WAIKOLOA, HAWAII — Dermatologic surveillance following diagnosis of a primary melanoma is often overly intensive, Dr. Daniel G. Coit asserted at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
“The key recommendation for mela- noma patients is that they ought to go on lifetime dermatologic surveillance. … We find a lot of patients who are fairly low risk undergoing dermatologic surveillance every 3 months for the rest of their lives,” said Dr. Coit, a surgeon who is coleader of the Melanoma Disease Management Team at Memorial Sloan-Kettering Cancer Center in New York and a member of the American Joint Committee on Cancer melanoma staging committee. “You don't need to follow up everybody three or four times a year.”
Annual skin surveillance is entirely appropriate in melanoma patients who are not in a subgroup at elevated risk for another primary melanoma, he said. These high-risk subgroups include melanoma patients who have dysplastic nevi, who have a positive family history for melanoma, or who have already been diagnosed with a second primary tumor, he continued.
Several years ago Dr. Coit and his Sloan-Kettering colleagues examined this issue of second primary melanomas in detail. They reported on 4,484 patients with primary melanoma who were followed prospectively at the tertiary cancer center; 8.6% went on to have two or more primary melanomas. Patients with more than one primary melanoma averaged 2.3.
The estimated cumulative 5-year risk of a second primary melanoma was 11.4%. Fifty-nine percent of patients presented with their second primary tumor within 1 year of their first. After that first year, the incidence in patients without a family history of dysplastic nevi leveled off at about 0.3% a year, less than many physicians might expect. That low long-term annual rate was quite similar to the figure reported in an earlier analysis of the Duke University (Durham, N.C.) melanoma database, he noted (Surgery 1993;113:330–9).
Not only were most of the second primary melanomas detected during the first year of surveillance in the Sloan-Kettering series, but most of those diagnosed in the first year were found when the initial primary was diagnosed. “With the heightened awareness created by finding a primary melanoma, these patients undergo a complete and very thorough review, and other suspicious lesions are biopsied. After that, the slope of the curve [of incident second primary melanoma] is actually pretty flat.” But this was not the case in the high-risk subgroups. In such patients, a case can be made for lifetime dermatologic surveillance more often than annually, Dr. Coit said.
In the Sloan-Kettering study, the subgroup of melanoma patients at highest risk of another primary tumor consisted of patients who had already been diagnosed with a second primary melanoma; they had a 15.6% incidence of a third primary tumor within 1 year of their second and a 31% probability of developing a third primary within 5 years (JAMA 2005;294:1647–54).
Forty-nine percent of patients had their second primary melanoma on the same body site as their first. The greatest site concordance was 60% for lesions on the extremities.
Dysplastic nevi, which for the most part were diagnosed clinically rather than histologically in this study, were present in 18% of patients with a single primary melanoma and 38% with multiple primary tumors.
Dr. Keith T. Flaherty, a medical oncologist at the University of Pennsylvania, Phi- ladelphia, noted the risk over time is not linear, depending instead on the stage of the first primary melanoma. The risk is greatest early on for those with high-risk disease and much more spread out over time in patients with early-stage disease. “That needs to inform our surveillance,” he said.
Dr. Coit concurred. “Almost no one with early-stage disease recurs early, and almost no one with late-stage disease recurs late.”
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