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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.86 no.6 Rio de Janeiro Nov./Dec. 2011
Clinical and epidemiological profile of cutaneous malignant melanomas in two referral institutions in the city of Manaus, Brazil*
Fabiano Bandeira ChibaI; Antonio Pedro Mendes SchettiniII; Ana Carolina Guimaraes DelfinoI; Carlos Alberto ChiranoIII; Silvana de Albuquerque Silva DamascenoIV
IMedical student, Federal University of Amazonas, Manaus, AM, Brazil
IIMSc. Physician at the Alfredo da Matta Foundation, Manaus, AM, Brazil
IIIDermatologist, Alfredo da Matta Foundation, Manaus, AM, Brazil
IVPathologist, Alfredo da Matta Foundation, Manaus, AM, Brazil
Knowledge on the frequency and clinical and pathological characteristics of cutaneous melanoma in the different geographical regions of Brazil is important in evaluating the magnitude of the problem and in directing healthcare actions appropriately. The present study reviewed data from 55 cases of cutaneous melanoma in patients treated at two healthcare institutions in the city of Manaus, Amazonas, Brazil. Rates were higher in brown-skinned males and in individuals of 70-80 years of age. Lesions were most commonly located on the lower limbs, were of the acral lentiginous melanoma type and at advanced stages of the disease, with Breslow thickness > 1 mm and Clark level V.
Keywords: Epidemiology; Medical oncology; Melanoma; Skin neoplasms
In Brazil, data on the epidemiology of cutaneous melanoma are limited; however, according to the statistics of the National Cancer Institute (INCA), incidence rates are higher in the south of the country. Lack of compulsory notification, lack of a central register and insufficient attention from public health managers because of the low prevalence of the disease in certain geographical areas are obstacles that must be overcome in order to gain a better understanding of the problem and implement control actions.1
The objective of the present study was to calculate the frequency of cutaneous melanoma and evaluate its clinical and epidemiological characteristics in two secondary referral centers in dermatology in the city of Manaus, northern region of Brazil. All the charts from patients with a diagnosis of cutaneous melanoma who received care between 2002 and 2007 were included in the study. Although the patients were not submitted to a standardized protocol, all were examined for the presence of adenopathy and visceromegaly and were submitted to imaging exams to identify metastases.
A total of 55 patients were included, 31 males (56%) and 24 females (44%). Most of the patients were of 70 to 79 years of age. None of the patients had palpable lymph nodes or any signs of visceral involvement at the time of diagnosis. Of the 25 patients for whom information regarding ethnicity was available, 16 (62%) described themselves as being other than white, while 10 (38%) considered themselves to be white. The lesions were situated on the lower limbs in 26 cases (60%), on the trunk/back in 16.2% of cases, on the face in 5 patients (11.6%) and on the upper limbs in another 5 patients (11.6%). In 12 cases, information regarding the site of the lesion was not available. The most common clinical-histopathological form was the acral lentiginous melanoma, which was found in 17 patients (30.9%), followed by nodular melanoma in 16 (29.1%), superficial spreading melanoma in 14 (25.5%) and lentigo maligna melanoma in 8 (14.5%). Breslow thickness was predominantly > 1 mm, as found in 32 patients (58%), < 1 mm in 22 patients (40%) and 1 mm in 1 patient (2%). With respect to Clark level, 18 patients (32.7%) had level V, 12 (21.8%) had level IV, 10 (18.2%) had level I or II, and 5 (9.1%) had level III.
The finding that most of the patients were between 70 and 79 years of age is in agreement with the results of a study conducted in Brasilia showing a predominance of individuals in the 61-80 years agegroup, while in another study conducted in Florianopolis age ranged from 17 to 83 years. 2,3 In patients from Rio de Janeiro, the most common agegroup for men was 50-59 years of age, while the women were predominantly in the 40-49 years agegroup. 4 The higher frequency of melanoma in older age groups is due to the cumulative effect of solar radiation, deterioration of the immune system and the peculiarities of individuals of this age, with the elderly perhaps being slower to recognize the presence of cancer. Thus, patients spontaneously seeking treatment may be those in whom the melanoma has been present for a greater period of time and is clinically more exuberant. 5
With respect to gender, there was a predominance of men in the present study (56%). This finding is in agreement with the results of a study conducted in Rio Grande do Sul in which 58% of the sample was male. 6 Epidemiological studies show that in some regions there is a greater frequency of women, while in other regions men predominate and in some areas both genders are equally affected. These contradictory data may be related to the high or low incidence of the disease in the region analyzed. 7
A higher frequency was found in individuals who regarded themselves as brown-skinned (62%). The predominant skin color of melanoma patients is white, with frequency rates of Caucasians in certain regions reaching 92% of cases. 8 The term "brownskinned" in Brazil defines individuals of native indian, European and African descent and is the predominant skin color in the north of Brazil. 9 Brown and blackskinned individuals were found to be diagnosed later and to have the acral lentiginous type of melanoma. However this finding may be related to the characteristics of the sample, since, according to studies conducted in samples of patients attending non-profit institutions such as this, the frequency of melanoma in non-white, older individuals and in those with the acral lentiginous type of melanoma is higher compared to samples from private clinics. 5
The lower limbs were the most common sites of lesions, occurring in 60% of the individuals, both men and women. Studies show that the incidence of lesions situated on the head or legs has increased in women, while the number of lesions situated on the trunk has increased in men, probably reflecting different dress styles and recreational habits. 10
The most common clinical and histological type was the acral lentiginous melanoma (30.9%), unlike the majority of studies in which the most common type is generally the superficial spreading melanoma. 7 The acral lentiginous melanoma is characterized by: its occurrence in older patients, a predomination of non-white-skinned patients, and greater thickness at the time of diagnosis. These characteristics are in agreement with the profile of the patients in the current study. This should be taken into account in educational campaigns, since the acral lentiginous type of melanoma occurs in individuals of an age-group and skin color that are not normally emphasized and it is probably unrelated to sun exposure. 5
In agreement with the findings of other investigators, Breslow thickness > 1 mm was the most common (58%), with this Breslow thickness having been found in 64.2% of cases in a study conducted in São Paulo. 8 Clark level V was the level most commonly found. This finding reveals a late diagnosis involving higher costs in treating the patient and reducing his/her survival.
In conclusion, this series of 55 patients receiving care at two different healthcare institutions located in northern Brazil revealed the following profile: brown-skinned males of 70-80 years of age with lesions on their lower limbs consisting of the acral lentiginous type of melanoma at an advanced stage, with Breslow thickness > 1 mm and Clark level V. The results found should serve as a subsidy to develop disease control measures, since they reveal singularities that are peculiar to this region.
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Mailing address: Received on 22.04.2010. * This study was conducted at the Alfredo da Matta Foundation and at the Araújo Lima Outpatient Unit of the Getúlio Vargas Teaching Hospital, Federal University of Amazonas, Manaus, AM, Brazil.
Antonio Pedro Mendes Schettini
Rua Benjamin Lima, 16 - Quadra 36 - Planalto
69044-040 Manaus - AM, Brazil
Approved by the Advisory Board and accepted for publication on 07.10.2010.
Conflict of interest: None
Financial funding: None
Received on 22.04.2010.
* This study was conducted at the Alfredo da Matta Foundation and at the Araújo Lima Outpatient Unit of the Getúlio Vargas Teaching Hospital, Federal University of Amazonas, Manaus, AM, Brazil.