Cumulative Incidence and Predictors of CNS Metastasis for Patients With American Joint Committee on Cancer 8th Edition Stage III Melanoma

Clinical, dermatoscopic, histological and molecular predictive factors of distant melanoma metastasis: A systematic review and meta-analysis

BACKGROUND

Melanoma metastasis to distant sites is associated with diminished survival rates and poor prognosis. Except of Breslow thickness and ulceration that are currently used in melanoma staging, the investigation of additional clinicopathological, dermatoscopic and molecular factors that could predict tumors with aggressive biologic behavior is of paramount importance.

METHODS

A literature search was conducted in PubMed, Scopus, Cochrane databases and gray literature until November 2023. Observational studies (including cohorts and case-control studies) were included and clinical and histopathological factors of primary cutaneous melanomas, along with dermatoscopic and molecular predictors of distant metastasis (DM) and distant metastasis-free survival (DMFS) were assessed. Random - effect models were preferred, the results were presented as Hazard Ratios (HRs) with 95 %Confidence Intervals (CIs) and the I2 index quantified heterogeneity. Subgroup analysis according to AJCC stage and sensitivity analysis were also conducted.

RESULTS

One hundred forty-three and 101 studies were included in the qualitive and quantitative synthesis, respectively. Regarding clinical factors, males, compared to females, and head and neck location, compared to trunk, demonstrated higher risk for DM [n=36, HR 1.49, 95%CI 1.36 - 1.63, I2 33% and n=21, HR 1.24, 95 %CI 1.01 - 1.52, I2 62 %]. Both factors had similar effects on DMFS. Breslow thickness and ulceration were significant predictors or DM. Additional factors that posed an increased risk for DM were nodular (n=15, HR 2.51, 95 %CI 1.83 - 3.43, I2 56 %) and lentigo maligna subtypes (n=12, HR 1.87, 95 %CI 1.27 - 2.75, I2 0 %), compared to superficial spreading subtype, lymphovascular invasion (n=9, HR 2.05, 95 %CI 1.18 - 3.58, I2 78 %), SLN positivity and BRAF+ mutational status. In contrast, regression was a negative predictor of DM (n=15, HR 0.59, 95 %CI 0.44 - 0.79, I2 68 %). Two studies focused on dermatoscopic factors and found that low pigmentation and the presence of blue-white veil might predict DM development. The results of subgroup analysis for stage I-II patients were essentially similar and sensitivity analysis did not reveal significant alterations, despite the moderate or high heterogeneity in some categories.

CONCLUSIONS

Clinical and histological characteristics of the tumor along with dermatoscopic features and molecular parameters hold significant prognostic information and could be incorporated into models to predict melanomas with high metastatic potential.

Melanoma Brain Metastasis: Biology and Therapeutic Advances

Metastasis to the brain is a frequent complication of advanced melanoma. Historically, patients with melanoma brain metastasis (MBM) have had dismal outcomes, but outcomes have improved with the development of more effective treatments, including stereotactic radiosurgery and effective immune and targeted therapies. Despite these advances, MBM remains a leading cause of death from this disease, and many therapies show decreased efficacy against these tumors compared with extracranial metastases. This differential efficacy may be because of recently revealed unique molecular and immune features of MBMs-which may also provide rational new therapeutic strategies.

Prevention of Brain Metastases: A New Frontier

This review discusses the topic of prevention of brain metastases from the most frequent solid tumor types, i.e., lung cancer, breast cancer and melanoma. Within each tumor type, the risk of brain metastasis is related to disease status and molecular subtype (i.e., EGFR-mutant non-small cell lung cancer, HER2-positive and triple-negative breast cancer, BRAF and NRAF-mutant melanoma). Prophylactic cranial irradiation is the standard of care in patients in small cell lung cancer responsive to chemotherapy but at the price of late neurocognitive decline. More recently, several molecular agents with the capability to target molecular alterations driving tumor growth have proven as effective in the prevention of secondary relapse into the brain in clinical trials. This is the case for EGFR-mutant or ALK-rearranged non-small cell lung cancer inhibitors, tucatinib and trastuzumab-deruxtecan for HER2-positive breast cancer and BRAF inhibitors for melanoma. The need for screening with an MRI in asymptomatic patients at risk of brain metastases is emphasized.

Atopy improves survival and decreases risk of brain metastasis in cutaneous melanoma

Importance

Development of new therapies in melanoma has increased survival, and as a result more patients are living to develop brain metastasis (BrM). Identifying patients at increased risk of BrM is therefore of significant public health importance.

Objective

To determine whether history of atopy is associated with improved survival or reduced incidence of BrM in cutaneous melanoma.

Design

A retrospective cohort study conducted from June 2022 to March 2024.

Setting

Population-based in states with Surveillance, Epidemiology and End Results (SEER) supported cancer registries.

Participants

Individuals (≥65 years) diagnosed with cutaneous melanoma between January 1, 2008 and December 31, 2017 that are participants in traditional Medicare.

Exposures

Individuals were compared that had history of atopy (allergic rhinitis, atopic dermatitis, asthma, and/or allergic/atopic conjunctivitis) diagnosed prior to melanoma diagnosis, ascertained using ICD-9 or ICD-10 codes in Medicare claims.

Main Outcomes and Measures

Primary endpoints were diagnosis with a BrM or death during the follow-up period. Associations between atopy and endpoints were assessed using cox proportional hazards models to estimate hazard ratios (HR) and p-values.

Results

A total of 29,956 cutaneous melanoma cases were identified (median age 76, 60% male and 97% non-Hispanic White). Overall, 7.1% developed BrM during follow up. Among the 35% that had history of atopy, the most common condition was atopic dermatitis (19%). After adjustment for demographic and prognostic factors, atopy was associated with a 16% decrease in death (HR=0.84 [95%CI:0.80-0.87], pFDR<0.001). Among those with non-metastatic disease at time of diagnosis, atopy conferred a 15% decrease in cumulative incidence BrM (HR=0.85 [95%CI: 0.76-0.94], pFDR=0.006), with a 25% decrease associated with atopic dermatitis (HR=0.75 [95%CI:0.65-0.86], pFDR<0.001). Among those with metastatic disease at diagnosis (any metastatic site), only those who received immune checkpoint inhibitors had a survival benefit associated with atopy (HR=0.31, [95%CI:0.15-0.64], p=0.001 vs HR=1.41, [95%CI:0.87-2.27], p=0.165).

Conclusions and Relevance

Atopy, particularly atopic dermatitis, was significantly associated with improved survival and decreased incidence of BrM. The improved survival associated with these conditions in the context of immunotherapy suggests that these conditions in the elderly may identify those with more robust immune function that may be more responsive to treatment.

Characteristics of long-survivor metastatic melanoma after polychemotherapy and interferon: a retrospective study

BACKGROUND

The development of immunotherapy and tyrosine kinase inhibitors dramatically improved the prognosis of metastatic melanoma. Consequently, chemotherapy is now rarely used. Here, we describe the characteristics of long-surviving patients with metastatic melanoma treated with immunochemotherapy.

MATERIAL AND METHODS

We retrieved retrospective clinical and pathological data for patients diagnosed with metastatic melanoma between January 1993 and December 2015 who received the CVD-INF (cisplatin, vinblastine, dacarbazine, and interferon α-2b) regimen at the Hôpitaux Universitaires de Genève. We estimated their progression-free survival and overall survival. This ad hoc study's primary aim was to describe the clinical and biological characteristics of long-term survivors, defined as patients surviving more than two years after immunochemotherapy initiation. The spatial distribution pattern of CD8+ T cells (inflamed, excluded, or desert) was immunohistochemically determined.

RESULTS

Ninety patients received CVD-INF. Their median age at metastatic melanoma diagnosis was 55 years (20-75). Their median progression-free survival was 2.8 months, and median overall survival was 7.2 months. Eleven (12%) patients were long-term survivors. In multivariate analysis, central nervous system metastases (hazard ratio [HR]: 2.66; 95% confidence interval [CI]: 1.43-4.95; p = 0.001), multiple metastases (HR: 1.82; 95% CI: 1.01-3.29; p = 0.047), and elevated lactate dehydrogenase (LDH) (HR: 1.92; 95% CI: 1.12-3.30; p = 0.016) were independently associated with shorter survival. Most long-survivors (6/8; 75%) had a tumour-inflamed pattern compared to 25% of non-long survivors (5/20; Fisher's test p = 0.030).

CONCLUSIONS

A subset of patients with metastatic melanoma and a tumour-inflamed phenotype treated with CVD-INF survived over two years. Factors associated with prolonged survival are consistent with those previously reported in metastatic melanoma.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of melanoma, version 3.0

Since the first approval for immune checkpoint inhibitors (ICIs) for the treatment of cutaneous melanoma more than a decade ago, immunotherapy has completely transformed the treatment landscape of this chemotherapy-resistant disease. Combination regimens including ICIs directed against programmed cell death protein 1 (PD-1) with anti-cytotoxic T lymphocyte antigen-4 (CTLA-4) agents or, more recently, anti-lymphocyte-activation gene 3 (LAG-3) agents, have gained regulatory approvals for the treatment of metastatic cutaneous melanoma, with long-term follow-up data suggesting the possibility of cure for some patients with advanced disease. In the resectable setting, adjuvant ICIs prolong recurrence-free survival, and neoadjuvant strategies are an active area of investigation. Other immunotherapy strategies, such as oncolytic virotherapy for injectable cutaneous melanoma and bispecific T-cell engager therapy for HLA-A*02:01 genotype-positive uveal melanoma, are also available to patients. Despite the remarkable efficacy of these regimens for many patients with cutaneous melanoma, traditional immunotherapy biomarkers (ie, programmed death-ligand 1 expression, tumor mutational burden, T-cell infiltrate and/or microsatellite stability) have failed to reliably predict response. Furthermore, ICIs are associated with unique toxicity profiles, particularly for the highly active combination of anti-PD-1 plus anti-CTLA-4 agents. The Society for Immunotherapy of Cancer (SITC) convened a panel of experts to develop this clinical practice guideline on immunotherapy for the treatment of melanoma, including rare subtypes of the disease (eg, uveal, mucosal), with the goal of improving patient care by providing guidance to the oncology community. Drawing from published data and clinical experience, the Expert Panel developed evidence- and consensus-based recommendations for healthcare professionals using immunotherapy to treat melanoma, with topics including therapy selection in the advanced and perioperative settings, intratumoral immunotherapy, when to use immunotherapy for patients with BRAFV600-mutated disease, management of patients with brain metastases, evaluation of treatment response, special patient populations, patient education, quality of life, and survivorship, among others.

A seven-immune-genes risk model predicts the survival and suitable treatments for patients with skin cutaneous melanoma

Background

Skin cutaneous melanoma is characterized by high malignancy and prognostic heterogeneity. Immune cell networks are critical to the biological progression of melanoma through the tumor microenvironment. Thus, identifying effective biomarkers for skin cutaneous melanoma from the perspective of the tumor microenvironment may offer strategies for precise prognosis prediction and treatment selection.

Methods

A total of 470 cases from The Cancer Genome Atlas and 214 from the Gene Expression Omnibus were systematically evaluated to construct an optimal independent immune cell risk model with predictive value using weighted gene co-expression network analysis, Cox regression, and least absolute shrinkage and selection operator assay. The predictive power of the developed model was estimated through receiver operating characteristic curves and Kaplan-Meier analysis. The association of the model with tumor microenvironment status, immune checkpoints, and mutation burden was assessed using multiple algorithms. Additionally, the sensitivity of immune and chemotherapeutics was evaluated using the ImmunophenScore and pRRophetic algorithm. Furthermore, the expression profiles of risk genes were validated using gene expression profiling interactive analysis and Human Protein Atlas resources.

Results

The risk model integrated seven immune-related genes: ARNTL, N4BP2L1, PARP11, NUB1, GSDMD, HAPLN3, and IRX3. The model demonstrated considerable predictive ability and was positively associated with clinical and molecular characteristics. It can be utilized as a prognostic factor for skin cutaneous melanoma, where a high-risk score was linked to a poor prognosis and indicated an immunosuppressive microenvironment. Furthermore, the model revealed several potential target checkpoints and predicted the therapeutic benefits of multiple clinically used drugs.

Conclusion

Our findings provide a comprehensive landscape of the tumor immune microenvironment in skin cutaneous melanoma and identify prognostic markers that may serve as efficient clinical diagnosis and treatment selection tools.

Cutaneous melanoma

Cutaneous melanoma is a malignancy arising from melanocytes of the skin. Incidence rates are rising, particularly in White populations. Cutaneous melanoma is typically driven by exposure to ultraviolet radiation from natural sunlight and indoor tanning, although there are several subtypes that are not related to ultraviolet radiation exposure. Primary melanomas are often darkly pigmented, but can be amelanotic, with diagnosis based on a combination of clinical and histopathological findings. Primary melanoma is treated with wide excision, with margins determined by tumour thickness. Further treatment depends on the disease stage (following histopathological examination and, where appropriate, sentinel lymph node biopsy) and can include surgery, checkpoint immunotherapy, targeted therapy, or radiotherapy. Systemic drug therapies are recommended as an adjunct to surgery in patients with resectable locoregional metastases and are the mainstay of treatment in advanced melanoma. Management of advanced melanoma is complex, particularly in those with cerebral metastasis. Multidisciplinary care is essential. Systemic drug therapies, particularly immune checkpoint inhibitors, have substantially increased melanoma survival following a series of landmark approvals from 2011 onward.

Burden and Risk Factors of Brain Metastases in Melanoma: A Systematic Literature Review

Melanoma can frequently metastasize to the brain with severe consequences. However, variation of melanoma brain metastases (MBM) development among populations is not well studied, and underlying mechanisms and risk factors for MBM development are not consistently documented. We conducted a systematic literature review (SLR) including a total of 39 articles to evaluate the proportion of melanoma patients who are diagnosed with, or develop, brain metastases, and summarize the risk factors of MBM. The average proportion of MBM was calculated and weighted by the sample size of each study. Meta-analyses were conducted for the selected risk factors using a random-effects model. The proportion of MBM at diagnosis was 33% (975 with MBM out of 2948 patients) among patients with cutaneous melanoma (excluding acral) and 23% (651/2875) among patients with cutaneous mixed with other types of melanoma. The proportion at diagnosis was lower among populations with mucosal (9/96, 9%) or uveal (4/184, 2%) melanoma and among populations outside the United States and Europe. Meta-analysis demonstrated that male vs. female gender and left-sided tumors vs. right-sided were significantly associated with increased risk of melanoma brain metastases. These data may help clinicians to assess an individual patient's risk of developing melanoma brain metastases.

Survival of patients with stage IIIC and IIID melanomas with nodal metastases in the light of new therapies

Introduction

Within stage III melanoma prognosis and outcomes significantly vary. Advances in systemic therapy improved prognosis in metastatic melanoma. Adjuvant therapy in stage III significantly lowered relapses, although the effect on survival is less evident. Analysis of treatment results in stage IIIC and IIID before introduction of the modern adjuvant therapy, but after introduction of the effective systemic therapy in metastatic relapse, is needed.

Aim

To analyse the clinical outcomes in patients with stage IIIC and IIID melanoma before the introduction of the novel adjuvant therapy.

Material and methods

Consecutive stage IIIC and IIID melanoma patients treated in 2015-2018 in 4 reference centres in Poland were enrolled in the analysis of RFS and OS (in-transit metastases excluded). Median follow-up was 26.6 months (1.7-67.2).

Results

There were 224 stage IIIC and 49 stage IIID patients. Recurrence was observed in 170 (62.2%); 102 (45.5%) deaths in stage IIIC and 28 (57.1%) in stage IIID were reported. RFS and OS were better in stage IIIC compared to stage IIID. RFS and OS in the IIIC group were 19.7 and 36.2 months, respectively, and in IIID - 8.9 and 27.8 months, respectively.

Conclusions

The survival of patients with high-risk melanomas has improved in recent years, however, it is still unsatisfactory. The major changes in melanoma management related to the introduction of the adjuvant therapy require further careful observation.

Cumulative incidence and risk factors of brain metastasis for acral and mucosal melanoma patients with stages I-III

PURPOSE

Few studies focused on the incidence of brain metastasis in patients with acral and mucosal melanoma, and a better understanding of the incidences and predictors of brain metastasis is needed in these patients.

METHOD

A prospectively accrued cohort of 799 patients with acral and mucosal melanoma in stages I-III from July 2011 to December 2015 at Peking University Cancer Hospital were included in this study. Competing risk models (Fine and Gray) were used to estimate the cumulative incidence of brain metastasis and compare the differences in cumulative incidence curves between different primary lesions, stages, and molecular types.

RESULTS

At a median follow-up time of 68.0 months, 60 of the 779 patients (7.7%) developed brain metastasis, and 261 (33.5%) patients developed extracranial metastasis. Considering the risk of competition, the cumulative incidence of brain metastasis at one year, two years, and five years after diagnosis were 5.1%, 10.2%, and 19.5%, respectively. Stage III, BRAF mutations, and NRAS mutations were associated with a high risk of brain metastasis in univariable analysis. Multivariate analysis showed BRAF mutations, and NRAS mutations had statistically correlated with an increased cumulative incidence of brain metastasis at diagnosis and all-time point of one year and two years after diagnosis.

CONCLUSION

This study is the first to report the cumulative incidence and risk factors of brain metastasis for patients with acral and mucosal melanoma in stages I-III. Patients with BRAF and NRAS mutations had a higher incidence at diagnosis and all-time point, providing the basis for surveillance guidelines and further mechanic exploration.

Risk and tropism of central nervous system (CNS) metastases in patients with stage II and III cutaneous melanoma

BACKGROUND

Recent data suggest that patients with stage III melanoma are at high risk for developing central nervous system (CNS) metastases. Because a subset of patients with stage II melanoma experiences worse survival outcomes than some patients with stage III disease, the authors investigated the risk of CNS metastasis in stage II melanoma to inform surveillance guidelines for this population.

METHODS

The authors examined clinicopathologic data prospectively collected from 1054 patients who had cutaneous melanoma. The χ² test, the cumulative incidence, and Cox multivariable regression analyses were performed to evaluate the association between baseline characteristics and the development of CNS metastases.

RESULTS

Patients with stage III melanoma had a higher rate of developing brain metastases than those with stage II melanoma (100 of 468 patients [21.4%] vs. 82 of 586 patients [14.0%], respectively; p = .002). However, patients who had stage IIC melanoma had a significantly higher rate of isolated first recurrences in the CNS compared with those who had stage III disease (12.1% vs. 3.6%; p = .002). The risk of ever developing brain metastases was similarly elevated for patients who had stage IIC disease (hazard ratio [HR], 3.16; 95% CI, 1.77-5.66), stage IIIB disease (HR, 2.83; 95% CI, 1.63-4.91), and stage IIIC disease (HR, 2.93; 95% CI, 1.81-4.74), and the risk was highest in patients who had stage IIID disease (HR, 8.59; 95% CI: 4.11-17.97).

CONCLUSIONS

Patients with stage IIC melanoma are at elevated risk for first recurrence in the CNS. Surveillance strategies that incorporate serial neuroimaging should be considered for these individuals until more accurate predictive markers can be identified.

A novel inflammatory response-related signature predicts the prognosis of cutaneous melanoma and the effect of antitumor drugs

Cutaneous melanoma (CM) is a skin cancer that is highly metastatic and aggressive, with a dismal prognosis. This is the first study to use inflammatory response-related genes to build a model and evaluate their predictive significance in CM. This study used public databases to download CM patients' mRNA expression profiles and clinical data to create multigene prognostic markers in the UCSC cohort. We compared overall survival (OS) between high- and low-risk groups using the Kaplan-Meier curve and determined independent predictors using Cox analysis. We also used enrichment analysis to assess immune cell infiltration fraction and immune pathway-related activity using KEGG enrichment analysis. Furthermore, we detected prognostic genes' mRNA and protein expression in CM and normal skin tissues using qRT-PCR and immunohistochemistry. Finally, we developed a 5-gene predictive model that showed that patients in the high-risk group had a considerably shorter OS than those in the low-risk group. The analysis of the receiver operating characteristic (ROC) curve proved the model's predictive ability. We also conducted a drug sensitivity analysis and discovered that the expression levels of prognostic genes were substantially linked with cancer cell sensitivity to antitumor medicines. The findings show that the model we developed, which consists of five inflammatory response-related genes, can be used to forecast the prognosis and immunological state of CM, giving personalized and precision medicine a new goal and direction.

Construction of immunotherapy-related prognostic gene signature and small molecule drug prediction for cutaneous melanoma

Background

Cutaneous melanoma (CM), a kind of skin cancer with a high rate of advanced mortality, exhibits a wide variety of driver and transmitter gene alterations in the immunological tumor microenvironment (TME) associated with tumor cell survival and proliferation.

Methods

We analyzed the immunological infiltration of TME cells in normal and malignant tissues using 469 CM and 556 normal skin samples. We used a single sample gene set enrichment assay (ssGSEA) to quantify the relative abundance of 28 cells, then used the LASSO COX regression model to develop a riskScore prognostic model, followed by a small molecule drug screening and molecular docking validation, which was then validated using qRT-PCR and IHC.

Results

We developed a prognosis model around seven essential protective genes for the first time, dramatically elevated in tumor tissues, as did immune cell infiltration. Multivariate Cox regression results indicated that riskScore is an independent and robust prognostic indicator, and its predictive value in immunotherapy was verified. Additionally, we identified Gabapentin as a possible small molecule therapeutic for CM.

Conclusions

A riskScore model was developed in this work to analyze patient prognosis, TME cell infiltration features, and treatment responsiveness. The development of this model not only aids in predicting patient response to immunotherapy but also has significant implications for the development of novel immunotherapeutic agents and the promotion of tailored treatment regimens.

Follow-up of primary melanoma patients with high risk of recurrence: recommendations based on evidence and consensus

In spite of the good prognosis of patients with early-stage melanoma, there is a substantial proportion of them that develop local or distant relapses. With the introduction of targeted and immune therapies for advanced melanoma, including at the adjuvant setting, early detection of recurrent melanoma and/or second primary lesions is crucial to improve clinical outcomes. However, there is a lack of universal guidelines regarding both frequency of surveillance visits and diagnostic imaging and/or laboratory evaluations. In this article, a multidisciplinary expert panel recommends, after careful review of relevant data in the field, a consensus- and experience-based follow-up strategy for melanoma patients, taking into account prognostic factors and biomarkers and the high-risk periods and patterns of recurrence in each (sub) stage of the disease. Apart from the surveillance intensity, healthcare professionals should focus on patients' education to perform regular self-examinations of the skin and palpation of lymph nodes.

The new horizon of biomarker in melanoma patients: A study based on autophagy-related long non-coding RNA

Autophagy-related long non-coding RNAs (arlncRNAs) play a crucial role in the pathogenesis and development of the tumor. However, there is a lack of systematic analysis of arlncRNAs in melanoma patients.Melanoma data for analysis were obtained from The Cancer Genome Atlas (TCGA) database. By establishing a co-expression network of autophagy-related mRNAs-lncRNAs, we identified arlncRNAs in melanoma patients. We evaluated the prognostic value of arlncRNAs by univariate and multivariate Cox analysis and constructed an arlncRNAs risk model. Patients were divided into high- and low-risk groups based on the arlncRNAs risk score. This model was evaluated by Kaplan-Meier (K-M) analysis, univariate-multivariate Cox regression analysis, and receiver operating characteristic (ROC) curve analysis. Characteristics of autophagy genes and co-expressive tendency were analyzed by principal component analysis and Gene Set Enrichment Analysis (GSEA) functional annotation.Nine arlncRNAs (USP30-AS1, LINC00665, PCED1B-AS1, LINC00324, LINC01871, ZEB1-AS1, LINC01527, AC018553.1, and HLA-DQB1-AS1) were identified to be related to the prognosis of melanoma patients. Otherwise, the 9 arlncRNAs constituted an arlncRNAs prognostic risk model. K-M analysis and ROC curve analysis showed that the arlncRNAs risk model has good discrimination. Univariate and multivariate Cox regression analysis showed that arlncRNAs risk model was an independent prognostic factor in melanoma patients. Principal component analysis and GSEA functional annotation showed different autophagy and carcinogenic status in the high- and low-risk groups.This novel arlncRNAs risk model plays an essential role in predicting of the prognosis of melanoma patients. The model reveals new prognosis-related biomarkers for autophagy, promotes precision medicine, and provides a lurking target for melanoma's autophagy-related treatment.

Re-thinking therapeutic development for CNS metastatic disease

There has been unprecedented progress in the development of systemic therapies for patients with metastatic melanoma over the last decade. There is now tremendous potential and momentum to further and markedly reduce the impact of this disease. However, developing more effective treatments for metastases to the CNS remains a critical challenge for patients with melanoma. Melanoma patients with active CNS metastases have largely been excluded from both early-phase and registration trials for all currently approved targeted and immune therapies for this disease. While this exclusion has generally been justified in clinical research due to concerns about poor prognosis, lack of CNS penetration of agents and/or risk of toxicities, recent post-approval trials have shown the feasibility, safety and clinical benefit of clinical investigation in these patients. These trials have also identified key areas for which more effective strategies are needed. In parallel, recent translational and preclinical research has provided insights into novel immune, molecular and metabolic features of melanoma brain metastases that may mediate the aggressive biology and therapeutic resistance of these tumors. Together, these advances suggest the need for new paradigms for therapeutic development for melanoma patients with CNS metastasis.

Mitotic rate in node-positive stage III melanoma: it might be as important a prognostic factor as node number

BACKGROUND

Stage III melanoma is a heterogenous disease, and the number of tumor-involved lymph nodes is the most significantly unfavorable prognostic indicator for relapse and outcome. The aim of this study is to investigate the possible effects of the various clinicopathological factors on the course of node-positive stage III disease.

METHODS

A total of 389 node-positive stage III cutaneous melanomas were included in the study and analyzed retrospectively. All underwent pathological nodal staging by sentinel lymph node biopsy or elective lymph node dissection.

RESULTS

The group was male-dominant (59%) and the median age was 50 years. The largest group of patients was N1 (n = 221, 56.8%) followed by N2 (n = 105, 27.0%) and N3 (n = 63, 16.2%). N1 melanomas were less frequently associated with relapses than melanomas with multiple lymph node metastases (P = 0.05). The 5-year relapse-free survival rate was 37.9%. The melanomas with multiple lymph nodes metastases (P = 0.01), higher mitotic rate (P = 0.005) and ulceration (P = 0.02) had worse RFS. In the multivariate analysis only the significances of the N2-N3 stage (P = 0.016) and higher mitosis (P = 0.012) persisted. The severe lymph node metastasis (N2-N3) was associated with a higher mortality rate in comparison with the single nodal involvement (P = 0.05). The 5-year overall survival rate was 52.1%. Presence of relapse (P = 0.0001), higher mitotic rate (P = 0.03) and N2-N3 stage (P = 0.04) were inversely correlated with the overall survival. When relapse was included in the multivariate analysis, it was the only significant prognostic factor on survival (P = 0.0001), whereas mitosis became the only significant factor on survival with the exclusion of relapse from the multivariate analysis (P = 0.031).

CONCLUSION

In node-positive stage III melanoma, tumor mitotic rate might be just as significant a prognostic indicator as the metastatic lymph node number.

Sex-specific survival benefit in early skin melanoma based on 8th AJCC edition: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database

Background

Females have been found to have a survival benefit over males in past studies. However, in early melanoma patients, this benefit occurred in only those aged >60 years. The 8th edition of the American Joint Committee on Cancer (AJCC) readjusted the melanoma staging system, specifically stage I. This study aims to verify whether the sex-specific benefit in females exists in different age groups according to the 8th edition of the staging system.

Methods

We collected the data of individuals diagnosed with skin melanoma between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Based on the 8th edition of the melanoma staging system, patients diagnosed with pathological stage T1a-T3a, N0 and M0 melanoma were enrolled.

Results

A total of 115,576 patients, including 62,938 male patients and 52,638 female patients, were enrolled in this study. The survival rates of males and females in each stage from IA–IIA were significantly different (P<0.001). In further analyses of each age group, it was found that the proportions of patients with stages IA, IB and IIA were significantly different in each age group. Cox analysis showed that females with stage IA in all age groups benefited significantly, but those in stage IB benefited only when they were aged >60 years. In stage IIA patients, there were significant differences between the <50 and 61–70 years age groups.

Conclusions

Based on data from the SEER database, we found that according to the 8th edition of the AJCC melanoma staging system, females had a higher survival rate than males, and this difference was significant in all age groups in the stage IA group but fluctuated with age in the stage IB and IIA groups.

The mutational landscape of melanoma brain metastases presenting as the first visceral site of recurrence

Brain metastases are a major cause of melanoma-related mortality and morbidity. We undertook whole-exome sequencing of 50 tumours from patients undergoing surgical resection of brain metastases presenting as the first site of visceral disease spread and validated our findings in an independent dataset of 18 patients. Brain metastases had a similar driver mutational landscape to cutaneous melanomas in TCGA. However, KRAS was the most significantly enriched driver gene, with 4/50 (8%) of brain metastases harbouring non-synonymous mutations. Hotspot KRAS mutations were mutually exclusive from BRAFV600, NRAS and HRAS mutations and were associated with a reduced overall survival from the resection of brain metastases (HR 10.01, p = 0.001). Mutations in KRAS were clonal and concordant with extracranial disease, suggesting that these mutations are likely present within the primary. Our analyses suggest that KRAS mutations could help identify patients with primary melanoma at higher risk of brain metastases who may benefit from more intensive, protracted surveillance.

The Expression of CD74-Regulated Inflammatory Markers in Stage IV Melanoma: Risk of CNS Metastasis and Patient Survival

Simple Summary

Although many immunotherapies produce positive initial clinical responses, most advanced cancer patients recur so that there is an urgent need to identify and counteract both the intrinsic resistance as well as acquired mechanisms. During our studies on the mechanisms of resistance, we have identified a set of related protein markers, which we now employ to generate a useful signature of, associated with microenvironmental oxidative stress. Our study examines inflammatory marker expression in stage IV melanoma that are associated with survival outcome and risk of developing central nervous system (CNS) metastasis. Our data here presents CD74 as a prognostic tumor marker associated with good survival in stage IV melanoma. Additionally, the tumor cell nitrotyrosine (NT) expression predicts a greater risk of developing CNS metastasis in those patients. Our understanding of complex cancer cell and their response in the chronic inflammation environment would help us develop better treatments for melanoma.

Abstract

Innate inflammatory features have been found in melanoma tumors from patients at all stages, and molecular analysis has identified definitive inflammatory proteins expressed by tumors cells in patients who presents the worst prognosis. We have previously observed weakened outcomes in patients with constitutive expression of inducible nitric oxide synthase (iNOS), macrophage migration inhibitory factor (MIF) and improved outcomes with CD74 expression in stage III melanoma. In our current study, we tested our hypothesis on CD74-regulated inflammatory markers’ expression in stage IV melanoma tumors whether the signature is associated with survival outcome and/or risk of developing CNS metastasis. We retrospectively identified 315 patients with stage IV melanoma. In a tissue microarray (TMA), we examined the expression of cells with CD74, its receptor MIF, and downstream inflammatory markers iNOS, nitrotyrosine (NT), cyclooxygenase (COX)-2 and microsomal prostaglandin E synthase-1 (mPGES1). We analyzed the association of those inflammatory markers with overall survival time (OS) and time to CNS metastasis using Kaplan–Meier survival analyses. Our data validates CD74 as a useful prognostic tumor cell protein marker associated with favorable OS as in stage III melanomas, while the tumor NT expression strongly predicts an increased risk of developing CNS metastasis (p = 0.0008) in those patients.

Skin melanoma survival is not superior in females in the new stage IIID of the 8th edition of the staging system: an analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database

Background

In the 8th edition of the melanoma staging system, stage III was divided into stages IIIA-IIID. Previous studies have found that the long-term survival rate of females is much higher than that of males. This study was designed to explore whether this sex-specific advantage still exists in the new staging subgroups.

Methods

We obtained data from individuals diagnosed with skin melanoma between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8,726 patients with stage III disease were enrolled in the study (5,370 males and 3,356 females). Among these patients, 505 had stage IIID disease (370 males and 135 females).

Results

In the 7th edition of the staging system, there were significant sex-specific differences in overall survival (OS) and melanoma-specific survival (MSS) in each subgroup of stage III. In stages IIIA-IIIC in the 8th edition, there were also significant differences between males and females (P<0.001), but in stage IIID patients, there were no significant differences in either OS (P=0.312) or MSS (P=0.288). Cox analysis confirmed that stage IIID does not affect prognosis in males. Further research found no difference between males and females with stage IIID disease in any age subgroup.

Conclusions

We compared sex-specific survival differences in patients with stage III disease according to the 8th edition of the staging system. Females with stage IIIA-IIIC disease have better survival rates than males. However, among patients with stage IIID disease, there is no significant difference in survival between males and females.