Merkel Cell Carcinoma: Changing Practice Patterns and Impact on Recurrence-Free and Overall Survival at a Single Institution and Nationally.

BACKGROUND: Merkel cell carcinoma (MCC) is an aggressive neuroendocrine carcinoma of the skin. Our report describes the evolution of management and characteristics associated with recurrence, disease-specific survival (DSS) and overall survival (OS) in the treatment of MCC. METHODS: A single institution retrospective review of MCC and SEER data to determine factors associated with RFS, DSS, and OS using a multivariable Cox regression on inverse-probability weighted cohorts. RESULTS: One hundred fifty-nine patients were identified with a median age of 75. Of these, 96% were Caucasian and 60% male. Fifty-eight out of 159 (36%) of all patients were deceased with 21/58 (36%) dead from MCC with a median follow-up of 3.1 years. Institutionally, trends over time demonstrated an increased use of immunotherapy with a concomitant decrease in chemotherapy and decreased use of radiotherapy alone. Institutionally and nationally, there has been increased surgical nodal staging. Institutionally, factors associated with shorter DSS included advanced age, active cigarette smoker (p = 0.002), cT2 disease (p = 0.007), and MCC with unknown primary (p < 0.001). Institutionally, factors associated with shorter OS included ages ≥ 75 years (p < 0.001), an immunocompromised state (p < 0.001), truncal primary site (p = 0.002), and cT2 disease (HR 9.59, p < 0.001). CONCLUSION: Changing practice patterns in MCC management have been driven by the adoption of immunotherapy. Our study highlights that competing risks of mortality in MCC patients likely prevents OS from being an accurate surrogate outcome measure to understand factors associated with DSS.

A Thirty-Year Experience With Head and Neck Flap Reconstruction.

BACKGROUND: Head and neck (HN) defects after tumor extirpation can be challenging to repair. Historically, pedicled flaps were the mainstay for reconstruction, but recently, free tissue transfer has been preferred. This study compares patient characteristics and flap outcomes for HN defects over a 30-year period at the authors' institution. METHODS: Head and neck cancer patients receiving flap reconstruction from 1983 to 2013 were included. Records were reviewed for demographic and perioperative data. Flap complications were compared and statistical tests were 2-tailed with a significance level of 0.05. RESULTS: Eight hundred sixty-one patients fulfilled inclusion and exclusion criteria. Pedicled reconstruction predominated during early time-points (96.3% pedicled), compared with later years (69.5% free-tissue). Free flaps were associated with significantly longer operative times (643.5 versus 429.7 minutes, P<0.0001) and postoperative stays (16.89 versus 14.01 nights, P = 0.0005) and had higher rates of emergent reoperation, total flap loss, hematoma, and donor site morbidity. Previous irradiation did not affect major complication rate for either flap type. CONCLUSIONS: A shift from pedicled to free flaps for HN reconstruction occurred over the last 30 years. Free flaps had a higher complication profile in this cohort, which was largely accounted for by a higher return rate to the operating room compared with pedicled flaps (17.31% versus 5.46%, P<0.0001). Additionally, this complication profile may reflect the increasingly common use of free tissue flaps for more complex reconstructions. Several of these differences in complication rates between flap types were no longer significant in the last 5 years of this study.

The Prognostic Significance of Sentinel Lymph Node Status for Patients with Thick Melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is recommended for patients with intermediate-thickness melanoma, but the use of SLNB for patients with thick melanoma is debated. This report presents a single-institution study investigating factors predictive of sentinel lymph node (SLN) metastasis and outcome for thick-melanoma patients . METHODS: A retrospective review of a single-institution database from 1997 to 2012 identified 147 patients with thick primary cutaneous melanoma (≥4 mm) who had an SLNB. Clinicopathologic characteristics were correlated with nodal status and outcome. RESULTS: The median age of the patients was 67 years, and 61.9 % of the patients were men. The median tumor thickness was 5.5 mm, and 54 patients (36.7 %) had a positive SLN. Multivariable analysis showed that only tumor thickness significantly predicted SLN metastasis (odds ratio 1.14; 95 % confidence interval (CI) 1.02-1.28; P = 0.02). The overall median follow-up period was 34.6 months. Overall survival (OS) and melanoma-specific survival (MSS) were significantly worse for the positive versus negative-SLN patients. Multivariable analysis showed that age [hazard ratio (HR) 1.04; 95 % CI 1.01-1.07; P = 0.02] and SLN status (HR 2.24; 95 % CI 1.03-4.88; P = 0.04) significantly predicted OS, whereas only SLN status (HR 3.85; 95 % CI 2.13-6.97; P < 0.01) significantly predicted MSS. CONCLUSIONS: Tumor thickness predicts SLN status in thick melanomas. Furthermore, SLN status is prognostic for OS and MSS in thick-melanoma patients, with positive-SLN patients having significantly worse OS and MSS. These findings show that SLNB should be recommended for thick-melanoma patients, particularly because detection of SLN metastasis can identify patients for potential systemic therapy and treatment of nodal disease at a microscopic stage.

Comparison of the expression of vimentin and actin in spitz nevi and spitzoid malignant melanomas.

INTRODUCTION: The differentiation between Spitz nevi (SN) and Spitzoid malignant melanomas (SMM) represents a challenge to dermatopathologists. We recently demonstrated differential expression of vimentin and Actin in SN and SMM by mass spectrometry (MS). We sought to investigate whether this differential expression could be detected using conventional immunohistochemistry or automated quantitative analysis (AQUA) of histological sections. METHODS: Cases of SN and SMM, which were previously studied by MS and have readily available blocks and enough material in the block, were selected from the Yale Spitzoid Neoplasm Repository. The cases were stained for vimentin and muscle-specific actin using standard protocols. H-scores were calculated by multiplying the percentage of cells staining and the intensity of staining. Selected cases were also studied for quantitative immunofluorescent staining using the AQUA method. RESULTS: All 21 cases of SN showed strong and diffuse staining for vimentin; 19 of 21 (91%) cases had an H-score of 300 (average, 294). Similar staining results were observed in SMM; 13 of 14 (93%) cases had an H-score of 300 (average, 297). Muscle-specific actin was weakly and focally positive in 5 of 21 (24%) SN (H-score = 3.3) and 5 of 14 (39%) SMM (H-score = 3.5). The AQUA method showed no significant difference in the staining intensity of SN and SMM for both vimentin and actin. CONCLUSIONS: There was no difference in the expression of vimentin and actin in SN and SMM shown by conventional immunohistochemistry or the AQUA method. This study shows that MS has much grater sensitivity in detecting the differential expression of these proteins.

Clinical characteristics associated with Spitz nevi and Spitzoid malignant melanomas: the Yale University Spitzoid Neoplasm Repository experience, 1991 to 2008.

BACKGROUND: Spitz nevi and Spitzoid malignant melanomas are uncommon and may be difficult to distinguish histopathologically. Identification of clinical features associated with these lesions may aid in diagnosis. OBJECTIVE: We sought to identify clinical characteristics associated with Spitz nevi and Spitzoid malignant melanomas. METHODS: We conducted a retrospective cohort study of Spitz nevi and Spitzoid malignant melanomas from the Yale University Spitzoid Neoplasm Repository diagnosed from years 1991 through 2008. Descriptive statistics and multivariate logistic regression were used to compare select patient- and tumor-level factors associated with each lesion. RESULTS: Our cohort included 484 Spitz nevi and 54 Spitzoid malignant melanomas. Spitz nevi were more common (P = .03) in females (65%; n = 316) compared with Spitzoid malignant melanomas (50%; n = 27), occurred more frequently in younger patients (mean age at diagnosis 22 vs 55 years; P < .001), and more likely presented as smaller lesions (diameter 7.6 vs 10.5 mm; P < .001). Increasing age (odds ratio 1.16, 95% CI [1.09, 1.14]; P< .001) and male gender (odds ratio 2.77, 95% CI [1.17, 6.55]; P< .02) predicted Spitzoid malignant melanoma diagnosis. LIMITATIONS: Small sample size, unmeasured confounding, and restriction to a single institution may limit the accuracy and generalizability of our findings. CONCLUSIONS: Age and gender help predict diagnosis of Spitz nevi and Spitzoid malignant melanomas.

Management of head and neck melanoma: results of a national survey.

We recently reported on the safety of minimally invasive parotid region sentinel node biopsy and level I-sparing radical neck dissection for head and neck melanoma. We therefore wished to assess the state of practice in the United States through a survey of specialists in head and neck surgery. We hypothesized that there would be significant variation in the management of these facets of head and neck melanoma. To test this hypothesis, a 10-question online survey on management of head and neck melanoma was distributed to the members of the American Head and Neck Society. Responses were matched to Internet Protocol addresses to ensure that each respondent completed the survey only once. Eighty-eight respondents completed the survey. For sentinel lymph nodes within the parotid gland, nearly half (47.7%) of surgeons surveyed perform a superficial parotidectomy, 13.6% perform a total parotidectomy, and only 38.6% perform parotid-sparing surgery; 71.6% of surgeons remove the submandibular nodes when carrying out a functional radical neck dissection. In conclusion, approaches to the management of head and neck melanoma vary widely, with only a minority of surgeons using morbidity-sparing surgical approaches. This study highlights the need for further randomized controlled trials in the surgical management of head and neck melanoma.

Immunotherapy utilization in stage IIIA melanoma: less may be more.

Background: Immunotherapy agents are approved for adjuvant treatment of stage III melanoma; however, evidence for survival benefit in early stage III disease is lacking. Current guidelines for adjuvant immunotherapy utilization in stage IIIA rely on clinician judgment, creating an opportunity for significant variation in prescribing patterns. This study aimed to characterize current immunotherapy practice variations and to compare patient outcomes for different prescribing practices in stage IIIA melanoma. Study design: Patients with melanoma diagnosed from 2015-2019 that met American Joint Committee on Cancer 8th edition criteria for stage IIIA and underwent resection were identified in the National Cancer Database. Multiple imputation by chained equations replaced missing values. Factors associated with receipt of adjuvant immunotherapy were identified. Multivariable Cox proportional hazards regression compared overall survival across groups. Results: Of 4,432 patients included in the study, 34% received adjuvant immunotherapy. Patients had lower risk-adjusted odds of receiving immunotherapy if they were treated at an academic center (OR=0.48, 95%CI=0.33-0.72, p<0.001 vs. community facility) or at a high-volume center (OR=0.69, 0.56-0.84, p<0.001 vs. low-volume). Immunotherapy receipt was not associated with risk-adjusted survival (p=0.095). Moreover, patients treated at high-volume centers experienced longer overall risk-adjusted survival than those treated at low-volume centers (HR=0.52, 0.29-0.93, p=0.030). Risk-adjusted survival trended toward being longer at academic centers than at community centers, but the difference was not statistically significant. Conclusion: Academic and high-volume centers utilize significantly less adjuvant immunotherapy in stage IIIA melanoma than community and low-volume centers without compromise in overall survival. These findings suggest that this population may benefit from more judicious immunotherapy utilization.

Case report: Metastatic Merkel cell carcinoma presenting seven years after loco-regional disease resection of primary tumor with interval in-transit and nodal metastases.

Merkel cell carcinoma (MCC) is a rare tumor with a high risk of recurrence after definitive therapy; however, the optimal duration of surveillance is unclear. First recurrences typically occur within 3 years. National guidelines recommend that patients undergo physical examination and imaging for surveillance during this time period. However, the duration of surveillance beyond this is not defined. Here, we describe a case of a patient developing a recurrence of MCC 7 years after the primary diagnosis with interval in-transit and regional lymph node metastases 15 months following the treatment of the primary MCC. Such late recurrences are rare, largely not reported, and the risk factors contributing to late recurrences are not well described. This case highlights the possibility of late recurrences of MCC after an initial in-transit and nodal recurrence and underscores the importance of identifying predictors of recurrence that may better guide the duration of surveillance.

Malignant Melanoma in Older Adults: Different Patient or Different Disease?

Objective In this study, we aimed to compare the clinical outcomes between older and younger patients with melanoma and to evaluate for differences in tumor genetic makeup that might explain differences in clinical behavior between older and younger cohorts. Materials and methods A consecutive sample of patients diagnosed with melanoma at a single institution from 1984 to 2019 was categorized by age into younger, middle, and older cohorts. Tumor characteristics, melanoma-specific survival, and recurrence-free survival were assessed while accounting for differential follow-up and death from other causes using Kaplan-Meier analysis with log-rank testing. Results A total of 4378 patients were included in the study. Older patients presented with a higher incidence of T3 and T4 tumors, and a lower incidence of T1 tumors (p<0.001). The same group of patients had a lower nodal positivity at any given Breslow thickness (p<0.01). Melanoma-specific survival was lower for older patients with T2 tumors (p=0.046). There was no difference in recurrence-free survival among all age groups and tumor thicknesses (p>0.05). For patients with a given genetic profile, the melanoma-specific survival and recurrence-free survival were equivalent across ages. BRAF was the most common driver in the younger group, while NRAS and other mutations increased in prevalence as age rose. Conclusions Older adults have decreased melanoma-specific survival for T2 tumors and lower nodal positivity, suggesting a different pattern of metastatic progression. The mutational drivers of cutaneous melanoma change with age and may play a role in the different metastatic progression as well as the differential melanoma-specific survival across all age cohorts.

The role of imaging and sentinel lymph node biopsy in patients with T3b-T4b melanoma with clinically negative disease.

Background: Previous studies demonstrate minimal utility of pre-operative imaging for low-risk melanoma; however, imaging may be more critical for patients with high-risk disease. Our study evaluates the impact of peri-operative cross-sectional imaging in patients with T3b-T4b melanoma. Methods: Patients with T3b-T4b melanoma who underwent wide local excision were identified from a single institution (1/1/2005 - 12/31/2020). Cross-sectional imaging was defined as body CT, PET and/or MRI in the perioperative period, with the following findings: in-transit or nodal disease, metastatic disease, incidental cancer, or other. Propensity scores were created for the odds of undergoing pre-operative imaging. Recurrence free survival was analyzed using the Kaplan-Meier method and log-rank test. Results: A total of 209 patients were identified with a median age of 65 (IQR 54-76), of which the majority were male (65.1%), with nodular melanoma (39.7%) and T4b disease (47.9%). Overall, 55.0% underwent pre-operative imaging. There were no differences in imaging findings between the pre- and post-operative cohorts. After propensity-score matching, there was no difference in recurrence free survival. Sentinel node biopsy was performed in 77.5% patients, with 47.5% resulting in a positive result. Conclusion: Pre-operative cross-sectional imaging does not impact the management of patients with high-risk melanoma. Careful consideration of imaging use is critical in the management of these patients and highlights the importance of sentinel node biopsy for stratification and decision making.

A proposal for the timing of management of patients with melanoma presenting during pregnancy.

The treatment of melanoma during and immediately after pregnancy poses a significant challenge to surgeons, oncologists, and patients alike. With the overall increase in incidence of melanoma in the United States and worldwide, it is likely that more surgeons will be faced with management decisions regarding pregnant patients with melanoma. We report on five patients who presented to the Yale Melanoma Unit with melanoma during their pregnancy. We propose the management option of resection of the primary tumor under local anesthesia, and postponing of the sentinel lymph node biopsy until after the birth of the child. The completion lymphadenectomy can be performed if these nodes are found to be harboring metastases. We further discuss treatment options and propose an algorithm for management of patients diagnosed with melanoma while pregnant.

A targeted approach to sentinel lymph node biopsies in the parotid region for head and neck melanomas.

INTRODUCTION: Cutaneous melanoma is on the rise in the United States, and the head and neck region is the primary site in 20% of patients. Lymph node status is the best indicator of prognosis for melanoma. In the head and neck, sentinel lymph node (SLN) biopsy presents particular challenges, with the parotid region posing difficulties that include locating the lymph nodes, less frequent visualization of blue dye, and the possibility of higher morbidity because of the proximity of lymph nodes to important neurovascular structures. Surgical approaches to the SLN dissection in the parotid region are variable, and may include superficial or total parotidectomies. Parotid-sparing SLN biopsies for head and neck melanomas were evaluated to determine rates of local recurrence. METHODS: The charts of 301 patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma were reviewed. The location of the primary melanoma was noted, and the sentinel lymph node dissections from the operative reports were documented. Demographic and outcome data were recorded, including course of melanoma management, local recurrence, and postoperative course. RESULTS: Fifty-eight patients underwent SLN biopsy of lymph nodes in the parotid region. Parotid-sparing SLN biopsies comprised 94.8% of total surgical approaches for SLN biopsies in the parotid region. Of the remaining patients who underwent SLN biopsies in the parotid region, 5.17% had a superficial parotidectomy and none had a total parotidectomy. Sentinel lymph nodes were found in all depth layers of the parotid, and LNs were dissected out successfully without the need to remove the parotid in the most cases. The parotid region recurrence rate was 0% for SLN biopsies that either included or spared the parotid gland. There were no localized complications from the sentinel lymph node biopsies. CONCLUSIONS: The parotid-sparing SLN biopsy was performed without any local recurrence in the parotid region. The parotid-sparing SLN biopsy can be carried out in a safe, efficient manner without affecting the rate of local recurrence or postoperative complication. This less-invasive SLN biopsy procedure precludes the complications associated with parotidectomies and may reduce the morbidity for patients with melanomas of the head and neck.

Level I sparing radical neck dissections for cutaneous melanoma in the lymphoscintigram era.

INTRODUCTION: Excision of regional lymph nodes (LNs) in the neck as part of the management for tumors of the head and neck dates back to the 19th century. Crile originally reported the technique of performing a radical neck block dissection in 1905, with notable modifications to the extensive dissection reported throughout the 20th century by Suarez, Ballantyne, Ariyan, and Shah among others. These modifications have aimed to reduce the morbidity encountered by performing the radical neck dissection while balancing the need to remove diseased structures in the head and neck. In this report, we evaluate the outcomes of performing a functional radical neck dissection while sparing the level I LNs as indicated by lymphoscintigraphy. METHODS: The charts of patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma from January 2000 to December 2006 were reviewed. The location of the primary melanoma and clinical course was noted. Those patients who underwent neck dissections were documented and the extent of the dissections from the operative reports was noted. Demographic and outcome data were recorded, including clinical course of melanoma presentation, local recurrence, and postoperative management. Student t test and χ tests were used to determine statistical significance between groups. P values less than 0.05 were considered statistically significant. RESULTS: A total of 41 patients who were documented to have had a head and neck primary melanoma underwent a functional radical neck dissection. Level I dissections were deemed necessary in 39% of these cases, whereas 61% of patients received functional radical neck dissections with sparing of level I LNs. Specific recurrence of melanoma in the submandibular basin was equivocal for LN sparing dissections (n=1) as compared to excision of level I LNs (n=1) (4% vs 6.25%, P=0.488). Follow-up metastatic rates between the 2 groups were also comparable (44% vs 56%, P=0.328). Overall metastatic rate in follow-up for all patients undergoing LN dissection was 48.8%. There was no statistically significant difference between the average age of patients at diagnosis, Breslow depth, Clark level, and staging between patients who underwent functional radical neck dissections with either excision or sparing of level I LNs. CONCLUSIONS: Clinical and pathological presentation between patients who needed level I sparing dissections and those who did not, failed to demonstrate a statistically significant difference allowing for an adequate comparison. Our results indicate that if lymphoscintigraphy does not show drainage to level I LNs, the functional radical neck dissection can be tailored to spare level I LNs without affecting local recurrence. When not indicated by lymphoscintigram, sparing of level I nodes can be performed safely without changing clinical outcomes, while saving operating room time and minimizing potential damage to the buccal branch of facial nerve and the submandiblular gland.

Integrated analysis of tumor samples sheds light on tumor heterogeneity.

The heterogeneity of tumor samples is a major challenge in the analysis of high-throughput profiling of tumor biopsies and cell lines. The measured aggregate signals of multigenerational progenies often represent an average of several tumor subclones with varying genomic aberrations and different gene expression levels. The goal of the present study was to integrate copy number analyses from SNP-arrays and karyotyping, gene expression profiling, and pathway analyses to detect heterogeneity, identify driver mutations, and explore possible mechanisms of tumor evolution. We showed the heterogeneity of the studied samples, characterized the global copy number alteration profiles, and identified genes whose copy number status and expression levels were aberrant. In particular, we identified a recurrent association between two BRAF(V600E) and BRAF(V600K) mutations and changes in DKK1 gene expression levels, which might indicate an association between the BRAF and WNT pathways. These findings show that the integrated approaches used in the present study can robustly address the challenging issue of tumor heterogeneity in high-throughput profiling.

Predictive accuracy of elevated mitotic rate on lymph node positivity and recurrence in thin melanomas.

Background: Mitotic rate (MR) is considered an important prognostic factor for melanoma but is not currently used for staging because its nuanced effect is not yet well-delineated. We sought to determine if T category-specific MR is predictive of sentinel lymph node (SLN) positivity, recurrence, and melanoma-specific mortality (MSM). Methods: A retrospective review of patients with primary cutaneous melanoma from 1994 to 2020 at a single academic center was performed. Patient demographics and tumor characteristics were recorded. MR was considered elevated for each AJCC8-defined T category if it was ≥2 mitoses/mm2 for T1, ≥4 mitoses/mm2 for T2, ≥6 mitoses/mm2 for T3, or ≥7 mitoses/mm2 for T4. Statistical analysis was performed to assess the predictive accuracy of MR on selected outcomes while controlling for ulceration. Results: Data from 2,984 patients with complete records were analyzed. Along with Breslow thickness and ulceration, elevated MR was associated with higher risk of MSM (HR 1.816, P=0.0001). There was no difference among patients with ulcerated T1 or T2 tumors regardless of MR, but those with non-ulcerated T1 or T2 tumors and elevated MR were more likely to have positive SLNs (P<0.0001 and P=0.0043, respectively) and recurrence (P=0.0007 and P=0.0004, respectively) compared to counterparts with low MR. There were no notable differences for T3 or T4 tumors based on MR. Conclusions: Elevated MR is associated with SLN positivity and recurrence in thin melanomas, independent of ulceration. SLN biopsy should therefore be strongly considered for patients with non-ulcerated lesions <0.8 mm thick if the MR is ≥2 mitoses/mm2.

Integrative molecular and clinical profiling of acral melanoma links focal amplification of 22q11.21 to metastasis.

Acral melanoma, the most common melanoma subtype among non-White individuals, is associated with poor prognosis. However, its key molecular drivers remain obscure. Here, we perform integrative genomic and clinical profiling of acral melanomas from 104 patients treated in North America (n = 37) or China (n = 67). We find that recurrent, late-arising focal amplifications of cytoband 22q11.21 are a leading determinant of inferior survival, strongly associated with metastasis, and linked to downregulation of immunomodulatory genes associated with response to immune checkpoint blockade. Unexpectedly, LZTR1 - a known tumor suppressor in other cancers - is a key candidate oncogene in this cytoband. Silencing of LZTR1 in melanoma cell lines causes apoptotic cell death independent of major hotspot mutations or melanoma subtypes. Conversely, overexpression of LZTR1 in normal human melanocytes initiates processes associated with metastasis, including anchorage-independent growth, formation of spheroids, and an increase in MAPK and SRC activities. Our results provide insights into the etiology of acral melanoma and implicate LZTR1 as a key tumor promoter and therapeutic target.

Detecting copy number status and uncovering subclonal markers in heterogeneous tumor biopsies.

BACKGROUND: Genomic aberrations can be used to determine cancer diagnosis and prognosis. Clinically relevant novel aberrations can be discovered using high-throughput assays such as Single Nucleotide Polymorphism (SNP) arrays and next-generation sequencing, which typically provide aggregate signals of many cells at once. However, heterogeneity of tumor subclones dramatically complicates the task of detecting aberrations. RESULTS: The aggregate signal of a population of subclones can be described as a linear system of equations. We employed a measure of allelic imbalance and total amount of DNA to characterize each locus by the copy number status (gain, loss or neither) of the strongest subclonal component. We designed simulated data to compare our measure to existing approaches and we analyzed SNP-arrays from 30 melanoma samples and transcriptome sequencing (RNA-Seq) from one melanoma sample.We showed that any system describing aggregate subclonal signals is underdetermined, leading to non-unique solutions for the exact copy number profile of subclones. For this reason, our illustrative measure was more robust than existing Hidden Markov Model (HMM) based tools in inferring the aberration status, as indicated by tests on simulated data. This higher robustness contributed in identifying numerous aberrations in several loci of melanoma samples. We validated the heterogeneity and aberration status within single biopsies by fluorescent in situ hybridization of four affected and transcriptionally up-regulated genes E2F8, ETV4, EZH2 and FAM84B in 11 melanoma cell lines. Heterogeneity was further demonstrated in the analysis of allelic imbalance changes along single exons from melanoma RNA-Seq. CONCLUSIONS: These studies demonstrate how subclonal heterogeneity, prevalent in tumor samples, is reflected in aggregate signals measured by high-throughput techniques. Our proposed approach yields high robustness in detecting copy number alterations using high-throughput technologies and has the potential to identify specific subclonal markers from next-generation sequencing data.

Melanoma of the head and neck.

This article represents a comprehensive review of melanoma of the head and neck. Upon completion of the article, the reader should have an understanding of the differential diagnoses, biopsy techniques, classification, staging, treatment modalities, and reconstructive options for melanoma of the head and neck.

Methods of Sentinel Lymph Node Identification in Auricular Melanoma.

Sentinel lymph node biopsy is used to evaluate for micrometastasis in auricular melanoma. However, lymphatic drainage patterns of the ear are not well defined and predicting the location of sentinel nodes can be difficult. The goal of this study was to define the lymphatic drainage patterns of the ear and to compare multiple modalities of sentinel node identification. METHODS: A retrospective review of a prospectively maintained database evaluated 80 patients with auricular melanoma who underwent sentinel lymph node biopsy by comparing preoperative imaging with intraoperative identification of sentinel nodes. Patients were placed into two cohorts, based on the modality of preoperative imaging: (1) planar lymphoscintigraphy only (n = 63) and (2) single-photon emission computerized tomography combined with computerized tomography (SPECT-CT) only (n = 17). Sites of preoperative mapping and sites of intraoperative identification were recorded as parotid/preauricular, mastoid/postauricular, and/or cervical. RESULTS: In patients that underwent planar lymphoscintigraphy preoperatively (n = 63), significantly more sentinel nodes were identified intraoperatively than were mapped preoperatively in both the parotid/preauricular (P = 0.0017) and mastoid/postauricular (P = 0.0047) regions. Thirty-two nodes were identified intraoperatively that were not mapped preoperatively in the planar lymphoscintigraphy group (n = 63), two of which were positive for micrometastatic disease. In contrast, there were no discrepancies between preoperative mapping and intraoperative identification of sentinel nodes in the SPECT-CT group (n = 17). CONCLUSIONS: SPECT-CT is more accurate than planar lymphoscintigraphy for the preoperative identification of draining sentinel lymph nodes in auricular melanoma. If SPECT-CT is not available, planar lymphoscintigraphy can also be used safely, but careful intraoperative evaluation, even in basins not mapped by lymphoscintigraphy, must be performed to avoid missed sentinel nodes.

Incidence of the V600K mutation among melanoma patients with BRAF mutations, and potential therapeutic response to the specific BRAF inhibitor PLX4032.

Activating mutations in BRAF kinase are common in melanomas. Clinical trials with PLX4032, the mutant-BRAF inhibitor, show promising preliminary results in patients selected for the presence of V600E mutation. However, activating V600K mutation is the other most common mutation, yet patients with this variant are currently excluded from the PLX4032 trials. Here we present evidence that a patient bearing the BRAF V600K mutation responded remarkably to PLX4032, suggesting that clinical trials should include all patients with activating BRAF V600E/K mutations.