Primary Skin Melanoma Research Articles

Expression of Erß and Bcl-2 in Skin Melanoma

Introduction: Skin melanoma has been one of the most researched malignant melanoma of today. Its "popularity" among the researchers and clinicians arises from variety of forms and biological behaviour, it's characteristic appearance, genetic and immunologic certainty and its prognostic uncertainty. Patients and methods: We analyzed 62 patients with a primary skin melanoma diagnosed in the period from January 2001, to June 2010 (patients were divided in two groups; Group A: patients with melanoma development based on pre-existed nevi and Group B: de novo melanomas). The clinicopathological parameters determined for each tumour were histological type, Breslow thickness, Clark level, and pathological disease stage. The results were correlated with expression of estrogen receptor beta (Erß) and Bcl2. Results: Comparing individual groups according to the intensity of positivity in relation to the stage of Clark, we recognize differences in the distribution of patients with pre-existent nevi (group A), but not in de novo melanoma (group B). Significant differences between individual groups for Erß and Bcl2 expression in terms of intensity of positivity in relation to Clark level (III/IV) showed differences in distribution in patients with pre-existing nevi (Group A). After adjusting for age and sex, we found that Erß and Bcl2 expression was significantly higher in patient with pre-existing nevi in higher melanoma tissue compared with thin melanoma tissue. Conclusion: Expression of ER in Clark level III and IV is higher in melanoma arising from pre-existing nevi, giving better chance of survival to our patients in comparison to de novo melanoma.

Breslow Thickness, Clark Index and Ulceration Are Associated with Sentinel Lymph Node Metastasis in Melanoma Patients: A Cohort Analysis of 612 Patients

Background: Sentinel lymph node biopsy (SLNB) is the most sensitive procedure for assessing nodal status in patients with primary melanoma. Objective: To evaluate the predictive ability of usual primary melanoma prognosis factors of detecting sentinel lymph node (SLN) metastasis in patients with melanoma. Patients and Methods: A cohort of 612 consecutive patients presenting with primary skin melanoma who underwent a SLNB was evaluated. Assessment of the determinants of SLN metastasis was based on general linear model analysis. The model performance was studied using the concordance statistic and the net reclassification index. The calibration was estimated using the Hosmer-Lemeshow test. Results: The discrimination ability did not differ significantly between Breslow thickness (0.57), Clark index (0.61), ulceration (0.57) and histological subtype (0.55). Clark index, ulceration and Breslow thickness were all significant and independent determinants of SLN metastasis. The predictive ability of the final model was 0.657. Conclusion: Breslow thickness, Clark index and ulceration are independent predictors of a SLN metastasis.

MicroRNA-218 inhibits melanogenesis by directly suppressing microphthalmia-associated transcription factor expression

The microphthalmia-associated transcription factor (MITF) is a pivotal regulator of melanogenic enzymes for melanogenesis, and its expression is modulated by many transcriptional factors at the transcriptional level or post-transcriptional level through microRNAs (miRNAs). Although several miRNAs modulate melanogenic activities, there is no evidence of their direct action on MITF expression. Out of eight miRNAs targeting the 3′-UTR of Mitf predicted by bioinformatic programs, our results show miR-218 to be a novel candidate for direct action on MITF expression. Ectopic miR-218 dramatically reduced MITF expression, suppressed tyrosinase activity, and induced depigmentation in murine immortalized melan-a melanocytes. MiR-218 also suppressed melanogenesis in human pigmented skin organotypic culture (OTC) through the repression of MITF. An inverse correlation between MITF and miR-218 expression was found in human primary skin melanocytes and melanoma cell lines. Taken together, our findings demonstrate a novel mechanism involving miR-218 in the regulation of the MITF pigmentary process and its potential application for skin whitening therapy.

Prognostic factors of primary cutaneus melanoma.

The purpose of this study was to identify tumor characteristics of primary malignant melanoma predictive of sentinel lymph node positive status, and then to determine whether sentinel lymph node status has an impact on recurrence and survival. A total of 100 patients with primary malignant skin melanoma were analyzed. The prospective melanoma database identified patients with histologically confirmed cutaneus melanoma, clinically negative and clinically positive regional lymph nodes with no evidence of distant disease, who had undergone surgery between April 2001 and May 2012. Univariate and multivariate analyses were performed to assess factors that predict sentinel lymph node positive status, recurrence and survival. We identified Breslow's thickness and lymphocytic response as independent predictors of sentinel lymph node status in cutaneous melanoma patients. Sentinel lymph node status was a significant predictor of disease free survival. Despite the limitation, this study confirms Breslow's thickness and tumor lymphocytic infiltration as two factors predictive of sentinel lymph node metastasis in cutaneous melanoma patients. We also found sentinel lymph node status to be the most significant independent predictor of disease free survival and identified sentinel lymph node status as an important variable to consider when estimating the risk of regional recurrence.

Primary Melanoma of the Breast: A Case Report

INTRODUCTION: Cutaneous malignant melanoma and breast can be interrelated in several contexts: primary melanoma of the skin of the breast, breast, melanoma metastasis to transit metastasis for breast tissue and skin of the breast, as well as primary melanoma of the breast. Each of these presentations is important to determine the strategies in treatment and especially in the follow-up of malignant melanoma. The present study reports a rare case of primary melanoma of the breast and its clinical outcome CASE REPORT: S. A.53anos, female, realized 2, 5 cm nodule in the right breast. She was subjected to lumpectomy with pathology: undifferentiated malignant neoplasm whose immunohistochemistry confirmed the diagnosis of primary melanoma of the breast. Surgical treatment complemented with quadrantectomy and axillary dissection right, taking two metastatic lymph nodes in the biopsy. Indicate adjuvant chemotherapy with high-dose interferon for 1 year after confirmation of staging a negative distance. Following 6 months of adjuvant finish noticed 2, 0 cm nodule in the contralateral breast, which the physical examination showed blackish color. Subject to nodulectomy now in left breast with immunohistochemical compatible with metastatic melanoma (Melan on positive). The PET SCAN showed disseminated disease, contra- indicated enlargement of the margin or contralateral lymphadenectomy. Palliative treatment with dacarbazine started, but after four cycles progressed to clinical worsening, several subcutaneous nodules in the body, right hemiplegia and cerebral metastases confirmed by MRI. DISCUSSION: The metastatic malignant melanoma, independent of primary site, is an aggressive disease, characterized by high mortality, indicating a median overall survival from 6 to 9 months. The therapies most commonly used are: dacarbazine, interferon, temozolomide and carboplatin, but none of these medications had long-term survival. It is possible that with the advancement of medical research, new drugs such as ipilimumab and vemurafenib may help in treatment of metastatic melanoma.

Alteration in E-Cadherin/β-Catenin Expression in Canine Melanotic Tumors

β-Catenin, encoded by the ctnnb1 gene, plays a critical role in intercellular adhesion, and its altered expression has been implicated in tumor progression in humans and animals. The aims of this study were to examine the alterations in β-catenin expression in canine melanoma as well as the causes of these changes (eg, E-cadherin or exon 3 mutations) and to compare identified changes between skin and oral melanomas. Forty-two primary canine skin and oral melanoma tissue samples were used in the study. The expression levels of ctnnb1 and the levels of E-cadherin/β-catenin complex in the tissues were determined by semiquantitative RT-PCR and immunohistochemistry, respectively. The mutational status of β-catenin exon 3 was examined by DNA sequencing. RT-PCR revealed higher levels of ctnnb1 expression in oral melanoma tissues compared with normal melanocytes, irrespective of sex or histopathological appearance of the tissue (ie, amelanotic vs melanotic). Immunohistochemistry revealed simultaneous loss of membrane E-cadherin/β-catenin complex and cytoplasmic accumulation of both proteins in 37 cases (84%). Intranuclear β-catenin was also detected in all tissues with reduced membrane β-catenin expression. In mutational analyses, one amelanotic oral melanoma showed 13 single nucleotide polymorphisms (SNPs); however, after protein translation, all the SNPs were silent mutations. The present study demonstrates that dysregulation of E-cadherin/β-catenin complexes is involved in both types of canine melanotic tumors and that the disruption of E-cadherin/β-catenin complexes and increased β-catenin may induce tumor progression and malignancy.

Expression of vascular endothelial growth factor‐C in primary cutaneous melanoma predicts sentinel lymph node positivity

Vascular endothelial growth factor-C (VEGF-C), a lymphatic vessel growth factor, has been involved in the formation of lymph nodal metastases in different tumor types. Early evidences indicate that VEGF-C expression in human primary melanoma could be predictive of lymph nodal metastases, whereas the role of lymphangiogenesis is still controversial. By immunohistochemical analysis, we investigated VEGF-C or CC chemokine receptor 7 expression, together with the lymphatic and blood vessel network, in 36 patients with primary skin melanomas and metastases at the sentinel lymph node biopsy (SLN-positive), and 26 melanoma patients with negative SLN biopsy (SLN-negative). We found that VEGF-C expression in primary melanoma specimens was significantly associated with SLN-positive (p < 0.001), particularly in thin melanomas. An association between augmented peritumoral lymphatic vessel area and SLN-positive (p < 0.02) was also seen. Conversely, no association between either expression of the CC chemokine receptor 7 in the primary tumor, or intratumoral lymphatic vessel or peritumoral and intratumoral blood vessel area, and SLN-positive was found. Our results, taking into account the expression of either VEGF-C or related histopathological markers, indicated the possibility to use VEGF-C immunohistochemistry as a marker of metastatic progression, especially in thin cutaneous melanomas.

Correlation of caveolin 1 expression with disease-free survival in skin melanoma.

e19016 Background: As clinical and histological parameters are unable to precisely predict the behavior of skin melanoma, new criteria are required to improve risk assessment. Caveolin 1 (CAV1), a scaffolding membrane protein, has been implicated in cell proliferation, death and transformation. In melanoma cell lines, CAV1 was found to have an antimetastatic role and loss of stromal CAV1 expression in lymph nodes metastases was associated with poor survival. The objectives of this analysis were to correlate CAV1 expression in primary skin melanoma cells with tumor thickness and disease free survival (DFS). Methods: CAV1 immunostaining was performed on the primary skin melanomas of 40 patients. CAV1 expression was scored semi-quantitatively using a 3-point scale: 0 (no staining), 1 (diffuse weak staining or strong staining in less then 30% of the cells) and 2 (strong staining of 30% or more of the cells). For analysis purposes, CAV1 was dichotomized as present (score 1 or 2) or absent (score 0). Primary melanoma was classified based on 2009 AJCC T-stage. DFS was measured from removal of primary skin melanoma to development of loco-regional or systemic recurrence. Pearson Chi-Square, Kaplan Meier, and Cox-Proportional Hazard Ratio were used for data analyses. Results: T-stage distribution was: Cis 12.5%, T1 32.5%, T2 22.5%, T3 17.5%, T4 15.0%. There was a clear inverse relationship between T stage and Cav 1 expression in tumor cells, with higher CAV1 expression in less invasive melanomas (P= 0.01). Fifteen patients experienced either locoregional or distant recurrence (median time to recurrence 14 months; range &lt;1 month -105 months). Twenty-five patients remained disease free for minimum of 3 years (median 77 months; range 36 – 111 months). Presence of CAV1 in primary melanoma tumor cells was correlated with increased DFS (P = 0.05) but this association was not significant when adjusting for T stage (P=0.59). Conclusions: CAV1 expression in melanoma tumor cells correlates with clinical behavior of skin melanoma as its loss is associated with invasiveness and distant recurrence. Whether the loss of CAV1 in primary melanoma tumor cells is just an epiphenomenon or a causal event is to be decided by further work on a larger population sample.

The role of surgery in the treatment of colorectal metastases from primary skin melanoma

The study assessed the role of colorectal surgery in the treatment of metastatic melanoma and identified patients who can most benefit from surgical resection. A retrospective analysis was made of 34 consecutive patients with skin melanoma who underwent surgical resection of large bowel metastasis. The median disease-free interval between diagnosis of the primary and metastatic melanoma was 24 (7-98) months. Nine (27%) patients underwent emergency surgery for obstruction and 25 (73%) had an elective procedure. Resection with curative intent was performed in 14 (41%) and palliative resection in 20 (59%) patients. There was no postoperative mortality and morbidity occurred in 9%. The median survival following surgery was 11.5 (4-68) months. The 1-, 2- and 5-year survival rates were 50%, 32% and 17% respectively. Median survival was significantly increased in patients without extra-abdominal metastases, with no evidence of non-large-bowel metastases, if the disease-free interval was longer than 24 months and when curative resection was performed. In multivariate analysis, an apparently complete or palliative resection and the absence or presence of extra-abdominal metastases were the most important prognostic factors. An aggressive surgical approach to large bowel metastatic melanoma results in good palliation and effective relief of symptoms with acceptable morbidity and mortality.

Abstract 2458: The expression of hyaluronan and hyaluronidases in cutaneous melanoma

Abstract Aberrant hyaluronan expression implicates aggressive disease progression and metastatic potential in many cancers. In tumors originating from simple epithelium, hyaluronan amount is increased both in the epithelial and stromal component and it correlates with patient's poor overall prognosis. The role of hyaluronan degrading enzymes (hyaluronidases, HYAL1-2) in cancer progression is controversial. Hyaluronidases are proposed to be both tumor suppressors and tumor promoters. In this retrospective study, we characterized the expression levels of HYAL1 and HYAL2 and correlated their expression to hyaluronan in the different stages of primary skin melanoma as well as in metastatic melanoma. Superfically (pT1) and deeply (pT4) invasive melanoma (Breslow &amp;lt; 1mm (n=18) and Breslow &amp;gt; 4mm (n=18)), in situ melanoma (n=17), lymph node metastasis (n=19), dysplastic nevi (n=28) and benign nevi samples (n=29) were analyzed for hyaluronan staining and HYAL1 and HYAL2 immunoreactivity (ABCAM antibodies) in paraffin tissue sections. Stainings were evaluated for their intensity and coverage. The tissue area for hyaluronan and HYAL1/HYAL2 positive staining was estimated with a five-level scoring from 0-4 and the staining intensity of melanocytic cells was evaluated with a four-level scoring (0-3; no color, weak, moderate and strong) by two independent observers. Compared to benign nevi and in situ melanoma, the cell-associated hyaluronan staining coverage and intensity were clearly reduced in the invasive part of melanoma with advanced Breslow depth. Strong hyaluronan staining intensity was detected in 36% of in situ melanoma cases and in 21% of superficial melanoma (Breslow &amp;lt; 1mm) cases, while in the deeply invasive melanoma group (Breslow &amp;gt; 4mm), only 6% of cases showed strong hyaluronan staining intensity. In addition, in lymph node metastases the melanoma cells showed low hyaluronan staining intensity or were totally hyaluronan negative. However, the tumor stroma was highly hyaluronan positive in all groups. HYAL1 immunoreactivity was found in melanocytic cells both in benign nevi and melanoma samples while the tumor stromal cells were negative. The coverage of HYAL2 immunoreactivity was parallel to HYAL1, although its staining intensity was lower than that of HYAL1. Our results suggest that hyaluronan content is clearly decreased in invasive primary and metastatic melanoma compared to benign nevi. The results from hyaluronan stainings will be compared with clinical follow-up data to study the prognostic value of hyaluronan in melanoma. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2458. doi:1538-7445.AM2012-2458

Simultaneous resection of metastatic melanoma in the esophagus and primary cutaneous melanoma showing partial regression: report of a case

We herein describe a case of melanoma that metastasized to the esophagus from a primary melanoma of the abdominal skin in a 40-year-old female. Esophagography and endoscopy demonstrated a 30-mm protruding mass in the proximal third of the esophagus, and this was diagnosed as malignant melanoma by mucosal biopsy. The patient also had a pigmented lesion on her abdominal skin, which was diagnosed immunohistochemically as a primary malignant melanoma from the resected specimen. The esophageal tumor was resected by transthoracic esophagectomy. Histopathologically, the radial growth phase of the tumor cells was not present in the esophageal lesion, which was diagnosed as melanoma metastatic to the esophagus. Postoperatively, the patient received 5 courses of DAV-Feron chemotherapy. Eight months after the chemotherapy, multiple metastases developed, including to the subcutis, bronchus, liver, adrenal gland and mediastinum. Chemotherapy was not effective at this stage. The patient died of multiple organ failure 21 months after initial esophagectomy.

Expression of the soluble vascular endothelial growth factor receptor-1 in cutaneous melanoma: role in tumour progression

Vascular endothelial growth factor (VEGF)-A, placenta growth factor (PlGF) and their corresponding membrane receptors are involved in autocrine and paracrine regulation of melanoma growth and metastasis. Besides the membrane receptors, a soluble form of the VEGF receptor (VEGFR)-1 (sVEGFR-1) has been identified, that behaves both as a decoy receptor, sequestering VEGF-A and PlGF, and as an extracellular matrix (ECM) molecule, promoting endothelial cell adhesion and migration through the interaction with α5β1 integrin. To analyse whether sVEGFR-1 plays a role during melanoma progression. sVEGFR-1 expression was evaluated in a panel of 36 melanoma cell lines and 11 primary human melanocyte cultures by quantitative real-time polymerase chain reaction analysis and in specimens of primary or metastatic melanoma lesions from 23 patients by immunohistochemical analysis. sVEGFR-1 expression was highly upregulated in melanoma cell lines with respect to human melanocytes. Interestingly, cell lines obtained from cutaneous metastases showed a significant reduction of sVEGFR-1 expression, as compared with cell lines derived from primary tumours. These results were confirmed by immunohistochemical analysis of sections from primary skin melanomas and the corresponding cutaneous metastases, suggesting that modulation of sVEGFR-1 expression influences ECM invasion by melanoma cells and metastasis localization. Moreover, we provide evidence that adhesion of melanoma cells to sVEGFR-1 is favoured by the activation of a VEGF-A/VEGFR-2 autocrine loop. Our data strongly suggest that sVEGFR-1 plays a role in melanoma progression and that low sVEGFR-1/VEGF-A and sVEGFR-1/transmembrane VEGFR-1 ratios might predict a poor outcome in patients with melanoma.

Role of ROC1 protein in the control of cyclin D1 protein expression in skin melanomas

A decrease in the level of the ROC1 protein, which is involved in cyclin D1 degradation, might explain an increase in cyclin D1 protein in the absence of gene overexpression. This study aimed to investigate the relationship between ROC1 and cyclin D1 expression in skin melanomas. A total of 62 cases of primary skin melanomas and 58 cases of compound melanocytic nevi were assessed. Immunohistochemistry was performed using cyclin D1 and ROC1 antibodies, and fluorescent in situ hybridization was used to assess the amplification of the CCND1 gene. ROC1 was expressed in >50% of cells in 87.9% of the melanocytic nevus cases and in 45.2% of the melanoma cases (p=0.0014). There was a significant negative correlation between ROC1 and cyclin D1 expression in all cases (p=0.0008985). In comparison with cyclin D1, ROC1 expression was increased in 86.2% of the melanocytic nevi and in 45.2% of the melanomas (p<0.001). Among the non-amplified melanomas, 50% expressed cyclin D1 in >50% of the cells and expressed ROC1 in <25%. ROC1 expression is negatively correlated with cyclin D1 expression, demonstrating its importance in the degradation of cyclin D1 in melanomas.

Secondary neoplasms of the urinary system and male genital organs

In this review we discuss those secondary tumours involving the urinary system and male genital organs that can pose differential diagnostic difficulties with primary lesions, and highlight morphological and ancillary features that could be helpful in reaching a proper assignment of primary origin. Based on MEDLINE database searches all reports of secondary tumours involving the urinary system (kidney and bladder) and male genital organs (prostate, testis and penis) were examined. Involvement by a secondary tumour occurs either as a metastasis or by direct extension. Among non-genitourinary primary sites, colorectal, pulmonary, skin (melanoma) and breast are the most common contributors. Secondary spread from a genitourinary site primary tumour to another genitourinary organ occurs most frequently between the prostate and urinary bladder, given the intimate topographic proximity of the two. The prognosis is very poor, as the secondary tumour usually occurs in patients with carcinoma in the late stages. Few secondary tumours have distinctive histological and immunohistochemical features, making it difficult to make the appropriate diagnosis. Hence, knowledge of the history and clinical setting are particularly important in these cases. The urinary system and male genital organs are not common sites for secondary tumours. They often go either undiagnosed or misdiagnosed in the clinical follow-up of patients with cancer. Accurate diagnosis is essential because of differing therapeutic approaches compared with a primary neoplasm.

Early Detection of Melanoma Skin Cancer

Primary skin melanoma and skin cancers have been more prevalent in the previous decades and therefore have become a very significant public health problem. Dermatologists of the Skin and Venereal Diseases Clinic of the University of Sarajevo Clinics Centre initiated the first public preventive action called "Days of Fighting Melanoma" in May 2008. The objective of the campaign was to provide free dermatological examinations to all volunteers and to inform, through the media, wider population on early signs and recognition of skin cancer and the importance of sun protection. The total of 325 citizens were examined clinically and with dermatoscope in the period between 5 and 31 May 2008. The examination also included histological diagnoses: 7 patients with confirmed melanoma, 30 with basal cell carcinoma and 2 with spinocellular carcinoma. The results suggested a need for the expansion of the campaign to other towns in our country in order to demonstrate the importance of early detection of the disease and treatment options.

Biological value of melanoma inhibitory activity serum concentration in patients with primary skin melanoma

Melanoma inhibitory activity (MIA) protein was identified in significant quantities in primary and metastatic malignant melanomas, where it has an important role in promoting tumor development and progression. Our hypothesis was that MIA serum level will be elevated in patients with metastases or local spreading of the disease before any symptom of such progression is clinically apparent. We compared MIA serum levels in two groups of patients with primary melanoma; those with positive as opposed to those with negative sentinel lymph nodes. In addition, MIA serum levels were studied in two control groups; patients with dysplastic nevi and patients with basal cell carcinoma. A blood sample was obtained from each patient included in the study and MIA levels were assessed using standard enzyme-linked immunosorbent assay method. Patients with histologically positive sentinel lymph nodes, meaning that tumor cells were found in the lymph nodes, had much higher mean MIA values than any other patient group considered in this study. With mean value of 14.53 ng/ml, it was almost twice as high as mean MIA value in patients with histologically negative sentinel lymph nodes (7.32 ng/ml) and more than twice as high than any of the two control groups (P<0.001). However, neither the classification by Clarke nor the classification by Breslow could be used to distinguish patients with positive sentinel lymph nodes from those with negative sentinel lymph nodes. In our opinion, MIA serum level is the ideal test for screening the tumor spread to sentinel lymph nodes.

Adequacy of sentinel node procedure in patients with synchronous primary skin melanoma: report of a patient with five melanomas

Nejc, Dariusza; Chalubinska, Justynaa; Piekarski, Janusza; Pluta, Piotra; Pasz-Walczak, Grazynab; Kusmierek, Jacekc; Berner, Andrzeja; Sek, Piotra; Bilski, Adama; Durczynski, Adama; Jeziorski, Arkadiusza Author Information

Metastatic Peritoneal Neurocutaneous Melanocytosis

Neurocutaneous melanosis, better referred to as neurocutaneous melanocytosis (NCM), is a rare congenital disorder occurring in childhood characterized by proliferation of melanocytes in the central nervous system (CNS), associated with large congenital melanocytic nevi. The phenotype of the CNS lesions varies, ranging from that of a benign, nevuslike lesion, to one of an aggressive-looking, atypical cell proliferation; however, specific diagnostic criteria allow the distinction from CNS metastasis of a primary skin melanoma. NCM can present with severe neurologic manifestations, and usually has a relentless clinical progression whence neurologic symptoms appear. Dissemination to the peritoneal surface by ventriculo-peritoneal shunting has been exceptionally observed, and we describe 2 cases of such occurrence, one of which was associated with a "bulky perineal nevocytoma" with complex cytogenetic rearrangements. This "metastatic" spreading supports an aggressive phenotype, able to seed and establish new colonies, although only after facilitated translocation of the proliferating cells through the shunt conduit; the aggressiveness of these lesions in our cases is further supported by the histopathologic features and clinical course. The biologic features of NCM cells merit further exploration, as they may shed light on a much more frequent neoplastic neurocristopathy, namely, malignant melanoma.

Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

Aim To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS). Materials and methods Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan–Meier were performed. Results Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness ( p < 0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR = 5.6, p < 0.001), positive SN (RR = 5.0, p < 0.001) and male sex (RR = 2.9, p = 0.001). The presence of a metastatic SN (RR = 8.4, p < 0.001), male sex (RR = 6.1, p < 0.001), Breslow thickness (RR = 3.2, p = 0.013) and ulceration (RR = 2.6, p = 0.015) were significantly associated with a poorer DSS. Conclusion SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure.

Mechanisms of local immunosuppression in cutaneous melanoma

Cutaneous melanoma is highly immunogenic, yet primary melanomas and metastases develop successfully in otherwise immunocompetent patients. To investigate the local immunosuppressive microenvironment, we examined the presence of suppressor T lymphocytes and tolerising dendritic cells (DCs), the expression of immunosuppressive cytokines (IL-10, TGFβ1 and TGFβ2) and the enzyme indoleamine 2,3-dioxygenase (IDO) using qRT–PCR and immunohistochemistry in primary skin melanomas, negative and positive sentinel lymph nodes (SLN), and lymph nodes with advanced metastases. Our results indicate that tolerogenic DCs and suppressor T lymphocytes are present in melanoma at all stages of disease progression. They express transforming growth factor β receptor 1 (TGFβR1), and are therefore susceptible to TGFβ1 and TGFβ2 specifically expressed by primary melanoma. We found that expression of IDO and interleukin 10 (IL-10) increased with melanoma progression, with the highest concentration in positive SLN. We suggest that negative SLN contain immunosuppressive cells and cytokines, due to preconditioning by tolerogenic DCs migrating from the primary melanoma site to the SLN. In primary melanoma, TGFβ2 is likely to render peripheral DCs tolerogenic, while in lymph nodes IDO and TGFβ1 may have a major effect. This mechanism of tumour-associated immunosuppression may inhibit the immune response to the tumour and may explain the discrepancy between the induction of systemic immunity by anti-melanoma vaccines and their poor performance in the clinic.