Thin malignant melanomas (< 1.5 mm) with metastasis: a histological study and survival analysis

It is known that not all thin malignant melanomas have an excellent prognosis and that the specific features identifying the patients at risk of metastasis have not been fully elucidated. We have looked at thin malignant melanomas (less than 1.5 mm) in the East of Scotland that had proven metastasis and death, and compared the clinical and histological features with a similar group (less than 1.5 mm) that have had no further recurrence after a minimum of 6-year follow-up. We identified 26 patients with thin melanomas who had developed histologically proven metastasis and/or died following adequate surgical treatment of their primary lesion. When compared with the control group, factors found to be significantly different between the two groups and present in the group that did badly were (a) histological regression, (b) lesion size, (c) Clark level IV and (d) depth of the uninvolved dermis.     

Spitz naevi and malignant melanomas of childhood and adolescence

We reviewed 33 cases of Spitz naevus and 19 of malignant melanoma in patients aged 20 years or less who were evaluated at our institution from 1950 to 1975 and followed-up for up to 32 years. The histological findings were studied prior to review of clinical data. There were no malignant melanomas in patients less than 9 years old; almost half (15/33) of the Spitz naevi were in this age group. Among the 25 histological criteria evaluated in the 52 lesions, the most striking differences between malignant melanomas and Spitz naevi were a higher degree of pagetoid spread, cellular pleomorphism, nuclear hyperchromasia and mitotic activity in the malignant melanomas, and a more prominent spindle cell component in Spitz naevi. We stress the importance of cytological as well as architectural criteria in distinguishing between Spitz naevi and malignant melanomas and emphasize the pitfalls that may be encountered because of overlap in histological features between the two groups.     

The prognostic significance of tumor vascularity in intermediate-thickness (0.76-4.0 mm thick) skin melanoma. A quantitative histologic study.

The vascularity of 20 primary skin melanomas was assessed histologically. These cases were selected from patients with intermediate thickness melanomas (0.76-4.0 mm thick) treated surgically to provide two groups of ten patients. One group had no evidence of recurrence with a minimum follow-up of 9 years. The second group of ten patients developed locoregional or systemic metastasis under follow-up, and seven of these patients died of disseminated melanoma. Age, sex, Breslow's tumor thickness, and Clark's level of invasion were similar in the two groups. Vascular quantitation was carried out by image analysis after vascular definition by Ulex europaeus-I agglutinin staining. The percentage vascular area at the tumor base in the recurrence group was more than twice that in the recurrence-free group. This study suggests that increased vascularity at the tumor base may have prognostic significance in intermediate thickness melanomas.     

p53-protein and Ki-67-antigen expression are both reliable biomarkers of prognosis in thick stage I nodular melanomas of the skin

The maximum tumour thickness is the most important prognostic factor in malignant melanomas of the skin. However, the clinical outcome of thick nodular melanomas remains unpredictable. Therefore, we investigated possible prognostic markers in this subset of melanomas. From a melanoma data base, 12 patients with thick (> 3 mm) stage I nodular melanomas of the skin were identified, who were still without signs of progression after five years of follow-up. These tumours were compared to a randomly selected series of 12 cases, who did not survive the first five years after removal of the tumours. We performed immunostaining for the p53-protein and the proliferation associated Ki-67-antigen. For quantification of immunostaining the tumours were entirely scanned. In addition, all tumours were investigated for any differences with conventionally applied prognostic features: the tumour thickness; the level of invasion; the prognostic index (tumour thickness multiplied by mitotic count); and the mean volume-weighted mean nuclear volume. We demonstrated significant differences between survivors and non-survivors exclusively in respect of the staining-indices for p53 and Ki-67 ( P < 0.03 and 0.02, respectively). With both antibodies the tumours of survivors showed lower counts as compared to non-survivors. However, within both groups we found no significant correlations between the p53- and Ki-67-staining results. We conclude that immunostaining for p53-protein and Ki-67-antigen is helpful to identify individuals with thick nodular melanomas who are at risk of metastatic disease.     

p53-protein and Ki-67-antigen expression are both reliable biomarkers of prognosis in thick stage I nodular melanomas of the skin

The maximum tumour thickness is the most important prognostic factor in malignant melanomas of the skin. However, the clinical outcome of thick nodular melanomas remains unpredictable. Therefore, we investigated possible prognostic markers in this subset of melanomas. From a melanoma data base, 12 patients with thick (> 3 mm) stage I nodular melanomas of the skin were identified, who were still without signs of progression after five years of follow-up. These tumours were compared to a randomly selected series of 12 cases, who did not survive the first five years after removal of the tumours. We performed immunostaining for the p53-protein and the proliferation associated Ki-67-antigen. For quantification of immunostaining the tumours were entirely scanned. In addition, all tumours were investigated for any differences with conventionally applied prognostic features: the tumour thickness; the level of invasion; the prognostic index (tumour thickness multiplied by mitotic count); and the mean volume-weighted mean nuclear volume. We demonstrated significant differences between survivors and non-survivors exclusively in respect of the staining-indices for p53 and Ki-67 (P < 0.03 and 0.02, respectively). With both antibodies the tumours of survivors showed lower counts as compared to non-survivors. However, within both groups we found no significant correlations between the p53- and Ki-67-staining results. We conclude that immunostaining for p53-protein and Ki-67-antigen is helpful to identify individuals with thick nodular melanomas who are at risk of metastatic disease.     

Immunoexpression of endoglin in brain metastasis secondary to malignant melanoma: evaluation of angiogenesis and comparison with brain metastasis secondary to breast and lung carcinomas

Brain metastases are linked to poor prognosis. After carcinomas of the lung and breast, malignant melanomas (MM) are the next type of neoplasm with the higher metastatic dissemination involving the central nervous system and that has the worst prognosis after metastasis has been diagnosed. Angiogenesis has been linked to tumor growth and metastasis. Among the immunomarkers of angiogenesis, endoglin (CD105) is the most specific antibody, since it is a marker for tumor endothelium, and expression of CD105 has been observed to be associated with prognosis in several types of tumor, which is not always observed in melanomas. This study investigated angiogenesis in brain metastasis secondary to malignant melanomas and compared these with brain metastasis secondary to carcinomas of the lung and breast, through expression of CD105 (endoglin). The study investigated 93 cases of brain metastasis secondary to MM (33) and carcinomas of the lung (31) and breast (29), assessing endoglin immunoexpression, number of microvessels and diameter of tumor vessels. Tumor microvessels were counted using a modified version of the Chalkley technique. The observed difference between MM and breast carcinoma was statistically significant (P = 0.026). The difference between MM and lung carcinoma was not significant (P = 0.218). Vascular diameter observation revealed no statistical difference between the vascular size of neoplastic vessels in MM and in breast and lung carcinomas. Of the tumors investigated here, malignant melanomas were shown to have the lowest number of microvessels and had intermediate tumor vessel diameter as compared to carcinomas of the lungs and breast. Such results were not expected to be found in neoplasms such as melanomas that, besides presenting high dissemination capacity, have a high index of hemorrhage secondary to brain metastasis.     

Tumor lymphangiogenesis: a novel prognostic indicator for cutaneous melanoma metastasis and survival

Malignant melanomas of the skin are distinguished by their propensity for early metastatic spread via lymphatic vessels to regional lymph nodes, and lymph node metastasis is a major determinant for the staging and clinical management of melanoma. However, the importance of tumor-induced lymphangiogenesis for lymphatic melanoma spread has remained unclear. We investigated whether tumor lymphangiogenesis occurs in human malignant melanomas of the skin and whether the extent of tumor lymphangiogenesis may be related to the risk for lymph node metastasis and to patient survival, using double immunostains for the novel lymphatic endothelial marker LYVE-1 and for the panvascular marker CD31. Tumor samples were obtained from clinically and histologically closely matched cases of primary melanomas with early lymph node metastasis (n = 18) and from nonmetastatic melanomas (n = 19). Hot spots of proliferating intratumoral and peritumoral lymphatic vessels were detected in a large number of melanomas. The incidence of intratumoral lymphatics was significantly higher in metastatic melanomas and correlated with poor disease-free survival. Metastatic melanomas had significantly more and larger tumor-associated lymphatic vessels, and a relative lymphatic vessel area of >1.5% was significantly associated with poor disease-free and overall survival. In contrast, no differences in the density of tumor-associated blood vessels were found. Vascular endothelial growth factor and vascular endothelial growth factor-C expression was equally detected in a minority of cases in both groups. Our results reveal tumor lymphangiogenesis as a novel prognostic indicator for the risk of lymph node metastasis in cutaneous melanoma.     

Malignant melanoma with neuroendocrine differentiation: clinical, histological, immunohistochemical and ultrastructural features of three cases

AIM: To document the clinical, histological, immunohistochemical and ultrastructural features of three malignant melanomas showing neuroendocrine differentiation. METHODS AND RESULTS: Three patients, two with primary cutaneous melanoma and one with nasal mucosal melanoma, subsequently developing or simultaneously presenting with metastatic malignant melanoma, were studied by conventional histological technique, immunohistochemistry of formalin-fixed paraffin-wax embedded tissues, and electron microscopy of epoxy-resin-embedded tumour tissue. Tumours showed either small cell or conventional malignant melanoma cell morphology. One of the three primary melanocytic lesions (the nasal melanoma) exhibited neuroendocrine differentiation immunohistochemically. All three metastatic malignant melanomas showed, in varying combinations, immunohistochemical and ultrastructural evidence for neuroendocrine differentiation: they were positive for the melanocytic markers, S100 protein, HMB-45, Melan-A and tyrosinase, and the neuroendocrine markers chromogranin, synaptophysin and neurofilament protein. Ultrastructural study in two of the metastases revealed neuroendocrine granules but no lattice-bearing melanosomes. CONCLUSIONS: The cases described are the most comprehensively investigated malignant melanomas showing neuroendocrine differentiation to date, and the first to document neuroendocrine differentiation ultrastructurally in these tumours. Malignant melanoma with neuroendocrine differentiation therefore needs to be recognized among the other, better known variants of malignant melanoma.     

Clinical and histological intercorrelations in pigmented naevi indicating potential melanoma precursor lesions

A series of 577 pigmented naevi from an equal number of patients has been studied histopathologically without access to clinical information. Later the histological findings have been compared with clinical information obtained by sending a questionnaire to the patients. The correlations between the many histological and clinical variables have been studied. Patients with a red or fair hair colour, a freckled, easily sunburnt skin type and/or a poor suntanning ability have the tendency to develop irregular and atypical naevi. Histological variables like nuclear atypia, mitoses, lymphocyte reaction, fibrosis and "shoulder"-phenomenon regarding the growth pattern of naevi are correlated to this delicate skin type. These findings support til theory that irregular and atypical naevi may be potential precursors to malignant melanomas as patients with this skin type belong to the melanoma risk group.     

Balloon cell melanoma mimicking clear cell carcinoma

Balloon cells may occur in both benign nevi and malignant melanomas. Sometimes they dominate the histological appearance and cause difficulties in biopsy interpretation. There are no specific clinical characteristics. We report a metastatic balloon cell melanoma where the primary tumour was not identified and the histological appearance mimicked that of a clear cell renal carcinoma.     

A comparative study of proliferation indices and ploidy in dysplastic naevi and malignant melanomas using flow cytometry

Cell proliferation indices and DNA content have been determined in 18 intradermal naevi, 40 dysplastic naevi and 16 superficial malignant melanomas (less than 0.76 mm depth of invasion) using flow cytometry. In this study, proliferation indices of intradermal naevi and dysplastic naevi were not significantly different from each other. Abnormalities of DNA ploidy were not identified in the intradermal naevi or dysplastic naevi; whereas three of the malignant melanomas were aneuploid. In addition, cellular proliferation was increased within the group of malignant melanomas, in comparison with the naevi. This study has found no evidence to indicate that sporadic dysplastic naevi were more likely than intradermal naevi to transform to malignant melanoma, when objective criteria were employed. However, dysplastic naevi could be distinguished from some early malignant melanomas by absence of aneuploidy and by low cell proliferation indices.     

Loss of S100 antigenicity in metastatic melanoma

Melanoma is a highly malignant disease that may initially present as a poorly differentiated metastatic tumor. Therefore, the S100 immunostain, immunoreactive in 96% to 99% of melanoma, is used to evaluate poorly differentiated malignant tumors. To develop criteria for correctly diagnosing S100-negative melanomas, we studied the immunohistochemical profile of 1553 patients enrolled in ongoing National Cancer Institute clinical trials for melanoma. Seventeen patients (1%) had metastatic melanoma specimens that were negative for S100. Of the 17 S100-negative lesions, 10 (59%) were immunoreactive for both GP100 and MART-1. Of the 17 S100-negative cases, 13 had a documented primary melanoma. Twenty-four percent of the S100-negative cases had an ocular primary, whereas only 6% of all melanomas had an ocular origin. In 11 of the 17 cases with previous surgical specimens, a prior documented S100-immunoreactive specimen was identified in 9 cases (82%). The time interval for loss of S100 immunoreactivity ranged from 3 weeks to 3 years (average, 13.5 months). There was no association between S100-negative status and histological appearance or site of metastasis. We conclude that all S100-negative melanomas could be correctly identified by negative workup for carcinoma, lymphoma, and sarcoma plus (1) GP100/MART-1 immunoreactivity and/or (2) prior documentation of melanoma.     

Thin stage I primary cutaneous malignant melanoma. Comparison of excision with margins of 1 or 3 cm

Although wide surgical excision is the accepted treatment for thin malignant melanomas, there is reason to believe that narrower margins may be adequate. We conducted a randomized prospective study to assess the efficacy of narrow excision (excision with 1-cm margins) for primary melanomas no thicker than 2 mm. Narrow excision was performed in 305 patients, and wide excision (margins of 3 cm or more) was performed in 307 patients. The major prognostic criteria were well balanced in the two groups. The mean thickness of melanomas was 0.99 mm in the narrow-excision group and 1.02 mm in the wide-excision group. The subsequent development of metastatic disease involving regional nodes and distant organs was not different in the two groups (4.6 and 2.3 percent, respectively, in the narrow-excision group, as compared with 6.5 and 2.6 percent in the wide-excision group). Disease-free survival rates and overall survival rates (mean follow-up period, 55 months) were also similar in the two groups. Only three patients had a local recurrence as a first relapse. All had undergone narrow excision, and each had a primary melanoma with a thickness of 1 mm or more. The absence of local recurrence in the group of patients with a primary melanoma thinner than 1 mm and the very low rate of local recurrences indicate that narrow excision is a safe and effective procedure for such patients.     

Genetic changes in neoplasms arising in congenital melanocytic nevi: differences between nodular proliferations and melanomas

Large congenital melanocytic nevi (CMN) are at an increased risk of developing melanoma. Several forms of secondary proliferations can arise in congenital nevi on rare occasions. Although some of these closely resemble melanoma both clinically and histologically, metastasis is rare. We used comparative genomic hybridization to analyze chromosomal aberrations in different types of proliferations arising in CMN and compared them to typical congenital nevi, clear-cut melanomas arising in congenital nevi, as well as primary cutaneous melanomas that were not associated with a CMN. Cases of CMN and CMN with secondary proliferations were assigned to six groups according to the predominant histological pattern: group I, bland congenital nevi (n = 6); group II, congenital nevi with foci of increased cellularity (n = 4); group III, CMN with a proliferation simulating superficial spreading melanoma in situ (n = 3); group IV, CMN with a proliferation simulating nodular melanoma (n = 9); group V, proliferating neurocristic hamartoma (n = 1); and group VI, melanoma arising in congenital nevus (n = 6). No aberrations were found in groups I to III, whereas seven of nine cases of group IV, and one of one case of group V, showed aberrations. In group IV six of seven cases with aberrations (86%) showed numerical aberrations of whole chromosomes exclusively. This pattern differed significantly from the findings in melanoma that arose within CMN (n = 6), group VI, or independent of CMN (n = 122) in which only 5% showed numerical changes only. The single case in group V showed aberrations similar to melanoma. The finding of frequent numerical chromosomal aberrations in atypical nodular proliferations arising in CMN identifies these as clonal neoplasms with a genomic instability consistent with a mitotic spindle checkpoint defect. This difference compared to the aberration pattern found in melanoma might explain their more benign clinical behavior and may be of diagnostic value in ambiguous cases.     

Tumor lymphangiogenesis predicts melanoma metastasis to sentinel lymph nodes.

Cutaneous melanoma is a common melanocytic neoplasm that can quickly metastasize to regional lymph nodes. Currently, prognosis is determined by measuring tumor thickness but more reliable markers for metastatic spread are urgently needed. We investigated whether the extent of tumor lymphangiogenesis can predict melanoma metastasis to sentinel lymph nodes. We quantified the extent of tumor lymphangiogenesis, as well as other factors, in excised primary tumors and in sentinel lymph node biopsy samples from 45 patients with primary cutaneous melanoma. The results were correlated with histological and clinical outcome. Primary melanomas from patients whose tumors had metastasized to the sentinel lymph nodes contained prominent 'hot spots' of increased lymphatic vessel density, compared to nonmetastatic tumors. Multivariate risk analysis revealed that the lymphatic vascular area of primary melanomas, an index of tumor lymphangiogenesis, was the most sensitive prognostic marker for sentinel lymph node metastasis, and was even able to more accurately predict which tumors were metastatic to sentinel lymph nodes than the currently used method of measuring tumor thickness. Highly lymphangiogenic melanomas maintained their lymphangiogenic activity after metastasis to the sentinel lymph node. The extent of tumor lymphangiogenesis is a highly sensitive (83%) and specific (89%) prognostic marker of lymph node metastasis. Assessment of lymphangiogenesis in primary melanomas may be a more effective approach than the currently used technique of measuring tumor thickness in selecting patients with early metastatic disease for aggressive therapy.     

p16ink4a expression in benign and malignant melanocytic conjunctival lesions

Acquired conjunctival melanocytic lesions include nevi, primary acquired melanoses (PAMs), and melanomas. Conjunctival melanoma is a malignant melanocytic neoplasm with a high metastasis and mortality rate. Usually, the diagnosis can be achieved only with routine microscopic analysis, but in some cases, the samples are small or have artifacts. In these cases, complementary studies will be helpful, but currently, there are no well-understood or studied complementary methods. Objective. To analyze the immunohistochemical expression of p16 in conjunctival melanocytic lesions and to assess its potential for differentiating between benign and malignant melanocytic lesions. Methods. Immunohistochemical study against p16ink4a (p16) was performed on paraffin-embedded sections on 45 melanocytic lesions (9 melanomas, 19 nevi, and 2 PAMs with atypia and 15 without atypia). Expression was scored according to the German immunoreactive score (IRS). Results. Expression of p16 IRS differed between nevi, PAMs, and melanomas. The mean IRS for melanomas was 3.3 ± 1.8 and was lower than those for nevi (7.63 ± 3.24; P < .05), PAM with atypia (12 ± 0; P < .05), and PAM without atypia (11 ± 1.69; P < .05). Lesions with infiltration depths lower than 2 mm showed higher levels of p16. There were no differences between favorable and unfavorable locations. Conclusion. p16 Expression in conjunctival melanocytic lesions showed an expression similar to that in skin and seems to be a good marker to differentiate nevi and PAMs from melanomas. However, additional studies of larger series and follow-up are needed to confirm these findings.     

卵巢癌患者调节性T细胞比率和肿瘤标志物CA125、CA19-9测定及临床意义

目的 探讨卵巢癌患者、卵巢良性疾病及健康成人女性调节性T细胞（Tregs）和肿瘤标志物CA125、CA19-9水平的差异,并将其与临床病理因素及预后进行相关分析。 方法 选择2016年10月~2017年10月承德医学院附属医院妇科收治的经病理确诊的卵巢癌患者43例,设为恶性组,另选择同期医院收治的卵巢良性疾病患者55例作为良性组,健康体检妇女50例作为对照组。比较3组患者Tregs和肿瘤标志物CA125、CA19 9在卵巢癌患者中的表达水平,分析其与临床病理因素及预后的关系。 结果 恶性组和良性组Tregs比例、CA125和CA19-9水平均高于对照组,恶性组Tregs比例、CA125和CA19-9水平高于良性组（P<0.05）。CA125、CA19-9、Tregs水平与患者的年龄差异无显著性（P>0.05）;CA125水平与卵巢癌患者的淋巴结是否转移、肿瘤分期和组织学类型均有关;Tregs表达水平与卵巢癌患者的淋巴结是否转移和肿瘤分期均相关,CA19-9水平只与肿瘤分期相关（P<0.05）。随访12个月后,Tregs-low组中位生存时间高于Tregs-high组（P<0.05）。卵巢癌中Tregs数与CA125存在显著正相关性（P<0.05）,而与CA19-9不具有相关性（P>0.05）。 结论 Tregs、CA125和CA19-9均可有望成为卵巢癌临床诊断、治疗和预后的指标。     

Expression of metastasis suppressor gene product, nm23 protein, is not inversely correlated with the tumour progression in human malignant melanomas

An inverse correlation between the nm23 RNA level and tumour progression of melanocytes has been reported. To elucidate whether the expression of nm23 gene product in malignant melanoma is also inversely correlated with metastatic potential, conventional prognostic parameters or the tumour suppressor protein p53, immunohistochemical studies using a monoclonal antibody against nm23-H1 protein were performed on 138 benign and malignant melanocytic tumours. The expression of nm23 protein was compared with that of p53 protein and conventional clinicopathological prognostic factors. The nm23 protein level in benign melanocytes and metastatic melanoma cells was also studied by Western blot analysis. No significant difference regarding the protein was observed between naevi and melanomas, either at histological or protein levels. The expression correlated with local recurrence within 1 year after surgery, level of invasion and tumour thickness, but no parallels were observed between the nm23 and p53 proteins, suggesting that gene is regulated by independent mechanisms, although located on the same chromosome. There was no inverse correlation between the nm23 protein and melanoma metastasis which suggested that the nm23 protein does not appear to be lost during melanoma metastasis.