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Orme SE, Moncrieff MD. A Review of Contemporary Guidelines and Evidence for Wide Local Excision in Primary Cutaneous Melanoma Management. Cancers (Basel) 2024; 16:895. [PMID: 38473257 DOI: 10.3390/cancers16050895] [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: 01/17/2024] [Revised: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
Surgical wide local excision (WLE) remains the current standard of care for primary cutaneous melanoma. WLE is an elective procedure that aims to achieve locoregional disease control with minimal functional and cosmetic impairment. Despite several prospective randomised trials, the optimal extent of excision margin remains controversial, and this is reflected in the persistent lack of consensus in guidelines globally. Furthermore, there is now the added difficulty of interpreting existing trial data in the context of the evolving role of surgery in the management of melanoma, with our increased understanding of clinicopathologic and genomic prognostic markers leading to the often routine use of sentinel node biopsy (SNB) as a staging procedure, in addition to the development of adjuvant systemic therapies for high-risk disease. An ongoing trial, MelMarT-II, has been designed with the aim of achieving a definitive answer to guide this fundamental surgical decision.
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Affiliation(s)
- Sophie E Orme
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Marc D Moncrieff
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
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2
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Lozada WA, Enokihara MM, Pedrosa MS, Gonzaga AL, Wainstein AJ, Drummond-Lage AP. Impact of second histopathological review of melanocytic skin lesions at a melanoma reference center in Brazil. Ital J Dermatol Venerol 2023; 158:49-54. [PMID: 36800805 DOI: 10.23736/s2784-8671.23.07494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND After the biopsy of a suspicious melanocytic lesion, patients depend on the pathologist's precision of specimen evaluation. METHODS We assessed the agreement between histopathological reports made by general pathologists and reviewed by a dermatopathologist to evaluate the impact on the patient's management. RESULTS In 79 cases analyzed, underdiagnosis was observed in 21.6% and overdiagnosis in 17.7%, resulting in changes in the patients' conduct. The assessment of the Clark level, ulceration and histological type showed mild agreement (P<0.001); the Breslow thickness, surgical margin, and staging showed moderate agreement (P<0.001). CONCLUSIONS A dermatopathologist's review should be incorporated into the routine of reference services for pigmented lesions.
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Affiliation(s)
- Walter A Lozada
- Department of Post-Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | - Milvia M Enokihara
- Department of Pathology, Federal University of São Paulo, São Paulo, Brazil
| | - Moises S Pedrosa
- Department of Post-Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | - Ana L Gonzaga
- Department of Post-Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | - Alberto J Wainstein
- Department of Post-Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | - Ana P Drummond-Lage
- Department of Post-Graduation, Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil -
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3
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Jacklin C, Tan M, Sravanam S, Harrison C. Appraisal of International Guidelines for Cutaneous Melanoma Management using the AGREE II assessment tool. JPRAS Open 2022; 31:114-122. [PMID: 35024406 PMCID: PMC8732330 DOI: 10.1016/j.jpra.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/17/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The evidence base behind new melanoma treatments is rapidly accumulating. This is not necessarily reflected in current guidance. A recent UK-based expert consensus statement, published in JPRAS, has called for updates to the widely accepted 2015 National Institute for Health and Care Excellence (NICE) guideline for melanoma (NG14). We aimed to compare the quality of NG14 to all other melanoma guidelines published since. METHODS We conducted a systematic search of PubMed, Medline, and online clinical practice guideline databases to identify melanoma guidelines published between 29th July 2015 and 23rd August 2021 providing recommendations for adjuvant treatment, radiotherapy, surgical management, or follow-up care. Three authors independently assessed the quality of identified guidelines using the Appraisal of Guidelines for Research & Evaluation Instrument II (AGREE II) assessment tool, which measures six domains of guideline development. Inter-rater reliability was assessed by Kendall's coefficient of concordance (W). RESULTS Twenty-nine guidelines were included and appraised with excellent concordance (Kendall's W for overall guideline score 0.88, p<0.001). Overall, melanoma guidelines scored highly in the domains of 'Scope and purpose' and 'Clarity of presentation', but poorly in the 'Applicability' domain. The NICE guideline on melanoma (NG14) achieved the best overall scores. CONCLUSION Melanoma treatment has advanced since NG14 was published, however, the NICE melanoma guideline is of higher quality than more recent alternatives. The planned update of NG14 in 2022 is in demand.
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Affiliation(s)
- C. Jacklin
- Medical Sciences Divisional Office, University of Oxford, Level 3, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - M. Tan
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London
| | - S. Sravanam
- Medical Sciences Divisional Office, University of Oxford, Level 3, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - C.J. Harrison
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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4
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Melanoma In Situ: A Critical Review and Re-Evaluation of Current Excision Margin Recommendations. Adv Ther 2021; 38:3506-3530. [PMID: 34047915 PMCID: PMC8280024 DOI: 10.1007/s12325-021-01783-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/07/2021] [Indexed: 11/02/2022]
Abstract
Most international clinical guidelines recommend 5-10 mm clinical margins for excision of melanoma in situ (MIS). While the evidence supporting this is weak, these guidelines are generally consistent. However, as a result of the high incidence of subclinical extension of MIS, especially of the lentigo maligna (LM) subtype, wider margins will often be needed to achieve complete histologic clearance. In this review, we assessed all available contemporary evidence on clearance margins for MIS. No randomized trials were identified and the 31 non-randomized studies were largely retrospective reviews of single-surgeon or single-institution experiences using Mohs micrographic surgery (MMS) for LM or staged excision (SE) for treatment of MIS on the head/neck and/or LM specifically. The available data challenge the adequacy of current international guidelines as they consistently demonstrate the need for clinical margins > 5 mm and often > 10 mm. For LM, any MIS on the head/neck, and/or ≥ 3 cm in diameter, all may require wider clinical margins because of the higher likelihood of subclinical spread. Histologic clearance should be confirmed prior to undertaking complex reconstruction. However, it is not clear whether wider margins are necessary for all MIS subtypes. Indeed, it seems that this is unlikely to be the case. Until optimal surgical margins can be better defined in a randomized trial setting, ideally controlling for MIS subtype and including correlation with histologic excision margins, techniques such as preliminary border mapping of large, ill-defined lesions and, most importantly, sound clinical judgement will be needed when planning surgical clearance margins for the treatment of MIS.
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5
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Wurcel V, Scherrer E, Aguiar-Ibanez R, Altuna JI, Carabajal F, Jain S, Baluni G. Cost-Effectiveness of Pembrolizumab for the Adjuvant Treatment of Melanoma Patients with Lymph Node Involvement Who Have Undergone Complete Resection in Argentina. Oncol Ther 2021; 9:167-185. [PMID: 33624271 PMCID: PMC8140053 DOI: 10.1007/s40487-021-00142-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/23/2021] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The KEYNOTE-054 trial demonstrated that adjuvant pembrolizumab improves recurrence-free survival in completely resected stage III melanoma versus watchful waiting (hazard ratio [HR] = 0.57; 98.4% confidence interval [CI], 0.43-0.74). We evaluated the cost-effectiveness of pembrolizumab in Argentina, where watchful waiting is still widely used among these patients despite the high risk of recurrence with surgery alone. METHODS A four-health state model was used (recurrence-free, locoregional recurrence [LR], distant metastases [DM], death). Lifetime medical costs to payers (72.08 Argentine pesos [AR$] = 1.00 U.S. dollar [USD]) and outcomes (3% annual discount) were assessed, together with incremental cost-effectiveness ratios (ICERs). First and LR→DM recurrences were modeled using KEYNOTE-054 and real-world data, respectively. No benefits of adjuvant treatment were assumed post-progression. Pre-DM and post-DM mortality was based on KEYNOTE-054 and on a network meta-analysis of advanced treatments expected in each arm, respectively. Utilities were derived from KEYNOTE-054 Euro-QoL data using an Argentinian algorithm, and from the literature. Public ex-factory drug prices were used. RESULTS Patients in the pembrolizumab and the watchful waiting arms accrued 8.78 and 5.83 quality-adjusted life-years (QALYs), 9.91 and 6.98 life-years, and costs of AR$12,698,595 (176,174 USD) and AR$11,967,717 (166,034 USD), respectively. The proportion of life-years accrued that were recurrence-free was 80.8% and 56.9% in the pembrolizumab and the watchful waiting arms, respectively. Pembrolizumab patients gained 2.94 life-years and 2.96 QALYs versus watchful waiting; the ICER per QALY was AR$247,094 (3428 USD). Recurrence rates and advanced melanoma treatments were the key drivers of the ICER. At a threshold of AR$1,445,325 (29,935 USD) per QALY, pembrolizumab had an 83.5% probability of being cost-effective versus watchful waiting. CONCLUSIONS Adjuvant pembrolizumab after complete resection of melanoma with node involvement is highly cost-effective relative to watchful waiting in Argentina, across disease stage subgroups and BRAF mutational status. This strongly supports its coverage and reimbursement across the entire health system.
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Affiliation(s)
| | | | | | | | | | - Shrishti Jain
- Complete HEOR Solutions, CHEORS, North Wales, PA, USA
| | - Gargi Baluni
- Complete HEOR Solutions, CHEORS, North Wales, PA, USA
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6
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Hughes TM, Williams GJ, Gyorki DE, Kelly JW, Stretch JR, Varey AHR, Hong AM, Scolyer RA, Thompson JF. Desmoplastic melanoma: a review of its pathology and clinical behaviour, and of management recommendations in published guidelines. J Eur Acad Dermatol Venereol 2021; 35:1290-1298. [PMID: 33544941 DOI: 10.1111/jdv.17154] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/08/2021] [Indexed: 12/15/2022]
Abstract
Desmoplastic melanomas are uncommon. Their behaviour differs from that of other melanoma subtypes; therefore, management guidelines for non-desmoplastic melanomas may not be applicable. This review sought to examine all available evidence relating to the behaviour and management of desmoplastic melanomas, based on review of all relevant English-language publications, and to critically assess the recommendations for their management in current published melanoma management guidelines. Compared with other melanoma subtypes, patients with 'pure' desmoplastic melanomas (where ≥90% of the invasive melanoma is of desmoplastic melanoma subtype) have much lower rates of sentinel node positivity and distant metastasis. Local recurrence rates are higher for desmoplastic melanomas, but resection margins wider than those recommended for non-desmoplastic melanomas have not been shown to be of benefit. Adjuvant radiotherapy reduces the risk of local recurrence when a satisfactory histological clearance (≥8 mm) cannot be achieved. Of 29 published melanoma management guidelines identified, only 11 specified management for desmoplastic melanomas, while seven simply stated that the feature should be reported. Desmoplastic melanoma is a unique melanoma subtype with biology that differs from that of other melanoma subtypes. It requires specific management strategies but few current guidelines address these.
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Affiliation(s)
- T M Hughes
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Sydney Adventist Hospital, Sydney, NSW, Australia
| | - G J Williams
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - D E Gyorki
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Peter MacCallum Cancer Centre, Melbourne, Vic., Australia
| | - J W Kelly
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Victorian Melanoma Service, Alfred Hospital, Melbourne, Vic., Australia
| | - J R Stretch
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - A H R Varey
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Sydney, NSW, Australia
| | - A M Hong
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - R A Scolyer
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Sydney, NSW, Australia.,NSW Health Pathology, Sydney, NSW, Australia
| | - J F Thompson
- Cancer Council Australia Melanoma Guidelines Working Party, Sydney, NSW, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Sydney, NSW, Australia
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7
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Trindade FM, de Freitas MLP, Bittencourt FV. Dermoscopic evaluation of superficial spreading melanoma. An Bras Dermatol 2021; 96:139-147. [PMID: 33637398 PMCID: PMC8007484 DOI: 10.1016/j.abd.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/28/2020] [Indexed: 11/08/2022] Open
Abstract
Background Dermoscopy increases the sensitivity of the diagnosis of melanoma, leading to its early identification and increasing the chances of cure. Objective To describe the clinical and dermoscopic characteristics of superficial spreading melanomas, and to detect the differences between in situ and invasive 1-mm thick melanomas. Methods This was a cross-sectional study in which dermoscopic images of 58 melanomas, grouped according to their thickness, were evaluated. Results 24 in situ melanomas were evaluated, 28 invasive melanomas with Breslow ≤ 1 mm (0.50 ± 0.22 mm) and six with Breslow > 1 mm (2.35 ± 2.02 mm). In situ melanomas were smaller than invasive melanomas. The most commonly found dermoscopic criteria were asymmetry (84.5%), three or more colors (81.0%), and atypical network (79.3%). A non-specific pattern was more common in in situ melanomas (p = 0.028) and atypical network in invasive melanomas with Breslow 1 mm presented inverted network (p = 0.018). Study limitations The sample was selected by convenience, since it was necessary to have a preoperative photo of the tumor, which may have led to the loss of clinically less significant lesions, as well as those highly suggestive of melanoma. Conclusions Melanomas in early stages showed a more frequent nonspecific pattern and atypical network, while invasive melanomas showed a multicomponent pattern, three or more colors, and an inverted network.
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Affiliation(s)
| | | | - Flávia Vasques Bittencourt
- Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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8
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de la Fouchardiere A, Blokx W, van Kempen LC, Luzar B, Piperno-Neumann S, Puig S, Alos L, Calonje E, Massi D. ESP, EORTC, and EURACAN Expert Opinion: practical recommendations for the pathological diagnosis and clinical management of intermediate melanocytic tumors and rare related melanoma variants. Virchows Arch 2021; 479:3-11. [PMID: 33432480 DOI: 10.1007/s00428-020-03005-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/17/2020] [Accepted: 12/21/2020] [Indexed: 01/17/2023]
Abstract
The recent WHO classification of skin tumors has underscored the importance of acknowledging intermediate grade melanocytic proliferations. A multistep acquisition of oncogenic events drives the progressive transformation of nevi into melanomas. The various pathways described are modulated by the initial oncogenic drivers that define the common, blue, and Spitz nevi groups. Intermediate lesions are most often the result of a clonal evolution within such nevi. Based on this established classification, we have suggested for each pathway a practical diagnostic approach, benefiting from the recently developed molecular tools, both in the setting of general pathology labs and expert centers. Moreover, recommendations regarding the re-excision and clinical follow-up are given to support decision-making in multidisciplinary tumor boards.
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Affiliation(s)
| | - Willeke Blokx
- Department of Pathology, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center, Utrecht, The Netherlands
| | - Léon C van Kempen
- Faculty of Medical Sciences, University Medical Center Groningen, Department of Pathology & Medical Biology, University of Groningen, Groningen, The Netherlands
| | - Boštjan Luzar
- Institute of Pathology, Medical Faculty University of Ljubljana, Ljubljana, Slovenia
| | - Sophie Piperno-Neumann
- Department of Medical Oncology, Institut Curie, 75005, Paris, France.,EURACAN network member (rare skin and eye melanoma domain), Leiden, The Netherlands
| | - Susana Puig
- Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.,Institut d'Investigació Biomèdica August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica En Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Llucia Alos
- Institut d'Investigació Biomèdica August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Department of Pathology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Eduardo Calonje
- Department of Dermatopathology, St John's Institute of Dermatology, St Thomas' Hospital, London, UK.
| | - Daniela Massi
- Section of Anatomic Pathology, Department of Health Sciences, University of Florence, Florence, Italy
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Steeb T, Wessely A, Drexler K, Salzmann M, Toussaint F, Heinzerling L, Reinholz M, Berking C, Heppt MV. The Quality of Practice Guidelines for Melanoma: A Methodologic Appraisal with the AGREE II and AGREE-REX Instruments. Cancers (Basel) 2020; 12:cancers12061613. [PMID: 32570843 PMCID: PMC7352745 DOI: 10.3390/cancers12061613] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/21/2022] Open
Abstract
Multiple guidelines on cutaneous melanoma (CM) are available from several consortia and countries. To provide up-to-date guidance in the rapidly changing field of melanoma treatment, guideline developers have to provide regular updates without compromises of quality. We performed a systematic search in guideline databases, Medline and Embase to identify guidelines on CM. The methodological quality of the identified guidelines was independently assessed by five reviewers using the instruments “Appraisal of Guidelines for Research and Evaluation” (AGREE II) and “Recommendation EXcellence” (AGREE-REX). We performed descriptive analysis, explored subgroup differences using the Kruskal–Wallis (H) test and examined the relationship between distinct domains and items of the instruments with Spearman’s correlation. Six guidelines by consortia from Australia, France, Germany, Scotland, Spain and the United States of America were included. The German guideline fulfilled 71%–98% of criteria in AGREE II and 78%–96% for AGREE-REX, obtaining the highest scores. Deficiencies in the domains of “applicability” and “values and preferences” were observed in all guidelines. The German and Spanish guidelines significantly differed from each other in most of the domains. The domains “applicability” and “values and preferences” were identified as methodological weaknesses requiring careful revision and improvement in the future.
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Affiliation(s)
- Theresa Steeb
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (T.S.); (A.W.); (F.T.); (L.H.); (C.B.)
- Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), 91054 Erlangen, Germany
| | - Anja Wessely
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (T.S.); (A.W.); (F.T.); (L.H.); (C.B.)
- Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), 91054 Erlangen, Germany
| | - Konstantin Drexler
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Martin Salzmann
- Department of Dermatology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Frédéric Toussaint
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (T.S.); (A.W.); (F.T.); (L.H.); (C.B.)
- Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), 91054 Erlangen, Germany
| | - Lucie Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (T.S.); (A.W.); (F.T.); (L.H.); (C.B.)
- Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), 91054 Erlangen, Germany
| | - Markus Reinholz
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian University, 80337 Munich, Germany;
| | - Carola Berking
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (T.S.); (A.W.); (F.T.); (L.H.); (C.B.)
- Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), 91054 Erlangen, Germany
| | - Markus V. Heppt
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (T.S.); (A.W.); (F.T.); (L.H.); (C.B.)
- Comprehensive Cancer Center Erlangen-European Metropolitan Area of Nürnberg (CCC ER-EMN), 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-9131-85-35747
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10
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Keppeke GD, Barcelos D, Fernandes M, Comodo AN, Guimarães DP, Cardili L, Carapeto FCL, Andrade LEC, Landman G. IMP dehydrogenase rod/ring structures in acral melanomas. Pigment Cell Melanoma Res 2020; 33:490-497. [PMID: 31883196 DOI: 10.1111/pcmr.12854] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/19/2019] [Accepted: 12/23/2019] [Indexed: 12/24/2022]
Abstract
Acral lentiginous melanoma (ALM) is a rare subtype of melanoma with aggressive behavior. IMPDH enzyme, involved in de novo GTP biosynthesis, has been reported to assemble into large filamentary structures called rods/rings (RR) or cytoophidium (cellular snakes). RR assembly induces a hyperactive state in IMPDH, usually to supply a high demand for GTP nucleotides, such as in highly proliferative cells. We investigate whether aggressive melanoma tumor cells present IMPDH-based RR structures. Forty-five ALM paraffin-embedded tissue samples and 59 melanocytic nevi were probed with anti-IMPDH2 antibody. Both the rod- and ring-shaped RR could be observed, with higher frequency in ALM. ROC curve analyzing the proportions of RR-positive cells in ALM versus nevi yielded a 0.88 AUC. Using the cutoff of 5.5% RR-positive cells, there was a sensitivity of 80% and specificity of 85% for ALM diagnosis. In ALM, 36 (80%) showed RR frequency above the cutoff, being classified as RR-positive, compared with only 9 (15%) of the nevi (p < .001). Histopathology showed that 71% of the RR-positive specimens presented Breslow thickness > 4.0mm, compared with only 29% in the RR-low/negative (p = .039). We propose that screening for RR structures in biopsy specimens may be a valuable tool helping differentiate ALM from nevi and accessing tumor malignancy.
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Affiliation(s)
- Gerson D Keppeke
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Denise Barcelos
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mariana Fernandes
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Andréia N Comodo
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Daiane P Guimarães
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Leonardo Cardili
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Fernando C L Carapeto
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis E C Andrade
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gilles Landman
- Department of Pathology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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11
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Suzuki NM, Saraiva MIR, Capareli GC, Castro LGM. Histologic review of melanomas by pathologists trained in melanocytic lesions may change therapeutic approach in up to 41.9% of cases. An Bras Dermatol 2018; 93:752-754. [PMID: 30156634 PMCID: PMC6106672 DOI: 10.1590/abd1806-4841.20187209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022] Open
Abstract
Melanoma Guidelines of the Brazilian Dermatology Society recommend histologic review by pathologists trained in melanocytic lesions whenever possible. Out of 145 melanoma cases identified at a private clinic in São Paulo/Brazil, 31 that had been submited to histologic review were studied to evaluate whether revision had led to change in therapeutic approach.. Differences in original/reviewed reports were found in 58.1% (n=18) of the reports, leading to changes in therapeutic approach in 41.9% (n=13). Change in diagnosis was observed in 6 out of 31 (19,3%) cases. These findings suggest that second opinion by pathologists trained in melanocytic lesions is likely to show significant differences from the original report.
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Affiliation(s)
| | - Maria Isabel Ramos Saraiva
- Oncoderma, São Paulo (SP), Brazil
- Center for Cutaneous Oncology, Hospital Alemão Oswaldo Cruz,
São Paulo (SP), Brazil
| | | | - Luiz Guilherme Martins Castro
- Oncoderma, São Paulo (SP), Brazil
- Center for Cutaneous Oncology, Hospital Alemão Oswaldo Cruz,
São Paulo (SP), Brazil
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Ponzo MG, Crawford RI, Kossintseva I. Amelanotic Lentigo Maligna Melanoma: Mohs Surgery as the Definitive Treatment of an Invisible Tumour. J Cutan Med Surg 2017; 22:51-57. [DOI: 10.1177/1203475417719046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Amelanotic lentigo maligna melanoma represents <2% of melanomas. Diagnosis is delayed owing to the lack of lesion pigmentation and advanced disease at presentation. Excision with appropriate margins is the treatment standard, but the starting point for such margins is often unclear. We describe 2 patients with amelanotic melanoma treated by Mohs micrographic surgery (MMS) that would not have been cleared by wide local excision alone and provide an extensive review of the literature. Both patients presented with histologic diagnoses of malignant melanoma, one with a barely perceptible biopsy site scar on the left infraorbital cheek/lower eyelid (Breslow 1.8 mm) and the second with an amelanotic tumour on the right helix (Breslow 10 mm). Due to location, aggressive histology, amelanotic appearance, and no apparent surrounding skin surface changes, MMS was elected to maximise margin control. For patient 1, invasive and in situ tumour was found at the American Joint Committee on Cancer–recommended margin of 1.5 cm, and the final defect measured 8.5 × 4.8 cm. Patient 2 had a significant invasive and amelanotic lentigo maligna component, resulting in a 9.0 × 6.5-cm defect. MMS allows for immediate histologic feedback on tumour margins of a clinically invisible tumour and thus offers the most definitive treatment.
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Affiliation(s)
- Marisa Grace Ponzo
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Ian Crawford
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Irèn Kossintseva
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
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Morris JB, Alfonso SV, Hernandez N, Fernández MI. Use of and intentions to use dermoscopy among physicians in the United States. Dermatol Pract Concept 2017; 7:7-16. [PMID: 28515986 PMCID: PMC5424655 DOI: 10.5826/dpc.0702a02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 12/09/2016] [Indexed: 12/19/2022] Open
Abstract
Background Dermatologists routinely use dermoscopy to improve diagnostic accuracy of skin cancers. Much less is known about its use among other physicians who routinely examine the skin, such as family physicians, internists and plastic surgeons. Objectives To document the use of dermoscopy in a sample of US physicians and to examine physician and practice characteristics associated with ever having used a dermascope and having some intentions to incorporate dermoscopy into clinical practice during the next 12 months. Methods From September 2015 to February 2016, we recruited 1,466 practicing physicians in person and online to complete an anonymous survey that assessed: demographic factors; physicians and practice characteristics; confidence differentiating skin lesions; knowledge and use of dermoscopy; and intentions and barriers to use dermoscopy. We conducted bivariate analysis to examine the relationship between key factors and the outcomes and entered the significant predictors into two separate logistic regressions. Results Fifteen percent of participants had ever used a dermascope and 6% were currently using it. Factors significantly associated with ever having used a dermascope (Model 1) and having intentions to use (Model 2) at the multivariate level were: recent graduation from medical school (strongest predictor in both models), identifying as a family physician, seeing a higher number of patients with skin cancer and having a higher level of confidence differentiating skin lesions. Both models were highly significant. Conclusion Use of dermoscopy was low. Promotional efforts to increase dermoscopy use in the US are needed.
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Affiliation(s)
- Jeffrey B Morris
- College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, USA
| | - Sara V Alfonso
- College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, USA
| | - Nilda Hernandez
- College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, USA
| | - M Isabel Fernández
- College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL, USA
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