Survival analysis of children and adolescents with melanoma

Objectives: to analyze the survival in juvenile melanoma. Methods: retrospective study conducted by hospital record review and cancer records of patients aged 0 to 19 years, with histologically proven melanoma and treated between 1997 and 2017 at the Erasto Gaertner Hospital in Curitiba-PR. Results: the sample comprised 24 patients, female (62.5%), mean 14.14 ± 4.72 years old, with head and neck melanoma (37.5%), chest (25%) and extremities. (20.8%). Signs and symptoms at diagnosis were increased lesion size (25%), bleeding (20.8%) and pruritus (16.6%). There was a Breslow II and IV index and Clark IV level, with a statistical tendency between Breslow IV and death (p = 0.127), and significance between Clark V and death (p = 0.067). Nine (37.5%) patients had metastases, six (25%) with distant metastases died (p = 0.001), five were girls (20.8%). Surgery was the standard treatment and chemotherapy the most used adjuvant (37.5%). The average time between diagnosis and death was 1.3 ± 1.2 years and survival were 3.7 ± 3.2 years. Conclusion: there was a delay in diagnosis, high morbidity and mortality and average survival less than five years.


RESULTS
There were 29 cases of melanoma in children and teens under 19  Survival distribution (Kaplan-Meier) was

DISCUSSION
Although the incidence of melanoma in children and adolescents has increased in recent decades 8,9 , it is considered rare in these age groups, especially among prepubertal individuals 7-11 . This first Brazilian historical Melanoma lesions affecting girls (62.5%) and located on the head and neck (41.7%), limbs (25%) and trunk (20.8%) contrast with the literature that points to a similar incidence between boys and girls and higher frequency in limbs (40%), chest (35%), and head and neck (17%) 9 .
Clinical manifestations, such as increased lesions, pruritus, and bleeding were similar to the literature 8 . However, they may go unnoticed or hidden.
Health professionals and parents / guardians must beware of skin lesions in children and adolescents with such characteristics, or with unusual aspects 3 , so as not to delay the detection and treatment of a possible cancer.
Regarding the histological classification, among the specified tumor types, superficial spreading melanoma predominated, followed by nodular and acral / mucous (  13 . These data point to the possibility of a later diagnosis of melanoma in children and adolescents when compared with adults 15 .

Survival analysis of children and adolescents with melanoma
A classic study by Saenz et al. (1999) 8 demonstrated that all patients with melanomas of thickness ≤ 1 mm had a survival greater than 10 years.
In the research by Averbook et al. (2013) 5 , young people with melanomas measuring ≤ 1 mm in thickness had a favorable prognosis, but when they measured > 1-2 mm, the survival rate, despite similar, decreased.
Tumor thickness and ulceration are strong predictors of sentinel lymph node metastasis in children 6,16,17 . Young people with melanoma with a Breslow Index greater than I and a negative sentinel node had 100% survival, while in those with a positive node the survival dropped to 89%, indicating that positive sentinel node is associated with an unfavorable prognosis 17 .
We observed a statistical trend for a lower survival rate from Clark's level IV and a strong relationship for level V. It was not possible to find a statistical relationship between reduced survival and higher Breslow indexes, nor with the presence of ulceration, due to the small sample size and absence of such records.