Impact of initial stage on metastatic melanoma survival.

Patients diagnosed with metastatic melanoma have varied clinical courses, even in patients with similar disease characteristics. We examine the impact of initial stage of melanoma diagnosis, BRAF status of primary melanoma, and receiving adjuvant therapy on postmetastatic overall survival (pmOS). We studied melanoma patients presenting to Perlmutter Cancer Center at New York University and prospectively enrolled in New York University melanoma biospecimen database and followed up on protocol-driven schedule. Patients were stratified by stage at initial melanoma diagnosis as per AJCC 7th ed. guidelines. pmOS was determined using the Kaplan-Meier method and Cox's proportional hazards models were used to assess hazard ratios (HRs). Three hundred and four out of 3204 patients developed metastatic disease over the time of follow-up (median follow-up 2.2 years, range: 0.08-35.2 years). Patients diagnosed with stage I (n=96) melanoma had longer pmOS (29.5 months) than those diagnosed with stage II (n=99, pmOS 14.9 months) or stage III (n=109, pmOS 15.1 months) melanoma (P=0.036). Initial stage of diagnosis remained significant in multivariate analysis when controlling for lactate dehydrogenase and site of metastases [primary diagnosis stage II (HR 1.44, P=0.046), stage III (HR 1.5, P=0.019)]. Adjuvant treatment was associated with better survival but BRAF mutation status did not show an association. Our data challenge the general assumption that primary melanomas converge upon diagnosis of metastatic disease and behave uniformly. Primary stage of melanoma at the time of diagnosis may be prognostic of outcome, similar to lactate dehydrogenase and metastatic disease sites.

Revisiting the Clinical and Biologic Relevance of Partial PTEN Loss in Melanoma.

The extent of PTEN loss that confers clinical and biological impact in melanoma is unclear. We evaluated the clinical and biologic relevance of PTEN dosage in melanoma and tested the postulate that partial PTEN loss is due to epigenetic mechanisms. PTEN expression was assessed by immunohistochemistry in a stage III melanoma cohort (n = 190) with prospective follow up. Overall, 21 of 190 (11%) tumors had strong PTEN expression, 51 of 190 (27%) had intermediate PTEN, 44 of 190 (23%) had weak PTEN, and 74 of 190 (39%) had absent PTEN. Both weak and absent PTEN expression predicted shorter survival in multivariate analyses (hazard ratio = 2.13, P < 0.01). We show a continuous negative correlation between PTEN and activated Akt in melanoma cells with titrated PTEN expression and in two additional independent tumor datasets. PTEN genomic alterations (deletion, mutation), promoter methylation, and protein destabilization did not fully explain PTEN loss in melanoma, whereas PTEN levels increased with treatment of melanoma cells with the histone deacetylase inhibitor LBH589. Our data indicate that partial PTEN loss is due to modifiable epigenetic mechanisms and drives Akt activation and worse prognosis, suggesting a potential approach to improve the clinical outcome for a subset of patients with advanced melanoma.

Association between Ki-67 expression and clinical outcomes among patients with clinically node-negative, thick primary melanoma who underwent nodal staging.

BACKGROUND: Patients with thick primary melanomas (≥4 mm) have highly variable survival outcomes. Cell proliferation marker Ki-67 has been identified as promising biomarker in thick melanoma but has not been evaluated since the wide spread adoption of sentinel lymph node biopsy. We revisit its prognostic relevance in the sentinel node era. METHODS: We studied patients with thick (≥4 mm) primary melanoma prospectively enrolled in a clinicopathological biospecimen database from 2002 to 2015, and evaluated the prognostic value of Ki-67 expression while controlling for features included in the existing staging criteria. RESULTS: We analyzed 68 patients who underwent lymph node sampling and who had an available tumor for Ki-67 immunohistochemical (IHC) staining. The median tumor thickness was 6.0 mm; the median follow-up was 2.6 years. In multivariable analysis including nodal status and primary tumor ulceration, Ki-67 expression was an independent predictor of worse recurrence-free survival (HR 2.19, P = 0.024) and overall survival (HR 2.49, P = 0.028). Natural log-transformed tumor thickness (ln [thickness]) was also significantly associated with worse OS (HR 2.39, P = 0.010). CONCLUSION: We identify Ki-67 and ln (thickness) as potential biomarkers for patients with thick melanoma who have undergone nodal staging. If validated in additional studies, these biomarkers could be integrated into the staging criteria to improve risk-stratification.

Computer-assisted measurement of primary tumor area is prognostic of recurrence-free survival in stage IB melanoma patients.

Current staging guidelines are insufficient to predict which patients with thin primary melanoma are at high risk of recurrence. Computer-assisted image analysis may allow for more practical and objective histopathological analysis of primary tumors than traditional light microscopy. We studied a prospective cohort of stage IB melanoma patients treated at NYU Langone Medical Center from 2002 to 2014. Primary tumor width, manual area, digital area, and conformation were evaluated in a patient subset via computer-assisted image analysis. The associations between histologic variables and survival were evaluated using Cox proportional hazards model. Logistic regressions were used to build a classifier with clinicopathological characteristics to predict recurrence status. Of the 655 patients with stage IB melanoma studied, a subset of 149 patient tumors (63 recurred, 86 did not recur) underwent computer-assisted histopathological analysis. Increasing tumor width (hazard ratios (HR): 1.17, P=0.01) and digital area (HR: 1.08, P<0.01) were significantly associated with worse recurrence-free survival, whereas non-contiguous conformation (HR: 0.57, P=0.05) was significantly associated with better recurrence-free survival. The novel histopathological classifier composed of digital area, conformation, and baseline variables effectively distinguished recurrent cases from non-recurrent cases (AUC: 0.733, 95% confidence interval (CI): 0.647-0.818), compared to the baseline classifier alone (AUC: 0.635, 95% CI: 0.545-0.724). Primary tumor cross-sectional area, width, and conformation measured via computer-assisted analysis may help identify high-risk patients with stage IB melanoma.

Dermatology in Ghana: a retrospective review of skin disease at the Korle Bu Teaching Hospital Dermatology Clinic.

INTRODUCTION: Ghana is currently developing its provision of dermatology services. Epidemiologic studies of the skin diseases seen by Ghanaian dermatologists are needed to guide these efforts. We aimed to describe the skin conditions seen by and management practices of Ghanaian dermatologists in a specialized clinic. METHODS: We conducted a chart review of new patients presenting to the Korle Bu Teaching Hospital dermatology clinic during 2014. RESULTS: Among the 529 patients studied, 700 discrete diagnoses were made. The most commonly diagnosed skin conditions were infections (24.6%) and dermatitis (24.6%); atopic dermatitis (8.4%), acne vulgaris (5.3%) and scabies (5.1%) were the most common specific diagnoses. Among infants, children, and adolescents, the most common diagnosis was atopic dermatitis (31.7%, 30.0%, and 14.9%, respectively). Acne vulgaris (12.0%) was the most common skin condition diagnosed in young adults. Irritant contact dermatitis (6.9%) was most common among adults. Lichen planus (9.9%) was the most commonly diagnosed skin condition in the senior population. Diagnoses made by dermatologists differed from the referral diagnosis documented by primary care providers for 65.8% of patients. The most frequently recommended treatments were antihistamines (47.8%) and topical steroids (38.4%). Only 18 diagnostic biopsies were performed. CONCLUSION: Our study summarizes the skin diseases seen and management practices of Ghanaian dermatologists in a specialized clinic at a large public teaching hospital. The results of this study can help to guide future dermatology education and development efforts in Ghana.

The Department of Defense: pioneers of early teledermatology.

The United States (US) Department of Defense(DoD) has been a leader in using telecommunicationstechnology to provide remote medical care. The DoDhas been using telemedicine for more than twentyyears to provide medical services to military personneldeployed throughout the world, and has largelyinfluenced the development of teledermatology. Theexperiences of early military teledermatology serviceshave yielded valuable lessons that have been essentialto the creation of successful civilian programs.

Skin Care in the Tattoo Parlor: A Survey of Tattoo Artists in New York City.

To understand the role that tattooists play in providing skin care advice, we conducted an online, survey-based study of 90 licensed tattooists in New York City. The survey asked tattooists about their exposure to adverse tattoo events, advising on tattoo removal/correction, behaviors regarding preexisting skin conditions and aftercare, confidence in addressing client questions about adverse events and preexisting conditions, and prior training about skin conditions related to tattoos. Most tattooists (92.8%) reported being asked by clients to evaluate adverse tattoo reactions, 85% were asked about tattoo removal, and 90% were asked about the safety of getting a tattoo with a preexisting skin condition. About half (56.1%) had received training about skin conditions related to tattoos. Tattooists with prior training reported higher rates of optimal skin care behaviors and higher confidence with tattoo-related skin conditions; 91.4% reported interest in skin care education. Tattooists play a major role in the skin health of their clients. Providing education for tattooists may improve skin care in populations less likely to see a dermatologist.

Colitis as the Sole Initial Presentation of Chronic Granulomatous Disease: Histopathologic Clues to Diagnosis.

Chronic granulomatous disease is a rare, inherited immunodeficiency disorder that reduces the superoxide generation ability of phagocytes, leading to recurrent infections and granulomatous inflammation. We report the case of a previously healthy 3-year-old boy who presented with classic features of Crohn disease. Suspicion from histopathologiclogic assessment allowed early diagnosis and treatment for chronic granulomatous disease before the onset of infections.

Skin Disease in the Uninsured: Diagnoses, Management Decisions, and Referral Outcomes of an Urban Free Clinic.

An understanding of the burden of skin disease in the uninsured population is needed to address the unique barriers they face to access dermatologic care. We conducted a retrospective chart review of patients seen for skin conditions over three years at the New York City (NYC) Free Clinic, a weekly primary care clinic operated by the NYU School of Medicine and the Institute for Family Health. Main outcomes of this study were descriptive analyses of demographic characteristics, diagnoses, management strategies, and referral outcomes, as well as key factors influencing referral to a dermatologist and referral attendance. Diagnosis was a significant predictor of referral (p<.000). The referral attendance rate was 52.5%. Patients older than 50 years were more likely to attend their appointments than younger patients (p=.025). Gender, wait time, and travel distance had no significant association with non-attendance. While demand for dermatologic care by uninsured patients in NYC is high, referral non-attendance remains a substantial barrier to care.