Skin biopsy utilization and melanoma incidence among Medicare beneficiaries

BACKGROUND

Melanoma incidence has increased in recent decades in the U.S.A. Uncertainty remains regarding how much of this increase is attributable to greater melanoma screening activities, potential detection bias and overdiagnosis.

OBJECTIVES

To use a cross-sectional ecological analysis to evaluate the relationship between skin biopsy and melanoma incidence rates over a more recent time period than prior reports.

METHODS

Examination of the association of biopsy rates and melanoma incidence (invasive and in situ) in SEER-Medicare data (including 10 states) for 2002-2009.

RESULTS

The skin biopsy rate increased by approximately 50% (6% per year) throughout this 8-year period, from 7012 biopsies per 100 000 persons in 2002 to 10 528 biopsies per 100 000 persons in 2009. The overall melanoma incidence rate increased approximately 4% (< 1% per year) over the same time period. The incidence of melanoma in situ increased approximately 10% (1% per year), while the incidence of invasive melanoma increased from 2002 to 2005 then decreased from 2006 to 2009. Regression models estimated that, on average, for every 1000 skin biopsies performed, an additional 5·2 (95% confidence interval 4·1-6·3) cases of melanoma in situ were diagnosed and 8·1 (95% confidence interval 6·7-9·5) cases of invasive melanoma were diagnosed. When considering individual states, some demonstrated a positive association between biopsy rate and invasive melanoma incidence, others an inverse association, and still others a more complex pattern.

CONCLUSIONS

Increased skin biopsies over time are associated with increased diagnosis of in situ melanoma, but the association with invasive melanoma is more complex.

Physical factors and angiogenesis

Angiogenesis consists of migration and mitosis of blood vessels and lymphatic endothelium. The control of angiogenesis is multifactorial, being determined by physical as well as chemical factors. The physical factors include contact, binding, scaffolds and barriers, attachment, spreading, lining and even phagocytosis. The vascular pattern in the skin suggests that epithelium is a principal influence on angiogenesis and that it may guide or obstruct the growth of its blood supply, using fibrin, collagen, elastin and ground substance as a means of exerting control. The hamster cheek pouch and the chorioallantoic membrane have been used to demonstrate that epithelium exerts both chemical and physical effects. There is a need for further investigation of mechanisms underlying the conversion of physical factors into chemical signals. They probably include the release of proteases or their inhibitors during the distortion of fibrillar material.

C16 laminin peptide increases angiotropic extravascular migration of human melanoma cells in a shell-less chick chorioallantoic membrane assay

BACKGROUND

As distinct from intravascular dissemination, extravascular migratory metastasis (EVMM) has been described as a potential additional mechanism of melanoma spread in which tumour cells migrate along the external surfaces of vessels. Recent experimental studies strongly suggest a correlation of angiotropism of melanoma cells with EVMM. Angiotropic melanoma cells are linked to the endothelium by an amorphous matrix confirmed to contain laminin.

OBJECTIVES

To investigate whether laminin plays a role in this extravascular mechanism of tumour spread.

METHODS

We tested the effect of the C16 laminin peptide on melanoma spread in a shell-less chick chorioallantoic membrane model.

RESULTS

After 3 days, green fluorescent protein-expressing melanoma cells were observed spreading along or in the immediate proximity of vessels. The C16 laminin peptide significantly lengthened the distance of extravascular, angiotropic migration of melanoma cells. Histopathology confirmed the angiotropism of melanoma cells without intravasation, compatible with that observed with human angiotropic melanoma.

CONCLUSIONS

The results of this study suggest that the C16 laminin gamma1 chain peptide has angiotropic, extravascular migration-promoting activity on human melanoma cells, and might be a molecular target for preventing melanoma metastasis.

Dysplastic naevi with moderate to severe histological dysplasia: a risk factor for melanoma

BACKGROUND

The risk of malignant melanoma associated with histologically dysplastic naevi (HDN) has not been defined. While clinically atypical naevi appear to confer an independent risk of melanoma, no study has evaluated the extent to which HDN are predictive of melanoma.

OBJECTIVES

To estimate the risk of melanoma associated with HDN. Secondarily, the risk associated with number of naevi and large naevi is estimated.

METHODS

We enrolled 80 patients with newly diagnosed melanoma along with 80 spousal controls. After obtaining information on melanoma risk factors and performing a complete cutaneous examination, the most clinically atypical naevus was biopsied in both cases and controls. Histological dysplasia was then assessed independently by 13 dermatopathologists (0, no dysplasia; 1, mild dysplasia; 2, moderate dysplasia; 3, severe dysplasia). The dermatopathologists were blinded as to whether the naevi were from melanoma subjects or controls. Multivariate analyses were performed to determine if there was an independent association between the degree of histological dysplasia in naevi and a personal history of melanoma.

RESULTS

In persons with naevi receiving an average score of > 1 (i.e. naevi considered to have greater than mild histological dysplasia), there was an increased risk of melanoma [odds ratio (OR) 2.60, 95% confidence interval (CI) 0.99-6.86] which persisted after adjustment for confounders (OR 3.99, 95% CI 1.02-15.71). Very few dermatopathologists reliably graded naevi of subjects with melanoma as being more dysplastic than naevi of control subjects. Among the entire group, the interobserver reliability associated with grading histological dysplasia in naevi was poor (weighted kappa 0.28).

CONCLUSIONS

HDN do appear to confer an independent risk of melanoma. However, this result may add more to our biological understanding of melanoma risk than to clinical assessment of risk, because HDN assessed by a single pathologist generally cannot be used to assess risk of melanoma. Future studies should be directed at establishing reproducible, predictive criteria for grading naevi.

Interobserver reproducibility of ulceration assessment in primary cutaneous melanomas

In the recently revised melanoma staging system proposed by the American Joint Committee on Cancer (AJCC), ulceration assessment by the pathologist is a pivotal parameter. Patients upstaged because of ulceration might be included in adjuvant trials conducted in AJCC stage II melanoma patients. Therefore, accuracy based on interobserver reproducibility for melanoma ulceration assessment is crucial for proper clinical management. In some cases, it is extremely difficult, even for an experienced pathologist, to distinguish between trauma-induced ulceration, artifact and tumoral ulceration. Whether this difficulty may be resolved by the use of a more precise definition of ulceration has not been evaluated. Therefore, we have proposed a refined definition of melanoma ulceration and we tested whether this definition might improve the interobserver interpretative reproducibility of ulceration in primary cutaneous melanomas. The results of this study support the need for a more precise definition of melanoma ulceration that rules out biopsy trauma or processing artifact and could be incorporated into a standardised pathology worksheet for reporting primary melanomas.

Epidermal hyperplasia overlying human melanoma correlates with tumour depth and angiogenesis

The aim of this study was to determine whether epidermal hyperplasia overlying cutaneous human melanoma is associated with increased tumour angiogenesis, tumour growth and the potential for metastasis. Forty-two surgical specimens of cutaneous human melanoma of different depths, each containing epidermis present in the tumour-free margin, were analysed by immunohistochemistry for the expression of the pro-angiogenic molecules basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) and the anti-angiogenic molecule interferon-beta (IFN-beta). The epidermis overlying intermediate and thick (1.0-10.0 mm), but not thin (0.5-1.0 mm), melanoma specimens was hyperplastic. Although the expression level of bFGF, VEGF and IL-8 in the epidermis directly overlying the tumour was similar to that in the distant epidermis, the expression of IFN-beta was significantly decreased in keratinocytes overlying intermediate and thick, but not thin, melanomas. The microvessel density was also increased in intermediate and thick specimens. Human melanoma cells were injected subcutaneously into nude mice. The resulting tumours were used to determine the association between overlying epidermal hyperplasia and neoplastic angiogenesis. Similar to human autochthonous melanomas, epidermal hyperplasia was found only over lesions produced by metastatic cells. Although there was no change in the expression of the pro-angiogenic molecules, the expression of IFN-beta was significantly decreased in the hyperplastic epidermis. Conditioned medium collected from cultures of the metastatic cell line induced in vitro proliferation of mouse keratinocytes, whereas conditioned medium collected from cultures of the non-metastatic cell line did not. Collectively, the data demonstrate that metastatic melanoma cells induce keratinocyte proliferation, leading to decreased expression of the negative regulator of angiogenesis, IFN-beta, and hence to increased angiogenesis.

Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas

BACKGROUND

The Intergroup Melanoma Surgical Trial began in 1983 to examine the optimal surgical margins of excision for primary melanomas of intermediate thickness (i.e., 1-4 mm). There is now a median 10-year follow-up.

METHODS

There were two cohorts entered into a prospective multi-institutional trial: (1) 468 patients with melanomas on the trunk or proximal extremity who randomly received a 2 cm or 4 cm radial excision margin and (2) 272 patients with melanomas on the head, neck, or distal extremities who received a 2 cm radial excision margin.

RESULTS

A local recurrence (LR) was associated with a high mortality rate, with a 5-year survival rate of only 9% (as a first relapse) or 11% (anytime) compared with an 86% survival for those patients who did not have a LR (P < .0001). The 10-year survival for all patients with a LR was 5%. The 10-year survival rates were not significantly different when comparing 2 cm vs. 4 cm margins of excision (70% vs. 77%) or comparing the management of the regional lymph nodes (observation vs. elective node dissection). The incidences of LR were the same for patients having a 2 cm vs. 4 cm excision margin regardless of whether the comparisons were made as first relapse (0.4% vs. 0.9%) or at anytime (2.1% vs. 2.6%). When analyzed by anatomic site, the LR rates were 1.1% for melanomas arising on the proximal extremity, 3.1% for the trunk, 5.3% for the distal extremities, and 9.4% for the head and neck. The most profound influence on LR rates was the presence or absence of ulceration; it was 6.6% vs. 1.1% in the randomized group involving the trunk and proximal extremity and was 16.2% vs. 2.1% in the non-randomized group involving the distal extremity and head and neck (P < .001). A multivariate (Cox) regression analysis showed that ulceration was an adverse and independent factor (P = .0001) as was head and neck melanoma site (P = .01), while the remaining factors were not significant (all with P > .12).

CONCLUSION

For this group of melanoma patients, a local recurrence is associated with a high mortality rate, a 2-cm margin of excision is safe and ulceration of the primary melanoma is the most significant prognostic factor heralding an increased risk for a local recurrence.

The biology of melanoma micrometastases

The biology and significance of micrometastases remain poorly understood. Whether such deposits represent hypothetical "dormant" metastases, simply the earliest metastases recognizable, or both has not been resolved. Attempting to answer the latter question among many others, we carried out studies on the rates of proliferation, and microvessel counts in melanoma micrometastases taken from sentinel lymph nodes as compared to conventional melanoma lymph node macrometastases. We found that these micrometastases were not vascularized and had low (and comparable) rates of both proliferation and apoptosis, suggesting a steady or dormant state. On the other hand, the macrometastases were fully vascularized and more proliferative, i.e., they had rates of proliferation that were significantly higher compared to the micrometastases and rate of apoptosis. How micrometastases develop is also poorly understood. Tumor cells are thought to arrive in lymph nodes and other sites through the blood and lymphatic circulation and to extravasate. However, in addition to the latter explanation, another mechanism may be operable which we have proposed as extravascular migratory metastasis. In studies of metastatic melanoma we have identified melanoma cells positioned on the surface of endothelial cells both by light and electron microscopy. We have also identified ultrastructurally the presence of an amorphous matrix interposed between the latter two cell types that shows immunostaining for laminin and, recently, the beta-2 chain of laminin. Thus, we currently believe that the latter form of "free" laminin may play a role in this proposed mechanism of metastasis and thus in the formation of micrometastases.

The histologic diagnosis of melanoma

The pathologic diagnosis of melanoma is of crucial importance because it provides the patient and his or her attending physician with the knowledge of a potentially life-threatening or an almost curable condition. The histopathologic diagnosis of melanoma is based on the simultaneous or systematic assessment of several well-known histopathologic features. This article discusses the author's approach to the histopathologic diagnosis of melanoma for specific situations.

Signs and symptoms of melanoma in older populations

We conducted a descriptive study to assess the relationship between increasing age and the reporting of melanoma signs/symptoms in 634 hospital-based and 624 population-based incident cases of melanoma. Multivariate logistic regression was used to evaluate the relationship between older age (> or = 50 years) and the reporting of melanoma signs/symptoms. Older patients were less likely to report itching and change in elevation of their lesions (P < 0.05). Change in color was also less likely to be reported by older patients, although not statistically significant. Ulceration of the lesion was reported significantly more by older patients (P < 0.05). Older individuals may be less likely to report itching and change in elevation/color of their lesions, but more likely to report ulceration, a symptom associated with advanced disease and poor prognosis. Further research is necessary to provide a better understanding of the development of melanoma in older populations so that new strategies can be explored to improve early detection in this age group.

Malignant melanoma, dysplastic melanocytic nevi, and Spitz tumors. Histologic classification and characteristics

The classification and pertinent histopathologic features of cutaneous melanoma, dysplastic melanocytic nevi, and Spitz tumors are presented. A discussion on melanoma emphasizes an objective approach to classification based on histomorphologic features including location in the skin, disposition and frequency of melanocytes, other specific morphologic features, and cell type. Other topics addressed include common and unusual variants of melanoma, the use of immunohistochemistry, and the histopathologic reporting of melanoma.

Histopathological features of flexural melanocytic nevi: a study of 40 cases

Melanocytic nevi in certain locations such as the genital and acral sites may have atypical histologic features simulating melanoma. We studied the microscopic findings of 40 melanocytic nevi of flexural sites (axilla, umbilicus, inguinal creases, pubis, scrotum and perianal area) to verify if flexural nevi show distinctive features similar to melanocytic nevi of the genital skin. The patients were young (mean age 20 years), the lesions were mostly removed for cosmetic reasons and we are not aware of any deaths or complications related to the removed nevi. We found that 22 (55.5%) out of 40 flexural nevi had "a nested and dyshesive pattern" similar to the melanocytic nevi of genital skin. This pattern was characterized by the confluence of enlarged nests with variation in size, shape and position at the dermo-epidermal junction and by the diminished cohesion of melanocytes. Dermatopathologists should pay attention to the "nested and dyshesive pattern" of flexural nevi that may mimick histologic changes of melanoma.

Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial

BACKGROUND

Ten- to 15-year survival results were analyzed from a prospective multi-institutional randomized surgical trial that involved 740 stages I and II melanoma patients with intermediate thickness melanomas (1.0 to 4.0 mm) and compared elective (immediate) lymph node dissection (ELND) with clinical observation of the lymph nodes as well as prognostic factors that independently predict outcomes.

METHODS

Eligible patients were stratified according to tumor thickness, anatomical site, and ulceration, and then prerandomized to either ELND or nodal observation. By using Cox stepwise multivariate regression analysis, the independent predictors of outcome were tumor thickness (P < .001), the presence of tumor ulceration (P < .001), trunk site (P = .003), and patient age more than 60 years (P = .01).

RESULTS

Overall 10-year survival was not significantly different for patients who received ELND or nodal observation (77% vs. 73%; P = .12). Among the prospectively stratified subgroups of patients, 10-year survival rates favored those patients with ELND, with a 30% reduction in mortality rate for the 543 patients with nonulcerated melanomas (84% vs. 77%; P = .03), a 30% reduction in mortality rate for the 446 patients with tumor thickness of 1.0 to 2.0 mm (86% vs. 80%; P = .03), and a 27% reduction in mortality rate for 385 patients with limb melanomas (84% vs. 78%; P = .05). Of these subgroups, the presence or absence of ulceration should be the key factor for making treatment recommendations with regard to ELND for patients with intermediate thickness melanomas.

CONCLUSIONS

These long-term survival rates from patients treated at 77 institutions demonstrate that ulceration and tumor thickness are dominant predictive factors that should be used in the staging of stages I and II melanomas, and confer a survival advantage for these subgroups of prospectively defined melanoma patients.

Plexiform spitz nevus: an intradermal spitz nevus with plexiform growth pattern

Two cases of a distinctive variant of Spitz (spindle and epithelioid cell) nevus are described. One lesion developed on the lower leg of a 17-year-old boy and the other lesion on the back of a 52-year-old man. The microscopic appearance was characterized by a plexiform arrangement of bundles and lobules of enlarged spindle to epithelioid melanocytes throughout the superficial and deep dermis. Intraepidermal melanocytic proliferation was unappreciated. Some lobules were circumscribed by a thin rim of compressed fibrous tissue. In both cases a myxoid stroma was present. The cells had abundant eosinophilic cytoplasm with well-defined borders. The nuclei were enlarged, consistently ovoid and vesicular, with small nucleoli. Both cases contained scattered multinucleate giant cells similar to those observed in classical form of Spitz nevi. No melanin pigment was detectable by light microscopy. No mitoses were observed in one case and a rare mitosis was present in the other. Tumor cells were strongly immunoreactive for S-100, but not for HMB-45, desmin, and actin. The differential diagnosis of this distinctive tumor includes desmoplastic/neurotropic melanoma, plexiform spindle cell nevus, cellular blue nevus, plexiform neurofibroma, and cellular neurothekeoma. The designation of "plexiform Spitz nevus" is chosen to emphasize its distinctive plexiform growth pattern.

Patient knowledge, awareness, and delay in seeking medical attention for malignant melanoma

We investigated the relationship between patient knowledge, awareness, and delay in seeking medical attention for melanoma. The study population was comprised of 255 cases with cutaneous melanoma newly diagnosed during January 15, 1987 to May 15, 1989, who were part of a population-based case control study. Personal interviews were conducted to obtain information on patient's knowledge of melanoma signs and symptoms, skin awareness, delay in seeking medical attention, and related covariates. The adjusted odds ratio for the association between skin awareness and delay was 0.30 (95% confidence interval 0.12-0.71). Odds ratios ranged from 0.43 to 0.81 for knowledge and delay. Awareness of skin changes was associated with a reduced Breslow depth for stage I melanomas. Individuals who are aware of skin changes and abnormalities appear to be less likely to delay seeking medical attention for melanoma. Knowledge of melanoma signs and symptoms may also contribute to a decreased delay in melanoma diagnosis.

Evaluation of factors associated with skin self-examination

Early detection and excision of thin lesions may be important in reducing mortality from melanoma. Periodic skin self-examination may be beneficial in identifying thin lesions. The purpose of this study was to evaluate factors associated with skin self-examination. The study population was comprised of 549 Caucasian residents of Connecticut 18 years of age or older who were selected as controls as part of a population-based case-control study on skin self-examination and melanoma conducted during 1987-1989. Personal interviews were conducted to obtain information on skin self-examination, demographics, history of cancer, phenotypic characteristics, sun exposure habits, and screening and health behaviors. Nevus counts were performed by trained nurse interviewers. Logistic regression was used to model the relationship between the variables of interest and skin self-examination. Female gender was identified a priori as a predictor of skin self-examination, and thus all analyses were stratified by gender. Age, education, and marital status were also identified a priori as important predictor variables and were selected for inclusion in the final models. Skin awareness was a strong factor associated with skin self-examination for both females and males. For females, previous benign biopsy or the presence of an abnormal mole was identified as important for future skin self-examination using our criteria. A family history of cancer, physician examination, and change in diet to reduce cancer risk increased the likelihood of skin self-examination in males but not females. In women, light hair color may increase the likelihood of performing skin self-examination. Older age and college or postgraduate education was associated with a decreased likelihood of performing skin self-examination in both males and females. Identifying factors associated with skin self-examination will enable health care providers to target individuals who may not be performing skin self-examination but who are at increased risk for developing melanoma.

Atypical Spitz nevi/tumors: lack of consensus for diagnosis, discrimination from melanoma, and prediction of outcome

The biological nature of Spitz nevi/tumors and their diagnostic distinction from, or relationship to, melanoma remain unresolved issues. In this report, a series of 30 melanocytic lesions removed from 28 patients, including atypical Spitz nevi/tumors and metastasizing Spitzoid tumors/melanomas, were evaluated by a panel of dermatopathologists to evaluate interobserver diagnostic concordance and to assess the prognostic power of histological criteria. For inclusion in the study, each lesion had to display some criteria for the Spitz nevus, and in addition one of the following was required: (1) definitive clinical outcome such as metastasis or death of disease, or (2) long-term follow-up if the patient remained disease free. Each lesion was reviewed independently and blinded as to the clinical data by 10 pathologists, who categorized them as (1) typical Spitz nevus/tumor, (2) atypical Spitz nevus/tumor, (3) melanoma, (4) tumor with unknown biological potential, or (5) other melanocytic lesion. There was limited discussion of criteria before the review. Evaluation of 17 Spitzoid lesions yielded no clear consensus as to diagnosis; in only one case did six or more pathologists agree on a single category, regardless of clinical outcome. Notably, however, some lesions that proved fatal were categorized by most observers as either Spitz nevi or atypical Spitz tumors. Conversely, seven or more pathologists scored 13 lesions as melanoma. These results illustrate (1) substantial diagnostic difficulties posed by many Spitz tumors, especially those with atypical features, even among experts, and (2) the lack of objective criteria for their distinction from melanoma and for gauging their malignant potential. Nevertheless, our observations do suggest that a biological relationship exists between the Spitz nevus/tumor and melanoma.

Tumor microvessels in melanoma express the beta-2 chain of laminin. Implications for melanoma metastasis

The ultrastructural localization of an amorphous matrix to the interface between microvessel endothelium and tumor cells has been recently reported in a series of melanomas. Laminin expression as documented by immunohistochemistry was localized to microvessels in melanomas showing the amorphous matrix. In order to identify more precisely the type of laminin present in this amorphous material, immunostaining was carried out on cryostat sections from 16 human melanoma specimens. Four murine monoclonal antibodies directed against the alpha-3, beta-2, beta-3 and gamma-2 laminin chains were employed. In the melanomas studied, alpha3, beta3 and gamma2 laminin chains showed only minimal focal vascular positivity. In contrast, the beta2 (16/16 cases) laminin chain exhibited a consistent positivity in an angiocentric pattern about tumor microvessels. In all melanomas, some tumor cells seemed to spread along the abluminal surface of the small vessels, exhibiting a pericytic location, particularly along the intratumoral projections formed by the beta2 laminin chain. Given the role of laminin in migration and tumor progression, the results suggest a role of the beta2 laminin chain in melanoma spread, promoting tumor migration along the abluminal surface of vessel, a phenomenon which has been termed extra-vascular migratory metastasis.

Spitz tumors in children: a grading system for risk stratification

OBJECTIVE

To describe a grading system for risk stratification of atypical Spitz tumors in children and adolescents. In some circumstances, unequivocal distinction between Spitz nevus and melanoma is practically impossible. It is likely that these lesions for which we lack specific diagnostic criteria represent a broad histological continuum extending from benign to malignant tumors. Therefore, we propose that Spitz tumors be categorized into low-, intermediate-, or high-risk categories based on the accumulation of abnormal features.

DESIGN

Retrospective study.

SETTINGS

Institutional practice.

PATIENTS

We present 30 cases of atypical Spitz tumors in patients younger than 18 years evaluated for at least 3 years or in whom a metastatic event developed during this period.

INTERVENTION

None.

MAIN OUTCOME MEASURE

The grading system was formulated after data collection.

RESULTS

Among the parameters studied, only diagnosis at age greater than 10 years, diameter of the lesion greater than 10 mm, presence of ulceration, involvement of the subcutaneous fat (level V), and mitotic activity of at least 6/mm2 carried a likelihood ratio greater than 1.50 and were therefore used for the grading system.

CONCLUSION

The application of an objective grading system, such as the one described herein for the first time, is the first step in providing useful information for the management of atypical Spitz tumors.

Ultrastructural and immunohistochemical studies of the periendothelial matrix in human melanoma: evidence for an amorphous matrix containing laminin

Angiogenesis and the extracellular matrix are fundamental to tumor progression from in situ to invasive and metastatic disease. Laminin, a major glycoprotein integrated into basement membranes, is observed in angiogenesis and tumorigenesis. A recent study described an association between melanoma cells and endothelial cells via an amorphous matrix containing laminin. In the current study, we have examined 45 cases of human primary and metastatic melanomas by electron microscopy for the presence of an amorphous matrix. We observed an amorphous matrix without a clearly delineated lamina or basement membrane in 41 of the 45 melanomas studied. 28 cases with tissue blocks available for study were examined by immunohistochemistry for the expression of laminin and type IV collagen. We observed the presence of an angiocentric matrix containing laminin in 24 of the 28 melanomas studied. Since laminin is involved in tumor migration, the presence of laminin between melanoma cells and small vessels suggests a role for this material in periendothelial tumor migration. However, further study is required to characterize the nature of this material and the mechanisms involved.

Validation of a melanoma prognostic model

BACKGROUND

A "clinically accessible," 4-variable (patient age, patient sex, tumor location, and tumour thickness) prognostic model has been published previously. This model evaluated variables that were commonly available to the clinician. Because models are heuristic, validity of a prognostic model should be evaluated in a population different from the original population.

OBJECTIVE

To evaluate the external validity of this 4-variable melanoma prognostic model.

DESIGN

To estimate the external validity of this model, we used a population-based cohort of individuals with melanoma. We also evaluated a 1-variable model (tumor thickness). Estimates of the external validity of these logistic regression models were made using the c statistic and the Brier score.

SETTINGS AND PATIENTS

A total of 1261 patients with melanoma evaluated in a multispecialty, university-based practice and 650 patients with melanoma from throughout Connecticut.

MAIN OUTCOME MEASURE

Death from melanoma within 5 years of diagnosis.

RESULTS

The c statistics for the 4-variable model were 0.86 (95% confidence interval [CI], 0.83-0.89) for the university-based practice data set and 0.81 (95% CI, 0.75-0.86) for the Connecticut data set. For thickness alone, the c statistics were 0.83 (95% CI, 0.80-0.86) and 0.79 (95% CI, 0.74-0.85), respectively. Brier scores for the 4-variable model were 0.09 (95% CI, 0.08-0.10) and 0.08 (95% CI, 0.06-0.09) and for the 1-variable model were 0.09 (95% CI, 0.08-0.10) and 0.08 (95% CI, 0.07-0.10), respectively. No significant differences exist between the data sets for the 4- and 1-variable models.

CONCLUSIONS

The 4- and 1-variable models are generalizable. The simpler 1-variable model--tumor thickness--can be used with a relatively small loss in accuracy.

Hormonal and reproductive influences and risk of melanoma in women

BACKGROUND

Evidence linking female hormones to the development of malignant melanoma has been contradictory. The purpose of this study was to examine the risk of melanoma in relation to exogenous and endogenous hormonal variables in women, including oral contraceptives, replacement oestrogens, pregnancy, and menopause.

METHODS

Hormonal and reproductive factors were evaluated using data from a personal-interview population-based case-control study of melanoma in women conducted in Connecticut during 1987-1989. Caucasian female incident invasive melanoma cases (n = 308) were confirmed by standardized histopathological review. Caucasian female controls (n = 233) were selected by random digit dialling and frequency-matched on age. Data were analysed using multivariate logistic regression.

RESULTS

Ever being pregnant, age at first pregnancy, current use of replacement oestrogens, ever use of oral contraceptives, duration of use of oral contraceptives, and age at first use of oral contraceptives were not associated with melanoma. Among other variables, cases were more than twice as likely as controls to report a single pregnancy lasting >6 months, but this association lacked a dose-response relationship. Menopause and body mass index were not independently associated with risk of melanoma. However, this analysis did suggest that menopause and body mass index may be interactive risk factors. Melanoma cases were three times more likely than controls to be obese and report natural menopause when compared to thin/acceptable premenopausal women (OR = 3.00, 95% CI: 1.03-8.73).

CONCLUSIONS

These data do not provide strong evidence that hormonal and reproductive factors are associated with risk of melanoma in women, although the few positive results should be explored further.

Sunlamp use and the risk of cutaneous malignant melanoma: a population-based case-control study in Connecticut, USA

BACKGROUND

The relationship between cutaneous malignant melanoma and sunlamp use is examined in a Caucasian population in Connecticut, United States.

METHODS

Cases were diagnosed between 15 January 1987 and 15 May 1987 with a first primary cutaneous melanoma. Controls were obtained from the general population, frequency matched to cases by sex and age, through random digit dialling of Connecticut telephone numbers.

RESULTS

Of all study subjects, 141 (23%) cases and 95 (19%) controls reported ever having used sunlamps. The crude odds ratio (OR) for developing malignant melanoma after ever having used sunlamps was 1.30 (95% confidence interval [CI]: 0.97-1.74). This was reduced to 1.13 (95% CI: 0.82-1.54) after further adjusting for cutaneous phenotype and recreational sun exposure. Those who used more than one type of sunlamp had a threefold higher risk for melanoma compared to never users. Subgroup analyses showed that sunlamp use was associated with a greater increase in risk for melanoma among those who used sunlamps at home and those who were first exposed to sunlamps prior to 1971. The first use of sunlamps before the age of 25 showed somewhat higher risk for melanoma compared to first use later in life.

CONCLUSION

The current study provides limited evidence that use of sunlamps increases the risk of melanoma. For future studies, it is crucial that type of sunlamp, year of first use and amount of exposure are all taken into account. The association between melanoma and tanning with both UV-A and UV-B lamps and tanning under sunlamps early in life merits further investigation.

Atypical or worrisome features in cellular neurothekeoma: a study of 10 cases

Cellular neurothekeoma is a recently characterized benign cutaneous neoplasm arising usually on the upper trunk or head and neck of children or young adults. Typical histology is that of a lobulated dermal tumor composed of spindle and epithelioid cells, arranged in fascicles and nests, lacking immunoreactivity for S-100 protein, but usually being NK1/C3 positive. We present 10 new cases of cellular neurothekeoma with atypical histologic features that have not been described previously and that suggested the possibility of malignancy. The age range of affected patients was 1 to 44 years (median, 20.5 years); sites included the head and neck (three cases), the upper limbs (two cases), the lower limbs (two cases), and the trunk (two cases). Atypical findings in individual cases included large size (up to 6 cm), deep penetration (extending into skeletal muscle or subcutaneous fat, or both), diffusely infiltrative borders, vascular invasion, high mitotic rate, and marked cytologic pleomorphism. Clinical follow-up was available in 7 of 10 cases. Although the atypical features raised concern about the biologic potential of these lesions, preliminary follow-up (1-5 years) has shown no recurrence and suggests that complete surgical excision of these lesions is curative. These new data expand the morphologic spectrum of cellular neurothekeoma.

Expression of melan-A (MART1) in benign melanocytic nevi and primary cutaneous malignant melanoma

The Melan-A (MART1) gene encodes an antigen recognized by cytotoxic T cells. Although its expression in metastatic melanoma has been documented in the literature by several investigators, little is known about its distribution in primary melanomas and benign melanocytic nevi. In this study, we evaluated Melan-A expression immunohistochemically on sections from paraffin-embedded material of 50 benign nevi and 40 primary cutaneous melanomas using the monoclonal antibody A103. To evaluate a potential role of A103 in the differential diagnosis of melanocytic from nonmelanocytic tumors, we also analyzed a number of benign and malignant peripheral nerve sheath tumors, fibrohistiocytic tumors, and leiomyosarcomas. Immunoreactivity with A103 was present in all "nonneurotized" nevi and in all nondesmoplastic primary melanomas, both in the intraepidermal and the dermal component. Only two nevi that underwent prominent neurotization showed no staining with A103. Although all melanomas with epithelioid cells tended to be strongly positive with A103, only 4 of 13 spindle cell and desmoplastic melanomas (all positive with anti-S-100 and negative with HMB-45) were immunoreactive with A103 (two focally, two diffusely). None of the nonmelanocytic lesions expressed Melan-A. Our results confirm that Melan-A protein is broadly expressed in the majority of benign and malignant melanocytic lesions and suggest that A103 can be helpful diagnostically, not only for metastatic tumors, but also for primary skin lesions. Its use in distinguishing between melanocytic and peripheral nerve sheath tumors, however, is limited because of the low or absent expression of Melan-A in nevi that underwent neurotization and spindle cell and desmoplastic melanomas.

Tumor vascularity, proliferation, and apoptosis in human melanoma micrometastases and macrometastases

BACKGROUND

Clinically undetectable or dormant metastases (micrometastases) probably account for disease recurrence, ie, clinically evident metastases, in patients after disease-free intervals of variable length. Recently developed animal models have shown that dormancy may potentially be explained by the fact that these micrometastases are not vascularized and have comparable rates of cellular proliferation and programmed cell death (apoptosis), enabling them to remain viable indefinitely but not to show progressive growth.

OBSERVATION

We report for the first time that melanoma micrometastases from humans are similarly not vascularized (mean number of microvessels, 10.2), have significantly lower rates of tumor cell proliferation (mean, 2.4%), comparable rates of proliferation and apoptosis (means, 2.4.% and 0.2%, respectively), compared with melanoma macrometastases, which have significantly greater tumor vascularity (mean number of microvessels, 18.7), higher rates of proliferation (mean, 18%), and higher rates of proliferation relative to apoptosis (means, 18% vs 1.6%). Tumor vascularity was quantified using the lectin Ulex europaeus agglutinin I to identify the number of microvessels per unit area (microscope ocular grid with an area of 7.84 x 10(-2) mm2 at x400 magnification). Melanoma cell proliferation rate was assessed with the MIB-1 antibody (Ki-67) as the number of positive nuclei per total number of tumor nuclei counted at x400 magnification. Apoptosis was quantified using the method of terminal deoxynucleotidyl transferase-medicated deoxyuridine triphosphate-biotin nick end labeling. The number of positive nuclei were quantified per total number of tumor nuclei; usually 200 tumor nuclei were counted at x400 magnification.

CONCLUSION

We report, for the first time, that human micrometastases demonstrate attributes, ie, the lack of significant tumor vascularity and low but comparable rates of proliferation and apoptosis, that may explain the dormant state.

Childhood melanoma

This article examines all cases of malignant melanoma referred to Children's Hospital, Boston, and to the author over the period 1959-1995. Criteria for inclusion in the study included (1) age up to 15 years, (2) availability of microscopic slides, and (3) availability of demographic data. There were 11 boys and 12 girls, ranging in age from 2 to 15 (mean age, 9.4) years. Histopathologically the 23 tumors were categorized into four subgroups: (1) small cell melanoma (five cases), (2) adultlike melanoma (six cases), (3) Spitz-like melanoma (three cases), and (4) atypical Spitz tumors (nine cases). The small cell melanomas were notable for localization to the scalp, significant thickness, and fatal outcome. The adultlike melanomas resembled typical tumors occurring in adults. The one fatal Spitz-like melanoma was located on the neck of a 14-year-old boy. Two tumors in this group metastasized to regional lymph nodes but have not been associated with further aggressive disease on follow-up despite having been treated with surgical excision only. The atypical Spitz tumors were characterized by significant thickness and abnormal features, including prominent cellularity and mitotic activity. Anatomic site and cell type may be important prognostic factors in addition to tumor thickness in childhood melanoma but require further study. The biological potential of atypical Spitz tumors has not been sufficiently characterized.

Congenital melanocytic nevi with placental infiltration by melanocytes: a benign condition that mimics metastatic melanoma

BACKGROUND

Placental metastases from cutaneous malignant melanoma from both the mother and the fetus have been reported. The finding of benign-appearing melanocytes in the placenta in association with congenital melanocytic nevi (CMN) is more exceptional, with only 6 reports in the literature. Clinically, the finding of melanocytes in the placenta in this setting can be alarming and might erroneously lead to the diagnosis of metastatic melanoma.

OBSERVATIONS

Herein, we describe 3 additional patients with CMN with placental infiltration by melanocytes with a benign phenotype. In the results of immunoperoxidase stains, the melanocytic cells were positive for S-100 protein and HMB-45 in the 2 lesions available for study. Staining of placental vessels with Ulex europaeus agglutinin I (Vector Laboratories, Burlingame, Calif) failed to show intravascular melanocytes in the 1 lesion available for study. We report for the first time DNA diploidy in 2 lesions available for study, which were analyzed by DNA image cytometry. We describe the first patient with a relatively small, nongiant CMN.

CONCLUSIONS

We support the notion of the aberrant migration of melanocytes from the neural crest during fetal development as the most likely explanation of this phenomenon and note the similarity to the association of CMN and leptomeningeal melanocytosis. However, the precise histogenesis of this process remains uncertain. Most importantly, our data provide further evidence for the benign nature of this condition. Awareness of this entity is of vital importance in avoiding overdiagnosis of melanoma in this clinical setting.

Analysis of vascularity of human neurofibromas

BACKGROUND

A common misperception is that the vascularity of a tumor can be determined by its gross appearance. Neurofibromas are grossly white in appearance. The degree of vascularity of neurofibromas has not been determined.

OBJECTIVE

The purpose of this study was to determine the extent of neovascularization of neurofibromas.

METHODS

Neurofibromas from patients with neurofibromatosis-1 or spontaneous neurofibromas were stained with antibodies against von Willebrand factor (factor VIII-related antigen) and vascular endothelial growth factor (VEGF).

RESULTS

Neurofibromas, both spontaneous and congenital, exhibit a high degree of vascularity. In addition, perivascular cells in neurofibromas stain with antibodies to VEGF, an angiogenic factor.

CONCLUSION

Neurofibromas, despite their gross appearance, are highly vascular. Their vascularity may be mediated, in part, through the angiogenic factor VEGF.

"Rush" skin biopsy specimens in a tertiary medical center: diagnostic yield and clinical utility

BACKGROUND

Skin biopsy specimens are submitted for "rush" or "stat" processing, thereby indicating a sense of urgency about the clinical situation.

OBJECTIVE

Our purpose was to determine the patient population who underwent biopsy on a "rush" basis and assess the way in which interpretation of the skin biopsy specimen influences clinical management.

METHODS

A retrospective study was performed on the "rush" biopsy specimens sequentially requested during 1 year. Histologic findings, the clinical situation, and the effect of the biopsy result on clinical management were determined.

RESULTS

A total of 90 adult patients, many critically ill, were identified. The majority of patients were admitted to hematology-oncology services (58%). The other 42% were admitted to a variety of clinical services. The chief clinical concerns in hematology-oncology patients were graft-versus-host disease and cutaneous infection. Only 5.5% of biopsy specimens taken to exclude graft-versus-host disease were used in immediate clinical decision-making compared with 45% of biopsy specimens for oncology patients with suspected infection and 42% for all other services.

CONCLUSION

Many urgent skin biopsy specimens were not used for immediate clinical decision-making. The usefulness of skin biopsy varies with the clinical situation, and some situations are more prone to yield equivocal histologic data. Knowledge of these situations may reduce the number of unhelpful biopsy specimens. Therapy based on clinical findings had often been initiated before receiving the biopsy results, but biopsy findings are often helpful as confirmatory data. Diagnostic findings were not necessary for a biopsy specimen to provide useful data and nonspecific findings interpreted in light of clinical findings were also useful.

Small cell sweat gland carcinoma in childhood

Sweat gland carcinomas are rare skin tumors that typically occur in older patients. The spectrum of their clinical and pathologic features is broad, and many different types of sweat gland carcinomas have been described, ranging from fairly indolent to highly aggressive neoplasms. We present two cases of sweat gland carcinoma with a predominant small cell morphology. Both tumors occurred in children. One lesion developed in an 8-year-old girl as an asymptomatic papule on her left forearm, which ultimately was evaluated using biopsy because of rapid growth and change in color. The other lesion occurred on the hand of a 12-year-old boy. Both tumors were pandermal and extended into fat. They were composed of monotonous cuboidal cells with scant cytoplasm that formed tubules and grew in anastomosing cords and trabeculae. The tumor cells were immunoreactive for cytokeratins but not for cytokeratin 20. Ultrastructural analysis (available in one case only) showed that the tumor cells lacked neurosecretory granules. This variant of sweat gland carcinoma needs to be distinguished from other small cell neoplasms of the skin, especially Merkel cell carcinoma, its closest mimic.

Theoretical and empirical arguments in relation to elective lymph node dissection for melanoma

Nearly a century of clinical inquiry has failed to incontrovertibly resolve the question of whether elective lymph node dissection is therapeutically beneficial in the management of clinically localized melanoma. The controversy has been renewed by a recent interim update from the Intergroup Melanoma Surgical Program, sponsored by the National Cancer Institute, which has indicated a small survival benefit in a narrowly defined subgroup of patients with primary melanoma. That report stimulated this review of the data, which are presented in the historical context that originally prompted the Intergroup study. Case selection bias has intractably hindered firm conclusions from the numerous nonrandomized studies of elective lymphadenectomy. The two original randomized trials that were executed during the 1970s failed to uncover any significant effect of the procedure on survival. Definitive conclusions from the recent Intergroup report are limited by the likelihood that the observed therapeutic benefits are a chance occurrence resulting from uncorrected multiple subgroup comparisons. It remains uncertain whether elective lymphadenectomy can be therapeutically beneficial in the management of melanoma. Nevertheless, it is clear that the procedure, or preferably sentinel lymphatic mapping with selective lymphadenectomy, can provide clinically relevant prognostic information, as well as the staging data requisite to adjuvant interferon alfa-2b therapy or enrollment into other adjunctive trials for patients at high risk of clinical relapse.

Reliability of the histopathologic diagnosis of melanocytic dysplasia. The Dysplastic Nevus Panel

OBJECTIVE

To determine the reliability of the histopathologic diagnosis of melanocytic dysplasia among diverse dermatopathologists who had no joint training, agreed to abide by predetermined criteria, and who were provided reference photomicrographs illustrative of the criteria.

DESIGN, SETTING, AND PARTICIPANTS

A stratified random sample of 112 melanocytic tumors were chosen from the files of the pathology department of a large staff-model health maintenance organization. The original diagnoses included typical and dysplastic melanocytic nevi and melanoma. A single representative slide for each case was interpreted independently by each of the 5 panel dermatopathologists and 2 melanoma specialists. They had no prior knowledge of the original diagnosis or the diagnoses of the other panel members.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Interrater reliability was measured by intraclass and Pearson correlation coefficients. Each case was graded on a 5-point scale from no dysplasia to melanoma.

RESULTS

The intraclass correlation among the panel members was 0.67 (95% confidence interval, 0.59-0.73). The Pearson correlations of each of the 5 panel dermatopathologists with the mean of the 2 melanoma specialists ranged from 0.67 to 0.84, and the correlations of the mean of the panel with the 2 melanoma specialists were 0.79 and 0.82; the mean reading of the melanoma specialists correlated 0.89 with the mean panel reading. Apparent protocol violations occurred in 6.5% of the readings.

CONCLUSIONS

Agreement was substantial to excellent for the histopathologic diagnosis of 112 melanocytic tumors by dermatopathologists. Using predetermined criteria, melanocytic dysplasia can be reproducibly graded among diverse general dermatopathologists.

Desmoplastic neurotropic melanoma

Desmoplastic neurotropic melanoma (DNM) is a rare variant of a spindle cell melanoma. The majority of these tumors occur on the head and neck of elderly patients. The rather variable clinical appearance (e.g. frequent lack of pigmentation) makes initial diagnosis often difficult. Histologically, DNM may show a lentiginous melanocytic proliferation with atypia and pleomorphic spindle cells in the dermis. Immunostaining for S-100 is usually positive although staining for HMB-45 is frequently absent. As with other melanomas, surgery is the first line treatment for DNM. Unlike other melanomas, however, survival for DNM may be better compared with other forms of melanoma.

Leukemic vasculitis: a feature of leukemia cutis in some patients

Cutaneous involvement is common in certain subtypes of acute leukemia and may be a reflection of a capacity of these tumors for tissue infiltration. We have recently noted that leukemia cutis can be accompanied by vasculitis in a subset of patients. We describe six cases of such leukemic vasculitis with findings ranging from mild microvascular injury to necrotizing arteritis. All cases were seen in patients with acute leukemia with myelomonocytic or monocytic features. In one patient, cutaneous leukemic vasculitis represented the initial manifestation of leukemia. In most cases, leukemic infiltration of the dermal blood vessels was the predominant pattern of involvement with minimal dermal infiltration. Vascular injury seemed to be mediated by leukemic blasts and not by reactive inflammatory cells. We propose the term leukemic vasculitis to describe such lesions.

CD99 (p30/32MIC2) immunoreactivity in the diagnosis of leukemia cutis

The diagnosis of leukemia cutis and distinction of early myeloid cells and blasts from lymphoblasts or other lymphoid cells can be difficult, particularly if only fixed tissue is available. O13, a monoclonal antibody that recognizes CD99, the p30/32MIC2 gene product, has been used to identify a number of cell types, including lymphoblasts, in paraffin sections. To evaluate the usefulness of CD99 immunoreactivity in the diagnosis of leukemia cutis, we analyzed cases of cutaneous involvement by acute lymphoblastic leukemia/lymphoblastic lymphoma and acute myelogenous leukemia for the presence of this marker. Without the use of antigen retrieval methods, lymphoblasts in cases of cutaneous involvement by acute lymphoblastic leukemia/lymphoblastic lymphoma were immunoreactive for CD99 in 9 of 9 cases. Myeloblasts and early myeloid cells in cases of cutaneous involvement by acute myelogenous leukemia were immunoreactive for CD99 in 12 (80%) of 15 cases. We conclude that CD99 is a sensitive but nonspecific marker for cutaneous involvement by acute lymphoblastic leukemia/lymphoblastic lymphoma and that CD99 is immunoreactive in the vast majority of cases (21 [88%] of 24 cases) of leukemia cutis.

Lesions resembling malignant atrophic papulosis in a patient with dermatomyositis

Many consider porcelain white atrophic papules as pathognomonic for malignant atrophic papulosis (MAP), or Degos' disease. During the past three decades, five patients with a collagen vascular disease have been reported to have MAP-like lesions as a manifestation of their underlying illness. We describe a patient with dermatomyositis who had porcelain-white atrophic papules resembling malignant atrophic papulosis.

Expression of platelet-derived growth factor (PDGF)-A, PDGF-B and the PDGF-alpha receptor, but not the PDGF-beta receptor, in human malignant melanoma in vivo

There has been considerable interest in the potential role of growth factors in the initiation and development of cutaneous malignant melanoma (CMM). Platelet-derived growth factor (PDGF) has been shown to be secreted by melanoma cell lines and by metastatic melanoma in vivo. PDGF also has been reported to stimulate the development of tumour stroma and new blood vessels. We studied the expression of PDGF and its receptors by both immunohistochemistry (IHC) and in situ hybridization (ISH) in primary and metastatic melanoma and in normal skin specimens. Cryostat sections were incubated with 35S-labelled riboprobes and antibodies for PDGF-AA, PDGF-alpha receptor, PDGF-BB and PDGF-beta receptor. Both primary and metastatic melanoma exhibited significant expression of PDGF-AA, PDGF-BB and PDGF-alpha receptor by both IHC and ISH, compared with only background expression in normal skin. We did not observe expression of PDGF-beta receptor in melanoma. Our results suggest that PDGF may function as an autocrine growth factor, as well as an angiogenesis factor, in CMM tumour development. This expression of the PDGF-alpha receptor rather than the beta receptor may be unique among solid tumours.

Loss of the p16INK4a and p15INK4b genes, as well as neighboring 9p21 markers, in sporadic melanoma

Although homozygous deletions of the cyclin-dependent kinase inhibitor 2 gene p16INK4a on 9p21 have been reported frequently in metastatic melanoma cell lines, and intragenic mutations within the p16INK4a gene have been detected in familial melanoma kindreds, specific targeting of this gene in the development of sporadic melanoma in vivo remains controversial. Southern analyses were performed in this study to initially assess the frequency of hemi- or homozygous losses of p16INK4a, as well as its neighboring family member, p15INK4b, and other candidate regions within 9p21, in sporadic melanoma. Overall, 22 of 40 (55%) uncultured sporadic melanoma DNAs were determined to harbor deletions of 1-11 markers/genes located on 9p21. This included 10 tumors (25%; 10 of 40) with homozygous deletions limited to either the p16INK4a gene only (20%; 2 of 10), both the p16INK4a and p15INK4b genes (10%; 1 of 10), another novel 9p21 gene, FB19 (10%; 1 of 10), or all three of these genes plus surrounding markers (60%; 6 of 10). In subsequent single-strand conformation polymorphism and sequencing analyses, intragenic mutations in the p16INK4a gene were also revealed in two (10%; 2 of 21) melanoma DNAs that retained one copy of this locus. By comparison, the frequency of pl6INK4a and p15INK4b homozygous deletions, as well as p16INK4a mutations, in melanoma cell lines (analyzed in parallel) was 2-3-fold higher at 61 (23 of 38) and 24% (9 of 38), respectively. These findings indicate that (a) p16INK4a is inactivated in vivo in over one-fourth (27.5%; 11 of 40) of sporadic melanomas; (b) mutation/deletion of p16INK4a may confer a selective growth advantage in vitro; and (c) other 9p21 tumor suppressor genes could be targeted during the development of melanoma.

Borrelial fasciitis: diffuse fasciitis and peripheral eosinophilia associated with Borrelia infection

We present four cases of diffuse fasciitis (DF) associated with peripheral eosinophilia in which spirochetal organisms were identified. Two patients had borderline positive results on serologic evaluation for Borrelia burgdorferi. Deep biopsy showed dermal sclerosis associated with variable degrees of perivascular mononuclear inflammation. Diffuse fasciitis, septal panniculitis, and myositis with mononuclear cell infiltrates and varying numbers of eosinophils were observed. All cases showed a striking lymphocytic vasculopathy associated with atypical reactive endothelial cells. Using modified Dieterle and Steiner silver stains, multiple organisms were seen in one specimen, a single unequivocal organism detected in two specimens. In one case, no organisms were detected on silver stain; however, organisms were demonstrated using rabbit polyclonal antibodies against B. burgdorferi. B. burgdorferi-specific DNA was identified in one patient by the polymerase chain reaction. These results indicate that some cases of eosinophilic fasciitis are an expression of Lyme disease. We have previously proposed the more specific term "borrelial fasciitis" to describe such lesions.

Malignant melanoma risk factors by anatomic site: a case-control study and polychotomous logistic regression analysis

This population-based case-control study systematically examined reported malignant melanoma risk factors by anatomic site. Study subjects consisted of 548 invasive melanoma cases diagnosed in Connecticut during 1987-1989 and 494 randomly selected controls. Multivariate polychotomous logistic regression was used to determine whether risk factors differed across anatomic sites. Risk factors examined included demographic and pigmentary characteristics, sun exposure-related factors, anatomic site-specific sunburn, recreational water activity clothing habits and number of nevi. A pattern of site-specificity was observed for sunburn. A history of sunburn at an anatomic site was specifically related to the development of malignant melanoma at that site more so than at other sites. This site-specificity was consistent with a direct role for intense, intermittent sun exposure in the development of melanoma. Age and gender were the only risk factors that differed significantly in effect across anatomic sites. The age difference was explained by differences in histologic subtype across sites. The gender difference could not be explained by sex differences in anatomic site-specific sunburns or in recreational water activity clothing habits. Alternative explanations include sex differences in behavioral patterns of sun exposure that we did not measure and as yet unelucidated differences in susceptibility to melanoma according to sex and anatomic site.

Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger

OBJECTIVE

A prospective multi-institutional randomized surgical trial involving 740 stage I and II melanoma patients was conducted by the Intergroup Melanoma Surgical Program to determine whether elective (immediate) lymph node dissection (ELND) for intermediate-thickness melanoma (1-4 mm) improves survival rates compared with clinical observation of the lymph nodes. A second objective was to define subgroups of melanoma patients who would have a higher survival with ELND.

METHODS

The eligible patients were stratified according to tumor thickness, anatomic site, and ulceration, and then were prerandomized to either ELND or nodal observation. Femoral, axillary, or modified neck dissections were performed using standardized surgical guidelines.

RESULTS

The median follow-up was 7.4 years. A multifactorial (Cox regression) analysis showed that the following factors independently influenced survival: tumor ulceration, trunk site, tumor thickness, and patient age. Surgical treatment results were first compared based on randomized intent. Overall 5-year survival was not significantly different for patients who received ELND or nodal observation. However, the 552 patients 60 years of age or younger (75% of total group) with ELND has a significantly better 5-year survival. Among these patients, 5-year survival was better with ELND versus nodal observation for the 335 patients with tumors 1 to 2 mm thick, the 403 patients without tumor ulceration, and the 284 patients with tumors 1 to 2 mm thick and no ulceration. In contrast, patients older than 60 years of age who had ELND actually had a lower survival trend than those who had nodal observation. When survival rates were compared based on treatment actually received (i.e., including crossover patients), the patients with significantly improved 5-year survival rates after ELND included those with tumors 1 to 2 mm thick, those without tumor ulceration, and those 60 years of age or younger with tumors 1 to 2 mm thick or without ulceration.

CONCLUSION

This is the first randomized study to prove the value of surgical treatment for clinically occult regional metastases. Patients 60 years or age or younger with intermediate-thickness melanomas, especially with nonulcerative melanoma and those with tumors 1 to 2 mm thick, may benefit from ELND. However, because some patients still are developing distant disease, these results should be considered an interim analysis.

Predicting five-year outcome for patients with cutaneous melanoma in a population-based study

BACKGROUND

In numerous studies tumor thickness has been shown to be the most important prognostic factor for patients with localized cutaneous melanoma. However, to our knowledge there are no population-based studies analyzing the prognosis of patients living in the United States with cutaneous melanoma.

METHODS

A prognostic model was developed with death as an outcome for 548 patients from Connecticut with localized cutaneous melanoma. Only patients with invasive melanoma who either died of the disease or were followed-up at least five years were studied. Fourteen pathologic parameters (histologic type of melanoma, Clark level, microscopic satellites, histologic regression, tumor thickness [Breslow], ulceration, vascular invasion, mitotic rate per mm2, tumor-infiltrating lymphocytes, radial vs. vertical growth phase, solar elastosis, co-existing nevus, lymphocytic response, and pigmentation) and three clinical variables (age, sex, and anatomic site) were analyzed using logistic regression.

RESULTS

After univariate analysis, 10 pathologic variables showed prognostic significance: histologic type (nodular and "other" types only), Clark level, microscopic satellites, regression (protective), tumor thickness, ulceration, vascular invasion, mitotic rate, vertical growth phase, and solar elastosis (protective). In the final model employing multivariate analysis, only tumor thickness and mitotic rate continued to have independent predictive value.

CONCLUSIONS

In this population-based study of 548 patients in Connecticut, tumor thickness was the most significant prognostic factor for survival of patients with localized cutaneous melanoma. Other prognostic factors studied to date have not been conclusively verified as providing any additional information beyond that of tumor thickness.

A factual, not arbitrary, basis for choice of resection margins in melanoma

Try as some might, it has proved exceedingly difficult to dispel the notion that primary melanoma should be treated by arbitrarily wide resection margins. There was never any substantive scientific foundation for the traditional 5-cm margin, but for much of this century it nevertheless found favor in medical folklore. Current opinions concerning melanoma management in the dermatologic literature, while careful to point out the limitations of supportive data, have continued the tradition of offering arbitrary guidelines for resection margins. The last 2 decades have witnessed the acquisition of sufficient experimental evidence to warrant further scrutiny of the practice.

Constitutive expression of B7-1 (CD80) on mouse keratinocytes does not prevent development of chemically induced skin papillomas and carcinomas

Expression of the B7-1 (CD80) costimulatory molecule in a variety of tumor cell lines leads to an enhanced CD8+ T cell response to tumor Ags. We used transgenic mice constitutively expressing B7-1 on keratinocytes (K14/B7-1 line) to determine whether keratinocyte B7-1 expression would inhibit the development of papillomas and carcinomas following two-stage chemical carcinogenesis in skin. FVB inbred mice carrying the K14/B7-1 transgene and controls were initiated with 25 micrograms of 7,12-dimethylbenz[a]anthracene and promoted weekly with 5 micrograms of 12-O-tetradecanoylphorbol-13-acetate for 20 wk. Expression of the B7-1 transgene did not result in statistically significant decreases in the mean number of papillomas or carcinomas compared with controls. The incidence of carcinomas in both transgenic and control mice reached 90% or greater by 60 wk after initiation. Carcinoma cell lines established from the K14/B7-1 mice maintained expression of B7-1 and Kq. These B7-1 expressing carcinomas grew progressively following intradermal injection into syngeneic FVB mice, further demonstrating their inability to evoke protective tumor immunity. These same carcinoma cell lines were rapidly rejected by minor alloantigen-mismatched SWR mice, confirming their susceptibility to immune effector mechanisms. The failure of constitutive B7-1 expression on keratinocytes to prevent the growth of squamous cell papillomas and carcinomas may reflect the limited immunogenicity of tumors arising after initiation-promotion carcinogenesis. Our results in this transgenic model system are further evidence that B7-1 gene therapy alone may not be sufficient to induce protective immunity to some types of tumors.