Kutanes Melanom

While the incidence of cutaneous melanoma (CM) continues to rise steadily, the mortality has stabilized. Risk factors for the development of CM are UV light exposure and individual characteristics relating to pigmentation, and especially the number of melanocytic nevi. The most important prognostic factor in CM is the vertical thickness of the primary tumor in the histological specimen. Excision of the primary tumor with adequate safety margins is the treatment of choice. In the case of a tumor 1.0 mm or more thick biopsy of the sentinel node is recommended. Interferon-α is currently the only adjuvant therapy shown to have significant benefit in prospective randomized trials. When distant metastases are present treatment is palliative and is aimed primarily at achieving tumor remission by operative, radiological, and pharmacological means. Dacarbazine is considered the standard drug for systemic treatment. Follow-up depends on the initial tumor parameters and the current stage of the disease.     

A first prospective population-based analysis investigating the actual practice of melanoma diagnosis, treatment and follow-up

Aim of the study: To describe the current management of patients diagnosed with cutaneous melanoma and melanoma in situ in Germany and assess for adherence with the existing German guideline in a first prospective population-based analysis.Methods: Prospective and longitudinal population-based study using online questionnaires. Registration by practitioners and hospitals was open for all patients diagnosed with melanoma between April and June 2008 in Germany. For data analysis, patients with melanoma stages 0-III (AJCC 2002) were included.Results: Data from 1081 patients registered by 106 different centres were available for analysis. Male patients were significantly older than female patients (61.4 years versus 55.8 years, p < 0.0001) and presented with thicker primary tumours (1.62 mm [median 0.9 mm] versus 1.48 mm [median 0.8 mm], p = 0.01). Excessive safety margin excisions were most often applied in melanoma in situ and in small centres. Insufficient excision margins (6.9%) were associated with head and neck localisation, geographical region and implementation of further staging procedures. Decision on sentinel lymph node biopsy complied with the German guideline in >85% of cases and was dependent on age and tumour localisation. Only 60% of patients received a complete lymph node dissection (CLND) after a positive SLNB, the rate of CLND was lowest in older patients. Adjuvant treatments were initiated in only 34% of patients formally qualifying for adjuvant treatment based on guideline recommendations. Approximately half of all staging procedures were done in no-risk/low-risk tumour patients.Conclusions: Management of melanoma in Germany did not show great dependency on centre size, geographical area or treating physician but rather on patient and tumour characteristics. The low rate of adjuvant treatment initiations reflects the need of treatment options in this patient group. Excessive initial staging procedures generate significant costs.     

Local surgical treatment of cutaneous squamous cell carcinoma: deficits and controversies in the literature

The prognostic impact of primary excision in the treatment of cutaneous squamous cell carcinoma depends on certain tumor characteristics (risk factors), the surgical approach chosen and the subsequent histological examination. For the development of the AWMF (Association of Scientific Medical Societies in Germany) guidelines for squamous cell carcinoma, the most conclusive guidelines available were evaluated using the DELBI tool (German Instrument for the Methodological Appraisal of Guidelines). These were the Scottish and Canadian guidelines as well as the joint guidelines published by EDF, EADO and EORTC. The primary literature on the aforementioned topics that was used for these guidelines included 49 studies and 9 reviews. None of the studies had a prospective, randomized design; 19 studies contained prospective data; 30 studies provided retrospective data. Overall, the results were heterogeneous. Not only were there discrepancies in terms of the validity of the various risk factors for locoregional disease progression – such as dedifferentiation, desmoplasia and perineural invasion – but also with respect to tumor thickness and surgical consequences. Differences were also found regarding the histological processing method used. In general, there are two such methods: conventional histology (bread loaf technique) and complete histological assessment of excision margins. The latter was found to be associated both with low recurrence rates and low metastatic rates, possibly due to the fact that patients treated with the latter method had lower‐risk tumors. Publications on bread loaf histology lacked precise information as to how the tissue was actually processed. Likewise, there was a lack of usable data in terms of the surgical margins used in the primary excision. Conclusion : The current literature is inconsistent and insufficient with regard to the various prognostic factors and the surgical approach to cutaneous squamous cell carcinoma.     

Serum markers lactate dehydrogenase and S100B predict independently disease outcome in melanoma patients with distant metastasis

Background:

Established prognostic factors are of limited value to predict long-term survival and benefit from metastasectomy in advanced melanoma. This study aimed to identify prognostic factors in patients with distant metastasis.

Methods:

We analysed overall survival of 855 institutional melanoma patients with distant metastasis by bivariate Kaplan–Meier survival probabilities and multivariate Cox hazard regression analysis.

Results:

Serum lactate dehydrogenases (LDH), S100B, the interval between initial diagnosis and occurrence of distant metastasis, the site of distant metastases, and the number of involved distant sites were significant independent prognostic factors in both bivariate and multivariate analyses. Visceral metastases other than lung (hazard ratio (HR) 1.8), elevated S100B (HR 1.7) and elevated LDH (HR 1.6) had the highest negative impact on survival. Complete metastasectomy was likewise an independent prognostic factor in multivariate analysis. This treatment was associated with favourable survival for patients with normal LDH and S100B values (5-year survival, 37.2%).

Conclusion:

The serum markers LDH and S100B were both found to be prognostic factors in melanoma patients with distant metastasis. Furthermore, complete metastasectomy had an independent favourable prognostic impact in particular for the patient subgroup with normal LDH and S100B values.     

S3 guideline for actinic keratosis and cutaneous squamous cell carcinoma – short version,part 1: diagnosis,interventions for actinic keratoses,care structures and quality‐of‐care indicators

Actinic keratoses (AK) are common lesions in light‐skinned individuals that can potentially progress to cutaneous squamous cell carcinoma (cSCC). Both conditions may be associated with significant morbidity and constitute a major disease burden, especially among the elderly. To establish an evidence‐based framework for clinical decision making, the guideline “actinic keratosis and cutaneous squamous cell carcinoma” was developed using the highest level of methodology (S3) according to regulations issued by the Association of Scientific Medical Societies in Germany (AWMF). The guideline is aimed at dermatologists, general practitioners, ENT specialists, surgeons, oncologists, radiologists and radiation oncologists in hospitals and office‐based settings as well as other medical specialties involved in the diagnosis and treatment of patients with AK and cSCC. The guideline is also aimed at affected patients, their relatives, policy makers and insurance funds. In the first part, we will address aspects relating to diagnosis, interventions for AK, care structures and quality‐of‐care indicators.