Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system

Real-World Experience of Talimogene Laherparepvec (T-VEC) in Old and Oldest-Old Patients with Melanoma: A Retrospective Single Center Study

Purpose

Rising melanoma incidences lead to an increasing need for individual therapy strategies in old patients. Talimogene laherparepvec (T-VEC) is a modified herpes simplex virus, approved for the local treatment of unresectable metastatic melanoma. Since data on the efficacy and safety of geriatric patients are sparse, this study was conducted to gain further real-world experience in the treatment of old and oldest-old patients with T-VEC and to obtain data on therapy costs in this population in Germany.

Patients and Methods

We performed a retrospective analysis, including all patients with a minimum age of 75 years who were treated with T-VEC from August 2016 to September 2020 in the Skin Cancer Center of the University Hospital Frankfurt, Germany. Patient clinicopathological data, treatment responses, toxicities, treatment-specific data and therapy costs were assessed.

Results

Twelve patients with a median age of 83 years (75-89 years) at the start of treatment were identified. By the end of the study, three (25%) patients experienced complete remission (CR), four (33%) experienced partial response (PR), two patients (17%) remained at stable disease (SD) and three (25%) patients suffered from progressive disease (PD). Overall response rate was 58.3%, and durable response rate was 41.7%. There were no treatment-related adverse events grade 3 or higher. The median duration of treatment was seventeen weeks (3-57 weeks). Median medication costs in the patients who had completed treatment (n=10) were calculated to be 27,325 Euros in Germany.

Conclusion

This study provides further evidence for an effective use of T-VEC in old and oldest-old patients. The low rate of adverse events seems to be favorable compared to other systemic melanoma therapies. Furthermore, duration of treatment was short and therapy costs were lower than would have been expected from clinical trial data. Altogether, these data encourage the use of T-VEC in this special patient cohort.

Trends in the characteristics of skin melanoma in accordance with time intervals: A single Turkish tertiary referral center experience

AIM

The incidence of skin melanoma has increased dramatically in recent years. The aim of this study was to analyze the trends in the features of Turkish cutaneous melanoma patients in a 25-year period.

MATERIALS AND METHODS

A total of 1258 adult melanoma patients who had been managed and followed up at a tertiary referral center between 1993 and 2017 were included in the study.

RESULTS

Males were predominant which did not vary between time intervals. There was an increase in the percentage of older patients over the years, whereas no change was observed in the percentage of younger patients. As the percentage of lower extremity melanoma dropped, the percentage of truncal melanomas rose. Both the incidences of thick (T3-T4) and thin melanomas (T1) were found to increase over time by 13.4% and 3.8%, respectively. There was no significant change in the percentage of the metastatic disease; however, Stage III disease was found to multiply by 10.1% and local disease was found to fall by 8.5% over the period. The percentages of patients with nodular histopathology and tumor-infiltrating lymphocytes were found to plummet, and there was a slight decline in the percentages of patients with high mitotic rate and lymphovascular invasion.

CONCLUSIONS

Most likely because of the delayed diagnosis, cutaneous melanoma was found to be associated with less favorable prognostic features as the time lapsed. We suggest that effective campaigns for public awareness of melanoma be implemented so the screening and early diagnosis of the disease can be promoted.

Location, location, location: Melanoma cells "living at the edge"

Abnormal cell migration and invasion underlie metastatic dissemination, one of the major challenges for cancer treatment. Melanoma is one of the deadliest and most aggressive forms of skin cancer due in part to its migratory and metastatic potential. Cancer cells use a variety of migratory strategies regulated by cytoskeletal remodelling. In particular, we discuss the importance of amoeboid invasive melanoma strategies, since they have been identified at the edge of human melanomas. We hypothesize that the presence of amoeboid melanoma cells will favour tumor progression since they are invasive and metastatic; they support immunosuppression; they harbour cancer stem cell properties and they are involved in therapy resistance. The Rho-ROCK-Myosin II pathway is key to maintain amoeboid melanoma invasion but this pathway is further regulated by pro-tumorigenic/pro-metastatic/pro-survival signalling pathways such as JAK-STAT3, TGFβ-SMAD, NF-κB, Wnt11/5-FDZ7 and BRAF^V600E -MEK-ERK. These pathways support amoeboid behaviour and are actionable in the clinic. After melanoma wide surgical margin removal, we propose that possible remaining melanoma cells should be eradicated using anti-amoeboid therapies.

Impact of multiple lymphatic basin drainage in truncal melanoma patients

INTRODUCTION

In many patients with cutaneous melanoma that affects the trunk area, there is lymphatic drainage to multiple basins (MLBD). This study aimed to examine whether MLBD is associated with disease outcomes.

METHODS

Lymphatic mapping and sentinel lymph node (SLN) biopsy were performed in 161 patients with truncal melanoma. The number and location of draining nodal basins were established during the preoperative lymphoscintigraphy using technetium-99 m rhenium sulphide nanocolloid.

RESULTS

MLBD was present in 59 (37%) patients, and single lymphatic basin drainage (SLBD) in 102 (63%) patients. Patients with MLBD showed no increased risk for SLN metastasis compared to patients with SLBD (27% versus 29%, respectively). There was no significant difference in disease-free survival (DFS) between patients with MLBD and those with SLBD. Five-year DFS was 64% for patients with MLBD and SLBD. Multivariate analysis showed that the presence of ulceration (p = 0.01) was an independent predictor of SLN metastasis, while melanoma thickness (p = 0.01) and SLN metastasis (p = 0.01) were independent predictors of DFS. In patients with a negative SLN, five-year DFS was 74% for patients with MLBD and 73% for those with SLBD. Multivariate analysis showed that melanoma thickness (p = 0.00) was an independent predictor of DFS.

CONCLUSION

MLBD does not negatively impact the disease outcome in patients with truncal melanoma.

Prognostic Factors and Clinical Outcomes of Clinical Node-Negative Cutaneous Malignant Melanoma Patients: An Asian Single Institute Study

INTRODUCTION

Cutaneous malignant melanoma is notorious for its aggressive behavior and relatively poor outcome compared with other common skin malignancies. Acral lentiginous melanoma (ALM) accounts for at least 50% of melanoma in the Asian population and has a significantly lower survival rate. However, previous studies of the prognostic factors of melanoma-specific survival were all conducted from Western institutions. Here, we performed a retrospective analysis to investigate this issue.

METHODS

Fifty patients diagnosed as having clinical node-negative cutaneous malignant melanoma who underwent sentinel lymph node (SLN) biopsy at Taipei Veterans General Hospital between January 2007 and December 2018 were enrolled. Patient demographics, tumor characteristics, and lymph node characteristics were evaluated by chart review.

RESULTS

Eighty-two percent of the melanoma in the sample population was ALM. Twelve patients (24.0%) presented at least 1 metastatic sentinel node, and the average number of retrieved SLNs was 3. Of the patients with positive SLNs who proceeded to completion lymph node dissection, only 2 (16.7%) had metastatic nonsentinel nodes (NSNs). The average follow-up time for all patients was 45 months. Recurrence and melanoma-specific death occurred in 21 patients (42.0%) and 15 patients (30.0%), respectively. Melanoma-specific survival was significantly lower in patients with ulcerative lesions (P = 0.005) and more metastatic SLNs (P = 0.036). The overall morbidity rate of completion lymph node dissection was 66.7%.

CONCLUSIONS

The presence of ulcerations and number of metastatic SLNs were the most important prognostic factors in this ALM-dominant Asian cohort. Among patients with clinically negative nodes but positive SLNs, less than one-fourth of patients harbored metastatic NSNs. Completion lymph node dissection carries a relatively high risk of morbidity; therefore, further research regarding predictors of positive NSNs in the Asian population is necessary.

The value of lymph node ultrasound and whole body 18F-FDG PET/CT in stage IIB/C melanoma patients prior to SLNB

BACKGROUND

Stage IIB/IIC (8th AJCC) melanoma patients are known to have high-risk primary tumors, however they follow the same routine to sentinel lymph node biopsy (SLNB) as more low risk tumors. Guidelines are not conclusive regarding the use of preoperative imaging for these patients. The aim of this pilot study was to assess the value of ultrasound (US) and 18F-FDG PET/CT prior to lymphoscintigraphy (LSG) and SLNB for stage IIB/C melanoma patients.

METHODS

From 2019-04 till 2020-01, all stage IIB/C melanoma patients underwent US of the regional lymph nodes and whole body 18F-FDG PET/CT before their planned LSG and SLNB. Suspected metastases were confirmed with fine needle aspiration (FNA), prior to surgery.

RESULTS

In total 23 patients were screened: six had metastases detected by imaging, two by US, one by 18F-FDG PET/CT and three were detected by both imaging modalities. All metastases were nodal and therefore treatment was altered to lymph node dissection and all but one also received adjuvant therapy. Eight (47%) of the 17 patients without macroscopic disease, still had a positive SN. Sensitivity, specificity and false negative rate for US and 18F-FDG PET/CT were 36%, 89%, 64% and 29%, 100% and 71%, respectively.

CONCLUSION

Preoperative negative imaging does not exclude the presence of SN metastases, therefore SLNB cannot be foregone. However, US detected metastases in 22% of patients, altering their treatment, which suggests it is effective in the work-up of stage IIB/C melanoma. Staging with 18F-FDG PET/CT is not of added value prior to LSG and SLNB and should therefore not be used.

Impact of Completion Lymphadenectomy on Quality of Life for Head and Neck Cutaneous Melanoma

OBJECTIVE

Recent randomized data suggest that completion lymph node dissection after a positive sentinel lymph node biopsy (SLNB) improves locoregional control but does not improve survival for melanoma patients. Locoregional recurrences of head and neck cutaneous melanoma (HNCM) may result in significant morbidity. A better understanding of morbidity is thus important to inform decisions about whether to pursue completion neck dissection (ND).

STUDY DESIGN

Cross-sectional study.

SETTING

Academic tertiary care hospital.

METHODS

Clinical data were collected for patients with HNCM seen between 2016 and 2019 who were at least 1-year disease free. Each patient completed the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS), Neck Dissection Impairment Index, and SF-36 (Short Form-36). Scores were compared by surgical treatment: wide local excision (WLE) only, SLNB, and ND. Univariate and multivariable regression was performed.

RESULTS

Of 474 patients, 140 returned questionnaires (29.5% response rate; WLE, n = 49; SLNB, n = 76; ND, n = 15). No significant differences in SLANSS or Neck Dissection Impairment Index scores were found between the WLE and SLNB groups. SLANSS scores differed by 2 SD (P = .001) in the ND cohort, which had a 36% rate of neuropathy. Neck impairment was worse by 1 SD (P = .01) in the ND cohort. No differences were found in SF-36 domains.

CONCLUSION

Neuropathy and neck impairment are components of morbidity after ND. These risks must be balanced with potential morbidity of locoregional recurrence in HNCM.

Patient-identified early clinical warning signs of nodular melanoma: a qualitative study

BACKGROUND

Nodular (NM) and superficial spreading melanoma (SSM) show different disease trajectories, with more rapid development in NM and fewer opportunities for early detection often resulting in worse outcomes. Our study described the patient-identified early signs of thin NM via comparisons to thin (≤ 2 mm) SSM and thick (> 2 mm) NM.

METHODS

We conducted semi-structured interviews with NM and SSM patients and analyzed the data using thematic analysis.

RESULTS

We enrolled 34 NM and 32 SSM patients. Melanoma early signs uniquely identified by patients with thin NM included white, blue or black coloration, "dot-like" size, fast changes in shape and color observed over 2 weeks, elevation and texture or "puffiness" over 6-12 months, and the sensation that the mole "did not feel right". Early signs reported by both thin NM and thin SSM patients included round or oblong shape, "jagged" border, pink/red, brown/reddish or dark coloration, "elevated like a pimple" or "tiny bump", fast color darkening, diameter growth, and border irregularity, and mole feeling "really itchy".

CONCLUSIONS

We found evidence that early signs of NM can be self-identified, which has important implications for the earlier detection of this most aggressive type of melanoma by both health professionals and patients.

Multiple combinations of melanocytic and vascular endothelial markers enhance the detection rate of lymphovascular invasion in cutaneous melanoma

BACKGROUND

Lymphovascular invasion (LVI) is believed to be the mechanism by which melanoma cells can disseminate to regional lymph nodes and distant sites and may be predictive of adverse outcome. Lymphovascular invasion often difficult to detect on hematoxylin-eosin (HE) stained sections, are readily identified with dual immunohistochemistry (IHC) for melanocytic and vascular markers.

METHODS

A total of 100 primary cutaneous malignant melanoma cases that had a Breslow thickness of 1-4 mm and lacked LVI by conventional HE assessment were included. We compared the LVI detection rates of double staining for CD31/S100 and CD34/S100, and D2-40/S100, and examined the association of LVI with clinical outcomes.

RESULTS

The dual immunohistochemical positivity for CD31/S100, CD34/S100, and D2-40/S100 were 40(40%), 17(17%) and 35(35%), respectively. On multivariate analysis, LVI was an independent predictor of SLN status. Multivariate analysis revealed that LVI and male gender were independent risk factors for overall survival.

CONCLUSIONS

The recognition of LVI is improved by dual IHC and predicts SLN metastasis. The detection of LVI using dual IHC, especially by a combination of CD31/S100 and D2-40/S100 is a useful step that inclusion should be recommended in basic evaluation parameters for cutaneous melanoma.

Construction and validation of a metabolic risk model predicting prognosis of colon cancer

Metabolic genes have played a significant role in tumor development and prognosis. In this study, we constructed a metabolic risk model to predict the prognosis of colon cancer based on The Cancer Genome Atlas (TCGA) and validated the model by Gene Expression Omnibus (GEO). We extracted 753 metabolic genes and identified 139 differentially expressed genes (DEGs) from TCGA database. Then we conducted univariate cox regression analysis and Least Absolute Shrinkage and Selection Operator Cox regression analysis to identify prognosis-related genes and construct the metabolic risk model. An eleven-gene prognostic model was constructed after 1000 resamples. The gene signature has been proved to have an excellent ability to predict prognosis by Kaplan-Meier analysis, time-dependent receiver operating characteristic, risk score, univariate and multivariate cox regression analysis based on TCGA. Then we validated the model by Kaplan-Meier analysis and risk score based on GEO database. Finally, we performed a weighted gene co-expression network analysis and protein-protein interaction network on DEGs, and Kyoto Encyclopedia of Genes and Genomes pathways and Gene Ontology enrichment analyses were conducted. The results of functional analyses showed that most significantly enriched pathways focused on metabolism, especially glucose and lipid metabolism pathways.

Vulvar and vaginal melanomas: A retrospective study spanning 19 years from a tertiary center

INTRODUCTION

Mucosal melanomas (MM) of the female genital tract are rare a. We aimed to study the prognostic factors of vulvar and vaginal locations of MM.

MATERIAL AND METHOD

A multicenter, retrospective cohort study conducted between 01/01/2000 and 01/06/2019.

RESULT

Of the 33 patients included 25 (75.8 %) had vulvar (VuM) and eight (24.2 %) vaginal melanomas (VaM). VaMs were deeper: median Breslow index: 17.5mm [3.5-22] versus 4.3mm [0.35-18] (p=0.013). Average follow-up was 24.0±59.8 months. Twenty-six patients (78.8 %) experienced recurrence. Disease-free survival was 52.9 % at 1year (64.7 % for VuM and 14.3 % for VaM) and 8.4 % at 3 years (11 % for VuM and 0% for VaM) (p=0.002). Median time to the first recurrence was 9.01 months [CI95 %: 2.07-56.71]. VaM recurred earlier than VuM (3.12 months [CI95 %: 2.07-12.49] versus 17.72 [CI95 %: 3.58-56.71], p=0.011). VaM had a higher risk of recurrence (HR=5.64 [CI95 %: 2.01-15.82], p=0.001) in multivariate analysis. Overall survival was 88.5 % at 1year (100 % for VuM and 50 % for VaM), and 59.4 % at 3 years (69.3 % for VuM and 25 % for VaM). Women with VaM died earlier: median specific death occurrence of 8.76 months [CI95 %: 6.54-24.72] versus 39.61 [CI95 %: 21.89-209.21], p=0.013 (HR=5.08 [CI95 %: 1.39-18.60], p=0.014). A lesion size ≥3cm was associated with an increased risk of mortality (HR=8.45 [CI95 %: 1.60-44.52], p=0.012). In multivariate analysis, vaginal location remained an independent and predictive variable of a higher risk of specific death (HR=8.56 [CI95 %: 1.95-37.64], p=0.005).

CONCLUSION

A vaginal location of MM is associated with a poorer prognosis than a vulvar location.

UTRN inhibits melanoma growth by suppressing p38 and JNK/c-Jun signaling pathways

Background

Utrophin (UTRN), as a tumor suppressor gene, is involved in various cancer progression. The function of UTRN in the melanoma process and the related molecular mechanisms are still unclear. Herein, we studied the function of UTRN in melanoma growth and the relevant molecular mechanisms.

Methods

Using the GEO database and UCSC Xena project, we compared the expression of UTRN in non-cancerous and melanoma tissues. Immunohistochemistry (IHC) staining, qRT-PCR and Western Blot (WB) were performed to evaluate UTRN expression in clinical samples. A total of 447 cases with UTRN expression data, patient characteristics and survival data were extracted from TCGA database and analyzed. After stable transduction and single cell cloning, the proliferation ability of A375 human melanoma cells was analyzed by Cell Counting Kit‑8 (CCK) and 5‑ethynyl‑2′‑deoxyuridine (EdU) incorporation assays. GSEA was performed to predict the mechanism by which UTRN regulated melanoma growth. Then WB analysis was used to assess the protein expression levels of pathway signaling in overexpression (EXP) melanoma cells. Epac activator 8-pCPT-2′-O-Me-cAMP was then used to evaluate the proliferation ability by activation of p38 and JNK/c-Jun signaling pathways.

Results

Data from GEO and UCSC Xena project indicated that UTRN expression was decreased in melanoma. Experiment on clinical samples further confirmed our finding. TCGA results showed that a reduced expression of UTRN in 447 melanoma samples was associated with advanced clinical characteristics (T stage, Clark level, ulceration), shorter survival time and poorer prognosis. In addition, up-regulated UTRN expression inhibited melanoma cell proliferation when compared to control group. MAPK signaling pathway was presented in both KEGG and BioCarta databases by using GSEA tool. WB results confirmed the down-regulated expression of p38, JNK1 and c-Jun in EXP group when compared to control group. Epac activator 8-pCPT-2′-O-Me-cAMP treatment could partially rescue proliferation of tumor cells.

Conclusion

We have demonstrated that reduced UTRN predicted poorer prognosis and UTRN inhibited melanoma growth via p38 and JNK1/c-Jun pathways. Therefore, UTRN could serve as a tumor suppressor and novel prognostic biomarker for melanoma patients.

Sentinel lymph node biopsy in acral melanoma: A Korean single-center experience with 107 patients (2006-2018)

BACKGROUND

Sentinel lymph node biopsy (SLNB) of primary cutaneous melanoma as an important staging method has not been popularly undertaken in Korea and only a few studies with small patient numbers have been published.

AIM

We examined the clinical feasibility and overall outcomes of SLNB in acral melanoma (AM) of Korean in Kyungpook National University Hospital (KNUH) over the past 13 years.

METHODS

SLNB in AM patients during 2006-2018 were analyzed retrospectively for sentinel lymph node (SLN) harvesting rate, positivity rate, positivity-relevant overall survival (OS) and disease-free survival (DFS), and its side effects.

RESULTS

A total of 109 AM patients who underwent SLNB were enrolled. Harvested nodes were identified from 107 patients and SLN harvesting rate was 98.2%. The mean Breslow thickness (±standard deviation) was 3.38 ± 3.03 mm, and the proportion of ulcerated melanomas was 64%. Twenty-two (20.6%) had a tumor-positive SLN and, among them, 82% (18/22) underwent immediate complete lymph node dissection (CLND). The metastasis-positive nodal basin after CLND was detected in 16.7% of cases (3/18). Tumor-negative SLN cohorts showed significantly better OS and DFS than tumor-positive ones (P = 0.006 and P < 0.001 for each). Two side effects, one seroma and one lymphocele, were observed without major sequelae.

CONCLUSION

SLNB, crucial management of melanoma, proved its efficacy to predict patients' prognosis and could be performed successfully and safely in Korean AM patients by interdisciplinary cooperation between dermatology and other surgical departments. SLN(-) showed significantly better OS and DFS than SLN(+). Significant risk factors for DFS were Breslow thickness, the presence of ulceration and the presence of SLN metastasis. SLNB should be encouraged in order to stage melanoma accurately and direct the proper management in Korean AM.

The Differential Diagnosis of Medullary-Based Renal Masses

CONTEXT.—

Renal malignancies can be divided into cortical- and medullary-based tumors, the latter of which classically infiltrate the renal parenchyma by extending between nonneoplastic structures. Although high-grade cortical tumors can rarely exhibit the same growth pattern, the infiltrative morphology should elicit a differential diagnosis to be considered in each case. However, these diagnoses can be challenging to distinguish, especially on small renal biopsy samples.

OBJECTIVE.—

To provide an overview of the clinical, gross, and microscopic findings; genetic and molecular alterations; and immunohistochemical evaluation of medullary-based renal tumors and other tumor types with overlapping morphologies and growth patterns.

DATA SOURCES.—

Literature review and personal observations were used to compile the information in this review.

CONCLUSIONS.—

Collecting duct carcinoma is a prototypical medullary-based tumor, and although diagnostic criteria exist, it remains a diagnosis of exclusion, especially with ancillary techniques aiding the recognition of established as well as more recently described neoplasms. Other medullary-based malignancies included in the differential diagnosis include renal medullary carcinoma/renal cell carcinoma unclassified with medullary phenotype, fumarate hydratase-deficient renal cell carcinoma, and upper tract urothelial carcinoma. Moreover, other rare entities should be excluded, including metastatic carcinoma, lymphoma, and melanoma. In addition to potential prognostic differences, accurate diagnoses can have important surgical and clinical management implications.

Plant Extracts as a Natural Source of Bioactive Compounds and Potential Remedy for the Treatment of Certain Skin Diseases

Skin ailments present a major health burden in both developed and undeveloped countries. Maintaining healthy skin is important for a healthy body. Medicinal plants have long provided reliable therapy in the treatment of skin diseases in humans through a diverse range of bioactive molecules. Skin diseases may have a various basis, or may be genetically determined; together, they constitute approximately 34% of all occupational diseases encountered in people of all ages. Of these, melanoma is one of the most dangerous forms, with very poor prognosis for patients if it is diagnosed too late. This review of the literature over the past five years examines the role and utilities of plant extracts in treating various skin diseases such as atopic dermatitis, acne or melanoma with various potential mechanisms of action.

Real-world experience with elective discontinuation of PD-1 inhibitors at 1 year in patients with metastatic melanoma

BACKGROUND

Randomized trials evaluating programmed cell death protein 1 (PD-1) inhibitors in metastatic melanoma either permitted treatment for 2 years (pembrolizumab) or more (nivolumab). The optimal duration of therapy is currently unknown due to limited data, and shorter therapies may be effective.

METHODS

Data of patients with metastatic cutaneous melanoma treated with single-agent PD-1 inhibitors at Huntsman Cancer Institute from January 1, 2015, to December 31, 2018, was reviewed to identify a continuous series of patients who made the joint decision with their provider to electively discontinue therapy at 1 year (>6 months and <18 months) in the setting of ongoing treatment response or disease stability. Patients were excluded if they received PD-1 inhibitors with other systemic therapy, had prior exposure to PD-1 therapy, or discontinued treatment due to disease progression or immune-related adverse event. Best objective response (BOR) per RECIST V.1.1 at treatment discontinuation, progression-free survival (PFS), and retreatment characteristics was analyzed.

RESULTS

Of 480 patients who received PD-1 inhibitors, 52 met the inclusion criteria. The median treatment duration from first to the last dose was 11.1 months (95% CI 10.5 to 11.4). BOR was complete response in 13 (25%), partial response in 28 (53.8%), and stable disease in 11 (21.2%) patients. After a median follow-up of 20.5 months (range 3-49.2) from treatment discontinuation, 39 (75%) patients remained without disease progression, while 13 (25%) had progression (median PFS 3.9 months; range 0.7-30.9). On multivariable analysis, younger age, history of brain metastasis, and higher lactate dehydrogenase at the time of anti-PD-1 discontinuation were associated with recurrence. Patients with recurrent melanoma were managed with localized treatment, anti-PD-1 therapies, and BRAF-MEK inhibitors. All patients except one were alive at data cutoff.

CONCLUSION

In this large real-world, observational cohort study, the majority of patients with metastatic melanoma after 1 year of anti-PD-1 therapy remained without progression on long-term follow-up. The risk of disease progression even in patients with residual disease on imaging was low. After prospective validation, elective PD-1 discontinuation at 1 year may reduce financial and immunotherapy-related toxicity without sacrificing outcomes.

Protocol for the Histologic Diagnosis of Cutaneous Melanoma: Consensus Statement of the Spanish Society of Pathology and the Spanish Academy of Dermatology and Venereology (AEDV) for the National Cutaneous Melanoma Registry

This article describes a proposed protocol for the histologic diagnosis of cutaneous melanoma developed for the National Cutaneous Melanoma Registry managed by the Spanish Academy of Dermatology and Venereology (AEDV). Following a review of the literature, 36 variables relating to primary tumors, sentinel lymph nodes, and lymph node dissection were evaluated using the modified Delphi method by a panel of 8 specialists (including 7 pathologists). Consensus was reached on the 30 variables that should be included in all pathology reports for cutaneous melanoma and submitted to the Melanoma Registry. This list can also serve as a model to guide routine reporting in pathology departments.

Multidimensional indicators of scholarly impact in the skin oncology literature: is there a correlation between bibliometric and altmetric profiles?

Introduction: Bibliometric and altmetric analyses are used to identify landmark publications in their respective research field. We hypothesised that highly cited skin oncology articles correlate positively with the Oxford Evidence Based Medicine scoring level, altmetric score (AS) and rank within the top 100 manuscripts.Methods: Thomson Reuter's Web of Science citation indexing database was searched to identify all English-language skin oncology full-text articles in the last 75 years. The top 100 articles with the highest citation count were analysed by subject matter, publishing journal, author, year, institution, individual and five-year impact factor, AS and Oxford EBM level. Results: 180,132 articles were identified. The most cited article (Hodi et al.) demonstrated improved survival with ipilimumab in patients with metastatic melanoma (7894 citations). The article with the highest AS was Esteva et al. (AS = 576.7, 'dermatologist-level classification of skin cancer with deep neural networks'). No difference was found between evidence level and citation count (r = -0.1239, p = 0.2291), but a significant difference was seen for AS (r = -0.3024, p = 0.0028). AS scores increased over time, whereas bibliometrics did not. Conclusion: This work highlights the most influential work in the skin oncology field in the last 75 years. We have identified a differential relationship between commonly used metrics and evidence level in the field of skin oncology. As the digitalisation of research output and consumption increases, both bibliometric and altmetric analyses need to be considered when an article's impact is being assessed.

Transformation of Malignant Melanoma From Giant Nevus in Infantile Penis

Background: Malignant melanoma is the most serious type of skin cancer, and its incidence rate increases with age. Malignant melanoma in infants has been rarely reported in the literature. Herein, we report a case of malignant transformation of a nodular lesion found in the penis of a patient with a giant congenital nevus.

Case presentation: A 1-month-old male patient was admitted due to the presence of a giant congenital nevus involving the lower abdomen, bilateral inguinal areas, genitals, and left thigh and knee. Six months later, nodules measuring 1 cm in diameter protruding from the genital area were noted, and a part of the nodule was removed via elliptical excision with the patient under general anesthesia. Gross examination showed an edematous lesion similar to a neurofibroma and with unclear boundaries. Biopsy revealed a malignant melanoma, with a Breslow thickness of at least 3 mm, and absence of lymphovascular invasion; the biopsy confirmed incomplete excision. The patient was scheduled for radical resection, but reconstruction was not performed following surgical resection due to the guardian's refusal. Hence, the patient only received an adjuvant medical treatment and eventually died.

Conclusion: We reported a rare case of an infant with a malignant melanoma in the penis. Congenital malignant melanoma rarely occurs in infants; however, due to its fatal consequences, follow-up should be performed to assess for malignant changes.

[Protocol for the histologic diagnosis of cutaneous melanoma: consensus statement of the Spanish Society of Pathology and the Spanish Academy of Dermatology and Venereology (AEDV) for the National Cutaneous Melanoma Registry]

This article describes a proposed protocol for the histologic diagnosis of cutaneous melanoma developed for the National Cutaneous Melanoma Registry managed by the Spanish Academy of Dermatology and Venereology (AEDV). Following a review of the literature, 36 variables relating to primary tumors, sentinel lymph nodes, and lymph node dissection were evaluated using the modified Delphi method by a panel of 8 specialists (including 7 pathologists). Consensus was reached on the 30 variables that should be included in all pathology reports for cutaneous melanoma and submitted to the Melanoma Registry. This list can also serve as a model to guide routine reporting in pathology departments.

Stage IIIa Melanoma and Impact of Multiple Positive Lymph Nodes on Survival

BACKGROUND

For patients with cutaneous melanoma, having >1 positive lymph node (LN) is associated with worse survival. We hypothesized that for stage IIIA patients, N2a disease (2 to 3 positive LN) would be associated with a worse prognosis compared to those with N1a disease (1 positive LN).

STUDY DESIGN

Stage IIIA melanoma patients in the NCDB Participant User File from 2010 to 2016 were analyzed. Overall survival (OS) between N1a and N2a patients was compared. Subgroup analyses were made between patients undergoing sentinel lymph node (SLN) biopsy alone and those undergoing subsequent completion lymph node dissection (CLND). A separate post hoc analysis of T2a patients undergoing SLN biopsy and CLND from a prospective multicenter randomized clinical trial was performed to validate the findings.

RESULTS

Records of 2,305 IIIA patients were evaluated. In an adjusted survival model, N2a disease was an independent risk factor for worse OS (hazard ratio [HR] 1.56, p = 0.0052). In the subgroup analysis, there was no difference in OS between N1a and N2a disease for patients who underwent SLN biopsy without CLND (p = 0.59), but there was a significant difference in OS for patients who underwent SLN biopsy plus CLND (p = 0.0009). The separate clinical trial database confirmed that for patients with SLN-only disease, there was no difference in OS between N1a and N2a disease.

CONCLUSIONS

For stage IIIA melanoma patients, the distribution of micrometastatic lymph node disease (SLN or non-SLN), rather than the absolute number of SLNs, should be considered when individualizing adjuvant therapy recommendations.

Survival prediction in patients with cutaneous melanoma by tumour lymphangiogenesis

Objectives: Melanoma induces lymphangiogenesis by secreting lymphangiogenic growth factors. The aim of this study was to examine the role of tumour lymphangiogenesis in survival of patients with cutaneous melanoma. Methods: Immunostaining of one hundred melanoma specimens was done with lymphatic-specific antibody D2-40. The quantification of tumour lymphangiogenesis - lymphatic vessel density (LVD) and lymphatic vessel area (LVA) - was calculated by computer-assisted morphometric analysis. Results: High intratumoural LVD, high peritumoural LVD, male gender, greater tumour thickness and Clark level IV/V were significantly associated with shorter disease-free survival (p= 0.001, p= 0.004, p= 0.004, p= 0.000 and p= 0.008, respectively) and melanoma-specific survival (p= 0.002, p= 0.002, p= 0.001, p= 0.000 and p= 0.017, respectively), while the trunk melanoma site was significantly associated only with shorter disease-free survival (p= 0.033). No significant association of LVA with survival was found. At multivariate analysis, peritumoural LVD [hazard ratio (HR) = 2.143, 95% confidence interval (CI) 1.097-4.189, p= 0.026)] and melanoma thickness (HR = 1.276, 95%CI 1.106-1.473, p= 0.001) were independent predictors of disease-free survival, while intratumoural LVD (HR = 3.446, 95%CI 1.465-8.109, p= 0.005), peritumoural LVD (HR = 2.742, 95%CI 1.313-5.725, p= 0.007) and gender (HR = 2.880, 95%CI 1.304-6.362, p= 0.009) were independent predictors of melanoma-specific survival. Conclusion: Тhis study shows that LVD enables better prediction of survival than melanoma thickness and other clinical-pathological parameters. Intratumoural LVD is the most significant predictor of melanoma-specific survival, while only peritumoural LVD has a significant impact on both, a disease-free survival and a melanoma-specific survival.

Listing Malignant Melanoma Patients for Renal Transplantation

BACKGROUND

Melanoma is an immune responsive malignancy and the need for immunosuppression for successful transplantation may lead to recurrent disease. The recommended waiting time is unknown with various groups recommending anywhere from no wait to 5 years.

METHODS

In this single-center, retrospective observational study all kidney transplant recipients' charts from 1991 to 2015 were reviewed for a diagnosis of melanoma before transplantation. The charts were reviewed for the clinical characteristics of melanoma pre transplantation, induction immunosuppression, maintenance immunosuppression, graft function, death, and recurrence of melanoma.

RESULTS

Thirteen patients with a history of melanoma underwent kidney transplantation during this period. Recipients had been in remission for an average of 7.0 years (range, 10 months to 20 years, median 6 years). Approximately 61.5% received a living donor transplant, antithymocyte globulin was administered in 23.1% of recipients, and the remaining 76.9% received basiliximab. Melanoma recurred in 1 patient (7.7%). Maintenance immunosuppression varied, but only 2 patients remained on standard triple therapy with prednisone, calcineurin inhibitor, and antimetabolite therapy. Average follow-up time since transplant was 7.5 years, with 1 patient death 9 years post transplant from sepsis.

CONCLUSION

In conclusion, with our center demonstrates safety of kidney transplantation in patients with a prior history of localized melanoma and shorter waiting time. In malignant melanoma stage 0 and 1, waiting the recommended 5 years from the time of remission to kidney transplantation should be reconsidered.

A glitch in the matrix: Age-dependent changes in the extracellular matrix facilitate common sites of metastasis

People over 55 years old represent the majority of cancer patients and suffer from increased metastatic burden compared to the younger patient population. As the aging population increases globally, it is prudent to understand how the intrinsic aging process contributes to cancer progression. As we age, we incur aberrant changes in the extracellular matrix (ECM) of our organs, which contribute to numerous pathologies, including cancer. Notably, the lung, liver, and bone represent the most common sites of distal metastasis for all cancer types. In this review, we describe how age-dependent changes in the ECM of these organs influence cancer progression. Further, we outline how these alterations prime the premetastatic niche and why these may help explain the disparity in outcome for older cancer patients.

A Framework of Major Tumor-Promoting Signal Transduction Pathways Implicated in Melanoma-Fibroblast Dialogue

Simple Summary

Melanoma cells reside in a complex stromal microenvironment, which is a critical component of disease onset and progression. Mesenchymal or fibroblastic cell type are the most abundant cellular element of tumor stroma. Factors secreted by melanoma cells can activate non-malignant associated fibroblasts to become melanoma associate fibroblasts (MAFs). MAFs promote tumorigenic features by remodeling the extracellular matrix, supporting tumor cells proliferation, neo-angiogenesis and drug resistance. Additionally, environmental factors may contribute to the acquisition of pro-tumorigenic phenotype of fibroblasts. Overall, in melanoma, perturbed tissue homeostasis contributes to modulation of major oncogenic intracellular signaling pathways not only in tumor cells but also in neighboring cells. Thus, targeted molecular therapies need to be considered from the reciprocal point of view of melanoma and stromal cells.

Abstract

The development of a modified stromal microenvironment in response to neoplastic onset is a common feature of many tumors including cutaneous melanoma. At all stages, melanoma cells are embedded in a complex tissue composed by extracellular matrix components and several different cell populations. Thus, melanomagenesis is not only driven by malignant melanocytes, but also by the altered communication between melanocytes and non-malignant cell populations, including fibroblasts, endothelial and immune cells. In particular, cancer-associated fibroblasts (CAFs), also referred as melanoma-associated fibroblasts (MAFs) in the case of melanoma, are the most abundant stromal cells and play a significant contextual role in melanoma initiation, progression and metastasis. As a result of dynamic intercellular molecular dialogue between tumor and the stroma, non-neoplastic cells gain specific phenotypes and functions that are pro-tumorigenic. Targeting MAFs is thus considered a promising avenue to improve melanoma therapy. Growing evidence demonstrates that aberrant regulation of oncogenic signaling is not restricted to transformed cells but also occurs in MAFs. However, in some cases, signaling pathways present opposite regulation in melanoma and surrounding area, suggesting that therapeutic strategies need to carefully consider the tumor–stroma equilibrium. In this novel review, we analyze four major signaling pathways implicated in melanomagenesis, TGF-β, MAPK, Wnt/β-catenin and Hyppo signaling, from the complementary point of view of tumor cells and the microenvironment.

Validation of a clinicopathological and gene expression profile model for sentinel lymph node metastasis in primary cutaneous melanoma

BACKGROUND

The Clinicopathological and Gene Expression Profile (CP-GEP) model was developed to accurately identify patients with T1-T3 primary cutaneous melanoma at low risk for nodal metastasis.

OBJECTIVES

To validate the CP-GEP model in an independent Dutch cohort of patients with melanoma.

METHODS

Patients (aged ≥ 18 years) with primary cutaneous melanoma who underwent sentinel lymph node biopsy (SLNB) between 2007 and 2017 at the Erasmus Medical Centre Cancer Institute were eligible. The CP-GEP model combines clinicopathological features (age and Breslow thickness) with the expression of eight target genes involved in melanoma metastasis (ITGB3, PLAT, SERPINE2, GDF15, TGFBR1, LOXL4, CXCL8 and MLANA). Using the pathology result of SLNB as the gold standard, performance measures of the CP-GEP model were calculated, resulting in CP-GEP high risk or low risk for nodal metastasis.

RESULTS

In total, 210 patients were included in the study. Most patients presented with T2 (n = 94, 45%) or T3 (n = 70, 33%) melanoma. Of all patients, 27% (n = 56) had a positive SLNB, with nodal metastasis in 0%, 30%, 54% and 16% of patients with T1, T2, T3 and T4 melanoma, respectively. Overall, the CP-GEP model had a negative predictive value (NPV) of 90·5% [95% confidence interval (CI) 77·9-96.2], with an NPV of 100% (95% CI 72·2-100) in T1, 89·3% (95% CI 72·8-96·3) in T2 and 75·0% (95% CI 30·1-95·4) in T3 melanomas. The CP-GEP indicated high risk in all T4 melanomas.

CONCLUSIONS

The CP-GEP model is a noninvasive and validated tool that accurately identified patients with primary cutaneous melanoma at low risk for nodal metastasis. In this validation cohort, the CP-GEP model has shown the potential to reduce SLNB procedures in patients with melanoma.

Cancer progression and the invisible phase of metastatic colonization

Metastatic dissemination occurs very early in the malignant progression of a cancer but the clinical manifestation of metastases often takes years. In recent decades, 5-year survival of patients with many solid cancers has increased due to earlier detection, local disease control and adjuvant therapies. As a consequence, we are confronted with an increase in late relapses as more antiproliferative cancer therapies prolong disease courses, raising questions about how cancer cells survive, evolve or stop growing and finally expand during periods of clinical latency. I argue here that the understanding of early metastasis formation, particularly of the currently invisible phase of metastatic colonization, will be essential for the next stage in adjuvant therapy development that reliably prevents metachronous metastasis.

Completely resected stage III melanoma controversy - 15 years of national tertiary centre experience

BACKGROUND

Two prospective randomized studies analysing cutaneous melanoma (CM) patients with sentinel lymph node (SLN) metastases and rapid development of systemic adjuvant therapy have changed our approach to stage III CM treatment. The aim of this study was to compare results of retrospective survival analysis of stage III CM patients' treatment from Slovenian national CM register to leading international clinical guidelines.

PATIENTS AND METHODS

Since 2000, all Slovenian CM patients with primary tumour ≥ TIb are treated at the Institute of Oncology Ljubljana and data are prospectively collected into a national CM registry. A retrospective analysis of 2426 sentinel lymph node (SLN) biopsies and 789 lymphadenectomies performed until 2015 was conducted using Kaplan-Meier survival curves and log-rank tests.

RESULTS

Positive SLN was found in 519/2426 (21.4%) of patients and completion dissection (CLND) was performed in 455 patients. The 5-year overall survival (OS) of CLND group was 58% vs. 47% of metachronous metastases group (MLNM) (p = 0.003). The 5-year OS of patients with lymph node (LN) metastases and unknown primary site (UPM) was 45% vs. 21% of patients with synchronous LN metastasis. Patients with SLN tumour burden < 0.3 mm had 5-year OS similar to SLN negative patients (86% vs. 85%; p = 0.926). The 5-year OS of patients with burden > 1.0 mm was similar to the MLNM group (49% vs. 47%; p = 0.280).

CONCLUSIONS

Stage III melanoma patients is a heterogeneous group with significant OS differences. CLND after positive SLNB might still remain a method of treatment for selected patients with stage III.

The impact of metformin on survival in patients with melanoma-national cohort study

PURPOSE

The primary study outcome was melanoma-specific mortality in patients with type 2 diabetes mellitus (T2DM) using metformin.

METHODS

Data regarding patients were provided by the Lithuanian Cancer Registry and were linked with National Health Insurance Fund in accordance with unique personal identification numbers during the period of thirteen years.

RESULTS

About 2817 patients met eligibility criteria and were included in the retrospective cohort study. About 163 patients had pre-existing T2DM and 103 of them were treated with metformin. In the multivariable analysis, there was significant risk difference in melanoma-specific survival between diabetic, metformin-using patients, and nondiabetic patients (P=0.02) in favor of metformin users.

CONCLUSION

Melanoma patients with T2DM treated with metformin had lower risk of melanoma-specific mortality; however, prospective controlled studies are mandatory to confirm this finding.

Relevance of sentinel lymph node biopsy for thick melanoma in the era of immunotherapy

BACKGROUND

Sentinel lymph node biopsy provides prognostic information in patients with thick melanoma but is often underutilized. We examine regional lymph node evaluation (RLNE) in patients with thick melanoma and the effect on treatment and overall survival (OS).

METHODS

Patients with clinical T4N0M0 melanoma were selected from the National Cancer Database (2004-2015). Binary logistic regression analysis was used to identify factors associated with RLNE and treatment. Overall survival analysis was performed.

RESULTS

A total of 14 286 patients with clinical T4N0M0 melanoma were identified; RLNE was performed in 70.2% of patients, and positive LNs were identified in 27.1%. RLNE was more likely in males (OR:1.44, 95%CI: 1.32-1.56, p < .001), and patients treated at academic centers (OR:1.58, 95%CI:1.46-1.71, p < .001). Immunotherapy was more commonly used in patients with RLNE (13.9% vs 3.4%, p < .001) and was associated with positive LNs (OR:2.50, 95%CI:2.19-2.86, p < .001). The 5-year OS for RLNE was 56.9% and for no RLNE was 32.7%. Independent factors associated with better OS were treatment at an academic center (HR:0.88, 95%CI:0.84-0.93, p < .001), and immunotherapy use (HR:0.86, 95%CI:0.76-0.96, p < .001).

CONCLUSION

The use of RLNE in patients with thick melanoma is important for prognosis and to risk stratify patients for selection of adjuvant therapies and clinical trials.

Malignant melanoma metastasis in the gallbladder. A case report of an unusual metastatic site

•

Malignant melanoma metastasis into the gallbladder is a rare issue.

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Surgical treatment in a metastasized situation has to be carefully evaluated.

•

Prevention of possible biliary complications is of significant importance.

Introduction

Malignant melanoma is a neoplasia with the ability to metastasize to all organs. Most frequently, metastases derives from a skin primary. A solitary metastasis in the gallbladder is rarely mentioned in current literature.

Presentation of case

We present the case of a 62-year-old female patient with the unusual metastatic spread of malignant melanoma into the gallbladder. The lesion was detected during routine follow up appointment six years after the initial surgical and radio-chemotherapeutic treatment of a malignant melanoma on the back. Following multidisciplinary team meeting, it was decided to perform a laparoscopic cholecystectomy to remove the gallbladder metastasis.

Discussion

New occurrence of a melanoma metastasis in the gallbladder is extremely rare, especially in stable disease. The therapeutical concept must be discussed extensively in the present of this metastasized tumor.

Conclusion

In otherwise stable disease, palliative surgery for metastasis in the gallbladder is a possible option to prevent biliary complications. In a palliative setting always weigh up the risks and benefits while maintaining the quality of life.

Extracapsular Spread in Melanoma Lymphadenopathy: Prognostic Implications, Classification, and Management

BACKGROUND

Extracapsular spread (ECS) is recognized to be a high-risk factor in melanoma patients with macrometastatic (N+) nodal disease; however, ECS risk in sentinel lymph node (SLN) biopsy, micrometastatic stage III disease is ambiguous.

OBJECTIVE

The aim of this study was to examine ECS incidence and its prognostic significance.

METHODS

A two-center, retrospective analysis of all patients with micro/macrometastatic lymphadenopathy undergoing nodal surgery from 2008 to 2014 was performed. Patient demographics, tumor characteristics, nodal ECS status, and patient outcomes were collected.

RESULTS

Overall, 515 patients with nodal disease were identified (males/females = 277/238); median age was 63 years (range 17-94). There was an increased frequency of ECS disease in N+ disease compared with SLN+ disease (52.4% vs. 16.2%; p < 0.0001). The absolute disease-specific survival (DSS) difference for SLN+ patients was approximately 30% at 10 years (66.2% vs. 37.2%; p < 0.0001), and the prognosis of SLN+/ECS+ patients was identical to N+/ECS- patients. Multivariate analysis demonstrated that ECS status was an independent prognostic indicator for DSS (hazard ratio 2.47, 95% confidence interval 1.87-3.26; p < 0.0001) in patients with SLN+ disease. There were significant differences in nodal burden according to ECS status between the SLN+ and N+ subgroups suggestive of differing biology in ECS+ tumors.

CONCLUSION

We found that ECS is a significant DSS, progression-free survival, and overall survival indicator in SLN+ and N+ disease. We demonstrated that ECS upstages stage III disease, similar to ulceration in primary melanoma (stage I/II disease). A simplified staging system substituting ECS for N stage accurately stages patients according to prognosis.

Clinicopathologic Features of Cutaneous Malignant Melanoma and Their Impact on Prognosis

Introduction: Melanoma ranks 19th among malignancies overall and second among cutaneous types. The incidence worldwide has been on the rise over the last seven decades. Various prognostic factors have been assessed and found to have a profound impact on patient outcome. However, no such studies have been attempted in our population. Our study aimed to have an insight into the behavior of malignant melanoma in our population.

Materials and Methods: Cases of cutaneous malignant melanoma treated and followed up at our institute were included in this study. Cases of mucosal and choroidal melanoma were excluded. The parameters noted were age, gender, tumor thickness, Clark level, and presence of ulceration. These parameters were individually correlated with development of distant metastasis, two-year survival, survival duration, and primary tumor and lymph node stage. Appropriate statistical analyses were done.

Results: Thirty patients of cutaneous malignant melanomas were treated and followed up at our institution. There was male predilection of 1:1.5. Mean age at diagnosis was 50.1 years. Two-year survival was significantly better in females. Sun-exposed areas of the skin were most commonly involved followed by anal canal that has an unusually high incidence in our society. Majority of our cases were pT4(25) on tumor, nodal status, metastasis (TNM) staging at time of diagnosis. Increasing tumor thickness in terms of primary tumor staging was not found to have any significant impact on two-year survival, distant metastasis, lymph node stage, or survival duration. Sixty percent of cases had ulceration. There was no statistically significant effect on two-year survival (78% in ulcerated group vs 75% in nonulcerated group) and distant metastasis (61% vs 58.3%). In terms of Clark level, 20 cases were level V, seven cases were level IV, two were level III, and one was level I. There was no statistically significant difference between the Clark levels in terms of two years survival, development of distant metastasis, and lymph node stages.

Conclusion: Melanoma is an aggressive malignancy that causes high morbidity and morality. It commonly presents at an advanced stage at time of diagnosis in our population. Broader studies are required with early-stage melanomas to compare the various prognostic factors and their impact on prognosis.

Tumor-Infiltrating Lymphocytes and Their Prognostic Value in Cutaneous Melanoma

Recent breakthroughs in tumor immunotherapy such as immune checkpoint blockade (ICB) antibodies, have demonstrated the capacity of the immune system to fight cancer in a number of malignancies such as melanoma and lung cancer. The numbers, localization and phenotypes of tumor-infiltrating lymphocytes (TIL) are not only predictive of response to immunotherapy but also key modulators of disease progression. In this review, we focus on TIL profiling in cutaneous melanoma using histopathological approaches and highlight the observed prognostic value of the primary TIL subsets. The quantification of TIL in formalin-fixed tumor samples ranges from visual scoring of lymphocytic infiltrates in H&E to multiplex immunohistochemistry and immunofluorescence followed by enumeration using image analysis software. Nevertheless, TIL enumeration in the current literature primarily relies upon single marker immunohistochemistry analyses of major lymphocyte subsets such as conventional T cells (CD3, CD4, CD8), regulatory T cells (FOXP3) and B cells (CD20). We review key studies in the literature on associations between TIL subsets and patient survival. We also cover recent findings with respect to the existence of ectopic lymphoid aggregates found in the TME which are termed tertiary lymphoid structures (TLS) and are generally a positive prognostic feature. In addition to their prognostic significance, the existence of various TIL sub-populations has also been reported to predict a patient's response to ICB. Thus, the literature on the predictive potential of TIL subsets in melanoma patients receiving ICB has also been discussed. Finally, we describe recently developed state-of-the-art profiling approaches for tumor infiltrating immune cells such as digital pathology scoring algorithms (e.g., Immunoscore) and multiplex proteomics-based immunophenotyping platforms (e.g., imaging mass cytometry). Translating these novel technologies have the potential to revolutionize tumor immunopathology leading to altering our current understanding of cancer immunology and dramatically improving outcomes for patients.

Prognostic significance of pretreatment neutrophil-to-lymphocyte ratio in patients with laryngeal cancer: a systematic review and meta-analysis

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been shown to be associated with the progression of laryngeal cancer (LC), but studies have reported inconsistent results. We systematically evaluated the effect of the pretreatment NLR on the prognosis of LC in the meta-analysis.

METHOD

The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched from January 1, 2000 to September 10, 2019, to identify studies investigating the relationship between the NLR and outcomes in LC patients. The fixed-effects model was used to assess the pooled hazard ratio (HR), along with the 95% confidence interval (95% CI).

RESULTS

A total of 105 records were obtained through the databases and 12 studies enrolling 3710 patients were included in the meta-analysis. The pooled overall survival (OS, HR = 1.76, 95% CI 1.53-2.03, P < 0.001), progression-free survival (PFS, HR = 1.72, 95% CI 1.38-2.13, P < 0.001) and disease-free survival (DFS, HR = 1.66, 95% CI 1.33-2.07, P < 0.001) indicated that a higher NLR led to a poorer prognosis for patients with LC. In terms of publication year, country, cutoff value, cutoff method, treatment modality, statistical model and NOS score, subgroup analyses consistently showed a worse OS in patients with an elevated NLR. Additionally, there was no significant difference among the subgroups (all P for heterogeneity > 0.05).

CONCLUSION

An elevated pretreatment NLR is significantly associated with poorer prognosis in patients with LC. NLR values are easily obtained from routinely collected blood samples and could assist clinicians in determining the prognosis of LC patients.

What's new in pediatric melanoma: An update from the APSA cancer committee

BACKGROUND/PURPOSE

Melanoma is the most common skin cancer in children and often presents in an atypical fashion when compared to adults. The purpose of this review is to present an update on the epidemiology, surgical and medical management and prevention strategies in pediatric melanoma.

METHODS

A comprehensive review of the current literature on the epidemiology, surgical and medical management and prevention of adult and pediatric melanoma was performed by the authors and the results of this review are summarized in the manuscript.

RESULTS

Most recently, the incidence of melanoma in children has been declining, possibly owing to increased awareness and sun exposure prevention. The mainstay of therapy is surgical resection, often with sentinel lymph node biopsy. A positive sentinel node has prognostic value; however, completion node dissection is no longer recommended in the absence of clinically or radiographically positive nodes. Those with advanced disease also receive adjuvant systemic therapy using increasingly targeted immunologic therapies.

CONCLUSIONS

Sentinel lymph node positive patients no longer require completion lymph node dissection and instead may be followed by ultrasound. However, it is important to note that children have been excluded from most melanoma clinical trials to date, and therefore, recommendations for management are based on existing pediatric retrospective data and extrapolation from adult studies.

LEVEL OF EVIDENCE

IV.

Clinicopathological Features, Staging, and Current Approaches to Treatment in High-Risk Resectable Melanoma

The incidence of melanoma in the United States has been increasing over the past several decades. Prognosis largely depends on disease stage, with 5-year melanoma-specific survival ranging from as high as 99% in patients with stage I disease to less than 10% for some patients with stage IV (distant metastatic) disease. Fortunately, in the last 5-10 years, there have been remarkable treatment advances for patients with high-risk resectable melanoma, including approval of targeted and immune checkpoint blockade therapies. In addition, results of recent clinical trials have confirmed the importance of sentinel lymph node biopsy and continue to refine the approach to regional lymph node basin management. Lastly, the melanoma staging system was revised in the eighth edition AJCC Cancer Staging Manual, which was implemented on January 1, 2018. Here we discuss these changes and the clinicopathological features that confer high risk for locoregional and distant disease relapse and poor survival. Implications regarding the management of melanoma in the metastatic and adjuvant settings are discussed, as are future directions for neoadjuvant therapies.

Associations between the ultrasound features of invasive breast cancer and breast cancer specific survival

AIM

To assess whether ultrasound features of breast cancer are associated with breast cancer specific survival (BCSS).

MATERIALS AND METHODS

Within a single breast service, data was collected prospectively (April 2010-April 2012) from 319 consecutive women (mean age 63 years) with 335 ultrasound-visible invasive breast cancers. Ultrasound features were evaluated retrospectively from the recorded images according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon by a radiologist blinded to outcomes. Survival and cause of death were ascertained from local and national sources. Kaplan-Meier survival curves were generated, and statistical significance tested using the log-rank test.

RESULTS

Mean follow-up in those alive was 80.9 months. Thirty breast cancer deaths and 45 non-breast cancer deaths occurred. Five-year BCSS in the presence of distal acoustic enhancement was 76% compared to 88%, 96%, and 100% for those with distal shadowing, no distal effect or combined effect respectively (p<0.0002). Patients with sonographic skin involvement had 73% 5-year BCSS compared to 92% for no skin involvement (p<0.0001). Focal oedema was associated with 56% 5-year BCSS compared to 89% for those without (p=0.0002). A significant association was demonstrated between ultrasound tumour size and BCSS (p<0.0001). At multivariate analysis, skin changes, distal enhancement, and focal oedema maintained prognostic significance.

CONCLUSION

Distal enhancement, focal oedema, and skin involvement have strong associations with breast cancer death. These factors could be taken into account, along with lesion size and other commonly used preoperative prognostic features, when considering management of women with breast cancer.

Features associated with melanoma metastasis in Latvia

Cutaneous melanoma (CM) is the most aggressive form of skin cancer, exhibits an increasing incidence worldwide and has a high potential to develop metastasis. The current study aimed to identify a set of parameters that may aid in predicting the probability and timing of the onset of CM metastasis. A retrospective analysis was performed using the archive data of 2,026 patients with CM that were treated at the Riga East University Hospital Latvian Oncology Centre, which is the largest oncological hospital in the country, between 1998 and 2015. A case-control study design was employed, where patients with metastasis (n=278) were used as the cases and patients without metastasis were used as the controls. The present study examined the associations between metastasis and potential risk factors and constructed multivariate models of features that predicted metastasis using stepwise regression. Time until metastasis was analyzed using negative binomial regression models. The results of the present study indicated an increase in the number of melanomas that developed metastases during 1998–2015. Tumor Breslow thickness was demonstrated to be significantly larger in patients with metastasis compared with those without (P=0.012). The presence of ulceration significantly increased the risk of metastases [odds ratio (OR), 1.66; 95% CI, 1.07-2.59; P=0.033]. The absence of pigment in melanoma tissues was indicated to lead to a greater likelihood of metastasis (OR, 2.14; 95% CI, 1.10-4.19; P=0.035). Shorter times from diagnosis until the onset of metastases were observed in older patients (incident rate ratio (IRR), 6.85; 95% CI, 2.43-19.30; P=2.78×10⁻⁴), and a borderline significant association was observed in those with ulcerated tumors (IRR, 1.33; 95% CI, 0.98-1.80; P=0.064). Therefore, the main features associated with the development of melanoma metastasis in Latvia were indicated to be tumor ulceration, absence of pigment and Breslow thickness.

Reappraisal of the prognostic significance of mitotic rate supports its reincorporation into the melanoma staging system

BACKGROUND

Mitotic rate is a strong, independent prognostic factor in patients with melanoma. However, incorporating it into the melanoma staging system has proved challenging.

METHODS

The prognostic impact of mitotic rate was assessed in a melanoma cohort comprising 5050 patients from 2 geographically distinct populations. Computer-generated cut points for mitotic rate were constructed to determine its impact on melanoma-associated survival using Kaplan-Meier and multivariate regression analyses. The impact of mitotic rate also was assessed in randomly split training and validation sets.

RESULTS

Mitotic rate had a nonlinear impact on survival, as evidenced by unequally spaced cut points. An index incorporating these cut points that was constructed from one population produced significantly more accurate predictions of survival in the other population than using the entire scale of mitotic rate. An index constructed from the combined cohort was found to be independently predictive of survival, with an impact comparable to that of ulceration. Optimal high-versus-low cut points for mitotic rate were generated separately for each T category (<2 mitoses/mm² vs ≥2 mitoses/mm² for T1 melanoma, <4 mitoses/mm² vs ≥4 mitoses/mm² for T2 melanoma, <6 mitoses/mm² vs ≥6/mitoses/mm² for T3 melanoma, and <7 mitoses/mm² vs ≥7 mitoses/mm² for T4 melanoma). Using Kaplan-Meier analysis, elevated mitotic rate was found to have an impact on survival comparable to that of ulceration within each T category. Application of the index for mitotic rate that was constructed from the training data set demonstrated an independent impact in the validation data set, with a significance similar to that of ulceration.

CONCLUSIONS

The results of the current study demonstrated the comparable prognostic impact of mitotic rate and ulceration, providing support for its reincorporation into the T category.

Melanoma: Prognostic Factors and Factors Predictive of Response to Therapy

BACKGROUND

A better understanding of prognostic factors and biomarkers that predict response to treatment is required in order to further improve survival rates in patients with melanoma. Prognostic Factors: The most important histopathological factors prognostic of worse outcomes in melanoma are sentinel lymph node involvement, increased tumor thickness, ulceration and higher mitotic rate. Poorer survival may also be related to several clinical factors, including male gender, older age, axial location of the melanoma, elevated serum levels of lactate dehydrogenase and S100B. Predictive Biomarkers: Several biomarkers have been investigated as being predictive of response to melanoma therapies. For anti-Programmed Death-1(PD-1)/Programmed Death-Ligand 1 (PD-L1) checkpoint inhibitors, PD-L1 tumor expression was initially proposed to have a predictive role in response to anti-PD-1/PD-L1 treatment. However, patients without PD-L1 expression also have a survival benefit with anti-PD-1/PD-L1 therapy, meaning it cannot be used alone to select patients for treatment, in order to affirm that it could be considered a correlative, but not a predictive marker. A range of other factors have shown an association with treatment outcomes and offer potential as predictive biomarkers for immunotherapy, including immune infiltration, chemokine signatures, and tumor mutational load. However, none of these have been clinically validated as a factor for patient selection. For combined targeted therapy (BRAF and MEK inhibition), lactate dehydrogenase level and tumor burden seem to have a role in patient outcomes.

CONCLUSION

With increasing knowledge, the understanding of melanoma stage-specific prognostic features should further improve. Moreover, ongoing trials should provide increasing evidence on the best use of biomarkers to help select the most appropriate patients for tailored treatment with immunotherapies and targeted therapies.

Immunotherapy for older patients with melanoma: From darkness to light?

Approximately 40% of malignant melanomas are diagnosed in patients older than 65 years. Elderly patients with melanoma present clinicopathological features related to a more aggressive biology, and they are often diagnosed with advanced stage of disease. Interestingly, in older patients the immune system can be altered with changes both in the innate system and in the adaptive immune system with the acquisition of a pro-inflammatory and immune suppressive phenotype. Immunotherapy with immune checkpoint inhibitors has reshaped the treatment strategies and prognosis of patients with melanoma, and particularly, older age should not be considered a contraindication for immunotherapy. However, data regarding efficacy and safety of immunotherapy in elderly population are still limited because frail older patients are generally excluded from clinical trials. Recently, real-world data have shed light on similar efficacy and safety of immunotherapy in older population compared with younger counterpart. The aim of the present review was to summarize the available knowledge on the underlying immune system in older patients with a diagnosis of melanoma and the immunotherapeutic approaches in this population.

Lentigo maligna melanoma in situ with neurotropism

Perineural invasion, or neurotropism, is defined by the presence of cancer cells either within the neuronal sheath or found along the nerves. In melanoma, it is most commonly associated with invasive desmoplastic melanoma, a melanoma that is most commonly associated with malignant melanoma in situ, lentigo maligna type. Initially, perineural invasion was included in the reported Breslow thickness; however, recent data suggest that it should not be included. In this report, we describe a case of malignant melanoma in situ, lentigo maligna type, with associated neurotropism in the absence of invasive component.

Orthopaedic Manifestations of Melanoma and Their Management

Melanoma is an aggressive form of skin cancer associated with significant morbidity and mortality. Although commonly seen in dermatologist clinics, orthopaedic surgeons must be aware of these lesions in various ways. The five common musculoskeletal manifestations of melanoma will be discussed as well as the epidemiology, pathogenesis, diagnosis, staging, treatment, and prognosis of melanoma. With an index of suspicion and awareness of melanoma, a thorough history and detailed physical examination are critical in establishing a diagnosis. An adequately performed biopsy will confirm the diagnosis and assist in determining prognosis. As ambassadors of health for the musculoskeletal system, orthopaedic surgeons may be the first practitioners to encounter a pigmented skin lesion. Acral pigmented lesions should prompt a concern for melanoma with appropriate subsequent steps for management to follow. Finally, it is important for every orthopaedic surgeon to consider disseminated melanoma in the differential diagnosis of a skeletal metastasis, a deep soft-tissue mass, or lymphadenopathy in a patient with a previous history of a melanotic lesion.

The prognostic impact of the extent of ulceration in patients with clinical stage I-II melanoma: a multicentre study of the Italian Melanoma Intergroup (IMI)

BACKGROUND

The presence of ulceration has been recognized as an adverse prognostic factor in primary cutaneous melanoma (PCM).

OBJECTIVES

To investigate whether the extent of ulceration (EoU) predicts relapse-free survival (RFS) and overall survival (OS) in PCM.

MATERIALS AND METHODS

We retrieved data for 477 patients with ulcerated PCM from databases of the Italian Melanoma Intergroup. Univariate and multivariable Cox proportional hazard models were used to assess the independent prognostic impact of EoU.

RESULTS

A significant interaction emerged between Breslow thickness (BT) and EoU, considering both RFS (P < 0·0001) and OS (P = 0·0006). At multivariable analysis, a significant negative impact of EoU on RFS [hazard ratio (HR) (1-mm increase) 1·26, 95% confidence interval (CI) 1·08-1·48, P = 0·0047] and OS [HR (1-mm increase) 1·25, 95% CI 1·05-1·48, P = 0·0120] was found in patients with BT ≤ 2 mm, after adjusting for BT, age, tumour-infiltrating lymphocytes, sentinel lymph node status and mitotic rate. No impact of EoU was found in patients with 2·01-4 mm and > 4 mm BT.

CONCLUSIONS

This study demonstrates that EoU has an independent prognostic impact in PCM and should be recorded as a required element in pathology reports.