Characterization of PRAME immunohistochemistry reveals lower expression in pediatric melanoma compared to adult melanoma

Pediatric melanomas are rare tumors that have clinical and histological differences from adult melanomas. In adult melanoma, the immunohistochemical marker PRAME is increasingly employed as a diagnostic adjunct. PRAME is also under investigation as a target structure for next-generation immunotherapies including T-cell engagers. Little is known about the characteristics of PRAME expression in pediatric melanoma. In this retrospective study, samples from 25 pediatric melanomas were compared with control groups of melanomas in young adults (18-30 years; n = 32), adult melanoma (>30 years, n = 30), and benign melanocytic nevi in children (0-18 years; n = 30) with regard to the immunohistochemical expression of PRAME (diffuse PRAME expression >75%/absolute expression). Pediatric melanomas show lower diffuse PRAME expression (4%) and lower absolute PRAME expression (25%) compared to young adult melanomas (15.6%/46.8%) and adult melanomas (50%/70%). A significant age-dependent expression could be observed. An analysis of event-free survival shows no prognostic role for PRAME in pediatric melanoma and young adult melanoma, but a significant association with diffuse PRAME expression in adulthood. The age dependency of PRAME expression poses a potential pitfall in the diagnostic application of melanocytic tumors in young patients and may limit therapeutic options within this age group. The immunohistochemical expression of the tumor-associated antigen PRAME is an increasingly important diagnostic marker for melanocytic tumors and is gaining attention as a possible immunotherapeutic target in melanoma. As the available data primarily stem from adult melanoma, and given the clinical and histological distinctions in pediatric melanomas, our understanding of PRAME expression in this specific patient group remains limited. The age-dependent low PRAME expression shown here constrains the use of this marker in pediatric melanoma and may also limit the use of immunotherapeutic strategies against PRAME in young patients.

Tumeszenz-Lokalanästhesie bei geriatrischen Patienten mit Hauttumoren im Kopf-Hals-Bereich - Eine retrospektive Studie an 782 Patienten: Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients

Hintergrund und Zielsetzung

Aufgrund ihrer Morbidität werden dermatochirurgische Eingriffe bei älteren Patienten vorzugsweise in Tumeszenz‐Lokalanästhesie durchgeführt. Allerdings ist die Datenlage hierzu begrenzt. Ziel der Arbeit war es, die Tumeszenz‐Lokalanästhesie für Hautkrebsoperationen bei älteren Patienten mit dem Fokus auf klinische Vorteile (Behandlungsprozesse, Schmerzmanagement) und dem lokalen postoperativen Komplikationsrisiko zu evaluieren.

Patienten und Methodik

Untersuchung von Patienten ≥75 Jahren mit stationär durchgeführten Hautkrebsoperationen im Kopf‐Hals‐Bereich unter Tumeszenz‐Lokalanästhesie.

Ergebnisse

2940 Eingriffe bei 782 Patienten (Durchschnittsalter 83,3 Jahre) mit dem Ziel einer vollständigen Tumorresektion während des stationären Aufenthaltes wurden durchgeführt. 3,8 (Bereich: 1–20) Eingriffe erfolgten über einen Zeitraum von durchschnittlich 4,9 Tagen (Bereich: 1–28). 43,2% benötigten keine postoperative Analgesie. 53,5% erhielten NSAID, 3,3% Opioide. Wundinfektionen (13,6%) waren die häufigste lokale postoperative Komplikation. Chirurgische Interventionen aufgrund von Nachblutungen waren in 2,8% der Fälle erforderlich. Keine der Blutungen waren hämoglobinrelevant oder lebensbedrohlich. Nahtdehiszenzen und Nekrosen waren selten (0,6%).

Schlussfolgerungen

Die Tumeszenz‐Lokalanästhesie ist für Hautkrebsoperationen bei älteren Menschen eine effektive Anästhesiemethode. Durch den Verzicht auf eine Vollnarkose können die Behandlungsabläufe optimiert und anästhesiologische Risiken minimiert werden. Lokale postoperative Komplikationen treten eher selten auf und sind gut behandelbar. Die langanhaltende Analgesie führt zu einem geringeren Analgetikabedarf und selteneren Medikamenteninteraktionen.

Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients

BACKGROUND AND OBJECTIVES

Due to frailty, dermatosurgery in the elderly is preferably performed under tumescent local anesthesia, but data is limited. The aim was to evaluate tumescent local anesthesia for skin cancer surgery in the elderly with focus on clinical benefits (treatment processes, pain management) and local postoperative complication risk.

PATIENTS AND METHODS

Investigation of patients ≥ 75 years with inpatient head and neck skin cancer surgery under tumescent local anesthesia.

RESULTS

2,940 procedures in 782 patients (mean age 83.3 years) were performed with the aim of complete tumor resection during the inpatient stay. 3.8 (range: 1-20) interventions were done over an average of 4.9 days (range: 1-28). 43.2% did not require any postoperative analgesia. 53.5% received NSAIDs, 3.3% opioids. Infection (13.6%) was the most common local postoperative complication. Surgical intervention due to bleeding was required in 2.8%. None was hemoglobin relevant or life-threatening. Suture dehiscence and necrosis were rare (0.6%).

CONCLUSIONS

Tumescent local anesthesia is an effective method for skin cancer surgery in the elderly. By avoiding general anesthesia, treatment processes can be optimized and anesthesiologic risks minimized. Local postoperative complications are still low and well treatable. The long-lasting analgesia results in a reduced need for analgesics and drug interactions.

Histopathologic abundance of pigmentation correlates with disease-specific survival in malignant melanoma but is not independent of current AJCC pT stage

The increasing number of melanoma patients makes it necessary to develop best possible strategies for prognosis assessment in order to recommend appropriate therapy and follow-up. The prognostic significance of tumor cell pigmentation has not been fully elucidated. Hematoxylin and eosin (H&E)-stained sections of 775 melanomas diagnosed between 2012 and 2015 were independently assessed for melanin pigment abundance by two investigators, and the impact on melanoma-specific survival was calculated. Unpigmented melanomas (n = 99) had a melanoma-specific survival of 67.7%, melanomas with moderate pigmentation (n = 384) had a melanoma-specific survival of 85.9%, and strongly pigmented melanomas (n = 292) had a melanoma-specific survival of 91.4% (p < .001). In an analysis of melanoma-specific survival adjusted for pT stage and pigmentation, we found a nonsignificant impact of pigmentation abundance with a hazard ratio of 1.277 (p = .74). The study presented here provides evidence in a German cohort that patients with pigmented melanomas have a more favorable prognosis than those diagnosed with nonpigmented melanomas. Moreover, the abundance of pigmentation already seems to provide a first prognostic estimate. However, it does not appear to provide significant additional value for prognostic assessment according to the AJCC 2017 pT classification.

Risk analysis of systemic side effects of tumescent local anaesthesia in the surgical treatment of geriatric and multimorbid patients with skin cancer

BACKGROUND

Due to demographic change and increased UV exposure, the number of dermatosurgical procedures in the elderly is increasing. Data on the occurrence of systemic side effects during and after treatment with tumescent local anaesthesia are limited and do not refer to details such as volume and composition of local anaesthetics or epinephrine additive.

OBJECTIVES

The aim of this study was to investigate the risk of systemic side effects in elderly patients undergoing skin tumour surgery with tumescent local anaesthesia.

METHODS

Investigation of systemic complications in patients (≥75 years) who underwent head and neck skin tumour surgery under tumescent local anaesthesia at the Department of Dermatology, University Medical Centre Tübingen, between October 2018 and March 2020.

RESULTS

In total 782 patients (479 males, 303 females) with a mean age of 83.3 years (range: 75.1-102.2 years) could be included. A total of 2940 procedures were performed. Patients were assigned to two groups. The old-old group (≥75-84 years) included 491 patients and the oldest-old group (≥85 years) included 291 patients. The total inpatient stay and thus mean follow-up period was 4.9 days (range 1-28 days). 92.0% (719/782) suffered from pre-existing comorbidities. Systemic complications occurred in 10.2% (80/782; old-olds: 8.6%, oldest-olds: 13.1%). Hypertensive crisis (>180/120 mmHg) requiring intervention (6.7%) that occurred intraoperatively or during the inpatient stay was the most frequent systemic complication. Cardiac arrhythmias occurred postoperatively in 0.8% of cases. No life-threatening complications directly related to tumescent local anaesthesia were found.

CONCLUSIONS

Skin tumour surgery in tumescent local anaesthesia for the elderly is safe, and complications caused by general anaesthesia can be avoided. Systemic complications can occur, but are usually mild, are caused by pre-existing diseases and perioperative excitement, and can be rapidly detected and well treated by monitoring. There is no direct correlation of complications to high-tumescent concentrations or volume quantities.