Melanoma epidemic: True or false?

Topical and Intralesional Immunotherapy for Melanoma In Situ: A Review

The incidence of in situ melanoma (MIS) has increased over the last decades. The mainstay of treatment for MIS, including lentigo maligna (LM), is complete surgical excision with clear margins (0.5 to 1.0 cm). Nevertheless, MIS lesions often affect elderly patients with comorbidities and involve large lesions in cosmetically sensitive areas, which means surgery is not always appropriate. Non-surgical treatments have a role in these cases, and include radiotherapy, cryosurgery, immunotherapy, laser therapy, and other topical medications. This study aims to review the applications of immunotherapy in MIS, either in monotherapy or in combination with other therapeutic alternatives. The main forms of immunotherapy used are imiquimod and, to a lesser extent, intralesional interferon-α (IL-INF-α) and ingenol mebutate (IM). IL-INF-α and IM have not been studied as extensively as imiquimod, whose results in real-life practice are encouraging. The clearance and recurrence rates reported in MIS treated with imiquimod as monotherapy, or as an adjuvant after surgery with affected or narrow margins, make imiquimod a reliable therapeutic alternative in selected cases. Also, its use as a neoadjuvant therapy before surgery was shown to reduce the final surgical defect size required to confirm negative histologic margins. In conclusion, local immunotherapy is frequently used in clinical practice and experience confirms it to be an excellent option for certain patients.

Clinical validity of a gene expression signature in diagnostically uncertain neoplasms

Aim: Evaluate the accuracy of a 23-gene expression signature in differentiating benign nevi from melanoma by comparing test results with clinical outcomes. Materials & methods: Seven dermatopathologists blinded to gene expression test results and clinical outcomes examined 181 lesions to identify diagnostically uncertain cases. Participants independently recorded diagnoses and responses to questions quantifying diagnostic certainty. Test accuracy was determined through comparison with clinical outcomes (sensitivity and percent negative agreement). Results: Overall, 125 cases fulfilled criteria for diagnostic uncertainty (69.1%; 95% CI: 61.8-75.7%). Test sensitivity and percent negative agreement in these cases were 90.4% (95% CI: 79.0-96.8%) and 95.5% (95% CI: 87.3-99.1%), respectively. Conclusion: The 23-gene expression signature has high diagnostic accuracy in diagnostically uncertain cases when evaluated against clinical outcomes.

Incidence and survival in patients with cutaneous melanoma by morphology, anatomical site and TNM stage: a Danish Population-based Register Study 1989-2011

INTRODUCTION

The incidence of melanoma of the skin has risen in Denmark in recent decades, the increase being steeper from 2004. It is unclear whether this represents a true rise in incidence or whether it is caused by an increased awareness of the condition.

METHODS

To assess whether the increase was characterised by early-stage melanomas and a higher proportion of melanomas with superficial spreading morphology, we studied all skin melanoma patients registered in the Danish Cancer Register 1989-2011 (n=27,010) and followed up for death through 2013. Trends in age-standardised incidence by sex, subsite and morphology, relative survival, TNM stage distribution and stage-specific relative survival from 2004 were analysed.

RESULTS

The incidence of melanoma more than doubled over 23 years. A steeper increase from 2004 was driven mainly by superficial spreading tumours, but the proportion of nodular melanomas in patients 50 years of age and over also increased significantly. The largest increase occurred for stage I tumours and for tumours on the trunk. From 1989-1993 to 2009-2011 the 5-year relative survival increased at 12% and 6% points for male and female patients, respectively.

INTERPRETATION

Greater awareness, and thus lower stage at diagnosis (mediated by a large skin cancer prevention campaign from 2007), might explain part of the increase, but the increase in nodular melanoma also points to a genuine increase in the risk of melanoma.

More skin, more sun, more tan, more melanoma

Although personal melanoma risk factors are well established, the contribution of socioeconomic factors, including clothing styles, social norms, medical paradigms, perceptions of tanned skin, economic trends, and travel patterns, to melanoma incidence has not been fully explored. We analyzed artwork, advertisements, fashion trends, and data regarding leisure-time activities to estimate historical changes in UV skin exposure. We used data from national cancer registries to compare melanoma incidence rates with estimated skin exposure and found that they rose in parallel. Although firm conclusions about melanoma causation cannot be made in an analysis such as this, we provide a cross-disciplinary, historical framework in which to consider public health and educational measures that may ultimately help reverse melanoma incidence trends.

No one should die of melanoma: a vision or impossible mission?

While the incidence of early-stage melanoma has dramatically increased over the past decades, the incidence and mortality rates of thick melanomas have remained relatively stable during the same period. A number of alternative theories have been postulated in order to explain these divergent trends between thin and thick melanomas, among which is the question of whether nodular melanoma may originate in the dermis. This concept has gained support from recent improvements in the understanding of the origin of melanocytes and the morphological and molecular diversity of melanoma. A dermal origin would plausibly explain why efforts at improving the early detection of melanoma largely fail, as it implies an initially intradermal growth that is hidden from our eyes until clinical signs and symptoms become only secondarily apparent. In light of this, at the current stage, the vision that no one should die of melanoma is an impossible mission.

Increasing burden of melanoma in the United States

It is controversial whether worldwide increases in melanoma incidence represent a true epidemic. Dramatic increases in incidence in the setting of relatively stable mortality trends have also been attributed to expanded skin screening and detection of biologically indolent tumors with low metastatic potential. To better understand how melanoma incidence trends varied by severity at diagnosis and factors relevant to screening access, we assessed recent United States incidence and mortality trends by histologic type, tumor thickness, and area-level socioeconomic status (SES). We obtained population-based data regarding diagnoses of invasive melanoma among non-Hispanic whites from nearly 291 million person-years of observation by the Surveillance Epidemiology and End Results (SEER) program (1992-2004). Age-adjusted incidence and mortality rates were calculated for SEER and a subset (California) for which small-area SES measure was available. Overall, melanoma incidence increased at 3.1% (P<0.001) per year. Statistically significant rises occurred for tumors of all histologic subtypes and thicknesses, including those >4 mm. Melanoma incidence rates doubled in all SES groups over a 10-year period whereas melanoma mortality rates did not increase significantly. We conclude that screening-associated diagnosis of thinner melanomas cannot explain the increasing rates of thicker melanomas among low SES populations with poorer access to screening.

Predicting clinical outcome through molecular profiling in stage III melanoma

PURPOSE

Patients with macroscopic stage III melanoma represent a heterogeneous cohort with average 5-year overall survival rates of <30%. With current algorithms, it is not possible to predict which patients will achieve longer-term survival. We hypothesized that molecular profiling could be used to identify prognostic groups within patients with stage III melanoma while also providing a greater understanding of the biological programs underpinning these differences.

EXPERIMENTAL DESIGN

Lymph node sections from 29 patients with stage IIIB and IIIC melanoma, with divergent clinical outcome including 16 "poor-prognosis" and 13 "good-prognosis" patients as defined by time to tumor progression, were subjected to molecular profiling using oligonucleotide arrays as an initial training set. Twenty-one differentially expressed genes were validated using quantitative PCR and the 15 genes with strongest cross-platform correlation were used to develop two predictive scores, which were applied to two independent validation sets of 10 and 14 stage III tumor samples.

RESULTS

Supervised analysis using differentially expressed genes was able to differentiate the prognostic groups in the training set. The developed predictive scores correlated directly with clinical outcome. When the predictive scores were applied to the two independent validation sets, clinical outcome was accurately predicted in 90% and 85% of patients, respectively.

CONCLUSION

We describe a gene expression profile that is capable of distinguishing clinical outcomes in a previously homogeneous group of stage III melanoma patients.

A recombinant protein based on Trypanosoma cruzi surface molecule gp82 induces apoptotic cell death in melanoma cells

Trypanosoma cruzi infection is known to confer resistance to tumor development in mice, and in-vitro studies have shown the toxic effects of parasite extracts on cancer cell cultures. Investigations in which T. cruzi molecules exhibit antitumor activity have just begun. Here, we used a tumorigenic cell line Tm5, derived from mouse melanocytes melan-a, to test the effect of J18, a recombinant protein based on T. cruzi surface molecule gp82 fused to glutathione-S-transferase (GST). J18 induced actin cytoskeleton disruption in Tm5 but not in melan-a cells. Several changes indicative of apoptosis were detected in Tm5 melanoma cells but not in melan-a cells treated with J18, such as the flipping of phosphatidylserine from the inner to the external side of the plasma membrane, altered nuclear morphology, DNA fragmentation, increase in mitochondria depolarization, and in caspase-3 activity. Retention of NF-kappaB in the cytoplasm was another alteration observed specifically in J18-treated Tm5 cells. No such alterations were found in Tm5 cells treated with GST. In-vivo experiments showed that C57BL/6 mice inoculated with Tm5 cells, treated at the site of tumor cell inoculation with J18, developed tumors of smaller size than mice treated with phosphate-buffered saline or GST and survived longer.

Pigmented lesions, cutaneous melanoma, and future challenges for primary care

The incidence of cutaneous melanoma is increasing amongst Caucasian populations worldwide. There are calls for melanoma to be regarded as a growing public health problem, with public and professional education to tackle it. Such programmes will increase public awareness of malignant melanoma and of pigmented lesions generally. In the UK, general practitioners face challenges in terms of primary prevention and education, diagnosis, primary treatment, and aftercare of patients with melanoma. Organizational changes are required to meet the increasing challenge posed to primary care by melanoma and should be based on the most rigorous evidence.

Trends in melanoma epidemiology suggest three different types of melanoma

BACKGROUND

It has been suggested that the incidence of thin melanomas but not of thick tumours is rising in fair-skinned populations, although the reason for this discrepancy is not understood.

OBJECTIVES

To describe temporal trends in melanoma epidemiology in a limited part of France in order to confirm this observation and to provide an explanation.

METHODS

This is a retrospective population- and academic centre-based study in which all melanomas diagnosed in the department of the Bas-Rhin, France between January 1980 and December 2004 were included.

RESULTS

The study included 2094 melanomas diagnosed in 2020 patients. There was a steady increase in incidence of thin (< 1 mm) melanomas, mainly located on the trunk, and to a lesser extent in the head and neck region, in both sexes, and of intermediate (1-2 mm) melanomas in men. The incidence of intermediate melanomas in women and of thick (> 2 mm) melanomas, as well as mortality related to melanoma, remained stable. There was a steady decline of mean and median Breslow thickness. The 12 months median delay to diagnosis of thick tumours was significantly shorter than the 24 months delay to diagnosis of thin tumours.

CONCLUSIONS

Temporal trends suggest the existence of three unrelated types of melanoma: type I, thick melanomas, with stable incidence; type II, thin melanoma with a steady and important increase in incidence, mainly located on the trunk; and type III, melanoma with a slower increase in incidence, mainly located on the head and neck region.

Reduced pSmad2 immunodetection correlates with increased primary melanoma thickness

Cutaneous melanoma is the most aggressive of cutaneous neoplasms. Identifying patients with an increased risk for the development of metastases is critical. This study investigates phospho-Smad2, a central factor of the transforming growth factor beta pathway, on formalin-fixed, paraffin-embedded tissues from 60 primary cutaneous melanomas (Breslow >1 mm), for its candidacy for being a prognostic marker in primary cutaneous melanoma. Phospho-Smad2 positivity was assessed for correlation with clinical parameters including Breslow index, melanoma type, survival, development of metastases, sentinel lymph node status and age. Phospho-Smad2 positivity was not associated with survival or development of metastases, suggesting that it would not be a useful prognostic marker. Despite this, we found phospho-Smad2 positivity to be correlated with low tumour thickness, indicating that as the primary tumour grows there is an increased inhibition of transforming growth factor beta signalling resulting in suppressed Smad2 phosphorylation. Additionally, phosphorylation of Smad2 in neighbouring melanoma cells and keratinocytes was interrelated, which is a further indication that Smad2 phosphorylation in primary melanoma is affected by local area microenvironmental factors. We hypothesize that the observed decrease in transforming growth factor beta signalling in thicker primary melanomas is due to the increased production of signalling inhibitors.

How gender, age, and geography influence the utilization of radiation therapy in the management of malignant melanoma

PURPOSE

Comparing radiation therapy utilization rates (RTUR) to those predicted by best evidence is a useful measure of the equity and accessibility of service delivery. In this study the RTUR for melanoma was established for British Columbia, Canada, and compared with the rate suggested by the evidence. Demographic variables, specifically age, gender, and geography that influenced the RTUR were examined with a view to identifying methods of improving underutilization.

METHODS AND MATERIALS

The RTUR in the management of malignant melanoma was taken from British Columbia Cancer registry data for 1986 to 1998. Variations in utilization based on age, gender, health authority, stage of disease, and referral patterns were analyzed.

RESULTS

An RTUR of 11% was identified. This was consistent over time. Referral rates decreased between 1986 and 1998. RT is used mostly for later stage disease. Males were more likely to receive RT than females, related to later stage of disease in men. Referral rates decreased, but RTUR for referred cases increased, in health authorities that did not have a cancer center.

CONCLUSIONS

Use of RT is influenced by age and by stage of disease. Overall RTUR in British Columbia is lower than suggested by best evidence. Referral patterns are influenced by geography. RTUR was higher in males, consistent with a different pattern of disease in males compared with females.

[Epidemiology of cutaneous melanoma: descriptive data in France and Europe]

INTRODUCTION

The incidence of melanoma and the resulting mortality have been the subject of many studies. However, controversy remains as to the interpretation of the number of cases observed and the existence of an actual "epidemic" of melanomas in fair-skinned populations.

OBJECTIVES

Analyze the descriptive epidemiological data available concerning cutaneous melanomas in France and in Europe.

METHODS

Data regarding incidence and mortality published in the literature and on the Internet were reviewed and analyzed.

RESULTS

In France, between 1980 and 2000, the standardized worldwide population incidence rate of melanoma increased from 2.4 to 7.6 per 100.000 inhabitants/years in men and from 3.9 to 9.5 in women. In the Haut-Rhin department in France, where Breslow indexes are registered, the increase in incidence was accompanied by an increase in the proportion of thin melanomas. In the year 2000, the estimated number of new cases of cutaneous melanomas was of 7231, with 58 p. 100 female and 42 p. 100 male cases. Great geographical disparity among the 9 departments in France equipped with registers was noted. This increase in incidence was accompanied by an increase in mortality. Between 1969 and 1997, mortality due to melanoma was multiplied by 2.7 in women and by 2.9 in men. In the year 2000, 1364 deaths were attributed to a melanoma. The standardized worldwide mortality rates were of 1.6/100000 inhabitants/years in men and 1.1/100000 inhabitants/years in women. In Europe, a great increase in the incidence and mortality has been registered in all countries since the nineteen fifties. It was earlier and greater in northern European countries, followed by western European countries, and finally by eastern and southern countries. There was great geographical disparity, with a double decreasing North-South East-West gradient. Analysis of the recent trends in development, in countries with high incidence such as those of northern Europe, showed a trend towards the stabilization in the incidence and decreased mortality in young adults.

DISCUSSION

In France, as in Europe, the extensive increase in incidence of melanoma and resulting mortality is a reality, reaching a peak in the northern European countries. The decrease in mortality observed recently in young cohorts in these countries and in Eastern Europe may announce an ultimate decrease in the older populations and the rest of Europe. Massive primary and secondary prevention campaigns seem effective and warrant reinforcement.

Chemotherapy for metastatic melanoma

Despite the limited efficacy of systemic chemotherapy in the treatment of metastatic melanoma, it remains the gold standard in the case of patients with a good performance status and no major comorbidities for whom radical surgery is unsuitable. Various drugs have been employed as monochemotherapy with response rates ranging from 0 to 20%. Many Phase III trials have compared the role of polychemotherapy with that of single-agent chemotherapy, or evaluated the impact of biological response modifiers alone or in combination with chemotherapeutic agents. However, the current scenario does not seem to be significantly different from the situation of 20 or 30 years ago. To date, no single drug, combination chemotherapy in addition to a hormonal or biotherapy compound, has demonstrated an overall survival benefit in a randomized clinical trial.

Skin biopsy rates and incidence of melanoma: population based ecological study

OBJECTIVES

To describe changes in skin biopsy rates and to determine their relation with changes in the incidence of melanoma.

DESIGN

Population based ecological study.

SETTING

Nine geographical areas of the United States.

PARTICIPANTS

Participants of the Surveillance Epidemiology and End Results (SEER) programme aged 65 and older.

MAIN OUTCOME MEASURES

For the period 1986 to 2001, annual skin biopsy rates for each surveillance area from Medicare claims and incidence rates for melanoma for the same population.

RESULTS

Between 1986 and 2001 the average biopsy rate across the nine participating areas increased 2.5-fold among people aged 65 and older (2847 to 7222 per 100,000 population). Over the same period the average incidence of melanoma increased 2.4-fold (45 to 108 per 100,000 population). Assuming that the occurrence of true disease was constant, the extra number of melanoma cases that were diagnosed after carrying out 1000 additional biopsies was 12.6 (95% confidence interval 11.2 to 14.0). After controlling for a potential increase in the true occurrence of disease, 1000 additional biopsies were still associated with 6.9 (3.1 to 10.8) extra melanoma cases diagnosed. Stage specific analyses suggested that 1000 biopsies were associated with 4.4 (2.1 to 6.8) extra cases of in situ melanoma diagnosed and 2.3 (0.0 to 4.6) extra cases of local melanoma, but not with the incidence of advanced melanoma. Mortality from melanoma changed little during the period.

CONCLUSION

The incidence of melanoma is associated with biopsy rates. That the extra cases diagnosed were confined to early stage cancer while mortality remained stable suggests overdiagnosis-the increased incidence being largely the result of increased diagnostic scrutiny and not an increase in the incidence of disease.

Merkel cell carcinoma: changing incidence trends

BACKGROUND

The objective of this study was to define the incidence trends of Merkel cell carcinoma (MCC), a rare and aggressive cutaneous malignancy.

MATERIALS AND METHODS

All cases of MCC of the skin between 1986 and 2001 were identified using the surveillance, epidemiology, and end results (SEER) program. Overall age-adjusted, gender-specific, age-specific, stage-specific, and regional incidence rates were calculated. All rates are per 100,000 and age-adjusted to the 2000 US standard population. Estimated annual percent change (EAPC) was calculated using a linear least squares model.

RESULTS

A total of 1,124 cases of MCC were identified in the SEER registries. The rate of MCC increased from 0.15 cases per 100,000 in 1986 to 0.44 cases per 100,000 in 2001. The EAPC for the time period was 8.08%. This was statistically significant (95% CI: 6.29, 9.90, P-value < 0.05). Age-specific incidence (5-year age groups) were highest in the elderly, 4.28 per 100,000 in the 85+ age group.

CONCLUSIONS

MCC incidence rates have increased threefold over the 1986-2001 period. Rates are highest in the elderly population. Further etiologic studies and identification of high-risk populations are warranted.