Opinion statement
In the era of molecular targeted therapy, the accurate detection of BRAF mutation in melanoma has become increasingly important. With the advances of molecular analyses and immunohistochemistry, the presence of BRAF mutational heterogeneity in melanoma has been widely recognized. Although most patients with melanoma have a homogeneous BRAF mutation status because the BRAF mutation occurs at an early stage of melanoma development and acts as a driver gene mutation, BRAF mutational heterogeneity does exist, among different tumor sites of a single patient (intertumor heterogeneity) and/or even within a single tumor (intratumor heterogeneity). To summarize the published reports, about 10% of melanoma patients may show intertumorally discordant BRAF status and about 15% of BRAF-mutated melanomas may have intratumor BRAF heterogeneity, although the reported results vary strikingly among the studies and methods used. Considering the BRAF heterogeneity of melanoma, a single biopsy from a single tumor may not be sufficient to uncover the entire BRAF status of a patient. Multiple samples from different sites may be preferable to assess the indication of BRAF/MEK inhibitors, as recommended by the current clinical guidelines. The impact of BRAF heterogeneity on patient survival or the response to treatment with BRAF/MEK inhibitors is an interesting issue, but requires further investigation.
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Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011;61:212–36.
Kohler BA, Ward E, McCarthy BJ, Schymura MJ, Ries LA, Eheman C, et al. Annual report to the nation on the status of cancer, 1975–2007, featuring tumors of the brain and other nervous system. J Natl Cancer Inst. 2011;103:714–36.
Dinnes J, Ferrante di Ruffano L, Takwoingi Y, Cheung ST, Nathan P, Matin RN, et al. Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma. Cochrane Database Syst Rev. 2019;7(7):CD012806. https://doi.org/10.1002/14651858.CD012806.pub2.
Bastian BC, de la Fouchardiere A, Elder DE, Gerami P, Lazar AJ, Massi D, et al. WHO classification of skin tumors. 4th ed: IARC; 2018.
Bradish JR, Cheng L. Molecular pathology of malignant melanoma: changing the clinical practice paradigm toward a personalized approach. Hum Pathol. 2014;45(7):1315–26.
Davies H, Bignell GR, Cox C, Stephens P, Edkins S, Clegg S, et al. Mutations of the BRAF gene in human cancer. Nature. 2002;417:949–54.
Ascierto PA, Kirkwood JM, Grob JJ, Simeone E, Grimaldi AM, Maio M, et al. The role of BRAF V600 mutation in melanoma. J Transl Med. 2012;10:85.
Meacham CE, Morrison SJ. Tumour heterogeneity and cancer cell plasticity. Nature. 2013;501:328–37.
Yancovitz M, Litterman A, Yoon J, Ng E, Shapiro RL, Berman RS, et al. Intra- and inter-tumor heterogeneity of BRAF(V600E) mutations in primary and metastatic melanoma. PLoS One. 2012;7:e29336.
Lin J, Goto Y, Murata H, Sakaizawa K, Uchiyama A, Saida T, et al. Polyclonality of BRAF mutations in primary melanoma and the selection of mutant alleles during progression. Br J Cancer. 2011;104(3):464–8.
Verlinden I, van den Hurk K, Clarijs R, Willig AP, Stallinga CM, Roemen GM, et al. BRAFV600E immunopositive melanomas show low frequency of heterogeneity and association with epithelioid tumor cells: a STROBE-compliant article. Medicine (Baltimore). 2014;93(28):e285.
• Grzywa TM, Paskal W, Włodarski PK. Intratumor and intertumor heterogeneity in melanoma. Transl Oncol. 2017;10(6):956–75 A comprehensive review on intratumor and intertumor heterogeneity of melanoma, including BRAF and other genes.
Bruno W, Martinuzzi C, Andreotti V, Pastorino L, Spagnolo F, Dalmasso B, et al. Heterogeneity and frequency of BRAF mutations in primary melanoma: comparison between molecular methods and immunohistochemistry. Oncotarget. 2017;8(5):8069–82.
Fisher KE, Cohen C, Siddiqui MT, Palma JF, Lipford EH 3rd, Longshore JW. Accurate detection of BRAF p.V600E mutations in challenging melanoma specimens requires stringent immunohistochemistry scoring criteria or sensitive molecular assays. Hum Pathol. 2014;45(11):2281–93.
Lamy PJ, Castan F, Lozano N, Montélion C, Audran P, Bibeau F, et al. Next-generation genotyping by digital PCR to detect and quantify the BRAF V600E mutation in melanoma biopsies. J Mol Diagn. 2015;17(4):366–73.
Chang GA, Wiggins JM, Corless BC, Syeda MM, Tadepalli JS, Blake S, et al. TERT, BRAF, and NRAS mutational heterogeneity between paired primary and metastatic melanoma tumors. J Invest Dermatol. 2020;140(8):1609–18.e7.
Ito T, Kaku-Ito Y, Murata M, Furue K, Shen CH, Oda Y, et al. Immunohistochemical BRAF V600E expression and intratumor BRAF V600E heterogeneity in acral melanoma: implication in melanoma-specific survival. J Clin Med. 2020;9(3):690.
Ito T, Kaku-Ito Y, Murata M, Ichiki T, Kuma Y, Tanaka Y, et al. Intra- and inter-tumor BRAF heterogeneity in acral melanoma: an immunohistochemical analysis. Int J Mol Sci. 2019;20(24):6191. https://doi.org/10.3390/ijms20246191.
NCCN Guidelines Version 4. 2020 Cutaneous Melanoma. https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf. Accessed 27 Sep 2020.
Thiel A, Moza M, Kytölä S, Orpana A, Jahkola T, Hernberg M, et al. Prospective immunohistochemical analysis of BRAF V600E mutation in melanoma. Hum Pathol. 2015;46(2):169–75.
• Valachis A, Ullenhag GJ. Discrepancy in BRAF status among patients with metastatic malignant melanoma: a meta-analysis. Eur J Cancer. 2017;81:106–15 A meta-analysis showing intertumor heterogeneity between primary–metastatic and metastatic–metastatic melanoma lesions.
Nakamura Y, Asai J, Igaki H, Inozume T, Namikawa K, Hayashi A, et al. Japanese dermatological association guidelines: outlines of guidelines for cutaneous melanoma 2019. J Dermatol. 2020;47(2):89–103.
Garbe C, Amaral T, Peris K, Hauschild A, Arenberger P, Bastholt L, et al. European consensus-based interdisciplinary guideline for melanoma. Part 2: treatment-update 2019. Eur J Cancer. 2020;126:159–77.
Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019;80(1):208–50.
Pellegrini C, Cardelli L, Padova M, Nardo LD, Ciciarelli V, Rocco T, et al. Intra-patient heterogeneity of BRAF and NRAS molecular alterations in primary melanoma and metastases. Acta Derm Venereol. 2020;100(1):adv00040.
• Kaji T, Yamasaki O, Takata M, Otsuka M, Hamada T, Morizane S, et al. Comparative study on driver mutations in primary and metastatic melanomas at a single Japanese institute: a clue for intra- and inter-tumor heterogeneity. J Dermatol Sci. 2017;85(1):51–7 A comparative study on driver mutations in melanoma showing intratumor and intertumor heterogeneity.
Yaman B, Kandiloğlu G, Akalin T. BRAF-V600 mutation heterogeneity in primary and metastatic melanoma: a study with pyrosequencing and immunohistochemistry. Am J Dermatopathol. 2016;38(2):113–20.
Manfredi L, Meyer N, Tournier E, Grand D, Uro-Coste E, Rochaix P, et al. Highly concordant results between immunohistochemistry and molecular testing of mutated V600E BRAF in primary and metastatic melanoma. Acta Derm Venereol. 2016;96(5):630–4.
Casula M, Colombino M, Manca A, Caracò C, Botti G, Ascierto PA, et al. Low levels of genetic heterogeneity in matched lymph node metastases from patients with melanoma. J Invest Dermatol. 2016;136(9):1917–20.
Bradish JR, Richey JD, Post KM, Meehan K, Sen JD, Malek AJ, et al. Discordancy in BRAF mutations among primary and metastatic melanoma lesions: clinical implications for targeted therapy. Mod Pathol. 2015;28(4):480–6.
Nardin C, Puzenat E, Prétet JL, Algros MP, Doussot A, Puyraveau M, et al. BRAF mutation screening in melanoma: is sentinel lymph node reliable? Melanoma Res. 2015;25(4):328–34.
Satzger I, Marks L, Kerick M, Klages S, Berking C, Herbst R, et al. Allele frequencies of BRAFV600 mutations in primary melanomas and matched metastases and their relevance for BRAF inhibitor therapy in metastatic melanoma. Oncotarget. 2015;6(35):37895–905.
Eriksson H, Zebary A, Vassilaki I, Omholt K, Ghaderi M, Hansson J. BRAFV600E protein expression in primary cutaneous malignant melanomas and paired metastases. JAMA Dermatol. 2015;151(4):410–6.
Riveiro-Falkenbach E, Villanueva CA, Garrido MC, Ruano Y, García-Martín RM, Godoy E, et al. Intra- and inter-tumoral homogeneity of BRAF(V600E) mutations in melanoma tumors. J Invest Dermatol. 2015;135(12):3078–85.
Menzies AM, Lum T, Wilmott JS, Hyman J, Kefford RF, Thompson JF, et al. Intrapatient homogeneity of BRAFV600E expression in melanoma. Am J Surg Pathol. 2014;38(3):377–82.
Saint-Jean M, Quéreux G, Nguyen JM, Peuvrel L, Brocard A, Vallée A, et al. Is a single BRAF wild-type test sufficient to exclude melanoma patients from vemurafenib therapy? J Invest Dermatol. 2014;134(5):1468–70.
Saroufim M, Habib RH, Gerges R, Saab J, Loya A, Amr SS, et al. Comparing BRAF mutation status in matched primary and metastatic cutaneous melanomas: implications on optimized targeted therapy. Exp Mol Pathol. 2014;97(3):315–20.
Harbst K, Lauss M, Cirenajwis H, Winter C, Howlin J, Törngren T, et al. Molecular and genetic diversity in the metastatic process of melanoma. J Pathol. 2014;233(1):39–50.
Boursault L, Haddad V, Vergier B, Cappellen D, Verdon S, Bellocq JP, et al. Tumor homogeneity between primary and metastatic sites for BRAF status in metastatic melanoma determined by immunohistochemical and molecular testing. PLoS One. 2013;8(8):e70826.
Heinzerling L, Baiter M, Kühnapfel S, Schuler G, Keikavoussi P, Agaimy A, et al. Mutation landscape in melanoma patients clinical implications of heterogeneity of BRAF mutations. Br J Cancer. 2013;109(11):2833–41.
Colombino M, Lissia A, Capone M, De Giorgi V, Massi D, Stanganelli I, et al. Heterogeneous distribution of BRAF/NRAS mutations among Italian patients with advanced melanoma. J Transl Med. 2013;11:202.
Zebary A, Omholt K, Vassilaki I, Höiom V, Lindén D, Viberg L, et al. KIT, NRAS, BRAF and PTEN mutations in a sample of Swedish patients with acral lentiginous melanoma. J Dermatol Sci. 2013;72(3):284–9.
Ekedahl H, Cirenajwis H, Harbst K, Carneiro A, Nielsen K, Olsson H, et al. The clinical significance of BRAF and NRAS mutations in a clinic-based metastatic melanoma cohort. Br J Dermatol. 2013;169(5):1049–55.
Colombino M, Capone M, Lissia A, Cossu A, Rubino C, De Giorgi V, et al. BRAF/NRAS mutation frequencies among primary tumors and metastases in patients with melanoma. J Clin Oncol. 2012;30(20):2522–9.
Shinozaki M, Fujimoto A, Morton DL, Hoon DS. Incidence of BRAF oncogene mutation and clinical relevance for primary cutaneous melanomas. Clin Cancer Res. 2004;10(5):1753–7.
Houben R, Becker JC, Kappel A, Terheyden P, Bröcker EB, Goetz R, et al. Constitutive activation of the Ras-Raf signaling pathway in metastatic melanoma is associated with poor prognosis. J Carcinog. 2004;3:6.
Omholt K, Platz A, Kanter L, Ringborg U, Hansson J. NRAS and BRAF mutations arise early during melanoma pathogenesis and are preserved throughout tumor progression. Clin Cancer Res. 2003;9(17):6483–8.
Hélias-Rodzewicz Z, Funck-Brentano E, Baudoux L, Jung CK, Zimmermann U, Marin C, et al. Variations of BRAF mutant allele percentage in melanomas. BMC Cancer. 2015;15:497.
Fernandes M, Barcelos D, Comodo AN, Guimarães DP, Lopes Carapeto FC, Cardili L, et al. Acral lentiginous melanomas harbour intratumor heterogeneity in BRAF exon 15, with mutations distinct from V600E/V600K. Am J Dermatopathol. 2019;41(10):733–40.
Sakaizawa K, Ashida A, Kiniwa Y, Okuyama R. BRAF mutation heterogeneity in melanoma lesions. Acta Derm Venereol. 2020;100(1):adv00045.
Betancourt LH, Szasz AM, Kuras M, Rodriguez Murillo J, Sugihara Y, Pla I, et al. The hidden story of heterogeneous B-raf V600E mutation quantitative protein expression in metastatic melanoma-association with clinical outcome and tumor phenotypes. Cancers (Basel). 2019;11(12):1981.
Cintra Lopes Carapeto F, Neves Comodo A, Germano A, Pereira Guimarães D, Barcelos D, Fernandes M, et al. Marker protein expression combined with expression heterogeneity is a powerful indicator of malignancy in acral lentiginous melanomas. Am J Dermatopathol. 2017;39(2):114–20.
Sakaizawa K, Goto Y, Kiniwa Y, Uchiyama A, Harada K, Shimada S, et al. Mutation analysis of BRAF and KIT in circulating melanoma cells at the single cell level. Br J Cancer. 2012;106(5):939–46.
Busam KJ, Hedvat C, Pulitzer M, von Deimling A, Jungbluth AA. Immunohistochemical analysis of BRAF(V600E) expression of primary and metastatic melanoma and comparison with mutation status and melanocyte differentiation antigens of metastatic lesions. Am J Surg Pathol. 2013;37(3):413–20.
Ito T, Kaku-Ito Y, Wada-Ohno M, Furue M. Narrow-margin excision for invasive acral melanoma: is it acceptable? J Clin Med. 2020;9(7):2266.
Wada M, Ito T, Tsuji G, Nakahara T, Hagihara A, Furue M, et al. Acral lentiginous melanoma versus other melanoma: a single-center analysis in Japan. J Dermatol. 2017;44(8):932–8.
Ito T, Wada M, Nagae K, Nakano-Nakamura M, Nakahara T, Hagihara A, et al. Acral lentiginous melanoma: who benefits from sentinel lymph node biopsy? J Am Acad Dermatol. 2015;72(1):71–7.
Fusi A, Berdel R, Havemann S, Nonnenmacher A, Keilholz U. Enhanced detection of BRAF-mutants by pre-PCR cleavage of wild-type sequences revealed circulating melanoma cells heterogeneity. Eur J Cancer. 2011;47(13):1971–6.
Mesbah Ardakani N, Leslie C, Grieu-Iacopetta F, Lam WS, Budgeon C, Millward M, et al. Clinical and therapeutic implications of BRAF mutation heterogeneity in metastatic melanoma. Pigment Cell Melanoma Res. 2017;30(2):233–42.
Wilmott JS, Menzies AM, Haydu LE, Capper D, Preusser M, Zhang YE, et al. BRAF(V600E) protein expression and outcome from BRAF inhibitor treatment in BRAF(V600E) metastatic melanoma. Br J Cancer. 2013;108(4):924–31.
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Takamichi Ito declares that he has no conflict of interest. Yuka Tanaka declares that he has no conflict of interest. Maho Murata declares that he has no conflict of interest. Yumiko Kaku-Ito declares that he has no conflict of interest. Kazuhisa Furue declares that he has no conflict of interest. Masutaka Furue declares that he has no conflict of interest.
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Ito, T., Tanaka, Y., Murata, M. et al. BRAF Heterogeneity in Melanoma. Curr. Treat. Options in Oncol. 22, 20 (2021). https://doi.org/10.1007/s11864-021-00818-3
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DOI: https://doi.org/10.1007/s11864-021-00818-3