Molecular Subtypes of Melanoma. Biological and Clinical Significance

Abstract: Cutaneous malignant melanoma (CMM) is the most lethal form of skin cancer and its incidence has increased faster than that of any other cancer, rendering it a major public health problem worldwide. High-throughput screenings have opened the door to a new scientific world, which enables molecular-based characterization of large cancer cohort collections. The aim of the research presented in this thesis was to explore the molecular landscapes of melanoma tumors on a genomic and transcriptomic level and subsequently correlate certain molecular features with patient survival, treatment response and tumor evolutionary patterns. In Paper I, it was concluded that metastatic melanoma could be divided into transcriptomic subtypes (gene expression (GEX) phenotypes) possessing diverse biological and clinical features. Patients harboring melanomas infiltrated by immune cells, i.e. the high-immune subtype, showed a superior survival, whereas highly proliferative melanomas, i.e. the proliferative subtype, was correlated to a poor survival outcome and resistance to targeted therapies. Moreover, it was also shown that, irrespectively of the GEX phenotypes, melanomas could be divided into genomic subtypes based on genetic aberrations in the mitogen-activated protein kinase (MAPK) signaling pathway. In Paper II, it was found that mutations in the tumor suppressor gene neurofibromin 1 (NF1), was linked to inferior survival. Today, it is well accepted that most tumors possess some level of intratumor heterogeneity (ITH), i.e. subclonality, influencing disease progression. In Papers III and IV, the evolutionary aspects of melanoma were considered by analyzing ITH, as well as disease progression on a molecular basis. When analyzing multiple metastatic lesions from individual patients, we found that most tumors were genetically different, with a common stem of genetic aberrations and the addition of new “private” ones, thus pointing to continued evolution during progression. Moreover, the GEX proliferative phenotype appeared to be correlated to a later disease course. From multiregional biopsies from single tumors, it was found that mutations in the MAPK signaling pathway appeared to be early events in tumorigenesis. Heterogeneous somatic mutations were found in the range of 3-38%, thus highlighting different levels of subclonality in melanoma. A high degree of mutational heterogeneity was associated with a more aggressive disease progression. In conclusion, melanoma is a complex molecular disease that can be characterized by genomic and transcriptomic signatures with clinical implications. However, a single biopsy might not reflect the true tumor complexity, and subclonality may be one reason behind resistance development.