The performance of solarscan : an automated dermoscopy image analysis instrument for the diagnosis of primary melanoma

Objective To describe the diagnostic performance of SolarScan (Polartechnics Ltd, Sydney, Australia), an automated instrument for the diagnosis of primary melanoma.

Design Images from a data set of 2430 lesions (382 were melanomas; median Breslow thickness, 0.36 mm) were divided into a training set and an independent test set at a ratio of approximately 2:1. A diagnostic algorithm (absolute diagnosis of melanoma vs benign lesion and estimated probability of melanoma) was developed and its performance described on the test set. High-quality clinical and dermoscopy images with a detailed patient history for 78 lesions (13 of which were melanomas) from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan.

Setting Seven specialist referral centers and 2 general practice skin cancer clinics from 3 continents. Comparison between clinician diagnosis and SolarScan diagnosis was by 3 dermoscopy experts, 4 dermatologists, 3 trainee dermatologists, and 3 general practitioners.

Patients Images of the melanocytic lesions were obtained from patients who required either excision or digital monitoring to exclude malignancy.

Main Outcome Measures Sensitivity, specificity, the area under the receiver operator characteristic curve, median probability for the diagnosis of melanoma, a direct comparison of SolarScan with diagnoses performed by humans, and interinstrument and intrainstrument reproducibility.

Results The melanocytic-only diagnostic model was highly reproducible in the test set and gave a sensitivity of 91% (95% confidence interval [CI], 86%-96%) and specificity of 68% (95% CI, 64%-72%) for melanoma. SolarScan had comparable or superior sensitivity and specificity (85% vs 65%) compared with those of experts (90% vs 59%), dermatologists (81% vs 60%), trainees (85% vs 36%; P =.06), and general practitioners (62% vs 63%). The intraclass correlation coefficient of intrainstrument repeatability was 0.86 (95% CI, 0.83-0.88), indicating an excellent repeatability. There was no significant interinstrument variation (P = .80).

Conclusions SolarScan is a robust diagnostic instrument for pigmented or partially pigmented melanocytic lesions of the skin. Preliminary data suggest that its performance is comparable or superior to that of a range of clinician groups. However, these findings should be confirmed in a formal clinical trial.

High expression of FOXP3 in primary melanoma is associated with tumour progression.

BACKGROUND The antitumour immune response plays an important role in the prognosis of melanoma. High numbers of circulating regulatory T cells have been associated with rapid disease progression. OBJECTIVES To assess the influence of forkhead box protein (FOXP)3, CD1a and langerin expression on the prognosis of primary melanoma. METHODS We analysed 185 primary melanomas by immunohistochemical staining for expression of the regulatory T-cell marker FOXP3 and the dendritic cell markers langerin and CD1a, and correlated marker expression with clinical outcome. RESULTS Disease-free survival and overall survival were significantly longer in patients expressing low levels of FOXP3 in the primary melanoma, whereas they were associated with high expression of CD1a. The negative prognostic value of FOXP3 expression was independent of the Breslow tumour thickness. Langerin expression did not correlate with the clinical outcome. CONCLUSIONS High expression of FOXP3 in the primary melanoma may be used as an additional independent prognostic marker for early tumour progression in patients with melanoma.

Primary Melanoma of the Small Intestine with a Metastatic Lymph Mass in the Inguinal Canal: A Case Report

Objectives: We report a case of primary melanoma of the small intestine. Primary intestinal melanoma (PIM) is an extremely rare neoplasm for which the cause is unknown. Materials and methods: A 67-year-old man was admitted to our department due to abdominal pain, constipation, a large, hard inguinal mass and severe anaemia. Results: After laboratory data, imaging techniques and histopathological examination, the diagnosis was confirmed. A surgical resection of the intestinal neoplasm, treatment with BRAF inhibitors and radiation therapy to the inguinal mass were performed. Conclusion: PIM is rare and it is usually difficult to establish its exact origin.

Functional Variants in Notch Pathway Genes NCOR2, NCSTN, and MAML2 Predict Survival of Patients with Cutaneous Melanoma.

BACKGROUND: The Notch signaling pathway is constitutively activated in human cutaneous melanoma to promote growth and aggressive metastatic potential of primary melanoma cells. Therefore, genetic variants in Notch pathway genes may affect the prognosis of cutaneous melanoma patients. METHODS: We identified 6,256 SNPs in 48 Notch genes in 858 cutaneous melanoma patients included in a previously published cutaneous melanoma genome-wide association study dataset. Multivariate and stepwise Cox proportional hazards regression and false-positive report probability corrections were performed to evaluate associations between putative functional SNPs and cutaneous melanoma disease-specific survival. Receiver operating characteristic curve was constructed, and area under the curve was used to assess the classification performance of the model. RESULTS: Four putative functional SNPs of Notch pathway genes had independent and joint predictive roles in survival of cutaneous melanoma patients. The most significant variant was NCOR2 rs2342924 T>C (adjusted HR, 2.71; 95% confidence interval, 1.73-4.23; Ptrend = 9.62 × 10(-7)), followed by NCSTN rs1124379 G>A, NCOR2 rs10846684 G>A, and MAML2 rs7953425 G>A (Ptrend = 0.005, 0.005, and 0.013, respectively). The receiver operating characteristic analysis revealed that area under the curve was significantly increased after adding the combined unfavorable genotype score to the model containing the known clinicopathologic factors. CONCLUSIONS: Our results suggest that SNPs in Notch pathway genes may be predictors of cutaneous melanoma disease-specific survival. IMPACT: Our discovery offers a translational potential for using genetic variants in Notch pathway genes as a genotype score of biomarkers for developing an improved prognostic assessment and personalized management of cutaneous melanoma patients.

Ultraviolet exposure of melanoma cells induces fibroblast activation protein-α in fibroblasts: Implications for melanoma invasion.

Fibroblast activation protein-a (FAP-a) promotes tumor growth and cell invasiveness through extracellular matrix degradation. How ultraviolet radiation (UVR), the major risk factor for malignant melanoma, influences the expression of FAP-a is unknown. We examined the effect of UVR on FAP-a expression in melanocytes, keratinocytes and fibroblasts from the skin and in melanoma cells. UVR induces upregulation of FAP-a in fibroblasts, melanocytes and primary melanoma cells (PM) whereas keratinocytes and metastatic melanoma cells remained FAP-a negative. UVA and UVB stimulated FAP-a-driven migration and invasion in fibroblasts, melanocytes and PM. In co-culture systems UVR of melanocytes, PM and cells from regional metastases upregulated FAP-a in fibroblasts but only supernatants from non-irradiated PM were able to induce FAP-a in fibroblasts. Further, UV-radiated melanocytes and PM significantly increased FAP-a expression in fibroblasts through secretory crosstalk via Wnt5a, PDGF-BB and TGF-ß1. Moreover, UV radiated melanocytes and PM increased collagen I invasion and migration of fibroblasts. The FAP-a/DPPIV inhibitor Gly-ProP(OPh)2 significantly decreased this response implicating FAP-a/DPPIV as an important protein complex in cell migration and invasion. These experiments suggest a functional association between UVR and FAP-a expression in fibroblasts, melanocytes and melanoma cells implicating that UVR of malignant melanoma converts fibroblasts into FAP-a expressing and ECM degrading fibroblasts thus facilitating invasion and migration. The secretory crosstalk between melanoma and tumor surrounding fibroblasts is mediated via PDGF-BB, TGF-ß1 and Wnt5a and these factors should be evaluated as targets to reduce FAP-a activity and prevent early melanoma dissemination.

Detection of micrometastases in sentinel lymph nodes from melanoma patients: direct comparison of multimarker molecular and immunopathological methods.

The technique of sentinel lymph node (SLN) dissection is a reliable predictor of metastatic disease in the lymphatic basin draining the primary melanoma. Reverse transcription-polymerase chain reaction (RT-PCR) is emerging as a highly sensitive technique to detect micrometastases in SLNs, but its specificity has been questioned. A prospective SLN study in melanoma patients was undertaken to compare in detail immunopathological versus molecular detection methods. Sentinel lymphadenectomy was performed on 57 patients, with a total of 71 SLNs analysed. SLNs were cut in slices, which were alternatively subjected to parallel multimarker analysis by microscopy (haematoxylin and eosin and immunohistochemistry for HMB-45, S100, tyrosinase and Melan-A/MART-1) and RT-PCR (for tyrosinase and Melan-A/MART-1). Metastases were detected by both methods in 23% of the SLNs (28% of the patients). The combined use of Melan-A/MART-1 and tyrosinase amplification increased the sensitivity of PCR detection of microscopically proven micrometastases. Of the 55 immunopathologically negative SLNs, 25 were found to be positive on RT-PCR. Notably, eight of these SLNs contained naevi, all of which were positive for tyrosinase and/or Melan-A/MART-1, as detected at both mRNA and protein level. The remaining 41% of the SLNs were negative on both immunohistochemistry and RT-PCR. Analysis of a series of adjacent non-SLNs by RT-PCR confirmed the concept of orderly progression of metastasis. Clinical follow-up showed disease recurrence in 12% of the RT-PCR-positive immunopathology-negative SLNs, indicating that even an extensive immunohistochemical analysis may underestimate the presence of micrometastases. However, molecular analyses, albeit more sensitive, need to be further improved in order to attain acceptable specificity before they can be applied diagnostically.

Étude du rôle de l'adaptateur Nck2 dans la progression métastatique du mélanome humain

La dissémination métastatique est associée à de faibles chances de survie dans les cas de mélanomes humains, comme pour d’autres cancers. Le développement de métastases est un processus qui se fait en plusieurs étapes et nécessite la réorganisation du cytosquelette d’actine pour permettre la migration et l’invasion cellulaire. La protéine Nck2 est un adaptateur protéique principalement impliqué dans la réorganisation du cytosquelette. Une étude préliminaire réalisée dans notre laboratoire avait révélé que les niveaux de la protéine Nck2 et de son ARNm sont augmentés dans les lignées de mélanome métastatiques en comparaison aux lignées primaires. Le but de la présente recherche était donc d’étudier le rôle de l’adaptateur Nck2 dans la progression métastatique. Les résultats obtenus confirment que l’expression de Nck2 augmente de façon marquée au cours de la progression métastatique du mélanome humain. Cette étude révèle en plus que l’expression de hauts niveaux de Nck2 dans les cellules de mélanome primaire stimule la prolifération cellulaire et la migration, n’affecte pas l’invasion d’une matrice de collagène de type I, mais semble affaiblir les contacts cellule-cellule et l’adhésion au substrat. Une étude préliminaire effectuée in vivo révèle que ces phénomènes se traduisent par une légère augmentation de la tumorigenèse et de la croissance tumorale. Dans l’ensemble, les résultats obtenus suggèrent que Nck2 pourrait effectivement jouer un rôle dans la progression métastatique du mélanome en favorisant la prolifération des cellules tumorales et en facilitant leur détachement de la tumeur primaire, les rendant plus aptes à se disperser dans l’organisme et à établir des colonies métastatiques. Au niveau moléculaire, nous proposons que Nck2 est recruté dans les invadopodes pour favoriser la formation de complexes protéiques qui stimulent l’invasion. La mobilisation de Nck2 dans ces structures membranaires diminuerait sa disponibilité pour l’établissent d’autres complexes protéiques, entre autres dans les complexes d’adhésion focaux (FAs) et dans les jonctions adhérentes, diminuant ainsi les contacts des cellules cancéreuses avec la matrice extracellulaire et les cellules avoisinantes.

Réparation par excision de nucléotides des dommages induits par rayons ultraviolets dans les mélanomes humains

Les mélanomes malins (MM) constituent le deuxième type de cancer le plus fréquent chez les jeunes adultes canadiens (entre 20 et 44 ans) ainsi qu’un des rares cancers dont l’incidence augmente annuellement. À moins que les MM ne soient excisés à temps par chirurgie, les chances de survie des patients sont pratiquement nulles puisque ce type de tumeur est très réfractaire aux traitements conventionnels. Il est bien connu que l’exposition aux rayons ultraviolets (UV), induisant des photoproduits génotoxiques, est une déterminante majeure dans l’acquisition de MM. À cet effet, la réparation par excision de nucléotides (NER) est la ligne de défense principale contre le développement des mélanomes puisqu’elle est la voie de réparation prépondérante en ce qui a trait aux dits photoproduits. Malgré cela, la contribution potentielle de défauts de la NER au développement des MM dans la population normale n’est toujours pas bien établie. Notre laboratoire a précédemment développé une méthode basée sur la cytométrie de flux qui permet de mesurer la NER en fonction du cycle cellulaire. Cette méthode a déjà mise en évidence qu’une déficience de l’activité de la protéine ATR peut mener à une déficience de la NER exclusive à la phase S dans des fibroblastes humains. Pareillement, nous avons démontré que plusieurs lignées cellulaires cancéreuses modèles comportent une déficience en NER en phase S, suggérant qu’une telle déficience puisse caractériser certains types de cancers. Nous avons voulu savoir si une déficience en NER en phase S pouvait être associée à une proportion significative de mélanomes et si le tout pouvait être attribuable à une diminution de l’activité d’ATR. Nos objectifs ont donc été de : (i) mesurer l’efficacité de la NER en fonction du cycle cellulaire dans les MM en comparaison avec les mélanocytes primaires, (ii) vérifier si le niveau d’activité d’ATR corrèle avec l’efficacité de la NER en phase S dans les lignées de MM et (iii) voir si un gène fréquemment muté dans les mélanomes (tels PTEN et BRAF) pouvait coopérer avec ATR pour réguler la NER en phase S dans les mélanomes. Nous avons démontré que 13 lignées de MM sur 16 ont une capacité grandement diminuée à réparer les photoproduits induits par UV spécifiquement en phase S. De plus, cette déficience corrèle fortement avec une réduction de l’activation d’ATR et, dans plusieurs lignées de MM, avec une phosphorylation d’Akt plus importante. L’utilisation d’ARN interférent ou d’un inhibiteur du suppresseur de tumeurs PTEN, a permis, en plus d’augmenter la phosphorylation d’Akt, de réduire la réparation des photoproduits et l’activation d’ATR dans les cellules en phase S. En addition, (i) l’expression ectopique de la protéine PTEN sauvage dans des lignées déficientes en PTEN (mais pas d’une protéine PTEN sans activité phosphatase) ou (ii) l’inhibition pharmacologique d’Akt a permis d’augmenter la réparation en phase S ainsi que l’activation d’ATR. En somme, cette étude démontre qu’une signalisation d’ATR dépendante de PTEN/Akt amenant à une réparation déficiente des photoproduits génomiques causés par les UV en phase S peut être déterminante dans le développement des mélanomes induits par UV.

Insights into the biology of lymphatic metastasis

Recent data suggest that the generation of new lymphatic vessels (i.e. lymphangiogenesis) may be a rate-limiting step in the dissemination of tumor cells to regional lymph nodes. However, efforts to study the cellular and molecular interactions that take place between tumor cells and lymphatic endothelial cells have been limited due to a lack of lymphatic endothelial cell lines available for study. ^ I have used a microsurgical approach to establish conditionally immortalized lymphatic endothelial cell lines from the afferent mesenteric lymphatic vessels of mice. Characterization of lymphatic endothelial cells, and tumor-associated lymphatic vessels revealed high expression levels of VCAM-1, which is known to facilitate adhesion of some tumor cells to vascular endothelial cells. Further investigation revealed that murine melanoma cells selected for high expression of α4, a counter-receptor for VCAM-1, demonstrated enhanced adhesion to lymphatic endothelial cells in vitro, and increased tumorigenicity and lymphatic metastasis in vivo, despite similar lymphatic vessel numbers. ^ Next, I examined the effects of growth factors that regulate lymphangiogenesis, and report that several growth factors are capable of activating survival and proliferation pathways of lymphatic endothelial cells. The dual protein tyrosine kinase inhibitor AEE788 (EGFR and VEGFR-2) inhibited the activation of Akt and MAPK in lymphatic endothelial cells responding to multiple growth factors. Moreover, oral treatment of mice with AEE788 decreased lymphatic vessel density and production of lymphatic metastasis by human colon cancer cells growing in the cecum of nude mice. ^ In the last set of experiments, I investigated the surgical management of lymphatic metastasis using a novel model of sentinel lymphadenectomy in live mice bearing subcutaneous B16-BL6 melanoma. The data demonstrate that this procedure when combined with wide excision of the primary melanoma, significantly enhanced survival of syngeneic C57BL/6 mice. ^ Collectively, these results indicate that the production of lymphatic metastasis depends on lymphangiogenesis, tumor cell adhesion to lymphatic endothelial cells, and proliferation of tumor cells in lymph nodes. Thus, lymphatic metastasis is a multi-step, complex, and active process that depends upon multiple interactions between tumor cells and tumor associated lymphatic endothelial cells. ^

Investigation of the role of long non-coding RNAs in oncogene induced cellular senescence

Cellular senescence is a stable arrest of cell proliferation induced by several factors such as activated oncogenes, oxidative stress and shortening of telomeres. Senescence acts as a tumour suppression mechanism to halt the progression of cancer. However, senescence may also impact negatively upon tissue regeneration, thus contributing to the effects of ageing. The eukaryotic genome is controlled by various modes of transcriptional and translational regulation. Focus has therefore centred on the role of long non- coding RNAs (lncRNAs) in regulating the genome. Accordingly, understanding how lncRNAs function to regulate the senescent genome is integral to improving our knowledge and understanding of tumour suppression and ageing. Within this study, I set out to investigate the expression of lncRNAs’ expression within models of senescence. Through a custom expression array, I have shown that expression of multiple different lncRNAs is up-regulated and down regulated in IMR90 replicative senescent fibroblasts and oncogene-induced senescent melanocytes. LncRNA expression was determined to be specific to stable senescence-associated cell arrest and predominantly within the nucleus of senescent cells. In order to examine the function of lncRNA expression in senescence, I selected lncRNA transcript ENST0000430998 (lncRNA_98) to focus my investigations upon. LncRNA_98 was robustly upregulated within multiple models of senescence and efficiently depleted using anti-sense oligonucleotide technology. Characterisation and unbiased RNA-sequencing of lncRNA_98 deficient senescent cells highlighted a list of genes that are regulated by lncRNA_98 expression in senescent cells and may regulate aspects of the senescence program. Specifically, the formation of SAHF was impeded upon depletion of lncRNA_98 expression and levels of total pRB protein expression severely decreased. Validation and recapitulation of consequences of pRB depletion was confirmed through lncRNA_98 knock-out cells generated using CRISPR technology. Surprisingly, inhibition of ATM kinase functions permitted the restoration of pRB protein levels within lncRNA_98 deficient cells. I propose that lncRNA_98 antagonizes the ability of ATM kinase to downregulate pRB expression at a post-transcriptional level, thereby potentiating senescence. Furthermore, lncRNA expression was detected within fibroblasts of old individuals and visualised within senescent melanocytes in human benign nevi, a barrier to melanoma progression. Conversely, mining of 337 TCGA primary melanoma data sets highlighted that the lncRNA_98 gene and its expression was lost from a significant proportion of melanoma samples, consistent with lncRNA_98 having a tumour suppressor functions. The data presented in this study illustrates that lncRNA_98 expression has a regulatory role over pRB expression in senescence and may regulate aspects of tumourigenesis and ageing.