Disparities in Patients with Choroidal Melanoma between Black and Hispanic versus Non-Hispanic White Patients

Uveal melanoma (UM) is a rare cancer with an annual incidence of approximately 5-8/million, but is the most common primary intraocular malignancy in adults. Treatment of this condition is generally successful with local primary tumour control being at 90-95%; localised radiotherapy in the form of plaque brachytherapy or proton beam radiotherapy are the most utilised in the UK, with primary enucleation still contributing to around a third of cases. Although the response to radiation treatment tends to be excellent, the basic mechanisms of radiation response, DNA repair and tissue reactions have not been well documented or established. The aim of this thesis was to investigate the DNA repair mechanisms in response to exogenous radiation sources (both x-rays and protons) in UM cell lines to determine the basic radiation sensitivity of these cells as well as the pathways involved in DNA repair; such pathways have been utilised in multiple other malignancies as targets for treatment strategies. Chapter 2 investigates this in detail and describes the differences in the radiosensitivities of different UM cell lines, which can be correlated with an upregulation in the ATM-checkpoint pathway involved in DNA repair in more radioresistant lines (OMM2.5 and Mel 270). The use of ATM inhibitors demonstrates this further with a disruption in both x-ray and proton-exposed cell culture analysis regarding both clonogenic assays for cell viability and comet assays for DNA repair response efficiency. Furthermore, tumour responses to radiation, although previously described, have not been correlated to these specific pathways. Chapter 3 describes the cellular and tissue responses in UM after radiotherapy (i.e. following both ruthenium-106 and proton exposure) with a time-independent marked inflammatory and necrotic reaction. The immunohistochemistry of these tissues with ATM demonstrated no significant differences in sample types, but may have been underpowered to do so, and should be investigated in future studies with fresh tissues. The thesis also aims to address the dilemmas in managing patients with UM with regards to reliability of prognostic genetic analysis of tumour biopsies following radiation, as well as the structural and subsequent visual sequelae following exposure to these forms of radiation. Chapter 4 shows the reliability of DNA-based prognostic analyses with regards to estimation of patient mortality from metastatic disease following radiotherapy. However, the reliability of these tests is time-limited with those samples taken many months after radiation treatments demonstrating anomalous results. The recommendation is therefore to aim for UM sample analysis for prognostication within 4 weeks of treatment. Structural radiation effects on local tissues has also been addressed in Chapter 5 with OCT assessment of retinal tissues following both ruthenium-106 and proton beam exposure. Brachytherapy leads to a rapid atrophic response with outer retinal layer disruption and destruction evident within 6 months in the majority of cases; proton beam exposure however shows a significantly different reaction and timeline with minimal outer retinal layer changes in the first 2 years. Visual outcomes following radiation exposure of essential structures for central vision, such as the fovea, therefore demonstrate rapid deterioration following plaque brachytherapy but much less pronounced over a longer time period in proton beam treated patients. This determines the form of treatment utilised for these patients in the medium and long term. In conclusion, this thesis has described the basic radiosensitivity linked with the DNA repair response and time efficiencies of UM cell lines, the UM tissue responses in response to radiation exposure, the structural changes in the tissues surrounding treatments and demonstrated the genetic reliability of post irradiation biopsies. Although answering many questions, it has formed the basis for future work, which may be carried on into more advanced models such as 3D spheroids, and into tissues examining a shorter term response to radiation exposure.

Expression of the Stem Cell Markers Nestin and CD133 on Circulating Melanoma Cells

Non-Hispanic black (NHB) and Hispanic patients have lower access to kidney transplantation compared to non-Hispanic whites (NHWs). We examined whether differences in the prevalence of comorbidities that affect eligibility for transplant contribute to disparities in receipt of transplantation. We performed a retrospective study of 986 019 adults who started dialysis between 2005 and 2014, according to the United States Renal Data System. We compared prevalence of comorbidities that could influence transplant eligibility by race/ethnicity. We examined time to first transplant by race/ethnicity in this overall cohort and in a very healthy sub-cohort without conditions that could be contraindications to transplantation. During 2.3 years of mean follow-up, 64 892 transplants occurred. NHBs and Hispanics had a lower prevalence of medical barriers to transplantation at the time of dialysis initiation than NHWs, including age >70 years (26% in NHB versus 47% in NHW) and malignancy (4% in Hispanics versus 10% in NHWs). Access to transplant was 65% lower (95% CI, 0.33-0.37) in NHBs and 43% lower (95% CI, 0.54-0.62) in Hispanics (versus NHWs) in the first year after end-stage renal disease, but by Year 4, access to transplantation was not statistically significantly different between Hispanics or NHBs (versus NHWs). In our very healthy cohort, racial and ethnic disparities in access to transplantation persisted up to Year 5 in NHBs and Year 4 in Hispanics after end-stage renal disease onset. Differences in medical eligibility do not appear to explain racial/ethnic disparities in receipt of kidney transplantation and may mask the actual magnitude of the inequities that are present.

Racial and Ethnic Disparities in Colorectal Cancer Screening Pose Persistent Challenges to Health Equity

Objective: To analyze the clinical characteristics and survival of Chinese uveal melanoma (UM) patients. Methods: It was a retrospective case series study. Clinical data and demography characteristics of 1 166 UM patients who were diagnosed in Beijing Tongren Hospital from January 2004 to January 2020 were collected. The disease was followed up after informed consent was obtained. Kaplan-Meier plots were used to visualize survival outcomes, and the different risk groups were compared using the Log-rank test. The multivariate Cox proportional hazards model was used to select independent prognostic risk factors. Results: A total of 1 166 individuals (598 men, 568 women) were included in this study. The average age was (47.6±12.2) years. Median follow-up time was 38 months. Treatment included episcleral brachytherapy in 881 (75.6%) patients, local tumor resection in 38 (3.2%) patients, laser therapy in 115 (9.9%) patients and primary enucleation in 119 (10.2%) patients. In 120 patients out of the 881 patients with primary brachytherapy, enucleation was performed due to an increasing tumor size or uncontrolled neovascular glaucoma. The Kaplan-Meier survival analysis showed the 5-and 10-year metastasis rates were 18.5% and 26.8%, and the melanoma-related mortality rates were 13.6% and 22.2%, respectively. The Log-rank test showed that patient age (χ²=5.01) and gender (χ²=7.19), as well as tumor grade (χ²=49.11), shape (χ²=34.73), location (χ²=18.60), pathological type (χ²=8.07), presence of subretinal fluid (χ²=15.71) and ciliary body involvement (χ²=19.72) were factors influencing patient prognoses (all P<0.05). In the multivariate Cox analysis, the T2, T3, T4 tumors (compared with the T1 tumor, HR=4.41, 6.82, 10.49), subretinal fluid (HR=1.98), ciliary body involvement (HR=1.79), being male (HR=1.53) and advanced age (greater than 53 years old) (HR=1.83) were independent risk factors for poor prognoses (all P<0.05). Conclusions: UM occurs at a significantly earlier age and non-pigmented tumors represent smaller proportion in Chinese patients. Higher T-stage, presence of subretinal fluid, ciliary body involvement, advanced age, and being male are independent risk factors for poor outcomes.

Racial and Ethnic Disparities in Healthcare Affordability, Access, and Provider Concordance for Low Back Pain: An All of Us Cross-Sectional Analysis.

To determine the clinical incidence and characteristics of symptomatic choroidal metastasis (CM) in breast cancer. Forty-six consecutive patients with CM from breast cancer were retrospectively reviewed in respect of ocular findings, medical history and systemic disease. Clinical incidence of CM was determined and compared with the incidence predicted from prevalence data obtained in ocular screening studies. Choroidal metastasis occurred with a median interval of 42.4 months after diagnosis of breast cancer and was predominantly unilateral (63% patients) and solitary (57% affected eyes). A total of 32% of patients had no history of metastatic tumour disease, but systemic screening with CT and scintigraphy revealed metastatic disease in 100% of patients. A median number of three other organs were affected by metastasis. Median survival from diagnosis of CM was 13.1 months. The mean number of local patients diagnosed with CM was 2.9 per year, which was one order of magnitude less than predicted from clinical screening studies. Choroidal metastasis occurs in advanced metastatic breast cancer, indicating a grave vital prognosis. In a minority of patients (32%) it is the first sign of metastatic disease. The clinical incidence of CM is far smaller than predicted from prevalence data obtained from ocular screening studies.

Patterns and Disparities of Ablative Radiation Therapy Use in Patients with Metastatic Cancer: a Study of the National Cancer Database

Tumor Necrosis Factor-α Blockade and Development of Uveal Melanoma: Expected Adverse Effect or Just Coincidence?

&lt;p dir="ltr"&gt;Uveal melanoma (UM) is a rare but deadly intraocular malignancy. As the most commonly occurring primary intraocular cancer in adults, it poses significant challenges in prognostication and treatment due to its high propensity for developing late-stage metastasis. Moreover, since a 100% accuracy rate is virtually impossible, improvements can still be made to current clinical tools used for prognostication, cellular composition assessment, detection of dormant micrometastatic tumor cells, and evaluation of early treatment impact. Consequently, the focus of this thesis is to improve the prognostication, highlight important cellular features of both primary tumors and micrometastases, and shine a light on the importance of early treatment of the primary tumor.&lt;/p&gt;&lt;p dir="ltr"&gt;In &lt;b&gt;paper I&lt;/b&gt;, we elaborated on the diagnostic importance of uveal melanoma involvement of the ciliary body, monosomy 3, as well as the size, clinical and histological factors of the tumor. Furthermore, these factors were combined with the American Joint Committee on Cancer and the Cancer Genome Atlas models to develop a new prognostic classification system. Clinicopathological factors of two patient groups, consisting of 1796 patients, were compared between those with, and without, involvement of the ciliary body and monosomy 3. We found that involvement of the ciliary body, tumor diameter, and patient age at diagnosis to be independent predictors of monosomy 3. Moreover, tumor diameter, age at diagnosis, male sex, involvement of the ciliary body, and monosomy 3 independently predicted metastasis. Our proposed prognostic classification system, combining sex, patient age, extraocular extension, involvement of the ciliary body, monosomy 3, tumor size, and 8q (optional), outperformed both the American Joint Committee on Cancer 4 T-categories and the Cancer Genome Atlas groups A-D in validation cohorts.&lt;/p&gt;&lt;p dir="ltr"&gt;In &lt;b&gt;paper II&lt;/b&gt;, we digitally measured and examined the cellular composition of different melanocytes in tumors, nevi, and metastases from enucleated eyes and resected liver tissue retrieved from the archives of Ophthalmic Pathology section at St. Erik Eye Hospital. We identified 4 different variations of melanocytes in normal choroid, primary UMs and liver metastases, which would correspond with previously described normal choroidal melanocytes, and malignant melanocytes of the spindle A, spindle B, and epithelioid type. Contrasting most previous studies performed on tumor cell morphology and staining patterns, where manual assessments were performed, we used the more objective approach of computerized analysis. Previously shown superior to manual assessment regarding reproducibility and prognostic utility. We also analyzed the expression of BRCA1 associated protein-1 (BAP-1), Indoleamine 2,3- dioxygenase (IDO), Insulin-like growth factor-1receptor (IGF-1R), and T-cell immunoreceptor with Ig and ITIM domains (TIGIT) as well as examined the area of the nucleus, the nucleus perimeter, nucleus maximum and minimum caliper, nucleus eccentricity, and nucleus to cell area ratio. Consequently, we demonstrated that spindle A cells are more commonly located in the center of primary UM, whilst spindle B cells, together with epithelioid cells, are more common in the base of UM - an area recognized as the initial path for hematogenous spread of tumor cells. No normal melanocytes or spindle A cells were identified in liver metastases, where only spindle B or epithelioid cells were seen. In addition, we demonstrated diverse expressions of BAP-1, IDO, IGF-1R, and TIGIT between the different subsets of melanocytes, highlighting the fact that 4 different cell types, with distinct levels of protein expressions, can be identified during the progression of uveal melanoma.&lt;/p&gt;&lt;p dir="ltr"&gt;In &lt;b&gt;paper III&lt;/b&gt;, we examined the presence of dormant micrometastatic tumor cells in autopsy tissue from patients diagnosed with primary UM, without any clinical or radiological signs of macrometastatic disease. Data from over 4000 patients diagnosed at St. Erik Eye Hospital over a period of 60 years was examined together with data from autopsy registers. In the end, 11 subjects were identified as suitable candidates. Afterwards, tissue blocks obtained at autopsy were collected and examined with hematoxylin and eosin staining (HE) and immunohistochemistry (IHC). Thereafter, we analyzed of a subset of patients with immunomagnetic separation (IMS). Conclusively, we found micrometastases in several distant organs in 5 of 5 patients with coexisting macrometastases, as well as in 5 of 6 patients without. All micrometastases had very low, or no, proliferative activity when examined with the immunohistochemical marker M MIB1-IgG1 antibody against Ki67 (MIB1). With this finding, we suggest that micrometastases are present in practically every patient diagnosed with primary UM, and that macrometastases indeed do develop from micrometastases.&lt;/p&gt;&lt;p dir="ltr"&gt;In &lt;b&gt;paper IV&lt;/b&gt;, we wanted to determine the impacts of delayed treatment on overall survival. As uveal melanoma shows a high metastatic rate, potential effects of delayed treatment regarding prognosis has been under debate. Thus, we performed a retrospective cohort study on 1256 patients diagnosed with UM and collected data on their diagnosis and treatment dates. The patients were split into two different groups based on the interval between diagnosis and treatment, namely a delay in treatment of over, and under, one month. Prognostic effects of the interval between the two patient groups were evaluated. Consequently, we found that patients with a treatment delay of at least one month has both shorter overall survival and disease-specific survival in stages II and III. In addition, there was also an increased hazard ratio for metastatic death in both univariate and competing risk regression models. When examined with a Markov multi-state model, those with a treatment delay of over one month showed a hazard ratio of 1.45 (95% Confidence Interval (CI) 1.12-1.89) for evolution to metastatic death. Interestingly, when performing competing risk incidence analyses based on treatment timing, we were not able to prove any statistically significant disparities in the incidence of any cause of death other than metastases. We conclude that treatment delays of uveal melanoma are linked with reduced overall and disease-specific survival rates, leading to the suggestion that primary treatment should be initiated with the shortest possible delay after diagnosing UM.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. VT Gill, S Sabazade, C Herrspiegel, et al. A prognostic classification system for uveal melanoma based on a combination of patient age and sex, the American Joint Committee on Cancer and the Cancer Genome Atlas models. Acta Ophthalmologica. 2023;101:34-48. &lt;a href="https://doi.org/10.1111/aos.15210"&gt;https://doi.org/10.1111/aos.15210&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Stålhammar G, VT Gill. Digital morphometry and cluster analysis identifies four types of melanocyte during uveal melanoma progression. Communications medicine. 2023;3(1):60. &lt;a href="https://doi.org/10.1038/s43856-023-00291-z" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1038/s43856-023-00291-z&lt;/a&gt; &lt;/p&gt;&lt;p dir="ltr"&gt;III. VT Gill, E Norrman, S Sabazade, A Karim, E Lardner, G Stålhammar. Multiorgan Involvement of Dormant Uveal Melanoma Micrometastases in Postmortem Tissue From Patients Without Coexisting Macrometastases. American Journal of Clinical Pathology. 2023;160:164-174. &lt;a href="https://doi.org/10.1093/ajcp/aqad029" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/ajcp/aqad029&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. A Moghadam, VT Gill, S Sabazade, A Hagström, G Stålhammar. The Prognostic Significance of Treatment Delays on Uveal Melanoma Survival. [Manuscript]&lt;/p&gt;&lt;p dir="ltr"&gt;All previously published papers were reproduced with permission from the publisher under a creative commons license.&lt;/p&gt;

Advanced cardiovascular-kidney-metabolic (CKM) syndrome refers to stages 3 and 4 of CKM syndrome, which are associated with higher mortality compared to earlier stages (0-2). The albumin (ALB)-to-neutrophil/lymphocyte ratio (ANLR) is a new predictive marker that participates in immune inflammation and dietary status. However, the influence of ANLR on all-cause mortality (ACM) and cardiovascular mortality (CVM) in individuals with advanced CKM syndrome remains unclear. This investigation aims to examine the link between ANLR and both ACM and CVM in this population using data from a large-scale cross-sectional survey in the United States. Data were from the National Health and Nutrition Examination Survey (NHANES) spanning 1999 to 2018, a nationally representative cross-sectional survey with longitudinal mortality follow-up from the National Death Index. The formula of ANLR is ALB/NLR. The diagnostic criteria of CKM syndrome was based on the concept proposed by the American Heart Association and modified criteria adapted for NHANES data availability. The outcomes of interested included ACM and CVM. A 1:1 propensity score matching (PSM) approach was used to control for potential confounding variables. The threshold value of ANLR influencing survival was determined using maximally selected rank statistics, which is based on the log-rank test. This method identifies the optimal cutoff for continuous variables where the difference in survival rates is most pronounced, making it particularly well-suited for analyzing time-to-event data, such as survival outcomes. Kaplan-Meier survival analysis and multivariate Cox proportional hazards models were employed to assess the effects of ANLR on both ACM and CVM. Restricted cubic spline (RCS) analysis evaluated the linear or non-linear association between ANLR and mortality outcomes. Stratified analysis and interaction testing were carried out to estimate the influence of covariates on the ANLR-mortality correlation. A total of 3,266 adults with advanced CKM syndrome (41.12% male) were included in the analysis, with median (interquartile range) age of 73 (63-80). Prior to PSM, and fully adjustment, the lowest ANLR Tertile 1 was related to significantly higher risks of ACM (hazard ratio [HR]: 1.58, 95% confidence interval [CI]: 1.39-1.78, p < 0.001) and CVM (HR: 1.65, 95% CI: 1.34-2.04, p < 0.001) compared to the highest Tertile 3. After applying PSM, and fully adjusting for confounders, an ANLR score below 1.04 was independently linked to increased risks of both CVM (HR: 2.02, 95% CI: 1.49-2.75, p < 0.001) and ACM (HR: 1.52, 95% CI: 1.27-1.81, p < 0.001). Interaction tests revealed no significant interactions for CVM across subgroups (All P interaction > 0.05). Regarding ACM, interactions were noted between ANLR and age, gender, and CKM stages (All P interaction < 0.05). RCS analysis indicated an L-shaped link between ANLR and both ACM and CVM, both before and after PSM (all P non-linearity < 0.001). The predictive value of ANLR, NLR, and ALB for CVM and ACM in individuals with advanced CKM syndrome demonstrated that ANLR and NLR exhibited comparable predictive capabilities for both ACM and CVM, outperforming ALB. Furthermore, the predictive performance of ANLR and NLR for ACM was superior to that for CVM. Lower ANLR values, indicative of elevated systemic inflammation and malnutrition, are independently linked to increased risks of both ACM and CVM in individuals with advanced CKM syndrome in the US. These readily accessible and low-cost blood markers could serve as valuable prognostic indicators for identifying high-risk individuals. Future research should focus on incorporating additional biomarkers, validating the indices in larger and more diverse cohorts, and employing advanced analytical methods to refine the diagnostic efficiency of ANLR and NLR for better clinical utility.

Uveal melanoma is the most common intraocular malignancy in adults. Despite the effective primary treatment, up to 50% of patients with uveal melanoma will develop metastatic lesions mainly in the liver, which are resistant to conventional chemotherapy and lead to patient's death. To date, no orthotopic murine models of uveal melanoma which can develop spontaneous metastasis are available for preclinical studies. Here, we describe a spontaneous metastatic model of uveal melanoma based on the orthotopic injection of human uveal melanoma cells into the suprachoroidal space of immunodeficient NSG mice. All mice injected with bioluminescent OMM2.5 ( n = 23) or MP41 ( n = 19) cells developed a primary tumor. After eye enucleation, additional bioluminescence signals were detected in the lungs and in the liver. At necropsy, histopathological studies confirmed the presence of lung metastases in 100% of the mice. Liver metastases were assessed in 87 and in 100% of the mice that received OMM2.5 or MP41 cells, respectively. All tumors and metastatic lesions expressed melanoma markers and the signaling molecules insulin-like growth factor type I receptor and myristoylated alanine-rich C-kinase substrate, commonly activated in uveal melanoma. The novelty of this orthotopic mouse xenograft model is the development of spontaneous metastases in the liver from the primary site, reproducing the organoespecificity of metastasis observed in uveal melanoma patients. The faster growth and the high metastatic incidence may be attributed at least in part, to the severe immunodeficiency of NSG mice. This model may be useful for preclinical testing of targeted therapies with potential uveal melanoma antimetastatic activity and to study the mechanisms involved in liver metastasis.

Outcomes of Uveal Melanoma with Distant Metastasis at Initial Staging: Impact of Primary Tumor Therapy

Conservation of eyes with choroidal melanoma by a multimodality approach to treatment: An audit of 1632 patients

Uveal melanoma is the most common primary malignant ocular cancer in adults. This tumor has a distinct expression pattern of markers compared with cutaneous melanoma. MC1R is under study as a potential target for antitumor immunity. Because of the potential immunogenicity of MC1R, it is important to evaluate its expression on uveal melanomas. Two novel monoclonal antibodies (MP1.1C11 and MP1.1B7) were used to examine the expression of MC1R in uveal melanomas. Tissue samples obtained from 17 patients were analyzed for expression of MC1R by immunohistochemistry. Additionally, uveal melanoma cell lines were treated with proinflammatory cytokines, after which MC1R cell surface expression was analyzed by flow cytometry. Results demonstrated that MC1R is expressed by uveal melanoma to a significantly greater extent than other melanoma markers. With the use of MP1.1C11 or MP1.1B7, MC1R was detected in 95% of the tested melanoma tissues, including one liver metastasis. In contrast, MART-1, S100-specific protein, and gp-100 were only expressed by 66%, 33%, and 67% of the analyzed samples, respectively. Results also demonstrated that even though MC1R is mainly located intracellularly, its cell surface expression can be promoted by cytokines such as IFN-gamma, TNF-alpha, IL-4, and IL-10. These observations support the inclusion of MC1R in the panel of markers for the diagnosis of uveal melanoma. Therapeutic use of MC1R-specific antibodies targeting cytokine-induced MC1R potentially requires expression of the target molecule on the surfaces of tumor cells. Data presented here support MC1R as a new marker and a putative therapeutic target for uveal melanoma.