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Romanian Journal of Morphology and Embryology logoLink to Romanian Journal of Morphology and Embryology
. 2023 Mar 31;64(1):41–48. doi: 10.47162/RJME.64.1.05

Assessment of tumoral and peritumoral inflammatory reaction in cutaneous malignant melanomas

Radu Florin Fruntelată 1, Assil Bakri 1, George Alin Stoica 2, Laurenţiu Mogoantă 3,4, Nina Ionovici 5, George Popescu 6, Denisa Floriana Vasilica Pîrşcoveanu 7, Andrada Raicea 8, Marius Eugen Ciurea 9
PMCID: PMC10257785  PMID: 37128790

Abstract

Skin cancer is one of the most common types of cancer, with an increasing worldwide incidence in recent decades. The main risk factor for increasing the skin cancer incidence is ultraviolet (UV) radiation. Of the two major forms of skin cancer (melanomas and non-melanotic cancers), the cutaneous melanoma (CM) is the most aggressive form, causing about 80% of the deaths resulted from this type of tumor. Malignant melanoma develops through malignant transformation of melanocytes in the skin because of prolonged exposure to solar or artificial UV. The malignant transformation of the melanocytes in the skin is accompanied by the presence of a local inflammatory reaction that, in the initial stages of carcinogenesis, would oppose to tumor development. Chronic exposure to UV or other etiopathogenic factors induces chronic inflammation, which, by producing inflammatory molecules (cytokines, chemokines, prostaglandins), constitutes a tumoral microenvironment that favors carcinogenesis, tumor invasion, metastasis, and the presence of neoplastic “mutant cells” that avoid the protective action of the immune system. Using immunohistochemistry techniques, we assessed the intra- and peritumoral inflammatory infiltrate cells in CM. The chronic inflammatory infiltrate presented more intense in the peritumoral stroma compared to the intratumoral one, heterogenous, more intensely composed of lymphocytes, plasma cells, macrophages, and mast cells (MCs), the most numerous cells in the inflammatory infiltrate being T-lymphocytes, plasma cells and macrophages; B-lymphocytes and MCs were in a small number, especially intratumorally. Inflammatory cells had a direct contact with tumor cells, blood vessels, connective matrix, suggesting that the inflammatory microenvironment plays an important role in carcinogenesis, tumor invasion, local angiogenesis, and tumor metastasis.

Keywords: melanoma , skin , inflammatory reaction , immunohistochemistry

Introduction

Cutaneous melanoma (CM) is the most aggressive form of skin cancer, with rapid progression and early metastasis, endangering the patient’s life. It causes about 80% of skin cancer deaths [1, 2]. CM became a major public health problem due to the rapid increase in incidence, high mortality, and treatment costs over the past 50 years [3, 4]. The CM incidence is increasing worldwide in both adult and pediatric populations [5]. In the USA, between 2017–2020, there were about 1 361 282 people diagnosed with CM [6]. In 2020, 324 635 new cases of CM were diagnosed at global level and 57 043 new deaths were reported due to this type of tumor [7]. Melanoma originates from a malignant transformation of melanocytes, cells originating in the neural crest, normally present in the structure of the skin. They synthesize melanin, a photoprotective pigment, which protects the deoxyribonucleic acid (DNA) of the epidermis proliferative cells [8]. The development of melanoma depends on multiple exogenous or endogenous factors, but the first one is exposure to ultraviolet (UV) light, either solar or artificial, produced by various UV lamps used in tanning cosmetics [9]. According to some studies, UV (both solar and artificial) radiation is responsible for 80% of skin cancers around the world, and solar radiation is responsible for at least 65% of CMs [10]. Other etiopathogenic factors involved in the onset and progression of CM are represented by the presence of premalignant skin lesions (pigmented nevi, congenital nevi, sunburn), immunosuppressive treatments, genetic susceptibility (close relative with the same pathology), genetic alteration (oncogenic and suppressor genes of tumors), geographic latitude, skin color (light-colored individuals are more affected than dark-colored individuals), age (the risk of developing the disease increases with age) [11, 12, 13, 14]. Some studies found significant correlations between exposure to certain chemicals and the melanoma incidence [15]. Tumor lesions are frequently accompanied by intra- and peritumoral inflammatory processes. Cancer-intrinsic metabolic changes, cellular stress, and cell death are important sources of cancer-associated inflammation [16]. Most often, chronic inflammation is a prolonged aberrant immune response that results in epigenetic changes that lead to cancer onset and progression, as well as the accumulation of growth factors that support cancer development [16, 17]. The continuous production of various inflammatory molecules (cytokines, chemokines, prostaglandins, etc.) and the recruitment of inflammatory cells into the tumor microenvironment promote tumor progression and metastasis [18, 19].

Aim

In this paper, we aimed to assess, through histopathology and immunohistochemistry studies, the presence, composition, and intensity of tumoral and peritumoral inflammatory infiltrate in cutaneous malignant melanomas.

Materials and Methods

The study was performed on a number of 43 pieces of surgical excision, coming from as many patients, hospitalized with suspicion of CMs and operated within the Clinic of Plastic Surgery and Reconstructive Microsurgery, Emergency County Hospital, Craiova, Romania, between 2017–2020. The biological material was placed immediately after harvesting in 10% neutral buffered formalin solution and sent to the Laboratory of Pathological Anatomy for the microscopic and immunohistochemical (IHC) study, to confirm and complete the clinical diagnosis. The time to fix the surgical excision material was at least 48 hours. After the formalin fixation, the tumor fragments were included in histological paraffin using the classical protocol. Then, 4-μm-thick serial sections were performed on the automatic, Microm HM 355S rotary microtome (Thermo Scientific) equipped with a Peltier-type paraffin cooler and a water bath section-transfer system, which allowed obtaining good quality sections without artifacts. For the histopathological (HP) diagnosis and the overall image of the tumor, the histological sections were stained with Hematoxylin–Eosin (HE), and for the IHC study, several antibodies were used, both for the specific identification of the tumor cells and for the quantification of the cells from the tumoral and peritumoral inflammatory infiltrate: anti-Melan-A (monoclonal mouse anti-human Melan-A, clone A103, 1/50 dilution, Dako); anti-human black melanoma 45 (HMB45) (monoclonal mouse anti-human melanosome, clone HMB45, 1/50 dilution, Dako); anti-S100 (polyclonal rabbit S100, 1/1000 dilution, Dako); anti-cluster of differentiation (CD)3 (monoclonal mouse anti-human CD3, clone F7.2.38, 1/25 dilution, Dako); anti-CD20 (monoclonal mouse anti-human CD20cy, clone L26, 1/50 dilution, Dako); anti-CD79a (monoclonal mouse anti-human CD79a, clone JCB117, 1/50 dilution, Dako); anti-CD68 (monoclonal anti-human CD68, clone KP1, 1/100 dilution, Dako); anti-tryptase [monoclonal mouse anti-human mast cell (MC) tryptase, clone AA1, 1/500 dilution, Dako].

Results

In the patients of our group, the suspicion of CM was based on the clinical and dermoscopic examination. Clinically, all patients presented asymmetric, irregularly contoured, black-brown pigmented spots of variable size, mainly located in areas of the skin exposed to the sun (hands, legs, face, neck, trunk). The dermoscopic examinations highlighted a great non-uniformity of the color of the pigment stains, going from gray to dark brown or even black, irregular surface, with multiple lifts in the form of nodules or pearls, irregular contour with pseudopod extensions, more intense atypical vascularization, with a network of tortuous vessels. The particular aspects of the pigment spots were more numerous in the larger lesions, some of them presenting superficial ulcerations. The HP examination performed by HE staining revealed the presence of multiple cellular and nuclear atypia in the melanic tumors. The tumors presented an irregular, asymmetric architecture, the melanocytes being organized in nests or cords, of different shapes and sizes. The cellular component consisted of pleomorphic cells, of very varied sizes and tinctoriality, from small and round cells, to large, polyhedral cells with an epithelioid or fusiform appearance, with abundant, vacuolar, or slightly acidophilic cytoplasm, with or without melanin granules. The presence of melanin in the cytoplasm was an essential element in the positive diagnosis of the condition. The amount of melanotic pigment in the tumor cells was highly variable from one cell to another (Figure 1). Many cells in the structure of nodular melanomas appeared to be lacking in melanotic pigment; they were considered as immature melanotic cells (Figure 2). Other cells showed large amounts of melanosomes in the cytoplasm (Figure 3). Many cells in the structure of nodular melanomas appeared to be devoid of melanic pigment. These were considered immature melanocytes. The analysis of tumor sections with high-powered microscopic objectives showed that many tumor cells were in various phases of mitosis, indicating their ability to multiply rapidly. Melanocyte nuclei presented in most cases as large, hypochromic, vesicular, with large nucleoli and often eosinophilic. IHC examinations showed that the tumor cells showed strong positive reaction to anti-Melan-A, anti-HBM45 and anti-S100 protein antibodies, which confirmed the diagnosis of malignant melanoma (Figures 4, 5, 6). The conjunctival component of melanomas was represented by conjunctival–vascular septa, more or less developed, representing the support structure of melanocytes. The structure of these septa was made of collagen fibers, fibroblasts, blood vessels, lymphatic vessels, amorphous intercellular matrix. In the tumor stroma, there was highlighted the presence of a chronic inflammatory infiltrate, irregularly developed, more intense peritumorally, made up mainly of round cells of the lymphocyte, plasma cells and macrophage type (Figures 7 and 8). Neutrophil granulocytes were quite rarely identified; their number was increased in ulcerated tumors. The intratumoral inflammatory infiltrate was present around the conjunctival–vascular septa penetrating the tumor. By using specific antibodies, we were able to identify the types of cells present in the tumoral and peritumoral inflammatory infiltrate. T-lymphocytes, involved in cellular immunity, were highlighted using the anti-CD3 antibody. They were mainly identified in the peritumoral inflammatory infiltrate (Figure 9) and less in the intratumoral one (Figure 10). The number of T-lymphocytes in the peritumoral inflammatory infiltrate varied between 102 and 181 cells/mm2, with a mean value of 140 cells/mm2, while in the intratumoral inflammatory infiltrate it varied from 12 to 50 cells/mm2, with a mean value of 31 cells/mm2. The ratio of the extratumoral and intratumoral T-lymphocytes was 4.5/1. The B-lymphocytes selectively identified by using the anti-CD20 antibody, similar to T-lymphocytes, were present in much larger numbers in the peritumoral inflammatory infiltrate (Figure 11), while, intratumorally, this type of lymphocytes was very little represented (Figure 12). The number of B-lymphocytes identified peritumorally varied from 18 to 60 cells/mm2, with a mean value of 42 cells/mm2, while, intratumorally, their number varied from 2 to 8 cells/mm2, with a mean value of 4 cells/mm2. The ratio of peritumoral and intratumoral B-lymphocytes was 10.5/1. Plasma cells, antibody-producing cells, were identified by using the anti-CD79a antibody. They had both a peritumoral and intratumoral presence in large numbers (Figures 13 and 14). Thus, in the peritumoral inflammatory infiltrate, the number of plasma cells varied from 55 to 99 cells/mm2, with a mean value of 75 cells/mm2, while intratumorally they varied from 17 to 27 cells/mm2, with a mean value of 23 cells/mm2, the ratio of extratumoral and intratumoral plasma cells being 3.2/1. CD68-positive macrophages were identified in large numbers both in the intratumoral (Figure 15) and in the peritumoral inflammatory infiltrate (Figure 16). The number of macrophages in the extratumoral stroma varied from 33 to 54 cells/mm2, with a mean value of 37 cells/mm2, while in the intratumoral environment the number of macrophages identified varied from 8 to 25 cells/mm2, with a mean number of 19 cells/mm2, the ratio of extratumoral and intratumoral macrophages being 1.9/1. MCs, identified through the anti-tryptase antibody, were present in large numbers in the peritumoral inflammatory infiltrate, most often around the blood vessels; in the intratumoral stroma, MCs were very rarely observed.

Figure 1.

Figure 1

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Image with tumor cells of various shapes and sizes, in various amounts of melanotic pigment in the cytoplasm. Hematoxylin–Eosin (HE) staining, ×200.

Figure 2.

Figure 2

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Cords of polyhedral-like tumor cells, with low cytoplasmic pigment content and multiple cellular and nuclear atypia, with large, hypochromic and nucleolate nuclei in a nodular melanoma. HE staining, ×100.

Figure 3.

Figure 3

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Tumor melanocytes with abundant melanotic pigment in the cytoplasm, diffusely disseminated in the superficial dermis. HE staining, ×100.

Figure 4.

Figure 4

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Anti-Melan-A antibody positive tumor cells. Immunomarking with anti-Melan A antibody, ×100.

Figure 5.

Figure 5

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Positive reaction of tumor cells to anti-human melanoma black 45 (HMB45) antibody. Immunomarking with anti-HMB45 antibody, ×200.

Figure 6.

Figure 6

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Area of malignant melanoma with intensely positive cells to the anti-S100 protein antibody. Immunomarking with anti-S100 protein antibody, ×200.

Figure 7.

Figure 7

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Abundant inflammatory infiltrate in the peritumoral area of the melanoma. HE staining, ×100.

Figure 8.

Figure 8

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Moderate intratumoral inflammatory infiltrate. HE staining, ×100.

Figure 9.

Figure 9

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Image from a peritumoral region with a large amount of T-lymphocytes in the inflammatory infiltrate. Immunomarking with anti-cluster of differentiation 3 (CD3) antibody, ×200.

Figure 10.

Figure 10

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Tumoral region with a moderate content of T-lymphocytes in the stroma. Immunomarking with the anti-CD3 antibody, ×200.

Figure 11.

Figure 11

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Peritumoral region with an abundant inflammatory infiltrate, but with a low number of B-lymphocytes. Immunomarking with anti-cluster of differentiation 20 (CD20) antibody, ×200.

Figure 12.

Figure 12

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Microscopic image of the intratumoral region with rare diffusely disseminated B-lymphocytes. Immunomarking with anti-CD20 antibody, ×200.

Figure 13.

Figure 13

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Image of a peritumoral area with an abundant inflammatory infiltrate consisting mostly of plasma cells. Immunomarking with anti-cluster of differentiation 79a (CD79a) antibody, ×200.

Figure 14.

Figure 14

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Intratumoral region with a high content of plasma cells. Immunomarking with anti-CD79a antibody, ×200.

Figure 15.

Figure 15

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Peritumoral stroma infiltrated with numerous macrophages. Immunomarking with anti-cluster of differentiation 68 (CD68) antibody, ×200.

Figure 16.

Figure 16

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Image from the intratumoral region with a relatively high macrophage content. Immunomarking with anti-CD68 antibody, ×200.

Discussions

The skin is the largest organ of the body; it envelops the body on the outside and acts as a physical, chemical, and immunological barrier to defend the human body against foreign antigens [20, 21]. Due to its complex structure and permanent interaction with exogenous factors, the skin presents a wide range of diseases, ranging from inflammatory lesions to tumoral ones [22]. Skin cancer is one of the most common types of cancer and its incidence is increasing worldwide. In many countries, skin cancer became a public health problem, increasing the financial burden on health systems. The main risk factor for increasing the incidence of skin cancer is represented by UV radiation [23]. There are two major forms of skin cancer: melanomas and non-melanoma cancers, represented by basal cell carcinoma, squamous cell carcinoma [24]. CM is a cancer with a lower incidence but a very high mortality rate. The CM origin is closely related to the presence and accumulation of UV-induced somatic mutations in melanocytes present in normal skin or in precursor lesions of CM (nevi or dysplastic nevi) [25, 26]. Although these somatic mutations can be produced by accumulated, unrepaired, DNA errors related to cell aging, most studies showed that UV exposure is actually the main risk factor associated with the CM development [27, 28]. UV radiation influences cell and tissue homeostasis, changes many gene expressions and generates reactive oxygen species (ROS). When the ROS production is prolonged or increased, tissue inflammation and oxidative stress occurs [29, 30, 31], factors that cause malignant transformation and proliferation. In recent decades, genomic studies highlighted that CM is the cancer with the greatest mutational heterogeneity [32]. In our study, we assessed the tumor and peritumoral inflammatory reaction in CMs, because tumor lesions are frequently associated with chronic inflammatory infiltrates, which seem to play a major role in initiating, developing invasion and metastasis of cancer [33, 34]. The presence of inflammatory infiltrates is a sign of malignant proliferation of melanocytes because benign melanocyte proliferation does not have such infiltrates. Given the roles of inflammation in cancer, measuring the levels of different types of inflammatory cells could serve as prognostic biomarkers, although studies in this direction are relatively rare [35, 36, 37]. In our study, T-lymphocytes were the most numerous cellular elements of the inflammatory reaction. They were identified in a large number, both intratumorally and peritumorally, still they were about 4.5 times more numerous in the peritumoral stroma than the intratumoral one. Our data confirm other studies that showed chronic inflammation is governed by regulatory T-cells and T-helper 2 (Th2) cells that secrete tumorigenic factors, including transforming growth factor-beta (TGF-β), tumor necrosis factor-alpha (TNF-α) and numerous interleukins, mediators that participate in tumor initiation and progression [18, 38]. Compared to T-lymphocytes, B-lymphocytes were present in much smaller numbers. They were mainly present in the peritumoral stroma and were very rarely identified in the intratumoral stroma, so the ratio between peritumoral and intratumoral B-lymphocytes was about 10.5/1. We must show that, so far, immuno-oncology studies focused on the importance of T-lymphocytes in the occurrence and development of tumors; recently, several papers highlighted that infiltrating tumors with B-cells show a better progression and a better response to immunotherapy. B-cells, through the antibodies they produce, recognize some extracellular domains on the surface of tumor cells, thus redirecting the cytotoxic activity of natural killer (NK) cells against tumor cells [39, 40]. In our cases, CM showed a reduced number of intratumoral B-lymphocytes, which explains the high capacity of invasion, metastasis, and local recurrence of melanomas. The presence of intra- or peritumoral plasma cells was assessed using the anti-CD79a antibody. Plasma cells were relatively numerous, both in the peritumoral and intratumoral environment, the ratio of the two areas being about 3.2/1. They were much more numerous compared to B-lymphocytes. It is known the fact that, after exposure to an antigen, B-lymphocytes can differentiate into plasma cells, intense antibody-secreting cells, which no longer express the CD20 antigen, but can be distinguished in tissues through the intracytoplasmic expression of the CD79a antigen [41]. Studies regarding the role of B-lymphocytes and plasma cells in the melanoma progression are quite few, and the results are controversial. The presence of intratumoral plasma cells seems to correlate with an increased risk of lymph node metastasis and a poor prognosis [42, 43]. Other immune system cells identified in CM were the macrophages. Similar to plasma cells, macrophages were identified in large numbers both peritumorally and intratumorally, with the ratio of peritumoral to intratumoral macrophages being 1.9/1. Macrophages are an important component of the immune system, but also of the tumor microenvironment [44]. As innate immune cells, macrophages can kill tumor cells by phagocytosis, activation of T-cells, etc., leading to early elimination of tumor cells. However, numerous studies showed that macrophages play an important role in malignant diseases, being considered as pro-tumorigenic cells, by creating a microenvironment favorable to the multiplication and metastasis of tumor cells [45, 46, 47]. They interact with both tumor cells and stromal cells, secreting mediators (cytokines and chemokines) that favor angiogenesis, local invasion and blocking of the anti-tumor immune response [48, 49]. In our study, the assessment of the distribution of MCs in CM showed that they were present in large numbers in the peritumoral stroma and very rarely intratumorally, which makes us believe that MCs do not play a major role in the development of malignant melanoma. Several studies showed contrary results on the relationship between MCs and CM [50, 51]. The tumor cells create a tumor microenvironment that, as a whole, is the environment that develops around a tumor and includes the extracellular matrix, fibroblasts, blood vessels, lymphatic vessels, stromal cells (T-lymphocytes, B-lymphocytes, neutrophils, leukocytes, dendritic cells, MCs). All these constitute an ecosystem in which they bidirectionally interact with tumor cells, modulating the malignant phenotype [52, 53]. Tumor microenvironment often presents an inflammatory aspect and plays an important role in carcinogenesis, by increasing the proliferation of mutant cells. Inflammatory cells can increase the mutation rates of tumor cells through DNA damage and genomic instability, because of the synthesis and release of oxygen free radicals (OFRs) [54, 55]. We believe that the connections between tumor cells and the local immune response are extremely complex and insufficiently known nowadays.

Conclusions

In all the studied CMs, the presence of a more or less intense chronic inflammatory reaction was found as a characteristic microscopic structure. Chronic inflammatory infiltrate, identified both in the tumoral and peritumoral connective stroma, presented as diffuse, heterogenous, consisting of lymphocytes, plasma cells, macrophages, and MCs. Inflammatory cells had direct contact with tumor cells, blood vessels, conjunctive matrix, which suggests that the inflammatory microenvironment plays an important role in carcinogenesis, tumor invasion, local angiogenesis, and tumor metastasizing. Peritumoral stroma was richer in inflammatory cells compared to the intratumoral stroma, especially in nodular melanomas. The most numerous cells in the inflammatory infiltrate were T-lymphocytes, plasma cells and macrophages; B-lymphocytes and MCs were less numerous, especially intratumorally. HP and IHC aspects suggested that the inflammatory cells associated with CM are not able to stop tumor progression, still they can favor its development.

Conflict of interests

The authors declare that they have no conflict of interests.

Acknowledgments

This work was supported by the grant POCU/993/6/13/153178, “Performanţă în cercetare” – “Research performance” co-financed by the European Social Fund within the Sectorial Operational Program Human Capital 2014–2020.

References

  • 1.Bertrand JU, Steingrimsson E, Jouenne F, Bressac-de Paillerets, Larue L. Melanoma risk and melanocyte biology. Acta Derm Venereol. 2020;100(11):adv00139–adv00139. doi: 10.2340/00015555-3494. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Huang B, Su W, Yu D. Data-driven analysis to identify prognostic immune-related biomarkers in BRAF mutated cutaneous melanoma microenvironment. Front Genet. 2022;13:1081418–1081418. doi: 10.3389/fgene.2022.1081418. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Ahmed B, Qadir MI, Ghafoor S. Malignant melanoma: skin cancer - diagnosis, prevention, and treatment. Crit Rev Eukaryot Gene Expr. 2020;30(4):291–297. doi: 10.1615/CritRevEukaryotGeneExpr.2020028454. [DOI] [PubMed] [Google Scholar]
  • 4.Bolick NL, Geller AC. Epidemiology of melanoma. Hematol Oncol Clin North Am. 2021;35(1):57–72. doi: 10.1016/j.hoc.2020.08.011. [DOI] [PubMed] [Google Scholar]
  • 5.Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–249. doi: 10.3322/caac.21660. [DOI] [PubMed] [Google Scholar]
  • 6. 2020 Melanoma Skin Cancer Report: stemming the global epidemic. 2020 Available from: https://www.melanomauk.org.uk/2020-melanoma-skin-cancer-report.
  • 7.Dong L, Tian X, Zhao Y, Tu H, Wong A, Yang Y. The roles of miRNAs (microRNAs) in melanoma immunotherapy. Int J Mol Sci. 2022;23(23):14775–14775. doi: 10.3390/ijms232314775. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Lo JA, Fisher DE. The melanoma revolution: from UV carcinogenesis to a new era in therapeutics. Science. 2014;346(6212):945–949. doi: 10.1126/science.1253735. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Berwick M, Buller DB, Cust A, Gallagher R, Lee TK, Meyskens F, Pandey S, Thomas NE, Veierød MB, Ward S. Melanoma epidemiology and prevention. Cancer Treat Res. 2016;167:17–49. doi: 10.1007/978-3-319-22539-5_2. [DOI] [PubMed] [Google Scholar]
  • 10.Armstrong BK, Kricker A. How much melanoma is caused by sun exposure. Melanoma Res. 1993;3(6):395–401. doi: 10.1097/00008390-199311000-00002. [DOI] [PubMed] [Google Scholar]
  • 11.Lasithiotakis K, Leiter U, Krüger-Krasagakis S, Tosca A, Garbe C. Comparative analysis of incidence and clinical features of cutaneous malignant melanoma in Crete (Greece) and southern Germany (central Baden-Württemberg) Br J Dermatol. 2006;154(6):1123–1127. doi: 10.1111/j.1365-2133.2006.07163.x. [DOI] [PubMed] [Google Scholar]
  • 12.Markovic SN, Erickson LA, Rao RD, Weenig RH, Pockaj BA, Bardia A, Vachon CM, Schild SE, McWilliams RR, Hand JL, Laman SD, Kottschade LA, Maples WJ, Pittelkow MR, Pulido JS, Cameron JD, Creagan ET; Malignant melanoma in the 21st century, Part 1: epidemiology, risk factors, screening, prevention, and diagnosis. Mayo Clin Proc. 2007;82(3):364–380. doi: 10.4065/82.3.364. [DOI] [PubMed] [Google Scholar]
  • 13.Narayanan DL, Saladi RN, Fox JL. Ultraviolet radiation and skin cancer. Int J Dermatol. 2010;49(9):978–986. doi: 10.1111/j.1365-4632.2010.04474.x. [DOI] [PubMed] [Google Scholar]
  • 14.Saginala K, Barsouk A, Aluru JS, Rawla P, Barsouk A. Epidemiology of melanoma. Med Sci (Basel) 2021;9(4):63–63. doi: 10.3390/medsci9040063. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Dika E, Fanti PA, Vaccari S, Patrizi A, Maibach HI. Causal relationship between exposure to chemicals and malignant melanoma? A review and study proposal. Rev Environ Health. 2010;25(3):255–259. doi: 10.1515/reveh.2010.25.3.255. [DOI] [PubMed] [Google Scholar]
  • 16.Hou J, Karin M, Sun B. Targeting cancer-promoting inflammation - have anti-inflammatory therapies come of age. Nat Rev Clin Oncol. 2021;18(5):261–279. doi: 10.1038/s41571-020-00459-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Mantovani A, Allavena P, Sica A, Balkwill F. Cancer-related inflammation. Nature. 2008;454(7203):436–444. doi: 10.1038/nature07205. [DOI] [PubMed] [Google Scholar]
  • 18.Landskron G, De la, Thuwajit P, Thuwajit C, Hermoso MA. Chronic inflammation and cytokines in the tumor microenvironment. J Immunol Res. 2014;2014:149185–149185. doi: 10.1155/2014/149185. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Greten FR, Grivennikov SI. Inflammation and cancer: triggers, mechanisms, and consequences. Immunity. 2019;51(1):27–41. doi: 10.1016/j.immuni.2019.06.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Pullar JM, Carr AC, Vissers MCM. The roles of vitamin C in skin health. Nutrients. 2017;9(8):866–866. doi: 10.3390/nu9080866. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Chambers ES, Vukmanovic-Stejic M. Skin barrier immunity and ageing. Immunology. 2020;160(2):116–125. doi: 10.1111/imm.13152. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Dainichi T, Hanakawa S, Kabashima K. Classification of inflam-matory skin diseases: a proposal based on the disorders of the three-layered defense systems, barrier, innate immunity and acquired immunity. J Dermatol Sci. 2014;76(2):81–89. doi: 10.1016/j.jdermsci.2014.08.010. [DOI] [PubMed] [Google Scholar]
  • 23.Dildar M, Akram S, Irfan M, Khan HU, Ramzan M, Mahmood AR, Alsaiari SA, Saeed AHM, Alraddadi MO, Mahnashi MH. Skin cancer detection: a review using deep learning techniques. Int J Environ Res Public Health. 2021;18(10):5479–5479. doi: 10.3390/ijerph18105479. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Greinert R. Skin cancer: new markers for better prevention. Pathobiology. 2009;76(2):64–81. doi: 10.1159/000201675. [DOI] [PubMed] [Google Scholar]
  • 25.Hernando B, Dietzen M, Parra G, Gil-Barrachina M, Pitarch G, Mahiques L, Valcuende-Cavero F, McGranahan N, Martinez-Cadenas C. The effect of age on the acquisition and selection of cancer driver mutations in sun-exposed normal skin. Ann Oncol. 2021;32(3):412–421. doi: 10.1016/j.annonc.2020.11.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Loras A, Gil-Barrachina M, Marqués-Torrejón MÁ, Perez-Pastor G, Martinez-Cadenas C. UV-induced somatic mutations driving clonal evolution in healthy skin, nevus, and cutaneous melanoma. Life (Basel) 2022;12(9):1339–1339. doi: 10.3390/life12091339. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Guhan S, Klebanov N, Tsao H. Melanoma genomics: a state-of-the-art review of practical clinical applications. Br J Dermatol. 2021;185(2):272–281. doi: 10.1111/bjd.20421. [DOI] [PubMed] [Google Scholar]
  • 28.Lotz M, Budden T, Furney SJ, Virós A. Molecular subtype, biological sex and age shape melanoma tumour evolution. Br J Dermatol. 2021;184(2):328–337. doi: 10.1111/bjd.19128. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Petersen AB, Gniadecki R, Vicanova J, Thorn T, Wulf HC. Hydrogen peroxide is responsible for UVA-induced DNA damage measured by alkaline comet assay in HaCaT keratinocytes. J Photochem Photobiol B. 2000;59(1-3):123–131. doi: 10.1016/s1011-1344(00)00149-4. [DOI] [PubMed] [Google Scholar]
  • 30.Schauen M, Hornig-Do HT, Schomberg S, Herrmann G, Wiesner RJ. Mitochondrial electron transport chain activity is not involved in ultraviolet A (UVA)-induced cell death. Free Radic Biol Med. 2007;42(4):499–509. doi: 10.1016/j.freeradbiomed.2006.11.016. [DOI] [PubMed] [Google Scholar]
  • 31.Ciążyńska M, Olejniczak-Staruch I, Sobolewska-Sztychny D, Narbutt J, Skibińska M, Lesiak A. Ultraviolet radiation and chronic inflammation - molecules and mechanisms involved in skin carcinogenesis: a narrative review. Life (Basel) 2021;11(4):326–326. doi: 10.3390/life11040326. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Kontogianni G, Piroti G, Maglogiannis I, Chatziioannou A, Papadodima O. Dissecting the mutational landscape of cutaneous melanoma: an omic analysis based on patients from Greece. Cancers (Basel) 2018;10(4):96–96. doi: 10.3390/cancers10040096. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Grivennikov SI, Greten FR, Karin M. Immunity, inflammation, and cancer. Cell. 2010;140(6):883–899. doi: 10.1016/j.cell.2010.01.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Yun SJ, Liu S, Buckley M, Wang T, Jin S, Karakousis G, Peters MG, Elder DE, Gimotty PA, Xu X. Stromal inflammatory cells are associated with poorer prognosis in primary cutaneous melanoma. Hum Pathol. 2019;88:78–86. doi: 10.1016/j.humpath.2019.03.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Gonzalez H, Hagerling C, Werb Z. Roles of the immune system in cancer: from tumor initiation to metastatic progression. Genes Dev. 2018;32(19-20):1267–1284. doi: 10.1101/gad.314617.118. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Hernando-Calvo A, García-Alvarez A, Villacampa G, Ortiz C, Bodet D, García-Patos V, Recio JA, Dienstmann R, Muñoz-Couselo E. Dynamics of clinical biomarkers as predictors of immunotherapy benefit in metastatic melanoma patients. Clin Transl Oncol. 2021;23(2):311–317. doi: 10.1007/s12094-020-02420-9. [DOI] [PubMed] [Google Scholar]
  • 37.Gambichler T, Stang A, Mansour R, Scheel CH, Nick C, Abu Rached, Becker JC, Susok L. Prognostic potential of the baseline pan-immune-inflammation value and neutrophil/lymphocyte ratio in stage I to III melanoma patients. Cancers (Basel) 2022;14(18):4410–4410. doi: 10.3390/cancers14184410. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Neagu M, Constantin C, Dumitrascu GR, Lupu AR, Caruntu C, Boda D, Zurac S. Inflammation markers in cutaneous melanoma - edgy biomarkers for prognosis. Discoveries (Craiova) 2015;3(1):e38–e38. doi: 10.15190/d.2015.30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Engelhard V, Conejo-Garcia JR, Ahmed R, Nelson BH, Willard-Gallo K, Bruno TC, Fridman WH. B cells and cancer. Cancer Cell. 2021;39(10):1293–1296. doi: 10.1016/j.ccell.2021.09.007. [DOI] [PubMed] [Google Scholar]
  • 40.Michaud D, Steward CR, Mirlekar B, Pylayeva-Gupta Y. Regulatory B cells in cancer. Immunol Rev. 2021;299(1):74–92. doi: 10.1111/imr.12939. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Kroeger DR, Milne K, Nelson BH. Tumor-infiltrating plasma cells are associated with tertiary lymphoid structures, cytolytic T-cell responses, and superior prognosis in ovarian cancer. Clin Cancer Res. 2016;22(12):3005–3015. doi: 10.1158/1078-0432.CCR-15-2762. [DOI] [PubMed] [Google Scholar]
  • 42.Mascaro JM, Molgo M, Castel T, Castro J. Plasma cells within the infiltrate of primary cutaneous malignant melanoma of the skin. A confirmation of its histoprognostic value. Am J Dermatopathol. 1987;9(6):497–499. doi: 10.1097/00000372-198712000-00005. [DOI] [PubMed] [Google Scholar]
  • 43.Bosisio FM, Wilmott JS, Volders N, Mercier M, Wouters J, Stas M, Blokx WA, Massi D, Thompson JF, Scolyer RA, van Baren, van den. Plasma cells in primary melanoma. Prognostic significance and possible role of IgA. Mod Pathol. 2016;29(4):347–358. doi: 10.1038/modpathol.2016.28. [DOI] [PubMed] [Google Scholar]
  • 44.Kashfi K, Kannikal J, Nath N. Macrophage reprogramming and cancer therapeutics: role of iNOS-derived NO. Cells. 2021;10(11):3194–3194. doi: 10.3390/cells10113194. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Mantovani A, Marchesi F, Malesci A, Laghi L, Allavena P. Tumour-associated macrophages as treatment targets in oncology. Nat Rev Clin Oncol. 2017;14(7):399–416. doi: 10.1038/nrclinonc.2016.217. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.DeNardo DG, Ruffell B. Macrophages as regulators of tumour immunity and immunotherapy. Nat Rev Immunol. 2019;19(6):369–382. doi: 10.1038/s41577-019-0127-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Zhou Q, Fang T, Wei S, Chai S, Yang H, Tao M, Cao Y. Macrophages in melanoma: a double-edged sword and targeted therapy strategies (Review) Exp Ther Med. 2022;24(4):640–640. doi: 10.3892/etm.2022.11577. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Pathria P, Louis TL, Varner JA. Targeting tumor-associated macrophages in cancer. Trends Immunol. 2019;40(4):310–327. doi: 10.1016/j.it.2019.02.003. [DOI] [PubMed] [Google Scholar]
  • 49.Pan Y, Yu Y, Wang X, Zhang T. Tumor-associated macrophages in tumor immunity. Front Immunol. 2020;11:583084–583084. doi: 10.3389/fimmu.2020.583084. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Ribatti D, Vacca A, Ria R, Marzullo A, Nico B, Filotico R, Roncali L, Dammacco F. Neovascularisation, expression of fibroblast growth factor-2, and mast cells with tryptase activity increase simultaneously with pathological progression in human malignant melanoma. Eur J Cancer. 2003;39(5):666–674. doi: 10.1016/s0959-8049(02)00150-8. [DOI] [PubMed] [Google Scholar]
  • 51.Biswas A, Richards JE, Massaro J, Mahalingam M. Mast cells in cutaneous tumors: innocent bystander or maestro conductor. Int J Dermatol. 2014;53(7):806–811. doi: 10.1111/j.1365-4632.2012.05745.x. [DOI] [PubMed] [Google Scholar]
  • 52.Villanueva J, Herlyn M. Melanoma and the tumor microenvironment. Curr Oncol Rep. 2008;10(5):439–446. doi: 10.1007/s11912-008-0067-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Georgoulias G, Zaravinos A. Genomic landscape of the immunogenicity regulation in skin melanomas with diverse tumor mutation burden. Front Immunol. 2022;13:1006665–1006665. doi: 10.3389/fimmu.2022.1006665. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Fan Y, Mao R, Yang J. NF-κB and STAT3 signaling pathways collaboratively link inflammation to cancer. Protein Cell. 2013;4(3):176–185. doi: 10.1007/s13238-013-2084-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Trandafir CM, Tischer AA, Horhat ID, Balica NC, Sitaru AM, Guran K, Morar R, Baderca F, Jifcu EM, Moţ IC, Burlacu ON, Poenaru M, Sarău CA. Fortuitous discovery of melanomas in the ENT Department - a histopathological and immunohistochemical study. Rom J Morphol Embryol. 2020;61(4):1163–1171. doi: 10.47162/RJME.61.4.18. [DOI] [PMC free article] [PubMed] [Google Scholar]

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