Sir, While only a minority (5%) of newly diagnosed melanoma patients present with distant metastasis at initial diagnosis, the remaining majority of the metastases/relapses will eventually develop as a consequence of disease progression in patients with early disease.[1] Approximately one-third of all melanoma patients will experience disease recurrence/metastasis.[2-5] Any organ can be involved, but the most frequent target sites are the lungs, liver, bones, and brain.[2-5] Until today, while the clinicopathological factors affecting metastases have been defined, this is the first study to shed light on the effect of histology on the distribution of metastasis. Similarly, we did not specifically focus on this issue in our previous studies on melanoma recurrence.[2-5] In this study, we investigated the role of histology in the distribution of metastases during the follow-up of resected early-stage melanoma patients. Patients with stage I–III who were excised and subsequently developed metastasis were included in the study. Patients with the most common histotypes, superficial spreading melanoma (SSM), nodular melanoma (NM), and acral lentiginous melanoma (ALM), were included in the study and evaluated retrospectively. Because metastases developed in only five patients with lentigo maligna melanoma (LMM), these patients, as well as patients with rare histological variants such as spitzoid, nevoid, verrucous, polypoid, and desmoplastic melanomas, were excluded from the study. Patients were treated with adjuvant therapy and/or followed up as required by their stage, in accordance with the standards and recommendations of international guidelines such as the NCCN and ESMO Guidelines. The metastasis stage (M1) used in the 8th edition of the AJCC Melanoma Staging System guide was used to evaluate metastasis sites. A total of 284 patients, including 140 patients with stages I–II and 144 patients with stage III were enrolled in the study. The number of patients was 127 (44.7%), 112 (39.4%), and 45 (15.9%) in SSM, NM, and ALM patients, respectively. In stages I–II, ALM patients had a significant local recurrence (M1a) rate (77%) compared to other histologies, whereas the distant metastases rates were very low (less than 10%) [Figure 1a]. While the rates of lung metastasis were similar in almost all histotypes, bone, liver, and brain metastases percentages were lower (6%) in ALM patients [Figure 1b]. In all types of metastases, the rates of SSM and NM were the nearly same. Likewise, local recurrence was the most common (58%) in ALM patients, while SSM and NM disseminated to all metastasis sites at the same percentages [Figure 2a]. While NM patients showed the most common spread to the lungs and liver, the lowest rates of metastases to the brain were found in ALM patients [Figure 2b].Figure 1: (a) Percentages of metastasis types by histology in stages I–II (b) Percentages of distant metastasis sites by histology in stages I–IIFigure 2: (a) Percentages of metastasis types by histology in stage III (b) Percentages of distant metastasis sites by histology in stage IIIThe histologic subtype was an independent predictor of relapse and outcome in cutaneous melanoma patients.[6] Both NM and ALM had unfavorable prognoses, and they were associated with known poor pathological and clinical indicators. In our earlier study, we determined that relapse/metastasis rates for nonmetastatic melanomas were higher in NMs (39.6%) and ALMs (35.3%) than in SSMs (24.3%).[6] Unlike SSMs, there were statistically significant correlations between NMs and ALMs and most aggressive histopathological prognostic indicators, such as higher Clark level, thick Breslow depth, presence of ulceration, and lymphovascular invasion. Furthermore, compared with other subtypes, NMs and ALMs were also associated with advanced clinical stages, node involvement, and metastasis. However, whether ALM has an effect on survival has not been clarified because of the controversial results of the studies. In another study, no correlations were found between ALMs and other major poor prognostic factors, such as tumor thickness, mitotic rate, lymphovascular invasion, nodal involvement, or distant metastasis.[7] The outcomes for ALM patients were similar to those of patients with other histotypes. Furthermore, because overall survival in metastatic disease decreases from M1a to M1d, ALM patients have a recurrence rate almost as much as NM patients, indicating that ALMs with more local recurrence and less visceral metastases (especially brain metastases) have a better prognosis than NM patients.[6] In conclusion, histology has an impact on the distribution of metastasis in patients with resected early-stage skin melanomas. There is a need for studies with more patients in order to make a more accurate assessment of this subject. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Background Body mass index (BMI) and serum albumin (ALB) level are long-established markers that reflect the nutritional status and eventually the prognosis of cancer patients. The objective of the study was to determine the clinical significance of these factors and specify their roles in outcomes compared with performance status (PS) and weight loss (WL), which are considered the most significant patient-related prognostic factors in small cell lung cancer (SCLC) treated with platinum-etoposide-based chemotherapy.
The incidence of cutaneous melanoma among the elderly has increased significantly. Unfavorable survival rates are associated with insufficient patient managements and poor prognostic features in the elderly. We aimed to compare elderly (≥75 years) and younger (<75 years) patients with cutaneous melanoma to determine the differences and the prognostic significance of age.The retrospective data of 117 elderly and 232 younger patients with cutaneous melanoma were compared.The median age of the elderly patients was 78 years (75-104), and 51.3% of the patients were female. Of the patients, 14.5% were in the metastatic stages. Clinicopathologic factors such as extremity melanomas (P = 0.01), Clark levels IV-V (P = 0.04), ulceration (P = 0.009), and neurotropism (P = 0.03) were significantly more common in elderly patients. However, BRAF mutation was significantly more common in younger patients (P = 0.003). Overall survival (OS) and recurrence-free survival (RFS) rates of both the groups were similar. Lymph node involvement (P < 0.005), distant metastasis (P < 0.005), and relapse of disease (P = 0.02) were associated with poor OS in elderly patients. Tumor-infiltrating lymphocytes was associated with prolonged RFS (P = 0.05), while extremity melanomas (P = 0.01), lymphovascular invasion (P = 0.006), and lymph node involvement (P < 0.005) had negative impact on RFS.Although elderly patients with cutaneous melanoma had different clinicopathologic features in our series, their survival rates are similar to those of younger patients, which shows that age alone is inadequate to determine the prognosis. Disease stage and a comprehensive geriatric assessment might assist to determine appropriate management.
Digital clubbing is a paraneoplastic phenomenon usually associated with non-small cell lung cancer. We report the development of clubbing in a 49-year old man diagnosed with cutaneous melanoma which had metastasized to the lungs. We also reviewed the literature to understand the association between metastatic melanoma and clubbing. Previous reports of melanoma associated with hypertrophic osteoarthropathy (HOA) are extremely rare; only 7 cases. In all these patients digital clubbing was the main component of the HOA. However, our patient developed digital clubbing in the absence of other features of HOA. Therefore, to our knowledge, our report is the first in the literature. In conclusion, it should be kept in mind that digital clubbing might be associated with metastatic melanoma to the lung, notwithstanding rarely, and successful treatment of the underlying disease is associated with rapid resolution of the clubbing, as occurs in most patients with paraneoplastic syndromes.
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