Ultraviolet Carcinogenesis in Nonmelanoma Skin Cancer Part II: Review and Update on Epidemiologic Correlations

UV-type specific alteration of miRNA expression and its association with tumor progression and metastasis in SCC cell lines

PURPOSE

UV exposure is the main risk factor for development of cutaneous squamous cell carcinoma (cSCC). While early detection greatly improves cSCC prognosis, locally advanced or metastatic cSCC has a severely impaired prognosis. Notably, the mechanisms of progression to metastatic cSCC are not well understood. We hypothesized that UV exposure of already transformed epithelial cSCC cells further induces changes which might be involved in the progression to metastatic cSCCs and that UV-inducible microRNAs (miRNAs) might play an important role.

METHODS

Thus, we analyzed the impact of UV radiation of different quality (UVA, UVB, UVA + UVB) on the miRNA expression pattern in established cell lines generated from primary and metastatic cSCCs (Met-1, Met-4) using the NanoString nCounter platform.

RESULTS

This analysis revealed that the expression pattern of miRNAs depends on both the cell line used per se and on the quality of UV radiation. Comparison of UV-induced miRNAs in cSCC cell lines established from a primary tumor (Met-1) and the respective (un-irradiated) metastasis (Met-4) suggest that miR-7-5p, miR-29a-3p and miR-183-5p are involved in a UV-driven pathway of progression to metastasis. This notion is supported by the fact that these three miRNAs build up a network of 81 potential target genes involved e.g. in UVA/UVB-induced MAPK signaling and regulation of the epithelial-mesenchymal transition. As an example, PTEN, a target of UV-upregulated miRNAs (miR-29a-3p, miR-183-5p), could be shown to be down-regulated in response to UV radiation. We further identified CNOT8, the transcription complex subunit 8 of the CCR4-NOT complex, a deadenylase removing the poly(A) tail from miRNA-destabilized mRNAs, in the center of this network, targeted by all three miRNAs.

CONCLUSION

In summary, our results demonstrate that UV radiation induces an miRNA expression pattern in primary SCC cell line partly resembling those of metastatic cell line, thus suggesting that UV radiation impacts SCC progression beyond initiation.

Extremity nevus count is an independent risk factor for basal cell carcinoma and melanoma, but not squamous cell carcinoma

BACKGROUND

The presence of nevi portends an increased risk for melanoma.

OBJECTIVE

We sought to examine the association between extremity nevus count and the risk of melanoma and keratinocyte cancers.

METHODS

We evaluated prospective cohorts of 176,317 women (the Nurses' Health Study, 1986-2012 and the Nurses' Health Study 2, 1989-2013) and 32,383 men (Health Professionals Follow-up Study, 1986-2012). Information on nevus count (none, 1-5, 6-14, ≥15) on the extremity was collected at baseline.

RESULTS

There were 1704 incident cases of melanoma, 2296 incident cases of squamous cell carcinoma, and 30,457 incident cases of basal cell carcinoma, with a total of 4,655,043 person-years for melanoma and 4,267,708 person-years for keratinocyte cancers. The presence of an extremity nevus was associated with an increased risk of melanoma in all anatomic areas and increased risk of basal cell carcinoma (BCC). Individuals with ≥15 nevi had the highest risk of melanoma and BCC compared to those without any extremity nevi (melanoma hazard ratio 2.79 [95% confidence interval 2.04-3.83]; BCC HR 1.40 [95% confidence interval 1.32-1.49]). No significant association was observed for squamous cell carcinoma.

LIMITATIONS

Limitations of our study included self-reported nevus count and detection bias.

CONCLUSIONS

Extremity nevus count is a helpful clinical marker in risk-stratifying individuals for BCC and melanoma on all body sites.

The association between osteoporotic hip fractures and actinic lesions as a biomarker for cumulative sun exposure in older people-a retrospective case-control study in Argentina

The aim of this study was to analyze the association between the presence of actinic lesions (solar keratosis and non-melanoma skin cancer) and osteoporotic hip fractures in older patients. Both pathologies are common conditions in this age group. Since cumulative sun exposure is difficult to quantify, the presence of actinic lesions can be used to indirectly analyze the association between ultraviolet radiation and osteoporotic hip fractures. This was an observational case-control study. We reviewed the centralized medical records of patients with hip fracture (cases, n = 51) and patients with other diseases hospitalized in the same institution and period (controls, n = 59). The mean age of the patients was 80 ± 8.3 years (range 50-103 years). Differences in maternal hip fracture history were found between cases and controls (14.8 and 8 %, respectively; p = 0.047). Falls history in the past year was higher in cases than in controls (p < 0.0001). Actinic lesions were observed in 32.7 % of patients (prevalence rate 23.5 % in cases, 40.7 % in controls; p = 0.04). When considering patients with actinic lesions, controls have a higher FRAX score compared with cases. Although sun exposure is recommended for bone health, it represents a risk factor for actinic lesions. The presence of actinic lesions may indicate a lower osteoporotic hip fracture risk. A balance between adequate lifetime sun exposure and protection against its adverse effects is required for each patient, in the context of geographic location.

Melanocytes are selectively vulnerable to UVA-mediated bystander oxidative signaling

Long-wave UVA is the major component of terrestrial UV radiation and is also the predominant constituent of indoor sunlamps, both of which have been shown to increase cutaneous melanoma risk. Using a two-chamber model, we show that UVA-exposed target cells induce intercellular oxidative signaling to non-irradiated bystander cells. This UVA-mediated bystander stress is observed between all three cutaneous cell types (i.e., keratinocytes, melanocytes, and fibroblasts). Significantly, melanocytes appear to be more resistant to direct UVA effects compared with keratinocytes and fibroblasts, although melanocytes are also more susceptible to bystander oxidative signaling. The extensive intercellular flux of oxidative species has not been previously appreciated and could possibly contribute to the observed cancer risk associated with prolonged UVA exposure.

The oncogenic GLI transcription factors facilitate keratinocyte survival and transformation upon exposure to genotoxic agents

Ultraviolet B (UVB) light is the principal aetiological factor associated with non-melanoma skin cancer, the most prevalent group of malignancies in the Caucasian population. Exposure to environmental chemicals has also been shown to promote skin carcinogenesis and, as for UVB, this is associated with the acquisition of genomic DNA damage. Cells respond to DNA damage by inducing cell cycle arrest to facilitate DNA repair, although apoptosis will occur if the damage is excessive. Oncogenes may drive carcinogenesis by disrupting the balanced control of cell cycle progression, DNA repair and apoptosis, allowing for the propagation of cells with damaged DNA. The transcription factors GLI1 and GLI2 have been implicated in both the initiation and progression of several cancers, including basal cell carcinoma. Here we show that GLI1 and an active mutant of GLI2 (ΔNGLI2) promote apoptotic resistance in N/TERT human keratinocytes upon exposure to UVB and the DNA-alkylating chemicals such as methyl methanesulphonate (MMS) and N-ethyl-N-nitrosurea. Compared with control and untreated N/TERT-GLI1 and -GLI2 cells, those that survived genotoxic insult formed significantly more colonies in soft agar and were significantly more invasive when grown in three-dimensional organotypic collagen gel cultures. Indeed, surviving N/TERT-GLI1 and -GLI2 cells expressed higher levels of the epithelial-to-mesenchymal transition markers Snail and vimentin, and a subpopulation of MMS-treated cells displayed an elongated fibroblast-like morphology with decreased levels of E-cadherin. Finally, whereas Bcl2 was strongly increased in N/TERT-GLI2 cells, the level of induction was weak in N/TERT-GLI1 cells, indicating that GLI1 may activate anti-apoptotic mechanisms(s) independently of Bcl2. In summary, our results show that GLI1 and GLI2 facilitate the propagation of cells with damaged DNA, and thus their expression may be naturally higher in cells that form the earliest precursor tumour lesions.

Occupational exposure to ultraviolet radiation and risk of non-melanoma skin cancer in a multinational European study

Background

Studies suggest that ambient sunlight plays an important role in the pathogenesis of non-melanoma skin cancers (NMSC). However, there is ongoing controversy regarding the relevance of occupational exposure to natural and artificial ultraviolet radiation (UV) radiation.

Objectives

We investigated potential associations between natural and artificial UV radiation exposure at work with NMSC in a case-control study conducted in Hungary, Romania, and Slovakia.

Methods

Occupational exposures were classified by expert assessment for 527 controls and 618 NMSC cases (515 basal cell carcinoma, BCC). Covariate information was collected via interview and multiple logistic regression models were used to assess associations between UV exposure and NMSC.

Results

Lifetime prevalence of occupational exposure in the participants was 13% for natural UV radiation and 7% for artificial UV radiation. Significant negative associations between occupational exposure to natural UV radiation and NMSC were detected for all who had ever been exposed (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.27–0.80); similar results were detected using a semi-quantitative metric of cumulative exposure. The effects were modified by skin complexion, with significantly decreased risks of BCC among participants with light skin complexion. No associations were observed in relation to occupational artificial UV radiation exposure.

Conclusions

The protective effect of occupational exposure to natural UV radiation was unexpected, but limited to light-skinned people, suggesting adequate sun-protection behaviors. Further investigations focusing on variations in the individual genetic susceptibility and potential interactions with environmental and other relevant factors are planned.

Risk factors for skin cancer among Finnish airline cabin crew

Increased incidence of skin cancers among airline cabin crew has been reported in several studies. We evaluated whether the difference in risk factor prevalence between Finnish airline cabin crew and the general population could explain the increased incidence of skin cancers among cabin crew, and the possible contribution of estimated occupational cosmic radiation exposure. A self-administered questionnaire survey on occupational, host, and ultraviolet radiation exposure factors was conducted among female cabin crew members and females presenting the general population. The impact of occupational cosmic radiation dose was estimated in a separate nested case-control analysis among the participating cabin crew (with 9 melanoma and 35 basal cell carcinoma cases). No considerable difference in the prevalence of risk factors of skin cancer was found between the cabin crew (N = 702) and the general population subjects (N = 1007) participating the study. The mean risk score based on all the conventional skin cancer risk factors was 1.43 for cabin crew and 1.44 for general population (P = 0.24). Among the cabin crew, the estimated cumulative cosmic radiation dose was not related to the increased skin cancer risk [adjusted odds ratio (OR) = 0.75, 95% confidence interval (CI): 0.57-1.00]. The highest plausible risk of skin cancer for estimated cosmic radiation dose was estimated as 9% per 10 mSv. The skin cancer cases had higher host characteristics scores than the non-cases among cabin crew (adjusted OR = 1.43, 95% CI: 1.01-2.04). Our results indicate no difference between the female cabin crew and the general female population in the prevalence of factors generally associated with incidence of skin cancer. Exposure to cosmic radiation did not explain the excess of skin cancer among the studied cabin crew in this study.

Factors associated with risky sun exposure behaviors among operating engineers

BACKGROUND

The objective of this study was to determine the factors associated with sun exposure behaviors among Operating Engineers (heavy equipment operators).

METHODS

Operating Engineers (N = 498) were asked to complete a cross-sectional survey. Linear and logistic regression analyses were used to determine health behavioral, perceptional, and demographic factors associated with sun exposure behavior (sun burns, blistering, use of sunscreen, and interest in sun protection services).

RESULTS

Almost half reported two or more sunburns/summer and the median times blistering was 2 with a range of 0-100. About one-third never used sun block, while just over one-third rarely used sun block. Almost one-quarter were interested in sun protection guidance. Multivariate analyses showed that perceptions of skin type, alcohol problems, fruit intake, BMI, sleep quality, age, sex, and race were significantly associated with at least one of the outcome variables (P < 0.05).

CONCLUSIONS

Operating Engineers are at high risk for skin cancer due to high rates of exposure to ultraviolet light and low rates of sun block use. Subgroups of Operating Engineers are particularly at risk for sun damage. Interventions are needed to decrease sun exposure among Operating Engineers.

Introduction to skin cancer

The incidence of skin cancer has been increasing throughout the United States and much of the world. Although the mortality rate of nonmelanoma skin cancer is low, that type of skin cancer accounts for considerable morbidity, including cosmetic and functional impairment. Melanoma, although less common, is a life-threatening malignancy if not detected and treated early. Skin cancer also significantly contributes to the rising costs of health care in the United States. Prevention, early diagnosis, and treatment are critical in helping to reduce the incidence, morbidity, and mortality associated with skin cancer. This article provides an introduction to skin cancer, including the changing incidence, clinical presentation, and summary of treatment and prognosis.

The benefits and risks of ultraviolet tanning and its alternatives: the role of prudent sun exposure

Sunlight- and indoor ultraviolet (UV)-induced tanning is a common behavior, especially among adolescents, young adults, and individuals who have lighter skin. Excessive sun exposure is associated with several health risks, including the acceleration of skin aging and the promotion of skin cancers. Several health benefits of UV exposure include vitamin D production and improved mood. This article analyzes these health risks and benefits and discusses pertinent issues surrounding indoor tanning, the role of sunless tanning products, and prudent sun exposure.

The benefits and risks of ultraviolet tanning and its alternatives: the role of prudent sun exposure

Sunlight- and indoor ultraviolet (UV)-induced tanning is a common behavior, especially among adolescents, young adults, and individuals who have lighter skin. Excessive sun exposure is associated with several health risks, including the acceleration of skin aging and the promotion of skin cancers. Several health benefits of UV exposure include vitamin D production and improved mood. This article analyzes these health risks and benefits and discusses pertinent issues surrounding indoor tanning, the role of sunless tanning products, and prudent sun exposure.

Child sun protection: sun-related attitudes mediate the association between children's knowledge and behaviours

AIM

To describe and investigate the relationship among the sun-related knowledge, attitudes and behaviours of New Zealand primary schoolchildren and consider the roles of sex and school year level.

METHODS

A randomly selected, two-stage cluster sample of 488 children from 27 primary schools in five regions of New Zealand was surveyed regarding their sun-related knowledge, attitudes and behaviours. A scoring system was used to assign a knowledge, attitude and behaviour score to each child.

RESULTS

Although knowledge increased with school year level, there was a decline in sun protective attitudes and behaviours. There was little variation in knowledge, attitudes and behaviour between boys and girls, but sex-year level interactions were found for knowledge and behaviour. When considering children's knowledge, attitudes and behaviours simultaneously, knowledge was only significantly associated with behaviours when mediated by attitudes.

CONCLUSIONS

When targeting child sun protection and skin cancer prevention programmes, a focus on attitudes towards sun exposure and a suntan may prove beneficial in influencing sun-related behaviours.

Cellular effects of long wavelength UV light (UVA) in mammalian cells

UVA should receive significant consideration as a human health risk as it is a large proportion of the solar spectrum that reaches the earth's surface and because of its ability to penetrate human skin. It is only relatively recently that this has been recognized and this previously under-researched part of the UV spectrum is becoming increasingly well characterized at doses that are quite low in relation to those experienced by humans. Absorption of UVA in a cell leads to the production of reactive oxygen and nitrogen species that can damage major biomolecules including DNA and membrane lipids. Various types of damage induced in these molecules lead to significant biological effects including cytotoxicity, mutations and alterations in cell signalling pathways. Longer-term effects such as persistent genomic instability and bystander effects have also been observed following UVA treatment of mammalian cells and, as with ionizing radiation, this changes some of the fundamental thinking around tissue effects of irradiation. Antioxidants have been assessed extensively for their ability to protect against the biological effects of UVA and a number have been shown to be successful at least in-vitro, for example vitamin E and epigallocatechin-3-gallate. Other potential targets for protection are suggested through the increased understanding of some of the signalling mechanisms activated following treatment, for example the inhibition of NADPH oxidase is seen to reduce a bystander effect. The search for appropriate and successful photoprotective agents remains an important area of research.

Reported skin cancer screening of US adult workers

BACKGROUND

Early detection of skin cancer by skin examination may reduce its associated morbidity and mortality, in particular for workers routinely exposed to sun.

OBJECTIVES

We sought to describe the proportion of US workers reporting skin cancer screening examination in a representative sample of the US worker population in the National Health Interview Survey.

METHODS

Report of skin cancer examination in the 2000 and 2005 National Health Interview Survey cancer control supplements were examined by a range of variables.

RESULTS

Lifetime and 12-month reported clinical skin examination prevalence was 15% and 8%, respectively. Workers with elevated occupational exposure to ultraviolet light were less likely to have ever received a skin examination than the average US worker. Logistic regression analysis identified occupational category and age, sex, race, education level, health insurance, and sun-protective behavior as significant independent correlates of skin cancer examination.

LIMITATIONS

A limitation is potential healthy worker effect and underestimation of skin cancer screening with self-reported data.

CONCLUSIONS

Routine examination by primary care physicians frequently does not include a thorough skin examination. Physicians should be even more vigilant with patients at increased risk of excessive occupational sun exposure, as early detection of skin cancer by periodic skin examination decreases morbidity and can improve survival.

Alcohol intake and risk of skin cancer: a prospective study

OBJECTIVE

To investigate the association between total alcohol intake and intake of different types of alcoholic beverages in relation to the risk of basal cell (BCC) and squamous cell (SCC) carcinoma of the skin.

DESIGN

Prospective cohort study.

SETTING

Follow-up data from a community-based skin cancer study in Australia.

SUBJECTS

Randomly selected sample of 1360 adult residents of the township of Nambour who completed a food frequency questionnaire in 1992 and were monitored for BCC and SCC until 31 December 2002.

RESULTS

No significant association was found between overall BCC or SCC risk and total alcohol intake, or intake of beer, white wine, red wine or sherry and port. However, among those with a prior skin cancer history, there was a significant doubling of risk of SCC for above-median consumption of sherry and port (multivariable adjusted relative risk 2.46, 95% confidence interval 1.06-5.72) compared with abstainers.

CONCLUSIONS

There are no associations between first occurrence of skin cancers and alcoholic beverage consumption. People with a history of skin cancer who consume above-average quantities of sherry or port may be at a raised risk of SCC, although replication of these findings in different study populations is needed to confirm this possible role of specific alcoholic beverages in secondary keratinocytic skin cancer risk.

Estudio de variables asociadas al cáncer de piel en Chile mediante análisis de componentes principales

BACKGROUND

The incidence of skin cancer in Chile has increased in recent years.

OBJECTIVE

To associate variables with skin cancer in Chile through indices generated using multivariate descriptive statistical techniques.

MATERIAL AND METHOD

During May 2004, information was gathered from demographic, meteorological and clinical data from Chile corresponding to fiscal year 2001, the latest complete, official information available for the country's Health Services as a whole. The variables developed by the following were studied: the National Statistics Institute (INE), the Ministry of Health (MINSAL), the Ministry of Planning and Cooperation (MIDEPLAN), the National Health Fund (FONASA), the Chilean Meteorological Directorate, Federico Santa María Technical University and the Directorate-General for Water. A Principal Component Analysis (PCA) was then performed on the data obtained.

RESULTS

The first three principal components were selected, with a cumulative explained variance percentage of 54.48 %. The first principal component explains 24.92 % of the variance, and is related to climatic and geographic variables. The second principal component explains 15.77 % of the variance, and is mainly related to FONASA's beneficiary population and the poverty rate. The mortality rate from skin cancer runs significantly against this component. The third principal component explains 13.79 % of the variance, and is related to population characteristics, such as total catchment population, female population and urban population.

CONCLUSION

Performing PCA is useful in studying the factors associated with skin cancer.

Genomewide Single Nucleotide Polymorphism Microarray Mapping in Basal Cell Carcinomas Unveils Uniparental Disomy as a Key Somatic Event

Basal cell carcinoma is the most common human cancer with increasing incidence reported worldwide. Despite the aberrant signaling role of the Hedgehog pathway, little is known about the genetic mechanisms underlying basal cell carcinomas. Towards a better understanding of global genetic events, we have employed the Affymetrix Mapping 10K single nucleotide polymorphism (SNP) microarray technique for "fingerprinting" genomewide allelic imbalance in 14 basal cell carcinoma-blood pair samples. This rapid high-resolution SNP genotyping technique has revealed a somatic recombination event-uniparental disomy, leading to a loss of heterozygosity (LOH), as a key alternative genetic mechanism to allelic imbalances in basal cell carcinomas. A highly conserved LOH region at 9q21-q31 was found in 13 of 14 (93%) basal cell carcinomas. Further statistical and fluorescence in situ hybridization analyses confirmed that the 9q LOH was a result of uniparental disomy in 5 of 13 (38%) basal cell carcinomas. De novo mutations in the Patched 1 gene (PTCH) were found in 9 of 13 (69%) basal cell carcinomas with 9q LOH. A second important locus, containing LOH at 6q23-q27 was found in 5 of 14 (36%) basal cell carcinomas, suggesting that the presence of an additional putative tumor suppressor gene may be contributing to basal cell carcinoma development. This study shows that the rate of 9q LOH in basal cell carcinomas has been previously underestimated. Furthermore, we provide the first evidence that uniparental disomy due to somatic recombination constitutes one of the mechanisms of LOH in basal cell carcinoma tumorigenesis.

Cytogenetic alterations in nonmelanoma skin cancer: a review

Since the advent of cytogenetic analysis, knowledge about fundamental aspects of cancer biology has increased, allowing the processes of cancer development and progression to be more fully understood and appreciated. Classical cytogenetic analysis of solid tumors had been considered difficult, but new advances in culturing techniques and the addition of new cytogenetic technologies have enabled a more comprehensive analysis of chromosomal aberrations associated with solid tumors. Our purpose in this review is to discuss the cytogenetic findings on a number of nonmelanoma skin cancers, including squamous- and basal cell carcinomas, keratoacanthoma, squamous cell carcinoma in situ (Bowen's disease), and solar keratosis. Through classical cytogenetic techniques, as well as fluorescence-based techniques such as fluorescence in situ hybridization and comparative genomic hybridization, numerous chromosomal alterations have been identified. These aberrations may aid in further defining the stages and classifications of nonmelanoma skin cancer and also may implicate chromosomal regions involved in progression and metastatic potential. This information, along with the development of newer technologies (including laser capture microdissection and comparative genomic hybridization arrays) that allow for more refined analysis, will continue to increase our knowledge about the role of chromosomal events at all stages of cancer development and progression and, more specifically, about how they are associated with nonmelanoma skin cancer.