Alessandra Chiarugi

Improvement of malignant/benign ratio in excised melanocytic lesions in the ‘dermoscopy era’: a retrospective study 1997–2001

Background  Because of the many limitations of studies based on the diagnostic setting of excised lesions, the impact of dermoscopy (epiluminescence microscopy, dermatoscopy) in melanoma screening during practice remains to be established.

Immunohistochemical evidence of cytokine networks during progression of human melanocytic lesions

Melanoma cells in culture express a variety of growth factors and cytokines and some of their autocrine and paracrine roles have been investigated. However, less information is available on the potential dynamic changes in expression of these molecules on cells during melanoma development and progression in situ. Using immunohistochemistry, we tested 40 nevi and primary and metastatic melanoma lesions for the expression of 10 growth factors and cytokines and the respective receptors representing 10 cell surface molecules. Nevi and thin (< 1 mm) primary melanomas showed little expression of ligands except weak reactivity of tumor necrosis factor‐α (TNF‐α), transforming growth factor‐β (TGF‐β), interleukin‐8 (IL‐8) and reactivity of TGF‐βR and c‐kit. Marked up‐regulation of growth factors, cytokines and receptor expression was observed in thick (> 1 mm) primary melanomas, which were stained with polyclonal or monoclonal antibodies (MAbs) for IL‐1α, IL‐1β, IL‐6, IL‐8, TNF‐α, TGF‐β, granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) and stem cell factor (SCF), but not IL‐2. Metastases showed similar expression patterns except that SCF was absent. Co‐expression of ligand and receptor was observed for TGF‐β, GM‐CSF and IL‐6, suggesting an autocrine role for these ligands. TNF‐α appears to be a marker of benign lesions; IL‐6 and IL‐8 expression is associated with biologically early malignancy; TGF‐β, GM‐CSF and IL‐1α are highly expressed in biologically late lesions; and TNF‐β is an apparent marker of metastatic dissemination. Our results indicate that melanoma cells utilize cascades of growth factors and cytokines for their progression. Int. J. Cancer (Pred. Oncol.) 84:160–168, 1999.

In situ expression of transforming growth factor beta is associated with melanoma progression and correlates with Ki67, HLA-DR and beta 3 integrin expression.

Transforming growth factor-beta (TGF beta), which is secreted by cultured melanoma cells constitutively, inhibits the proliferation of normal melanocytes and of most melanoma cells in vitro, but some melanoma cells from advanced stages of the disease develop resistance to TGF beta-dependent growth inhibition, without developing any change in TGF beta cell surface binding. In vitro TGF beta also downregulates the expression of HLA-DR molecules on melanoma cells, and upregulates the expression of the beta 3 integrin subunit on some cell lines. Immunohistochemical analysis of 53 melanocytic lesions (12 naevi, 30 primary melanomas and 11 metastases) revealed a trend of increasing expression of TGF beta and TGF beta receptor type III with tumour progression, and a significantly higher expression of both TGF beta (P < 0.0001) and the receptor (P < 0.05) in metastatic and thick (> 1 mm) primary melanomas compared with thin (< 1 mm) primary melanomas. The expression of TGF beta correlated with expression of a marker of proliferation, Ki67, and with HLA-DR and beta 3 integrin subunit expression. Coexpression of the four molecules was observed in all metastases and in most thick primary melanomas. These findings argue against an inhibitory effect of TGF beta on cell proliferation or HLA-DR antigen expression in melanoma, and suggest the upregulation of the beta 3 subunit. TGF beta protein appears to be a biological marker of melanoma progression in situ.

Serum imbalance of cytokines in melanoma patients

The cytokines interleukin (IL)6 and IL10 appear to be involved in the progression of melanoma because they are secreted by malignant cells and their serum levels are associated with poor survival and with advanced stages of the disease. Antitumour immunity is considered to be a T-cell response, mediated mainly by type 1 cytokines such as IL12 and interferon-γ (IFNγ). We evaluated the serum levels of cytokines involved in the host response against tumour (IL12, IFNγ) and/or the progression of melanoma (IL6, IL10) in 45 melanoma patients with localized and metastatic disease and in 45 controls, using commercially available enzyme-linked immunosorbent assay (ELISA) kits. In the controls, IL6 and IL12 were nearly undetectable, whereas the IL10 and IFNγ ranges were 0.5–9 pg/ml and 2–4.8 pg/ml, respectively. In the melanoma patients, pathologically high values were found in 44.4% for IL6, in 24.4% for IL10, and in 60% for IL12. Significantly higher values were found for IL6 and IL12, and lower values for IFNγ. This study highlights a significant difference in serum cytokine profiles between controls and melanoma patients, which is mainly due to the high levels of IL6 and IL12 and the low levels of IFNγ.

The thickness of melanomas has decreased in central Italy, but only for thin melanomas, while thick melanomas are as thick as in the past.

The objective of this study was to evaluate the time trend of melanoma thickness in a population-based case series. All invasive (n=2862) and in-situ (n=605) cutaneous melanoma incident cases diagnosed in 1985–2004 were retrieved from the Tuscany Cancer Registry, central Italy. Standardized (European population) incidence rates were computed for four periods: 1985–1989, 1990–1994, 1995–1999, 2000–2004, and for Breslow thickness classes (≤1, 1.01–2.00, >2 mm). The annual percent change (APC) of the standardized rates was computed. Thickness was evaluated on the basis of sex, age, morphology type, site and period of time. Median thickness was evaluated by means of a nonparametric K-sample test. The incidence rate of melanoma rose significantly for both invasive (APC=+5.1%) and in-situ lesions (APC=+11.1). The sex distribution of patients with invasive melanoma did not change over time (mean male/female ratio 0.95). The mean age at diagnosis did not change (57.2 years; SD=17.2 years). From 1985–1989 to 2000–2004 the median value of thickness decreased from 1.68 to 0.8 mm (P<0.001). Within the Breslow categories the median value of thickness decreased significantly for thin melanomas (≤1 mm) but not for intermediate (1.01–2.00) or for thick melanomas (>2 mm). Among the most common melanoma types, the median thickness decreased for superficial spreading melanomas but not for nodular melanomas. Over time, the incidence of melanoma has increased notably and the median thickness has decreased. However, median thickness has decreased only among thin melanomas, whereas it has not changed for thick melanomas, most of which are of the nodular type.

In vivo characterization of the inflammatory infiltrate and apoptotic status in imiquimod‐treated basal cell carcinoma

Background  Imiquimod use in the treatment of basal cell carcinoma (BCC) has proven to be successful in a large percentage of cases, inducing tumor regression; however, the exact cellular mechanism has not been fully clarified.

Melanoma survival: sex does matter, but we do not know how.

The objective of this study was to provide further insights into the prognostic role of female sex in skin melanoma. The prognostic effect of sex in a population-based case series of 3900 skin melanomas in central Italy has been evaluated considering the possible confounding role of many demographic and clinical variables (age, period of diagnosis, Breslow’s thickness, Clark level, ulceration, lymph node status, metastasis, histological type, skin site, and pathological T and N). Multiple imputations, according to chained equations, have been used for imputing incomplete values. A Cox proportional hazards model on the risk of death caused by melanoma was fitted. Univariate and multivariate effects of sex and of other variables were computed. The 5-year cause-specific survival was 87% (95% confidence interval: 86–89%) for women and 80% (78–82%) for men. Women had higher rates at any time since diagnosis. After adjustment for other confounders, women had a 34% reduced risk compared with men of dying from skin melanoma (hazard ratio=0.66, 95% confidence interval: 0.56–0.79). The present study confirmed a strong protective effect of female sex on skin melanoma mortality. The protective factor is still unknown.

The p.G23S CDKN2A founder mutation in high-risk melanoma families from Central Italy.

We have investigated the frequency and spectrum of CDKN2A/CDK4 mutations in 23 cutaneous melanoma families from Central Italy (Tuscany). Three distinct mutations were identified in five families. One mutation, p.G23S, was present in three families. Several lines of evidence indicate that p.G23S is a pathogenic mutation: it is located in the functionally important first ankyrinic domain of p16, it was not detected in a sample of 100 control individuals, and it was present in all tested affected individuals from the three families. Haplotype analysis showed a common ancestral origin of the p.G23S mutation. Our data show that the p.G23S mutation is an important cause of hereditary melanoma in Tuscany.

Oral carcinoma in a young man: a case of dyskeratosis congenita

We report a 28‐year‐old male with a voluminous growth of the tongue, present for 6 months. The histological examination revealed a squamous cell carcinoma. The patient was also affected by oral leukoplakia, nail dystrophy, reticulated poikiloderma of the neck and hyperkeratosis of palms and soles. On the basis of clinical features and histological findings, as well as findings from the family, the diagnosis of dyskeratosis congenita (DKC) was made.

Effect of Lesion Size on the Diagnostic Performance of Dermoscopy in Melanoma Detection

Background: Dermoscopy is able to correctly classify a higher number of melanomas than naked-eye examination. Little is known however about factors which may influence the diagnostic performance during practice. The aim of the study was to analyze the effect of size of the lesion on diagnostic performance of dermoscopy in melanoma detection. Methods: Eight dermatologists examined clinical and, separately, clinical and dermoscopic (combined examination) images of 200 melanocytic lesions previously excised [64 melanomas, 24 in situ and 40 invasive (median thickness 0.30 mm) and 136 melanocytic nevi]. After examination, diagnostic performance was analyzed in accordance with the major diameter of the lesions divided into 3 groups, i.e. small (less than 6 mm), intermediate (between 6 and 9 mm) and large (10 mm or more) lesions. These groups were shown to be highly comparable concerning the microstaging of melanomas (median thickness value 0.30, 0.22 and 0.32 mm, respectively). Results: Dermoscopy increased the diagnostic performance of naked-eye examination of both intermediate and large lesions [sensitivity value: +19.3 (p = 0.002) and +10.3 (p = 0.007); diagnostic accuracy value: +7.4 (p = 0.004) and +6.1 (p = 0.07)]. On the contrary, no statistically significant increase was found dealing with small lesions (sensitivity +3.7, p = 0.66; diagnostic accuracy –1.7, p = 0.55). Conclusions: The diagnostic improvement associated with the addition of dermoscopy to naked-eye examination is influenced by the size of the lesion, i.e. it is lacking with lesions up to 6 mm in diameter. The optimized use of dermoscopy in melanoma detection is obtained dealing with melanocytic lesions 6 mm in diameter or larger.