Improved methodology in determining melanoma mortality and selecting patients for immunotherapyDear Editor, Sentinel lymph node biopsy (SLNB) benefits are said to include identifying the presence and degree of micrometastases, improving staging, predicting prognosis and determining eligibility for adjuvant drug therapy. Sentinel lymph node biopsy is an invasive procedure, which needs nuclear medicine and operating room facilities. Neither SLNB nor early identification of micrometastases provides an overall survival benefit for melanoma patients. 1,2 Adverse events in the order of 11% are expected. 3 Predicting the likelihood of mortality can assist patient selection for adjuvant drug therapy. Breslow thickness, ulceration status and other clinical and pathologic predictors (CAPP) assist predicting melanoma survival. 4 Sentinel lymph node biopsy status (SLNBS) might contribute only a marginal survival predictability above that of an algorithm of CAPP. 5,6 Until recently, no quality research has been available to test this hypothesis.El Sharouni et al (ESS) 7 recently detailed the prognostic value of CAPP, with or without SLNBS, for calculating overall survival (OS) for melanoma patients. Predictors including Breslow thickness, tumour, ulceration, patient age, sex, mitotic activity, regression, tumour subtype and location were evaluated in 9272 Dutch patients. The findings were validated in 5644 Australian patients. 7 El Sharouni et al evaluated the accuracy of each CAPP in predicting OS using appropriate Area Under Curve (AUC) cstatistic methodology. 7 The higher the C-statistic, the better the model separates patients who will die from those who will not die. Combined CAPP was significantly superior to SLNBS at predicting OS. Combining SLNBS with CAPP increased c-statistic for OS by only 3%, with overlapping confidence intervals indicating an absence of statistical significance (Figure 1).El Sharouni et al found Breslow thickness to be the most accurate OS predictor followed by patient age. Subsequently, SLNBS and ulceration were similar. Mitotic activity and regression fell below 0.54, suggesting they might not provide relevant information 7 (Figure 2).El Sharouni et al also reported that SLNBS detected 1.4 more net high-risk melanoma patients (HRMP) for every 100 patients experiencing recurrence within 3 years when used in combination with CAPP. 7 Recurrence rates of approximately 13%-15% have been reported in HRMP. 8 Assuming

Objective: To make available a simple, quantitative formula for preoperative assessment of both the complexity and the associated time required to complete Mohs surgical cases. It will improve office efficiency, technical performance, and resource management.Design: Surveys were sent to 94 Mohs surgeons requesting information on 10 consecutive cases, including tumor size, recurrence, location, aggressiveness, stages required, and case duration. The data were then aggregated, scored, and statistically evaluated.Setting: Private practice dermatology offices performing Mohs surgery were included.Participants: Sequential randomized selection of Mohs College and Mohs Society fellows was used for inclusion. Sequential selection of patients for data acquisition was performed by the surgeons.Main Outcome Measure: The statistical significance of a proposed preoperative assessment tool was to be determined. Results:The score values were 0.34 and 0.41 for the time and number of stages, respectively. In addition, the Mohs score obtained a statistically significant P value of Ͻ.001 for both the time and number of stages required. Conclusions:The Webb and Rivera (WAR) score is a low-effort, efficient, reproducible tool to be used in preoperative Mohs surgery planning and office efficiency improvement. The components of the score include maximum tumor dimension, recurrence, location, and aggressiveness. Each is assigned a numerical value that is totaled, resulting in a final quantitative score.

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BackgroundBreslow thickness, patient age and ulceration are the three most valuable clinical and pathological predictors of melanoma survival. A readily available reliable online tool that accurately considers these and other predictors could be valuable for clinicians managing melanoma patients.ObjectiveTo compare online melanoma survival prediction tools that request user input on clinical and pathological features.MethodsSearch engines were used to identify available predictive nomograms. For each, clinical and pathological predictors were compared.ResultsThree tools were identified. The American Joint Committee on Cancer tool inappropriately rated thin tumours as higher risk than intermediate tumours. The University of Louisville tool was found to have six shortcomings: a requirement for sentinel node biopsy, unavailable input of thin melanoma or patients over 70 years of age and less reliable hazard ratio calculations for age, ulceration and tumour thickness. The LifeMath.net tool was found to appropriately consider tumour thickness, ulceration, age, sex, site and tumour subtype in predicting survival.LimitationsThe authors did not have access to the base data used to compile various prediction tools.ConclusionThe LifeMath.net prediction tool is the most reliable for clinicians in counselling patients with newly diagnosed primary cutaneous melanoma regarding their survival prospects.