Prognostic significance of mitotic rate in localized primary cutaneous melanoma: an analysis of patients in the multi-institutional American Joint Committee on Cancer melanoma staging database

High-frequency ultrasound accuracy in preoperative cutaneous melanoma assessment: A meta-analysis

BACKGROUND

High-frequency ultrasound (HFUS) can safely and efficiently visualize cutaneous tumour characteristics including depth.

OBJECTIVES

We aimed to evaluate its accuracy in measuring melanoma depth against the gold standard, histopathology, for treatment planning.

METHODS

A review of publications was conducted in March 2023 through five electronic databases. Thirty-six included articles studied patients who received HFUS (≥10 MHz) measurements, melanoma biopsy or excision, and reported a tumour depth correlation coefficient between HFUS and histopathology. We analysed correlation coefficients between HFUS and histopathology, measured tumour depths and shed light on reasons for mismeasurements. Additionally, we identified the reporting of critical metrics including, lesion characteristics, melanoma subtype, type of correlation coefficient, 95% confidence intervals for Pearson coefficients and sample size.

RESULTS

The most common tumour imaged was superficial spreading melanoma on the trunk and extremities, followed by head/face. Maximum ultrasound frequencies ranged from 13 MHz to 100 MHz with participants ranging from 5 to 264. Histopathology and HFUS correlation coefficients ranged from 0.417 to 0.997 (median: 0.94, mean: 0.89 and SD: 0.13). Lower frequency probes (10-20 MHz) were less accurate in assessing melanoma thickness, with a cumulative mean correlation coefficient of 0.87 compared to 0.94 (20-25 MHz) and 0.98 (≥70 MHz). Studies demonstrated higher sonographic accuracy in melanomas >0.75 mm. Additionally, ultrasound may report increased melanoma depth compared to histopathology for reasons including lymphocytic infiltration, presence of a nevus and shrinkage during specimen processing. Furthermore, we found a gap in the reporting of details such as fundamental characteristics of lesion populations. Specifically, 86% (31 out of 36) of the studies failed to report one or more critical metrics, such as mean, median or range of lesion depths.

CONCLUSIONS

HFUS may serve as a supplementary tool for preoperative melanoma assessment, with increased accuracy in thicker tumours. Frequencies <20 MHz are less reliable in assessing depth. Frequencies ≥70 MHz demonstrate stronger correlations to histopathology. Higher ultrasound accuracy was seen for melanomas with Breslow depth >0.75 mm.

The Prognostic Value of Proliferative Activity in Cutaneous Melanoma: A Pilot Study Evaluating the Mitotic Rate and Ki67 Index to Predict Patient Outcomes

Proliferative activity in cutaneous melanomas can be appreciated both histopathologically by counting mitotic figures and immunohistochemically through the Ki67 index, but the prognostic value of each method is still a matter of debate. In this context, we performed a retrospective study on 33 patients diagnosed with cutaneous melanomas between 2013 and 2018 in order to evaluate progression-free survival and overall survival. Multivariate Cox proportional hazards regression was performed by considering both clinical histopathological and immunohistochemical features. The mitotic rate was significantly independently associated with both outcomes, while the Ki67 index was not an independent prognostic factor. However, the Ki67 predictive accuracy could be improved by establishing both a cut-off value and a standardized protocol for evaluating its expression. Until these desiderata are met, the mitotic rate remains superior to the Ki67 index for predicting prognosis in cutaneous melanomas, as also has the advantage of being easily interpreted in a standard histopathological examination regardless of the pathologist's experience and with no further financial expenses. Importantly, this is one of very few articles that has shown perineural invasion to be an independent prognostic factor for both progression-free survival and overall survival in cutaneous melanomas. As a consequence, this parameter should become a mandatory feature in the histopathological evaluation of cutaneous melanomas as it can improve the identification of patients who are at high risk for disease progression.

Macroscopic tumor dimension, sentinel lymph node outcome, and survival analysis among cutaneous melanoma

BACKGROUND

Cutaneous melanoma is characterized by a high risk of metastasis to distant organs and a substantial mortality rate. For planning treatment and assessing outcomes, the Breslow micrometric measurement is critical. The tumor macroscopic dimension is not considered a prognostic parameter in cutaneous melanoma, although there are studies showing that tumor size is an independent prognostic factor for melanoma-specific survival. Therefore, this study aimed to evaluate the macroscopic dimension of melanoma and other known prognostic factors (i.e., Breslow index, mitoses, regression, and ulceration) as predictors of sentinel lymph node outcome and survival outcome.

METHODS

We performed a retrospective cross-sectional study of 227 melanoma lesions subjected to sentinel lymph node biopsy at two Brazilian referral centers.

RESULTS

On univariate analysis, there was a statistically significant correlation between the largest macroscopic tumor dimension and the sentinel lymph node result (P = 0.001); however, on multivariate analysis considering all evaluated parameters, there was no significant difference between the sentinel lymph node result and the tumor macroscopic dimension (P = 0.2689). Regarding melanoma-specific survival, the macroscopic dimension showed no significant correlation (P = 0.4632) in contrast to Breslow's dimension (P < 0.0001).

CONCLUSION

The Breslow thickness was the only significant factor related to both the sentinel lymph node outcome and melanoma specific survival among the evaluated variables.

Could the mitotic count improve personalized prognosis in melanoma patients?

A number of studies have indicated that the mitotic rate may be a predictive factor for poor prognosis in melanoma patients. The aim of this study was to investigate whether the mitotic rate is associated with other prognostic clinical and anatomopathological characteristics. After adjusting for other anatomopathological characteristics, we then verified the prognostic value of the number of mitoses, determining in which population subgroup this variable may have greater prognostic significance on 3-year mortality. The Veneto Cancer Registry (Registro Tumori del Veneto-RTV), a high-resolution population-based dataset covering the regional population of approximately 4.9 million residents, served as the clinical data source for the analysis. Inclusion criteria included all incident cases of invasive cutaneous malignant melanoma recorded in the RTV in 2015 (1,050 cases) and 2017 (1,205 cases) for which the number of mitoses was available. Mitotic classes were represented by Kaplan-Meier curves for short-term overall survival. Cox regression calculated hazard ratios in multivariable models to evaluate the independent prognostic role of different mitotic rate cut-offs. The results indicate that the mitotic rate is associated with other survival prognostic factors: the variables comprising the TNM stage (e.g., tumor thickness, ulceration, lymph node status and presence of metastasis) and the characteristics that are not included in the TNM stage (e.g., age, site of tumor, type of morphology, growth pattern and TIL). Moreover, this study demonstrated that, even after adjusting for these prognostic factors, mitoses per mm2 are associated with higher mortality, particularly in T2 patients. In conclusion, these findings revealed the need to include the mitotic rate in the histological diagnosis because it correlates with the prognosis as an independent factor. The mitotic rate can be used to develop a personalized medicine approach in the treatment and follow-up monitoring of melanoma patients.

Prognostic and predictive biomarkers in melanoma

Biomarkers help to inform the clinical management of patients with melanoma. For patients with clinically localised primary melanoma, biomarkers can help to predict post-surgical outcome (including via the use of risk prediction tools), better select patients for sentinel lymph node biopsy, and tailor catch-all follow-up protocols to the individual. Systemic drug treatments, including immune checkpoint inhibitor (ICI) therapies and BRAF-targeted therapies, have radically improved the prognosis of metastatic (stage III and IV) cutaneous melanoma patients, and also shown benefit in the earlier setting of stage IIB/C primary melanoma. Unfortunately, a response is far from guaranteed. Here, we review clinically relevant, established, and emerging, prognostic, and predictive pathological biomarkers that refine clinical decision-making in primary and metastatic melanoma patients. Gene expression profile assays and nomograms are emerging tools for prognostication and sentinel lymph node risk prediction in primary melanoma patients. Biomarkers incorporated into clinical practice guidelines include BRAF V600 mutations for the use of targeted therapies in metastatic cutaneous melanoma, and the HLA-A∗02:01 allele for the use of a bispecific fusion protein in metastatic uveal melanoma. Several predictive biomarkers have been proposed for ICI therapies but have not been incorporated into Australian clinical practice guidelines. Further research, validation, and assessment of clinical utility is required before more prognostic and predictive biomarkers are fluidly integrated into routine care.

Immunotherapy utilization in stage IIIA melanoma: less may be more

Background

Immunotherapy agents are approved for adjuvant treatment of stage III melanoma; however, evidence for survival benefit in early stage III disease is lacking. Current guidelines for adjuvant immunotherapy utilization in stage IIIA rely on clinician judgment, creating an opportunity for significant variation in prescribing patterns. This study aimed to characterize current immunotherapy practice variations and to compare patient outcomes for different prescribing practices in stage IIIA melanoma.

Study design

Patients with melanoma diagnosed from 2015-2019 that met American Joint Committee on Cancer 8th edition criteria for stage IIIA and underwent resection were identified in the National Cancer Database. Multiple imputation by chained equations replaced missing values. Factors associated with receipt of adjuvant immunotherapy were identified. Multivariable Cox proportional hazards regression compared overall survival across groups.

Results

Of 4,432 patients included in the study, 34% received adjuvant immunotherapy. Patients had lower risk-adjusted odds of receiving immunotherapy if they were treated at an academic center (OR=0.48, 95%CI=0.33-0.72, p<0.001 vs. community facility) or at a high-volume center (OR=0.69, 0.56-0.84, p<0.001 vs. low-volume). Immunotherapy receipt was not associated with risk-adjusted survival (p=0.095). Moreover, patients treated at high-volume centers experienced longer overall risk-adjusted survival than those treated at low-volume centers (HR=0.52, 0.29-0.93, p=0.030). Risk-adjusted survival trended toward being longer at academic centers than at community centers, but the difference was not statistically significant.

Conclusion

Academic and high-volume centers utilize significantly less adjuvant immunotherapy in stage IIIA melanoma than community and low-volume centers without compromise in overall survival. These findings suggest that this population may benefit from more judicious immunotherapy utilization.

Predicting Recurrence-Free and Overall Survival for Patients With Stage II Melanoma: The MIA Calculator

PURPOSE

Improvements in recurrence-free survival (RFS) were demonstrated in two recent randomized trials for patients with sentinel node (SN)-negative stage IIB or IIC melanoma receiving adjuvant systemic therapy (pembrolizumab/nivolumab). However, adverse events also occurred. Accurate individualized prognostic estimates of RFS and overall survival (OS) would allow patients to more accurately weigh the risks and benefits of adjuvant therapy. Since the current American Joint Committee on Cancer eighth edition (AJCC-8) melanoma staging system focuses on melanoma-specific survival, we developed a multivariable risk prediction calculator that provides estimates of 5- and 10-year RFS and OS for these patients.

METHODS

Data were extracted from the Melanoma Institute Australia (MIA) database for patients diagnosed with stage II (clinical or pathological) melanoma (n = 3,220). Survival prediction models were developed using multivariable Cox regression analyses (MIA models) and externally validated twice using data sets from the United States and the Netherlands. Each model's performance was assessed using C-statistics and calibration plots and compared with Cox models on the basis of AJCC-8 staging (stage models).

RESULTS

The 5-year and 10-year RFS C-statistics were 0.70 and 0.73 (MIA-model) versus 0.61 and 0.60 (stage-model), respectively. For OS, the 5-year and 10-year C-statistics were 0.71 and 0.75 (MIA-model) compared with 0.62 and 0.61 (stage-model), respectively. The MIA models were well calibrated and externally validated.

CONCLUSION

The MIA models offer accurate and personalized estimates of both RFS and OS in patients with stage II melanoma even in the absence of pathological staging with SN biopsy. These models were robust on external validations and may be used in everyday practice both with (ideally) and without performing SN biopsy to identify high-risk patients for further management strategies. An online tool will be available at the MIA website (Risk Prediction Tools).

Artificial Intelligence in Melanoma Dermatopathology: A Review of Literature

ABSTRACT

Pathology serves as a promising field to integrate artificial intelligence into clinical practice as a powerful screening tool. Melanoma is a common skin cancer with high mortality and morbidity, requiring timely and accurate histopathologic diagnosis. This review explores applications of artificial intelligence in melanoma dermatopathology, including differential diagnostics, prognosis prediction, and personalized medicine decision-making.

Lower limb cutaneous melanoma surgery: location matters

The anatomical location of cutaneous melanoma is a relevant independent prognostic factor in melanoma. The aim of the study is to know the prognosis of lower limb cutaneous melanoma related to their location within the limb, regardless of the histological type, and if there are any other influencing variables. A real-world data observational study was developed. The lesions were divided depending on the location of the melanoma (thigh, leg and foot). Bivariate and multivariate analysis were performed, and melanoma-specific survival and disease-free survival rates were calculated. When these analysis were done, the results showed that, in melanomas of the lower limb, location on the foot presented a lower melanoma-specific survival rate compared to more proximal locations, and only the anatomical location presents statistical significance to discriminate cases with a higher mortality risk and a lower disease-free survival rate among distal melanomas (mainly on the foot). In conclusion, this study confirms that a more distal location of lower limb cutaneous melanoma is a relevant prognostic factor.Trial registration number NCT04625491 retrospectively registered.

Invasive Cutaneous Melanoma: Evaluating the Prognostic Significance of Some Parameters Associated with Lymph Node Metastases

Background and Objectives: This study aimed to assess the clinical-pathological profile of patients with invasive cutaneous melanomas and to identify the parameters with a prognostic role in the lymph nodal spread of this malignant tumor. Materials and Methods: We performed a retrospective study on patients with invasive cutaneous melanomas who underwent surgery in the "Pius Brînzeu" County Clinical Emergency Hospital from Timișoara, Romania, and were evaluated for the status of loco-regional lymph nodes. We selected and analyzed some parameters searching for their relationship with lymph node metastases. Results: We identified 79 patients with invasive cutaneous melanomas (29 men and 50 women, mean age 59.36 years). A percentage of 58.3% of melanomas had Breslow tumor thickness >2 mm; 69.6% of melanomas showed a Clark level IV-V. Tumor ulceration was present in 59.5% of melanomas. A mitotic rate of ≥5 mitoses/mm² was observed in 48.1% of melanomas. Tumor-infiltrating lymphocytes (TILs), non-brisk, were present in 59.5% of cases and 22.8% of patients had satellite/in-transit metastasis (SINTM). Tumor regression was identified in 44.3% of cases. Lymph nodes metastases were found in 43.1% of patients. Statistical analysis showed that lymph node metastases were more frequent in melanomas with Breslow thickness >2 mm (p = 0.0002), high Clark level (p = 0.0026), mitotic rate >5 mitoses/mm² (p = 0.0044), ulceration (p = 0.0107), lymphovascular invasion (p = 0.0182), SINTM (p = 0.0302), and non-brisk TILs (p = 0.0302). Conclusions: The Breslow thickness >2 mm, high Clark level, high mitotic rate and ulceration are the most important prognostic factors for lymph nodal spread in cutaneous melanomas. However, some melanomas without these clinical-pathological features can have an unexpected, aggressive evolution, which entails the necessity of close and prolonged clinical follow-up of patients, including those with lesions considered without risk.

Primary malignant melanoma of rectum: A rare case report

INTRODUCTION

Malignant melanoma of the gastrointestinal tract is an extremely rare event of which 50 % occurs in anorectal region. The lesion can easily be misdiagnosed as rectal-carcinoma, which comprises >90 % of rectal tumors and has a different treatment. The behavior of the anorectal melanoma is very aggressive and has very poor prognosis with fatal outcome.

PRESENTATION OF CASE

A 48-year-old man presented complaining of rectal bleeding of two months' duration, without any other significant history. Colonoscopy showed a polypoidal mass in the rectum that was in favor of adenocarcinoma. The microscope examination of biopsy tissue showed sheets of poorly differentiated malignant neoplasm. Immuno-histochemical (IHC) staining showed negativity of pan Cytokeratin and CD31. IHC for HMB45 showed diffuse and strong positivity in neoplastic cells, confirming the diagnosis of malignant melanoma.

CLINICAL DISCUSSION

According to a report by the National Cancer Database of the United States, primary rectal melanoma is very rare. Mucosal surface of the body is third most common site for primary melanoma after skin and eye. The first case of anorectal melanoma was reported in 1857. Histopathological examinations are gold standard for diagnosis, but histopathology examination without immunohistochemistry will misdiagnose some cases as poorly differentiated adenocarcinoma which has completely different treatment. Surgical resection has been reported as the most useful treatment option.

CONCLUSION

Malignant melanoma of the rectum is extremely rare and difficult to diagnose in low resources settings. Histopathologic examination with IHC stains can differentiate poorly differentiated adenocarcinoma from melanoma and other rare tumors of anorectal region.

Per- and polyfluoroalkyl substances (PFAS) exposure in melanoma patients: a retrospective study on prognosis and histological features

Per- and polyfluoroalkyl substances (PFAS) are endocrine disrupting chemicals which could be associated with cancer development, such as kidney and testicular cancers, pancreatic and hepatocellular carcinoma and thyroid tumor. Available scientific literature offers no information on the role of PFAS in melanoma development/progression. Since 1965, a massive environmental contamination by PFAS has occurred in northeastern Italy. This study compared histopathology and prognosis between melanoma patients exposed (n = 194) and unexposed (n = 488) to PFAS. All patients were diagnosed and/or treated for melanoma at the Veneto Oncological Institute and the University Hospital of Padua (Italy) in 1998-2014. Patients were categorized in exposed or unexposed groups according to their home address and the geographical classification of municipalities affected by PFAS contamination as provided by Veneto Government in 2018. Presence of mitoses was found in 70.5% of exposed patients and 58.7% of unexposed patients (p = 0.005). Median follow-up was 90 months (IQR 59-136). 5-year overall survival was 83.7% in exposed patients and 88.0% in unexposed patients (p = 0.20); 5-year disease-specific survival was 88.0% in exposed patients and 90.9% in unexposed patients (p = 0.50); 5-year disease-free survival was 83.8% in exposed patients and 87.3% in unexposed patients (p = 0.20). Adjusting for imbalanced characteristics at baseline (presence of mitoses), survival was not statistically different between exposed and unexposed patients (overall survival: HR 1.10, 95% CI 0.77 to 1.58, p = 0.57; disease-specific survival: HR 0.99, 95% CI 0.62 to 1.59, p = 0.99; disease-free survival: HR 1.10, 95% CI 0.74 to 1.64, p = 0.62). Although the magnitude of PFAS exposure was not quantifiable, our findings suggested that exposure to PFAS was associated with higher level of mitosis in melanoma patients, but this did not translate into a survival difference. Further studies are required to investigate this relationship and all effects of PFAS on prognosis.

Ulceration vs Mitosis in Cutaneous Melanoma: which is Superior for Predicting Prognosis Across Clinical Stages?

Ulceration and high mitosis are considered among the major unfavorable prognostic factors in the survival of cutaneous melanoma patients. The aim of this study was to investigate the clinical significance of these parameters and to compare them to see which one is superior to predicting prognosis across all clinical stages of melanoma. A total of 1,074 melanomas were analyzed retrospectively. Tumor ulceration was found to be limited to the local stage for predicting survival, whereas, mitosis maintained its prognostic strength for predicting survival across all clinical stages. Furthermore, no survival differences were observed between ulceration and mitosis across clinical stages.

Automated analysis of whole slide digital skin biopsy images

A rapidly increasing rate of melanoma diagnosis has been noted over the past three decades, and nearly 1 in 4 skin biopsies are diagnosed as melanocytic lesions. The gold standard for diagnosis of melanoma is the histopathological examination by a pathologist to analyze biopsy material at both the cellular and structural levels. A pathologist's diagnosis is often subjective and prone to variability, while deep learning image analysis methods may improve and complement current diagnostic and prognostic capabilities. Mitoses are important entities when reviewing skin biopsy cases as their presence carries prognostic information; thus, their precise detection is an important factor for clinical care. In addition, semantic segmentation of clinically important structures in skin biopsies might help the diagnosis pipeline with an accurate classification. We aim to provide prognostic and diagnostic information on skin biopsy images, including the detection of cellular level entities, segmentation of clinically important tissue structures, and other important factors toward the accurate diagnosis of skin biopsy images. This paper is an overview of our work on analysis of digital whole slide skin biopsy images, including mitotic figure (mitosis) detection, semantic segmentation, diagnosis, and analysis of pathologists' viewing patterns, and with new work on melanocyte detection. Deep learning has been applied to our methods for all the detection, segmentation, and diagnosis work. In our studies, deep learning is proven superior to prior approaches to skin biopsy analysis. Our work on analysis of pathologists' viewing patterns is the only such work in the skin biopsy literature. Our work covers the whole spectrum from low-level entities through diagnosis and understanding what pathologists do in performing their diagnoses.

Hypoxia and Ezrin Expression in Primary Melanoma Have High Prognostic Relevance

Hypoxia affects tumor aggressiveness and activates pathways associated with epithelial mesenchymal transition (EMT) which are crucial for tumor progress. In this study, the correlation of hypoxia and EMT with sentinel lymph node status and tumor-specific survival was investigated in primary melanomas. CD34 for capillary count and Hypoxia inducible factor-1α (HIF-1α) as hypoxia indicators as well as Ezrin and L1-Cell Adhesion Molecule (L1CAM), both critical proteins contributing to EMT, were analyzed using immunohistochemistry in 49 melanoma patients with long follow-up (F/U, mean 110 months; range 12−263 months). We found a significant correlation between Breslow tumor thickness and Ezrin expression (p = 0.018). L1CAM expression in primary melanoma was significantly associated with HIF-1α expression (p < 0.0001) and sentinel lymph node metastasis (p = 0.011). Furthermore, low capillary count, reflecting hypoxic condition, was significantly associated with Ezrin expression (p = 0.047) and decreased tumor-specific survival (p = 0.035). In addition, patients with high Ezrin expression in their primary melanoma had a dramatic loss of life early in their F/U period (mean survival time 29 months; range 15−44 month). Our results highlight the relevance of Ezrin, L1CAM and HIF-1α as prognostic markers in melanoma patients. Additionally, we demonstrate that hypoxia in primary melanoma affects EMT and is at least partly responsible for early metastatic dissemination.

Evaluation of the Indications for Sentinel Node Biopsy in Early-Stage Melanoma with the Advent of Adjuvant Systemic Therapy: An International, Multicenter Study

BACKGROUND

Patients presenting with early-stage melanoma (AJCC pT1b-pT2a) reportedly have a relatively low risk of a positive SNB (~5-10%). Those patients are usually found to have low-volume metastatic disease after SNB, typically reclassified to AJCC stage IIIA, with an excellent prognosis of ~90% 5-year survival. Currently, adjuvant systemic therapy is not routinely recommended for most patients with AJCC stage IIIA melanoma. The purpose was to assess the SN-positivity rate in early-stage melanoma and to identify primary tumor characteristics associated with high-risk nodal disease eligible for adjuvant systemic therapy METHODS: An international, multicenter retrospective cohort study from 7 large-volume cancer centers identified 3,610 patients with early primary cutaneous melanomas 0.8-2.0 mm in Breslow thickness (pT1b-pT2a; AJCC 8th edition). Patient demographics, primary tumor characteristics, and SNB status/details were analyzed.

RESULTS

The overall SNB-positivity rate was 11.4% (412/3610). Virtually all SNB-positive patients (409/412; 99.3%) were reclassified to AJCC stage IIIA. Multivariate analysis identified age, T-stage, mitotic rate, primary site and subtype, and lymphovascular invasion as independent predictors of sentinel node status. A mitotic rate of >1/mm2 was associated with a significantly increased SN-positivity rate and was the only significant independent predictor of high-risk SNB metastases (>1 mm maximum diameter).

CONCLUSIONS

The new treatment paradigm brings into question the role of SNB for patients with early-stage melanoma. The results of this large international cohort study suggest that a reevaluation of the indications for SNB for some patients with early-stage melanoma is required.

Ulcerated Cutaneous Melanoma: A Review of the Clinical, Histologic, and Molecular Features Associated with a Clinically Aggressive Histologic Phenotype

The presence of ulceration in melanoma is associated with poor clinical outcomes and is the third most powerful predictor of survival in the AJCC Melanoma Staging System after tumor thickness and mitotic activity. The aggressive biological behavior associated with ulceration has been hypothesized to be the result of an intrinsic biological attribute that favors dissemination and presents locally with the loss of epidermal integrity. Among the features of ulcerated melanoma, many show promise as potential prognostic tools, markers of differential immunogenicity and indicators of oncogenic drivers of invasion and metastasis. The incidence of ulcerated melanoma is greater in males, increases with age and with systemic inflammatory risk factors (diabetes, smoking, low vitamin D, elevated body mass index). Patients with ulcerated primary tumors seem to exclusively benefit from adjuvant interferon (IFN) therapy, which is likely the consequence of an altered tumor microenvironment. When ulceration is present, there is a higher density of macrophages and dendritic cells and enhanced expression of pro-inflammatory cytokines, such as IL-6. There is also an increased expression of proteins involved in tumor antigen presentation in ulcerated melanomas. Histologically, vascular density, vasculogenic mimicry and angiotropism are all significantly correlated with ulceration in melanoma. The presence of ulceration is associated with reduced protein expression of E-cadherin and PTEN and elevated levels of N-cadherin and the matrix metalloproteinases. Differential microRNA expression also holds promise as a potential prognostic biomarker of malignancy and disease spread within the setting of ulceration. However, the molecular and cellular differences associated with the ulcerated state are complex and further study will aid in determining how these differences can be harnessed to improve care for patients with melanoma.

Sinonasal Mucosal Melanoma: Role of Tumor Proliferative Indices and Pathological Factors in Survival

OBJECTIVE

The objective of this study is to determine the association of proliferation indices and pathologic biomarkers on overall and recurrence/metastasis-free survival (OS and RMFS) in patients with sinonasal mucosal melanoma (SNMM) and to assess the genetic mutational landscape of SNMM.

METHODS

This is a retrospective cohort study of 45 SNMM patients without neoadjuvant therapy who underwent surgical therapy with curative intent and had tumor tissue available for histopathologic review, molecular analysis, and genetic mutational assessment. The OS and RMFS were assessed for associations with numerous tumor and patient-related factors.

RESULTS

Among proliferative indices, higher Ki67 and mitotic rates were associated with worsened OS and RMFS (Ki67: p = 0.0007 and p < 0.0001; mitotic rate: p = 0.005 and p = 0.0009, respectively). The presence of brisk tumor-infiltrating lymphocytes (TILs) was associated with improved RMFS (p = 0.007) and the presence of lymphovascular invasion was associated with worsened OS and RMFS (p = 0.02 and p = 0.04, respectively). Patients with amelanotic tumors were more likely to have higher T-stage (p = 0.046), less likely to have brisk TILs (p = 0.02) and had worsened RMFS (p = 0.03). Patients on immunotherapy with tumor Ki67 < 40% had better 3-year OS compared to those with higher Ki67 index (p = 0.004). Actionable genetic mutations such as BRAF V600E are rare and present in only 1 of 20 patients tested.

CONCLUSION

In SNMM patients, pathologic and proliferation markers such as Ki67, mitotic rate and brisk TILs are associated with survival and may be considered in future staging systems. Clinical response to immunotherapy appears to correlate with the Ki67 index. Given the distinct genetic profile of SNMM, targeted therapies against the MAPK kinase pathway have limited utility.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Classification and Staging of Melanoma in the Head and Neck

The rates of melanoma continue to rise, with recent estimates have shown that 18% to 22% of new melanoma cases occur within the head and neck in the United States each year. The mainstay of treatment of nonmetastatic primary melanomas of the head and neck includes the surgical resection and management of regional disease as indicated. Thorough knowledge of the classification and staging of melanoma is paramount to evaluate prognosis, determine the appropriate surgical intervention, and assess eligibility for adjuvant therapy and clinic trials. The traditional clinicopathologic classification of melanoma is based on morphologic aspects of the growth phase and distinguishes 4 of the most common subtypes as defined by the World Health Organization: superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. The data used to derive the AJCC TNM Categories are based on superficial spreading melanoma and nodular subtypes. Melanoma is diagnosed histopathologically following initial biopsy that will assist with classifying the tumor to guide treatment. Classification is based on tumor thickness and ulceration (T stage, Breslow Staging), Regional Lymph Node Involvement (N Stage), and presence of metastasis (M Stage). Tumor thickness (Breslow thickness) and ulceration are 2 independent prognostic factors that have been shown to be the strongest predictors of survival and outcome. Clark level of invasion and mitotic rate are no longer incorporated into the current AJCC staging system, but still have shown to be important prognostic factors for cutaneous melanoma. For patients with metastatic (Stage IV) disease Lactate Dehydrogenase remains an independent predictor of survival. The Maxillofacial surgeon must remain up to date on the most current management strategies in this patient population. Classification systems and staging provide the foundation for clinical decision making and prognostication for the Maxillofacial surgeon when caring for these patients.

MelRisk: Using neutrophil-to-lymphocyte ratio to improve risk prediction models for metastatic cutaneous melanoma in the sentinel lymph node

BACKGROUND

Identifying metastatic melanoma in the sentinel lymph node (SLN) is important because 80% of SLN biopsies are negative and 11% of patients develop complications. The neutrophil-to-lymphocyte ratio (NLR), a biomarker of micrometastatic disease, could improve prediction models for SLN status. We externally validated existing models and developed 'MelRisk' prognostic score to better predict SLN metastasis.

METHODS

The models were externally validated using data from a multicenter cohort study of 1,251 adults. Additionally, we developed and internally validated a new prognostic score `MelRisk', using candidate predictors derived from the extant literature.

RESULTS

The Karakousis model had a C-statistic of 0.58 (95% CI, 0.54-0.62). The Sondak model had a C-statistic of 0.57 (95% CI 0.53-0.61). The MIA model had a C-statistic of 0.60 (95% CI. 0.56-0.64). Our 'MelRisk' model (which used Breslow thickness, ulceration, age, anatomical site, and the NLR) showed an adjusted C-statistic of 0.63 (95% CI, 0.56-0.64).

CONCLUSION

Our prediction tool is freely available in the Google Play Store and Apple App Store, and we invite colleagues to externally validate its performance .

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.

Excision Margin and Survival in Patients with High-Risk, Primary Cutaneous Melanoma: A Retrospective Study Based on Surveillance Epidemiology and End Result (SEER) Database

OBJECTIVES

The optimal excision margin of primary cutaneous melanoma greater than 2 mm in thickness is still a controversial topic. The aim of the present study was to compare the long-term survival between narrow and wide excision margins in the surgical excision of patients with high-risk primary melanoma.

METHODS

We chose the patients with primary melanoma of the skin thicker than 2 mm in The Surveillance, Epidemiology, and End Results database. Patients were divided into a narrow margin group (1-2 cm) and a wide margin group (>2 cm) according to the resection margin information. The primary outcome was overall survival and disease-specific survival.

RESULTS

From 2004 to 2015, a total of 2,772 patients diagnosed as having melanoma of the skin were recruited into this study and were assigned to the narrow margin group (n = 1996) and the wide margin group (n = 776). A total of 1,098 patients died during the follow-up, and 681 of these were due to melanoma. There were 779 deaths in the narrow margin group and 319 deaths in the wide margin group (HR: 0.96, 95% CI: 0.84-1.10, p = 0.26). A total of 490 melanoma-specific deaths were reported in the narrow margin group and 191 were reported in the wide margin group (HR: 1.01, 95% CI: 0.85-1.19, p = 0.91).

CONCLUSIONS

Wider excision margin greater than 2 cm did not provide any additional therapeutic benefits compared to narrow excision margin between 1 and 2 cm. A 2-cm margin is adequate and safe for high-risk primary melanoma of the skin thicker than 2 mm.

Cooperation between melanoma cell states promotes metastasis through heterotypic cluster formation

Melanomas can have multiple coexisting cell states, including proliferative (PRO) versus invasive (INV) subpopulations that represent a "go or grow" trade-off; however, how these populations interact is poorly understood. Using a combination of zebrafish modeling and analysis of patient samples, we show that INV and PRO cells form spatially structured heterotypic clusters and cooperate in the seeding of metastasis, maintaining cell state heterogeneity. INV cells adhere tightly to each other and form clusters with a rim of PRO cells. Intravital imaging demonstrated cooperation in which INV cells facilitate dissemination of less metastatic PRO cells. We identified the TFAP2 neural crest transcription factor as a master regulator of clustering and PRO/INV states. Isolation of clusters from patients with metastatic melanoma revealed a subset with heterotypic PRO-INV clusters. Our data suggest a framework for the co-existence of these two divergent cell populations, in which heterotypic clusters promote metastasis via cell-cell cooperation.

More sentinel lymph node biopsies for thin melanomas after transition to AJCC 8th edition do not increase positivity rate: A Danish population-based study of 7148 patients

BACKGROUND

We evaluated the outcome of sentinel lymph node biopsies (SLNB) in patients with thin melanoma before and after the implementation of AJCC 8th edition (AJCC8) and identified predictors of positive sentinel lymph nodes (+SLN).

METHODS

Patients diagnosed with T1 melanomas (Breslow thickness ≤1 mm) during 2016-2017 as per AJCC 7th edition (AJCC7) (n = 3414) and 2018-2019 as per AJCC8 (n = 3734) were identified in the Danish Melanoma Database.

RESULTS

More SLNBs were performed in the AJCC8 cohort compared to the AJCC7 (22.2% vs. 16.2%, p < 0.001), with no significant difference in +SLN rates (4.7% vs. 6.7%, p = 0.118). In the AJCC7 + SLN subgroup, no melanomas were ulcerated, 94.6% had mitotic rate (MR) ≥ 1, 67.6% were ≥0.8 mm and 32.4% would be T1a according to AJCC8. In the AJCC8 + SLN subgroup, 10.3% were ulcerated, 74.4% had MR≥ 1, 97.4% were ≥0.8 mm and 23.1% would be T1a according to AJCC7. On multivariable analysis younger age and MR ≥ 1 were significant predictors of +SLN.

CONCLUSION

More SLNBs were performed in T1 melanomas after transition to AJCC8 without an increase in +SLN rate. None of the AJCC8 T1b criteria were significant predictors of +SLN. We suggest that mitosis and younger age should be considered as indications for SLNB in thin melanoma.

Different mitotic rates are associated with different prognostic factors, relapses, and survival rates in melanoma

BACKGROUND

Mitotic rate is one of the major prognostic factors in melanoma.

OBJECTIVE

To investigate the significance of mitotic rate and possible impacts of clinicopathological factors on the course of all staged melanoma patients.

METHODS

A total number of 970 melanoma patients were analyzed. Mitotic rates were grouped for analysis as follows: 0-1, 1.1-4.9, 5-9.9, and ≥10 mitoses/mm² .

RESULTS

Melanomas with higher mitotic rates were more likely to be associated with nodular histology (P = 0.0001), higher Clark level (P = 0.0001), thick Breslow depth (P = 0.0001), ulceration (P = 0.0001), vertical growth pattern (P = 0.0001), neurotropism (P = 0.04), lymphovascular invasion (P = 0.01), de novo melanoma (P = 0.0001), absence of tumor infiltrating lymphocytes (P = 0.02), advanced stage (P = 0.0001), and relapse (P = 0.0001). The 5-year overall survival (OS) rate of all patients was 68.7%, and it decreased significantly from 87% in melanomas with 0-1 mitoses/mm² to 65.2%, 56.6%, and 50.4% in melanomas with 1.1-4.9, 5-9.9, and ≥10 mitoses/mm² , respectively (P = 0.0001). Age (P = 0.04), gender (P = 0.03), histology (P = 0.0001), Clark level (P = 0.001), T-stage (P = 0.003), ulceration (0.006), node involvement (P = 0.0001), metastasis (P = 0.005), and relapse (P = 0.0001) were correlated with OS in 0-1 mitoses/mm² melanomas, whereas lymphovascular invasion (P = 0.0001), BRAF mutation (P = 0.01), metastasis (P = 0.0001), relapse (P = 0.0001), and relapse pattern (P = 0.005) were found significant for ≥10 mitoses/mm² melanomas.

CONCLUSION

Higher tumor mitotic rates associated with known histopathological and clinical poor prognostic factors were found to be significantly independent predictors of early relapse and unfavorable survival for cutaneous melanoma patients. Moreover, different prognostic variables were found to be affecting survivals in melanoma patients with lower and higher mitosis.

Genetic variants of SDCCAG8 and MAGI2 in mitosis-related pathway genes are independent predictors of cutaneous melanoma-specific survival

Mitosis is a prognostic factor for cutaneous melanoma (CM), but accurate mitosis detection in CM tissues is difficult. Therefore, the 8th Edition of the American Joint Committee on Cancer staging system has removed the mitotic rate as a category criterion of the tumor T-category, based on the evidence that the mitotic rate was not an independent prognostic factor for melanoma survival. As single-nucleotide polymorphisms (SNPs) have been shown to be potential predictors for cutaneous melanoma-specific survival (CMSS), we investigated the potential prognostic value of SNPs in mitosis-related pathway genes in CMSS by analyzing their associations with outcomes of 850 CM patients from The University of Texas MD Anderson Cancer Center in a discovery dataset and validated the findings in another dataset of 409 CM patients from the Harvard University Nurses' Health Study and Health Professionals Follow-up Study. In both datasets, we identified two SNPs (SDCCAG8 rs10803138 G>A and MAGI2 rs3807694 C>T) as independent prognostic factors for CMSS, with adjusted allelic hazards ratios of 1.49 (95% confidence interval = 1.17-1.90, P = .001) and 1.45 (1.13-1.86, P = .003), respectively. Furthermore, their combined unfavorable alleles also predicted a poor survival in both discovery and validation datasets in a dose-response manner (Ptrend  = .0006 and .0001, respectively). Additional functional analysis revealed that both SDCCAG8 rs10803138 A and MAGI2 rs3807694 T alleles were associated with elevated mRNA expression levels in normal tissues. Therefore, these findings suggest that SDCCAG8 rs10803138 G>A and MAGI2 rs3807694 C>T are independent prognostic biomarkers for CMSS, possibly by regulating the mRNA expression of the corresponding genes involved in mitosis.

American Joint Committee on Cancer Staging and Other Platforms to Assess Prognosis and Risk

The eighth edition of the American Joint Committee on Cancer melanoma staging system relies on assessments of the primary tumor (T), regional lymph nodes (N), and distant metastatic sites (M). Its notable updates include tumor thickness measurements to the nearest 0.1 mm, revision of T1a and T1b definitions, re-evaluation of N category descriptors, increased number of stage III subgroupings, and incorporation of a new M1d designation, among others. These changes were based on analyses of a large contemporary international melanoma database. Ultimately, these revisions were made to improve staging and prognostication, risk stratification, and selection of patients for clinical trials.

Histopathologic and Molecular Diagnosis of Melanoma

Conventional histopathology is the primary means of melanoma diagnosis. Both architectural and cytologic features aid in discrimination of melanocytic nevi from melanoma. Communication between the clinician and pathologist regarding the history, examination, differential diagnosis, prior biopsy findings, method of sampling, and specimen orientation is critical to an accurate diagnosis. A melanoma pathology report includes multiple prognostic indicators to guide surgical and medical management. In challenging cases, immunohistochemistry and molecular diagnostics may be of benefit.

Recognition, Staging, and Management of Melanoma

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

Recent developments in head and neck melanoma

PURPOSE OF REVIEW

To provide an overview of recently published articles covering melanoma management of the head and neck region.

RECENT FINDINGS

Melanoma management represents a rapidly evolving field. The advent of immunotherapy has led to significant changes in diagnosis, treatment, and surveillance for these patients. Invasive interventions including completion lymph node dissection have been largely replaced with increased surveillance driven by robust data showing no significant difference in overall survival. Studies have explored various treatment regimens that offer improved outcomes with the least adverse events, with a recent trend towards neoadjuvant therapy. Research has also shifted towards better understanding genetics and biomarkers that influence response to these medications. The best means to both identify and monitor these changes is being explored. As our understanding of this complex disease process continues to grow, prognosis in patients suffering with melanoma should continue to improve.

SUMMARY

The expansion of immunotherapy use in melanoma management has led to significantly improved prognosis in diagnosed patients. Present research is largely focused on better understanding the ideal patient populations, dosing, and surveillance for these therapies. Data from these studies will be crucial in better staging and treating patients with melanoma.

Green Propolis Compounds (Baccarin and p-Coumaric Acid) Show Beneficial Effects in Mice for Melanoma Induced by B16f10

Background: Cutaneous melanoma is the most aggressive form of skin cancer, with the worst prognosis, and it affects a younger population than most cancers. The high metastatic index, in more advanced stages, and the high aggressiveness decrease the effectiveness of currently used therapies, such as surgical removal, radiotherapy, cryotherapy, and chemotherapy, used alone or in combination. Based on these disadvantages, research focused on alternative medicine offers great potential for therapeutic innovation. Medicinal plants represent a remarkable source of compounds for the treatment of various diseases. Methods: In this study, we investigated the tumoral behavior of melanoma under treatment with the compounds baccharin and p-coumaric acid, extracted from green propolis, in mice inoculated with B16F10 cells for 26 days. Results: A significant modulation in the number of inflammatory cells recruited to the tumor region and blood in the groups treated with the compounds was observed. In addition, a significant reduction in the amount of blood vessels and mitosis in the neoplastic area was noticed. Conclusions: Through our research, we confirmed that baccharin and coumaric acid, isolated substances from Brazilian green propolis, have a promising anticarcinogenic potential to be explored for the development of new antitumor agents, adhering to the trend of drugs with greater tolerance and biological effectiveness.

Phenotypic Characteristics and Melanoma Thickness in Women

Patients' phenotypic characteristics might be associated with melanoma aggressiveness, but the evidence is scarce. This study examined the associations be-tween pigmentary characteristics, naevi and melanoma thickness. Data from the Norwegian Women and Cancer (NOWAC) study were analysed. By 2014, 1,243 women were diagnosed with a primary melanoma, and 1,140 had information on thickness. Using ordinal logistic regression models, the probability of being diagnosed with a specific thickness category was calculated by pigmentary score and naevi. Fair pigmentary score was associated with thinner trunk melanomas (probabilities of being diagnosed with a tumour ≤1.0 mm thickness were 74%, 66%, and 51% for fair, medium and dark pigmentary scores, respectively), but not the other sites. High number of naevi was associated with thicker nodular melanoma (NM) but not with super-ficial spreading melanoma. These findings suggest the need for greater overall vigilance and skin checks among women with fair pigmentary score. The association between naevi and NM suggest possible biological mechanisms.

Nodal Recurrence is a Primary Driver of Early Relapse for Patients with Sentinel Lymph Node-Positive Melanoma in the Modern Therapeutic Era

BACKGROUND

Management of patients with sentinel lymph node (SLN)-positive melanoma has changed dramatically over the last few years such that completion lymph node dissection (CLND) has become uncommon, and many patients receive adjuvant immunotherapy or targeted therapy. This study seeks to characterize patterns and predictors of early recurrence in this setting.

PATIENTS AND METHODS

All patients with primary cutaneous melanoma undergoing sentinel lymph node biopsy (SLNB) between 3/2016 and 12/2019 were identified. The subset with a positive SLN who did not undergo CLND were examined for further analysis of outcomes and predictors of recurrence.

RESULTS

Overall, 215 patients with SLN-positive melanoma who did not have CLND were identified. Adjuvant systemic therapy was administered to 102 (47%), with 93% of this subset receiving immunotherapy (n = 95). Median follow-up from SLNB was 20 months (IQR 12-28.5 months), and 57 patients (27%) recurred during this time. The SLN basin was the most common site of recurrence (n = 38, 67% of recurrence), with isolated nodal recurrence being the most common first site of recurrent disease (n = 22, 39% of recurrence). On multivariable analysis, lymphovascular invasion (LVI) of the primary tumor, two or more involved nodes, and > 1 mm nodal deposit were independently associated with higher rates of nodal relapse.

CONCLUSIONS

Nodal recurrence is a primary driver of early disease relapse for patients with SLN-positive melanoma who do not undergo CLND in the era of effective adjuvant systemic therapy. LVI, ≥ 2 nodes, or > 1 mm nodal disease identifies patients at particularly high risk of nodal relapse.

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

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

Standardized Method for Defining a 1-mm2 Region of Interest for Calculation of Mitotic Rate on Melanoma Whole Slide Images

CONTEXT.—

Mitotic rate counting is essential in pathologic evaluations in melanoma. The American Joint Committee on Cancer recommends reporting the number of mitotic figures (MFs) in a 1-mm2 area encompassing the "hot spot." There is currently no standard procedure for delineating a 1-mm2 region of interest for MF counting on a digital whole slide image (WSI) of melanoma.

OBJECTIVE.—

To establish a standardized method to enclose a 1-mm2 region of interest for MF counting in melanoma based on WSIs and assess the method's effectiveness.

DESIGN.—

Whole slide images were visualized using the ImageScope viewer (Aperio). Different monitors and viewing magnifications were explored and the annotation tools provided by ImageScope were evaluated. For validation, we compared mitotic rates obtained from WSIs with our method and those from glass slides with traditional microscopy with 30 melanoma cases.

RESULTS.—

Of the monitors we examined, a 32-inch monitor with 3840 × 2160 resolution was optimal for counting MFs within a 1-mm2 region of interest in melanoma. When WSIs were viewed in the ImageScope viewer, ×10 to ×20 magnification during screening could efficiently locate a hot spot and ×20 to ×40 magnification during counting could accurately identify MFs. Fixed-shape annotations with 500 × 500-μm squares or circles can precisely and efficiently enclose a 1-mm2 region of interest. Our method on WSIs was able to produce a higher mitotic rate than with glass slides.

CONCLUSIONS.—

Whole slide images may be used to efficiently count MFs. We recommend fixed-shape annotation with 500 × 500-μm squares or circles for routine practice in counting MFs for melanoma.

Machine learning techniques for mitoses classification

BACKGROUND

Pathologists analyze biopsy material at both the cellular and structural level to determine diagnosis and cancer stage. Mitotic figures are surrogate biomarkers of cellular proliferation that can provide prognostic information; thus, their precise detection is an important factor for clinical care. Convolutional Neural Networks (CNNs) have shown remarkable performance on several recognition tasks. Utilizing CNNs for mitosis classification may aid pathologists to improve the detection accuracy.

METHODS

We studied two state-of-the-art CNN-based models, ESPNet and DenseNet, for mitosis classification on six whole slide images of skin biopsies and compared their quantitative performance in terms of sensitivity, specificity, and F-score. We used raw RGB images of mitosis and non-mitosis samples with their corresponding labels as training input. In order to compare with other work, we studied the performance of these classifiers and two other architectures, ResNet and ShuffleNet, on the publicly available MITOS breast biopsy dataset and compared the performance of all four in terms of precision, recall, and F-score (which are standard for this data set), architecture, training time and inference time.

RESULTS

The ESPNet and DenseNet results on our primary melanoma dataset had a sensitivity of 0.976 and 0.968, and a specificity of 0.987 and 0.995, respectively, with F-scores of .968 and .976, respectively. On the MITOS dataset, ESPNet and DenseNet showed a sensitivity of 0.866 and 0.916, and a specificity of 0.973 and 0.980, respectively. The MITOS results using DenseNet had a precision of 0.939, recall of 0.916, and F-score of 0.927. The best published result on MITOS (Saha et al. 2018) reported precision of 0.92, recall of 0.88, and F-score of 0.90. In our architecture comparisons on MITOS, we found that DenseNet beats the others in terms of F-Score (DenseNet 0.927, ESPNet 0.890, ResNet 0.865, ShuffleNet 0.847) and especially Recall (DenseNet 0.916, ESPNet 0.866, ResNet 0.807, ShuffleNet 0.753), while ResNet and ESPNet have much faster inference times (ResNet 6 s, ESPNet 8 s, DenseNet 31 s). ResNet is faster than ESPNet, but ESPNet has a higher F-Score and Recall than ResNet, making it a good compromise solution.

CONCLUSION

We studied several state-of-the-art CNNs for detecting mitotic figures in whole slide biopsy images. We evaluated two CNNs on a melanoma cancer dataset and then compared four CNNs on a public breast cancer data set, using the same methodology on both. Our methodology and architecture for mitosis finding in both melanoma and breast cancer whole slide images has been thoroughly tested and is likely to be useful for finding mitoses in any whole slide biopsy images.

Distribution pattern of tumor infiltrating lymphocytes and tumor microenvironment composition as prognostic indicators in anorectal malignant melanoma

Anorectal malignant melanoma (ARMM) is a rare disease with poor prognosis. Determining ARMM prognosis precisely is difficult due to the lack of proper assessment techniques. Immunotherapy has proven effective against cutaneous malignant melanoma and may show efficacy in ARMM. Herein, we assessed the immune profile of ARMM to identify possible prognostic biomarkers. Twenty-two ARMM formalin-fixed and paraffin-embedded samples were evaluated using an nCounter^® PanCancer Immune Profiling Panel. Validation was performed through immunohistochemical staining for CD3, CD8, Foxp3, CD68, CD163, and PD-L1. RNA analysis revealed significantly decreased scores for pathways involved in cell regulation and function, as well as chemokines, in recurrent patients compared to nonrecurrent patients. In cell-type profiling, the recurrent cases displayed significantly low tumor infiltrating lymphocyte (TIL) scores. Recurrence/death prediction models were defined using logistic regression and showed significantly lower scores in recurrent and deceased patients (all, P < 0.001) compared to those in nonrecurrent and surviving patients. The high total TIL and tumor-associated macrophage (TAM) groups had significantly better overall survival outcomes compared to the low total TIL and TAM groups (P = 0.007 and P = 0.035, respectively). In addition, the presence of CD3 + TILs in the invasion front was an independent favorable prognostic indicator (P = 0.003, hazard ratio = 0.21, 95% confidential interval, 0.01-0.41). Patients with inflamed or brisk-infiltration type tumors also had a significantly better overall survival than that of patients with immune-desert/excluded and absent/non-brisk type tumors (P = 0.03 and P = 0.0023, respectively). In conclusion, TILs have a strong prognostic value in ARMM, and the quantification of TILs and an analysis of the TIL phenotype and infiltration pattern during pathological diagnosis are essential to guide treatment strategies and accurate prognosis in ARMM.

Prognostic significance of regression and mitotic rate in head and neck cutaneous melanoma

Importance

While regression is a commonly reported microscopic feature of melanoma, its prognostic significance is unclear.

Objective

To examine the impact of regression on sentinel node status and the likelihood of recurrence in primary cutaneous melanoma of the head and neck.

Design

Retrospective analysis of 191 adults who underwent surgical management for primary cutaneous melanoma of the head and neck between May 2002 and March 2019.

Setting

Tertiary academic center.

Participants

Patients appropriate for the study were identified by the Academic Health Center Information Exchange using a list of current procedural terminology codes. One hundred and ninety‐one cases of invasive melanoma of the head and neck were included from 830 patients identified. Clinical features assessed for each patient included age, sex, location of primary lesion, date of diagnosis, and current disease status (alive with or without disease). Histologic features assessed were histological melanoma subtype (nodular vs non‐nodular), Breslow thickness, Clark level, presence/absence of ulceration, mitotic rate per square millimeter, and regression. If applicable, sentinel lymph node biopsy (SLNB) status, date of recurrence, interval treatments, and date of death related to melanoma were recorded. Exclusion criteria included melanoma outside the anatomic parameters of head and neck, ocular or choroidal melanoma, mucosal melanoma, metastatic melanoma to the head or neck with no known primary tumor, melanoma of the head or neck with no surgical intervention, and non‐melanoma skin cancers of the head and neck.

Intervention/Exposure

Surgery for cutaneous melanoma of the head and neck.

Main Outcome(s) and Measure(s)

The association between presence of regression and Breslow thickness, sentinel node status, and recurrence.

Results

Of the 191 patients identified, 30.9% were female and 69.1% were male with a mean age at diagnosis of 62.6 (range 20‐97) years. Mean Breslow thickness was 1.2 mm in those with regression and 2.0 mm in those without regression. In patients with regression, 17.6% had a positive sentinel node, and 13.0% experienced a recurrence. In patients without regression, 26.5% had a positive sentinel node, and 31.4% experienced a recurrence. When adjusted for other factors above, regression was not associated with positive sentinel node (odds ratio [OR] = 0.59, 95% confidence interval [CI] = 0.13‐2.00) or recurrence (OR = 0.33, CI = 0.07‐1.01). Mitotic rate >2 was associated with recurrence (OR = 2.71, CI = 1.11‐6.75, P = .03).

Conclusions and Relevance

Patients with presence of regression had thinner melanomas and trended toward decreased rates of sentinel node positivity and recurrence, suggesting regression may not be a negative prognostic indicator in patients with cutaneous melanoma of the head and neck.

Overcoming Immune Evasion in Melanoma

Melanoma is the most aggressive and dangerous form of skin cancer that develops from transformed melanocytes. It is crucial to identify melanoma at its early stages, in situ, as it is "curable" at this stage. However, after metastasis, it is difficult to treat and the five-year survival is only 25%. In recent years, a better understanding of the etiology of melanoma and its progression has made it possible for the development of targeted therapeutics, such as vemurafenib and immunotherapies, to treat advanced melanomas. In this review, we focus on the molecular mechanisms that mediate melanoma development and progression, with a special focus on the immune evasion strategies utilized by melanomas, to evade host immune surveillances. The proposed mechanism of action and the roles of immunotherapeutic agents, ipilimumab, nivolumab, pembrolizumab, and atezolizumab, adoptive T- cell therapy plus T-VEC in the treatment of advanced melanoma are discussed. In this review, we implore that a better understanding of the steps that mediate melanoma onset and progression, immune evasion strategies exploited by these tumor cells, and the identification of biomarkers to predict treatment response are critical in the design of improved strategies to improve clinical outcomes for patients with this deadly disease.

Prognostic value of intratumoral lymphocyte-to-monocyte ratio and M0 macrophage enrichment in tumor immune microenvironment of melanoma

Skin cutaneous melanoma is characterized by significant heterogeneity in its molecular, genomic and immunologic features. Whole transcriptome RNA sequencing data from The Cancer Genome Atlas of skin cutaneous melanoma (n = 328) was utilized. CIBERSORT was used to identify immune cell type composition, on which unsupervised hierarchical clustering was performed. Analysis of overall survival was performed using Kaplan–Meier estimates and multivariate Cox regression analyses. Membership in the lymphocyte:monocyte^low, monocyte^high and M0^high cluster was an independently poor prognostic factor for survival (HR: 3.03; 95% CI: 1.12–8.20; p = 0.029) and correlated with decreased predicted response to immune checkpoint blockade. In conclusion, an M0-macrophage-enriched, lymphocyte-to-monocyte-ratio-low phenotype in the primary melanoma tumor site independently characterizes an aggressive phenotype that may differentially respond to treatment.

WNT11-FZD7-DAAM1 signalling supports tumour initiating abilities and melanoma amoeboid invasion

Melanoma is a highly aggressive tumour that can metastasize very early in disease progression. Notably, melanoma can disseminate using amoeboid invasive strategies. We show here that high Myosin II activity, high levels of ki-67 and high tumour-initiating abilities are characteristic of invasive amoeboid melanoma cells. Mechanistically, we find that WNT11-FZD7-DAAM1 activates Rho-ROCK1/2-Myosin II and plays a crucial role in regulating tumour-initiating potential, local invasion and distant metastasis formation. Importantly, amoeboid melanoma cells express both proliferative and invasive gene signatures. As such, invasive fronts of human and mouse melanomas are enriched in amoeboid cells that are also ki-67 positive. This pattern is further enhanced in metastatic lesions. We propose eradication of amoeboid melanoma cells after surgical removal as a therapeutic strategy.

Development and validation of prognostic nomogram in patients with nonmetastatic malignant melanoma: a SEER population-based study

BACKGROUND

The condition of tumor recurrence and overall death can be worried in the progress of nonmetastatic malignant melanoma (NMMM). Our goal was to construct and validate a prognostic nomogram from a large population database, which is vital for physicians to predict the 3- and 5-year overall survival (OS) rates of patients with NMMM.

METHODS

According to the Surveillance, Epidemiology, and End Results (SEER) program, patients were collected and randomly assigned into the training and validation cohorts. Several independent risk factors were identified based on the methods of univariable and multivariable cox hazards regression and were incorporated to develop a nomogram. The concordance index (C-index), the area under the receiver operating characteristics (AUC) curve and calibration plot were confirmed to assess predictive power of the nomogram. Decision curve analysis (DCA) was performed to measure nomogram for the clinical practice.

RESULTS

A total of 66192 eligible patients, randomly assigned into 70% of training (n = 46 336) and 30% of validation cohorts (n = 19 856), were selected in this study. The selected independent factors were applied to develop a nomogram, and validated indexes indicated nomogram had a good discrimination ability. The C-index for OS rates was 0.817 (95% CI: 0.811-0.823) in training cohort and 0.817 (95% CI: 0.809-0.825) in validation cohort, respectively. The AUCs of 3- and 5-year OS rates were more than 0.79, and the calibration plots also showed a good power for the nomogram. DCA demonstrated that constructed nomogram can provide clinical net benefit.

CONCLUSION

We constructed a novel nomogram that more accurately and comprehensively predict OS with nonmetastatic malignant melanoma patients, which is vital for clinician to improve individual treatment, make reasonable clinical decisions, and set appropriate follow-up strategies.

Mitotic count: A need for standardization

PURPOSE

The mitotic count (MC), number of mitosis per unit area, is a very important parameter frequently used for classification and grading of some tumors. Traditionally, the MC has been expressed in terms of number of mitoses per high power field. The size of the field of view can vary greatly among different microscopes. In order to avoid under or overestimation of mitotic count, a conversion needs to be made.

METHODS

A simple formula based on a simple rule of three has been devised to standardize the mitotic count to the reference area by multiplying the number of mitotic figures by a correction factor which has been calculated for the most frequently used microscopes and various common tumors.

RESULTS AND CONCLUSIONS

We propose this simple method, which involves only a single multiplication, to standardize the mitotic count to the reference area.

The role of cyclin D1 and Ki-67 in the development and prognostication of thin melanoma

AIMS

Despite their low individual metastatic potential, thin melanomas (≤1 mm Breslow thickness) contribute significantly to melanoma mortality overall. Therefore, identification of prognostic biomarkers is particularly important in this subgroup of melanoma. Prompted by preclinical results, we investigated cyclin D1 protein and Ki-67 expression in in-situ, metastatic and non-metastatic thin melanomas.

METHODS AND RESULTS

Immunohistochemistry was performed on 112 melanoma specimens, comprising 22 in situ, 48 non-metastatic and 42 metastatic thin melanomas. Overall, epidermal and dermal cyclin D1 and Ki-67 expression were semiquantitatively evaluated by three independent investigators and compared between groups. Epidermal Ki-67 expression did not differ statistically in in-situ and invasive melanoma (P = 0.7). Epidermal cyclin D1 expression was significantly higher in thin invasive than in in-situ melanoma (P = 0.003). No difference was found in cyclin D1 expression between metastatic and non-metastatic invasive tumours. Metastatic and non-metastatic thin melanomas did not show significant differences in epidermal expression of Ki-67 and cyclin D1 (P = 0.148 and P = 0.611, respectively). In contrast, strong dermal expression of Ki-67 was more frequent in metastatic than non-metastatic samples (28.6 versus 8.3%, respectively, P = 0.001). The prognostic value of dermal Ki-67 expression was confirmed by multivariate analysis (P = 0.047).

CONCLUSION

We found an increased expression of cyclin D1 in invasive thin melanomas compared to in-situ melanomas, which supports a potential role of this protein in early invasion in melanoma, as suggested by preclinical findings. Moreover, our results confirm that high dermal Ki-67 expression is associated with an increased risk of development of metastasis in thin melanoma and could possibly serve as a prognostic biomarker in clinical practice, especially if combined with additional methods.

Clinicopathological Features, Staging, and Current Approaches to Treatment in High-Risk Resectable Melanoma

The incidence of melanoma in the United States has been increasing over the past several decades. Prognosis largely depends on disease stage, with 5-year melanoma-specific survival ranging from as high as 99% in patients with stage I disease to less than 10% for some patients with stage IV (distant metastatic) disease. Fortunately, in the last 5-10 years, there have been remarkable treatment advances for patients with high-risk resectable melanoma, including approval of targeted and immune checkpoint blockade therapies. In addition, results of recent clinical trials have confirmed the importance of sentinel lymph node biopsy and continue to refine the approach to regional lymph node basin management. Lastly, the melanoma staging system was revised in the eighth edition AJCC Cancer Staging Manual, which was implemented on January 1, 2018. Here we discuss these changes and the clinicopathological features that confer high risk for locoregional and distant disease relapse and poor survival. Implications regarding the management of melanoma in the metastatic and adjuvant settings are discussed, as are future directions for neoadjuvant therapies.