Follow-up in melanoma patients

Surveillance After a Previous Cutaneous Melanoma Diagnosis: A Scoping Review of Melanoma Follow-Up Guidelines

INTRODUCTION

Cutaneous melanoma accounts for more than 70% of all skin cancer deaths. Follow-up surveillance is an integral part of melanoma patient care, to facilitate early detection of recurrences and subsequent primary melanomas. The purpose of this scoping review is to provide an overview of recently published melanoma surveillance guidelines from regional and national melanoma working groups.

METHODS

A systematic search for relevant studies in MEDLINE and Embase was conducted in September 2022 and was limited to publications from 2010 or later.

RESULTS

A total of 1047 articles were retrieved, and after abstract and full text review, 26 articles from 19 different organizations met inclusion criteria. Life-long annual skin surveillance with a physician was recommended by 53% (9/17) of guidelines. Routine laboratory investigations were recommended by 7/19 guidelines. Regional lymph node ultrasound was recommended by 9/16 guidelines, most often in stage IB or higher, and was optional in 7/16 for patients who met specific criteria. Surveillance with PET-CT or CT and MRI was recommended by 15 and 11 guidelines, respectively, most commonly in stage IIC or higher, with a variable frequency and total duration. Five out of 9 guidelines indicated a preference for skin surveillance to be completed with a dermatologist.

CONCLUSION

Guidelines were highly variable for many aspects of melanoma surveillance, which may be partly attributed to regional differences in healthcare workforce distribution and availability of imaging technologies. Further high-level studies are recommended to provide more evidence on the most effective clinical and imaging follow-up surveillance protocols.

Conventional versus Reduced-Frequency Follow-Up in Early-Stage Melanoma Survivors: A Systematic Review with Meta-Analysis

To date, there have been multiple studies and clinical guidelines or recommendations for complex management of melanoma patients. The most controversial subjects included the frequency of follow-up. This study provides a coherent and comprehensive comparison of conventional vs. reduced-frequency follow-up strategies for early-stage melanoma patients. The value of our study consists in the precise analysis of a large collection of articles and the selection of the most valuable works in relation to the topic according to rigorous criteria, which allowed for a thorough study of the topic. The search strategy was implemented using multiple databases. The inclusion criteria were randomized clinical trial or cohort studies that compared the outcomes of a conventional follow-up schedule versus a reduced-frequency follow-up schedule for patients diagnosed with melanoma. In this study, authors analyzed recurrence and 3-year survival. Meta-analysis of outcomes presented by Deckers et al. and Moncrieff et. al. did not reveal a significant difference favoring one of the groups (OR 1.14; 95%CI: 0.65–2.00; p = 0.64). The meta-analysis of 3-year overall survival included two studies. The statistical analysis showed no significant difference in favor of the conventional follow-up group. (OR 1.10; 95%CI: 0.57–2.11; p = 0.79). Our meta-analysis shows that there is no advantage in a conventional follow-up regimen over a reduced-frequency regimen in early-stage melanoma patients.

Melanoma stimulates the proteolytic activity of HaCaT keratinocytes

Background

Keratinocytes constitute a major part of the melanoma microenvironment, considering their protective role towards melanocytes in physiological conditions. However, their interactions with tumor cells following melanomagenesis are still unclear.

Methods

We used two in vitro models (melanoma-conditioned media and indirect co-culture of keratinocytes with melanoma cells on Transwell inserts) to activate immortalized keratinocytes towards cancer-associated ones. Western Blotting and qPCR were used to evaluate keratinocyte markers and mediators of cell invasiveness on protein and mRNA expression level respectively. The levels and activity of proteases and cytokines were analysed using gelatin-FITC staining, gelatin zymography, chemiluminescent enzymatic test, as well as protein arrays. Finally, to further study the functional changes influenced by melanoma we assessed the rate of proliferation of keratinocytes and their invasive abilities by employing wound healing assay and the Transwell filter invasion method.

Results

HaCaT keratinocytes activated through incubation with melanoma-conditioned medium or indirect co-culture exhibit properties of less differentiated cells (downregulation of cytokeratin 10), which also prefer to form connections with cancer cells rather than adjacent keratinocytes (decreased level of E-cadherin). While they express only a small number of cytokines, the variety of secreted proteases is quite prominent especially considering that several of them were never reported as a part of secretome of activated keratinocytes’ (e.g., matrix metalloproteinase 3 (MMP3), ADAM metallopeptidase with thrombospondin type 1 motif 1). Activated keratinocytes also seem to exhibit a high level of proteolytic activity mediated by MMP9 and MMP14, reduced expression of TIMPs (tissue inhibitor of metalloproteinases), upregulation of ERK activity and increased levels of MMP expression regulators-RUNX2 and galectin 3. Moreover, cancer-associated keratinocytes show slightly elevated migratory and invasive abilities, however only following co-culture with melanoma cells on Transwell inserts.

Conclusions

Our study offers a more in-depth view of keratinocytes residing in the melanoma niche, drawing attention to their unique secretome and mediators of invasive abilities, factors which could be used by cancer cells to support their invasion of surrounding tissues.

TERT Promoter Mutational Status in the Management of Cutaneous Melanoma: Comparison with Sentinel Lymph Node Biopsy

BACKGROUND

While BRAF mutations seem important for early melanomagenesis, mutations in the TERT promoter (TERTp) are related to metastasis. Yet, in conventional melanoma management, risk stratification does not depend on molecular biomarkers that can indicate the stage of progression, but rather on clinical, pathological, sentinel lymph node (SLN), and radiologic evaluation. The aim of this work was to evaluate the frequency and prognostic impact of TERTp mutations, comparing their predictive value to those of conventional procedures in melanoma management.

METHODS

Mutational analysis of a series of 91 cases was performed. The correlations between TERTp and BRAF mutational status and clinicopathological features were assessed.

RESULTS

The mutation rate was 33% for TERTp and 30% for BRAF. There was 68% concordance between primary and metastatic samples for TERTp mutations and 92% for BRAF mutations. TERTp mutations are significantly associated with the presence of BRAF mutations, features of worse prognosis, and a reduced disease-free survival. Also, TERTp mutational status was similar to SLN biopsy as a predictive factor of cutaneous melanoma recurrence and metastasis.

CONCLUSIONS

The predictive value of TERTp mutations may be similar to that of SLN biopsy and its integration in the management algorithm of melanoma patients should be considered.

Serum markers improve current prediction of metastasis development in early-stage melanoma patients: a machine learning-based study

Metastasis development represents an important threat for melanoma patients, even when diagnosed at early stages and upon removal of the primary tumor. In this scenario, determination of prognostic biomarkers would be of great interest. Serum contains information about the general status of the organism and therefore represents a valuable source for biomarkers. Thus, we aimed to define serological biomarkers that could be used along with clinical and histopathological features of the disease to predict metastatic events on the early‐stage population of patients. We previously demonstrated that in stage II melanoma patients, serum levels of dermcidin (DCD) were associated with metastatic progression. Based on the relevance of the immune response on the cancer progression and the recent association of DCD with local and systemic immune response against cancer cells, serum DCD was analyzed in a new cohort of patients along with interleukin 4 (IL‐4), IL‐6, IL‐10, IL‐17A, interferon γ (IFN‐γ), transforming growth factor‐β (TGF‐ β), and granulocyte–macrophage colony‐stimulating factor (GM‐CSF). We initially recruited 448 melanoma patients, 323 of whom were diagnosed as stages I‐II according to AJCC. Levels of selected cytokines were determined by ELISA and Luminex, and obtained data were analyzed employing machine learning and Kaplan–Meier techniques to define an algorithm capable of accurately classifying early‐stage melanoma patients with a high and low risk of developing metastasis. The results show that in early‐stage melanoma patients, serum levels of the cytokines IL‐4, GM‐CSF, and DCD together with the Breslow thickness are those that best predict melanoma metastasis. Moreover, resulting algorithm represents a new tool to discriminate subjects with good prognosis from those with high risk for a future metastasis.

An indirect treatment comparison of the efficacy of pembrolizumab versus competing regimens for the adjuvant treatment of stage III melanoma

Objective: To determine the efficacy of pembrolizumab relative to other treatments used in stage III melanoma by conducting a systematic literature review (SLR) and network meta-analysis (NMA).

Methods: A SLR was conducted to identify randomized clinical trials (RCTs) evaluating approved adjuvant treatments including interferon-containing regimens, BRAF-inhibitors, and PD-L1 inhibitors in stage III melanoma patients. Relative treatment effects for recurrence-free survival (RFS) were synthesized with Bayesian NMA models that allowed for hazard ratios (HRs) to vary over time.

Results: Included studies formed a connected network of evidence composed of eight trials. In high-risk stage III patients, the HR for pembrolizumab vs observation decreased significantly over time with the superiority of pembrolizumab over observation becoming statistically meaningful before 3 months. By 9 months, the HR for pembrolizumab vs observation was statistically significantly lower than the HR for most other treatments vs observation, with the exception of ipilimumab and biochemotherapy due to overlapping 95% credible intervals. In BRAF + patients, pembrolizumab was statistically significantly better than observation after 3 months. The HR for both BRAF-inhibitors vs observation increased significantly over time and pembrolizumab was statistically superior to both BRAF-inhibitors after 15 months.

Conclusions: Pembrolizumab results in statistically significantly improved RFS compared to all competing regimens after 9 months, except ipilimumab and biochemotherapy, for the adjuvant treatment of stage III melanoma. However, point estimate HRs vs observation for pembrolizumab are much lower than those for ipilimumab. In BRAF + patients, the advantage of pembrolizumab versus competing interventions increases over time with respect to RFS.