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Progress in Cutaneous Cancer Research1

  • Andrzej Dlugosz
    Affiliations
    Department of Dermatology and Comprehensive Cancer Center, University of Michigan School of Medicine, Ann Arbor, Michigan, U.S.A.
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  • Glenn Merlino
    Affiliations
    Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, U.S.A.
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  • Stuart H. Yuspa
    Correspondence
    Laboratory of Cellular Carcinogenesis and Tumor Promotion, Center for Cancer Research, National Cancer Institute, 37 Convent Drive, MSC-4255, Building 37, Room 3B25, Bethesda, MD 20892-4255
    Affiliations
    Laboratory of Cellular Carcinogenesis and Tumor Promotion, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, U.S.A.
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      Cutaneous cancers represent a major public health concern due to the very high incidence, associated medical costs, substantial mortality, and cosmetic deformities associated with treatment. Considerable progress in basic research has provided new insights into the underlying genetic basis of the major human cutaneous cancers, malignant melanoma, basal cell carcinoma, and squamous cell carcinoma. In turn, these genetic insights have illuminated biochemical pathways that promise to provide new approaches to the prevention and treatment of cutaneous neoplasms. This review will detail the evolving genetic information and indicate how this information is being used to refine experimental models that serve to both define the biochemistry of cancer pathogenesis and test novel approaches to cancer therapy. Combined with preventive measures to reduce exposure to sunlight, these advances are likely to reduce this major public health burden in the coming decade.

      Keywords

      Abbreviations:

      APAF-1
      apoptotic protease activating factor-1
      BCC
      basal cell carcinoma
      CDK4
      cyclin-dependent kinase 4
      CMM
      cutaneous malignant melanoma
      EGFR
      EGF receptor
      HGF/SF
      hepatocyte growth factor/scatter factor
      LOH
      loss of heterozygosity
      NBCCS
      nevoid basal cell carcinoma syndrome
      RTK
      receptor tyrosine kinases
      TRAIL
      TNF-related apoptosis-inducing ligand.
      Perhaps no other dermatologic condition dominates a major area of human pathology as does cutaneous cancer. More than half of all cancers in North America occur on the skin, and this is likely to be an underestimate. This year more than 1 million nonmelanoma skin cancers will be reported in the U.S.A. Although the mortality from these cancers is relatively low, the magnitude of the incidence is so great that mortality from nonmelanoma skin cancers equals that of Hodgkin's disease and uterine cancer. Furthermore, the health care costs, morbidity, and cosmetic defects resulting from current treatments make nonmelanoma skin cancers a major public health issue. The statistics for melanomas are even more discouraging. This tumor type is displaying the second largest increase in incidence among cancers in the American population, with over 50,000 cases expected in 2001 and a 7% mortality rate. As exposure to sunlight is the primary etiologic agent for all skin cancers, ultraviolet (UV) radiation must be considered the major carcinogen in the human environment. Ultraviolet radiation is a powerful carcinogenic stimulus by virtue of its ability to damage DNA and cause mutations, its capacity to activate signaling pathways that enhance selection of incipient neoplastic cells, and its activity as an immune suppressant (
      • De Gruijl F.R.
      Skin cancer and solar UV radiation.
      ). Skin cancer prevention therefore should be achievable through education and lifestyle modifications that reduce exposure to UV radiation. Although both government agencies and dermatologic societies have instituted approaches to educate the population on the dangers of sunlight exposure, societal experience indicates that such programs will have only limited success. Thus, the need for basic and applied research into the causes and potential nondeforming therapies for cutaneous cancers has never been more urgent.
      Although sun exposure is a major etiologic component of most skin cancers, other exogenous exposures also contribute to this epidemic of human neoplasia. As shown in Table I, lifestyle factors such as smoking and diet, occupational exposures, and certain topical or systemic medicinal therapies contribute to the overall incidence of both melanoma and nonmelanoma cancers (
      • Black H.S.
      • Herd J.A.
      • Goldberg L.H.
      • et al.
      Effect of a low-fat diet on the incidence of actinic keratosis.
      ;
      • Gallagher R.P.
      • Bajdik C.D.
      • Fincham S.
      • Hill G.B.
      • Keefe A.R.
      • Coldman A.
      • McLean D.I.
      Chemical exposures, medical history, and risk of squamous and basal cell carcinoma of the skin.
      ;
      • De Hertog S.
      • Wensveen C.
      • Bastiaens M.T.
      • et al.
      Relation between smoking and skin cancer.
      ). Arsenic exposure, through occupational or environmental contact, also may contribute to the rising skin cancer rate (
      • Schwartz R.A.
      Arsenic and the skin.
      ).
      Table IEnvironmental agents associated with the development of human skin cancer
      T, topical; S, systemic; SCC, squamous cell carcinoma; BD, Bowen's disease; BCC, basal cell carcinoma; AK, actinic keratosis; PCB, polychlorinated biphenyl; M, melanoma, CTCL, cutaneous T-cell lymphoma.
      AgentIndividual at riskRoute of exposureTumor types
      UVA/UVB (sunlight)AllTAK, BD, SCC, BCC, M
      Cigarette smokeSmokersT or SSCC, BCC
      SootChimney sweepTSCC
      Coat tar, pitchCoker of coal, steel workerTSCC
      Petroleum oilsMachinest, textile workerT and SSCC
      ArsenicAgriculture worker, etc.S and/or TBD, SCC, BCC
      4,4′-BipridylPesticide manufacturerTSCC, BD
      PCBPetrochemical workerT or SM
      Dry cleaning reagentsDry cleanersT or SBCC
      FiberglassInsulatorsTBCC
      Psoralen (PUVA)Psoriasis patientT and SSCC, BCC, M
      Nitrogen mustardCTCL patientTSCC
      ImmunosuppressantsTransplant recipients, etcSSCC, BCC
      Therapeutic x-rayCutaneous infectionsTBCC
      a T, topical; S, systemic; SCC, squamous cell carcinoma; BD, Bowen's disease; BCC, basal cell carcinoma; AK, actinic keratosis; PCB, polychlorinated biphenyl; M, melanoma, CTCL, cutaneous T-cell lymphoma.

      Hereditary cancer syndromes

      Considerable insight into the genetic basis of sporadic skin cancers has come from the elucidation of specific genes or genetic loci that define hereditary skin tumor syndromes (Table II) (
      • Halpern A.C.
      • Altman J.F.
      Genetic predisposition to skin cancer.
      ). Perhaps the best defined and most broadly relevant are the DNA repair genes that comprise the complementation groups of skin cancer prone xeroderma pigmentosum families (
      • van Steeg H.
      • Kraemer K.H.
      Xeroderma pigmentosum and the role of UV-induced DNA damage in skin cancer.
      ). At least six independent genes, on distinct chromosomal loci, define proteins involved in nucleotide excision repair. Among these are proteins that recognize and bind to sites of DNA damage (XPA, XPC), helicases (XPB, XPD), and endonuclease components (XPG, XPF), defects in any of which give a skin cancer prone phenotype. Potential polymorphisms with functional consequences in these and other DNA repair genes may contribute to susceptibility states in the general population as well (
      • Wei Q.
      • Matanoski G.M.
      • Farmer E.R.
      • Hedayati M.A.
      • Grossman L.
      DNA repair related to multiple skin cancers and drug use.
      ). Chromosomal mapping studies in the basal cell nevus syndrome, coupled with genetic and functional studies of Drosophila development, revealed the Sonic hedgehog pathway, and specifically mutations in the PTCH1 gene, as the basis for hereditary and many sporadic basal cell cancers (
      • Bale A.E.
      • Yu K.P.
      The hedgehog pathway and basal cell carcinomas.
      ). Likewise the mapping of the inheritance pattern of the dysplastic nevus syndrome focused attention on the INK4a locus and specifically mutations in the p16INK4a gene in the etiology of heredity-prone and sporadic melanoma (
      • Hussussian C.J.
      • Struewing J.P.
      • Goldstein A.M.
      • et al.
      Germline p16 mutations in familial melanoma.
      ). Subsequently, defects in p16INK4a or other components of the cyclin-CDK signaling pathway have been associated with both melanoma and nonmelanoma skin cancer (
      • Soufir N.
      • Moles J.P.
      • Vilmer C.
      • et al.
      P16 UV mutations in human skin epithelial tumors.
      ). Detection of specific mutations in Cowden's syndrome (PTEN), Muir–Torre syndrome (MSH2, MLH1), pilomatricoma (CTNNB [β-catenin]), and trichoepithelioma (PTCH1, p16INK4aA) has illuminated the underlying pathways associated with adnexal tumors. The delineation of the specific genes mutated in other syndromes where locus mapping is confirmed should reveal even more insight into the broader spectrum of skin neoplasms.
      Table IIGene targets for mutations in hereditary and sporadic cutaneous cancers
      GeneFunctionLocusTumor typeSyndromeSpontaneous
      p53DNA repair, apoptosis, cell cycle regulation17 p13.1BCC, SCCLi Fraumeni (but no increase in skin cancers)yes
      XPA, XPBDNA repair3p25, 2q21BCC, SCC, melanomaxeroderma pigmentosumpossible
      XPC, XPD9q22.3, 19q13.3
      XPF, XPG16p13.3-13, 13q22
      PTCH1Sonic hedgehog receptor9q22.3BCC, trichoepitheliomanevoid basal cell carcinomayes
      SMOSonic hedgehog effector7q31-32BCC?yes
      p16INK4acyclin inhibitor9p21melanoma, SCC, trichoepitheliomadysplastic nevusyes
      BRAFkinase7q34melanoma?yes
      CTNNB (β-catenin)cell–cell adhesion, transcription factor3p22-p21.3pilomatricoma?yes
      CYLD1unknown16q12-13cylindromamultiple cylindromayes
      PTENphosphatase10q23.3trichilemmomaCowden'sunknown
      MSH2mismatch repair2p22-p21sebaceous gland carcinomaMuir-Torreunknown
      MLH13p21.3
      ??9p21trichoepitheliomamultiple trichoepitheliomaunknown
      ??Xq24-q27BCCBazexunknown
      ??9q31keratoacanthomaFerguson-Smithunknown

      Cutaneous malignant melanoma

      Etiology and genetics

      Cutaneous malignant melanoma (CMM) typically presents as a pigmented lesion that evolves either from a pre-existing nevus or arises de novo in normal-appearing skin. Compared with benign nevi, CMM frequently exhibit one or more of the following features (the ABCD of melanoma): asymmetry, border irregularity, color variegation, and diameter greater than 6 mm. CMM is notorious for its highly aggressive nature and its resistance to currently existing radiation and chemotherapeutic modalities. In fact, no standard therapy exists for patients with disseminated melanoma, who have a dismal prognosis. Recently, this potentially fatal disease has exhibited an alarming increase in incidence (
      • Rigel D.S.
      • Friedman R.J.
      • Kopf A.W.
      Lifetime risk for development of skin cancer in the U.S. population: current estimate is now 1 in 5.
      ), evolving into a considerable health crisis. Epidemiologic evidence now points to a causal role for exposure to the UV spectrum of sunlight in the etiology of CMM (
      • IARC
      ;
      • Armstrong B.K.
      • Kricker A.
      Skin cancer.
      ), although the relative contributions of UVA (320–400 nm) and UVB (280–320 nm) are still disputed. Whereas UVA is thought to incite oxidative DNA damage, UVB can suppress cell-mediated immunity and induce the formation of characteristic pyrimidine dimers (
      • De Gruijl F.R.
      Photocarcinogenesis. UVA vs UVB.
      ). Notably, unlike the more common squamous cell carcinoma (SCC), which is associated with cumulative lifetime UV exposure, melanoma appears to be induced by intense, intermittent exposure to UV, particularly during childhood (
      • Holman C.D.
      • Armstrong B.K.
      • Heenan P.J.
      A theory of the etiology and pathogenesis of human cutaneous malignant melanoma.
      ;
      • Whiteman D.C.
      • Whiteman C.A.
      • Green A.C.
      Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies.
      ). In addition to sun exposure, other strong melanoma risk factors include the total number of nevi and dysplastic nevi, skin and hair color, and germline mutations in specific tumor suppressor genes (
      • Goldstein A.M.
      • Tucker M.A.
      Etiology, epidemiology, risk factors, and public health issues of melanoma.
      ;
      • Marks R.
      Epidemiology of melanoma.
      ).
      Cytogenetic, linkage, and molecular analyses have provided compelling evidence for a strong underlying genetic basis for the genesis and progression of CMM (
      • Chin L.
      • Merlino G.
      • DePinho R.A.
      Malignant melanoma: modern black plague and genetic black box.
      ) (Figure 1). With few exceptions, however, these same studies have failed to identify consistent melanoma-associated genetic alterations. One significant exception is the INK4a locus at 9p21, which encodes in alternative reading frames two distinct tumor suppressor genes, p16INK4a and p19ARF (
      • Quelle D.E.
      • Zindy F.
      • Ashmun R.A.
      • Sherr C.J.
      Alternative reading frames of the INK4a tumor suppressor gene encode two unrelated proteins capable of inducing cell cycle arrest.
      ). Germline mutations in the p16INK4a gene, a negative regulator of the cell cycle, and subsequent loss of heterozygosity (LOH) in arising melanoma, are frequently observed in CMM-prone kindreds (
      • Hussussian C.J.
      • Struewing J.P.
      • Goldstein A.M.
      • et al.
      Germline p16 mutations in familial melanoma.
      ;
      • Kamb A.
      • Shattuck-Eidens D.
      • Eeles R.
      • et al.
      Analysis of the p16 gene (CDKN2) as a candidate for the chromosome 9p melanoma susceptibility locus.
      ;
      • FitzGerald M.G.
      • Harkin D.P.
      • Silva-Arrieta S.
      • et al.
      Prevalence of germ-line mutations in p16, p19ARF, and CDK4 in familial melanoma: analysis of a clinic-based population.
      ). In sporadic CMM, INK4a mutations are less frequent, but functional loss of p16INK4a in tumors can also occur through epigenetic mechanisms, such as promoter hypermethylation (
      • Gonzalgo M.L.
      • Bender C.M.
      • You E.H.
      • et al.
      Low frequency of p16/CDKN2A methylation in sporadic melanoma: comparative approaches for methylation analysis of primary tumors.
      ;
      • Funk J.O.
      • Schiller P.I.
      • Barrett M.T.
      • Wong D.J.
      • Kind P.
      • Sander C.A.
      p16INK4a expression is frequently decreased and associated with 9p21 loss of heterozygosity in sporadic melanoma.
      ). The significance of the pRB pathway, of which p16INK4a is a major regulator in melanomagenesis, can be gleaned from the identification of germline mutations in two additional melanoma-prone kindreds of cyclin-dependent kinase 4 (CDK4), a promoter of cell cycle progression and a target of p16INK4a inhibition (
      • Zuo L.
      • Weger J.
      • Yang Q.
      • et al.
      Germline mutations in the p16INK4a binding domain of CDK4 in familial melanoma.
      ;
      • Russo A.A.
      • Tong L.
      • Lee J.O.
      • Jeffrey P.D.
      • Pavletich N.P.
      Structural basis for inhibition of the cyclin-dependent kinase Cdk6 by the tumour suppressor p16INK4a.
      ;
      • Soufir N.
      • Avril M.F.
      • Chompret A.
      • et al.
      Prevalence of p16 and CDK4 germline mutations in 48 melanoma-prone families in France. The French Familial Melanoma Study Group.
      ). Interestingly, p53, situated at the regulatory nexus of cellular growth and apoptosis, and the most common mutational target in human cancer (
      • Cariello N.F.
      • Cui L.
      • Beroud C.
      • Soussi T.
      Database and software for the analysis of mutations in the human p53 gene.
      ), is infrequently mutated in primary melanoma (
      • Zerp S.F.
      • van Elsas A.
      • Peltenburg L.T.
      • Schrier P.I.
      p53 mutations in human cutaneous melanoma correlate with sun exposure but are not always involved in melanomagenesis.
      ;
      • Bardeesy N.
      • Bastian B.C.
      • Hezel A.
      • Pinkel D.
      • DePinho R.A.
      • Chin L.
      Dual inactivation of RB and p53 pathways in RAS-induced melanomas.
      ;and references within). It has been postulated that this rarity can be at least partially accounted for by the positioning of p19ARF, often inactivated in melanoma as a component of the INK4a locus, upstream of p53 (
      • Chin L.
      • Merlino G.
      • DePinho R.A.
      Malignant melanoma: modern black plague and genetic black box.
      ). Such a configuration would render inactivating mutations in both genes redundant with respect to cell cycle regulation.
      Figure thumbnail gr1
      Figure 1Genetic changes associated with melanoma progression. The multistage evolution of metastatic melanoma is depicted schematically with frequently associated stage-specific genetic changes detailed below. Trisomy of 7q, detected in invasive vertical growth phase melanoma, would amplify the listed tyrosine kinase receptors (EGFR, c-MET) the ligand HGF, and BRAF, but a causal relation to progression is not proven. The loss of APAF-1 may occur through gene deletion or gene silencing.
      A second exception where specific genetic alterations have been clearly associated with CMM is in the MAPK signaling pathway. Although activating mutations in members of the RAS proto-oncogene family are among the most common in human cancer, demonstrating a causal role in CMM has proven elusive; however, more recent molecular analysis of primary and metastatic melanoma has implicated N-RAS and H-RAS mutations in CMM progression (
      • Chin L.
      • Pomerantz J.
      • Polsky D.
      • et al.
      Cooperative effects of INK4a and ras in melanoma susceptibility in vivo.
      ). More significantly, a recent report has identified activating mutations in BRAF, which acts downstream of Ras, in almost 70% of human CMM (
      • Davies H.
      • Bignell G.R.
      • Cox C.
      • et al.
      Mutations of the BRAF gene in human cancer.
      ).
      Point mutations with characteristic UV-associated signatures have been found in genes situated within those molecular pathways described above, including p16INK4a (
      • Kamb A.
      • Shattuck-Eidens D.
      • Eeles R.
      • et al.
      Analysis of the p16 gene (CDKN2) as a candidate for the chromosome 9p melanoma susceptibility locus.
      ;
      • Pollock P.M.
      • Yu F.
      • Qiu L.
      • Parsons P.G.
      • Hayward N.K.
      Evidence for u.v. induction of CDKN2 mutations in melanoma cell lines.
      ), N-RAS (
      • van’t Veer L.J.
      • Burgering B.M.
      • Versteeg R.
      • et al.
      N-ras mutations in human cutaneous melanoma from sun-exposed body sites.
      ;
      • van Elsas A.
      • van der Scheibenbogen C.M.C.
      • Zerp S.F.
      • Keilholz U.
      • Schrier P.I.
      UV-induced N-ras mutations are T-cell targets in human melanoma.
      ;
      • Jiveskog S.
      • Ragnarsson-Olding B.
      • Platz A.
      • Ringborg U.
      N-ras mutations are common in melanomas from sun-exposed skin of humans but rare in mucosal membranes or unexposed skin.
      ), and p53 (
      • Zerp S.F.
      • van Elsas A.
      • Peltenburg L.T.
      • Schrier P.I.
      p53 mutations in human cutaneous melanoma correlate with sun exposure but are not always involved in melanomagenesis.
      ), but not ARF (
      • Peris K.
      • Chimenti S.
      • Fargnoli M.C.
      • Valeri P.
      • Kerl H.
      • Wolf P.
      UV fingerprint CDKN2a but no p14ARF mutations in sporadic melanomas.
      ). These findings suggest that such critical genes can be the target of both hereditary and environmental insults. Recent epidemiologic data indicate that INK4a-associated melanoma-prone kindreds in geographic areas with the greatest exposure to sunlight are also at highest risk for melanoma, linking UV irradiation to the INK4a locus (
      • Bishop D.T.
      • Demenais F.
      • Goldstein A.M.
      • et al.
      Geographical variation in the penetrance of CDKN2A mutations for melanoma.
      ). Therefore, assessing the consequences of exposure to combinations of such risk factors represents an area of great experimental opportunity; however, at this time functional relationships between candidate genes and environmental factors in melanomagenesis are largely unknown.
      Other classes of molecules have been implicated in melano-magenesis as well. Receptor tyrosine kinases (RTK), critical modulators of virtually all fundamental cellular behavior, including growth, differentiation, motility, and survival, play significant roles in normal melanocyte development and function (
      • Bennett D.C.
      Genetics, development, and malignancy of melanocytes.
      ;
      • Halaban R.
      Growth factors and melanomas.
      ). These include c-Kit (
      • Witte O.N.
      Steel locus defines new multipotent growth factor.
      ), c-Met (
      • Halaban R.
      • Rubin J.S.
      • Funasaka Y.
      • et al.
      Met and hepatocyte growth factor/scatter factor signal transduction in normal melanocytes and melanoma cells.
      ;
      • Takayama H.
      • La Rochelle W.J.
      • Anver M.
      • Bockman D.E.
      • Merlino G.
      Scatter factor/hepatocyte growth factor as a regulator of skeletal muscle and neural crest development.
      ;
      • Kos L.
      • Aronzon A.
      • Takayama H.
      • Maina F.
      • Ponzetto C.
      • Merlino G.
      • Pavan W.
      Hepatocyte growth factor/scatter factor-MET signaling in neural crest- derived melanocyte development.
      ), and the platelet-derived growth factor receptor (
      • Stephenson D.A.
      • Mercola M.
      • Anderson E.
      • Wang C.Y.
      • Stiles C.D.
      • Bowen-Pope D.F.
      • Chapman V.M.
      Platelet-derived growth factor receptor alpha-subunit gene (Pdgfra) is deleted in the mouse patch (Ph) mutation.
      ;
      • Soriano P.
      The PDGF alpha receptor is required for neural crest cell development and for normal patterning of the somites.
      ). Multiple reports have either supported or refuted the role of specific RTK in primary and metastatic melanoma cells and their cultured derivatives (
      • Albino A.P.
      The role of oncogenes and growth factors in progressive melanoma- genesis.
      ;
      • Shih I.M.
      • Herlyn M.
      Autocrine and paracrine roles for growth factors in melanoma.
      ;
      • Halaban R.
      Growth factors and melanomas.
      ). Of central importance to the aspiring melanoma cell is the acquisition of autonomous growth control through the creation of autocrine RTK signaling loops, i.e., a cell is able to manufacture both an RTK and its associated ligand. Examples of such loops include basic fibroblast growth factor (bFGF)-FGF receptor, considered a hallmark of CMM development, and transforming growth factor α (TGFα)-epidermal growth factor (EGF) receptor.
      Recently, progress has been made in identifying new candidate therapeutic targets associated with melanoma cell survival. Soengas et al (2001) demonstrated that melanoma cells avoid apoptotic destruction through inactivation of apoptotic protease activating factor-1 (APAF-1), a requisite caspase-9 activator functioning downstream of p53. Common APAF-1 loss of function, which can occur by allelic loss and methylation silencing, also helps account for the relative rarity of p53 mutations in CMM. Significantly, restoration of APAF-1 pro-apoptotic function by the methylation inhibitor 5aza2dC rendered melanoma cells chemosensitive (
      • Soengas M.S.
      • Capodieci P.
      • Polsky D.
      • et al.
      Inactivation of the apoptosis effector Apaf-1 in malignant melanoma.
      ). In a related development,
      • Griffith T.S.
      • Anderson R.D.
      • Davidson B.L.
      • Williams R.D.
      • Ratliff T.L.
      Adenoviral-mediated transfer of the TNF-related apoptosis-inducing ligand/Apo-2 ligand gene induces tumor cell apoptosis.
      showed that adenovirus-mediated expression of TNF-related apoptosis-inducing ligand (TRAIL), which induces caspase-8-associated apoptosis, can serve as gene therapy in the destruction of melanoma cells.

      Experimental models of CMM

      A major impediment to the study of melanoma has been the lack of relevant, tractable experimental animal models. Historically, the animal models studied in most detail have been the Xiphophorus hybrid fish and the South American opossum, as well as a number of rodent models (
      • Kusewitt D.F.
      • Ley R.D.
      Animal models of melanoma.
      ) (Table III). The problem with all such models, however, is that arising melanocytic tumors do not resemble human CMM at the histopathologic level, and extensive genetic manipulation is not possible. The mouse represents an especially attractive system because of the availability of an extensive genetic base upon which to build. Unfortunately, murine melanocytes, unlike those in human skin, are typically confined to hair follicles and are exceedingly resistant to both spontaneous and UV-induced melanoma. Moreover, melanomas that arise do so with low penetrance, long latencies, and poor metastatic capacity.
      Table IIIExperimental models for melanoma induction
      Exogenous inducers
      AgentSpeciesComments
      DMBA/TPASyrian golden hamsterrequires transplantation
      DMBAguinea pigfrequent metastasis
      UVR (280-400 nm)monodelphus domestica100 week exposure
      DMBA/UVRhuman skin grafted to nude micecarcinoma and melanoma after repeated exposure
      Heritable models
      SpeciesEnhandersComments
      XiphorphorusUVRoverexpression of RTK-ONC-Xmrk
      Sinclair swine2 locioften regress with vitiligo
      Genetic modified mouse models
      ModificationsEnhandersComments
      Tyr-TagUVRmostly ocular, cutaneous requires UVR
      TP-rasUVR or DMBA requiredmetastatic
      MT-RETmelanosis; metastatic
      MT-HGFUVRmelanosis; metastatic
      Tyr-RASINK4a-/-, p53-/-non-metastatic
      Ink4a*/ARF Δ2,3DMBAmetastatic
      Cdk4+/R24CDMBA and TPAknock in mutant; invasive
      Genetically engineered mouse models have proven to be amenable to the genetic dissection of molecular pathways in tumorigenesis, and a number of melanoma-prone, transgenic mice have recently been described (
      • Satyamoorthy K.
      • Meier F.
      • Hsu M.Y.
      • Berking C.
      • Herlyn M.
      Human xenografts, human skin and skin reconstructs for studies in melanoma development and progression.
      ;
      • Tietze M.K.
      • Chin L.
      Murine models of malignant melanoma.
      ). Among these, melanoma induction in transgenic mice has been achieved through melanocytic expression of the oncogenes SV40 T-antigen, c-RET and H-RAS (
      • Bradl M.
      • Klein-Szanto A.
      • Porter S.
      • Mintz B.
      Malignant melanoma in transgenic mice.
      ;
      • Klein-Szanto A.J.
      • Silvers W.K.
      • Mintz B.
      Ultraviolet radiation-induced malignant skin melanoma in melanoma-susceptible transgenic mice.
      ;
      • Kato M.
      • Takahashi M.
      • Akhand A.A.
      • et al.
      Transgenic mouse model for skin malignant melanoma.
      ;
      • Bardeesy N.
      • Bastian B.C.
      • Hezel A.
      • Pinkel D.
      • DePinho R.A.
      • Chin L.
      Dual inactivation of RB and p53 pathways in RAS-induced melanomas.
      ). The success of these models can be credited, in part, to earlier seminal work identifying candidate oncogenic pathways in human CMM: T-antigen disrupts pRB and p53 function in a fashion analogous to loss of both p16INK4a and p19ARF at the INK4a locus; c-RET, although not normally expressed in melanocytes, is a potent RTK whose presence would unbalance multiple kinase signaling pathways; and the potential role of activated RAS genes has already been noted. In an elegant set of genetic experiments, the activated H-RAS transgene was placed on a background deficient in Ink4a resulting in the efficient development of spontaneous nonmetastatic melanoma (
      • Chin L.
      • Pomerantz J.
      • Polsky D.
      • et al.
      Cooperative effects of INK4a and ras in melanoma susceptibility in vivo.
      ). Moreover, when the H-RAS transgene was configured with a tetracycline-regulatable promoter, it could be demonstrated that activated H-RAS was required for melanoma maintenance in this model (
      • Chin L.
      • Tam A.
      • Pomerantz J.
      • et al.
      Essential role for oncogenic Ras in tumour maintenance.
      ). Recently, mice bearing p16Ink4a-specific inactivating mutations, or the Cdk4 R24C mutation described in patients with familial CMM, were reported to be susceptible to DMBA-induced melanoma (
      • Krimpenfort P.
      • Quon K.C.
      • Mooi W.J.
      • Loonstra A.
      • Berns A.
      Loss of p16INK4a confers susceptibility to metastatic melanoma in mice.
      ;
      • Sharpless N.E.
      • Bardeesy N.
      • Lee K.H.
      • et al.
      Loss of p16Ink4a with retention of p19 Arf predisposes mice to tumorigenesis.
      ;
      • Sotillo R.
      • Garcia J.F.
      • Ortega S.
      • Martin J.
      • Dubus P.
      • Barbacid M.
      • Malumbres M.
      Invasive melanoma in Cdk4-targeted mice.
      ;
      • Rane S.G.
      • Cosenza S.C.
      • Mettus R.V.
      • Reddy E.P.
      Germ line transmission of the Cdk4 (R24C) mutation facilitates tumorigenesis and escape from cellular senescence.
      ), strongly supporting a role for the p16INK4a/Cdk4/Rb pathway in melanomagenesis. As in other animal models, however, murine melanocytic neoplasms arising in these various transgenic mice do not closely resemble human lesions, in that they arise within the dermis and lack the epidermal component characteristic of conventional human CMM.
      In melanoma-prone transgenic mice overexpressing hepatocyte growth factor/scatter factor (HGF/SF), the c-Met ligand, metastasis occurs in approximately 15% of tumor-bearing animals (
      • Takayama H.
      • La Rochelle W.J.
      • Anver M.
      • Bockman D.E.
      • Merlino G.
      Scatter factor/hepatocyte growth factor as a regulator of skeletal muscle and neural crest development.
      ;
      • Takayama H.
      • Larochelle W.J.
      • Sharp R.
      • et al.
      Diverse tumorigenesis associated with aberrant development in mice overexpressing hepatocyte growth factor/scatter factor.
      ;
      • Otsuka T.
      • Takayama H.
      • Sharp R.
      • et al.
      c-Met autocrine activation induces development of malignant melanoma and acquisition of the metastatic phenotype.
      ). Unlike other genetically engineered animals, melanocytes in HGF/SF transgenic mice demonstrate extra-follicular survival, residing within the epidermis, dermis, and epidermal–dermal junction. The resulting “humanized” skin has the potential to yield melanomas with a histopathologic profile reminiscent of human CMM (
      • Noonan F.P.
      • Recio J.A.
      • Takayama H.
      • et al.
      Neonatal sunburn and melanoma in mice.
      ). As an alternative to making mouse skin morphologically resemble human, human/mouse chimeras have been created in which human skin is grafted onto immunodeficient mice, and then subjected to experimental analysis (
      • Satyamoorthy K.
      • Meier F.
      • Hsu M.Y.
      • Berking C.
      • Herlyn M.
      Human xenografts, human skin and skin reconstructs for studies in melanoma development and progression.
      ). Such chimeras provide an orthotopic milieu in which to study spontaneous and UV-induced melanomagenesis in vivo. In fact, UVB exposure was capable of inducing melanocytic lesions, including a nodular melanoma, in xenografted human skin in concert with either DMBA treatment or adenovirus-mediated bFGF overexpression (
      • Atillasoy E.S.
      • Seykora J.T.
      • Soballe P.W.
      • et al.
      UVB induces atypical melanocytic lesions and melanoma in human skin.
      ;
      • Berking C.
      • Takemoto R.
      • Satyamoorthy K.
      • Elenitsas R.
      • Herlyn M.
      Basic fibroblast growth factor and ultraviolet B transform melanocytes in human skin.
      ).
      The ability to evaluate the consequences of UV irradiation on melanoma development is a paramount feature in any animal model, as exposure to sunlight is thought to be a causal agent in up to 80% of CMM. With respect to genetically tractable transgenic mouse models of melanoma, some demonstrate UV sensitivity, although responses have been relatively inefficient (
      • Kelsall S.R.
      • Mintz B.
      Metastatic cutaneous melanoma promoted by ultraviolet radiation in mice with transgene-initiated low melanoma susceptibility.
      ;
      • Broome P.M.
      • Gause P.R.
      • Hyman P.
      • Gregus J.
      • Lluria-Prevatt M.
      • Nagle R.
      • Bowden G.T.
      Induction of melanoma in TPras transgenic mice.
      ). The extra-follicular melanocytes in the HGF/SF transgenic skin, however, appear to be highly susceptible to neonatal UV irradiation (
      • Noonan F.P.
      • Otsuka T.
      • Bang S.
      • Anver M.R.
      • Merlino G.
      Accelerated ultraviolet radiation-induced carcinogenesis in hepatocyte growth factor/scatter factor transgenic mice.
      ), linking both the power of genetic manipulation and the relevance of environmental challenge within the same model system. Taken together, these advances brighten future prospects of creating relevant mouse models to rigorously assess genetic and environmental melanoma risk factors, facilitate development of efficacious sun protection strategies, and establish effectual antimelanoma therapeutics.

      Basal cell carcinoma (BCC)

      Etiology and genetics

      BCC is a very common, slow-growing, locally invasive tumor that typically presents as a pink or pearly papule with superficial telangiectasia and occasional ulceration. There are three clinical variants: nodular (the most common), superficial, and sclerosing. In contrast to cutaneous SCC, BCC precursor lesions have not been identified, there is no evidence of neoplastic progression, and metastases are exceedingly rare (
      • Miller S.J.
      Etiology and pathogenesis of basal cell carcinoma.
      ). BCC are probably derived from hair follicles, and analogous to hair follicle epithelium, BCC growth is dependent on proper signaling between neoplastic keratinocytes and surrounding mesenchymal cells. This may account, in part, for the low incidence of BCC metastases, as well as the difficulty in establishing and maintaining BCC as xenografts in vivo or as immortalized cell lines in vitro.
      Chromosomal losses involving 9q have been found in both sporadic and inherited BCC. The latter tumors occur in patients with the autosomal dominant disorder nevoid basal cell carcinoma syndrome (NBCCS), which is characterized by a predisposition to BCC (frequently multiple and appearing at an early age), an increased incidence of several other tumors, and a variety of developmental anomalies (
      • Gorlin R.J.
      Nevoid basal–cell carcinoma syndrome.
      ). These clinical features suggested that the gene involved in BCC formation is also important during embryogenesis, and this notion was confirmed with the discovery in NBCCS patients of germline mutations of PTCH1 (
      • Hahn H.
      • Wicking C.
      • Zaphiropoulous P.G.
      • et al.
      Mutations of the human homolog of Drosophila patched in the nevoid basal cell carcinoma syndrome.
      ;
      • Johnson R.L.
      • Rothman A.L.
      • Xie J.
      • et al.
      Human homolog of patched, a candidate gene for the basal cell nevus syndrome.
      ), a homolog of the Drosophila ptc gene involved in embryonic development. BCC from NBCCS patients had lost the remaining normal PTCH1 allele, which was also found to be deficient in spontaneous BCC, suggesting that PTCH1 is a tumor suppressor. A second PTCH gene has subsequently been identified (PTCH2) (
      • Zaphiropoulos P.G.
      • Unden A.B.
      • Rahnama F.
      • Hollingsworth R.E.
      • Toftgard R.
      PTCH2, a novel human patched gene, undergoing alternative splicing and up-regulated in basal cell carcinomas.
      ), but its role in BCC development is not yet known.
      Ptch1 is a 12-pass transmembrane molecule that functions as a receptor for Sonic hedgehog (Shh), a secreted ligand that regulates proliferation and patterning of multiple tissues and organs during embryogenesis (
      • Chuang P.T.
      • Kornberg T.B.
      On the range of hedgehog signaling.
      ). According to the current model (Figure 2), Ptch1 normally antagonizes signaling activity by repressing Smoothened (Smo), a cell-surface molecule with homology to G protein-coupled receptors. Shh initiates signaling in responsive cell types by inhibiting Ptch, resulting in derepression of Smo and, ultimately, the activation of Shh target genes. Two “universal” Shh target genes are Gli1 (which encodes a transcription factor) and Ptch1, and the expression level of these transcripts has proven to be a reliable indicator of physiologic and pathologic Shh signaling. Under normal conditions, activation of this pathway is dependent on Shh, whose expression is tightly regulated both in space and in time. In human BCC, however, loss of PTCH1 results in constitutive signaling that is irreversible and independent of SHH. In addition to loss-of-function PTCH1 mutations, gain-of-function (oncogenic) SMO mutations have been found in some BCC where PTCH1 appears to be normal (
      • Xie J.
      • Murone M.
      • Luoh S.M.
      • et al.
      Activating Smoothened mutations in sporadic basal-cell carcinoma.
      ;
      • Lam C.W.
      • Xie J.
      • To K.F.
      • et al.
      a frequent activated smoothened mutation in sporadic basal cell carcinomas.
      ). Together, PTCH1 or SMO mutations have been identified in less than 75% of BCC whereas hedgehog target genes are upregulated in essentially all tumors examined (
      • Dahmane N.
      • Lee J.
      • Robins P.
      • Heller P.
      • Altaba A.
      Activation of the transcription factor Gli1 and the Sonic hedgehog signalling pathway in skin tumours.
      ), indicating that additional mechanisms must exist for uncontrolled activation of this pathway. The current data suggest that constitutive Shh signaling, regardless of how this is brought about, plays a central role in the genesis of BCC. PTCH1 gene alterations have also been found in trichoepitheliomas (
      • Vorechovsky I.
      • Unden A.B.
      • Sandstedt B.
      • Toftgard R.
      • Stahle-Backdahl M.
      Trichoepitheliomas contain somatic mutations in the overexpressed PTCH gene: support for a gatekeeper mechanism in skin tumorigenesis.
      ) and nevus sebaceous of Jadassohn (
      • Xin H.
      • Matt D.
      • Qin J.Z.
      • Burg G.
      • Boni R.
      The sebaceous nevus nevus. A with deletions of the PTCH gene.
      ), suggesting that deregulation of Shh signaling plays a role in the genesis of other follicle-derived tumors. Although mutations in p53 have been found in up to 50% of BCC, their involvement in the development or maintenance of these tumors is not known, particularly as most BCC fail to exhibit the genomic instability associated with other cancers where p53 function is compromised.
      Figure thumbnail gr2
      Figure 2Proposed model depicting the molecular basis of BCC. In contrast to the multistep evolution of SCC and melanoma, deregulation of the SHH signaling pathway may be sufficient for BCC development. During physiologic activation in responsive cell types, SHH binds and inhibits PTCH1, which normally represses SMO. Derepression of SMO results in transient activation of SHH target genes, including PTCH1, GLI1, and cell type-specific genes, which are likely to play an important role in growth control. In BCC, mutations involving PTCH1 or SMO result in uncontrolled signaling and constitutive expression of SHH target genes.
      What is the normal function of Shh signaling in skin? Analysis of genetically engineered mutant mice has revealed a crucial requirement for Shh during hair follicle growth and morphogenesis, but not terminal differentiation (
      • St Jacques B.
      • Dassule H.R.
      • Karavanova I.
      • et al.
      Sonic hedgehog signaling is essential for hair development.
      ;
      • Chiang C.
      • Swan R.Z.
      • Grachtchouk M.
      • et al.
      Essential role for Sonic hedgehog during hair follicle morphogenesis.
      ). In addition, both loss-of-function (
      • Wang L.C.
      • Liu Z.Y.
      • Gambardella L.
      • et al.
      Conditional disruption of hedgehog signaling pathway defines its critical role in hair development and regeneration.
      ) and gain-of-function (
      • Sato N.
      • Leopold P.L.
      • Crystal R.G.
      Induction of the hair growth phase in postnatal mice by localized transient expression of Sonic hedgehog.
      ) studies implicate Shh signaling in the regulation of hair follicle growth during the anagen phase of the hair cycle. Thus, whereas physiologic Shh signaling in skin may govern growth of follicle keratinocytes at appropriate times, uncontrolled Shh signaling due to PTCH1 or SMO mutations may cause sustained proliferation, resulting in the development of follicle-derived tumors.
      How does stimulation of Shh signaling alter cell function? Transcriptional responses in the highly homologous Drosophila hedgehog pathway are mediated by ci (reviewed in
      • Aza-Blanc P.
      • Kornberg T.B.
      Ci: a complex transducer of the hedgehog signal.
      ), which belongs to the Gli family of zinc finger-containing transcription factors. Vertebrate ci homologs include Gli1, Gli2, and Gli3, all of which bind to the consensus DNA sequence GACCACCCA (
      • Matise M.P.
      • Joyner A.L.
      Gli genes in development and cancer.
      ). In contrast to Gli3, which appears to function primarily as a transcriptional repressor, both Gli1 and Gli2 are transcriptional activators. Major emphasis has been placed on Gli1 as a potential effector of normal and constitutive Shh signaling for several reasons: it is consistently upregulated in cells where the Shh pathway is active, both during embryogenesis and in neoplasms; ectopic Gli1 expression can mimic responses to Shh in certain settings; and when overexpressed in frog skin, GLI1 can give rise to primitive skin tumors (
      • Dahmane N.
      • Lee J.
      • Robins P.
      • Heller P.
      • Altaba A.
      Activation of the transcription factor Gli1 and the Sonic hedgehog signalling pathway in skin tumours.
      ). Despite these findings Gli1 knockout mice are phenotypically normal (
      • Morris R.J.
      • Potten C.S.
      Highly persistent label-retaining cells in the hair follicles of mice and their fate following induction of anagen.
      ), arguing against an essential role for this Gli protein in physiologic Shh signaling, whereas Gli2 knockout mice exhibit abnormalities in multiple organs whose development is dependent on Shh. In particular, loss of Gli2 function results in severe impairment of hair follicle growth (
      • Grachtchouk M.
      • Mo R.
      • Hui C.C.
      • Dlugosz A.A.
      The Sonic hedgehog target gene Gli2 plays a pivotal role in hair follicle development.
      ).

      Experimental models of BCC

      Rats exposed to chemical carcinogens (MCA, DMBA) or ionizing radiation preferentially develop BCC rather than squamous tumors, and frequently at a high incidence (reviewed in
      • Zackheim H.S.
      Experimental basal cell carcinoma in the rat.
      ; Table IV). Rat BCC appear to arise in the outer root sheath of hair follicles and have a slow growth rate, similar to human BCC. The molecular basis for experimentally induced BCC in rats is not yet known, but is expected to result in Shh pathway activation if the current model is accurate. In striking contrast to their strong predisposition to squamous tumor development, mice appear to be remarkably resistant to BCC induction. One notable exception is the chemical carcinogen dehydroretronecine, which is effective at inducing mouse BCC (and other tumors) following subcutaneous or topical administration (
      • Johnson W.D.
      • Robertson K.A.
      • Pounds J.G.
      • Allen J.R.
      Dehydroretronecine-induced skin tumors in mice.
      ).
      Table IVExperimental models for basal cell carcinoma
      Exogenous inducers
      AgentSpeciesComments
      MCARatother skin tumors
      DMBARatSCC > BCC; lower DMBA doses may increase BCC incidence
      Ionizing radiationRatother skin tumors
      DehydroretronecineMouseBCC > SCC, also internal tumors
      Genetic models
      ModificationEhancersComments
      K14-SHH?lethal phenotype, not transplantable
      LTR-SHH?superficial BCC
      K5-M2SMO?impaired survival
      Ptch+/-UV, IR, Arsenicother tumor types
      K5-GLI1?other tumor types
      K5-Gli2?exclusively BCC
      The discovery of inactivating PTCH1 mutations in BCC fueled the development of a number of transgenic and knockout mouse models exploring the potential role of deregulated Shh signaling in BCC tumorigenesis. Overexpression of SHH using a K14 promoter resulted in upregulation of Shh target genes and development of basal cell-like proliferations in newborn mouse skin (
      • Oro A.E.
      • Higgins K.M.
      • Hu Z.
      • Bonifas J.M.
      • Epstein Jr, E.H.
      • Scott M.P.
      Basal cell carcinomas in mice overexpressing sonic hedgehog.
      ), with similar results obtained using the K5 promoter to drive expression of a gain-of-function SMO mutant, M2SMO (
      • Xie J.
      • Murone M.
      • Luoh S.M.
      • et al.
      Activating Smoothened mutations in sporadic basal-cell carcinoma.
      ). Overexpression of SHH in human keratinocytes followed by grafting onto SCID mice resulted in development of BCC-like changes as well (
      • Fan H.
      • Oro A.E.
      • Scott M.P.
      • Khavari P.A.
      Induction of basal cell carcinoma features in transgenic human skin expressing Sonic Hedgehog.
      ). These studies supported the hypothesis that constitutive activation of Shh signaling in keratinocytes is sufficient for BCC development, but analysis of tumor phenotypes in adult transgenic mice could not be performed due to impaired viability of these animals. When K14-SHH mouse skin was transplanted onto SCID mouse hosts, BCC-like proliferations were apparently replaced by well-differentiated hair-follicle-like structures (
      • Oro A.E.
      • Higgins K.M.
      • Hu Z.
      • Bonifas J.M.
      • Epstein Jr, E.H.
      • Scott M.P.
      Basal cell carcinomas in mice overexpressing sonic hedgehog.
      ), supporting the proposed requirement for an appropriate tumor stroma to maintain BCC growth. Mouse models have also been developed in which Ptch gene function has been disrupted (
      • Goodrich L.V.
      • Milenkovic L.
      • Higgins K.M.
      • Scott M.P.
      Altered neural cell fates and medulloblastoma in mouse patched mutants.
      ;
      • Hahn H.
      • Wojnowski L.
      • Zimmer A.M.
      • Hall J.
      • Miller G.
      • Zimmer A.
      Rhabdomyosarcomas and radiation hypersensitivity in a mouse model of Gorlin syndrome.
      ), and Ptch+/– mice have many features in common with NBCCS patients. Detailed analysis of skin from PtchlacZ/+ mice has revealed microscopic hair-follicle-derived proliferations, with the appearance of a variety of macroscopic skin tumors, including BCC, following exposure to ionizing or UV radiation (
      • Aszterbaum M.
      • Epstein J.
      • Oro A.
      • Douglas V.
      • LeBoit P.E.
      • Scott M.P.
      • Epstein Jr, E.H.
      Ultraviolet and ionizing radiation enhance the growth of BCC and trichoblastomas in patched heterozygous knockout mice.
      ). Taken together, these findings strongly support the concept that deregulated Shh signaling plays a central role in BCC development.
      Other transgenic mouse studies have focused on Gli proteins as potential mediators of constitutively activated Shh signaling in BCC. GLI1 and Gli2 have both been overexpressed in mouse skin using the same bovine K5 promoter with intriguingly different results. K5-GLI1 transgenic mice developed a variety of follicle-derived tumor types with relatively few BCC (
      • Nilsson M.
      • Unden A.B.
      • Krause D.
      • Malmqwist U.
      • Raza K.
      • Zaphiropoulos P.G.
      • Toftgard R.
      Induction of basal cell carcinomas and trichoepitheliomas in mice overexpressing GLI-1.
      ), whereas K5-Gli2 transgenic mice developed only BCC (
      • Grachtchouk M.
      • Mo R.
      • Yu S.
      • Zhang X.
      • Sasaki H.
      • Hui C.C.
      • Dlugosz A.A.
      Basal cell carcinomas in mice overexpressing Gli2 in skin.
      ). These findings, coupled with the results of knockout mouse studies described above, strongly implicate Gli2 both in physiologic (hair follicle growth) and pathologic (BCC development) Shh signaling in skin. Despite the compelling phenotypes produced in these mouse models, there is as yet no direct evidence that Gli transcription factors are required for tumorigenesis associated with PTCH1 or SMO mutations.
      As it appears that deregulation of Shh signaling is sufficient for BCC development, these tumors may be uniquely responsive to mechanism-based therapeutic intervention. The steroidal alkaloid cyclopamine has been shown to inhibit Shh signaling by blocking SMO (
      • Taipale J.
      • Chen J.K.
      • Cooper M.K.
      • et al.
      Effects of oncogenic mutations in Smoothened and Patched can be reversed by cyclopamine.
      ), but it is not yet known whether BCC could be successfully treated, or their appearance prevented, using this agent. In September 2001, one small-molecule inhibitor of Shh signaling had been granted FDA approval for phase I clinical trials in patients with BCC. Although this type of work is just getting under way, it may eventually lead to novel nonsurgical approaches to treating BCC and possibly other cancers associated with deregulated Shh signaling, such as medulloblastomas and a subset of rhabdomyosarcomas.

      Cutaneous SCC

      Etiology and genetics

      Cutaneous SCC frequently presents as a firm, pink papule or nodule, with a conspicuous hyperkeratotic surface. Although they represent only about 20% of nonmelanoma skin cancers, SCC are generally more aggressive and occasionally lethal. SCC is more frequent with higher cumulative sunlight exposure, as cancers associated with occupational exposures, and in immunosuppressed patients. Hereditary syndromes uniquely associated with SCC risk have not been described although DNA repair defects in xeroderma pigmentosum substantially increase the risk for SCC development. Insight into the pathogenesis of cutaneous SCC has come from studies of the frequent precursor lesion, actinic keratosis (AK) (Figure 3). These benign hyperproliferative-hyperkeratotic lesions frequently have sunlight-induced clonal p53 mutations suggesting clonal expansion from a single cell carrying a specific p53 mutation. Most frequently, these mutations are in codon 278 or other codons of the DNA-binding domain of p53 that contain dipyrimidine sites (
      • Hussain S.P.
      • Harris C.C.
      Molecular epidemiology of human cancer: contribution of mutation spectra studies of tumor suppressor genes.
      ). Of particular interest is the common finding of LOH at particular chromosomal sites such as 13q, 17p, 17q, 9p, and 9q (
      • Rehman I.
      • Quinn A.G.
      • Healy E.
      • Rees J.L.
      High frequency of loss of heterozygosity in actinic keratoses, a usually benign disease.
      ). Frequently, multiple sites of allelic loss are detected in the same lesion. As actinic keratoses progress to SCC at an extremely low frequency, the challenge is to determine which of these genetic lesions, if any, contributes to premalignant progression. Analyses of SCC have also revealed frequent LOH and p53 mutations, but a modal allelic loss or specific p53 codon strongly associated with the acquisition of a malignant phenotype is yet to be identified (
      • Quinn A.G.
      • Sikkink S.
      • Rees J.L.
      Basal cell carcinomas and squamous cell carcinomas of human skin show distinct patterns of chromosome loss.
      ). Other genetic changes have been associated with progression in SCC, and their possible involvement in pathogenesis has been explored in experimental studies. Mutations in the K-RAS and Ha-RAS gene are detected in both AK and SCC, and activation of the RAS pathway through mutation of the gene or growth factor stimulation may be extremely common in squamous tumors, particularly in sites with intense exposure to UV radiation (
      • Pierceall W.E.
      • Goldberg L.H.
      • Tainsky M.A.
      • Mukhopadhyay T.
      • Ananthaswamy H.N.
      Ras gene mutation and amplification in human nonmelanoma skin cancers.
      ;
      • Kreimer-Erlacher H.
      • Seidl H.
      • Back B.
      • Kerl H.
      • Wolf P.
      High mutation frequency at Ha-ras exons 1–4 in squamous cell carcinomas from PUVA-treated psoriasis patients.
      ). Inactivating mutations or epigenetic silencing of p16INK4a and activation of telomerase are other pathways associated with SCC development (
      • Taylor R.S.
      • Ramirez R.D.
      • Ogoshi M.
      • Chaffins M.
      • Piatyszek M.A.
      • Shay J.W.
      Detection of telomerase activity in malignant and nonmalignant skin conditions.
      ;
      • Soufir N.
      • Moles J.P.
      • Vilmer C.
      • et al.
      P16 UV mutations in human skin epithelial tumors.
      ). Constitutive activation of the EGF receptor (EGFR) by amplification or expression of ligands with the formation of an autocrine loop is a frequent finding in SCC (
      • Moghal N.
      • Sternberg P.W.
      Multiple positive and negative regulators of signaling by the EGF- receptor.
      ). Although these correlations have provided clues to pathways involved in SCC pathogenesis, definitive causal associations in human SCC have not yet been confirmed. For this reason, model systems utilizing human and mouse keratinocytes in culture and animal models in vivo have been developed and utilized to test causal relationships at the molecular, cellular, and organism levels.
      Figure thumbnail gr3
      Figure 3Genetic changes associated with human cutaneous SCC. The multistage evolution of invasive SCC is depicted schematically with frequently associated genetic changes detailed below. Single base mutations in early lesions frequently are characteristic of UV light-induced damage, whereas later changes are associated with genomic instability. Increased activity of telomerase (deletion of inhibitor) or EGFR tyrosine kinase (gene amplification) may also result from epigenetic changes.

      Experimental models of cutaneous SCC

      The induction of squamous cell cancers on mouse skin by chemical carcinogens or UV light has been an excellent model to study cancer pathogenesis in general and skin cancer development in particular. These models have shown remarkable phenotypic homology to human SCC development and have provided additional information on the contribution of specific genetic changes to particular stages of tumor progression. The addition of genetically modified mice to the mix of models available has further clarified the specific requirements for particular genes and their downstream pathways in benign and malignant tumor formation (Table V). Together with in vitro analysis of keratinocytes, the biochemistry of SCC development is being revealed.
      Table VExperimental models for squamous cell tumor induction
      Exogenous inducers
      AgentSpeciesComments
      (PAH, NA, AA) + promotermouse, ratpredominantly papilloma
      (PAH, NA, AA) repeatedmouse, ratpredominantly SCC
      ultraviolet Bmousep53 mutations, immune suppression, SCC
      ultraviolet Amousepapillomas and SCC
      Gentically modified mouse models
      ModificationEnhancersComments
      Tg.AC (ζ globin-v-rasHa)promoters, drugsenhancers upregulate transgene
      Tg.ACUVBp53 mutations are absent
      K1-ras, K10-raspromoterspredominantly papillomas
      ΔK5-raspapillomas, KA, SCC
      K6-raspromotersSCC
      K1-TGFα, K14-TGFα, MT-TGFαpromoterspredominantly papillomas that regress
      Inv-c-MycERpapilloma
      K1-v-fospromoterspapilloma
      K5-E2F1p53 deficiencypapilloma, SCC, BCC
      K5-Igf1promoterspapilloma, SCC
      K5-ErbB2promoterspapilloma, SCC
      K5-SOS-Ftumors inhibited by Egfr deficiency
      K14-HPV16FVB/N mouse straintumors inhibited by difluoromethylornithine
      K6-ODCDMBASCC, K-ras mutations
      XP mutant models (A, C, D)initiation/promotion/UVRenhanced sensitivity
      Egfr null mutantv-rasHareduced tumor size
      p53 null mutantDMBA/TPAenhanced malignant conversion
      p21waf1 null mutantDMBA/TPAenhanced papilloma formation
      c-fos null mutantcross with Tg.ACpapilloma but no SCC
      K14-PKCεDMBA/TPAenhanced SCC, metastases
      K14-PKCδDMBA/TPAreduced papilloma development
      Animal model studies indicate that heterozygous activating Ras gene mutations are sufficient to induce a benign squamous lesion, and this is coupled to constitutive activation of the EGFR (
      • Yuspa S.H.
      The pathogenesis of squamous cell cancer: lessons learned from studies of skin carcinogenesis –Thirty-third G.H.A. Clowes Memorial Award Lecture.
      ) (Figure 4). Activation of the keratinocyte EGFR through transgenic targeting of TGFα to the epidermis can also produce a benign tumor phenotype in the absence of Ras mutations, but tumors regressed unless subjected to continuous exposure to tumor promoters (
      • Vassar R.
      • Hutton M.E.
      • Fuchs E.
      Transgenic overexpression of transforming growth factor α bypasses the need for c-Ha-ras mutations in mouse skin tumorigenesis.
      ;
      • Dominey A.M.
      • Wang X.J.
      • King Jr, L.E.
      • et al.
      Targeted overexpression of transforming growth factor α in the epidermis of transgenic mice elicits hyperplasia, hyperkeratosis, and spontaneous squamous papillomas.
      ;
      • Jhappan C.
      • Takayama H.
      • Dickson R.B.
      • Merlino G.
      Transgenic mice provide genetic evidence that transforming growth factor α promotes skin tumorigenesis via H-ras-dependent and H-ras-independent pathways.
      ). This suggests that activation of the EGFR is not sufficient for autonomous tumor formation, and alterations in other pathways are required. Under conditions of high expression or homozygosity of a mutant Ras gene, progression to malignancy is enhanced (
      • Quintanilla M.
      • Brown K.
      • Ramsden M.
      • Balmain A.
      Carcinogen-specific mutation and amplification of Ha-ras during mouse skin carcinogenesis.
      ;
      • Greenhalgh D.A.
      • Yuspa S.H.
      Malignant conversion of murine squamous papilloma cell lines by transfection with the fos oncogene.
      ), suggesting that the Ras pathway can recruit additional changes required for progression. The target cell for Ras activation in the epidermis may also determine the tumor phenotype as transgenic targeting of oncogenic Ras to keratinocytes committed to the differentiation program produces terminally benign tumors whereas targeting to less differentiated cells permits progression to SCC (
      • Brown K.
      • Strathdee D.
      • Bryson S.
      • Lambie W.
      • Balmain A.
      The malignant capacity of skin tumours induced by expression of a mutant H-ras transgene depends on the cell type targeted.
      ). In contrast, suprabasal targeting of c-Myc produces the papilloma phenotype, possibly through reducing apoptosis, whereas basal cell targeting of c-Myc is not oncogenic (
      • Pelengaris S.
      • Littlewood T.
      • Khan M.
      • Elia G.
      • Evan G.
      Reversible activation of c-Myc in skin: induction of a complex neoplastic phenotype by a single oncogenic lesion.
      ;
      • Waikel R.L.
      • Kawachi Y.
      • Waikel P.A.
      • Wang X.J.
      • Roop D.R.
      Deregulated expression of c-Myc depletes epidermal stem cells.
      ). Deletion of the cyclin/CDK inhibitor p21waf1, a downstream effector of p53, increases the number of benign tumors but does not influence the rate of premalignant progression (
      • Missero C.
      • Di Cunto F.
      • Kiyokawa H.
      • Koff A.
      • Dotto G.P.
      The absence of p21Cip1/WAF1 alters keratinocyte growth and differentiation and promotes ras-tumor progression.
      ;
      • Weinberg W.C.
      • Fernandez-Salas E.
      • Morgan D.L.
      • et al.
      Genetic deletion of p21WAF1 enhances papilloma formation but not malignant conversion in experimental mouse skin carcinogenesis.
      ). In contrast, p53 depletion enhances malignant progression but does not increase benign tumor formation (
      • Kemp C.J.
      • Donehower L.A.
      • Bradley A.
      • Balmain A.
      Reduction of p53 gene dosage does not increase initiation or promotion but enhances malignant progression of chemically induced skin tumors.
      ). These results suggest that the p53 pathway involving cell cycle inhibition through p21waf1 does not determine the risk for malignant conversion, but another p53 regulated pathway is critical for suppression of premalignant progression. TGFβ plays a dual role in experimental SCC development, suppressing premalignant progression while enhancing phenotypic progression from SCC to a spindle cell phenotype (
      • Glick A.B.
      • Lee M.M.
      • Darwiche N.
      • Kulkarni A.B.
      • Karlsson S.
      • Yuspa S.H.
      Targeted deletion of the TGF-β 1 gene causes rapid progression to squamous cell carcinoma.
      ;
      • Portella G.
      • Cumming S.A.
      • Liddell J.
      • Cui W.
      • Ireland H.
      • Akhurst R.J.
      • Balmain A.
      Transforming growth factor β is essential for spindle cell conversion of mouse skin carcinoma in vivo: implications for tumor invasion.
      ;
      • Go C.
      • Li P.
      • Wang X.J.
      Blocking transforming growth factor β signaling in transgenic epidermis accelerates chemical carcinogenesis: a mechanism associated with increased angiogenesis.
      ). Members of the AP-1 transcription factor family also play a dual role in experimental skin tumor development, where c-June is essential for papilloma and c-Fos is essential for SCC development (
      • Saez E.
      • Rutberg S.E.
      • Mueller E.
      • Oppenheim H.
      • Smoluk J.
      • Yuspa S.H.
      • Spiegelman B.M.
      c-fos is required for malignant progression of skin tumors.
      ;
      • Young M.R.
      • Li J.J.
      • Rincon M.
      • Flavell R.A.
      • Sathyanarayana B.K.
      • Hunziker R.
      • Colburn N.
      Transgenic mice demonstrate AP-1 (activator protein-1) transactivation is required for tumor promotion.
      ). Other pathways now implicated in SCC development and progression to spindle cell tumors from experimental studies are cyclin D1, ornithine decarboxylase, p16ink4A, p15ink4A, and E-cadherin (
      • Navarro P.
      • Gömez M.
      • Pizarro A.
      • Gamallo C.
      • Quintanilla M.
      • Cano A.
      A role for the E-cadherin cell-cell adhesion molecule during tumor progression of mouse epidermal carcinogenesis.
      ;
      • Clifford A.
      • Morgan D.
      • Yuspa S.H.
      • Soler A.P.
      • Gilmour S.
      Role of ornithine decarboxylase in epidermal tumorigenesis.
      ;
      • Linardopoulos S.
      • Street A.J.
      • Quelle D.E.
      • Parry D.
      • Peters G.
      • Sherr C.J.
      • Balmain A.
      Deletion and altered regulation of p16INK4a and p15INK4b in undifferentiated mouse skin tumors.
      ;
      • Robles A.I.
      • Rodriguez-Puebla M.L.
      • Glick A.B.
      • et al.
      Reduced skin tumor development in cyclin D1-deficient mice highlights the oncogenic ras pathway in vivo.
      ). These pathways are frequently altered in human SCC, but their contribution to pathogenesis remains to be proven by studies that directly transform human keratinocytes in an in vivo setting.
      Figure thumbnail gr4
      Figure 4Genetic changes associated with chemically induced mouse cutaneous SCC. The multistage evolution of anaplastic or spindle cell tumors in this model is highly ordered both temporally and genetically. Ras mutations are characteristic of chemical mutagens used to initiate tumor formation. Early upregulation of cyclin D1 and later up-regulation of TGFα1 occur through epigenetic mechanisms and appear to be important components of carcinogenesis.
      Mouse models promise to reveal another essential aspect of skin cancer pathogenesis, that of individual susceptibility. Inbred mouse strains differ in susceptibility to particular exposures by several orders of magnitude (
      • DiGiovanni J.
      • Imamoto A.
      • Naito M.
      • Walker S.E.
      • Beltran L.
      • Chenicek K.J.
      • Skow L.
      Further genetic analyses of skin tumor promoter susceptibility using inbred and recombinant inbred mice.
      ). Carcinogenesis studies on cultured mouse keratinocytes derived from different background strains or on skin from specific strains grafted to nude mice indicate that sensitivity is determined by the target tissue rather than systemically (
      • Yuspa S.H.
      • Morgan D.L.
      Mouse skin cells resistant to terminal differentiation associated with initiation of carcinogenesis.
      ;
      • Yuspa S.H.
      • Spangler E.F.
      • Donahoe R.
      • Geusz S.
      • Ferguson E.
      • Wenk M.
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      Sensitivity to two-stage carcinogenesis of SENCAR mouse skin grafted to nude mice.
      ;
      • Glick A.
      • Popescu N.
      • Alexander V.
      • Ueno H.
      • Bottinger E.
      • Yuspa S.H.
      Defects in transforming growth factor-β signaling cooperate with a ras oncogene to cause rapid aneuploidy and malignant transformation of mouse keratinocytes.
      ). Tumor induction on F1 hybrid backcrosses between sensitive and resistant strains followed by genome scans using microsatellite markers has revealed that determinants for susceptibility or resistance are multigenic and distinct for benign tumor formation or premalignant progression and malignant conversion (
      • Nagase H.
      • Bryson S.
      • Cordell H.
      • Kemp C.J.
      • Fee F.
      • Balmain A.
      Distinct genetic loci control development of benign and malignant skin tumours in mice.
      ;
      • Mock B.A.
      • Lowry D.T.
      • Rehman I.
      • Padlan C.
      • Yuspa S.H.
      • Hennings H.
      Multigenic control of skin tumor susceptibility in SENCAR/Part mice.
      ). Analysis of congenic strains and other approaches indicate that specific loci are epistatic, and the interactions are specific for benign or malignant tumor formation (
      • Nagase H.
      • Mao J.H.
      • de Koning J.P.
      • Minami T.
      • Balmain A.
      Epistatic interactions between skin tumor modifier loci in interspecific (spretus/musculus) backcross mice.
      ). Genetic loci also determine the survival potential for tumor-bearing animals (
      • Nagase H.
      • Mao J.H.
      • Balmain A.
      A subset of skin tumor modifier loci determines survival time of tumor- bearing mice.
      ). As the specific genes are identified for these determinants, syntenic sites in the human genome that determine skin cancer susceptibility may be revealed.

      Conclusion

      The rapidly accumulating genetic details of cutaneous cancer pathogenesis combined with the illumination of interacting signaling pathways downstream from the genes involved provides an opportunity to model the biochemistry of cutaneous tumors, a scheme that must ultimately be understood for rational therapy or medical intervention. Currently any biochemical model would almost certainly be incomplete. Alternatively, a general biologic scheme that may fit the multistage development of both melanoma and squamous cell skin cancers might be constructed with current information. The scheme has value as an organizational foundation to focus on emerging understanding of the biochemistry of the individual biologic processes and to test the biochemical principles in cutaneous cancer models. Such a scheme (Figure 5) assigns aberrations in control of proliferation, normal differentiation, apoptosis or senescence, or developmental processes (in the case of some hereditary syndromes) as early events. As a consequence of these changes or coupled to p53 mutations, resistance to terminal cell death produces a survival advantage for the incipient cancer cells. Under selective pressure (cytotoxicity from sunlight or environmental chemicals being the most obvious exogenous sources), clonal expansion produces a clinically apparent benign lesion (AK) or dysplastic nevus. Premalignant progression is associated with genomic instability that could be inherent in a lesion with enhanced survival and a high proliferation rate. Nevertheless, other important changes must occur in this growing lesion that could be modulated by the host response. An inflammatory reaction could deposit cytokines in the lesional environment as well as mutagenic reactive oxygen or nitrogen species (
      • Smith C.W.
      • Chen Z.
      • Dong G.
      • Loukinova E.
      • Pegram M.Y.
      • Nicholas-Figueroa L.
      • Van Waes C.
      The host environment promotes the development of primary and metastatic squamous cell carcinomas that constitutively express proinflammatory cytokines IL-1alpha, IL-6, GM-CSF, and KC.
      ;
      • Hussain S.P.
      • Raja K.
      • Amstad P.A.
      • et al.
      Increased p53 mutation load in nontumorous human liver of Wilson disease and hemochromatosis: oxyradical overload diseases.
      ;
      • Fitzpatrick F.A.
      Inflammation, carcinogenesis and cancer.
      ). Angiogenesis and immune surveillance may play opposing roles or systemic immunosuppression may act in concert with angiogenesis to enhance progression (
      • Prehn R.T.
      • Prehn L.M.
      Immunostimulation of cancer versus immunosurveillance.
      ;
      • Smith-McCune K.
      • Zhu Y.H.
      • Hanahan D.
      • Arbeit J.
      Cross-species comparison of angiogenesis during the premalignant stages of squamous carcinogenesis in the human cervix and K14- HPV16 transgenic mice.
      ). Many cell generations may pass as the positive and negative influences of the organismal response interact with the endogenous activities of the neoplastic lesion. Subsequent clones evolve and subclones from these as further survival advantage is acquired and selected. Alternatively, lethal genetic aberrations may arise and account for the spontaneous regression of some AK or melanotic lesions. The tumor environment evolves concomitant with clonal selection, altering the interactions of stromal, epithelial, and inflammatory components and the tumor matrix itself. It is this balance that finally allows for the invasive properties of tumor cells to be displayed. Thus, we see experimental evidence for stromal and matrix determinants of tumor cell behavior (
      • Arias A.M.
      Epithelial mesenchymal interactions in cancer and development.
      ;
      • Liotta L.A.
      • Kohn E.C.
      The microenvironment of the tumour–host interface.
      ). The advantage the host has over the tumor cell is time. The opportunity for intervention is long. Our goal, in addition to education and lifestyle change, should be reduction in mortality, morbidity, and deformity. The knowledge to achieve this goal is rapidly evolving. Cutaneous cancer intervention and therapy is ideally suited to showcase the opportunities for rational approaches to cancer control and cancer cure.
      Figure thumbnail gr5
      Figure 5Stage-specific biologic changes associated with multistage cutaneous carcinogenesis. This scheme is proposed to focus on processes that may be common for multistage tumor development where precise biochemical pathways are still under study. Early events reflect changes occuring in incipient tumor cells whereas progression incorporates processes at the tissue and organismal level that must be addressed to fully comprehend cutaneous cancer pathogenesis.

      ACKNOWLEDGMENTS

      Due to the breadth of this review, we apologize for the unavoidable exclusion of references to work done by many outstanding investigators working in these areas. We wish to acknowledge the contribution of Dr. Luowei Li to the construction of the figures and Ms. Bettie Sugar for outstanding editorial assistance.

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