Collection of cancer Patient Reported Outcome Measures (PROMS) to link with primary and secondary electronic care records to understand and improve long term cancer outcomes: A protocol paper.

INTRODUCTION: More people are living with and beyond a cancer diagnosis. There is limited understanding of the long-term effects of cancer and cancer treatment on quality of life and personal and household finances when compared to people without cancer. In a separate protocol we have proposed to link de-identified data from electronic primary care and hospital records for a large population of cancer survivors and matched controls. In this current protocol, we propose the linkage of Patient Reported Outcomes Measures data to the above data for a subset of this population. The aim of this study is to investigate the full impact of living with and beyond a cancer diagnosis compared to age and gender matched controls. A secondary aim is to test the feasibility of the collection of Patient Reported Outcomes Measures (PROMS) data and the linkage procedures of the PROMs data to electronic health records data. MATERIALS AND METHODS: This is a cross-sectional study, aiming to recruit participants treated at the Leeds Teaching Hospitals National Health Service Trust. Eligible patients will be cancer survivors at around 5 years post-diagnosis (breast, colorectal and ovarian cancer) and non-cancer patient matched controls attending dermatology out-patient clinics. They will be identified by running a query on the Leeds Teaching Hospitals Trust patient records system. Approximately 6000 patients (2000 cases and 4000 controls) will be invited to participate via post. Participants will be invited to complete PROMs assessing factors such as quality of life and finances, which can be completed on paper or online (surveys includes established instruments, and bespoke instruments (demographics, financial costs). This PROMs data will then be linked to routinely collected de-identified data from patient's electronic primary care and hospital records. DISCUSSION: This innovative work aims to create a truly 'comprehensive patient record' to provide a broad picture of what happens to cancer patients across their cancer pathway, and the long-term impact of cancer treatment. Comparisons can be made between the cases and controls, to identify the aspects of life that has had the greatest impact following a cancer diagnosis. The feasibility of linking PROMs data to electronic health records can also be assessed. This work can inform future support offered to people living with and beyond a cancer diagnosis, clinical practice, and future research methodologies.

Pathological review of primary cutaneous malignant melanoma by a specialist skin cancer multidisciplinary team improves patient care in the UK.

AIMS: The National Institute for Health and Care Excellence advocated the development of specialist skin cancer multidisciplinary teams (SSMDTs) for the management of higher risk invasive skin cancers in the UK. The interobserver variability in the histopathological assessment of primary cutaneous malignant melanoma (PCMM) is well recognised. METHODS: We evaluated the discordance rates in the assessment of the histopathological criteria of PCMM based on the eighth American Joint Committee on Cancer (AJCC) melanoma staging system and subsequent change in prognosis and management following pathology review by an SSMDT. RESULTS: 353 cases of PCMM were referred to our SSMDT between April 2015 and May 2016. Cases in which there was a discrepancy in one or more histological parameters following expert review were collected retrospectively. Of 341 eligible cases, there were 94 (27.6%) in which there was an alteration in any parameter. There was interobserver agreement in final diagnosis in 96.8%, Breslow thickness in 86.8%, ulceration in 98.2%, microsatellites in 98.5%, tumour mitotic rate in 88.9%, histological subtype in 92.4%, growth phase in 98.5%, angiolymphatic invasion in 97.7%, perineural invasion in 98.8%, regression in 95.3% and tumour-infiltrating lymphocytes in 95.0%. A corresponding change in AJCC stage occurred in 23 cases (6.7%), with a resulting change in clinical management in 10 cases (2.9%). CONCLUSIONS: Disagreements in the pathological assessment of PCMM can have significant clinical implications for a small number of patients. Our findings highlight the value of the SSMDT for high-quality care of patients with melanoma in the UK.

Cutaneous lupus associated with pembrolizumab therapy for advanced melanoma: a report of three cases.

Checkpoint blockade immunotherapy has revolutionized the treatment of advanced melanoma, with impressive survival benefits attained through upregulation of the anticancer immune response. Blockade of regulatory checkpoint molecules can, however, also result in aberrant immune activation leading to undesirable inflammation and autoimmunity. Although many genetic determinants have been described in patients with primary autoimmune diseases, it is uncertain whether patients developing autoimmune skin disease as an adverse effect of anti-PD-1 therapy share the same genetic risks. Furthermore, it is also unclear whether treatment with these agents can result in the unveiling of underlying 'silent' autoimmunity resulting in chronic inflammatory disease. We report three cases of cutaneous lupus associated with pembrolizumab therapy for advanced melanoma. One patient had a previous diagnosis of histologically proven discoid lupus erythematosus, well-controlled without treatment for over 2 years, which flared on first exposure to pembrolizumab. The remaining two patients had no previous history of autoimmune disease; both developed cutaneous eruptions, histologically and immunohistologically, in keeping with subacute cutaneous lupus following treatment with pembrolizumab. Our report bolsters what is currently an exceedingly small body of evidence documenting the development of cutaneous lupus in the setting of pembrolizumab therapy. Our third case specifically documents an otherwise unreported severe reflare of previously diagnosed, quiescent discoid lupus erythematosus in the setting of pembrolizumab, vividly highlighting the potential for autoimmune and specifically, lupus reactivation in the setting of anti-PD-1 therapy.

The clinicopathological and gene expression patterns associated with ulceration of primary melanoma.

Ulceration of primary melanomas is associated with poor prognosis yet is reported to predict benefit from adjuvant interferon. To better understand the biological processes involved, clinicopathological factors associated with ulceration were determined in 1804 patients. From this cohort, 348 primary tumor blocks were sampled to generate gene expression data using a 502-gene cancer panel and 195 blocks were used for immunohistochemistry to detect macrophage infiltration and vessel density. Gene expression results were validated using a whole genome array in two independent sample sets. Ulceration of primary melanomas was associated with more proliferative tumors, tumor vessel invasion, and increased microvessel density. Infiltration of tumors with greater number of macrophages and gene expression pathways associated with wound healing and up-regulation of pro-inflammatory cytokines suggests that ulceration is associated with tumor-related inflammation. The relative benefit from interferon reported in patients with ulcerated tumors may reflect modification of signaling pathways involved in inflammation.

Contact allergy to sodium sulfite and its relationship to sodium metabisulfite.

BACKGROUND: Sulfites are in widespread use as preservatives/antioxidants. There is increasing recognition of allergic contact dermatitis caused by sodium metabisulfite; however, contact allergy to sodium sulfite is less well recognized. OBJECTIVES: We sought to establish the prevalence of positive patch test reactions to sodium sulfite in our patient population and investigate its relationship with sodium metabisulfite. METHODS: Over a 4-month period, 183 patients referred for patch testing were tested with sodium sulfite 1% pet. in addition to sodium metabisulfite 1% pet., which already forms part of our baseline series. RESULTS: Positive allergic reactions occurred to sodium metabisulfite in 5.5% of the tested patients and to sodium sulfite in 3.8% of the tested patients. Sixty per cent of patients with a positive reaction to sodium metabisulfite were positive to sodium sulfite. Only 1 patient (0.6%) with a negative reaction to sodium metabisulfite showed a positive reaction to sodium sulfite. CONCLUSIONS: This study shows that the majority of patients with positive reactions to sodium metabisulfite are also positive to sodium sulphite. Routinely patch testing with sodium sulfite is probably unnecessary, as most patients with positive reactions will also react to sodium metabisulfite. Clinicians should consider advising patients to avoid sodium sulfite and other sulfites when a positive allergic reaction to sodium metabisulfite occurs.

Objective assessment of blood and lymphatic vessel invasion and association with macrophage infiltration in cutaneous melanoma.

The aims of this study were to investigate the role of vascular invasion (blood and lymphatic), vessel density and the presence of tumour-associated macrophages as prognostic markers in 202 cutaneous melanoma patients. Sections of primary melanoma were stained with lymphatic-specific antibody D2-40 to assess lymphatic vessel invasion and density in intratumoural and peritumoural areas; an antibody against endothelial marker CD34 was used to determine blood vessel invasion and density, and an antibody against CD68 was used to determine macrophage counts. Immunohistochemically determined vascular invasion (combined blood and lymphatic) was compared with that determined using haematoxylin and eosin (H&E) staining. The use of immunohistochemistry increased detection of vascular invasion from 8-30% of patients, and histological exam of H&E-stained tissue was associated with a false positive rate of 64%. Lymphatic vessel invasion occurred at a much higher frequency than blood vessel invasion (27 and 4% of patients, respectively). Although immunohistochemically detected vessel invasion was significantly associated with histological markers of adverse prognosis, such as increased Breslow thickness, ulceration and mitotic rate (all P<0.001), no associations with relapse-free or overall survival were observed. High macrophage counts were significantly associated with markers of aggressive disease, such as Breslow thickness, ulceration and mitotic rate (P<0.001, P<0.001, P=0.005, respectively), and lymphatic vessel invasion and high microvessel density (P=0.002 and P=0.003, respectively). These results suggest that vascular invasion is more accurately detected using immunohistochemistry and occurs predominantly via lymphatic vessels. The association of vessel characteristics with histological characteristics of the primary melanoma provides evidence for their biological importance in melanoma, but that they were not associated with clinical outcome attests to the value of existing histological prognostic biomarkers. We note that a high macrophage count may be associated with neovascularisation and primary tumour growth, and may also promote invasion through lymphatic vessels.

Prognosis in patients with sentinel node-positive melanoma is accurately defined by the combined Rotterdam tumor load and Dewar topography criteria.

PURPOSE: Prognosis in patients with sentinel node (SN)-positive melanoma correlates with several characteristics of the metastases in the SN such as size and site. These factors reflect biologic behavior and may separate out patients who may or may not need additional locoregional and/or systemic therapy. PATIENTS AND METHODS: Between 1993 and 2008, 1,080 patients (509 women and 571 men) were diagnosed with tumor burden in the SN in nine European Organisation for Research and Treatment of Cancer (EORTC) melanoma group centers. In total, 1,009 patients (93%) underwent completion lymph node dissection (CLND). Median Breslow thickness was 3.00 mm. The median follow-up time was 37 months. Tumor load and tumor site were reclassified in all nodes by the Rotterdam criteria for size and in 88% by the Dewar criteria for topography. RESULTS: Patients with submicrometastases (< 0.1 mm in diameter) were shown to have an estimated 5-year overall survival rate of 91% and a low nonsentinel node (NSN) positivity rate of 9%. This is comparable to the rate in SN-negative patients. The strongest predictive parameter for NSN positivity and prognostic parameter for survival was the Rotterdam-Dewar Combined (RDC) criteria. Patients with submicrometastases that were present in the subcapsular area only, had an NSN positivity rate of 2% and an estimated 5- and 10-year melanoma-specific survival (MSS) of 95%. CONCLUSION: Patients with metastases < 0.1 mm, especially when present in the subcapsular area only, may be overtreated by a routine CLND and have an MSS that is indistinguishable from that of SN-negative patients. Thus the RDC criteria provide a rational basis for decision making in the absence of conclusions provided by randomized controlled trials.

Patterns of expression of DNA repair genes and relapse from melanoma.

PURPOSE: To use gene expression profiling of formalin-fixed primary melanoma samples to detect expression patterns that are predictive of relapse and response to chemotherapy. EXPERIMENTAL DESIGN: Gene expression profiles were identified in samples from two studies (472 tumors). Gene expression data for 502 cancer-related genes from these studies were combined for analysis. RESULTS: Increased expression of DNA repair genes most strongly predicted relapse and was associated with thicker tumors. Increased expression of RAD51 was the most predictive of relapse-free survival in unadjusted analysis (hazard ratio, 2.98; P = 8.80 × 10(-6)). RAD52 (hazard ratio, 4.73; P = 0.0004) and TOP2A (hazard ratio, 3.06; P = 0.009) were independent predictors of relapse-free survival in multivariable analysis. These associations persisted when the analysis was further adjusted for demographic and histologic features of prognostic importance (RAD52 P = 0.01; TOP2A P = 0.02). Using principal component analysis, expression of DNA repair genes was summarized into one variable. Genes whose expression correlated with this variable were predominantly associated with the cell cycle and DNA repair. In 42 patients treated with chemotherapy, DNA repair gene expression was greater in tumors from patients who progressed on treatment. Further data supportive of a role for increased expression of DNA repair genes as predictive biomarkers are reported, which were generated using multiplex PCR. CONCLUSIONS: Overexpression of DNA repair genes (predominantly those involved in double-strand break repair) was associated with relapse. These data support the hypothesis that melanoma progression requires maintenance of genetic stability and give insight into mechanisms of melanoma drug resistance and potential therapies.

Gene expression profiling of paraffin-embedded primary melanoma using the DASL assay identifies increased osteopontin expression as predictive of reduced relapse-free survival.

PURPOSE: Gene expression studies in melanoma have been few because tumors are small and cryopreservation is rarely possible. The purpose of this study was to evaluate the Illumina DASL Array Human Cancer Panel for gene expression studies in formalin-fixed melanoma primary tumors and to identify prognostic biomarkers. EXPERIMENTAL DESIGN: Primary tumors from two studies were sampled using a tissue microarray needle. Study 1: 254 tumors from a melanoma cohort recruited from 2000 to 2006. Study 2: 218 tumors from a case-control study of patients undergoing sentinel node biopsy. RESULTS: RNA was obtained from 76% of blocks; 1.4% of samples failed analysis (transcripts from <250 of the 502 genes on the DASL chip detected). Increasing age of the block and increased melanin in the tumor were associated with reduced number of genes detected. The gene whose expression was most differentially expressed in association with relapse-free survival in study 1 was osteopontin (SPP1; P = 2.11 x 10(-6)) and supportive evidence for this was obtained in study 2 used as a validation set (P = 0.006; unadjusted data). Osteopontin level in study 1 remained a significant predictor of relapse-free survival when data were adjusted for age, sex, tumor site, and histologic predictors of relapse. Genes whose expression correlated most strongly with osteopontin were PBX1, BIRC5 (survivin), and HLF. CONCLUSION: Expression data were obtained from 74% of primary melanomas and provided confirmatory evidence that osteopontin expression is a prognostic biomarker. These results suggest that predictive biomarker studies may be possible using stored blocks from mature clinical trials.