Diagnostic utility of PRAME expression by immunohistochemistry in subungual and non-subungual acral melanocytic lesions

The combined diagnostic value of 5-hmC and PRAME immunohistochemistry in melanocytic neoplasms

The diagnosis of melanocytic neoplasms, particularly those with borderline morphologic features, remains a challenging area in dermatopathology. 5-hydroxymethylcytosine (5-hmC) and PRAME (PReferentially expressed Antigen in MElanoma) are recent immunohistochemical markers which have been shown to be valuable in distinguishing benign from malignant melanocytic neoplasms. A retrospective cohort of 144 benign, borderline (Spitz nevi, atypical Spitz tumors and dysplastic nevi) and malignant melanocytic tumors at our institution were analyzed for 5-hmC and PRAME expression by immunohistochemistry. Compared to benign nevi, melanoma cases had higher PRAME expression (p < 0.0001) and lower 5-hmC (p < 0.0001) expression. In receiver operator curve analysis, 5-hmC and PRAME were good discriminators between benign and malignant neoplasms; the area under the curve (AUC) was 0.91 for 5-hmC (p < 0.0001) and 0.94 for PRAME (p < 0.001). Subgroup analysis showed that 5-hmC expression was significantly different between dysplastic nevi and melanoma. The combination of PRAME and 5-hmC significantly improved the predictive ability of these markers (AUC 0.97, p < 0.001). Having both PRAME expression of 4 + (> 75 % lesional cells positive) and 5-hmC of < 0.2 was highly specific for malignancy (98 %) with a sensitivity of 61 %. Utilizing 5-hmC and PRAME in conjunction improves their diagnostic value in distinguishing benign from malignant melanocytic neoplasms.

KS-NailMel-1: a novel cell line of nail apparatus melanoma

Nail apparatus melanoma (NAM) is a specific type of cutaneous melanoma that develops in the nail apparatus of the hands and feet. The prognosis for metastatic NAM is poor due to a lack of fully effective systemic therapies. However, the difficulty in obtaining a NAM model has hindered basic research aimed at discovering effective treatment strategies. In this study, we established a NAM cell line, named KS-NailMel-1, from a primary tumor located on the nail apparatus of the left ring finger of a 68-year-old Japanese female. The cells were successfully maintained for over 9 months, exhibiting a doubling time of 38.6 ± 1.94 h. KS-NailMel-1 displayed consistent growth, spheroid formation, and invasiveness, and was confirmed to be identical to the original tumor through short tandem repeat analyses, whole-exome sequencing, and immunohistochemistry. Western blotting of the cells demonstrated the protein expression of NECTIN4, which has recently attracted attention as a potential therapeutic target for melanoma. The KS-NailMel-1 cell line represents a valuable resource for basic and preclinical research on NAM, deepening our understanding of the tumor characteristics and facilitating the development of treatment strategies for this rare form of cancer.

Subungual Amelanotic Melanoma

This case report describes a light pink plaque underneath an atrophied and broken nail plate that was surrounded by depigmentation.

Subungual melanoma: molecular analysis of 31 cases from early stage to invasive melanoma

AIMS

The distinction between the benign subungual melanocytic lesions and an early lesion of subungual melanoma (SUM) remains a diagnostic challenge. We evaluated the routine diagnostic utility of array Comparative Genomic Hybridization (aCGH) to detect whole-genome copy number variations (CNV) as well as targeted next-generation sequencing (NGS) in SUM.

METHODS AND RESULTS

This retrospective study included 20 cases of in situ SUM and 11 cases of invasive SUM. Analysis by aCGH detected common oncogene amplifications in all but one case of invasive SUM (n = 10) and in all cases of in situ SUM with a melanocyte count (MC) >45/mm (n = 4 true positive) and the average number of CNV was 8.5. Thirteen remaining cases of in situ SUM gave false negative results (n = 13), owing to a lack of sufficient melanocytes to analyse (median MC of 35.35; range: 10.16-39.5). Molecular analysis failed in four cases (three in situ SUM and one invasive SUM) due to insufficient amounts of DNA. Across the whole cohort, the sensitivity of aCGH was 52%, but when adjusting the cutoff to MC >45/mm, the sensitivity was 93%. Targeted NGS was less informative than aCGH analyses in our series of SUM.

CONCLUSION

To distinguish malignant from benign lesions, especially in situ SUM versus atypical lentiginous melanocytic proliferations, aCGH analysis should be performed when the MC is above 45 melanocytes per linear millimetre. This pangenomic method can detect oncogene amplifications, as well as a number of CNV >3, which strongly support the diagnosis of malignancy.

Combined immunohistochemistry of PRAME and p16 in the differentiation of melanocytic neoplasms, with a detailed focus on acral lesions

BACKGROUND

Isolated immunohistochemical indicators are limited to diagnose melanocytic neoplasms. This retrospective study is to assess the diagnostic value of combined immunohistochemical analysis targeting preferentially expressed antigen in melanoma (PRAME) and p16 in melanocytic neoplasms, with a detailed focus on arcal lesions.

METHODS

This was a single center cohort study from January 2022 to June 2023. A total of 165 identified cases were collected, including 112 melanomas (MMs) and 53 melanocytic nevi, which were composed of 122 acral samples and 43 non-acral samples. Immunohistochemistry(IHC) for both PRAME and p16 was performed in these cases, which was subsequently statistically analyzed to assess the diagnosis ability of PRAME and p16.

RESULTS

In total samples, the sensitivity and specificity of PRAME(+) for MM are 82.1% and 94.3% (AUC = 0.882, 95%CI:0.827-0.938), while of p16(-) for MM are 31.25% and 94.3% (AUC = 0.628, 95%CI:0.542-0.714); PRAME(+)/p16(-) (meaning as PRAME(+) or p16(-)) displayed a sensitivity and specificity of 85.7% and 88.7% for MM (AUC = 0.872, 95%CI:0.810-0.934), while PRAME(+) &p16(-) (meaning as PRAME(+) and p16(-)) revealed a sensitivity and specificity of 27.7% and 100% in MM (AUC = 0.638, 95%CI:0.555-0.722). In acral samples, PRAME(+)/p16(-) exhibited a specificity of 94.7% and a sensitivity of 86.9% for MM (AUC = 0.908, 95%CI: 0.849-0.968), with sensitivities of 90.9% for invasive MM and 82.5% for preinvasive MM, respectively; The sensitivity and specificity of PRAME(+) &p16(-) for MM is 22.6% and 100% (AUC = 0.613, 95%CI: 0.513-0.714) respectively. In non-acral samples, the sensitivity and specificity of PRAME(+)/p16(-) for MM are 82.1% and 73.3% (AUC = 0.777, 95%CI: 0.622-0.933), while of PRAME(+) &p16(-) are 42.9% and 100% (AUC = 0.714, 95%CI:0.564-0.864).

CONCLUSION

Combined IHC of PRAME and p16 contributes to discriminating melanocytic neoplasms, especially for in situ acral MM.

A Review of the Histopathology of Nail Unit Tumors Including Selection of the Optimal Surgical Sampling

Background

A wide variety of tumors can affect the nail unit, with some commonly mistaken as inflammatory or infectious diseases. Obtaining an optimal sample for histopathologic evaluation requires understanding of nail unit anatomy as well as the histopathology of the suspected nail tumor.

Summary

This review discusses clinical and histopathologic features of a subset of benign and malignant nail tumors, including subungual melanoma, nail unit squamous cell carcinoma in situ, nail unit squamous cell carcinoma, onychomatricoma, onychopapilloma, onychocytic matricoma, and onychocytic carcinoma. Optimal surgical sampling techniques for each lesion are presented.

Key Messages

In summary, the clinical and histopathologic features of several common and rare nail unit tumors and the optimal sampling techniques for each lesion are presented in this manuscript. Knowledge of the clinical and histopathologic features of these tumors informs the surgical approach to them and will produce the best patient outcomes.

PRAME Immunohistochemistry in Thin Melanomas Compared to Melanocytic Nevi

PRAME (PReferentially expressed Antigen in Melanoma) immunohistochemistry has proven helpful in distinguishing malignant from benign melanocytic tumors. We studied PRAME IHC expression in 46 thin melanomas and 39 melanocytic nevi, mostly dysplastic nevi. Twenty-six percent (26.09%) of the melanomas showed diffuse PRAME staining in over 76% of the tumor cells (4+), and 34.78% of the melanomas showed PRAME expression in over 51% of the tumor cells (3+ or 4+), while 8% were entirely negative for PRAME. No melanocytic nevi were PRAME 4+ or 3+. More than half of the nevi (64%) were entirely negative for PRAME staining, and 36% of the nevi showed staining expression in 1-25% (1+) or 26-50% of the cells (2+). No nevi were stained with a color intensity of 3, while 16.67% of the melanomas were stained with this color intensity. Most nevi (78.57%) were stained with an intensity of 1. With a lower positivity threshold, sensitivity increases with still reasonable specificity. The best accuracy was obtained for the 2+ positivity threshold. In conclusion, PRAME staining helps distinguish thin melanomas from dysplastic nevi. However, the threshold of positivity should be lowered in order not to miss thin melanomas.

Analysis of PRAME immunocytochemistry in 109 acral malignant melanoma in situ

AIMS

Preferentially expressed antigen in melanoma (PRAME) recently is a reliable immunohistochemistry (IHC) marker for distinguishing melanoma from other lesions. However, there are few articles focused on PRAME use in acral malignant melanoma, the most common type in Asians. This study investigated PRAME IHC expression in a large series of acral malignant melanoma in situ to add to the body of clinical knowledge.

METHODS

PRAME IHC was performed in unequivocal cases of primary acral lentiginous melanoma in situ (ALMIS), subungual melanoma in situ (SMIS) and acral recurrent nevi as the control. PRAME tumour cell percentage positivity and intensity were expressed as categorised in a cumulative score by adding the quartile of positive tumour cells to intensity labelling. The final IHC expression was interpreted as negative (0-1), weak (2-3), moderate (4-5) or strong (6-7).

RESULTS

In 91 ALMIS patients, 32 cases (35.16%) were strong, 37 (40.66%) were moderate and 22 (24.18%) were weak. In 18 SMIS patients, strong positivity of PRAME was observed in 4 (22.22%) cases, moderate in 10 (55.56%) and weak in the remaining 4 (22.22%). No melanoma sample was negative for PRAME. By comparison, only 2 of the 40 acral recurrent nevi cases were positive.

CONCLUSIONS

Our study supports the ancillary value of PRAME for diagnosing ALMIS and SMIS with high sensitivity and specificity.

PRAME Updated: Diagnostic, Prognostic, and Therapeutic Role in Skin Cancer

Preferentially Expressed Antigen in Melanoma (PRAME), a member of the cancer/testis antigen family, is central to the field of skin cancer diagnostics and therapeutics. As a nuclear receptor and transcriptional regulator, PRAME plays a critical role in inhibiting retinoic acid signalling, which is essential for cell differentiation and proliferation. Its aberrant overexpression in various malignancies, particularly cutaneous melanoma, is associated with more aggressive tumour phenotypes, positioning PRAME as both a diagnostic and prognostic marker. In melanoma, PRAME is typically highly expressed, in contrast to its weak or absent expression in benign nevi, thereby improving the accuracy of differential diagnoses. The diagnostic value of PRAME extends to various lesions. It is significantly expressed in uveal melanoma, correlating to an increased risk of metastasis. In acral melanomas, especially those with histopathological ambiguity, PRAME helps to improve diagnostic accuracy. However, its expression in spitzoid and ungual melanocytic lesions is inconsistent and requires a comprehensive approach for an accurate assessment. In soft tissue sarcomas, PRAME may be particularly helpful in differentiating melanoma from clear cell sarcoma, an important distinction due to their similar histological appearance but different treatment approaches and prognosis, or in detecting dedifferentiated and undifferentiated melanomas. In non-melanoma skin cancers such as basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma, the variable expression of PRAME can lead to diagnostic complexity. Despite these challenges, the potential of PRAME as a therapeutic target in melanoma is significant. Emerging immunotherapies, including T-cell-based therapies and vaccines targeting PRAME, are being investigated to exploit its cancer-specific expression. Ongoing research into the molecular role and mechanism of action of PRAME in skin cancer continues to open new avenues in both diagnostics and therapeutics, with the potential to transform the management of melanoma and related skin cancers.

Pitfalls of PRAME Immunohistochemistry in a Large Series of Melanocytic and Nonmelanocytic Lesions With Literature Review

ABSTRACT

Preferentially expressed antigen in melanoma (PRAME) immunohistochemistry is currently used to facilitate distinction of benign and malignant melanocytic proliferations. We hypothesized that evaluation of 1 institution's experience with PRAME labeling in a large number of consecutive cases might elucidate additional strengths and potential pitfalls and reveal base rates of positivity versus negativity in 1 academic practice. Pathology reports for all specimens on which PRAME labeling was performed at our institution between January 2021 and May 2022 were retrieved from our database. Eighty percent of conventional malignant melanomas were labeled diffusely positive with PRAME; there were no significant differences in mean age, sex, site, Breslow depth, ulceration status, or American Joint Committee on Cancer pathological tumor stage when comparing diffusely PRAME-positive malignant melanomas with those that lack diffuse labeling. Although no banal melanocytic nevi were labeled with PRAME, 13% of dysplastic nevi were diffusely PRAME positive, with junctional proliferations, severe atypia, male gender, and older age being associated with PRAME positivity. As some but not all ambiguous melanocytic lesions in which malignancy could not be excluded based on morphology alone were diffusely PRAME positive, PRAME's accuracy in predicting malignancy remains unclear to the authors; further study is needed to assess the precision to which PRAME immunohistochemistry can separate benign borderline lesions from their malignant counterparts. Among nonmelanocytic lesions, some poorly differentiated tumors, including atypical fibroxanthomas, can be PRAME positive. This series underscores the importance of clinicopathologic correlation and shows that diffuse PRAME positivity is highest in conventional malignant melanomas (∼80%, or 8 of 10 lesions), is seen in about half of challenging borderline lesions at our institution, and can be observed in lesions diagnosed as dysplastic nevi by our group (∼10% or 1 in 10 lesions), as well as in rare poorly differentiated malignancies.

Immunohistochemistry for PRAME in Dermatopathology

ABSTRACT

Preferentially expressed antigen in melanoma (PRAME) is a tumor-associated antigen first identified in a melanoma patient and found to be expressed in most melanomas as well as in variable levels in other malignant neoplasms of epithelial, mesenchymal, or hematolymphoid lineage. Detection of PRAME expression in formalin-fixed paraffin-embedded tissue is possible by immunohistochemistry (IHC) with commercially available monoclonal antibodies. In situ and invasive melanoma frequently show a diffuse pattern of nuclear PRAME immunoreactivity which contrasts with the infrequent and typically nondiffuse staining seen in nevi. In many challenging melanocytic tumors, results of PRAME IHC and other ancillary tests correlate well, but not always: The tests are not interchangeable. Most metastatic melanomas are positive for PRAME, whereas nodal nevi are not. Numerous studies on PRAME IHC have become available in the past few years with results supporting the value of PRAME IHC as an ancillary tool in the evaluation of melanocytic lesions and providing insights into limitations in sensitivity and specificity as well as possible pitfalls that need to be kept in mind by practicing pathologists.

Basic Concepts in Nail Pathology

ABSTRACT

Understanding nail pathology is complex for general pathologists and even for those dermatopathologists who do not receive many nail samples in their laboratories. In this article, we attempt to review some of the primary entities in nail pathology with the aid of modern interpretations of nail histology and embryology. We also provide diagrams that can aid in comprehending this field of pathology.

Update on nail unit histopathology

Histopathologic evaluation of the nail unit is an essential component in the diagnosis of nail unit disorders. This review highlights recent updates in nail unit histopathology and discusses literature covering a wide range of nail disorders including melanoma/melanocytic lesions, squamous cell carcinoma, onychomatricoma, onychopapilloma, onychomycosis, lichen planus, and other inflammatory conditions. Herein we also discuss recent literature on nail clipping histopathology, a useful and noninvasive diagnostic tool that continues to grow in popularity and importance to both dermatologists and dermatopathologists.

Diagnostic test accuracy meta-analysis of PRAME in distinguishing primary cutaneous melanomas from benign melanocytic lesions

PRAME is a novel immunohistochemical marker that aids the diagnosis of melanocytic lesions. Diffuse PRAME positivity suggests melanoma, whereas benign naevi are negative or only weakly positive. However, the factual diagnostic accuracy of PRAME is not well established. Moreover, some studies have suggested that the threshold of 3+/50% positive cells may be more useful in practice than the most widely used cut-off (4+/75% of positive cells). Hence, we performed a systematic review and diagnostic accuracy meta-analysis to evaluate sensitivity, specificity, likelihood ratios and optimal threshold for PRAME in distinguishing benign melanocytic proliferations from melanomas. Twenty-six studies were enrolled into the meta-analysis. A total of 2915 melanocytic lesions were analysed. The optimal threshold for PRAME positivity was estimated at 3.11, which translates into 3+ in practice. Sensitivity and specificity calculated from SROC at the 3+ threshold were 0.735 (0.631-0.818) and 0.915 (0.834-0.958), respectively, compared to 0.679 (0.559-0.957) and 0.957 (0.908-0.981) at the 4+ cut-off. In subgroup analysis, the spitzoid subgroup was characterised by the lowest sensitivity and diagnostic odds ratio of PRAME. Our findings indicate that PRAME immunohistochemistry may serve as an ancillary marker to support the diagnosis of melanoma. Nevertheless, the accuracy of PRAME may be lower in spitzoid neoplasms. Our meta-analysis suggests that the 3+/50% threshold might be more useful in practice than the 4+/75% cut-off, as it shows higher sensitivity with retained satisfactory specificity.

Nail Apparatus Melanoma: Current Management and Future Perspectives

Nail apparatus melanoma (NAM) is a rare type of cutaneous melanoma that belongs to the acral melanoma subtype. NAM is managed principally in accordance with the general treatment for cutaneous melanoma, but there is scarce evidence in support of this in the literature. Acral melanoma is genetically different from non-acral cutaneous melanoma, while recently accumulated data suggest that NAM also has a different genetic background from acral melanoma. In this review, we focus on recent advances in the management of NAM. Localized NAM should be surgically removed; amputation of the digit and digit-preserving surgery have been reported. Sentinel lymph node biopsy can be considered for invasive NAM for the purpose of accurate staging. However, it is yet to be clarified whether patients with metastatic sentinel lymph nodes can be safely spared completion lymph node dissection. Similar to cutaneous melanoma, immune checkpoint inhibitors and BRAF/MEK inhibitors are used as the first-line treatment for metastatic NAM, but data on the efficacy of these therapies remain scarce. The therapeutic effects of immune checkpoint inhibitors could be lower for NAM than for cutaneous melanoma. This review highlights the urgent need to accumulate data to better define the optimal management of this rare melanoma.

Acral Melanocytic Neoplasms: A Comprehensive Review of Acral Nevus and Acral Melanoma in Asian Perspective

Acral melanocytic neoplasms, including acral melanocytic nevus and acral melanoma, are common melanocytic lesions in Asian populations. Both lesions occur on the volar surface of the hands and feet, and on nail units. Acral melanocytic nevi occur on the arch area of the sole, whereas acral melanomas frequently occur on weight-bearing areas of the sole, and on the fingernails. Therefore, the development of acral melanoma may be associated with chronic pressure, physical stress, or trauma. Dermoscopy is a useful adjunctive diagnostic tool for differential diagnosis. Acral melanocytic nevus is characterized by a parallel furrow pattern, whereas acral melanoma has a parallel ridge pattern. Genetic alterations are also different between the two types of lesion. BRAF and NRAS mutations are common in acral melanocytic nevus, whereas acral melanoma shows lower rates of KIT, NF1, BRAF, and NRAS mutations and remarkable copy number variations in genes such as CCND1, CDK4, hTERT, PAK1, and GAB2. Sentinel lymph node biopsy is important for staging and prognosis. Contemporary treatments for melanoma include targeted therapy for mutations and immunotherapy, such as anti-PD1 inhibitors.