Management of cutaneous melanoma at the Joliot Curie Institute in Dakar

AIM: To study the clinical and therapeutic aspects of cutaneous melanoma at the Joliot Curie Institute of Dakar. PATIENTS AND METHODS: We performed a retrospective, descriptive and critical study at the Joliot Curie Institute of Dakar including all histologically confirmed melanoma cases between January 2008 and December 2013. RESULTS: During the study period, 21 cases were managed. The location was plantar in 76% of cases. Acral type was found in 85.7% of cases. All patients had a Clark level of IV or higher with a Breslow index of more than two mm. Fourteen patients underwent excision surgery and 12 had inguinal lymph node dissection. The average follow-up was 16 months with an overall survival of 58.7% at six months and 51% at one year. CONCLUSION: The majority of patients have benefited from surgical treatment, without prescription of immunotherapy which to date has revolutionized the management of advanced melanoma.

Melanocytic lesions ≤ 6mm: Prospective series of 481 melanocytic trunk and limb lesions in Brazil

Early diagnosis when melanoma is still small and thin is essential for improving mortality and morbidity. However, the diagnosis of small size melanoma might be particularly difficult, not only clinically but also dermoscopically. This study aimed to define clinical and dermatoscopic parameters in the diagnosis of suspicious pigmented cutaneous lesions with a diameter of ≤ 6mm and determine the sensitivity, specificity, positive and negative predictive values as well as the accuracy of each clinical and dermatoscopic criterion. This is a transversal, descriptive and analytical study of dermatoscopic analysis with the gold standard being the pathologic examination obtained from the excisional biopsy of suspicious melanocytic lesions with a diameter of ≤ 6mm. Trunk and limb lesion data from a public health service and a private clinic were prospectively collected from 2011 to 2017 by a unique observer. In total, 481 melanocytic lesions were included, with 73.8% being ≤ 4mm in diameter. Overall, 123 were diagnosed as melanoma, 56.0% in situ and 22.0% as thin melanomas (Breslow index 0.1 to 1.0mm). Melanoma presented symmetry in 53.7% of cases, regular borders in 54.5% and a single color in 60.2%. Regarding evolution, 13.8% of melanomas versus 10.9% of benign lesions (p = 0.116) were new by comparing photos from baseline with photos from the follow-up. The majority of melanomas (65%) were found on the limbs compared to 37.2% of the benign lesions at this location (p<0.001). A multiple logistic regression model adjusted for age, gender and location was created. The independent variables associated with the diagnosis of melanoma ≤ 6mm, adjusted for age, gender and location, were: streaks (adjusted Odds Ratio [aOR] 2.5; 95% CI 1.3–4.7; p = 0.006), and the presence of a structureless area (aOR 2.2, 95% CI 1.2–4.0, p = 0.011). Conversely, a symmetric typical pigment network was a protection variable (aOR 0.4, 95% 0.7–0.9, p = 0.040). In conclusion, dermatoscopic criteria have been identified which help to diagnose cases of small size melanoma. These include streaks and structureless areas that can be taken, particularly in consideration for the diagnosis of this subset of small difficult melanomas.

Dynamische OCT − was verraten uns die Gefäße?

ZusammenfassungDie Weiterentwicklung der optischen Kohärenztomografie (OCT) zur dynamischen OCT (D-OCT) erlaubt die gleichzeitige Darstellung der oberflächlichen Blutgefäße. Blut ist das wichtigste Transportsystem unseres Körpers, und sowohl durch äußere als auch durch innere Einflüsse können physiologische Prozesse beeinträchtigt werden. Die D-OCT ermöglicht erstmals die Darstellung dieser Veränderungen anhand der Gefäßdichte und Durchblutung. Durch wiederholtes schnelles Messen der gleichen untersuchten Region können mithilfe einer speziellen Software Unterschiede in einer Bildserie erfasst werden und so sich bewegende Teilchen, die den Blutbestandteilen entsprechen, bis zu einer Tiefe von 0,5 mm vom statischen Hautgewebe differenziert werden. Die Software bildet den Blutfluss im D-OCT-Bild in roter Farbe als Überlagerung über das grau-weiß strukturelle Gewebe ab. Mithilfe der D-OCT konnten physiologische Einflüsse auf die Durchblutung, wie Vasokonstriktion und Positionsänderung, Unterschiede aufgrund der anatomischen Körperregionen, aber auch therapeutische Effekte, wie z. B. durch die lokale Behandlung mit vasokonstringierendem Brimonidin-Gel (einem selektiven α2-Adrenorezeptor-Agonisten) oder bei der Lasertherapie nachgewiesen werden. Weiterhin fanden sich bestimmte Blutgefäßformen nur bei chronisch venösen Ulzera (wie Knäuel am Wundrand oder geschlängelte Gefäße bei Dermatosklerose), während die Blutgefäße bei akuten Wunden eine Häufung von anderen Gefäßformen und Verteilungsmustern zeigten. Bei ausgewählten entzündlichen und autoimmunbedingten Erkrankungen konnten die damit einhergehenden vaskulären Prozesse exemplarisch dargestellt werden. Auch ließ sich mit der D-OCT feststellen, dass eine erhöhte Blutgefäßdichte und gewisse Formen erst mit einer größeren Tumordicke von Melanomen (Breslow-Index) einhergehen. Außerdem können die Blutgefäße zur Differenzierung sowie zur Therapieauswahl von nicht-melanozytärem Hautkrebs beitragen. Die D-OCT ist jedoch nicht nur ein diagnostisches Gerät, sondern eignet sich auch zur bildgeführten Therapie wie der D-OCT-geführten Lasertherapie.Die D-OCT bietet durch die Darstellung von Blutgefäßen zahlreiche diagnostische und therapeutische Einsatzmöglichkeiten. Die Blutgefäße verraten uns so viel über physiologische und pathologische Prozesse in unserer Haut, und ihre Darstellung wird in Zukunft eine individuellere, patienten-orientiertere Therapie erlauben, als es bisher möglich ist. So könnten z. B. Ulzera verschiedener Genese mittels D-OCT differenziert werden oder Melanome anhand der Gefäßmuster bereits präoperativ risikostratifiziert werden.

A Preliminary Study for Quantitative Assessment with HFUS (High- Frequency Ultrasound) of Nodular Skin Melanoma Breslow Thickness in Adults Before Surgery: Interdisciplinary Team Experience

Background: Cutaneous melanoma is one of the most severe skin diseases. Nodular melanoma is the second melanoma subtype in order of frequency. The prognosis of skin melanoma depends on the vertical growth of the tumor (Breslow index). For this measurement, excisional biopsy is strongly recommended. This is, however, an invasive procedure and may cause damage to the lymphatic drainage system. The HFUS system, , can be extremely useful for determining tumor thickness in the preoperative phase, given its high resolution capacity. The aim of this preliminary study is to define the role of HFUS for the nodular skin melanoma Breslow thickness in adults before surgery by making a comparison with histological features. Methods: In this study, 14 melanocytic lesions (8 male and 6 female) were evaluated with dermatoscopic clinical features strongly indicative of nodular melanoma. Out of these, excisional biopsy of 7 lesions was requested. The ultrasounds were performed preoperatively. The images were acquired through the first ultrasound scanner with ultra-high frequency probes (range from 50MHz to 70 MHz) available on the market under the EEC mark (Vevo "MD, FUJIFILM Visual Sonics, Amsterdam, the Netherlands) equipped with a linear probe of 50-70 MHz. Results: From the ultrasonographic analysis of 14 nodular melanoma thickness was determined for the presence of two hyperechogenic laminae, separated by a hypo / anechoic space. The twelve lesions were in situ while the other two lesions showed ultrasonography for example; the satellite lesions (less than two centimeters from the primary lesion) and in transit (localizable to more than two centimeters from the primary lesion). Four of these lesions were ulcerated. A comparsion was made the 7 lesions on between the thickness calculated with this method, and that obtained on the bioptic piece. The presence of a positive concordance has been evident in all of the cases. Conclusions: If further studies are needed to support its widespread clinical use, its is believed that, in expert hands and with an interdisciplinary team, HFUS is already capable to reliably calculate a Breslow index in a large majority of patients with cutaneous melanoma.

The accuracy of elastographic strain ratio and ultrasound thickness in the differentiation of thin and thick cutaneous melanoma

Background Cutaneous melanoma is the most deadly of skin neoplasms. Few studies have investigated the role of elastography characteristics so the ability of elastography in the differentiation of thin and thick cutaneous melanoma is still narrow. Purpose To investigate the accuracy of elastography in differentiating thin and thick melanoma, by measuring strain ratio (SR) between the lesion and adjacent dermis and hypodermis. Material and Methods We investigated by ultrasound and elastography 52 melanoma lesions in 49 patients. The receiver operating characteristic (ROC) curve method was used to investigate the accuracy of ultrasound and elastographic measurement of SR to surrounding tissue, in the differentiation of thin and thick melanomas. The histopathological measurement of lesions depth called Breslow index was the golden standard test. Results Areas under the curve (AUC) showed low accuracy for SR to hypodermis in distinguishing between thin melanomas and others (AUC = 0.739, 95% confidence interval [CI] = 0.508–0.970]) with a cut-off value of 0.950, being the only statistically significant result in matter of elastographic measurements. Highly statistically significant results were obtained for B-mode ultrasound depth measurements of the lesion, with an AUC = 0.970 (95% CI = 0.927–1.0) in discriminating thin melanomas of others and 0.951 (95% CI = 0.869–1.0) in discriminating thick melanomas of other types. Conclusion Despite the appearance that SR may correlate with the depth of the lesion, elastography, by measuring the SRs to dermis and hypodermis, does not have enough accuracy in distinguishing thin and thick melanoma.

Soluble PD-L1 is a potential biomarker of cutaneous melanoma aggressiveness and metastasis in obstructive sleep apnoea patients

Obstructive sleep apnoea (OSA) upregulates the programmed cell death-1 receptor and its ligand (PD-L1) pathway, potentially compromising immunosurveillance. We compared circulating levels of soluble PD-L1 (sPD-L1) in patients with cutaneous melanoma according to the presence and severity of OSA, and evaluated relationships with tumour aggressiveness and invasiveness.In a multicentre observational study, 360 patients with cutaneous melanoma underwent sleep studies, and serum sPD-L1 levels were assayed using ELISA. Cutaneous melanoma aggressiveness indices included mitotic rate, Breslow index, tumour ulceration, Clark level and tumour stage, and sentinel lymph node (SLN) metastasis was recorded as a marker of invasiveness.sPD-L1 levels were higher in severe OSA compared to mild OSA or non-OSA patients. In OSA patients, sPD-L1 levels correlated with Breslow index and were higher in patients with tumour ulceration, advanced primary tumour stages or with locoregional disease. The incorporation of sPD-L1 to the classic risk factors to SLN metastasis led to net improvements in the classification of 27.3%.Thus, sPD-L1 levels are increased in melanoma patients with severe OSA, and, in addition, might serve as a potential biomarker of cutaneous melanoma aggressiveness and invasiveness in this group of subjects.

Markers Usefulness in the Melanic Metastatic Cellular Epitops Identification in the Sentinel Lymph Node

Cutaneous melanoma is the most severe skin neoplasia with an increased incidence in the recent decades, particularly due to the intense exposure to sunlight. Our study analyzed the characteristics of malignant melanoma and the role of sentinel node biopsy in the diagnosis and prognosis of the patients with cutaneous melanoma by identifying the regional metastasis. The small or large clusters of circulating cancer cells are expressing epitops identified by some chemical reaction. These reagents are usually monoclonal antibodies with high sensitivity and specificity which are matching with the right receptor from the melanoma cells. The result is an antibody-antigen complex high-light in the microscopic examination by 3,3`-diaminobenzidine (DAB). The study was conducted on a sample of 151 patients diagnosed with melanoma in different developmental stages: 62 had Breslow index between 1-4 mm, 71 patients had Breslow index � 4 mm and 18 patients had Breslow index [ 1 mm. 45 patients (out of 62) with Breslow index between 1-4 mm had SLN positive. The mortality rate was 5% in the case of the patients with SLN positive. Comparing the rate of mortality by considering the Breslow index, 65% of the patients with Breslow index � 4 mm died. The correct identification of the patients with negative sentinel node or positive sentinel node improves staging and can facilitate the subsequent therapeutic decision, which is useful for early identification of the micro metastases and of the patients who require regional complete lymph node dissection.

Dermoscopic features of thin melanomas: a comparative study of melanoma in situ and invasive melanomas smaller than or equal to 1mm

BACKGROUND: Dermoscopy allows the early detection of melanomas. The preoperative determination of Breslow index by dermoscopy could be useful in planning the surgical approach and in selecting patients for sentinel lymph node biopsy. OBJECTIVES: This study aims at describing the dermoscopic features of thin melanomas and comparing melanomas in situ with invasive melanomas less than or equal to 1 mm thick. METHODS: This was an observational retrospective study in which the dermoscopy photographs of 41 thin melanomas were evaluated. Three observers evaluated together 14 dermoscopic criteria. RESULTS: Among thin melanomas, the most frequent criteria were presence of asymmetry in two axes in 95% of cases (39 cases), 3 or more colors in 80.4% of cases (33 cases), atypical dots or globules in 58.5% of cases (24 cases) and atypical network or streaks in 53.6% of cases (22 cases). The group of invasive melanomas presented with a higher frequency and statistical significance (p <0.05) 3 or more colors (OR: 16.1), milky red areas (OR: 4.8) and blue-white veil (OR: 20.4), and a greater tendency to have streaks or atypical network (OR: 3.66). CONCLUSIONS: Thin melanomas tend to have asymmetry in the two axes, 3 or more colors, atypical dots or globules and atypical network or streaks. Melanomas in situ tend to have up to 2 colors, no blue-white veil and no milky red area. Invasive melanomas tend to have 3 or more colors, a milky red area, blue-white veil, and atypical network or streaks. Further studies are needed to confirm these findings.