Nodular type but not vitamin D levels increases the risk of second primary cancers in melanoma patients: An observational study of 663 patients

BACKGROUND

Vitamin D deficiency associates with the risk of developing many diseases, including cancer. At the molecular level, vitamin D appears to have an antineoplastic effect. However, the role of vitamin D deficiency in cancer pathogenesis remains unelucidated and numerous studies have resulted in discordant results. This study aimed to determine whether vitamin D deficiency during melanoma diagnosis increases the risk of developing non-cutaneous second primary cancers (SPC).

MATERIALS AND METHODS

A retrospective study on 663 patients diagnosed with melanoma between 1 January 2011 and 31 October 2022. The effect of each variable on the development of a subsequent non-cutaneous cancer was performed using Kaplan-Meier curves and differences were assessed by log-rank tests. Cox proportional hazard univariate and multivariate models were used to quantify the effect of each variable in the time to develop a non-cutaneous neoplasia.

RESULTS

Out of 663 patients, 34 developed a non-cutaneous SPC. There was no statistically significant association between vitamin D levels and non-cutaneous SPC development (log-rank, p=0.761). Age>60 years, stage III/IV, and nodular melanoma subtype were significantly associated with the development of a SPC. After multivariate analysis, only age>60 years (HR 3.4; HR CI 95%: 1.5-7.6) and nodular melanoma subtype (HR 2.2; HR CI 95%: 1.0-4.8) were included in the final model.

CONCLUSIONS

Our results suggest that vitamin D deficiency is not associated with an increased risk of developing non-cutaneous SPC in melanoma patients. However, age over 60 years and nodular melanoma subtype increase the risk for non-cutaneous SPC development.

Nodular Type but Not Vitamin D Levels Increases the Risk of Second Primary Cancers in Melanoma Patients: An Observational Study of 663 Patients

BACKGROUND

Vitamin D deficiency associates with the risk of developing many diseases, including cancer. At the molecular level, vitamin D appears to have an antineoplastic effect. However, the role of vitamin D deficiency in cancer pathogenesis remains unelucidated and numerous studies have resulted in discordant results. This study aimed to determine whether vitamin D deficiency during melanoma diagnosis increases the risk of developing non-cutaneous second primary cancers (SPC).

MATERIALS AND METHODS

A retrospective study on 663 patients diagnosed with melanoma between 1 January 2011 and 31 October 2022. The effect of each variable on the development of a subsequent non-cutaneous cancer was performed using Kaplan-Meier curves and differences were assessed by log-rank tests. Cox proportional hazard univariate and multivariate models were used to quantify the effect of each variable in the time to develop a non-cutaneous neoplasia.

RESULTS

Out of 663 patients, 34 developed a non-cutaneous SPC. There was no statistically significant association between vitamin D levels and non-cutaneous SPC development (log-rank, p=0.761). Age>60 years, stage III/IV, and nodular melanoma subtype were significantly associated with the development of a SPC. After multivariate analysis, only age>60 years (HR 3.4; HR CI 95%: 1.5-7.6) and nodular melanoma subtype (HR 2.2; HR CI 95%: 1.0-4.8) were included in the final model.

CONCLUSIONS

Our results suggest that vitamin D deficiency is not associated with an increased risk of developing non-cutaneous SPC in melanoma patients. However, age over 60 years and nodular melanoma subtype increase the risk for non-cutaneous SPC development.

Prognosis of naevoid melanomas

INTRODUCTION

There appear to be several variants of naevoid melanoma suspected as having different outcomes, but follow-up studies have been few. We aimed to assess the prognosis of naevoid melanomas in a multi-centre study.

MATERIAL AND METHODS

From histopathology records we ascertained patients in the UK, Australia and Italy diagnosed with maturing naevoid melanoma (n = 65; 14; 7 respectively) and nodular/papillomatous naevoid melanoma (12; 6; 0), and patients with superficial spreading melanoma (SSM) from UK (73) and Australia (26). Melanoma deaths in UK patients were obtained from NHS Digital; in Australia, via the National Death Index and cancer registry; and in Italy, through clinical records. For maturing naevoid vs. SSM, we used Cox-proportional hazard regression models to compare survival adjusted for age, sex, tumour thickness, and ulceration, and additionally Fine-Gray regression analysis, to calculate sub-hazard ratios (SHR) in the UK cohort, accounting for competing causes of death.

RESULTS

Among UK patients, there was a non-significantly lower risk of melanoma death in maturing naevoid vs SSM, including after accounting for competing causes of death (SHR 0.40, 95% confidence interval (CI) 0.12-1.31), while among nodular/papillomatous naevoid melanoma patients, there were no melanoma deaths on follow-up. Two melanoma deaths occurred in Australian SSM patients, and none in maturing or nodular/papillomatous naevoid melanoma patients, after 5 years' minimum follow-up. None of the 7 Italian patients with maturing naevoid melanoma died of melanoma after nearly 12 years' average follow-up.

CONCLUSIONS

There was no significant difference in risk of death from melanomas with naevoid features, and SSM. Nodular/ papillomatous naevoid melanoma patients did not carry higher risk of death than SSM patients though the very few cases of the papillomatous naevoid variant limited our assessment.

Nodular malignant melanoma in vulvar skin without pigmentation: a case report

Background

Polypoid nodule growing without apparent pigmentation on the vulvar skin usually reminds us of the diagnostic pitfall, which is commonly and mistakenly diagnosed as other types of tumors. Although there are several manifestations of amelanotic melanoma are known, these malignancies are usually pigmented because they are derived from melanocytes containing melanin. However, amelanotic melanomas are easily misdiagnosed or their diagnoses were commonly delayed due to lack of pigmentation. Therefore, a solitary polypoid nodule is worth noting and further reporting. Particularly, the clinical characteristics and outcomes of the solitary polypoid nodule are rare in Asian patients.

Case presentation

We presented an interesting case of a 33-year-old female with a solitary polypoid nodule without apparent pigmentation on her vulvar skin. Her medical history was unclear, no ulcer was seen in the lesion area, and dermatoscopy was indicated a possible tumorous change, which has caught the attention of clinicians, and then further examined by the pathologist. The final diagnosis was nodular malignant melanoma (NM) (Breslow thickness 9.5mm, Clark level 4).

Conclusions

Hence, though reviewing this case record, the relevant literature and NM-related materials, we suggest that the combination of skin imaging technology and histopathological examination could provide us a better understanding and reduce the possibility of misdiagnosis in clinic practice.

Patient-identified early clinical warning signs of nodular melanoma: a qualitative study

BACKGROUND

Nodular (NM) and superficial spreading melanoma (SSM) show different disease trajectories, with more rapid development in NM and fewer opportunities for early detection often resulting in worse outcomes. Our study described the patient-identified early signs of thin NM via comparisons to thin (≤ 2 mm) SSM and thick (> 2 mm) NM.

METHODS

We conducted semi-structured interviews with NM and SSM patients and analyzed the data using thematic analysis.

RESULTS

We enrolled 34 NM and 32 SSM patients. Melanoma early signs uniquely identified by patients with thin NM included white, blue or black coloration, "dot-like" size, fast changes in shape and color observed over 2 weeks, elevation and texture or "puffiness" over 6-12 months, and the sensation that the mole "did not feel right". Early signs reported by both thin NM and thin SSM patients included round or oblong shape, "jagged" border, pink/red, brown/reddish or dark coloration, "elevated like a pimple" or "tiny bump", fast color darkening, diameter growth, and border irregularity, and mole feeling "really itchy".

CONCLUSIONS

We found evidence that early signs of NM can be self-identified, which has important implications for the earlier detection of this most aggressive type of melanoma by both health professionals and patients.

Multivariate analysis of prognostic factors in patients with nodular melanoma

PURPOSE

Nodular melanoma (NM) is associated with worse disease outcome when compared to superficial spreading melanoma (SSM). We aimed to perform a single-center analysis of prognostic factors in patients with NM and compare the data with SSM patients.

METHODS

We studied 228 patients with NN and 396 patients with SSM. Patients with in situ melanomas or stage IV at diagnosis were not included in the study. Data were analyzed using the Mann-Whitney test, Chi-square test, Kaplan-Meier curves including the log-rank test, and logistic regression model.

RESULTS

When compared to patients with SSM, patients with NM had less likely lower Clark level, higher tumor thickness, less likely tumor regression, more often ulcerated tumors, and less likely a history of precursor lesions such as a nevus. Within a 5-year follow-up we observed significantly more disease relapses and deaths in NM patients than in SSM patients. On multivariate analysis, disease relapse in NM patients was independently predicted by tumor thickness and positive SLNB, whereas melanoma-specific death of NM patients was independently predicted by male sex and tumor thickness. Histologic regression also remained in the logistic regression model as a significant independent negative predictor of NM death.

CONCLUSIONS

We did not observe that NM subtype was per se a significant independent predictor for disease relapse or melanoma-specific death. Among the well-known prognostic factors such as tumor thickness and male sex, NM is also associated with other unfavorable factors such as absence of regression.

[Three independent melanomas over a span of 2 years in a 31-year-old man-a case report]

We present the case of a 31-year-old soldier who developed three independent melanomas in only 2 years. We saw two mucosal melanomas and one nodular melanoma of the scalp. The last one led to a cerebral metastasis during the course of the follow-up. After complete resection and under ongoing immunotherapy with nivolumab, there was no progression of disease until December 2019. The Karnofsky index remained at 100% and there were no side effects of therapy. Besides fair skin type, no other risk factors for the development of melanomas were identified, even after performing genetic analysis.

Low BRAF V600 mutation prevalence in primary skin nodular melanoma in Indonesia: a real-time PCR detection among Javanese patients

BACKGROUND

Cutaneous melanoma is a rare, aggressive skin malignancy with a high mortality rate. Although only contributing 7.6% of the cases worldwide, Asia is responsible for 18.6% of deaths from cutaneous melanoma. BRAF V600 mutation presents a potential prognostic predictor in melanoma. Unfortunately, studies on that mutation in melanoma, particularly nodular subtype, in Indonesia are still scarce. This research aimed to investigate the prevalence of BRAF V600 mutation in primary skin nodular melanoma in Yogyakarta and Central Java, Indonesia. Its association with clinicopathological parameters was also analyzed.

METHODS

Forty paraffin-embedded tissue samples from primary skin nodular melanoma cases in 2011-2018 were collected from the two biggest referral hospitals in Yogyakarta and Central Java, Indonesia. The BRAF V600 mutation status was assessed using qualitative real-time PCR and its associations with age, sex, anatomic location, lymph node metastasis, tumor thickness, ulceration, mitotic index, necrosis, lymphovascular invasion, and tumor-infiltrating lymphocytes were analyzed.

RESULTS

BRAF V600 mutations were found in 4 (10%) samples. These mutations were significantly associated with the central (non-extremity) region (p = 0.013) and presence of lymphovascular invasion (p = 0.005). However, it was not associated with any other variables analyzed in this study.

CONCLUSION

The prevalence of BRAF V600 mutation in Indonesian primary skin nodular melanoma cases is low and significantly associated with anatomic location and lymphovascular invasion. It is lower than prevalences in other Asian populations as well as in Caucasian populations and suggests that melanoma cases in Javanese people may have distinct clinicopathological characteristics from other Asian ethnicities.

Clinicopathological predictors of recurrence in nodular and superficial spreading cutaneous melanoma: a multivariate analysis of 214 cases

BACKGROUND

Nodular melanoma (NM) accounts for most thick melanomas and because of their frequent association with ulceration, fast growth rate and high mitotic rate, contribute substantially to melanoma-related mortality. In a multicentric series of 214 primary melanomas including 96 NM and 118 superficial spreading melanoma (SSM), histopathological features were examined with the aim to identify clinicopathological predictors of recurrence.

METHODS

All consecutive cases of histopathologically diagnosed primary invasive SSM and NM during the period 2005-2010, were retrieved from the 12 participating Italian Melanoma Intergroup (IMI) centers. Each center provided clinico-pathological data such as gender, age at diagnosis, anatomical site, histopathological conventional parameters, date of excision and first melanoma recurrence.

RESULTS

Results showed that NM subtype was significantly associated with Breslow thickness (BT) at multivariate analysis: [BT 1.01-2 mm (OR 7.22; 95% CI 2.73-19.05), BT 2.01-4 mm (OR 7.04; 95% CI 2.54-19.56), and BT > 4 mm (OR 51.78; 95% CI 5.65-474.86) (p < 0.0001)]. Furthermore, mitotic rate (MR) was significantly correlated with NM histotype: [(MR 3-5 mitoses/mm2 (OR 2.62; 95% CI 1.01-6.83) and MR > 5 mitoses/mm2 (OR 4.87; 95% CI 1.77-13.40) (p = 0.002)]. The risk of recurrence was not significantly associated with NM histotype while BT [BT 1.01-2.00 mm (HR 1.55; 95% CI 0.51-4.71), BT 2.01-4.00 mm (HR 2.42; 95% CI 0.89-6.54), BT > 4.00 mm. (HR 3.13; 95% CI 0.95-10.28) (p = 0.05)], mitotic rate [MR > 2 mitoses/mm2 (HR 2.34; 95% CI, 1.11-4.97) (p = 0.03)] and the positivity of lymph node sentinel biopsy (SNLB) (HR 2.60; 95% CI 1.19-5.68) (p = 0.007) were significantly associated with an increased risk of recurrence at multivariate analysis.

CONCLUSIONS

We found that NM subtype was significantly associated with higher BT and MR but it was not a prognostic factor since it did not significantly correlate with melanoma recurrence rate. Conversely, increased BT and MR as well as SNLB positivity were significantly associated with a higher risk of melanoma recurrence.