Immunosuppression is an independent prognostic factor associated with aggressive tumor behavior in cutaneous melanoma.

BACKGROUND: A number of factors other than those identified by the American Joint Committee on Cancer (AJCC) may have prognostic significance in the evaluation of melanoma. OBJECTIVE: We sought to evaluate commonly recorded clinical features potentially associated with aggressive melanoma. METHODS: We conducted a retrospective case-control study. We included patients given a diagnosis of cutaneous melanoma with at least 5 years of follow-up or documented metastases. Patients were divided into nonaggressive and aggressive groups. Univariate and multivariate statistical analyses were performed to evaluate the association of multiple clinical and histologic parameters and metastases. RESULTS: We included 141 patients. Significant prognostic factors in univariate analysis associated with nonaggressive disease included history of dysplastic nevus syndrome and ABCDE criteria. Significant factors in univariate analysis associated with aggressive disease included age and immunosuppression. Only age and immunosuppression remained significant in multivariate analysis when controlled across statistically significant histologic variables from AJCC. LIMITATIONS: The study is retrospective and has a small sample size. CONCLUSION: Older patients and those with a history of immunosuppression may be at higher risk for aggressive disease and should be closely monitored after an initial diagnosis of melanoma.

Stress and melanoma: increasing the evidence towards a causal basis.

Melanoma is a multifactorial disease with a strong genetic component and known risk factors such as excessive ultraviolet exposure, intermittent sunburns and fair skin type. The prognosis is poor if diagnosis is delayed, in spite of recent treatment advances. Evidence is mounting that the incidence of melanoma is higher in the immunosuppressed and individuals with highly stressful occupations. We present a case series of individuals diagnosed with multiple cutaneous melanomas over a few months to 1 year. All had encountered psychological stressors in their lives, and the melanomas were diagnosed briefly after encountering these stressors. No known causes of immunosuppression were detected to explain the sporadic occurrence of melanomas in these individuals. There is evidence in the current literature that stress can lead to immune disregulation, predisposing an individual to various disease states including melanoma. Stress hormones such as norepinephrine have been shown to cause upregulation of cytokines such as Interleukin 6 and 8, which are proangiogenic and support tumour progression. Coupled with genetic and environmental factors, stress appears to play a role in melanoma formation and progression. Large prospective studies are required to study the link between stress and melanoma and gain further insight into the etiology of melanoma.

Melanocyte-specific immune response in a patient with multiple regressing nevi and a history of melanoma.

BACKGROUND/AIM: Regressing nevi are considered an example of an efficient early antitumoral response preventing the development of neoplasia. The underlying mechanism has not been elucidated, although an immune-based destruction of melanocytes is supposed. The aim of this study was to provide evidence of an effective immunosurveillance of pigment lesions in a patient at high risk of melanoma. CASE REPORT: A patient with the dysplastic nevus syndrome and a history of melanoma was included in this study. Since 2003, a marked regression of almost all nevi was observed. Immunohistochemistry was performed and the antigen specificity of T-cells was analyzed on T-cells isolated from a regressing nevus by flow cytometry using HLA-A2-peptide tetramers containing Mart-1(26-35), gp100(280-288), gp100(209-217) and tyrosinase(369-377). Immunohistochemistry of the regressing nevi showed a strong infiltrate of CD4 + and CD8 + T-cells. Flow cytometric analyses demonstrated the presence of a CD8 + T-cell response against gp100(280-288) and Mart-1(26-35) both in peripheral blood and in a regressing nevus. CONCLUSION: These findings indicate that an immune reaction against melanocyte differentiation antigens can target specifically nevi without signs of vitiligo and suggests that boosting the anti-melanocyte immune response in patients at high risk for melanoma may prevent tumor development at an early stage.

Tumor antigen expression in compound dysplastic nevi and superficial spreading melanoma defined by a panel of nevomelanoma monoclonal antibodies.

Studies of antigen expression in dysplastic nevi have been limited to some extent by difficulties in obtaining frozen nevi with which to react monoclonal antibodies. Accordingly, we obtained a panel of antibodies that binds to antigens preserved in paraffin-embedded tissue. This panel of monoclonal antibodies, raised against nevomelanoma antigens, was used on 26 dysplastic compound nevi and additionally on 14 invasive superficial spreading melanomas. Among the dysplastic nevi, two basic dermal staining patterns emerged. One pattern designated "Type 1" shows a histologically well-developed dermal component that tends to be antigenically well stratified, with the cells in the upper dermis expressing the most antigen, and gradual loss of antigenicity in the lower dermis as maturation of nevic cells occurs. A second ("Type 2") pattern was seen in which nevic cells tended to remain in the upper dermis, with less downgrowth, and to express antigen in a diffuse or patchy, but nonstratified distribution. Some differential distribution of the antigens was noted, with antibodies 404-101, HMB-45, and ME 109 binding to the activated junctional zone, but showing lower binding affinity within the dermis. ME 491, NKI-C3, and 506 bind to antigens abundant in the junctional zone as well as the dermis. The antibody ME 67-6 binds to both junction and dermis, but is more useful for delineation of antigenic stratification and presence of abnormal "clones."

[Multiple cutaneous neoplasms in cyclosporine therapy after kidney transplantation]. / Multiple kutane Neoplasien bei Cyclosporin-Therapie nach Nierentransplantation.

We report on a 56-year-old renal allograft recipient receiving cyclosporin A immunosuppression. During this therapy he subsequently developed the following cutaneous neoplasms: squamous cell carcinomas, basal cell carcinomas, Bowen's disease, actinic keratosis, sebaceous hyperplasia, a dysplastic naevus and, finally a nodular malignant melanoma. Adverse effects of the cyclosporin A therapy are discussed, with special reference to dermatologic effects and the implications for patient and doctor.

Normal reactivation of plasmid DNA inactivated by UV irradiation by lymphocytes from individuals with hereditary dysplastic naevus syndrome.

Hereditary dysplastic naevus syndrome (DNS) is a familial disorder characterized by dysplastic naevi and an approximately 85-fold increased risk of developing malignant cutaneous melanoma. Cell lines from individuals with DNS have shown hypermutability following exposure to UV irradiation. The cause of this hypermutability is unknown, and no DNA repair defect has been identified. We have studied the capacity of lymphocytes from individuals with DNS to reactivate the chloramphenicol acetyltransferase gene in transfected plasmids that had been inactivated by UV irradiation. We found no difference in plasmid reactivation between lymphocytes from individuals with DNS and those obtained from healthy control persons matched for sex, age and smoking habits. This finding indicates that DNS is not associated with a significant quantitative defect in nucleotide excision repair of DNA.

Ultrastructural localization of HMB-45 binding sites.

Three malignant melanomas, two melanoma metastases, two junctional dysplastic nevi, and normal skin were embedded in Lowicryl. Ultrathin sections were incubated with HMB-45 and a gold-labeled anti-mouse antibody. Gold particles indicating the presence of HMB-45 were found in melanosomes Stage 1 and 2 and in the non-melanized portion of melanosomes Stage 3. Melanosomes Stage 4 and melanosome complexes in keratinocytes, as well as in melanophages, were consistently negative. No specific labelling with HMB-45 was seen in eccrine glands of normal skin.

Detection of cytokine-induced protein gamma-immune protein-10 (gamma-IP10) in atypical melanocytic proliferations.

gamma-Immune protein-10 (gamma-IP10) is a cytokine whose expression has been shown to be induced by interferon-gamma. It is a member of a group of closely related cytokines (e.g., interleukin 8 and platelet factor 4) with chemotactic properties. gamma-IP10 has been detected in keratinocytes, lymphocytes, monocytes, and endothelial cells in immunologically mediated processes, such as positive tuberculin skin tests, and in growth-activated keratinocytes, such as in psoriasis. Keratinocytes in normal epidermis do not produce gamma-IP10. We tested the hypothesis that keratinocytes adjacent to dysplastic nevi and melanomas would produce gamma-IP10, perhaps as part of an immune response to a tumor, and that this response would not be seen in ordinary melanocytic nevi. We used an affinity-purified, polyclonal rabbit anti-gamma-IP10 antibody to examine 10 nevi with moderate to severe histologic dysplasia, one superficial spreading melanoma, and 10 compound melanocytic nevi with no features of dysplasia. As predicted, keratinocytes surrounding all of the cytologically atypical melanocytic lesions displayed strong staining with gamma-IP10. There was no staining of keratinocytes adjacent to ordinary melanocytic nevi. The observed keratinocyte staining with gamma-IP10 may be related to a host immune response to antigenically abnormal cells.

Evaluation of human monoclonal antibody (2-139-1) in cutaneous melanocytic neoplasms in fixed tissue sections.

Despite the growing list of xenogeneic monoclonal antibodies (MAb) that recognize malignant melanoma-associated antigens (MAA) in formalin-fixed, paraffin-embedded tissue, none has been able to detect epitopes found in malignant melanomas and not in melanocytic nevi. A human MAb, 2-139-1, that showed promise in this regard was evaluated against 85 melanocytic neoplasms, including malignant melanoma and histological simulators, particularly Spitz's nevus. MAb 2-139-1 stained 18 (53%) of 34 melanomas, eight (57%) of 14 dysplastic nevi, six (38%) of 16 Spitz's nevi, and three (14%) of 21 banal nevi, which included three small congenital nevi. We observed a significant increasing trend in reactivity (% positive cells x intensity) associated with the potential for malignancy (p for linear trend = 0.002). We conclude that human MAb 2-139-1 is applicable to the study of melanocytic neoplasms in routinely processed tissue. Although the ability of this MAb to separate benign from malignant cells is not absolute, our results suggest that the expression of the 2-139-1 epitope may be an early event in melanocytic tumor progression.

Dysplastic melanocytic nevus. Immunohistochemical heterogeneity by melanosomal markers and S-100.

This study evaluates the expression of human melanosome specific antigen-1 and -2 (HMSA-1, -2) by dysplastic melanocytic nevus (DMN) and its significance by (a) immunostaining pattern, (b) other immunohistochemical markers (e.g., S-100), and (c) mesenchymal responses (e.g., lymphocytic infiltration). From 31 patients with DMN syndrome, 55 clinically characteristic and histologically (H&E) proven dysplastic nevi were assessed for HMSA expression. Approximately 70% of DMN lesions expressed the HMSA antigens; similar gross staining patterns were seen with both monoclonal antibodies (MoAbs). The expression of HMSA-2 was invariably associated with that of HMSA-1, but the converse did not apply. Two general staining patterns with MoAbs HMSA were appreciated: (a) uniform staining of the epidermal melanocytes in the DMN lesion (type I) and (b) nonuniform staining, with the epidermal melanocytes at the periphery of the DMN lesion reacting most intensely (type II). Although anti-S-100 antibody demonstrated a similar sensitivity (67%), it lacked specificity and did not distinguish different types of DMN, as compared with MoAbs HMSA. There was no correlation between these observed staining patterns and common histological features of DMN. There was a poor correlation between lymphocytic infiltrate (as judged by immunostaining for pan-T, Ti/h, Tc/s, and pan-B markers) and heterogeneity of immunostaining. We conclude that HMSA-1 and -2 are able to delineate two types of DMN and possibly bind different epitopes of the same antigen. Their potential usefulness in predicting malignant transformation of DMN has yet to be established.

Infiltrating lymphocytes in benign and malignant naevomelanocytic lesions.

Cutaneous melanocytic tumors include benign (naevi) and malignant (melanoma), potentially metastatic lesions. In this report, we show that infiltrating lymphocytes from benign tumors may be expanded in vitro as TIL from melanoma in the presence of autologous tumoral cells and recombinant IL2. Moreover it seems that TIL from primary cutaneous benign or malignant lesions more frequently express the T-cell receptor gamma delta than TIL from metastatic melanoma. Otherwise, a gamma delta + line and a gamma delta + clone extracted from a primary cutaneous melanoma exhibit a specific non MHC-restricted cytotoxic activity against autologous tumor cells. This is the first report of a TCR gamma delta + T lymphocyte cytotoxic activity against a human solid cutaneous tumor.

Positive reactivity of dysplastic melanocytes with a monoclonal antibody against melanoma melanosomes, MoAb HMSA-2.

A mouse-mouse monoclonal antibody, MoAb HMSA-2, was raised against the melanosomal protein of human malignant melanoma. To characterize the nature of dysplastic melanocytic nevi (DMN), we examined the reactivity of DMN with MoAb HMSA-2 in comparison to that of superficial spreading melanoma (SSM) and common melanocytic nevi (CMN) including junctional melanocytic nevi (JMN) on routine paraffin sections. MoAb HMSA-2 showed several unique immunohistochemical findings: a) MoAb HMSA-2 reacted with melanocytes of DMN in both the epidermis and the dermis, including the pigment granules in the keratinocytes; b) the pigment granules in the keratinocytes of DMN were found to be immature melanosomes transferred from dysplastic melanocytes to keratinocytes; c) the reactivity of epidermal melanocytes in DMN and SSM was stronger than that of junctional component in CMN, though SSM revealed a much stronger reaction than DMN; and d) keratinocytes, especially in a "shoulder" lesion of DMN which was associated with dermal lymphocytic infiltrates, often showed a strong reactivity with MoAb HMSA-2. Thus our study suggested a unique immunohistochemical feature of DMN with deranged melanogenesis as indicated by the reactivity with MoAb HMSA-2.

Monoclonal antibody (AFH1) immunoreactive on morphologically abnormal basal melanocytes within dysplastic nevi, nevocellular nevus nests, and melanoma.

The mouse monoclonal antibody AFH1 was produced using formalin-fixed, sham paraffin-embedded human melanoma cell culture line A375 as immunogen. Reactivity of this antibody was assessed by immunohistochemical techniques against formalin- or acid alcohol-fixed paraffin-embedded tissue as well as formalin- or acid alcohol-fixed unembedded lesions. Ninety-seven nevomelanocytic lesions, neurofibromas, epithelial lesions, and a plasmacellular infiltrate were evaluated. AFH1 was immunoreactive on 54 of 55 nevocytic lesions (98.2%), 15 of 16 primary melanomas (93.7%), a lentigo maligna, and nests in 21 of 21 dysplastic nevi (100%). Of 100 consecutive basal melanocytes of intraepidermal melanoma cells counted in each lesion, mean AFH1 immunoreactivity for nonnested basal melanocytes in nevocellular nevi was 3.8%; for dysplastic nevi, 13.8%; and for intraepidermal melanoma cells, 78.0%. When nonnested basal melanocytes were subdivided into cytologically normal and abnormal cell groups, AFH1 immunoreactivity was 9.4% and 72.6%, respectively. AFH1 recognition of the lentiginous portion of dysplastic nevi corresponds statistically to the appearance of abnormal melanocyte cytology, nest formation, or both. Using 50% immunoreactive nonnested melanocytes as the criterion, AFH1 seems to distinguish primary melanoma from dysplastic nevi with a sensitivity of 93.8% and a specificity of 95.8%.

Melanocytic atypia in dysplastic nevi. Immunohistochemical and cytophotometrical analysis.

In a double-blind study a correlation was found between the histologically assessed degree of nevomelanocytic atypia in 58 dysplastic nevi (DN) and the presence of two markers associated with malignant transformation. The markers included a marked expression of histocompatibility locus Class I antigens on nevomelanocytes (P less than 0.01) and abnormalities in the nuclear DNA content as measured by DNA cytophotometry (P = 0.01). Both markers were present in most of the markedly atypical DN, in about half of the moderately atypical DN, and in less than 30% of the mildly atypical DN. These findings suggest that a DN with marked or moderate melanocytic atypia indicates a premalignant condition and identifies a patient at risk for melanoma.

Thymine dimer repair in fibroblasts of patients with dysplastic naevus syndrome (DNS).

Dysplastic naevus syndrome (DNS) is frequently observed in association with familial melanoma and xeroderma pigmentosum (XP), but the role of UV-light in the development of DNS has not been elucidated. Previous work has shown that UV-induced unscheduled DNA synthesis is associated with the early loss of antigenicity observed in immunoassays using a monoclonal antibody specific for thymine-thymine dimers. We now show that the rate of loss of antigenicity, which reflects the relative amount of bound antibody, observed during the first 60 min following 10 Jm-2 UVC irradiation is significantly reduced (p = 0.02) in cultures of fibroblasts from 7 out of 8 DNS patients compared with the results from cells of a group of 30 healthy volunteers. This observation suggests an early event in excision repair is altered in the majority of DNS patients.

Immunoglobulin allotypes and familial cutaneous malignant melanoma/dysplastic nevi. A family study.

Gm and Km allotypes were examined in 355 members of 14 large pedigrees segregating for autosomal dominant cutaneous malignant melanoma/dysplastic nevi. No evidence for linkage was found between the disease locus and the immunoglobulin loci. Furthermore, there was no association of G1m(2) or Gm(-1) with cutaneous malignant melanoma in the 14 independent family probands.