|Ahead of print publication
Trends in the characteristics of skin melanoma in accordance with time intervals: A single Turkish tertiary referral center experience
Faruk Tas, Kayhan Erturk
Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul, Turkey
|Date of Submission||03-Aug-2019|
|Date of Acceptance||19-Dec-2019|
|Date of Web Publication||26-Nov-2020|
Department of Medical Oncology, Institute of Oncology, Istanbul University, Capa, Istanbul 34390
Source of Support: None, Conflict of Interest: None
Aim: The incidence of skin melanoma has increased dramatically in recent years. The aim of this study was to analyze the trends in the features of Turkish cutaneous melanoma patients in a 25-year period
Materials and Methods: A total of 1258 adult melanoma patients who had been managed and followed up at a tertiary referral center between 1993 and 2017 were included in the study.
Results: Males were predominant which did not vary between time intervals. There was an increase in the percentage of older patients over the years, whereas no change was observed in the percentage of younger patients. As the percentage of lower extremity melanoma dropped, the percentage of truncal melanomas rose. Both the incidences of thick (T3–T4) and thin melanomas (T1) were found to increase over time by 13.4% and 3.8%, respectively. There was no significant change in the percentage of the metastatic disease; however, Stage III disease was found to multiply by 10.1% and local disease was found to fall by 8.5% over the period. The percentages of patients with nodular histopathology and tumor-infiltrating lymphocytes were found to plummet, and there was a slight decline in the percentages of patients with high mitotic rate and lymphovascular invasion.
Conclusions: Most likely because of the delayed diagnosis, cutaneous melanoma was found to be associated with less favorable prognostic features as the time lapsed. We suggest that effective campaigns for public awareness of melanoma be implemented so the screening and early diagnosis of the disease can be promoted.
Keywords: Characteristics, cutaneous, melanoma, time intervals, trends
|How to cite this URL:|
Tas F, Erturk K. Trends in the characteristics of skin melanoma in accordance with time intervals: A single Turkish tertiary referral center experience. J Can Res Ther [Epub ahead of print] [cited 2021 Jan 17]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=301001
| > Introduction|| |
Cutaneous melanoma, the most lethal skin cancer worldwide, is the fifth (6%) and the sixth (4%) most common type of cancer in men and women, respectively, in the US. In 2017, ~87,110 patients will have been diagnosed with melanoma, ~9730 of whom will have lost their lives in the US. The incidence of melanoma continues to increase dramatically; the lifetime risk of developing melanoma is 1 in 28 and 1 in 44 for men and for women, respectively. It is increasing in men more rapidly than any other tumor and in women more rapidly than any other malignancy, except for lung carcinoma. The outcome of melanoma mainly depends on the stage at presentation., For patients with localized melanomas, survival rates also depend on some factors, such as regional nodal involvement, tumor thickness, ulceration, and mitotic rate.,
A number of epidemiological studies on melanoma have examined the variations in the prognostic factors over time and conflicting results have come up eventually.,,,,, This study aims to analyze the changes of cutaneous melanoma features in Turkish patients between time intervals in a 25-year period.
| > Materials and Methods|| |
The data of 1258 adult Caucasian Turkish cutaneous melanoma patients who had been admitted, treated, and followed up at Istanbul University Institute of Oncology, a single tertiary referral center, between the years 1993 and 2017 were included in the study and analyzed retrospectively. Intermediate-thickness patients underwent pathological nodal staging by either sentinel lymph node biopsy (SLNB) or elective lymph node dissection. Patients with pathologically positive SLNB underwent a completion lymphadenectomy. After lymph node status was determined by radical lymph node dissection, the disease was staged according to the American Joint Committee on Cancer (seventh edition) staging system. Patients were treated and followed up according to standard international guidelines including the National Comprehensive Cancer Network guidelines.
The records were retrieved from the cancer registry for review of the pathological features and clinical data, such as relapses and outcomes. The trends in characteristics of the patients were evaluated in accordance with five time intervals divided from the total period of 25 years, between 1993 and 2017. The study was reviewed and approved by our local ethical committee.
Kaplan–Meier analysis was used for estimation of survival of patients. Overall survival (OS) was determined from the date of pathologic diagnosis to death resulting from any cause. Statistical analysis was carried out using SPSS 21.0 software (SPSS Inc., Chicago, Illinois, USA).
| > Results|| |
The median age of the patients was 51 years (range, from 16 to 104) and men were predominant (54.1%) [Table 1]. The majority of the patients had axial melanomas (57.6%), thick Breslow depth (>2 mm) (62.6%), ulcerated lesions (54.3%), and higher mitotic rate (>2/mm2) (50.7%). The largest group of patients presented with local disease (Stage I–II) (59.9%), followed by regional disease (Stage III) (29.0%) and systemic disease (Stage IV) (11.1%).
|Table 1: Changes (percentage) in patient-, clinical-, and pathological-related parameters of cutaneous melanoma patients between 1993 and 2017|
Click here to view
The percentage of the males was higher than that of the females (54.1% vs. 45.9%) which remained unchanged between time intervals [Table 1]. On the other hand, the median age of the patients at diagnosis was about 50 years, which varied significantly between time intervals. As the percentage of older patients (≥70 years) was found increased (9.47% in 1993–1997 vs. 15.83% in 2013–2017), the percentage of patients between ages 35 and 40 years was found decreased (36.09% in 1993–1997 vs. 23.74% in the last 5-year period) [Table 1]. However, no change was observed for younger patients (younger than age 35).
The percentage of the lower extremity melanoma fell from 30.9% in 1993 to 25.6% in 2017, whereas the percentage of truncal melanomas rose apparently (30.3% in 1993 vs. 37.8% in 2017) [Table 1]. The incidences of thick (T3–T4) and thin melanomas (T1, i.e., 1 mm or less) were found to escalate over time by 13.4% and 3.8%, respectively. Majority of the patients had local disease (Stage I–II) (70%) which was followed by regional disease (Stage III) (29%) and systemic disease (Stage IV) (11%). As Stage III disease was found increased by 10.1%, the local disease was found decreased by 8.5% over time; however, no significant variations in metastatic disease percentages were observed between time intervals.
The percentages of patients with nodular histopathology and tumor-infiltrating lymphocytes plummeted by 11% and 10.8%, respectively [Table 1]. However, the high mitotic rate and positive lymphovascular invasion percentages slightly fell by 6.5% and 2.6%, respectively. On the other hand, the percentages of the lesions with ulceration and regression did not vary over time.
The 5- and 10-year OS rates were 61% and 52%, respectively, for all melanoma patients [Figure 1].
|Figure 1: Overall survival curve of all patients (5- and 10-year survival rates 61% and 52%, respectively)|
Click here to view
| > Discussion|| |
The recent studies already concluded that cutaneous melanoma incidence had increased worldwide. Even though the Turkish data on variations of melanoma incidence in accordance with time are lacking, a few numbers of publications revealed a similar rise in the incidence of melanoma in Turkish patients., Despite the fact that the number of patients at our institute, each year might be affected by problems in patient referrals – thus, it might be considered unreliable from an epidemiologic perspective – it has to be taken into consideration in our study that the number of the patients has increased over the 25-year period, with the percentages escalating from 13.9% (between 1993 and 1997) to 20.7% (in the last 5-year period).
Melanoma is generally diagnosed in dermatology departments and excised in plastic surgery departments. Therefore, the data from these centers, particularly a thumping majority, nearly 90% of cases are diagnosed early, might be considered more reliable than the data from other medical departments, such as oncology. In our clinic, the distribution of the data regarding the stages is found different from that at the National Cancer Registry. That is why the percentage of early-stage disease that did not need any type of oncologic treatment (Stage I and may be Stage II) did not exist adequately in our cohort.
The increase in the incidence of skin melanoma worldwide has not been co-existed with a proportional increase in mortality. The major explanation of this fortunate outcome is the early diagnosis of the lesions.,,,,, The authors attribute this improvement in the diagnosis to the efforts made in recent years to raise awareness in the population. In our study, poor prognostic factors, such as old patient age, truncal lesion, advanced tumor stages (T3–4), and regional disease (Stage III), were found to multiply as the time had lapsed; that is a finding which might be held accountable for the worse survival.
| > Conclusions|| |
This study shows that the proportion of primary melanomas diagnosed in advanced stages enlarged in the 25-year period. Since it is uttermost important that the disease be diagnosed at an early stage, we suggest that effective and extensive campaigns for public awareness of melanoma be introduced immediately, so the screening and early diagnosis of the disease can be promoted, especially in the elderly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin 2017;67:7-30.
Balch CM, Gershenwald JE, Soong SJ, Thompson JF, Atkins MB, Byrd DR, et al
. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol 2009;27:6199-206.
Balch CM, Soong SJ, Gershenwald JE, Thompson JF, Reintgen DS, Cascinelli N, et al
. Prognostic factors analysis of 17,600 melanoma patients: Validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol 2001;19:3622-34.
Buettner PG, Leiter U, Eigentler TK, Garbe C. Development of prognostic factors and survival in cutaneous melanoma over 25 years: An analysis of the Central Malignant Melanoma Registry of the German Dermatological Society. Cancer 2005;103:616-24.
Cavalieri R, Macchini V, Mostaccioli S, Sonego G, Ferranti G, Corona R, et al
. Time trends in features of cutaneous melanoma at diagnosis: Central-south Italy, 1962-1991. Ann Ist Super Sanita 1993;29:469-72.
Warycha MA, Christos PJ, Mazumdar M, Darvishian F, Shapiro RL, Berman RS, et al
. Changes in the presentation of nodular and superficial spreading melanomas over 35 years. Cancer 2008;113:3341-8.
Hollestein LM, van den Akker SA, Nijsten T, Karim-Kos HE, Coebergh JW, de Vries E. Trends of cutaneous melanoma in the Netherlands: Increasing incidence rates among all Breslow thickness categories and rising mortality rates since 1989. Ann Oncol 2012;23:524-30.
Marcoval J, Moreno A, Torras A, Baumann E, Graells J, Gallego MI. Changes in incidence of malignant melanoma in the last 19 years in a tertiary hospital on the Mediterranean coast. Actas Dermosifiliogr 2008;99:464-8.
Jemal A, Saraiya M, Patel P, Cherala SS, Barnholtz-Sloan J, Kim J, et al
. Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992-2006. J Am Acad Dermatol 2011;65:S17-25.e1-3.
Melanoma, NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Version 1.2017; 10 November, 2016.
Tas F, Kurul S, Camlica H, Topuz E. Malignant melanoma in Turkey: A single institution's experience on 475 cases. Jpn J Clin Oncol 2006;36:794-9.
Baykal C, Atci T, Akay BN. Is the frequency of primary cutaneous melanoma increasing in Turkey? An evaluation of the experiences of two dermatology centers. J Oncol Sci 2018;4:19-23.
Tas F. Age-specific incidence ratios in malignant melanoma in Turkey: Melanoma in older people is increasing. Acta Derm Venereol 2011;91:353-4.