Incidence, mortality and survival in cutaneous melanoma

Risk factors for sentinel lymph node metastasis in Korean acral and non-acral melanoma patients

Breslow thickness, ulceration, and mitotic rate are well-known prognostic factors for sentinel lymph node (SLN) metastasis in cutaneous melanoma. We investigated risk factors, including especially the degree of pigmentation, for SLN metastasis in Korean melanoma patients. We enrolled 158, composed of Korean 107 acral and 51 non-acral melanoma patients who underwent SLN biopsy. Clinicopathologic features such as Breslow thickness, ulceration, mitotic rate, and the degree of pigmentation were evaluated. The recurrence-free survival (RFS) rate and date of recurrence were determined. Fifty-four patients (34.2%) had a positive SLN biopsy result. In a multivariate analysis, Breslow thickness (odds ratio [OR] 1.93; 95% confidence interval [CI], 1.12-3.47; p = .022) and heavy pigmentation (OR 13.14; 95% CI, 2.96-95.20, p = .002) were associated with SLN metastasis. Positive SLN patients had a higher rate of loco-regional and/or distant recurrence (hazard ratio 6.32; 95% CI, 3.39-11.79; p < .001). Heavy pigmentation was associated with poor RFS. Heavy pigmentation is an independent predictor of SLN metastasis in both acral and non-acral melanoma. Our results suggest the need for in-depth SLN evaluation of cutaneous melanoma patients with heavy pigmentation and provide clinicians with important information for determining patient prognosis.

Looking Beyond the Hutchinson Sign: A Retrospective Study of Clinical Factors Indicating the Presence and Invasiveness of Nail Unit Melanoma in Patients With Longitudinal Melanonychia

BACKGROUND

The data underlying this article are available in the article.Longitudinal melanonychia (LM) presents a challenge because nail unit melanoma (NUM) must be considered as a differential diagnosis. Because nail matrix biopsy may result in nail dystrophy, it is important to distinguish NUM from LM.

OBJECTIVE

To provide evidence of previously reported clinical factors indicative of NUM in patients with LM.

METHODS

This was a retrospective study of patients who presented with LM and had biopsy-confirmed NUM from 2005 to 2021. Benign LM was either confirmed by biopsy or considered benign if followed without the need for biopsy. Clinical factors associated with LM and NUM were compared by multivariate regression.

RESULTS

A total of 177 patients (97 LM and 80 NUM) were included. Multivariate regression showed that high band color intensity (p = .0031), variegation (p = .0005), nail plate splitting (p = .0017), Hutchinson sign (p = .0027), and band change (p = .001) correlated with malignancy. Nail plate splitting was associated with Breslow thickness.

CONCLUSION

Malignancy should be suspected and biopsy performed in patients with LM and high band color intensity, variegation, nail plate splitting, Hutchinson sign, and band change.

Exploring and validating the prognostic value of pathomics signatures and genomics in patients with cutaneous melanoma based on bioinformatics and deep learning

BACKGROUND

Cutaneous melanoma (CM) is the most common malignant tumor of the skin. Our study aimed to investigate the prognostic value of pathomics signatures for CM by combining pathomics and genomics.

PURPOSE

The purpose of this study was to explore the potential application value of pathomics signatures.

METHODS

Pathology full scans, clinical information, and genomics data for CM patients were downloaded from The Cancer Genome Atlas (TCGA) database. Exploratory data analysis (EDA) was used to visualize patient characteristics. Genes related to a poorer prognosis were screened through differential analysis. Survival analysis was performed to assess the prognostic value of gene and pathomics signatures. Artificial neural network (ANN) models predicted prognosis using signatures and genes. Correlation analysis was used to explore signature-gene links.

RESULTS

The clinical traits for 468 CM samples and the genomic data and pathology images for 471 CM samples were obtained from the TCGA database. The EDA results combined with multiple machine learning (ML) models suggested that the top 5 clinical traits in terms of importance were age, biopsy site, T stage, N stage and overall disease stage, and the eight ML models had a precision lower than 0.56. A total of 60 differentially expressed genes were obtained by comparing sequencing data. A total of 413 available quantitative signatures of each pathomics image were obtained with CellProfile software. The precision of the binary classification model based on pathomics signatures was 0.99, with a loss value of 1.7119e-04. The precision of the binary classification model based on differentially expressed genes was 0.98, with a loss value of 0.1101. The precision of the binary classification model based on pathomics signatures and differentially expressed genes was 0.97, with a loss value of 0.2088. The survival analyses showed that the survival rate of the high-risk group based on gene expression and pathomics signatures was significantly lower than that of the low-risk group. A total of 222 pathomics signatures and 51 differentially expressed genes were analyzed for survival with p-values of less than 0.05. There was a certain correlation between some pathomics signatures and differential gene expression involving ANO2, LINC00158, NDNF, ADAMTS15, and ADGRB3, etc. CONCLUSION: This study evaluated the prognostic significance of pathomics signatures and differentially expressed genes in CM patients. Three ANN models were developed, and all achieved accuracy rates higher than 97%. Specifically, the pathomics signature-based ANN model maintained a remarkable accuracy of 99%. These findings highlight the CellProfile + ANN model as an excellent choice for prognostic prediction in CM patients. Furthermore, our correlation analysis experimentally demonstrated a preliminary link between disease quantification and qualitative changes. Among various features, including M stage and treatments received, special attention should be given to age, biopsy site, T stage, N stage, and overall disease stage in CM patients.

Significant improvement in melanoma survival over the last decade: A Hungarian nationwide study between 2011 and 2019

BACKGROUND

Recent real-world studies have reported significant improvements in the survival of malignant melanoma in the past few years, mainly as a result of modern therapies. However, long-term survival data from Central Eastern European countries such as Hungary are currently lacking.

METHODS

This nationwide, retrospective study examined melanoma survival in Hungary between 2011-2019 using the databases of the National Health Insurance Fund (NHIF) and Central Statistical Office (CSO) of Hungary. Crude overall survival and age-standardized 5-year net survival as well as the association between age, sex and survival were calculated.

RESULTS

Between 2011 and 2019, 22,948 newly diagnosed malignant melanoma cases were recorded in the NHIF database (47.89% male, mean age: 60.75 years (SD: ±16.39)). Five-year overall survival was 75.40% (women: 80.78%; men: 69.52%). Patients diagnosed between 2017-2019 had a 20% lower risk of mortality compared to patients diagnosed between 2011-2012 (HR 0.80, 95% CI 0.73-0.89; p < 0.0001). Age-standardized 5-year net survival rates in 2011-2014 and 2015-2019 were 90.6% and 95.8%, respectively (women: 93.1% and 98.4%, men: 87.8% and 92.7%, respectively). The highest age-standardized 5-year net survival rates were found in the 0-39 age cohort (94.6% in the 2015-2019 period).

CONCLUSION

Hungary has similar melanoma survival rates to Western European countries. Based on net survival, the risk of dying of melanoma within 5 years was cut by more than half (55%) during the study period, which coincides with the successful implementation of awareness campaigns and the wide availability of modern therapies.

The Treatment of Advanced Melanoma: Therapeutic Update

Cutaneous melanoma is the main cause of death for skin cancer. The majority of patients with a diagnosis of melanoma have localized disease, which can be successfully treated with surgical treatment. However, the surgical approach is not curative for advanced melanoma (AM). Indeed, the management of AM is still challenging, since melanoma is the solid tumor with the highest number of mutations and cancer cells have the capacity to evade the immune system. In the past, the treatment of AM relied on chemotherapeutic agents, without showing efficacy data. Recent knowledge on melanoma pathogenesis as well as the introduction of immunotherapies, targeted therapies vaccines, small molecules, and combination therapies has revolutionized AM management, showing promising results in terms of effectiveness and safety. The aim of this review is to assess and to discuss the role of emerging therapies for AM management in order to obtain a complete overview of the currently available treatment options and future perspectives.

PRAME immunohistochemistry is useful in the diagnosis of oral malignant melanoma

OBJECTIVES

While the incidence of cutaneous melanoma has dramatically increased in recent years, oral malignant melanoma (OMM) remains a rare form of noncutaneous melanoma with poor survival. PRAME (PReferentially expressed Antigen in MElanoma) is reported to have diagnostic and some prognostic utility in cutaneous melanomas and some head and neck malignancies. We sought to explore the diagnostic utility of PRAME in OMM.

METHODS

A total of ten specimens from eight unique cases of OMM were identified from the Oral Pathology Biopsy Service (OPBS) at University of Washington School of Dentistry between 2005 and 2019. For all cases, standard histology and immunohistochemistry stains were performed, including a stain against PRAME. The diagnoses were reviewed and confirmed by two pathologists. Clinical and epidemiologic features were described.

RESULTS

Patient ages ranged from 55 to 82. The group consisted of five males and three females. All eight cases were located on the hard palate. Six cases represented invasive melanoma while two were early melanoma in situ. PRAME immunohistochemistry was successfully performed on seven of eight cases: six were positive (86%), one was negative (14%) and one case lacked sufficient tissue for staining.

CONCLUSIONS

Our results suggest that PRAME immunohistochemistry may be useful in the diagnosis of OMM, including early melanoma in situ. Further studies with clinical follow-up and a larger number of cases are needed to explore prognostic value as well as the ability to distinguish between benign, intermediate and malignant melanocytic proliferations of the oral cavity.

Novel human melanoma brain metastasis models in athymic nude fox1nu mice: Site-specific metastasis patterns reflecting their clinical origin

BACKGROUND

Malignant melanomas frequently metastasize to the brain, but metastases in the cerebellum are underrepresented compared with metastases in the cerebrum.

METHODS

We established animal models by injecting intracardially in athymic nude fox1nu mice two human melanoma cell lines, originating from a cerebral metastasis (HM19) and a cerebellar metastasis (HM86).

RESULTS

Using magnetic resonance imaging (MRI), metastases were first detected after a mean of 34.5 days. Mean survival time was 59.6 days for the mice in the HM86 group and significantly shorter (43.7 days) for HM19-injected animals (p < 0.001). In the HM86 group, the first detectable metastasis was located in the cerebellum in 15/55 (29%) mice compared with none in the HM19 group (p < 0.001). At sacrifice, cerebellar metastases were found in 34/55 (63%) HM86-injected mice compared with 1/53 (2%) in the HM19-injected (p < 0.001) mice. At that time, all mice in both groups had detectable metastases in the cerebrum. Comparing macroscopic and histologic appearances of the brain metastases with their clinical counterparts, the cell line-based tumors had kept their original morphologic characteristics.

CONCLUSIONS

The present work demonstrates that human brain-metastatic melanoma cells injected intracardially in mice had retained inherent characteristics also in reproducing interaction with subtle microenvironmental brain tissue compartment-specific features. The models offer new possibilities for investigating tumor- and host-associated factors involved in determining tissue specificity of brain metastasis.

The Incidence of Cutaneous Malignant Melanoma in Eastern Newfoundland and Labrador, Canada, from 2007 to 2015

BACKGROUND

The incidence of cutaneous malignant melanoma continues to increase worldwide and in Canada. It is unclear whether the increase in incidence and clinical characteristic trends of cutaneous malignant melanoma are similar in the province of Newfoundland and Labrador.

OBJECTIVE

The objective of this study is to examine the incidence and trends of cutaneous malignant melanoma in Eastern Newfoundland and Labrador.

METHODS

Patients aged 18 years or older diagnosed with cutaneous malignant melanoma were identified from the Eastern Health Authority's Cancer Registry. The diagnosis was confirmed by a pathologist via histological subtype. Patients were excluded if the diagnosis was unspecified, a nonmelanoma skin cancer or if there was a recurrence in the same lesion location. In total 298 patients diagnosed with cutaneous malignant melanoma from 2007 to 2015 were included in the analysis.

RESULTS

The total incidence increased from 4.1 to 15.6 cases/100,000 person-years, which represents a 283.0% increase from 2007 to 2015. The largest increases in incidence were seen in males and patients aged from 60 to 79 years. The most common lesion anatomical locations were the trunk in males and the lower extremity in females. The majority of cases had a Breslow thickness below 1.0 mm.

CONCLUSION

The incidence of cutaneous malignant melanoma in Eastern Newfoundland and Labrador is increasing at a faster rate than in any other region in Canada. Health care providers should work to be aware of the clinical trends and risk factors associated with this disease to facilitate early detection and prevent morbidity.

Malignant melanoma of parotid glands from a neglected lesion: A case report

Observing a metastatic malignant melanoma and its primary lesion at the same time is rare. The histopathological detection of any unusual pigmented lesion is critical.

Expression of the cancer stem cell marker OCT4 is associated with worse prognosis and survival in cutaneous melanoma

Cutaneous melanoma has an aggressive clinical presentation, showing rapid rate of growth and metastatic dissemination due to the permanence of cancer stem cells. The present study was to evaluate the expression of the self-renewal regulatory factor and the clinical significance of the transcription factor OCT4 in melanoma. Melanoma tissues were stained by immunohistochemistry and the correlation between the expression of this marker was determined through clinical-pathological variables and survival outcomes. Positive expression of nuclear and cytoplasmic OCT4 was observed in 49% and 41.2% of cases, respectively. The positive expression of nuclear OCT4 in melanoma was significantly associated with prognostic factors, such as Breslow depth, Clark's level, ulceration and metastasis. Survival of patients was 56% compared to positive nuclear OCT4 expression and 94.2% when compared to the low expression of the gene. Nuclear OCT4 positive genotype indicated aggressive tumor behavior with a worse clinical outcome, which indicates OCT4 as a useful biomarker in the prognosis of melanoma.

Estimating parameters of a stochastic cell invasion model with fluorescent cell cycle labelling using approximate Bayesian computation

We develop a parameter estimation method based on approximate Bayesian computation (ABC) for a stochastic cell invasion model using fluorescent cell cycle labelling with proliferation, migration and crowding effects. Previously, inference has been performed on a deterministic version of the model fitted to cell density data, and not all parameters were identifiable. Considering the stochastic model allows us to harness more features of experimental data, including cell trajectories and cell count data, which we show overcomes the parameter identifiability problem. We demonstrate that, while difficult to collect, cell trajectory data can provide more information about the parameters of the cell invasion model. To handle the intractability of the likelihood function of the stochastic model, we use an efficient ABC algorithm based on sequential Monte Carlo. Rcpp and MATLAB implementations of the simulation model and ABC algorithm used in this study are available at https://github.com/michaelcarr-stats/FUCCI.

Reasons for indoor tanning use and the acceptability of alternatives: A qualitative study

RATIONALE

Using indoor tanning devices is associated with substantial health consequences, such as an increased risk of melanoma and other skin cancers. Many people including minors and some at high risk of skin cancer continue to use these devices. In the absence of effective restrictions on use, it is important that behaviour change interventions are designed to reduce indoor tanning.

OBJECTIVE

To explore reasons for use of indoor tanning devices and the acceptability of alternatives in adult users residing in North-West England.

METHODS

Participants were required to be current indoor tanners aged 18 years and above and were recruited online. Twenty-one participants took part in either a focus group or semi-structured interview. An inductive thematic analysis was conducted.

RESULTS

Six themes were identified: psychological benefits; improving physical health; denial of health risks; alternatives do not meet psychological needs; alternatives do not meet physical needs; and perceived side-effects. Participants used indoor tanning devices to improve their self-esteem and to prevent sun damage to their skin (by gaining a 'base tan'). Participants appeared to justify their usage by responding defensively to avoid accepting they were at risk, exaggerating the benefits of indoor tanning, and discounting alternatives to indoor tanning. Alternatives to indoor tanning were perceived as risky for health, inadequate to provide the desired aesthetic, and incapable of meeting their self-esteem needs.

CONCLUSIONS

Interventions to reduce indoor tanning behaviour should increase sources of self-esteem other than appearance, increase media literacy and address defensive responses to information around indoor tanning and alternatives. Further research is needed to develop these interventions and assess their feasibility.

A Review of Epidemiology and Cancer Biology of Malignant Melanoma

Malignant melanoma is a neoplasm originating in the melanocytes in the skin. Although malignant melanoma is the third most common cutaneous cancer, it is recognized as the main cause of skin cancer-related mortality, and its incidence is rising. The natural history of malignant melanoma involves an inconsistent and insidious skin cancer with great metastatic potential. Increased ultra-violet (UV) skin exposure is undoubtedly the greatest risk factor for developing cutaneous melanoma; however, a plethora of risk factors are now recognized as causative. Moreover, modern oncology now considers melanoma proliferation a complex, multifactorial process with a combination of genetic, epigenetic, and environmental factors all known to be contributory to tumorgenesis. Herein, we wish to outline the epidemiological, molecular, and biological processes responsible for driving malignant melanoma proliferation.

Epidemiology of Melanoma in the Czech Republic in East Bohemia in the Period 2002-2017 and the Effect of the Annual Sunshine Exposure

AIM

The evaluation of the trend in the occurrence of melanoma nodulare, melanoma superficiale, lentigo maligna and melanoma in situ in the period of 2002-2017 in East Bohemia region in the Czech Republic. We examine if the annual numbers of hours of sunshine could affect the number of patients with melanoma.

METHOD

In the peridod of 2002-2017, altogether 2230 patients with new diagnosis of melanoma were examined. We studied 1) If there is some trend in the occurrence of lentigo maligna and melanoma in situ, melanoma superficiale, and melanoma nodulare and if there is a difference in the age of patients with this diagnosis (adjusted calculation of specific kind of melanomas and adjusted calculation of age). 2) If the annual numbers of hours of sunshine affect the trend in the occurrence of melanoma and if the annual numbers of hours of sunshine affect the body site of melanoma.

RESULTS AND CONCLUSION

Our study confirmed that the number of patients with lentigo maligna and melanoma in situ had increased in East Bohemia region in the period of 2002-2017. The number of melanomas of nodular and superficial type does not increase. The total number of melanomas in this period does not increase either. No difference of the age of patients with melanoma nodulare, superficiale, lentigo maligna and melanoma in situ was confirmed. We confirmed no relation of the annual numbers of hours of sunshine to the number of melanoma and to the body site of melanoma.

Melanoma Incidence in Czech Republic, the Relation between Histology, Body Site of Melanoma, and Duration of Lesions

AIM

To evaluate the occurrence of melanoma in the period 1996-2017 in East Bohemia region in the Czech Republic.

METHOD

We studied the incidence of melanoma and the age of diagnosis (adjusted calculation) and the parameters such as histology, body site of lesions, the length of the duration of lesions in 2810 patients.

RESULTS AND CONCLUSION

No change in the occurrence of melanoma and in age of melanoma during this period was found. The difference between men and women was not confirmed in histology, but the difference between men and women was confirmed in the body site of lesion and in the length of duration of lesion. No relation between the length of duration of lesions from which melanoma had originated and its histology was confirmed. The relation was confirmed between histology and body site of melanoma. The relation between the body site and the length of duration of previous lesions was confirmed also. The increasing occurrence of melanoma on the trunk according to the duration of the previous lesions was confirmed.

The effect of two porphyrine photosensitizers TMPyP and ZnTPPS4 for application in photodynamic therapy of cancer cells in vitro

Photodynamic therapy (PDT) is one of the treatments for cancer. This therapy uses a combination of a photosensitizer (PS), light irradiation, and oxygen O₂, which is converted to cytotoxic ¹O₂ and other forms of reactive oxygen species (ROS), causing selective damage to the target tissue. In this work, we studied effect of two porphyrin photosensitizers TMPyP and ZnTPPS₄ at three different concentrations (0.25, 0.5, 5μM) after two irradiation doses (5 and 25 J/cm²). Photodynamic efect of TMPyP and ZnTPPS₄ were confirmed by a battery of in vitro tests including MTT, reactive oxygen species (ROS) production and mitochondrial membrane potential test (MMP). Morphological changes of the cells before and after treatment were imaged by atomic force microscopy (AFM). The most effective combination of irradiation dose and concentration for both PSs showed a concentration of 5 μM and a irradiation dose of 25 J/cm² in both cell cultures.

Melanoma mortality in Spain: predictions up to 2043

BACKGROUND

Melanoma mortality rates are stabilizing and in certain regions and age groups are trending down. Although there are some studies that predict melanoma mortality in other countries, there are currently no studies that predict mortality in Spain in the coming years. The main aim of this study is to calculate melanoma mortality projections in Spain for the period 2019-2043.

METHODS

This is a population-based ecological study that utilized information from the Spanish National Statistics Institute. Analysis included deaths as a result of cutaneous melanoma in Spain in the period 1979-2018, and data was analyzed according to gender and age group. Projections were made until 2043 in five-year periods, calculated in Nordpred (within the R software).

RESULTS

Our estimates predict that in the period 2019-2043, there will be 30,477.9 deaths from melanoma in Spain, with the age group of >85 years being the group with the highest number of deaths. The expected average annual death rate for melanoma in both genders for the period 2019-2043 is 1,269.9 deaths / year. The predicted age-standardized mortality rates varied between 4.62/100.000 inhabitants in the 2019-2023 period and 3.94/100.000 inhabitants in the 2039-2043 period.

CONCLUSIONS

Overall mortality rate and age-standardized melanoma death rates in older people of both genders will increase in the coming years in Spain, while rates in younger people will stabilize or decrease progressively. In the coming years, prevention efforts should focus on the young, but the emphasis should also be on educating the elderly in early detection of melanoma.

Cutaneous malignant melanoma mortality in Andalusia from 1979 to 2018. Toward new perspectives?

Malignant melanoma accounts for 80% of deaths due to skin cancer. Its incidence is globally increasing. However, melanoma mortality seems to be decreasing. The aim of this study was to analyze mortality rates due to melanoma in Andalusia between 1979 and 2018. Deaths due to melanoma and mid-year population in Andalusia were collected from the National Institute of Statistics. Age-adjusted mortality rates were calculated for overall population and for each sex and age group. Regression models were used to calculate significant points of change. Sex ratio and the independent effects of age, period, and cohort were also analyzed. Age-adjusted mortality due to melanoma rose from 0.61 to 1.94 deaths per 100.000 from 1979 to 2018 for the overall population. A significant change of trends was detected around 1994 when, after a steady rise from 1979, mortality rates stabilized up to the end of the period studied. The cited increase was more pronounced in >64 year males. From the end of the 2000s, there was a decrease in mortality rates to date in all population groups, producing a period effect. A stabilization in melanoma mortality rates was observed in Andalusia from 1994 with a decrease in some groups at the beginning of the 21st century. Trends observed in Andalusia do not differ substantially from those in Spain. The development of new therapies and an earlier diagnosis may have an influence in those changes. Studies that compare differences between Spanish regions are needed to define better prevention strategies.

Electrical Impedance Tomography - Recent Applications and Developments

Electrical impedance tomography (EIT) is a low-cost noninvasive imaging method. The main purpose of this paper is to highlight the main aspects of the EIT method and to review the recent advances and developments. The advances in instrumentation and in the different image reconstruction methods and systems are demonstrated in this review. The main applications of the EIT are presented and a special attention made to the papers published during the last years (from 2015 until 2020). The advantages and limitations of EIT are also presented. In conclusion, EIT is a promising imaging approach with a strong potential that has a large margin of progression before reaching the maturity phase.

Neferine induces p38 MAPK/JNK1/2 activation to modulate melanoma proliferation, apoptosis, and oxidative stress

Background

Melanoma is a malignant skin cancer that has a poor prognosis in advanced patients. The aim of the present study was to investigate the antitumor role of neferine in melanoma.

Methods

A375 and C32 cells were selected as research vectors in vitro. Cell counting Kit-8, 5-ethynyl-2’-deoxyuridine staining, transwell, and flow cytometry assay were used to examined cell malignant phenotypes. Mitochondrial dysfunction was detected by 5,50,6,60-tetrachloro-1,10,3,30-tetraethyl-imidacarbocyanine iodide staining and enzyme-linked immunosorbent assay. Reactive oxygen species (ROS) generation was measured using oxidation sensitive fluorescent probe. The phosphorylation activity of p38 and Jun-N-terminal kinase (JNK) 1/2 were examined by Western blot. A xenograft model was established via the subcutaneous injection of A375 cells into the right flank of BALB/c mice in vivo.

Results

Neferine (2.5, 5, or 10 µM) treatment inhibited proliferation, invasion, and enhanced apoptotic rate of A375 and C32 cells. Neferine treatment induced abnormal changes in mitochondrial membrane potential. Further studies showed that neferine could significantly increase the production of reactive oxygen species (ROS) and 3,4-methylenedioxyamphetamine (MDA) content, decreased the superoxide dismutase (SOD) level. Neferine (5, 10, or 20 mg/kg) obviously suppressed the weight and size of the xenograft tumor, the number of apoptotic cells in vivo, and the expression of Ki67⁺ and survivin⁺ decreased. Notably, neferine also activated the phosphorylation of p38 and JNK1/2.

Conclusions

Neferine inhibits the proliferative and invasion ability of melanoma cells and promotes their apoptosis, ameliorating the malignant progression of melanoma, likely achieved by upregulating the phosphorylation levels of p38 mitogen-activated protein kinase and JNK1/2.

Late Metastatic Melanoma after 25 Years: A Case Report and a Brief Literature Review

The incidence of cutaneous malignant melanoma has shown a drastic increase over recent decades, and approximately 70% of newly diagnosed melanoma are tumors with a Breslow thickness less or equal to 1 mm. In the literature, there are well-documented rare cases of late metastasis of thin melanoma, and given their growing incidence, it is expected in the future to see more cases of late recurrence. We present a case report of a metastatic cutaneous melanoma 25 years from diagnosis and a review of the literature. A 61-year-old female patient presented with a newly discovered asymptomatic nodule on her thigh. Her relevant past medical history included a completely excided lesion with Breslow 1.4 mm thickness in 1989 for which she was followed up according to the guidelines and subsequently declared cured after 10 years of surveillance. Fine-needle aspiration and cytological analysis of the lesion proved to be a subcutaneous localization of malignant melanoma. The lesion was completely excised, and the patient has remained disease free since her surgery. The aim of this case report is to emphasize that late metastasis remains uncommon but a definitive cure from melanoma cannot always be considered a disease-free interval of 10 years. Physicians should always be aware of previous melanoma diagnosis with newly discovered suspicious lesions. Better patient education could improve the detection of recurrence and secondary melanomas without any need for more frequent follow-up visits and a prolonged follow-up time.

Cost-Utility Analysis of Nivolumab in Adjuvant Treatment of Melanoma in France

Introduction

The aim of the current study is to estimate the cost-effectiveness of adjuvant treatment with nivolumab relative to clinically relevant comparators in adult patients with melanoma with lymph node involvement or metastatic disease who have undergone complete resection from a French societal perspective.

Methods

The comparators were observation, low-dose interferon and pembrolizumab. A subgroup analysis was carried out in patients with BRAF mutation, adding dabrafenib plus trametinib. A three-state partitioned survival model was developed to project costs and health benefits over a 20-year time horizon. Extrapolation for recurrence-free survival (RFS) and overall survival (OS) was carried out using spline-based models. Because of the immaturity of OS data in pivotal trials for nivolumab and pembrolizumab, a predictive model of OS treatment effect based on RFS effect was developed using a correlation equation. Health state utilities and adverse events disutilities were derived from the CheckMate 238 trial and literature. Costs were estimated in 2019 euros. The model’s primary outcome was efficiency frontier. Deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of results.

Results

Observation, low-dose interferon and nivolumab were on the efficiency frontier. The incremental cost–utility ratio of nivolumab versus low-dose interferon (closest therapy on the efficiency frontier) was €37,886/quality-adjusted life year (QALY). Probabilistic sensitivity analysis reported an 80% probability of nivolumab being a cost-effective strategy for a willingness-to-pay threshold of €52,000/QALY. In the subgroup with BRAF mutation, the efficiency frontier was not changed by the addition of dabrafenib plus trametinib.

Conclusions

Nivolumab is a cost-effective strategy as adjuvant treatment in adult patients with surgically resected melanoma in France.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00446-z) contains supplementary material, which is available to authorized users.

HSP27 Expression as a Novel Predictive Biomarker for Bevacizumab: is it Cost Effective?

BACKGROUND

Despite the extensive use of bevacizumab in a range of oncology indications, the US FDA revoked its approval for breast cancers, and multiple negative trials in several solid malignancies have been reported, so the need for predictive biomarkers has increased. The development of predictive biomarkers for anti-angiogenic bevacizumab therapy has long been pursued but without success.

INTRODUCTION

Heat shock protein (HSP)-27 expression has recently been identified as a predictive biomarker for bevacizumab in treating metastatic melanoma. This study aimed to evaluate the cost effectiveness of HSP27 biomarker testing before administration of bevacizumab.

METHODS

A partitioned survival analysis model with three mutually exclusive health states (progression-free survival, progressed disease, and death) was developed using a Norwegian health system perspective. The proportion of patients in each state was calculated using the area under the Kaplan-Meier curve for progression-free and overall survival derived from trials of bevacizumab and dacarbazine. Three strategies were compared: (1) test-treat with HSP27 biomarker and bevacizumab, (2) treat-all with dacarbazine without HSP27 testing, (3) treat-all with bevacizumab without HSP27 testing. Quality-adjusted life-years (QALYs) and costs were calculated for each strategy and discounted at 4%. A lifetime horizon was applied. Uncertainty analyses were performed. Expected value of perfect information (EVPI) was estimated to assess the potential value of further research to generate more evidence.

RESULTS

Although the test-treat strategy was cost effective compared with treat-all with dacarbazine, it was not cost effective compared with treat-all with bevacizumab without HSP27 testing. However, EVPI results showed very minimal or no value in conducting further research efforts to reduce uncertainties around current information.

CONCLUSION

The results of this study suggested that testing for HSP27 expression before administering bevacizumab is not cost effective compared with treat-all with bevacizumab without testing. It indicates that HSP27 expression is not cost effective as a potential predictive biomarker for bevacizumab. This may not necessarily mean that HSP27 is a bad biomarker for bevacizumab, but it may mean that bevacizumab is much better than dacarbazine regardless of HSP27 expression, so patient stratification according to HSP27 status is meaningless. Or, indeed, it may imply that HSP27 is not sufficiently good at identifying the right patients for bevacizumab.

Immune Checkpoint Inhibitor-Associated Primary Adrenal Insufficiency: WHO VigiBase Report Analysis

BACKGROUND

Immune checkpoint inhibitors (ICIs) have transformed cancer therapy but may also trigger autoimmune adverse drug reactions (ADRs) referred to as immune-related adverse events (irAEs). Although endocrinopathies are among the most common form of irAEs, primary adrenal insufficiency (PAI) is infrequent and has only been published in case reports. The aim of this study was to identify and characterize the main features of PAI-irAE.

MATERIALS AND METHODS

Suspected PAI-irAE cases were identified using VigiBase, the World Health Organization's pharmacovigilance database of individual case safety reports.

RESULTS

From September 2, 2008, through October 5, 2018, a total of 50,108 ICI-associated ADRs were reported. Since 2008, there were 451 cases of PAI-irAE identified of which 45 were "definite PAI" and 406 "possible PAI." Patients were mainly male (58.1%) with a median age of 66 years (range, 30-95). Indications of ICI were predominantly for melanoma (41.2%) and lung cancer (28.6%). The majority of patients were treated with ICI monotherapy (nivolumab: 44.3%, pembrolizumab: 11.7%, ipilimumab: 23.6%), and 17.9% were treated with ICI combination therapy. These events occurred with a median time to onset of 120 days (range, 6-576). ICI-associated PAI was associated with significant morbidity (≥90% severe) and mortality (7.3%). Fatality rates were similar in the subgroups of combination therapy versus monotherapy. There were no relevant differences in clinical or demographical characteristics and outcomes between "definite" versus "possible" PAI group.

CONCLUSION

Our study represents the largest clinical description and characterization of PAI-irAE. Although ICI-associated PAI is a rare adverse event, early recognition is important to implement corticosteroid treatment. Further studies are required to elucidate risk factors and reversibility of this rare but severe irAE. Clinical trial identification number. NCT03492242 IMPLICATIONS FOR PRACTICE: Immune checkpoint inhibitor (ICI)-associated primary adrenal insufficiency (PAI) is a rare adverse event that is important to recognize because it may be severe and life-threatening, requiring emergent and often lifelong hormonal replacement therapy. Awareness regarding this ICI-related endocrinopathy is strongly encouraged among clinicians in addition to patient education about common PAI symptoms that should prompt urgent medical evaluation. In clinical practice, close monitoring and investigation for PAI is crucial to allow for early management and to further define the pathophysiology and prognosis of ICI-PAI. Corticotrophin (adrenocorticotrophic hormone) circulating level evaluation may be often lacking but should be considered as part of the diagnostic workup to differentiate PAI from secondary (central) adrenal insufficiency.

Age Does Matter in Adolescents and Young Adults versus Older Adults with Advanced Melanoma; A National Cohort Study Comparing Tumor Characteristics, Treatment Pattern, Toxicity and Response

Cutaneous melanoma is a common type of cancer in Adolescents and Young Adults (AYAs, 15–39 years of age). However, AYAs are underrepresented in clinical trials investigating new therapies and the outcomes from these therapies for AYAs are therefore unclear. Using prospectively collected nation-wide data from the Dutch Melanoma Treatment Registry (DMTR), we compared baseline characteristics, mutational profiles, treatment strategies, grade 3–4 adverse events (AEs), responses and outcomes in AYAs (n = 210) and older adults (n = 3775) who were diagnosed with advanced melanoma between July 2013 and July 2018. Compared to older adults, AYAs were more frequently female (51% versus 40%, p = 0.001), and had a better Eastern Cooperative Oncology Group performance status (ECOG 0 in 54% versus 45%, p = 0.004). BRAF and NRAS mutations were age dependent, with more BRAF V600 mutations in AYAs (68% versus 46%) and more NRAS mutations in older adults (13% versus 21%), p < 0.001. This finding translated in distinct first-line treatment patterns, where AYAs received more initial targeted therapy. Overall, grade 3–4 AE percentages following first-line systemic treatment were similar for AYAs and older adults; anti-PD-1 (7% versus 14%, p = 0.25), anti-CTLA-4 (16% versus 33%, p = 0.12), anti-PD-1 + anti-CTLA-4 (67% versus 56%, p = 0.34) and BRAF/MEK-inhibition (14% versus 23%, p = 0.06). Following anti-CTLA-4 treatment, no AYAs experienced a grade 3–4 colitis, while 17% of the older adults did (p = 0.046). There was no difference in response to treatment between AYAs and older adults. The longer overall survival observed in AYAs (hazard ratio (HR) 0.7; 95% CI 0.6–0.8) was explained by the increased cumulative incidence of non-melanoma related deaths in older adults (sub-distribution HR 2.8; 95% CI 1.5–4.9), calculated by competing risk analysis. The results of our national cohort study show that baseline characteristics and mutational profiles differ between AYAs and older adults with advanced melanoma, leading to different treatment choices made in daily practice. Once treatment is initiated, AYAs and older adults show similar tumor responses and melanoma-specific survival.

Karyopherin α 2 promotes proliferation, migration and invasion through activating NF-κB/p65 signaling pathways in melanoma cells

AIMS

Melanoma is a fatal malignancy. Karyopherin α 2 (KPNA2) plays an important role in many carcinogenesis. This study was aimed to study the role of KPNA2 in cellular functions and molecular mechanisms of melanoma.

MAIN METHODS

We investigated the expression and prognosis of KPNA2 in melanoma using the GEPIA database (http://gepia.cancer-pku.cn/). The effect of KPNA2 on melanoma cells was determined using real-time PCR, western blot, immunofluorescence assay, CCK-8, colony formation, wound healing assay, transwell assay, EMSA, and immunohistochemistry. The influence of KPNA2 on the tumorigenicity of melanoma cells was evaluated in a nude mice model in vivo.

KEY FINDINGS

Our results showed that KPNA2 expression is relatively high in melanoma tissues and cells, and melanoma patients with higher expression of KPNA2 had lower overall survival rate and disease free survival rate. KPNA2 promoted proliferation ability and increased the expression of PCNA, Ki67, and C-MYC in melanoma cells. Further, KPNA2 could promote migration and invasion and increase the expression of MMP2 and MMP9. Mechanism studies showed that KPNA2 activated NF-κB/p65 signaling pathways, as evidenced by the nuclear translocation of p65 and increased the expression of COX-2, ICAM-1, iNOS, and MCP1 in melanoma cells. NF-κB inhibitor JSH-23 could reverse the pro-tumor effects of KPNA2 on melanoma cells. Moreover, upregulation of KPNA2 facilitated the tumorigenicity of melanoma cells.

SIGNIFICANCE

KPNA2 promotes proliferation, migration and invasion through enhancing NF-κB/p65 signaling pathways in melanoma cells. Our study suggests KPNA2 as a potential therapeutic target for the treatment of melanoma.

LncRNA MEG3 promotes melanoma growth, metastasis and formation through modulating miR-21/E-cadherin axis

Background

Melanoma is the most aggressive type of skin cancer with high mortality rate and poor prognosis. lncRNA MEG3, a tumor suppressor, is closely related to the development of various cancers. However, the role of lncRNA MEG3 in melanoma has seldom been studied.

Methods

RT-PCR was used to examine the expressions of lncRNA MEG3 and E-cadherin in melanoma patients and cell lines. Then, the biological functions of lncRNA MEG3 and E-cadherin were demonstrated by transfecting lncRNA MEG3-siRNA, lncRNA MEG3-overexpression, E-cadherin-siRNA and E-cadherin-overexpression plasmids in melanoma cell lines. Moreover, CCK8 assay and colony formation assay were utilized to assess the cell proliferation; Transwell assay was performed to evaluate the cell invasive ability; and tumor xenografts in nude mice were applied to test the tumor generation. Additionally, the target interactions among lncRNA MEG3, miR-21 and E-cadherin were determined by dual luciferase reporter assay. Finally, RT-PCR and WB were further conducted to verify the regulatory roles among lncRNA MEG3, miR-21 and E-cadherin.

Results

The clinical data showed that lncRNA MEG3 and E-cadherin expressions were both declined in carcinoma tissues as compared with their para-carcinoma tissues. Moreover, lncRNA MEG3 and E-cadherin expressions in B16 cells were also higher than those in A375 and A2058 cells. Subsequently, based on the differently expressed lncRNA MEG3 and E-cadherin in these human melanoma cell lines, we chose B16, A375 and A2058 cells for the following experiments. The results demonstrated that lncRNA MEG3 could suppress the tumor growth, tumor metastasis and formation; and meanwhile E-cadherin had the same effects on tumor growth, tumor metastasis and formation. Furthermore, the analysis of Kaplan–Meier curves also confirmed that there was a positive correlation between lncRNA MEG3 and E-cadherin. Ultimately, dual luciferase assays were further used to verify that lncRNA MEG3 could directly target miR-21 which could directly target E-cadherin in turn. Additionally, the data of RT-PCR and WB revealed that knockdown of lncRNA MEG3 in B16 cells inhibited miR-21 expression and promoted E-cadherin expression, but overexpression of lncRNA MEG3 in A375 and A2058 cells presented completely opposite results.

Conclusion

Our findings indicated that lncRNA MEG3 might inhibit the tumor growth, tumor metastasis and formation of melanoma by modulating miR-21/E-cadherin axis.

Towards Improving Skin Cancer Diagnosis by Integrating Microarray and RNA-Seq Datasets

Many clinical studies have revealed the high biological similarities existing among different skin pathological states. These similarities create difficulties in the efficient diagnosis of skin cancer, and encourage to study and design new intelligent clinical decision support systems. In this sense, gene expression analysis can help find differentially expressed genes (DEGs) simultaneously discerning multiple skin pathological states in a single test. The integration of multiple heterogeneous transcriptomic datasets requires different pipeline stages to be properly designed: from suitable batch merging and efficient biomarker selection to automated classification assessment. This article presents a novel approach addressing all these technical issues, with the intention of providing new sights about skin cancer diagnosis. Although new future efforts will have to be made in the search for better biomarkers recognizing specific skin pathological states, our study found a panel of 8 highly relevant multiclass DEGs for discerning up to 10 skin pathological states: 2 healthy skin conditions a priori, 2 cataloged precancerous skin diseases and 6 cancerous skin states. Their power of diagnosis over new samples was widely tested by previously well-trained classification models. Robust performance metrics such as overall and mean multiclass F1-score outperformed recognition rates of 94% and 80%, respectively. Clinicians should give special attention to highlighted multiclass DEGs that have high gene expression changes present among them, and understand their biological relationship to different skin pathological states.

Melanoma Growth Analysis in Blood Serum and Tissue Using Xenograft Model with Response to Cold Atmospheric Plasma Activated Medium

Background: Cold atmospheric plasma (CAP) proposed as a novel therapeutic tool for the various kinds of cancer treatment. Cold atmospheric Plasma-Activated Media (PAM) has exhibited its promising application in plasma medicine for the treatment of cancer. Methods: We investigated the role of PAM on the human melanoma cancer G-361 cells xenograft in vivo by estimating the biochemical and gene expression of apoptotic genes. Results: Reactive oxygen and nitrogen species (RONS) generated by PAM could significantly decrease the tumor volume (40%) and tumor weight (26%) when administered intradermally (i.d.) into the melanoma region continuously for three days. Biochemical studies in blood serum along with excised melanoma samples revealed an increase in protein carbonylation and MDA content as compared to the control, while LDH and L-DOPA in serum and melanoma tissues were decreased significantly in PAM treated group. PAM generated RONS increased apoptotic genes like Bcl-2, Bax, Parp, Casp8, and P53 in melanoma tissue. Immunohistochemistry data confirms that PAM treatment increased apoptosis at the tissue level. Conclusions: These results suggested that RONS present in PAM inhibit the induction of xenograft melanoma cancer cells through the induction of apoptosis and upregulating of various biochemical parameters within blood serum and melanoma.

Trends in mortality from cutaneous malignant melanoma in Spain (1982-2016): sex-specific age-cohort-period effects

BACKGROUND

Mortality from malignant cutaneous melanoma increased alarmingly during the second half of the 20th century in Spain and other European countries.

OBJECTIVE

The aim was to analyse sex- and age-specific trends in melanoma mortality in Spain in the period 1982-2016.

METHODS

European age-standardized melanoma mortality rates during the period 1982-2016 were calculated from mortality figures provided by the National Statistics Institute. Joinpoint regressions were used to identify significant points of change in trends and to compute average annual per cent change (AAPC). Age-cohort-period models were fitted to explore the effect of these variables on mortality.

RESULTS

During the period 1982-2016, age-standardized melanoma mortality rates increased in Spain from 0.90 to 1.80 deaths per 100 000 people in men and from 0.64 to 1.11 per 100 000 in women, rising noticeably from 1982 to 1995 in both sexes and in all age groups. From the mid-90s different trends were observed depending on sex and age: there was a decrease in mortality in the population younger than 45 years (AAPC -2 in both sexes) and aged 45-64 years (AAPC -1 among men and -0.2 among women), but in the group over 64 years rates continued to increase (AAPC 1.7 and 0.2, respectively, for men and women). The mortality sex ratio decreased in the younger population but increased in older individuals. A cohort effect was observed with lower mortality in the cohorts born after 1943 in men and 1956 in women. There was also a period effect with decreased mortality rates at the beginning of the 1990s.

CONCLUSIONS

Melanoma mortality rates in Spain increased during the last decades of the 20th century; however, later they stabilized in women and began to decrease in younger cohorts and middle-aged men. Promotion of primary and secondary prevention measures should continue, with particular emphasis on males over 65 years.

Dietary Fat Intake and the Risk of Skin Cancer: A Systematic Review and Meta-Analysis of Observational Studies

We conducted a meta-analysis to evaluate the association between fat intake and the risk of three major types of skin cancer including basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and cutaneous malignant melanoma (CMM). A comprehensive search of PubMed and EMBASE was performed to identify all relevant observational studies published up to December 1, 2018. Specific odds ratio (OR) or relative risk (RR) estimates for the highest versus the lowest intake of dietary fat and 95% confidence intervals (CI) from the included studies were pooled using random effect model. Three prospective cohort studies (175,675 participants and 30,915 BCC cases, 4,106 SCC cases and 1,638 CMM cases) and nine case-control studies (328 BCC cases, 493 SCC cases, 1,547 CMM cases and 2,660 controls) were identified. The pooled results indicated that dietary consumption of total fat and saturated fat were not associated with three major types of skin cancer. High consumption of monounsaturated fat was significantly associated with a decreased risk of BCC (RR: 0.90, 95% CI: 0.85-0.96) and high level of polyunsaturated fat intake was potentially positively associated with SCC (RR: 1.19, 95% CI: 1.06-1.33). Our findings should be confirmed by further evidence from well-designed and large-scale prospective cohort studies.

Current controversies in early-stage melanoma: Questions on incidence, screening, and histologic regression

In the first article in this continuing medical education series we review controversies and uncertainties relating to the epidemiology and initial diagnosis of localized cutaneous melanoma (ie, stage 0, I, or II). Many of these issues are unsettled because of conflicting evidence. Melanoma incidence appears to be increasing, yet its basis has not been fully explained. Despite the advantages of early detection, the US Preventive Services Task Force does not recommend skin screening for the general population. Occasionally, biopsy specimens of melanoma will show histologic regression, but the prognostic importance of this phenomenon is uncertain. Some practitioners recommend obtaining a sentinel lymph node biopsy specimen for thin melanomas showing regression, although this histologic finding is not part of the staging system for thin melanomas. Our goal is to provide the clinician who cares for patients with (or at risk for) melanoma with up-to-date contextual knowledge to appreciate the multiple sides of each controversy so that they will be better informed to discuss these issues with their patients and their families.

miR‑367 enhances the proliferation and invasion of cutaneous malignant melanoma by regulating phosphatase and tensin homolog expression

Melanoma presents a serious threat to human health but the underlying mechanisms have not been fully identified. Increasing evidence indicates that microRNAs exert a significant influence on the tumorigenesis and metastasis of different types of cancer. The present study aimed to identify the role of microRNA (miR)‑367 in the initiation and progression of melanoma and investigate its potential target. A total of 50 melanoma samples and 25 benign nevi tissues were used in the present study. Reverse transcription‑quantitative polymerase chain reaction and western blot analysis were performed to determine the expression of mRNA and protein, respectively. Cell proliferation and invasion were assessed by CCK‑8, wound healing and Transwell assays. A proposed target mRNA of miR‑367 was determined using a luciferase reporter assay and an in vivo xenograft model was used to evaluate the function of miR‑367 in the progression of melanoma. It was revealed that miR‑367 was overexpressed in melanoma tissues and cell lines. The miR‑367 level in tumor tissues was positively correlated with tumor thickness, tumor stage, lymph node involvement, distant metastasis and the patient survival rate. A high miR‑367 level was observed to enhance the growth, migration and invasion of melanoma cells. Conversely, low miR‑367 levels suppressed the proliferation and invasion of melanoma cells. Furthermore, miR‑367 was revealed to bind directly to phosphatase and tensin homolog (PTEN) mRNA and regulate the expression of the PTEN protein. miR‑367 markedly increased the growth and invasion of melanoma cells, whereas the cotransfection of PTEN vectors limited the promoting function of miR‑367 in the proliferation and invasion of A375 cells. The upregulation of miR‑367 promoted tumor growth in vivo. In conclusion, the results revealed that miR‑367 serves a positive role in the development of melanoma and may be an important target for the treatment of cutaneous melanoma.

Estimates of cancer burden in Veneto

Aims and background

In Veneto a regional cancer registry has been operating since 1987 which provides incidence and survival data for the region. It currently covers 48% of the regional population. The aim of this paper is to provide estimates of the incidence, mortality and prevalence of the major cancers for the whole Veneto region in the period 1970—2015.

Methods

The estimates were obtained by applying the MIAMOD method, a statistical back-calculation approach to derive incidence and prevalence figures starting from mortality and relative survival data. Survival was modeled on the basis of published data from the Italian cancer registries.

Results

In 2012 the most frequent cancer sites were colon-rectum, prostate and breast with 4,677, 3,760 and 3,729 new diagnosed cases, respectively. The incidence rates were estimated to increase constantly for female lung cancer, prostate cancer, colorectal cancer and melanoma, while they were decreasing for cervical cancer and stomach cancer. For male lung cancer and female breast cancer the rates increased, reaching a peak, and then decreased. In the last years of the period of analysis, mortality declined for all cancers: the highest number of deaths (2,390 in both sexes) was estimated for lung cancer in 2012. Prevalence was increasing for all the considered cancer sites with the exception of lung cancer in men, for which the prevalence was estimated to increase until 2007 and then stabilize. By contrast, the cervical cancer decreased during the whole period. In 2012 breast cancer had the highest prevalence, with about 52,000 cases.

Conclusion

This paper provides a description of the burden of the major cancers in Veneto until 2015. The estimates highlight the continuing reduction of cancer mortality. This decline can be related to the improvement of clinical treatments and to multidisciplinary treatment approaches. In order for this positive trend to continue, implementation and reinforcement of the screening programs is needed, especially for breast and colorectal cancer.

Protocol for the TIDAL Melanoma Study: topical imiquimod or diphenylcyclopropenone for the management of cutaneous in-transit melanoma metastases-a phase II, single centre, randomised, pilot study

INTRODUCTION

Patients with in-transit melanoma metastases present a therapeutic challenge. Complete surgical excision of localised disease is considered as the gold standard; however, surgery is not always acceptable and alternatives are required. Treatment results reported using imiquimod and diphenylcyclopropenone (DPCP) suggest that topical immunotherapies can be used to successfully treat select patients with melanoma metastases. A phase II, randomised, single centre, pilot study was designed to assess the clinical efficacy and safety of DPCP and imiquimod for the treatment of superficial, cutaneous in-transit melanoma metastases.

METHODS AND ANALYSIS

This is an open-label, non-superiority, pilot study with no treatment cross-over. Eligible patients are randomised in a 1:1 ratio to receive topical therapy for up to 12 months with a minimum follow-up period of 12 months. The target sample size is 30 patients, with 15 allocated to each treatment arm. The primary endpoint is the number of patients experiencing a complete response of treated lesions as determined clinically using Response Evaluation Criteria in Solid Tumours. This trial incorporates health-related quality of life measures and biological tissue collection for further experimental substudies. The study will also facilitate a health economic analysis.

ETHICS AND DISSEMINATION

Approval was obtained from the Human Research Ethics Committee at the participating centre, and recruitment has commenced. The results of this study will be submitted for formal publication within a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Prospectively registered on 16 October 2015 with the Australian New Zealand Clinical Trials Registry (ACTRN12615001088538). This study conforms to WHO Trial Registration Data Set.

Isolation and detection of circulating tumour cells from metastatic melanoma patients using a slanted spiral microfluidic device

Circulating Tumour Cells (CTCs) are promising cancer biomarkers. Several methods have been developed to isolate CTCs from blood samples. However, the isolation of melanoma CTCs is very challenging as a result of their extraordinary heterogeneity, which has hindered their biological and clinical study. Thus, methods that isolate CTCs based on their physical properties, rather than surface marker expression, such as microfluidic devices, are greatly needed in melanoma. Here, we assessed the ability of the slanted spiral microfluidic device to isolate melanoma CTCs via label-free enrichment. We demonstrated that this device yields recovery rates of spiked melanoma cells of over 80% and 55%, after one or two rounds of enrichment, respectively. Concurrently, a two to three log reduction of white blood cells was achieved with one or two rounds of enrichment, respectively. We characterised the isolated CTCs using multimarker flow cytometry, immunocytochemistry and gene expression. The results demonstrated that CTCs from metastatic melanoma patients were highly heterogeneous and commonly expressed stem-like markers such as PAX3 and ABCB5. The implementation of the slanted microfluidic device for melanoma CTC isolation enables further understanding of the biology of melanoma metastasis for biomarker development and to inform future treatment approaches.

A Systems Biology Approach Identifies FUT8 as a Driver of Melanoma Metastasis

Association of aberrant glycosylation with melanoma progression is based mainly on analyses of cell lines. Here we present a systems-based study of glycomic changes and corresponding enzymes associated with melanoma metastasis in patient samples. Upregulation of core fucosylation (FUT8) and downregulation of α-1,2 fucosylation (FUT1, FUT2) were identified as features of metastatic melanoma. Using both in vitro and in vivo studies, we demonstrate FUT8 is a driver of melanoma metastasis which, when silenced, suppresses invasion and tumor dissemination. Glycoprotein targets of FUT8 were enriched in cell migration proteins including the adhesion molecule L1CAM. Core fucosylation impacted L1CAM cleavage and the ability of L1CAM to support melanoma invasion. FUT8 and its targets represent therapeutic targets in melanoma metastasis.

Using global gene expression to discriminate thin melanomas with poor outcomes

Most melanomas present as thin lesions (≤1.0 mm) with a good prognosis; however, a small percentage of patients with thin lesions experience recurrence or metastasis. The aim of our study was to identify a distinct pattern of gene expression within thin melanomas known to have eventually metastasized to regional lymph nodes or distant sites compared with those that followed the typical course with good response to wide local excision alone. Patients who were disease-free for a minimum of 10 y served as controls (n = 10) to the experimental group who developed metastasis (n = 9). Laser capture microdissection was used to specifically isolate cancer cells from formalin-fixed paraffin-embedded tissue with subsequent gene expression analysis on Affymetrix Human Transcriptome Array 2.0 Arrays. Although gene expression differences were observed between the patients with thin melanoma with poor clinical outcome and those with good clinical outcome, neither the number of genes nor the magnitude of the fold difference was very substantial or significant. Cluster analysis with this subset of genes could definitively separate a subset of the poor responders from the good responders, but there remained a mixed group of tumors that could not be predicted from gene expression alone. Pathway analysis identified cellular processes that were regulated based on the response, including categories commonly associated with melanoma progression. Ultimately, we concluded that there were very few differences between these groups. Future research will be required and investigation of the mutational landscape may be another strategy to uncover genomic changes that drive recurrence and metastasis in thin melanoma.

Copy number variation in archival melanoma biopsies versus benign melanocytic lesions

BACKGROUND

Skin melanocytes can give rise to benign and malignant neoplasms. Discrimination of an early melanoma from an unusual/atypical benign nevus can represent a significant challenge. However, previous studies have shown that in contrast to benign nevi, melanoma demonstrates pervasive chromosomal aberrations.

OBJECTIVE

This substantial difference between melanoma and benign nevi can be exploited to discriminate between melanoma and benign nevi.

METHODS

Array-comparative genomic hybridization (aCGH) is an approach that can be used on DNA extracted from formalin-fixed paraffin-embedded (FFPE) tissues to assess the entire genome for the presence of changes in DNA copy number. In this study, high resolution, genome-wide single-nucleotide polymorphism (SNP) arrays were utilized to perform comprehensive and detailed analyses of recurrent copy number aberrations in 41 melanoma samples in comparison with 21 benign nevi.

RESULTS

We found statistically significant copy number gains and losses within melanoma samples. Some of the identified aberrations are previously implicated in melanoma. Moreover, novel regions of copy number alterations were identified, revealing new candidate genes potentially involved in melanoma pathogenesis.

CONCLUSIONS

Taken together, these findings can help improve melanoma diagnosis and introduce novel melanoma therapeutic targets.

Trends in mortality rates of cutaneous melanoma in East Asian populations

The incidence of cutaneous melanoma (CM) has rapidly increased over the past four decades. CM is often overlooked in East Asian populations due to its low incidence, despite East Asia making up 22% of the world’s population. Since the 1990s, Caucasian populations have seen a plateau in CM mortality rates; however, there is little data investigating the mortality rates of CM in East Asian populations. In this study, the World Health Organization Mortality Database with the joinpoint regression method, and a generalized additive model were used to investigate trends in age standardized mortality rates (ASMRs) of CM in four East Asia regions (Japan, Republic of Korea (Korea), China: Hong Kong (Hong Kong), and Singapore) over the past six decades. In addition, mortality rate ratios by different variables (i.e., sex, age group, and region) were analyzed. Our results showed ASMRs of CM in East Asia significantly increased non-linearly over the past six decades. The joinpoint regression method indicated women had greater annual percentage changes than men in Japan, Korea, and Hong Kong. Men had significantly greater mortality rate ratio (1.51, 95% CI [1.48–1.54]) than women. Mortality rate ratios in 30−59 and 60+ years were significant greater than in the 0−29 years. Compared to Hong Kong, mortality rate ratio was 0.72 (95% CI [0.70–0.74]) times, 0.73 (95% CI [0.70–0.75]) times, and 1.02 (95% CI [1.00–1.05]) times greater in Japan, Korea, and Singapore, respectively. Although there is limited research investigating CM mortality rates in East Asia, results from the present study indicate that there is a significant growth in the ASMRs of CM in East Asian populations, highlighting a need to raise awareness of CM in the general population.

Tribbles breaking bad: TRIB2 suppresses FOXO and acts as an oncogenic protein in melanoma

TRIB2 (tribbles homolog 2) encodes one of three members of the tribbles family in mammals. These members share a Trb (tribbles) domain, which is homologous to protein serine-threonine kinases, but lack the active site lysine. The tribbles proteins interact and modulate the activity of signal transduction pathways in a number of physiological and pathological processes. TRIB2 has been identified as an oncogene that inactivates the transcription factor CCAAT/enhancer-binding protein α (C/EBPα) and causes acute myelogenous leukaemia (AML). Recent research provided compelling evidence that TRIB2 can also act as oncogenic driver in solid tumours, such as lung and liver cancer. In particular, our recent work demonstrated that TRIB2 is dramatically overexpressed in malignant melanomas compared with normal skin and promotes the malignant phenotype of melanoma cells via the down-regulation of FOXO (forkhead box protein O) tumour suppressor activity in vitro and in vivo. TRIB2 was found to be expressed in normal skin, but its expression consistently increased in benign nevi, melanoma and was highest in samples from patients with malignant melanoma. The observation that TRIB2 strongly correlates with the progression of melanocyte-derived malignancies suggests TRIB2 as a meaningful biomarker to both diagnose and stage melanoma. In addition, interfering with TRIB2 activity might be a therapeutic strategy for the treatment of several different tumour types.

Coffee consumption and the risk of cutaneous melanoma: a meta-analysis

PURPOSE

Results from epidemiologic studies on coffee consumption and the risk of cutaneous melanoma are inconsistent. We conducted a meta-analysis to assess the associations between the consumption of total coffee, caffeinated coffee and decaffeinated coffee and the risk of cutaneous melanoma, respectively.

METHODS

A literature search was performed in PubMed, Web of Science and EMBASE for relevant articles published up to August 2015. Pooled relative risks (RRs) with 95 % confidence intervals (CIs) were calculated with a random-effects model. Dose-response relationship was assessed by restricted cubic spline.

RESULTS

Twelve studies involving 832,956 participants for total coffee consumption, 5 studies involving 717,151 participants for caffeinated coffee consumption and 6 studies involving 718,231 participants for decaffeinated coffee consumption were included in this meta-analysis. Compared with the lowest level of consumption, the pooled RRs were 0.80 (95 % CI 0.69-0.93, I (2) = 53.5 %), 0.85 (95 % CI 0.71-1.01, I (2) = 65.0 %) and 0.92 (95 % CI 0.81-1.05, I (2) = 0.0 %) for the consumption of total coffee, caffeinated coffee and decaffeinated coffee, respectively. In subgroup analysis by study design, the pooled RRs in cohort studies and case-control studies were 0.83 (95 % CI 0.72-0.97) and 0.74 (95 % CI 0.51-1.07) for total coffee consumption, respectively. Dose-response analysis suggested cutaneous melanoma risk decreased by 3 % [0.97 (0.93-1.00)] and 4 % [0.96 (0.92-1.01)] for 1 cup/day increment of total coffee and caffeinated coffee consumption, respectively.

CONCLUSIONS

This meta-analysis suggests that coffee consumption may reduce the risk of cutaneous melanoma.

Combined approach for the biomechanical characterization of skin lesions

Melanocytic nevi are common benign skin lesions, known as moles, due to proliferation of melanocytes, the pigmented skin cells. The uncontrolled growth of these cells leads instead to cutaneous malignant melanoma, an aggressive tumour whose rate of survival dramatically increases if early diagnosis is provided. Alteration on the mechanical properties of the skin in presence of lesions has been assessed. In this context, we aim at developing a combined approach consisting of an experimental and a computational study to biomechanically characterize the skin and both malign and benign skin lesions (i.e., nevi and malignant melanoma). In particular, the former study is performed to evaluate the biomechanical response of the different skin layers after the application of a displacement field and relies on a multi-scale strategy, ranging from the tissue level to the cellular level. Computational models will be tuned against experimental data (e.g., confocal laser scanning microscopy data) to estimate the mechanical properties of the different layers of the skin and the skin lesions. In particular, the confocal laser scanning microscopy is able to provide non-invasive histomorphological analysis of skin in vivo. The integration of the experimental and the computational results will allow the evaluation of possible alterations of the local mechanical properties occurring in case of pathological condition.

Enhancement of melphalan activity by buthionine sulfoximine and electroporation in melanoma cells

Melphalan represents the reference drug for locoregional chemotherapy of melanoma; nevertheless, treatment failure may occur because of resistance to chemotherapy. Refractory melanoma cells show either an increased capability of drug inactivation, which is known to be associated with elevated intracellular levels of glutathione (GSH), or a decreased melphalan uptake. The aim of this study was to explore a biochemical and a biophysical strategy, and their combination, to overcome melphalan resistance in melanoma cells. The biochemical strategy was based on the treatment of melanoma cells with DL-buthionine (S,R)-sulfoximine (BSO) to deplete the GSH levels, thus reducing melphalan inactivation. In the biophysical strategy, cell membrane electroporation was used to increase melphalan uptake. The SK-MEL 28-resistant human melanoma cell line was pretreated with 50 μmol/l BSO for 24 h and then treated with increasing melphalan doses, with or without electroporation. Spectrophotometric quantification of cell viability was used to determine melphalan cytotoxicity. Intracellular total GSH was measured using a kinetic enzymatic assay. BSO induced 3.50-fold GSH depletion in untreated cells and a similar reduction was also maintained in melphalan-treated cells. BSO pretreatment produced a 2.46-fold increase in melphalan cytotoxicity. Electroporation increased melphalan cytotoxicity 1.42-fold. The combination of both BSO pretreatment with melphalan plus electroporation led to a 4.40-fold increase in melphalan cytotoxicity compared with melphalan alone. Pretreatment with BSO and cell membrane permeabilization by electroporation enhanced the cytotoxic activity of melphalan in melanoma cells. Their rational combination deserves further investigation and may improve the efficacy of locoregional chemotherapy of melanoma.

Melanoma in situ: Part I. Epidemiology, screening, and clinical features

The incidence of melanoma has steadily increased over the past 3 decades, with melanoma in situ comprising a disproportionately high percentage of the rising incidence. Our understanding of melanoma in situ has been shaped by epidemiologic and clinical studies. Central to a review of melanoma in situ is a focus on its epidemiology, pathology, biologic behavior, treatment, and clinical outcome, which may differ significantly from that of malignant melanoma. Part I of this continuing medical education article reviews the epidemiology, risk factors, and clinical features of melanoma in situ; part II covers the histopathology, treatment options, and clinical management.

Familial risk of melanoma and links with other cancers

The genetic risk factors for melanoma are complex and involve both familial and environmental components. Of the thousands of melanomas diagnosed each year, only a fraction are due to familial causes. These melanomas typically present in younger individuals, and may be associated with genetic factors that put these individuals at risk for other tumors. CDKN2A and CDK4 are the most well-characterized mutations, as they have been identified in up to 40% of familial melanomas. Individuals with CDKN2A are also at risk for pancreatic cancer. The BRCA2 mutation has also been implicated in familial melanomas, breast and ovarian cancer. The BAP1, TERC and POT1 mutations are associated with melanomas and several other familial tumors.