Current molecular and clinical insights into uveal melanoma (Review)

Metastases from uveal melanoma may lack S100 expression: A clinico-pathologic and immunohistochemical study with emphasis on potential causes and diagnostic implications

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults, with a high mortality rate due to metastasis, primarily to the liver. The differential diagnosis of metastatic UM, particularly in distinguishing it from cutaneous melanoma (CM), can be challenging due to overlapping histopathological features. This study investigates the immunohistochemical expression of S100 in a cohort of 41 cases, including 13 metastatic UMs, 18 metastatic CMs, and 10 primary UMs. Our results demonstrate a significant lack of S100 immunoreactivity in metastatic UM, with 84.6 % of cases showing negativity, in contrast to the diffuse positivity seen in both primary UM and metastatic CM. This finding suggests that the absence of S100 could serve as a useful marker to differentiate metastatic UM from CM, especially in cases where the primary tumor is unknown. Furthermore, the study highlights the potential diagnostic pitfall of relying solely on S100 expression on small biopsies. The absence of S100 in metastatic UM may reflect a shift in antigenic expression, possibly due to tumor dedifferentiation or clonal selection of S100-negative cells with a higher metastatic potential. Our findings emphasize the importance of employing a comprehensive immunohistochemical panel, including markers such as HMB45, SOX10, and Melan-A, in the accurate diagnosis of metastatic melanomas.

Intraocular Myxo-Papillary Ependymoma versus Retinal Gliosis Mimicking Uveal Melanoma: Report of 2 Adult Patients with Clinical, Imaging, and Histopathologic Features

Introduction

To report two cases of primary retinal ependymoma occurring in adults, both enucleated following initial suspicion of uveal melanoma. Uveal melanoma is the most frequent primary tumor of the eye in adults but other rare benign intraocular tumors such as leiomyoma, adenoma or ependymomas may also occur. To diagnose them properly is critical to adapt the patient's management, prognosis and follow-up. Ependymomas are exquisitely rare glial tumors arising from the retina, with only three cases reported yet. Primary clinical diagnosis and distinction between benign or malignant tumor is usually not possible without enucleation and histopathologic analysis. Ependymomas are glial tumors, usually occurring during childhood and arising within the central nervous system (CNS, brain or spinal cord). However, they may also occur outside the CNS, either as a primary or a secondary location.

Case Presentations

Case series from two adults aged 41 and 42 years with blindness and painful eye due to neovascular glaucoma who were enucleated for intraocular tumors. Imaging demonstrated in both cases nonspecific vascularized solid tumors consistent with uveal melanoma. Histopathologic findings showed radial arrangement of cuboidal to elongated tumor cells around hyalinized fibrovascular cores, presence of myxoid material and diffuse expression of GFAP but not Olig2, orienting the diagnosis to myxopapillary retinal ependymomas. No primary of distant CNS location was identified and follow-up at one and 3 years was favorable.

Conclusions

Intraocular ependymoma is a rare intraocular primary retinal tumor which can mimic uveal melanoma at ocular fundus examination and imaging. The diagnosis requires histopathology after enucleation, and can mimic reactive retinal gliosis, whether ependymomas can arise from retina or if retinal gliosis can have ependymoma characteristics is still to be determined. Survival and metastatic prognosis after surgery are favorable according to our experience and previously published cases, confirming the presumed benign nature of the lesions.

Microvascular changes after proton beam radiotherapy for iris melanoma: An optical coherence tomography angiography study

PurposeTo evaluate macular and peripapillary microvascular changes after proton beam radiotherapy for iris melanoma using optical coherence tomography angiography (OCT-A).MethodsPatients treated with proton beam radiotherapy for iris melanoma were included in the iris melanoma group. Fellow eyes were used as controls. Vessel density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) of the macula, radial peripapillary capillary plexus (RPCP) and foveal avascular zone (FAZ) were evaluated using OCT-A. Central macular thickness (CMT) and nerve fiber layer thickness (RNFL) were also investigated.ResultsA total of 11 patients were included. Vessel density in the whole SCP was comparable between treated eyes and untreated fellow eyes (p = 0.32). Vessel density in the whole DCP was lower in the iris melanoma group compared with untreated fellow eyes: 39% [standard deviation (SD) 1.9] versus 49% (SD 4.1), respectively (p < 0.001). Vessel density of the whole RPCP was lower in the iris melanoma group compared with untreated fellow eyes: 44% (SD 3.5) versus 48% (SD 2.2), respectively (p = 0.02). No differences between treated eyes and untreated fellow eyes were noted when evaluating FAZ, CMT and RNFL thickness.ConclusionIrradiation of the iris may determine vascular damage in the uveal tract, which, consequently, can affect the retinal vascular network. Changes in OCT-A parameters detected in DCP and RPCP may be early signs of microvascular impairment in these patients.

Integrated analyses of prognostic and immunotherapeutic significance of EZH2 in uveal melanoma

The EZH2 expression shows significantly associated with immunotherapeutic resistance in several tumors. A comprehensive analysis of the predictive values of EZH2 for immune checkpoint blockade (ICB) effectiveness in uveal melanoma (UM) remains unclear. We analyzed UM data from The Cancer Genome Atlas (TCGA) database, identified 888 differentially expressed genes (DEGs) associated with EZH2 expression, then conducted Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses to elucidate biological features of EZH2 in UM assays. The correlation of the expression of EZH2 with tumor immunity related factors such as immune-related pathways, infiltration of various immune cells, immune score and immune checkpoints were explored. The evaluation of EZH2's capability to predict immune therapy outcomes in UM was assessed by incorporating the Tumor Immune Dysfunction and Exclusion (TIDE) score. Lastly, programmed death-ligand 1 (PD-L1) expression was detected in an independent UM patient cohort by immunohistochemical analyses, the correlation of EZH2 with PD-L1 was evaluated. Results highlighted that the EZH2 expression was correlated with immune-related pathways, infiltration of various immune cells, immune score, the expression of immune checkpoints and immunotherapy sensitivity. Collectively, we suggested that EZH2 might be considered as predictor on the therapeutic effects of ICBs on UM patients, and a potential target for combined immunotherapy.

Efficacy and safety of robotic Cyberknife radiotherapy in uveal melanoma: a systematic review and meta-analysis

OBJECTIVES

This systematic review is aimed to evaluate the efficacy and safety of robotic Cyberknife radiotherapy (CKRT) in the treatment of uveal melanoma (UM).

METHODS

Clinical studies published in English that assessed the efficacy and safety of robotic CKRT in UM were systematically searched in PubMed, Web of Science, Cochrane and Embase from inception to July 2023. Studies reporting extraocular tumours or other radiosurgery approaches were excluded. Outcomes measured were tumour size, reflectivity, local tumour control rate, eye retention rate, survival rate, complication rate, recurrence rate, and metastasis rate.

RESULTS

Ten eligible articles involving 2370 patients with 2372 UMs were included in evidence synthesis. Meta-analysis showed 811 of 912 patients (0.89, 95% Cl: 0.86, 0.92) maintained local control for three years, and 1448 of 1724 patients (0.84, 95% Cl: 0.81, 0.88) preserved the eye in three years. During follow-up, 91% (0.91, 95% Cl: 0.85, 0.97) patients survived and 351 of 1720 patients (0.23, 95% Cl: 0.09, 0.37) involving 1722 eyes had tumour recurrence. In addition, 1376 patients (0.79, 95% Cl: 0.77, 0.82) preserved the eyeball in five years. Following treatment, approximately 20% of patients had radiation retinopathy (95% Cl: 0.13, 0.28), 19% developed glaucoma (95% Cl: 0.11, 0.28), and 22% experienced retinal detachment (95% Cl: 0.07, 0.36).

CONCLUSIONS

CKRT is a viable, noninvasive RT for UM. The rate of local tumour control following treatment is comparable to that of other RT approaches, providing additional options based on the patient's condition.

The role of circulating tumor DNA in melanomas of the uveal tract

Melanoma of the uveal tract or uveal melanoma (UM) originates from melanocytes of the eye and is the most common intraocular malignancy in adults. Despite considerable advances in diagnostic procedures and treatments, prognosis remains poor in those with advanced disease. Accordingly, although current treatments have an excellent local disease control rate, approximately 50% of patients develop metastatic relapse within 10 years. The high risk for metastatic disease with a variable and often long latency period is thought to be due to early spread of cancer cells disseminating into organs such as the liver, followed by a period of dormancy, before the eventual emergence of radiologically measurable disease. Early detection of disease relapse or metastasis is therefore crucial to allow timely treatment and ultimately improve patient outcome. Recently, advances in minimally-invasive liquid biopsy techniques and biomarkers such as circulating tumor DNA (ctDNA) have demonstrated potential to transform the field of cancer care by aiding diagnosis, prognosis and monitoring of various cancer types. UM is particularly suitable for ctDNA-based approaches due to the relatively well-characterized spectrum of genetic mutations, along with the inherent difficulties and risks associated with getting sufficient tumor samples via traditional biopsy methods. Key potential advantage of ctDNA are the detection of molecular residual disease (MRD) in patients post definitive treatment, and in the early identification of metastasis. This is particularly relevant contemporarily with the recent demonstration of tebentafusp improving survival in metastatic UM patients, and opens avenues for further research to investigate the potential utilization of tebentafusp combined with ctDNA-based strategies in adjuvant settings and early intervention for MRD. The present review illustrates the current understanding of ctDNA-based strategies in UM, discusses the potential clinical applications, explores the potential of utilizing ctDNA in UM MRD in the context of an ongoing clinical trial, and highlights the challenges that need to be overcome prior to routine clinical implementation.

Ang-1 promotes tumorigenesis and mediates the anti-cancer effects of Artesunate on Choroidal melanoma via the regulation of Akt/mTOR signaling pathway

The impact of Ang-1 on tumors remains a subject of contention, with its mechanism of action exhibiting complexity in the progression of diverse tumor types. Ang-1 has been shown to promote the progression of glioma, glioma, esophageal and human cervical cancer, whereas it exerts inhibitory effects on the growth of breast and colon cancer. However, the specific function of Ang-1 in CM has not been clarified. This research aims to explore the function of Ang-1 on CM and the underlying mechanism. WB and qPCR were utilized to measure the expression levels of different factors in CM cells. Clonogenic, CCK-8 and Transwell migration assay were used to probe CM cells' proliferation and migration ability. Xenograft tumor model was used to testify the effect of Ang-1 and Artesunate (ART) on the growth of CM in vivo. We found Ang-1 promoted CM proliferation and migration, while it was inhibited by ART in vitro. Moreover, both ART treatment and Ang-1 knockdown had the effect of suppressing tumor growth in CM xenograft model. Mechanically, Ang-1 activated Akt/mTOR pathway and induced epithelial-mesenchymal transition (EMT) in CM cells. Furthermore, ART regulated Akt/mTOR pathway by decreasing the expression of Ang-1 in CM cells. Ang-1 promotes tumorigenesis of CM by regulating Akt/mTOR pathway, which can be inhibited by ART.

Gq/G11 oncogenic mutations promote PD-L1 expression and suppress tumor immunity

Uveal melanoma (UM) is the predominant form of eye cancer. The genes GNAQ and GNA11, encoding Gq and G11 respectively, are most frequently mutated in UM and are considered the major drivers of UM carcinogenesis by activating YAP. However, the mechanisms by which metastatic UM evades the immune system remain poorly understood. In this study, we found that oncogenic mutations of Gq/G11 promoted YAP and PD-L1 expression, modifying the tumor microenvironment and promoting immune evasion of UM. Consistently, the levels of GNAQ/GNA11 and YAP positively correlated to PD-L1 expression in UM patients. Furthermore, silencing YAP or treating with its inhibitor, Verteporfin, attenuated PD-L1 expression induced by Gq/G11 mutations, thereby enhancing T cell activation and T cell-mediated cytotoxicity. Collectively, this study reveals a potential role of Gq/G11 mutations on immune evasion of UM, a new mechanism of Gq/11 mutations-induced tumorigenesis, highlighting Gq/G11 and YAP as potential immunotherapeutic targets and suggesting Verteporfin as an adjuvant for immunotherapy of UM patients with GNAQ or GNA11 mutations.

GNAQ/GNA11-Related Benign and Malignant Entities-A Common Histoembriologic Origin or a Tissue-Dependent Coincidence

Uveal melanoma (UM), recognized as the most prevalent primary intraocular malignancy in adults, is primarily driven by mutations in the GNAQ and GNA11 genes. These genetic alterations are also implicated in other conditions, which exhibit distinct morphological characteristics. In this article, we investigate the role of GNAQ and GNA11 mutations across varied disorders (e.g., UM, skin blue nevi, and hemangiomas), emphasizing the shared pathogenic mechanisms that connect them despite their differing clinical manifestations. By investigating the molecular pathways affected by these mutations, we provide insights into the potential for targeted therapies that could address not only UM but also other disorders associated with GNAQ/GNA11 mutations. Moreover, we discuss the role of SOX10-positive perivascular cells that may be implicated in the complex pathophysiology of GNAQ/GNA11-related entities. Understanding the common molecular foundation of these conditions opens new ways for research and treatment opportunities, potentially leading to more effective, personalized therapeutic strategies.

Genetic Features of Uveal Melanoma

BACKGROUND/OBJECTIVES

Although it comprises only 5% of all melanomas, uveal melanoma (UM) is the most commonly observed primary intraocular cancer.

METHODS

Poor patient survival persists in spite of innovative systemic therapies. In fact, approximately fifty percent of UM patients develop metastases from micro-metastases that remain undetected at the exact time of diagnosis.

RESULTS

The molecular understanding of UM is significantly enhanced by the recent identification of several mutations that are responsible for the metastasis, growth, and survival of UM. The crucial point is a more accurate genetic analysis for patient follow-up and metastatic risk prediction.

CONCLUSIONS

This review provides a brief summary of the molecular features of UM that are recently discovered, as well as cytogenetic markers and biochemical pathways that are associated with the development of UM metastases.

Biological characteristics and clinical management of uveal and conjunctival melanoma

Uveal and conjunctival melanomas are relatively rare tumors; nonetheless, they pose a significant risk of mortality for a large number of affected individuals. The pathogenesis of melanoma at different sites is very similar, however, the prognosis for patients with ocular melanoma remains unfavourable, primarily due to its distinctive genetic profile and tumor microenvironment. Regardless of considerable advances in understanding the genetic characteristics and biological behaviour, the treatment of uveal and conjunctival melanoma remains a formidable challenge. To enhance the prospect of success, collaborative efforts involving medical professionals and researchers in the fields of ocular biology and oncology are essential. Current data show a lack of well-designed randomized clinical trials and limited benefits in current forms of treatment for these tumors. Despite advancements in the development of effective melanoma therapeutic strategies, all current treatments for uveal melanoma (UM) and conjunctival melanoma (CoM) remain unsatisfactory, resulting in a poor long-term prognosis. Ongoing trials offer hope for positive outcomes in advanced and metastatic tumors. A more comprehensive understanding of the genetic and molecular abnormalities involved in the development and progression of ocular melanomas opens the way for the development of personalized therapy, with various potential therapeutic targets currently under consideration. Increased comprehension of the molecular pathogenesis of UM and CoM and their specificities may aid in the development of new and more effective systemic therapeutic agents, with the hope of improving the prognosis for patients with metastatic disease.

Naevi Characterization Using Hyperspectral Imaging: A Pilot Study

PURPOSE

The prevalence of choroidal naevi is common and has been found to be up to 10%. Little is known regarding the optical properties of choroidal naevi. A novel hyperspectral eye fundus camera was used to investigate choroidal naevi's optical density spectra in the retina.

METHODS

In an ophthalmology clinic setting, patients with choroidal naevi were included in the study. Visual acuity and pressure were tested. Following mydriatics, optical coherence tomography and fundus photography were taken as a reference, after which a hyperspectral image with 12 nm spectral resolution at 450-700 nm was taken. The optical density spectra was measured across the area of the naevus.

RESULTS

Nine patients with 11 naevi were examined. The visual acuity was not affected by any of the naevi. All the naevi were flat as measured either with the optical coherence tomography and/or on inspection, and only one naevi had a risk factor (orange pigmentation). The Wasserstein distance between the background and the naevi was higher at 695 nm compared to 555 nm (p = .002). The naevi could be grouped into three clusters based on the extracted optical density spectra.

CONCLUSION

Choroidal naevi are better visible in longer wavelengths compared to shorter wavelengths. This finding can be used to contour and follow choroidal naevi. Choroidal naevi expose different optical density spectra that can be grouped into three different clusters. One of these clusters has an optical density spectra resembling the absorption spectra of lipofuscin, which may indicate the content of this pigment.

Heterogeneity and molecular landscape of melanoma: implications for targeted therapy

Uveal cancer (UM) offers a complex molecular landscape characterized by substantial heterogeneity, both on the genetic and epigenetic levels. This heterogeneity plays a critical position in shaping the behavior and response to therapy for this uncommon ocular malignancy. Targeted treatments with gene-specific therapeutic molecules may prove useful in overcoming radiation resistance, however, the diverse molecular makeups of UM call for a patient-specific approach in therapy procedures. We need to understand the intricate molecular landscape of UM to develop targeted treatments customized to each patient's specific genetic mutations. One of the promising approaches is using liquid biopsies, such as circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA), for detecting and monitoring the disease at the early stages. These non-invasive methods can help us identify the most effective treatment strategies for each patient. Single-cellular is a brand-new analysis platform that gives treasured insights into diagnosis, prognosis, and remedy. The incorporation of this data with known clinical and genomics information will give a better understanding of the complicated molecular mechanisms that UM diseases exploit. In this review, we focused on the heterogeneity and molecular panorama of UM, and to achieve this goal, the authors conducted an exhaustive literature evaluation spanning 1998 to 2023, using keywords like "uveal melanoma, "heterogeneity". "Targeted therapies"," "CTCs," and "single-cellular analysis".

Cancer stem-like cells in uveal melanoma: novel insights and therapeutic implications

Uveal melanoma (UM) is the most common primary ocular tumor in the adult population. Even though these primary tumors are successfully treated in 90% of cases, almost 50% of patients ultimately develop metastasis, mainly in the liver, via hematological dissemination, with a median survival spanning from 6 to 12 months after diagnosis. In this context, chemotherapy regimens and molecular targeted therapies have demonstrated poor response rates and failed to improve survival. Among the multiple reasons for therapy failure, the presence of cancer stem-like cells (CSCs) represents the main cause of resistance to anticancer therapies. In the last few years, the existence of CSCs in UM has been demonstrated both in preclinical and clinical studies, and new molecular pathways and mechanisms have been described for this subpopulation of UM cells. Here, we will discuss the state of the art of CSC biology and their potential exploitation as therapeutic target in UM.

Influence of Post-radiation Ocular Surface Disorder on Ocular Surgery: A Case Report and Review of the Literature

BACKGROUND

Ocular surface disorder after ocular radiation therapy, even though commonly reported, is often overlooked. Any delay in diagnosis may lead to complications that threaten vision. The presented case highlights the clinical outcome of a severe post-radiation disorder of the ocular surface, the importance of intensive therapy, and the limitations of further surgical interventions.

CASE PRESENTATION

A 34-year-old woman was referred for a second opinion due to a years-long history of pain and redness in her right eye (OD) after proton beam therapy for recurrent iris melanoma. The patient then developed post-radiation retinopathy with macula edema, secondary glaucoma, cataract, as well as a severe ocular surface disorder with corneal decompensation and band keratopathy. Several surgical treatments have been attempted, including phacoemulsification with IOL implantation and trabeculectomy with mitomycin C. Due to refractory glaucoma, Baerveldt glaucoma drainage was then necessary. Given the worsening clinical presentation of post-radiation ocular surface disorder with progressing band keratopathy, the possibility of penetrating keratoplasty (PKP) was discussed.

CONCLUSION

The continuous worsening of clinical symptoms of the disorder of the ocular surface after proton beam radiotherapy can be the result of a post-radiation syndrome. Gradual expansion of ischemia, vasculitis, and inflammatory mediators compresses the retinal tissue, leading to recurrent macular edema as well as to secondary glaucoma and corneal decompensation. Band keratopathy is occasionally noted and seems to result from severe post-radiation disorder of the ocular surface. However, PKP would typically be indicated in cases of corneal perforation, uncontrolled infectious keratitis, or for improving vision in the presence of corneal opacification, none of which applied to our patient. Furthermore, post-radiation keratopathy implies compromised corneal stromal lymphogenesis and angiogenesis, both of which are now considered essential conditions for allograft rejection. Moreover, a previously performed Baerveldt glaucoma drainage surgery can affect the survival rate of the endothelial cells of the recipient cornea. Therefore, a penetrating or endothelial keratoplasty should be viewed as a high-risk procedure. In this instance, the rigorous treatment of the severe ocular surface disorder was crucial. We managed our patient's complex situation by following the latest guidelines set by the Tear Film & Ocular Surface Society and aimed to alleviate the symptoms as effectively as possible. In conclusion, careful decision-making regarding surgical treatment options should be considered, taking into account the complexities and potential risks involved.

New immunotherapy approaches as the most effective treatment for uveal melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults. Conventional methods of UM treatment are based on chemotherapy and radiotherapy, which have been able to control tumor growth in a limited way. But due to the inadequacy and many side effects of these treatments, many UM patients die during treatment, and approximately 50% of patients develop metastasis. Meanwhile, the 2-year survival rate of these patients from the time of metastasis is 8%. Since immunotherapy has the potential to be the most specific and efficient method in the treatment of tumors, it is considered an attractive and promising research field in the treatment of UM. This review highlights recent advances in UM immunotherapy and provides new immunological approaches on how to overcome the challenges of UM immunotherapy.

Troponin Elevation in Patients Undergoing Percutaneous Hepatic Perfusion for Metastatic Uveal Melanoma

BACKGROUND

Percutaneous Hepatic Perfusion (PHP) is a liver directed regional therapy recently FDA approved for metastatic uveal melanoma to the liver involving percutaneous isolation of liver, saturation of the entire liver with high-dose chemotherapy and filtration extracorporeally though in line filters and veno-venous bypass. The procedure is associated with hemodynamic shifts requiring hemodynamic support and blood product resuscitation due to coagulopathy.

OBJECTIVE

To assess the cardiac safety and subsequent clinically significant sequalae of this therapy.

METHODS

Consecutive PHP procedures done at our center between 2010-2022 were assessed retrospectively. Cardiac risk factors, post procedural cardiac enzymes, electrocardiograms, and transthoracic echocardiograms along with 90-day cardiac outcomes were reviewed. All data were reviewed by cardio-oncologists at our institution.

RESULTS

Of 37 patients reviewed, mean age was 63 years and 57% were women. 132 procedures were performed with an average of 3.57 procedures per patient. 68.6% of patients had elevated troponin during at least 1 procedure. No patients were found to have acute coronary syndrome, heart failure, unstable arrhythmias, or cardiac death. No patients had notable echocardiographic changes. 10.8% of patients with positive troponin had asymptomatic transient electrocardiographic changes not meeting criteria for myocardial infarction. One patient had non-sustained ventricular tachycardiac intra-operatively which did not recur subsequently. Three patients died from non-cardiac causes within 90-days. There was no oncology treatment interruption, even in those with troponin elevation. In multivariable analysis, a history of hyperlipidemia was a predictor of postoperative troponin elevation. (P = .042).

CONCLUSION

Percutaneous Hepatic Perfusion is safe and associated with a transient, asymptomatic troponin elevation peri-operatively without major adverse cardiac events at 90 days. The observed troponin elevation is likely secondary to coronary demand-supply mismatch related to procedural hemodynamic shifts, hypotension, and anemia.

Radioembolisation of liver metastases

This review aims to present contemporary data for SIRT in the treatment of secondary hepatic malignancies including colorectal, neuroendocrine, breast and uveal melanoma.

A Novel Method for Transillumination

PURPOSE

To introduce a cost-efficient device for transillumination in the management of uveal melanoma.

METHODS

Todorich Illuminated Depressor is a ball-point depressor, designed to work with the 23-, 25- and 27-gauge Alcon Constellation endoillumination. It was invented to allow indentation and peripheral vitreous visualization for vitrectomy.

RESULTS

Todorich depressor combined with endoillumination can also work as a device for transillumination for tumor localization. We started using this method of transillumination for the management of uveal melanomas since September 2020 and have successfully performed Ru-106 plaque brachytherapy for 10 cases of uveal melanoma. Three were large choroidal melanoma cases, and en bloc tumor resection by partial lamellar sclerouvectomy was successfully performed after precise localization of tumors using this method.

CONCLUSION

Alcon Constellation endoillumination capped with Todorich Illuminated Depressor is an affordable and viable alternative for transillumination of intraocular tumors.

Tumor-Associated Retinal Pigmentation in Choroidal Melanoma

PURPOSE

To report a previously unrecognized choroidal melanoma clinical feature termed tumor-associated retinal pigmentation (TARP) and determine any correlation with tumor biology.

DESIGN

Imaging and histologic analysis of a retrospective cohort of patients.

PARTICIPANTS

Patients with choroidal melanoma identified as having TARP on funduscopy at the Liverpool Ocular Oncology Centre (LOOC), United Kingdom, from January 2020 through January 2023.

METHODS

Clinical and imaging characteristics of patients diagnosed with choroidal melanoma and exhibiting TARP on fundoscopy were documented. Details of these choroidal melanomas were collated and correlated with histopathology and molecular genetic reports. The chromosome 3 status of each tumor was assessed. In enucleated samples, immunostaining was undertaken to determine the nature of the TARP using specific markers (CD68 and MelanA).

MAIN OUTCOME MEASURES

Features of TARP on widefield fundus color imaging, fundus autofluorescence (FAF), and OCT were described. Tumor chromosome 3 status and the immunoprofile of the TARP also were collated.

RESULTS

Tumor-associated retinal pigmentation had a prevalence rate of 7.47 per 100 cases of choroidal melanoma at the LOOC. Twenty-three eyes with TARP were analyzed, with a mean age of 71.4 years (range, 51-88 years). The median largest basal diameter was 16.10 mm (range, 9.17-21.32 mm), and the mean tumor thickness was 8.04 mm (range, 1.40-13.80 mm). Tumor-associated retinal pigmentation was observed on widefield color fundus imaging, with hypofluorescence on FAF images and represented hyperreflective foci located in intraretinal and subretinal spaces on OCT scans. Seventeen patients (73.9%) underwent enucleation, and 6 patients (26.1%) underwent globe-sparing treatment. Molecular genetic analysis of 20 choroidal melanomas (after enucleation or radiotherapy biopsy) revealed monosomy 3 in 18 tumors (90%). Immunostaining of the TARP in enucleated eyes showed CD68+ melanophages in all 17 patients appearing as scattered cells and aggregates; MelanA findings were negative.

CONCLUSIONS

Tumor-associated retinal pigmentation represents tumor-associated macrophages, not melanocytes, within intraretinal and subretinal spaces of larger choroidal melanomas. Radiation treatments need not involve this area in the treatment plan, minimizing radiation-related complications. This novel clinical sign seems to be linked to tumors of high metastatic-risk clinical and genetic characteristics, with a preponderance having monosomy 3 anomalies.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Genetic and Epigenetic Features of Uveal Melanoma-An Overview and Clinical Implications

Uveal melanoma (UM) is rare, but it is the most common primary intraocular malignancy among adults. This review represents the molecular, genetic, and immunobiological mechanisms involved in UM carcinogenesis and progression, as well as data about the association of chromosomal changes, genetic mutations, selective proteins, and biochemical biomarkers with the clinical implications of UM. Genetic analysis has the potential to identify patients with a high risk of UM metastasis, enabling management that is more effective and allowing for the follow-up of patients. Advancements in molecular characterization of UM offer opportunities to develop targeted therapeutic strategies by focusing on relevant signaling pathways. Changes in miRNA expression could be useful in the diagnosis and prognosis of UM, due to unique miRNA profiles in melanoma cells or tissue and its association with metastasis. Although liver function tests do not provide enough data on the prognosis of UM, due to the high frequency of liver metastasis, liver function tests (LFTs) might be useful indicators; however, the absence of rising LFT values cannot lead to the exclusion of liver metastases. Molecular analysis of tumor tissue will allow us to identify patients with the added benefit of new therapeutic agents and provide a better insight into melanoma pathogenesis and its biological behavior.

Deep learning classification of uveal melanoma based on histopathological images and identification of a novel indicator for prognosis of patients

BACKGROUND

Deep learning has been extensively used in digital histopathology. The purpose of this study was to test deep learning (DL) algorithms for predicting the vital status of whole-slide image (WSI) of uveal melanoma (UM).

METHODS

We developed a deep learning model (Google-net) to predict the vital status of UM patients from histopathological images in TCGA-UVM cohort and validated it in an internal cohort. The histopathological DL features extracted from the model and then were applied to classify UM patients into two subtypes. The differences between two subtypes in clinical outcomes, tumor mutation, and microenvironment, and probability of drug therapeutic response were investigated further.

RESULTS

We observed that the developed DL model can achieve a high accuracy of >  = 90% for patches and WSIs prediction. Using 14 histopathological DL features, we successfully classified UM patients into Cluster1 and Cluster2 subtypes. Compared to Cluster2, patients in the Cluster1 subtype have a poor survival outcome, increased expression levels of immune-checkpoint genes, higher immune-infiltration of CD8 + T cell and CD4 + T cells, and more sensitivity to anti-PD-1 therapy. Besides, we established and verified prognostic histopathological DL-signature and gene-signature which outperformed the traditional clinical features. Finally, a well-performed nomogram combining the DL-signature and gene-signature was constructed to predict the mortality of UM patients.

CONCLUSIONS

Our findings suggest that DL model can accurately predict vital status in UM patents just using histopathological images. We found out two subgroups based on histopathological DL features, which may in favor of immunotherapy and chemotherapy. Finally, a well-performing nomogram that combines DL-signature and gene-signature was constructed to give a more straightforward and reliable prognosis for UM patients in treatment and management.

Precision information extraction for rare disease epidemiology at scale

BACKGROUND

The United Nations recently made a call to address the challenges of an estimated 300 million persons worldwide living with a rare disease through the collection, analysis, and dissemination of disaggregated data. Epidemiologic Information (EI) regarding prevalence and incidence data of rare diseases is sparse and current paradigms of identifying, extracting, and curating EI rely upon time-intensive, error-prone manual processes. With these limitations, a clear understanding of the variation in epidemiology and outcomes for rare disease patients is hampered. This challenges the public health of rare diseases patients through a lack of information necessary to prioritize research, policy decisions, therapeutic development, and health system allocations.

METHODS

In this study, we developed a newly curated epidemiology corpus for Named Entity Recognition (NER), a deep learning framework, and a novel rare disease epidemiologic information pipeline named EpiPipeline4RD consisting of a web interface and Restful API. For the corpus creation, we programmatically gathered a representative sample of rare disease epidemiologic abstracts, utilized weakly-supervised machine learning techniques to label the dataset, and manually validated the labeled dataset. For the deep learning framework development, we fine-tuned our dataset and adapted the BioBERT model for NER. We measured the performance of our BioBERT model for epidemiology entity recognition quantitatively with precision, recall, and F1 and qualitatively through a comparison with Orphanet. We demonstrated the ability for our pipeline to gather, identify, and extract epidemiology information from rare disease abstracts through three case studies.

RESULTS

We developed a deep learning model to extract EI with overall F1 scores of 0.817 and 0.878, evaluated at the entity-level and token-level respectively, and which achieved comparable qualitative results to Orphanet's collection paradigm. Additionally, case studies of the rare diseases Classic homocystinuria, GRACILE syndrome, Phenylketonuria demonstrated the adequate recall of abstracts with epidemiology information, high precision of epidemiology information extraction through our deep learning model, and the increased efficiency of EpiPipeline4RD compared to a manual curation paradigm.

CONCLUSIONS

EpiPipeline4RD demonstrated high performance of EI extraction from rare disease literature to augment manual curation processes. This automated information curation paradigm will not only effectively empower development of the NIH Genetic and Rare Diseases Information Center (GARD), but also support the public health of the rare disease community.

TAP1, a potential immune-related prognosis biomarker with functional significance in uveal melanoma

BACKGROUND

TAP1 is an immunomodulation-related protein that plays different roles in various malignancies. This study investigated the transcriptional expression profile of TAP1 in uveal melanoma (UVM), revealed its potential biological interaction network, and determined its prognostic value.

METHODS

CIBERSORT and ESTIMATE bioinformatic methods were used on data sourced from The Cancer Genome Atlas database (TCGA) to determine the correlation between TAP1 expression, UVM prognosis, biological characteristics, and immune infiltration. Gene set enrichment analysis (GSEA) was used to discover the signaling pathways associated with TAP1, while STRING database and CytoHubba were used to construct protein-protein interaction (PPI) and competing endogenous RNA (ceRNA) networks, respectively. An overall survival (OS) prognostic model was constructed to test the predictive efficacy of TAP1, and its effect on the in vitro proliferation activity and metastatic potential of UVM cell line C918 cells was verified by RNA interference.

RESULTS

There was a clear association between TAP1 expression and UVM patient prognosis. Upregulated TAP1 was strongly associated with a shorter survival time, higher likelihood of metastasis, and higher mortality outcomes. According to GSEA analysis, various immunity-related signaling pathways such as primary immunodeficiency were enriched in the presence of elevated TAP1 expression. A PPI network and a ceRNA network were constructed to show the interactions among mRNAs, miRNAs, and lncRNAs. Furthermore, TAP1 expression showed a significant positive correlation with immunoscore, stromal score, CD8+ T cells, and dendritic cells, whereas the correlation with B cells and neutrophils was negative. The Cox regression model and calibration plots confirmed a strong agreement between the estimated OS and actual observed patient values. In vitro silencing of TAP1 expression in C918 cells significantly inhibited cell proliferation and metastasis.

CONCLUSIONS

This study is the first to demonstrate that TAP1 expression is positively correlated with clinicopathological factors and poor prognosis in UVM. In vitro experiments also verified that TAP1 is associated with C918 cell proliferation, apoptosis, and metastasis. These results suggest that TAP1 may function as an oncogene, prognostic marker, and importantly, as a novel therapeutic target in patients with UVM.

Genetics and RNA Regulation of Uveal Melanoma

Uveal melanoma (UM) is the most common intraocular malignant tumor and the most frequent melanoma not affecting the skin. While the rate of UM occurrence is relatively low, about 50% of patients develop metastasis, primarily to the liver, with lethal outcome despite medical treatment. Notwithstanding that UM etiopathogenesis is still under investigation, a set of known mutations and chromosomal aberrations are associated with its pathogenesis and have a relevant prognostic value. The most frequently mutated genes are BAP1, EIF1AX, GNA11, GNAQ, and SF3B1, with mutually exclusive mutations occurring in GNAQ and GNA11, and almost mutually exclusive ones in BAP1 and SF3B1, and BAP1 and EIF1AX. Among chromosomal aberrations, monosomy of chromosome 3 is the most frequent, followed by gain of chromosome 8q, and full or partial loss of chromosomes 1 and 6. In addition, epigenetic mechanisms regulated by non-coding RNAs (ncRNA), namely microRNAs and long non-coding RNAs, have also been investigated. Several papers investigating the role of ncRNAs in UM have reported that their dysregulated expression affects cancer-related processes in both in vitro and in vivo models. This review will summarize current findings about genetic mutations, chromosomal aberrations, and ncRNA dysregulation establishing UM biology.

Construction and Verification of the Molecular Subtype and a Novel Prognostic Signature Based on Inflammatory Response-Related Genes in Uveal Melanoma

The significance of inflammation in tumorigenesis and progression has become prominent. This study aimed to construct and validate the molecular subtype and a novel prognostic signature based on inflammatory response-related genes in uveal melanoma (UM). Patients from the TCGA, GSE84976, and GSE22138 UM cohorts were enrolled. According to the consensus cluster analysis, patients were divided into two molecular subtypes, namely IC1 and IC2. Survival curves showed that patients in IC1 had a better prognosis. The IC2 subgroup had higher levels of immune cell infiltration and more enriched immunological pathways. There were statistical differences in the immune-inflammation microenvironment, immune checkpoint genes expression, and drug sensitivity. The prognostic signature constructed based on inflammatory response-related genes exhibited a stable predictive power. Multivariate analysis confirmed that the signature was a prognostic factor independent of clinical characteristics. Functional analyses showed that the high-risk group was associated with immunological response, inflammatory cell activation, and tumor-related signal pathways. The riskscore had a negative relationship with tumor purity and was positively correlated with immune and stromal scores. Furthermore, the prognostic signature could sensitively predict the response to drug treatments. In conclusion, the prognostic signature might aid in stratifying patients at risk premised on the prognosis and immunotherapy sensitivity.

Choroidal melanoma tumor profile and treatment pattern for newly diagnosed patients at a reference public hospital in Sao Paulo, Brazil

BACKGROUND

Choroid, ciliary body, and iris melanomas are often grouped as uveal melanoma, the most common intraocular primary malignancy. The purpose of the current study was to analyze the tumor profile of newly diagnosed cases of choroidal melanoma at a reference center in Sao Paulo, Brazil, and to investigate the frequency of eyes treated by enucleation that could have been treated with brachytherapy if available in the service.

METHODS

Medical records of patients referred to our service with initial diagnostic hypothesis of choroidal melanoma from July 2014 to June 2020 were analysed on demographics, diagnosis confirmation, tumor measurement by ultrasonography and established treatment. Data were evaluated on clinical and demographic characteristics as age, sex, affected eye, ultrasound parameters, and treatment management of patients with clinically diagnosed choroidal melanoma. Among the patients submitted to enucleation, we investigated how many could have been selected to receive brachytherapy.

RESULTS

From the 102 patients referred with the choroidal melanoma diagnosis hypothesis, 70 (68.62%) were confirmed. Mean measurements from the tumors in millimetres were: 9.19 ± 3.69 at height and 12.97 ± 3.09 by 13.30 ± 3.30 at basal. A total of 48 cases (68.57%) were enucleated, 8 (11.43%) were treated by brachytherapy in a different service, and 14 patients (20.00%) returned for enucleation at their original referral center. Out of the 48 patients enucleated, 26 (54.17%) could have been selected to brachytherapy treatment.

CONCLUSIONS

The results indicate a late diagnosis of choroidal melanoma cases referred to our service. Most enucleated cases could have been treated with brachytherapy if it was broadly available at the national public health insurance. Further public health political efforts should focus on early diagnosis and better quality of life post-treatment for oncologic patients.

Development of a 3-MicroRNA Signature and Nomogram for Predicting the Survival of Patients with Uveal Melanoma Based on TCGA and GEO Databases

Background. The aim of this study was to apply bioinformatic analysis to develop a robust miRNA signature and construct a nomogram model in uveal melanoma (UM) to improve prognosis prediction. Methods. miRNA and mRNA sequencing data for 80 UM patients were obtained from The Cancer Genome Atlas (TCGA) database. The patients were further randomly assigned to a training set (n = 40, used to identify key miRNAs) and a testing set (n = 40, used to internally verify the signature). Then, miRNAs data of GSE84976 and GSE68828 were downloaded from Gene Expression Omnibus (GEO) database for outside verification. Combining univariate analysis and LASSO methods for identifying a robust miRNA biomarker in training set and the signature was validated in testing set and outside dataset. A prognostic nomogram was constructed and combined with decision curve as well as reduction curve analyses to assess the application of clinical usefulness. Finally, we constructed a miRNA-mRNA regulator network in UM and conducted pathway enrichment analysis according to the mRNAs in the network. Results. In total, a 3-miRNA was identified and validated that can robustly predict UM patients’ survival. According to univariate and multivariate cox analyses, age at diagnosis, tumor node metastasis (TNM) classification, stage, and the 3-miRNA signature significantly correlated with the survival outcomes. These characteristics were used to establish nomogram. The nomogram worked well for predicting 1 and 3 years of overall survival time. The decision curve of nomogram revealed a good clinical usefulness of our nomogram. What’s more, a miRNA-mRNA network was constructed. Pathway enrichment showed that this network was largely involved in mRNA processing, the mRNA surveillance pathway, the spliceosome, and so on. Conclusions. We developed a 3-miRNA biomarker and constructed a prognostic nomogram, which may afford a quantitative tool for predicting the survival of UM. Our finding also provided some new potential targets for the treatment of UM.

A Necroptosis-Related Gene Signature to Predict the Prognosis of Skin Cutaneous Melanoma

The prognosis of skin cutaneous melanoma (SKCM) remains poor, and patients with SKCM show a poor response to immunotherapy. Thus, we aimed to identify necroptosis-related biomarkers, which can help predict the prognosis of SKCM and improve the effectiveness of precision medicine. Data of SKCM were obtained from The Cancer Genome Atlas (TCGA) and GEO databases. TCGA samples were classified into two clusters by consensus clustering of necroptosis-related genes. Univariate Cox and least absolute shrinkage and selection operator regression analyses led to the identification of 11 genes, which were used to construct a prognostic model. GSE65904 was used as the test set. Principal component, t-distributed stochastic neighbor embedding, and Kaplan–Meier survival analyses indicated that samples in the train and test sets could be divided into two groups, with the high-risk group showing a worse prognosis. Univariate and multivariate Cox regression analyses were performed, and a nomogram, calibration curve, and time-dependent receiver operating characteristic curve were constructed to verify the efficacy of our model. The 1-, 3-, and 5-year areas under the receiver operating characteristic curves for the train set were 0.702, 0.663, and 0.701 and for the test set were 0.613, 0.627, and 0.637, respectively. Moreover, we performed Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses between the high- and low-risk groups. Single sample gene set enrichment analysis, immune cell infiltration analysis, tumor microenvironment scores, immune checkpoint analysis, and half-maximal inhibitory concentration prediction indicated that the high-risk group showed weaker antitumor immunity; further, the response to immune checkpoint inhibitors was worse, and the high-risk group was sensitive to fewer antitumor drugs. Tumor mutational burden analysis, Kaplan–Meier survival analysis, and correlation analysis between risk score and RNA stemness score revealed that the high-risk group with low tumor mutational burden and high RNA stemness score was potentially associated with poor prognosis. To conclude, our model, which was based on 11 necroptosis-related genes, could predict the prognosis of SKCM; in addition, it has guiding significance for the selection of clinical treatment and provides new research directions to enhance necroptosis against SKCM.

Clinical and Multimodal Imaging Features of Choroidal Nevi in the Korean Population

Choroidal nevus is a precursor of choroidal melanoma. Multimodal imaging has become vital in predicting the malignant transformation of choroidal nevi. This single-center, retrospective study analyzed clinical characteristics and multimodal imaging findings of 168 choroidal nevi (164 patients) of the Korean population. The mean age at presentation was 50 ± 15 (range, 13−85) (women, n = 88 [53.7%]). Choroidal nevi (melanotic, n = 164 [97.6%]; postequatorial, n = 160 [95.2%]) were densely located between the optic disc and foveola (65.5%). The mean maximum linear basal diameter on fundus photography and thickness on optical coherence tomography were 2.97 ± 1.51 mm and 521 ± 297 μm, respectively. On ultrasonography, the mean thickness was 0.87 ± 0.60 mm. Choroidal nevi in women were associated with a higher maximum linear basal diameter (3.23 ± 1.65 vs. 2.68 ± 1.21 mm; p = 0.033) and age at diagnosis (52 ± 14 vs. 47 ± 16 years; p = 0.046) than those in men. Choroidal nevi with associated subretinal fluid (23.2%) presented with larger basal diameter (p = 0.049) and thickness on B-scan and optical coherence tomography (p < 0.001), but a younger age at diagnosis (p < 0.001) than those of dry nevi. This multimodal imaging study of choroidal nevi revealed some distinct characteristics, including topographic distribution, sex-related differences, and a younger age at diagnosis of nevi with fluid.

METTL14 promotes migration and invasion of choroidal melanoma by targeting RUNX2 mRNA via m6A modification

The modification of N6-methyladenosine is involved in the progression of various cancers. This study aimed to clarify its regulatory mechanism in the pathogenesis of choroidal melanoma. Expression of methyltransferase-like 14 in choroidal melanoma or normal choroidal tissues was determined by Western blot and immunohistochemistry. The impacts of methyltransferase-like 14 on invasion and migration of choroidal melanoma cells were determined using functional and animal experiments. The interaction between methyltransferase-like 14 and its downstream target was identified by methylated RNA immunoprecipitation and a dual-luciferase reporter assay. Additionally, Wnt/β-catenin signalling pathway was evaluated by Western blot. Methyltransferase-like 14 was upregulated in choroidal melanoma compared to the normal choroidal tissues. Overexpression or knockdown of methyltransferase-like 14 enhanced or inhibited the invasion and migration of choroidal melanoma cells, respectively, both in vivo and in vitro. Methyltransferase-like 14 directly targeted downstream runt-related transcription factor 2 mRNA, depending on N6-methyladenosine. Additionally, the Wnt/β-catenin signalling pathway was activated by methyltransferase-like 14 in choroidal melanoma cells. Our study identified a novel RNA regulatory mechanism in which runt-related transcription factor 2 was upregulated by enhanced expression of methyltransferase-like 14 via N6-methyladenosine modification, thus facilitating migration and invasion of choroidal melanoma cells.

Genetic risk factors in melanoma etiopathogenesis and the role of genetic counseling: A concise review

Melanoma is a highly aggressive cancer originating from melanocytes. Its etiopathogenesis is strongly related to genetic, epigenetic, and environmental factors. Melanomas encountered in clinical practice are predominantly sporadic, whereas hereditary melanomas account for approximately 10% of the cases. Hereditary melanomas mainly develop due to mutations in the CDKN2A gene, which encodes two tumor suppressor proteins involved in the cell cycle regulation. CDKN2A, along with CDK4, TERT, and POT1 genes, is a high-risk gene for melanoma. Among the genes that carry a moderate risk are MC1R and MITF, whose protein products are involved in melanin synthesis. The environment also contributes to the development of melanoma. Patients at risk of melanoma should be offered genetic counseling to discuss genetic testing options and the importance of skin UV protection, avoidance of sun exposure, and regular preventive dermatological examinations. Although cancer screening cannot prevent the development of the disease, it allows for early diagnosis when the survival rate is the highest.

MITF deficiency and oncogenic GNAQ each promote proliferation programs in zebrafish melanocyte lineage cells

Uveal melanoma (UM) is the most common primary malignancy of the adult eye but lacks any FDA-approved therapy for the deadly metastatic disease. Thus, there is a great need to dissect the driving mechanisms for UM and develop strategies to evaluate potential therapeutics. Using an autochthonous zebrafish model, we previously identified MITF, the master melanocyte transcription factor, as a tumor suppressor in GNAQQ209L -driven UM. Here, we show that zebrafish mitfa-deficient GNAQQ209L -driven tumors significantly up-regulate neural crest markers, and that higher expression of a melanoma-associated neural crest signature correlates with poor UM patient survival. We further determined how the mitfa-null state, as well as expression of GNAQQ209L , YAPS127A;S381A , or BRAFV600E oncogenes, impacts melanocyte lineage cells before they acquire the transformed state. Specifically, examination 5 days post-fertilization showed that mitfa-deficiency is sufficient to up-regulate pigment progenitor and neural crest markers, while GNAQQ209L expression promotes a proliferative phenotype that is further enhanced by YAPS127A;S381A co-expression. Finally, we show that this oncogene-induced proliferative phenotype can be used to screen chemical inhibitors for their efficacy against the UM pathway. Overall, this study establishes that a neural crest signature correlates with poor UM survival, and describes an in vivo assay for preclinical trials of potential UM therapeutics.

Uveal melanoma patient attitudes towards prognostic testing using gene expression profiling

Aim:

This study explored uveal melanoma patient experiences and regret following molecular prognostic testing using a 15-gene expression profile (GEP) test.

Materials & methods:

A retrospective, cross-sectional survey study was conducted through an online questionnaire capturing patient-reported experiences with prognostic biopsy/molecular testing.

Results:

Of 177 respondents, 159 (90%) wanted prognostic information at diagnosis. Most 15-GEP-tested patients who shared their results (99%) reported gaining value from testing, as did patients tested with other methods. Patients who received prognostic testing experienced lower decision regret than those who opted out. Decision regret did not differ based on GEP class.

Conclusion:

Most uveal melanoma patients desire prognostic testing and gain value from the GEP, independent of a high- or low-risk result.

Uveal melanoma is a rare but aggressive eye cancer, resulting in distant metastasis in nearly 50% of patients. Molecular prognostic testing is often employed to determine who is at high or low risk of developing metastatic disease. A prognostic 15-gene expression profiling (GEP) test is commonly used throughout the USA and parts of Canada. The goal of this survey was to assess patient experiences with the 15-GEP and other prognostic methods. Of the 177 patients who participated in the survey, the majority reported that they wanted prognostic information at the time of diagnosis. Of patients who underwent 15-GEP testing, nearly all reported gaining value from their test result, regardless of their individual risk profile. This study supports prior findings using other prognostic methods that patients prefer information about their risk of metastasis and reinforces the importance of discussing prognostic testing options with newly diagnosed uveal melanoma patients.

N6-Methyladenosine regulator RBM15B acts as an independent prognostic biomarker and its clinical significance in uveal melanoma

Uveal melanoma (UM) is the most frequent intraocular malignant tumor in adults. N⁶-Methyladenosine (m⁶A) methylation is recognized as the most critical epigenetic change and is implicated in the development of many malignancies. However, its prognostic value in UM is poorly understood. RNA-seq and clinical data from The Cancer Genome Atlas (TCGA) help us better understand the relationship between m⁶A regulators and UM patients. Herein, four UM groups established by consensus clustering were shown to have different immune cell infiltrations and prognostic survival. Five m⁶A regulators, including RBM15B, IGF2BP1, IGF2BP2, YTHDF3, and YTHDF1, were associated with the prognosis of UM patients. Intriguingly, RBM15B was confirmed to be the only independent prognostic factor for UM and it was significantly correlated with clinicopathologic characteristics of UM. Notably, RBM15B expression was significantly negatively correlated with immune checkpoints. Furthermore, LINC00665/hsa-let-7b-5p/RBM15B axis and LINC00638/hsa-miR-103a-3p/RBM15B axis were found to be potential prognostic biomarkers in UM. In a nutshell, this work, through bioinformatics analysis, systematically described the gene signatures and prognostic values of m⁶A regulators. RBM15B is an independent protective prognostic factor, which may help us better understand the crosstalk within UM.

Imaging of Uveal Melanoma—Current Standard and Methods in Development

Simple Summary

Uveal melanoma is the most prevalent intraocular tumor in adults, derived from melanocytes; the liver is the most common site of its metastases. Due to troublesome tumor localization, different imaging techniques are utilized in diagnostics, i.e., fundus imaging (FI), ultrasonography (US), optical coherence tomography (OCT), single-photon emission computed tomography (SPECT), positron emission tomography/computed tomography (PET/CT), magnetic resonance imaging (MRI), fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), or fundus autofluorescence (FAF). Specialists eagerly use these techniques, but sometimes the precision and quality of the obtained images are imperfect, raising diagnostic doubts and prompting the search for new ones. In addition to analyzing the currently utilized methods, this review also introduces experimental techniques that may be adapted to clinical practice in the future. Moreover, we raise the topic and present a perspective for personalized medicine in uveal melanoma treatment.

Abstract

Uveal melanoma is the most common primary intraocular malignancy in adults, characterized by an insidious onset and poor prognosis strongly associated with tumor size and the presence of distant metastases, most commonly in the liver. Contrary to most tumor identification, a biopsy followed by a pathological exam is used only in certain cases. Therefore, an early and noninvasive diagnosis is essential to enhance patients’ chances for early treatment. We reviewed imaging modalities currently used in the diagnostics of uveal melanoma, including fundus imaging, ultrasonography (US), optical coherence tomography (OCT), single-photon emission computed tomography (SPECT), fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), fundus autofluorescence (FAF), as well as positron emission tomography/computed tomography (PET/CT) or magnetic resonance imaging (MRI). The principle of imaging techniques is briefly explained, along with their role in the diagnostic process and a summary of their advantages and limitations. Further, the experimental data and the advancements in imaging modalities are explained. We describe UM imaging innovations, show their current usage and development, and explain the possibilities of utilizing such modalities to diagnose uveal melanoma in the future.

A Predictive Web-Based Nomogram for Elderly Patients Newly Diagnosed as Uveal Melanoma: A Population-Based Study

Background

Uveal melanoma (UM) is the most frequent primary intraocular tumor in adults. This study aims to develop a nomogram and an individualized web-based calculator to predict the overall survival (OS) of elderly patients with UM.

Methods

Patients aged more than 60 years and diagnosed with UM were derived from the Surveillance, Epidemiology, and End Results (SEER) database during 2004–2015. The selected patients were randomly divided into training and validation cohorts. In the training cohort, the univariate and multivariate Cox analyses were carried out to determine the independent prognostic factors, and the predictors were integrated to establish a nomogram for predicting the 1-, 2-, and 3-year OS of elderly patients with UM. The discrimination of the nomogram was validated by receiver operating characteristic (ROC) curves and the area under the curve (AUC). The clinical practicability and accuracy of the nomogram were evaluated by the calibration curves and decision curve analysis (DCA). A web-based survival calculator was then constructed using a fitted survival prediction model (https://yuexinupup.shinyapps.io/DynNomapp/).

Results

A total of 1,427 patients with UM were included in this study. Age, T stage, N stage, M stage, marital status, sex, and radiotherapy (RT) were identified as independent prognostic factors. Based on the abovementioned factors, the nomogram was then constructed. The AUC values of the nomogram predicting 1-, 2-, and 3-year OS were 0.841, 0.801, and 0.768 in the training cohort, and 0.745, 0.717, and 0.710 in the validation cohort, respectively. The calibration curves and DCA also indicated the good performance of the predictive model.

Conclusion

This study established and validated a novel nomogram risk stratification model and a web-based survival rate calculator that can dynamically predict the long-term OS for elderly patients with UM.

GNAQ and GNA11 Genes: A Comprehensive Review on Oncogenesis, Prognosis and Therapeutic Opportunities in Uveal Melanoma

The GNAQ and GNA11 genes are mutated in almost 80-90% of uveal melanomas in a mutually exclusive pattern. These genes encode the alpha subunits of the heterotrimeric G proteins, Gq and G11; thus, mutations of these genes result in the activation of several important signaling pathways, including phospholipase C, and activation of the transcription factor YAP. It is well known that both of them act as driver genes in the oncogenic process and it has been assumed that they do not play a role in the prognosis of these tumours. However, it has been hypothesised that mutations in these genes could give rise to molecularly and clinically distinct types of uveal melanomas. It has also been questioned whether the type and location of mutation in the GNAQ and GNA11 genes may affect the progression of these tumours. All of these questions, except for their implications in carcinogenesis, remain controversial. Uveal melanoma has a distinctive genetic profile, and specific recurrent mutations, which make it a potential candidate for treatment with targeted therapy. Given that the most frequent mutations are those observed in the GNAQ and GNA11 genes, and that both genes are involved in oncogenesis, these molecules, as well as the downstream signalling pathways in which they are involved, have been proposed as promising potential therapeutic targets. Therefore, in this review, special attention is paid to the current data related to the possible prognostic implications of both genes from different perspectives, as well as the therapeutic options targeting them.

Case Report: GNAQ- and SF3B1 Mutations in an Aggressive Case of Relapsing Uveal Ring Melanoma

The molecular mechanisms for uveal ring melanoma are still unclear until today. In this case report, we describe a patient with a malignant uveal melanoma with exudative retinal detachment that had been treated with plaque brachytherapy, resulting in successful tumor regression. After 1 year, a ring-shaped recurrence with extraocular extension appeared, and the eye required enucleation. Histological and molecular genetic analyses revealed an epithelioid-cell-type melanoma with complete circumferential involvement of the ciliary body and, so far, unreported GNAQ and SF3B1 mutations in ring melanoma. Therefore, this report gives new genetic background information on this ocular tumor usually leading to enucleation.

Managing Metastatic Melanoma in 2022: A Clinical Review

Cutaneous melanoma remains the most lethal of the primary cutaneous neoplasms, and although the incidence of primary melanoma continues to rise, the mortality from metastatic disease remains unchanged, in part through advances in treatment. Major developments in immunomodulatory and targeted therapies have provided robust improvements in response and survival trends that have transformed the clinical management of patients with metastatic melanoma. Additional advances in immunologic and cancer cell biology have contributed to further optimization in (1) risk stratification, (2) prognostication, (3) treatment, (4) toxicity management, and (5) surveillance approaches for patients with an advanced melanoma diagnosis. In this review, we provide a comprehensive overview of the historical and future advances regarding the translational and clinical implications of advanced melanoma and share multidisciplinary recommendations to aid clinicians in the navigation of current treatment approaches for a variety of patient cohorts.

Genetic Basis and Molecular Mechanisms of Uveal Melanoma Metastasis: A Focus on Prognosis

Uveal melanoma (UM) is the most frequently found primary intraocular tumor, although it accounts for only 5% of all melanomas. Despite novel systemic therapies, patient survival has remained poor. Indeed, almost half of UM patients develop metastases from micro-metastases which were undetectable at diagnosis. Genetic analysis is crucial for metastatic risk prediction, as well as for patient management and follow-up. Several prognostic parameters have been explored, including tumor location, basal dimension and thickness, histopathologic cell type, vascular mimicry patterns, and infiltrating lymphocytes. Herein, the Authors review the available literature concerning cytogenetic prognostic markers and biochemical pathways correlated to UM metastasis development.

A Novel Four Genes of Prognostic Signature for Uveal Melanoma

Autophagy and immunity play critical roles in various cancers, but the prognostic impact of autophagy and immunity for uveal melanoma (UM) remains lacking. Therefore, the RNA sequencing of data in the TCGA-UVM dataset was downloaded from UCSC Xena database. The prognostic autophagy- and immunity-related genes (AIRGs) were selected via univariate Cox regression. Next, we applied LASSO method to construct four genes of signature in the TCGA-UVM and verified in another two GEO datasets (GSE84976 and GSE22138). This signature intimately associated with overall survival (OS) time and metastasis-free survival (MFS) time of UM, which could be considered as a prognostic indicator. Besides, by applying risk assessment, the patients of UM can be divided into two subgroups (high/low risk) with different survival time, distinct clinical outcomes, and immune microenvironments. Gene set enrichment analysis (GSEA) manifested that cancer hallmark epithelial-mesenchymal transition and KRAS pathways were positively activated in the high-risk group. Moreover, the high-risk group could be more sensitive to chemotherapies than the low-risk group. Thus, our finding suggested that the four genes of signature closely linked with UM risk and survival can afford more accurate survival prediction and potential therapeutic targets for clinical application.

Circulating MicroRNAs as Quantitative Biomarkers for Diagnosis and Prognosis of Uveal Melanoma

For uveal melanoma (UM) patients, it is significant to establish diagnosis and prognosis evaluation systems through imaging techniques. However, imaging examinations are short of quantitative biomarkers and it is difficult to finish early diagnosis of UM. In order to discover new molecular biomarkers for the diagnosis and prognostic evaluation of UM, six circulating miRNAs (mir-132-3p, mir-21-5p, mir-34a-5p, mir-126-3p, mir-199a-3p, mir-214-3p) were chosen as candidates for independent validation. Validation of these miRNAs was performed in a cohort of 20 patients, including 10 spindle-shaped melanoma and 10 epithelioid cell melanoma, and 10 healthy donors. Then 5 patients with metastatic UM were included to validate the performance of miRNAs in advanced UM. Serum levels of miRNAs were determined using quantitative real-time PCR. We confirmed significantly higher levels of three miRNAs in serum of UM patients in comparison to healthy controls, and miR-199a-3p had the best performance (p < 0.0001; AUC = 0.985). MiR-214-3p and miR-21-5p were significantly upregulated in serum of epithelioid cell melanoma patients compared to spindle-shaped melanoma patients and miR-132-3p and, conversely, were significantly downregulated in serum of epithelioid cell melanoma patients. MiR-21-5p shows their best performance (p < 0.0001; AUC = 0.980). Both miR-199a-3p and miR-21-5p showed great performance in advanced UM. Significantly higher levels of miR-21-5p (p < 0.001) were found in serum of metastatic UM patients compared to patients with localized spindle-shaped melanoma, and significantly higher levels of miR-199a-3p (p < 0.001) were detected in serum of metastatic UM patients compared to healthy controls. Our preliminary data indicate promising diagnostic utility of circulating miR-199a-3p and promising prognostic utility of circulating miR-21-5p in both early and advanced UM patients.

Integrative analysis identifies key genes related to metastasis and a robust gene-based prognostic signature in uveal melanoma

PURPOSE

Uveal melanoma (UM) is an aggressive intraocular malignancy, leading to systemic metastasis in half of the patients. However, the mechanism of the high metastatic rate remains unclear. This study aimed to identify key genes related to metastasis and construct a gene-based signature for better prognosis prediction of UM patients.

METHODS

Weighted gene co-expression network analysis (WGCNA) was used to identify the co-expression of genes primarily associated with metastasis of UM. Univariate, Lasso-penalized and multivariate Cox regression analyses were performed to establish a prognostic signature for UM patients.

RESULTS

The tan and greenyellow modules were significantly associated with the metastasis of UM patients. Significant genes related to the overall survival (OS) in these two modules were then identified. Additionally, an OS-predicting signature was established. The UM patients were divided into a low- or high-risk group. The Kaplan-Meier curve indicated that high-risk patients had poorer OS than low-risk patients. The receiver operating curve (ROC) was used to validate the stability and accuracy of the final five-gene signature. Based on the signature and clinical traits of UM patients, a nomogram was established to serve in clinical practice.

CONCLUSIONS

We identified key genes involved in the metastasis of UM. A robust five-gene-based prognostic signature was constructed and validated. In addition, the gene signature-based nomogram was created that can optimize the prognosis prediction and identify possible factors causing the poor prognosis of high-risk UM patients.

Pigment Epithelia of the Eye: Cell-Type Conversion in Regeneration and Disease

Pigment epithelial cells (PECs) of the retina (RPE), ciliary body, and iris (IPE) are capable of altering their phenotype. The main pathway of phenotypic switching of eye PECs in vertebrates and humans in vivo and/or in vitro is neural/retinal. Besides, cells of amphibian IPE give rise to the lens and its derivatives, while mammalian and human RPE can be converted along the mesenchymal pathway. The PECs’ capability of conversion in vivo underlies the lens and retinal regeneration in lower vertebrates and retinal diseases such as proliferative vitreoretinopathy and fibrosis in mammals and humans. The present review considers these processes studied in vitro and in vivo in animal models and in humans. The molecular basis of conversion strategies in PECs is elucidated. Being predetermined onto- and phylogenetically, it includes a species-specific molecular context, differential expression of transcription factors, signaling pathways, and epigenomic changes. The accumulated knowledge regarding the mechanisms of PECs phenotypic switching allows the development of approaches to specified conversion for many purposes: obtaining cells for transplantation, creating conditions to stimulate natural regeneration of the retina and the lens, blocking undesirable conversions associated with eye pathology, and finding molecular markers of pathology to be targets of therapy.

Assessing Choroidal Nevi, Melanomas and Indeterminate Melanocytic Lesions Using Multimodal Imaging—A Retrospective Chart Review

Using multimodal imaging, the literature proposed the following risk factors for choroidal nevus growth into melanoma: increased tumor thickness, subretinal fluid, decreased visual acuity, presence of orange pigment, ultrasound acoustic hollowness, and increased tumor diameter. This study investigated the presence of the mentioned risk factors in choroidal nevi, choroidal melanomas, and indeterminate choroidal melanocytic lesions. This retrospective, single-center chart review assessed choroidal melanocytic tumors with multimodal imaging. We defined our primary outcome as the cumulative presence of mentioned risk factors. Further, we evaluated various optical coherence tomography (OCT), ultrasound, and autofluorescence findings. We analyzed 51 tumors from 49 patients during the period from April 2008 to June 2021. The median (IQR) age was 64.0 (56.0 to 70.5) years, with 23 of 49 (46.9%) patients being female. The follow-up time for all tumors was median (IQR) 25.0 (12.0 to 39.0) months. The choroidal nevi had a median (range) risk score of 0.0 (0.0 to 3.0), and the choroidal melanoma of 5.0 (3.0 to 6.0), with statistically significant different ratings (p < 0.001). Multimodal imaging creates a score that may help to distinguish choroidal nevi from choroidal melanomas objectively.

New Perspectives for Eye-Sparing Treatment Strategies in Primary Uveal Melanoma

Simple Summary

Uveal melanoma is the most common intraocular cancer. The current eye-sparing treatment options include mostly plaque brachytherapy. However, the effectiveness of these methods is still unsatisfactory. In this article, we review several possible new treatment options. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Another approach may be based on improving the penetration of the anti-cancer agents. It seems that the most promising technologies from this group are based on enhancing drug delivery by applying electric current. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced studies on experimental animals and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Abstract

Uveal melanoma is the most common intraocular malignancy and arises from melanocytes in the choroid, ciliary body, or iris. The current eye-sparing treatment options include surgical treatment, plaque brachytherapy, proton beam radiotherapy, stereotactic photon radiotherapy, or photodynamic therapy. However, the efficacy of these methods is still unsatisfactory. This article reviews several possible new treatment options and their potential advantages in treating localized uveal melanoma. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Two examples of such an approach are High-Intensity Focused Ultrasound (HIFU)—a promising technology of thermal destruction of solid tumors located deep under the skin and sonodynamic therapy (SDT) that induces reactive oxygen species. Another approach may be based on improving the penetration of anti-cancer agents into UM cells. The most promising technologies from this group are based on enhancing drug delivery by applying electric current. One such approach is called transcorneal iontophoresis and has already been shown to increase the local concentration of several different therapeutics. Another technique, electrically enhanced chemotherapy, may promote drug delivery from the intercellular space to cells. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced and targeted preclinical studies and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Current Therapeutics and Future Perspectives to Ocular Melanocytic Neoplasms in Dogs and Cats

Neoplasms of melanocytic origin are diseases relevant to dogs and cats' ophthalmic oncology due to their incidence, potential visual loss, and consequent decrease in life quality and expectancy. Despite its non-specific clinical presentation, melanocytic neoplasms can be histologically distinguished in melanocytomas, which present benign characteristics, and malignant melanomas. The diagnosis often occurs in advanced cases, limiting the therapeutic options. Surgery, cryotherapy, radiotherapy, photodynamic therapy (PDT), and laser are currently available therapeutic strategies. As no clinical guidelines are available, the treatment choice is primarily based on the clinician's preference, proficiency, and the owner's financial constraints. While surgery is curative in benign lesions, ocular melanomas present a variable response to treatments, besides the potential of tumour recurrences or metastatic disease. This review presents the currently available therapies for ocular melanocytic neoplasms in dogs and cats, describing the therapeutic, indications, and limitations. Additionally, new therapeutics being developed are presented and discussed, as they can improve the current treatment options.