The Melanoma Pathology Report: What to Expect and How to Interpret It Alexander Nirenberg, Richard Williams, Howard Steinman, Stuart Anderson, Anthony Dixon Journal of Dermatology, 2026 Pathological information is critical to patient management in melanoma. A uniform approach based on current evidence is crucial and is summarized in this paper. Essential clinical and pathological parameters to report are the BAUSSS biomarker prognostic criteria, that is, Breslow thickness, patient age, presence of ulceration, melanoma subtype, patient sex, and anatomic site. Other important parameters to include are adnexal and periadnexal extension, tumor infiltrating lymphocytes, intravascular and abluminal lymphovascular invasion, microsatellites, in‐transit metastases, perineural invasion, and margins. Additional parameters that have been recommended for inclusion are mitotic activity, regression, association with nevi and atypical melanocytic hyperplasia. The significance of special stains and genetic studies is also discussed.
Sentinel lymph node biopsy may no longer be a critical component of melanoma management Athanassios Kyrgidis, Anthony J. Dixon, Michael Sladden, Howard K. Steinman, Christos C. Zouboulis, Aimilios Lallas, Samantha Schneider, Harvey Smith, Alexander Nirenberg, Caterina Longo, Giuseppe Argenziano, Catalin Popescu, Thrasyvoulos Tzellos, Stuart Anderson, J. Meirion Thomas Journal of the European Academy of Dermatology and Venereology, 2025 We thank Faries and colleagues1 for their comments.1, 2 They argue mixing data from two different online platforms to estimate survival outcome and nodal metastasis risk is problematic, because the platforms are based on different populations. Both large populations consist of melanoma patients, similar baseline demographics and variables; hence, they are comparable. Fairies1 point to the discrepancy between the LifeMath.net and Melanoma Institute of Australia (MIA) algorithms in predicting sentinel lymph node positivity (SLNB+) with probabilities varying in our examples. This may partly be owing to the MIA algorithm incorporating statistically insignificant variables, (mitoses and lymphovascular invasion) while excluding the important tumour site variable, included by LifeMath.net.3 Faries1 report that Lifemath prediction of SLNB+ for a 20 years old with a 0.4-mm ulcerated melanoma is 6%, half the risk we used. Our published figure 4b2 presents 15-year melanoma specific mortality rate (MSMR) for a patient with a Breslow 0.4 mm superficial spreading melanoma on the trunk with no lymphovascular invasion or mitoses.2 SLNB+ data were derived from the MIA nomogram (https://www.melanomarisk.org.au/SNLForm). This practice was uniformly adopted because MSMR data were only available in Lifemath.3 The SLNB+ result for the given patient is 12% using the MIA tool, but 6.1% when using the http://www.lifemath.net/cancer/melanoma/nodal/index.php tool. Our 12% estimate is based on Lo et al.4 Faries1 assert that ‘extrapolation of predictions for such uncommon situations to 1000 hypothetical patients implies precision that is not supported by the underlying data’. We disagree. The extrapolation presents an easy to interpret result for journal readership. There is no decreased precision. It is reporting exactly the same results. In their figure 1,1 Fairies visualize our table 1. The dots do not align. The under 40-year-old population apparently differs from the remainder. The purpose of analysing the Tübingen-data in our study was to determine whether the hazard ratio (HR) for death in SLNB+ patients is different at different age points. We then used those HRs to further manage/scrutinize the data from El-Sharouni's publication.5 Based on identified HRs, our table 2 details that 2.6% of low-risk young people who are SLNB+ will die of melanoma. These young people have a >10% SLNB+ risk and hence will be encouraged to undertake SLNB based on Lo/MIA recommendations. Faries state that ‘a patient's understanding of their individual risk of recurrence or death is only possible when their nodal status is known’. They argue that without SLNB, one cannot differentiate between a 6.7% MSMR for SLNB-negative patients <40 years and a 24% MSMR for those SLNB+. We disagree. BAUSSS biomarker effectively discriminates between patients, while SLNB adds only negligibly to BAUSSS. We are surprised that Faries still advocate that SLNB has intrinsic therapeutic benefit. The Multicenter Selective Lymphadenectomy Trial (MSLT-1) clearly showed that long-term overall survival is not altered by SLNB.6 Completion lymphadenectomy in MSLT-2 SLNB+ patients offers no long term survival benefit.7 Faries1 insist that young patients with thin melanomas should be offered SLNB, arguing that young people with very low risk of death can still benefit from SLNB status knowledge. That is suggesting that if a patient has a 2% MSMR, we could perform SLNB to further refine whether their MSMR is closer to 1.7% or 4.4%. To date, such small incremental changes are unlikely to be of clinical significance. What is known, however, are the inherent risks of surgery and costs associated with these procedures. Thus, there seem to be no obvious benefits of SLNB in this cohort, but rather risks for the individual patient, and increased costs for the healthcare system.2 In conclusion, we encourage prognostic models for melanoma to consolidate around the BAUSSS biomarker. All work on this manuscript was undertaken entirely voluntarily by all researchers. None. No author declares a conflict of interest. Not applicable. The data that support the findings of this study are openly available through Lifemath at [http://www.lifemath.net/cancer/] together with findings published by: El Sharouni et al.5 and Lo et al.4 SLNB positivity risk data is publicly available at www.melanomarisk.org.au
Squamous Cell Carcinoma In Situ on High-Risk Sites and With Larger Sizes Require More Stages for Clearance With Mohs Surgery Howard K. Steinman, Anthony J. Dixon Journal of Drugs in Dermatology, 2025 BACKGROUND Few studies have evaluated Mohs micrographic surgery (MMS) for the treatment of squamous cell carcinoma in situ or evaluated the results by Mohs Appropriate Use Criteria. OBJECTIVE Evaluate the clinical and surgical characteristics of squamous cell carcinoma in situ treated with MMS and categorize the results by Mohs Appropriate Use Criteria. METHODS AND MATERIALS A single Mohs surgeon, prospective, longitudinal cohort study of all squamous cell carcinoma in situ tumors treated with MMS between April 2018 and May 2021. RESULTS A total of 485 tumors were treated and 96.9% were primary tumors. Mean age of patients was 73.8 years; 80.6% were male. Mean tumor length, wound length, and subclinical extension were 0.98 cm, 1.58 cm, and 0.7 cm, respectively. These dimensions were lowest in Area H and highest in Area L. Mean stages to clear margins was 1.14. Area H tumors required significantly more stages than those in Areas M and L (P=0.031). CONCLUSIONS Mean tumor and wound sizes, stages to clearance, and subclinical extension were lower than previously reported. Area H tumors required more stages to clearance than those in Areas M and L. Stages to clearance increased with increased tumor size. Curettage before surgery did not decrease the number of required stages to achieve clear tumor margins. CITATION Steinman HK, Dixon AJ. Squamous cell carcinoma in situ on high-risk sites and with larger sizes require more stages for clearance with Mohs surgery. J Drugs Dermatol. 2025;24(5):494-497. doi:10.36849/JDD.8609.
BAUSSS biomarker improves melanoma survival risk assessment Anthony J. Dixon, Howard K. Steinman, Alexander Nirenberg, Christos C. Zouboulis, Michael Sladden, Catalin Popescu, Stuart Anderson, Caterina Longo, J. Meirion Thomas Journal of the European Academy of Dermatology and Venereology, 2025 BackgroundThe American Joint Committee on Cancer (AJCC) method of staging melanoma is dated and inaccurate. It ignores important prognostic melanoma features, especially the patient's age. BAUSSS is more accurate in determining survival risk for primary cutaneous melanoma patients who have no clinical or imaging evidence of nodal or distant metastases. BAUSSS is an algorithm incorporating analysis of Breslow thickness, Age, Ulceration, Subtype of melanoma, Sex and Site. These are the six features from the patient history along with the details from the melanoma pathology report that are most predictive of mortality outcome.ObjectiveTo develop a single‐page document that allows the clinician to determine BAUSSS biomarker‐predicted prognosis in consultation with the patient.MethodFrom various data sources, we developed an algorithm to predict melanoma mortality using the BAUSSS biomarker system. The single‐page algorithm was made available to download at https://globalmelanoma.net/bausss‐survival‐chart, thus being readily available without charge to all clinicians and their patients.ResultsBAUSSS method of determining melanoma prognosis is more accurate and less costly than the AJCC staging system. The only surgery the patient requires is wide local excision of the primary tumour. This method of ascertaining melanoma risk does not require added surgery, costs, hospitalization, tests and anaesthesia, such as would be required if sentinel lymph node biopsy was undertaken. BAUSSS can be a useful tool in determining which primary melanoma patients are at sufficiently high risk to be considered for adjuvant drug therapy.ConclusionWe encourage clinicians to download and print in colour this single‐page BAUSSS mortality prediction tool, laminate it, and use it face to face with the patient in consultations. Not only will the patient be able to recognize his/her long‐term prognosis but will also be able to see how their tumour severity compares with others.
BAUSSS biomarker further validated as a key risk staging tool for patients with primary melanoma Anthony J. Dixon, Athanassios Kyrgidis, Michael Sladden, Alexander Nirenberg, Howard K. Steinman, Harvey Smith, Christopher B. Zachary, Stuart Anderson, Ulrike Leiter‐Stöppke, Caterina Longo, Zoe Apalla Journal of the European Academy of Dermatology and Venereology, 2024 Lifemath data are publicly available at http://www.lifemath.net/cancer/. Lo et al. SLNB positivity risk data are publicly available at www.melanomarisk.org.
Age-associated metastatic potential of melanoma in lymph nodes: A preliminary gene association study C. C. Zouboulis, A. J. Dixon, H. K. Steinman, M. Sladden, A. Kyrgidis Journal of the European Academy of Dermatology and Venereology, 2024 The data that support the findings of this study are available from the corresponding author upon reasonable request. Data sets related to this article are hosted at the Gene Expression Omnibus (https://www.ncbi.nlm.nih.gov/geo/) data repositories GSE8401 and GSE43081.
Sentinel lymph node biopsy is unreliable in predicting melanoma mortality for both younger and older patients Anthony J. Dixon, Athanassios Kyrgidis, Howard K. Steinman, John B. Dixon, Michael Sladden, Claus Garbe, Aimilios Lallas, Christopher B. Zachary, Ulrike Leiter‐Stöppke, Harvey Smith, Alexander Nirenberg, Christos C. Zouboulis, Caterina Longo, Giuseppe Argenziano, Zoe Apalla, Catalin Popescu, Thrasyvoulos Tzellos, Stuart Anderson, Lena Nanz, Lloyd Cleaver, J. Meirion Thomas Journal of the European Academy of Dermatology and Venereology, 2024 BackgroundMelanoma disease patterns vary with patient age.AimTo evaluate sentinel lymph node biopsy (SLNB) in managing melanoma at differing patient ages.MethodsOnline prediction tools were applied to compare SLNB positivity (SLNB+) and survival risk at patient ages 20–80. Tübingen melanoma data were used to determine variations in the hazard ratio of SLNB+ for mortality at different patient ages.ResultsRegardless of tumour thickness, predicted SLNB+ rates were markedly higher than mortality rates for 20‐year‐old patients. For 80‐year‐old patients, it is the opposite.DiscussionIf 1000 20‐year‐olds with a 0.4 mm thickness non‐ulcerated melanoma underwent SLNB, 100 would likely be positive. If all 100 were to be offered adjuvant drug therapy (ADT), fewer than three more melanoma deaths in those 1000 patients would be avoided. In total, 97 patients would have received medication they may never have needed. If 1000 80‐year‐olds with a 3 mm thickness non‐ulcerated melanoma underwent SLNB, only 40 would likely be positive. In total, 274 patients would be predicted to die of melanoma, 245 being SLNB negative and 29 SLNB+. ADT linked to SLNB+ could deny treatment to 89% of these high‐risk patients.LimitationsThe authors relied on published risk data.ConclusionSLNB has poor specificity at predicting mortality in young melanoma patients and poor sensitivity in older patients. SLNB is not indicated in managing cutaneous melanoma for patients under 40 or over 60 years of age. Many such patients could be managed with wide local excision alone in their clinician's office‐based practice. For all cutaneous melanoma patients at all ages, linking ADT to BAUSSS biomarker, (an algorithm of Breslow thickness, age, ulceration, subtype, sex and Site) rather than SLNB+ is likely more appropriate. BAUSSS provides a more accurate melanoma‐specific mortality risk assessment for patients without burdening them with added surgery, hospitalization, costs or morbidity risk.
Primary Cutaneous Melanoma—Management in 2024 Anthony Joseph Dixon, Michael Sladden, Christos C. Zouboulis, Catalin M. Popescu, Alexander Nirenberg, Howard K. Steinman, Caterina Longo, Zoe Lee Dixon, Joseph Meirion Thomas Journal of Clinical Medicine, 2024
Online prediction tools for melanoma survival: A comparison A. Dixon, H. K. Steinman, A. Kyrgidis, H. Smith, M. Sladden, C. Zouboulis, G. Argenziano, Z. Apalla, A. Lallas, C. Longo, A. Nirenberg, C. Popescu, T. Tzellos, L. Cleaver, C. Zachary, S. Anderson, J. M. Thomas Journal of the European Academy of Dermatology and Venereology, 2023
Improved methodology in determining melanoma mortality and selecting patients for immunotherapy A. J. Dixon, H. K. Steinman, A. Kyrgidis, H. Smith, M. Sladden, C. Zouboulis, G. Argenziano, Z. Apalla, A. Lallas, C. Longo, A. Nirenberg, C. Popescu, J. B. Dixon, T. Tzellos, C. Zachary, L. Cleaver, S. Anderson, S. Zagarella, J. M. Thomas Journal of the European Academy of Dermatology and Venereology, 2023
Multicentre Selective Lymphadenectomy Trial 1: key primary data remain unavailable Anthony Dixon, Athanassios Kyrgidis, Christopher Zachary, John Dixon, Catalin Popescu, Michael Sladden, Zoe Apalla, Stuart Anderson, Giuseppe Argenziano, Demitrios Ioannides, Alexander Nirenberg, Aimillios Lallas, Samuel Zagarella, Caterina Longo, Harvey Smith, Howard Steinman, Thrasivoulos Tzellos, Lloyd Cleaver, Ken Leahey, Christos C. Zouboulis, J. Meirion Thomas British Journal of Dermatology, 2022
It is time to change … a better way for representative governance Sharon F. Billon, John Kasch, Donald O. Hayden, Michael Franzblau, Lenore Kakita, Victor Newcomer, Ellis Seligman, William Shellow, Terence F. Maloy, Howard Steinman, Thomas E. Hoffman, David Fisher, Robert Melnikoff, Robert R. Carson Journal of the American Academy of Dermatology, 1990
