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ORIGINAL ARTICLE
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Cutaneous melanoma survival rates of the elderly are not worse than those of the young, yet they have some specific differences


1 Department of Medical Oncology, Istanbul University Institute of Oncology, Istanbul, Turkey
2 Department of Medical Oncology, Koc University, Istanbul, Turkey

Date of Submission20-May-2021
Date of Acceptance09-Jul-2021
Date of Web Publication14-Jan-2022

Correspondence Address:
Ferhat Ferhatoglu,
Department of Medical Oncology, İstanbul University Institute of Oncology, Millet Street, 34093 Capa-Fatih-Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.jcrt_815_21

 > Abstract 


Introduction: The incidence of cutaneous melanoma among the elderly has increased significantly. Unfavorable survival rates are associated with insufficient patient managements and poor prognostic features in the elderly. We aimed to compare elderly (≥75 years) and younger (<75 years) patients with cutaneous melanoma to determine the differences and the prognostic significance of age.
Materials and Methods: The retrospective data of 117 elderly and 232 younger patients with cutaneous melanoma were compared.
Results: The median age of the elderly patients was 78 years (75–104), and 51.3% of the patients were female. Of the patients, 14.5% were in the metastatic stages. Clinicopathologic factors such as extremity melanomas (P = 0.01), Clark levels IV–V (P = 0.04), ulceration (P = 0.009), and neurotropism (P = 0.03) were significantly more common in elderly patients. However, BRAF mutation was significantly more common in younger patients (P = 0.003). Overall survival (OS) and recurrence-free survival (RFS) rates of both the groups were similar. Lymph node involvement (P < 0.005), distant metastasis (P < 0.005), and relapse of disease (P = 0.02) were associated with poor OS in elderly patients. Tumor-infiltrating lymphocytes was associated with prolonged RFS (P = 0.05), while extremity melanomas (P = 0.01), lymphovascular invasion (P = 0.006), and lymph node involvement (P < 0.005) had negative impact on RFS.
Conclusions: Although elderly patients with cutaneous melanoma had different clinicopathologic features in our series, their survival rates are similar to those of younger patients, which shows that age alone is inadequate to determine the prognosis. Disease stage and a comprehensive geriatric assessment might assist to determine appropriate management.

Keywords: Elderly, melanoma, prognosis, prognostic factor, survival



How to cite this URL:
Ferhatoglu F, Erturk K, Faruk T. Cutaneous melanoma survival rates of the elderly are not worse than those of the young, yet they have some specific differences. J Can Res Ther [Epub ahead of print] [cited 2022 Dec 4]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=335491




 > Introduction Top


Aging is a physiological process involving all organs and systems. Adaptation to environmental stressors gradually decreases with aging. With many accompanying comorbidities, elderly patients constitute a special population that needs more care in terms of treatment.

According to the World Health Organization, ≥65 years and ≥ 80 years are defined as elderly and oldest-old, respectively.[1] The United States National Institute of Aging subdivided elderly patients into three groups: “young-old” (65–74 years), “older-old” (75–84 years), and “oldest-old” (≥85 years).[2] National Comprehensive Cancer Network states that ≥65 years is generally accepted as a chronological limit for elderly patients, but the definition based on functional capacity is more appropriate.[3] Due to different chronological definitions in the literature, it is difficult to determine certain categorical values to define the elderly.

Cutaneous melanoma is the fifth (7%) and the sixth (4%) most common types of cancer in men and women, respectively, in the US.[4] The incidence of the disease has been increasing significantly in recent years.[5] According to the SEER data, the median age at diagnosis is 65 years, and the annual incidence had increased approximately 60% in people ≥65 years between 2000 and 2017.[6] Significant increase rates in cutaneous melanoma in patients ≥65 years are also observed in other developed and developing countries.[7] These data prove that cutaneous melanoma will be seen more and more in the future in elderly patients. Furthermore, in a study investigating the economic burden of elderly cancer patients, it was observed that the cost of melanoma patients was quite high, especially in case of distant metastasis, the cost increased eight times compared to the early stage.[8] Therefore, it is becoming increasingly important to investigate the clinicopathological features and treatment approaches of cutaneous melanoma in the elderly population.

Cutaneous melanomas in head-and-neck regions are more common in the elderly,[9],[10] so are some of the pathologic subtypes, such as nodular melanomas, lentigo malign melanomas, and acral lentiginous melanomas,[11],[12],[13] and some of the prognostic indicators, such as deeper Breslow thickness and ulceration.[13],[14],[15] In addition to these, the elderly are diagnosed at more advanced stages.[14] In retrospective cohort studies, elderly patients have been shown to have lower melanoma-specific survival than younger patients.[16],[17] So what could be the etiological factors that make up these different patterns?

First, as the cumulative effect of ultraviolet (UV) light manifests itself, especially in the head-and-neck region with advancing age, the frequency of cutaneous melanoma might be higher in these regions. Likewise, the association between lentigo maligna melanoma, which is more common in the elderly, and UV exposure is more pronounced than other histological types. [18],[19],[20] Second, attention deficit and visual defects that develop with aging make it difficult to detect skin changes and cause delays in diagnosis. Third, it has been reported that both surgical approaches and systemic treatments applied to elderly patients are more limited compared to younger ones.[14],[21],[22]

It should be noted that most of these studies were conducted in northern Europe, North America, and Australia. However, as the angle of sunlight and climatic conditions vary at every latitude, the effect of UV exposure also varies. Another important risk factor for the development of cutaneous melanoma is racial differences, including skin color, hair, and eye color.[23]

In our study, we aimed to compare the demographic and clinicopathological characteristics and survivals of the elderly cutaneous melanoma patients with the younger patients.


 > Materials And Methods Top


Patients

The medical records of 117 cutaneous melanoma patients, aged ≥75 years and followed up at the Institute of Oncology Istanbul University – a tertiary referral center – from January 1993 to January 2021, were evaluated retrospectively. For comparison, 232 cutaneous melanoma patients aged <75 years and selected randomly from 1466 patients were included in the analysis as a control group. We defined the patients ≥75 years as “elderly” and the patients <75 years as “younger.” Demographic informations including age and gender, clinicopathologic features, and survival outcomes were retrieved from the medical records of the patients. Clinical staging was done according to the 8th edition of the American Joint Committee on Cancer melanoma staging system. Lymph node status was determined by either sentinel lymph node biopsy (SLNB) or lymph node dissection. Patients with confirmed pathologically positive sentinel lymph nodes underwent complete lymph node dissection. The study was reviewed and approved by the regional ethical committee.

Statistical analysis

IBM SPSS Statistics for Windows, Version 21.0 (SPSS Inc, Chicago, Ill), was used for statistical analysis. For descriptive statistics, categorical variables were represented as numbers and percentages. Proportions in younger and older groups were analyzed using the Chi-square test. Overall survival (OS) and recurrent free survival (RFS) were primarily targeted in the survival analysis. OS was described to be the time interval from the date of diagnosis of the disease to the date of death. RFS was considered to be the time interval from the completion of primary therapy to the time of the first relapse. Survival rates were calculated using the Kaplan–Meier analysis. To evaluate risk factors, univariate Cox regression analysis was used. The statistical significance was accepted as P ≤ 0.05.


 > Results Top


Demographic and clinicopathologic features

The median age was 78 years (range: 75–104) in the elderly patients. The female-to-male ratio was 51.3% versus 48.7%. In elderly patients, extremity melanomas (54.0%) were more common than in other localizations. At the time of diagnosis, 57.3% of the elderly patients were in early stages (stage I-II) and 14.5% were in metastatic stages. Some other prognostic factors such as Clark level IV-V (83.9%), Breslow depth ≥ 2 mm (72.4%), ulceration (71.6%), vertical growth phase (93.0%), and BRAF wild-type (86.4%) were found to be more common in elderly patients.

Compared to younger patients, the ratio of extremity lesions (54.0% vs. 40.2%, P = 0.01) and the Clark levels IV–V (83.9% vs. 72.8%, P = 0.04) were significantly higher in elderly patients. In addition, elderly patients were associated more frequently with ulcerated lesions (71.6% vs. 54.1%, P = 0.009). While neurotropism was less common among younger patients (3.5% vs. 11.9%, P = 0.03), BRAF mutation was less common in the elderly patients (13.6% vs. 49.2%, P = 0.003). The comparative demographic and clinicopathological characteristics of both groups are listed in [Table 1].
Table 1: Demographic and clinicopathological characteristics of the patients

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Survival and risk factors

The median OS of the elderly patients was 22.0 months. In addition, 5-year OS and 5-year RFS were 49.6% and 61.7%, respectively. There was no statistically significant difference between the two groups regarding OS (P = 0.6) and RFS (P = 0.2) [Table 2]. The comparative OS and RFS curves of both the groups are shown in [Figure 1] and [Figure 2], respectively.
Table 2: Survival rates of the patients (5 years)

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Figure 1: Recurrence free survival curves of both elderly and younger patients (0.6)

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Figure 2: Overall survival curves of both elderly and younger patients (0.2)

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Univariate Cox regression analyses of possible clinicopathological parameters in elderly melanoma patients showed that lymph node involvement (hazard rate (HR) = 3.30, 95% confidence interval [CI]: 1.78–6.13, P < 0.005), distant metastasis (HR = 6.39, 95% CI: 3.07–13.30, P < 0.005), and relapse of disease (HR = 2.30, 95% CI: 1.14–4.66, P = 0.02) were unfavorable on OS. In addition, extremity melanoma (HR = 2.53, 95% CI: 1.17–5.46, P = 0.01), lymphovascular invasion (LVI) (HR = 4.05, 95% CI: 1.49–10.96, P = 0.006), and lymph node involvement (HR = 4.30, 95% CI: 2.04–9.04, P < 0.005) have negative impact on RFS. Tumor-infiltrating lymphocytes (TIL) might also be accepted as a significant predictor on RFS (HR = 0.37, 95% CI: 0.14–1.00, P = 0.052) [Table 3].
Table 3: Univariate analyses on survivals of elderly patients

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 > Discussion Top


We compared clinicopathologic features of 117 elderly cutaneous melanoma patients (≥75 years) with 232 younger melanoma patients to detect unique characteristics of the disease regarding advanced age.

Similar to our results, a study conducted in Brazil showed that the ratio of females in melanoma patients above 60 years of age was slightly higher (52.5%).[24] However, the SEER database and other studies concluded that the number of males was higher in elderly patients.[6],[9],[14],[25] This might be so because, in developed countries, women use sunscreen more frequently and consult a doctor more often for suspicious skin lesions. Contrary to current literature, the rates of metastatic stage were insignificant between elderly and younger patients in our results (14.5% vs. 12.9%, respectively; P = 0.6). In addition, the frequency of nodular melanoma, which is associated with advanced stage and mortality, was not significant between the two groups (P = 0.7).[13],[14],[26] These differences might be attributed to different study designs and both regional and sociocultural factors.

In elderly patients, extremity melanomas were more common (54.0% vs. 40.2%, P = 0.01). A possible explanation might be that the damage caused by the cumulative effect of UV is more pronounced on the extremities.[27] The head-and-neck region is another susceptible area exposed to UV, and it has been shown that the prevalence of melanoma in this region increases with age.[10],[28],[29] With the increase of the elderly population following years, the frequency of cutaneous melanomas on body areas exposed to intense sun exposure is expected to increase as well.

In our cohort, the prognostic factors such as Clark level (III-IV) (P = 0.04), ulceration (P = 0.009), and neurotropism (P = 0.03) were significantly higher among elderly patients compared to younger patients. A study conducted by Rees et al. showed that in the oldest-old (≥85 years) cutaneous melanoma patients' group, most of the patients had ulcerated lesions with high mitotic activity and deep Breslow thickness.[13] Higher rates of poor prognostic factors in elders were also observed in other studies.[14],[24],[25] Gordon et al. showed that cumulative UV exposure in poor-visible areas of the body (scalp, retroauricular area, back, posterior upper arms and thighs, buttocks, pubic area) has poorer survival than well-visible areas (face, chest, abdomen, anterior upper arms and thighs, lower arms and legs, dorsum of hands and feet, palms).[27] Such an anatomical classification might be more helpful in determining the prognostic features of elderly patients. In addition, elderly patients' accesses to health services are worse than young patients, and they less likely to participate in skin screening programs.[30] And finally, comorbidities that increase with aging and difficulties in recognizing skin changes might contribute to poor prognostic features in elderly patients.

About 60% of cutaneous melanomas have oncogenic mutation in BRAF gene (V600E), an important therapeutic target.[31],[32] Besides, 80% of benign melanocytic nevi also have oncogenic BRAF mutation.[33] Bauer et al. showed in patients from Europe, North America, and Australia that BRAF mutation was more common in patients under <60 years of age and less frequent in head-and-neck melanomas.[34] Similarly, melanoma patients with a precursor lesion are less likely to be older.[9] In accordance with the current literature, we found that the rates of precursor nevus (25.5%) and BRAF mutation (13.6%) were lower in elderly patients. Hence, it can be hypothetically argued that as age increases, chronic sun exposure and presence of a precursor lesion have an inverse relationship with BRAF mutation. The conclusion that the incidence of BRAF-mutant melanoma is higher on the trunk of people exposed to intermittent sunlight also supports this view.[35] In addition, owing to various immune system deteriorations, immune escape mechanisms might help explain the carcinogenesis of de novo and BRAF-wild melanomas in elderly patients.

Axial melanomas, LVI, and nodal involvement increased the risk of recurrence; however, TIL was found to have a favorable effect on RFS. The detrimental factors on OS were lymph node involvement, metastasis, and recurrence of disease. There was no survival disadvantage in elderly patients compared to younger patients. In a study evaluating 399 early-stage melanoma patients, who underwent SLNB, the patients were divided into two groups at the age of 50 as a cutoff. There were no differences in metastasis rates between the two groups, but OS was better in the younger ones. The authors associated the difference in survival with more males in the elderly group.[36] There are other studies demonstrating that advanced age is one of the most important factors that negatively affect survival.[17],[36] However, recent studies proved that the treatments applied at each stage in elderly patients were more limited than in younger patients.[14],[37] Hence, our study showed that the prognostic value of advanced age alone might be misleading. We believe that comprehensive geriatric assessment, life expectancy, and consideration of the disease stage in elderly patients might contribute more to more accurate treatment.

Due to the retrospective nature of our study, some medical information on the patients was absent. In addition, due to the changing treatment protocols over time, there might be differences in treatments applied to the patients. And since we are a tertiary reference center, the rate of advanced-stage patients is higher. These limitations make it difficult to interpret the results of our study. To eliminate the conflicting literature results, more comprehensive studies should be supported.


 > Conclusions Top


Certain poor prognostic features are more common in elderly cutaneous melanoma patients. In our study, extremity melanomas, high Clark level, ulceration, and neurotropism were more common in patients ≥ 75 years of age; however, the BRAF mutation rate was significantly lower in elderly patients. The most important factors affecting survival in elderly patients were lymph node involvement, metastasis, and relapse of disease. There was no difference in RFS and OS between the two groups. Our results show that age alone is inadequate at determining the prognosis. When evaluating elderly patients, disease stage and comprehensive geriatric assessment will assist in decision-making for an appropriate treatment.

Acknowledgment

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
World Health O. Men, Ageing and Health: Achieving Health Across the Life Span. Geneva: World Health Organization; 2001.  Back to cited text no. 1
    
2.
Kennedy BJ. Aging and cancer. J Clin Oncol 1988;6:1903-11.  Back to cited text no. 2
    
3.
National Comprehensive Cancer Network. Older Adult Oncology (Version 1.2020-February 7, 2020); 2020. Available from: https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf. [Last accessed on 2021 Jan 22].  Back to cited text no. 3
    
4.
Miller KD, Fidler-Benaoudia M, Keegan TH, Hipp HS, Jemal A, Siegel RL. Cancer statistics for adolescents and young adults, 2020. CA Cancer J Clin 2020;70:443-59.  Back to cited text no. 4
    
5.
Guy GP Jr., Thomas CC, Thompson T, Watson M, Massetti GM, Richardson LC, et al. Vital signs: Melanoma incidence and mortality trends and projections – United States, 1982-2030. MMWR Morb Mortal Wkly Rep 2015;64:591-6.  Back to cited text no. 5
    
6.
National Cancer Institute; Surveillance E, and End Results Program., Melanoma of the Skin Recent Trends in SEER Age-Adjusted Incidence Rates; 2000-2017 2021. Available from: https://seer.cancer.gov/explorer/application.html?site=53&data_type=1&graph_type=2&compareBy=sex&chk_sex_1=1&race=1&age_range=160&stage=101&rate_type=2&advopt_precision=1&advopt_display=2. [Last accessed on 2021 Jan 22].  Back to cited text no. 6
    
7.
Bray F, Ferlay J, Laversanne M, Brewster DH, Gombe Mbalawa C, Kohler B, et al. Cancer incidence in five continents: Inclusion criteria, highlights from Volume X and the global status of cancer registration. Int J Cancer 2015;137:2060-71.  Back to cited text no. 7
    
8.
Yabroff KR, Lamont EB, Mariotto A, Warren JL, Topor M, Meekins A, et al. Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008;100:630-41.  Back to cited text no. 8
    
9.
Macdonald JB, Dueck AC, Gray RJ, Wasif N, Swanson DL, Sekulic A, et al. Malignant melanoma in the elderly: Different regional disease and poorer prognosis. J Cancer 2011;2:538-43.  Back to cited text no. 9
    
10.
Hoersch B, Leiter U, Garbe C. Is head and neck melanoma a distinct entity? A clinical registry-based comparative study in 5702 patients with melanoma. Br J Dermatol 2006;155:771-7.  Back to cited text no. 10
    
11.
Rigual NR, Popat SR, Jayaprakash V, Jaggernauth W, Wong M. Cutaneous head and neck melanoma: The old and the new. Expert Rev Anticancer Ther 2008;8:403-12.  Back to cited text no. 11
    
12.
Duarte AF, Sousa-Pinto B, Barros AM, Haneke E, Correia O. Lentigo maligna – Not always a face and neck disease of the elderly. Dermatology 2018;234:37-42.  Back to cited text no. 12
    
13.
Rees MJ, Liao H, Spillane J, Speakman D, McCormack C, Donahoe S, et al. Melanoma in the very elderly, management in patients 85 years of age and over. J Geriatr Oncol 2018;9:488-93.  Back to cited text no. 13
    
14.
Ciocan D, Barbe C, Aubin F, Granel-Brocard F, Lipsker D, Velten M, et al. Distinctive features of melanoma and its management in elderly patients: A population-based study in France. JAMA Dermatol 2013;149:1150-7.  Back to cited text no. 14
    
15.
Geller AC, Elwood M, Swetter SM, Brooks DR, Aitken J, Youl PH, et al. Factors related to the presentation of thin and thick nodular melanoma from a population-based cancer registry in Queensland Australia. Cancer 2009;115:1318-27.  Back to cited text no. 15
    
16.
Enninga EA, Moser JC, Weaver AL, Markovic SN, Brewer JD, Leontovich AA, et al. Survival of cutaneous melanoma based on sex, age, and stage in the United States, 1992-2011. Cancer Med 2017;6:2203-12.  Back to cited text no. 16
    
17.
Green AC, Baade P, Coory M, Aitken JF, Smithers M. Population-based 20-year survival among people diagnosed with thin melanomas in Queensland, Australia. J Clin Oncol 2012;30:1462-7.  Back to cited text no. 17
    
18.
DeWane ME, Kelsey A, Oliviero M, Rabinovitz H, Grant-Kels JM. Melanoma on chronically sun-damaged skin: Lentigo maligna and desmoplastic melanoma. J Am Acad Dermatol 2019;81:823-33.  Back to cited text no. 18
    
19.
Rastoder E, Glud M. Diagnostics and treatment of lentigo maligna melanoma in Denmark. Ugeskr Laeger 2019;181:V08180544.  Back to cited text no. 19
    
20.
Tas F, Erturk K. Cheek cutaneous melanomas: A review of 98 cases. Ann Plast Surg 2019;82:407-10.  Back to cited text no. 20
    
21.
Sondak VK, Taylor JM, Sabel MS, Wang Y, Lowe L, Grover AC, et al. Mitotic rate and younger age are predictors of sentinel lymph node positivity: Lessons learned from the generation of a probabilistic model. Ann Surg Oncol 2004;11:247-58.  Back to cited text no. 21
    
22.
Shah DR, Yang AD, Maverakis E, Martinez SR. Age-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis. J Surg Res 2013;185:240-4.  Back to cited text no. 22
    
23.
Dawes SM, Tsai S, Gittleman H, Barnholtz-Sloan JS, Bordeaux JS. Racial disparities in melanoma survival. J Am Acad Dermatol 2016;75:983-91.  Back to cited text no. 23
    
24.
Purim KS, Bonetti JP, Silva JY, Marques LB, Pinto MC, Ribeiro LC. Characteristics of melanoma in the elderly. Rev Col Bras Cir 2020;47:e20202441.  Back to cited text no. 24
    
25.
Tragos C, Hieken TJ. Optimizing the management of cutaneous melanoma in the elderly. Surgery 2011;150:828-35.  Back to cited text no. 25
    
26.
Egger ME, Dunki-Jacobs EM, Callender GG, Quillo AR, Scoggins CR, Martin RC 2nd, et al. Outcomes and prognostic factors in nodular melanomas. Surgery 2012;152:652-9.  Back to cited text no. 26
    
27.
Gordon D, Hansson J, Eloranta S, Gordon M, Gillgren P, Smedby KE. Primary tumor sites in relation to ultraviolet radiation exposure and skin visibility correlate with survival in cutaneous melanoma. Int J Cancer 2017;141:1345-54.  Back to cited text no. 27
    
28.
Grénman R, Chevalier D, Gregoire V, Myers E, Rogers S. Treatment of head and neck cancer in the elderly: European Consensus (panel 6) at the EUFOS Congress in Vienna 2007. Eur Arch Otorhinolaryngol 2010;267:1619-21.  Back to cited text no. 28
    
29.
Whiteman DC, Stickley M, Watt P, Hughes MC, Davis MB, Green AC. Anatomic site, sun exposure, and risk of cutaneous melanoma. J Clin Oncol 2006;24:3172-7.  Back to cited text no. 29
    
30.
Geller AC, Sober AJ, Zhang Z, Brooks DR, Miller DR, Halpern A, et al. Strategies for improving melanoma education and screening for men age >or=50 years: Findings from the American Academy of Dermatological National Skin Cancer Sreening Program. Cancer 2002;95:1554-61.  Back to cited text no. 30
    
31.
Davies H, Bignell GR, Cox C, Stephens P, Edkins S, Clegg S, et al. Mutations of the BRAF gene in human cancer. Nature 2002;417:949-54.  Back to cited text no. 31
    
32.
Satyamoorthy K, Li G, Gerrero MR, Brose MS, Volpe P, Weber BL, et al. Constitutive mitogen-activated protein kinase activation in melanoma is mediated by both BRAF mutations and autocrine growth factor stimulation. Cancer Res 2003;63:756-9.  Back to cited text no. 32
    
33.
Pollock PM, Harper UL, Hansen KS, Yudt LM, Stark M, Robbins CM, et al. High frequency of BRAF mutations in nevi. Nat Genet 2003;33:19-20.  Back to cited text no. 33
    
34.
Bauer J, Büttner P, Murali R, Okamoto I, Kolaitis NA, Landi MT, et al. BRAF mutations in cutaneous melanoma are independently associated with age, anatomic site of the primary tumor, and the degree of solar elastosis at the primary tumor site. Pigment Cell Melanoma Res 2011;24:345-51.  Back to cited text no. 34
    
35.
Candido S, Rapisarda V, Marconi A, Malaponte G, Bevelacqua V, Gangemi P, et al. Analysis of the B-RafV600E mutation in cutaneous melanoma patients with occupational sun exposure. Oncol Rep 2014;31:1079-82.  Back to cited text no. 35
    
36.
Caracò C, Marone U, Botti G, Celentano E, Lastoria S, Mozzillo N. Age as predictor in patients with cutaneous melanoma submitted to sentinel lymph node biopsy. Eur J Surg Oncol 2006;32:970-3.  Back to cited text no. 36
    
37.
Livingstone E, Windemuth-Kieselbach C, Eigentler TK, Rompel R, Trefzer U, Nashan D, et al. A first prospective population-based analysis investigating the actual practice of melanoma diagnosis, treatment and follow-up. Eur J Cancer 2011;47:1977-89.  Back to cited text no. 37
    


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    Tables

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