Seth B. Forman

Is superficial spreading melanoma still the most common form of malignant melanoma

BACKGROUND Most epidemiological studies suggest that superficial spreading melanoma is the most common histological subtype of malignant melanoma, but past data may not reflect current patterns of sun exposure or other risk factors. OBJECTIVE We sought to determine the prevalence of melanoma subtypes among recent specimens in a South Texas dermatopathology practice. RESULTS Lentigo maligna was the most common subtype of melanoma among the cases studied. Of 771 cases of melanoma reviewed, lentigo maligna and lentigo maligna melanoma accounted for 429 (56%). There were 220 cases of pagetoid (superficial spreading) melanoma (29%). Nodular melanoma with no apparent radial growth phase accounted for 27 cases (4%), and there were 23 cases of acral lentiginous melanoma (3%). The remaining 72 specimens (9%) included cutaneous metastases, spitzoid melanoma, melanoma in situ arising within a nevus, nevoid melanoma, desmoplastic melanoma, and patterns that could not be classified. LIMITATIONS Although the dermatopathology practice is located in South Texas, most patients are active duty military, military retirees, and military dependents. The majority currently resides in Texas, but the patients have lived in many locations around the world and traveled extensively. Sun exposure patterns and other risk factors may not reflect those of other populations. We were not able to perform subgroup analysis based on ethnicity or skin type as such data were not typically submitted with the specimens. CONCLUSION Our results challenge the notion that pagetoid (superficial spreading) melanoma is the most common subtype of malignant melanoma, at least in patients with extensive sun exposure. Changing patterns of sun exposure or environmental factors may contribute to the changing epidemiology of malignant melanoma. The current prevalence of subtypes of melanoma should be studied in other populations.

Glomeruloid hemangiomas without POEMS syndrome: series of three cases

To the Editor, Glomeruloid hemangioma is considered to be a specific marker for POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein and Skin changes) syndrome. The features of POEMS syndrome were first described by Shimpo in 1968. The actual acronym POEMS, developed by Bardwick et al. in 1980, remains a fixture in the medical literature. The association of the glomeruloid hemangioma with POEMS syndrome has become a fixture, as well. This association was recently reported by Phillips et al. However, recently, we have diagnosed three patients with solitary glomeruloid hemangiomas (Figs. 1 and 2). All three patients had subsequent negative serum protein electrophoresis (SPEP). Our series of patients, a 33-year-old white woman, a 29year-old white man and a 53-year-old white man, also have no evidence of neuropathy. Therefore, the patients fail to meet any of the major criteria for POEMS syndrome proposed by Dispenzieri and Gertz.

Collision tumor composed of Merkel cell carcinoma and lentigo maligna melanoma

We report the case of an immunocompetent 79‐year‐old white man with a history of melanoma in situ on the back with a collision tumor composed of a Merkel cell carcinoma (MCC) and lentigo maligna melanoma on the left cheek. The cells of the MCC expressed cytokeratin 20 (CK 20) in a diffuse cytoplasmic pattern, AE1 and AE3 in a perinuclear dot‐like pattern and diffusely with neuron‐specific enolase. The tumor cells of the MCC failed to express thyroid transcription factor‐1. The atypical melanocytes of lentigo maligna melanoma expressed Melan‐A and S‐100. At the same visit, a lentigo maligna was diagnosed by excisional biopsy on the right cheek. The variability in expression of CK 20, AE1 and AE3 in MCC are reviewed. Prior reports of MCC in collision with non‐melanoma skin cancers are reviewed. Additionally, the role of immunosuppression in the development of MCC is considered.

Baricitinib in adult patients with moderate-to-severe atopic dermatitis: a phase 2 parallel, double-blinded, randomized placebo-controlled multiple-dose study

Background: Baricitinib, an oral selective inhibitor of Janus kinase 1 and Janus kinase 2, modulates proinflammatory cytokine signaling. Objectives: The efficacy and safety of baricitinib were evaluated in patients with moderate‐to‐severe atopic dermatitis (AD). Methods: In this phase 2, randomized, double‐blind, placebo‐controlled study, 124 patients with moderate‐to‐severe AD applied topical corticosteroids (TCSs) for 4 weeks before randomization to once‐daily placebo, 2 mg of baricitinib, or 4 mg of baricitinib for 16 weeks. Use of TCSs was permitted during the study. The primary outcome was the proportion of patients achieving at least a 50% reduction in the Eczema Area and Severity Index (EASI‐50) compared with placebo. Results: Significantly more patients who received baricitinib, 4 mg, achieved EASI‐50 than did patients receiving placebo (61% vs 37% [P = .027]) at 16 weeks. The difference between the proportion of patients receiving baricitinib, 2 or 4 mg, who achieved EASI‐50 and the proportion of patients receiving placebo and achieving EASI‐50 was significant as early as week 4. Baricitinib also improved pruritus and sleep loss. Treatment‐emergent adverse events were reported in 24 of the patients receiving placebo (49%), 17 of those receiving 2 mg of baricitinib (46%), and 27 of those receiving 4 mg of baricitinib (71%). Limitations: A TCS standardization period before randomization reduced disease severity, limiting the ability to compare results with those of baricitinib monotherapy. Longer studies are required to confirm baricitinibs efficacy and safety in patients with AD. Conclusions: Baricitinib used with TCSs reduced inflammation and pruritus in patients with moderate‐to‐severe AD.

S100 A6 immunohistochemical staining for spindle cell and desmoplastic melanomas.

To the Editor, S100A6, otherwise known as calcyclin, is a calcium-binding protein belonging to the S100 protein family. It has been found in fibroblastic and epithelial cell lines, cells with rapid proliferative activity and cells undergoing differentiation. S100A6 expression is present in a variety of cutaneous and non-cutaneous neoplasms. It has been well documented that melanomas, as well as other benign melanocytic lesions including some melanocytic nevi and blue nevi express S100A6. Approximately 62–100% of previously reported metastatic and primary melanomas have expressed S100A6. To our knowledge, there have been no reports evaluating desmoplastic or spindle cell melanomas using S100A6 expression. We reviewed 11 desmoplastic melanomas (Fig. 1) and three spindle cell melanomas, all of which were positive for polyclonal antibody S100 protein. These cases were retrieved from the archives at Geisinger Medical Center from 2002 to 2007 and stained with anti-S100A6 protein. We also reviewed five conventional melanomas, one noduloulcerative melanoma and two metastatic melanomas to the lymph nodes. These cases were also positive for polyclonal anti-S100 protein. Our results showed that all three spindle cell melanomas and 7 of 11 desmoplastic melanomas (63.6%) stained diffusely with anti-S100A6 protein (Figs. 2 and 3). One of the desmoplastic melanomas stained focally, while the three remaining desmoplastic melanomas (27.3%) did not stain with anti-S100A6. The conventional melanomas, noduloulcerative melanoma and metastatic melanomas all stained with anti-S100A6 in different distributions. Four of the five conventional melanomas stained diffusely, while the remaining melanoma had rare positive cells. The noduloulcerative melanoma stained diffusely with anti-S100A6. One of the metastatic melanomas stained positive in a patchy distribution and the other metastatic melanoma had rare positive cells.

The significance of melanoma subsets

To the Editor: I read with interest the article by Johnson in the December 2008 issue of the Journal. The author does not mention an important ethical issue: guest authorship. This problem—also known as gift, honorary, or unjustified authorship—is perhaps hard to detect. It occurs when the name of an individual who did not contribute substantially to the paper appears on the byline. One reason why guest authorship exists is to increase the chance for publication. One solution, as mentioned by Johnson, is to clarify each author’s contribution to a paper.