A new American Joint Committee on Cancer staging system for cutaneous melanoma

Identification of Melanoma Subsets Based on DNA Methylation Sites and Construction of a Prognosis Evaluation Model

Background

Melanoma is a lethal skin malignant tumor, and its formation or development is regulated by various genetic and epigenetic molecules. Although there are traditional methods provided for the doctors to evaluate the patients' prognosis or make the diagnosis, the novel method based on epigenetic markers is still needed to make the early diagnosis.

Results

We identified 256 melanoma-independent prognosis-related methylation sites (P < 0.0001) and divided patients into seven methylation subgroups. Methylation levels and survival time in the C2 subgroup were lower than that of other clusters (P < 0.05). We established the predicted model of prognosis risk for melanoma using the significantly changed methylation sites in C2. The model efficiently divided patients into high- and low-risk groups (area under the receiver operating characteristic curve, 0.833). Risk scores and patient survival time were negatively correlated (r_s = −0.325, P < 0.0001). Genes corresponding to the independent prognosis-associated methylation sites were enriched in cancer- and immunology-related pathways. We identified 35 hub genes. DOK2, GBP4, PSMB9, and NLRC5 were significantly changed according to methylation subgroups, survival, tumor stages, and T categories and were positively correlated, which was validated in the testing group (P < 0.05). The levels of DOK2, GBP4, PSMB9, and NLRC5 had an opposite trend to their methylation sites in patients with poor prognosis.

Conclusions

We identified seven DNA methylation subtypes and constructed a highly effective prognosis risk assessment model. The transcript levels of key genes corresponding to the independent prognosis-related methylation sites were significantly changed in patients according to prognosis and positively correlated with each other, indicating they may collaboratively promote melanoma formation. These findings further our understanding of the mechanism of melanoma and provide new targets for diagnosis and treatment.

An Examination of Melanoma Detection and Characteristics at a Nova Scotia Tertiary Care Centre, From 2015-2019

BACKGROUND

Melanoma is one of the most common cancers in Canada,1 with the highest incidence in Nova Scotia (NS).

OBJECTIVES

To describe the demographics, lesion characteristics, and diagnostic accuracy of suspected melanomas excised at the largest center in NS.

METHODS

The dermatopathology database was interrogated for cases of possible melanoma from 2015 through 2019. Age, gender, site of lesion, pathologic diagnosis, Breslow depth, and equivocal pathology were assessed.

RESULTS

984 lesions had a clinical diagnosis of possible melanoma, identifying 301 melanomas. Of these, 142 (47%) were melanoma in situ (MIS) which in females occurred mostly on the extremities, while in males the head predominated. For invasive melanoma (IM), the extremities remained predominant for women, while the back was most common in men. Lower extremity lesions were more likely to be invasive and female patients were more likely to present with them at a younger age compared to males. The pathology was challenging for 23.94% of MIS, and 16.18% of IM. A mean of 3.1 lesions were excised for every melanoma identified.

CONCLUSIONS

Early diagnosis of melanoma is challenging clinically and pathologically. Our melanoma detection rate was 31%, with an increasing trend in the proportion of MIS, and decreasing trend in the proportion of IM over the years. Almost 50% of melanomas were detected in early stages, supporting positive outcomes. Melanomas were more common on extremities in females and the back in males. Melanomas on the lower limbs were more likely to be invasive regardless of gender.

Melanoma secretion of transforming growth factor-β2 leads to loss of epidermal AMBRA1 threatening epidermal integrity and facilitating tumour ulceration

BACKGROUND

For patients with early American Joint Committee on Cancer (AJCC)-stage melanoma the combined loss of the autophagy regulatory protein AMBRA1 and the terminal differentiation marker loricrin in the peritumoral epidermis is associated with a significantly increased risk of metastasis.

OBJECTIVES

The aim of the present study was to evaluate the potential contribution of melanoma paracrine transforming growth factor (TGF)-β signalling to the loss of AMBRA1 in the epidermis overlying the primary tumour and disruption of epidermal integrity.

METHODS

Immunohistochemistry was used to analyse AMBRA1 and TGF-β2 in a cohort of 109 AJCC all-stage melanomas, and TGF-β2 and claudin-1 in a cohort of 30 or 42 AJCC stage I melanomas, respectively, with known AMBRA1 and loricrin (AMLo) expression. Evidence of pre-ulceration was analysed in a cohort of 42 melanomas, with TGF-β2 signalling evaluated in primary keratinocytes.

RESULTS

Increased tumoral TGF-β2 was significantly associated with loss of peritumoral AMBRA1 (P < 0·05), ulceration (P < 0·001), AMLo high-risk status (P < 0·05) and metastasis (P < 0·01). TGF-β2 treatment of keratinocytes resulted in downregulation of AMBRA1, loricrin and claudin-1, while knockdown of AMBRA1 was associated with decreased expression of claudin-1 and increased proliferation of keratinocytes (P < 0·05). Importantly, we show loss of AMBRA1 in the peritumoral epidermis was associated with decreased claudin-1 expression (P < 0·05), parakeratosis (P < 0·01) and cleft formation in the dermoepidermal junction (P < 0·05).

CONCLUSIONS

Collectively, these data suggest a paracrine mechanism whereby TGF-β2 causes loss of AMBRA1 overlying high-risk AJCC early-stage melanomas and reduced epidermal integrity, thereby facilitating erosion of the epidermis and tumour ulceration.

Multiple antigen-engineered DC vaccines with or without IFNα to promote antitumor immunity in melanoma

Background

Cancer vaccines are designed to promote systemic antitumor immunity and tumor eradication. Cancer vaccination may be more efficacious in combination with additional interventions that may build on or amplify their effects.

Methods

Based on our previous clinical and in vitro studies, we designed an antigen-engineered DC vaccine trial to promote a polyclonal CD8⁺ and CD4⁺ T cell response against three shared melanoma antigens. The 35 vaccine recipients were then randomized to receive one month of high-dose IFNα or observation.

Results

The resulting clinical outcomes were 2 partial responses, 8 stable disease and 14 progressive disease among patients with measurable disease using RECIST 1.1, and, of 11 surgically treated patients with no evidence of disease (NED), 4 remain NED at a median follow-up of 3 years. The majority of vaccinated patients showed an increase in vaccine antigen-specific CD8⁺ and CD4⁺ T cell responses. The addition of IFNα did not appear to improve immune or clinical responses in this trial. Examination of the DC vaccine profiles showed that IL-12p70 secretion did not correlate with immune or clinical responses. In depth immune biomarker studies support the importance of circulating Treg and MDSC for development of antigen-specific T cell responses, and of circulating CD8⁺ and CD4⁺ T cell subsets in clinical responses.

Conclusions

DC vaccines are a safe and reliable platform for promoting antitumor immunity. This combination with one month of high dose IFNα did not improve outcomes. Immune biomarker analysis in the blood identified several predictive and prognostic biomarkers for further analysis, including MDSC.

Trial registration

NCT01622933.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0552-x) contains supplementary material, which is available to authorized users.

Inter-observer variation in the histopathology reports of head and neck melanoma; a comparison between the seventh and eighth edition of the AJCC staging system

BACKGROUND

TNM staging of melanoma has recently been altered by the introduction of the 8th edition of the AJCC Cancer Staging manual. The purpose of this study is to analyze the inter-observer variation of histopathology reports and its effect on recommended treatment policy.

METHODS

We retrospectively analyzed 296 cases, diagnosed as primary cutaneous head and neck melanoma (2005-2016), referred to the Netherlands Cancer Institute (NCI) for treatment after prior diagnosis in another hospital (non-NCI). All reports were analyzed for patients demographics, tumor characteristics and histopathologic features.

RESULTS

In 53% and 40% of the cases, the histopathologic parameters were discordant, according to AJCC 7th and 8th edition, respectively. This indicated a perfect inter-observer agreement for the measurement of Breslow thickness (Intraclass correlation coefficient (ICC) = 0.981) and a substantial agreement for subtype (kappa statistic (κ) = 0.648) and ulceration (κ = 0.802), while only moderate for dermal mitotic activity (κ = 0.472). After NCI review, recommended treatment policies were changed in 13% and 11% of the patients when applying TNM 7 and TNM 8, respectively. Scheduling sentinel lymph node biopsy (SLNB) changed in 14 (5%) and 10 (3%) cases when using TNM 7 and TNM 8, respectively.

CONCLUSION

Review by a NCI pathologist of histopathologic parameters of primary cutaneous head and neck melanoma led to significant changes in treatment decision. Introduction of the AJCC 8th edition led to slightly less discordances between NCI and non-NCI reports and consequently smaller impact on treatment planning. Expert review remains indicated when a SLNB is considered for additional staging in selected cases.

Electrochemotherapy in the treatment of melanoma

Electrochemotherapy is a new therapeutic option for patients with locally spread melanoma. It is based on the phenomenon of reversible electroporation, i.e. a transient increase in permeability of cell membranes under the influence of an appropriately modulated electric field. This allows multiplication of toxicity of a cytostatic agent entering the tumour cell. It is highly effective, especially in the palliative treatment of cancers located in the integument of the human body (skin and subcutaneous tissue). Available literature provides a mandate both for the application of this method in the aforementioned cases as well as for further work on its development.

This paper focuses on reviewing the literature concerning the use of electrochemotherapy in the treatment of melanoma.

Sentinel Node Biopsy for Thin Melanomas: Which Patients Should be Considered?

BACKGROUND

As the incidence of melanoma increases, thin melanomas are being diagnosed at an increasingly frequent rate. Currently available prognostic factors are limited in their ability to reliably discriminate which patients will manifest regional nodal metastasis and would be identified early through sentinel node biopsy.

METHODS

We summarized our experience with sentinel node biopsy for patients with cutaneous melanomas less than 1.00 mm in Breslow thickness, with evaluation of Clark level as a predictor of positive sentinel node metastasis.

RESULTS

Among the 409 patients identified, micrometastases were found in the sentinel node in 20 patients, for an overall incidence of nodal progression of 4.9%. A total of 252 (62%) were Clark level II or III (11 of whom had a positive sentinel node) and 157 (38%) were Clark level IV (9 of whom had a positive sentinel node). We reviewed the literature to identify reliable indicators that might be helpful in determining which patients with "thin melanomas" would be likely to manifest regional progression to warrant routinely undergoing a preoperative lymphoscintigraphy followed by a sentinel node biopsy.

CONCLUSIONS

Based on available data, patients with melanomas between 0.75 and 1.00 mm are appropriate candidates to be considered for sentinel node biopsy after discussing the likelihood of finding evidence of nodal progression, the risks of sentinel node biopsy (including the risk of a false-negative result), and the lack of proven survival benefit from any form of surgical nodal staging.

Immunologic heterogeneity of tumor-infiltrating lymphocyte composition in primary melanoma

Tumor-infiltrating lymphocytes (TILs) in primary melanomas are thought to represent the host antitumor immune response, but controversy exists over whether TILs offer independent prognostication of survival. We studied a cohort of 1241 patients with primary melanoma to assess the association of absent, nonbrisk, and brisk TIL grade with survival outcomes. We tested whether quantitative TIL counts using immunohistochemical lymphocyte markers CD3, CD45, and FOXP3 add prognostic value to TIL grading compared with histology alone in 15% of the cohort. To assess for intergroup immunologic heterogeneity among TIL grades, we investigated differential expression of 594 immunoregulatory genes in 67 primary melanomas. On histologic evaluation of 1241 primary melanomas, TILs were graded as absent (n=388, 31%), nonbrisk (n=330, 27%), and brisk (n=523, 42%). Patients with brisk TILs had improved recurrence-free survival (P=.025) and overall survival (P=.006) compared with patients with nonbrisk and absent TILs, for which there were no differences in recurrence-free survival (P=.40) or overall survival (P=.41). TIL quantitation by immunohistochemistry did not improve prognostication compared with TIL grading on hematoxylin and eosin-stained sections. Melanomas with nonbrisk and absent TILs share similar immunoregulatory gene expression profiles. In contrast, melanomas with brisk TILs demonstrate upregulation of T-cell activation pathways and inhibition of upstream immune checkpoint regulators. The presence of TILs in primary melanomas represents a heterogeneous group, and caution in prognostic interpretation is warranted. Melanomas with brisk TILs are defined by an immunostimulatory gene expression profile and improved prognosis compared with melanomas with nonbrisk or absent TILs.

Efficacy of superficial and deep regional hyperthermia combined with systemic chemotherapy and radiotherapy in metastatic melanoma

BACKGROUND AND OBJECTIVE

Response rates of cutaneous-subcutaneous or lymph node metastases of melanoma to systemic chemotherapy are rather low. We report our clinical experience with superficial and deep regional hyperthermia in combination with radiotherapy and/or chemotherapy with carboplatin.

PATIENTS/METHODS

We treated 15 patients with metastatic melanoma (6 men, 9 women; age 39-84 years, mean age 60 years) by using superficial or deep regional hyperthermia produced by electromagnetic energy. Superficial hyperthermia was delivered to skin or lymph node metastases in combination with radiochemotherapy in 12 patients, while deep regional hyperthermia was administered with an annular array applicator to lymph node metastases either in combination with radiochemotherapy (1 patient) or with carboplatin alone (2 patients). The clinical response was assessed by clinical evaluation and/or computer tomography and/or ultrasonography at monthly intervals.

RESULTS

Both superficial and deep regional hyperthermia was well tolerated. We observed 5 complete local remissions (34%), 6 partial local remissions (40%) and 2 patients with stable disease (13%). The best results were obtained in cutaneous or retroperitoneal metastases.

CONCLUSIONS

Local response can be achieved in inoperable metastatic melanoma using superficial or deep regional hyperthermia in combination with radiochemotherapy or chemotherapy.

[Molecular and pathomorphological prognostic markers for melanoma: Current approaches and prospects]

The incidence of melanoma demonstrates a persistent increasing tendency, which justifies the need to study and identify new prognostic markers for the development and course of this disease. The given paper shows current approaches to melanoma staging, including those to applying pathomorphological prognostic criteria, and discusses prospects for using the results of genomic and epigenomic studies of the carcinoma in clinical practice.

Risk of subsequent melanoma after melanoma in situ and invasive melanoma: a population-based study from 1973 to 2011

BACKGROUND

Patients with melanoma in situ are at an increased risk of subsequent melanoma compared with the general population, but the risk of subsequent melanoma after initial melanoma in situ versus after initial invasive melanoma is not known.

OBJECTIVE

We sought to compare the risk of subsequent melanoma in the cohort whose first cancer was melanoma in situ to the risk in the cohort whose first cancer was invasive melanoma.

METHODS

In this cohort study, we identified individuals whose first cancer was either melanoma in situ or invasive melanoma from the Surveillance, Epidemiology, and End Results (SEER) program between 1973 and 2011 and used Cox proportional hazards models for comparison.

RESULTS

Compared with the invasive melanoma cohort, the melanoma in situ cohort was more likely to develop subsequent melanoma of any stage after 2 years, subsequent invasive melanoma after 10 years, and subsequent melanoma in situ at all the time points (P < .001, P = .003, P < .001, respectively).

LIMITATIONS

Underreporting of melanomas, particularly melanoma in situ cases, and missing cases of subsequent melanomas as a result of patient migration from the SEER registry areas could affect results.

CONCLUSION

Given the increased long-term risk of subsequent melanoma in the melanoma in situ cohort, the patients with melanoma in situ diagnosis may benefit from a long-term surveillance for subsequent melanomas.

P, Tarantini L, Calista D, Cavalleri T, Angelici L, Consonni D, Pier A. B, Angela C. P, Maria T. L, Bollati V. Blood DNA methylation, nevi number, and the risk of melanoma

Germline mutations determining increased cutaneous malignant melanoma (CMM) risk have been identified in familial and sporadic CMM cases, but they account only for a small proportion of CMM cases. Recent evidence suggests that germline epimutations (e.g. DNA methylation alterations), which can be inherited similarly to genomic mutations and can be detected in normal body cells (including blood), might increase susceptibility to cancer. The aim of the study was to identify germline epimutations of genes that were found to be mutated in familial CMM (p16, p14, CDK4, MC1R, hTERT), immune and inflammatory genes (ICAM-1, TNFα), DNA mismatch repair gene (MLH1), and repetitive elements (ALU, LINE-1, HERV-w). We measured DNA methylation using bisulfite pyrosequencing in peripheral blood mononuclear cells from 167 CMM cases and 164 sex-matched and age-matched controls. We used multivariable logistic regression models to evaluate the association between methylation levels and CMM status or presence of dysplastic nevi. We found an association between the risk of CMM and peripheral blood mononuclear cell methylation levels of TNFα [odds ratio (OR)=1.11, 95% confidence interval (CI)=1.03-1.18], CDK4 (OR=0.76, 95% CI=0.64-0.91), and MLH1 (OR=1.12, 95% CI=1.02-1.22). In control participants, the risk of developing dysplastic nevi was associated with methylation levels of TNFα (OR=0.81, 95% CI=0.69-0.95), hTERT (OR=0.90, 95% CI=0.82-0.99), and ALU (OR=1.56, 95% CI=1.02-2.39). Epimutations in CMM susceptibility genes and in genes involved in response to oxidative damage are associated with the risk of developing CMM or dysplastic nevi. Further studies measuring methylation levels of these genes in prospectively collected samples are warranted to further elucidate their role in the development and progression of CMM.

Pathological staging of melanoma

Staging of cancer is a shorthand system of describing the extent of disease. Pathological staging, often called microstaging, uses the methods of histopathology to achieve this goal. Microstaging for melanoma utilizes attributes that are associated with outcome, generally in association with prognostic models that allow for estimation of survival rates, based on large groups of patients with similar tumors. Microstaging can be performed on primary tumors and to a lesser extent on metastases. Attributes that are important in microstaging in primary tumors include, in particular, those that are utilized in the AJCC/UICC staging system. These are, more or less in order of importance, Breslow's thickness, ulceration, and mitogenicity (the presence or absence of mitoses). Other attributes that have relevance to prognosis at least in some well-conducted studies include tumor-infiltrating lymphocytes, lymphovascular invasion, perineural invasion, Clark's level of invasion, the presence or absence of vertical growth phase and of regression, and other attributes. The pathologic interpretation and significance of these "prognostic variables" are discussed in this chapter. In addition, prognostic models including the AJCC staging system are presented in some detail.

Predictive factors for loco regional recurrence and distant metastasis following primary surgical treatment of cutaneous melanoma

Background:

Cutaneous melanoma (CM) has a high propensity for regional and systemic spread. This is one of the largest series of CM reported from India.

Aims:

To predict factors for loco regional recurrence (LRR) and distant metastasis in patients with CM primarily treated with surgery.

Study Design:

Retrospective analysis of patient database at a tertiary care cancer center with evaluation of factors for LRR and distant metastasis for CM.

Materials and Methods:

Data from 68 patients treated for CM between January 2006 and December 2010 were reviewed. Data recorded included age, sex, symptoms, investigations, treatment given, histopathology, recurrence and follow-up. Patient factors, tumor factors, pathologic variables, and adjuvant treatment were investigated as predictors’ of LRR and distant metastasis.

Results:

Mean age of patients was 54 years. Melanoma was more common in males (44). Tumor thickness > 4 mm was found in 43 patients. Lymph node involvement was found in 43 patients. Adjuvant radiotherapy was given in seven patients. At mean follow-up of 16.5 months, LRR was seen in 34 patients and distant metastasis in 28 patients. LRR and distant metastasis were more commonly found in females, age > 40 years, Clark's level IV and V, Breslow's depth > 4 mm, patients with lymph node involvement and extra-capsular spread.

Conclusion:

The age, sex, site, thickness of lesion, involvement of lymph node, and extra-capsular spread were important factors in predicting LRR and distant metastasis. Distant metastasis was also more commonly found in patients with LRR.

[Melanomas of the female genital tract: state of the art]

Melanoma of the female genital tract is a rare location (less than 2% of melanomas all sites combined). These cancers have a very poor prognosis, due to the delay in diagnosis. Vulvar location is about 1% of melanomas then the vaginal location, uterine and ovarian. There is no consensus to date regarding their care, due to the rarity of the lesions. Their treatment must however be based on the current data concerning gynaecological cancers as well as standard management of cutaneous melanoma. The treatment is often based on conservative surgery, because radical resection does not improve survival. For the vulva and vagina, reconstructive surgery is possible. Treatment is sometimes supplemented by chemotherapy or radiotherapy, which could improve local control. The interest in the use of targeted therapy in these locations is not well known because of their rarity, but the study of genes c-Kit and BRAF provides new prospects for treatment. The objective of this review is to describe and report the current state of knowledge about gynaecologic melanomas.

Berberine in combination with doxorubicin suppresses growth of murine melanoma B16F10 cells in culture and xenograft

Melanoma is very aggressive and major cause of mortality due to skin cancer. Herein, we studied the anticancer effects of berberine, a plant alkaloid, in combination with doxorubicin on murine melanoma B16F10 cells in vitro and in vivo. This drug combination strongly inhibited cell growth and induced cell death, and caused G2/M arrest in cell cycle together with a decrease in Kip1/p27. Berberine showed stronger inhibitory effect on ERK1/2 phosphorylation as compared to Akt phosphorylation, whereas the combination of the drugs showed greater inhibitory effect on Akt phosphorylation. In murine B16F10 xenograft, cells were implanted into mice and treated with vehicle (methyl cellulose) or berberine (100mg/kg of body weight/day by oral gavage) or doxorubicin (4 mg/kg of body weight/week by intraperitoneal injection) or combination of berberine and doxorubicin. Berberine alone did not show any considerable effect on tumor growth as observed with doxorubicin, however, the combination of the two drugs resulted in a significant and strong decrease in tumor volume (85%, p<0.005) and tumor weight (78%, p<0.05) as compared to control. Immunohistochemical analysis of tumor samples showed that drug combination decreased PCNA-positive cells (82%, p<0.001) and increased cleaved caspase-3 positive cells (3-fold, p<0.05) indicating inhibition of proliferation and an increase in apoptosis, respectively. Overall, our findings suggest that berberine and doxorubicin could be a novel combination to inhibit melanoma tumor growth.

Importance of tumor size in soft tissue sarcomas: a proposal for a nomogram based on a score system to staging soft tissue sarcomas in the postoperative setting

In order to adequately stage patients with extremity soft tissue sarcomas (ESTS), it is mandatory to include all adverse prognostic factors and create an integral staging system. We were able to evaluate a nomogram based on a score (STSSS), to improve ESTS staging. We retrospectively evaluated 596 patients with ESTS in stages I-III, of the American Joint Committee on Cancer (AJCC), who had a complete resection. We analyzed the influence of clinicopathological factors on metastasis, recurrence, and disease-specific survival. The STSSS was based on histologic grade (HG), profundity, tumor size (TS), and surgical margins; we also compared STSSS versus AJCC systems in their ability to stage ESTS. The mean TS was 11.8 cm, with 50%>10 cm. Large TS and high HG were independent but adverse prognostic factors for metastasis. In addition, large TS, high grade, and R1 resection were independent adverse prognostic factors for decreased survival. There was a progressive decline in survival as TS increased, although AJCC staging did not correlate well between stages (IA vs. IB p=0.233, IA vs. IIA p=0.123, IA vs. IIB p=0.075, IB vs. IIA p=0.472, IB vs. IIB p=0.211). STSSS showed differences between these categories for 5-year survival (I vs. II p=0.003, II vs. III p=0.002, III vs. IV p<0.001). Surgical margins, HG, and TS are important determinants for metastases and survival. We also found a strong correlation between survival and prognosis with the use of STSSS in the immediate postoperative setting.

Is head and neck melanoma different from trunk and extremity melanomas with respect to sentinel lymph node status and clinical outcome?

BACKGROUND

Previous studies showed conflicting and inconsistent results regarding the effect of anatomic location of the melanoma on sentinel lymph node (SLN) positivity and/or survival. This study was conducted to evaluate and compare the effect of the anatomic locations of primary melanoma on long-term clinical outcomes.

METHODS

All consecutive cutaneous melanoma patients (n=2,079) who underwent selective SLN dissection (SLND) from 1993 to 2009 in a single academic tertiary-care medical center were included. SLN positive rate, disease-free survival (DFS), and overall survival (OS) were determined. Kaplan-Meier survival, univariate, and multivariate analyses were performed to determine predictive factors for SLN status, DFS, and OS.

RESULTS

Head and neck melanoma (HNM) had the lowest SLN-positive rate at 10.8% (16.8% for extremity and 19.3% for trunk; P=0.002) but had the worst 5-year DFS (P<0.0001) and 5-year OS (P<0.0001) compared with other sites. Tumor thickness (P<0.001), ulceration (P<0.001), HNM location (P=0.001), mitotic rate (P<0.001), and decreasing age (P<0.001) were independent predictive factors for SLN-positivity. HNM with T3 or T4 thickness had significantly lower SLN positive rate compared with other locations (P≤0.05). Also, on multivariate analysis, HNM location versus other anatomic sites was independently predictive of decreased DFS and OS (P<0.001). By Kaplan-Meier analysis, HNM was associated significantly with the worst DFS and OS.

CONCLUSIONS

Primary melanoma anatomic location is an independent predictor of SLN status and survival. Although HNM has a decreased SLN-positivity rate, it shows a significantly increased risk of recurrence and death as compared with other sites.

Emerging phytochemicals for prevention of melanoma invasion

Cutaneous malignant melanoma is the leading cause of death from skin diseases due to its propensity to metastasize. Once diagnosed with metastatic melanoma, most patients will die of their disease within 2years. As suppression of metastases requires long-term interventions, potential anti-metastatic agents must not only be efficacious but also have low toxicity. Many phytochemicals used in traditional medicine have low toxicity and recent studies suggest that some are promising candidates for the prevention or treatment of metastatic melanoma. Here, we review the recent literature regarding phytochemicals that have shown inhibitory effects on melanoma cell migration or invasion.

Assessment of reproducibility of cancer survival risk predictions across medical centers

BACKGROUND

Two most important considerations in evaluation of survival prediction models are 1) predictability - ability to predict survival risks accurately and 2) reproducibility - ability to generalize to predict samples generated from different studies. We present approaches for assessment of reproducibility of survival risk score predictions across medical centers.

METHODS

Reproducibility was evaluated in terms of consistency and transferability. Consistency is the agreement of risk scores predicted between two centers. Transferability from one center to another center is the agreement of the risk scores of the second center predicted by each of the two centers. The transferability can be: 1) model transferability - whether a predictive model developed from one center can be applied to predict the samples generated from other centers and 2) signature transferability - whether signature markers of a predictive model developed from one center can be applied to predict the samples from other centers. We considered eight prediction models, including two clinical models, two gene expression models, and their combinations. Predictive performance of the eight models was evaluated by several common measures. Correlation coefficients between predicted risk scores of different centers were computed to assess reproducibility - consistency and transferability.

RESULTS

Two public datasets, the lung cancer data generated from four medical centers and colon cancer data generated from two medical centers, were analyzed. The risk score estimates for lung cancer patients predicted by three of four centers agree reasonably well. In general, a good prediction model showed better cross-center consistency and transferability. The risk scores for the colon cancer patients from one (Moffitt) medical center that were predicted by the clinical models developed from the another (Vanderbilt) medical center were shown to have excellent model transferability and signature transferability.

CONCLUSIONS

This study illustrates an analytical approach to assessing reproducibility of predictive models and signatures. Based on the analyses of the two cancer datasets, we conclude that the models with clinical variables appear to perform reasonable well with high degree of consistency and transferability. There should have more investigations on the reproducibility of prediction models including gene expression data across studies.

Effects of T-cadherin expression on B16F10 melanoma cells

Melanoma is one of the most deadly skin cancers. T-cadherin is an atypical member of the cadherin superfamily as it lacks the transmembrane and cytoplasmic domains and is anchored to cell membranes through glycosylphosphatidylinositol (GPI) anchors. T-cadherin downregulation is associated with a poorer prognosis in various carcinomas, such as lung, ovarian, cervical and prostate cancer, while in the majority of cancer cell lines, T-cadherin re-expression inhibits cell proliferation and invasiveness, increases susceptibility in apoptosis and reduces tumor growth in in vivo models. The functional relevance of T-cadherin gene expression in melanoma progression remains to be clarified. The present study was designed for this purpose. The T-cadherin gene was transfected into B16F10 melanoma cells to express T-cadherin in the cells which were originally deficient in T-cadherin expression. The proliferation, invasiveness, apoptosis and cell cycle of the transfected B16F10 melanoma cells were analyzed. The present study showed that the expression of T-cadherin in B16F10 melanoma cells markedly reduced cell proliferation and permeation through Matrigel-coated membranes, representing invasiveness. The percentage of early apoptotic cells and cells in the G₂/M phase of the cell cycle was markedly increased compared with either parental B16F10 (without transfection) or empty pEGFP-N1 (without T-cadherin gene)-transfected B16F10 cells, suggesting G₂/M arrest, with similarity between the parental and empty pEGFP-N1-transfected B16F10 cells. T-cadherin is important in melanoma progression and may be a possible target for therapy in melanoma and certain other types of cancer.

Dermatology of the head and neck: skin cancer and benign skin lesions

Skin lesions are extremely common, and early detection of dangerous lesions makes skin cancer one of the most highly curable malignancies. By simply becoming aware of common lesions and their phenotypic presentation, dental professionals are empowered to detect suspicious dermatologic lesions in unaware patients. This article serves as an introduction to skin cancer and benign skin lesions for dental professionals.

Melanoma staging: where are we now?

The seventh version of the American Joint Committee on Cancer (AJCC) Melanoma Staging guidelines, published in 2009, has significant revisions compared with the previous version. The current schema was based on the largest melanoma patient cohort analyzed to date and is the result of a multivariate analysis of 30,946 patients with stages I, II, and III melanoma and 7972 patients with stage IV melanoma. This article summarizes the findings and the new definitions included in the 2009 AJCC Melanoma Staging and Classification. The TNM categories and the stage groupings are defined. Changes in the melanoma staging system are summarized.

Up-regulation of miR-182 expression after epigenetic modulation of human melanoma cells

PURPOSE

We sought to investigate the epigenetic regulation of microRNAs (miRNAs) in melanoma.

METHODS

We treated two highly metastatic human melanoma cell lines, C8161.9 and WM266-4, with the demethylating agents DAC (5-aza-2'-deoxycytidine) and trichostatin A. Locked nucleic acid-based miRNA expression profiling was utilized to examine the differential expression of miRNAs before and after treatment.

RESULTS

We found that miR-182, a miRNA with oncogenic properties, was significantly up-regulated in human melanoma cells after epigenetic modulation. Genome sequence analysis revealed the presence of a prominent CpG island 8-10 kb upstream of mature miR-182. Methylation analysis showed that this genomic region was exclusively methylated in melanoma cells but not in human melanocytes, skin, or peripheral blood mononuclear cells.

DISCUSSION

These results indicate that an epigenetic mechanism is likely involved in modulating the expression level of miR-182 in melanoma, and increased expression of oncogenic-like miR-182 could be a concern for melanoma patients after epigenetic therapy.

Prognostic importance of the extent of ulceration in patients with clinically localized cutaneous melanoma

OBJECTIVE

To determine the prognostic value of the extent of ulceration, categorized as diameter of ulceration and as percentage of invasive melanoma diameter.

BACKGROUND

Ulceration is an adverse prognostic factor for clinically localized primary cutaneous melanoma. However, the prognostic significance of the extent of ulceration remains unclear.

METHODS

Clinicopathologic and follow-up data on 4661 patients treated at a single center were analyzed.

RESULTS

Both the presence and extent of ulceration were independent predictors of survival. The 5-year melanoma-specific survival (MSS) for ulcerated and nonulcerated melanomas was 77.6% and 91.3%, respectively. The 5-year MSS for minimally/moderately ulcerated melanomas (≤70% or ≤5 mm) was 80.4% and 82.7%, respectively, compared to extensively ulcerated melanomas (>70% or >5 mm), which had a 5-year MSS of 66.4% and 59.3%. On multivariate analysis, tumor thickness and the presence/absence of mitoses were the most powerful predictors of MSS. The presence of ulceration was also an independent predictor of poorer MSS (hazard ratio [HR] = 1.55, P < 0.001). Patients with minimally/moderately ulcerated tumors (≤70% or ≤5 mm) had a significantly higher risk of death (HR = 1.53 and HR = 1.39, respectively) compared to nonulcerated melanoma, as did patients with extensively ulcerated tumors (>70%: HR = 2.20 and >5 mm: HR = 2.03).

CONCLUSIONS

Extent of ulceration (measured either as diameter or percentage of tumor width) provides more accurate prognostic information than the mere presence of ulceration. This has potential implications for melanoma patients with regard to prognosis, staging, management, and eligibility for clinical trials. We recommend that extent of ulceration be recorded in pathology reports for all ulcerated primary cutaneous melanomas.

Influence of sporting activity and smoking on peripheral lymph nodes in patients with melanoma analyzed by high-resolution ultrasound

BACKGROUND

The sonographic examination of peripheral lymph nodes (LNs) plays an important role in the preoperative treatment and in the follow-up of patients with melanoma.

OBJECTIVE

A prospective study including 200 consecutive patients with a history of invasive cutaneous melanoma was performed at the Department of Dermatology and Allergy, University of Bonn, Germany, to examine the influence of sporting activity, physical workload, interferon alfa therapy, smoking habits, and infections of the upper respiratory tract on morphology and number of LNs analyzed by high-resolution ultrasound.

METHODS

Between May 2010 and June 2011, 106 men and 94 women (mean age 51.1 ± 12.8 years) were included in this study. During their follow-up visits for cutaneous melanoma, high-resolution ultrasound examination of cervical, axillary, and inguinal LN regions were performed. LN diameters and volumes were measured and correlated with the above given factors.

RESULTS

Sports-active patients had more LNs in inguinal regions, a higher volume and a larger LN diameter, and a higher maximum width of the hypoechoic LN margin in comparison with the nonactive patients. Patients with a hard physical workload in their occupations had a significantly higher volume of the biggest LN. Compared with nonsmoking patients smokers presented higher values in the total quantity of the LNs, in the greatest volume of LN, and in the greatest diameter of LN in the cervical regions. The other factors had no significant influence on the LN parameters.

LIMITATIONS

Our study population was too small to comment on influencing factors in more detail especially the influences of different sporting activities or smoking habits.

CONCLUSION

Sporting activity, physical workload, and smoking habits as associated cofactors influencing sonomorphologic aspects in patients with cutaneous melanoma should always be considered.

Green tea catechins reduce invasive potential of human melanoma cells by targeting COX-2, PGE2 receptors and epithelial-to-mesenchymal transition

Melanoma is the most serious type of skin disease and a leading cause of death from skin disease due to its highly metastatic ability. To develop more effective chemopreventive agents for the prevention of melanoma, we have determined the effect of green tea catechins on the invasive potential of human melanoma cells and the molecular mechanisms underlying these effects using A375 (BRAF-mutated) and Hs294t (Non-BRAF-mutated) melanoma cell lines as an in vitro model. Employing cell invasion assays, we found that the inhibitory effects of green tea catechins on the cell migration were in the order of (-)-epigallocatechin-3-gallate (EGCG)>(-)-epigallocatechin>(-)-epicatechin-3-gallate>(-)-gallocatechin>(-)-epicatechin. Treatment of A375 and Hs294t cells with EGCG resulted in a dose-dependent inhibition of cell migration or invasion of these cells, which was associated with a reduction in the levels of cyclooxygenase (COX)-2, prostaglandin (PG) E₂ and PGE₂ receptors (EP2 and EP4). Treatment of cells with celecoxib, a COX-2 inhibitor, also inhibited melanoma cell migration. EGCG inhibits 12-O-tetradecanoylphorbol-13-acetate-, an inducer of COX-2, and PGE₂-induced cell migration of cells. EGCG decreased EP2 agonist (butaprost)- and EP4 agonist (Cay10580)-induced cell migration ability. Moreover, EGCG inhibited the activation of NF-κB/p65, an upstream regulator of COX-2, in A375 melanoma cells, and treatment of cells with caffeic acid phenethyl ester, an inhibitor of NF-κB, also inhibited cell migration. Inhibition of melanoma cell migration by EGCG was associated with transition of mesenchymal stage to epithelial stage, which resulted in an increase in the levels of epithelial biomarkers (E-cadherin, cytokeratin and desmoglein 2) and a reduction in the levels of mesenchymal biomarkers (vimentin, fibronectin and N-cadherin) in A375 melanoma cells. Together, these results indicate that EGCG, a major green tea catechin, has the ability to inhibit melanoma cell invasion/migration, an essential step of metastasis, by targeting the endogenous expression of COX-2, PGE₂ receptors and epithelial-to-mesenchymal transition.

Local recurrence and assessment of sentinel lymph node biopsy in deep soft tissue leiomyosarcoma of the extremities

Background

Leiomyosarcoma of deep soft tissues of the extremities is a rare malignant tumour treated primarily by surgery. The incidence of local recurrence and lymph node metastasis is uncertain and it is not known whether a sentinel lymph node biopsy is indicated in these tumours.

Methods

A retrospective review of patients treated for extremity deep soft tissue leiomyosarcoma at our institution over a 10-year period was conducted. Patients developing local recurrence or lymph node metastasis were identified. The presence or absence of lymphatics in the primary tumours was assessed by immunohistochemical expression of LYVE-1 and podoplanin.

Results

27 patients (mean age 62 years) were included in the study. 15 were female and 12 male. Lymph node metastasis was seen in only two cases (7%); intratumoural lymphatics were identified in the primary tumours of both these cases. Local recurrence occurred in 25.9% of cases despite complete excision and post-operative radiotherapy; the mean time to recurrence was 10.1 months.

Conclusion

On the basis of this study, we do not advocate sentinel lymph node biopsy in this group of patients except in those cases in which intratumoural lymphatics can be demonstrated. Close follow up is important especially for high grade leiomyosarcomas, particularly in the first year, as these tumours have a high incidence of local recurrence.

Analysis of predictive factors for the outcome of complete lymph node dissection in melanoma patients with metastatic sentinel lymph nodes

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a widely accepted procedure to accurately stage patients with melanoma. However, there is no consensus concerning the practical consequences of a positive SLN, since a survival benefit of a complete lymph node dissection (CLND) has not yet been demonstrated.

OBJECTIVE

We wondered whether we could identify a subgroup of patients with metastatic involvement of the SLN who could be excluded from the recommendation to undergo CLND.

METHODS

At the Department of Dermatology at the University of Munich, a total of 213 patients with metastatic SLNs (24.9%) were identified among 854 patients who had undergone SLNB between 1996 and 2007. All SLN-positive patients had been advised to have CLND. Survival analyses were performed by using the Kaplan-Meier approach.

RESULTS

A total of 176 (82.6%) of 213 SLN-positive patients underwent CLND. In this group, 26 patients (14.8%) showed metastatic disease in non-sentinel lymph nodes (NSLN). The 5-year overall survival (OS) was 26.1% in NSLN-positive patients and 74% in NSLN-negative patients. SLN-positive patients who refused CLND had a better prognosis than patients with CLND. Breslow tumor thickness was significantly associated with positive CLND status with higher median values in CLND-positive than CLND-negative patients (3.03 vs 2.22 mm).

LIMITATIONS

The subgroup of patients with metastatic disease in CLND may have been too small to reach statistical significance for other tumor- or patient-related parameters. Mitotic indices of the primary melanomas had not been determined in this retrospective study; thus a possible correlation with lymph node status could not be tested.

CONCLUSION

Among SLN-positive patients, the presence of metastatic NSLN is a highly significant poor prognostic factor. Tumor thickness is a significant prognostic parameter for positive CLND status and might be considered in the decision to perform CLND in case of metastatic SLN.

Neural cell adhesion molecule potentiates the growth of murine melanoma via β-catenin signaling by association with fibroblast growth factor receptor and glycogen synthase kinase-3β

The neural cell adhesion molecule (NCAM) was recently shown to be involved in the progression of various tumors with diverse effects. We previously demonstrated that NCAM potentiates the cellular invasion and metastasis of melanoma. Here we further report that the growth of melanoma is obviously retarded when the expression of NCAM is silenced. We found that the proliferation of murine B16F0 melanoma cells, their colony formation on soft agar, and growth of transplanted melanoma in vivo are clearly inhibited by the introduction of NCAM siRNA. Interestingly, change of NCAM expression level is shown to regulate the activity of Wnt signaling molecule, β-catenin, markedly. This novel machinery requires the function of FGF receptor and glycogen synthase kinase-3β but is independent of the Wnt receptors, MAPK-Erk and PI3K/Akt pathways. In addition, NCAM is found to form a functional complex with β-catenin, FGF receptor, and glycogen synthase kinase-3β. Moreover, up-regulation of NCAM140 and NCAM180 appears more potent than NCAM120 in activation of β-catenin, suggesting that the intracellular domain of NCAM is required for facilitating the β-catenin signaling. Furthermore, the melanoma cells also exhibit distinct differentiation phenotypes with the NCAM silencing. Our findings reveal a novel regulatory role of NCAM in the progression of melanoma that might serve as a new therapeutic target for the treatment of melanoma.

[Malignant transformation of a nevus of Ito: description of a rare case]

Dermal melanocytosis refers to congenital or acquired lesions characterized by the presence of dendritic cells derived from melanocytes that migrate from the neural crest to the epidermis. The nevus of Ito develops in the territory supplied by the acromioclavicular nerve. Malignant transformation in dermal melanocytosis is extremely rare, with only isolated case reports; only 2 cases of malignant transformation of a nevus of Ito have been reported. We report a very rare case that is the third to be described in the literature. The patient was a 24-year-old man who presented with a subcutaneous nodule that had developed in the anterolateral region of the thorax over the previous 8 months. The nodule was located beneath a faint blue-gray macule with poorly defined borders. Biopsy of the nodule revealed malignant melanoma; biopsies of the adjacent skin lesion showed a diffuse proliferation of scattered melanocytes in a collagen stroma in the reticular dermis. A diagnosis of malignant transformation of a nevus of Ito was made after other possibilities were ruled out.

AJCC melanoma staging update: impact on dermatopathology practice and patient management

Changes in the 2010 American Joint Commission on Cancer melanoma staging guidelines include the evaluation of primary tumor mitotic index (mitogenicity) and the recognized prognostic significance of a single melanoma cell in a sentinel lymph node. These revised criteria have important practice implications for dermatopathologists as well as for dermatologists, oncologists and surgeons who treat patients with cutaneous melanoma.

Genetic and morphologic features for melanoma classification

Melanoma is comprised of biologically distinct subtypes. The defining clinical, histomorphologic, and molecular features are not fully established. This study sought to validate the association between genetic and histomorphologic features previously described and to determine their reproducibility and association with important clinical variables. Detailed clinical and histomorphologic features of 365 primary cutaneous melanomas were assessed by 11 pathologists and correlated with mutation status of BRAF and NRAS. There was substantial agreement in the quantitative assessment of histomorphologic features showing similar or better interobserver reproducibility than the established World Health Organization classification scheme. We confirmed that melanomas with BRAF mutations showed characteristic morphologic features (P < 0.0001) and metastasized more frequently to regional lymph nodes (P = 0.046). Importantly, melanomas without mutations were a heterogeneous group, with a subset having very similar clinical and morphological features as those with BRAF mutation raising the possibility that they are biologically related. Our study confirms an association between histomorphologic features, mutation status, and pattern of metastasis, providing criteria for a refined melanoma classification aimed at defining biologically homogeneous disease subgroups.

Epitrochlear lymph nodes: Anatomy, clinical aspects, and sonography features. Pictorial essay()

The normal and abnormal aspects of the epitrochlear lymphatic station are not well known, mainly because the axillary basin is commonly regarded as the primary lymphatic target of all upper limb disorders. The purpose of this paper is to illustrate, through a review of specific cases, the normal and abnormal findings that can emerge during ultrasonographic (US) and color-Doppler US exploration of the epitrochlear region. We illustrate the normal anatomy and variations of the epitrochlear lymph nodes and highlight the functional role of this lymphatic station. Subsequently we describe the US and color-Doppler US findings. A number of different abnormalities are reviewed, including metastases (mainly from upper limb cutaneous melanomas), Hodgkin disease, and non-Hodgkin lymphoma, lymphadenitis (cat-scratch disease, foreign bodies, and IV drug abuse). Measures are suggested to avoid interpretative pitfalls and to carry out an effective differential diagnosis of elbow masses. This article represents a pictorial essay of the US and color-Doppler US features of various epitrochlear lymph node abnormalities that clinicians may not be familiar with.

Berberine, an isoquinoline alkaloid, inhibits melanoma cancer cell migration by reducing the expressions of cyclooxygenase-2, prostaglandin E₂ and prostaglandin E₂ receptors

Melanoma is the leading cause of death from skin disease due, in large part, to its propensity to metastasize. We have examined the effect of berberine, an isoquinoline alkaloid, on human melanoma cancer cell migration and the molecular mechanisms underlying these effects using melanoma cell lines, A375 and Hs294. Using an in vitro cell migration assay, we show that over expression of cyclooxygenase (COX)-2, its metabolite prostaglandin E₂ (PGE₂) and PGE₂ receptors promote the migration of cells. We found that treatment of A375 and Hs294 cells with berberine resulted in concentration-dependent inhibition of migration of these cells, which was associated with a reduction in the levels of COX-2, PGE₂ and PGE₂ receptors (EP2 and EP4). Treatment of cells with celecoxib, a COX-2 inhibitor, or transient transfection of cells with COX-2 small interfering RNA, also inhibited cell migration. Treatment of the cells with 12-O-tetradecanoylphorbol-13-acetate (TPA), an inducer of COX-2 or PGE₂, enhanced cell migration, whereas berberine inhibited TPA- or PGE₂-promoted cell migration. Berberine reduced the basal levels as well as PGE₂-stimulated expression levels of EP2 and EP4. Treatment of the cells with the EP4 agonist stimulated cell migration and berberine blocked EP4 agonist-induced cell migration activity. Moreover, berberine inhibited the activation of nuclear factor-kappa B (NF-κB), an upstream regulator of COX-2, in A375 cells, and treatment of cells with caffeic acid phenethyl ester, an inhibitor of NF-κB, inhibited cell migration. Together, these results indicate for the first time that berberine inhibits melanoma cell migration, an essential step in invasion and metastasis, by inhibition of COX-2, PGE₂ and PGE₂ receptors.

Prognostic factors associated with sentinel lymph node positivity and effect of sentinel status on survival: an analysis of 1049 patients with cutaneous melanoma

Sentinel lymph node biopsy (SLNB) is a widely accepted staging procedure in patients with melanoma. However, it is unclear which factors predict the occurrence of micrometastasis and overall prognosis and whether SLNB should also be performed in patients with thin primary tumors. At our Department of Dermatology, University of Munich (Germany), 1049 consecutive melanoma patients were identified for SLNB between 1996 and 2007, and were followed-up to assess disease-free and overall survival. Of those, a total of 854 patients were analyzed prospectively. Patients with positive SLN were subjected to selective lymphadenectomy. The association of patient characteristics with SLN was assessed by multivariate logistic regression. Survival curves were performed using the Kaplan-Meier method. Cox proportional hazard regression with different adjustments was used to estimate the effect of SLN on survival. The detection rate of SLN was 97.24%, of which 24.9% were metastatic. Significant parameters upon SLN positivity were tumor thickness and nodular type of melanoma. The 5-year overall survival was 90.1 and 58.1% in SLN-negative and SLN-positive patients, respectively. Upon multivariate analysis tumor thickness and SLN status were significant factors influencing both disease-free survival and overall survival. In conclusion, our data confirm that SLNB is relevant as a diagnostic and staging procedure and that tumor thickness is of predictive importance. SLN status should be taken into account when designing clinical trials and informing patients about the probable course of their disease. Our data suggest that in case of a nodular melanoma subtype SLNB should also be considered at a tumor thickness below 1 mm.

Sentinel lymph node biopsy in melanoma: Facts and controversies

Three decades after its introduction in the 1990s, the sentinel lymph node biopsy for patients with localized cutaneous melanoma is still the subject of great debate in dermatology. Many questions remain unanswered, and studies currently in progress may or may not bring us any closer to determining the truth about sentinel lymph node biopsy and melanoma. We discuss the effect of sentinel lymph node biopsy on overall survival, the clinical and therapeutic implications of sentinel lymph node biopsy, and the melanoma patients who might be candidates for sentinel lymph node biopsy.

Persistent ex vivo low number and functional in vitro recovery of circulating gammadelta T cells after removal of a cutaneous primary melanoma

We recently described gammadelta T cells alterations in patients with a cutaneous primary melanoma. To evaluate whether gammadelta T cells alterations persisted after melanoma removal, we performed a follow-up study comparing the number and function of gammadelta T lymphocytes from 19 subjects, 4 years after the removal of a cutaneous primary melanoma, with the data obtained in the same subjects before the surgical intervention and with control donors. The number of circulating gammadelta(+) T cells after melanoma removal was not recovered to the levels found in controls. gammadelta(+) T cells producing TNF-alpha or IFN-gamma were increased after melanoma removal in comparison with the same subjects before surgical intervention or with control donors. After in vitro culture, both the percentage and the expansion of gammadelta T cells were recovered to the values found in controls. In conclusion, the functional capacity of gammadelta T cells was in vitro recovered after melanoma removal, whereas their ex vivo number remained at lower levels than control donors.