Poorer Melanoma-specific Survival Research Articles

Use of early circulating tumour DNA dynamics in patients with stage III melanoma receiving neoadjuvant combination immunotherapy.

9577 Background: Neoadjuvant therapy in resectable stage III cutaneous melanoma improves relapse-free survival compared to adjuvant therapy alone and is now a standard of care.While pathological response can help predict recurrence risk and the need for further treatment, more biomarkers are required. We investigated circulating tumour DNA (ctDNA) as a predictive biomarker for recurrence in stage IIIB/C melanoma patients following neoadjuvant immunotherapy and surgery. Methods: We retrospectively analysed plasma samples collected at baseline and six weeks post-surgery from 30 patients enrolled in the OpACIN-neo and PRADO clinical trials, who received two cycles of ipilimumab (anti-CTLA-4) and nivolumab (anti-PD-1) before surgery. Cell free DNA (cfDNA) underwent pre-amplification followed by tumour-informed mutation detection analysis using droplet digital polymerase chain reaction (ddPCR) with the Bio-Rad QX600 PCR system. BRAF mutations were identified in 60% of patients through tumour tissue sequencing. Following neoadjuvant therapy, 7/30 (23%) achieved complete pathological response (pCR), 5/30 (17%) near pCR, 4/30 (13%) partial response, and 14/30 (47%) non-response (pNR). Results: Baseline ctDNA was detectable in 15/30 (50%) patients using the pre-amplification ddPCR method. At median follow-up of 47 months, 9/30 (30%) patients recurred, with a median time to recurrence of 8 months (range 6 to 29 months). Post-surgery, ctDNA was detectable in 4/9 patients who recurred; all four were pathological non-responders and recurred with distant, unresectable disease. Among the 15 ctDNA-positive patients at baseline, 13/15 (87%) patients achieved ctDNA clearance while 2/15 (13%) remained persistently ctDNA-positive; with a subsequent relapse rate of 0% and 100% respectively. ctDNA detection post-surgery predicted patients at higher risk of disease recurrence [relapse-free survival (RFS) hazard ratio (HR) 7.83, 95%CI 0.82-74.48; p=0.0002] and poorer melanoma-specific survival (MSS) [HR 6.35, 95% CI 0.36-110.70; p=0.0337]. Conclusions: Post-surgery ctDNA positivity can signal imminent recurrence, thus offering a window for personalised adjuvant therapy modification.

A role for pelvic sentinel lymph nodes in lower extremity melanoma?

Consensus on management of pelvic sentinel lymph nodes (PSLNs) has not been reached and thus the extent of sentinel lymph node biopsy (SLNB) of the groin in melanoma patients varies among centers and surgeons. Lymphatic drainage to PSLNs is often identified in, but the diagnostic and clinical relevance of PSLNs has been debated. Our aim was to determine if the presence of PSLNs affected recurrence or survival rates in patients with melanoma in the lower extremities. This retrospective study consisted of 702 patients with cutaneous melanoma operated between 2005 and 2018. Of these, 134 patients with melanoma in the lower extremities were included in the study. Images of lymphoscintigraphy and SPECT-CT studies were thoroughly observed together with surgery reports to define the status of SLNs. Overall, 85 of 134 patients went through SLNB and 28 of them had PSLN identified. Two had their PSLN removed, which led 26 patients with PSLN to be compared to the 57 who did not have PSLN identified. We did not find statistically significant differences in overall recurrence (26.9% versus 28.0%, p = 1.00), regional nodal recurrence (11.5% versus 15.8%, p = 0.67), local or in-transit recurrence (19.2% versus 8.8%, p = 0.17), or distant recurrence rates (15.4% versus 19.3%, p = 0.66). Disease-free survival did not differ between the groups (median 23.0 (IQR 15.0-39.0) versus 19.0 (IQR 10.3-61.8) months, p = 0.82). Likewise, there was no statistically significant difference in melanoma-specific 5-year survival (78.6% versus 87.2%, p = 0.42). We did not find more frequent recurrence, shorter disease-free survival, or poorer melanoma-specific survival in patients with drainage to PSLN. Our findings strengthen the evidence that PSLNs should not be routinely biopsied if they are not the first-tier nodes.

Sentinel Lymph Node Gene Expression Signature Predicts Recurrence-Free Survival in Cutaneous Melanoma.

Simple SummaryDespite a negative SLN status, patients with Stage IIB/IIC melanoma demonstrate poor melanoma-specific survival when compared to Stage IIIA patients. In this study, we hypothesized that a molecular profile at the level of the SLN would provide potential insights into risk of disease recurrence and serve as a prognostic biomarker of patient outcomes regardless of the presence of SLN melanoma metastases. Gene expression profiling was performed on SLN biopsies using U133A 2.0 Affymetrix gene chips. Our study suggests a novel 12-gene SLN signature risk score which may predict disease recurrence in cutaneous melanoma patients managed with wide excision of the primary tumor and SLN biopsy.We sought to develop a sentinel lymph node gene expression signature score predictive of disease recurrence in patients with cutaneous melanoma. Gene expression profiling was performed on SLN biopsies using U133A 2.0 Affymetrix gene chips. The top 25 genes associated with recurrence-free survival (RFS) were selected and a penalized regression function was used to select 12 genes with a non-zero coefficient. A proportional hazards regression model was used to evaluate the association between clinical covariates, gene signature score, and RFS. Among the 45 patients evaluated, 23 (51%) had a positive SLN. Twenty-one (46.7%) patients developed disease recurrence. For the top 25 differentially expressed genes (DEG), 12 non-zero penalized coefficients were estimated (CLGN, C1QTNF3, ADORA3, ARHGAP8, DCTN1, ASPSCR1, CHRFAM7A, ZNF223, PDE6G, CXCL3, HEXIM1, HLA-DRB). This 12-gene signature score was significantly associated with RFS (p < 0.0001) and produced a bootstrap C index of 0.888. In univariate analysis, Breslow thickness, presence of primary tumor ulceration, SLN positivity were each significantly associated with RFS. After simultaneously adjusting for these prognostic factors in relation to the gene signature, the 12-gene score remained a significant independent predictor for RFS (p < 0.0001). This SLN 12-gene signature risk score is associated with melanoma recurrence regardless of SLN status and may be used as a prognostic factor for RFS.

Ultraviolet light-induced collagen degradation inhibits melanoma invasion

Ultraviolet radiation (UVR) damages the dermis and fibroblasts; and increases melanoma incidence. Fibroblasts and their matrix contribute to cancer, so we studied how UVR modifies dermal fibroblast function, the extracellular matrix (ECM) and melanoma invasion. We confirmed UVR-damaged fibroblasts persistently upregulate collagen-cleaving matrix metalloprotein-1 (MMP1) expression, reducing local collagen (COL1A1), and COL1A1 degradation by MMP1 decreased melanoma invasion. Conversely, inhibiting ECM degradation and MMP1 expression restored melanoma invasion. Primary cutaneous melanomas of aged humans show more cancer cells invade as single cells at the invasive front of melanomas expressing and depositing more collagen, and collagen and single melanoma cell invasion are robust predictors of poor melanoma-specific survival. Thus, primary melanomas arising over collagen-degraded skin are less invasive, and reduced invasion improves survival. However, melanoma-associated fibroblasts can restore invasion by increasing collagen synthesis. Finally, high COL1A1 gene expression is a biomarker of poor outcome across a range of primary cancers.

Comparative study of cutaneous melanoma and its associated issues between people of African decent and Caucasians.

Cutaneous melanoma is uncommon in people of African descent unlike their Caucasian counterparts. This rarity of cutaneous melanoma in people of African descent makes studies in this group difficult. In the few studies that are available, several differences exist in the incidence, disease severity, course of the disease, treatment modalities and survival rates between these two groups. Observed difference in cutaneous melanoma between people of African descent and Caucasians include; a higher incidence and better prognosis in Caucasians, a low awareness of melanoma, no definite risk factors, presentation with advanced disease, poor melanoma specific survival in people of African descent. Other differences are a better UV-induced DNA damage recovery, acral as opposed to truncal melanoma, female preponderance and lack of preventive measures in people of African descent.

Genetic alterations in primary melanoma in Taiwan

Acral melanoma (AM) is the most common histopathological subtype of malignant melanoma in Asians. However, differences in the mutational profiles underlying AM and nonacral cutaneous melanoma (NAM) in Asians are not well understood. To augment the understanding of the prevalence, patterns and associations of various mutations between different subtypes of melanoma. We performed comprehensive genomic profiling of 409 cancer-associated genes, using next-generation sequencing, in 66 primary melanomas comprised of 45 AMs and 21 NAMs. Most of the AMs (n = 27/45; 60%), but only five of 21 (24%) NAMs, were triple wild-type (triple-WT) tumours. Compared with AMs, NAMs exhibited a significantly higher frequency of BRAF mutations. The frequencies of NRAS/KRAS mutations, cell-cycle aberrations, copy number gains in BIRC2, BIRC3 and BIRC5, and gains of receptor tyrosine kinase genes were significantly higher in AMs. Ulceration was found at significantly higher rates in the AMs and NAMs with cell-cycle aberrations and gains of receptor tyrosine kinase genes. Notably, cell-cycle aberrations and copy number gains in BIRC2, BIRC3 and BIRC5 were significantly associated with poor melanoma-specific survival in the 66 patients with melanoma and especially in the 45 patients with AM. Multivariate analysis showed that lymph node metastasis and cell-cycle aberrations were independent prognostic factors of melanoma-specific survival. This study strengthens our understanding of the patterns and clinical associations of oncogenic mutations in AMs and NAMs in Asians. What's already known about this topic? Mutation frequencies of driver genes vary between melanoma subtypes. Acral melanoma is the most common subtype of melanoma in Asians. KIT mutations and copy number variations occur more frequently in the acral subtype of melanoma than in the nonacral subtype What does this study add? NRAS/KRAS mutations, cell-cycle aberrations, copy number gains in BIRC2, BIRC3 and BIRC5, and amplifications of receptor tyrosine kinase genes were significantly enriched in acral melanoma and could be potential targets for treatment. Melanomas with cell-cycle aberrations and gains in receptor tyrosine kinase genes were significantly more likely to contain ulceration. What is the translational message? Cell-cycle aberrations and copy number gains in BIRC2, BIRC3 and BIRC5 were significantly associated with poor melanoma-specific survival. These observations should be explored further for future drug development.

Clinicopathologic, misdiagnosis, and survival differences between clinically amelanotic melanomas and pigmented melanomas

Amelanotic malignant melanoma (AMM) is challenging to diagnose. Clinical risk factors for AMM are not well defined. To investigate clinicopathologic, misdiagnosis, and survival differences between patients with AMM and those with pigmented malignant melanoma (PMM). A cross-sectional retrospective medical record review at a tertiary academic medical center. A total of 933 patients with melanoma with known presenting tumor color were identified (342 with AMM vs 591 with PMM). AMM was associated with older age, history of nonmelanoma skin cancer, and red hair, whereas AMM was inversely associated with a family history of melanoma, more than 50 nevi, and a history of dysplastic nevi. Compared with PMM, AMM was more likely to be located on the head and/or neck, had more aggressive pathologic features (greater Breslow depth and/or mitoses, ulceration, nodular subtype), and was less likely to be associated with a precursor nevus or regression. Finally, patients with AMM were more likely to be misdiagnosed than were patients with PMM (25% vs 12% clinically and 12% vs 7% pathologically), and they had poorer melanoma-specific survival (5-year overall survival rate, 0.77 [95% confidence interval, 0.72-0.82] vs 0.84 [95% confidence interval, 0.80-0.87]). Retrospective study design, single-institutional study. Greater clinician awareness, lower biopsy thresholds, and increased patient education may be useful to enhance AMM detection in patients with certain characteristics.

Microsatellitosis in Patients with Melanoma.

Microsatellitosis (mS) in melanoma has been considered a marker of unfavorable tumor biology, leading to the current American Joint Committee on Cancer staging of IIIB/C/D disease, despite few investigative studies of this entity limited by the small sample sizes and incomplete nodal microstaging. We sought to better characterize outcomes and prognostic factors in a multi-institutional cohort of patients with mS and nodal microstaging. The Sentinel Lymph Node Working Group cohort included 414 mS patients who underwent sentinel lymph node (SLN) biopsy. Cox regression analysis was used to evaluate the prognostic significance of established clinicopathologic characteristics. Melanoma-specific survival (MSS) of patients with mS was compared with 3002 similarly staged patients from the Surveillance, Epidemiology, and End Results (SEER) Program registry. The median age of the mS cohort was 64.9years; 39.6% were female. Median thickness was 3mm, 40.6% of cases were ulcerated, and the SLN positivity rate was 46.7%. Increasing thickness, male sex, and SLN positivity were significantly associated with poorer MSS. Stage IIIB/C/D 5-year MSS rates were 86.3% (95% confidence interval [CI] 79.4-93.3%), 54.1% (95% CI 45.4-59.7%), and 44.2% (95% CI 25.4-63.0%), respectively. MSS survival for the stage IIIB mS cohort was significantly better than a similarly staged SEER cohort (5-year MSS of 70.1%, 95% CI 66.0-74.2%), while no significant difference was observed for the stage IIIC or D cohorts. SLN metastases are common and are a significant prognostic factor in patients with mS. Survival in stage IIIB patients with mS was considerably more favorable than their stage would otherwise suggest, which has important implications for decisions regarding adjuvant therapy for patients with mS.

Telomere length and survival in primary cutaneous melanoma patients

Telomere repeats at chromosomal ends, critical to genomic integrity, undergo age-dependent attrition. Telomere length, a polygenic trait, has been associated with risk of several disorders including cancers. In contrast to association of long telomeres with increased risk of several cancers, including melanoma, emerging reports suggest that short telomeres predict poor survival in patients with different cancers. In this study based on 1019 stage I and II cutaneous melanoma patients, we show an association between the patients with short telomeres and poor melanoma-specific survival (HR 2.05, 95% CI 1.33–3.16) compared to patients with long telomeres. Due to inverse correlation between age and telomere length (r -0.19, P < 0.0001), we stratified the patients into quantiles based on age at diagnosis and also carried out age-matched analysis. The effect of short telomeres on survival was determined by using multivariate Cox regression that included composite genetic risk score computed from genotyping of the patients for telomere-length associated polymorphisms. The effect of decreased telomere length on poor melanoma-specific survival was particularly strong in patients within the age quantile below 30 years (HR 3.82, 95% CI 1.10–13.30) and between 30–40 years (HR 2.69, 95% CI 1.03–7.03). Our study shows that in contrast to increased melanoma risk associated with increased telomere length, decreased telomere length predicts poor survival in melanoma subgroups.

Worse outcome for patients with recurrent melanoma after negative sentinel lymph biopsy as compared to sentinel-positive patients

BackgroundThe long-term outcome of patients with melanoma who had recurrence after negative sentinel lymph node (SLN) biopsy has rarely been evaluated systematically. MethodsWe searched our databases for melanoma patients with SLN biopsy from the end of 1999 and the beginning of 2011. Data was analyzed using uni- and multivariate statistics as well as Kaplan–Meier curves. ResultsData of 651 patients with melanoma was available for statistics. We observed 451 (69.3%) patients with negative SLN who had no evidence of disease recurrence during follow-up. Recurrence in SLN negative patients was found in 50 (7.7%) cases. Tumor subtypes such as invasive lentigo maligna melanoma and acral melanoma (odds ratio 15.2, P = 0.015) and tumor thickness > 2 mm (odds ratio 3.1, P = 0.0017) were independent predictors for recurrence in patients with negative SLN. Patients with negative SLN and subsequent recurrence had a significantly (P = 0.036) reduced 5-year melanoma-specific survival (MSS) when compared with positive SLN patients. Recurrence of disease in positive SLN patients was observed after a median of 39 months when compared to patients with negative SLN and recurrence (28 months, P = 0.0079). Negative SLN with recurrence was an independent predictor for worse recurrence free and melanoma-related survival. ConclusionsPatients with negative SLN and recurrence experience earlier disease relapses and poorer MSS when compared to patients with positive SLN status implicating that more stringent follow-up procedures are warranted in patients with higher tumor thickness and invasive lentigo maligna and acral melanoma, despite a negative SLN.

The role of BRAF mutations in primary melanoma growth rate and survival.

The clinical behaviour and prognosis of primary melanomas harbouring BRAF mutations is not fully understood. To investigate the effect of mutation status on primary melanoma growth rate and melanoma-specific survival (MSS). A prospective cohort of 196 patients with stage I-III primary cutaneous melanoma were followed for a median of 92 months, pre-dating the institution of BRAF inhibitor therapy. Clinicopathological variables were correlated with mutation status and hazard ratios (HRs) estimated for MSS. Of 196 tumours, 77 (39.2%) were BRAF V600E, 10 (5.1%) BRAF V600K and 33 (16.8%) were NRAS mutant. BRAF V600E mutant melanomas were associated with favourable clinical characteristics and tended to be slower growing compared with BRAF V600K, NRAS mutant or BRAF/NRAS wild-type tumours (0.12 mm per month, 0.61 mm per month, 0.36 mm per month and 0.23 mm per month, respectively; P = 0.05). There were 39 melanoma deaths, and BRAF mutant melanomas were associated with poorer MSS in stage I-III disease [HR 2.60, 95% confidence interval (CI) 1.20-5.63; P = 0.02] and stage I-II disease (HR 3.39, 95% CI 1.12-10.22; P = 0.03) after adjusting for other prognostic variables. Considered separately, BRAF V600E mutant melanomas were strongly associated with MSS independently of thickness and nodal status (HR 3.89, 95% CI 1.67-9.09; P < 0.01) but BRAF V600K mutant tumours were not (HR 1.19, 95% CI 0.36-3.92; P = 0.77). The presence of a BRAF mutation does not necessarily 'drive' more rapid tumour growth but is associated with poorer MSS in patients with early-stage disease.

25-Hydroxyvitamin D2 /D3 levels and factors associated with systemic inflammation and melanoma survival in the Leeds Melanoma Cohort.

Lower 25-hydroxyvitamin D2 /D3 levels at melanoma diagnosis are associated with thicker primaries and poorer survival. We postulated that this might relate to the deleterious effect of systemic inflammation as 25-hydroxyvitamin D2 /D3 levels are inversely associated with levels of C-reactive protein. 2,182 participants in the Leeds Melanoma Cohort (median follow-up 7.98 years) provided data on drug exposure, comorbidities and a serum 25-hydroxyvitamin D2 /D3 level at recruitment. Factors reported to modify systemic inflammation (low vitamin D levels, high body mass index, use of aspirin or nonsteroidal anti-inflammatory drugs or smoking were tested as predictors of microscopic ulceration (in which primary tumors are inflamed) and melanoma-specific survival (MSS). Ulceration was independently associated with lower 25-hydroxyvitamin D2 /D3 levels (odds ratio (OR) = 0.94 per 10 nmol/L, 95% CI 0.88-1.00, p = 0.05) and smoking at diagnosis (OR = 1.47, 95% CI 1.00-2.15, p = 0.04). In analyses adjusted for age and sex, a protective effect was seen of 25-hydroxyvitamin D2 /D3 levels at diagnosis on melanoma death (OR = 0.89 per 10 nmol/L, 95% CI 0.83-0.95, p < 0.001) and smoking increased the risk of death (OR = 1.13 per 10 years, 95% CI 1.05-1.22, p = 0.001). In multivariable analyses (adjusted for tumor thickness) the associations with death from melanoma were low 25-hydroxyvitamin D2 /D3 level at recruitment (<20 nmol/L vs. 20-60 nmol/L, hazard ratio (HR) = 1.52, 95% CI 0.97-2.40, p = 0.07) and smoking duration at diagnosis (HR = 1.11, 95% CI 1.03-1.20, p = 0.009). The study shows evidence that lower vitamin D levels and smoking are associated with ulceration of primary melanomas and poorer MSS. Further analyses are necessary to understand any biological mechanisms that underlie these findings.

Prognostic stratification of ulcerated melanoma: not only the extent matters.

For patients with melanoma, ulceration is an important prognostic marker and interestingly also a predictive marker for the response of adjuvant interferon. A consensual definition and accurate assessment of ulceration are therefore crucial for proper staging and clinical management. We evaluated the prognostic impact of the extent and type of ulceration and the epidermal involvement theoretically preceding it (consumption of epidermis and cleft formation) or seen subsequent to the inflammation (reepithelialization and reactive epidermal hyperplasia), aiming for better prognostic stratification of ulcerated lesions. From H&E-stained sections, the status (presence vs absence), extent (percentage of the total tumor length), and type (infiltrative vs attenuative) of ulceration and epidermal involvement were evaluated from 385 patients with cutaneous melanoma. The presence of ulceration (hazard ratio [HR], 1.83), an attenuative type of ulceration (HR, 3.02), and excessive ulceration (HR, 3.57) were independent predictors of poor melanoma-specific survival. Further subdivision of minimal/moderate ulceration showed independent prognostic value only for lesions with epidermal involvement of the surrounding epidermis (HR, 1.78). The extent and type of ulceration and involvement of the surrounding epidermis provided more accurate prognostic information than the mere absence or presence and may be useful markers allowing better stratification of ulcerated lesions.

The relationship between blood IL-12p40 level and melanoma progression.

Cytokines such as Interleukin (IL)-12p70 ("IL-12") and IL-23 can influence tumor progression. We tested the hypothesis that blood levels of IL-12p40, the common subunit of both cytokines, are associated with melanoma progression. Blood from 2,048 white melanoma patients were collected at a single institution between March 1998 and March 2011. Plasma levels of IL-12p40 were determined for 573 patients (discovery), 249 patients (Validation 1) and 244 patients (Validation 2). Per 10-unit change of IL-12p40 level was used to investigate associations with melanoma patient outcome among all patients or among patients with early or advanced stage. Among stage I/II melanoma patients in the pooled data set, after adjustment for sex, age, stage and blood draw time from diagnosis, elevated IL-12p40 was associated with melanoma recurrence [hazard ratio (HR) = 1.04 per 10-unit increase in IL-12p40, 95% CI 1.02-1.06, p = 8.48 × 10(-5) ]; Elevated IL-12p40 was also associated with a poorer melanoma specific survival (HR = 1.06, 95% CI 1.03-1.09, p = 3.35 × 10(-5) ) and overall survival (HR = 1.05, 95% CI 1.03-1.08, p = 8.78×10(-7) ) in multivariate analysis. Among stage III/IV melanoma patients in the pooled data set, no significant association was detected between elevated IL-12p40 and overall survival, or with melanoma specific survival, with or without adjustment for the above covariates. Early stage melanoma patients with elevated IL-12p40 levels are more likely to develop disease recurrence and have a poorer survival. Further investigation with a larger sample size will be needed to determine the role of IL-12p40 in advanced stage melanoma patients.

Triple-marker PCR assay of sentinel lymph node as a prognostic factor in melanoma.

Metastasis of sentinel lymph node (SLN) is generally evaluated on histopathological examination and controversy still exists over the usefulness of PCR assay of SLN. To investigate the prognostic value of triple-marker PCR assay of SLN. A total of 165 patients with primary cutaneous melanoma who underwent SLN biopsy were included. Clinical and histopathological data were retrieved from each patient's file and triple-marker PCR assay (tyrosinase, GP-100 and MART-1) was performed on the SLN as well as routine histopathological evaluation. PCR positivity was defined as the expression of all three PCR markers. To evaluate melanoma-specific survival (MSS) and disease-free survival (DFS), we used the Kaplan-Meier method and the log-rank test. Multivariate analyses using the Cox proportional hazards regression model were also performed. Sentinel lymph nodes were identified in all 165 patients: 61 patients (37.0%) were male and 104 (63.0%) were female, with a mean age of 60.2 years. Of the 165 melanomas, 81 (49.1%) were acral lentiginous melanomas. Compared with the patients with PCR positivity (1-2 markers) or PCR negativity, patients with PCR positivity (3 markers) had significantly poor MSS (5-year survival rate, 58.7% vs. 84.4%; P < 0.0001) and DFS (5-year survival rate, 25.0% vs. 83.9%; P < 0.0001), with median follow-up of 42 months for MSS and 38 months for DFS. These survival rates of patients with PCR positivity (3 markers) were lower than those of patients with histopathologically positive SLN. In multivariate analysis, PCR positivity (3 markers) was an independent prognostic factor for both MSS (hazard ratio [HR], 2.81; 95% confidence interval [CI], 1.07-7.33; P = 0.035) and DFS (HR, 2.48; 95% CI, 1.08-5.69; P = 0.032). The expression of three PCR markers was a significant prognostic factor for both MSS and DFS and might be closely correlated to a dismal prognosis.

Loss of CDKN2A expression is a frequent event in primary invasive melanoma and correlates with sensitivity to the CDK4/6 inhibitor PD0332991 in melanoma cell lines

We have investigated the potential for the p16-cyclin D-CDK4/6-retinoblastoma protein pathway to be exploited as a therapeutic target in melanoma. In a cohort of 143 patients with primary invasive melanoma, we used fluorescence in situ hybridization to detect gene copy number variations (CNVs) in CDK4, CCND1, and CDKN2A and immunohistochemistry to determine protein expression. CNVs were common in melanoma, with gain of CDK4 or CCND1 in 37 and 18% of cases, respectively, and hemizygous or homozygous loss of CDKN2A in 56%. Three-quarters of all patients demonstrated a CNV in at least one of the three genes. The combination of CCND1 gain with either a gain of CDK4 and/or loss of CDKN2A was associated with poorer melanoma-specific survival. In 47 melanoma cell lines homozygous loss, methylation or mutation of CDKN2A gene or loss of protein (p16(INK) (4A) ) predicted sensitivity to the CDK4/6 inhibitor PD0332991, while RB1 loss predicted resistance.

The prognostic significance of sentinel node tumour burden in melanoma patients: An international, multicenter study of 1539 sentinel node-positive melanoma patients

IntroductionSentinel node (SN) biopsy (SNB) and completion lymph node dissection (CLND) when SN-positive have become standard of care in most cancer centres for melanoma. Various SN tumour burden parameters are assessed to determine the heterogeneity of SN-positivity. The aim of the present study was to validate the prognostic significance of various SN tumour burden micromorphometric features and classification schemes in a large cohort of SN-positive melanoma patients. MethodsIn 1539 SN-positive patients treated between 1993 and 2008 at 11 melanoma treatment centres in Europe and Australia, indices of SN tumour burden (intranodal location, tumour penetrative depth (TPD) and maximum size of SN tumour deposits) were evaluated. ResultsNon-subcapsular location, increasing TPD and increasing maximum size were all predictive factors for non-SN (NSN) status and were independently associated with poorer melanoma-specific survival (MSS). Patients with subcapsular micrometastases <0.1mm in maximum dimension had the lowest frequency of NSN metastasis (5.5%). Despite differences in SN biopsy protocols and clinicopathologic features of the patient cohorts (between centres), most SN parameters remained predictive in individual centre populations. Maximum SN tumour size>1mm was the most reliable and consistent parameter independently associated with higher non-SN-positivity, poorer disease-free survival (DFS) and poorer MSS. ConclusionsIn this large retrospective, multicenter cohort study, several parameters of SN tumour burden including intranodal location, TPD and maximum size provided prognostic information, but their prognostic significance varied considerably between the different centres. This could be due to sample size limitations or to differences in SN detection, removal and examination techniques.

Increased levels of DUSP6 phosphatase stimulate tumourigenesis in a molecularly distinct melanoma subtype

The mitogen-activated protein kinase (MAPK) pathway is important in melanoma. In this pathway, DUSP6 phosphatase negatively controls the activation of extracellular signal-regulated (ERK) kinase. Through comparison of melanoma signalling pathways between immortal mouse melanocytes and their tumourigenic derivatives, retrieved from mouse xenografts, we identified a molecularly distinct subtype of melanoma, characterized by reduced ERK activity and increased DUSP6 expression. Overexpression of DUSP6 enhanced anchorage-independent growth and invasive ability of immortal mouse melanocytes, suggesting that increased DUSP6 expression contributes to melanoma formation in the mouse xenografts. In contrast, reduced tumourigenicity was observed after DUSP6 overexpression in human melanoma cells. A minority of thick human primary melanomas had high DUSP6 expression and the same poor melanoma-specific survival as the majority of thick primaries with low DUSP6 levels. We have demonstrated that DUSP6 is important in melanoma and that it plays a different role in our distinct subtype of mouse melanoma compared with that in classic human melanoma.

31. Prognostic importance of the extent of ulceration of clinically localised cutaneous melanoma

Background The presence of ulceration is an adverse prognostic factor in clinically-localised cutaneous primary melanoma (PM). However, whether the extent of ulceration has any prognostic importance remains unclear. We sought to determine the prognostic value of the extent of ulceration categorised as diameter of ulceration and as percentage of invasive melanoma. Methods Clinico-pathological data on patients with PM were collected from the Melanoma Institute Australia database. In patients with ulcerated melanomas, diameter and percentage ulceration (ratio of diameter of ulceration to diameter of invasive melanoma) were identified from the database or measured if slides were available for review. Ulceration was defined as full-thickness loss of epidermis overlying melanoma. The impact of clinico-pathologic parameters and extent of ulceration on survival was analysed. Results Male sex, head/neck anatomical location, increasing Breslow thickness and presence of mitoses were independent predictors of poorer melanoma-specific survival (MSS). Presence of ulceration was an independent predictor of poorer MSS (HR=1.55, 95%CI 1.21-2.00). Patients with tumours ulcerated ≤70% and ≤5 mm had significantly poorer MSS than non-ulcerated melanoma [HR = 1.53, 95%CI 1.07-2.21 and HR=1.39, 95%CI 1.04-1.87, respectively). Compared with all patients with ulcerated melanoma (HR = 1.55) patients with tumours ulcerated >70% or >5 mm had a significantly higher risk of death (HR = 2.20, 95%CI 1.26-3.82 and HR = 2.03, 95%CI 1.37-3.03, respectively). Conclusions Extent of ulceration provides more prognostic information than the mere presence of ulceration, and this has important implications for melanoma patients with regard to prognosis, staging, management and eligibility for clinical trials. We recommend that extent of ulceration be recorded in pathology reports for all ulcerated PMs.

Tumor Location Predicts Survival in Cutaneous Head and Neck Melanoma

Prior studies documented poorer outcomes in patients with cutaneous head and neck melanoma (CHNM) relative to those with melanoma at other sites. We evaluated survival differences attributable to tumor location in patients with CHNM. We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients undergoing surgery for CHNM from 1988 to 2006, excluding patients without biopsy-proven diagnoses, those diagnosed at autopsy, and patients with distant metastases. Using the Kaplan-Meier method, we assessed patient, tumor, and treatment-specific factors on overall survival (OS) and melanoma specific survival (MSS). Cox proportional hazards models assessed the role of tumor location (ear, eyelid, face, lip, scalp/neck) on OS and MSS, while controlling for patient age, gender, race, tumor thickness, tumor ulceration, lymph node status, histologic subtype, type of surgery, and use of radiation. Risks of overall and melanoma-specific mortality were reported as hazard ratios (HR) with 95% confidence intervals (CI). Among 27,097 patients, 10-y rates of OS and MSS were 56.1% and 84.7%, respectively. On multivariate analysis, scalp/neck primary site was associated with an increased risk of overall (HR 1.20, CI 1.14-1.26; P < 0.001) and melanoma-specific mortality (HR 1.64, CI 1.49-1.80, P < 0.001) relative to melanomas of the face. Tumors of the lip had poorer MSS (HR 1.55; CI 1.05-2.28, P = 0.03) but not OS (HR 1.03, CI 0.80-1.34; P = 0.80). Patients with melanomas of the scalp/neck have poorer OS and MSS and those with lip melanomas have poorer MSS. These anatomic areas should not be overlooked when performing skin examinations.