Early-stage Melanoma Patients Research Articles

Detection of molecular residual disease in stage II and III melanoma utilizing circulating tumor DNA.

e21564 Background: Overall survival for patients with melanoma has significantly improved with advancements in immunotherapy, especially with immune checkpoint inhibitors and BRAF/MEK inhibitors becoming standard of care for advanced melanoma. However, the decision to proceed with adjuvant therapy should be considered against the risk of adverse side effects, particularly in early-stage melanoma patients. Accurate biomarkers are needed to risk stratify patients, determine who will most likely benefit from adjuvant therapy, and identify when the ideal time is to initiate treatment. This study evaluates the prognostic value of personalized, tumor-informed circulating tumor DNA (ctDNA) testing in patients with stage II and III melanoma. Methods: In this real-world study, plasma samples (n =429) were analyzed from 90 stage IIA-IIID cutaneous melanoma patients treated at Rush University Medical Center between 03/30/2021 and 01/30/2024. A clinically-validated, personalized, tumor-informed 16-plex PCR assay (SignateraTM, Natera, Inc.) was used for detection and quantification of ctDNA in plasma samples. Results: Personalized, tumor-informed ctDNA assays were created using tissue samples from either initial biopsy or surgical excision specimen. Assay design was successful for 100% (90/90) of patients with sufficient tissue; test requests for 4 patients could not proceed due to insufficient tissue. ctDNA was detectable in 28% (25/90) of patients at one or more time points. There was a higher ctDNA-positivity rate in stage III patients (20/50, 40%) compared to stage II patients (5/40, 13%). Of the 25 patients with identifiable ctDNA during surveillance, 13 tested positive on the initial test (2 stage II and 11 stage III). Eighteen of the 25 ctDNA-positive patients received immunotherapy; eight patients achieved sustained ctDNA clearance, 2 had transient clearance, 2 have remained positive on ctDNA testing, and 6 continue to receive adjuvant IO and follow-up ctDNA testing. Clinical or radiographic recurrence occurred in 11/90 patients, 10 of whom tested positive for ctDNA. Conclusions: Personalized, tumor-informed ctDNA offers an adjunct to conventional monitoring for melanoma patients to detect molecular residual disease and was found to be prognostic in our patient cohort. Prospective studies are needed to evaluate the role of ctDNA in clinical decision making for surveillance imaging intervals and appropriate initiation, intensification, or discontinuation of adjuvant therapy.

Correlation of eTILs with recurrence free survival (RFS) in stage IIB-IIIA melanoma and use as biomarker for stratification for clinical trials.

9567 Background: Immunotherapy is approved for resected stage IIB-IIIC, but treatment of all patients, particularly those with IIB-IIIA disease, incurs unneeded expense and toxicity. Biomarkers are urgently needed for patient stratification. Time constraints in clinical trial design have led to the adoption of recurrence free survival (RFS) as a primary endpoint in adjuvant melanoma trials. Tumor infiltrating lymphocytes (TILs) are a well-established biomarker in primary melanoma, but quantification is subjective. Electronic TILs (eTILs) are a previously published automated digital pathology tool to quantify TILs. Methods: A retrospective cohort of 194 patients with Stage II-III melanoma from Roswell Park Comprehensive Cancer Center (RPCCC, n=133) and Geisinger Medical Center (GMC, n=61) were evaluated for eTILS by blinded investigators. Patients were included based on a search of dermatopathology databases and tissue availability. Digital images of diagnostic slides were analyzed using quPath, a publicly available software. Briefly, tumor areas were selected to include infiltrating lymphocytes with minimal adjacent stroma. Color variations in H&E images were standardized, and cell types quantified utilizing a machine learning algorithm. A previously published threshold of 16.6% eTILs, calculated as lymphocytes/tumor cells x 100, was used. Patients were staged using American Joint Committee on Cancer (AJCC) guidelines, version 8. Survival was assessed using Kaplan-Meier Curves and correlation of clinic-pathologic features with survival was tested using Cox Proportional Hazards Models. Results: Of 194 patients, 56 were stage IIA, 85 were IIB-IIIA, and 53 were IIIB-D. Median follow up was 47.5 months. 103 patients had eTILs >16.6% of whom 13 (12.6%) died and 84 had eTILS <16.6% of whom 23 (27.4%) died during follow-up. HR for death from melanoma within 5 years for the high eTIL group was 0.53 (CI 0.21-0.90, p=0.024). DSS was significantly longer in the high eTIL group than the low eTIL group (p=0.0095). Among 85 stage IIB-IIIA patients, local and distant recurrence data was available for the RPCCC cohort of 68 patients. 46 of these patients had high eTILs of whom 9(19.6%) recurred and 22 had low eTILS of whom 10 (45.95%) recurred. HR for recurrence within 5 years for the high eTIL group was 0.44 (CI0.23-0.83, p=0.012). RFS was significantly longer in the high TIL group (p=0.016) as was distant metastatic recurrent survival (p= 0.0063). eTIL score correlated with RFS in a univariable Cox model (p=0.033) and added to stage and depth in a multivariable Cox model (p=0.018). Conclusions: eTILs, readily evaluable at low cost using diagnostic slides, correlate with clinical outcome in a retrospective cohort of 194 patients. eTILS should be prospectively evaluated as a biomarker to stratify early-stage melanoma patients for adjuvant clinical trials.

Abstract 1058: Immune biomarkers for recurrence in stage II and III melanoma to guide patient stratification

Abstract Stage II-III melanoma patients lack needed biomarkers to avoid over-treatment and determine need for combination immunotherapy. A “hot” tumor immune micro-environment (TIME) is predictive of survival and immunotherapy benefit in multiple tumor types. We have previously identified the ratio of CD8+/CD68+ cells as well as a 53-gene melanoma immune panel (MIP) as indicative of a favorable “hot” TIME. CD8/CD68 ratio and MIP were evaluated in specimens from 213 previously untreated patients including 164 from Roswell Park Comprehensive Cancer Center (RPCCC) and 49 from Geisinger Health Systems (GHS, n=36). Tumors were stained with Sox10, CD8, CD68, MPO, PDL1 and HLA-DR using the MOTiF workflow (Akoya Biosciences, AB). Image analysis was completed using inForm software (AB). RNA was extracted and NanoString analysis performed using published methods. Receiving Operator Curves (ROC) were generated and KM curves using cutoffs selected using maximally selected log-rank statistics to quantify survival benefit. We tested whether the CD8/CD68 ratio correlated with disease specific survival (DSS) and distant metastatic recurrence (DMR). In the RPCCC cohort (n=164), 138 specimens were evaluated by a pathologist and stained of which 15 were excluded based on tissue quality, and inForm analysis was completed on 80. Of these 80, 16 had DMR of whom 8 had died. ROC showed CD8/CD68 ratio to correlate with DMR (p=0.0397). KM analysis showed high CD8/CD68 ratio correlated with DMR free survival (p=0.00079). Within the GHS samples, 36 of 49 patients had sufficient quality tissue, of whom 13 had died. DMR data was not available. A high CD8/CD68 ratio correlated with DSS by ROC curve (p=0.027) and KM analysis (p=0.0009). MIP was run on 166 patients of whom 147 passed quality control for analysis. MIP correlated with DSS in the RPCCC cohort by ROC analysis (p=0.025) and cutoff defined based on prior cohort showed correlation with DSS (p=0.01) and trend towards correlation with DMRFS (p=0.065). To include diverse samples in the training set, MIP was retrained with the addition of 81 patients from Columbia University (CUMC). KM analysis performed using the retrained signature showed a favorable signature correlated with DSS (p=0.032) and DMRFS (p=0.00077). Immune based biomarkers including CD8/CD68 ratio and immune gene signature have potential to assist clinicians in selecting early-stage melanoma patients for more intensive immunotherapy regimens. Full analysis of the data from the RPCCC and GHS cohorts will be presented at the conference. Citation Format: Gerardo A. Espinoza, Chenxin Zhang, Jee-Young Moon, Divya B. Kenchappa, Matteo Abbruzzese, Lydia Bioh, Yadriel M. Bracero, Sharmin Sultana, Ajay Singh, Thazin Aung, John J. Krolewski, Robyn D. Gartrell, Larisa J. Geskin, Lawrence W. Leung, Tammie Ferringer, Rui Chang, Basil Horst, Kent Nastiuk, Yvonne M. Saenger. Immune biomarkers for recurrence in stage II and III melanoma to guide patient stratification [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1058.

Absence of Tils in Biopsy is Associated with Worse Progression Free Survival in Early Stage Melanoma

Background: Recent data suggest that a subset of early stage melanoma patients may benefit from adjuvant immunotherapy. Objective: To identify findings in biopsy or surgical pathology reports associated with poor prognosis in patients diagnosed with stage I and II cutaneous melanoma. Methods: This was a retrospective cohort study of 68 stage I and II cutaneous melanoma patients treated at our institution from 2010 to 2022. Inclusion criteria were patients with stage I or II melanoma with both a biopsy and surgical pathology report. The primary outcome of the study was the prognostic value of biopsy findings on progression free survival (PFS). KaplanMeier and Cox-proportional hazards models were used to evaluate risk factors for progression. Results: Patients with ulceration on biopsy had a 16.1x greater risk of progression than those without ulceration [HR 16.1, 95% CI: 2.60-99.5]. Patients with absent lymphocytes on biopsy had a 9.5x greater risk of progressing compared to those with lymphocytes present [HR 9.45, 95% CI: 1.99-44.8]. Ulceration or absent TILs were associated with significantly worse PFS. Conclusions: Ulceration and absence of TILs on biopsy are associated with increased risk of progression in stage I and II melanoma patients.

Correlation Analyses between Histological Staging and Molecular Alterations in Tumor-Derived and Cell-Free DNA of Early-Stage Primary Cutaneous Melanoma.

Here, we investigate the correlation and statistical analyses between histological staging and molecular alterations in tumor-derived (tdDNA) and cell-free DNA (cfDNA) obtained from early-stage primary cutaneous melanoma (PCM) patients using digital PCR (dPCR) for the detection of the BRAF p.V600E somatic pathogenic variant. In the prospective study, a total of 68 plasma and paired tdDNA samples, and in the retrospective cohort, a total of 100 tdDNA samples were analyzed using dPCR and reverse hybridization StripAssay. The Breslow depth (BD) and Clark level were applied to categorize the study population. Our results demonstrate that dPCR is a highly sensitive and specific method for the detection of BRAF p.V600E somatic variants in cfDNA samples from PCM patients. A strong correlation was detected between BD and cfDNA concentration in all mutant and negative cases, between the tdDNA concentration and the tumor-derived variant allele frequency (VAF) of BRAF p.V600E, between the tdVAF and the cfVAF in all cases, and between the cfDNA and cfVAF in mutant cases. The tdVAF and cfVAF of BRAF p.V600E and cfDNA concentration were the highest in Clark's V category. The cfDNA concentration was statistically significantly higher in Clark's III, IV, and V groups compared to cases with a better prognosis. It can also be explained by the fact that cases with a more advanced stage classification release more cfDNA into the peripheral circulation.

Longitudinal circulating tumor DNA monitoring for detection of molecular residual disease in patients with surgically resected stage II/III melanoma.

9582 Background: Over the past decade, advances in immunotherapy (IO) have dramatically improved overall survival (OS) for patients with metastatic melanoma. Immune checkpoint inhibitors and BRAF/MEK inhibitors also became standard of care for surgically resected stage III melanoma, and most recently pembrolizumab was approved for stage IIB/C patients. Although the phase III trials that led to their respective approvals met their primary endpoints for relapse-free survival, no benefit in OS has been observed. Given that a large proportion of early-stage melanoma patients are cured with surgery alone, the decision to proceed with adjuvant therapy should be weighed against the risk of potential life-altering toxicity. There is a high unmet need to develop biomarkers to accurately select patients who are most likely to benefit from adjuvant IO while sparing a group of low risk patients from unnecessary treatment. In this study, we evaluated the prognostic value of personalized, tumor-informed circulating tumor DNA (ctDNA) testing in patients with resectable stage II/III melanoma. Methods: In this real-world study, longitudinal plasma samples (n = 159) were analyzed in real-time from 45 stage IIA-IIID cutaneous melanoma patients treated at Rush University between 03/30/2021 and 01/12/2023. A personalized, tumor-informed ctDNA assay (Signatera bespoke, mPCR-NGS assay) was used for detection and quantification of ctDNA in plasma samples. Results: Personalized, tumor-informed ctDNA assays were successfully designed for 93% (42/45) of patients using tissue samples from either surgical resection (14/42, 33%) or biopsy (26/42, 67%; 16 shave, 10 excisional, 1 punch, 1 core). ctDNA was detectable at one or more time points in 36% (15/42) of patients. We observed a higher ctDNA-positivity rate in stage III patients (11/20, 55%) compared to stage II patients (4/22, 18%). Twelve of the 15 ctDNA-positive patients received adjuvant IO/treatment escalation after a positive ctDNA result; 6 patients had sustained ctDNA clearance, 2 had transient clearance, and 4 continue to receive adjuvant IO and follow-up ctDNA testing. Radiographic recurrence was observed in 7/42 patients, 6 of whom were ctDNA-positive. Ninety-six percent (26/27) of patients with persistent ctDNA-negativity remain clinically and radiographically progression-free. Conclusions: Our data suggest that molecular residual disease detection using a personalized, tumor-informed ctDNA assay is highly prognostic in melanoma patients undergoing curative resection. Sustained clearance of ctDNA was achieved with adjuvant therapy in a subset of this cohort. Prospective studies evaluating the utility of ctDNA to aid clinical decision-making regarding adjuvant treatment intensification or de-escalation are warranted.

Melanoma Clinical Decision Support System: An Artificial Intelligence-Based Tool to Diagnose and Predict Disease Outcome in Early-Stage Melanoma Patients.

This study set out to assess the performance of an artificial intelligence (AI) algorithm based on clinical data and dermatoscopic imaging for the early diagnosis of melanoma, and its capacity to define the metastatic progression of melanoma through serological and histopathological biomarkers, enabling dermatologists to make more informed decisions about patient management. Integrated analysis of demographic data, images of the skin lesions, and serum and histopathological markers were analyzed in a group of 196 patients with melanoma. The interleukins (ILs) IL-4, IL-6, IL-10, and IL-17A as well as IFNγ (interferon), GM-CSF (granulocyte and macrophage colony-stimulating factor), TGFβ (transforming growth factor), and the protein DCD (dermcidin) were quantified in the serum of melanoma patients at the time of diagnosis, and the expression of the RKIP, PIRIN, BCL2, BCL3, MITF, and ANXA5 proteins was detected by immunohistochemistry (IHC) in melanoma biopsies. An AI algorithm was used to improve the early diagnosis of melanoma and to predict the risk of metastasis and of disease-free survival. Two models were obtained to predict metastasis (including "all patients" or only patients "at early stages of melanoma"), and a series of attributes were seen to predict the progression of metastasis: Breslow thickness, infiltrating BCL-2 expressing lymphocytes, and IL-4 and IL-6 serum levels. Importantly, a decrease in serum GM-CSF seems to be a marker of poor prognosis in patients with early-stage melanomas.

Conventional versus Reduced-Frequency Follow-Up in Early-Stage Melanoma Survivors: A Systematic Review with Meta-Analysis

To date, there have been multiple studies and clinical guidelines or recommendations for complex management of melanoma patients. The most controversial subjects included the frequency of follow-up. This study provides a coherent and comprehensive comparison of conventional vs. reduced-frequency follow-up strategies for early-stage melanoma patients. The value of our study consists in the precise analysis of a large collection of articles and the selection of the most valuable works in relation to the topic according to rigorous criteria, which allowed for a thorough study of the topic. The search strategy was implemented using multiple databases. The inclusion criteria were randomized clinical trial or cohort studies that compared the outcomes of a conventional follow-up schedule versus a reduced-frequency follow-up schedule for patients diagnosed with melanoma. In this study, authors analyzed recurrence and 3-year survival. Meta-analysis of outcomes presented by Deckers et al. and Moncrieff et. al. did not reveal a significant difference favoring one of the groups (OR 1.14; 95%CI: 0.65-2.00; p = 0.64). The meta-analysis of 3-year overall survival included two studies. The statistical analysis showed no significant difference in favor of the conventional follow-up group. (OR 1.10; 95%CI: 0.57-2.11; p = 0.79). Our meta-analysis shows that there is no advantage in a conventional follow-up regimen over a reduced-frequency regimen in early-stage melanoma patients.

Abstract IA024: Cellular plasticity during metastatic colony formation in patients

Abstract Systemic cancer spread is a process whose complexity is only poorly understood. We have learned over the past years that metastatic dissemination starts very early in the evolution of a malignant clone of most cancers and that disseminated cancer cells (DCC) continue to acquire genomic alterations at the distant site. Consequently, it seems plausible that cellular phenotypes change during metastatic colony formation as well, although the impact of genotype changes on the cellular phenotypes is not clear at all. We studied this process in malignant melanoma, exploiting the unique chance that routine sentinel lymph node (SLN) biopsies provide for a cancer that is diagnosed much earlier and at smaller size than most other cancers. Moreover, mouse models suggest that lymph nodes serve as exit routes for systemic dissemination of cancer cells and that their colonization indues tumor-immune tolerance promoting distal metastasis. Melanoma DCC enter SLNs and may or may not give rise to a metastatic colony. We therefore first assessed in a large patient cohort comprising more than 500 early-stage melanoma patients, which melanoma marker is best suited to identify candidate metastasis founder cells and then progressed to provide their detailed molecular characterization. We found that melanoma cellular phenotypes indeed change over metastatic colony formation, indicating that differential molecular stage-specific targeting may be required to prevent metastasis formation. Of note, we observed mechanisms of very early immune suppression via DCC-derived EVs suggesting early DCC must find immune-escape strategies at the metastatic site. Citation Format: Melanie Werner-Klein. Cellular plasticity during metastatic colony formation in patients [abstract]. In: Proceedings of the AACR Special Conference: Cancer Metastasis; 2022 Nov 14-17; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;83(2 Suppl_2):Abstract nr IA024.

Prognostic modeling of cutaneous melanoma stage I patients using cancer registry data identifies subsets with very-low melanoma mortality.

Evidence exists that escalating melanoma incidence is due in part to overdiagnosis, the diagnosis of lesions that will not lead to symptoms or death. The authors aimed to characterize subsets of melanoma patients with very-low risk of death that may be contributing to overdiagnosis. Melanoma patients diagnosed in 2010 and 2011 with stage I lesions ≤1.0mm thick and negative clinical lymph nodes from the Surveillance, Epidemiology, and End Results database were selected. Classification and regression tree and logistic regression models were developed and validated to identify patients with very-low risk of death from melanoma within 7years. Logistic models were also used to identify patients at higher risk of death among this group of stage I patients. Compared to an overall 7-year mortality from melanoma of 2.5% in these patients, a subset comprising 25% had a risk below 1%. Younger age at diagnosis and Clark level II were associated with low risk of death in all models. Breslow thickness below 0.4mm, absence of mitogenicity, absence of ulceration, and female sex were also associated with lower mortality. A small subset of high-risk patients with >20% risk of death was also identified. Patients with very-low risk of dying from melanoma within 7years of diagnosis were identified. Such cases warrant further study and consensus discussion to develop classification criteria, with the potential to be categorized using an alternative term such as "melanocytic neoplasms of low malignant potential." Although melanoma is the most serious skin cancer, most melanoma patients have high chances of survival. There is evidence that some lesions diagnosed as melanoma would never have caused symptoms or death, a phenomenon known as overdiagnosis. In this study, we used cancer registry data to identify a subset of early-stage melanoma patients with almost no melanoma deaths. Using two statistical approaches, we identified patients with <1% risk of dying from melanoma in 7 years. Such patients tended to be younger with minimal invasion into the skin. We also identified a very small patient subset with higher mortality risk.

Transcutaneous sentinel lymph node detection in cutaneous melanoma with indocyanine green and near-infrared fluorescence: A diagnostic sensitivity study.

Sentinel lymph node (SLN) biopsy with preoperative radiocolloid-based lymphoscintigraphy and blue dye injection is considered the standard procedure for staging nodal metastases in early-stage cutaneous melanoma patients with clinically uninvolved lymph nodes. While this combination renders good accuracy in SLN detection, radiation exposure and the frequent allergic reactions to the blue dye are considered drawbacks of this technique. Indocyanine green (ICG) is a water-soluble fluorescent dye that can be identified through near-infrared fluorescence imaging (NIRFI). The aim of this prospective diagnostic sensitivity study was to assess the feasibility of ICG and NIRFI to identify SLNs in melanoma transcutaneously ("before skin incision") and to analyze the various factors influencing detection rate, in comparison to lymphoscintigraphy. This study included 93 patients undergoing SLN biopsy for cutaneous melanoma. The region and the number of the SLNs identified with lymphoscintigraphy and with ICG were recorded. Patients' characteristics, as well as tumor details were also recorded preoperatively. One hundred and ninety-four SLNs were identified through lymphoscintigraphy. The sensitivity of ICG for transcutaneous identification of the location of the SLNs was 96.1% overall, while the sensitivity rate for the number of SLNs was 79.4%. Gender and age did not seem to influence detection rate, but a body mass index >30 kg/m2 was associated with a lower identification rate of the number of SLNs (P = .045). Transcutaneous identification of SLNs through ICG and NIRFI technology is a feasible technique that could potentially replace in selected patients the standard SLN detection methodology in cutaneous melanoma.

1055P Prognostic relevance of tumor-infiltrating lymphocytes in early-stage melanoma

The use of immune checkpoint therapies is being investigated in early-stage melanoma patients (pts). So far there is no definitive prognostic and/or predictive biomarker. The presence of tumor-infiltrating lymphocytes (TILs) has been associated with a better prognosis in several malignancies, including melanoma. Using a digital pathology approach, we intended to identify a cut-off based on the percentage of TILs (%TILs) as a prognostic factor in this setting.

An Integrated Microfluidic‐SERS Platform Enables Sensitive Phenotyping of Serum Extracellular Vesicles in Early Stage Melanomas

AbstractPrecise detection of early melanomas is essential as the stage of disease guides treatment options. One growing field that may facilitate the advancement of early melanoma detection, is achieved through profiling serum extracellular vesicles (EVs) using sensitive nanotechnology. As a proof of principle, using a detection platform that combines a microfluidic device and surface‐enhanced Raman spectroscopy (SERS), the expression profiles of 4 protein biomarkers in serum EVs (termed as “EV SERS signatures”) derived from 20 early stage melanoma patients (including in situ melanoma) and 21 healthy participants are multiplexed. Significantly higher signal intensities of selected protein biomarkers are observed in serum EVs from melanoma patients compared with healthy participants, with mean fold‐changes ranging from 3.7 to 4.2. It is demonstrated that the EV SERS signatures can accurately separate melanoma patients and healthy individuals, with an area under the curve of 0.95. Thus, with further development, this ultra‐sensitive detection platform, combined with the panel of melanoma‐associated biomarkers, has the ability to differentiate early stage melanoma patients from healthy participants.

The Bayesian Multiple Logistic Random Effects Model for Analysis of Clinical Trial Data

A prospective, multi-institutional and randomized surgical trial involving 724 early stage melanoma patients was conducted to determine whether excision margins for intermediate-thickness melanomas (1.0 to 4.0 mm) could be safely reduced from the standard 4-cm radius. Patients with 1- to 4-mm-thick melanomas on the trunk or proximal extremities were randomly assigned to receive either a 2- or 4-cm surgical margin with or without immediate node dissection (i.e. immediate vs. later -within 6 months). The median follow-up time was 6 years. Recurrence rates did not correlate with surgical margins, even among stratified thickness groups. The hospital stay was shortened from 7.0 days for patients receiving 4-cm surgical margins to 5.2 days for those receiving 2-cm margins (p = 0.0001). This reduction was largely due to reduced need for skin grafting in the 2cm group. The overall conclusion was that the narrower margins significantly reduced the need for skin grafting and shortened the hospital stay. Due to the adequacy of subject follow up, recently a statistical focus was on what prognostics factors usually called covariates actually determined recurrence. As was anticipated, the thickness of the lesion (p = 0.0091) and whether or not the lesion was ulcerated (p = 0.0079), were determined to be significantly associated with recurrence events using the logistic regression model. This type of fixed effect analysis is rather a routine. The authors have determined that a Bayesian consideration of the results would afford a more coherent interpretation of the effect of the model assuming a random effect of the covariates of thickness and ulceration. Thus, using a Markov Chain Monte Carlo method of parameter estimation with non informative priors, one is able to obtain the posterior estimates and credible regions of estimates of these effects as well as their interaction on recurrence outcome. Graphical displays of convergence history and posterior densities affirm the stability of the results. We demonstrate how the model performs under relevant clinical conditions. The conditions are all tested using a Bayesian statistical approach allowing for the robust testing of the model parameters under various recursive partitioning conditions of the covariates and hyper parameters which we introduce into the model. The convergence of the parameters to stable values are seen in trace plots which follow the convergence patterns This allows for precise estimation for determining clinical conditions under which the response pattern will change.

Digital Immunophenotyping Predicts Disease Free and Overall Survival in Early Stage Melanoma Patients.

Background: the prognostic significance of tumor infiltrating lymphocytes (TILs) in intermediate/thick primary cutaneous melanoma (PCM) remains controversial, partially because conventional evaluation is not reliable, due to inter-observer variability and diverse scoring methods. We aimed to assess the prognostic impact of the density and spatial distribution of immune cells in early stage intermediate/thick PCM. Materials and Methods: digital image acquisition and quantitative analysis of tissue immune biomarkers (CD3, CD4, CD8, CD68, PD-L1, CD163, FOX-P3, and PD-1) was carried out in a training cohort, which included patients with primary PCM ≥ 2 mm diagnosed, treated, and followed-up prospectively in three Italian centers. Results were validated in an independent Italian cohort. Results: in the training cohort, 100 Stage II–III melanoma patients were valuable. At multivariable analysis, a longer disease free survival (DFS) was statistically associated with higher levels of CD4+ intratumoral T-cells (aHR [100 cell/mm2 increase] 0.98, 95%CI 0.95–1.00, p = 0.041) and CD163+ inner peritumoral (aHR [high vs. low] 0.56, 95%CI 0.32–0.99, p = 0.047). A statistically significant longer DFS (aHR [high-high vs. low-low] 0.52, 95%CI 0.28–0.99, p = 0.047) and overall survival (OS) (aHR [high-high vs. low-low] 0.39, 95%CI 0.18–0.85, p = 0.018) was found in patients with a high density of both intratumoral CD8+ T-cells and CD68+ macrophages as compared to those with low density of both intratumoral CD8+ T-cells and CD68+ macrophages. Consistently, in the validation cohort, patients with high density of both intratumoral CD8+ and CD3+ T-cells were associated to a statistically better DFS (aHR[high-high vs. low-low] 0.24, 95%CI 0.10–0.56, p < 0.001) and those with high density of both intratumoral CD8+ and CD68+ were associated to a statistically longer OS (aHR[high-high vs. low-low] 0.28, 95%CI 0.09–0.86, p = 0.025). Conclusion: our findings suggest that a specific preexisting profile of T cells and macrophages distribution in melanomas may predict the risk of recurrence and death with potential implications for the stratification of stage II–III melanoma patients.

Serum markers improve current prediction of metastasis development in early-stage melanoma patients: a machine learning-based study.

Metastasis development represents an important threat for melanoma patients, even when diagnosed at early stages and upon removal of the primary tumor. In this scenario, determination of prognostic biomarkers would be of great interest. Serum contains information about the general status of the organism and therefore represents a valuable source for biomarkers. Thus, we aimed to define serological biomarkers that could be used along with clinical and histopathological features of the disease to predict metastatic events on the early‐stage population of patients. We previously demonstrated that in stage II melanoma patients, serum levels of dermcidin (DCD) were associated with metastatic progression. Based on the relevance of the immune response on the cancer progression and the recent association of DCD with local and systemic immune response against cancer cells, serum DCD was analyzed in a new cohort of patients along with interleukin 4 (IL‐4), IL‐6, IL‐10, IL‐17A, interferon γ (IFN‐γ), transforming growth factor‐β (TGF‐ β), and granulocyte–macrophage colony‐stimulating factor (GM‐CSF). We initially recruited 448 melanoma patients, 323 of whom were diagnosed as stages I‐II according to AJCC. Levels of selected cytokines were determined by ELISA and Luminex, and obtained data were analyzed employing machine learning and Kaplan–Meier techniques to define an algorithm capable of accurately classifying early‐stage melanoma patients with a high and low risk of developing metastasis. The results show that in early‐stage melanoma patients, serum levels of the cytokines IL‐4, GM‐CSF, and DCD together with the Breslow thickness are those that best predict melanoma metastasis. Moreover, resulting algorithm represents a new tool to discriminate subjects with good prognosis from those with high risk for a future metastasis.

Predicting Metastasis in Melanoma by Enumerating Circulating Tumor Cells Using Photoacoustic Flow Cytometry.

Background and ObjectivesEnumerating circulating tumor cells has been used as a method of monitoring progression of various cancers. Various methods for detecting circulating melanoma cells (CMCs) have been reported, but none has had sufficient sensitivity to determine if the presence of rare CMCs in the blood of Stage I–III melanoma patients predicts if those patients eventually develop metastatic disease.Study DesignWe quantified CMCs in serial blood samples from 38 early stage melanoma patients to determine if CMC numbers predict development of metastatic melanoma. CMCs were enumerated using a photoacoustic flow cytometric detection system that uses a laser to induce high frequency acoustic signals in pigmented CMCs.ResultsWe observed that detection of greater than 2 CMCs/ml of blood from patients with Stage I–III melanoma predicts metastatic disease. Of the 11 patients we studied who had two or fewer CMCs detected at all time points tested, none progressed to metastatic disease over a mean follow‐up of 1288 days. In contrast, 18 of the 27 patients (67%) having more than 2 CMCs/ml at one or more time points progressed to metastatic disease over a mean follow‐up of 850 days.ConclusionsPhotoacoustic flow cytometry can detect rare CMCs in the blood of Stage I–III melanoma patients and detectionof these cells is predictive of subsequent development of metastatic disease. Lasers Surg. Med.

Patterns in progression from early stage melanoma to late stage melanoma: Implications for survivorship follow up.

e24055 Background: Despite an encouraging 99% five-year survival in patients diagnosed with early-stage melanoma, a higher proportion of fatal melanomas initially present with thin ( &lt; 1mm) rather than thick ( &gt; 4mm) melanoma.1 Therefore, early-stage melanoma survivorship remains a topic of high interest. We examined a cohort of early-stage melanomas which progressed to stage IV to inform survivorship and risk-stratification approaches in this large, understudied population. Methods: From a retrospective single-center study of 880 consecutive melanoma patients from 2016-2020, we identified new, non- de novo diagnoses of stage IV melanoma which progressed from an initial early-stage (IA-IIA) diagnosis. Descriptive data were collected via chart review on demographics, clinical features, presentation at time of progression, and follow up prior to progression. Results: A total of 50 patients met the inclusion criterion of an initial stage IA-IIA diagnosis with subsequent progression to stage IV melanoma. Primary early stage melanomas were diagnosed an average of 6.1 years prior to metastatic disease progression, with 46% (n = 23) diagnosed within 3 years, 22% (n = 11) between 4-6 years, 12% (n = 6) between 7-10 years, 8% (n = 4) between 10-12 years, and 12% (n = 6) beyond the 12 year mark from their initial early-stage diagnosis. Average age at time of diagnosis was 57.7 (median 60, range 21-68), and 62% (n = 31) were male. The two most common early-stage diagnostic sites were lower extremities (27.5%, n = 14) and back (23.5%, n = 12). The two most common sites of metastatic disease were lung (46%, n = 23) and brain (28%, n = 14). A total of 30% (n = 15) and 34% (n = 17) of this cohort maintained follow up with oncology and dermatology, respectively, prior to their stage IV diagnosis. Symptomatic disease lead to 80% (n = 40) of stage IV diagnoses, while 14% (n = 7) were diagnosed through routine oncologic or dermatologic follow up, and the final 6% were diagnosed incidentally. Conclusions: Early stage melanoma patients who develop stage IV disease exhibit wide ranges in onset of disease progression, thus survivorship plans for this group could include a combination of early provider screening and patient education for later presentations of metastatic disease. Due to relatively common metastatic involvement of the lung and brain, a high suspicion to screen for metastatic disease with symptoms involving these organs may be appropriate.

Using a clinicopathologic and gene expression model to identify melanoma patients at high risk for disease relapse.

10068 Background: The identification of early stage melanoma patients at high risk for relapse is still difficult. Roughly 50% of melanoma deaths occur in patients who were initially diagnosed with nonmetastatic melanoma. Therefore, a strong clinical need has emerged for diagnostic tools that can identify melanoma patients at high risk for relapse. Here, we assessed the performance of a recently developed model (Bellomo et al., JCO Precis Oncol. 2020: in press), combining clinicopathologic and gene expression variables (CP-GEP), in identifying melanoma patients that have a high risk for disease relapse. Methods: We assessed the prognostic performance of the CP-GEP model in a cohort of 837 consecutive melanoma patients from Mayo Clinic who had a sentinel lymph node biopsy (SLNb) performed within 90 days of their diagnosis. The CP-GEP model combines Breslow thickness and patient age, with the expression of 8 genes in the primary tumor, to stratify patients according to their risk of relapse: CP-GEP High Risk or CP-GEP Low Risk. The main clinical endpoint of this study was five-year relapse free survival (RFS). Results: Patients were stratified based on SLNb status and CP-GEP classification. 76% of the patients were SLNb negative and had an RFS of 79% versus 52% for SLNb positive patients; HR, 3.21; P &lt; 0.0001. 60% of the patients were identified as CP-GEP High Risk and had an RFS of 62% versus 87% for CP-GEP Low Risk patients; HR, 4.12; P &lt; 0.0001. Within the SLNb negative group (637 patients of which 65% stage I), 51% of patients were classified as CP-GEP High Risk. Here, RFS was 70% for CP-GEP High Risk patients versus 89% for CP-GEP Low Risk patients; HR, 3.61; P &lt; 0.0001. The prognosis of these CP-GEP High Risk patients is similar to stage IIC/IIIA patients with reported RFS ranging from 63% to 77%. This confirms the heterogeneity in prognosis among patients with stage I/II melanoma disease. Conclusions: The CP-GEP model can be successfully used to stratify patients based on their risk for relapse. In particular, it can be used to identify SLNb negative patients with a high risk for disease relapse who may benefit from therapeutic interventions. Independent validation studies are ongoing to validate the CP-GEP model in various patient populations. [Table: see text]

Longitudinal associations between coping strategies, locus of control and health-related quality of life in patients with breast cancer or melanoma.

A diagnosis of breast cancer or melanoma is a traumatic life event that patients have to face. However, their locus-of-control (LOC) beliefs and coping strategies as well as the associations with health-related quality of life (HRQoL) changes over time are still not well known and rarely compared by cancer site. The objective of this longitudinal study was to assess the association of LOC (Cancer Locus-of-Control Scale) and coping (Brief Cope) changes, with change in HRQoL (EORTC QLQ-C30) over time in newly diagnosed breast cancer and melanoma patients at 1, 6, 12, and 24 month post-diagnosis. Mixed models were used to compare LOC and coping longitudinal changes as well as their associations with HRQoL changes in early-stage breast cancer and melanoma patients. Overall, 215 breast cancer and 78 melanoma patients participated in the study. At baseline, HRQoL levels were often higher for breast cancer compared to melanoma patients. For breast cancer and melanoma patients, negative coping strategies and perceived control over the course of illness were negatively and positively associated with HRQoL changes, respectively. For breast cancer patients only, emotional coping and internal causal attribution were negatively associated with HRQoL changes. For both cancer sites, living with a partner correlated with worse HRQoL. Understanding coping strategies and LOC beliefs used by patients soon after their cancer diagnosis and over the course of illness can help identifying psychological and supportive care to modify maladaptive thoughts and beliefs and promote more adaptive behaviors to ultimately improve patients' well-being and HRQoL.