Epidemiology, Staging (New System), and Prognosis of Cutaneous Melanoma

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.

Risk factors for positive sentinel lymph nodes in head and neck melanoma - a survival analysis

Introduction

Sentinel lymph node biopsy is the gold standard procedure for head and neck cutaneous melanoma staging.

Objective

To evaluate the technical aspects, positivity and prognostic effect of the cervico-facial sentinel lymph node biopsy.

Methods

Retrospective, unicentric study. From 2009 to 2014, 49 patients with cutaneous melanoma of the head and neck underwent surgery at Instituto do Câncer do Estado de São Paulo (ICESP).

Results

Of the 49 patients, 5 had cervical metastasis at the moment of admission. Clark, Breslow and mitotic index were predictors of death. Among the 31 patients undergoing sentinel lymph node biopsy, 3 had positive sentinel lymph nodes (9.7%). Deaths were recorded in two of the cases with positive sentinel lymph nodes (66.6%), and in 5 (17.8%) of the patients with negative lymph nodes. The mean Breslow index was 11.3 mm for primary melanomas with positive sentinel lymph nodes and 4.3 mm for those with negative sentinel lymph nodes. Positivity was associated with Clark and Breslow levels. Malar location showed a protective effect on prognosis. The mean survival for patients with a mitotic index <3.5 was 181 months and 63.4 months for those with a mitotic index >3.5.

Conclusion

The frequency of positive sentinel lymph node biopsy in patients with malignant melanoma of the head and neck was lower than in other studies, although the sample consisted of individuals with advanced melanomas. The mitotic index was important for prognosis prediction.

Multi-omics analysis of tumor mutation burden combined with immune infiltrates in melanoma

BACKGROUND

In multiple malignancies, whether tumor mutation burden (TMB) correlated with increased survival or promotion of immunotherapy remained a debate. Our aim was to analyze the prognosis of TMB and the possible connection with immune infiltration of the skin cutaneous melanoma (SKCM).

METHODS

We gathered somatic mutation data from the 472 SKCM patients using the Cancer Genome Atlas (TCGA) database and analyzed the mutation profiles using ""maftools" package. TMB was determined and samples were divided into high and low TMB groups. We undertook differential analysis to determine the profiles of expression between two groups using the "limma" package and established the 10 Hub TMB signature from a batch survival study. Gene ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis and Gene Set Enrichment Analysis (GSEA) were performed in order to test considerably enriched pathways between the two groups. The connections of 10 TMB-related signature mutants with immune infiltration in SKCM were further assessed based on the TIMER database. We used the CIBERSORT package to measure the amount of 22 immune fractions between low and high TMB groups, and Wilcoxon's rank-sum amounts estimated the significant difference. In addition, the Cox regression model and survival analysis were used to determine the prognostic importance of immune cells. Finally, we estabilished a multivaried Cox results Tumor Mutation Burden Prognostic Index (TMBPI) and built a Receiver Operating Characteristic (ROC) curve to check the predictive accuracy.

RESULTS

Single nucleotide polymorphism (SNP) was more frequent than insertion or deletion and C > T was SKCM's most frequently single nucleotide variants (SNV). Higher TMB levels provided poor survival outcomes, associated with tumor stage, age, and gender. In addition, 224 differentially expressed genes were obtained and Venn diagram established the top 25 immune-related genes. GSEA observed that patients in high TMB groups associated with nucleotide excision repair, pyrimidine metabolism, basal transcription factors, spliceosome, RNA polymerase, and RNA degradation in cancers. 10 hub TMB-related immune genes were also established and 10 signature mutants were correlated with lower immune infiltrates. In addition, the infiltration levels of macrophages M1 and macrophages M2 in the low-TMB group were lower. Eventually, the TMBPI was developed and the AUC of ROC curve was 0.604.

CONCLUSIONS

High TMB contributed to low survival outcomes and may prevent SKCM immune infiltration. The 10 hub immune signature TMB-related mutants conferred lower immune cell infiltration that required further confirmation.

A novel immune-related genes prognosis biomarker for melanoma: associated with tumor microenvironment

BACKGROUND

Melanoma is a cancer of the skin with potential to spread to other organs and is responsible for most deaths due to skin cancer. It is imperative to identify immune biomarkers for early melanoma diagnosis and treatment.

RESULTS

63 immune-related genes of the total 1039 unique IRGs retrieved were associated with overall survival of melanoma. A multi-IRGs classifier constructed using eight IRGs showed a powerful predictive ability. The classifier had better predictive power compared with the current clinical data. GSEA analysis showed multiple signaling differences between high and low risk score group. Furthermore, biomarker was associated with multiple immune cells and immune infiltration in tumor microenvironment.

CONCLUSIONS

The immune-related genes prognosis biomarker is an effective potential prognostic classifier in the immunotherapies and surveillance of melanoma.

METHODS

Melanoma samples of genes were retrieved from TCGA and GEO databases while the immune-related genes (IRGs) were retrieved from the ImmPort database. WGCNA, Cox regression analysis and LASSO analysis were used to classify melanoma prognosis. ESTIMATE and CIBERSORT algorithms were used to explore the relationship between risk score and tumor immune microenvironment. GSEA analysis was performed to explore the biological signaling pathway.

Overexpressed VEPH1 inhibits epithelial-mesenchymal transition, invasion, and migration of human cutaneous melanoma cells through inactivating the TGF-β signaling pathway

Malignant melanoma has a profound influence on populations around the world, with the underlying mechanisms controlling this disease yet to be fully identified. Hence, the current study aimed to investigate effects associated with VEPH1 on epithelial-mesenchymal transition (EMT), proliferation, invasion, migration and the apoptosis of human cutaneous melanoma (CM) cells through the TGF-β signaling pathway. Microarray-based gene analysis was initially performed to screen the CM-related differentially expressed genes. The expression of VEPH1, TGF-β signaling pathway- and EMT-related genes in CM tissues and cell lines was subsequently evaluated. Gain-of- and loss-of-function experiments were conducted to examine the effects of VEPH1 and the TGF-β signaling pathway on the expression of EMT-related genes, cell proliferation, migration, invasion, cell cycle and apoptosis in vitro. Finally, tumor formation in nude mice was conducted. VEPH1 was lowly expressed and regulated the progression of CM with involvement in the TGF-β signaling pathway. Human CM tissues were noted to activate the TGF-β signaling pathway and EMT. A375 cells treated with overexpressed VEPH1 plasmids or/and TGF-β signaling pathway inhibitor SB-431542 displayed diminished TGF-β, SMAD4, Vimentin and N-cadherin expression while the expression of E-cadherin was elevated, accompanied by decreased cell proliferation, migration, invasion, inhibited cell cycle entry. However, si-VEPH1 or TGF-β signaling pathway activator contributed to reverse results. Taken together, the key findings of the current study present evidence suggesting that VEPH1 protects against human CM by inhibiting the activation of the TGF-β signaling pathway, highlighting its potential as a target for the prognosis and diagnosis of CM.

Possible immune adverse events as predictors of durable response to BRAF inhibitors in patients with BRAF V600-mutant metastatic melanoma

BRAF inhibitors (BRAFi) and MEK inhibitors (MEKi) are among the cornerstones of metastatic melanoma therapy demonstrating excellent response rates with duration of 7-12 m. Long-term benefit from these agents was reported in patients with normal lactate dehydrogenase (LDH) and less than three disease sites. However, a treatment-dependent marker for long-term efficacy is lacking. Data suggest that immune-related adverse events (irAEs) are associated with clinical benefit in patients treated with immunotherapy and that response to BRAF/MEK therapy may have an underlying immune mechanism. We hypothesised that AEs with an underlying immune mechanism may be associated with a durable response to targeted therapy. We retrospectively identified a cohort of 78 BRAF V600-mutant metastatic melanoma patients treated with BRAFi or BRAFi + MEKi between November 2010 and November 2013. Four treatment-related AEs including vitiligo, uveitis, erythema nodosum and keratitis sicca were defined as irAEs of interest. Retrospective analysis of AEs in relationship to progression-free survival (PFS), disease burden and LDH levels was performed. Median PFS (mPFS) for all patients was 7.5 months with responses ongoing in eight patients as of April 2017. Ten patients were identified with the AEs defined previously. Cox regression analysis revealed a very strong association between those AEs and PFS; mPFS was 42.8 m in patients with at least one AE versus 6.1 m in those without an AE (hazard ratio [HR] 0.22, p = 0.002). This association was independent of LDH levels and disease burden (HR 0.24, p = 0.035). This analysis demonstrates a strong association between immune AEs and durable response to targeted therapy and may provide a treatment-related biomarker to estimate the outcome of therapy.

The enhanced antitumour response of pimozide combined with the IDO inhibitor L‑MT in melanoma

Melanoma is one of the most fatal and therapy-resistant types of cancer; therefore, identifying novel therapeutic candidates to improve patient survival is an ongoing effort. Previous studies have revealed that pimozide is not sufficient to treat melanoma; therefore, enhancing the treatment is necessary. Indoleamine 2, 3‑dioxygenase (IDO) is an immunosuppressive, intracellular rate-limiting enzyme, which contributes to immune tolerance in various tumours, including melanoma, and inhibition of IDO may be considered a novel therapeutic strategy when combined with pimozide. The present study aimed to assess the antitumour activities of pimozide in vitro, and to investigate the effects of pimozide combined with L‑methyl-tryptophan (L‑MT) in vivo. For in vitro analyses, the B16 melanoma cell line was used. Cell cytotoxicity assay, cell viability assay, wound‑healing assay and western blotting were conducted to analyse the effects of pimozide on B16 cells. Furthermore, B16 cell-bearing mice were established as the animal model. Haematoxylin and eosin staining, immunohistochemistry, terminal deoxynucleotidyl transferase dUTP nick end-labelling staining, western blotting and flow cytometry were performed to determine the effects of monotherapy and pimozide and L‑MT cotreatment on melanoma. The results demonstrated that pimozide exhibited potent antitumour activity via the regulation of proliferation, apoptosis and migration. Furthermore, the antitumour effects of pimozide were enhanced when combined with L‑MT, not only via regulation of proliferation, apoptosis and migration, but also via immune modulation. Notably, pimozide may regulate tumour immunity through inhibiting the activities of signal transducer and activator of transcription (Stat)3 and Stat5. In conclusion, the present study proposed the use of pimozide in combination with the IDO inhibitor, L‑MT, as a potential novel therapeutic strategy for the treatment of melanoma.

Anticancer potential of sanguinarine for various human malignancies

Sanguinarine (Sang) - a benzophenanthridine alkaloid extracted from Sanguinaria canadensis - exhibits antioxidant, anti-inflammatory, proapoptotic and growth inhibitory activities on tumor cells of various cancer types as established by in vivo and in vitro studies. Although the underlying mechanism of Sang antitumor activity is yet to be fully elucidated, Sang has displayed multiple biological effects, which remain to suggest its possible use in plant-derived treatments of human malignancies. This review covers the anticancer abilities of Sang including inhibition of aberrantly activated signal transduction pathways, induction of cell death and inhibition of cancer cell proliferation. It also highlights Sang-mediated inhibition of angiogenesis, inducing the expression of tumor suppressors, sensitization of cancer cells to standard chemotherapeutics to enhance their cytotoxic effects, while addressing the present need for further pharmacokinetic-based studies.

Antitumor effect of combination of the inhibitors of two new oncotargets: proton pumps and reverse transcriptase

Tumor therapy needs new approaches in order to improve efficacy and reduce toxicity of the current treatments. The acidic microenvironment and the expression of high levels of endogenous non-telomerase reverse transcriptase (RT) are common features of malignant tumor cells. The anti-acidic proton pump inhibitor Lansoprazole (LAN) and the non-nucleoside RT inhibitor Efavirenz (EFV) have shown independent antitumor efficacy. LAN has shown to counteract drug tumor resistance. We tested the hypothesis that combination of LAN and EFV may improve the overall antitumor effects. We thus pretreated human metastatic melanoma cells with LAN and then with EFV, both in 2D and 3D spheroid models. We evaluated the treatment effect by proliferation and cell death/apoptosis assays in classical and in pulse administration experiments. The action of EFV was negatively affected by the tumor microenvironmental acidity, and LAN pretreatment overcame the problem. LAN potentiated the cytotoxicity of EFV to melanoma cells and, when administered during the drug interruption period, prevented the replacement of tumor cell growth.This study supports the implementation of the current therapies with combination of Proton Pumps and Reverse Transcriptase inhibitors.

Metastatic melanoma of the tongue: a case report with immunohistochemical profile

BACKGROUND

Melanoma of the skin is characterised by a high metastatic potential, but reports of metastasis to the tongue are rare. We report a case of skin melanoma with metastasis to the lymph nodes, tongue and brain.

OBJECTIVES

This report highlights the clinical and histological features of oral metastatic melanoma.

CASE REPORT

A 72-year-old man was seen with a nodule on the tongue. The differential diagnosis included salivary gland tumour, lymphoma and metastatic melanoma. His medical history revealed treatment for melanoma in the periumbilical region and micrometastases in the inguinal lymph nodes. An incisional biopsy was obtained and histological analysis showed the presence of a solid, epithelioid malignant tumour of monotonous appearance infiltrating the skeletal musculature. Immunohistochemistry showed reactivity of neoplastic cells to anti-HMB45, anti-melan A and anti-S100 antibodies and negativity for anti-PAN cytokeratin, confirming the diagnosis of metastatic melanoma.

CONCLUSION

The present findings highlight the importance of a complete medical evaluation of the patient by anamnesis to identify possible oral repercussions of primary diseases in other organs and/or systems.

Sentinel lymph node biopsy for melanoma: is there a correlation of preoperative lymphatic mapping with sentinel lymph nodes harvested?

BACKGROUND

Nodal status is the most significant prognostic factor in melanoma. No study has examined the relationship between lymphoscintigraphy, γ probe counts, harvested nodes, and nodal status.

METHODS

Two-hundred sixty two patients were identified who underwent sentinel lymph node biopsy for melanoma between 2001 and 2010. Clinicopathologic and treatment information was collected. The number of lymph nodes and basins demonstrated on lymphoscintigraphy was compared to those at surgery. γ Probe counts were compared.

RESULTS

Median age was 54.5 years (range, 18-90 years) with 52.3% male. Average Breslow depth was 2.0 (1.9) mm; 99.6% of lymphoscintigraphy studies identified at least 1 basin, 80% showed only 1 (range, 0-4). Lymphoscintigraphy identified on average 1.5 (0.9) sentinel nodes and 31% with secondary node. Surgery excised on average 2.6 (1.4) nodes involving 1.2 (0.5) basins; 17.6% had a positive sentinel lymph node. There was no difference in the sum or average of γ counts between positive and negative sentinel lymph node groups (P = 0.2, P = 0.5). When comparing lymphoscintigraphy and surgical excision, the correlation of lymphatic basins was r = 0.67 and of lymph node numbers was r = 0.33.

CONCLUSIONS

Lymphoscintigraphy should be used to identify the proper lymphatic basins for a sentinel node procedure, however, the removal of nodes must continue until the background count is less than 10%. The correlation of lymph node number identified on lymphoscintigraphy to surgical excision is weak. γ Probe counts cannot be used to differentiate positive from negative nodes and the positive lymph node is not always the hottest node.

Rapid human melanoma cell death induced by sanguinarine through oxidative stress

Sanguinarine is a natural isoquinoline alkaloid derived from the root of Sanguinaria canadensis and from other poppy fumaria species, and is known to have a broad spectrum of pharmacological properties. Here we have found that sanguinarine, at low micromolar concentrations, showed a remarkably rapid killing activity against human melanoma cells. Time-lapse videomicroscopy showed rapid morphological changes compatible with an apoptotic cell death, which was further supported by biochemical markers, including caspase activation, poly(ADP-ribose) polymerase (PARP) cleavage and DNA breakdown. Pan-caspase inhibition blocked sanguinarine-induced cell death. Sanguinarine treatment also induced an increase in intracellular calcium concentration, which was inhibited by dantrolene, and promoted cleavage of BAP-31, thus suggesting a putative role for Ca(2+) release from endoplasmic reticulum and a cross-talk between endoplasmic reticulum and mitochondria in the anti-melanoma action of sanguinarine. Sanguinarine disrupted the mitochondrial transmembrane potential (ΔΨm), released cytochrome c and Smac/DIABLO from mitochondria to cytosol, and induced oxidative stress. Overexpression of Bcl-XL by gene transfer did not prevent sanguinarine-mediated cell death, oxidative stress or release of mitochondrial apoptogenic proteins. However, preincubation with N-acetyl-l-cysteine (NAC) prevented sanguinarine-induced oxidative stress, PARP cleavage, release of apoptogenic mitochondrial proteins, and cell death. Pretreatment with glutathione (GSH) also inhibited the anti-melanoma activity of sanguinarine. Thus, pretreatment with the thiol antioxidants NAC and GSH abrogated the killing activity of sanguinarine. Taking together, our data indicate that sanguinarine is a very rapid inducer of human melanoma caspase-dependent cell death that is mediated by oxidative stress.

Coping styles in decision-making among men and women diagnosed with malignant melanoma

Early care seeking is important for prognosis of malignant melanoma. Coping styles in decision-making to seek care can relate to prognosis since avoidant strategies could delay care seeking. The aim of this study was to compare self-reported coping styles in decision-making between men and women diagnosed with malignant melanoma. We used the Swedish version of the Melbourne Decision-Making Questionnaire to assess coping styles. Men generally scored higher in buck-passing while women and those living without a partner scored higher in hypervigilance. This knowledge could be used in the development of preventive programmes with intention to reach those who delay care seeking.

Image and statistical analysis of melanocytic histology

AIMS

We applied digital image analysis techniques to study selected types of melanocytic lesions.

METHODS AND RESULTS

We used advanced digital image analysis to compare melanocytic lesions as follows: (i) melanoma to nevi, (ii) melanoma subtypes to nevi, (iii) severely dysplastic nevi to other nevi and (iv) melanoma to severely dysplastic nevi. We were successful in differentiating melanoma from nevi [receiver operating characteristic area (ROC) 0.95] using image-derived features, among which those related to nuclear size and shape and distance between nuclei were most important. Dividing melanoma into subtypes, even greater separation was obtained (ROC area 0.98 for superficial spreading melanoma; 0.95 for lentigo maligna melanoma; and 0.99 for unclassified). Severely dysplastic nevi were best differentiated from conventional and mildly dysplastic nevi by differences in cellular staining qualities (ROC area 0.84). We found that melanomas were separated from severely dysplastic nevi by features related to shape and staining qualities (ROC area 0.95). All comparisons were statistically significant (P < 0.0001).

CONCLUSIONS

We offer a unique perspective into the evaluation of melanocytic lesions and demonstrate a technological application with increasing prevalence, and with potential use as an adjunct to traditional diagnosis in the future.

Skin cancers of the hand: a series of 541 malignancies

BACKGROUND

Skin cancers of the hand are uncommon and poorly documented. The objective of this study was to review a large cohort of patients with hand skin malignancies to determine tumor characteristics, management techniques, and outcomes.

METHODS

A retrospective review of consecutive patients with surgically excised primary cutaneous hand malignancies at the John Radcliffe Hospital between 1993 and 2010 was performed. Records were reviewed to determine tumor characteristics, demographics, and management details. Outcome parameters included margins and completeness of excision, recurrence, metastatic spread, and survival.

RESULTS

A total of 407 patients (65.8 percent male; mean age, 72.2 ± 0.7 yr) presented with 541 primary cutaneous hand malignancies and were followed up for a mean period of 24 months. Half the cohort had previous skin cancers and almost one in five developed further hand skin cancers. Squamous cell carcinoma comprised 78.0 percent, basal cell carcinoma 11.3 percent, and melanoma 3.9 percent of cases. Incidence was highest on the dorsum of the hand. Surgical margins were proportionate to tumor size, and most defects required soft-tissue reconstruction. Recurrence was uncommon in melanoma and rare in squamous and basal cell carcinomas. Lymph node metastasis and death were rare in patients with squamous cell carcinoma but relatively common in those with melanoma.

CONCLUSIONS

Squamous cell carcinomas are the most common skin malignancy of the hand, frequently require soft-tissue reconstruction, and those occurring in the web spaces or on the dorsum of the proximal phalanges are more sinister malignancies with a greater propensity for metastatic spread.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

A decade of melanomas: identification of factors associated with delayed detection in an academic group practice

BACKGROUND

Melanoma incidence is increasing, but the effect of various clinical factors on tumor stage is unclear.

OBJECTIVE

To review histologic and clinical features of melanomas diagnosed in our group over a 10-year period to determine trends in diagnosis and lesion derivation, predictive value of clinical lesion size, and effect of physician and patient concerns before biopsy.

METHOD

Relevant pathology reports and physician clinic notes were reviewed for 572 melanomas.

RESULT

From 1999 to 2008, melanoma biopsies increased significantly more than nevus biopsies and patient visits. Melanomas predominantly (81%) arose de novo, with remaining lesions as likely to arise from common as dysplastic nevi. Melanomas were detected at twice the rate, and at earlier stage, in established as in new patients. Clinical size of invasive melanomas was related to lesion depth. For 64% of melanomas, patient and physician concern drove the decision to biopsy, whereas 1.4% of melanomas were biopsied only for patient concern.

CONCLUSION

The increase in melanoma diagnoses was largely due to increases in cases of lentigo maligna on the head and neck. Delayed detection was associated with location on trunk and extremities, new patient status, patient concern before biopsy, and physician suspicion of nonmelanoma skin cancer.

A mouse model of melanoma driven by oncogenic KRAS

The small G-protein NRAS is mutated in 22% of human melanomas, whereas the related proteins KRAS and HRAS are mutated in only 2% and 1% of melanomas, respectively. We have developed a mouse model of melanoma in which Cre recombinase/LoxP technology is used to drive inducible expression of (G12V)KRAS in the melanocytic lineage. The mice develop skin hyperpigmentation, nevi, and tumors that bear many of the cardinal histopathology features and molecular characteristics of human melanoma. These tumors invade and destroy the underlying muscles and cells derived from them can grow as subcutaneous tumors and colonize the lungs of nude mice. These data establish that oncogenic KRAS can be a founder event in melanomagenesis.