title: Association Between NRAS and BRAF Mutational Status and Melanoma-Specific Survival Among Patients With Higher-Risk Primary Melanoma.
abstract: OBJECTIVE
  NRAS and BRAF mutations in melanoma inform current treatment paradigms, but their role in survival from primary melanoma has not been established. Identification of patients at high risk of melanoma-related death based on their primary melanoma characteristics before evidence of recurrence could inform recommendations for patient follow-up and eligibility for adjuvant trials.
  
  
  OBJECTIVE
  To determine tumor characteristics and survival from primary melanoma by somatic NRAS and BRAF status.
  
  
  METHODS
  A population-based study with a median follow-up of 7.6 years (through 2007), including 912 patients from the United States and Australia in the Genes, Environment, and Melanoma (GEM) Study, with first primary cutaneous melanoma diagnosed in the year 2000 and analyzed for NRAS and BRAF mutations.
  
  
  METHODS
  Tumor characteristics and melanoma-specific survival of primary melanoma by NRAS and BRAF mutational status.
  
  
  RESULTS
  The melanomas were 13% NRAS+, 30% BRAF+, and 57% with neither NRAS nor BRAF mutation (wildtype [WT]). In a multivariable model including clinicopathologic characteristics, relative to WT melanoma (with results reported as odds ratios [95% CIs]), NRAS+ melanoma was associated with presence of mitoses (1.8 [1.0-3.3]), lower tumor-infiltrating lymphocyte (TIL) grade (nonbrisk, 0.5 [0.3-0.8]; and brisk, 0.3 [0.5-0.7] [vs absent TILs]), and anatomic site other than scalp/neck (0.1 [0.01-0.6] for scalp/neck vs trunk/pelvis), and BRAF+ melanoma was associated with younger age (ages 50-69 years, 0.7 [0.5-1.0]; and ages >70 years, 0.5 [0.3-0.8] [vs <50 years]), superficial spreading subtype (nodular, 0.5 [0.2-1.0]; lentigo maligna, 0.4 [0.2-0.7]; and unclassified/other, 0.2 [0.1-0.5] [vs superficial spreading]), and presence of mitoses (1.7 [1.1-2.6]) (P < .05 for all). There was no significant difference in melanoma-specific survival (reported as hazard ratios [95% CIs]) for melanoma harboring mutations in NRAS (1.7 [0.8-3.4]) or BRAF (1.5 [0.8-2.9]) compared with WT melanoma, as adjusted for age, sex, site, American Joint Committee on Cancer (AJCC) tumor stage, TIL grade, and study center. However, melanoma-specific survival was significantly poorer for higher-risk (T2b or higher stage) tumors with NRAS (2.9 [1.1-7.7]) or BRAF (3.1 [1.2-8.5]) mutations (P = .04) but not for lower-risk (T2a or lower) tumors with NRAS (0.9 [0.3-3.0]) or BRAF (0.6 [0.2-1.7]) (P = .65), as adjusted for age, sex, site, AJCC tumor stage, TIL grade, and study center.
  
  
  CONCLUSIONS
  Lower TIL grade for NRAS+ melanoma suggests it has a more immunosuppressed microenvironment, which may affect its response to immunotherapies. The approximate 3-fold increased risk of death for higher-risk tumors harboring NRAS or BRAF mutations after adjusting for other prognostic factors compared with WT melanomas indicates that the prognostic implication of these mutations deserves further investigation, particularly in higher–AJCC stage primary melanomas.
authors.forename: Nancy E
authors.initials: NE
authors.lastname: Thomas
authors.forename: Sharon N
authors.initials: SN
authors.lastname: Edmiston
authors.forename: Audrey
authors.initials: A
authors.lastname: Alexander
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Groben
authors.forename: Eloise
authors.initials: E
authors.lastname: Parrish
authors.forename: Anne
authors.initials: A
authors.lastname: Kricker
authors.forename: Bruce K
authors.initials: BK
authors.lastname: Armstrong
authors.forename: Hoda
authors.initials: H
authors.lastname: Anton-Culver
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Gruber
authors.forename: Lynn
authors.initials: L
authors.lastname: From
authors.forename: Klaus J
authors.initials: KJ
authors.lastname: Busam
authors.forename: Honglin
authors.initials: H
authors.lastname: Hao
authors.forename: Irene
authors.initials: I
authors.lastname: Orlow
authors.forename: Peter A
authors.initials: PA
authors.lastname: Kanetsky
authors.forename: Li
authors.initials: L
authors.lastname: Luo
authors.forename: Anne S
authors.initials: AS
authors.lastname: Reiner
authors.forename: Susan
authors.initials: S
authors.lastname: Paine
authors.forename: Jill S
authors.initials: JS
authors.lastname: Frank
authors.forename: Jennifer I
authors.initials: JI
authors.lastname: Bramson
authors.forename: Lorraine D
authors.initials: LD
authors.lastname: Marrett
authors.forename: Richard P
authors.initials: RP
authors.lastname: Gallagher
authors.forename: Roberto
authors.initials: R
authors.lastname: Zanetti
authors.forename: Stefano
authors.initials: S
authors.lastname: Rosso
authors.forename: Terence
authors.initials: T
authors.lastname: Dwyer
authors.forename: Anne E
authors.initials: AE
authors.lastname: Cust
authors.forename: David W
authors.initials: DW
authors.lastname: Ollila
authors.forename: Colin B
authors.initials: CB
authors.lastname: Begg
authors.forename: Marianne
authors.initials: M
authors.lastname: Berwick
authors.forename: Kathleen
authors.initials: K
authors.lastname: Conway
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000235:genetics*; D004252:DNA Mutational Analysis; D005260:Female; D020558:GTP Phosphohydrolases / Q000235:genetics*; D005787:Gene Frequency; D020022:Genetic Predisposition to Disease; D006801:Humans; D053208:Kaplan-Meier Estimate; D016246:Lymphocytes, Tumor-Infiltrating; D008297:Male; D008545:Melanoma / Q000201:enzymology / Q000235:genetics* / Q000276:immunology / Q000401:mortality / Q000473:pathology / Q000628:therapy; D008565:Membrane Proteins / Q000235:genetics*; D008875:Middle Aged; D015999:Multivariate Analysis; D009154:Mutation; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D009517:New South Wales; D016017:Odds Ratio; D010641:Phenotype; D016016:Proportional Hazards Models; D048493:Proto-Oncogene Proteins B-raf / Q000235:genetics*; D018570:Risk Assessment; D012307:Risk Factors; D012878:Skin Neoplasms / Q000201:enzymology / Q000235:genetics* / Q000276:immunology / Q000401:mortality / Q000473:pathology / Q000628:therapy; D013997:Time Factors; D059016:Tumor Microenvironment; D014481:United States
chemical_list: D014408:Biomarkers, Tumor; D008565:Membrane Proteins; C482119:BRAF protein, human; D048493:Proto-Oncogene Proteins B-raf; D020558:GTP Phosphohydrolases; C579846:NRAS protein, human