- Email: [email protected]
Prognostic value of inositol polyphosphate-5-phosphatase expression in recurrent and metastatic cutaneous squamous cell carcinoma
Journal Pre-proof Prognostic Value of Inositol Polyphosphate-5-Phosphatase Expression in Recurrent and Metastatic Cutaneous Squamous Cell Carcinoma Connor J. Maly, B.S., Helen J.L. Cumsky, M.D., Collin M. Costello, M.D., Jessica E. Schmidt, M.S., Richard J. Butterfield, M.S., Nan Zhang, M.S., David J. DiCaudo, M.D., Steven A. Nelson, M.D., Maxwell L. Smith, M.D., Shari A. Ochoa, M.D., Christian L. Baum, M.D., Thomas H. Nagel, M.D., Mark R. Pittelkow, M.D., Aleksandar Sekulic, M.D. Ph.D., Aaron R. Mangold, M.D. PII:
S0190-9622(19)32574-5
DOI:
https://doi.org/10.1016/j.jaad.2019.08.027
Reference:
YMJD 13747
To appear in:
Journal of the American Academy of Dermatology
Received Date: 29 April 2019 Revised Date:
5 August 2019
Accepted Date: 10 August 2019
Please cite this article as: Maly CJ, Cumsky HJL, Costello CM, Schmidt JE, Butterfield RJ, Zhang N, DiCaudo DJ, Nelson SA, Smith ML, Ochoa SA, Baum CL, Nagel TH, Pittelkow MR, Sekulic A, Mangold AR, Prognostic Value of Inositol Polyphosphate-5-Phosphatase Expression in Recurrent and Metastatic Cutaneous Squamous Cell Carcinoma, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2019.08.027. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1
1
Title: Prognostic Value of Inositol Polyphosphate-5-Phosphatase Expression in Recurrent and
2
Metastatic Cutaneous Squamous Cell Carcinoma
3
Connor J. Maly B.S.1, Helen J.L. Cumsky M.D.1, Collin M. Costello M.D.1, Jessica E. Schmidt
4
M.S.1, Richard J. Butterfield M.S.2, Nan Zhang M.S.2, David J. DiCaudo M.D.1, Steven A.
5
Nelson M.D.1, Maxwell L. Smith M.D.3, Shari A. Ochoa M.D.1, Christian L. Baum M.D.4,
6
Thomas H. Nagel M.D.5, Mark R. Pittelkow M.D.1, Aleksandar Sekulic M.D. Ph.D.1 and Aaron
7
R. Mangold M.D.1*
8
1
Mayo Clinic – Department of Dermatology; Scottsdale, AZ, USA
9
2
Mayo Clinic – Department of Health Science Research, Scottsdale, AZ, USA
10
3
Mayo Clinic – Department of Pathology; Scottsdale, AZ, USA
11
4
Mayo Clinic – Department of Dermatology; Rochester, MN, USA
12
5
Mayo Clinic – Department of Otolaryngology; Scottsdale, AZ, USA
13
*
Corresponding Author: Aaron Mangold, MD; Mayo Clinic – Department of Dermatology;
14
13400 E Shea Blvd, Scottsdale, AZ 85259 Email: [email protected]; Phone: 480-301-
15
8508; Fax: 480-301-9272
16
Funding: Dermatology Foundation – Career Development Award & NIH Grant 5R01CA179157
17
Conflicts of Interest: The authors declare that they have no conflict of interest and no financial
18
disclosure
19
Data presented at the 2019 Society for Investigative Dermatology Meeting.
20
Word Count: 2331
21
Tables: 1
22
Keywords: Inositol polyphosphate-5-phosphatase (INPP5A); Squamous Cell Carcinoma (SCC);
23
Immunohistochemistry (IHC)
References: 20
Figures: 4
2
24
Abstract
25
Background:
26
Inositol polyphosphate-5-phosphatase (INPP5A) has been shown to play a role in the progression
27
of actinic keratosis to cutaneous squamous cell carcinoma (cSCC) and the progression of
28
localized disease to metastatic disease. Currently, no cSCC biomarkers are able to risk stratify
29
recurrent and metastatic disease (RMD).
30
Objective:
31
To determine the prognostic value of INPP5A expression in cSCC RMD.
32
Methods:
33
This was a multi-center, single-institutional, retrospective cohort study within the Mayo Clinic
34
Health System using immunohistochemical staining to examine cSCC INPP5A protein
35
expression in primary tumors and RMD. Dermatologists and dermatopathologists were blinded
36
to outcome.
37
Results:
38
Low staining expression (LSE) of INPP5A of RMD was associated with poor overall survival
39
(OS) of 31.0 months vs. 62.0 months for high staining expression (HSE) (p=0.0272). A
40
composite risk score (CRS) (CRS=primary + RMD; with HSE=0 & LSE=1; range 0-2) of 0 was
41
predictive of improved OS compared to a CRS of ≥1 (HR = 0.42, 95%CI: 0.21 to 0.84,
42
p=0.0113).
43
Limitations:
44
This is a multi-center, but single institution study with a Caucasian population.
45
Conclusion:
46
Loss of INPP5A expression predicts poor OS in RMD of cSCC.
3
47
48
Capsule Summary •
with a poor prognosis. Currently, no biomarkers are able to risk stratify this population.
49 50
Recurrent and metastatic disease of cutaneous squamous cell carcinoma is associated
•
Low immunohistochemical staining expression of inositol polyphosphate-5-phosphatase
51
predicts poor overall survival in recurrent and metastatic cutaneous squamous cell
52
carcinoma.
4
53 54
Introduction: Non-melanoma skin cancer (NMSC) is the most common cancer in humans with five
55
million cancers per year in the United States.1 Cutaneous squamous cell carcinoma (cSCC) is the
56
second most common type of NMSC with a 14-20% lifetime risk in the non-Hispanic Caucasian
57
population.2,3 According to recent Medicare data, the incidence of cSCC has doubled from 1992
58
to 2012 with an equal incidence of cSCC and basal cell carcinoma (BCC).1 The economic burden
59
and incidence of cSCC has increased disproportionally to other cancers.4-6 As such, optimal,
60
cost-effective risk stratification and management is critical.
61
Unlike BCC, cSCC have higher risks of local recurrence (4.6%), nodal metastasis (3.7%),
62
and of disease-specific death (2.1%).7 Metastatic cSCC has a poor 5-year survival of 25-35% and
63
accounts for up to 8791 deaths annually.8 The most widely used staging systems, the American
64
Joint Committee on Cancer (AJCC) and Brigham and Women’s Hospital (BWH), focus on
65
clinical and histological risk factors of the primary tumor as a predictor of recurrence and
66
metastasis. 9-11 There is a paucity of data predicting outcomes of recurrent and metastatic disease
67
(RMD).
68
Inositol polyphosphate-5-phosphatase (INPP5A), a membrane-associated type I inositol
69
phosphatase, plays a role in the progression of actinic keratosis to cSCC as well as localized
70
disease to metastatic disease in oropharyngeal SCC and cSCC.12-14 Loss of INPP5A expression
71
in cSCC is correlated with aggressive tumor behavior and worse clinical outcomes.14 The
72
prognostic value of INPP5A in RMD is unknown. We hypothesize that loss of INPP5A
73
expression level in RMD will correlate with aggressive disease and predict a poor outcome.
5
74
Methods:
75
This study was approved by the Mayo Clinic institutional review board. Cases were
76
identified through our retrospective cSCC database which includes patients from Rochester,
77
Arizona, and Florida. All cases within the database that had a clear delineation of the causal
78
lesion that recurred or metastasized with a minimum of two years follow-up were included in the
79
study. If it was not possible to determine the primary cSCC for the RMD, the case was excluded.
80
All clinical data was obtained through a retrospective chart review. All cases in the database used
81
for this study underwent histological re-review and staging (DJD). The protocol was written for
82
discrepant cases to be reviewed by two dermatopathologists (DJD & SAN) for consensus
83
however, no cases were discrepant. Immunohistochemical staining was used to examine INPP5A
84
protein expression in both primary tumors and RMD (defined as locally recurrent (LR), locally
85
metastatic, and distantly metastatic). First, RMD was analyzed as one group. As a sub-analysis,
86
we analyzed local recurrence and metastasis separately. The metastatic group was composed of
87
in-transit metastasis, nodal metastasis, and distant metastasis. In-transit metastasis was defined as
88
cSCC without an epidermal connection that had spread at least 2cm from the lesion of origin but
89
was not within a lymph node. Locally metastatic disease was defined as in-transit metastases or
90
nodal metastatic disease within the draining lymph node basin. Distant metastatic disease was
91
defined as nodal disease outside the draining node basin or other organ involvement.
92
All slides were stained using the technique outlined in our previous study.14 INPP5A
93
protein expression levels were scored on a 4-point scale (0-3) by the consensus diagnosis (ARM
94
& DJD). Both reviewers were blinded to patient outcome. An INPP5A score of 3 was defined as
95
normal expression, a score of 2 was partially diminished, a score of 1 was significantly
96
diminished, and a score of 0 was complete loss. INPP5A staining examples are shown in Fig. 1.
97
High staining expression (HSE) was defined as a score of 2 or 3. Low staining expression (LSE)
6
98
was defined as a score of 0 or 1. All expression levels were compared with adjacent normal
99
epidermis. A control of normal epidermis was used to gauge the overall strength of the INPP5A
100
signal for each corresponding batch; this was used to adjust for any slight variations in staining
101
batch to batch. If normal epidermis was not available, the control of normal epidermis for the
102
same batch was utilized.
103
Overall survival (OS) was compared based upon INPP5A expression at the primary
104
tumor level, change in INPP5A status from primary tumor to events (HSE to LSE, LSE to HSE,
105
unchanged HSE, unchanged LSE), and an INPP5A Composite Risk Score (CRS) (LSE = 1, HSE
106
= 0, score range of 0-2 based upon the summation of primary tumor and the RMD tumor). A
107
CRS of zero indicated both the primary and RMD had HSE, a CRS of one demonstrated either
108
the primary or RMD had LSE, and a CRS of two indicated both the primary and RMD had LSE.
109
Statistical analysis:
110
Demographic characteristics and clinical characteristics at the patient and tumor level
111
were summarized and compared between INPP5A groups using Fisher’s exact, Wilcoxon rank
112
sum test, or Kuskal-Wallis test when applicable. Wilcoxon signed-rank test was used to test if
113
there was a difference between primary tumor INPP5A level and event tumor INPP5A level. The
114
OS was estimated using the Kaplan-Meier method and compared between INPP5A groups using
115
a log-rank test. Cox regression was used to estimate the hazard ratio for INPP5Agroups. A
116
subgroup analysis of recurrent disease, metastatic disease, and RMD excluding 5 SCC in-situ
117
cases were implemented in a similar manner.
7
118 119
Results: 50 patients with RMD cSCC, 52 tumors, and 64 events (27 local recurrence, 32 local
120
metastasis, and five distant metastasis) were examined. Ten primary tumors had multiple events:
121
eight tumors with two events and two tumors with three events. There were no significant
122
differences in age, gender, race, Fitzpatrick skin type, number of tumors, skin cancer history,
123
number of skin cancer diagnoses when comparing patients with local recurrence and metastasis
124
(Table 1). 14 patients (28.6%) were immunosuppressed: 64.3% were solid organ transplant
125
recipients, 21.4% had chronic lymphocytic leukemia, and 14.3% had iatrogenic
126
immunosuppression secondary to an inflammatory disease. There were significantly more
127
immunosuppressed patients in the metastatic group (33% vs 11.1%, p = 0.0271).
128
The primary tumors were comprised of 9.6% BWH T0, 32.7% BWH T1, 28.8% BWH
129
T2a, 23.1% BWH T2b, and 5.8% BWH T3 (Table 1). We compared the INPP5A expression of
130
the primary tumors and RMD event tumors. 41/52 (78.8%) of primary tumors had HSE and
131
11/52 (21.2%) had LSE. 36/52 (69.2%) of RMD had HSE and 16/52 (30.8%) had LSE. Primary
132
tumors with LSE had greater depth (5.8mm vs 3.7mm, p=0.0415) and higher rates of perineural
133
invasion (44% vs 9%, p=0.0257), but were not significantly different by BWH staging (p =
134
0.0645) or differentiation (p = 0.0521) (Table 1).
135
Patients with RMD disease had only metastatic tumors in 55.8% of cases, LR tumors in
136
38.5% of cases, and both metastatic and LR disease in 5.8% of cases. All three groups of RMD
137
(local recurrence, metastasis, and both) differed significantly in BWH staging, primary tumor
138
diameter, depth of invasion, tumor differentiation, and perineural invasion (Table 1). When
139
comparing CRS 0, 1, and 2 for RMD tumors, there were significant differences in primary tumor
140
depth of invasion (p = 0.0372) and primary tumor differentiation (p = 0.0102). After excluding 5
8
141
SCC in-situ patients, depth of invasion and tumor differentiation were no longer different
142
between RMD risk factor groups (p = 0.25 and p = 0.20, respectively).
143
OS of RMD was not affected by INPP5A level of the primary tumor (31.0 months LSE
144
vs 57.0 months HSE, p = 0.0897). However, INPP5A level of the RMD event tumor was
145
predictive of OS (31.0 months LSE vs 62.0 months HSE, p = 0.0272, Fig. 2a). OS was not
146
different between INPP5A group transitions (HSE to LSE group, 31.0 months, 20% of cases;
147
LSE to HSE group, 26.0 months, 12% of cases; unchanged HSE group, 62.0 months, 58% of
148
cases; and unchanged LSE group, 10% of cases, 31.0 months, p = 0.0899). The CRS of INPP5A
149
was predictive of OS (risk score = 0, 62.0 months; risk score = 1, 26.0 months; and risk score =
150
2, 31.0 months, p = 0.039, Fig. 2b). OS comparing CRS of zero versus CRS ≥ 1 was significantly
151
different (risk score = 0, 62.0 months; risk score = 1 or more, 31.0 months, p = 0.0113, Fig. 2c).
152
Due to the difference in tumor characteristics amongst the CRS of 0-2, a sub-analysis
153
excluding the five SCC in-situ cases was performed. OS of INPP5A levels of the primary tumor
154
and CRS of 0-2 was non-significant. However, the OS of CRS risk score of zero versus CRS ≥ 1
155
remained significant (CRS=0 62.0 months vs CRS ≥ 1 31.0 months, p = 0.0325).
156
A subgroup analysis of LR and metastatic disease was performed. For LR, patient
157
demographics and tumor characteristics across all analysis were non-significant except for
158
immunosuppression, which was more common in those with a CRS ≥ 1 (p = 0.0005). In LR
159
disease, LSE of INPP5A at the primary tumor level was associated with a worse OS (HSE 71.0
160
months and LSE 31.0 months, p = 0.0296). INPP5A expression at the event level of LR was non-
161
significant (HSE 71.0 months and LSE 45.5 months, p = 0.0884). A CRS ≥ 1 was associated
162
with a poor OS (CRS = 0 median survival 71.0 months vs CRS ≥ 1 median survival 42.0 months,
9
163
p = 0.0225) (Fig. 3). LSE of INPP5A at the primary tumor, event tumor level or CRS ≥ 1 of
164
metastatic disease was not associated with a worse OS.
10
165 166
Discussion: We found that LSE of INPP5A of RMD was associated with poor OS (median survival
167
31.0 months LSE vs. 62.0 months HSE, p = 0.0272) and HSE of INPP5A in the primary and
168
RMD (CRS of 0) was predictive of improved OS (HR = 0.42, 95% CI: 0.21 to 0.84, p=0.0113).
169
The OS of high-risk RMD by INPP5A staining (26% & 31% at 2 years) and CRS ≥ 1 (31% at 2
170
years), was similar to prior studies with lymph node metastasis, in which OS ranged from 33% at
171
2 years to 46.7% at 3 years, and recurrent head and neck cSCC, in which the OS at 1-year was
172
43.2%.15-17 Once verified, INPP5A expression at the primary tumor and nodal level may be used
173
to risk stratify individuals both for and with RMD. Furthermore, risk stratification may be
174
possible in cases of RMD without primary tissue and in tumors of unknown primary.
175
Prior studies have identified tumor size, differentiation, depth, and location as risk factors
176
for the development of RMD.7,8,10,18,19 LSE of INPP5A at the primary tumor is predictive of
177
more aggressive behavior, HR of 2.71 for OS and an HR of 4.71 for local/regional metastasis.14
178
Tumors in our cohort with LSE had higher rates of perineural invasion (44% vs 9%, p=0.0257)
179
and greater depth (5.8mm vs 3.7mm, p=0.0415), but no difference by BWH stages or
180
differentiation. These findings are similar to our prior work which found an association of LSE
181
and perineural invasion, poor differentiation, tumor size greater than 2cm, and invasion beyond
182
the fat.14 The cohort in this study was smaller and all tumors were high risk with RMD and
183
similar risk factors.
184
We examined INPP5A expression of primary tumors, RMD, and created a CRS. LSE of
185
the RMD and a CRS ≥ 1 were noted of being associated with poor OS. However, there were
186
significant differences between tumor groups with more aggressive tumors in both groups. These
187
differences were thought to be secondary to 5 SCCIS in the study. Therefore, we excluded the 5
11
188
cases of SCC in-situ, and the differences between groups were non-significant. Re-analysis
189
without the SCCIS found a trend with LSE score at the primary tumor or RMD and decreased
190
OS (p=0.089) and a decreased OS in those with a CRS ≥ 1 (CRS=0 62.0 months vs CRS ≥ 1 31.0
191
months, p = 0.0325). Therefore, we believe that a CRS ≥ 1 is a potential marker of poor outcome
192
independent of BWH T-stage. Larger studies are needed to verify these findings.
193
We performed a sub-analysis of LR and metastatic tumors. LSE in primary tumors with
194
LR was associated with poor OS (median survival 31.0 months LSE vs 71.0 months HSE,
195
p=0.0296). Interestingly, there was only a trend for LSE of the LR event tumor (p = 0.0884).
196
This difference is likely due to a lack of power. A CRS ≥ 1 in LR tumors was predictive of poor
197
OS (HR = 3.88, 95% CI: 1.10 – 13.69, p=0.0225). Importantly, there were no differences in
198
tumor characteristics suggesting that CRS may be useful in risk stratification independent of
199
BWH T-stage. Subgroup analysis of the demographics of LR cSCC by CRS found a higher rate
200
of immunosuppression in the CRS≥ 1. Immunosuppressed patients have worse OS which may
201
account for the findings in the LR CRS≥ 1 group.20 INPP5A expression and CRS were not able
202
to risk-stratify metastatic tumors for OS. The metastatic cohort was advanced at initial diagnosis,
203
had a worse OS at baseline, and therefore would require a larger number of cases to risk stratify.
204
86.2% of primary tumors that went on to have metastatic disease were T2a or above versus 15%
205
of tumors for recurrent disease. Further studies with larger cohorts of metastatic disease need to
206
be conducted.
207
This study had several limitations. This was a single institution study with a Caucasian
208
population. Our study was underpowered to detect differences in outcome of INPP5A at the
209
primary tumor level for all RMD and disease-specific death. Additionally, the metastatic cohort
210
was significantly more stage advanced than the recurrent cohort.
12
211
In conclusion, loss of INPP5A expression predicts poor OS in RMD of cSCC. INPP5A
212
CRS of 0 is associated with a superior OS of locally recurrent cSCC. Our study demonstrates the
213
potential for INPP5A expression level to be used as an adjunct tumor marker for clinical
214
management and risk stratification of locally RMD disease in cSCC. An additional study with a
215
larger cohort is justified in order to determine if INPP5A expression may serve as a biomarker to
216
stratify OS in individuals with metastatic disease.
13
217
Abbreviations and acronyms:
218
Non-melanoma skin cancer: NMSC
219
Cutaneous squamous cell carcinoma: cSCC
220
Basal cell carcinoma: BCC
221
American Joint Committee on Cancer: AJCC
222
Brigham and Women’s Hospital: BWH
223
Recurrent and metastatic disease: RMD
224
Inositol polyphosphate-5-phosphatase: INPP5A
225
Local recurrence: LR
226
High staining expression: HSE
227
Low staining expression: LSE
228
Overall survival: OS
229
Composite risk score: CRS
230
Hazard ratio: HR
14
231
References:
232
1.
Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of
233
Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012.
234
JAMA Dermatol. 2015;151(10):1081-1086.
235
2.
Potenza C, Bernardini N, Balduzzi V, Losco L, Mambrin A, Marchesiello A, et al. A
236
Review of the Literature of Surgical and Nonsurgical Treatments of Invasive Squamous
237
Cells Carcinoma. Biomed Res Int. 2018;2018:9489163.
238
3.
North Am. 2019;33(1):1-12.
239 240
Waldman A, Schmults C. Cutaneous Squamous Cell Carcinoma. Hematol Oncol Clin
4.
Housman TS, Feldman SR, Williford PM, Fleischer AB, Jr., Goldman ND,
241
Acostamadiedo JM, et al. Skin cancer is among the most costly of all cancers to treat for
242
the Medicare population. Journal of the American Academy of Dermatology.
243
2003;48(3):425-429.
244
5.
Christenson LJ, Borrowman TA, Vachon CM, Tollefson MM, Otley CC, Weaver AL, et
245
al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40
246
years. Jama. 2005;294(6):681-690.
247
6.
Muzic JG, Schmitt AR, Wright AC, Alniemi DT, Zubair AS, Olazagasti Lourido JM, et
248
al. Incidence and Trends of Basal Cell Carcinoma and Cutaneous Squamous Cell
249
Carcinoma: A Population-Based Study in Olmsted County, Minnesota, 2000 to 2010.
250
Mayo Clin Proc. 2017;92(6):890-898.
251
7.
Schmults CD, Karia PS, Carter JB, Han J, Qureshi AA. Factors predictive of recurrence
252
and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort
253
study. JAMA Dermatol. 2013;149(5):541-547.
15
254
8.
Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence
255
of disease, nodal metastasis, and deaths from disease in the United States, 2012. Journal
256
of the American Academy of Dermatology. 2013;68(6):957-966.
257
9.
7 ed. New York2010.
258 259
Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti A. AJCC Cancer Staging Manual.
10.
Karia PS, Jambusaria-Pahlajani A, Harrington DP, Murphy GF, Qureshi AA, Schmults
260
CD. Evaluation of American Joint Committee on Cancer, International Union Against
261
Cancer, and Brigham and Women's Hospital tumor staging for cutaneous squamous cell
262
carcinoma. J Clin Oncol. 2014;32(4):327-334.
263
11.
Motaparthi K, Kapil JP, Velazquez EF. Cutaneous Squamous Cell Carcinoma: Review of
264
the Eighth Edition of the American Joint Committee on Cancer Staging Guidelines,
265
Prognostic Factors, and Histopathologic Variants. Adv Anat Pathol. 2017;24(4):171-194.
266
12.
Sekulic A, Kim SY, Hostetter G, Savage S, Einspahr JG, Prasad A, et al. Loss of inositol
267
polyphosphate 5-phosphatase is an early event in development of cutaneous squamous
268
cell carcinoma. Cancer prevention research. 2010;3(10):1277-1283.
269
13.
Patel AB, Mangold AR, Costello CM, Nagel TH, Smith ML, Hayden RE, et al. Frequent
270
loss of inositol polyphosphate-5-phosphatase in oropharyngeal squamous cell carcinoma.
271
J Eur Acad Dermatol Venereol. 2018;32(1):e36-e37.
272
14.
Cumksy HJ, Costello CM, Zhang N, Butterfield R, Buras M, Schmidt J, et al. The
273
Prognostic Value of Inositol Polyphosphate 5-Phosphatase in Cutaneous Squamous Cell
274
Carcinoma. Journal of the American Academy of Dermatology. 2018.
16
275
15.
Moore BA, Weber RS, Prieto V, El-Naggar A, Holsinger FC, Zhou X, et al. Lymph node
276
metastases from cutaneous squamous cell carcinoma of the head and neck.
277
Laryngoscope. 2005;115(9):1561-1567.
278
16.
squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 1998;124(5):582-587.
279 280
Kraus DH, Carew JF, Harrison LB. Regional lymph node metastasis from cutaneous
17.
Sun L, Chin RI, Gastman B, Thorstad W, Yom SS, Reddy CA, et al. Association of
281
Disease Recurrence With Survival Outcomes in Patients With Cutaneous Squamous Cell
282
Carcinoma of the Head and Neck Treated With Multimodality Therapy. JAMA Dermatol.
283
2019.
284
18.
Wermker K, Kluwig J, Schipmann S, Klein M, Schulze HJ, Hallermann C. Prediction
285
score for lymph node metastasis from cutaneous squamous cell carcinoma of the external
286
ear. Eur J Surg Oncol. 2015;41(1):128-135.
287
19.
Mullen JT, Feng L, Xing Y, Mansfield PF, Gershenwald JE, Lee JE, et al. Invasive
288
squamous cell carcinoma of the skin: defining a high-risk group. Ann Surg Oncol.
289
2006;13(7):902-909.
290
20.
Thompson AK, Kelley BF, Prokop LJ, Murad MH, Baum CL. Risk Factors for
291
Cutaneous Squamous Cell Carcinoma Recurrence, Metastasis, and Disease-Specific
292
Death: A Systematic Review and Meta-analysis. JAMA Dermatol. 2016;152(4):419-428.
293 294
17
Table 1: Patient Demographics and Tumor Characteristics Patient Demographics (n=50) Age at Biopsy of cSCC of interest Mean (SD) 73.1 (10.5) Gender Female 14 (28.0%) Male 36 (72.0%) Race Caucasian 49 (100%) Missing 1 Fitzpatrick skin type I 1 (4.3%) II 18 (78.3%) III 4 (17.4%) Missing 27 Immunosuppressed and History of Skin Cancer Immunosuppressed 14 (28.6%) History of Skin Cancer 45 (90.0%) Reason for Immunosuppression (One or Multiple) Organ Transplant 9 (64.3%) Chronic Lymphocytic Leukemia 3 (21.4%) Inflammatory Disease 2 (14.3%) Tumor Characteristics of Primary Tumors for High and Low INPP5A Expression Brigham and Women’s Hospital T-Staging High INPP5A Low INPP5A (n=41) (n=11) T0 5 (12.2%) 0 (0.0%) T1 15 (36.6%) 2 (18.2%) T2a 13 (31.7%) 2 (18.2%) T2b 7 (17.1%) 5 (45.5%) T3 1 (2.4%) 2 (18.2%) Primary Tumor Diameter (cm) High INPP5A Low INPP5A (n=40) (n=11) Mean (SD) 2.2 (1.9) 2.5 (2.1) Primary Tumor Depth of Invasion High INPP5A Low INPP5A (n=41) (n=11) In Situ 5 (41.7%) 0 (0.0%) Dermis/Subcutaneous Fat 5 (41.7%) 3 (50.0%) Cartilage/Muscle 2 (16.7%) 3 (50.0%) Primary Tumor Depth (mm) High INPP5A Low INPP5A (n=21) (n=9)
Total (n=52) 5 (9.6%) 17 (32.7%) 15 (28.8%) 12 (23.1%) 3 (5.8%)
P-value
Total (n=51) 2.3 (1.9)
P-value
Total (n=52) 5 (27.8%) 8 (44.4%) 5 (27.8%) Total (n=30)
0.06451
0.41552 P-value 0.14081
P-value
18
Mean (SD)
Well Moderate Poor
Perineural Invasion
3.7 (2.8) 5.8 (3.1) Primary Tumor Differentiation High INPP5A Low INPP5A (n=41) (n=11) 9 (28.1%) 0 (0.0%) 15 (46.9%) 3 (33.3%) 8 (25.0%) 6 (66.7%) Perineural Invasion High INPP5A Low INPP5A (n=41) (n=11) 3 (8.8%) 4 (44.4%)
4.3 (3.0)
0.04152
Total (n=52) 9 (22.0%) 18 (43.9%) 14 (34.1%)
P-value
Total (n=52) 7 (16.3%)
P-value
0.05211
0.02571
Tumor Characteristics: Local Recurrence, Metastasis, and Both Brigham and Women’s Hospital T-Staging Local Recurrence Metastasis (n=29) Both (n=3) (n=20) T0 5 (25.0%) 0 (0.0%) 0 (0.0%) T1 12 (60.0%) 4 (13.8%) 1 (33.3%) T2a 1 (5.0%) 13 (44.8%) 1 (33.3%) T2b 2 (10.0%) 9 (31.0%) 1 (33.3%) T3 0 (0.0%) 3 (10.3%) 0 (0.0%) Primary tumor diameter (cm) Local Recurrence Metastasis (n=29) Both (n=3) (n=19) Mean (SD) 1.6 (1.5) 2.7 (2.1) 2.2 (1.1) Primary Tumor Depth of Invasion Local Recurrence Metastasis Both (n=1) (n=5) (n=12) In Situ 5 (100.0%) 0 (0.0%) 0 (0.0%) Dermis / 0 (0.0%) 7 (58.3%) 1 (100.0%) Subcutaneous Fat Cartilage / Muscle 0 (0.0%) 5 (41.7%) 0 (0.0%) Primary Tumor Depth (mm) Local Recurrence Metastasis (n=26) Both (n=2) (n=2) Mean (SD) 2.9 (1.6) 4.4 (3.1) 5.4 (4.0) Primary Tumor Differentiation Local Recurrence Metastasis (n=29) Both (n=2) (n=10) Well 8 (80.0%) 1 (3.4%) 0 (0.0%) Moderate 0 (0.0%) 17 (58.6%) 1 (50.0%) Poor 2 (20.0%) 11 (37.9%) 1 (50.0%) Perineural Invasion Local Recurrence Metastasis (n=24) Both (n=2) (n=17) Perineural 0 (0.0%) 7 (29.2%) 0 (0.0%)
Total (n=52) P-Value 5 (9.6%) 17 (32.7%) 15 (28.8%) 12 (23.1%) 3 (5.8%)
<0.00011
Total (n=51) P-Value 2.3 (1.9)
0.00853
Total (n=18) 5 (27.8%) 8 (44.4%) 5 (27.8%) Total (n=30) P-Value 4.3 (3.0)
0.70903
Total (n=41) P-Value 9 (22.0%) 18 (43.9%) 14 (34.1%)
<0.00011
Total (n=43) P-Value 7 (16.3%)
0.06221
19
Invasion 1 Fisher’s Exact, 2Wilcoxon Rank-Sum, 3Kruskal Wallis, INPP5A: inositol polyphosphate-5phosphatase 295
20
296
Figure Legend:
297 298
Figure 1. Examples of the INPP5A stain. (A) cSCC with a grade 3 staining intensity. (B) cSCC with a grade 1 staining intensity.
299 300 301 302
Figure 2. Recurrent and metastatic disease overall survival by (A) any event tumor INPP5A levels, (B) INPP5A composite risk score (LSE = 1, HSE = 0, score range of 0-2 based upon the summation of primary and RMD score), (C) INPP5A composite risk score grouping of zero risk factors vs. one or more risk factors.
303 304
Figure 3. Local recurrence overall survival comparing composite risk factor grouping of zero vs. one or more risk factors.
S0190-9622(19)32574-5
DOI:
https://doi.org/10.1016/j.jaad.2019.08.027
Reference:
YMJD 13747
To appear in:
Journal of the American Academy of Dermatology
Received Date: 29 April 2019 Revised Date:
5 August 2019
Accepted Date: 10 August 2019
Please cite this article as: Maly CJ, Cumsky HJL, Costello CM, Schmidt JE, Butterfield RJ, Zhang N, DiCaudo DJ, Nelson SA, Smith ML, Ochoa SA, Baum CL, Nagel TH, Pittelkow MR, Sekulic A, Mangold AR, Prognostic Value of Inositol Polyphosphate-5-Phosphatase Expression in Recurrent and Metastatic Cutaneous Squamous Cell Carcinoma, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2019.08.027. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1
1
Title: Prognostic Value of Inositol Polyphosphate-5-Phosphatase Expression in Recurrent and
2
Metastatic Cutaneous Squamous Cell Carcinoma
3
Connor J. Maly B.S.1, Helen J.L. Cumsky M.D.1, Collin M. Costello M.D.1, Jessica E. Schmidt
4
M.S.1, Richard J. Butterfield M.S.2, Nan Zhang M.S.2, David J. DiCaudo M.D.1, Steven A.
5
Nelson M.D.1, Maxwell L. Smith M.D.3, Shari A. Ochoa M.D.1, Christian L. Baum M.D.4,
6
Thomas H. Nagel M.D.5, Mark R. Pittelkow M.D.1, Aleksandar Sekulic M.D. Ph.D.1 and Aaron
7
R. Mangold M.D.1*
8
1
Mayo Clinic – Department of Dermatology; Scottsdale, AZ, USA
9
2
Mayo Clinic – Department of Health Science Research, Scottsdale, AZ, USA
10
3
Mayo Clinic – Department of Pathology; Scottsdale, AZ, USA
11
4
Mayo Clinic – Department of Dermatology; Rochester, MN, USA
12
5
Mayo Clinic – Department of Otolaryngology; Scottsdale, AZ, USA
13
*
Corresponding Author: Aaron Mangold, MD; Mayo Clinic – Department of Dermatology;
14
13400 E Shea Blvd, Scottsdale, AZ 85259 Email: [email protected]; Phone: 480-301-
15
8508; Fax: 480-301-9272
16
Funding: Dermatology Foundation – Career Development Award & NIH Grant 5R01CA179157
17
Conflicts of Interest: The authors declare that they have no conflict of interest and no financial
18
disclosure
19
Data presented at the 2019 Society for Investigative Dermatology Meeting.
20
Word Count: 2331
21
Tables: 1
22
Keywords: Inositol polyphosphate-5-phosphatase (INPP5A); Squamous Cell Carcinoma (SCC);
23
Immunohistochemistry (IHC)
References: 20
Figures: 4
2
24
Abstract
25
Background:
26
Inositol polyphosphate-5-phosphatase (INPP5A) has been shown to play a role in the progression
27
of actinic keratosis to cutaneous squamous cell carcinoma (cSCC) and the progression of
28
localized disease to metastatic disease. Currently, no cSCC biomarkers are able to risk stratify
29
recurrent and metastatic disease (RMD).
30
Objective:
31
To determine the prognostic value of INPP5A expression in cSCC RMD.
32
Methods:
33
This was a multi-center, single-institutional, retrospective cohort study within the Mayo Clinic
34
Health System using immunohistochemical staining to examine cSCC INPP5A protein
35
expression in primary tumors and RMD. Dermatologists and dermatopathologists were blinded
36
to outcome.
37
Results:
38
Low staining expression (LSE) of INPP5A of RMD was associated with poor overall survival
39
(OS) of 31.0 months vs. 62.0 months for high staining expression (HSE) (p=0.0272). A
40
composite risk score (CRS) (CRS=primary + RMD; with HSE=0 & LSE=1; range 0-2) of 0 was
41
predictive of improved OS compared to a CRS of ≥1 (HR = 0.42, 95%CI: 0.21 to 0.84,
42
p=0.0113).
43
Limitations:
44
This is a multi-center, but single institution study with a Caucasian population.
45
Conclusion:
46
Loss of INPP5A expression predicts poor OS in RMD of cSCC.
3
47
48
Capsule Summary •
with a poor prognosis. Currently, no biomarkers are able to risk stratify this population.
49 50
Recurrent and metastatic disease of cutaneous squamous cell carcinoma is associated
•
Low immunohistochemical staining expression of inositol polyphosphate-5-phosphatase
51
predicts poor overall survival in recurrent and metastatic cutaneous squamous cell
52
carcinoma.
4
53 54
Introduction: Non-melanoma skin cancer (NMSC) is the most common cancer in humans with five
55
million cancers per year in the United States.1 Cutaneous squamous cell carcinoma (cSCC) is the
56
second most common type of NMSC with a 14-20% lifetime risk in the non-Hispanic Caucasian
57
population.2,3 According to recent Medicare data, the incidence of cSCC has doubled from 1992
58
to 2012 with an equal incidence of cSCC and basal cell carcinoma (BCC).1 The economic burden
59
and incidence of cSCC has increased disproportionally to other cancers.4-6 As such, optimal,
60
cost-effective risk stratification and management is critical.
61
Unlike BCC, cSCC have higher risks of local recurrence (4.6%), nodal metastasis (3.7%),
62
and of disease-specific death (2.1%).7 Metastatic cSCC has a poor 5-year survival of 25-35% and
63
accounts for up to 8791 deaths annually.8 The most widely used staging systems, the American
64
Joint Committee on Cancer (AJCC) and Brigham and Women’s Hospital (BWH), focus on
65
clinical and histological risk factors of the primary tumor as a predictor of recurrence and
66
metastasis. 9-11 There is a paucity of data predicting outcomes of recurrent and metastatic disease
67
(RMD).
68
Inositol polyphosphate-5-phosphatase (INPP5A), a membrane-associated type I inositol
69
phosphatase, plays a role in the progression of actinic keratosis to cSCC as well as localized
70
disease to metastatic disease in oropharyngeal SCC and cSCC.12-14 Loss of INPP5A expression
71
in cSCC is correlated with aggressive tumor behavior and worse clinical outcomes.14 The
72
prognostic value of INPP5A in RMD is unknown. We hypothesize that loss of INPP5A
73
expression level in RMD will correlate with aggressive disease and predict a poor outcome.
5
74
Methods:
75
This study was approved by the Mayo Clinic institutional review board. Cases were
76
identified through our retrospective cSCC database which includes patients from Rochester,
77
Arizona, and Florida. All cases within the database that had a clear delineation of the causal
78
lesion that recurred or metastasized with a minimum of two years follow-up were included in the
79
study. If it was not possible to determine the primary cSCC for the RMD, the case was excluded.
80
All clinical data was obtained through a retrospective chart review. All cases in the database used
81
for this study underwent histological re-review and staging (DJD). The protocol was written for
82
discrepant cases to be reviewed by two dermatopathologists (DJD & SAN) for consensus
83
however, no cases were discrepant. Immunohistochemical staining was used to examine INPP5A
84
protein expression in both primary tumors and RMD (defined as locally recurrent (LR), locally
85
metastatic, and distantly metastatic). First, RMD was analyzed as one group. As a sub-analysis,
86
we analyzed local recurrence and metastasis separately. The metastatic group was composed of
87
in-transit metastasis, nodal metastasis, and distant metastasis. In-transit metastasis was defined as
88
cSCC without an epidermal connection that had spread at least 2cm from the lesion of origin but
89
was not within a lymph node. Locally metastatic disease was defined as in-transit metastases or
90
nodal metastatic disease within the draining lymph node basin. Distant metastatic disease was
91
defined as nodal disease outside the draining node basin or other organ involvement.
92
All slides were stained using the technique outlined in our previous study.14 INPP5A
93
protein expression levels were scored on a 4-point scale (0-3) by the consensus diagnosis (ARM
94
& DJD). Both reviewers were blinded to patient outcome. An INPP5A score of 3 was defined as
95
normal expression, a score of 2 was partially diminished, a score of 1 was significantly
96
diminished, and a score of 0 was complete loss. INPP5A staining examples are shown in Fig. 1.
97
High staining expression (HSE) was defined as a score of 2 or 3. Low staining expression (LSE)
6
98
was defined as a score of 0 or 1. All expression levels were compared with adjacent normal
99
epidermis. A control of normal epidermis was used to gauge the overall strength of the INPP5A
100
signal for each corresponding batch; this was used to adjust for any slight variations in staining
101
batch to batch. If normal epidermis was not available, the control of normal epidermis for the
102
same batch was utilized.
103
Overall survival (OS) was compared based upon INPP5A expression at the primary
104
tumor level, change in INPP5A status from primary tumor to events (HSE to LSE, LSE to HSE,
105
unchanged HSE, unchanged LSE), and an INPP5A Composite Risk Score (CRS) (LSE = 1, HSE
106
= 0, score range of 0-2 based upon the summation of primary tumor and the RMD tumor). A
107
CRS of zero indicated both the primary and RMD had HSE, a CRS of one demonstrated either
108
the primary or RMD had LSE, and a CRS of two indicated both the primary and RMD had LSE.
109
Statistical analysis:
110
Demographic characteristics and clinical characteristics at the patient and tumor level
111
were summarized and compared between INPP5A groups using Fisher’s exact, Wilcoxon rank
112
sum test, or Kuskal-Wallis test when applicable. Wilcoxon signed-rank test was used to test if
113
there was a difference between primary tumor INPP5A level and event tumor INPP5A level. The
114
OS was estimated using the Kaplan-Meier method and compared between INPP5A groups using
115
a log-rank test. Cox regression was used to estimate the hazard ratio for INPP5Agroups. A
116
subgroup analysis of recurrent disease, metastatic disease, and RMD excluding 5 SCC in-situ
117
cases were implemented in a similar manner.
7
118 119
Results: 50 patients with RMD cSCC, 52 tumors, and 64 events (27 local recurrence, 32 local
120
metastasis, and five distant metastasis) were examined. Ten primary tumors had multiple events:
121
eight tumors with two events and two tumors with three events. There were no significant
122
differences in age, gender, race, Fitzpatrick skin type, number of tumors, skin cancer history,
123
number of skin cancer diagnoses when comparing patients with local recurrence and metastasis
124
(Table 1). 14 patients (28.6%) were immunosuppressed: 64.3% were solid organ transplant
125
recipients, 21.4% had chronic lymphocytic leukemia, and 14.3% had iatrogenic
126
immunosuppression secondary to an inflammatory disease. There were significantly more
127
immunosuppressed patients in the metastatic group (33% vs 11.1%, p = 0.0271).
128
The primary tumors were comprised of 9.6% BWH T0, 32.7% BWH T1, 28.8% BWH
129
T2a, 23.1% BWH T2b, and 5.8% BWH T3 (Table 1). We compared the INPP5A expression of
130
the primary tumors and RMD event tumors. 41/52 (78.8%) of primary tumors had HSE and
131
11/52 (21.2%) had LSE. 36/52 (69.2%) of RMD had HSE and 16/52 (30.8%) had LSE. Primary
132
tumors with LSE had greater depth (5.8mm vs 3.7mm, p=0.0415) and higher rates of perineural
133
invasion (44% vs 9%, p=0.0257), but were not significantly different by BWH staging (p =
134
0.0645) or differentiation (p = 0.0521) (Table 1).
135
Patients with RMD disease had only metastatic tumors in 55.8% of cases, LR tumors in
136
38.5% of cases, and both metastatic and LR disease in 5.8% of cases. All three groups of RMD
137
(local recurrence, metastasis, and both) differed significantly in BWH staging, primary tumor
138
diameter, depth of invasion, tumor differentiation, and perineural invasion (Table 1). When
139
comparing CRS 0, 1, and 2 for RMD tumors, there were significant differences in primary tumor
140
depth of invasion (p = 0.0372) and primary tumor differentiation (p = 0.0102). After excluding 5
8
141
SCC in-situ patients, depth of invasion and tumor differentiation were no longer different
142
between RMD risk factor groups (p = 0.25 and p = 0.20, respectively).
143
OS of RMD was not affected by INPP5A level of the primary tumor (31.0 months LSE
144
vs 57.0 months HSE, p = 0.0897). However, INPP5A level of the RMD event tumor was
145
predictive of OS (31.0 months LSE vs 62.0 months HSE, p = 0.0272, Fig. 2a). OS was not
146
different between INPP5A group transitions (HSE to LSE group, 31.0 months, 20% of cases;
147
LSE to HSE group, 26.0 months, 12% of cases; unchanged HSE group, 62.0 months, 58% of
148
cases; and unchanged LSE group, 10% of cases, 31.0 months, p = 0.0899). The CRS of INPP5A
149
was predictive of OS (risk score = 0, 62.0 months; risk score = 1, 26.0 months; and risk score =
150
2, 31.0 months, p = 0.039, Fig. 2b). OS comparing CRS of zero versus CRS ≥ 1 was significantly
151
different (risk score = 0, 62.0 months; risk score = 1 or more, 31.0 months, p = 0.0113, Fig. 2c).
152
Due to the difference in tumor characteristics amongst the CRS of 0-2, a sub-analysis
153
excluding the five SCC in-situ cases was performed. OS of INPP5A levels of the primary tumor
154
and CRS of 0-2 was non-significant. However, the OS of CRS risk score of zero versus CRS ≥ 1
155
remained significant (CRS=0 62.0 months vs CRS ≥ 1 31.0 months, p = 0.0325).
156
A subgroup analysis of LR and metastatic disease was performed. For LR, patient
157
demographics and tumor characteristics across all analysis were non-significant except for
158
immunosuppression, which was more common in those with a CRS ≥ 1 (p = 0.0005). In LR
159
disease, LSE of INPP5A at the primary tumor level was associated with a worse OS (HSE 71.0
160
months and LSE 31.0 months, p = 0.0296). INPP5A expression at the event level of LR was non-
161
significant (HSE 71.0 months and LSE 45.5 months, p = 0.0884). A CRS ≥ 1 was associated
162
with a poor OS (CRS = 0 median survival 71.0 months vs CRS ≥ 1 median survival 42.0 months,
9
163
p = 0.0225) (Fig. 3). LSE of INPP5A at the primary tumor, event tumor level or CRS ≥ 1 of
164
metastatic disease was not associated with a worse OS.
10
165 166
Discussion: We found that LSE of INPP5A of RMD was associated with poor OS (median survival
167
31.0 months LSE vs. 62.0 months HSE, p = 0.0272) and HSE of INPP5A in the primary and
168
RMD (CRS of 0) was predictive of improved OS (HR = 0.42, 95% CI: 0.21 to 0.84, p=0.0113).
169
The OS of high-risk RMD by INPP5A staining (26% & 31% at 2 years) and CRS ≥ 1 (31% at 2
170
years), was similar to prior studies with lymph node metastasis, in which OS ranged from 33% at
171
2 years to 46.7% at 3 years, and recurrent head and neck cSCC, in which the OS at 1-year was
172
43.2%.15-17 Once verified, INPP5A expression at the primary tumor and nodal level may be used
173
to risk stratify individuals both for and with RMD. Furthermore, risk stratification may be
174
possible in cases of RMD without primary tissue and in tumors of unknown primary.
175
Prior studies have identified tumor size, differentiation, depth, and location as risk factors
176
for the development of RMD.7,8,10,18,19 LSE of INPP5A at the primary tumor is predictive of
177
more aggressive behavior, HR of 2.71 for OS and an HR of 4.71 for local/regional metastasis.14
178
Tumors in our cohort with LSE had higher rates of perineural invasion (44% vs 9%, p=0.0257)
179
and greater depth (5.8mm vs 3.7mm, p=0.0415), but no difference by BWH stages or
180
differentiation. These findings are similar to our prior work which found an association of LSE
181
and perineural invasion, poor differentiation, tumor size greater than 2cm, and invasion beyond
182
the fat.14 The cohort in this study was smaller and all tumors were high risk with RMD and
183
similar risk factors.
184
We examined INPP5A expression of primary tumors, RMD, and created a CRS. LSE of
185
the RMD and a CRS ≥ 1 were noted of being associated with poor OS. However, there were
186
significant differences between tumor groups with more aggressive tumors in both groups. These
187
differences were thought to be secondary to 5 SCCIS in the study. Therefore, we excluded the 5
11
188
cases of SCC in-situ, and the differences between groups were non-significant. Re-analysis
189
without the SCCIS found a trend with LSE score at the primary tumor or RMD and decreased
190
OS (p=0.089) and a decreased OS in those with a CRS ≥ 1 (CRS=0 62.0 months vs CRS ≥ 1 31.0
191
months, p = 0.0325). Therefore, we believe that a CRS ≥ 1 is a potential marker of poor outcome
192
independent of BWH T-stage. Larger studies are needed to verify these findings.
193
We performed a sub-analysis of LR and metastatic tumors. LSE in primary tumors with
194
LR was associated with poor OS (median survival 31.0 months LSE vs 71.0 months HSE,
195
p=0.0296). Interestingly, there was only a trend for LSE of the LR event tumor (p = 0.0884).
196
This difference is likely due to a lack of power. A CRS ≥ 1 in LR tumors was predictive of poor
197
OS (HR = 3.88, 95% CI: 1.10 – 13.69, p=0.0225). Importantly, there were no differences in
198
tumor characteristics suggesting that CRS may be useful in risk stratification independent of
199
BWH T-stage. Subgroup analysis of the demographics of LR cSCC by CRS found a higher rate
200
of immunosuppression in the CRS≥ 1. Immunosuppressed patients have worse OS which may
201
account for the findings in the LR CRS≥ 1 group.20 INPP5A expression and CRS were not able
202
to risk-stratify metastatic tumors for OS. The metastatic cohort was advanced at initial diagnosis,
203
had a worse OS at baseline, and therefore would require a larger number of cases to risk stratify.
204
86.2% of primary tumors that went on to have metastatic disease were T2a or above versus 15%
205
of tumors for recurrent disease. Further studies with larger cohorts of metastatic disease need to
206
be conducted.
207
This study had several limitations. This was a single institution study with a Caucasian
208
population. Our study was underpowered to detect differences in outcome of INPP5A at the
209
primary tumor level for all RMD and disease-specific death. Additionally, the metastatic cohort
210
was significantly more stage advanced than the recurrent cohort.
12
211
In conclusion, loss of INPP5A expression predicts poor OS in RMD of cSCC. INPP5A
212
CRS of 0 is associated with a superior OS of locally recurrent cSCC. Our study demonstrates the
213
potential for INPP5A expression level to be used as an adjunct tumor marker for clinical
214
management and risk stratification of locally RMD disease in cSCC. An additional study with a
215
larger cohort is justified in order to determine if INPP5A expression may serve as a biomarker to
216
stratify OS in individuals with metastatic disease.
13
217
Abbreviations and acronyms:
218
Non-melanoma skin cancer: NMSC
219
Cutaneous squamous cell carcinoma: cSCC
220
Basal cell carcinoma: BCC
221
American Joint Committee on Cancer: AJCC
222
Brigham and Women’s Hospital: BWH
223
Recurrent and metastatic disease: RMD
224
Inositol polyphosphate-5-phosphatase: INPP5A
225
Local recurrence: LR
226
High staining expression: HSE
227
Low staining expression: LSE
228
Overall survival: OS
229
Composite risk score: CRS
230
Hazard ratio: HR
14
231
References:
232
1.
Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of
233
Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012.
234
JAMA Dermatol. 2015;151(10):1081-1086.
235
2.
Potenza C, Bernardini N, Balduzzi V, Losco L, Mambrin A, Marchesiello A, et al. A
236
Review of the Literature of Surgical and Nonsurgical Treatments of Invasive Squamous
237
Cells Carcinoma. Biomed Res Int. 2018;2018:9489163.
238
3.
North Am. 2019;33(1):1-12.
239 240
Waldman A, Schmults C. Cutaneous Squamous Cell Carcinoma. Hematol Oncol Clin
4.
Housman TS, Feldman SR, Williford PM, Fleischer AB, Jr., Goldman ND,
241
Acostamadiedo JM, et al. Skin cancer is among the most costly of all cancers to treat for
242
the Medicare population. Journal of the American Academy of Dermatology.
243
2003;48(3):425-429.
244
5.
Christenson LJ, Borrowman TA, Vachon CM, Tollefson MM, Otley CC, Weaver AL, et
245
al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40
246
years. Jama. 2005;294(6):681-690.
247
6.
Muzic JG, Schmitt AR, Wright AC, Alniemi DT, Zubair AS, Olazagasti Lourido JM, et
248
al. Incidence and Trends of Basal Cell Carcinoma and Cutaneous Squamous Cell
249
Carcinoma: A Population-Based Study in Olmsted County, Minnesota, 2000 to 2010.
250
Mayo Clin Proc. 2017;92(6):890-898.
251
7.
Schmults CD, Karia PS, Carter JB, Han J, Qureshi AA. Factors predictive of recurrence
252
and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort
253
study. JAMA Dermatol. 2013;149(5):541-547.
15
254
8.
Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence
255
of disease, nodal metastasis, and deaths from disease in the United States, 2012. Journal
256
of the American Academy of Dermatology. 2013;68(6):957-966.
257
9.
7 ed. New York2010.
258 259
Edge S, Byrd D, Compton C, Fritz A, Greene F, Trotti A. AJCC Cancer Staging Manual.
10.
Karia PS, Jambusaria-Pahlajani A, Harrington DP, Murphy GF, Qureshi AA, Schmults
260
CD. Evaluation of American Joint Committee on Cancer, International Union Against
261
Cancer, and Brigham and Women's Hospital tumor staging for cutaneous squamous cell
262
carcinoma. J Clin Oncol. 2014;32(4):327-334.
263
11.
Motaparthi K, Kapil JP, Velazquez EF. Cutaneous Squamous Cell Carcinoma: Review of
264
the Eighth Edition of the American Joint Committee on Cancer Staging Guidelines,
265
Prognostic Factors, and Histopathologic Variants. Adv Anat Pathol. 2017;24(4):171-194.
266
12.
Sekulic A, Kim SY, Hostetter G, Savage S, Einspahr JG, Prasad A, et al. Loss of inositol
267
polyphosphate 5-phosphatase is an early event in development of cutaneous squamous
268
cell carcinoma. Cancer prevention research. 2010;3(10):1277-1283.
269
13.
Patel AB, Mangold AR, Costello CM, Nagel TH, Smith ML, Hayden RE, et al. Frequent
270
loss of inositol polyphosphate-5-phosphatase in oropharyngeal squamous cell carcinoma.
271
J Eur Acad Dermatol Venereol. 2018;32(1):e36-e37.
272
14.
Cumksy HJ, Costello CM, Zhang N, Butterfield R, Buras M, Schmidt J, et al. The
273
Prognostic Value of Inositol Polyphosphate 5-Phosphatase in Cutaneous Squamous Cell
274
Carcinoma. Journal of the American Academy of Dermatology. 2018.
16
275
15.
Moore BA, Weber RS, Prieto V, El-Naggar A, Holsinger FC, Zhou X, et al. Lymph node
276
metastases from cutaneous squamous cell carcinoma of the head and neck.
277
Laryngoscope. 2005;115(9):1561-1567.
278
16.
squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 1998;124(5):582-587.
279 280
Kraus DH, Carew JF, Harrison LB. Regional lymph node metastasis from cutaneous
17.
Sun L, Chin RI, Gastman B, Thorstad W, Yom SS, Reddy CA, et al. Association of
281
Disease Recurrence With Survival Outcomes in Patients With Cutaneous Squamous Cell
282
Carcinoma of the Head and Neck Treated With Multimodality Therapy. JAMA Dermatol.
283
2019.
284
18.
Wermker K, Kluwig J, Schipmann S, Klein M, Schulze HJ, Hallermann C. Prediction
285
score for lymph node metastasis from cutaneous squamous cell carcinoma of the external
286
ear. Eur J Surg Oncol. 2015;41(1):128-135.
287
19.
Mullen JT, Feng L, Xing Y, Mansfield PF, Gershenwald JE, Lee JE, et al. Invasive
288
squamous cell carcinoma of the skin: defining a high-risk group. Ann Surg Oncol.
289
2006;13(7):902-909.
290
20.
Thompson AK, Kelley BF, Prokop LJ, Murad MH, Baum CL. Risk Factors for
291
Cutaneous Squamous Cell Carcinoma Recurrence, Metastasis, and Disease-Specific
292
Death: A Systematic Review and Meta-analysis. JAMA Dermatol. 2016;152(4):419-428.
293 294
17
Table 1: Patient Demographics and Tumor Characteristics Patient Demographics (n=50) Age at Biopsy of cSCC of interest Mean (SD) 73.1 (10.5) Gender Female 14 (28.0%) Male 36 (72.0%) Race Caucasian 49 (100%) Missing 1 Fitzpatrick skin type I 1 (4.3%) II 18 (78.3%) III 4 (17.4%) Missing 27 Immunosuppressed and History of Skin Cancer Immunosuppressed 14 (28.6%) History of Skin Cancer 45 (90.0%) Reason for Immunosuppression (One or Multiple) Organ Transplant 9 (64.3%) Chronic Lymphocytic Leukemia 3 (21.4%) Inflammatory Disease 2 (14.3%) Tumor Characteristics of Primary Tumors for High and Low INPP5A Expression Brigham and Women’s Hospital T-Staging High INPP5A Low INPP5A (n=41) (n=11) T0 5 (12.2%) 0 (0.0%) T1 15 (36.6%) 2 (18.2%) T2a 13 (31.7%) 2 (18.2%) T2b 7 (17.1%) 5 (45.5%) T3 1 (2.4%) 2 (18.2%) Primary Tumor Diameter (cm) High INPP5A Low INPP5A (n=40) (n=11) Mean (SD) 2.2 (1.9) 2.5 (2.1) Primary Tumor Depth of Invasion High INPP5A Low INPP5A (n=41) (n=11) In Situ 5 (41.7%) 0 (0.0%) Dermis/Subcutaneous Fat 5 (41.7%) 3 (50.0%) Cartilage/Muscle 2 (16.7%) 3 (50.0%) Primary Tumor Depth (mm) High INPP5A Low INPP5A (n=21) (n=9)
Total (n=52) 5 (9.6%) 17 (32.7%) 15 (28.8%) 12 (23.1%) 3 (5.8%)
P-value
Total (n=51) 2.3 (1.9)
P-value
Total (n=52) 5 (27.8%) 8 (44.4%) 5 (27.8%) Total (n=30)
0.06451
0.41552 P-value 0.14081
P-value
18
Mean (SD)
Well Moderate Poor
Perineural Invasion
3.7 (2.8) 5.8 (3.1) Primary Tumor Differentiation High INPP5A Low INPP5A (n=41) (n=11) 9 (28.1%) 0 (0.0%) 15 (46.9%) 3 (33.3%) 8 (25.0%) 6 (66.7%) Perineural Invasion High INPP5A Low INPP5A (n=41) (n=11) 3 (8.8%) 4 (44.4%)
4.3 (3.0)
0.04152
Total (n=52) 9 (22.0%) 18 (43.9%) 14 (34.1%)
P-value
Total (n=52) 7 (16.3%)
P-value
0.05211
0.02571
Tumor Characteristics: Local Recurrence, Metastasis, and Both Brigham and Women’s Hospital T-Staging Local Recurrence Metastasis (n=29) Both (n=3) (n=20) T0 5 (25.0%) 0 (0.0%) 0 (0.0%) T1 12 (60.0%) 4 (13.8%) 1 (33.3%) T2a 1 (5.0%) 13 (44.8%) 1 (33.3%) T2b 2 (10.0%) 9 (31.0%) 1 (33.3%) T3 0 (0.0%) 3 (10.3%) 0 (0.0%) Primary tumor diameter (cm) Local Recurrence Metastasis (n=29) Both (n=3) (n=19) Mean (SD) 1.6 (1.5) 2.7 (2.1) 2.2 (1.1) Primary Tumor Depth of Invasion Local Recurrence Metastasis Both (n=1) (n=5) (n=12) In Situ 5 (100.0%) 0 (0.0%) 0 (0.0%) Dermis / 0 (0.0%) 7 (58.3%) 1 (100.0%) Subcutaneous Fat Cartilage / Muscle 0 (0.0%) 5 (41.7%) 0 (0.0%) Primary Tumor Depth (mm) Local Recurrence Metastasis (n=26) Both (n=2) (n=2) Mean (SD) 2.9 (1.6) 4.4 (3.1) 5.4 (4.0) Primary Tumor Differentiation Local Recurrence Metastasis (n=29) Both (n=2) (n=10) Well 8 (80.0%) 1 (3.4%) 0 (0.0%) Moderate 0 (0.0%) 17 (58.6%) 1 (50.0%) Poor 2 (20.0%) 11 (37.9%) 1 (50.0%) Perineural Invasion Local Recurrence Metastasis (n=24) Both (n=2) (n=17) Perineural 0 (0.0%) 7 (29.2%) 0 (0.0%)
Total (n=52) P-Value 5 (9.6%) 17 (32.7%) 15 (28.8%) 12 (23.1%) 3 (5.8%)
<0.00011
Total (n=51) P-Value 2.3 (1.9)
0.00853
Total (n=18) 5 (27.8%) 8 (44.4%) 5 (27.8%) Total (n=30) P-Value 4.3 (3.0)
0.70903
Total (n=41) P-Value 9 (22.0%) 18 (43.9%) 14 (34.1%)
<0.00011
Total (n=43) P-Value 7 (16.3%)
0.06221
19
Invasion 1 Fisher’s Exact, 2Wilcoxon Rank-Sum, 3Kruskal Wallis, INPP5A: inositol polyphosphate-5phosphatase 295
20
296
Figure Legend:
297 298
Figure 1. Examples of the INPP5A stain. (A) cSCC with a grade 3 staining intensity. (B) cSCC with a grade 1 staining intensity.
299 300 301 302
Figure 2. Recurrent and metastatic disease overall survival by (A) any event tumor INPP5A levels, (B) INPP5A composite risk score (LSE = 1, HSE = 0, score range of 0-2 based upon the summation of primary and RMD score), (C) INPP5A composite risk score grouping of zero risk factors vs. one or more risk factors.
303 304
Figure 3. Local recurrence overall survival comparing composite risk factor grouping of zero vs. one or more risk factors.