Melanoma incidence, recurrence, and mortality in an integrated healthcare system: A retrospective cohort study

Identification of immune-related genes and integrated analysis of immune-cell infiltration in melanoma

OBJECTIVE

This study was conducted to screen out immune-related genes in connection with the prognosis of melanoma, construct a prognosis model and explore the relevant mechanisms.

METHODS AND MATERIALS

1973 genes associated with immune system were derived from the Immport database, and RNA-seq data of melanoma and information of patients were searched from the Xena database. Cox univariate analysis, Lasso analysis and Cox multivariate analysis were used to screen out six genes to construct the model. Then the risk scores were estimated for patients based on our constructed prognosis model. Estimate was used to affirm that the model was about immune infiltration, and CIBERSORT was used to screen out immune cells associated with prognosis. TIDE was applied to predict the efficacy of immunotherapy. Finally, GSE65904 and GSE19234 were used to confirm the effectiveness of the model.

RESULTS

ADCYAP1R1, GPI, NTS might cause poor prognosis while IFITM1, KIR2DL4, LIF were more likely conductive to prognosis of melanoma patients and a model of prognosis was constructed on the basis of these six genes. The effectiveness of the model has been proven by the ROC curve, and the miRNAs targeting the screened genes were found out, suggesting that the immune system might impact on the prognosis of melanoma by T cell CD8+, T cell CD4+ memory and NK cells.

CONCLUSIONS

In this study, the screened six genes were associated with the prognosis of melanoma, which was conductive to clinical prognostic prediction and individualized treatment strategy.

Temporal Recurrence of Cutaneous Melanoma: Analysis of a Case Series

Introduction

The recurrence of cutaneous melanoma is one of the main reasons for surveillance after primary tumor treatment, and there is still little data on melanoma recurrence related to the Brazilian population.

Objective

We sought to evaluate the profile of patients with cutaneous melanoma recurrence within five years of (early) and five years after (late) initial diagnosis.

Methods

Patients diagnosed between 2006 and 2014 in a private reference service in Belo Horizonte, Brazil, were included. Demographic, clinical, histopathological, and disease evolution variables were collected and analyzed using the R version 4.0.0 program. A p-value less than 0.05 was considered significant.

Results

The sample was composed of 331 patients with melanoma, and the 43 patients with recurrence presented with higher mean age (p=0.049), male predominance (p=0.030), a lower proportion of Breslow thickness under 0.8mm (p<0.001), and a more significant presence of mitosis (p=0.007). The 29 patients (8.8%) with early recurrence presented with tumors with ulceration (p<0.018). Late recurrence occurred in 14 patients (4.2%). Five patients relapsed after 10 years; most of them had tumors up to 1mm thick, without ulceration, regression, or satellitosis, but with the presence of mitosis.

Conclusion

The possibility of cutaneous melanoma recurrence after five, and even 10, years, although rare, might indicate the need for longer medical follow-up. Multicenter studies may better characterize Brazilian patient profiles of those with early and late recurrence of melanoma.

Tebentafusp in combination with durvalumab and/or tremelimumab in patients with metastatic cutaneous melanoma: a phase 1 study

BACKGROUND

Immune checkpoint inhibitors have significantly improved outcomes in first line cutaneous melanoma. However, there is a high unmet need for patients who progress on these therapies and combination therapies are being explored to improve outcomes. Tebentafusp is a first-in-class gp100×CD3 ImmTAC bispecific that demonstrated overall survival (OS) benefit (HR 0.51) in metastatic uveal melanoma despite a modest overall response rate of 9%. This phase 1b trial evaluated the safety and initial efficacy of tebentafusp in combination with durvalumab (anti-programmed death ligand 1 (PDL1)) and/or tremelimumab (anti-cytotoxic T lymphocyte-associated antigen 4) in patients with metastatic cutaneous melanoma (mCM), the majority of whom progressed on prior checkpoint inhibitors.

METHODS

In this open-label, multicenter, phase 1b, dose-escalation trial, HLA-A*02:01-positive patients with mCM received weekly intravenous tebentafusp with increasing monthly doses of durvalumab and/or tremelimumab starting day 15 of each cycle. The primary objective was to identify the maximum tolerated dose (MTD) or recommended phase 2 dose for each combination. Efficacy analyses were performed in all tebentafusp with durvalumab±tremelimumab treated patients with a sensitivity analysis in those who progressed on prior anti-PD(L)1 therapy.

RESULTS

85 patients were assigned to receive tebentafusp in combination with durvalumab (n=43), tremelimumab (n=13), or durvalumab and tremelimumab (n=29). Patients were heavily pretreated with a median of 3 prior lines of therapy, including 76 (89%) who received prior anti-PD(L)1. Maximum target doses of tebentafusp (68 mcg) alone or in combination with durvalumab (20 mg/kg) and tremelimumab (1 mg/kg) were tolerated; MTD was not formally identified for any arm. Adverse event profile was consistent with each individual therapy and there were no new safety signals nor treatment-related deaths. In the efficacy subset (n=72), the response rate was 14%, tumor shrinkage rate was 41% and 1-year OS rate was 76% (95% CI: 70% to 81%). The 1-year OS for triplet combination (79%; 95% CI: 71% to 86%) was similar to tebentafusp plus durvalumab (74%; 95% CI: 67% to 80%).

CONCLUSION

At maximum target doses, the safety of tebentafusp with checkpoint inhibitors was consistent with safety of each individual therapy. Tebentafusp with durvalumab demonstrated promising efficacy in heavily pretreated patients with mCM, including those who progressed on prior anti-PD(L)1.

TRIAL REGISTRATION NUMBER

NCT02535078.

Utilizing shared frailty with the Cox proportional hazards regression: Post discharge survival analysis of CHF patients

Understanding patients' survival probability as well as the factors affecting it constitute a significant concern for researchers and practitioners, in particular for patients with severe chronic illnesses such as congestive heart failure (CHF). CHF is a clinical syndrome characterized by comorbidities and adverse medical events. Risk stratification to identify patients most likely to die shortly after hospital discharge can improve the quality of care by better allocating organizational resources and personalized interventions. Probability assessment improves clinical decision-making, contributes to personalized care, and saves costs. Although one of the most informative indices is the time to an adverse event for each patient, commonly analyzed using survival analysis methods, these are often challenging to implement due to the complexity of the medical data. Numerous studies have used the Cox proportional hazards (PH) regression method to generate the survival distribution pattern and factors affecting survival. This model, although advantageous for survival analysis, assumes the homogeneity of the hazard ratio across patients and independence of the observations in terms of survival time. These assumptions are often violated in real-world data, especially when the dataset is composed of readmission data for chronically ill patients, since these recurring observations are inherently dependent. This study ran the Cox PH regression on a feature set selected by machine learning algorithms from a rich hospital dataset. The event modeled here was patient mortality within 90 days post-hospital discharge. The sample was composed of medical records of patients hospitalized in the Israeli Sheba Medical Center more than once, with CHF as the primary diagnosis. We modeled the survival of CHF patients using the Cox PH regression with and without the shared frailty correction that addresses the shortcomings of the Cox Model. The results of the two models of the Cox PH regression - with and without the shared frailty correction were compared. The results demonstrate that the shared frailty correction, which was statistically significant in our analysis, improved the performance of the basic Cox PH model. While this is the main contribution, we also show that this model outperforms two commonly used measures (ADHERE and EFFECT) for predicting early mortality of CHF patients. Thus, the results illustrate how applying advanced analytics can outperform traditional methods. An additional contribution is the feature set selected using machine-learning methods that is different from those used in the extant literature.

A study on skin tumor classification based on dense convolutional networks with fused metadata

Skin cancer is the most common cause of death in humans. Statistics show that competent dermatologists have a diagnostic accuracy rate of less than 80%, while inexperienced dermatologists have a diagnostic accuracy rate of less than 60%. The higher rate of misdiagnosis will cause many patients to miss the most effective treatment window, risking the patients' life safety. However, the majority of the current study of neural network-based skin cancer diagnosis remains at the image level without patient clinical data. A deep convolutional network incorporating clinical patient metadata of skin cancer is presented to realize the classification model of skin cancer in order to further increase the accuracy of skin cancer diagnosis. There are three basic steps in the approach. First, the high-level features (edge features, color features, texture features, form features, etc.). Implied by the image were retrieved using the pre-trained DenseNet-169 model on the ImageNet dataset. Second, the MetaNet module is introduced, which uses metadata to control a certain portion of each feature channel in the DenseNet-169 network in order to produce weighted features. The MetaBlock module was added at the same time to improve the features retrieved from photos using metadata, choosing the most pertinent characteristics in accordance with the metadata data. The features of the MetaNet and MetaBlock modules were finally combined to create the MD-Net module, which was then used as input into the classifier to get the classification results for skin cancers. On the PAD-UFES-20 and ISIC 2019 datasets, the suggested methodology was assessed. The DenseNet-169 network model combined with this module, according to experimental data, obtains 81.4% in the balancing accuracy index, and its diagnostic accuracy is up between 8% and 15.6% compared to earlier efforts. Additionally, it solves the problem of actinic keratosis and poorly classified skin fibromas.

Melanoma awareness and prevention among latinx and non-latinx white adults in urban and rural California: A qualitative exploration

BACKGROUND

Melanoma mortality rates in the US are highest among older men, individuals of lower socioeconomic status (SES), and people of color. To better understand these inequities, a qualitative exploratory study was conducted in Northern and Southern California to generate knowledge about barriers and facilitators of awareness, prevention, and early detection of melanoma in lower SES Latinx and non-Latinx White (NLW) individuals living in urban and semi-rural areas.

METHODS

Nineteen focus groups were conducted (N = 176 adult participants), stratified by race/ethnicity (Latinx, low-income NLW), geography (semi-rural, urban), and language (English and Spanish). Inductive and deductive thematic analysis was conducted, and the findings were organized using the socioecological model framework: individual, interpersonal, community, and health system/policy levels.

RESULTS

Four socioecological themes describe how key factors affect knowledge, perceived risk, preventive behaviors, and melanoma screening. Individual level findings revealed that many participants were not familiar with melanoma, yet were willing to learn through trusted sources. Having brown or darker skin tone was perceived as being associated with lower risk for skin cancer. Interpersonally, social relationships were important influences for skin cancer prevention practice. However, for several Latinx and semi-rural participants, conversations about melanoma prevention did not occur with family and peers. At the community level, semi-rural participants reported distance or lack of transportation to a clinic as challenges for accessing dermatology care. Healthcare systems barriers included burdens of additional healthcare costs for dermatology visits and obtaining referral.

CONCLUSIONS

Varying factors influence the awareness levels, beliefs, and behaviors associated with knowledge, prevention, and early detection of melanoma among low-income Latinx and NLW individuals and in semi-rural areas. Results have implications for health education interventions. Navigation strategies that target individuals, families, and health care settings can promote improved prevention and early detection of melanoma in these communities.

Prediction of early-stage melanoma recurrence using clinical and histopathologic features

Prognostic analysis for early-stage (stage I/II) melanomas is of paramount importance for customized surveillance and treatment plans. Since immune checkpoint inhibitors have recently been approved for stage IIB and IIC melanomas, prognostic tools to identify patients at high risk of recurrence have become even more critical. This study aims to assess the effectiveness of machine-learning algorithms in predicting melanoma recurrence using clinical and histopathologic features from Electronic Health Records (EHRs). We collected 1720 early-stage melanomas: 1172 from the Mass General Brigham healthcare system (MGB) and 548 from the Dana-Farber Cancer Institute (DFCI). We extracted 36 clinicopathologic features and used them to predict the recurrence risk with supervised machine-learning algorithms. Models were evaluated internally and externally: (1) five-fold cross-validation of the MGB cohort; (2) the MGB cohort for training and the DFCI cohort for testing independently. In the internal and external validations, respectively, we achieved a recurrence classification performance of AUC: 0.845 and 0.812, and a time-to-event prediction performance of time-dependent AUC: 0.853 and 0.820. Breslow tumor thickness and mitotic rate were identified as the most predictive features. Our results suggest that machine-learning algorithms can extract predictive signals from clinicopathologic features for early-stage melanoma recurrence prediction, which will enable the identification of patients that may benefit from adjuvant immunotherapy.

Proteasomal down-regulation of the proapoptotic MST2 pathway contributes to BRAF inhibitor resistance in melanoma

The loss of MST2 pathway protein expression in BRAF inhibitor resistant melanoma cells is due to ubiquitination and subsequent proteasomal degradation and prevents MST2-mediated apoptosis.

The RAS-RAF-MEK-ERK pathway is hyperactivated in most malignant melanomas, and mutations in BRAF or NRAS account for most of these cases. BRAF inhibitors (BRAFi) are highly efficient for treating patients with BRAF^V600E mutations, but tumours frequently acquire resistance within a few months. Multiple resistance mechanisms have been identified, due to mutations or network adaptations that revive ERK signalling. We have previously shown that RAF proteins inhibit the MST2 proapoptotic pathway in a kinase-independent fashion. Here, we have investigated the role of the MST2 pathway in mediating resistance to BRAFi. We show that the BRAF^V600E mutant protein, but not the wild-type BRAF protein, binds to MST2 inhibiting its proapoptotic signalling. Down-regulation of MST2 reduces BRAFi-induced apoptosis. In BRAFi-resistant cell lines, MST2 pathway proteins are down-regulated by ubiquitination and subsequent proteasomal degradation rendering cells refractory to MST2 pathway–induced apoptosis. Restoration of apoptosis can be achieved by increasing MST2 pathway protein expression using proteasome inhibitors. In summary, we show that the MST2 pathway plays a role in the acquisition of BRAFi resistance in melanoma.

Dermoscopy lesion classification based on GANs and a fuzzy rank-based ensemble of CNN models

Background and Objective. Skin lesion classification by using deep learning technologies is still a considerable challenge due to high similarity among classes and large intraclass differences, serious class imbalance in data, and poor classification accuracy with low robustness. Approach. To address these issues, a two-stage framework for dermoscopy lesion classification using adversarial training and a fuzzy rank-based ensemble of multilayer feature fusion convolutional neural network (CNN) models is proposed. In the first stage, dermoscopy dataset augmentation based on generative adversarial networks is proposed to obtain realistic dermoscopy lesion images, enabling significant improvement for balancing the number of lesions in each class. In the second stage, a fuzzy rank-based ensemble of multilayer feature fusion CNN models is proposed to classify skin lesions. In addition, an efficient channel integrating spatial attention module, in which a novel dilated pyramid pooling structure is designed to extract multiscale features from an enlarged receptive field and filter meaningful information of the initial features. Combining the cross-entropy loss function with the focal loss function, a novel united loss function is designed to reduce the intraclass sample distance and to focus on difficult and error-prone samples to improve the recognition accuracy of the proposed model. Main results. In this paper, the common dataset (HAM10000) is selected to conduct simulation experiments to evaluate and verify the effectiveness of the proposed method. The subjective and objective experimental results demonstrate that the proposed method is superior over the state-of-the-art methods for skin lesion classification due to its higher accuracy, specificity and robustness. Significance. The proposed method effectively improves the classification performance of the model for skin diseases, which will help doctors make accurate and efficient diagnoses, reduce the incidence rate and improve the survival rates of patients.

Clinical Practice Guidelines on Sentinel Lymph Node Biopsy for Melanoma: A Systematic Review and Quality Appraisal Using the AGREE II Instrument

Sentinel lymph node biopsy (SLNB) is a minimally invasive surgical procedure that is standard of care for the evaluation of clinically negative regional lymph nodes in patients with cutaneous melanoma. As the presence of metastases dictates patient prognosis and determines the need for further regional disease control or adjuvant therapy, SLNB is invaluable to clinical decision-making in patients presenting with melanoma. However, the indications for SLNB, specifically among patients with thin (<1 mm) or thick (>4 mm) melanomas, remain unclear. A number of clinical practice guidelines (CPGs) have been developed outlining recommendations for the role of lymph node biopsy in the management of melanoma. However, to date, their quality has not been critically appraised. Our objective was to systematically evaluate all available CPGs on this topic using the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Four total guidelines met the inclusion criteria and underwent appraisal. Only one CPG achieved a "high" quality rating, indicating scores of >60% in at least five of the six AGREE II domains. Across all CPGs, the lowest scoring domains were "Applicability" and "Stakeholder involvement," which had average scores of 41.2% and 48.3%, respectively. Based on the AGREE II instrument, the quality of existing CPGs for the indications of SLNB for melanoma is low. Future guidelines should be pilot tested to evaluate barriers to application and should utilize multidisciplinary guideline development teams that include patients and key stakeholders in addition to clinical experts from all relevant disciplines.

The Multi-Omics Landscape and Clinical Relevance of the Immunological Signature of Phagocytosis Regulators: Implications for Risk Classification and Frontline Therapies in Skin Cutaneous Melanoma

Simple Summary

In this study, we focused on exploring phagocytosis regulators’ expression and mutational characteristics in skin cutaneous melanoma samples and delineating two molecular subtypes based on expression characteristics. We determined the relationship between phagocytosis regulators and survival by survival analysis of molecular subtypes. We then constructed a survival model (PRRS) to further quantify the criteria. Moreover, we combined pathway analysis, immune infiltration analysis, and mutation analysis to deeply explore the effects of phagocytosis regulators on skin cutaneous melanoma samples.

Abstract

Tumor-associated macrophages (TAMs) have gained considerable attention as therapeutic targets. Monoclonal antibody treatments directed against tumor antigens contribute significantly to cancer cell clearance by activating macrophages to phagocytose tumor cells. Due to its complicated genetic and molecular pathways, skin cutaneous melanoma (SKCM) has not yet attained the expected clinical efficacy and prognosis when compared to other skin cancers. Therefore, we chose TAMs as an entrance point. This study aimed to thoroughly assess the dysregulation and regulatory role of phagocytosis regulators in SKCM, as well as to understand their regulatory patterns in SKCM. This study subtyped prognosis-related phagocytosis regulators to investigate prognostic differences between subtypes. Then, we screened prognostic factors and constructed phagocytosis-related scoring models for survival prediction using differentially expressed genes (DEGs) between subtypes. Additionally, we investigated alternative treatment options using chemotherapeutic drug response data and clinical cohort treatment data. We first characterized and generalized phagocytosis regulators in SKCM and extensively examined the tumor immune cell infiltration. We created two phagocytosis regulator-related system (PRRS) phenotypes and derived PRRS scores using a principal component analysis (PCA) technique. We discovered that subtypes with low PRRS scores had a poor prognosis and decreased immune checkpoint-associated gene expression levels. We observed significant therapeutic and clinical improvements in patients with higher PRRS scores. Our findings imply that the PRRS scoring system can be employed as an independent and robust prognostic biomarker, serving as a critical reference point for developing novel immunotherapeutic methods.

Assessment of the Novel, Practical, and Prognosis-Relevant TNM Staging System for Stage I-III Cutaneous Melanoma

Background

The clinical TNM staging system does not differ between the 7^th and 8^th editions of the American Joint Committee on Cancer (AJCC) staging manual. A more practical TNM staging system for patients with stage I-III cutaneous melanoma are needed.

Methods

Data were accessed from the Surveillance, Epidemiology, and End Results (SEER) open database. We divided the patients into 32 groups based on the T and N categories. The Kaplan-Meier survival curves and treatment guidelines were used to proposed a new TNM staging system. Cox proportional hazards model and 1000-person-years were used to verify accuracy.

Results

This retrospective study included 68 861 patients from 2010 to 2015. The new proposed staging system was as follows: stage IA, T1aN0M0; stage IB, T1b/T2aN0M0; stage IIA, T3-4aN0M0 and T2bN0M0; stage IIB, T1-4aN1-2M0 and T3-4bN0M0; and stage III, T1-4aN3M0 and T1-4bN1-3M0. Hazard ratios for the new stages IB, IIA, IIB, and III, with stage IA as reference, were 4.311 (95% confidence interval [CI]: 3.217-5.778), 8.993 (95% CI: 6.637-12.186), 13.179 (95% CI: 9.435-18.407), and 20.693 (95% CI: 13.655-31.356), respectively (all p-values < 0.001). Cancer-specific mortality rates per 1000-person-years were 0.812 (95% CI: 0.674-0.978), 6.612 (95% CI: 5.936-7.364), 22.228 (95% CI: 20.128-24.547), 50.863 (95% CI: 47.472-54.496) and 120.318 (95% CI: 112.596-128.570) for stages IA, IB, IIA, IIB and III, respectively.

Conclusion

We developed a more practical and prognosis-relevant staging system than that of the 8^th edition AJCC manual for patients with stage I-III cutaneous melanoma. Treatments using this new model would improve the quality of life and survival rates of patients with melanoma.

A Cohort Study: Comorbidity and Stage Affected the Prognosis of Melanoma Patients in Taiwan

Background

Comorbidities and stages may influence the prognosis of melanoma patients in Taiwan and need to be determined.

Methods

We performed a retrospective cohort study by using the national health insurance research database in Taiwan. Patients with a primary diagnosis of melanoma by the Taiwan Cancer Registry from 2009 to 2017 were recruited as the study population. The comparison group was never diagnosed with melanoma from 2000 to 2018. The Charlson comorbidity index was conducted to calculate the subjects’ disease severity. The Cox proportional hazards model analysis was used to estimate the hazard ratio of death.

Results

We selected 476 patients, 55.5% of whom had comorbidity. A higher prevalence of comorbidity was associated with a more advanced cancer stage. The mortality rate increased with an increasing level of comorbidity in both cohorts and was higher among melanoma patients. The interaction between melanoma and comorbidity resulted in an increased mortality rate.

Conclusion

An association between poorer survival and comorbidity was verified in this study. We found that the level of comorbidity was strongly associated with mortality. A higher risk of mortality was found in patients who had localized tumors, regional metastases, or distant metastases with more comorbidity scores. Advanced stage of melanoma patients with more comorbidities was significantly associated with the higher risk of mortality rate.

circITCH suppresses cell proliferation and metastasis through miR-660/TFCP2 pathway in melanoma

BACKGROUND

Melanoma is an aggressive disease that is rising in incidence. Advanced melanoma is still a life-threatening disease. CircRNAs are documented to be involved in melanoma progression. But circITCH role in melanoma remains unclear.

METHODS AND RESULTS

To explore the functions of circITCH in melanoma, levels of circITCH in melanoma tissues and paracarcinoma normal tissues were detected. To study the roles of circITCH in melanoma in terms of cell proliferation and migration, in vitro and in vivo experiments were performed. Mechanism study was designed to investigate the potential regulatory effect of circITCH in melanoma. Results revealed that circITCH expression was repressed in melanoma versus adjacent normal tissues. Function study showed that circITCH suppressed melanoma cell proliferation and metastasis. The mechanism study showed that circITCH-sponged miR-660 to upregulate TFCP2 and suppress melanoma progression.

CONCLUSIONS

The circITCH/miR-660/TFCP2 axis is involved in melanoma progression hence circITCH can be a diagnostic biomarker as well as a target for treating melanoma.

The heterogeneity of population with high risk for melanoma and other skin cancer: a latent class analysis

OBJECTIVE

To examine whether there is heterogeneity in the risk factors for skin cancer among the high-risk population in Slovenia, a Central European country with the second-largest age-standardized melanoma-related mortality rate in Europe.

METHODS

We analyzed data collected during the 'Euromelanoma Day' 2010-2019. The outcome was the prevalence of newly suspected skin cancer. The independent variables were 17 known risk factors and protective behaviors. We performed a latent class analysis with skin cancer as a covariate.

RESULTS

We analyzed data from 1711 participants with a median (interquartile range) age of 52 (39-63) years, 52% of whom were women. During the 10 years, 81 cases of melanoma and 213 cases of other skin cancers were suspected. The model with three latent classes had the best fit. Two latent classes had a high risk for melanoma and other skin cancer: 3 and 19% respectively in class 2; 14 and 29% in class 3. The largest significant differences between the two high-risk classes were the older age and lower frequency of sunscreen use in high-risk class 2 and the number of atypical nevi, a large number of common moles, many moles as the primary motive to participate in Euromelanoma examination and having a skin phototype I or II in the highest-risk latent class 3.

CONCLUSIONS

There is heterogeneity in the risk factors for skin cancer among the Euromelanoma high-risk population. This heterogeneity should be tested in other countries, and if the findings are consistent, they should be used to refine secondary prevention programs.

Oncolytic viruses in melanoma

Malignant melanoma recurrence remains heterogeneous in presentation, ranging from locoregional disease (i.e., local recurrence, satellites, in transit disease) to distant dermal and visceral metastases. This diverse spectrum of disease requires a personalized approach to management and has resulted in the development of both local (e.g., surgery, radiation, intralesional injection) and systemic (intravenous or oral) treatment strategies. Intralesional agents such as oncolytic viruses may also evoke local immune stimulation to induce and enhance the antitumor immune response. Further, it is hypothesized that these oncolytic viruses may convert immunologically "cold" tumors to more reactive "hot" tumor microenvironments and thereby overcome anti-PD-1 therapy resistance. Currently, talimogene laherparepvec (T-VEC), a modified herpes virus, is FDA-approved in this population, with many other oncolytic viruses under investigation in both preclinical and trial settings. Herein, we detail the scientific rationale, current landscape, and future directions of oncolytic viruses in melanoma.

BRAF-Inhibitor-Induced Metabolic Alterations in A375 Melanoma Cells

Acquired drug tolerance has been a major challenge in cancer therapy. Recent evidence has revealed the existence of slow-cycling persister cells that survive drug treatments and give rise to multi-drug-tolerant mutants in cancer. Cells in this dynamic persister state can escape drug treatment by undergoing various epigenetic changes, which may result in a transient metabolic rewiring. In this study, with the use of untargeted metabolomics and phenotype microarrays, we characterize the metabolic profiles of melanoma persister cells mediated by treatment with vemurafenib, a BRAF inhibitor. Our findings demonstrate that metabolites associated with phospholipid synthesis, pyrimidine, and one-carbon metabolism and branched-chain amino acid metabolism are significantly altered in vemurafenib persister cells when compared to the bulk cancer population. Our data also show that vemurafenib persisters have higher lactic acid consumption rates than control cells, further validating the existence of a unique metabolic reprogramming in these drug-tolerant cells. Determining the metabolic mechanisms underlying persister cell survival and maintenance will facilitate the development of novel treatment strategies that target persisters and enhance cancer therapy.

Racial Differences in the Prognosis and Survival of Cutaneous Melanoma From 1990 to 2020 in North America: A Systematic Review and Meta-Analysis

Background

Factors influencing the difference in the diagnosis and treatment of melanoma in racial minority groups are well-described in the literature and include atypical presentations and socioeconomic factors that impede access to care.

Objective

To characterize the differences in melanoma survival outcomes between non-Hispanic white patients and ethnic minority patients in North America.

Methods

We conducted searches of Embase via Ovid and MEDLINE via Ovid of studies published from 1989 to August 5, 2020. We included observational studies in North America which reported crude or effect estimate data on patient survival with cutaneous melanoma stratified by race.

Results

Forty-four studies met our inclusion criteria and were included in this systematic review. Pooled analysis revealed that black patients were at a significantly increased risk for overall mortality (HR 1.42, 95% CI, 1.25-1.60), as well as for melanoma-specific mortality (HR 1.27, 95% CI, 1.03-1.56). Pooled analyses using a representative study for each database yielded similar trends. Other ethnic minorities were also more likely report lower melanoma-specific survival compared to non-Hispanic white patients.

Conclusion

Our results support findings that melanoma patients of ethnic minorities, particularly black patients, experience worse health outcomes with regards to mortality. Overall survival and melanoma-specific survival are significantly decreased in black patients compared to non-Hispanic white patients. With the advent of more effective, contemporary treatments such as immunotherapy, our review identifies a gap in the literature investigating present-day or prospective data on melanoma outcomes, in order to characterize how current racial differences compare to findings from previous decades.

Segmentation of dermoscopy images based on deformable 3D convolution and ResU-NeXt +

Melanoma is one of the most dangerous skin cancers. The current melanoma segmentation is mainly based on FCNs (fully connected networks) and U-Net. Nevertheless, these two kinds of neural networks are prone to parameter redundancy, and the gradient of neural networks disappears that occurs when the neural network backpropagates as the neural network gets deeper, which will reduce the Jaccard index of the skin lesion image segmentation model. To solve the above problems and improve the survival rate of melanoma patients, an improved skin lesion segmentation model based on deformable 3D convolution and ResU-NeXt++ (D3DC- ResU-NeXt++) is proposed in this paper. The new modules in D3DC-ResU-NeXt++ can replace ordinary modules in the existing 2D convolutional neural networks (CNNs) that can be trained efficiently through standard backpropagation with high segmentation accuracy. In particular, we introduce a new data preprocessing method with dilation, crop operation, resizing, and hair removal (DCRH), which improves the Jaccard index of skin lesion image segmentation. Because rectified Adam (RAdam) does not easily fall into a local optimal solution and can converge quickly in segmentation model training, we also introduce RAdam as the training optimizer. The experiments show that our model has excellent performance on the segmentation of the ISIC2018 Task I dataset, and the Jaccard index achieves 86.84%. The proposed method improves the Jaccard index of segmentation of skin lesion images and can also assist dermatological doctors in determining and diagnosing the types of skin lesions and the boundary between lesions and normal skin, so as to improve the survival rate of skin cancer patients. Overview of the proposed model. An improved skin lesion segmentation model based on deformable 3D convolution and ResU-NeXt++ (D3DC- ResU-NeXt++) is proposed in this paper. D3DC-ResU-NeXt++ has strong spatial geometry processing capabilities, it is used to segment the skin lesion sample image; DCRH and transfer learning are used to preprocess the data set and D3DC-ResU-NeXt++ respectively, which can highlight the difference between the lesion area and the normal skin, and enhance the segmentation efficiency and robustness of the neural network; RAdam is used to speed up the convergence speed of neural network and improve the efficiency of segmentation.

Melanoma mimicking atypical fibroxanthoma: Report of an unusual case

Melanoma may mimic a variety of skin lesions clinically and histopathologically, and presents diagnostic challenges. In this article, we describe a case of melanoma in an 89-year-old man with a very rare histopathologic presentation, namely the presence of pleomorphic and multinucleated giant cells with abundant cytoplasm, highly resembling an atypical fibroxanthoma. The differential diagnoses in conjunction with the findings in immunohistochemical study are also discussed.

A Review of Epidemiology and Cancer Biology of Malignant Melanoma

Malignant melanoma is a neoplasm originating in the melanocytes in the skin. Although malignant melanoma is the third most common cutaneous cancer, it is recognized as the main cause of skin cancer-related mortality, and its incidence is rising. The natural history of malignant melanoma involves an inconsistent and insidious skin cancer with great metastatic potential. Increased ultra-violet (UV) skin exposure is undoubtedly the greatest risk factor for developing cutaneous melanoma; however, a plethora of risk factors are now recognized as causative. Moreover, modern oncology now considers melanoma proliferation a complex, multifactorial process with a combination of genetic, epigenetic, and environmental factors all known to be contributory to tumorgenesis. Herein, we wish to outline the epidemiological, molecular, and biological processes responsible for driving malignant melanoma proliferation.

Neuroendocrine Factors in Melanoma Pathogenesis

Simple Summary

Melanoma is a very aggressive and fatal malignant tumor. While curable if diagnosed in its early stages, advanced melanoma, despite the complex therapeutic approaches, is associated with one of the highest mortality rates. Hence, more and more studies have focused on mechanisms that may contribute to melanoma development and progression. Various studies suggest a role played by neuroendocrine factors which can act directly on tumor cells, modulating their proliferation and metastasis capability, or indirectly through immune or inflammatory processes that impact disease progression. However, there are still multiple areas to explore and numerous unknown features to uncover. A detailed exploration of the mechanisms by which neuroendocrine factors can influence the clinical course of the disease could open up new areas of biomedical research and may lead to the development of new therapeutic approaches in melanoma.

Abstract

Melanoma is one of the most aggressive skin cancers with a sharp rise in incidence in the last decades, especially in young people. Recognized as a significant public health issue, melanoma is studied with increasing interest as new discoveries in molecular signaling and receptor modulation unlock innovative treatment options. Stress exposure is recognized as an important component in the immune-inflammatory interplay that can alter the progression of melanoma by regulating the release of neuroendocrine factors. Various neurotransmitters, such as catecholamines, glutamate, serotonin, or cannabinoids have also been assessed in experimental studies for their involvement in the biology of melanoma. Alpha-MSH and other neurohormones, as well as neuropeptides including substance P, CGRP, enkephalin, beta-endorphin, and even cellular and molecular agents (mast cells and nitric oxide, respectively), have all been implicated as potential factors in the development, growth, invasion, and dissemination of melanoma in a variety of in vitro and in vivo studies. In this review, we provide an overview of current evidence regarding the intricate effects of neuroendocrine factors in melanoma, including data reported in recent clinical trials, exploring the mechanisms involved, signaling pathways, and the recorded range of effects.

Circular RNA circ_0079593 enhances malignant melanoma progression by the regulation of the miR-573/ABHD2 axis

BACKGROUND

Malignant melanoma is the most fatal type of skin tumor. Circular RNAs (circRNAs) have been implicated in the malignant progression of melanoma.

OBJECTIVE

The main purpose of this paper was to identify the precise parts of circ_0079593 in the malignant progression of melanoma.

METHODS

The levels of circ_0079593, miR-573 and abhydrolase domain containing 2 (ABHD2) were determined by quantitative real-time polymerase chain reaction (qRT-PCR) and western blot. Cell proliferation, colony formation, cell cycle progression, apoptosis, migration, and invasion were evaluated using the Cell Counting Kit-8 (CCK-8), colony formation, flow cytometry, and transwell assays, respectively. Targeted correlations among circ_0079593, miR-573 and ABHD2 were confirmed by dual-luciferase reporter, RNA immunoprecipitation (RIP) and RNA pull-down assays. Animal studies were performed to assess the role of circ_0079593 in vivo.

RESULTS

Our data showed that circ_0079593 level was up-regulated in melanoma tissues and cells. The knockdown of circ_0079593 suppressed cell proliferation, cell cycle progression, migration, invasion, and enhanced apoptosis in vitro and inhibited tumor growth in vivo. Mechanistically, circ_0079593 directly targeted miR-573, and circ_0079593 controlled ABHD2 expression by miR-573. MiR-573 mediated the regulation of circ_0079593 on melanoma cell progression in vitro. Moreover, ABHD2 was a functional target of miR-573 in regulating melanoma cell progression in vitro.

CONCLUSION

Our findings identified that the knockdown of circ_0079593 suppressed melanoma progression at least partially through targeting the miR-573/ABHD2 axis, providing evidence for developing circ_0079593 as a promising therapeutic target for melanoma treatment.

Age-related transcriptome changes in melanoma patients with tumor-positive sentinel lymph nodes

Age is an important factor for determining the outcome of melanoma patients. Sentinel lymph node (SLN) status is also a strong predictor of survival for melanoma. Paradoxically, older melanoma patients have a lower incidence of SLN metastasis but a higher mortality rate when compared with their younger counterparts. The mechanisms that underlie this phenomenon remain unknown. This study uses three independent datasets of RNA samples from patients with melanoma metastatic to the SLN to identify age-related transcriptome changes in SLNs and their association with outcome. Microarray was applied to the first dataset of 97 melanoma patients. NanoString was performed in the second dataset to identify the specific immune genes and pathways that are associated with recurrence in younger versus older patients. qRT-PCR analysis was used in the third dataset of 36 samples to validate the differentially expressed genes (DEGs) from microarray and NanoString. These analyses show that FOS, NR4A, and ITGB1 genes were significantly higher in older melanoma patients with positive SLNs. IRAK3- and Wnt10b-related genes are the major pathways associated with recurrent melanoma in younger and older patients with tumor-positive SLNs, respectively. This study aims to elucidate age-related differences in SLNs in the presence of nodal metastasis.

Bioinformatic Analysis Identifies Potential Key Genes in the Pathogenesis of Melanoma

Melanoma is the deadliest skin tumor and is prone to distant metastases. The incidence of melanoma has increased rapidly in the past few decades, and current trends indicate that this growth is continuing. This study was aimed to explore the molecular mechanisms of melanoma pathogenesis and discover underlying pathways and genes associated with melanoma. We used high-throughput expression data to study differential expression profiles of related genes in melanoma. The differentially expressed genes (DEGs) of melanoma in GSE15605, GSE46517, GSE7553, and the Cancer Genome Atlas (TCGA) datasets were analyzed. Differentially expressed genes (DEGs) were identified by paired t-test. Then the DEGs were performed cluster and principal component analyses and protein–protein interaction (PPI) network construction. After that, we analyzed the differential genes through bioinformatics and got hub genes. Finally, the expression of hub genes was confirmed in the TCGA databases and collected patient tissue samples. Total 144 up-regulated DEGs and 16 down-regulated DEGs were identified. A total of 17 gene ontology analysis (GO) terms and 11 pathways were closely related to melanoma. Pathway of pathways in cancer was enriched in 8 DEGs, such as junction plakoglobin (JUP) and epidermal growth factor receptor (EGFR). In the PPI networks, 9 hub genes were obtained, such as loricrin (LOR), filaggrin (FLG), keratin 5 (KRT5), corneodesmosin (CDSN), desmoglein 1 (DSG1), desmoglein 3 (DSG3), keratin 1 (KRT1), involucrin (IVL), and EGFR. The pathway of pathways in cancer and its enriched DEGs may play important roles in the process of melanoma. The hub genes of DEGs may become promising melanoma candidate genes. Five key genes FLG, DSG1, DSG3, IVL, and EGFR were identified in the TCGA database and melanoma tissues. The results suggested that FLG, DSG1, DSG3, IVL, and EGFR might play important roles and potentially be valuable in the prognosis and treatment of melanoma. These hub genes might well have clinical significance as diagnostic markers.

Sentinel Lymph Node Biopsy Is Prognostic in Thickest Melanoma Cases and Should Be Performed for Thick Melanomas

BACKGROUND

Sentinel lymph node biopsy (SLNB) is recommended for intermediate thickness melanoma, but for thick melanoma, guidelines are less definitive about the use of SLNB in this population. We present a study on thick melanoma evaluating for prognostic factors.

PATIENTS AND METHODS

The Sentinel Lymph Node Working Group database was queried for thick (> 4 mm) melanoma cases that had a SLNB from 1993 to 2018. Clinicopathologic characteristics were correlated with SLN status and melanoma-specific survival (MSS).

RESULTS

There were 1235 patients. Median follow-up was 28 months. Median thickness was 5.9 mm, with 956, 175, and 104 cases presenting thickness > 4-8, > 8-12, and > 12 mm, respectively. SLN metastases were seen in 439 of 1235 (35.5%) cases and in 33.9%, 40.6%, and 42.3% of melanomas > 4-8, > 8-12, and > 12 mm, respectively. In each thickness group, MSS was significantly worse for SLN-positive compared with SLN-negative cases (all P < 0.005). Multivariable analysis showed that SLN metastasis, male gender, increasing thickness, lymphovascular invasion, and microsatellitosis significantly predicted worse MSS for melanomas > 4-8 mm, with SLN metastasis showing the greatest risk (HR 2.17, 95% CI 1.64-2.87, P < 0.0001). For melanomas > 8 mm, only SLN metastasis significantly predicted MSS (> 8-12 mm: HR 3.93, 95% CI 2.00-7.73, P < 0.0001; > 12 mm: HR 3.58, 95% CI 1.56-8.22, p < 0.0027).

CONCLUSIONS

Thick melanoma patients with SLN metastasis have significantly worse MSS compared with SLN-negative patients, even in the thickest cases, and SLN status is the most powerful and/or only predictor of MSS. Given these results, SLNB shows important prognostic value in this population and is indicated for clinically localized thick melanoma.

Melanoma incidence, recurrence, and mortality in an integrated healthcare system: A retrospective cohort study

Background

Numerous studies have examined melanoma incidence and survival, but studies on melanoma recurrence are limited. We examined melanoma incidence, recurrence, and mortality among members of Kaiser Permanente Colorado (KPCO) between January 1, 2000 and December 31, 2015.

Methods

Age‐adjusted incidence rates were computed to examine trends among KPCO members aged 21 years and older. Cox proportional hazards models were used to examine factors associated with recurrence and mortality.

Results

Our cohort included 1931 cases of invasive melanoma. Incidence rates increased over time and were higher than SEER rates; however, the increase was limited to early stage disease. In multivariable models, stage at initial diagnosis, gender, and age were associated with melanoma recurrence. Men were more likely to have a recurrence than women (adjusted hazard ratio [HR]: 1.70, 95% confidence interval [CI]: 1.19‐2.43), and for each decade of increasing age, the adjusted HR = 1.20 (95% CI: 1.06‐1.37). Factors associated with all‐cause mortality included stage (HR = 12.87, 95% CI: 6.63‐24.99, for stage IV vs stage I), male gender (HR = 1.42, 95% CI: 1.12‐1.79), older age at diagnosis, lower socioeconomic status, and comorbidity index. For melanoma‐specific mortality, results were similar, with one exception: age was not associated with melanoma‐specific death (HR = 1.09, 95% CI: 0.94‐1.25, P = 0.253).

Conclusions

Data derived from an insured patient population, such as KPCO, have the potential to enhance our understanding of emerging trends in melanoma. This is the first population‐based study in the United States to examine patient characteristics associated with risk of recurrence. Men have an increased risk of both recurrence and death, and thus may benefit from more intensive follow‐up than women.