Juvenile melanomas: Western Australian Melanoma Advisory Service experience.

BACKGROUND/OBJECTIVES: Juvenile melanoma (before 20 years of age) is a rare condition with poorly defined risk factors. We describe features of juvenile melanoma in Western Australia over the last two decades. METHOD: A retrospective review of juvenile melanomas was conducted from prospectively maintained databases, reviewed for patients' characteristics, clinical information, histology, treatment, recurrence and survival data. RESULTS: Altogether 95 cases of juvenile melanoma were reported to the Western Australian Cancer Registry between 2000 and 2013. Of these, 27 patients were referred to the Western Australian Melanoma Advisory Service. Over 72% were aged between 13 and 19 years. The most common site for primary melanoma was the head and neck (31.8%). Eight patients (36.4%) had a pre-existing naevus, 13.6% reported 1-5 blistering sunburns in the past and 59.1% had a Fitzpatrick skin grade of 3 or less. Most (88%) were diagnosed with a primary invasive lesion at presentation. Superficial spreading melanomas predominated (27.3%). All but one patient had localised disease at presentation, with six patients undergoing further treatment, including chemotherapy and neck dissection for metastases. At the time of review, two patients had died, due to stroke and metastatic disease. CONCLUSIONS: Juvenile melanoma remains a rarity in Western Australia despite a very high incidence of adult melanoma. Unlike in adults, no definitive risk factors have been established. A significant proportion of this cohort had a pre-existing naevus and while most melanomas occurred in sun-exposed areas in light-skinned individuals the association between sunburn and melanoma was not strong.

When is a sentinel node biopsy indicated for patients with primary melanoma? An update of the 'Australian guidelines for the management of cutaneous melanoma'.

A sentinel lymph node biopsy is a surgical staging procedure performed for patients with primary cutaneous melanoma who are clinically lymph-node negative to determine whether there is low volume nodal metastasis in the draining lymph node field. A systematic review was recently performed to update the Australian clinical practice guidelines for the diagnosis and management of melanoma, addressing the question, 'When is a sentinel lymph node biopsy indicated?' This article discusses the findings of the systematic review and the evidence base for the updated guidelines.

Primary dermal melanoma: a West Australian cohort.

BACKGROUND: The objectives of this study were to identify a subgroup of patients with putative primary dermal melanoma after thorough multidisciplinary clinical and histological evaluation, and to describe the clinical, histological and selected molecular features of these lesions. METHODS: The records of the Western Australian Melanoma Advisory Service were searched for potential cases of primary dermal melanoma. The clinical and histological features were reviewed, immunohistochemical assessment was performed and clinical outcomes recorded. RESULTS: Eighteen cases of putative primary dermal melanoma with available clinical data were identified. Two of 12 cases in which further histological sections could be obtained were excluded because of the presence of findings suggesting an epidermal origin on these further sections. In one additional case, such origin could not be histologically excluded. Median follow-up period for the remaining cases was 68 months. Confirmed primary dermal melanoma accounts for 0.87% of cases of melanoma referred to a subspecialist melanoma advisory service. These cases show significant histological overlap with dermal/subcutaneous metastases of melanoma, but display a relatively good prognosis, with a 5-year survival of 87.5%. CONCLUSION: Our results support the recognition of a distinct group of melanoma that mimics metastatic melanoma, but is associated with a relatively favourable outcome. The group of putative primary dermal melanoma is likely to be heterogenous, including cases of primary nodular melanoma in which epidermal connection has not been identified, metastatic melanoma with an occult primary lesion and true primary dermal melanoma.

A critical review of melanoma pathology reports for patients referred to the Western Australian Melanoma Advisory Service.

AIM: To assess concordance between the histopathological reports of referring pathologists and those of pathologists reviewing the cases for the Western Australia Melanoma Advisory Service. METHODS: A retrospective review of 721 pathology reports from 2000 to 2009 was conducted. Histological features including Breslow thickness, Clark level, tumour type and clinicopathological staging [American Joint Committee on Cancer (AJCC)] were compared. Further analysis was undertaken for 169 cases to compare mitotic rate, excision margins, regression, growth phase, vascular invasion, neurotropism, tumour infiltrating lymphocytes, microsatellites and predominant cell type. RESULTS: Referring pathologists consistently reported Breslow thickness, Clark level and excision margins. Reporting of other parameters including ulceration, mitotic rate and vascular invasion, however, was variable. There was almost perfect concordance (kappa = 0.81-1.00) for tumour thickness, ulceration, microsatellites and growth phase; substantial concordance (κ = 0.61-0.80) for Clark level, mitotic rate, completeness of excision and neurotropism; moderate concordance (κ = 0.41-0.60) for vascular invasion, regression, predominant cell type and histological type; and only slight concordance (κ = 0-0.2) for tumour infiltrating lymphocytes. There was a high level of agreement for diagnosis of lesions as melanoma versus benign (97.3%). Overall concordance for pathological tumour staging was substantial (81.9%, κ = 0.79). Lowest concordance was found for stage 1b (91.3%, κ = 0.62). CONCLUSION: Overall concordance in clinicopathological stage was high due to consistency of reporting of tumour thickness and ulceration. Lower concordance was found for pathological substages due to discrepancies in Clark level, highlighting its limited reliability as a prognostic indicator and supporting the revision of its use in the latest AJCC melanoma staging protocol.