Ulcerated Melanoma: Aspects and Prognostic Impact

ABSTRACT

Ulceration is an important prognostic factor for patients with melanoma and also a predictive marker for the response of adjuvant immune-stimulating therapy. A consensual definition and accurate assessment of ulcer­ation is therefore crucial for proper staging and clinical management but can be difficult even between experienced pathologists. The definition of ulceration is stated differently in the available literature but is generally understood as loss of epidermal matrix. Thinning of the epidermis, also termed consumption of the epidermis (COE), is associated with ulcerated lesions and correlates with enhanced tumor cell proliferation in nonulcerated melanoma. These results sug­gest that COE may be a proliferative precursor of ulceration, characterized by erosive growth into the epidermal layer (infiltrative type) or expansive growth that may stretch and eventually disrupt the epidermis (attenuative type), which is reflected in the histopathology. We have no means to determine the dynamic changes of human ulcerated melanoma or to determine whether these wounds have re-epithelialization (RE) potential. However, the presence of reactive hyper­plasia (REH) and changes indicating RE associates with increased density of neutrophils and may herald resolved or late-stage ulcerations. Combining the extent of ulceration (> or <70% of the total tumor length) and the presence of epidermal involvement (COE, REH, and/or RE) stratifies prognosis more accu rately and supports the relevance of including these factors in the definition of ulceration and to define ulceration of a primary melanoma as loss of epidermis with evidence of a host response (infiltration of neutrophils or fibrin deposition) and thinning, effacement, or REH of the surrounding epidermis.