Melanoma epidemic: Facts and controversies

Topographical and Chronological Analysis of Thin Cutaneous Melanoma's Progressions: A Multicentric Study

A great portion of cutaneous melanoma's diagnoses nowadays is attributed to thin tumors with up to 1 mm in Breslow thickness (hereafter thin CMs), which occasionally metastasize. The objective of this study was to identify thin CM's metastatic patterns from a topographical and chronological standpoint. A total of 204 cases of metastatic thin CMs from five specialized centers were included in the study, and corresponding data were collected (clinical, epidemiological, histopathological information of primary tumor and the number, anatomical site, and time intervals of their progressions). First progressions occurred locally, in regional lymph nodes, and in a distant site in 24%, 15% and 61% of cases, respectively, with a median time to first progression of 3.10 years (IQR: 1.09-5.24). The median elapsed time between the first and second progression and between the second and third progression was 0.82 (IQR: 0.34-1.97) and 0.49 (IQR: 0.21-2.30) years, respectively, while the median survival time was about 4 years since first progression. Furthermore, the sequences of locations and time intervals of the progressions were associated with the clinicopathological and demographic features of the primary tumors along with the features of the preceding progressions. In conclusion, the findings of this study describe the natural history of thin CMs, thus highlighting the necessity to identify subgroups of thin CMs at a higher risk for metastasis and contributing to the optimization of the management and follow-up of thin CM patients.

Evidence concerning the accusation that melanoma is overdiagnosed

BACKGROUND

Melanoma is one of the most commonly diagnosed malignancies in the United States and is responsible for the majority of deaths from skin cancer.

OBJECTIVE

Since the 1970s, the incidence of melanoma has risen appreciably while melanoma-specific mortality has remained stable. This has raised a debate about potential overdiagnosis of melanoma. Herein, we review temporal trends in melanoma incidence and mortality and explore factors that may contribute to observed trends, including an aging population in the United States, ultraviolet exposure, increased numbers of biopsies by dermatologists and physician extenders, skin cancer screenings, histopathology criteria, and historic underdiagnosis. Additionally, we discuss melanoma overdiagnosis and the extent to which it may contribute to current trends.

METHODS

The literature was reviewed.

RESULTS

Several factors may contribute to an increased incidence of melanoma, including an aging population, ultraviolet exposure, increased skin biopsies, skin cancer screenings, histopathologic criteria, historic underdiagnosis, and current overdiagnosis.

LIMITATIONS

Further studies are required to determine exactly which tumors are being overdiagnosed, and how to improve patient outcomes with adjustment to physician's practice.

CONCLUSION

The rise in the incidence of melanoma observed since the 1970s is likely multifactorial.

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.

Orthopaedic Manifestations of Melanoma and Their Management

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

Regulatory T Cells Induce Metastasis by Increasing Tgf-β and Enhancing the Epithelial–Mesenchymal Transition

Malignant melanoma is the most aggressive form of skin cancer; a substantial percentage of patients present with distant metastases. However, the mechanism of metastasis is not well understood. Here, we demonstrate that the administration of exogenous regulatory T cells (Tregs) into melanoma tumor-bearing mice results in a significant increase in lung metastasis. An increase in the invasive and metastatic phenotype of melanoma was mediated by cell-to-cell contact between melanoma cells and Tregs, which elevated the expression level of transforming growth factor-β (TGF-β) and the subsequent induction of the epithelial-to-mesenchymal transition (EMT).B16-BL6 melanoma tumors co-cultured with Tregs showed a larger population of migrating cells compared to B16-BL6 tumors cultured without Tregs. Additionally, the injection of exogenous Tregs into B16-BL6 melanoma tumors led to the recruitment and infiltration of endogenous Tregs into tumor tissues, thus increasing the overall Treg percentage in the tumor infiltrating lymphocyte population. Collectively, our findings propose novel mechanisms in which exogenous Treg-dependent upregulation of TGF-β and mesenchymal markers is important for augmenting the migration capacity and invasiveness of melanoma, thereby contributing to the metastasis.

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.

Epidemiological trends in skin cancer

Skin cancer, including melanoma and non-melanoma skin cancer (NMSC), represents the most common type of malignancy in the white population. The incidence rate of melanoma is increasing worldwide, while the associated mortality remains stable, or is slightly decreasing. On the other hand, the incidence for NMSC varies widely, with the highest rates reported in Australia. In the current review, we highlight recent global trends in epidemiology of skin cancer. We discuss controversial issues raised in current epidemiological data, we analyze the most important risk factors associated with the development of melanoma and NMSC and the impact of skin cancer on health care services. Furthermore, we underline the pressing need for improved registration policies, especially for NMSC, and lastly, we refer to the ongoing primary and secondary prevention strategies and their outcomes so far.

Molecular Pathology: A Requirement for Precision Medicine in Cancer

The increasing importance of targeting drugs and check-point inhibitors in the treatment of several tumor entities (breast, colon, lung, malignant melanoma, lymphoma, etc.) and the necessity of a companion diagnostic (HER2, (pan)RAS, EGFR, ALK, BRAF, ROS1, MET, PD-L1, etc.) is leading to new challenges for surgical pathology. Since almost all the biomarkers to be specifically detected are tissue based, a precise and reliable diagnostic is absolutely crucial. To meet this challenge surgical pathology has adapted a number of molecular methods (semi-quantitative immunohistochemistry, fluorescence in situ hybridization, PCR and its multiple variants, (pyro/Sanger) sequencing, next generation sequencing (amplicon, whole exome, whole genome), DNA arrays, methylation analyses, etc.) to be applicable for formalin-fixed paraffin-embedded tissue. Reading a patient's tissue as 'deeply' as possible and obtaining information on the morphological, genetic, proteomic and epigenetic background are the tasks of pathologists and molecular biologists and provide the clinicians with information relevant for precision medicine. Intensified cooperation between clinicians and pathologists will provide the basis of improved clinical drug selection and guide development of new cancer gene therapies and molecularly targeted drugs by research units and the pharmaceutical industry.

Trends in the diagnosis and clinical features of melanoma in situ (MIS) in US men and women: A prospective, observational study

BACKGROUND

The incidence of melanoma in situ (MIS) is increasing, but little is known about its clinical and epidemiologic features.

OBJECTIVE

We sought to determine trends in diagnosis and clinical features of MIS.

METHODS

Incident cases of melanoma were collected prospectively from the Nurses' Health Study (1976-2010) and Health Professionals Follow-up Study (1986-2010).

RESULTS

MIS incidence increased from 2 to 42 per 100,000 person-year among women, and from 11 to 73 per 100,000 person-year among men, exceeding the rate of increase of invasive melanomas. Melanoma mortality initially increased during the follow-up period then plateaued. Men were more likely than women to develop in situ melanomas on the upper half of the body (P < .001). Invasive melanomas were diagnosed at a younger age than MIS (P < .001), and were more likely to be found on the lower extremities than MIS (P < .001).

LIMITATIONS

This is a strictly descriptive study without examination into mechanisms.

CONCLUSION

We found epidemiologic and clinical differences for in situ and invasive melanomas, which support further examination into the variations in etiologic pathways. The lack of improvement in mortality despite the increase in detection of in situ relative to invasive lesions further highlights the need to improve invasive melanoma-specific clinical screening features.

Delay in cutaneous melanoma diagnosis: Sequence analyses from suspicion to diagnosis in 211 patients

Advanced melanoma is an incurable disease with complex and expensive treatments. The best approach to prevent melanoma at advanced stages is an early diagnosis. A knowledge of factors associated with the process of detecting cutaneous melanomas and the reasons for delays in diagnosis is essential for the improvement of the secondary prevention of the disease.Identify sociodemographic, individual, and medical aspects related to cutaneous melanoma diagnosis delay.Interviews evaluated the knowledge of melanoma, signals, symptoms, persons who were suspected, delays in seeking medical attention, physician's deferrals, and related factors of 211 patients.Melanomas were self-discovered in 41.7% of the patients; healthcare providers detected 29.9% of patients and others detected 27%. The main component in delay was patient-related. Only 31.3% of the patients knew that melanoma was a serious skin cancer, and most thought that the pigmented lesion was not important, causing a delay in seeking medical assistance. Patients (36.4%) reported a wait interval of more than 6 months from the onset of an observed change in a pigmented lesion to the first visit to a physician. The delay interval from the first physician visit to a histopathological diagnosis was shorter (<1 month) in 55.5% of patients. Improper treatments without a histopathological confirmation occurred in 14.7% of patients. A professional delay was related to both inappropriate treatments performed without histopathological confirmation (P = 0.003) and long requirements for medical referrals (P < 0.001).A deficient knowledge in the population regarding melanoma and physicians' misdiagnoses regarding suspicious lesions contributed to delays in diagnosis.

Increasing time trends of thin melanomas in The Netherlands: What are the explanations of recent accelerations?

BACKGROUND

A disproportional increase in in situ or thin melanomas may point at underlying causes such as increased melanoma awareness, as well as 'overdiagnosis' of melanoma in diagnostically equivocal small lesions.

OBJECTIVES

The purposes of this study were to estimate trends in melanoma incidence by sex, Breslow thickness (thin melanomas subdivided into four subgroups: <0.25 mm, 0.25-0.49 mm, 0.50-0.74 mm, and 0.75-1.0 mm), age and location, and to compare these with trends in subgroups of thicker melanomas.

METHODS

Data on all histologically confirmed in situ and invasive melanomas diagnosed between 1994 and 2010 were retrieved from the Netherlands Cancer Registry. Trends in European standardised rates (ESRs) were assessed using joinpoint analysis, and expressed as estimated annual percentage change (EAPC).

RESULTS

Between 1994 and 2010, 34,156 persons were diagnosed with an in situ or thin melanoma. The ESR of in situ melanomas doubled for males and females with a recent steeper rise in incidence (EAPC 12% (95% confidence interval [CI]: 8.1-16) and 13% (95% CI: 5.9-20), respectively). ESR for thin melanomas amongst males approximately doubled with a steep, but non-significant acceleration compared to other thickness categories since 2006 for <0.25 mm melanomas (EAPC 26% (95% CI: 2.1-35)). For female patients with thin melanomas the ESRs increased almost two-fold, except for <0.25 mm melanomas.

CONCLUSIONS

The incidence rates of in situ, thin and thick melanomas increased similarly between 1994 and 2010. Recently steep increases were found for in situ melanomas and thin melanomas in men. Explanations are 'overdiagnosis' in conjunction with increased ultraviolet exposure (natural and artificial) and therefore a 'true' increase, increased awareness, early detection, diagnostic drift and changed market forces in the Dutch health care system.

A 2015 update on predictive molecular pathology and its role in targeted cancer therapy: a review focussing on clinical relevance

In April 2013 our group published a review on predictive molecular pathology in this journal. Although only 2 years have passed many new facts and stimulating developments have happened in diagnostic molecular pathology rendering it worthwhile to present an up-date on this topic. A major technical improvement is certainly given by the introduction of next-generation sequencing (NGS; amplicon, whole exome, whole genome) and its application to formalin-fixed paraffin-embedded (FFPE) tissue in routine diagnostics. Based on this 'revolution' the analyses of numerous genetic alterations in parallel has become a routine approach opening the chance to characterize patients' malignant tumors much more deeply without increasing turn-around time and costs. In the near future this will open new strategies to apply 'off-label' targeted therapies, e.g. for rare tumors, otherwise resistant tumors etc. The clinically relevant genetic aberrations described in this review include mutation analyses of RAS (KRAS and NRAS), BRAF and PI3K in colorectal cancer, KIT or PDGFR alpha as well as BRAF, NRAS and KIT in malignant melanoma. Moreover, we present several recent advances in the molecular characterization of malignant lymphoma. Beside the well-known mutations in NSCLC (EGFR, ALK) a number of chromosomal aberrations (KRAS, ROS1, MET) have become relevant. Only very recently has the clinical need for analysis of BRCA1/2 come up and proven as a true challenge for routine diagnostics because of the genes' special structure and hot-spot-free mutational distribution. The genetic alterations are discussed in connection with their increasingly important role in companion diagnostics to apply targeted drugs as efficient as possible. As another aspect of the increasing number of druggable mutations, we discuss the challenges personalized therapies pose for the design of clinical studies to prove optimal efficacy particularly with respect to combination therapies of multiple targeted drugs and conventional chemotherapy. Such combinations would lead to an extremely high complexity that would hardly be manageable by applying conventional study designs for approval, e.g. by the FDA or EMA. Up-coming challenges such as the application of methylation assays and proteomic analyses on FFPE tissue will also be discussed briefly to open the door towards the ultimate goal of reading a patients' tissue as 'deeply' as possible. Although it is yet to be shown, which levels of biological information are most informative for predictive pathology, an integrated molecular characterization of tumors will likely offer the most comprehensive view for individualized therapy approaches. To optimize cancer treatment we need to understand tumor biology in much more detail on morphological, genetic, proteomic as well as epigenetic grounds. Finally, the complex challenges on the level of drug design, molecular diagnostics, and clinical trials make necessary a close collaboration among academic institutions, regulatory authorities and pharmaceutical companies.

Molecular alterations in signal pathways of melanoma and new personalized treatment strategies: Targeting of Notch

Despite modern achievements in therapy of malignant melanomas new treatment strategies are welcomed in clinics for survival of patients. Now it is supposed that personalized molecular therapies for each patient are needed concerning a specificity of molecular alterations in patient's tumors. In human melanoma, Notch signaling interacts with other pathways, including MAPK, PI3K-AKT, NF-kB, and p53. This article discusses mutated genes and leading aberrant signal pathways in human melanoma which are of interest concerning to their perspective for personalized treatment strategies in melanoma. We speculate that E3 ubiquitin ligases MDM2 and MDM4 can be attractive therapeutic target for p53 and Notch signaling pathways in malignant melanoma by using small molecule inhibitors. It is possible that restoration of p53-MDM2-NUMB complexes in melanoma can restore wild type p53 function and positively modulate Notch pathway. In this review we summarize recent data about novel US Food and Drug Administration approved target drugs for metastatic melanoma treatment, and suppose model for treatment strategy by targeting Notch.

Treating advanced melanoma: current insights and opportunities

Whereas thin melanomas have an excellent prognosis after sufficient surgical treatment, melanoma disease in advanced stages is still a therapeutic challenge. After decades of frustrating studies, new therapeutic strategies have come up in the past few years. On the one hand, increasing insights into the molecular aberrations in melanoma have led to specific “targeted” therapies to affect only the mutated tumor cells, as in many other types of cancers. Today there are few “targeted” substances which are already approved and successfully used for single or combination therapy, but many others are under development. While on the other hand, nonpersonalized strategy substances have been developed successfully inducing an immunologic tumor response. Both kinds of therapy have been found to result in an improvement not only of the response rate, but also of the overall survival in metastatic disease, which represents a milestone in melanoma therapy. However, using these therapies there is still much to learn regarding the effects, the side effects, and the limitations of these promising substances.

Conditional survival of malignant melanoma in The Netherlands: 1994-2008

BACKGROUND

Cutaneous malignant melanoma causes the majority of skin cancer related deaths and features increasing incidence and mortality rates in the Netherlands. Conditional survival analysis is performed on patients who survived the preceding year(s).

METHODS

Patients with invasive melanoma, as recorded in the population-based Netherlands Cancer Registry, were included. To assess prognosis of melanoma survivors according to gender and Breslow thickness, conditional five-year relative survival was calculated for lymph node negative melanoma patients and conditional one-year relative survival was analysed for melanoma patients with and without nodal involvement.

FINDINGS

Between 1994 and 2008, 40,050 patients developed a melanoma (stage I-III, of whom 6% with nodal involvement). Six to 8years after diagnosis, survival of patients with a 1-2mm (T2) thick melanoma equalised the general population. Conditional five-year relative survival for patients with >4mm thick (T4) melanomas increased from about 60% at diagnosis to 90% at 7years after diagnosis. Largest improvements were found in patients with thick melanomas and female patients with nodal involvement.

INTERPRETATION

The prognosis for melanoma survivors improved with each additional year of survival after diagnosis, except for patients with a ⩽1mm thick melanoma, who never had any excess mortality during follow-up. Conditional survival of melanoma was better amongst females, amongst those with lower Breslow thickness and nodal stage.

Malignant melanoma: epidemiologic aspects, diagnostic and therapeutic approach

In faired skinned population the incidence of melanoma is rapidly increasing. Beside environmental factors (UV-exposure) certainly other reasons for the observed "melanoma epidemic" have to be discussed. For diagnostic procedure classical histopathology is accompanied by immunohistochemistry and more recently molecular techniques. For therapy new modalities are available which-after many years of frustrating search for new drugs-are now able to prolong both disease/progression free and overall survival.

Adoptive immunotherapy of advanced melanoma

Adoptive cell therapy (ACT) has emerged as an effective therapy for patients with metastatic melanoma. Since the first introduction of the protocol in 1988 [1], major improvements have been achieved with response rates of 40%-72% among patients who were resistant to previous treatment lines. Both cell product and conditioning regimen are major determinants of treatment efficacy; therefore, developing ACT protocols explore diverse ways to establish autologous intra-tumoral lymphocyte cultures or peripheral effector cells as well as different lymphodepleting regimens. While a proof of feasibility and a proof of concept had been established with previous published results, ACT will need to move beyond single-center experiences, to confirmatory, multi-center studies. If ACT is to move into widespread practice, it will be necessary to develop reproducible high quality cell production methods and accepted lymphodepleting regimen. Two new drugs, ipilimumab (Yervoy, Bristol-Myers Squibb) and vemurafenib (Zelboraf, Roche), were approved in 2011 for the treatment of metastatic melanoma based on positive phase III trials. Both drugs show a clear overall survival benefit, so the timing of when to use ACT will need to be carefully thought out. In contrast to these 2 new, commercially available outpatient treatments, ACT is a personally-specified product and labor-intensive therapy that demands both acquisition of high standard laboratory procedures and close clinical inpatient monitoring during treatment. It is unique among other anti-melanoma treatments, providing the potential for a durable response following a single, self-limited treatment. This perspective drives the efforts to make this protocol accessible for more patients and to explore modifications that may optimize treatment results.

Incidence and mortality trends of melanoma in Croatia

Aim

To analyze melanoma incidence and mortality trends in Croatia 1988-2008, compare them with the trends in other populations, and identify possible changes in the trends.

Methods

Incidence data were obtained from the Croatian National Cancer Registry and the mortality data from the Croatian Bureau of Statistics. United Nations population estimates were used for calculating the age-specific rates. Age-standardized rates were calculated by the direct standardization method, using the world standard population as a reference. To estimate incidence and mortality trends, we performed joinpoint regression analysis.

Results

A significantly increasing incidence trend, with estimated annual percent change (EAPC) of 5.9% for men and 5.6% for women, was observed over the whole 21-year period and no additional joinpoints were identified. The overall incidence increase between the first and the last five-year period was 149% for men and 130% for women. Significant increase in the mortality trend was observed, with EAPC of 3.0% for men and 2.4% for women. No joinpoints were identified. The overall increase in mortality between the first and the last five-year period was 45% for men and 50% for women.

Conclusion

Melanoma rates in Croatia are steadily and markedly rising, with similar trends to those in the countries with lower/intermediate incidence. It is important to further investigate the more specific causes of the increasing trends, as well as to implement effective public policies targeting the melanoma burden.

Conditional random fields and supervised learning in automated skin lesion diagnosis

Many subproblems in automated skin lesion diagnosis (ASLD) can be unified under a single generalization of assigning a label, from an predefined set, to each pixel in an image. We first formalize this generalization and then present two probabilistic models capable of solving it. The first model is based on independent pixel labeling using maximum a-posteriori (MAP) estimation. The second model is based on conditional random fields (CRFs), where dependencies between pixels are defined using a graph structure. Furthermore, we demonstrate how supervised learning and an appropriate training set can be used to automatically determine all model parameters. We evaluate both models' ability to segment a challenging dataset consisting of 116 images and compare our results to 5 previously published methods.

Melanoma: epidemiology, diagnosis, treatment, and outcomes

Melanoma is a skin cancer that arises from the malignant transformation of melanocytes. Although it is typically considered a pigmented lesion, the clinical presentation of melanoma can vary greatly. With increased efforts in screening and detection of early-stage melanoma, researchers and clinicians hope to improve clinical outcomes for patients with melanoma. Novel immunotherapies directed at specific molecular targets in the pathogenesis of melanoma usher in a new era of treatment of advanced melanoma.