Malignant Melanoma in the 21st Century, Part 1: Epidemiology, Risk Factors, Screening, Prevention, and Diagnosis

Does patient sex affect the treatment outcome of immune checkpoint inhibitors? A Danish, observational melanoma study

AIM

The objective of this study was to evaluate whether patient biological sex influences treatment outcomes in patients with metastatic melanoma (MM) undergoing first-line immune checkpoint inhibitor (ICI) therapy.

METHODS

The Danish Metastatic Melanoma Database (DAMMED) was employed to identify patients who underwent first-line ICI therapy for MM in Denmark from 2013 to 2021. Excluding adjuvant treatment, uveal and mucosal histological subtypes, the study conducted univariable and multivariable analyses to evaluate the influence of patient sex in survival analyses. Further, landmark survival of this real-world national cohort was described for progression free survival (PFS), overall survival (OS) and melanoma-specific survival (MSS).

RESULTS

The analysis encompassed a cohort of 1378 patients with MM. Compared to male sex, females had significantly improved OS (p = 0.003) when tested in univariable testing. Multivariable analyses, controlling for age, performance status, lactate dehydrogenase level, BRAF status, M-stage, and number of metastatic sites revealed significant favourable outcomes associated with female sex irrespective of the considered survival metrics (pPFS = 0.014, pOS = 0.002, and pMSS = 0.03). The observed five-year OS rates of the entire cohort were 47% and 38%, while melanoma-specific survival were 50% and 45% for female and male, respectively.

CONCLUSION

In this nationwide cohort of patients with MM undergoing first-line ICI treatment females exhibited superior treatment outcomes compared to males. Sex was identified as an independent predictive variable for treatment outcomes, irrespective of the chosen outcome measures considered. Our analyses are not able to conclude whether the differences in outcome is attributable to differences in biology or to treatment strategy.

Rosacea is strongly associated with melanoma in Caucasians

Rosacea is often considered a cosmetic problem but is known to be associated with a variety of comorbidities. To identify such risks, we generated two age- and sex-matched real-world cohorts of 122,444 patients each with and without rosacea. In contrast to earlier studies, we found significant associations with malignant melanoma (OR 6.02, 95% CI 5.76-6.32). This association does not exist for an Asian sub-cohort, which could explain previous inconclusive or conflicting reports. Several strongly associated comorbidities like visual disturbances (ICD-10: H53-H54; OR 4.80, 4.68-4.92), metabolic disorders (E73-E79; OR 3.17, 3.11-3.22), joint problems (M25; OR 4.16, 4.08-4.25) and type 2 diabetes (E11; OR 1.62, 1.58-1.65) should be watched as a risk for rosacea patients. Rosacea is associated with some comorbidities and ethnicity may be a risk factor in melanoma development. The retrospective nature of this study and the sole use of ICD-10 code based filtering calls for future validation of our findings. Additionally, confounding factors such as skin type and previous UV exposure should be included in future studies.

Review of the comparative pathological and immunohistochemical features of human and canine cutaneous melanocytic neoplasms

Melanocytic neoplasms originate from melanocytes and melanoma, the malignant form, is a common canine neoplasm and the most aggressive human skin cancer. Despite many similarities between these neoplasms in both species, only a limited number of studies have approached these entities in a comparative manner. Therefore, this review compares benign and malignant melanocytic neoplasms in dogs and humans, exclusively those arising in the haired skin, with regard to their clinicopathological, immunohistochemical and molecular aspects. Shared features include spontaneous occurrence, macroscopic features and microscopic findings when comparing human skin melanoma in the advanced/invasive stage and canine cutaneous melanoma, immunohistochemical markers and several histopathological prognostic factors. Differences include the apparent absence of active mutations in the BRAF gene in canine cutaneous melanoma and less aggressive clinical behaviour in dogs than in humans. Further studies are required to elucidate the aetiology and genetic development pathways of canine cutaneous melanocytic neoplasms. Evaluation of the applicability of histopathological prognostic parameters commonly used in humans for dogs are also needed. The similarities between the species and the recent findings regarding genetic mutations in canine cutaneous melanomas suggest the potential utility of dogs as a natural model for human melanomas that are not related to ultraviolet radiation.

Adjuvant PD-1 Checkpoint Inhibition in Early Cutaneous Melanoma: Immunological Mode of Action and the Role of Ultraviolet Radiation

Melanoma ranks as the fifth most common solid cancer in adults worldwide and is responsible for a significant proportion of skin-tumor-related deaths. The advent of immune checkpoint inhibition with anti-programmed death protein-1 (PD-1) antibodies has revolutionized the adjuvant treatment of high-risk, completely resected stage III/IV melanoma. However, not all patients benefit equally. Current strategies for improving outcomes involve adjuvant treatment in earlier disease stages (IIB/C) as well as perioperative treatment approaches. Interfering with T-cell exhaustion to counteract cancer immune evasion and the immunogenic nature of melanoma is key for anti-PD-1 effectiveness. Yet, the biological rationale for the efficacy of adjuvant treatment in clinically tumor-free patients remains to be fully elucidated. High-dose intermittent sun exposure (sunburn) is a well-known primary risk factor for melanomagenesis. Also, ultraviolet radiation (UVR)-induced immunosuppression may impair anti-cancer immune surveillance. In this review, we summarize the current knowledge about adjuvant anti-PD-1 blockade, including a characterization of the main cell types most likely responsible for its efficacy. In conclusion, we propose that local and systemic immunosuppression, to some extent UVR-mediated, can be restored by adjuvant anti-PD-1 therapy, consequently boosting anti-melanoma immune surveillance and the elimination of residual melanoma cell clones.

Exploring the role of epigenetic alterations and non-coding RNAs in melanoma pathogenesis and therapeutic strategies

Melanoma is a rare but highly lethal type of skin cancer whose incidence is increasing globally. Melanoma is characterized by high resistance to therapy and relapse. Despite significant advances in the treatment of metastatic melanoma, many patients experience progression due to resistance mechanisms. Epigenetic changes, including alterations in chromatin remodeling, DNA methylation, histone modifications, and non-coding RNA rearrangements, contribute to neoplastic transformation, metastasis, and drug resistance in melanoma. This review summarizes current research on epigenetic mechanisms in melanoma and their therapeutic potential. Specifically, we discuss the role of histone acetylation and methylation in gene expression regulation and melanoma pathobiology, as well as the promising results of HDAC inhibitors and DNMT inhibitors in clinical trials. We also examine the dysregulation of non-coding RNA, particularly miRNAs, and their potential as targets for melanoma therapy. Finally, we highlight the challenges of epigenetic therapies, such as the complexity of epigenetic mechanisms combined with immunotherapies and the need for combination therapies to overcome drug resistance. In conclusion, epigenetic changes may be reversible, and the use of combination therapy between traditional therapies and epigenetically targeted drugs could be a viable solution to reverse the increasing number of patients who develop treatment resistance or even prevent it. While several clinical trials are underway, the complexity of these mechanisms presents a significant challenge to the development of effective therapies. Further research is needed to fully understand the role of epigenetic mechanisms in melanoma and to develop more effective and targeted therapies.

Acral melanoma: new insights into the immune and genomic landscape

Acral melanoma is a rare subtype of melanoma that arises on the non-hair bearing skin of the nail bed, palms of the hand and soles of the feet. It is unique among melanomas in not being linked to ultraviolet radiation (UVR) exposure from the sun, and, as such, its incidence is similar across populations who are of Asian, Hispanic, African and European origin. Although research into acral melanoma has lagged behind that of sun-exposed cutaneous melanoma, recent studies have begun to address the unique genetics and immune features of acral melanoma. In this review we will discuss the latest progress in understanding the biology of acral melanoma across different ethnic populations and will outline how these new discoveries can help to guide the therapeutic management of this rare tumor.

Virtual reality-based training and pre-operative planning for head and neck sentinel lymph node biopsy

OBJECTIVE

Sentinel lymph node biopsy (SLNB) is crucial for managing head and neck skin cancer. However, variable lymphatic drainage can complicate SLN detection when using Single-Photon Emission Computed Tomography (SPECT) or lymphoscintigraphy. Virtual Reality (VR) can contribute to pre-operative planning by simulating a realistic 3D model, which improves orientation. VR can also facilitate real-patient training outside the operating room. This study explored using a VR platform for pre-operative planning in head and neck skin cancer patients undergoing SLNBs and assessed its value for residential training.

MATERIALS AND METHODS

In this prospective technology pilot study, attending surgeons and residents who performed 21 SLNB operations on patients with head and neck skin cancers (81% males, mean age 69.2 ± 11.3) used a VR simulation model based on each patient's pre-operative SPECT scan to examine patient-specific anatomy. After surgery, they completed a questionnaire on the efficiency of the VR simulation as a pre-operative planning tool and training device for residents.

RESULTS

The attending surgeons rated the VR model's accuracy at 8.3 ± 1.6 out of 10. Three-quarters (76%) of residents reported increased confidence after using VR. The physicians rated the platform's contribution to residents' training at 7.4 ± 2.1 to 8.9 ± 1.3 out of 10.

CONCLUSION

A VR SLNB simulation can accurately portray marked sentinel lymph nodes. It was rated high as a surgical planning and teaching tool among attending surgeons and residents alike and may play a role in pre-operative planning and resident training. Further studies are needed to explore its applications in practice.

A nomogram incorporating Ki67 to predict survival of acral melanoma

BACKGROUND

The proliferation marker Ki67 is associated with the progression and prognosis of melanoma. However, its prognostic impact on acral melanoma (AM) remains unclear.

METHODS

A total of 314 AM patients were enrolled from a cohort of 5758 patients with melanoma at Peking University Cancer Hospital between 2006 and 2018. The patients were divided into Ki67 high- and low-expressing groups using a cut-off value of 30%. The associations between Ki67 and clinicopathologic characteristics as well as survival were analyzed. Cox proportional regression analysis was used to establish a nomogram to predict the survival probabilities of AM.

RESULTS

Among 314 patients, the Ki67-high group (Ki67 ≥ 30%) included 49.4% of patients at diagnosis. Patients in the Ki67-high group had lower median melanoma-specific survival (MSS) than those in the Ki67-low group (60.7 months vs. not reached, p < 0.001). In multivariate analyses, Ki67, lymph node metastasis and primary site were independent prognostic factors for MSS. The nomogram showed that Ki67 had the fourth greatest impact on survival, following Breslow thickness, lymph node metastasis and primary site. The C-index of the nomogram was 0.765 and 0.758 in the training and validation cohort, respectively. Area under the curve values were both near 0.8 in the training and validation cohorts. Net reclassification improvement and integrated discrimination improvement demonstrated that the predictive nomogram performed better than the traditional AJCC staging system.

CONCLUSION

Ki67 expression is an independent prognostic factor for MSS in AM. A predictive model incorporating Ki67 and clinical factors was constructed to predict the prognosis of AM.

Insights into Melanoma Clinical Practice: A Perspective for Future Research

BACKGROUND

Early diagnosis is the key to improving outcomes for patients with melanoma, and this requires a standardized histological assessment approach. The objective of this survey was to understand the challenges faced by clinicians when assessing melanoma cases, and to provide a perspective for future studies.

METHODS

Between April 2022 and February 2023, national and international dermatologists, pathologists, general practitioners, and laboratory managers were invited to participate in a six-question online survey. The data from the survey were assessed using descriptive statistics and qualitative responses.

RESULTS

A total of 54 responses were received, with a 51.4% (n = 28) full completion rate. Of the respondents, 96.4% reported ambiguity in their monthly melanoma diagnosis, and 82.1% routinely requested immunohistochemistry (IHC) testing to confirm diagnosis. SOX10 was the most frequently requested marker, and most respondents preferred multiple markers over a single marker. Diagnostic and prognostic tests, as well as therapeutic options and patient management, were all identified as important areas for future research.

CONCLUSIONS

The respondents indicated that the use of multiple IHC markers is essential to facilitate diagnostic accuracy in melanoma assessment. Survey responses indicate there is an urgent need to develop new biomarkers for clinical decision making at multiple critical intervention points.

Rosmarinic acid decreases viability, inhibits migration and modulates expression of apoptosis-related CASP8/CASP3/NLRP3 genes in human metastatic melanoma cells

Cutaneous melanoma is the most aggressive type of skin cancer; it is difficult to treat, and has been highlighted in recent years due to increasing numbers of cases worldwide. The use of antitumoral therapeutics for this neoplasm has been associated with severe side effects, low quality of life, and resistance. We aimed in this study to explore the effect of the phenolic compound rosmarinic acid (RA) on human metastatic melanoma cells. SK-MEL-28 melanoma cells were treated for 24 h with different concentrations of RA. In parallel, peripheral blood mononuclear cells (PBMCs) also were treated with RA under the same experimental conditions to verify the cytotoxic effect on non-tumoral cells. Then, we assessed cell viability and migration, levels of intracellular and extracellular reactive oxygen species (ROS), as well as nitric oxide (NOx), non-protein thiols (NPSH), and total thiol (PSH). Gene expression of the caspase 8, caspase 3 and NLRP3 inflammasome was evaluated by RT-qPCR. The enzymatic activity of the caspase 3 protein was assessed by a sensitive fluorescent assay. Fluorescence microscopy was employed to corroborate the effects of RA on melanoma cell viability, mitochondria transmembrane potential and apoptotic bodies formation. We found that RA potently reduces melanoma cell viability and migration after 24 h of treatment. On the other hand, it has no cytotoxic effect on non-tumoral cells. The fluorescence micrographics indicated that RA reduces transmembrane potential of mitochondria and induces apoptotic bodies formation. Moreover, RA significantly decreases intracellular and extracellular ROS levels, and increases the antioxidant defenders NPSH and PSH. A remarkable feature found in our study was that RA strongly upregulates the gene expression of the caspase 8 and caspase 3, and downregulates NLRP3 inflammasome expression. Similar to gene expression, RA greatly increases the enzymatic activity of caspase 3 protein. Taken together, we have shown for the first time that RA reduces cell viability and migration of human metastatic melanoma cells, in addition to modulates apoptosis-related gene expression. We suggest that RA may have the potential to be used in a therapeutic perspective, particularly for CM cell treatment.

Understanding Real-World Treatment Patterns and Clinical Outcomes among Metastatic Melanoma Patients in Alberta, Canada

Immunotherapy and targeted therapies have been shown to considerably improve long-term survival outcomes in metastatic melanoma patients. Real-world evidence on the uptake of novel therapies and outcomes for this patient population in Canada are limited. We conducted a population-based retrospective cohort study of all metastatic melanoma patients diagnosed in Alberta, Canada (2015-2018) using electronic medical records and administrative data. Information on BRAF testing for patients diagnosed in 2017 or 2018 was obtained through chart abstraction. In total, 434 metastatic melanoma patients were included, of which 110 (25.3%) were de novo metastatic cases. The median age at diagnosis was 66 years (IQR: 57-76) and 70.0% were men. BRAF testing was completed for the majority of patients (88.7%). Among all patients, 60.4%, 19.1%, and 6.0% initiated first-line, second-line, and third-line systemic therapy. The most common therapies were anti-PD-1 and targeted therapies. The two-year survival probability from first-line therapy, second-line therapy, and third-line therapy was 0.50 (95% CI: 0.44-0.57), 0.26 (95% CI: 0.17-0.40), and 0.14 (95% CI: 0.40-0.46), respectively. In the first-line setting, survival was highest for patients that received ipilimumab or ipilimumab plus nivolumab, while targeted therapy had the highest survival in the second-line setting. This study indicates that novel therapies improve survival in the real world but a considerable proportion of patients do not receive treatment with systemic therapy.

Investigation of oncolytic effect of recombinant Newcastle disease virus in primary and metastatic oral melanoma

Malignant melanoma is aggressive cancer with a high rate of local invasiveness and metastasis. Currently, the treatment options for patients with advanced-stage and metastatic oral melanoma are limited. A promising treatment option is oncolytic viral therapy. This study aimed to evaluate novel therapies for malignant melanoma using a canine model. Oral melanoma, which frequently occurs in dogs is used as a model for human melanoma, was isolated and cultured and used for the evaluation of the tumor lytic effect induced by viral infection. We constructed a recombinant Newcastle disease virus (rNDV) that promotes the extracellular release of IFNγ from the virus-infected melanoma. The expression of oncolytic and apoptosis-related genes, the immune response by lymphocytes, and IFNγ expression were evaluated in virus-infected melanoma cells. The results showed that the rate of rNDV infection varied according to the isolated melanoma cells and the oncolytic effect differed between melanoma cells owing to the infectivity of the virus. The oncolytic effect tended to be greater for the IFNγ-expressing virus than for the GFP-expressing prototype virus. Additionally, lymphocytes co-cultured with the virus showed induced expression of Th1 cytokines. Therefore, recombinant NDV expressing IFNγ is expected to induce cellular immunity and oncolytic activity. This oncolytic treatment shows promise as a therapeutic approach for melanoma treatment once evaluated using clinical samples from humans.

Deep-learning-based survival prediction of patients with cutaneous malignant melanoma

Background

This study obtained data on patients with cutaneous malignant melanoma (CMM) from the Surveillance, Epidemiology, and End Results (SEER) database, and used a deep learning and neural network (DeepSurv) model to predict the survival rate of patients with CMM and evaluate its effectiveness.

Methods

We collected information on patients with CMM between 2004 and 2015 from the SEER database. We then randomly divided the patients into training and testing cohorts at a 7:3 ratio. The likelihood that patients with CMM will survive was forecasted using the DeepSurv model, and its results were compared with those of the Cox proportional-hazards (CoxPH) model. The calibration curves, time-dependent area under the receiver operating characteristic curve (AUC), and concordance index (C-index) were used to assess the prediction abilities of the model.

Results

This study comprised 37,758 patients with CMM: 26,430 in the training cohort and 11,329 in the testing cohort. The CoxPH model demonstrated that the survival of patients with CMM was significantly influenced by age, sex, marital status, summary stage, surgery, radiotherapy, chemotherapy, postoperative lymph node dissection, tumor size, and tumor extension. The C-index of the CoxPH model was 0.875. We also constructed the DeepSurv model using the data from the training cohort, and its C-index was 0.910. We examined how well the aforementioned two models predicted outcomes. The 1-, 3-, and 5-year AUCs were 0.928, 0.837, and 0.855, respectively, for the CoxPH model, and 0.971, 0.947, and 0.942 for the DeepSurv model. The DeepSurv model presented a greater predictive effect on patients with CMM, and its reliability was better than that of the CoxPH model according to both the AUC value and the calibration curve.

Conclusion

The DeepSurv model, which we developed based on the data of patients with CMM in the SEER database, was found to be more effective than the CoxPH model in predicting the survival time of patients with CMM.

Burden of Care for Patients With In-Transit Melanoma

INTRODUCTION

Patient burden of cancer care can be significant, especially for cancers like melanoma where patients are living longer, even with advanced disease. The purpose of this study is to compare the burden of treatment of melanoma patients with in-transit metastases (ITM). There are multiple treatment options for ITM, but no standard due to lack of large cohort comparative studies; thus, the anticipated burden of care may influence therapy choice.

METHODS

Included patients had in-transit melanoma without distant metastasis and were managed at our institution from July 1, 2015 through December 31, 2020 using a combination of surgery, systemic, intralesional, and radiation therapy. We compared treatment burden, (number of treatments, clinic visits, inpatient hospital days, and distance traveled) and response rates using Kruskal-Wallis and chi-squared tests. Recurrence-free survival and estimated charges were exploratory endpoints.

RESULTS

There were 42 patients who met the inclusion criteria. As initial treatment, patients had surgery (n = 20), surgery with adjuvant (n = 6), systemic (n = 9), and intralesional therapy (n = 2). Surgery had the lowest treatment burden (median of 1 treatment, 3 clinic visits, and 0 inpatient days) while surgery with adjuvant systemic therapy had the highest burden (median of 13 treatments, 12 clinic visits, and 0 inpatient days). Systemic, intralesional, and radiation therapy were used more often for recurrent ITM. Travel distance (P = 0.88) and response rates did not statistically differ between the four options for first line therapy (P = 0.99). At a median follow-up time of 8.8 mo, 22 (52%) of the cohort required more than 1 therapy to manage recurrent or progressive disease and 14 (33%) progressed to distant disease.

CONCLUSIONS

Treatment of in-transit melanoma is associated with high burden of care and often requires multiple therapies, even with maximally effective first treatment choice. Factors evaluated in this study may be used to set expectations of treatment course for newly diagnosed patients and may aid in patients' decisions on therapy selection.

TREM2 as a Potential Immune-Related Biomarker of Prognosis in Patients with Skin Cutaneous Melanoma Microenvironment

Background

The skin cutaneous melanoma (SKCM) is a devastating form of skin cancer triggered by genetic and environmental factors, and the incidence of SKCM has rapidly increased in recent years. Immune infiltration of the tumor microenvironment is positively associated with overall survival in many tumors. Triggering receptor expressed on myeloid cells 2 (TREM2) is a transmembrane receptor of the immunoglobulin superfamily and a crucial signaling hub for multiple pathological pathways that mediate immunity. Although numerous evidences suggest a crucial role for TREM2 in tumorigenesis of some tumors, no systematic SKCM analysis of TREM2 is available. Mehods. The relationship between TREM2 expression and diagnostic and prognostic value of SKCM patients via using The Cancer Genome Atlas (TCGA) data. The expression level of TREM2 and clinical characteristic correlation in SKCM patients were assessed by the Wilcoxon rank sum test. The cox regression methods, Kaplan-Meier (KM), and log-rank test were used to assess the impact of TREM2 expression on the overall survival (OS). Furthermore, the Gene Set Enrichment Analysis (GSEA) and TIMER were performed to evaluate the enrichment pathways and potential functions and quantify the immune cell infiltration level for TREM2 expression.

Results

The TREM2 in SKCM sample expression levels was significantly higher than in normal tissues. Moreover, this expression level of TREM2 was also associated with the BMI of SKCM patients. KM overall survival analysis and OS curve displayed that a high-level TREM2 expression was significantly correlated with a better SKCM prognosis of patients as compared with a low level of TREM2 expression. The GSEA analysis also revealed that TREM2 was associated with immune functions, such as neutrophil activation.

Conclusion

TREM2 played a crucial role in SKCM, which might be a prognostic biomarker and correlated with immune infifiltrates in SKCM patients.

Educational level-dependent melanoma awareness in a high-risk population in Switzerland

Introduction

The worldwide incidence of melanoma has been increasing rapidly in recent decades with Switzerland having one of the highest rates in Europe. Ultraviolet (UV) radiation is one of the main risk factors for skin cancer. Our objective was to investigate UV protective behavior and melanoma awareness in a high-risk cohort for melanoma.

Methods

In this prospective monocentric study, we assessed general melanoma awareness and UV protection habits in at-risk patients (≥100 nevi, ≥5 dysplastic nevi, known CDKN2A mutation, and/or positive family history) and melanoma patients using questionnaires.

Results

Between 01/2021 and 03/ 2022, a total of 269 patients (53.5% at-risk patients, 46.5% melanoma patients) were included. We observed a significant trend toward using a higher sun protection factor (SPF) in melanoma patients compared with at-risk patients (SPF 50+: 48% [n=60] vs. 26% [n=37]; p=0.0016). Those with a college or university degree used a high SPF significantly more often than patients with lower education levels (p=0.0007). However, higher educational levels correlated with increased annual sun exposure (p=0.041). Neither a positive family history for melanoma, nor gender or Fitzpatrick skin type influenced sun protection behavior. An age of ≥ 50 years presented as a significant risk factor for melanoma development with an odd's ratio of 2.32. Study participation resulted in improved sun protection behavior with 51% reporting more frequent sunscreen use after study inclusion.

Discussion

UV protection remains a critical factor in melanoma prevention. We suggest that melanoma awareness should continue to be raised through public skin cancer prevention campaigns with a particular focus on individuals with low levels of education.

Mortality Trends Due to Skin Melanoma in Poland in the Years 2000-2020

The aim of this article is to assess mortality trends due to skin melanoma in Poland between the years 2000 and 2020, taking into account gender and place of residence (urban, rural). The subject of the analyses was data on 25,061 deaths that occurred between 2000 and 2020 due to skin melanoma (C43 according to ICD-10). Mortality rates due to this cancer, both crude (CDR) and standardised (SDR), were calculated. Trends on the calculated rates were analysed using the annual percentage change (APC) and average annual percentage change (AAPC), obtained from joinpoint regression models. Over the study period, the standardised death rate (SDR) due to skin melanoma in Poland increased from 3.60 to 4.03 per 100,000 population (AAPC = 1.1; p < 0.05), for urban residents it increased from 3.56 to 3.91 (APC = 1.2; p < 0.05) and for rural residents it increased from 3.00 to 4.24 (APC = 2.2; p < 0.05). A higher growth rate in terms of the SDR value between the years 2000 and 2020 was recorded in men compared to women and in rural when compared to urban residents. In Poland, mortality due to skin melanoma is on the rise. The early diagnosis of this cancer should become common practice in the Polish population.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. Part II: Differences in clinical presentation and disparities in cutaneous disorders in skin of color

Skin of color (SOC) patients are projected to comprise the majority of the population by 2044, yet knowledge gaps in the clinical presentation and treatment of both common and uncommon dermatologic conditions in skin of color persist. Improved awareness of disparities that disproportionately impact SOC patients is necessary to address health inequity in the field of dermatology. The first part of this CME discussed structural, genetic, and immunophenotypic differences in SOC in common inflammatory disorders as well as cutaneous malignancies. The second part of this CME highlights clinical differences in the phenotypic presentation of the inflammatory disorders of atopic dermatitis, psoriasis, and hidradenitis suppurativa as well as the cutaneous malignancies of melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma. Health disparities associated with each of these conditions are also discussed.

The Role of IL-6 in Cancer Cell Invasiveness and Metastasis-Overview and Therapeutic Opportunities

Interleukin 6 (IL-6) belongs to a broad class of cytokines involved in the regulation of various homeostatic and pathological processes. These activities range from regulating embryonic development, wound healing and ageing, inflammation, and immunity, including COVID-19. In this review, we summarise the role of IL-6 signalling pathways in cancer biology, with particular emphasis on cancer cell invasiveness and metastasis formation. Targeting principal components of IL-6 signalling (e.g., IL-6Rs, gp130, STAT3, NF-κB) is an intensively studied approach in preclinical cancer research. It is of significant translational potential; numerous studies strongly imply the remarkable potential of IL-6 signalling inhibitors, especially in metastasis suppression.

Association of UV Radiation Exposure, Diagnostic Scrutiny, and Melanoma Incidence in US Counties

Importance

Although UV radiation exposure is the conventionally reported risk factor for cutaneous melanoma, an alternative exposure is diagnostic scrutiny: the more physicians look for and biopsy moles, the more melanoma they find.

Objective

To assess the association of proxies for UV radiation exposure and diagnostic scrutiny with geographical patterns of melanoma incidence.

Design, Setting, and Participants

This was a cross-sectional ecological analysis of the 727 continental US counties reporting to the Surveillance, Epidemiology, and End Results (SEER) Program (among a total of 3108 counties). Environmental data relevant to UV radiation exposure (from a variety of sources), Health Resources and Services Administration data relevant to diagnostic scrutiny, and SEER data on melanoma incidence among the non-Hispanic White population diagnosed with melanoma from 2012 through 2016 were combined. Data analysis was performed between January 2020 and July 2022.

Exposures

Three UV radiation proxies (UV daily dose, cloud variability, and temperature variability) and 3 diagnostic scrutiny proxies (median household income, dermatologists, and primary care physician supply).

Main Outcomes and Measures

Melanoma incidence (in situ and invasive cancers).

Results

In total, 235 333 melanomas were diagnosed. Proxies for UV radiation exposure changed gradually across geography, while melanoma incidence and proxies for diagnostic scrutiny changed abruptly across contiguous counties. The UV daily dose, a variable the National Cancer Institute specifically developed for melanoma analyses, was uncorrelated with incidence (r = 0.03; P = .42). For context, smoking prevalence was highly correlated with lung cancer incidence in the same counties (r = 0.81; P < .001). Melanoma incidence was correlated with median household income (r = 0.43; P < .001). Counties with no dermatologists and shortages of primary care physicians had the lowest incidence, while counties amply supplied with both had the highest, despite having lower mean UV daily dose. There was little association between melanoma incidence and melanoma mortality (r = 0.09; P = .05), while the analogous association in lung cancer was strong (r = 0.96; P < .001).

Conclusions and Relevance

In this cross-sectional ecological study, the current geographical pattern of melanoma incidence across US counties was less associated with proxies for UV radiation exposure and more so with proxies for diagnostic scrutiny. Incidence-the fundamental epidemiologic measure of disease frequency-now had little association with the feared outcome of melanoma: death.

Additive Interactions between Betulinic Acid and Two Taxanes in In Vitro Tests against Four Human Malignant Melanoma Cell Lines

The incidence of melanoma is steadily increasing worldwide. Melanoma is the most lethal skin cancer, and new therapeutic methods are being sought. Our research aimed to investigate the cytotoxic and antiproliferative effects of betulinic acid in vitro, used alone and in combination with taxanes (paclitaxel, docetaxel) in four melanoma cell lines. Isobolographic analysis allowed us to assess the interactions between these compounds. Betulinic acid had no cytotoxic effect on normal human keratinocyte HaCaT cells; the amount of LDH released by them was significantly lower compared to melanoma cell lines. The present study shows that betulinic acid significantly inhibits the growth of melanoma cell lines in vitro. The IC50 values of betulinic acid ranged from 2.21 µM to 15.94 µM against the four melanoma lines. Co-treatment of betulinic acid with paclitaxel or docetaxel generated desirable drug–drug interactions, such as an additive and additive with a tendency to synergy interactions.

The pharmacotherapeutic management of nail unit and acral melanomas

INTRODUCTION

Acral and nail unit melanomas are rare subtypes of melanoma, which have poor prognoses. Current guidelines for optimal treatment are lacking. Recent clinical trials have evaluated new pharmacotherapeutic agents for melanoma treatment, with dramatically improved survival rates; however, studies on acral and nail unit melanomas are limited in comparison to trials on cutaneous melanoma.

AREAS COVERED

This is a comprehensive review of the literature regarding the available treatment options for acral and nail unit melanomas, with consideration of safety and tolerability.

EXPERT OPINION

Programmed cell death protein 1 inhibitors are more efficacious than cytotoxic T lymphocyte-associated antigen-4 blockers in acral and nail unit melanomas, although both are well-tolerated. Tyrosine kinase inhibitors have good clinical activity, however, data on safety is relatively limited. There is minimal data on high dose interferon α-2b and cyclin-dependent kinase 4 and 6 inhibitors, and efficacy and safety must be evaluated in future trials before they can be recommended for use in this patient population. Prospective clinical trials on acral and nail unit melanomas are lacking, and must be performed in large patient populations, with international collaboration likely necessary in order to enroll adequate participants.

Acral lentiginous melanoma histotype predicts outcome in clinical stage I-II melanoma patients: an International multicenter study

BACKGROUND

In the American Joint Committee on Cancer (AJCC) classification, acral lentiginous melanoma (ALM) histotype ALM is not included as an independent prognostic factor; in small series its negative prognostic impact on disease-free survival (DFS) and overall survival (OS) has been linked to the greater Breslow thickness (BT).

PATIENTS AND METHODS

The study was carried out at four referral melanoma centers (three Italian and one Polish). Clinical consecutive patients with stage I-II melanoma, who were diagnosed, treated, and followed up between January 1998 and March 2018 in annotated specific databases were included.

RESULTS

Overall, 6734 were evaluable, 4349 with superficial spreading melanoma (SSM), 2132 with nodular melanoma (NM), and 253 with ALM. At univariable analysis, a statistically significant worse DFS [hazard ratio (HR) 2.72, 95% confidence interval (CI) 2.24-3.30; P < 0.001] and OS (HR 2.67, 95% CI 2.15-3.32; P < 0.001) were found in patients with ALM compared with SSM. Similarly, the NM histotype was associated with a worse prognosis compared with the SSM histotype (DFS: HR 2.29, 95% CI 2.08-2.52; P < 0.001 and OS: HR 2.21, 95% CI 1.99-2.46; P < 0.001). At multivariable analysis, after adjusting for age, sex, BT, ulceration, and the sentinel lymph node status, a statistically significant worse DFS [adjusted HR (aHR; ALM versus SSM) 1.25, 95% CI 1.02-1.52; P = 0.028] was confirmed for patients with ALM. For patients with NM, instead, no impact of histology was found in terms of DFS [aHR (NM versus SSM) 1.04, 95% CI 0.93-1.15; P = 0.513] and OS [aHR (NM versus SSM) 0.96, 95% CI 0.86-1.08; P = 0.548].

CONCLUSIONS

ALM is associated with a worse long-term DFS. Our results could have important clinical implications for patients' stratification in future clinical trials and the incorporation of ALM histotype in the new AJCC classification as an independent prognostic factor.

Melanopsin (Opn4) is an oncogene in cutaneous melanoma

The search for new therapeutical targets for cutaneous melanoma and other cancers is an ongoing task. We expanded this knowledge by evaluating whether opsins, light- and thermo-sensing proteins, could display tumor-modulatory effects on melanoma cancer. Using different experimental approaches, we show that melanoma cell proliferation is slower in the absence of Opn4, compared to Opn4WT due to an impaired cell cycle progression and reduced melanocyte inducing transcription factor (Mitf) expression. In vivo tumor progression of Opn4KO cells is remarkably reduced due to slower proliferation, and higher immune system response in Opn4KO tumors. Using pharmacological assays, we demonstrate that guanylyl cyclase activity is impaired in Opn4KO cells. Evaluation of Tumor Cancer Genome Atlas (TCGA) database confirms our experimental data as reduced MITF and OPN4 expression in human melanoma correlates with slower cell cycle progression and presence of immune cells in the tumor microenvironment (TME). Proteomic analyses of tumor bulk show that the reduced growth of Opn4KO tumors is associated with reduced Mitf signaling, higher translation of G2/M proteins, and impaired guanylyl cyclase activity. Conversely, in Opn4WT tumors increased small GTPase and an immune-suppressive TME are found. Such evidence points to OPN4 as an oncogene in melanoma, which could be pharmacologically targeted.

Prevalence and burden of skin diseases among the elderly in Singapore: A 15-year clinical cohort study

BACKGROUND

Populations around the world are rapidly ageing. The profile of skin diseases in the elderly is likely to present unique demands on the healthcare system.

OBJECTIVES

To provide current data on the burden of skin diseases in Singaporean patients and identify differences in the pattern of skin diseases between elderly patients and the rest of the population.

METHODS

This was a retrospective cohort study of 858,117 patients who attended the National Skin Centre between 2004 to 2018. Prevalence was calculated by grouping International Classification of Diseases codes into different categories of skin conditions based on Global Burden of Disease and American Academy of Dermatology classifications. Years lost to disability (YLD) and disability-adjusted life years (DALY) were calculated to report the morbidity and mortality of skin diseases. Differences of each skin condition between age groups were compared.

RESULTS

The three most prevalent dermatoses across all age groups were dermatitis (33.3%), acne vulgaris (8.3%) and viral skin diseases (7.5%). The top three most common skin conditions among the elderly were dermatitis (37.7%), viral skin diseases (6.2%), and fungal skin diseases (4.3%). Decubitus ulcers, keratinocyte carcinomas and scabies represented a significant proportion of YLD per 100,000 in the elderly (p <0.001). Malignant melanomas, keratinocyte carcinomas, cellulitis, pyoderma, and decubitus ulcers contributed to high DALY in patients aged 70 - 80 years old.

CONCLUSION

Aligning health systems with specific healthcare needs will reduce the disproportionately high burden of skin disease observed in the elderly.

Low doses of niclosamide and quinacrine combination yields synergistic effect in melanoma via activating autophagy-mediated p53-dependent apoptosis

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We developed a new strategy for melanoma by using low doses of niclosamide (N) and quinacrine (QC).

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N+QC exerts anti-melanoma effect through autophagy-mediated p53-dependent apoptosis.

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The strategy is verified to be a safe, effective and universal role for other types of cancer.

Malignant melanoma is a highly aggressive, malignant, and drug-resistant tumor. It lacks an efficient treatment approach. In this study, we developed a novel anti-melanoma strategy by using anti-tapeworm drug niclosamide and anti-malarial drug quinacrine, and investigated the molecular mechanism by in vitro and in vivo assays. Meanwhile, other types of tumor cells, immortalized epithelial cells and bone marrow mesenchymal stem cells were used to evaluate the universal role of anti-cancer and safety of the strategy. The results showed, briefly, an exposure to niclosamide and quinacrine led to an increased apoptosis-related protein p53, cleaved caspase-3 and cleaved PARP and autophagy-related protein LC3B expression, and a decreased expression of autophagy-related protein p62, finally leading to cell apoptosis and autophage. After inhibiting autophagy by Baf-A1, flow cytometry and western blot showed that the expression of apoptosis-related proteins was down-regulated and the number of apoptotic cells decreased. Subsequently, in the siRNA-mediated p53 knockdown cells, the expression of apoptosis-related proteins and the number of apoptotic cells were also reduced, while the expression of autophagy-related proteins including LC3B, p62 did not change significantly. To sum up, we developed a new, safe strategy for melanoma treatment by using low doses of niclosamide and quinacrine to treat melanoma; and found a novel mechanism by which the combination application of low doses of niclosamide and quinacrine exerts an efficient anti-melanoma effect through activation of autophagy-mediated p53-dependent apoptosis. The novel strategy was verified to exert a universal anti-cancer role in other types of cancer.

Increased relative proportions of advanced melanoma among Veterans: a comparative analysis with the SEER registry

BACKGROUND

The Surveillance, Epidemiology, and End Results (SEER) program reflects one-third of the U.S.

POPULATION

However, SEER may not be generalizable to the Veteran population. Since Veterans comprise a high-risk population, this discrepancy may limit our understanding of melanoma epidemiology in such high-risk populations.

OBJECTIVE

To assess differences in demographics, tumor characteristics, and melanoma-specific survival in Veterans compared to the general population.

METHODS

Data were collected from the Veterans Affairs Central Cancer Registry (VACCR) and SEER (18 registries) from 2009 to 2017.

RESULTS

15,334 Veterans and 166,265 SEER patients with melanoma were identified. Veterans were more likely to present with regional or distant disease (17.5% vs. 13.0% in SEER). 5-year melanoma specific survival (MSS) was lower across all ages, except those diagnosed at ≥80 years, in VACCR relative to SEER. Similarly, from 2009-2017, MSS by stage was lower across all stages in VACCR. However, for stage IV melanomas diagnosed in 2015-2017, compared to 2011-2014, 2-year MSS increased from 37.8% to 51.5% in VACCR versus 36.4% to 44.8% in SEER.

LIMITATIONS

Unique Veteran demographics and missing data inherent to VACCR.

CONCLUSION

Compared to SEER, Veterans with melanoma were diagnosed at later stages, but both exhibited recent improvement in stage IV MSS.

Primary Pulmonary Malignant Melanoma Presenting as Bilateral Multiple Subsolid Nodules: A Case Report

Primary pulmonary malignant melanoma is an extremely rare type of melanoma. The radiologic features of primary pulmonary malignant melanoma are nonspecific; however, it almost always presents as a well-demarcated round or lobulated solitary solid nodule or mass. Herein, we report the case of a 78-year-old male with primary pulmonary malignant melanoma that was mistaken for primary pulmonary adenocarcinoma with lepidic growth and was seen as bilateral multiple subsolid nodules on CT.

Genetic characteristics and response to systemic therapies of acral lentiginous melanoma at a tertiary care center-a retrospective review

BACKGROUND

Acral lentiginous melanoma (ALM) is an aggressive subtype of cutaneous malignant melanomas that accounts for 50-80% of melanomas in ethnic minorities. Studies on the genetic profile of these tumors largely result from cohorts in Europe, Asia, and Latin America, few inclusive of Black patients.

OBJECTIVE

We aim to describe the clinicopathological and genetic characteristics in a diverse cohort of ALM patients.

METHODS

A retrospective analysis of 93 patients with a pathology confirmed diagnosis of ALM between March 1984 and October 2020 was conducted at a large tertiary care center. Melanoma mutation panel testing for frequently mutated regions of the BRAF, NRAS, KIT and PIK3CA genes were reviewed in patient records when available.

RESULTS

Of the 93 patients identified, 62.4% were Caucasian, 25.8% Black, 4.30% Hispanic, 4.30% Asian, and 3.22% identified as other. Fourteen of 17 patients receiving targeted or immunologic agents experienced disease progression during treatment, including all patients with a BRAF V600E mutation.

LIMITATIONS

This was a single-center retrospective analysis.

CONCLUSION

Response to targeted and immunologic therapies in ALM patients was overwhelming poor, particularly in BRAF V600E-mutated tumors in contrast to the positive prognosis associated with BRAF V600E mutations in other advanced cutaneous melanoma subtypes.

The impact of physician support on skin self-examination among melanoma patients: A serial mediation model with self-efficacy and intentions to perform skin exams

OBJECTIVE

Melanoma is the most lethal of skin cancers; however, survival rates are excellent if the tumor is detected early. Clinical practice guidelines for melanoma follow-up care recommend regular skin self-examination (SSE) for individuals at high risk for melanoma. The current analyses tested whether self-efficacy for SSE and intention to perform SSE mediate the relationship between physician support for SSE and SSE behavior among a sample of melanoma patients.

METHODS

We ran a serial mediation model on a cross-sectional sample of melanoma patients (n = 154) drawn from an observational study with longitudinal follow-up.

RESULTS

Self-efficacy and intention to perform SSE sequentially mediated the relationship between physician support and SSE behaviors (β = .31, t(152) = 3.61, p < .001 without mediators versus β = .11, t(150) = 1.50, p = .14 with mediators), as supported by a significant total indirect effect (β = .21, [95 % CI = .08-.35]).

CONCLUSION

Self-efficacy for SSE and intention to perform SSE together explain the link between perceived physician support for SSE and the practice of SSE.

PRACTICE IMPLICATIONS

Physician communication about the importance of SSE plays an important role in encouraging patient adherence to SSE recommendations and, thus, supporting early detection efforts.

Recognition, Staging, and Management of Melanoma

Melanoma accounts for approximately 1% of all skin cancers but contributes to almost all skin cancer deaths. The developing picture suggests that melanoma phenotypes are driven by epigenetic mechanisms that reflect a complex interplay between genotype and environment. Furthermore, the growing consensus is that current classification standards, notwithstanding pertinent clinical history and appropriate biopsy, fall short of capturing the vast complexity of the disease. This article summarizes the current understanding of the clinical picture of melanoma, with a focus on the tremendous breakthroughs in molecular classification and therapeutics.

Clinical characteristics and prognosis of acral lentiginous melanoma: a single-center series of 211 cases in China

BACKGROUND

Acral lentiginous melanoma (ALM) is common in China with poor prognosis. However, there are only a few studies of ALM in the Asian population. We aimed to summarize and analyze the clinical characteristics, treatment strategy, treatment effect, and prognostic factors of ALM in a Chinese population.

METHODS

We included a total of 249 ALM patients (211 with follow-up data) from a single institution. Demographic, laboratory data, treatment strategy, and prognosis were analyzed.

RESULTS

The ratio of male and female was 1.3 ∶ 1.0. The median age was 58 years old. The majority of patients (70.3%) had lesions on the sole. Trauma history and irritation were associated with lesion size increase in some patients. The prognosis of patients in stage II-III undergoing standard operation was significantly better compared with those without surgical treatment. Patients who did not receive postoperative adjuvant treatment had shorter time to distant metastasis. In multivariable analysis, distant metastasis, duration of disease, LDH level, and Ki67 index were independently associated with survival.

CONCLUSIONS

Prognosis for ALM patients was poor in our study. Distant metastasis, duration of disease, LDH level, and Ki67 index were independently associated with prognosis.

Trends in Incidence and Mortality of Skin Melanoma in Lithuania 1991-2015

Background. We aimed to investigate age-specific and sex-specific incidence trends of melanoma in Lithuania from 1991 to 2015. Methods. Analysis was based on data from the population-based Lithuanian Cancer Registry database for 1991–2015, and 6024 cases of skin melanoma were identified. Age-adjusted rates (ASRs) by sex and age group were calculated. Adjustment for ASRs was done using the old European standard population, where a total of three age groups were considered: 0–39, 40–59 and 60+. Additionally, the annual percent change (APC) was calculated, and 95% confidence intervals for APC were calculated. Results. Between 1991 and 2015, the overall melanoma rates increased by an annual percent change (APC) of 3.9% in men (95% CI, 3.6–4.1%) and 2.3% in women (95% CI, 2.1–2.5%). The highest incidences of new cutaneous melanoma cases were observed between old adults (60+) of both sexes, while the lowest incidence rates were observed in the young adult group (up to 39 years old), with the lowest APC (1.6% in males and 0.4% in females). The overall number of melanoma deaths during 1991 and 2015 increased from 64 to 103 deaths per year, and the age-standardized rate (ASR) increased 1.3 times (from 1.8 to 2.4). Conclusions. The incidence and mortality of skin melanoma seem to be increased in all age groups. These trends indicate that skin protection behavior is not sufficient in our population and more efforts need to be taken in order to decrease incidence and mortality rates.

The curcumin analog EF24 is highly active against chemotherapy-resistant melanoma cells

BACKGROUND

Malignant melanoma (MM) is an aggressive type of skin cancer with a poor prognosis, because MM cells are characterized by unresponsiveness to chemotherapy.

OBJECTIVE

In this study, we evaluated the effectiveness of several curcumin analogs on four MM cell lines (SK-MEL-28, MeWo, A-375, and CHL-1), and explored their underlying mechanisms of action.

METHODS

Cell viability was measured by a Tetrazolium-based MTS assay. Cell apoptosis, reactive oxygen species (ROS), and cell cycle were assayed by flow cytometry. Protein levels were assayed by western blotting.

RESULTS

MM cells are quite resistant to the conventional chemotherapeutics cisplatin and dacarbazine, and the targeted therapy drug vemurafinib. Among the curcumin analogs, EF24 is the most potent compound against the resistant MM cells. EF24 dose- and time-dependently reduced the viability of MM cells by inducing apoptosis. Although EF24 did not increase the production of reactive oxygen species (ROS), it upregulated the endoplasmic reticulum (ER) stress marker BiP, but downregulated the unfolded protein response (UPR) signaling. Moreover, treatment of MM cells with EF24 downregulated the expression of the anti-apoptotic protein Bcl-2, as well as the inhibitor of apoptosis proteins (IAPs) XIAP, cIAP1, and Birc7, which are known to protect MM cells from apoptosis. The downregulation of Bcl-2 and IAP expression by EF24 was associated with the inhibition of the NF-κB pathway.

CONCLUSION

These findings demonstrate that EF24 is a potent anti-MM agent. The anti-MM effect is likely mediated by the suppression of UPR and the NF-κB pathway.

The Relationship Between Epidermal Mitotic Density, Atypical Mitotic Figure Density, Breslow Depth, Ulceration, and Dermal Mitotic Rate in Cutaneous Melanoma: A Retrospective Cohort Study

Prognostic factors for melanoma include Breslow depth (BD), ulceration, and dermal mitotic rate (DMR). No studies have queried the effect of epidermal mitotic density (EMD) or atypical mitotic figure density (AMD) in an outcome-based assessment. Our objective was to determine if there is a relationship between EMD, AMD, BD, DMR, and ulceration and patient outcomes. This was a retrospective cohort study of 185 cases of thick and thin melanomas. Univariate and multivariate cause-specific regression analysis was performed. There was a positive correlation between EMD and BD (P = .0001). The difference between AMD in thick and thin melanomas was statistically significant. For every unit increase in EMD, patients had a 2.8-fold increase in the risk of distant metastasis; however, statistical significance was lost in the multivariate analysis. In adjusted analyses, ulceration, DMR, and BD were associated with outcomes. There were no statistically significant correlations between AMD and outcomes. This study is limited by its small sample size, diminution of the epidermis in some thick melanomas preventing EMD estimates, and reproducibility of mitotic figure counting. EMD and AMD do not seem to have any independent value in multivariate analyses for melanoma. Ulceration, BD, and DMR were significantly associated with outcomes and further solidify these known predictors of prognosis.

Ultrastructural and clinical features of central nervous system melanoma:Analysis of nine cases

To investigate the ultrastructural and clinical characteristics of melanoma of the central nervous system (CNS). The clinical and electron microscopy pathology data of nine patients with melanoma surveyed from 1993 to 2017 were analyzed. All the CNS melanomas were confirmed by transmission electron microscopy (TEM), including eight cases of primary melanomas and one case of metastatic melanoma. In this study, four stage II melanosomes were intracranial space-occupying, three of which were malignant melanoma, the other one was melanoma. Among the five stage IV melanosomes, four cases were intraspinal space-occupying, the other one was intracranial space-occupying, and the pathological diagnoses were all melanoma. At present, TEM is an important tool for the diagnosis of CNS melanomas. Malignant melanoma has high malignancy and recurrence rate and poor prognosis, while benign melanoma with relatively low recurrence rate, so we speculate that patients with mainly immature melanosomes are more likely to exhibit recurrence.

Association of Bariatric Surgery With Skin Cancer Incidence in Adults With Obesity: A Nonrandomized Controlled Trial

Importance

Obesity is a cancer risk factor, and bariatric surgery in patients with obesity is associated with reduced cancer risk. However, evidence of an association among obesity, bariatric surgery, and skin cancer, including melanoma, is limited.

Objective

To investigate the association of bariatric surgery with skin cancer (squamous cell carcinoma and melanoma) and melanoma incidence.

Design, Setting, and Participants

This nonrandomized controlled trial, the Swedish Obese Subjects (SOS) study, is ongoing at 25 surgical departments and 480 primary health care centers in Sweden and was designed to examine outcomes after bariatric surgery. The study included 2007 patients with obesity who underwent bariatric surgery and 2040 contemporaneously matched controls who received conventional obesity treatment. Patients were enrolled between September 1, 1987, and January 31, 2001. Data analysis was performed from June 29, 2018, to November 22, 2018.

Interventions

Patients in the surgery group underwent gastric bypass (n = 266), banding (n = 376), or vertical banded gastroplasty (n = 1365). The control group (n = 2040) received the customary treatment for obesity at their primary health care centers.

Main Outcomes and Measures

The SOS study was cross-linked to the Swedish National Cancer Registry, the Cause of Death Registry, and the Registry of the Total Population for data on cancer incidence, death, and emigration.

Results

The study included 4047 participants (mean [SD] age, 47.9 [6.1] years; 2867 [70.8%] female). Information on cancer events was available for 4042 patients. The study found that bariatric surgery was associated with a markedly reduced risk of melanoma (adjusted subhazard ratio, 0.43; 95% CI, 0.21-0.87; P = .02; median follow-up, 18.1 years) and risk of skin cancer in general (adjusted subhazard ratio, 0.59; 95% CI, 0.35-0.99; P = .047). The skin cancer risk reduction was not associated with baseline body mass index or weight; insulin, glucose, lipid, and creatinine levels; diabetes; blood pressure; alcohol intake; or smoking.

Conclusions and Relevance

The results of this study suggest that bariatric surgery in individuals with obesity is associated with a reduced risk of skin cancer, including melanoma.

Trial Registration

ClinicalTrials.gov identifier: NCT01479452.

Improving the prevention and diagnosis of melanoma on a national scale: A comparative study of performance in the United Kingdom and Australia

We undertook this study in light of an uncontrolled rise of melanoma incidence and mortality rates in the United Kingdom (UK). We aim to assess the effectiveness of prevention and early melanoma diagnosis in the UK's National Health Service (NHS) in comparison to the Australian system that has limited the melanoma rise. We compare the prevention campaigns against skin cancer and the stage at which melanoma is diagnosed. We analyse key drivers of early diagnosis. Overall, Australia has performed better than the UK and provides an example for the UK's NHS for better preventing melanoma and diagnosing it. Technologies under development, such as tele-dermatology and artificial intelligence applications, could aid in making melanoma early diagnosis easier, more cost-efficient, and lessen the burden on health systems. Diagnoses also provide the data to help public health officials target prevention programs.

Acral lentiginous melanoma: Clinicopathologic and survival differences according to tumour location

BACKGROUND/OBJECTIVES

Acral lentiginous melanoma (ALM) is a melanoma subtype associated with atypical locations on the hands and feet and advanced disease at diagnosis. There is a limited understanding of whether the survival is similar for nail, non-nail, lower limb and upper limb ALM patients. We therefore explored clinicopathologic characteristics and melanoma-specific survival of ALM patients according to tumour location.

METHODS

A prospectively collected cohort study was performed of all primary invasive cutaneous acral lentiginous melanomas with known thickness and tumour location reviewed at a tertiary referral centre over 21 years.

RESULTS

A total of 101 ALM patients were reviewed from 1994 until 2016. The majority of cases (82/101) occurred on the feet. Hand ALMs were thicker and more likely to be ulcerated than feet ALMs (P = 0.05 and 0.02, respectively); however, survival was not statistically different between these two groups (univariate HR 0.48 P = 0.11, 95% CI, 0.20-1.17; multivariate HR 0.67 P = 0.40, 95% CI, 0.27-1.69, respectively). Non-nail ALM patients had longer survival when compared to nail ALM on univariate analysis (HR 0.40, 95% CI, 0.17 to 0.90) which was accounted for by Breslow thickness and ulceration (multivariate HR 0.56, 95% CI, 0.24 to 1.34).

CONCLUSIONS

The reduced melanoma-specific survival in nail ALM patients was likely due to their greater thickness and ulceration. Although hand ALMs are thicker and more frequently ulcerated, this is likely due to the higher proportion of nail ALMs present in this location.

Ferroptosis: a new unexpected chance to treat metastatic melanoma?

Human skin melanoma is one of the most aggressive and difficult to treat human malignancies, with an increasing incidence over the years. While the resection of the early diagnosed primary tumor remains the best clinical approach, advanced/metastatic melanoma still remains with a poor prognosis. Indeed, although enormous progress in the therapeutic treatment of human tumors has been made in recent years, patients affected by metastatic melanoma are still poorly affected by these clinical advances. Therefore, new valuable therapeutic approaches are urgently needed, to design and define effective treatments to consistently increase the overall survival rate of patients affected by this malignancy. In this review we summarize the main signaling pathways studied to kill human skin melanoma, and introduce the ferroptotic cell death as a new pathway to be explored to eradicate this tumor.

Anti-Melanoma Activities and Phytochemical Compositions of Sorbus commixta Fruit Extracts

Sorbus commixta Hedl. (Rosaceae family) has a long history as a medicinal plant in East Asian countries. In this study, we evaluated the effect of S. commixta fruit extracts prepared with different ethanol concentrations on anti-melanoma activity, and the extraction yield of phenolic compounds and flavonoids. Using the partitioned fractions from the EtOH extract, we found that the butanol fraction (BF) possessed strong cytotoxic activity against SK-MEL-2 cells (human melanoma cells) but not against HDFa cells (human dermal fibroblast adult cells). Additionally, BF-induced cell death was mediated by the inhibition of the mitogen-activated protein kinase/extracellular regulated kinase (MEK/ERK) signaling pathway, coupled with the upregulation of caspase-3 activity in SK-MEL-2 cells. Furthermore, HPLC analysis of polyphenolic compounds suggested that S. commixta fruits contained several active compounds including chlorogenic acid, rutin, protocatechuic acid, and hydroxybenzoic acid, all of which are known to possess anti-cancer activities. Although this study has been carried out by cell-based approach, these results suggest that S. commixta fruits contain promising anti-melanoma compounds.

Mediterranean diet, Dietary Approaches to Stop Hypertension, and Pro-vegetarian dietary pattern in relation to the risk of basal cell carcinoma: a nested case-control study within the Seguimiento Universidad de Navarra (SUN) cohort

BACKGROUND

The association of dietary pattern with the risk of basal cell carcinoma (BCC) is little understood and has scarcely been investigated.

OBJECTIVES

We assessed the association of several complete dietary patterns [Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and Pro-vegetarian dietary pattern] with the risk of BCC, conducting a nested case-control study (4 controls for each case).

METHODS

Cases and controls were selected from the SUN (Seguimiento Universidad de Navarra) cohort using risk set sampling. Cases were identified among subjects free of skin cancer at baseline but who later reported a physician-made BCC diagnosis during the follow-up period. In the cohort we identified 101 incident cases of BCC.

RESULTS

In multivariable-adjusted conditional logistic regression analyses, better adherence to the Mediterranean diet (highest compared with lowest quintile) was associated with a 72% relative reduction in the odds of BCC (OR: 0.28; 95% CI: 0.10, 0.77; Ptrend = 0.014); the DASH diet was associated with a 68% RR reduction (OR: 0.32; 95% CI: 0.14, 0.76; Ptrend = 0.013) for the comparison between extreme quintiles. No association was found between a Pro-vegetarian dietary pattern and BCC. Higher fruit consumption (highest compared with lowest quintile, OR: 0.27; 95% CI: 0.11, 0.64; Ptrend < 0.001) and low-fat dairy products (OR: 0.39; 95% CI: 0.16, 0.92; Ptrend = 0.014) were associated with a lower BCC risk.

CONCLUSIONS

Our results suggest that Mediterranean and DASH dietary patterns may be associated with a lower risk of BCC, but confirmatory studies are required.

Risk of melanoma following keratinocyte malignancies

Patients diagnosed with keratinocyte cancer experience heightened risk for melanoma, yet patients who go on to develop this malignancy have not been well-characterized. We followed a population-based cohort of 2243 participants with histologically confirmed KC identified from dermatology and pathology practices who did not have a history of internal malignancy (1363 BCC, 880 SCC). A total of 77 participants went on to develop melanoma. Individual-level data were collected via personal interviews including demographic information and skin cancer risk factors, as well as KC tumor characteristics such as anatomic site and histologic subtype. Using adjusted Cox proportionate hazards models, older patients (age 61 or older vs 60 or younger) were at twofold increased risk for developing melanoma following KC (age 61-65 HR = 2.5; 95% CI = 1.3-4.6) (age > 65 HR = 2.0; 95% CI = 1.2-3.4) and women were at reduced risk compared to men (HR = 0.5; 95% CI = 0.3-0.8). Among patients with BCC, those with tumors on the trunk/limbs compared to the head/neck were at greater risk for subsequent melanoma (HR = 2.7; 95% CI = 1.3-5.7). Subsequent risk of melanoma also related to established risk factors including blond/red vs dark hair (HR = 1.9; 95% CI = 1.1-3.4), tendency to burn rather than tan (HR = 1.7; 95% CI = 1.0-2.7), ≥1 nevi on their back compared to no nevi (HR = 2.2; 95% CI = 1.2-3.8) and a history of ≥1 painful childhood sunburns vs none (HR = 2.1; 95% CI = 1.2-3.6). Thus, in addition to pigmentary traits, ultraviolet radiation (UVR)-related factors and clinical features of KC such as anatomic site may be useful in identifying patients at increased risk for melanoma after KC.

Concurrence of primary pulmonary malignant melanoma with invasive pulmonary adenocarcinoma: a case report

Background

Primary pulmonary malignant melanoma (PPMM) is an extreme rarity in clinic practice, accounting for only 0.01% of all primary pulmonary tumors. And its diagnosis should meet clinical and pathological diagnosis criteria in addition to excluding the possibility of metastatic melanoma. The mainstay of treatment is surgery. The concurrence of primary pulmonary malignant melanoma and invasive pulmonary adenocarcinoma has not been reported before.

Case presentation

Herein we report the case of a 39-year-old woman who was asymptomatic and accidently found to have the concurrence of PPMM with invasive pulmonary adenocarcinoma. Before considering the diagnosis of primary pulmonary malignant melanoma, a systemic positron emission tomography-computed tomography (PET-CT) was done to excluding primary tumor metastasis from other sites. The pathological biopsy proved that two lesions in the right middle lobe were invasive pulmonary adenocarcinomas and the mass in the right lower lobe was malignant melanoma. She underwent right middle and lower lobectomy of the lung with mediastinal and hilar lymph dissection. She refused adjuvant chemotherapy, genetic molecular testing or immunotherapy. Fifteen months later she had brain metastasis. Then she received brain radiotherapy and underwent follow-up at the outpatient clinic regularly.

Conclusions

We experienced a case of concurrent PPMM and invasive pulmonary adenocarcinoma. The patient reported here is the first case of primary pulmonary malignant melanoma combined with invasive pulmonary adenocarcinoma. This patient remained disease-free 15 months after lung surgery.

Recognising Skin Cancer in Primary Care

Skin cancer, including melanoma, basal cell carcinoma and cutaneous squamous cell carcinoma, has one of the highest global incidences of any form of cancer. In 2016 more than 16,000 people were diagnosed with melanoma in the UK. Over the last decade the incidence of melanoma has increased by 50% in the UK, and about one in ten melanomas are diagnosed at a late stage. Among the keratinocyte carcinomas (previously known as non-melanoma skin cancers), basal cell carcinoma is the most common cancer amongst Caucasian populations. The main risk factor for all skin cancer is exposure to ultraviolet radiation-more than 80% are considered preventable. Primary care clinicians have a vital role to play in detecting and managing patients with skin lesions suspected to be skin cancer, as timely diagnosis and treatment can improve patient outcomes, particularly for melanoma. However, detecting skin cancer can be challenging, as common non-malignant skin lesions such as seborrhoeic keratoses share features with less common skin cancers. Given that more than 80% of skin cancers are attributed to ultraviolet (UV) exposure, primary care clinicians can also play an important role in skin cancer prevention. This article is one of a series discussing cancer prevention and detection in primary care. Here we focus on the most common types of skin cancer: melanoma, squamous cell carcinoma and basal cell carcinoma. We describe the main risk factors and prevention advice. We summarise key guidance on the symptoms and signs of skin cancers and their management, including their initial assessment and referral. In addition, we review emerging technologies and diagnostic aids which may become available for use in primary care in the near future, to aid the triage of suspicious skin lesions.