Age and Cohort Trends of Malignant Melanoma in the United States

Does Sex Matter? Temporal Analyses of Melanoma Trends among Men and Women Suggest Etiologic Heterogeneity

The incidence and distribution of cutaneous melanoma differ between the sexes, but it is unclear whether these differences have been constant through time or across generations. We compared incidence trends by age, sex, and anatomic site by analyzing long-term melanoma data (1982-2018) in 3 populations residing at high-, moderate-, and low-ambient sun exposure: Queensland, Australia; United States White; and Scotland. We fit age-period-cohort models and compared trends in the male-to-female incidence rate ratio by site and sex. In men, melanoma incidence was always highest on the trunk; in women, incidence was historically highest on limbs, but there have been recent increases in truncal melanoma among females in all populations. The incidence rate ratio showed excess melanoma on the lower limb in females in most age groups in all populations. In contrast, there was a male excess of melanoma on the trunk (from about age 25 years) and head/neck (from about age 40 years), which increased with age. Birth cohort analyses identified turning points in incidence from high to low incidence among recent birth cohorts, which differed by population and site. Changing exposure to UVR is implicated, possibly superimposed upon innate differences between the sexes in site-specific susceptibility.

The reduced mortality of malignant melanoma at the population level is mainly attributable to treatment advances for the past decade

BACKGROUND

Cutaneous malignant melanoma (CMM) causes most skin cancer deaths in the United States (US). The mortality has been decreasing in the US population. We hypothesize that this population-level reduction is mainly attributable to the treatment advances, rather than the successful primary and secondary prevention.

METHODS

Using data from the Surveillance, Epidemiology, and End Results (SEER) databases, we collected the incidence, incidence-based mortality (IBM), and 5-year survival (5-YS) rates of CMM from 1994 to 2019. Trends by stage and sex were examined by joinpoint regression analyses and age-period-cohort analyses.

RESULTS

The overall incidence of CMM rose by 1.6% yearly from 1994 to 2006 (95% confidence interval [CI]: 0.9% to 2.2%) and then increased with a numerical trend. And we projected the incidence will continue to increase until 2029. In contrast, the IBM for all CMM has decreased yearly by 2.8% (95% CI: -3.9% to -1.8%) since 2010 after continuously increasing by 3.8% annually (95% CI: 3.2% to 4.4%) from 1996 to 2010. For early-stage (localized and regional) CMM, we found the incidence since 2005 plateaued without further increase, while the incidence for CMM at distant stage continuously increased by 1.4% per year (95% CI: 0.9% to 2.0%). Improvements in 5-YS were observed over the study period for all CMM and were most obvious in distant stage. And significant period effects were noted around the year 2010.

CONCLUSION

This study demonstrated improved survival and reduced mortality of CMM at the US population level since 2010, which were consistent with the introduction of novel therapies. Encouraging effects of primary prevention among adolescents in the most recent cohorts were found. However, the plateaued overall incidence and early diagnosis rates indicated that advances in primary and secondary prevention are very much needed to further control the burden of CMM.

Topical and Intralesional Immunotherapy for Melanoma In Situ: A Review

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

Integrative CRISPR Activation and Small Molecule Inhibitor Screening for lncRNA Mediating BRAF Inhibitor Resistance in Melanoma

The incidence of melanoma, being one of the most commonly occurring cancers, has been rising since the past decade. Patients at advanced stages of the disease have very poor prognoses, as opposed to at the earlier stages. The conventional targeted therapy is well defined and effective for advanced-stage melanomas for patients not responding to the standard-of-care immunotherapy. However, targeted therapies do not prove to be as effective as patients inevitably develop V-Raf Murine Sarcoma Viral Oncogene Homolog B (BRAF)-inhibitor resistance to the respective drugs. Factors which are driving melanoma drug resistance mainly involve mutations in the mitogen-activated protein kinase (MAPK) pathway, e.g., BRAF splice variants, neuroblastoma RAS viral oncogene homolog (NRAS) amplification or parallel survival pathways. However, those mechanisms do not explain all cases of occurring resistances. Therefore, other factors accounting for BRAFi resistance must be better understood. Among them there are long non-coding RNAs (lncRNAs), but these remain functionally poorly understood. Here, we conduct a comprehensive, unbiased, and integrative study of lncRNA expression, coupled with a Clustered Regularly Interspaced Short Palindromic Repeats/Cas9-mediated activation (CRISPRa) and small molecule inhibitor screening for BRAF inhibitor resistance to expand the knowledge of potentially druggable lncRNAs, their function, and pave the way for eventual combinatorial treatment approaches targeting diverse pathways in melanoma.

The effects of exposure to solar radiation on human health

This assessment by the Environmental Effects Assessment Panel (EEAP) of the Montreal Protocol under the United Nations Environment Programme (UNEP) evaluates the effects of ultraviolet (UV) radiation on human health within the context of the Montreal Protocol and its Amendments. We assess work published since our last comprehensive assessment in 2018. Over the last four years gains have been made in knowledge of the links between sun exposure and health outcomes, mechanisms, and estimates of disease burden, including economic impacts. Of particular note, there is new information about the way in which exposure to UV radiation modulates the immune system, causing both harms and benefits for health. The burden of skin cancer remains high, with many lives lost to melanoma and many more people treated for keratinocyte cancer, but it has been estimated that the Montreal Protocol will prevent 11 million cases of melanoma and 432 million cases of keratinocyte cancer that would otherwise have occurred in the United States in people born between 1890 and 2100. While the incidence of skin cancer continues to rise, rates have stabilised in younger populations in some countries. Mortality has also plateaued, partly due to the use of systemic therapies for advanced disease. However, these therapies are very expensive, contributing to the extremely high economic burden of skin cancer, and emphasising the importance and comparative cost-effectiveness of prevention. Photodermatoses, inflammatory skin conditions induced by exposure to UV radiation, can have a marked detrimental impact on the quality of life of sufferers. More information is emerging about their potential link with commonly used drugs, particularly anti-hypertensives. The eyes are also harmed by over-exposure to UV radiation. The incidence of cataract and pterygium is continuing to rise, and there is now evidence of a link between intraocular melanoma and sun exposure. It has been estimated that the Montreal Protocol will prevent 63 million cases of cataract that would otherwise have occurred in the United States in people born between 1890 and 2100. Despite the clearly established harms, exposure to UV radiation also has benefits for human health. While the best recognised benefit is production of vitamin D, beneficial effects mediated by factors other than vitamin D are emerging. For both sun exposure and vitamin D, there is increasingly convincing evidence of a positive role in diseases related to immune function, including both autoimmune diseases and infection. With its influence on the intensity of UV radiation and global warming, the Montreal Protocol has, and will have, both direct and indirect effects on human health, potentially changing the balance of the risks and benefits of spending time outdoors.

Trends in three major histological subtypes of cutaneous melanoma in the Netherlands between 1989 and 2016

BACKGROUND

Time trend analysis of cutaneous melanoma (CM) mortality in fair skin populations shows both a gradual decrease and/or an increase. To explain these differences, we analyzed long-term time trends in the incidence of the most common histological subtypes of CM: superficial spreading melanoma (SSM), lentigo maligna melanoma (LMM), and nodular melanoma (NM).

METHODS

Using data from the Netherlands Cancer Registry and Statistics Netherlands, the number and rates of cases diagnosed with SSM, LLM, and NM from 1989 to 2016 were analyzed by age, calendar period, and birth cohort of people born in successive periods from 1925 to 1973.

RESULTS

Primary CM was diagnosed in 52,000 men and 66,588 women in the study period. The annual age-standardized incidence rate increased three-fold from 14 to 42 per 100,000 person-years. The most common subtype was SSM (50%), followed by LMM (23%) and NM (14%). Age-specific subtype rates showed an upward trend over time for both men and women. Younger birth cohorts had higher rates of SSM and LMM diagnosis than older birth cohorts. This birth cohort pattern was not observed for NM.

CONCLUSIONS

We observed a strong increase in the melanoma epidemic curves in the light-skinned Dutch population over the last three decades. This increase is explained by younger generations having higher rates of SSM and LMM than older generations.

Hybrid Techniques for the Diagnosis of Acute Lymphoblastic Leukemia Based on Fusion of CNN Features

Acute lymphoblastic leukemia (ALL) is one of the deadliest forms of leukemia due to the bone marrow producing many white blood cells (WBC). ALL is one of the most common types of cancer in children and adults. Doctors determine the treatment of leukemia according to its stages and its spread in the body. Doctors rely on analyzing blood samples under a microscope. Pathologists face challenges, such as the similarity between infected and normal WBC in the early stages. Manual diagnosis is prone to errors, differences of opinion, and the lack of experienced pathologists compared to the number of patients. Thus, computer-assisted systems play an essential role in assisting pathologists in the early detection of ALL. In this study, systems with high efficiency and high accuracy were developed to analyze the images of C-NMC 2019 and ALL-IDB2 datasets. In all proposed systems, blood micrographs were improved and then fed to the active contour method to extract WBC-only regions for further analysis by three CNN models (DenseNet121, ResNet50, and MobileNet). The first strategy for analyzing ALL images of the two datasets is the hybrid technique of CNN-RF and CNN-XGBoost. DenseNet121, ResNet50, and MobileNet models extract deep feature maps. CNN models produce high features with redundant and non-significant features. So, CNN deep feature maps were fed to the Principal Component Analysis (PCA) method to select highly representative features and sent to RF and XGBoost classifiers for classification due to the high similarity between infected and normal WBC in early stages. Thus, the strategy for analyzing ALL images using serially fused features of CNN models. The deep feature maps of DenseNet121-ResNet50, ResNet50-MobileNet, DenseNet121-MobileNet, and DenseNet121-ResNet50-MobileNet were merged and then classified by RF classifiers and XGBoost. The RF classifier with fused features for DenseNet121-ResNet50-MobileNet reached an AUC of 99.1%, accuracy of 98.8%, sensitivity of 98.45%, precision of 98.7%, and specificity of 98.85% for the C-NMC 2019 dataset. With the ALL-IDB2 dataset, hybrid systems achieved 100% results for AUC, accuracy, sensitivity, precision, and specificity.

Predictive accuracy of elevated mitotic rate on lymph node positivity and recurrence in thin melanomas

Background

Mitotic rate (MR) is considered an important prognostic factor for melanoma but is not currently used for staging because its nuanced effect is not yet well-delineated. We sought to determine if T category-specific MR is predictive of sentinel lymph node (SLN) positivity, recurrence, and melanoma-specific mortality (MSM).

Methods

A retrospective review of patients with primary cutaneous melanoma from 1994 to 2020 at a single academic center was performed. Patient demographics and tumor characteristics were recorded. MR was considered elevated for each AJCC8-defined T category if it was ≥2 mitoses/mm² for T1, ≥4 mitoses/mm² for T2, ≥6 mitoses/mm² for T3, or ≥7 mitoses/mm² for T4. Statistical analysis was performed to assess the predictive accuracy of MR on selected outcomes while controlling for ulceration.

Results

Data from 2,984 patients with complete records were analyzed. Along with Breslow thickness and ulceration, elevated MR was associated with higher risk of MSM (HR 1.816, P=0.0001). There was no difference among patients with ulcerated T1 or T2 tumors regardless of MR, but those with non-ulcerated T1 or T2 tumors and elevated MR were more likely to have positive SLNs (P<0.0001 and P=0.0043, respectively) and recurrence (P=0.0007 and P=0.0004, respectively) compared to counterparts with low MR. There were no notable differences for T3 or T4 tumors based on MR.

Conclusions

Elevated MR is associated with SLN positivity and recurrence in thin melanomas, independent of ulceration. SLN biopsy should therefore be strongly considered for patients with non-ulcerated lesions <0.8 mm thick if the MR is ≥2 mitoses/mm².

Not Your Mother's Melanoma: Causes and Effects of Early Melanoma Diagnosis

The year 2022 will herald approximately 100,000 new cases of cutaneous melanoma (CM), and over 7000 deaths from CM. Over the past 40 years, CM incidence has increased nearly six-fold; however, annual mortality has remained relatively constant. These trends encapsulate the phenomenon of overdiagnosis. Increased recognition of indolent lesions that appear histologically malignant may be leading to a melanoma epidemic. Enhanced melanoma awareness, screening efforts, physician uncertainty, medical-legal pressures, and diagnostic scrutiny using tools like immunohistochemical staining, mole mapping, dermoscopy, confocal microscopy, and molecular diagnostics contribute to increased CM diagnosis. As a result, current melanoma staging and treatment guidelines are being challenged. Existing standards fail to accurately identify histologically benign lesions that are lethal or, conversely, histologically malignant lesions that are innocuous. Healthcare systems and, more importantly, patients suffer from this diagnostic ambiguity that leads to the over-treatment of innocuous melanomas and under-treatment of aggressive melanomas. As dermatology continues to experience a shift towards earlier diagnosis of melanoma, management strategies must adapt. Herein, we review factors that may contribute to the increased incidence of melanoma, emphasize deficiencies in current staging systems, and provide insights into the future of melanoma management via precision medicine.

Expert Consensus on the Use of Prognostic Gene Expression Profiling Tests for the Management of Cutaneous Melanoma: Consensus from the Skin Cancer Prevention Working Group

BACKGROUND

Prognostic assessment of cutaneous melanoma relies on historical, clinicopathological, and phenotypic risk factors according to American Joint Committee on Cancer(AJCC) and National Comprehensive Cancer Network (NCCN) guidelines but may not account for a patient's individual additional genetic risk factors.

OBJECTIVE

To review the available literature regarding commercially available gene expression profile (GEP) tests and their use in the management of cutaneous melanoma.

METHODS

A literature search was conducted for original, English-language studies or meta-analyses published between 2010 and 2021 on commercially available GEP tests in cutaneous melanoma prognosis, clinical decision-making regarding sentinel lymph node biopsy, and real-world efficacy. After the literature review, the Skin Cancer Prevention Working Group, an expert panel of dermatologists with specialized training in melanoma and non-melanoma skin cancer diagnosis and management, utilized a modified Delphi technique to develop consensus statements regarding prognostic gene expression profile tests. Statements were only adopted with a supermajority vote of > 80%.

RESULTS

The initial search identified 1064 studies/meta-analyses that met the search criteria. Of these, we included 21 original articles and meta-analyses that studied the 31-GEP test (DecisionDx-Melanoma; Castle Biosciences, Inc.), five original articles that studied the 11-GEP test (Melagenix; NeraCare GmbH), and four original articles that studied the 8-GEP test with clinicopathological factors (Merlin; 8-GEP + CP; SkylineDx B.V.) in this review. Six statements received supermajority approval and were adopted by the panel.

CONCLUSION

GEP tests provide additional, reproducible information for dermatologists to consider within the larger framework of the eighth edition of the AJCC and NCCN cutaneous melanoma guidelines when counseling regarding prognosis and when considering a sentinel lymph node biopsy.

Shared Gene Expression and Immune Pathway Changes Associated with Progression from Nevi to Melanoma

Simple Summary

Melanoma is a deadly skin cancer, and the incidence of melanoma is rising. Chemoprevention, using small molecule drugs to prevent the development of cancer, is a key strategy that could reduce the burden of melanoma on society. The long-term goal of our study is to develop a gene signature biomarker of progression from nevi to melanoma. We found that a small number of genes can distinguish nevi from melanoma and identified shared genes and immune-related pathways that are associated with progression from nevi to melanoma across independent datasets. This study demonstrates (1) a novel approach to aid melanoma chemoprevention trials by using a gene signature as a surrogate endpoint and (2) the feasibility of determining a gene signature biomarker of melanoma progression.

Abstract

There is a need to identify molecular biomarkers of melanoma progression to assist the development of chemoprevention strategies to lower melanoma incidence. Using datasets containing gene expression for dysplastic nevi and melanoma or melanoma arising in a nevus, we performed differential gene expression analysis and regularized regression models to identify genes and pathways that were associated with progression from nevi to melanoma. A small number of genes distinguished nevi from melanoma. Differential expression of seven genes was identified between nevi and melanoma in three independent datasets. C1QB, CXCL9, CXCL10, DFNA5 (GSDME), FCGR1B, and PRAME were increased in melanoma, and SCGB1D2 was decreased in melanoma, compared to dysplastic nevi or nevi that progressed to melanoma. Further supporting an association with melanomagenesis, these genes demonstrated a linear change in expression from benign nevi to dysplastic nevi to radial growth phase melanoma to vertical growth phase melanoma. The genes associated with melanoma progression showed significant enrichment of multiple pathways related to the immune system. This study demonstrates (1) a novel application of bioinformatic approaches to aid clinical trials of melanoma chemoprevention and (2) the feasibility of determining a gene signature biomarker of melanomagenesis.