There is NO single Melanoma Stain. > 6000 Mutations in Melanoma. What else can be done to discriminate atypical nevi from melanoma?

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1 Las Vegas Fall Clinical 2016: The Assessment and Diagnosis of Melanoma Whitney A. High, MD, JD, MEng Associate Professor, Dermatology & Pathology Director of Dermatopathology (Dermatology) University of Colorado Health Sciences Center October 2016 Las Vegas, Nevada > 6000 Mutations in Melanoma Makes for Messy Model How good is grading? Duncan et al. (1993) 10 cases of nevi, dysplastic nevi (mild, mod, sev) and melanoma concordance 69-80% for nevus vs dysplastic nevus vs melanoma only 35-58% concordance for grading of dysplasia Piepkorn, et al. (1994) 149 atypical nevi graded by 6 expert dermatopathologists re-interpreted 6 mos later by same dermatopathologist correlation coefficients ( moderate to substantial ) best correlation by person using only two categories (mild/mod vs sev) Farmer, et al. (1996) 37 classic melanomas/nevi & 8 expert dermatopathologists unanimity for melanoma in only 11 cases (30%) What else can be done to discriminate atypical nevi from melanoma? Immunostains There is NO single Melanoma Stain Combination stains Kimart Mart1 highlights melanocytes Ki67 marks proliferative index 1

2 KiMart (MART-1/Ki67) P16 P16 is a tumor suppressor protein Often used for Spitz vs. melanoma ddx Dermal P16 staining was best discriminator: loss of nuclear staining (<25% of cells) 3 fold more likely to be melanoma loss of nuclear and cytoplasmic staining 8 fold more likely to be melanoma George E, et al: Am J Clin Pathol 130:370, 2010 P16 in Spitz Nevus HMB-45 Benign melanocytic lesions: junctional/superficial component stains normal zonation in the deeper component Confusing in situations of dusty cells: deeply pigmented nevi deep penetrating nevi clonal nevi Expression of p16 is favorable Compound nevus Melanoma Sensitivity vs Specificity S100 vs Mart1 ZONATION LACK OF ZONATION 2

3 Desmoplastic (Spindle Cell) Melanoma S100 Mart1 vs. S100 Melan A But atypical nevi, particularly mild and even moderate nevi are not that big a deal, right? But hold on Are we simply bad at distinguishing atypical nevi from melanoma? 3

4 Illustrative Example Re-examination of Original Called compound moderately atypical nevus by a well-known Colorado dermatopathologist. No stains or levels were performed. MART1/Ki67 4

5 HMB45 Spitz Nevus Classic Spitz Nevus ale of the Spitz tumor Histology 17 year-old girl seen in 2007 Eruptive lesion on leg only noticed for a few weeks No personal or FH of melanoma Otherwise healthy 5

6 No win situation. Overcall and a 17 year-old receives: huge disfiguring scar ruined insurance status chronic leg edema no real hope Undercall and there are: medicolegal issues is the patient harmed? Her Sentinel Lymph Node Patients may not always want (or need) what you think they want (or need) 6

7 Real case Ki67/Mart1 P16 Update Thoughts? Signed out as: Combined nevus (common nevus and Spitz nevus) Patient presented in 2016 with right sided cervical LAD and was told initially was mononucleosis. Ultimately, she had melanoma in a cervical lymph node, and tumor nodules in the right lung. 7

8 On the verge of assessing the genetics of melanoma Tests That Cay Be Employed Comparative Genomic Hybridization (acgh) Fluorescent In Situ Hybridization (FISH) Gene Expression Profiling (GEP) Comparative Genomic Hybridization FISH for Additions/Deletions Examines entire genome Detects gains or losses in copy number Gains/losses exist in >95% of melanoma Performed on FFPE tx Bauer & Bastian,Derm Therapy, 2006; 19:40-9. (Am J Surg Pathol 2009;33: ) Best probe set 6p25 (RREB1) 11q13 (CCDN1) 6q23 (MYB) CEP6 86.7% sensitive 95.4% specific identified 6/6 metastasizing ambiguous lesions Only 60% sensitivity and only 60% specificity in ambiguous lesions. 8

9 23 Gene Expression Profiling qrt-pcr on FFPE that is microdissected Developed and validated on N=400+ nevi/mm Acknowledged that for difficult Spitzoid lesions the old probe set was probably only around 70% sensitive Proposes new probe set - 6p25, 9p21, 11q13, and 8q24 Particularly interesting is addition of loss of 9p21 (p16) Overall improvement in sensitivity reported to be 94% No lab test works all the time DermTech Another GEP based test Uses tape stripping Set for high SENSITIVITY and lesser SPECIFICITY Impact of a Threshold on Sensitivity and Specificity Conservative Dermpath Low FISH threshold Low proprietary threshold any test Cowboy Dermpath High FISH threshold High proprietary threshold any test 9

10 On the horizon Prognostic test for melanoma Clin Cancer Res. 2015; 21: Castle 31 GEP Test All stage disease (I-IV) Technology developed in uveal melanoma GEP accurately distinguishes low risk (95% 5-year metastasis-free survival) high risk (20% 5-year metastasis-free survival) Critics contend uveal MM is a genetically simpler problem than cutaneous MM almost all are GNAQ or GNA11 driven (80%) compared to 2% of GNAQ/GNA11 in all melanoma BAP-1 mutation confers increased metastatic risk Validation set data for the Castle Biosciences DecisionRx Kaplan-Meier Survival Curves for Low Risk vs High Risk GEP Measurements Only stage I & II Where this test might be used Patients that simply need to know everything that can be known Patients with lesions less than 1 mm but with high mitotic activity Patients s/p SLN to identify those at risk Class 2 67% and 83% of SLN negative cases with recurrence or death, respectively Zager et al. ASCO

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