Trends in incidence and predictions of cutaneous melanoma across Europe up to 2015

North-south differences in incidence and surveillance of cutaneous malignant melanoma in Italy

BACKGROUND

In Italy, the incidence of cutaneous malignant melanoma is two-fold higher in the north than in the south. This gradient might be associated with differences in incidence trends and disease surveillance. We compared the time trends in incidence rates, mortality rates, dermatologic office visit rates and skin biopsy rates between the Emilia-Romagna Region (northern Italy) and the Sicily Region (southern Italy).

METHODS

The cancer registries of Parma, Modena, Ferrara and Romagna (current population, 2,606,465) and Catania-Messina-Enna, Siracusa and Ragusa (2,775,019) provided incidence and mortality records for the years 2008-2017. The records of outpatient services delivered in public health facilities were obtained from the two Regional Administrations. Trends in rates were assessed with the estimated average annual percent change. North-south differences were expressed as age-standardised rate ratios.

RESULTS

In the context of a generalised increasing incidence trend, which was more moderate in the female population of the Sicily Region, the standardised rate ratios were: 5.31 (males) and 5.20 (females) for in situ cutaneous malignant melanoma; 2.10 and 2.07 for invasive cutaneous malignant melanoma, with an excess incidence concentrated in lesions ⩽1.00 mm thick (3.58 and 3.05); 3.00 and 2.44 for dermatologic office visits; and 5.25 and 5.02 for skin biopsies. Mortality was stable in both Regions.

CONCLUSIONS

In the Emilia-Romagna Region, as compared with the Sicily Region, a higher incidence of cutaneous malignant melanoma -especially of in situ and early invasive cutaneous malignant melanoma- coexisted with a higher level of clinical surveillance. The question of the direction of the cause-effect relationship between increased incidence and increased diagnostic scrutiny remains open.

Cutaneous Melanoma Mortality-to-Incidence Ratio and Its Association With Socioeconomic and Healthcare Factors in Canada: A National Ecological Study

INTRODUCTION

The mortality-to-incidence ratio (MIR) can be used to approximate healthcare inequities and is helpful to understand/compare cancer survival between geographic regions/jurisdictions. We investigated cutaneous melanoma (CM) outcomes through MIR analysis in Canadian jurisdictions and census divisions (CDs) between 1992 and 2016.

METHODS

Data were obtained from the national databases from 1992 to 2016 for all Canadian jurisdictions, except Quebec. Age-standardized overall and median MIRs were calculated per province per year, while crude MIRs were calculated for CDs. Generalized linear regression models were conducted to study the effect of province and year on MIR, while a mixed effect regression model was used to determine how healthcare and socioeconomic factors affect MIR, while accounting for possible clustering effects (eg, year and province).

RESULTS

We identified 106,015 CM cases and 20,570 CM deaths between 1992 and 2016. National MIR from 1992 to 2016 demonstrated a significant linear decrease (P value < .0001). The national median MIR was 15.4 (ie, 0.154 × 100), whereby Manitoba (19.9), Ontario (19.5), Saskatchewan (18.5), British Columbia (16.1), and Newfoundland and Labrador (15.9) demonstrated higher MIRs than the Canadian average. CDs with the highest MIRs were commonly identified in the southern regions of provinces. No healthcare or socioeconomic factors were found to be significantly associated with higher MIR at the provincial level.

CONCLUSION

MIRs have decreased at the national and provincial levels in recent decades, which is reassuring. Higher MIRs were noted in select rural CDs and in the Canadian territories, reinforcing the importance of proper dermatological care in all parts of the country.

Malignant melanoma in Portuguese adult population: a scoping review of the real-world evidence

PURPOSE

Malignant melanoma is an aggressive cancer, and there is a notable dearth on epidemiology, clinical and treatment characterization within the Portuguese population. We performed a scoping review to identify real-world evidence studies focused in Portuguese adult patients with malignant melanoma.

METHODS

A comprehensive search was conducted. After screening, we described the studies by design, sample size, geographics, setting, population, and outcomes reported.

RESULTS

The search yielded 54 studies, mainly retrospective (79.6%). The population assessed was heterogeneous varying from patients with melanoma in general to specific types of melanoma, or even more restricted to patients with specific conditions. The evidence found was mostly concerning clinical outcomes (n=46), patients' clinical profile (n=44) and demographic characterization (n=48). Treatment information was described in 30 studies whereas only 18 reported epidemiological parameters. Studies were mainly performed by the major oncology centers in Lisbon, Oporto and Coimbra, and only two evaluated the entire Portuguese population. To allow comparability, only studies including patients with cutaneous malignant melanoma were considered (13 of the 54) for outcomes evaluation analysis. Median OS varied from 18 to 36 months, assessed after melanoma treatment. Incidence was the most reported epidemiological parameter, confirming the increasing number of cutaneous malignant melanoma patients over the years. Only one study reported prevalence and four reported mortality rates.

CONCLUSIONS

The evidence found confirms the lack of information about malignant melanoma in Portugal, highlighting the need of real-world studies to assess melanoma prevalence and incidence rates, current treatment approaches, and clinical characterization of these patients.

Factors Associated with Adoption of Immune Checkpoint Inhibitor Treatment for Advanced Melanoma: A SEER-Medicare Cohort Study

We aimed to explore the differences in immune checkpoint inhibitor (ICI) immunotherapy utilization for advanced melanoma by examining patient and neighborhood characteristics. We performed a retrospective cohort study using a deidentified, random sample of SEER-Medicare beneficiaries aged ≥65 years with stage III or stage IV melanoma (2011-2017). Our primary outcome was initiation of ICI immunotherapy (ipilimumab, pembrolizumab, nivolumab, or atezolizumab) after stage III or stage IV melanoma diagnosis. We analyzed ICI usage with multivariable logistic regression. After analyzing the entire 2011-2017 cohort, we conducted a secondary analysis in which we separately analyzed the 2011-2014 and 2015-2017 cohorts to assess possible differences over time. We included 3531 beneficiaries, with mean follow-up of 2.1 (SD = 2.0) years. Higher likelihood of ICI usage was associated with male sex (OR = 1.21, 95% confidence interval = 1.04-1.42) and higher density of medical oncologists (OR = 1.02, 95% confidence interval = 1.01-1.04). Lower likelihood of ICI usage was associated with older age group and Charlson comorbidity score (score ≥2; OR = 0.72, 95% confidence interval = 0.60-0.86). These associations were diminished in more recent years (no association with sex, medical oncologist density, Charlson comorbidity score, and association with only the oldest age group in years 2015-2017). We found significant sex- and age-related differences in initiation among SEER-Medicare beneficiaries with stage III or stage IV melanoma, which appear to be improving over time.

Melanoma epidemiology in Europe: what is new?

Every year in Europe over 150,000 new cases of melanoma are reported and over 25,000 lives are lost to this tumor. Incidence has been rising rapidly, faster than for any other cancer, and it is expected to continue to do so in most regions. Mortality also crept up, decades-long, with only few very recent exceptions. Thus, melanoma remains a public health problem that will not go away soon, nor easy. Some notable progress has been made in the last decade in the fight against this tumor. Registration and reporting for skin cancers improved across Europe. Incidence trends have begun to plateau or even to descend in younger age groups, in some countries, and there are encouraging signs that mortality might do the same, after the recent therapeutic breakthroughs. Survival rates are on average above 80% at 5 years for European patients, while diagnosis trends toward ever thinner tumors. Yet this progress is far from uniform across the continent, with many Southern-and Eastern European countries still struggling with sub-optimal cancer reporting, delayed access to innovative treatments, late detection and insufficient healthcare funding, that push survival rates down to harrowing 50%. This article aims to give an updated overview of the epidemiological situation of melanoma in Europe, highlighting the progress but also the persisting disparities in tumor burden, prognosis and access to quality cancer care and surveillance between European countries, as a reminder that relentless efforts must continue in order to tackle this aggressive tumor in an effective and equitable manner.

Advancing Differentiation of Hepatic Metastases in Malignant Melanoma through Dual-Energy Computed Tomography Rho/Z Maps

OBJECTIVES

The aim of this study is to evaluate the diagnostic accuracy of dual-energy computed tomography (DECT)-based Rho/Z maps in differentiating between metastases and benign liver lesions in patients diagnosed with malignant melanoma compared to conventional CT value measurements.

METHODS

This retrospective study included 73 patients (mean age, 70 ± 13 years; 43 m/30 w) suffering from malignant melanoma who had undergone third-generation DECT as part of tumor staging between December 2017 and December 2021. For this study, we measured Rho (electron density) and Z (effective atomic number) values as well as Hounsfield units (HUs) in hypodense liver lesions. Values were compared, and diagnostic accuracy for differentiation was computed using receiver operating characteristic (ROC) curve analyses. Additional performed MRI or biopsies served as a standard of reference.

RESULTS

A total of 136 lesions (51 metastases, 71 cysts, and 14 hemangiomas) in contrast-enhanced DECT images were evaluated. The most notable discrepancy (p < 0.001) between measured values and the highest diagnostic accuracy for distinguishing melanoma metastases from benign cysts was observed for the Z (0.992; 95% CI, 0.956-1) parameters, followed by Rho (0.908; 95% CI, 0.842-0.953) and finally HU120kV (0.829; 95% CI, 0.751-0.891). Conversely, when discriminating between liver metastases and hemangiomas, the HU120kV parameters showed the most significant difference (p < 0.001) and yielded the highest values for diagnostic accuracy (0.859; 95% CI, 0.740-0.937), followed by the Z parameters (0.790; 95% CI, 0.681-0.876) and finally the Rho values (0.621; 95% CI, 0.501-0.730).

CONCLUSIONS

Rho and Z measurements derived from DECT allow for improved differentiation of liver metastases and benign liver cysts in patients with malignant melanoma compared to conventional CT value measurements. In contrast, in differentiation between liver hemangiomas and metastases, Rho/Z maps show inferior diagnostic accuracy. Therefore, differentiation between these two lesions remains a challenge for CT imaging.

Tumour Recurrence, Depth of Invasion, and Temple Location as Independent Prognostic Parameters of Lymph Node Metastases of Head and Neck Cutaneous Squamous Cell Carcinomas

The excellent survival rate of cutaneous squamous cell carcinoma (cSCC) exceeding 90% is reduced by the presence of nodal metastases by over 50%. We analysed various risk parameters of cSCC to predict the incidence of nodal metastases. A total of 118 patients with the head cSCC were included in a single-institution retrospective study covering the period from 2008 to 2020. Tumour recurrence, temple location, and tumour infiltration depth were found to be independent predictors of nodal metastases (increasing the probability of metastases by 8.0, 8.1, and 4.3 times, respectively). Furthermore, univariate analysis shows that the tumour size and T stage are significant factors increasing the risk of metastases. Several independent risk factors for the development of metastases in the head cSCC have been confirmed. These findings might help identify at-risk patients who require additional attention for adequate radical treatment and close follow-up. In contrast, elective treatment of lymph nodes is not recommended due to the low incidence of regional metastases.

Dormancy of cutaneous melanoma

Many cancer-related deaths including melanoma result from metastases that develop months or years after the initial cancer therapy. Even the most effective drugs and immune therapies rarely eradicate all tumor cells. Instead, they strongly reduce cancer burden, permitting dormant cancer cells to persist in niches, where they establish a cellular homeostasis with their host without causing clinical symptoms. Dormant cancers respond poorly to most drugs and therapies since they do not proliferate and hide in niches. It therefore remains a major challenge to develop novel therapies for dormant cancers. In this review we focus on the mechanisms regulating the initiation of cutaneous melanoma dormancy as well as those which are involved in reawakening of dormant cutaneous melanoma cells. In recent years the role of neutrophils and niche components in reawakening of melanoma cells came into focus and indicate possible future therapeutic applications. Sophisticated in vitro and in vivo melanoma dormancy models are needed to make progress in this field and are discussed.

The descriptive epidemiology of melanoma in Italy has changed - for the better

A recent research project using data from a total of 40 cancer registries has provided new epidemiologic insights into the results of efforts for melanoma control in Italy between the 1990s and the last decade. In this article, the authors present a summary and a commentary of their findings. Incidence increased significantly throughout the study period in both sexes. However, the rates showed a stabilization or a decrease in men and women aged below 35 years. The risk of disease increased for successive cohorts born until 1973 (women) and 1975 (men) while subsequently tending to decline. The trend towards decreasing tumor thickness and increasing survival has continued, but a novel favorable prognostic factor has emerged since 2013 for patients - particularly for males - with thick melanoma, most likely represented by molecular targeted therapies and immune checkpoint inhibitors. Due to this, the survival gap between males and females has been filled out. In the meanwhile, and despite the incidence increase, dermatologists have not lowered their threshold to perform skin biopsy. Skin biopsy rate has increased because of the increasingly greater volume of dermatologic office visits, but the proportion of skin biopsies out of dermatologic office visits has remained constant. In summary, an important breakthrough in melanoma control in Italy has taken place. Effective interventions have been implemented across the full scope of care, which involve many large local populations - virtually the whole national population. The strategies adopted during the last three decades represent a valuable basis for further steps ahead in melanoma control in Italy.

Potential risk factors, clinicopathological features and determinants of survival for multiple primary melanoma patients compared to single primary melanoma: a large single-center Italian study

Melanoma patients have a high risk of developing subsequent primary melanomas, a condition known as multiple primary melanoma (MPM). We aimed to compare risk factors of patients with MPM and single primary melanoma (SPM). Primary MPM and SPM consecutively treated at the National Cancer Institute in Milan, Italy, from 1978 to 2021 were retrospectively investigated. Demographic and clinicopathological characteristics were analyzed. Multivariate hazard ratios and mortality were estimated using Cox proportional hazards regression models. Overall, 9122 patients with SPM and 944 with MPM were included. A total of 1437 and 85 deaths occurred in SPM and MPM group, respectively. Of these, 1315 (14.4%) within SPM patients and 60 (6.4%) in MPM group were melanoma-specific deaths (MSDs). Males had a higher risk for MPM (hazard ratio = 1.29), while age was not associated with MPM (hazard ratio = 0.98). The risk of MPM decreased by about 50% for Breslow thickness >1 mm, and by about 45 and 75% in presence of mitoses and ulceration, respectively. The multivariate hazard ratio of death for MPM compared to SPM patients was 0.85 (95% confidence interval, CI: 0.67-1.06), while considering MSD the corresponding hazard ratio was 0.93 (95% CI: 0.71-1.22). Melanoma patients should receive regular follow-up with complete skin examination to detect early subsequent primary melanoma. Patients with more advanced primary have decreased risk of MPM, while males have higher risk. Our study reported no significant difference in mortality between SPM and MPM, but the issue is still open for discussion and further studies.

Deep learning detection of melanoma metastases in lymph nodes

BACKGROUND

In melanoma patients, surgical excision of the first draining lymph node, the sentinel lymph node (SLN), is a routine procedure to evaluate lymphogenic metastases. Metastasis detection by histopathological analysis assesses multiple tissue levels with hematoxylin and eosin and immunohistochemically stained glass slides. Considering the amount of tissue to analyze, the detection of metastasis can be highly time-consuming for pathologists. The application of artificial intelligence in the clinical routine has constantly increased over the past few years.

METHODS

In this multi-center study, a deep learning method was established on histological tissue sections of sentinel lymph nodes collected from the clinical routine. The algorithm was trained to highlight potential melanoma metastases for further review by pathologists, without relying on supplementary immunohistochemical stainings (e.g. anti-S100, anti-MelanA).

RESULTS

The established method was able to detect the existence of metastasis on individual tissue cuts with an area under the curve of 0.9630 and 0.9856 respectively on two test cohorts from different laboratories. The method was able to accurately identify tumour deposits>0.1 mm and, by automatic tumour diameter measurement, classify these into 0.1 mm to -1.0 mm and>1.0 mm groups, thus identifying and classifying metastasis currently relevant for assessing prognosis and stratifying treatment.

CONCLUSIONS

Our results demonstrate that AI-based SLN melanoma metastasis detection has great potential and could become a routinely applied aid for pathologists. Our current study focused on assessing established parameters; however, larger future AI-based studies could identify novel biomarkers potentially further improving SLN-based prognostic and therapeutic predictions for affected patients.

Diagnostic performance of augmented intelligence with 2D and 3D total body photography and convolutional neural networks in a high-risk population for melanoma under real-world conditions: A new era of skin cancer screening?

BACKGROUND

Convolutional neural networks (CNNs) have outperformed dermatologists in classifying pigmented skin lesions under artificial conditions. We investigated, for the first time, the performance of three-dimensional (3D) and two-dimensional (2D) CNNs and dermatologists in the early detection of melanoma in a real-world setting.

METHODS

In this prospective study, 1690 melanocytic lesions in 143 patients with high-risk criteria for melanoma were evaluated by dermatologists, 2D-FotoFinder-ATBM and 3D-Vectra WB360 total body photography (TBP). Excision was based on the dermatologists' dichotomous decision, an elevated CNN risk score (study-specific malignancy cut-off: FotoFinder >0.5, Vectra >5.0) and/or the second dermatologist's assessment with CNN support. The diagnostic accuracy of the 2D and 3D CNN classification was compared with that of the dermatologists and the augmented intelligence based on histopathology and dermatologists' assessment. Secondary end-points included reproducibility of risk scores and naevus counts per patient by medical staff (gold standard) compared to automated 3D and 2D TBP CNN counts.

RESULTS

The sensitivity, specificity, and receiver operating characteristics area under the curve (ROC-AUC) for risk-score-assessments compared to histopathology of 3D-CNN with 95% confidence intervals (CI) were 90.0%, 64.6% and 0.92 (CI 0.85-1.00), respectively. While dermatologists and augmented intelligence achieved the same sensitivity (90%) and comparable classification ROC-AUC (0.91 [CI 0.80-1.00], 0.88 [CI 0.77-1.00]) with 3D-CNN, their specificity was superior (92.3% and 86.2%, respectively). The 2D-CNN (sensitivity: 70%, specificity: 40%, ROC-AUC: 0.68 [CI 0.46-0.90]) was outperformed by 3D CNN and dermatologists. The 3D-CNN showed a higher correlation coefficient for repeated measurements of 246 lesions (R = 0.89) than the 2D-CNN (R = 0.79). The mean naevus count per patient varied significantly (gold standard: 210 lesions; 3D-CNN: 469; 2D-CNN: 1324; p < 0.0001).

CONCLUSIONS

Our study emphasises the importance of validating the classification of CNNs in real life. The novel 3D-CNN device outperformed the 2D-CNN and achieved comparable sensitivity with dermatologists. The low specificity of CNNs and the lack of automated counting of TBP nevi currently limit the use of augmented intelligence in clinical practice.

Conjunctival Melanoma in Aotearoa-New Zealand: A 21-Year Analysis of Incidence and Survival

PURPOSE

Conjunctival melanoma (CM) is a rare and aggressive malignancy. Global studies demonstrate increased burden of disease in countries with high rates of cutaneous melanoma. There are currently no reports on CM incidence, trends, or survival within Aotearoa-New Zealand (NZ), a country with the highest global rates of cutaneous melanoma, which this study aims to address.

DESIGN

This was a retrospective review using the national cancer registry.

METHODS

Data on histologically confirmed CM diagnosed between January 1, 2000, and December 31, 2020, were obtained from the NZ Cancer Registry. Cases were identified using the International Classification of Disease, 10th edition (ICD-10) codes. Primary outcome measures were age-standardized incidence, trends, and survival.

RESULTS

A total of 68 CM cases were identified. There was a preponderance for females (n=40, 58.8%) and CM predominantly affected European patients (n=63, 92.6%). Median follow-up was 5.0 years [interquartile range (IQR)=2.4-9.9 y] and the median age at diagnosis was 68.5 years (IQR=57.0-79.0 y), with non-Europeans presenting at a significantly younger age [-17.3 y (95% CI: -31.3 to -3.2), P =0.019] than Europeans. The annual age-adjusted incidence(±SD) was 0.6±0.2 cases per million population per year with a stable incidence trend over 21 years. All-cause mortality was found in 28 cases (41.2%) and the median time to death was 3.76 years (IQR=2.1-5.7 y). Five-year all-cause survival and disease-specific survival was 69% and 90%, respectively.

CONCLUSIONS

This is the first report on CM incidence, trends, and mortality in NZ. The CM burden is in line with European and North American data, despite NZ having the highest rate of cutaneous melanoma. The incidence remained stable over 2 decades.

Significant improvement in melanoma survival over the last decade: A Hungarian nationwide study between 2011 and 2019

BACKGROUND

Recent real-world studies have reported significant improvements in the survival of malignant melanoma in the past few years, mainly as a result of modern therapies. However, long-term survival data from Central Eastern European countries such as Hungary are currently lacking.

METHODS

This nationwide, retrospective study examined melanoma survival in Hungary between 2011-2019 using the databases of the National Health Insurance Fund (NHIF) and Central Statistical Office (CSO) of Hungary. Crude overall survival and age-standardized 5-year net survival as well as the association between age, sex and survival were calculated.

RESULTS

Between 2011 and 2019, 22,948 newly diagnosed malignant melanoma cases were recorded in the NHIF database (47.89% male, mean age: 60.75 years (SD: ±16.39)). Five-year overall survival was 75.40% (women: 80.78%; men: 69.52%). Patients diagnosed between 2017-2019 had a 20% lower risk of mortality compared to patients diagnosed between 2011-2012 (HR 0.80, 95% CI 0.73-0.89; p < 0.0001). Age-standardized 5-year net survival rates in 2011-2014 and 2015-2019 were 90.6% and 95.8%, respectively (women: 93.1% and 98.4%, men: 87.8% and 92.7%, respectively). The highest age-standardized 5-year net survival rates were found in the 0-39 age cohort (94.6% in the 2015-2019 period).

CONCLUSION

Hungary has similar melanoma survival rates to Western European countries. Based on net survival, the risk of dying of melanoma within 5 years was cut by more than half (55%) during the study period, which coincides with the successful implementation of awareness campaigns and the wide availability of modern therapies.

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.

Targeting the epigenome in malignant melanoma: Facts, challenges and therapeutic promises

Malignant melanoma is the most lethal type of skin cancer with high rates of mortality. Although current treatment options provide a short-clinical benefit, acquired-drug resistance highlights the low 5-year survival rate among patients with advanced stage of the disease. In parallel, the involvement of an aberrant epigenetic landscape, (e.g., alterations in DNA methylation patterns, histone modifications marks and expression of non-coding RNAs), in addition to the genetic background, has been also associated with the onset and progression of melanoma. In this review article, we report on current therapeutic options in melanoma treatment with a focus on distinct epigenetic alterations and how their reversal, by specific drug compounds, can restore a normal phenotype. In particular, we concentrate on how single and/or combinatorial therapeutic approaches have utilized epigenetic drug compounds in being effective against malignant melanoma. Finally, the role of deregulated epigenetic mechanisms in promoting drug resistance to targeted therapies and immune checkpoint inhibitors is presented leading to the development of newly synthesized and/or improved drug compounds capable of targeting the epigenome of malignant melanoma.

Made in the shade: A qualitative study of factors impacting shade provision at outdoor public parks

Shade provides a variety of public health benefits; however, outdoor recreation sites often have limited shade. We conducted semi-structured interviews (n = 13) with shade stakeholders (i.e. individuals with a professional role involving shade design or provision) to gain in-depth understanding of the factors impacting shade provision at public parks. Interview transcripts were analyzed using inductive thematic analysis. Five main themes emerged: (1) attitudes toward shade at parks; (2) designing shade at parks; (3) advantages and disadvantages of natural and built shade; (4) barriers to shade at parks; and, (5) approaches to reduce shade barriers. Shade stakeholders indicated shade is important and necessary and they strive to design shade in park spaces with park user patterns in mind. However, barriers including competing interests, budget, space constraints, and maintenance and operational concerns can limit their ability to do so. Future research should determine strategies to overcome these barriers.

Trends in cutaneous melanoma mortality in Italy from 1982 to 2016

BACKGROUND

In Italy, comprehensive national studies, about mortality rates for cutaneous melanoma, are missing. The aim of this study was to analyze the trend of cutaneous melanoma mortality in Italy from 1982 to 2016.

METHODS

Data on death certificates were obtained from Italian National Institute of Statistics (ISTAT: Istituto nazionale di STATistica, Indagine sulle cause di morte). Mortality rates were age-standardized on the European population 2013 and presented per 100,000 individuals. Age-adjusted mortality rates (AMRs) were calculated by sex, age group, and geographic areas. To identify changes in mortality rate trends, a joinpoint regression model was used, and the annual percent change (APC) was estimated.

RESULTS

In Italy, a total number of 49,312 patients (44.0% women) died for cutaneous melanoma from 1982 to 2016. Melanoma mortality rates significantly increased in the study period in both sexes, with higher AMR values and a steeper increase in men (from 2.71 to 4.02; APC: 1.43; 95% CI 1.26-1.61) than women (from 1.94-2.10; APC: 0.23; 95% CI 0.00-0.46). The largest difference between men and women was observed in patients aged ≥65 years with APC of 2.17 in men (95% CI 1.97-2.37) and 0.37 in women (95% CI 0.08-0.66).

CONCLUSION

In conclusion, the melanoma mortality rate in Italy progressively increased especially in elderly men. Several hypotheses might explain the observed age and geographic differences such as sun exposure habits or different strategies of prevention campaigns.

Global Burden of Cutaneous Melanoma in 2020 and Projections to 2040

Importance

Despite many cases being preventable, cutaneous melanoma remains the most serious skin cancer worldwide. Understanding the scale and profile of the disease is vital to concentrate and reinforce global prevention efforts.

Objective

To examine global patterns of cutaneous melanoma in 2020 and to provide projected estimates of cases and deaths by 2040.

Design, Setting, and Participants

This population-based study used the GLOBOCAN 2020 database for global epidemiological assessment of new cases and deaths due to invasive melanoma.

Main Outcomes and Measures

Age-standardized incidence and mortality rates were calculated per 100 000 person-years by country, world region, and 4-tier level of human development. Estimated numbers of cases and deaths were calculated for the year 2040.

Results

A worldwide total of 325 000 new melanoma cases (174 000 males, 151 000 females) and 57 000 deaths (32 000 males, 25 000 females) was estimated for 2020. Large geographic variations existed across countries and world regions, with the highest incidence rates among males (42 per 100 000 person-years) and females (31 per 100 000 person-years) observed in Australia/New Zealand, followed by Western Europe (19 per 100 000 person-years for males and females), North America (18 per 100 000 person-years for males, 14 per 100 000 person-years for females), and Northern Europe (17 per 100 000 person-years for males, 18 per 100 000 person-years for females). Melanoma continued to be rare in most African and Asian countries, with incidence rates commonly less than 1 per 100 000 person-years. Mortality rates peaked at 5 per 100 000 person-years in New Zealand, and geographic variations were less pronounced than for incidence. Melanoma was more frequent among males than females in most world regions. If 2020 rates continue, the burden from melanoma is estimated to increase to 510 000 new cases (a roughly 50% increase) and to 96 000 deaths (a 68% increase) by 2040.

Conclusions and Relevance

This epidemiological assessment suggests that melanoma remains an important challenge to cancer control and public health globally, especially in fair-skinned populations of European descent.

Magnetic nanoparticles in theranostics of malignant melanoma

Malignant melanoma is an aggressive tumor with a tendency to metastasize early and with an increasing incidence worldwide. Although in early stage, melanoma is well treatable by excision, the chances of cure and thus the survival rate decrease dramatically after metastatic spread. Conventional treatment options for advanced disease include surgical resection of metastases, chemotherapy, radiation, targeted therapy and immunotherapy. Today, targeted kinase inhibitors and immune checkpoint blockers have for the most part replaced less effective chemotherapies. Magnetic nanoparticles as novel agents for theranostic purposes have great potential in the treatment of metastatic melanoma. In the present review, we provide a brief overview of treatment options for malignant melanoma with different magnetic nanocarriers for theranostics. We also discuss current efforts of designing magnetic particles for combined, multimodal therapies (e.g., chemotherapy, immunotherapy) for malignant melanoma.

Prognosis for Cutaneous Melanoma by Clinical and Pathological Profile: A Population-Based Study

Introduction

Among white people, the incidence of cutaneous malignant melanoma (CMM) has been increasing steadily for several decades. Meanwhile, there has also been a significant improvement in 5-year survival among patients with melanoma. This population-based cohort study investigates the five-year melanoma-specific survival (MSS) for all melanoma cases recorded in 2015 in the Veneto Tumor Registry (North-Est Italian Region), taking both demographic and clinical-pathological variables into consideration.

Methods

The cumulative melanoma-specific survival probabilities were calculated with the Kaplan-Meier method, applying different sociodemographic and clinical-pathological variables. Cox’s proportional hazards model was fitted to the data to assess the association between independent variables and MSS, and also overall survival (OS), calculating the hazard ratios (HR) relative to a reference condition, and adjusting for sex, age, site of tumor, histotype, melanoma ulceration, mitotic count, tumor-infiltrating lymphocytes (TIL), and stage at diagnosis.

Results

Compared with stage I melanoma, the risk of death was increased for stage II (HR 3.31, 95% CI: 0.94-11.76, p=0.064), almost ten times higher for stage III (HR 10.51, 95% CI: 3.16-35.02, p<0.001), and more than a hundred times higher for stage IV (HR 117.17, 95% CI: 25.30-542.62, p<0.001). Among the other variables included in the model, the presence of mitoses and histological subtype emerged as independent risk factors for death.

Conclusions

The multivariable analysis disclosed that older age, tumor site, histotype, mitotic count, and tumor stage were independently associated with a higher risk of death. Data on survival by clinical and morphological characteristics could be useful in modelling, planning, and managing the most appropriate treatment and follow-up for patients with CMM.

Cutaneous melanoma attributable to UVR exposure in Denmark and Germany

BACKGROUND

Increasing incidence rates of cutaneous melanoma (CM) observed during the last five decades in white populations are largely attributed to increased exposure to solar ultraviolet radiation (UVR), often expressed as population attributable fraction (PAF). Thus, many CMs could be prevented by reducing UVR exposure. The aim of this study was to estimate the PAF of CM attributable to UVR exposure and demographic changes in Denmark and Saarland/Germany for the period 1943 to 2036.

MATERIAL AND METHODS

CM incidence data (ICD-10, C43) for Denmark (1943-2016) and the German Federal State of Saarland (1972-2016) were retrieved from the NORDCAN database and from the Saarland Cancer Registry. The number of CMs attributable to UVR exposure was calculated by comparing contemporary or predicted CM incidence rates with CM rates in Denmark during the years 1943-1946.

RESULTS

In Denmark, the proportion of CM cases attributable to UVR exposure increased from around 20% in 1947-1951 to 96% in 2012-2016; in the Federal State of Saarland, it increased from 50% in 1972-1976 to 90% in 2012-2016. Until 2032-2036, the PAF is expected to rise in Denmark to 97% and in the Saarland to 92%. The demographic influence, on the other hand, is rather small.

CONCLUSIONS

More than 90% of all CM in Germany and Denmark are attributable to UVR exposure, and in principle, preventable. These findings underline the need for primary prevention strategies, aiming to increase the awareness of melanoma and its risk factors and to promote behavioural changes that decrease sun exposure.

Improving Quality Indicator of Melanoma Management - Change of Melanoma Mortality-to-Incidence Rate Ratio Based on a Hungarian Nationwide Retrospective Study

Introduction

The incidence of melanoma has been increasing in the last decades. A retrospective Hungarian epidemiological study provided real-world data on incidence and mortality rates. There have been changing trends in incidence in Hungary in the last decade and mortality decreased, shifting mortality-to-incidence rate ratios (MIR). MIR is an indicator of cancer management quality.

Objectives

Our aim is to show the changes of melanoma MIR in Hungary between 2011 and 2018 and to compare the real-world evidence-based results of our Hungarian nationwide retrospective study with other European countries.

Methods

MIR is calculated from the age-specific standardized incidence and mortality rates from our study. Annual MIR values are presented for the total population and for both sexes between 2011 and 2018, along with 95% confidence intervals. Comparison with European countries are shown for 2012 and 2018 based on the GLOBOCAN database and Eurostat health care expenditure per capita data.

Results

MIR decreased by 0.035 during the study years. The decrease was same in both sexes (0.031). Male had higher MIRs in all study years. In both 2012 and 2018, Hungarian MIR in both sexes was lower than the European Union average (males: 0.192 vs. 0.212 and 0.148 vs. 0.174 respectively, women: 0.107 vs. 0.129 and 0.083 vs. 0.107 respectively).

Discussion

Hungarian mortality-to-incidence ratio is the lowest in Central and Eastern Europe and is close to the level of Western and Northern European countries. The results are driven by the high number of new diagnosed melanoma cases.

Road to Metastasis: The TWEAK Pathway as a Discriminant between Metastasizing and Non-Metastasizing Thick Melanomas

Cutaneous melanoma (CM) is the most aggressive form of skin cancer, and its worldwide incidence is rapidly increasing. Early stages can be successfully treated by surgery, but once metastasis has occurred, the prognosis is poor. However, some 5-10% of thick (≥2 mm) melanomas do not follow this scenario and run an unpredictable course. Little is known about the factors that contribute to metastasis in some patient with thick melanomas and the lack thereof in thick melanoma patients who never develop metastatic disease. We were therefore interested to study differential gene expression and pathway analysis and compare non-metastatic and metastatic thick melanomas. We found that the TNF-like weak inducer of apoptosis (TWEAK) pathway was upregulated in thick non-metastasizing melanomas. MAP3K14 (NIK1), BIRC2 (cIAP1), RIPK1, CASP7, CASP8, and TNF play an important role in inhibiting proliferation and invasion of tumor cells via the activation of the non-canonical NF-κB signaling pathway. In particular, this pathway sensitizes melanoma cells to TNF-alpha and activates the apoptosis module of the TWEAK pathway in thick non-metastasizing melanomas. Hence, our study suggests a potential role of the TWEAK pathway in inhibiting thick melanoma from metastasis. Exploitation of these genes and the pathway they control may open future therapeutic avenues.

Changing epidemiology and age-specific incidence of cutaneous malignant melanoma in England: An analysis of the national cancer registration data by age, gender and anatomical site, 1981-2018

Background

The incidence of cutaneous malignant melanoma, which is mostly attributable (86%) to UV radiation exposure, has been steadily increasing over the past four decades in predominantly fair-skinned populations. Although public health campaigns are increasing sun-protective behaviour in England, their effect on melanoma incidence is largely unknown. We conducted a retrospective population-based cohort study to examine whether there have been changes in the epidemiology of melanoma in England during the past four decades.

Methods

Individual level data for patients diagnosed with melanoma in England during 1981–2018 were obtained from the Office for National Statistics/Public Health England. Average annual incidence rates were calculated by three age categories (0–34, 35–64, 65+ years), gender and anatomical site during the seven five-year time periods (1981–85 to 2011–15) and the recent three-year period (2016–18). The percentage change in incidence was calculated as change in the average incidence rate from the first (1981–85) to the last time period (2016–18). The Average Annual Percentage Change (AAPC) was estimated using the slope of the linear trend line fitted to the incidence rates by year of diagnosis.

Findings

During the 38-year period (1981–2018), a total of 265,302 cases of melanoma (45.7% males, 54.3% females) were registered in England. The average annual number of cases increased from 837/year in 1981–85 to 6963/year in 2016–18 in males (+732%), and from 1609/year in 1981–85 to 6952/year in 2016–18 in females (+332%). In the young age-group (0–34 years), the average annual incidence rates initially increased from 1981–85 to 2001–05 and then stabilised during the recent period (2006–18). In the middle age group (35–64 years), the rates increased by +332% (AAPC, 10.4%) in males (from 5.6/100,000 in 1981–85 to 24.2/100,000 in 2016–18) and +185% (AAPC, 5.7%) in females (from 10.2/100,000 in 1981–85 to 29.1/100,000 in 2016–18); and in the old age-group (65+ years) the rates increased by +842% (AAPC, 25.7%) in males (from 9.6/100,000 in 1981–85 to 90.4/100,000 in 2016–18) and +381% (AAPC, 11.2%) in females (from 12.5/100,000 in 1981–85 to 60.1/100,000 in 2016–18). The largest increase in incidence in both males and females was observed for melanoma of the trunk (+817%, AAPC, 24.8% in males and +613%, AAPC, 18.3% in females), followed by melanoma of upper limb (+750%, AAPC, 22.9% in males and 518%, AAPC, 15.5% in females).

Interpretation

It appears that the incidence of melanoma among young people in England has stabilised (or levelled off) in recent decades, whereas it continues to increase substantially in older population. These findings suggest that public health campaigns targeted at children/adolescents/parents may be favourably influencing melanoma incidence. The steeper increase in incidence in males is consistent with their relatively greater sun exposure and poor sun-protective behaviour. All the available evidence suggests that the enormous increase in the melanoma of the trunk and upper limb, since the 1980s, is most likely due to increasing trend in intermittent high intensity recreational UV radiation exposure (e.g. sunbathing, holidaying in places with strong sunlight, indoor tanning).

Funding

This work was supported by Brighton and Sussex Medical School (BSMS).

Regional variability of melanoma incidence and prevalence in Hungary. Epidemiological impact of ambient UV radiation and socioeconomic factors

BACKGROUND

The incidence of cutaneous melanoma has risen faster than almost any other type of cancer in the last 50 years. Ultraviolet (UV) radiation and genetic susceptibility are the most important risk factors.

OBJECTIVE

We aimed to determine the epidemiologic indicators of melanoma in Hungary, a country with an estimated population of 9.8 million and an area of 93 030 km2.

METHODS

Anonymized patient records from the National Health Insurance Fund Management covering the entire population were used to determine the incidence and prevalence of melanoma in the counties of Hungary from 2013 to 2017. Altogether 20 030 melanoma cases were identified for inclusion in this study.

RESULTS

The prevalence of melanoma increased over the investigated period and was significantly higher among women than men. The incidence of melanoma stagnated during this period and the incidence rate was the highest among the elderly. Interestingly, the incidence was higher in males in the elderly population, while the incidence was higher in females in the younger (<60 years) population. Geographical variations in ambient UV radiation did not show statistically significant correlation with the regional variability of epidemiologic indicators, probably due to small differences in the number of bright sunshine hours per year between regions. Although Hungary is a relatively small country, we observed regional heterogeneity in socioeconomic factors. Notably, a significant and strong negative correlation was found between single-person household rates and melanoma prevalence.

CONCLUSION

In addition to ambient UV radiation, melanoma incidence and prevalence appear to be related to age, gender and socioeconomic factors.

Demographic, Clinical, and Pathologic Features of Patients With Cutaneous Melanoma: Final Analysis of the Brazilian Melanoma Group Database

PURPOSE

National epidemiologic data on melanoma are scarce in Brazil. The current work presents final demographic, clinical, and pathologic results from the Brazilian Melanoma Group database to detail how patients with melanoma present at diagnosis.

METHODS

The online database includes patients diagnosed between 1982 and 2015 and evaluated at their centers of origin between 2001 and 2016. The primary objective was to describe the demographic, clinical, and pathologic characteristics of the patients, and secondary objectives were to investigate the association between clinical and pathologic variables of interest.

RESULTS

A total of 1,596 patients were included. Median age was 52 years, 57% were women, and the majority were identified as white. Invasive melanoma was diagnosed in 1,297 patients, mostly localized, whereas 299 (19%) had in situ disease (TisN0M0). Only 165 patients had initial lymph node involvement. Fitzpatrick skin types I or II were slightly more frequent with in situ melanoma (73%) than with invasive disease (67%; P = .054). The median Breslow thickness was 0.95 mm, Clark levels 2 and 3 comprised nearly 70% of cases, and ulceration was present in 18% of patients. The mitotic rate was significantly associated with the presence of ulceration and both vascular and perineural invasion but not with margin positivity, whereas histologic regression was associated with both intratumoral and peritumoral inflammatory infiltrates.

CONCLUSION

Despite the limitations of an observational, registry-based study, the current results provide a general profile of patients with cutaneous melanoma in Brazil at the time of diagnosis.

Profiling Cancer-Associated Fibroblasts in Melanoma

Solid tumors are complex systems characterized by dynamic interactions between neoplastic cells, non-tumoral cells, and extracellular components. Among all the stromal cells that populate tumor microenvironment, fibroblasts are the most abundant elements and are critically involved in disease progression. Cancer-associated fibroblasts (CAFs) have pleiotropic functions in tumor growth and extracellular matrix remodeling implicated in local invasion and distant metastasis. CAFs additionally participate in the inflammatory response of the tumor site by releasing a variety of chemokines and cytokines. It is becoming clear that understanding the dynamic, mutual melanoma-fibroblast relationship would enable treatment options to be amplified. To better characterize melanoma-associated fibroblasts, here we analyzed low-passage primary CAFs derived from advanced-stage primary skin melanomas, focusing on the immuno-phenotype. Furthermore, we assessed the expression of several CAF markers and the production of growth factors. To deepen the study of CAF-melanoma cell crosstalk, we employed CAF-derived supernatants and trans-well co-culture systems to evaluate the influences of CAFs on (i) the motogenic ability of melanoma cells, (ii) the chemotherapy-induced cytotoxicity, and (iii) the release of mediators active in modulating tumor growth and spread.

Cytoplasmic CK1ε Protein Expression Is Correlated With Distant Metastasis and Survival in Patients With Melanoma

BACKGROUND/AIM

Casein kinase 1 epsilon (CK1ε) is a member of the casein kinase 1 family, which includes highly conserved and ubiquitous serine/threonine protein kinases. Recent research has revealed that CK1ε plays an important role in a variety of human cancer types; however, its role in human melanoma remains unclear. The aim of this study was to elucidate the clinical role of CK1ε in patients with melanoma.

PATIENTS AND METHODS

Samples from 34 patients with melanoma were analyzed by immunohistochemical staining. Formalin-fixed paraffin-embedded tissue microarrays were also examined by two histopathologists to assess CK1ε protein expression in humans.

RESULTS

Cytoplasmic CK1ε protein expression was significantly lower in tumor tissue than in normal tissue. Lack of cytoplasmic CK1ε protein was significantly correlated with distant metastasis (p=0.022) and poorer survival (p=0.030). However, Kaplan-Meier survival analysis revealed that elevated expression of cytoplasmic CK1ε protein was not significantly associated with the overall survival of patients with melanoma. Univariate and multivariate analyses demonstrated that lack of cytoplasmic CK1ε protein expression was related to distant metastasis (p<0.001 and p=0.004), showing that CK1ε was a prognostic factor.

CONCLUSION

CK1ε protein expression might serve as a prognostic indicator in the treatment of patients with melanoma.

Auswirkungen des „dunklen Rand‐Artefakts“ in dermatoskopischen Bildern auf die diagnostische Leistungsfähigkeit eines deep learning neuronalen Netzwerkes mit Marktzulassung

HINTERGRUND UND ZIELE

Systeme künstlicher Intelligenz (durch "deep learning" faltende neuronale Netzwerke; engl. convolutional neural networks, CNN) erreichen inzwischen bei der Klassifikation von Hautläsionen vergleichbar gute Ergebnisse wie Dermatologen. Allerdings müssen die Limitationen solcher Systeme vor flächendeckendem klinischem Einsatz bekannt sein. Daher haben wir den Einfluss des "dunklen Rand-Artefakts" (engl. dark corner artefact; DCA) in dermatoskopischen Bildern auf die diagnostische Leistung eines CNN mit Marktzulassung zur Klassifikation von Hautläsionen untersucht.

PATIENTEN UND METHODEN

Ein Datensatz aus 233 Bildern von Hautläsionen (60 maligne und 173 benigne) ohne DCA (Kontrolle) wurde digital so modifiziert, dass kleine, mittlere oder große DCA zu sehen waren. Alle 932 Bilder wurden dann mittels CNN mit Marktzulassung (Moleanalyzer-Pro^® , FotoFinder Systems) auf Malignitätsscores hin analysiert. Das Spektrum reichte von 0-1; ein Score von > 0,5 wurde als maligne klassifiziert.

ERGEBNISSE

In der Kontrollserie ohne DCA erreichte das CNN eine Sensitivität von 90,0 % (79,9 %-95,3 %), eine Spezifität von 96,5 % (92,6 %-98,4 %) sowie eine Fläche unter der Kurve (AUC, area under the curve) der "receiver operating characteristic" (ROC) von 0,961 (0,932-0,989). In den Datensätzen mit kleinen beziehungsweise mittleren DCA war die diagnostische Leistung vergleichbar. In den Bildersätzen mit großen DCA wurden allerdings signifikant höhere Malignitätsscores erzielt. Dies führte zu einer signifikant verminderten Spezifität (87,9 % [82,2 %-91,9 %], P < 0,001) sowie einer nicht signifikant erhöhten Sensitivität (96,7 % [88,6 %-99,1 %]). Die ROC-AUC blieb mit 0,962 (0,935-0,989) unverändert.

SCHLUSSFOLGERUNGEN

Die Klassifizierung mittels des CNN war bei dermatoskopischen Bildern mit kleinen oder mittleren DCA nicht beeinträchtigt, das System zeigte jedoch Schwächen bei großen DCA. Wenn Ärzte solche Bilder zur Klassifikation mittels CNN einreichen, sollten sie sich dieser Grenzen der Technologie bewusst sein.

Trend Shifts in Age-Specific Incidence for In Situ and Invasive Cutaneous Melanoma in Sweden

BACKGROUND

The incidence of invasive cutaneous melanoma (CM) is increasing in Sweden. The aim was to present age- and sex-specific trends of the age-standardised incidence and the average annual percentage change (AAPC) for in situ and invasive CM.

METHODS

Joinpoint regression models were used to analyse data from the Swedish Cancer Register and the Swedish Melanoma Registry 1997-2018 (N = 35,350 in situ CM; 59,932 CM).

RESULTS

The AAPC of CM for women was 4.5 (4.1-5.0; p < 0.001) for the period 1997-2018. For men, the APCC was 4.2 (3.0-5.4; p < 0.001), with a significantly higher annual percentage change (APC) for the period 2000-2018 (5.0; 4.6-5.4; p < 0.001) compared to 1997-1999. An increasing annual incidence of CM ≤ 0.6 mm and 0.7 mm Breslow tumour thickness was found for men with a significant incidence shift for the period 2006-2015, respectively. Similarly for women, with a significantly higher APC for CM ≤ 0.6 mm from 2005. The incidence of intermediate thick CM (2.1-4.0 mm) has not increased since 2011. The incidence of CM > 4.0 mm has been increasing among both sexes, with a significantly lower APC among women from 2005.

CONCLUSIONS

The incidence of in situ and low-risk CM ≤ 1.0 mm in tumour thickness has been rising among both sexes since the 2000s.

Dark corner artefact and diagnostic performance of a market-approved neural network for skin cancer classification

BACKGROUND AND OBJECTIVES

Convolutional neural networks (CNN) have proven dermatologist-level performance in skin lesion classification. Prior to a broader clinical application, an assessment of limitations is crucial. Therefore, the influence of a dark tubular periphery in dermatoscopic images (also called dark corner artefact [DCA]) on the diagnostic performance of a market-approved CNN for skin lesion classification was investigated.

PATIENTS AND METHODS

A prospective image set of 233 skin lesions (60 malignant, 173 benign) without DCA (control-set) was modified to show small, medium or large DCA. All 932 images were analyzed by a market-approved CNN (Moleanalyzer-Pro^® , FotoFinder Systems), providing malignancy scores (range 0-1) with the cut-off > 0.5 indicating malignancy.

RESULTS

In the control-set the CNN achieved a sensitivity of 90.0 % (79.9 % - 95.3 %), a specificity of 96.5 % (92.6 % - 98.4 %), and an area under the curve (AUC) of receiver operating characteristics (ROC) of 0.961 (0.932 - 0.989). Comparable diagnostic performance was observed in the DCAsmall-set and DCAmedium-set. Conversely, in the DCAlarge-set significantly increased malignancy scores triggered a significantly decreased specificity (87.9 % [82.2 % - 91.9 %], P < 0.001), non-significantly increased sensitivity (96.7 % [88.6 % - 99.1 %]) and unchanged ROC-AUC of 0.962 (0.935 - 0.989).

CONCLUSIONS

Convolutional neural network classification was robust in images with small and medium DCA, but impaired in images with large DCA. Physicians should be aware of this limitation when submitting images to CNN classification.

Incidence, mortality and medical costs of patients hospitalized with melanoma in Spain: a retrospective multicentre observational study

OBJECTIVE

This study aimed to update and analyze the in-hospital incidence and in-hospital mortality of melanoma in Spain, to evaluate any temporal trends in both measures and to quantify the direct medical costs of specialized care that are associated to this malignancy.

METHODS

Anonymized specialized care admission records registered between 1 Jan 2011 and 31 Dec 2017 were extracted from a Spanish nationwide hospital discharge database.

RESULTS

Records included corresponded to 16,657 patients, of which 50.62% were male. In nearly 38% of all admissions secondary malignant tumors were registered, principally tumors in the lymph nodes. In-hospital incidence of melanoma was 67.5 and 58.2 per 100,000 males and females, respectively, in the study period (2011-2017), with a decreasing tendency measured after the year 2014. Mortality increased with patients' age and over time in patients over 75 years of age. In-hospital mortality was 7.73% for males and 5.29% for female patients, and was principally associated to metastatic tumors, principally in the lungs, liver and brain. Mean length of hospital stay was 4.36 days, with a readmission rate of 6.93% and a 15.70% of urgent admissions. The mean annual direct medical cost per patient was €4175, increasing between 2014 and 2017.

CONCLUSIONS

The increasing in-hospital incidence of melanoma appeared to reverse in 2014, as did the increasing mortality rate measured in older males. The shift in melanoma in-hospital incidence could respond to the increasing trend to treat patients in primary care settings. Further studies will be required to confirm these trends in order to adapt the healthcare system.

An Evaluation of the Anti-Carcinogenic Response of Major Isothiocyanates in Non-Metastatic and Metastatic Melanoma Cells

Malignant melanoma is one of the most deadly types of solid cancers, a property mainly attributed to its highly aggressive metastatic form. On the other hand, different classes of isothiocyanates, a class of phytochemicals, present in cruciferous vegetables have been characterized by considerable anti-cancer activity in both in vitro and in vivo experimental models. In the current study, we investigated the anti-cancer response of five isothiocyanates in an in vitro model of melanoma consisting of non-metastatic (A375, B16F-10) and metastatic (VMM1, Hs294T) malignant melanoma as well as non-melanoma epidermoid carcinoma (A431) and non-tumorigenic melanocyte-neighboring keratinocyte (HaCaT) cells. Our aim was to compare different endpoints of cytotoxicity (e.g., reactive oxygen species, intracellular glutathione content, cell cycle growth arrest, apoptosis and necrosis) descriptive of an anti-cancer response between non-metastatic and metastatic melanoma as well as non-melanoma epidermoid carcinoma and non-tumorigenic cells. Our results showed that exposure to isothiocyanates induced an increase in intracellular reactive oxygen species and glutathione contents between non-metastatic and metastatic melanoma cells. The distribution of cell cycle phases followed a similar pattern in a manner where non-metastatic and metastatic melanoma cells appeared to be growth arrested at the G2/M phase while elevated levels of metastatic melanoma cells were shown to be at sub G1 phase, an indicator of necrotic cell death. Finally, metastatic melanoma cells were more sensitive apoptosis and/or necrosis as higher levels were observed compared to non-melanoma epidermoid carcinoma and non-tumorigenic cells. In general, non-melanoma epidermoid carcinoma and non-tumorigenic cells were more resistant under any experimental exposure condition. Overall, our study provides further evidence for the potential development of isothiocyanates as promising anti-cancer agents against non-metastatic and metastatic melanoma cells, a property specific for these cells and not shared by non-melanoma epidermoid carcinoma or non-tumorigenic melanocyte cells.

Changing Trends in Melanoma Incidence and Decreasing Melanoma Mortality in Hungary Between 2011 and 2019: A Nationwide Epidemiological Study

Background

The incidence of malignant melanoma has continually increased during the past few decades, however, certain reports suggest a recent change in trends. The aim of our study was to examine the epidemiology of melanoma in Hungary.

Methods

This nationwide, retrospective, longitudinal study included melanoma patients diagnosed between 1 January 2009 and 31 December 2019 using the databases of the National Health Insurance Fund (NHIF) and Central Statistical Office (CSO) of Hungary. Age-standardized incidence and cause-specific mortality rates were calculated.

Results

We identified 2,426 and 2,414 new melanoma cases in 2011 and in 2019. Age-standardized incidence rates were higher in males and varied between 28.28 and 34.57/100,000 person-years (PYs), and between 22.63 and 26.72/100,000 PYs in females. We found 16.14 and 18.82% increases in male and female incidence rates from 2011 to 2015 (p=0.067 and p<0.001, respectively), and 12.77 and 11.35% decreases from 2015 to 2019 (p=0.062 and p=0.004, respectively). The change of incidence trends (2011–2015 vs. 2015–2019) was significant in females (p=0.002) and in the total melanoma population (p=0.011), but not in the male population (p=0.063). A 16.55% (95% CI: −27.07 to −4.59; p=0.013) decrease in mortality rates was found in the overall melanoma population.

Conclusions

We observed a significant trend change in melanoma incidence in the female and total melanoma population, and a significant decrease in mortality in the total melanoma population. These changes may be attributed to intensive melanoma awareness campaigns as well as to the increase in screening and access to modern therapies.

Association between different scale bars in dermoscopic images and diagnostic performance of a market-approved deep learning convolutional neural network for melanoma recognition

BACKGROUND

Studies systematically unravelling possible causes for false diagnoses of deep learning convolutional neural networks (CNNs) are scarce, yet needed before broader application.

OBJECTIVES

The objective of the study was to investigate whether scale bars in dermoscopic images are associated with the diagnostic accuracy of a market-approved CNN.

METHODS

This cross-sectional analysis applied a CNN trained with more than 150,000 images (Moleanalyzer-pro®, FotoFinder Systems Inc., Bad Birnbach, Germany) to investigate seven dermoscopic image sets depicting the same 130 melanocytic lesions (107 nevi, 23 melanomas) without or with digitally superimposed scale bars of different manufacturers. Sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for the CNN's binary classification of images with or without superimposed scale bars were assessed.

RESULTS

Six dermoscopic image sets with different scale bars and one control set without scale bars (overall 910 images) were submitted to CNN analysis. In images without scale bars, the CNN attained a sensitivity [95% confidence interval] of 87.0% [67.9%-95.5%] and a specificity of 87.9% [80.3%-92.8%]. ROC AUC was 0.953 [0.914-0.992]. Scale bars were not associated with significant changes in sensitivity (range 87%-95.7%, all p ≥ 1.0). However, four scale bars induced a decrease of the CNN's specificity (range 0%-43.9%, all p < 0.001). Moreover, ROC AUC was significantly reduced by two scale bars (range 0.520-0.848, both p ≤ 0.042).

CONCLUSIONS

Superimposed scale bars in dermoscopic images may impair the CNN's diagnostic accuracy, mostly by increasing the rate of the false-positive diagnoses. We recommend avoiding scale bars in images intended for CNN analysis unless specific measures counteracting effects are implemented.

CLINICAL TRIAL NUMBER

This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; URL: https://www.drks.de/drks_web/).

Cutaneous malignant melanoma mortality in Andalusia from 1979 to 2018. Toward new perspectives?

Malignant melanoma accounts for 80% of deaths due to skin cancer. Its incidence is globally increasing. However, melanoma mortality seems to be decreasing. The aim of this study was to analyze mortality rates due to melanoma in Andalusia between 1979 and 2018. Deaths due to melanoma and mid-year population in Andalusia were collected from the National Institute of Statistics. Age-adjusted mortality rates were calculated for overall population and for each sex and age group. Regression models were used to calculate significant points of change. Sex ratio and the independent effects of age, period, and cohort were also analyzed. Age-adjusted mortality due to melanoma rose from 0.61 to 1.94 deaths per 100.000 from 1979 to 2018 for the overall population. A significant change of trends was detected around 1994 when, after a steady rise from 1979, mortality rates stabilized up to the end of the period studied. The cited increase was more pronounced in >64 year males. From the end of the 2000s, there was a decrease in mortality rates to date in all population groups, producing a period effect. A stabilization in melanoma mortality rates was observed in Andalusia from 1994 with a decrease in some groups at the beginning of the 21st century. Trends observed in Andalusia do not differ substantially from those in Spain. The development of new therapies and an earlier diagnosis may have an influence in those changes. Studies that compare differences between Spanish regions are needed to define better prevention strategies.

Mortality from malignant skin melanoma in elderly Brazilians: 2001 to 2016

BACKGROUND

Malignant skin melanoma is a serious public health problem, especially among the elderly population. Knowing the dynamics of the mortality rates of this disease in Brazil is essential to support the creation of public health policies.

OBJECTIVE

To analyze the temporal trend of mortality from malignant skin melanoma in elderly people in Brazil, from 2001 to 2016.

METHODS

This was a descriptive analytical study of mortality rates from malignant skin melanoma in the elderly. The data were obtained from the Mortality Information System, and information related to the population was obtained from the 2010 population census and population estimates from the Brazilian Institute of Geography and Statistics. Mortality coefficients were calculated and simple linear regression analysis of the coefficients was performed by sex and macro-region.

RESULTS

A total 12,712 deaths due to malignant skin melanoma in the elderly were registered. The majority (56.8%) occurred in the male population. In females, a tendency of increase in mortality rates due to malignant skin melanoma was observed in the Northeast (p ≤ 0.001), Midwest (p = 0.002), and Brazil as a whole (p = 0.003). In males, an upward trend was observed in all regions, except for the Southeast region. For both sexes, there was also an upward trend in all regions, with the exception of the Southeast region.

STUDY LIMITATIONS

Secondary databases are directly influenced by the quality of death certificate completion and their heterogeneous scope in Brazilian regions.

CONCLUSION

The increase in mortality indicates a potential public health challenge for the coming decades. The prevention of skin cancer among the elderly should become a priority, mainly through the implementation of preventive measures.

Análise de prevalência e mortalidade associada ao melanoma cutâneo em pacientes atendidos em centro de referência no Oeste do estado de Santa Catarina, Brasil, de 2002 a 2016

Objetivo: determinar a epidemiologia e as características clínicas do melanoma cutâneo (MC) na região Oeste do estado de Santa Catarina, Brasil. Métodos: este estudo transversal e descritivo avaliou o comportamento clínico e o perfil epidemiológico do MC em pacientes de 78 municípios do Oeste do Estado de Santa Catarina, Brasil, no período de 2002 a 2016, tratados no Sistema Único de Saúde. Para a análise dos dados foi utilizado o teste do Qui-quadrado. Para elaborar as curvas de sobrevida, foi considerado um período de 10 anos (teste Log Rank). Resultados: dados de 1.146 pacientes foram avaliados, e houve uma média de 20 casos/100.000 habitantes/ano. Encontravam-se nos estágios I e II 63,5% dos pacientes. A sobrevida global em 10 anos de acompanhamento foi de 89%(IC95% 87,7% - 91,5%). Pacientes do sexo feminino apresentaram maior sobrevida (94,5%; IC95% 92,7% - 96,4% vs. 82,6%; IC95% 78,9% - 86,3%; p < 0,001) e variáveis de melhor prognóstico. Conclusões: o Oeste do estado de Santa Catarina apresentou uma alta prevalência de MC. As características clínicas e epidemiológicas encontradas concordam com as descritas nas populações que residem em regiões geográficas equivalentes; mas diferem de outras regiões do Brasil. Essas diferenças, associadas à organização do sistema público de saúde de referência e contra-referência, podem explicar aos resultados de sobrevida encontrados.

A Framework of Major Tumor-Promoting Signal Transduction Pathways Implicated in Melanoma-Fibroblast Dialogue

Simple Summary

Melanoma cells reside in a complex stromal microenvironment, which is a critical component of disease onset and progression. Mesenchymal or fibroblastic cell type are the most abundant cellular element of tumor stroma. Factors secreted by melanoma cells can activate non-malignant associated fibroblasts to become melanoma associate fibroblasts (MAFs). MAFs promote tumorigenic features by remodeling the extracellular matrix, supporting tumor cells proliferation, neo-angiogenesis and drug resistance. Additionally, environmental factors may contribute to the acquisition of pro-tumorigenic phenotype of fibroblasts. Overall, in melanoma, perturbed tissue homeostasis contributes to modulation of major oncogenic intracellular signaling pathways not only in tumor cells but also in neighboring cells. Thus, targeted molecular therapies need to be considered from the reciprocal point of view of melanoma and stromal cells.

Abstract

The development of a modified stromal microenvironment in response to neoplastic onset is a common feature of many tumors including cutaneous melanoma. At all stages, melanoma cells are embedded in a complex tissue composed by extracellular matrix components and several different cell populations. Thus, melanomagenesis is not only driven by malignant melanocytes, but also by the altered communication between melanocytes and non-malignant cell populations, including fibroblasts, endothelial and immune cells. In particular, cancer-associated fibroblasts (CAFs), also referred as melanoma-associated fibroblasts (MAFs) in the case of melanoma, are the most abundant stromal cells and play a significant contextual role in melanoma initiation, progression and metastasis. As a result of dynamic intercellular molecular dialogue between tumor and the stroma, non-neoplastic cells gain specific phenotypes and functions that are pro-tumorigenic. Targeting MAFs is thus considered a promising avenue to improve melanoma therapy. Growing evidence demonstrates that aberrant regulation of oncogenic signaling is not restricted to transformed cells but also occurs in MAFs. However, in some cases, signaling pathways present opposite regulation in melanoma and surrounding area, suggesting that therapeutic strategies need to carefully consider the tumor–stroma equilibrium. In this novel review, we analyze four major signaling pathways implicated in melanomagenesis, TGF-β, MAPK, Wnt/β-catenin and Hyppo signaling, from the complementary point of view of tumor cells and the microenvironment.

Gender differences in cutaneous melanoma: Demographics, prognostic factors, and survival outcomes

Several recent studies have reported a considerably higher overall survival (OS) rate in females in various geographic regions This study further investigates the characteristics of melanoma that contribute to OS of women residing in the United States. Chi-square, Kaplan-Meier, and Cox regression models were used to analyze differences in demographics, treatment, and survival of invasive cutaneous melanoma in men and women diagnosed from 2004 to 2016 in the National cancer database. In 316 966 patients met inclusion criteria. Men had a significantly higher median age of diagnosis at 61 years (interquartile range or IQR: 51-72) in comparison to women where the median age of diagnosis was 55 years (IQR: 43-68) (P < .0001). The most common primary site for men was the trunk (35.5%), whereas the lower extremities were the most common primary site for women (30.3%). Women had a higher 5 year (82.6%) and 10 year (73.1%) OS compared to 5 year and 10 year OS of 72.2% and 58.7%, respectively, in men (P < .0001). When adjusting for confounders, female gender was independently associated with improved OS (ref: male HR = 0.791; 95% confidence interval 0.773-0.809; P < .0001). Overall, we conclude that female gender is an independent favorable prognostic factor for melanoma survival.

A novel side effect of mitogen-activated protein kinase inhibitor cobimetinib: Acute corneal decompensation

A 38-year-old man with a diagnosis of BRAF-mutated metastatic melanoma was referred to our clinic. He had been under treatment with 60-mg oral cobimetinib daily for 21 days/7 day off in combination with 960 mg vemurafenib twice daily. The patient had symptoms of blurred vision and photophobia in his right eye. A slit-lamp examination revealed bilateral central corneal stromal opacity and epithelial microcystic edema Involvement was more severe in the right eye compared with the left eye. Fourteen days after the first visit, the patient's symptoms and slit-lamp findings were largely resolved. We suggest that endothelium pump failure was involved in this acute corneal decompensation case similar to the mechanism in retinal pigment epithelium.

Inflammatory Activation of Astrocytes Facilitates Melanoma Brain Tropism via the CXCL10-CXCR3 Signaling Axis

Melanoma is the deadliest skin cancer due to its high rate of metastasis, frequently to the brain. Brain metastases are incurable; therefore, understanding melanoma brain metastasis is of great clinical importance. We used a mouse model of spontaneous melanoma brain metastasis to study the interactions of melanomas with the brain microenvironment. We find that CXCL10 is upregulated in metastasis-associated astrocytes in mice and humans and is functionally important for the chemoattraction of melanoma cells. Moreover, CXCR3, the receptor for CXCL10, is upregulated in brain-tropic melanoma cells. Targeting melanoma expression of CXCR3 by nanoparticle-mediated siRNA delivery or by shRNA transduction inhibits melanoma cell migration and attenuates brain metastasis in vivo. These findings suggest that the instigation of pro-inflammatory signaling in astrocytes is hijacked by brain-metastasizing tumor cells to promote their metastatic capacity and that the CXCL10-CXCR3 axis may be a potential therapeutic target for the prevention of melanoma brain metastasis.

Mid-term trends and recent birth-cohort-dependent changes in incidence rates of cutaneous malignant melanoma in Italy

In Oceania, North America and north-western Europe, after decades of increase, cutaneous malignant melanoma (CMM) rates began to stabilise or decline before 2000. Anecdotal evidence suggests that the reversal of the incidence trend is extending to southern Europe. To obtain a formal confirmation, this nationwide study from Italy investigated the incidence trends by birth cohort. Twenty-one local cancer registries covering a population of 15 814 455 provided incidence data for primary CMM registered between 1994 and 2013. Trends in age-standardised rates were analysed using joinpoint regression models and age-period-cohort models. Age-standardised incidence showed a consistent increase throughout the period (estimated annual percent change, 3.6 [95% confidence interval, 3.2-4.0] among men and 2.5 [2.0-3.1] among women). This pattern was confirmed by a sensitivity analysis with removal of low-risk populations of southern Italy. The rates, however, showed a stabilisation or a decrease in men and women aged below 35. Using the cohort of 1949-the median cohort with respect to the number of cases for both genders-as a reference, the incidence rate ratio increased for successive cohorts born until 1973 (women) and 1975 (men), and subsequently tended to decline. For the most recent cohorts in both genders, the risk of disease returned to the level of the cohort of 1949. The changes observed in the latest generations can be interpreted as the earliest manifestations of a birth-cohort-dependent incidence decrease. Our study adds to previous data indicating that the reversal of the long-term upward incidence trend of CMM is extending to southern Europe.

Increasing melanoma incidence in the elderly in North-East Hungary: is this a more serious problem than we thought?

There is a great need for efficient and cost-effective melanoma screening, but this is not yet solved. Epidemiological studies on trends in melanoma incidence by tumour thickness, anatomical site and demographical data can help to improve public health efforts regarding earlier melanoma diagnosis. We aimed to study the trends in the incidence and characteristics of patients and their melanoma in North-East Hungary from 2000 to 2014. Data were obtained from a university hospital-based registry. A total of 1509 cutaneous invasive melanomas of 1464 patients were included in the study. A moderate but significant increase in incidence was observed in the region [average annual percentage change: 3.04 (0.07; 6.11); P = 0.045], with a breakpoint in 2007. From 2001 to 2007, the trend was increasing [APC: 9.84 (3.52; 16.55); P=0.006], but it stalled from 2007 [APC: -2.45 (-5.99; 1.23); P = 0.164]. However, in the age groups over the age of 60 years, where the standardised incidence was the highest, the incidence continued to rise. Furthermore, older age, male sex and trunk or lower extremity localization were found to be associated with thicker melanomas. Our results support that regular screening examination for melanoma would be desirable for people over the age of 60 years.

[Immunotherapy for malignant melanoma]

Although cutaneous melanoma accounts for only about 4% of all skin cancers (including nonmelanocytic skin cancer), it is responsible for 80% of all deaths caused by skin cancer. The introduction of immune checkpoint inhibitors led to a significant improvement in long-term survival of patients in an advanced stage regardless of BRAF mutation status. In addition to targeted therapy for patients with BRAF-mutated melanoma, immunotherapies are the therapies of choice in advanced stages and, since 2018, also in the adjuvant setting. The effectiveness of combination therapies and sequences of targeted and immunotherapies are currently being tested.