A Hypoxia-Apoptosis Stress-Adaptation State Defines Immune-Low Melanoma and Predicts Metastatic Risk.

Background/Objectives: Chronic microenvironment stress contributes to the progression of melanoma, yet practical tools for quantifying tumor stress adaptation remain limited. Methods: Using disulfiram as a system-level probe, we identified shared regulatory modules between disulfiram-related targets and melanoma-associated genes, which are integrated into pathways regulating apoptosis and hypoxia/oxidative stress. From these modules, we devised a stress adaptation score (BiScore) based on hallmark gene characteristics and assessed its prognostic significance in melanoma cohorts. Results and Conclusions: In the TCGA-SKCM dataset, a higher binuclear score correlated with poorer overall survival and remained an independent prognostic factor even after adjusting for clinical covariates. This observation was externally validated for distant metastasis-free survival rate in the GSE65904 cohort. Tumors with high binuclear expression consistently exhibited reduced immune infiltration and were weakly associated with mutation load, suggesting that the stress adaptation axis operates independently of gene mutation burden. Single-cell analyses demonstrated that stress-related signals were distributed across both malignant and stress-responsive microenvironmental compartments. In melanoma cell lines, hypoxia induces HIF-1α expression and shifts apoptosis-related proteins towards an anti-apoptotic state, and NAC attenuated CoCl2-induced ROS accumulation. In conclusion, these findings establish BiScore as a quantitative framework for capturing stress adaptation states linked to adverse outcomes in melanoma.