Survival Outcomes of a Large Cohort of Acral Melanoma Patients Treated at a South African Referral Hospital

Acral melanoma (AM) is the most common type of melanoma arising in people with skin of color. AM is often diagnosed late and associated with poor outcomes. Melanoma outcomes are also impacted by socioeconomic status. Although uncommon, AM is a public health concern in South Africa because of its epidemiology and association with health access issues, which predispose to late diagnosis. South African patients are managed based on staging systems and treatment guidelines developed for other populations. This cohort study aimed to determine the survival outcomes in a cohort of South African AM patients and how these were associated with demographic, clinical, pathological, and management data. The study included patients diagnosed at a referral hospital between 1 January 2010 and 31 December 2021. Analysis occurred in 2022 and 2023. The main outcomes of interest were survival time in months (overall and progression-free, OS and PFS). Survival outcomes were analyzed using Kaplan-Meier survival curves. Survival probabilities were compared between subgroups using log-rank tests. Univariate and multivariable analyses were performed using the Cox proportional hazards models to assess factors associated with survival. Ninety-one patients were included in the analysis. After a median follow-up of 28 months (range: 0-151 months), 48 patients (52.7%) had died. The 3- and 5-year survival rates for the entire cohort were 64.8% and 56.0% respectively. Notably, the OS and PFS were not affected by the population group (p value = 0.628, not significant). The examination of OS and PFS by the clinical stage group demonstrated proportional hazard. Although SLNB comprised a small group, the results appear to be prognostically valid, specifically for OS. The results indicate that the AJCC eighth edition staging is broadly applicable to AM in this population; however, a rigorous comparison was not possible. SLNB appears to be prognostically valid. No difference in survival outcomes by population group was shown.

The Effectiveness of Adjuvant PD-1 Inhibitors in Patients With Surgically Resected Stage III/IV Acral Melanoma

Our aim was to assess the efficacy of adjuvant programmed cell death protein-1 (PD-1) inhibitors and compare the other adjuvant treatments in patients with surgically resected stage III or IV acral melanoma. This study is a multicenter, retrospective analysis. We included 114 patients with stage III or IV acral malignant melanoma who underwent surgery within the past 10 years. We analyzed the effect of adjuvant programmed cell death protein-1 inhibitors on disease-free survival (DFS). The mean follow-up was 40 months, during which 69 (59.5%) patients experienced recurrence. Among the participants, 64 (56.1%) received systemic adjuvant therapy. Specifically, 48.4% received anti-PD-1 therapy, 29.7% received interferon, 14.1% received tezozolomide, and 7.8% received B-Raf proto-oncogene/mitogen-activated protein kinase inhibitors. Patients who received adjuvant therapy had a median DFS of 24 (10.9-37.2) months, whereas those who did not receive adjuvant therapy had a median DFS of 15 (9.8-20.2) months. Multivariate analysis for DFS revealed that the receipt of adjuvant therapy and lymph node metastasis stage were independent significant parameters ( P = 0.021, P = 0.018, respectively). No statistically significant difference was observed for DFS between programmed cell death protein-1 inhibitor treatment and other adjuvant treatments. Regarding overall survival (OS), patients who received adjuvant treatment had a median OS of 71 (30.4-111.7) months, whereas those who did not receive adjuvant treatment had a median OS of 38 (16.7-59.3; P = 0.023) months. In addition, there were no significant differences in OS observed between various adjuvant treatment agents ( P = 0.122). In our study, we have shown that adjuvant therapy had a positive effect on both DFS and OS in patients with stages III-IV acral melanoma who underwent curative intent surgery. Notably, we found no significant differences between anti-PD-1 therapy and other adjuvant therapies.

Gain of CCND1 May Occur Too Infrequently in Cutaneous Melanoma, and Too Late in Melanomagenesis, to Be Diagnostically Useful: Genomic Analysis of 88 Cases

ABSTRACT

Genomic analysis is an important tool in the diagnosis of histologically ambiguous melanocytic neoplasms. Melanomas, in contrast to nevi, are characterized by the presence of multiple copy number alterations. One such alteration is gain of the proto-oncogene CCND1 at 11q13. In melanoma, gain of CCND1 has been reported in approximately one-fifth of cases. Exact frequencies of CCND1 gain vary by melanoma subtype, ranging from 15.8% for lentigo maligna to 25.1% for acral melanoma. We present a cohort of 72 cutaneous melanomas from 2017-2022 in which only 6 (8.3%) showed evidence of CCND1 gain by chromosomal microarray. This CCND1 upregulation frequency falls well below those previously published and is significantly lower than estimated in the literature ( P < 0.05). In addition, all 6 melanomas with CCND1 gain had copy number alterations at other loci (most commonly CDKN2A loss, followed by RREB1 gain), and 5 were either thick or metastatic lesions. This suggests that CCND1 gene amplification may be a later event in melanomagenesis, long after a lesion would be borderline or equivocal by histology. Data from fluorescence in situ hybridization, performed on 16 additional cutaneous melanomas, further corroborate our findings. CCND1 gain may not be a common alteration in melanoma and likely occurs too late in melanomagenesis to be diagnostically useful. We present the largest chromosomal microarray analysis of CCND1 upregulation frequencies in cutaneous melanoma, conjecture 3 hypotheses to explain our novel observation, and discuss implications for the inclusion or exclusion of CCND1 probes in future melanoma gene panels.

Major Histotypes in Skin Melanoma: Nodular and Acral Lentiginous Melanomas Are Poor Prognostic Factors for Relapse and Survival

ABSTRACT

The histological subtype is not considered one of the major prognostic factors in melanoma, yet it is known to have an impact on survival. The aim of this study was to investigate the clinical significance of histological subtypes and the possible impacts of clinicopathological factors on the course of melanoma patients of all stages. A total of 1017 cutaneous melanoma patients were analyzed retrospectively. Four major melanoma histotypes that were studied in this study were as follows: (1) superficial spreading melanoma (SSM), (2) nodular melanoma (NM), (3) acral lentiginous melanoma (ALM), and (4) lentigo maligna melanoma (LMM). Unlike SSMs and LMMs, there were statistically significant correlations between NMs and ALMs and most aggressive histopathological prognostic indicators, such as higher Clark level ( P = 0.0001), thick Breslow depth ( P = 0.0001), presence of ulceration ( P = 0.0001), and lymphovascular invasion ( P = 0.0001). Furthermore, NMs and ALMs were also associated with advanced clinical stages, that is, node involvement and metastasis. Relapse rates for nonmetastatic melanomas were higher in NMs (39.6%) and ALMs (35.3%) than in SSMs (24.3%) and LMMs (10.3%) ( P = 0.0001). Additionally, 5-year relapse-free survival rates were 90.5%, 70.5%, 55.7%, and 50.5% in LMMs, SSMs, ALMs, and NMs, respectively ( P = 0.0001). Moreover, 5-year overall survival rates plummeted from 84.3% in LMMs to 74.8%, 64.3%, and 46% in SSMs, ALMs, and NMs, respectively ( P = 0.0001). In conclusion, we observed that the histologic subtype was an independent predictor for relapse and outcome for cutaneous melanoma patients. Both NM and ALM had unfavorable prognoses, and they were associated with known poor pathological and clinical indicators.

Limb melanomas: acral melanomas have worse survival

BACKGROUND

The anatomic site of primary melanoma is significantly correlated with survival, and extremity melanomas have better prognosis than trunk or head and neck melanomas.

AIM

The aim of this study was to review and evaluate the prognostic factors and survival outcomes associated with both upper and lower extremity melanomas.

METHODS

A total of 524 limb-located melanomas were analyzed retrospectively.

RESULTS

Lower extremity melanomas were predominant in number and feet/toes melanomas were more frequently found in the elderly. Acral lentiginous melanomas were found to affect more frequently lower limbs and showed mainly distal distributions for both limbs. However, acral melanomas were more often ulcerated and they were more frequently BRAF wild-type melanomas associated with significant lymphovascular invasion. Foot and toe melanomas relapsed more frequently than leg melanomas. The 5-year overall survival rates for upper and lower limbs were the same, 62%. The finger (p = .0001) and toe (p = .005) melanomas had worse overall survivals than arm and leg melanomas, respectively. Both overall and disease-free survivals of acral melanoma patients were found worse than those of nonacral melanoma patients, p = .0001 and p = .001 respectively. Despite not having adjusted by Breslow, ulceration and nodal involvement status, acral location per se could be associated with poorer outcome in our retrospective study.

CONCLUSION

Even though they were not found to be correlated with major predictors of poor prognosis, acral melanomas significantly predict poor survival.

Digit melanomas are associated with poor prognostic factors and unfavorable survivals

BACKGROUND

The anatomic location of primary melanoma is significantly associated with outcome.

OBJECTIVE

To evaluate the prognostic factors and survival outcomes associated with melanomas on hand and foot digits.

METHODS

The data of 106 patients with digit melanomas were analyzed retrospectively.

RESULTS

Median age of patients was 55 years, and male-to-female ratio was one. Majority of the patients had skin melanomas (74.5%); and 25.5% of them had ungual melanomas. The lesions slightly more frequently affected toes (53.8%) and thumbs (55.9%); and 57.4% of the lesions were right-sided. Acral lentiginous melanoma was the major histological subtype (67.5%). Digit melanomas were associated with aggressive histological features, such as high Clark level (75%), thick Breslow depth (72.3%), presence of ulceration (74.3%), and high mitotic rate (58.3%). At admission, the rates of stage I-II, stage III, and stage IV diseases were 57.6%, 33%, and 9.4%, respectively. The recurrence and mortality rates were 41.7% and 46.2%, respectively. The 5-year RFS and OS rates were similar: 47%. Melanoma origins (skin vs. ungual), locations (finger vs. toe; first digit vs. others; and right vs. left), and histological subtypes (acral lentiginous melanoma vs. others) had no impact on survivals. The known poor prognostic histological factors, such as Clark level, Breslow thickness, mitotic rate, ulceration, and neurotropism, were found to be associated with both RFS and OS.

CONCLUSION

Digit melanomas are associated with poor clinicopathological prognostic features, and they might predict unfavorable survivals.

Differences by Anatomical Site of Non-Acral Lentiginous Melanomas of the Lower Limb

BACKGROUND

Acral location of melanomas is associated with poor survival. It can be due, at least in part, to the fact that acral lentiginous melanoma, a distinct melanoma subtype, has a particular biological profile and a bad clinical behavior. However, since almost 50% of acral melanomas are not of acral lentiginous melanoma subtype, the worse clinical behavior could also be attributable to the intrinsic characteristics of the location.

OBJECTIVE

This study aimed to investigate if melanomas of the lower limb excluding acral lentiginous melanoma differ by location.

METHODS

This retrospective, observational study recruited patients from an oncology referral center in Spain. We included 285 patients with superficial spreading and nodular melanomas of the lower limb. We compare melanomas by site, clinical and pathological characteristics, and the differences by location of disease-free and melanoma-specific survival by the Kaplan-Meier method and Cox proportional hazard method.

RESULTS

Patients with melanomas on the foot, compared to those on the rest of the limb, were older and reported having suffered less sunburns; the melanoma more frequently appeared in areas that had been rarely sun exposed, were more frequently of nodular type, presented thicker tumors, with more ulceration, less regression, and more advanced stage of the disease. Foot location increased the risk of relapse and decreased melanoma-specific survival.

CONCLUSION

Melanoma development in foot is less related to sun exposure and is associated with pathological features that can account for the worse prognosis and poorer survival.

Factors influencing locoregional recurrence and distant metastasis in Asian patients with cutaneous melanoma after surgery: A retrospective analysis in a tertiary hospital in Taiwan

BACKGROUND

The goal of this study was to investigate the prognostic factors for locoregional recurrence and metastasis in patients with cutaneous melanoma (CM) who underwent surgery, especially in the acral lentiginous melanoma (ALM) subtype.

METHODS

This study was a retrospective review of patients who underwent surgery for CM at Taipei Veterans General Hospital between 2000 and 2018. We investigated the risk factors for locoregional and distant metastases. The association between clinicopathological factors and locoregional recurrence and distant metastasis of the CM and ALM subtypes was analyzed. In addition, the outcomes between the ALM and non-ALM groups were compared.

RESULTS

A total of 161 patients were included in the analysis. The most common histological subtype was ALM. The overall locoregional recurrence rate of CM was 13.0% and the distant metastasis rate was 42.9%, whereas that of the ALM subtype was 12.5% and 45.5%, respectively. In patients with CM, male sex, tumor with lymphovascular invasion, and positive lymph node status were the prognostic factors for both locoregional recurrence and distant metastasis. Among the patients with ALM, positive lymph node status was significantly associated with both locoregional recurrence and distant metastasis.

CONCLUSION

In this cohort, factors influencing locoregional recurrence and distant metastasis were similar between the ALM and non-ALM groups. The above-recommended surgical margin did not show any benefit in either the CM or the ALM subtype. ALM can be handled using the same surgical strategy as CM in the Asian population.

Caucasians with acral lentiginous melanoma have the same outcome as patients with stage- and limb-matched superficial spreading melanoma

PURPOSE

Acral lentiginous melanoma (ALM), a relatively rare subtype of cutaneous melanoma, has been reported to have a worse prognosis than other melanomas. We aimed to assess clinical findings in Caucasian ALM patients and compare the data with a matched cohort of superficial spreading melanoma (SSM) patients.

METHODS

We studied 63 patients with ALM and 63 randomly stage- and limb-matched patients with SSM (non-ALM). In both cohorts, guideline-adjusted diagnosis, treatment and follow-up were performed.

RESULTS

We did not observe differences in prognostic factors (e.g., tumor thickness, ulceration) between the two cohorts. Both in ALM and non-ALM patients positive sentinel lymph node was a significant independent predictor for disease relapse and melanoma-specific death. However, disease relapse and melanoma-specific death rates did not significantly differ between ALM and non-ALM patients. An overall 5-year melanoma-specific survival of 82.5% and 81% was observed in ALM and non-ALM patients, respectively.

CONCLUSIONS

Our data confirm that patients with ALM have no worse outcome than non-ALM patients when correcting for significant prognostic factors. Hence, the reportedly high rates of fatal ALM cases should not be ascribed to pathobiological differences between ALM and non-ALM but are most likely are a consequence of a delay in diagnosis and thus advanced stage of ALM.

High Expression of COX-2 Associated with the Depth of Invasion on Acral Melanoma by Increasing TGF-β1

Introduction

Acral melanoma (AM) has a poor prognosis since it is easily metastatic and resistant to chemo and immunotherapy. Cyclooxygenase-2 (COX-2) is an enzyme that plays a role in the carcinogenesis process. The increased expression of COX-2 has an impact on increasing levels of Myeloid-Derived Suppressor Cell (MDSC), which is a key regulator of immune. The increase in MDSC produces Transforming Growth Factor β1 (TGF-β1), which will suppress Natural Killer (NK) cells and Dendritic Cells (DC) function so that tumor cells are spared from the immune systems and are easier to invade surrounding tissues.

Purpose

This study aimed to determine the role of COX-2 and TGF-β1 on the depth of invasion on AM.

Materials and Methods

This study was a cross-sectional observational study on 40 paraffin blocks of AM cases during 2014-2019 in the Department of Pathology Anatomy, Faculty of Medicine, Dr. Hasan Sadikin General Hospital, Bandung. The depth of invasion of all samples was measured by dotSlide imaging software and the immunohistochemical staining of COX-2 and TGF-β1 was performed. The association between COX-2 and TGF-β1 expression and AM depth of invasion were analyzed using Mann Whitney.

Results

The result showed a significant association between COX-2 and TGF-β1 expression and depth of invasion on AM. COX-2 expression had a significant association with TGF-β1 expression (0.0001). Through multivariate analysis, it was found that COX-2 had the greatest association with the depth of invasion (p=0.0001).

Conclusion

The findings showed that increasing expression of COX-2 in AM is associated with the depth of invasion by increasing TGF-β1 and it might play important roles during the invasion process of AM.

Acral lentiginous melanoma: Clinicopathologic and survival differences according to tumour location

BACKGROUND/OBJECTIVES

Acral lentiginous melanoma (ALM) is a melanoma subtype associated with atypical locations on the hands and feet and advanced disease at diagnosis. There is a limited understanding of whether the survival is similar for nail, non-nail, lower limb and upper limb ALM patients. We therefore explored clinicopathologic characteristics and melanoma-specific survival of ALM patients according to tumour location.

METHODS

A prospectively collected cohort study was performed of all primary invasive cutaneous acral lentiginous melanomas with known thickness and tumour location reviewed at a tertiary referral centre over 21 years.

RESULTS

A total of 101 ALM patients were reviewed from 1994 until 2016. The majority of cases (82/101) occurred on the feet. Hand ALMs were thicker and more likely to be ulcerated than feet ALMs (P = 0.05 and 0.02, respectively); however, survival was not statistically different between these two groups (univariate HR 0.48 P = 0.11, 95% CI, 0.20-1.17; multivariate HR 0.67 P = 0.40, 95% CI, 0.27-1.69, respectively). Non-nail ALM patients had longer survival when compared to nail ALM on univariate analysis (HR 0.40, 95% CI, 0.17 to 0.90) which was accounted for by Breslow thickness and ulceration (multivariate HR 0.56, 95% CI, 0.24 to 1.34).

CONCLUSIONS

The reduced melanoma-specific survival in nail ALM patients was likely due to their greater thickness and ulceration. Although hand ALMs are thicker and more frequently ulcerated, this is likely due to the higher proportion of nail ALMs present in this location.

The Clinicopathological and Survival Profiles Comparison Across Primary Sites in Acral Melanoma

Background

The clinicopathological and survival profiles across primary sites in acral melanoma (AM) are still controversial and unclear.

Methods

This is a multi-center retrospective study. Clinicopathological data of AM patients diagnosed between 1 January 2000 and 31 December 2017 from 6 large tertiary hospitals in China were extracted. Chi square tests were used to compare basic characteristics between primary sites of sole, palm and nail bed. Melanoma-specific survival (MSS) differences based on primary sites were compared by log-rank tests and multivariate Cox regressions were used to identify prognostic factors for MSS.

Results

In total, 1157 AM patients were included. The sole group had a more advanced initial stage, deeper Breslow thickness, higher recurrence rate and distant metastases risk (all P < 0.05). The proportion of age < 65 years and ulceration were statistically lower in nail bed and palm groups, respectively. A total of 294 patients underwent sentinel lymph node biopsy and rates of positive SLN status had no statistical difference across primary sites. Among 701 patients with genetic profiles, the mutational frequency of BRAF, C-KIT, and PDGFRA were similar except for NRAS (higher in sole group, P = 0.0102). The median MSS of sole, nail bed and palm patients were 65.0 months, 112.0 months, and not reached, respectively (log-rank P = 0.0053). In multivariate analyses, primary site, initial stage, ulceration and recurrence were the prognostic factors for MSS in overall population, but the statistical significance varied over primary sites.

Conclusions

Substantial clinicopathological and survival heterogeneities exist across different primary sites in the AM population. Sole melanoma has worse prognosis compared with palm and nail bed subtypes.

Clinical Outcomes of Immune Checkpoint Blocker Therapy for Malignant Melanoma in Korean Patients: Potential Clinical Implications for a Combination Strategy Involving Radiotherapy

PURPOSE

We investigated the clinical efficacy of immune checkpoint blocker (ICB) therapy for metastatic or advanced melanoma in Korean patients. As well, we assessed whether the effects of ICBs can be enhanced by combination therapy with palliative radiotherapy (RT).

Materials and Methods

We retrospectively reviewed the records of 127 patients with metastatic melanoma who received ICB with or without palliative RT between 2014 and 2018. The melanoma subtypes were classified as follows: chronic sun-damaged (CSD), acral, mucosal, and uveal. The primary endpoint was the objective response rate (ORR).

RESULTS

The overall ORR was 15%, with 11 complete and eight partial responses. ORRs for CSD, acral/mucosal, and uveal melanomas were 50%, 16.5%, and 0%, respectively (p=0.009). In addition to the subtype, stage at treatment, total tumor burden at treatment, and ICB type were significantly associated with ORR (all p < 0.05). Palliative RT was administered in 44% of patients during the treatment, and it did not affect ORR. Clinical responders to ICB therapy exhibited significantly higher 1-year progression-free and overall survival rates than nonresponders.

CONCLUSION

ORR for ICB monotherapy in Korean patients with melanoma is relatively modest compared with that in Western patients because the non-CSD subtypes are predominant in the Korean population. Our findings regarding combination therapy with ICB provided a rationale for the initiation of our phase II study (NCT04017897).