Melanoma diagnosis at a specialist dermatology practice without the use of photographic surveillance

Background/Objective

Photographic aides are increasingly used in melanoma surveillance. We report melanoma characteristics detected using traditional surveillance without photographic technologies.

Methods

Retrospective study of melanomas diagnosed by three dermatologists at a private dermatology practice over 7 years. Patients underwent full skin examinations with dermoscopy and suspect lesions were excised or biopsied. Total body photography (TBP) and serial digital dermoscopic imaging (SDDI) were not used. Patient demographics, melanoma subtype and thickness, location, biopsy technique and keratinocyte cancers diagnosed at the same visit were recorded. Ratio of in situ to invasive melanomas was calculated. Melanoma risk factors were recorded for 69 randomly-selected patients.

Results

492 patients were diagnosed with 615 melanomas during 579 visits. 505 (82%) were in situ (in situ to invasive ratio of 4.6:1). Of the invasive melanomas, 85.5% had a Breslow thickness <0.8 mm, 10 (9.1%) 0.8–1 mm and 6 (5.5%) >1 mm. 43.3% of in situ melanomas were lentiginous or lentigo maligna and 41.6% were superficial spreading melanomas (SSM). Of invasive melanomas, 24.3% were lentigo maligna melanoma and 59.5% were SSM. 48.4% of melanomas were diagnosed by shave procedures. Where risk factors were known, 25% were very-high-risk and 43% had a history of melanoma. Keratinocyte carcinoma was diagnosed by biopsy at 26.1% of visits. Studies using TBP and/or SDDI report in situ to invasive ratios of 0.59:1 to 2.17:1.

Conclusion

Tradiational melanoma surveillance with immediate biopsy of suspect lesions results in high in situ to invasive ratios. Studies using photographic surveillance show lower ratios of in situ to invasive disease.     

Invasive cutaneous melanoma in elderly patients

Clinical and pathologic variables were compared between "older" (greater than or equal to 70 years) and "younger" (30 to 39 years) patients with primary invasive cutaneous melanoma. Older patients had more nodular melanomas and acral lentiginous melanomas (58%); superficial spreading melanomas predominated in younger patients (74%). Mean tumor thickness was greater in the older patients (3.95 vs 2.02 mm). Invasive levels 2 and 3 occurred more often in younger patients (41.1% vs 13%); level 5 occurred more often in older patients (30.4% vs 5.3%). Microscopic ulceration occurred more often in older (46.4%) than in younger patients (19.4%). Older patients classified as clinical stage I at presentation or with primary lesions 1.50- to 3.00-mm thick had poorer survival. Younger women survived longer than younger men; this was not true of older patients. The elderly patients with cutaneous melanoma were more likely to have poor prognostic features and thus more likely to die from melanoma than the younger patients.     

A rational approach to melanoma follow-up in patients with primary cutaneous melanoma. Scottish Melanoma Group

From the Scottish Melanoma Group database for south-east Scotland we evaluated 5-year follow-up in patients with cutaneous malignant melanoma excised between 1979 and 1994 and devised an 'evidence-based' review protocol. Of the 1568 with stage I melanoma, 293 (19%) developed a recurrence, 32 had a second primary melanoma and 97 had an in-situ melanoma. The disease-free interval shortened progressively with increasing tumour thickness. Overall, 80% of recurrences were within the first 3 years, but a few patients (< 8%) had recurrences 5 or 10 years after the initial surgery. In-situ melanomas did not recur. Almost half (47%) the recurrences were noted first by the patient, and only 26% were detected first at a follow-up clinic. One hundred and thirty-nine patients (89%) were still under review when their recurrences were detected, and 102 (65%) had been seen within the previous 3 months. Questionnaires were completed by 120 patients: sun protection and avoidance, and mole examination were more likely after melanoma excision. We recommend 3-monthly review of patients with invasive lesions for the first 3 years. Thereafter, those with lesions >/= 1.0 mm need two further annual reviews. Patients with in-situ lesions should be reviewed once, to confirm adequate excision (0.5 cm margins) and to give appropriate education. Surveillance beyond 5 years is only justified if there are special risk factors.     

Enhanced survival in patients with multiple primary melanoma

OBJECTIVE: To calculate survival probabilities of patients with 3 or more multiple primary melanomas. DESIGN: Retrospective cohort study of patients with primary melanoma. SETTING: Patients treated at a tertiary center (Sydney Melanoma Unit, Sydney, Australia) for stage I or II melanoma between 1983 and 1999.Patients From 5250 patients with primary melanoma, 264 (5.0%) had double and 34 (0.6%) had 3 or more primary melanoma lesions. RESULTS: The estimated 10-year risk for developing a second primary melanoma in these patients was 12.7% (95% confidence interval [CI], 10.5%-14.9%). For those patients who had 2 primary melanomas, the estimated 10-year risk of developing a third lesion was 27.7% (95% CI, 14.7%-36.7%). When controlling for known prognostic factors in a proportional hazards regression model, the number of primary melanomas was a significant favorable survival predictor when the thickest or the first tumor was modeled. In patients with 3 or more primary melanomas, 31 survived when 25 (95% CI, 22-27) were expected to survive. Patients who survive longer may have the opportunity to develop multiple primary melanomas. Patients who encountered all their primary lesions within 2 years may not be subject to this bias. Within the 3 or more melanoma set, 11 patients had all primary melanomas within 2 years. All survived, whereas 9 (95% CI, 8-10) were expected to survive. CONCLUSIONS: Patients with 3 or more primary melanoma lesions survive longer than anticipated. Such enhanced survival in patients with 3 or more primary melanomas may be consistent with observations of an "immunization effect" in animals inoculated with multiple tumors.     

Clinical and prognostic reports from 270 patients with multiple primary melanomas: a 34‐year single‐institution study

Background Development of more than one primary melanoma in a sole patient is frequent, accounting for 1.2–8.2% of melanoma patients in most recent series. Objective and methods Clinical, histological and epidemiological characteristics of 270 multiple primary melanomas patients were reviewed. Results Two‐hundred and seven patients (76.7%) had two melanomas, whereas in the remaining 63 the number of primary ranged from three to eight; on the whole, 639 multiple primary melanomas were identified. Synchronous melanomas developed more frequently in patients with three or more lesions; median age was significantly lower in the group of patients with more than three melanomas than in the others. Mean Breslow’s thickness significantly decreases (P < 0.001) from the first (1.77 ± 1.76 mm) to subsequent primaries (0.85 ± 1.25 mm for the second and 0.66 ± 0.48 mm for the third melanoma). Percentage of ‘in situ’ melanomas was 5.6% as first diagnosis, but increased to 24.8% for the second melanoma; number of nodular melanomas was significantly lower for succeeding diagnosis. AJCC stage at diagnosis showed a statistical prognostic significance, whereas outcome and survival did not depend on the number of primary lesions. Multivariate analysis confirmed the prognostic role of Breslow’s thickness, ulceration, gender and patient age, and the better prognosis of patients with multiple melanomas, respect to those with single primary melanoma. Conclusions Skin examination and long‐term follow‐up are mandatory for patients affected by melanoma, with the intent to promptly diagnose not only a disease progression but also possible new primary melanomas.     

Patient education and regular surveillance results in earlier diagnosis of second primary melanoma

BACKGROUND: As the incidence of cutaneous melanoma continues to rise, more individuals will be at risk for developing second primary melanomas. We hypothesize that patient education and follow-up surveillance will lead to the early detection of subsequent primary melanomas as demonstrated by a decrease in Breslow thickness at diagnosis. METHODS: A computer-based investigation was performed to identify patients who had developed a second primary melanoma following treatment of in situ and American Joint Commission on Cancer (AJCC) Stage I or II melanoma. Patients are routinely educated on the increased risk of developing a second primary lesion and characteristic clinical features of melanoma. Patient surveillance was performed on a regular basis. Differences in Breslow thickness between the initial and subsequent primary melanomas were analyzed by a paired t-test. RESULTS: Among 877 individuals identified in the Mount Sinai School of Medicine Department of Dermatopathology database with in situ or AJCC Stage I or II melanoma, 111 developed a second primary melanoma. The mean thickness was 0.239 +/- 0.661 mm for the initial melanoma and 0.1135 +/- 0.319 mm for the subsequent melanoma. By paired t-test, the difference in tumor thickness was statistically significant (P = 0.019). CONCLUSIONS: Upon analysis of our data, subsequent primary cutaneous melanomas were found to be significantly thinner than initial primary melanomas at the time of diagnosis. This suggests that earlier diagnosis may be the result of patient education and careful follow up. Counselling on the risk of developing a second primary melanoma, education regarding clinical characteristics of melanoma, and routine lifelong follow up should be provided to all patients diagnosed with a cutaneous melanoma.     

Clinicopathological comparisons of index and second primary melanomas in paediatric and adult populations

Summary Background The high incidence of cutaneous melanoma globally has sparked interest in the features associated with second primary melanomas (SPMs). Objectives To identify differences and similarities between index and second primary melanomas while comparing the absolute and relative risk of subsequent melanoma development in paediatric and adult patients. Methods A retrospective analysis of patients diagnosed with invasive malignant melanoma from 1973 to 2008 inclusive was completed with data obtained from the Surveillance, Epidemiology and End Results (SEER) database. Results In total, 208 289 patients were diagnosed with invasive melanoma in the SEER database from 1973 to 2008, with subsequent primary melanomas diagnosed in 6888 (3·3%). The incidence of SPMs increased with increasing age of diagnosis of the patient’s first melanoma. However, the relative risk of developing a subsequent melanoma was nearly double for patients diagnosed with their first melanoma at the age of 19 years and younger compared with patients greater than the age of 19 years. Compared with a patient’s initial invasive melanoma, 44% of the subjects had a different melanoma subtype with their subsequent melanoma. SPMs were located in a different anatomical site from the index malignancy in 55% of patients. Nodular melanomas were more common as index melanomas compared with SPMs. Conclusions Although invasive cutaneous melanoma is primarily a malignancy of adulthood, the heightened relative risk of SPMs in the paediatric population calls for careful long‐term scrutiny in this latter population following an index melanoma diagnosis.     

A lack of significantly increased incidence of regression in second primary melanomas does not support an ‘immunization effect’

Objective: To compare the incidence of regression in first and second primary melanomas as a possible indication of an ‘immunization effect'. Methods: The first and second primary melanomas of 18 patients were studied histopathologically for signs of regression. At least 1 month elapsed between the removal of the two primary lesions. Results: Histopathological evidence of regression was found in 7 of the 18 (38.8%) first melanomas and in 8 of the 18 (44.4%) second melanomas [p = non‐significant (N.S.)]. Among the nine patients in whom the removal of the second primary melanoma was >6 months after the removal of the first primary melanoma, one (11%) first melanoma and three (33%) second melanomas showed regression, respectively, but this difference did not reach statistical significance. Among the nine patients in whom the removal of the second primary melanoma was ≤6 months after the removal of the first primary melanoma, six (67%) first melanoma and five (56%) second melanomas showed regression (p = N.S.). Conclusions: Our study does not provide evidence for a statistically significant increased rate of regression in second primary melanomas compared to the first primary melanomas, but larger groups of studied cases may be needed. Bergman R, Zoller L, Mayer E, Itzhak OB. A lack of significantly increased incidence of regression in second primary melanomas does not support an ‘immunization effect’.     

A series of melanomas smaller than 4 mm and implications for the ABCDE rule

BACKGROUND: Although multiple studies have reported that a significant number of melanomas have diameters of less than or equal to 6 mm at the time of diagnosis, there has been only one series evaluating the proportion of melanomas less than 4 mm in diameter. OBJECTIVE: The objective of this study was to determine the proportion of melanomas, in a single-practitioner, general dermatology practice, with clinical diameters less than 4 mm. METHODS: Information regarding each new diagnosis of melanoma had been recorded during the study period of 2000-2004. Patient records and pathology reports were examined from these patients. RESULTS: Thirteen (13.7%) of the 95 melanomas had diameters less than 4 mm at the time of presentation, including five invasive and eight in situ melanomas. The defining clinical characteristic of these lesions was intensity of pigment. Three of these 13 melanomas, including one invasive and two in situ lesions, showed features of regression. CONCLUSIONS: The findings of this study support those authors who have suggested elimination of the 6-mm diameter criterion in the ABCDE rule. In addition, this study provides further evidence that dark colour as a diagnostic criterion for melanoma should be given more emphasis. The substitution of 'D' to represent dark instead of diameter is worthy of consideration to enhance the value of the ABCDE mnemonic.     

A profile of invasive cutaneous malignant melanoma in Malta: 1993–2002

BACKGROUND: The incidence of malignant melanoma of the skin has risen in every part of the world where reliable cancer registration data are found. OBJECTIVE: Our study aims to describe the changing incidence of and survival from invasive cutaneous malignant melanoma in Malta, by analysing the data from the 211 cases that were registered at the Malta National Cancer Registry between 1993 and 2002. RESULTS: The age standardized incidence rates for invasive cutaneous malignant melanoma rose from 3.7 per 100,000 population per year for males and 5.1 for females in the first 5-year period, to 8.0 per 100,000 population per year for males and 5.9 for females in the second 5-year period. In both sexes, numbers of thin (< or = 1.0 mm) invasive melanomas increased significantly between 1993 and 2002; males also registered a significant increase in intermediate-thickness (1.01-4.0 mm) melanomas. The increase in numbers of thin and intermediate-thickness melanomas between the two 5-year periods was greatest in patients aged 60 years and over. The overall absolute 5-year survival rate for the first period was 74% and for the second period 92%. CONCLUSION: Numbers of reported cases of invasive cutaneous malignant melanoma in Malta have more than doubled during the 10-year study period. This is mostly due to a marked rise in the diagnosis of thin melanomas in both sexes, occurring mainly in patients aged 60 years and over. As thin melanomas are of low metastasizing potential, this has resulted in an increase in survival between the two 5-year study periods.     

Addition of dermoscopy to conventional naked-eye examination in melanoma screening: a randomized study

OBJECTIVE: We sought to assess the difference in lesion management between combined examination (naked-eye and dermoscopy) and conventional naked-eye examination in evaluations for melanoma; and to assess the impact on patient treatment of facilities for digital follow-up of diagnostically equivocal lesions. METHODS: We conducted a randomized, controlled trial at a pigmented lesion clinic in a university hospital. A total of 938 consecutive subjects presenting between November 1, 2001, and March 31, 2002, were eligible and 25 were excluded because they were younger than 12 years of age; hence 913 subjects were enrolled. Participants were randomized to combined examination with mandatory excision of equivocal lesion (arm B) and with possibility of digital follow-up according to the clinician's decision (arm C), or to conventional naked-eye examination (mandatory excision of equivocal lesion) (arm A). The same pigmented lesion clinic staff examined all subjects. RESULTS: Combined examination determined a significant reduction in the percentage of patients referred for operation (9.0% vs 15.6%) (P =.013). When facilities for digital follow-up of equivocal lesions were available, the percentage of patients classified as harboring lesions difficult to diagnose increased (group C, 35.8%; group B, 17.8%; P <.01). About half of them were immediately referred for operation whereas the remainder submitted to second examination (digital follow-up). Two melanomas (1 in situ and 1 invasive, 0.40-mm thick) were diagnosed after second examination performed 6 months later. The number of melanomas eventually excised within the study were similar among the 3 allocation groups (3, 2, and 3, respectively). CONCLUSIONS: the addition of dermoscopy to conventional naked-eye examination is associated with a significant reduction of number of pigmented skin lesions excised for diagnostic verification. The possibility of digital follow-up of equivocal lesions is associated with a not negligible occurrence of initial melanomas left unexcised until the second consultation.     

An evidence base for reconsidering current follow-up guidelines for patients with cutaneous melanoma less than 0.5 mm thick at diagnosis

Background  Despite current guidelines, there is uncertainty about the required duration and frequency of follow-up visits for patients with invasive primary cutaneous melanoma < 0·5 mm thick.
Objectives  To review patients with invasive melanoma thinner than 0·5 mm followed for at least 5 years to provide an evidence base for considering modification of guidelines.
Methods  A retrospective review of 430 patients diagnosed in the west of Scotland during 1992–2001 with melanoma < 0·5 mm was carried out. Recurrence, deaths from melanoma and second primary melanomas were all identified.
Results  From 1992 to 2001, 430 melanomas < 0·5 mm thick at diagnosis were diagnosed out of a total of 3036 primary cutaneous melanomas. To date there have been 593 deaths from melanoma (19%) in the whole group. Five of these deaths were reported in patients with melanomas < 0·5 mm, but on pathological review two were thicker than 0·5 mm at diagnosis (1·5 and > 3 mm), and the remaining three patients all developed thicker second primary melanomas (2·7, 12·0 and 19·0 mm) with a recurrence pattern and timing indicating that these thicker primaries were the cause of death. Fourteen further patients developed a second primary melanoma, and 13 are currently alive and disease free, one dying of other causes.
Conclusions  Our data indicate that recurrence and subsequent death from melanomas < 0·5 mm is a very rare event, and that quarterly follow-up for 3 years will yield very few events. Modification of current guideline recommendations are suggested to include a period of patient education concentrating on recognition of second primary tumours followed by rapid access to an expert opinion if required.     

Prognostic significance of vascularity in cutaneous melanoma: pilot study using in vivo confocal scanning laser microscopy

BACKGROUND: Tumor vascularity may be of strong prognostic significance in cutaneous melanoma. We are the first to use a novel, noninvasive, in vivo confocal scanning laser microscope (CSLM) to evaluate vascularity in cutaneous melanoma. OBJECTIVE: Our purpose was to apply a CSLM to assess vascularity in melanoma and to evaluate the prognostic significance of these findings. METHODS: Patients with a suspicious pigmented lesion were prospectively recruited to undergo CSLM prior to skin biopsy, and those diagnosed with melanoma were included in this study. A blinded observer graded tumor vascularity from still digital CSLM images. The CSLM vascularity grading was correlated to tumor thickness and ulceration as a proxy for clinical prognosis. RESULTS: Sixty-six patients and 67 lesions underwent imaging with CSLM. Eleven patients were diagnosed with melanoma, including six in situ and five invasive melanomas. Prominent vascularity was observed in all advanced melanomas. There was an overall increase in mean tumor thickness between the absent (x = 0.315 mm) to prominent (x = 1.51 mm) categories. CONCLUSION: In this pilot study, vascularity was readily detected in cutaneous melanomas using CSLM. Prominent vascularity was observed in patients with advanced cutaneous melanomas. Our preliminary results are encouraging and indicate potential for the use of CSLM to assess vascularity in cutaneous melanoma, with potential prognostic and therapeutic implications.     

Thick melanoma: the challenge persists

BACKGROUND: Considerable resources have been channelled into primary and secondary prevention of cutaneous melanoma over the past 20 years. These efforts have been associated with a significant increase in the proportion of thin, good prognosis lesions and this is felt to be the principal reason for the current overall improvement in melanoma survival. OBJECTIVES: Analysis of Scottish Melanoma Group (SMG) data was carried out to identify the proportion of thick melanomas presenting over time. SMG data were used to characterize the patients presenting with thick melanoma. METHODS: Using data from the SMG database 915 patients (392 male and 523 female) first diagnosed with invasive melanoma > or = 3.5 mm thick in the two decades between 1979 and 1998, inclusive, were identified. The patients were from regions designated South-east Scotland, Tayside, Grampian and Highland, which together form half of all Scottish cases. RESULTS: The analysis shows that, although the proportion of thick, poor prognosis melanomas has decreased over time, the number presenting per year has not significantly altered. In the first decade, 50.5% of registrations were thick lesions and these fell to 31.0% in the second decade. In the first decade there were 419 cases (173 male), median age 66 years (range 5-99). Fifty-five patients were under the age of 40 years. Two hundred and twelve melanomas were nodular, 116 superficial spreading (SSM), 34 acral and 26 lentigo maligna melanoma. Sixty-nine patients had either lymph node involvement or distant spread at presentation. Despite a 93.3% increase in the total number of melanoma registrations by the end of the second decade, there was relatively little change in the absolute numbers of thick lesions. The total number of thick lesions was 496 (220 male), an increase of 18.4%. Median age was greater, at 70 years (range 1-98), and 31 patients were under the age of 40 years. Nodular was still the commonest type but its proportion had dropped significantly compared with the first decade, with a corresponding increase in SSM and acral types. CONCLUSIONS: Over a 20-year period there was little change in the absolute number of patients presenting with thick melanoma each year, though these form a diminishing proportion of the rising number of total melanomas. This thick melanoma group is characterized by an increasingly older age group and a changing type profile, nodular and SSM being the most common types. This work suggests that the resources currently directed at public and professional education on melanoma are having no effect on this group of patients and that alternative strategies may need to be considered.     

Problems in the interpretation of apparent "radial growth phase" malignant melanomas that metastasize

BACKGROUND: The delineation of radial and vertical growth phases in primary cutaneous malignant melanomas has contributed to our understanding of melanoma progression and has enhanced the ability of pathologists to provide clinicians with meaningful prognostic information. Vertical growth phase (VGP) lesions have the potential to metastasize, but radial growth phase (RGP) melanomas are believed to lack competence for metastasis. METHODS: We have identified three cases in which metastasis occurred in association with lesions initially interpreted as RGP melanomas. To determine whether these cases truly represented exceptional metastasizing RGP melanomas or VGP lesions incorrectly identified as RGP lesions, careful microscopic re-review of these cases was performed. RESULTS: In one case, additional microscopic sectioning revealed a focus of vertical growth that was not evident on the original sections. In the other two cases, only radial growth was found. In one of these cases there was melanoma in situ with regressive changes, but no evidence for invasive melanoma. In the other, a RGP lesion was associated with an adjacent compound nevus with periadnexal involvement. CONCLUSIONS: These cases suggest that, while true RGP melanomas have an excellent prognosis, caution must be exercised in defining a lesion as having no metastatic potential when multiple sections of the primary lesion are unavailable, when the lesion is accompanied by regressive changes, or when there is an associated melanocytic nevus. It is possible that strictly defined RGP melanomas may metastasize in very rare cases. Our observations also suggest that metastatic potential is a function of numerous factors, and may not be evaluable on morphological grounds alone.     

Multiple synchronous cutaneous melanomas: implications for prevention

BACKGROUND: A subset of about 3-5% of melanoma patients present a second primary melanoma. OBSERVATIONS: We describe two cases of primary multiple synchronous melanomas consecutively observed in the last 6 months in our department in two male patients presenting multiple atypical nevi. In both patients, the second melanoma was diagnosed by the clinician who had identified the first one, but at the time of the first follow-up consultation, 3 months later. The delayed discovery of the second melanoma required another referral for surgery with additional discomfort for the patients. Concern about the first lesion (the thickest in both cases) probably rendered the second one less evident to both patients and clinician, until the first follow-up examination after excision of the first lesion. CONCLUSION: We stress the need for careful and thorough examination of the whole body surface at the time of detection of a cutaneous melanoma in subjects with multiple atypical moles because the finding of synchronous multiple melanomas is not uncommon.     

Small diameter melanoma: a follow-up of the Norwegian Melanoma Project

BACKGROUND: Melanoma prognosis is dependent upon early recognition and treatment. There is a need for good clinical guidelines that focus on the early signs of melanoma. The ABCD (asymmetry, border, colour and diameter) rule states that most melanomas are more than 6 mm in diameter. Critics crave a modification, arguing that small diameter melanomas are not infrequent. OBJECTIVES: The aim of the present study was to describe the frequency and prognosis of melanomas less than 7 mm in a clinical setting. METHODS: The Norwegian Melanoma Project was conducted as a multicentre, prospective study with inclusion criteria. Patients were recruited from five dermatological departments in Norway from 1990 to 1993. RESULTS: The frequency of small melanomas was 11.4% (18/158). One-third was in situ melanoma, the rest invasive with a median thickness of 0.8 mm. Four small melanomas were T2 lesions, with a Breslow thickness of more than 1 mm. One nodular T2 melanoma recurred locally 2 years after diagnosis and the patient died of distant metastasis only months later. CONCLUSIONS: The ABCD rule remains a practical guide for early recognition of melanoma. Clinicians must be aware of its limitations.     

Two cutaneous malignant melanomas at the same anatomic site: a case report with molecular evaluation

Patients who have had malignant melanoma are at an increased risk of developing a second primary melanoma compared with the general population risk of developing a first melanoma. Many of these second primary melanomas occur at a similar anatomic site as the first lesion. Determining whether a second lesion is indeed a separate primary vs. a metastasis or locoregional recurrence can be very difficult histologically. We report the case of a patient who developed a second melanoma, 2 years after the initial diagnosis, within 3 cm of the site of the original lesion. Because of distinct histomorphologic features, the second lesion was favored to be a separate primary. However, because of the nearly identical anatomic location, molecular testing for loss of heterozygosity and BRAF mutation was performed to help further make this distinction. The first lesion was found to have loss of heterozygosity and a BRAF mutation that were not present in the second lesion. While these tests cannot elucidate the true molecular origin of these lesions, they provide a useful clinical tool to assess whether a second lesion should be treated as a recurrence or as a separate lesion with unique biologic potential.     

Risk of second primary malignancies in patients with cutaneous melanoma

BACKGROUND: In several studies an increased risk for development of breast cancer, malignant lymphoma and neoplasms of the kidney as second primary cancers in patients with cutaneous melanomas was discussed. OBJECTIVES: To determine the risk for development of second primary neoplasms in patients with cutaneous melanomas. METHODS: A prospective study was performed between 1977 and 1992 to evaluate the occurrence of second primary malignancies in 4597 patients (2083 men, 2514 women) with invasive cutaneous melanomas, diagnosed and treated at the Department of Dermatology and Allergology, Ludwig-Maximilians-University, Munich, Germany. RESULTS: During a median follow-up of 7.2 years, 296 of 4597 patients (6.4%) developed one or more neoplasms at the time of or subsequent to the diagnosis of the first cutaneous melanoma. More than half of these patients developed one or more further melanomas (152, 3.3%). Cancers of the breast, prostate, colon, rectum and kidney occurred less frequently. Statistical calculations revealed a 33.8-fold increased risk for the development of a second melanoma in the entire group [relative risk 38.5 for men (95% CI, 30.4-48.1), 29.0 for women (95% CI, 22.0-37.5)]. Moreover, a significantly increased risk for the development of kidney carcinoma in men was found [relative risk 3.5 (95%, CI, 1.4-7.2)]. CONCLUSIONS: Thorough follow-up and skin examination in patients with cutaneous melanomas is recommended for early detection of other primary melanomas. Furthermore, ultrasound examinations routinely performed in melanoma patients for the detection of melanoma metastases may also be of value for early detection of kidney carcinomas in male patients.