Tumor‐to‐bone distance of invasive subungual melanoma: An analysis of 30 cases

Subungual melanoma (SUM) is rare and represents approximately 2–3% and 20% of all cutaneous melanomas in Caucasians and Asians, respectively. Amputation has usually been performed for invasive SUM; however, not all invasive SUMs invade or attach to the distal phalanx. To investigate the possibility of non‐amputative surgery for patients with invasive SUM, the distances between the deepest base of the melanoma cells and the bony surface in the surgical specimens of invasive SUM were measured. Thirty surgical specimens of invasive SUM were retrospectively reviewed. The contents of the specimens were as follows: 14 first toes, 10 thumbs, three second fingers, two third fingers, and one fifth finger. Four specimens showed bone invasion, and the tumor was attached to the bone in four specimens. The tumor‐to‐bone distance exceeded 0.9 mm in all the specimens with thicknesses <4 mm. In the non‐ulcerated SUMs (nine specimens), only one SUM specimen showed bone attachment. There was a higher likelihood of bone attachment or invasion when tumor thickness (TT) exceeded 4 mm (Pearson chi‐square test, P = 0.009; Fisher exact test, P = 0.004; student t test, 0.033). Univariate and multivariate analysis also revealed that thick TT had a statistically significant affect (odds ratio 1.807 and 1.865, 95% CI 1.11–3.01 and 1.11–3.13, P = 0.023 and 0.018). Non‐amputative surgery may be possible for SUM tumors that are of intermediate‐thickness. However, there has been little evidence demonstrating survival with non‐amputative surgery for invasive SUM. A large, randomized, prospective clinical study is required to address this issue.     

The time from diagnostic excision biopsy to wide local excision for primary cutaneous malignant melanoma may not affect patient survival

BACKGROUND: The surgical management of primary cutaneous malignant melanoma usually involves an excision biopsy of the suspected lesion followed by wide local excision. No study has addressed whether a delay between these two surgical procedures influences patient outcome. OBJECTIVES: To determine if the surgical interval (SI) between the diagnostic excision biopsy and wide local excision for primary cutaneous malignant melanoma affects recurrence or survival outcome. METHODS: A cohort of 986 patients who had a diagnostic excision biopsy followed by wide local excision was identified from those registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. The cohort was divided into five arbitrary groups determined by the length of the SI as follows:< or =14 days, 15-28 days, 29-42 days, 43-91 days and > or = 92 days. Overall survival, disease-free survival and recurrence-free interval between the groups were compared univariately and multivariately. RESULTS: The mean age at excision biopsy was 47.4 years and the median period of follow-up was 5 years (range 27 days to 20.7 years). The median SI was 30 days (range 1-468 days). The SI was: (i)< or =14 days for 130 (13%); (ii) 15-28 days for 320 (33%); (iii) 29-42 days for 262 (27%); (iv) 43-91 days for 251 (25%); and (v) > or = 92 days for 23 (2%) patients. The latter group was older, had thinner melanomas, a higher percentage of lesions on the head and neck, fewer superficial spreading malignant melanomas and ulceration present less often compared with patients treated earlier. Univariately, there was no significant difference in overall survival (P = 0.60) or disease-free survival (P = 0.24) between the groups. Although there was a statistically significant difference in the percentage of recurrence-free patients between the groups (P = 0.011), the better recurrence-free rates occurred in the 29-42 and 43-91 day groups. After adjusting for age, sex, tumour thickness, site, histology, ulceration and mitotic activity using Cox's proportional hazards model, there was no statistically significant difference in overall survival, disease-free survival and recurrence-free percentages between the surgical groups (P = 0.88, P = 0.44 and P = 0.084, respectively). CONCLUSIONS: There was no evidence that survival outcome or recurrence was related to the time interval between the diagnostic excision biopsy and wide local excision of melanoma.     

局部扩大切除术治疗隆突性皮肤纤维肉瘤43例临床分析

对我院43例隆突性皮肤纤维肉瘤(dermatofibrosarcoma protuberance, DFSP)临床病理资料进行回顾性分析。43例患者中,男18例,女25例;发病前有肿瘤家族史者2例,有局部外伤史者5例,无明显诱因者36例;皮损表现为肿块40例,斑片1例,表皮萎缩1例,瘢痕样增生1例。组织病理示40例为经典型DFSP,2例为萎缩型,1例为黏液型。39例沿皮损边界扩切2~4 cm,其中随访28例（1例复发）;3例扩切＜2 cm,2例失访,1例转移;1例扩切＞4 cm,失访。     

A retrospective observational study of primary cutaneous malignant melanoma patients treated with excision only compared with excision biopsy followed by wider local excision

BACKGROUND: For primary cutaneous malignant melanoma the guidelines recommend an excision biopsy of the suspected lesion followed by wider local excision; the diagnosis can then be confirmed and excision margins planned. OBJECTIVES: To compare retrospectively the clinicopathological features, surgical margins and survival of patients from the Scottish Melanoma Group database whose tumour was removed by excision only (one-stage) or excision biopsy followed by wider local excision (two-stage) surgery. METHODS: The Scottish Melanoma Group database records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. From this 1595 patients were identified over a 19-year interval from 1979 to 1997 with follow-up until the end of December 1999. Overall survival, disease-free survival and recurrence-free interval were examined with univariate and multivariate statistical methods. RESULTS: The patients in the one-stage excision group (n = 547) were statistically significantly older (P < 0.001), had thicker melanomas (P < 0.001), a higher proportion of lentigo maligna melanomas (P < 0.001), head and neck (P < 0.001), and ulcerated lesions (P < 0.003) compared with the two-stage group (n = 1048). The margins of excision were significantly narrower in the one-stage compared with the two-stage group (P < 1 x 10(-5)). Fifty-two percent of all one-stage excisions were performed with a margin < 1 cm compared with 20% of the two-stage group. The excision margin was more positively correlated with the Breslow thickness for the two-stage over the one-stage group (Spearman rho = 0.38, P < 0.001; and 0.27, P < 0.001, respectively). Overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RF) were all statistically significantly better in the two-stage compared with the one-stage excision group, P < 1 x 10(-5), P < 1 x 10(-5) and P = 0.001, respectively (log rank test). After adjusting for the prognostic factors of age, sex, tumour thickness, site, histology and ulceration, OS, DFS and RF were still significantly better in the two-stage compared with the one-stage group [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.61-0.92, P = 0.006; HR 0.75, CI 0.62-0.90, P = 0.002; and HR 0.78, CI 0.62-0.99, P = 0.04, respectively]. CONCLUSIONS: This study showed that one-stage excisions were more common in patients with poorer prognostic features and that excision with margins narrower than those suggested by current guidelines was more likely. Patient survival was statistically significantly better with the two-stage procedure, although the reasons for this were unclear.     

Clinical risk factors and prognostic significance of local recurrence in cutaneous melanoma

BACKGROUND: True local recurrence (LR) means clinically detectable regrowth of parts of the tumour which were not completely excised. In the literature the term 'LR' has been used in a vague and inconsistent manner that may include satellite and in-transit metastasis. OBJECTIVE: The aim of this study was to establish clinical, histological and surgical risk factors for the manifestation of LR and to evaluate the prognostic significance of LR. STUDY DESIGN: Data from 3960 Stage I and II melanoma patients who visited the melanoma clinic of the Department of Dermatology at the University of Tuebingen from 1980 to 1999 were documented in a prospective manner. A retrospective comparative analysis of patients with and without LR was performed. RESULTS: Of all patients 1.4% had a LR as a first recurrence and 1.7% had a LR in the course of the follow-up period. LR were most frequent after previous clinical or histological misdiagnosis and inadequate therapy. In the univariate analysis significant risk factors for LR-free survival were age, tumour surface area, locality, tumour thickness, level of invasion, histological type, associated naevus, surgery (one step vs. multiple steps) and compliance with recommended excision margins. In the multivarate analysis the factors locality (P < 0.0001), tumour thickness (P = 0.0086) and compliance with recommendations on excision margins (P = 0.014) were significant independent risk factors for the manifestation of LR. The overall survival of patients with LR as first progression did not significantly differ from the overall survival of the other patients with melanoma (P = 0.60). CONCLUSION: True LR is a rare event for which tumour locality, tumour thickness and surgery are independent risk factors. The occurrence of LR might not impair the prognosis of melanoma patients. However, in the published literature numerous definitions of 'LR', including lymphogenic metastasis, complicate comparison.     

State of the art in non‐invasive imaging of cutaneous melanoma

Background: This review focuses on looking at recent developments in the non‐invasive imaging of skin, in particular at how such imaging may be used at present or in the future to detect cutaneous melanoma. Methods: A MEDLINE search was performed for papers using imaging techniques to evaluate cutaneous melanoma, including melanoma metastasis. Results: Nine different techniques were found: dermoscopy, confocal laser scanning microscopy (including multiphoton microscopy), optical coherence tomography, high frequency ultrasound, positron emission tomography, magnetic resonance imaging, and Fourier, Raman, and photoacoustic spectroscopies. This review contrasts the effectiveness of these techniques when seeking to image melanomas in skin. Conclusions: Despite the variety of techniques available for detecting melanoma, there remains a critical need for a high‐resolution technique to answer the question of whether tumours have invaded through the basement membrane.     

Reliability and cost‐effectiveness of sentinel lymph node excision under local anaesthesia versus general anaesthesia for malignant melanoma: a retrospective analysis in 300 patients with malignant melanoma AJCC Stages I and II

Background Sentinel lymph node excision (SLNE) for the detection of regional nodal metastases and staging of malignant melanoma has resulted in some controversies in international discussions, as it is a cost‐intensive surgical intervention with potentially significant morbidity. Objective The present retrospective study seeks to clarify the effectiveness and reliability of SLNE performed under tumescent local anaesthesia (TLA) and whether SLNE performed under TLA can reduce costs and morbidity. Therefore, our study is a comparison of SLNE performed under TLA and general anaesthesia (GA). Patients We retrospectively analysed data from 300 patients with primary malignant melanoma with a Breslow index of ≥1.0 mm. Results Altogether, 211 (70.3%) patients underwent SLNE under TLA and 89 (29.7%) patients underwent SLNE under GA. A total of 637 sentinel lymph nodes (SLN) were removed. In the TLA group 1.98 SLN/patient and in the GA group 2.46 SLN/patient were removed (median value). Seventy patients (23.3%) had a positive SLN. No major complications occurred. The costs for SLNE were significantly less for the SLNE in a procedures room performed under TLA (mean € 30.64) compared with SLNE in an operating room under GA (mean € 326.14, P < 0.0001). Conclusion In conclusion, SLNE performed under TLA is safe, reliable, and cost‐efficient and could become the new gold standard in sentinel lymph node diagnostic procedures.     

Efficacy of oregonin investigated by non‐invasive evaluation in a B16 mouse melanoma model

Oregonin has been reported to act as a mediator of antibiosis, a liver‐protective agent, an antioxidant, an anti‐inflammatory agent, and to prevent cancer outbreaks. B16 melanoma cells were separated with trypsin‐ethylenediaminetetraacetic acid, resuspended in 50 μl of phosphate‐buffered saline and transplanted into the backs of 6‐ to 8‐week‐old male Balb/c nude mice through subcutaneous injection. Treatment doses of oregonin were administered three times weekly, for 30 days from the 11th day after transplantation of the melanoma cells, in each group. The study consisted of a control group, a dacarbazine group, an oregonin group and a dacarbazine + oregonin group. Measurements were taken before treatment and on the 5th, 7th, 10th and 15th days after treatment for each group. Based on survival rates after transplantation, the control group showed less than 50% survival after 20 days, while the treatment groups showed at least 50% survival up to the 41st day.     

Long‐term prognosis after surgical excision of basal cell carcinoma: A single institutional study in Japan

Conventional surgical excision (SE) is commonly used to treat patients with basal cell carcinoma (BCC). There have been few studies, however, evaluating the long‐term prognosis of Japanese patients receiving SE for treatment of BCC. The purpose of this retrospective study is to determine the effectiveness of SE in accomplishing the long‐term cure of patients with BCC. We enrolled 290 patients with primary BCC who underwent SE during 1998–2006. The prognosis of treated patients was subsequently investigated using data obtained through our hospital cancer registration section. In total, 205 patients (70.7%) were treated for BCC lesions located on the face. The mean tumor diameter of excised lesions was 12.8 mm. A majority of patients in the study (256 patients, 88.3%) had pigmented BCC. The mean surgical margin at SE was 3.8 mm. Two patients developed local recurrence during the postoperative course of 290 patients (mean duration, 80 months). One patient developed recurrent disease 21 months after surgery, and the other developed recurrence at 66 months after surgery. The 5‐ and 10‐year cumulative recurrence rates were 0.4% and 0.8%, respectively. In conclusion, this study demonstrated that long‐term high cure rates of BCC in Japanese patients may be achieved through conventional SE. A better prognosis was obtained in this study compared with similar studies reported previously in Caucasians. This may be related to the predominance of pigmented versus non‐pigmented lesions in the Japanese population.     

Case–control study of chronic low‐level exposure of inorganic arsenic species and non‐melanoma skin cancer

A significant relationship between arsenic exposure and non‐melanoma skin cancer (NMSC) is well known. The toxicity of arsenics which develop NMSC is dependent on their species. Accordingly, total arsenic levels are unreliable for risk assessment of NMSC. However, there are few studies on quantitative exposure assessment of arsenic species in NMSC patients. To validate the contribution of each arsenic species to NMSC, we compared the creatinine‐adjusted urinary concentration of arsenic species in NMSC patients and community controls. A total of 124 biopsy‐proven NMSC cases and 125 age‐ and sex‐matched community controls, drinking tap water with low‐level arsenic concentration (<5 μg/L), were included in the study. High‐performance liquid chromatography and inductively coupled plasma mass spectrometry were used for the measurement. The NMSC group was found to have significantly higher levels of total inorganic arsenic, trivalent and pentavalent arsenic and monomethylarsonic acid than the control group. Total arsenic, organic arsenic and dimethylarsonic acid levels were lower in the NMSC group. We suggest that inorganic arsenic species, trivalent arsenic and pentavalent arsenic may influence the prevalence of NMSC, in spite of these levels being lower than the Agency for Toxic Substances and Disease Registry‐recommended standard or the levels reported by other highly contaminated areas and neighboring countries in East Asia. Furthermore, it also suggests that total arsenic level cannot represent the risk of NMSC.     

Diagnosis of an additional in situ melanoma does not influence survival for patients with a single invasive melanoma: A registry‐based follow‐up study

Using a large (N= 25 493) population‐based cohort from Queensland, Australia, we compared melanoma survival among cases with a single invasive melanoma only against those who also had a diagnosis of a single in situ melanoma. After adjustment for sex, age, body site, clinicopathological subtype, thickness and ulceration, it was found that there was no difference (P = 0.99) in 10‐year melanoma‐specific mortality following a diagnosis of an invasive lesion, whether or not an in situ melanoma was also present. We conclude that in situ melanomas do not alter the prognosis of an invasive melanoma.     

Incidence and prevalence of non‐melanoma skin cancer in Australia: A systematic review

Non‐melanoma skin cancer (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common cancer occurring in people with fair skin. Australia has been reported to have the highest incidence of NMSC in the world. Using a systematic search of the literature in EMBASE and Medline, we identified 21 studies that investigated the incidence or prevalence of NMSC in Australia. Studies published between 1948 and 2011 were identified and included in the analysis. There were six studies that were conducted on national level, two at state level and 13 at the regional level. Overall, the incidence of NMSC had steadily increased over calendar‐years in Australia. The incidence of NMSC per 100 000 person‐years was estimated to be 555 in 1985; 977 in 1990; 1109 in 1995; 1170 in 2002 and 2448 in 2011. The incidence was higher for men than women and higher for BCC than SCC. Incidence varied across the states of Australia, with the highest in Queensland. The prevalence of NMSC was estimated to be 2% in Australia in 2002. The incidence and prevalence of NMSC still need to be accurately established at both national and state levels to determine the costs and burden of the disease on the public health system in Australia.     

Trends in the prognosis of metastatic melanoma in the era of targeted therapy and immunotherapy: A single‐institution survey in Japan

Advances in anticancer therapy, including the development of targeted therapy and immunotherapy, have drastically changed treatment options for metastatic melanoma. However, to date, only a few studies have been published that directly compare overall survival (OS) before and after introduction of these new therapeutic options in Japan. We retrospectively surveyed patients with metastatic melanoma treated in our hospital between 1989 and 2019 to investigate the OS benefit of the new therapies. A total of 115 patients with metastatic melanoma (cutaneous origin, 92; mucosal, 14; uveal, two) were included in the study. Kaplan–Meier analysis showed that the patient group receiving targeted therapy/immunotherapy (TT/IT) (n = 47) had a median OS of 19.0 months, which was longer than that in patients receiving conventional chemotherapy (n = 42, 8.0 months) or no treatment (n = 26, 6.0 months) (P < 0.001). In the subgroup analysis performed for the TT/IT group, patients of younger age and with the BRAF mutation had significantly improved OS. As the number of treatment lines increased, the median OS tended to become longer. Our real‐world data confirmed an improvement of median OS upon the introduction of the new therapies for metastatic melanoma. However, the long‐term OS benefit was limited, possibly because of racial differences in some of the clinical characteristics. To improve the overall melanoma prognosis, the entire treatment strategy, including perioperative therapy needs strengthening.     

Cosmetic results of histographically controlled excision of non‐melanoma skin cancer in the head and neck region

Background: Beside the primary goal of complete eradication, the cosmetic result is an important aspect of the treatment of non‐melanoma skin tumors especially in the head and neck region. Patients and Methods: From 1990 to 2000, we treated a total of 5,227 large basal cell carcinomas (BBC) and 1,189 squamous cell carcinomas (SCC) in the head and neck region by surgical excision in 4,239 inpatients at the Department of Dermatology, University of Tübingen. The procedure used in all patients was a conservative excision controlled by complete three dimensional histology of all margins (3D‐histology) and specifically targeted follow‐up surgery where required (histographic surgery). As part of the prospective tumor follow‐up, we asked the treating outdoor physician one and four years later to evaluate the results of our surgical procedures. Results: Of the 5,565 follow‐up questionnaires sent back, 4,868 contained answers regarding the cosmetic result. The data from both answers were pooled. In 1,972 (40,5 %) patients the cosmetic result was evaluated as “excellent”, in 1,992 (40,9 %) as “good”, in 662 (13,6 %) as “satisfactory”, in 191 (3,9 %) as “mediocre” and in 51 (< 1,0 %) as “poor”. In 697 of the responses, the physician did not comment the cosmetic results or the patient was lost for follow up. Conclusion: With respect to both long term safety and cosmetic outcome, tumor surgery with 3D‐histology of excisional margins has set very high quality standards in the treatment of non‐melanoma skin cancer of the head and neck area.