Reducing workload in malignant melanoma sentinel node examination: a national study of pathology reports from 507 melanoma patients

AIMS

Even though extensive melanoma sentinel node (SN) pathology protocols increase metastasis detection, there is a need for balancing high detection rates with reasonable workload. A newly tested Danish protocol recommended examining nodes at six levels 150 µm apart (six-level model) and using SOX10 and Melan-A immunohistochemistry (IHC). We explored if a protocol examining 3 levels 300 µm apart (three-level model) combined with IHC would compromise metastasis detection. The study aim was to optimise the protocol to reduce workload without compromising detection rate.

METHODS

8 months after protocol implementation, we reviewed the pathology reports of SNs from 507 melanoma patients nationwide, including 117 SN-positive patients. Each report was reviewed to determine histopathological features, including detection of metastasis, exact levels with metastasis, exact levels with metastasis >1 mm in diameter and IHC results.

RESULTS

The six-level model detected metastases in 23% of patients, whereas the three-level model would have detected metastases in 22% of patients. The three-level model would have missed a few small metastases (n=4), measuring <0.1 mm, 0.1 mm, 0.4 mm and 0.1 mm, respectively. The six-level model detected metastases >1 mm in 7% of patients. One of these metastases (measuring 1.1 mm) would have been detected by the three-level model, but not as >1 mm. SOX10 and Melan-A had equal sensitivity.

CONCLUSIONS

Reducing the number of levels examined to three levels 300 µm apart combined with IHC does not have significant impact on metastasis detection rate, and we will therefore recommend that the future melanoma SN guideline takes this into consideration to reduce overall workload.

Thin or early melanoma, risk factors and associated mortality

INTRODUCTION

The incidence of thin and early-stage melanoma is increasing in many populations, but the clinical significance of these lesions remains partly unknown.

METHODS

Firstly, melanoma deaths in Denmark (2009-2018) were followed back to establish melanoma debut in these persons. Secondly, using national registries of cancer incidence and mortality, 27,036 persons with thin or early-stage melanoma were followed-up for melanoma death.

RESULTS

It is estimated that in 11% of the persons who died from melanoma, the debut was a thin or early-stage melanoma. On follow-up of persons with thin or early-stage melanoma, the 20-year risk of dying from melanoma was 3%.

CONCLUSION

The absolute risk of melanoma death after a diagnosis with thin or early-stage melanoma is low. A subgroup of patients who are at a high risk may possibly be identified by a combination of stage, thickness, ulceration and dermal mitoses.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Rare cause of spontaneous haemothorax: mediastinal and distant lymph node metastases from uveal melanoma

We report a rare case of isolated mediastinal and inferior mediastinal lymph node metastases from choroidal melanoma. The patient was treated for primary choroidal melanoma with local tumour resection and radioactive plaque brachytherapy. Eleven years later, he was diagnosed with metastatic disease. Molecular analysis of the metastatic tumour demonstrated a GNAQ Q209P mutation. There was no evidence of malignant blue naevus or primary melanoma of the central nervous system on physical examination or imaging. The rare modality of clinical presentation highlights the unpredictable nature of metastatic uveal melanoma.

The Danish Melanoma Database

AIM OF DATABASE

The aim of the database is to monitor and improve the treatment and survival of melanoma patients.

STUDY POPULATION

All Danish patients with cutaneous melanoma and in situ melanomas must be registered in the Danish Melanoma Database (DMD). In 2014, 2,525 patients with invasive melanoma and 780 with in situ tumors were registered. The coverage is currently 93% compared with the Danish Pathology Register.

MAIN VARIABLES

The main variables include demographic, clinical, and pathological characteristics, including Breslow's tumor thickness, ± ulceration, mitoses, and tumor-node-metastasis stage. Information about the date of diagnosis, treatment, type of surgery, including safety margins, results of lymphoscintigraphy in patients for whom this was indicated (tumors > T1a), results of sentinel node biopsy, pathological evaluation hereof, and follow-up information, including recurrence, nature, and treatment hereof is registered. In case of death, the cause and date are included. Currently, all data are entered manually; however, data catchment from the existing registries is planned to be included shortly.

DESCRIPTIVE DATA

The DMD is an old research database, but new as a clinical quality register. The coverage is high, and the performance in the five Danish regions is quite similar due to strong adherence to guidelines provided by the Danish Melanoma Group. The list of monitored indicators is constantly expanding, and annual quality reports are issued. Several important scientific studies are based on DMD data.

CONCLUSION

DMD holds unique detailed information about tumor characteristics, the surgical treatment, and follow-up of Danish melanoma patients. Registration and monitoring is currently expanding to encompass even more clinical parameters to benefit both patient treatment and research.

[Challenging investigation of a metastatic adnexal cutaneous tumour]

Adnexal cutaneous tumours are very rare. A lack of knowledge about their clinical presentations can lead to prolonged diagnostic investigations and disease progression. This case report presents a challenging investigation of a metastatic malignant adnexal tumour due to misleading histology, immunohistochemical analysis and clinical findings.

[Primary mucinous carcinoma of the skin]

Primary mucinous carcinoma of the skin is a rare malignant tumour originating from the sweat glands. It is often misdiagnosed clinically since it has an uncharacteristic and variable presentation, and microscopically because it resembles a cutaneous metastasis from the more frequent mucinous adenocarcinomas of the colon, mammae, lungs and ovaries. The tumour often recurs, but mortality is low. We present a case with regional lymph node metastases five years after excision of the primary tumour.

BRCA1 and BRCA2 mutation status and cancer family history of Danish women affected with multifocal or bilateral breast cancer at a young age

INTRODUCTION

A small fraction of breast cancer is the result of germline mutations in the BRCA1 and BRCA2 cancer susceptibility genes. Mutation carriers frequently have a positive family history of breast and ovarian cancer, are often diagnosed at a young age, and may have a higher incidence of double or multiple primary breast tumours than breast cancer patients in general.

OBJECTIVES

To estimate the prevalence and spectrum of BRCA1 and BRCA2 mutations in young Danish patients affected with bilateral or multifocal breast cancer and to determine the relationship of mutation status to family history of cancer.

SUBJECTS

From the files of the Danish Breast Cancer Cooperative Group (DBCG), we selected 119 breast cancer patients diagnosed before the age of 46 years with either bilateral (n=59) or multifocal (n=61) disease.

METHODS

DNA from the subjects was screened for BRCA1 and BRCA2 mutations using single strand conformation analysis (SSCA) and the protein truncation test (PTT). Observed and expected cancer incidence in first degree relatives of the patients was estimated using data from the Danish Cancer Registry.

RESULTS

Twenty four mutation carriers were identified (20%), of whom 13 had a BRCA1 mutation and 11 carried a BRCA2 mutation. Two mutations in BRCA1 were found repeatedly in the material and accounted for seven of the 24 (29%) mutation carriers. The mutation frequency was about equal in patients with bilateral (22%) and multifocal breast cancer (18%). The incidence of breast and ovarian cancer was greatly increased in first degree relatives of BRCA1 and BRCA2 mutation carriers, but to a much lesser degree in relatives of non-carriers. An increased risk of cancer was also noted in brothers of non-carriers.

CONCLUSIONS

A relatively broad spectrum of germline mutations was observed in BRCA1 and BRCA2 and most of the mutations are present in other populations. Our results indicate that a diagnosis of bilateral and multifocal breast cancer is predictive of BRCA1 and BRCA2 mutation status, particularly when combined with information on the patients' age at diagnosis and family history of breast/ovarian cancer.

Doctors and dying declarations: the role of the state in abortion regulation in British Columbia, 1917-37

In Canada, the history of state regulation of abortion is underexamined, leaving the general impression that the state played a secondary role to that of the medical profession in attempting to enforce the federal anti-abortion law. Studies have focused on "regular" physicians as a regulator of abortion to such an extent that the state's involvement in this process has been largely neglected or obscured. In contrast, this study highlights the actions taken by lower-level state agencies, namely, the Coroner's Inquisition and municipal and provincial police, to enforce the federal abortion law in British Columbia. The study examines the records of the inquests held into the deaths of 34 women from illegal abortion and offers three main observations. First, state agencies consistently sought information about abortionists and the circumstances surrounding the abortions from the women in hospital, their families, lovers, and doctors. Especially important is how authorities routinely attempted to extract dying declarations from the ill women. Second, while it is clear doctors participated in the investigative process, the records suggest they were often ambivalent or reluctant to do so. Finally, this study concludes that many of the actors involved in these events resisted the authorities' attempts to enforce the law, some successfully, thereby effectively undermining state regulatory practices as a result.

Partial moles with maze-like vascular anomaly

Two cases of combined maze-like vascular anomaly and partial mole are described. Immunohistochemical staining showed the abnormal vessels to be of endothelial origin. The vessels had been a functioning part of the fetal circulation. Both partial moles were triploid, and both were evacuated in the second trimester.