Evaluation of extensive initial staging procedure in intermediate/high-risk melanoma patients

INTRODUCTION: Early diagnosis and treatment of metastases have been shown to improve overall survival of melanoma patients. The purpose of this study was to evaluate the impact of extensive initial staging, including positron emission tomography (PET) scan on the management of melanoma patients. PATIENTS AND METHODS: Forty-three patients with intermediate/poor prognosis primary melanoma benefited from complementary excision and sentinel lymph node biopsy (SLB) after clinical and paraclinical staging (computed tomography, nuclear magnetic resonance and whole body fluorodeoxyglucose PET scan). RESULTS: No systemic metastases were demonstrated, while the SLB procedure emphasized the presence of regional lymph node metastases in 10 patients as suggested by the PET scan in four patients (sensitivity of the PET scan 40%). These 10 patients with early diagnosed lymph node involvement benefited from early surgery and were included in adjuvant treatment protocols. A secondary primary cancer was fortuitously diagnosed and treated early in two patients. CONCLUSIONS: The development of new adjuvant therapies and therapeutic procedures (specific and non-specific immunotherapy, gamma-knife radiosurgery, etc.) now raises the relevance of extensive staging in intermediate/poor prognosis melanoma patients. We confirm in our series that PET scan is not useful to detect micrometastasis and cannot replace SLB in initial regional staging. However, we show in our study that 12 of 43 patients were treated early or were included early in treatment protocols thanks to the extensive staging procedure. Nevertheless, it seems important to evaluate through larger prospective trials the real impact of these early diagnoses and new treatments on overall survival before defining new diagnostic and therapeutic guidelines.     

AJCC melanoma staging update: impact on dermatopathology practice and patient management

Changes in the 2010 American Joint Commission on Cancer melanoma staging guidelines include the evaluation of primary tumor mitotic index (mitogenicity) and the recognized prognostic significance of a single melanoma cell in a sentinel lymph node. These revised criteria have important practice implications for dermatopathologists as well as for dermatologists, oncologists and surgeons who treat patients with cutaneous melanoma.     

The new melanoma staging system

The new melanoma staging system from The American Joint Committee on Cancer (AJCC) is described. This major revision includes new criteria for staging the primary tumor (T), metastatic nodes (N) and distant metastases (M) as well as stage groupings. These criteria more accurately reflect those prognostic features of the primary and metastatic melanoma that correlate with survival outcome. Physicians managing melanoma should use this staging system in their clinical practice and in the conduct of melanoma clinical trials.     

Management of high-risk melanoma.

Improved treatment options for patients with high-risk melanoma are of great importance for clinicians who participate in the care of these patients. There remains an overall lack of response to existing treatment options, which continues to fuel the efforts of basic scientists and clinicians to pursue other approaches for the treatment of melanoma that is no longer limited to the skin. Continued investigation into the innovative and concurrent use of surgery, chemotherapy, immunotherapy, and radiation therapy holds significant promise for improved outcomes in the management of patients with this devastating disease.     

Impact of dermoscopy on the management of high-risk patients from melanoma families: a prospective study

Few studies have investigated the impact of dermoscopy on the management of relatives from melanoma families. The objective of this study was to assess the impact of dermoscopy on clinical diagnosis and management decisions in high-risk familial melanoma patients. In a prospective study 132 consecutive patients were recruited from the pigmented lesions clinic of a tertiary reference centre for familial melanoma. Dermatologists expert in dermoscopy identified 49 suspicious pigmented lesions and recorded pre- and post-dermoscopy diagnoses and management decisions. Dermoscopy was performed in 37% of the patients. Two melanomas were identified. Dermoscopy did not influence sensitivity (1.0), but resulted in 42% fewer excisions, increasing specificity from 0.53 to 0.74 (p = 0.031). Dermoscopy resulted in a large reduction in the number of unnecessary excisions. These results suggest that the main effect of dermoscopy in clinical practice for this high risk population is a significant increase in specificity, rather than sensitivity.     

Malignant melanoma in HIV: Epidemiology,pathogenesis, and management

People affected by immunodeficiency, and especially those infected by HIV, are burdened by a higher risk of developing malignancies. It has been estimated that the incidence of melanoma in HIV‐infected people is 2.6‐fold higher than in uninfected ones. In this group of patients, melanoma shows a more aggressive phenotype and poorer survival rates compared to HIV‐negative people. Standard guidelines of diagnosis and care do not exist yet. Studies suggest high index of suspicion and a low threshold for biopsy in HIV‐positive patients regardless of their CD4⁺ count and the use of standard surgical margins for re‐excision procedures. In case of diagnosis of melanoma in HIV‐positive patients, a thorough search for metastatic disease is recommended because of the more aggressive course of this cancer in HIV‐positive patients. Moreover, to rapidly find out any recurrence or metastatic disease after treatment, these patients need a close follow‐up, every 3 months, for the first 2 years and at least twice yearly thereafter. Although surgery remains the main therapeutic option, application of immune checkpoint‐based immunotherapy is being studied and seems to be promising. The aim of this review is to present the current knowledge and future options for melanoma diagnosis and treatment in people living with HIV.     

Variation in the diagnosis, treatment, and management of melanoma in situ: a survey of US dermatologists

OBJECTIVE: To assess current practices of US dermatologists regarding the diagnosis, treatment, and management of melanoma in situ (MIS). DESIGN: Survey. PARTICIPANTS: A total of 1200 dermatologists randomly selected from the American Board of Medical Specialists Directory of Board Certified Medical Specialists. MAIN OUTCOME MEASURES: Results based on 597 questionnaires returned. RESULTS: The overall response rate was 63% (597 of 945 eligible participants). To aid in clinical assessment, respondents reported using a magnifying lens (57.4%) and dermoscopy (17.4%). Most dermatologists preferred excisional and saucerization biopsies as the method of choice for sampling. A large percentage of physicians (78.9%) preferentially used dermatopathologists for the evaluation of the majority of pigmented lesions. Although most respondents would not unquestioningly accept a benign pathology diagnosis when there was a clinical suspicion of MIS, 16.1% would accept a pathologist's diagnosis without further action. There was no consensus on the appropriate surgical margins or depth of excision for MIS. Of the respondents who characterized MIS as premalignant and malignant, 63.2% and 46.4%, respectively, did not know what percentage of MISs would progress to metastatic disease if left untreated. CONCLUSIONS: Considerable variability exists in the clinical concept and management of MIS. Dermoscopy is underutilized. The true nature of the evolution of MIS is unknown. Surgical margins and depth of excision need to be standardized to help dermatologists manage disease. Further research in the specific area of MIS is warranted to develop clear guidelines in the management and prevention of further disease.     

Malignant melanoma: advances in diagnosis, prognosis, and treatment

The detection of cutaneous melanoma still largely relies on clinical suspicion, skin biopsy, and histopathologic evaluation. New technologies are being evaluated to bypass the skin biopsy in the detection of melanoma. The quest for reliable biomarkers, with respect to subclinical detection, prognosis, and predicting treatment response, is longstanding and ongoing. New therapies have been developed for metastatic disease, including targeted small molecule inhibitors as well as immune modulators.     

Childhood melanoma: update and treatment

Childhood melanoma is a rare but potentially fatal disease that is important to include in the differential diagnosis of any pigmented lesion in a child. The best prognosis is achieved with early diagnosis and definitive surgical excision. Adjuvant chemotherapy and immunotherapy are options for those with more advanced tumors. Melanoma in children must be treated as aggressively as in adults because childhood melanoma may be equally devastating.     

Lip cancer: important management issues

Lip cancer should be diagnosed and treated at an early stage. It most often presents on the lower lip of middle-aged to elderly males. The aetiology is similar to non-melanoma skin cancer, that is, chronic sun exposure. Despite treatment, a proportion of patients will experience delayed relapse and one in 10 will die from lip cancer. Clinicians need to be aware of the natural history of this disease. Two cases of squamous cell carcinoma of the lip treated by radiotherapy are presented and discussed to highlight important aspects in the management of lip cancer.