Cutaneous melanoma with nodal metastases in elderly people

Age-related transcriptome changes in melanoma patients with tumor-positive sentinel lymph nodes

Age is an important factor for determining the outcome of melanoma patients. Sentinel lymph node (SLN) status is also a strong predictor of survival for melanoma. Paradoxically, older melanoma patients have a lower incidence of SLN metastasis but a higher mortality rate when compared with their younger counterparts. The mechanisms that underlie this phenomenon remain unknown. This study uses three independent datasets of RNA samples from patients with melanoma metastatic to the SLN to identify age-related transcriptome changes in SLNs and their association with outcome. Microarray was applied to the first dataset of 97 melanoma patients. NanoString was performed in the second dataset to identify the specific immune genes and pathways that are associated with recurrence in younger versus older patients. qRT-PCR analysis was used in the third dataset of 36 samples to validate the differentially expressed genes (DEGs) from microarray and NanoString. These analyses show that FOS, NR4A, and ITGB1 genes were significantly higher in older melanoma patients with positive SLNs. IRAK3- and Wnt10b-related genes are the major pathways associated with recurrent melanoma in younger and older patients with tumor-positive SLNs, respectively. This study aims to elucidate age-related differences in SLNs in the presence of nodal metastasis.

Epidemiology and survival outcomes in stages II and III cutaneous melanoma: a systematic review

Aim

Management of cutaneous melanoma (CM) is continually evolving with adjuvant treatment of earlier stage disease. The aim of this review was to identify published epidemiological data for stages II-III CM.

Materials & methods

Systematic searches of Medline and Embase were conducted to identify literature reporting country/region-specific incidence, prevalence, survival or mortality outcomes in stage II and/or III CM. Screening was carried out by two independent reviewers.

Results & conclusion

Of 41 publications, 14 described incidence outcomes (incidence rates per stage were only reported for US and Swedish studies), 33 reported survival or mortality outcomes and none reported prevalence data. This review summarizes relevant data from published literature and highlights an overall paucity of epidemiological data in stages II and III CM.

Prognostic factors for metastasis in cutaneous melanoma

BACKGROUND

Melanoma is a malignant neoplasia that shows high mortality when diagnosed in advanced stages. Early identification of high-risk patients for the development of melanoma metastases is the main strategy to reduce mortality.

OBJECTIVE

To assess the influence of eight epidemiological and histopathologic features on the development of metastases in patients diagnosed with primary cutaneous melanoma.

METHODS

Our historical cohort comprised patients with invasive primary cutaneous melanoma seen between 1995 and 2012 at a public university hospital and a private oncologic surgery institution in Southeastern Brazil. The following variables were analyzed: gender, age, family history of melanoma, site of the primary tumor, clinical and histologic subtype, Breslow thickness, histologic ulceration and the mitotic index. Kaplan-Meier univariate test and multivariate Cox proportional hazard analysis were used to assess factors associated with disease-free survival.

RESULTS

Five hundred and fourteen patients were enrolled. The univariate analysis identified the following significant risk factors: gender, age, site of the tumor, clinical and histologic subtype, Breslow thickness, histologic ulceration and mitotic index. Multivariate analysis included 244 patients and detected four significant prognostic factors: male gender, nodular clinical and histologic subtype, Breslow thickness > 4mm, and histologic ulceration. The mitotic index was not included in this analysis.

STUDY LIMITATIONS

Small number of patients in multivariate analysis.

CONCLUSIONS

The following prognostic factors to the development of melanoma metastasis were identified in the study: male gender, nodular histologic subtype, Breslow thickness > 4mm and ulceration.

Patient age and cutaneous malignant melanoma: Elderly patients are likely to have more aggressive histological features and poorer survival

Patient age has been reported as a highly significant and strong predictor of the outcome in patients with cutaneous melanoma. The aim of the present study was to determine the clinical significance of patient age in Turkish patients with cutaneous melanoma. A total of 1,169 patients with pathologically proven cutaneous melanoma were enrolled. Age of patients was classified as young (<40 years), middle-aged (40-59 years) and old (≥60 years). The median age of the patients was 51 years (range, 16-104 years). Non-superficial spreading histology was significantly more observed in old patients than in the other age groups (P<0.001). A lower Clark invasion level was significantly more observed in young patients compared with the other age groups (P=0.013) and higher levels were significantly more observed in older patients compared with the other age groups (P=0.002). Furthermore, the rate of thin Breslow depth was significantly higher in young patients compared with others (P=0.038). Although a lower mitotic rate was observed predominantly in young patients compared with others (P=0.007), ulceration was significantly more present in older patients (P<0.001) and absent in the young patients (P=0.003). Patient age was not significantly associated with relapse-free survival (P=0.327), whereas a significant correlation was demonstrated for overall survival (OS) (P=0.007). The old patients had poorer survival compared with the other ages (P=0.009 for young patients and P=0.012 for middle-aged patients). However, patient age did not remain significant for OS in multivariate analysis (P=0.768). In conclusion, although patient age does not have a significant predictive role on nodal involvement, recurrence and metastasis, an age of ≥60 years may be associated with more aggressive histological features and poorer outcome in patients with cutaneous melanoma.

Melanoma early detection and awareness: how countries developing melanoma awareness programs could benefit from melanoma-proficient countries

Risk factors for melanoma are well known and have guided plans for primary and secondary prevention. The presentation of the disease, however, varies widely depending on the geographic area, ethnicity, and socioeconomic status. For this reason, many countries have developed specific strategies to increase public awareness and favor early diagnosis. Awareness campaigns, doctor education, and screening of high-risk subjects have all contributed to improve disease outcome in developed countries. The role of primary care physicians is particularly relevant in this regard. Developing countries are trying to implement similar measures. Future efforts to further improve the efficacy of preventive strategies should focus on populations that usually escape campaigns, such as elderly men and people with low socioeconomic status. Fast-growing tumors also require specific attention.

Molecular alterations in clinical stage III cutaneous melanoma: Correlation with clinicopathological features and patient outcome

The aim of the present study was to evaluate the frequency and type of oncogenic v-raf murine sarcoma viral oncogene homolog B1 (BRAF)/neuroblastoma RAS viral (v-ras) oncogene homolog (NRAS) mutations in cutaneous melanoma with clinically detected nodal metastases (stage IIIB and C) in relation to clinicopathological features and outcome. The clinicopathological data of 250 patients following therapeutic lymphadenectomy (LND) between 1995 and 2010, as well as BRAF/NRAS mutational status in corresponding nodal metastases, were analyzed. The median follow-up time was 53 months. BRAF mutations were detected in 154 (62%) cases (141 p.V600E, nine p.V600K and four others) and mutually exclusive NRAS mutations were detected in 42 (17%) cases. The presence of a BRAF mutation was found to correlate with patients of a younger age. The five-year overall survival (OS) rate was 33 and 43% for LND and primary tumor excision, respectively, and the five-year disease-free survival (DFS) rate for LND was 25%. No correlation was identified between BRAF/NRAS mutational status and RFS or OS (calculated from the date of the LND and primary tumor excision); for BRAF- and NRAS-mutated melanoma, the prognosis was the same for patients with wild-type (WT) melanoma. The important factors which had a negative impact on OS and DFS were as follows: Male gender, >1 metastatic lymph node and extracapsular extension of nodal metastases. The interval between the diagnosis of the initial melanoma to regional nodal metastasis (median, 10 months) was not significantly different between BRAF-mutant and -WT patients. Our largest comprehensive molecular analysis of clinical stage III melanoma revealed that BRAF and NRAS mutational status is not a prognostic marker in stage III melanoma patients with macroscopic nodal involvement, but may have implications for potential adjuvant therapy.

Superior Outcome of Women With Stage I/II Cutaneous Melanoma: Pooled Analysis of Four European Organisation for Research and Treatment of Cancer Phase III Trials

Purpose

Several studies observed a female advantage in the prognosis of cutaneous melanoma, for which behavioral factors or an underlying biologic mechanism might be responsible. Using complete and reliable follow-up data from four phase III trials of the European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group, we explored the female advantage across multiple end points and in relation to other important prognostic indicators.

Patients and Methods

Patients diagnosed with localized melanoma were included in EORTC adjuvant treatment trials 18832, 18871, 18952, and 18961 and randomly assigned during the period of 1984 to 2005. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% CIs for women compared with men, adjusted for age, Breslow thickness, body site, ulceration, performed lymph node dissection, and treatment.

Results

A total of 2,672 patients with stage I/II melanoma were included. Women had a highly consistent and independent advantage in overall survival (adjusted HR, 0.70; 95% CI, 0.59 to 0.83), disease-specific survival (adjusted HR, 0.74; 95% CI, 0.62 to 0.88), time to lymph node metastasis (adjusted HR, 0.70; 95% CI, 0.51 to 0.96), and time to distant metastasis (adjusted HR, 0.69; 95% CI, 0.59 to 0.81). Subgroup analysis showed that the female advantage was consistent across all prognostic subgroups (with the possible exception of head and neck melanomas) and in pre- and postmenopausal age groups.

Conclusion

Women have a consistent and independent relative advantage in all aspects of the progression of localized melanoma of approximately 30%, most likely caused by an underlying biologic sex difference.