The incidence of cutaneous melanoma (CM) has shown one of the higher increases of any form of cancer during the past two generations [1]. Worldwide, about 100.000 new cases of CM are diagnosed each year and account for more than 70% of all the deaths from skin tumors [1–5].

The increase in CM incidence is shared by Australia, New Zealand, United States and most of European States, notwithstanding the better knowledge of environmental and phenotypic risk factors and ongoing primary and secondary prevention strategies [6–9]. To date, according to the updated AJCC staging system, the most reliable predictors of patient outcome remain the extent of infiltration (Breslow thickness), the presence of ulceration and, to a lesser extent, the tumor proliferation index [10]. The estimated 10-year survival rates for non-metastatic CM range from 93% for patients with "thin" tumors (</= 1.0 mm of dermal invasion, without ulceration and/or mitotic index < 1/mm², Stage Ia), to 39% for patients with ulcerated tumors deeper than 4.0 mm [10]. In about two-third of progressing CM, loco-regional (skin and/or lymphatic) metastatic spreading occurs, whereas in the remaining cases, haematogenous metastases arise directly, at distant anatomic sites [11].

Recent improvements in diagnostic techniques (i.e.: epiluminescence dermoscopy) have led to diagnose most CM at an early stage. However, the number of patients that die for the disease remains still substantially unchanged.

This disappointing result could be explained, at least in part, by the heterogeneous nature of this malignancy [5]. At present, it is thought that the aggressiveness of melanoma may be conditioned by the variable concurrence of multiple factors, intrinsic to neoplastic cells (i.e., imbalance of cell proliferation and apoptosis control pathways), and/or micro-environmental (i.e., degree of tumor neo-angiogenesis, expression of adhesion molecules facilitating the migration of malignant cells) [12].

As a result, CM may ultimately show a biological behavior often unpredictable by means of the classical histological prognostic parameters [10].

"Thin" melanomas can metastasize early, while some "thick" tumors may show only late metastasis ("dormant" melanoma) [13].

At present, except for high-dose IFN as adjuvant therapy for stage III disease, effective strategies to treat metastasizing melanomas are lacking; the median survival of patients with distant metastases ranges from 6 to 10 months, with a 5-years survival lesser than 5% [14]. Therefore, the attention of the melanoma research community is devoted to the chance of translate significant molecular studies results on melanoma biology into clinical correlates and new therapeutic agents directed at specific pathways.

Proteomic and genomic studies have revealed, in CM, alterations of the expression of many oncogenes and tumor suppressor genes responsible of either the DNA damage repair and cell cycle control [15–19].

A fundamental role in the regulation of both these processes has emerged for the molecular factors responsible of the epigenetic regulation of nuclear chromatin dynamics, that control also the packaging and interpretation of the genome, in response to environmental stimuli [20–24].

Histone chaperones play a pivotal role in this process. They drive the incorporation of different histones into DNA to the sites where nuclear chromatin has to be newly formed or remodeled [25].

Among these, the Chromatin Assembly Factor-1 (CAF-1), a trimeric protein complex formed by the p48, p60, and p150 subunits, promotes histone incorporation into chromatin and acts in strict association with both the S-phase and DNA repair [26–29].

CAF-1 ensures the restoration of chromatin structure, providing that all aspects, including nucleosome position and epigenetic imprints, are re-established during the final step of DNA-repair, before cell-replication.

Recently, CAF-1/p60 has been proposed as a new proliferation and prognostic marker, since it has been found over-expressed in a series of human malignancies, in close association with their biological aggressiveness [30–32].

Starting from these postulates, we sought to examine the immunohistochemical expression of CAF-1/p60 on a selected series of primary CM. These tumors notoriously look at UV-radiation as a major environmental pathogenetic factor, and are characterized, in metastasizing cases, by an extreme deregulation of cell proliferation and defects in DNA-repair. We have previously evaluated the expression of the poly(ADP-ribose)polymerase 1 (PARP 1) in a series of melanomas of photo-exposed skin areas [18]. As it is known, the family of PARP proteins is directly involved in the epigenetic control of DNA-repair and cell death triggered by DNA damage. We found a significative statistical correlation between the inhibition of the PARP-1 mediated apoptosis and DNA repair process, and the metastasizing behavior of CM [18]. In addition, we hypothesized that the imbalance of PARP-1 activity could also be responsible, at least in part, for the chemoresistence of metastatic CM [18].

In the present study, considering the key role of CAF-1 in the epigenetic regulation of either cell proliferation and DNA-repair, we focused on the expression of CAF-1/p60 on a series of 130 CM, among which were comprised the cases previously matched for poly(ADP-ribosyl)ation. The aim of the study was to verify the hypothesis that the metastasizing behavior of CM could be correlated with the alteration of more than a single epigenetic pathway of DNA-repair and cell proliferation control, and to establish the possible role of CAF-1/p60 as a new valuable predictor of prognosis for skin melanoma patients.

As it is known, despite its location within the protective chromatin microenvironment, DNA is subject to repeated damage by exogenous agents, such as ultraviolet radiation (UV), which can impair replication and/or transcription and must be corrected to prevent mutations [24].

Chromatin dynamics tightly controls activation and function of genes, by modulating the access of regulatory factors to DNA, and highly influences cellular behavior of normal and neoplastic cells [21]. A highly ordered coordination and organization of factors regulating the opening and closing of chromatin is crucial to ensure that the correct epigenetic code is maintained within the genome [24].

Genomic instability is a major hallmark of tumor progression. It contributes to the gain of the invasive-metastatic phenotype of neoplastic cells by favoring the accumulation of sequential genetic and epigenetic events. These latter include DNA methylation, histone modifications, small, non-coding RNAs, and factors involved in the regulation of chromatin architecture [34–36].

Chromatin dynamics control nucleosome assembly and higher order chromatin structure, and are responsible for the global nuclear organization and compartmentalization, tightly regulating gene expression and controlling protein-DNA interactions within the cell nucleus [37, 38]. In particular, it allows the recognition of DNA-damaged sequences and the segregation of the damaged chromosomes, potential cause of genomic instability, determining chromatin reshaping and warranting the correct progression of the cell cycle and the maintenance of genome integrity [39–41].

In melanomagenesis, the deregulation of cell proliferation results, at least in part, from the alteration of epigenetic control checkpoints. In particular, the inactivation of UV-specific pathways of DNA repair is a critical step.

In normal melanocytes, UV trigger histone acetylation and the immediate activation of the histone poly-(ADP-ribosyl)ation, a post-synthetic DNA epigenetic modification which causes the generation of intracellular signals, leading to the DNA repair or, in the case of excessive damage, to apoptosis [24, 41–43].

Recent data concerning the "chromatin ambient" of the nucleus indicate a highly qualified role for chromatin modifying proteins in the control of DNA replication and DNA-repair [27, 44, 45]. The CAF-1 molecular complex looks fundamental for the maintenance of the epigenetic information; in particular, the deletion of CAF-1 subunits in S. cerevisiae confers sensibility to UV radiation [24]. CAF-1, to date, is the only known chromatin assembly factor able to drive nucleosome assembly onto newly synthesized DNA, and has a central role in ensuring chromatin replication in S phase through the interaction with the polymerase sliding clamp, PCNA [26, 30, 31, 46–48]. It constitutes the first example of a factor involved in chromatin dynamics useful to assess cell proliferation [30]. The behavior of its p60 and p150 subunits shares a number of similarities with PCNA, which plays crucial roles in both DNA replication and repair. Experimental data indicate that particularly p60 is active in either the control of cell proliferation and DNA-repair. Silencing of the p60 subunit by RNAi leads to the accumulation of double-strand DNA breaks and to the induction of programmed cell death in proliferating but not quiescent human cells [49].

Recently, the involvement of CAF-1/p60 in neoplastic progression has been reported, and its expression has been proposed as a new tool to define the biological behavior of some types of human malignancies (breast, tongue, and prostate cancer) [30–32].

This opens up the possibility that its use could be extended to malignancies of different histogenesis.

Here we show results supporting a role of CAF-1 in predicting the aggressiveness of CM.

In our cases, the maximum level of over-expression of CAF-1/p60 was found in the vertical growth phase of CM characterized by a metastasizing behavior, besides the Breslow thickness, ulceration and/or high mitotic index. This suggests that CAF-1/p60 may shows a promising role as a relevant, adjunctive prognostic marker for CM. Our results are in-line with previous data concerning the alteration of the poly-(ADP-ribosil)ation process in highly aggressive CM [18]. In particular, the occurrence of CAF-1/p60 hyperexpression in the same cases of CM previously found to bear an altered expression of PARP-1, indicates that the co-existence of the deregulation of two of the major epigenetic pathways responsible of DNA-repair and cell replication control, constitutes a hallmark predictive of metastasizing behavior in CM of photoexposed skin.

Investigations are being undertaken from our research group to determine whether the alteration of such mechanisms still retains with the same statistical significance among a multi-institutional greater series of cases. This perspective looks extremely attractive, because give us means to built up a model in which the evaluation of the CAF-1/p60 status of expression could get over the limitations of current prognostic evaluation, particularly for that concerning the "grey area" of CM with an intermediate thickness (Breslow >1 and <2 mm).

In addition, it would be worth investigating how the CAF-1 molecular pathway can be regulated, by modulating the expression of its subunits and their interactions with the other histone chaperones and ATP-dependent chromatin remodelers. It has to be remembered, to this regard, that in contrast to genetic alterations, epigenetic modifications, although heritable in cells, are progressive, quantitatively evaluable, potentially reversible, and may serve as potential targets for drug treatment [22, 50, 51]. Given the absence of effective therapy for metastatic melanoma, the CAF-1 pathway may provide a window of opportunity for novel post-surgical molecular therapies. Undoubtedly, future studies will provide many exciting advances towards fully understanding of the critical link between chromatin, DNA repair and cell proliferation control, and the biology of CM.

Considering its essential role for cell cycle progression, it might constitute a new therapeutic target with cytostatic and/or cytotoxic effects that deserve to be investigated in the future.

Basing on the results of the present study, however, we believe that CAF-1/p60 expression is an exciting chance to better predict the biological behavior of CM, besides the traditional prognostic parameters.

This paper constitutes the first report of CAF-1/p60 up-regulation in CM, and supports a noteworthy role for CAF-1 in linking chromatin dynamics to the metastasizing behavior of this tumor.

Basing on results, CAF-1 looks like a promising candidate as a new prognostic marker which might give us the chance to early detect the subset of CM patients affected by metastasizing, hence deadly tumors, which cannot be correctly detected on the basis of the existing traditional parameters.

Many interesting questions remain still unanswered about how chromatin remodeling influences replication, transcription and repair within the tumorigenesis cascade of CM. However, according to our opinion, our findings have opened up new intriguing horizons that may enable a better understanding of the biology of skin melanoma, providing further insights into the contribution of the epigenetic control of cell proliferation and DNA repair to the gain of a metastasizing phenotype of CM.