sunburn, hair color, and skin color. Despite the different factors included and different cutoff values for sensitivity and specificity, almost all models yielded sensitivities and specificities that fit along a summary ROC with area under the ROC (AUROC) of 0.755, suggesting that most models had similar discrimination. Only two models have been validated in separate populations and both also showed good discrimination with AUROC values of 0.79 (0.70-0.86) and 0.70 (0.64-0.77). Further research should focus on validating existing models rather than developing new ones.

Natural history of atypical and equivocal melanocytic lesions in children: an observational study of 19 cases

Digital dermoscopy follow-up helps to identify patterns of change typical of common atypical nevi and early melanoma and improves the follow-up of patients with atypical nevi. We report the morphologic changes observed over time in 19 atypical or equivocal acquired melanocytic nevi that underwent dermoscopic follow-up. Two observers retrospectively examined digitalized dermoscopic images of 19 atypical melanocytic nevi from 15 children and young adults (median age 12 years, range 3-26 years). The images were assessed for global dermoscopic patterns at baseline and after a median 25-month (range 6-138 mos) follow-up. Ten (52.6%) nevi changed and nine (47.4%) retained a stable dermoscopic pattern. Of the 10 changing lesions, 2 of 4 homogeneous nevi evolved into a reticular pattern and 2 into a mixed pattern; 1 of 2 nevi with a mixed pattern evolved into a homogeneous nevus and 1 into a regressing nevus; 1 of 2 nevi with "other" patterns, such as negative pigment network and peppering throughout the lesion, evolved into a mixed nevus and 1 into a regressing nevus; 1 globular nevus evolved into a mixed pattern; and 1 starburst nevus evolved into a homogeneous nevus. The most striking results of our study were that atypical nevi can evolve into common nevi or they can regress, as documented by long-term dermoscopic follow-up. In children and young adults, dermoscopic follow-up of atypical nevi might be a valid alternative to surgical excision and enables us to achieve new insights into the natural history of these nevi.

Perioral lesions and dermatoses

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.

CDKN2A and MC1R variants influence dermoscopic and confocal features of benign melanocytic lesions in multiple melanoma patients

Non-invasive diagnostic tools are effective in the histomorphological study of melanocytic lesions. The role of melanoma susceptibility genes on melanocytic nevi histopathological features is not clear. The current study aimed to correlate genetic alterations and histomorphological features of melanocytic nevi. Clinical, dermoscopic and confocal features of 34 multiple melanoma patients and 34 controls were compared. Among patients with melanoma, carriers of CDKN2A mutations and/or MC1R variants, and wild-type genes were also compared. In patients with melanoma, a lighter phototype (P = 0.051), a higher number of nevi (P < 0.01) and clinically atypical nevi (P < 0.01) were observed. At dermoscopy, these nevi showed a complex pattern (P = 0.011), atypical network (P = 0.018) and irregular pigmentation (P = 0.037); at confocal, an irregular meshwork pattern (P = 0.026) with atypical nests (P = 0.016) and an inflammatory infiltrate (P = 0.048) were observed. Among patients with melanoma genetically tested, CDKN2A G101W mutation carriers were more frequently younger (P = 0.023), with clinically atypical nevi (P = 0.050), with cytological atypia (P = 0.033) at confocal. G101W mutation and MC1R variants carriers showed hypopigmented nevi (P = 0.002) and, at confocal, roundish cells infiltrating the junction (P = 0.019). These data suggest an influence of CDKN2A mutation and MC1R variants in the development of dysplastic melanocytic lesions. Non-invasive histomorphological evaluation, together with genetic studies, improves melanoma risk identification and early diagnosis, for a patient-tailored management.

When algorithms falter: a case report of a very small melanoma excised due to the dermatoscopic "ugly duckling" sign

We present a case report of a 3.5 mm diameter superficial spreading melanoma on the upper back of a 27-year-old woman, signed out as Clark level 2, Breslow thickness 0.2 mm with regression to 0.45 mm. The patient, with Fitzpatrick type 1 skin and minimal actinic damage, had presented for a routine skin check with no previous history of skin cancers. At the age of 17 she had received chemotherapy and radiotherapy for Ewing’s sarcoma of the right hip with pulmonary metastases. The skin lesion was assessed as dermatoscopically symmetrical and was not predicted as a melanoma by any algorithmic method. The provisional diagnosis of melanoma was made on the basis that this lesion was completely different in dermatoscopic pattern to her other nevi, a dermatoscopic “ugly duckling” lesion. We draw attention to the recently established link between defects in the STAG2 gene and Ewing’s sarcoma, glioblastoma and melanoma.

Identifying Persons at Highest Risk of Melanoma Using Self-Assessed Risk Factors

OBJECTIVE: To develop a self-assessed melanoma risk score to identify high-risk persons for screening METHODS: We used data from a 1997 melanoma case-control study from Washington State, USA, where 386 cases with invasive cutaneous melanoma and 727 controls were interviewed by telephone. A logistic regression prediction model was developed on 75% of the data and validated in the remaining 25% by calculating the area under the receiver operating characteristic curve (AUC), a measure of predictive accuracy from 0.5-1 (higher scores indicating better prediction). A risk score was calculated for each individual, and sensitivities for various risk cutoffs were calculated. RESULTS: The final model included sex, age, hair color, density of freckles, number of severe sunburns in childhood and adolescence, number of raised moles on the arms, and history of non-melanoma skin cancer. The area under the receiver operating characteristic curve(AUC) was 0.70 (95% CI: 0.64, 0.77). The top 15% risk group included 50% of melanomas (sensitivity 50%). CONCLUSIONS: This self-assessed score could be used as part of a comprehensive melanoma screening and public education program to identify high-risk individuals in the general population. This study suggests it may be possible to capture a large proportion of melanomas by screening a small high-risk group. Further study is needed to determine the costs, feasibility, and risks of this approach.

Multicenter case-control study of risk factors for cutaneous melanoma in Valencia, Spain

INTRODUCTION

It is important to identify subgroups within the general population that have an elevated risk of developing cutaneous melanoma because preventive and early-detection measures are useful in this setting. The findings of most studies that have evaluated risk factors for cutaneous melanoma are of limited application in Spain because the populations studied have different pigmentary traits and are subject to different environmental factors.

OBJECTIVE

To identify the phenotypic characteristics and amount of exposure to sunlight that constitute risk factors for cutaneous melanoma in the population of the Autonomous Community of Valencia, Spain.

METHODS

We performed a multicenter observational case-control study. In total, the study included 242 patients with melanoma undergoing treatment in 5 hospitals and 173 controls enrolled from among the companions of the patients between January 2007 and June 2008. The information was collected by means of a standardized, validated questionnaire. The odds ratio (OR) was calculated for each variable and adjusted using a multiple logistic regression model.

RESULTS

The risk factors found to be statistically significant were skin phototypes I and II, blond or red hair, light eye color, abundant melanocytic nevi, and a personal history of actinic keratosis or nonmelanoma skin cancer. After the multivariate analysis, only blond or red hair (OR=1.9), multiple melanocytic nevi (OR=3.1), skin phototypes i and ii (OR=2.1), and a personal history of actinic keratosis (OR=3.5) or nonmelanoma skin cancer (OR=8.1) maintained significance in the model as independent predictive variables for melanoma.

CONCLUSIONS

Our study supports the importance of certain factors that indicate genetic predisposition (hair color and skin phototype) and environmental factors associated with exposure to sunlight. Patients with multiple acquired melanocytic nevi and patients with markers of chronic skin sun damage (actinic keratosis and nonmelanoma cancer) presented a significant increase in risk.

Malignant melanoma as second malignant neoplasm in long-term childhood cancer survivors: a systematic review

This systematic review provides information on malignant melanoma as second malignant neoplasm (SMN) after childhood cancer and evaluates its risk factors. Study reports describing incidences of SMN and malignant melanoma as SMN in a population of childhood cancer survivors (CCS) were included. Of 151,575 CCS, 4,010 (2.6%) children developed an SMN, 212 of which were melanoma (5.3% or 0.14% of all CCS). The following risk factors for malignant melanoma as SMN were identified: radiotherapy, or the combination alkylating agents and anti-mitotic drugs. Melanomas are most frequently observed after Hodgkin disease, hereditary retinoblastoma, soft tissue sarcoma, and gonadal tumors.

Outdoor sports and risk of ultraviolet radiation-related skin lesions in children: evaluation of risks and prevention

BACKGROUND

Excessive ultraviolet (UV) radiation exposure can cause skin cancers, skin photoageing and cataracts. Children are targeted by sun-protection campaigns because high sun exposure and sunburn in childhood increase the risk of melanoma in adulthood. Little information is available about UV radiation risk and exposure in children who take part in outdoor sports.

OBJECTIVE

To evaluate the risk of developing UV radiation-induced skin lesions run by children who practise outdoor sports, and UV radiation exposure and sun-protection measures during a soccer tournament.

METHODS

Firstly, we evaluated the relationship between melanocytic naevus - a skin lesion linked with exposure to UV radiation - and outdoor sports in 660 11-year-old children. Secondly, we used the occasion of a 1-day soccer tournament held in the spring to evaluate UV radiation-protective measures used by soccer players and the public. We also evaluated the UV radiation index and cloud cover during the tournament, and calculated the UV radiation dose and minimal erythema dose depending on skin phototype.

RESULTS

The naevus count and acquired naevus count measured over the 2 years of the study were higher in the 344 children who practised outdoor sports. Sun-protective measures were insufficient for soccer players and the public.

CONCLUSIONS

This study shows that outdoor sports increase the risk of developing UV radiation-induced skin lesions in childhood. During a 1-day soccer tournament held in the spring, children and their parents were inadequately protected against the sun. These results suggest that sun-protection campaigns should be aimed at children who practise popular outdoor sports.

Neonatal blue light phototherapy and melanocytic nevi: a twin study

BACKGROUND

Neonatal blue light phototherapy (NBLP) has been widely and successfully used for the treatment of neonatal jaundice to reduce the plasma concentration of bilirubin and, hence, to prevent kernicterus. Only a few and controversial data are available in the literature as to how NBLP influences melanocytic nevus development.

OBJECTIVE

Our goal was to conduct a twin study with the aim of better understanding the role of NBLP in melanocytic nevus development. We also investigated the roles of other environmental and constitutional factors in nevus formation.

METHODS

Fifty-nine monozygotic and dizygotic twins were included in this cross-sectional study. One of the twin members received NBLP, and the other did not. A whole-body skin examination was performed to determine the density of melanocytic skin lesions. The prevalence of benign pigmented uveal lesions was evaluated during a detailed ophthalmologic examination. A standardized questionnaire was used to assess data relating to constitutional, sun-exposure, and other variables. To search for possible gene-environmental interactions involved in the appearance of pigmented lesions, the melanocortin 1 receptor variants and the I439V polymorphism of histidine ammonia-lyase genes were also determined in the enrolled twins.

RESULTS

NBLP was associated with a significantly higher prevalence of both cutaneous and uveal melanocytic lesions. No association was found between the examined gene polymorphisms and the number of pigmented alterations in the examined study group.

CONCLUSIONS

Our data suggest that NBLP could well be a risk factor for melanocytic nevus development. Phototherapy with blue-light lamps is a standard and essential therapeutic modality in neonatal care; therefore, additional in vivo and in vitro studies are necessary to establish its potential long-term adverse effects.

Melanoma in association with acquired melanocytic nevus in Japan: a review of cases in the literature

BACKGROUND

Malignant melanomas clinically and/or histologically associated with melanocytic nevi have been reported worldwide. Approximately 20% of malignant melanomas in Caucasians, most of which are found on the trunk and proximal extremities, develop in association with pre-existing melanocytic nevi. In Japan, however, over half of all melanomas are acral lentiginous melanomas (ALMs) on the hands and feet; melanomas on sun-exposed areas are seen less frequently in Japanese people than in Caucasians. As ALMs are not usually accompanied by melanocytic nevi and there have been no reviews of the literature or statistical data regarding Japanese cases of melanomas with melanocytic nevi, dermatologists in Japan have few opportunities to see melanomas associated with pre-existing melanocytic nevi.

METHODS

Here we report a case of a superficial spreading melanoma that was formed on a melanocytic nevus on the trunk, and we review for the first time the case reports from the Japanese literature.

RESULTS AND CONCLUSIONS

With regard to the reported cases, melanomas associated with melanocytic nevi were mainly superficial spreading melanomas and nodular melanomas on the trunk or extremities; ALMs were rarely associated with nevi, indicating a trend similar to that observed in Caucasians. These findings suggest that the low frequency of associations between melanomas and melanocytic nevi in Japan reflects racial differences in the frequencies of each type of melanoma.

Compliance with Self-Examination Surveillance in Patients with Melanoma and Atypical Moles: An Anonymous Questionnaire Study

Background:

Regular skin self-examination is suggested as a means to detect melanomas at an early stage and thus improve prognosis. Compliance, however, has seldom been assessed in a routine clinical setting and anonymously.

Objectives:

To assess compliance with self-examination in patients with either a previous melanoma or atypical moles (dysplastic nevi) and to examine the perceived utility of supplied photographs.

Methods:

An anonymous questionnaire was sent to all patients seen with either a melanoma or atypical moles between the years 1995 and 2005. The melanoma cohort consisted of 143 patients. There were 440 patients with atypical moles.

Results:

Replies to the questionnaire were received from 94 of the melanoma patients and from 185 patients in the atypical mole cohort. Only 22% (12) in the melanoma group performed a total skin examination monthly. Fewer than 10% of those with atypical moles did a monthly skin examination, but about half of the patients examined their entire skin more than once a year.

Conclusion:

Self-examination is practiced in the majority of patients with either a previous melanoma or atypical moles. Those doing this on a regular monthly basis are a small minority.