Dr. Frederick Fish reviews the increased risk previously diagnosed melanoma patients face for developing new lesions while noting modalities that should be used to survey for new primary melanomas.
and our final speaker before the cases we will bring dr fish back. Um and uh if you get one melanoma, if a patient gets one melanoma that can certainly get another melanoma and to discuss that doctor fish, we'll cover that. Now, fred. Thank you. So I'm going to discuss the evaluation of the melanoma patients for other primary melanoma lesions. Yeah. Okay, let's see. Control. Yeah. So I have no disclosures and thanks for dr winning anna stein who helped me with the presentation. Yeah. So an overview of the presentation, I'm going to talk about some of the important review articles discussing multiple primary melanomas and patients and their findings discuss risk factors in multiple primary melanoma patients look a little bit of survival. That as single melanoma patients and multiple primary melanoma patients. And then summarize considerations for following multiple primary melanoma patients. So, first I want to start with reviewing an article that was done at Scripps Clinic by dr burrows back in 2010. And the overall risk of developing Primary melanoma multiple primary melanomas over the lifetime of somewhere between two and 5%. Uh huh. It's scripts they looked at 1,258 patients From 1990 to 2000 And they found 149 of the patients develop multiple primary melanomas. This was about a 12% finding, which was approximately double what the finding was in previous literature. And dr burrows suggests a couple of possibilities. One was that the criteria they were using for diagnosing melanoma insight to might be a little different and have a lower threshold for diagnosis or possibly that the incident was rising faster than expected. A high sun exposure area like around san Diego. Yeah. And in the scripts experience, 75% of the patients were found to have two primary melanomas. During the time they looked, 15% of the patients had three primary melon. Almost 10% of the patients had four more primary melanomas and they found about a twofold increase of multiple primary melanomas and men as compared to women. And they found that the time of initial primary melanoma diagnosis was around 64 years old and men and 56 years old and women And subs in the scripts experienced 70% of the subsequent primary melanoma patients who had their second melanoma occurred at a different site. 30% had occurrence of the second melanoma in around the same site and the distribution of other melanomas was found to be similar to what we find a kind of a normal distribution of melanomas. 30% of the subsequent primary melanomas in the scripts experience were found within two months or less of the primary melanoma, which is I think it's an important thing to think about. And then 49% of the patients develop the subsequent melanoma within three years after the initial primary diagnosis. So the first few years after the diagnosis, the initial monem are at higher risk for developing another melanoma. The primary melanoma depth was similar to national statistics and the secondary melanomas tended to be a little thinner than the first melanoma, and this was felt to possibly make some sense in terms of the patients were being monitored more closely and they were monitoring themselves more closely. So some of their recognized risk factors for multiple primary melanomas include the presence of the typical or this plastic nearby a family history of melanoma in the early age of onset of the first primary melanoma. So we're going to look at the paper now that was published in Jama and it looked at it group of patients, patients were primarily from the Sloan Kettering cancer center And it looked at the incidence of multiple primary melanomas. Again, with a range between 1.3, and they use a prospective type of study to review and looked at. The 4000 484 patients were diagnosed with the first primary melanoma. Between 1996 and 2002, they found that 358 or 85 patients are approximately 8.6% had two or more primary melanomas, with an average of 2.3 for multiple melanoma patient. And again, 78% of these patients had two primary melanomas, 74% of the patients. The initial melanoma was as thick as tumor and 59% of the primary melanoma patients presented with their second primary melanoma. Within a year of diagnosis of the first melanoma. Mhm. 21% of multiple multiple primary melanoma patients had a positive family history of melanoma, compared to only 12% of patients with a single primary melanoma And 38% of multiple primary melanoma patients had this plastic Niva compared with only 18% of single primary melanoma patients. And the estimated cumulative five year risk of second primary tumor for the entire Cohort was about 11.4%,, with almost half occurring in the first year. So similar results with the scripts group were the first year to have a high risk of having the second melanoma develop for patients with a positive family history Or dis plastic nearby. The estimated five year risk of multiple primary melanomas was significantly elevated, with 19.1%. In the family history group, 23.7% of the dis plastic Nevis group. The most striking incidents of the multiple primary melanoma population was seen for the development of a third primary melanoma from the time of the primary melanoma, Which was 15.6% at one year, 30.9% at five years. Yeah, in conclusion, the incidence of the multiple primary melanoma patients, or multiple primary melanomas has increased in patients with a positive family history or this plastic Niva and patients should undergo intense thermal logic screening should consider genetic testing in cases where they have Probably two or 3 multiple or two or 3 melanomas. And although the percentage of subsequent primary melanomas thicker than one is lower than for the first multiple primary melanoma, it was still of significant thickness in the second primary melanoma melanoma survivors need to remain under surveillance not only further recurrences, but for future primary melanomas. Also for other cancers, which we're going to talk about a little bit later. So this is another interesting paper, I guess looking at multiple primary melanomas, do they look the same? This is a paper that was done by Harold, Rabinovitz and muscarello and a group of people from several different areas. They basically wanted to look at a group of melanoma patients and compare the clinical and Durmus coptic features of multiple primary melanomas with an individual. Yeah. And have a group of patients since most of the other things have just been similar case reports and they wanted to look at whether the mountain almost had much similarity or dissimilarity where they occurred. So they gathered Durmus coptic images of melanoma patients with diagnosed multiple primary melanomas from databases of the US Italy and spain, which they've got a nice mix of patients And they found 58 patients with multiple primary melanomas, 53% of those had Durmus comically similar melanomas and 47% had Durmus comically different melanoma, so pretty much kind of a toss of a coin as to whether the second melanoma would like look similar to the first melanoma. In older patients. Uh there was a slightly higher chance that there would be Dermot Dermot psychotically similar than younger patients and in similar thickness melanomas, the Durmus coptic appearance had a higher incidence of being similar, 65% of the synchronous lesions were similar, compared to 36% of the non synchronous, lesions, 69% of the melanomas on sun damaged skin were similar versus 37% on non sun damaged skin, which makes some sense. No. And the percentage of microscopically different melanomas was higher in patients with the family history of melanoma. Here's an example of two similar melanomas with similar thickness. Sure from the chest and back showing similar Durmus coptic features. Here's two melanomas that were synchronised but with very different Durmus coptic features. One being an insight to melanoma and the other being a 4.5 millimeter melanoma. Here's some Durmus coptic images basically melanomas occurring on sun damaged skin with two melon, oman sites on the back and lower limb and two other melanoma size. Use the cnd coming from the trunk looking very similar in Durmus coptic features. This is a patient for my own practice that had a primary melanoma developed on his scalp. When I first saw it, I was suspicious of it but actually looked more like a pigmented basal cell carcinoma. The melanoma, however, it was very firm when I biopsied it. When I. By accident you can see the pathology here is fairly typical for melanoma and then when I brought him back after we treated that melanoma to do a complete body scan, which I found this area behind his knee. And the popular till area which was really kind of a pinkish tan paypal. That was not too dramatic looking. But because of his history of melanoma, I thought it actually might be a basil cell carcinoma. Biopsy of this lesion reveals an a melodramatic melanoma. You can see the pathology of that over here. I guess I just put this in to remind everyone that melanoma is not always pigmented and that email an attic melanin was probably one of the more humbling things that we diagnosed because Even after 30 plus years of experience a lot of times you still don't get the diagnosis right. You think that something is wrong. But eight million like Melanoma was not the first thing I was thinking of. This gentleman. Here's a woman with fairly fairly significant sun damage on her shoulder and arm area with a melon on, on site to over the shoulder cap. We can see the pathology here shows sun damaged skin with Nasa. The typical milana sites and some Padgett widespread of mint milano sites. The significant because of Philip two generations of Collagen on the same lady on the interior shoulder at the same time she had this lesion and biopsy of that proved to be another melanoma on site to with fairly similar history pathologic features. So again, people who have a lot of sun damage, which in southern California, that's a common thing. It's not uncommon to see multiple melanomas in a certain area if they've had a significant amount of damage there and they looked similar both clinically and histological. E so some of the conclusions multiple primary melanoma patients or multiple primary melanomas and given patient have almost the same chance of looking Durmus, topically similar or different. The exception, probably being an elderly patients with significant sun damage. The chance of seeing similar appearing clinical and Durmus coptic melanomas is higher in these people with chronically sun damaged skin. Yeah, so this is another paper, this is a multi institutional paper part of the Seer group, which we've talked about a little bit before during this conference. And they basically looked at the increased risk of second primary cancers. After the diagnosis of melanoma. And they wanted to look at the risk of primary cancers among patients with primary cutaneous malignant melanoma. It was a population based type study And it used cancer registries from the sear program from a large time period from 1973 to 2006 And it captured 89,515 patients. Mhm. Well, the second year, sorry, who survived ah at least several months beyond their initial melanoma. And they found that 10,000 of the patients or 12% developed one or more primary Subsequent primary cancer is about one quarter of these are 25% or actually primary melanomas. Women with head and neck melanomas, Younger patients had about 30 Are younger than 30 out of markedly increased risk developing a subsequent melanoma. The second melanomas were more likely to be thin than the first melanoma. As we've seen previously, the survivors had an increased risk of developing several cancers. Besides with those other cancers being breast cancer, prostate and Nagy had non Hodgkin's lymphoma, respectively, Melanoma survivors have an approximately nine for risk of developing subsequent melanomas compared to the general population. The initial risk remains elevated for more than 20 years after the initial diagnosis, the increased risk maybe going to behavioral factors, genetic factors and medical surveillance. So look briefly patients with multiple and single primary melanomas and survival. And what they found is that basically the survival was fairly similar in the groups, but the survival was basically melanoma thickness was probably one of the greatest determinants of for survival and ulceration and methodic figures as well as location on the scalp were also independent predictors of poor outcome. After adjustment for these predictors, they found little difference in the fatality rate between these two groups. However, the single primary melanoma group had a slightly higher fatality rates and the multiple primary melanoma group and why this occurs not totally clear, but probably worth further X. A discussion and study. So in terms of summarizing things. So the presence of a typical or this plastic nearby increase your risk of multiple primary melanomas. An early age of onset of the first primary melanoma increases your risk for a second. Primary melanoma. Men have about a 2-fold higher incidence of multiple primary melanomas. Roughly twice as many multiple primary melanoma patients have a positive family history. Compared to a single primary melanoma patients, Melanoma survivors have approximately 9-fold increased risk of developing subsequent melanoma compared to the general population. The risk remains elevated for more than 20 years after the initial diagnosis, the increased risk, maybe owing to behavioral genetic factors, are possibly surveillance factors. The risk of the second primary melanoma is greatest in the first year after diagnosis with Diagnosis, the second primary occurring in up to 50% of people. So during the first year after the diagnosis of a primary melanoma, you want to definitely have more frequent surveillance of the patient and then multiple primary uh melanoma patients are also at increased risk developing a 2nd and 3rd primary melanoma. Over long term monitoring, 70% of the subsequent primary melanomas occur under different site, elderly patients on sun damaged skin may have similar appearing lesions. Multiple primary melanomas in the same patient have about an equal chance of looking similar and different in the average patient. Full scale and examination, including Durmus coptic examination is important. Full skin examination on subsequent visits and more frequent visits. In the first two years with lifelong follow up education is important, genetic testing is also possibly important in certain high risk patients. It's important to remember that melanoma survivor should remain under surveillance not only for recurrences but for future primary melanomas and for also cancers with elevated risk of melanoma survivor patients, including breast cancer, prostate and non Hodgkin's lymphoma. That concludes my talk. Thank you Doctor Fish. Very nice presentation, and we will ford questions to you to answer over the next week.
