Diagnosis and Work-up of Malignant Melanoma in the Age of Fine Needle Aspiration and Molecular Testing

European Oncology & Haematology, 2014;10(1):58–61

Abstract:

Melanoma is one of the most aggressive skin cancers and is prone to both local recurrence and distant metastases. Primary treatment usually includes wide excision and sentinel lymph node biopsy. Clinical and pathologic staging is important for estimating the potential for metastasis and influences post-resection follow-up protocols. Because stage I and II melanomas metastasize infrequently, asymptomatic patients with these low-stage malignancies do not require routine imaging studies. Patients with positive sentinel lymph nodes often undergo routine examination (for staging) using computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) despite evidence showing a very low yield for such testing. Patients with stage III disease and local recurrence should undergo further testing including serum lactate dehydrogenase (LDH), chest radiograph, CT, and PET due to increased risk for systemic metastases. Imaging abnormalities may undergo fine needle aspiration, core biopsy, or open biopsy for confirmation of diagnosis and to obtain tissue for ancillary studies. Depending on the availability of treatment protocols ancillary testing may include mutational analysis for BRAF V600-E, CKIT, and NRAS.

Keywords: Melanoma, metastases, biopsy, imaging, FNA
Disclosure: The author has no conflicts of interests to declare.
Received: December 23, 2013 Accepted March 12, 2014 Citation European Oncology & Haematology, 2014;10(1):58–61
Correspondence: Lester J Layfield, MD, Professor and Chair, Department of Pathology & Anatomical Sciences, University of Missouri, One Hospital Drive, M263 Medical Sciences Building, Columbia, MO 65212, US. E: layfieldl@health.missouri.edu

Malignant melanoma is an aggressive form of skin cancer and has demonstrated an increasing mortality among men in the last quarter century.1 The 5-year survival rate is approximately 15–20 % for stage IV melanoma.2 Surgical management of primary melanoma remains wide excision with or without the addition of sentinel lymph node biopsy. While 5-year survival for stage I and II melanomas is good, outcome for stage IV melanoma remains bleak. Recently, a number of directed therapies have been developed for treatment of metastatic malignant melanoma. Many of these are predicated on the presence of specific mutations sensitizing the malignant cells to specific chemotherapeutic agents. Molecular techniques are required to document the specific mutations, thus tissue from metastatic sites is needed to guide selection of specific therapies. Given that specific therapies with efficacy against metastatic disease now exist, the early recognition of distant metastases by imaging modalities and their biopsy have become important in the management of stage III and IV melanoma patients. Herein, we review blood marker testing, imaging methods and indications, biopsy techniques, and ancillary testing for directed therapies in patients with metastatic malignant melanoma. The current review is limited to cutaneous melanoma and its metastases.

Clinical History and Initial Physical Examination
Following the identification of a clinically suspicious pigmented lesion, the patient should have a focused medical history taken documenting the presence of any family history of melanoma or other skin cancer as well as whether or not there is a family history of multiple, irregular, or prominent moles. The history should also include documentation of the presence or absence of pancreatic ductal carcinoma or astrocytoma within the family. The patient should be specifically questioned about a history of prior personal melanomas. A history of significant prior sun exposure should be documented. The patient should be asked about changes they have noted in other moles specifically regarding alterations in size, color, shape, or the presence of bleeding or ulceration. A personal history or family history of multiple nevus syndrome should be queried.

Physical examination should include a total body skin examination with photography of nevi and other suspicious cutaneous lesions. This total body skin examination is performed to assess the number of nevi present and to distinguish between typical and atypical lesions.

Biopsy of Primary Lesion and Histologic Examination
The index atypical pigmented lesion should be excised in total if possible. Shave biopsies are suboptimal specimens as they may preclude accurate evaluation of depth of invasion and assessment of architectural features that are important for diagnosis. Excisional biopsies are recommended because they allow the evaluation of junctional activity at the edges of the lesion and the deep margin. Such assessment also aids in the diagnosis of melanoma because it allows evaluation of lesional symmetry.

Histopathologic evaluation is performed and expert consultation is desirable for difficult lesions. The College of American Pathologists synoptic report should be addended to the diagnostic report. This synoptic checklist should include a statement as to the type of melanoma (superficial spreading, lentigo maligna melanoma, acral lentiginous, nodular, or other types) present. Clark’s level of invasion and Breslow thickness should be given. The thickness should be measured with the aid of a micrometer. The checklist should also include a statement on the lymphoid host response at the base of the lesion being designated as none/minimal, mild (nonbrisk), marked (brisk), or other. Associated lesions should be documented. The presence or absence of ulceration should be documented as well as the mitotic index (rate). Angiolymphatic invasion should be documented as present or absent. The presence of regression should be described as well as satellitosis, if present. Operative margins need to be evaluated. The presence or absence of involvement of peripheral margins should be documented and the distance between the melanoma and margin stated for uninvolved peripheral margins. Similarly, the status of the deep margin should be documented and when negative, the distance between the melanoma and the deep margin stated.

Both Clark’s level and Breslow thickness have prognostic value.3–5 Many experts in dermatopathology believe that both should be reported. Determination of Breslow thickness requires a micrometer while Clark’s level does not and may be the easier measurement to determine. Tables 1 and 2 describe Clark’s level and Breslow thickness cutpoints.

Following a histopathologic diagnosis of melanoma, re-excision should generally be performed. Elective lymph node dissection for patients with clinically enlarged lymph nodes should be undertaken. When lymph nodes are clinically within normal limits, sentinel lymph node biopsy is often performed for staging purposes.6–8 Dynamic lymphoscintigraphy is used for localization of sentinel lymph nodes.9,10 Sentinel lymph nodes histopathologic examination may include either microscopic examination of multiple hematoxylin and eosin stain (H&E) stained levels or the use of immunohistochemistry for s100 protein, melanin-A, and, perhaps, HMB- 45.11,12 Subsequent therapy is based upon status of the sentinel lymph nodes and the thickness of the primary melanoma.

Histopathologic Staging
Histopathologic staging involves assessment of Clark’s level and Breslow thickness as defined in Tables 1 and 2. The American Joint Committee on Cancer (AJCC) has proposed a TNM system for staging melanoma.13 T classification is based on thickness and the presence of ulceration as shown in Table 3.

Imaging Techniques and Indications
Traditionally, imaging studies are performed in patients with recently diagnosed melanoma. While low-cost studies such as chest radiographs are useful in establishing a baseline, more-expensive imaging techniques may not be cost-effective.14 Few guidelines exist that define appropriate testing protocols for initial evaluation and follow-up of patients with melanoma.15 Malignant melanoma has a propensity to metastasize widely with common sites for deposits of melanoma being skin, lymph nodes, liver, bone, lung, gastrointestinal tract, and brain. Multi-institutional studies have shown that ultrasound (US) is the superior technique for documentation of metastases to sentinel lymph nodes while positron emission tomography (PET) and computed tomography (CT) appear to be the best methods for identifying metastases at other sites.16 Current American Academy of Dermatology guidelines do not recommend baseline testing in asymptomatic patients with stage 1a–2c cutaneous melanoma.17 Similarly, guidelines proposed by the National Comprehensive Cancer Network (NCCN) indicate that no laboratory testing or baseline imaging studies should be obtained in asymptomatic patients with stage IA, IB, or IIA melanomas. Chest radiographs are optional for stage IIB and IIC patients.18 The NCCN guidelines support the concept that most melanoma recurrences are initially recognized clinically. Imaging studies are indicated for confirmation of clinically suspected metastatic disease and potentially in patients with stage IIB to IV disease.18 Scheduling of followup imaging studies for patients with thick melanomas or after treatment for metastatic disease is controversial and definitive guidelines do not exist. Patients with positive sentinel lymph nodes often undergo extensive imaging studies either before or after completion lymphadenectomy or when being considered for further therapy.15 Despite the widespread use of such testing in patients with only a positive sentinel lymph node, the yield of such studies is small bringing into question their utility.19–21 Patients with stage III disease with locoregional melanoma should have further imaging studies including CT, magnetic resonance imaging (MRI), or PET due to their relatively high (50 %) risk for systemic disease. CT examination should include the chest and abdomen/pelvis.22–24 PET-CT is the dominate imaging technique for evaluation of patients with highstage disease.25 PET-CT has considerable advantages including: 1) higher sensitivity in comparison to CT and 2) gives whole-body coverage in one examination possibly eliminating the need for other tests. Patients with known stage IV disease should undergo comprehensive imaging evaluation to detect additional sites of involvement.15

References:
  1. Dummer R, Hauschild A, Pentheroudakis G, Cutaneous malignant melanoma: ESMO clinical recommendations for diagnosis, treatment and follow-up, Ann Oncol, 2009;20(Suppl. 4)129–31
  2. Bhatia S, Tykodi SS, Thompson JA, Treatment of metastatic melanoma: an overview, Oncology (Williston Park), 2009;23:488–96.
  3. Breslow A, Cascinelli N, van der Esch EP, Morabito A, Stage I melanoma of the limbs: assessment of prognosis by levels of invasion and maximum thickness, Tumori, 1978;64:273–84.
  4. Breslow A, Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma, Ann Surg, 1970;172:902–8.
  5. Büttner P, Garbe C, Bertz J, et al., Primary cutaneous melanoma. Optimized cutoff points of tumor thickness and importance of Clark’s level for prognostic classification, Cancer, 1995;75:2499–506.
  6. Gershenwald JE, Thompson W, Mansfield PF, et al., Multiinstitutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients, J Clin Oncol, 1999;17:976–83.
  7. Hauschild A, Christophers E, Sentinel node biopsy in melanoma, Virchows Arch, 2001;438:99–106.
  8. Kanzler MH, Sentinel node biopsy and standard of care for melanoma: a re-evaluation of the evidence, J Am Acad Dermatol, 2010;62:880–4.
  9. Gennari R, Bartolomei M, Testori A, et al., Sentinel node localization in primary melanoma: preoperative dynamic lymphoscintigraphy, intraoperative gamma probe, and vital dye guidance, Surgery, 2000;127:19–25.
  10. Czerniecki BJ, Bedrosian I, Faries M, Alavi A, Revolutionary impact of lymphoscintigraphy and intraoperative sentinel node mapping in the clinical practice of oncology, Semin Nucl Med, 2001;31:158–64.
  11. Lawrence WD, Association of Directors of Anatomic and Surgical Pathology. ADASP recommendations for processing and reporting of lymph node specimens submitted for evaluation of metastatic disease, Virchows Arch, 2001;439:601–3.
  12. Baisden BL, Askin FB, Lange JR, Westra WH, HMB-45 immunohistochemical staining of sentinel lymph nodes: a specific method for enhancing detection of micrometastases in patients with melanoma, Am J Surg Pathol, 2000;24:1140–6.
  13. American Joint Committee on Cancer, AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010.
  14. Sabel MS, Wong SL, Review of evidence-based support for pretreatment imaging in melanoma, J Natl Compr Canc Netw, 2009;7:281–9.
  15. Buzaid AC, Gershenwald JE, Staging work-up and surveillance after treatment of melanoma. Avaialble at: http://www.uptodate. com/contents/staging-work-up-and-surveillance-after-treatmentof- melanoma (accessed March 28, 2014).
  16. Xing Y, Bronstein Y, Ross MI, et al., Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis, J Natl Cancer Inst, 2011;103:129–42.
  17. Bichakjian CK, Halpern AC, Johnson TM, et al., American Academy of Dermatology. Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology, J Am Acad Dermatol, 2011;65:1032–47.
  18. Swetter SM, Cutaneous melanoma workup. Available at: http:// emedicine.medscape.com/article/1100753-workup (accessed April 12, 2013).
  19. Aloia TA, Gershenwald JE, Andtbacka RH, Johnson MM, et al., Utility of computed tomography and magnetic resonance imaging staging before completion lymphadenectomy in patients with sentinel lymph node-positive melanoma, J Clin Oncol, 2006;24:2858–65.
  20. Miranda EP, Gertner M, Wall J, et al., Routine imaging of asymptomatic melanoma patients with metastasis to sentinel lymph nodes rarely identifies systemic disease, Arch Surg, 2004;139:831–6; discussion 836–7.
  21. Gold JS, Jaques DP, Busam KJ, et al., Yield and predictors of radiologic studies for identifying distant metastases in melanoma patients with a positive sentinel lymph node biopsy, Ann Surg Oncol, 2007;14:2133–40.
  22. Buzaid AC, Tinoco L, Ross MI, et al., Role of computed tomography in the staging of patients with local-regional metastases ofmelanoma, J Clin Oncol, 1995;13:2104–8.
  23. Kuvshinoff BW, Kurtz C, Coit DG, Computed tomography in evaluation of patients with stage III melanoma, Ann Surg Oncol, 1997;4:252–8.
  24. Johnson TM, Fader DJ, Chang AE, et al., Computed tomography in staging of patients with melanoma metastatic to the regional nodes, Ann Surg Oncol, 1997;4:396–402.
  25. Bronstein Y, Ng CS, Rohren E, et al., PET/CT in the management of patients with stage IIIC and IV metastatic melanoma considered candidates for surgery: evaluation of the additive value after conventional imaging, AJR Am J Roentgenol, 2012;902–8.
  26. Voit C, Kron M, Schäfer G, et al., Ultrasound-guided fine needle aspiration cytology prior to sentinel lymph node biopsy in melanoma patients, Ann Surg Oncol, 2006;13:1682–9.
  27. van Rijk MC, Teertstra HJ, Peterse JL, et al., Ultrasonography and fine-needle aspiration cytology in the preoperative evaluation of melanoma patients eligible for sentinel node biopsy, Ann Surg Oncol, 2006;13:1511–6.
  28. Sanki A, Uren RF, Moncrieff M, et al., Targeted high-resolution ultrasound is not an effective substitute for sentinel lymph node biopsy in patients with primary cutaneous melanoma, J Clin Oncol, 2009;27:5614–9.
  29. Voit CA, van Akkooi AC, Schäfer-Hesterberg G, et al., Rotterdam Criteria for sentinel node (SN) tumor burden and the accuracy of ultrasound (US)-guided fine-needle aspiration cytology (FNAC): can US-guided FNAC replace SN staging in patients with melanoma?, J Clin Oncol, 2009;27:4994–5000.
  30. Chai CY, Zager JS, Szabunio MM, et al., Preoperative ultrasound is not useful for identifying nodal metastasis in melanoma patients undergoing sentinel node biopsy: preoperative ultrasound in clinically node-negative melanoma, Ann Surg Oncol, 2012;19:1100–6.
  31. Hall BJ, Schmidt RL, Sharma RR, Layfield LJ, Fine-needle aspiration cytology for the diagnosis of metastatic melanoma: systematic review and meta-analysis, Am J Clin Pathol, 2013;140:635–42.
  32. Fernando SS, Johnson S, Bäte J, Immunohistochemical analysis of cutaneous malignant melanoma: comparison of S-10 protein, HMB-45 monoclonal antibody and NKI/C3 monoclonal antibody, Pathology, 1994;26:16–9.
  33. Smoller BR, Immunohistochemistry in the diagnosis of melanocytic neoplasms, Pathology, 1994;2:371–83.
  34. Orchard GE, Comparison of immunohistochemical labelling of melanocyte differentiation antibodies melan-A, tyrosinase and HMB 45 with NKIC3 and S100 protein in the evaluation of benign naevi and malignant melanoma, Histochem J, 2000;32:475–81.
  35. Anaka M, Hudson C, Lo PH, et al., Intratumoral genetic heterogeneity in metastatic melanoma is accompanied by variation in malignant behaviors, BMC Med Genomics, 2013;6:40.
  36. Heinzerling L, Baiter M, Kühnapfel S, et al., Mutation landscape in melanoma patients clinical implications of heterogeneity of BRAF mutations, Br J Cancer, 2013;109:2833–41.
  37. Busam KJ, Hedvat C, Pulitzer M, et al., Immunohistochemical analysis of BRAF(V600E) expression of primary and metastatic melanoma and comparison with mutation status and melanocyte differentiation antigens of metastatic lesions, Am J Surg Pathol, 2013;37:413–20.
  38. Rastetter M, Schagdarsurengin U, Lahtz C, et al., Frequent intra-tumoural heterogeneity of promoter hypermethylation in malignant melanoma, Histol Histopathol, 2007;22:1005–15.
  39. Shiino K, Sakamoto K, Yamanaka K, Sekido H, Needle tract implantation of hepatocellular carcinoma after sonographically guided percutaneous needle biopsy, Kyobu Geka, 2010;63:388–91.
  40. Doi S, Yasuda I, Iwashita T, et al., Needle tract implantation on the esophageal wall after EUS-guided FNA of metastatic mediastinal lymphadenopathy, Gastrointest Endosc, 2008;67:988–90.
  41. Vignoli M, Rossi F, Chierici C, et al., Needle tract implantation after fine needle aspiration biopsy (FNAB) of transitional cell carcinoma of the urinary bladder and adenocarcinoma of the lung, Schweiz Arch Tierheilkd, 2007;149:314–8.
  42. Voravud N, Shin DM, Dekmezian RH, et al., Implantation metastasis of carcinoma after percutaneous fine-needle aspiration biopsy, Chest, 1992;102:313–5.
  43. Glasgow BJ, Brown HH, Zargoza AM, Foos RY, Quantitation of tumor seeding from fine needle aspiration of ocular melanomas, Am J Ophthalmol, 1988;105:538–46.
  44. Bradish JR, Montironi R, Lopez-Beltran A, et al., Towards personalized therapy for patients with malignant melanoma: molecular insights into the biology of BRAF mutations, Future Oncol, 2013;9:245–53.
  45. Ravnan MC, Matalka MS, Vemurafenib in patients with BRAF V600E mutation-positive advanced melanoma, Clin Ther, 2012;34:1474–86.
  46. Menzies AM, Long GV, Murali R, Dabrafenib and its potential for the treatment of metastatic melanoma, Drug Des Devel Ther, 2012;6:391–405.
  47. Zebary A, Omholt K, Vassilaki I, et al., KIT, NRAS, BRAF and PTEN mutations in a sample of Swedish patients with acral lentiginous melanoma, J Dermatol Sci, 2013;72:284–9.
  48. Santini D, Vincenzi B, Venditti O, Dell’aquila E, et al.,Sunitinib in malignant melanoma: a treatment option only for KIT-mutated patients? Future Oncol, 2013;9:1809–11.
Keywords: Melanoma, metastases, biopsy, imaging, FNA