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Michielin O, van Akkooi ACJ, Ascierto PA, Dummer R, Keilholz U. Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol 2019; 30:1884-1901. [PMID: 31566661 DOI: 10.1093/annonc/mdz411] [Citation(s) in RCA: 360] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- O Michielin
- Department of Oncology, University Hospital Lausanne, Lausanne, Switzerland
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - P A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Napoli, Italy
| | - R Dummer
- Department of Dermatology, Skin Cancer Centre, University Hospital Zürich, Zürich, Switzerland
| | - U Keilholz
- Charité Comprehensive Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Risk factors for post-operative complications after sentinel lymph node biopsy for cutaneous melanoma: Results from a large cohort study. J Plast Reconstr Aesthet Surg 2019; 72:1956-1962. [DOI: 10.1016/j.bjps.2019.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 08/03/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022]
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53
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Satzger I, Leiter U, Gräger N, Keim U, Garbe C, Gutzmer R. Melanoma-specific survival in patients with positive sentinel lymph nodes: Relevance of sentinel tumor burden. Eur J Cancer 2019; 123:83-91. [DOI: 10.1016/j.ejca.2019.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
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Leiter U, Stadler R, Mauch C, Hohenberger W, Brockmeyer NH, Berking C, Sunderkötter C, Kaatz M, Schatton K, Lehmann P, Vogt T, Ulrich J, Herbst R, Gehring W, Simon JC, Keim U, Verver D, Martus P, Garbe C. Final Analysis of DeCOG-SLT Trial: No Survival Benefit for Complete Lymph Node Dissection in Patients With Melanoma With Positive Sentinel Node. J Clin Oncol 2019; 37:3000-3008. [PMID: 31557067 DOI: 10.1200/jco.18.02306] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 12/17/2023] Open
Abstract
PURPOSE We have previously reported on the 3-year results of the phase III German Dermatologic Cooperative Oncology Group trial (DeCOG; ClinicalTrials.gov identifier: NCT02434107) comparing distant metastasis-free survival (DMFS), recurrence-free survival (RFS), and overall survival (OS) in patients with positive sentinel lymph-node biopsy who were randomly assigned to complete lymph node dissection (CLND) or observation. Here, we report the final analysis with 72 months of median follow up. PATIENTS AND METHODS The multicenter randomized phase III trial included patients with cutaneous melanoma of the trunk and extremities who were randomly assigned (1:1) to undergo CLND or observation. DMFS was analyzed as the primary end point, and RFS, OS, and recurrences in the regional lymph node basin were secondary end points. The analysis was by intention to treat. Disease and survival information were collected quarterly. RESULTS From January 2006 to December 2014, 5,547 patients were screened to identify 1,256 with metastases in the sentinel lymph node (SLN). Of these, 483 (39%) were included: 241 in the observation arm and 242 in the CLND arm. In the final analysis, median follow up was 72 months (interquartile range, 67-77 months). No significant treatment-related difference was seen in the 5-year DMFS between the observation and CLND arms (67.6% v 64.9%, respectively; hazard ratio [HR], 1.08; P = .87). The 5-year RFS and OS also showed no difference (HR, 1.01 and 0.99, respectively). Grade 3 and 4 adverse effects occurred in 32 patients (13%) in the CLND arm; lymphedema (n = 20) and delayed wound healing (n = 5) were most common and no serious adverse events were reported. CONCLUSION The final results of the German Dermatologic Cooperative Oncology Group trial with a median follow up of 72 months showed higher event rates, but similar HRs compared with those at the 3-year analysis. These results confirm that immediate CLND in SLN-positive patients is not superior to observation in terms of DMFS, RFS, or OS and support not recommending CLND in patients with SLN metastasis.
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Affiliation(s)
- Ulrike Leiter
- Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | | | | | | | | | - Cord Sunderkötter
- University of Munster, Munster, Germany
- University Hospital Halle, Halle, Germany
| | - Martin Kaatz
- SRH Wald-Klinikum Gera, Gera, Germany
- University of Jena, Jena, Germany
| | | | | | | | - Jens Ulrich
- University of Magdeburg, Quedlinburg, Germany
| | | | | | | | - Ulrike Keim
- Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | - Peter Martus
- Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Claus Garbe
- Eberhard Karls University of Tübingen, Tübingen, Germany
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Eggermont AM, Chiarion-Sileni V, Grob JJ, Dummer R, Wolchok JD, Schmidt H, Hamid O, Robert C, Ascierto PA, Richards JM, Lebbe C, Ferraresi V, Smylie M, Weber JS, Maio M, Hosein F, de Pril V, Kicinski M, Suciu S, Testori A. Adjuvant ipilimumab versus placebo after complete resection of stage III melanoma: long-term follow-up results of the European Organisation for Research and Treatment of Cancer 18071 double-blind phase 3 randomised trial. Eur J Cancer 2019; 119:1-10. [DOI: 10.1016/j.ejca.2019.07.001] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 12/19/2022]
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Eggermont AMM, Blank CU, Mandala M, Long GV, Atkinson VG, Dalle S, Haydon A, Lichinitser M, Khattak A, Carlino MS, Sandhu S, Larkin J, Puig S, Ascierto PA, Rutkowski P, Schadendorf D, Koornstra R, Hernandez-Aya L, Di Giacomo AM, van den Eertwegh AJ, Grob JJ, Gutzmer R, Jamal R, Lorigan PC, Lupinacci R, Krepler C, Ibrahim N, Kicinski M, Marreaud S, van Akkooi AC, Suciu S, Robert C. Prognostic and predictive value of AJCC-8 staging in the phase III EORTC1325/KEYNOTE-054 trial of pembrolizumab vs placebo in resected high-risk stage III melanoma. Eur J Cancer 2019; 116:148-157. [PMID: 31200321 DOI: 10.1016/j.ejca.2019.05.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer-8 (AJCC) classification of melanoma was implemented in January 2018. It was based on data gathered when checkpoint inhibitors were not used as adjuvant therapy in stage III melanoma. The European Organization for Research and Treatment of Cancer (EORTC) 1325/KEYNOTE-054 double-blind phase III trial evaluated pembrolizumab vs placebo in AJCC-7 stage IIIA (excluding lymph node metastasis ≤1 mm), IIIB or IIIC (without in-transit metastasis) patients after complete lymphadenectomy. PATIENTS, METHODS AND RESULTS Patients (n = 1019) were randomised 1:1 to pembrolizumab 200 mg or placebo every 3 weeks (total of 18 doses, ∼1 year). At 1.25-year median follow-up, pembrolizumab prolonged relapse-free survival (RFS) in the total population (1-year RFS rate: 75.4% vs 61.0%; hazard ratio [HR] 0.57; logrank P < 0.0001) and consistently in the AJCC-7 subgroups. Prognostic and predictive values of AJCC-8 for RFS were evaluated in this study. Patient distribution according to the AJCC-8 stage subgroups was 8% (IIIA), 34.7% (IIIB), 49.7% (IIIC), 3.7% (IIID) and 3.8% (unknown). AJCC-8 classification was strongly associated with RFS (HRs for stage IIIB, IIIC and IIID vs IIIA were 4.0, 5.7 and 12.2, respectively) but showed no predictive importance for the treatment comparison regarding RFS (test for interaction: P = 0.68). The 1-year RFS rate for pembrolizumab vs placebo and the HRs (99% confidence interval) within each AJCC-8 subgroup were as follows: stage IIIA (92.7% vs 92.5%; 0.76 [0.11-5.43]), IIIB (79.0% vs 65.5%; 0.59 [0.35-0.99]), IIIC (73.6% vs 53.9%; 0.48 [0.33-0.70]) and IIID (50.0% vs 33.3%; 0.69 [0.24-2.00]). CONCLUSIONS AJCC-8 staging had a strong prognostic importance for RFS but no predictive importance: the RFS benefit of pembrolizumab was observed across AJCC-8 subgroups in resected high-risk stage III melanoma patients.
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Affiliation(s)
| | - Christian U Blank
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Mario Mandala
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, and Mater and Royal North Shore Hospitals, Sydney, NSW, Australia
| | | | | | | | | | - Adnan Khattak
- Fiona Stanley Hospital/University of Western Australia, Perth, WA, Australia
| | - Matteo S Carlino
- Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney, Sydney, NSW, Australia
| | | | | | - Susana Puig
- Hospital Clinic Universitari de Barcelona, Barcelona, Spain
| | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Piotr Rutkowski
- Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
| | | | - Rutger Koornstra
- Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
| | | | | | | | | | - Ralf Gutzmer
- Skin Cancer Center, Hannover Medical School, Hannover, Germany
| | - Rahima Jamal
- Centre Hospitalier de l'Université de Montréal (CHUM), Centre de recherche du CHUM, Montreal, QC, Canada
| | - Paul C Lorigan
- Christie NHS Foundation Trust, Manchester, United Kingdom
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Small and Isolated Immunohistochemistry-positive Cells in Melanoma Sentinel Lymph Nodes Are Associated With Disease-specific and Recurrence-free Survival Comparable to that of Sentinel Lymph Nodes Negative for Melanoma. Am J Surg Pathol 2019; 43:755-765. [DOI: 10.1097/pas.0000000000001229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hindié E. What Is the Role of Dabrafenib Plus Trametinib Adjuvant Therapy in Stage IIIA Melanoma? J Clin Oncol 2019; 37:1355-1356. [DOI: 10.1200/jco.18.02075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Elif Hindié
- Elif Hindié, MD, PhD, Bordeaux University Hospital, Bordeaux, France
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Abstract
PURPOSE OF REVIEW We review the results from relevant clinical trials and discuss current strategies in the melanoma adjuvant setting. RECENT FINDINGS The favorable therapeutic efficacy and the significant less toxicity of nivolumab compared with ipilimumab, fully substitutes today's approval of ipilimumab, regardless mutation status, whereas in BRAF-mutated patients, dabrafenib and trametinib seem to confirm their high efficacy also in adjuvant setting. The use of interferon is restricted to patients with ulcerated melanoma and countries with no access to the new drugs. SUMMARY Systemic adjuvant treatment after complete disease resection in high-risk melanoma patients aims to increase relapse-free survival (RFS) and overall survival (OS). According to the eighth edition of melanoma classification of American Joint Committee on Cancer (AJCC), the prognosis in stage III patients is heterogeneous and depends not only on N (nodal) but also on T (tumor thickness) category criteria. Recent data from randomized, phase-3 clinical trials analyzing the use of adjuvant anti-programmed death-1 and targeted therapies ultimately affect the standard of care and change the landscape of the adjuvant treatment.
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Enhancing the prognostic role of melanoma sentinel lymph nodes through microscopic tumour burden characterization: clinical usefulness in patients who do not undergo complete lymph node dissection. Melanoma Res 2019; 29:163-171. [DOI: 10.1097/cmr.0000000000000481] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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61
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Angeles CV, Kang R, Shirai K, Wong SL. Meta-analysis of completion lymph node dissection in sentinel lymph node-positive melanoma. Br J Surg 2019; 106:672-681. [PMID: 30912591 DOI: 10.1002/bjs.11149] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/27/2018] [Accepted: 02/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND The role of completion lymph node dissection (CLND) in patients with sentinel lymph node (SLN)-positive melanoma continues to be debated. This systematic review and meta-analysis evaluated survival and recurrence rate in these patients who underwent CLND, compared with observation. METHODS A comprehensive MEDLINE and Embase database search was performed for cohort studies and RCTs published between January 2000 and June 2017 that assessed the outcomes of CLND compared with observation in patients with SLN-positive melanoma. The primary outcome was survival and the secondary outcome was recurrence rate. Studies were assessed for quality using the Cochrane risk-of-bias tool for RCTs and Newcastle-Ottawa Scale for cohort studies. Pooled relative risk or hazard ratio with 95 per cent confidence intervals were calculated for each outcome. The extent of heterogeneity between studies was assessed with the I2 test. The protocol was registered in PROSPERO (CRD42017070152). RESULTS Fifteen studies (13 cohort studies with 7868 patients and 2 RCTs with 2228 patients) were identified for qualitative synthesis. Thirteen studies remained for quantitative meta-analysis. Survival was similar in patients who underwent CLND and those who were observed (risk ratio (RR) for death 0·85, 95 per cent c.i. 0·71 to 1·02). The recurrence rate was also similar (RR 0·91, 0·79 to 1·05). CONCLUSION Patients with SLN-positive melanoma do not have a significant benefit in survival or recurrence rate if they undergo CLND rather than observation.
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Affiliation(s)
- C V Angeles
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - R Kang
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - K Shirai
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - S L Wong
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Klemen ND, Han G, Leong SP, Kashani‐Sabet M, Vetto J, White R, Schneebaum S, Pockaj B, Mozzillo N, Charney K, Hoekstra H, Sondak VK, Messina JL, Zager JS, Han D. Completion lymphadenectomy for a positive sentinel node biopsy in melanoma patients is not associated with a survival benefit. J Surg Oncol 2019; 119:1053-1059. [DOI: 10.1002/jso.25444] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/03/2019] [Accepted: 02/26/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas D. Klemen
- Section of Surgical OncologyYale School of MedicineNew Haven Connecticut
| | - Gang Han
- Department of Epidemiology and BiostatisticsSchool of Public Health, Texas A&M UniversityCollege Station Texas
| | - Stanley P. Leong
- California Pacific Medical Center and Research InstituteSan Francisco California
| | | | - John Vetto
- Division of Surgical OncologyOregon Health & Science UniversityPortland Oregon
| | - Richard White
- Levine Cancer InstituteCarolinas Medical CenterCharlotte North Carolina
| | | | | | | | - Kim Charney
- St. Joseph Hospital of OrangeOrange California
| | | | | | | | | | - Dale Han
- Division of Surgical OncologyOregon Health & Science UniversityPortland Oregon
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Belgrano V, Katsarelias D, Mattsson J, Olofsson Bagge R. Sentinel node for malignant melanoma: An observational study of a consecutive single centre experience. Eur J Surg Oncol 2019; 45:225-230. [DOI: 10.1016/j.ejso.2018.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 08/24/2018] [Accepted: 08/30/2018] [Indexed: 01/25/2023] Open
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Bertolli E, Franke V, Calsavara VF, de Macedo MP, Pinto CAL, van Houdt WJ, Wouters MWJM, Duprat Neto JP, van Akkooi ACJ. Validation of a Nomogram for Non-sentinel Node Positivity in Melanoma Patients, and Its Clinical Implications: A Brazilian–Dutch Study. Ann Surg Oncol 2018; 26:395-405. [DOI: 10.1245/s10434-018-7038-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Indexed: 12/14/2022]
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Vertical Growth Phase as a Prognostic Factor for Sentinel Lymph Node Positivity in Thin Melanomas: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2018; 141:1529-1540. [PMID: 29579032 DOI: 10.1097/prs.0000000000004395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The 2010 American Joint Committee on Cancer guidelines recommended consideration of sentinel lymph node biopsy for thin melanoma (Breslow thickness <1.0 mm) with aggressive pathologic features such as ulceration and/or high mitotic rate. The therapeutic benefit of biopsy-based treatment remains controversial. The authors conducted a meta-analysis to estimate the risk and outcomes of sentinel lymph node positivity in thin melanoma, and examined established and potential novel predictors of positivity. METHODS Three databases were searched by two independent reviewers for sentinel lymph node positivity in patients with thin melanoma. Study heterogeneity, publication bias, and quality were assessed. Data collected included age, sex, Breslow thickness, mitotic rate, ulceration, regression, Clark level, tumor-infiltrating lymphocytes, and vertical growth phase. Positivity was estimated using a random effects model. Association of positivity and clinicopathologic features was investigated using meta-regression. RESULTS Ninety-three studies were identified representing 35,276 patients with thin melanoma who underwent sentinel lymph node biopsy. Of these patients, 952 had a positive sentinel lymph node biopsy, for an event rate of 5.1 percent (95 percent CI, 4.1 to 6.3 percent). Significant associations were identified between positivity and Breslow thickness greater than 0.75 mm but less than 1.0 mm, mitotic rate, ulceration, and Clark level greater than IV. Seven studies reported on vertical growth phase, which was strongly associated with positivity (OR, 4.3; 95 percent CI, 2.5 to 7.7). CONCLUSIONS To date, this is the largest meta-analysis to examine predictors of sentinel lymph node biopsy positivity in patients with thin melanoma. Vertical growth phase had a strong association with biopsy positivity, providing support for its inclusion in standardized pathologic reporting.
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Masoud SJ, Perone JA, Farrow NE, Mosca PJ, Tyler DS, Beasley GM. Sentinel Lymph Node Biopsy and Completion Lymph Node Dissection for Melanoma. Curr Treat Options Oncol 2018; 19:55. [PMID: 30232648 PMCID: PMC6684152 DOI: 10.1007/s11864-018-0575-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT This review critically evaluates recent trials which have challenged the practice of completion lymph node dissection (CLND) for melanoma patients diagnosed with regional metastasis by positive sentinel lymph node biopsy (SLNB). Two trials in the last 2 years, DeCOG-SLT and MSLT-II, found no significant differences in melanoma-specific survival between patients, whether they received immediate CLND or observation after positive SLNB, despite decreases in nodal recurrence achieved by dissection. These trials together disfavor routine CLND in most patients after positive SLNB. However, their conclusions are limited by study populations which overall harbored a lower burden of SLN disease. Special attention needs to be given to patients who do have higher risk disease, with SLN tumor burdens exceeding 1 mm in diameter, for whom CLND may remain both prognostic and therapeutic. Current guidelines thus recommend either CLND or careful observation after positive SLNB after appropriate risk stratification of patients. While a decline in CLND is inevitable, treatment of stage III melanoma is witnessing the concurrent rise of effective adjuvant therapies. PD-1 inhibitors such as nivolumab, or combination BRAF/MEK inhibitors for V600E or K mutant melanoma, which were previously available to only trial patients with completely resected stage III disease, are now approved for use in patients with positive SLNB alone. Providers are better equipped than ever to treat clinically occult, regional metastatic disease with SLNB followed by adjuvant therapy for most patients, but should take steps to avoid undertreatment of high-risk patients who may proceed to disease relapse or progression.
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Affiliation(s)
- Sabran J Masoud
- Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Jennifer A Perone
- Department of Surgery, University Texas Medical Branch, Galveston, TX, USA
| | - Norma E Farrow
- Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Paul J Mosca
- Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Douglas S Tyler
- Department of Surgery, University Texas Medical Branch, Galveston, TX, USA
| | - Georgia M Beasley
- Department of Surgery, Duke University, Durham, NC, 27710, USA.
- Duke University Medical Center, DUMC Box 3118, Durham, NC, 27710, USA.
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Moreno-Ramírez D, Boada A, Ferrándiz L, Samaniego E, Carretero G, Nagore E, Redondo P, Ortiz-Romero P, Malvehy J, Botella-Estrada R. Lymph Node Dissection in Patients With Melanoma and Sentinel Lymph Node Metastasis: An Updated, Evidence-Based Decision Algorithm. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2018.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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68
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Gershenwald JE, Scolyer RA. Melanoma Staging: American Joint Committee on Cancer (AJCC) 8th Edition and Beyond. Ann Surg Oncol 2018; 25:2105-2110. [PMID: 29850954 DOI: 10.1245/s10434-018-6513-7] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Jeffrey E Gershenwald
- Departments of Surgical Oncology and Cancer Biology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Melanoma and Skin Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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69
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Eggermont AMM, Blank CU, Mandala M, Long GV, Atkinson V, Dalle S, Haydon A, Lichinitser M, Khattak A, Carlino MS, Sandhu S, Larkin J, Puig S, Ascierto PA, Rutkowski P, Schadendorf D, Koornstra R, Hernandez-Aya L, Maio M, van den Eertwegh AJM, Grob JJ, Gutzmer R, Jamal R, Lorigan P, Ibrahim N, Marreaud S, van Akkooi ACJ, Suciu S, Robert C. Adjuvant Pembrolizumab versus Placebo in Resected Stage III Melanoma. N Engl J Med 2018; 378:1789-1801. [PMID: 29658430 DOI: 10.1056/nejmoa1802357] [Citation(s) in RCA: 1254] [Impact Index Per Article: 209.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The programmed death 1 (PD-1) inhibitor pembrolizumab has been found to prolong progression-free and overall survival among patients with advanced melanoma. We conducted a phase 3 double-blind trial to evaluate pembrolizumab as adjuvant therapy in patients with resected, high-risk stage III melanoma. METHODS Patients with completely resected stage III melanoma were randomly assigned (with stratification according to cancer stage and geographic region) to receive 200 mg of pembrolizumab (514 patients) or placebo (505 patients) intravenously every 3 weeks for a total of 18 doses (approximately 1 year) or until disease recurrence or unacceptable toxic effects occurred. Recurrence-free survival in the overall intention-to-treat population and in the subgroup of patients with cancer that was positive for the PD-1 ligand (PD-L1) were the primary end points. Safety was also evaluated. RESULTS At a median follow-up of 15 months, pembrolizumab was associated with significantly longer recurrence-free survival than placebo in the overall intention-to-treat population (1-year rate of recurrence-free survival, 75.4% [95% confidence interval {CI}, 71.3 to 78.9] vs. 61.0% [95% CI, 56.5 to 65.1]; hazard ratio for recurrence or death, 0.57; 98.4% CI, 0.43 to 0.74; P<0.001) and in the subgroup of 853 patients with PD-L1-positive tumors (1-year rate of recurrence-free survival, 77.1% [95% CI, 72.7 to 80.9] in the pembrolizumab group and 62.6% [95% CI, 57.7 to 67.0] in the placebo group; hazard ratio, 0.54; 95% CI, 0.42 to 0.69; P<0.001). Adverse events of grades 3 to 5 that were related to the trial regimen were reported in 14.7% of the patients in the pembrolizumab group and in 3.4% of patients in the placebo group. There was one treatment-related death due to myositis in the pembrolizumab group. CONCLUSIONS As adjuvant therapy for high-risk stage III melanoma, 200 mg of pembrolizumab administered every 3 weeks for up to 1 year resulted in significantly longer recurrence-free survival than placebo, with no new toxic effects identified. (Funded by Merck; ClinicalTrials.gov number, NCT02362594 ; EudraCT number, 2014-004944-37 .).
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Affiliation(s)
- Alexander M M Eggermont
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Christian U Blank
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Mario Mandala
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Georgina V Long
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Victoria Atkinson
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Stéphane Dalle
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Andrew Haydon
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Mikhail Lichinitser
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Adnan Khattak
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Matteo S Carlino
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Shahneen Sandhu
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - James Larkin
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Susana Puig
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Paolo A Ascierto
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Piotr Rutkowski
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Dirk Schadendorf
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Rutger Koornstra
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Leonel Hernandez-Aya
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Michele Maio
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Alfonsus J M van den Eertwegh
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Jean-Jacques Grob
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Ralf Gutzmer
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Rahima Jamal
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Paul Lorigan
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Nageatte Ibrahim
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Sandrine Marreaud
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Alexander C J van Akkooi
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Stefan Suciu
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
| | - Caroline Robert
- From the Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif (A.M.M.E., C.R.), Hospices Civils de Lyon Cancer Institute, Cancer Research Center of Lyon, Lyon University, Lyon (S.D.), and Aix-Marseille University, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Marseille (J.-J.G.) - all in France; Netherlands Cancer Institute-Antoni van Leeuwenhoek (C.U.B., A.C.J.A.) and VU University Medical Center (A.J.M.E.), Amsterdam, and Radboud University Medical Center Nijmegen, Nijmegen (R.K.) - all in the Netherlands; Azienda Ospedaliera Papa Giovanni XXIII, Bergamo (M. Mandala), Istituto Nazionale Tumori Istituto di Ricovero e Cura a Carattere Scientifico Fondazione G. Pascale, Naples (P.A.A.), and Universita Degli Studi Di Siena-Policlinico le Scotte, Siena (M. Maio) - all in Italy; Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals (G.V.L.) and Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney (M.S.C.), Sydney, Princess Alexandra Hospital, University of Queensland, Brisbane (V.A.), Alfred Hospital (A.H.) and Peter MacCallum Cancer Centre (S. Sandhu), Melbourne, VIC, and Fiona Stanley Hospital-University of Western Australia-Edith Cowan University Perth, Perth (A.K.) - all in Australia; Cancer Research Center, Moscow (M.L.); Royal Marsden Hospital, London (J.L.); Hospital Clinic Universitari de Barcelona, Barcelona (S.P.); Maria Sklodowska-Curie Institute-Oncology Center, Warsaw, Poland (P.R.); University Hospital Essen, Essen and German Cancer Consortium, Heidelberg (D.S.), and the Skin Cancer Center, Department of Dermatology, Hannover Medical School, Hannover (R.G.) - all in Germany; Washington University School of Medicine, St. Louis (L.H.-A.); Centre Hospitalier de l'Université de Montréal (CHUM), Centre de Recherche du CHUM, Montreal (R.J.); Christie NHS Foundation Trust, Manchester, United Kingdom (P.L.); Merck, Kenilworth, NJ (N.I.); and the European Organization for the Research and Treatment of Cancer Headquarters, Brussels (S.M., S. Suciu)
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70
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Stiegel E, Xiong D, Ya J, Funchain P, Isakov R, Gastman B, Vij A. Prognostic value of sentinel lymph node biopsy according to Breslow thickness for cutaneous melanoma. J Am Acad Dermatol 2018; 78:942-948. [DOI: 10.1016/j.jaad.2018.01.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 12/27/2017] [Accepted: 01/21/2018] [Indexed: 10/18/2022]
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Lymph Node Dissection in Patients With Melanoma and Sentinel Lymph Node Metastasis: An Updated, Evidence-Based Decision Algorithm. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:390-398. [PMID: 29650221 DOI: 10.1016/j.ad.2018.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/26/2018] [Accepted: 02/04/2018] [Indexed: 11/22/2022] Open
Abstract
Recent publication of the results of clinical trials in which lymph node dissection was not associated with any survival benefit in patients with sentinel node metastasis makes it necessary to reconsider the treatment of patients with melanoma. This article provides an update on the available evidence on the diverse factors (routes of metastatic spread, predictors, adjuvant therapy, etc.) that must be considered when treating patients with sentinel node-positive melanoma. The authors propose a decision-making algorithm for use in this clinical setting. The current evidence no longer supports lymph node dissection in patients with low-risk sentinel node metastasis (sentinel node tumor load ≤1mm).
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Egger ME, Xiao D, Hao H, Kimbrough CW, Pan J, Rai SN, Cambon AC, Waigel SJ, Zacharias W, McMasters KM. Unique Genes in Tumor-Positive Sentinel Lymph Nodes Associated with Nonsentinel Lymph Node Metastases in Melanoma. Ann Surg Oncol 2018; 25:1296-1303. [PMID: 29497912 DOI: 10.1245/s10434-018-6377-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Current risk assessment tools to estimate the risk of nonsentinel lymph node metastases after completion lymphadenectomy for a positive sentinel lymph node (SLN) biopsy in cutaneous melanoma are based on clinical and pathologic factors. We identified a novel genetic signature that can predict non-SLN metastases in patients with cutaneous melanoma staged with a SLN biopsy. METHODS RNA was collected for tumor-positive SLNs in patients staged by SLN biopsy for cutaneous melanoma. All patients with a tumor-positive SLN biopsy underwent completion lymphadenectomy. A 1:10 case:control series of positive and negative non-SLN patients was analyzed by microarray and quantitative RT-PCR. Candidate differentially expressed genes were validated in a 1:3 case:control separate cohort of positive and negative non-SLN patients. RESULTS The 1:10 case:control discovery set consisted of 7 positive non-SLN cases matched to 70 negative non-SLN controls. The cases and controls were similar with regards to important clinicopathologic factors, such as gender, primary tumor site, age, ulceration, and thickness. Microarray and RT-PCR identified six potential differentially expressed genes for validation. In the 40-patient separate validation set, 10 positive non-SLN patients were matched to 30 negative non-SLN controls based on gender, ulceration, age, and thickness. Five of the six genes were differentially expressed. The five gene panel identified patients at low (7.1%) and high risk (66.7%) for non-SLN metastases. CONCLUSIONS A novel, non-SLN gene score based on differential expressed genes in a tumor-positive SLN can identify patients at high and low risk for non-SLN metastases.
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Affiliation(s)
- Michael E Egger
- Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Deyi Xiao
- Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Hongying Hao
- Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Charles W Kimbrough
- Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jianmin Pan
- Biostatistics Shared Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA
| | - Shesh N Rai
- Biostatistics Shared Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA.,Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, USA
| | - Alexander C Cambon
- Biostatistics Shared Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA
| | - Sabine J Waigel
- University of Louisville Genomics Facility, Louisville, KY, USA
| | - Wolfgang Zacharias
- University of Louisville Genomics Facility, Louisville, KY, USA.,Departments of Medicine and Pharmacology and Toxicology, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, KY, USA.
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Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection? Am J Surg 2018; 215:868-872. [PMID: 29397888 DOI: 10.1016/j.amjsurg.2018.01.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/21/2018] [Accepted: 01/22/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity. METHODS Retrospective review of prospectively collected data on melanoma patients undergoing SLNB. RESULTS 116 patients underwent 119 CLNDs. The incidence of NSN positivity was 17.6%; the average number of positive NSNs in those cases was 1.5. Cervical and inguinofemoral location were most likely to yield positive NSN(s) (40% each). Conversely, the axilla was least likely at 18% (p < 0.001). The average number of nodes harvested was 13 for NSN negative cases and 20 for NSN positive cases (p = 0.005). Tumor thickness increased the probability of positive NSN(s) (OR 1.2, p = 0.02). CONCLUSIONS Tumor thickness and nodal basin were predictors of NSN metastasis, factors that could help determine which patients may benefit from CLND. Further, CLNDs with fewer nodes may inadequately clear residual nodal disease.
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Madu MF, Franke V, Bruin MM, Berger DM, Bierman C, Jóźwiak K, Klop WM, Wouters MW, van Akkooi AC, Van de Wiel BA. Immediate completion lymph node dissection in stage IIIA melanoma does not provide significant additional staging information beyond EORTC SN tumour burden criteria. Eur J Cancer 2017; 87:212-215. [DOI: 10.1016/j.ejca.2017.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/01/2017] [Indexed: 10/18/2022]
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Madu MF, van de Wiel B, van Akkooi ACJ. Comment: Detailed Pathologic Examination of Completion Node Dissection Specimens and Outcome for Melanoma Patients with Minimal (< 0.1 mm) Sentinel Lymph Node Metastases. Ann Surg Oncol 2017; 24:658-659. [PMID: 29116486 DOI: 10.1245/s10434-017-6169-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Indexed: 11/18/2022]
Affiliation(s)
- M F Madu
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - B van de Wiel
- Department of Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
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Gershenwald JE, Scolyer RA, Hess KR, Sondak VK, Long GV, Ross MI, Lazar AJ, Faries MB, Kirkwood JM, McArthur GA, Haydu LE, Eggermont AMM, Flaherty KT, Balch CM, Thompson JF. Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017; 67:472-492. [PMID: 29028110 PMCID: PMC5978683 DOI: 10.3322/caac.21409] [Citation(s) in RCA: 1475] [Impact Index Per Article: 210.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/09/2017] [Accepted: 08/10/2017] [Indexed: 02/06/2023] Open
Abstract
Answer questions and earn CME/CNE To update the melanoma staging system of the American Joint Committee on Cancer (AJCC) a large database was assembled comprising >46,000 patients from 10 centers worldwide with stages I, II, and III melanoma diagnosed since 1998. Based on analyses of this new database, the existing seventh edition AJCC stage IV database, and contemporary clinical trial data, the AJCC Melanoma Expert Panel introduced several important changes to the Tumor, Nodes, Metastasis (TNM) classification and stage grouping criteria. Key changes in the eighth edition AJCC Cancer Staging Manual include: 1) tumor thickness measurements to be recorded to the nearest 0.1 mm, not 0.01 mm; 2) definitions of T1a and T1b are revised (T1a, <0.8 mm without ulceration; T1b, 0.8-1.0 mm with or without ulceration or <0.8 mm with ulceration), with mitotic rate no longer a T category criterion; 3) pathological (but not clinical) stage IA is revised to include T1b N0 M0 (formerly pathologic stage IB); 4) the N category descriptors "microscopic" and "macroscopic" for regional node metastasis are redefined as "clinically occult" and "clinically apparent"; 5) prognostic stage III groupings are based on N category criteria and T category criteria (ie, primary tumor thickness and ulceration) and increased from 3 to 4 subgroups (stages IIIA-IIID); 6) definitions of N subcategories are revised, with the presence of microsatellites, satellites, or in-transit metastases now categorized as N1c, N2c, or N3c based on the number of tumor-involved regional lymph nodes, if any; 7) descriptors are added to each M1 subcategory designation for lactate dehydrogenase (LDH) level (LDH elevation no longer upstages to M1c); and 8) a new M1d designation is added for central nervous system metastases. This evidence-based revision of the AJCC melanoma staging system will guide patient treatment, provide better prognostic estimates, and refine stratification of patients entering clinical trials. CA Cancer J Clin 2017;67:472-492. © 2017 American Cancer Society.
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Affiliation(s)
- Jeffrey E. Gershenwald
- Professor of Surgery and Cancer Biology, Department of Surgical Oncology; Medical Director, Melanoma and Skin Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard A. Scolyer
- Conjoint Medical Director, Melanoma Institute Australia; Clinical Professor, The University of Sydney, Sydney, New South Wales, Australia
- Senior Staff Pathologist, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kenneth R. Hess
- Professor, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vernon K. Sondak
- Chair, Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - Georgina V. Long
- Conjoint Medical Director and Chair of Melanoma Medical Oncology and Translational Research, Melanoma Institute Australia, The University of Sydney and Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Merrick I. Ross
- Professor of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexander J. Lazar
- Professor of Pathology, Dermatology, and Translational Molecular Pathology; Director, Melanoma Molecular Diagnostics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mark B. Faries
- Co-Director, Melanoma Program; Head, Surgical Oncology, The Angeles Clinic and Research Institute, Los Angeles, CA
| | - John M. Kirkwood
- Professor of Medicine, Dermatology, and Translational Science, The University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Grant A. McArthur
- Executive Director, Victorian Comprehensive Cancer Center, Melbourne, Victoria, Australia
| | - Lauren E. Haydu
- Manager, Clinical Data Management Systems, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Keith T. Flaherty
- Director, Termeer Center for Targeted Therapy, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Charles M. Balch
- Professor of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John F. Thompson
- Professor of Melanoma and Surgical Oncology, Melanoma Institute Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Eggermont AMM, Dummer R. The 2017 complete overhaul of adjuvant therapies for high-risk melanoma and its consequences for staging and management of melanoma patients. Eur J Cancer 2017; 86:101-105. [PMID: 28968566 DOI: 10.1016/j.ejca.2017.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 12/19/2022]
Abstract
The spectacular outcomes of the phase III trials regarding nivolumab versus ipilimumab in fully resected stage IIIB/C-IV and of the combination of dabrafenib (D) plus trametinib (T) in BRAF-mutant stage III patients demonstrate that effective treatments in advanced melanoma are also highly effective in the adjuvant setting. In 2016, an overall survival benefit with adjuvant high-dose ipilimumab was demonstrated, and the European Organisation for Research and Treatment of Cancer trial 1325 comparing pembrolizumab versus placebo will complete the picture in the early 2018. Toxicity profiles are in line with the experience in advanced melanoma, i.e. favourable for the anti-PD1 agents and for D + T and problematic for ipilimumab. The 2017 outcomes are practice changing and put an end to the use of interferon (IFN) and ipilimumab. In countries with only access to IFN, its use can be restricted to patients with ulcerated melanoma, based on the individual patient data meta-analysis recently published. Because of the results of the Melanoma Sentinel Lymph node Trial-2 (MSLT-2) trial, completion lymph node dissection (CLND) will decrease sharply, leading to a lack of optimal prognostic information. Prognosis in sentinel node-positive stage IIIA/B patients is extremely heterogeneous with 5-year survival rates varying from 90% to 40% and depends mostly on the number of positive nodes identified by CLND. This information is crucial for clinical decision-making. How to guarantee optimal staging information needs to be discussed urgently. Further improvements of adjuvant therapies will have to address all these questions as well as the exploration of neoadjuvant use of active drugs and combination approaches. Important paradigm shifts in the management of high-risk melanoma patients are upon us.
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Affiliation(s)
- Alexander M M Eggermont
- Gustave Roussy Cancer Campus Grand Paris, Villejuif, France; Universite Paris-Sud, Kremlin-Bicêtre, France.
| | - Reinhard Dummer
- University Hospital Zürich, Department of Dermatology, Zürich, Switzerland
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van den Hout MFCM, Koster BD, Sluijter BJR, Molenkamp BG, van de Ven R, van den Eertwegh AJM, Scheper RJ, van Leeuwen PAM, van den Tol MP, de Gruijl TD. Melanoma Sequentially Suppresses Different DC Subsets in the Sentinel Lymph Node, Affecting Disease Spread and Recurrence. Cancer Immunol Res 2017; 5:969-977. [PMID: 28935649 DOI: 10.1158/2326-6066.cir-17-0110] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/16/2017] [Accepted: 09/15/2017] [Indexed: 11/16/2022]
Abstract
Melanoma exerts immune-suppressive effects to facilitate tumor progression and metastatic spread. We studied these effects on dendritic cell (DC) and T-cell subsets in 36 melanoma sentinel lymph node (SLN) from 28 stage I-III melanoma patients and determined their clinical significance. Four conventional DC subsets, plasmacytoid DCs, and CD4+, CD8+, and regulatory T cells (Tregs), were analyzed by flow cytometry. We correlated these data to clinical parameters and determined their effect on local and distant melanoma recurrence, with a median follow-up of 75 months. In stage I and II melanoma, increased Breslow thickness (i.e., invasion depth of the primary melanoma) was associated with progressive suppression of skin-derived migratory CD1a+ DC subsets. In contrast, LN-resident DC subsets and T cells were only affected once metastasis to the SLN had occurred. In stage III patients, increased CD4:CD8 ratios in concert with the accumulation of Tregs resulted in decreased CD8:Treg ratios. On follow-up, lower frequencies of migratory DC subsets proved related to local melanoma recurrence, whereas reduced maturation of LN-resident DC subsets was associated with distant recurrence and melanoma-specific survival. In conclusion, melanoma-mediated suppression of migratory DC subsets in the SLN precedes local spread, whereas suppression of LN-resident DC subsets follows regional spread and precedes further melanoma dissemination to distant sites. This study offers a rationale to target migratory as well as LN-resident DC subsets for early immunotherapeutic interventions to prevent melanoma recurrence and spread. Cancer Immunol Res; 5(11); 969-77. ©2017 AACR.
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Affiliation(s)
- Mari F C M van den Hout
- Department of Pathology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands.,Department of Pathology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bas D Koster
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Berbel J R Sluijter
- Department of Surgical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Barbara G Molenkamp
- Department of Surgical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Rieneke van de Ven
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Alfons J M van den Eertwegh
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Rik J Scheper
- Department of Pathology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Paul A M van Leeuwen
- Department of Surgical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - M Petrousjka van den Tol
- Department of Surgical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Tanja D de Gruijl
- Department of Medical Oncology, VU University Medical Center/Cancer Center Amsterdam, De Boelelaan, Amsterdam, the Netherlands.
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79
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Rios-Cantu A, Lu Y, Melendez-Elizondo V, Chen M, Gutierrez-Range A, Fadaki N, Thummala S, West-Coffee C, Cleaver J, Kashani-Sabet M, Leong SPL. Is the non-sentinel lymph node compartment the next site for melanoma progression from the sentinel lymph node compartment in the regional nodal basin? Clin Exp Metastasis 2017; 34:345-350. [PMID: 28699042 DOI: 10.1007/s10585-017-9854-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/28/2017] [Indexed: 01/12/2023]
Abstract
Melanoma patients with additional positive lymph nodes in the completion lymph node dissection (CLND) following a positive sentinel lymph node (SLN) biopsy would have a poorer prognosis than patients with no additional positive lymph nodes. We hypothesize that the progression of disease from the SLN to the non-SLN compartment is orderly and is associated with the worsening of the disease status. Thus, the SLN and non-SLN compartments are biologically different in that cancer cells, in general, arrive in the SLN compartment before spreading to the non-SLN compartment. To validate this concept, we used a large cohort of melanoma patients from our prospective SLN database in an academic tertiary medical center. Adult cutaneous melanoma patients (n = 291) undergoing CLND after a positive SLN biopsy from 1994 to 2009 were analyzed. Comparison of 5-year disease-free survival and 5-year overall survival between positive (n = 66) and negative (n = 225) CLND groups was made. The 5-year disease-free survival rates were 55% (95% CI 49-62%) for patients with no additional LN on CLND versus 14% (95% CI 8-26%) in patients with positive LN on CLND (p < 0.0001, log-rank test). The median disease-free survival time was 7.4 years with negative CLND (95% CI 4.4-15+ years) and 1.2 years with positive CLND (95% CI 1.0-1.8 years). The 5-year overall survival rates were 67% (95% CI 61-74%) for negative CLND versus 38% (95% CI 28-52%) for positive CLND (p < 0.0001, log-rank test). The median overall survival time was 12.1 years for negative CLND (95% CI 9.3-15+ years) and 2.5 years for positive CLND (95% CI 2.2-5.7 years). This study shows that CLND status is a significant prognostic factor for patients with positive SLNs undergoing CLND. Also, it suggests an orderly progression of metastasis from the SLN to the non-SLN compartment. Thus, the SLN in the regional nodal basin draining the primary melanoma may serve as an important gateway for metastasis to the non-SLN compartment and beyond to the systemic sites.
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Affiliation(s)
- Andrei Rios-Cantu
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.,Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Consorcio de Universidades Mexicanas (CuMEX), Pachuca, Mexico
| | - Ying Lu
- Departments of Biomedical Data Science, Health Research and Policy, and Radiology, The Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Victor Melendez-Elizondo
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.,Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Consorcio de Universidades Mexicanas (CuMEX), Pachuca, Mexico
| | - Michael Chen
- Departments of Biomedical Data Science, Health Research and Policy, and Radiology, The Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Alejandra Gutierrez-Range
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.,Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Consorcio de Universidades Mexicanas (CuMEX), Pachuca, Mexico
| | - Niloofar Fadaki
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - Suresh Thummala
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - Carla West-Coffee
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - James Cleaver
- Department of Dermatology, University of California, San Francisco, CA, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - Stanley P L Leong
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.
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80
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Baum C, Weiss C, Gebhardt C, Utikal J, Marx A, Koenen W, Géraud C. Sentinel node metastasis mitotic rate (SN-MMR) as a prognostic indicator of rapidly progressing disease in patients with sentinel node-positive melanomas. Int J Cancer 2017; 140:1907-1917. [PMID: 27935036 DOI: 10.1002/ijc.30563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/25/2016] [Accepted: 11/30/2016] [Indexed: 11/11/2022]
Abstract
Risk stratification of sentinel lymph node biopsy (SNB)-positive patients with malignant melanoma differs among current classification systems. To improve classification of patients with rapidly progressive disease who may profit from adjuvant therapy with novel immune or targeted treatment modalities, a single-center retrospective analysis was performed including all melanoma patients diagnosed with a positive SN at a university-based skin cancer center over a 10-year period (2002-2012) (96 of 419 patients). Sentinel node metastasis mitotic rate (SN-MMR) and further histologic parameters were determined by blinded histological re-evaluation and correlated with clinical follow-up (overall [OS], melanoma-specific [MSS], and disease-free survival [DFS]). Median follow-up was 53 months. In univariate analyses, SN tumor penetrative depth (TPD), maximum tumor diameter (MTD), number of positive SN, SN-MMR and the S-, Rotterdam, RDC, Hannover I and II classification systems correlated with OS, MSS and DFS. Multivariate Cox regression analyses showed that a binary classification system based only on the SN-MMR (<1 vs. ≥1 mitoses/mm2 ) was the strongest independent prognostic indicator for all endpoints analyzed. Kaplan-Meier analyses confirmed binary SN-MMR to be superior to stratify patients into high- and low-risk groups (45.45% vs. 87.92% 5-yr MSS). The general prognostic validity of the published SN classification systems was confirmed. The novel SN-MMR classification system may improve discrimination of patients with slowly and rapidly progressive disease. We therefore propose its implementation into clinical practice as the SN-MMR can be easily and reliably determined in routine pathology reports. Its prognostic value for the selection of patients amenable to adjuvant therapies should be studied in clinical trials.
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Affiliation(s)
- Cornelia Baum
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christel Weiss
- Department for Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoffer Gebhardt
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jochen Utikal
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander Marx
- Institute of Pathology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolfgang Koenen
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Cyrill Géraud
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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81
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Oude Ophuis CM, Koppert L(LB, Monyé CD, Deurzen CHV, Koljenović S, Akkooi ACV, Verhoef C(K, Grünhagen DJ. Gamma probe and ultrasound guided fine needle aspiration cytology of the sentinel node (GULF) trial - overview of the literature, pilot and study protocol. BMC Cancer 2017; 17:258. [PMID: 28403815 PMCID: PMC5389093 DOI: 10.1186/s12885-017-3236-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/25/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Sentinel node (SN) biopsy (SNB) detects clinically occult metastases of breast cancer and melanoma in 20-30%. Wound infections, seroma and lymph edema occur in up to 10%. Targeted ultrasound (US) of the SN, (with fine needle aspiration cytology (FNAC) if appropriate) has been investigated as a minimally invasive alternative, but reported sensitivity rates are too low to replace SNB. Our hypothesis is that the use of a handheld gamma probe concomitant with US may improve sensitivity. Our aim is to provide an overview of the current literature on preoperative nodal staging of clinical N0 melanoma patients, report on a pilot, and present a study protocol for a minimally invasive alternative to the SNB: Gamma probe and Ultrasound guided Fine needle aspiration cytology of the sentinel node (GULF trial). METHODS The GULF trial is a multicenter open single arm observational trial. Newly diagnosed cT1b-4N0M0 cutaneous melanoma or cT1-3N0M0 breast cancer patients, aged >18 years, presenting for SNB are eligible. 120 patients will be included for preoperative targeted gamma probe guided US and FNAC of the SN. Afterwards all patients proceed to surgical SNB. Primary endpoint is the sensitivity of FNAC. Secondary endpoints include SN identification rate and the histopathological compatibility of Core Needle Biopsy and FNAC vs. SNB. Secondary endpoints were investigated in a pilot with 10 FNACs and marker placements, and 10 FNACs combined with Core Needle Biopsy. RESULTS A pilot in 20 patients showed that SN identification rate was 90%, supporting the feasibility of this technique. DISCUSSION There is broad experience with US (in combination with FNAC) prior to SNB, but sensitivity and specificity are too low to completely abandon SNB. Promising alternative techniques potentially will replace SNB in the future but more evidence is needed in the form of prospective studies. Accurate identification of the SN for US-FNAC has been proven feasible in our pilot. When adequate sensitivity can be reached, US-FNAC provides a minimally invasive alternative for the surgical SNB procedure. TRIAL REGISTRATION The GULF trial is registered in the Netherlands Trial Registry (NTR), ID: NRT5193 . May 1st 2015.
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Affiliation(s)
- Charlotte M.C. Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Lisa (Linetta) B. Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Cécile de Monyé
- Department of Radiology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | | | - Senada Koljenović
- Department of Pathology, Erasmus Medical Center, Wytemaweg 80, 3015 Rotterdam, CN The Netherlands
| | - Alexander C.J. van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 Amsterdam, CX The Netherlands
| | - Cornelis (Kees) Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Dirk J. Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
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82
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Madu M, Wouters M, van Akkooi A. Sentinel node biopsy in melanoma: Current controversies addressed. Eur J Surg Oncol 2017; 43:517-533. [DOI: 10.1016/j.ejso.2016.08.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/17/2022] Open
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83
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Coens C, Suciu S, Chiarion-Sileni V, Grob JJ, Dummer R, Wolchok JD, Schmidt H, Hamid O, Robert C, Ascierto PA, Richards JM, Lebbé C, Ferraresi V, Smylie M, Weber JS, Maio M, Bottomley A, Kotapati S, de Pril V, Testori A, Eggermont AMM. Health-related quality of life with adjuvant ipilimumab versus placebo after complete resection of high-risk stage III melanoma (EORTC 18071): secondary outcomes of a multinational, randomised, double-blind, phase 3 trial. Lancet Oncol 2017; 18:393-403. [PMID: 28162999 DOI: 10.1016/s1470-2045(17)30015-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/17/2016] [Accepted: 10/24/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND The EORTC 18071 phase 3 trial compared adjuvant ipilimumab with placebo in patients with stage III melanoma. The primary endpoint, recurrence-free survival, was significantly longer in the ipilimumab group than in the placebo group. Investigator-reported toxic effects of ipilimumab consisted mainly of skin, gastrointestinal, endocrine, and hepatic immune-related adverse events. Adjuvant treatment with ipilimumab in this setting was approved in October, 2014, by the US Food and Drug Administration based on the results of the primary outcome of this trial. Here, we report the results of the secondary endpoint, health-related quality of life (HRQoL), of this trial. METHODS EORTC 18071 was a multinational, double-blind, randomised, phase 3 trial in patients with stage III cutaneous melanoma (excluding lymph node metastasis ≤1 mm or in-transit metastasis) in 19 countries worldwide. Participants were randomly assigned (1:1) centrally by an interactive voice response system, to receive either ipilimumab 10 mg/kg or placebo every 3 weeks for four doses, then every 3 months for up to 3 years. Using a minimisation technique, randomisation was stratified by disease stage and geographical region. HRQoL was assessed with the EORTC QLQ-C30 quality-of-life instrument at baseline, weeks 4, 7, 10, and 24, and every 12 weeks thereafter up to 2 years, irrespective of disease progression. Results were summarised by timepoint and in a longitudinal manner in the intention-to-treat population. Two summary scores were calculated for each HRQoL scale: the average score reported during induction (ipilimumab or placebo at a dose of 10 mg/kg, administered as one single dose at the start of days 1, 22, 43, and 64-ie, four doses in 3 weeks), and the average score reported after induction. A predefined threshold of a 10 point difference between arms was considered clinically relevant. The primary HRQoL endpoint was the global health scale, with the predefined hypothesis of no clinically relevant differences after induction between groups. This trial is registered with EudraCT, number 2007-001974-10, and ClinicalTrials.gov, number NCT00636168. FINDINGS Between July 10, 2008, and Aug 1, 2011, 951 patients were randomly assigned to treatment: 475 in the ipilimumab group and 476 in the placebo group. Compliance with completing the HRQoL questionnaire was 893 (94%) of 951 patients at baseline, 693 (75%) of 924 at week 24, and 354 (51%) of 697 at week 108. Patient mean global health scores during (77·32 [SD 17·36] vs 72·96 [17·82]; p=0·00011) and after induction (76·48 [17·52] vs 72·32 [18·60]; p=0·00067) were statistically significantly different between groups but were not clinically relevant. Mean global health scores differed most between the groups at week 7 (77 [SD 19] in the placebo group vs 72 [22] in the ipilimumab group) and week 10 (77 [20] vs 70 [23]). Mean HRQoL scores differed by more than 10 points at week 10 between treatment groups for diarrhoea (7·67 [SD 17·05] for placebo vs 18·17 [28·35] for ipilimumab) and insomnia (15·17 [22·53] vs 25·60 [29·19]). INTERPRETATION Despite increased toxicity, which led to treatment discontinuation for most patients during the induction phase of ipilimumab administration, overall HRQoL, as measured by the EORTC QLQ-C30, was similar between groups, as no clinically relevant differences (10 points or more) in global health status scores were observed during or after induction. Clinically relevant deterioration for some symptoms was observed at week 10, but after induction, no clinically relevant differences remained. Together with the primary analysis, results from this trial show that treatment with ipilimumab results in longer recurrence-free survival compared with that for treatment with placebo, with little impairment in HRQoL despite grade 3-4 investigator-reported adverse events. FUNDING Bristol-Myers Squibb.
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Affiliation(s)
| | | | | | | | | | - Jedd D Wolchok
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Omid Hamid
- The Angeles Clinic and Research Institute, Los Angeles, CA, USA
| | | | - Paolo A Ascierto
- Istituto Nazionale Tumori Fondazione "G. Pascale", Naples, Italy
| | | | - Celeste Lebbé
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Saint-Louis, Paris
| | | | | | | | - Michele Maio
- University Hospital of Siena, Istituto Toscano Tumori, Siena, Italy
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84
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Crookes TR, Scolyer RA, Lo S, Drummond M, Spillane AJ. Extranodal Spread is Associated with Recurrence and Poor Survival in Stage III Cutaneous Melanoma Patients. Ann Surg Oncol 2017; 24:1378-1385. [PMID: 28130620 DOI: 10.1245/s10434-016-5723-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Inconsistent data suggests extranodal spread (ENS) is an adverse prognostic factor in Stage III melanoma patients but it remains contentious. By rigorously matching cohorts, this study sought to clarify associations with recurrence and survival. METHODS Melanoma patients with lymph node metastases (AJCC Stage III), with or without ENS, sub-classified on the basis of known (MKP) or unknown primary (MUP), were identified from a single institution prospective database. Of 725 ENS patients identified, 567 were able to be precisely matched 1:1 with a non-ENS cohort. Clinicopathologic factors were analyzed for associations with outcome. RESULTS There were 481 MKP and 86 MUP patients in each cohort. ENS, compared to non-ENS, was an independent predictor of worse melanoma specific survival (MSS) (HR = 1.71, 95% CI = 1.39-2.11, P < 0.0001) with median MSS 56.4 versus 175.2 months, P < 0.001; worse disease free survival (DFS) (HR = 1.16, 95%CI = 1.00-1.34, P = 0.044) with median DFS 15.6 versus 21.5 months, P = 0.009; and worse post-recurrence survival (PRS) (HR = 1.66, 95%CI = 1.37-2.02, P < 0.0001) with median PRS 20.1 versus 51.1 months, P < 0.001. ENS was also associated with reduced time to distant recurrence (Distant Disease Free Survival [DDFS]) (HR = 2.00, 95% CI = 1.24-3.24, P = 0.0047), however median time to distant recurrence not reached within the study time period. CONCLUSIONS ENS represents a significant independent predictor of worse MSS, DFS, PRS and DDFS in Stage III melanoma patients. ENS should be considered in the stratification of patients in adjuvant therapy trials.
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Affiliation(s)
- Thomas R Crookes
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia.,School of Medicine Sydney, The University of Notre Dame, Sydney, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Serigne Lo
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia
| | - Martin Drummond
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia. .,Sydney Medical School, The University of Sydney, Sydney, Australia.
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85
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van Akkooi ACJ, Atkins MB, Agarwala SS, Lorigan P. Surgical Management and Adjuvant Therapy for High-Risk and Metastatic Melanoma. Am Soc Clin Oncol Educ Book 2017; 35:e505-14. [PMID: 27249760 DOI: 10.1200/edbk_159087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Wide local excision is considered routine therapy after initial diagnosis of primary melanoma to reduce local recurrences, but it does not impact survival. Sentinel node staging is recommended for melanomas of intermediate thickness, but it has also not demonstrated any indisputable therapeutic effect on survival. The prognostic value of sentinel node staging has been long established and is therefore considered routine, especially in light of the eligibility criteria for adjuvant therapy (trials). Whether completion lymph node dissection after a positive sentinel node biopsy improves survival is the question of current trials. The MSLT-2 study is best powered to show a potential benefit, but it has not yet reported any data. Another study, the German DECOG study, presented at the 2015 American Society of Clinical Oncology (ASCO) Annual Meeting did not show any benefit but is criticized for the underpowered design and insufficient follow-up. There is no consensus on the use of adjuvant interferon in melanoma. This topic has been the focus of many studies with different regimens (low-, intermediate-, or high-dose and/or short- or long-term treatment). Adjuvant interferon has been shown to improve relapse-free survival but failed to improve overall survival. More recently, adjuvant ipilimumab has also demonstrated an improved relapse-free survival. Overall survival data have not yet been reported due to insufficient follow-up. Currently, studies are ongoing to analyze the use of adjuvant anti-PD-1 and molecular targeted therapies (vemurafenib, dabrafenib, and trametinib). In the absence of unambiguously positive approved agents, clinical trial participation remains a priority. This could change in the near future.
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Affiliation(s)
- Alexander C J van Akkooi
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Michael B Atkins
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Sanjiv S Agarwala
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Lorigan
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
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86
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Eggermont AM. Adjuvant ipilimumab in stage III melanoma: New landscape, new questions. Eur J Cancer 2016; 69:39-42. [DOI: 10.1016/j.ejca.2016.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
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87
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Oude Ophuis C, Verhoef C, Rutkowski P, Powell B, van der Hage J, van Leeuwen P, Voit C, Testori A, Robert C, Hoekstra H, Grünhagen D, Eggermont A, van Akkooi A. The interval between primary melanoma excision and sentinel node biopsy is not associated with survival in sentinel node positive patients – An EORTC Melanoma Group study. Eur J Surg Oncol 2016; 42:1906-1913. [DOI: 10.1016/j.ejso.2016.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/15/2016] [Accepted: 05/15/2016] [Indexed: 11/17/2022] Open
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88
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Eggermont AMM, Chiarion-Sileni V, Grob JJ, Dummer R, Wolchok JD, Schmidt H, Hamid O, Robert C, Ascierto PA, Richards JM, Lebbé C, Ferraresi V, Smylie M, Weber JS, Maio M, Bastholt L, Mortier L, Thomas L, Tahir S, Hauschild A, Hassel JC, Hodi FS, Taitt C, de Pril V, de Schaetzen G, Suciu S, Testori A. Prolonged Survival in Stage III Melanoma with Ipilimumab Adjuvant Therapy. N Engl J Med 2016; 375:1845-1855. [PMID: 27717298 PMCID: PMC5648545 DOI: 10.1056/nejmoa1611299] [Citation(s) in RCA: 969] [Impact Index Per Article: 121.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND On the basis of data from a phase 2 trial that compared the checkpoint inhibitor ipilimumab at doses of 0.3 mg, 3 mg, and 10 mg per kilogram of body weight in patients with advanced melanoma, this phase 3 trial evaluated ipilimumab at a dose of 10 mg per kilogram in patients who had undergone complete resection of stage III melanoma. METHODS After patients had undergone complete resection of stage III cutaneous melanoma, we randomly assigned them to receive ipilimumab at a dose of 10 mg per kilogram (475 patients) or placebo (476) every 3 weeks for four doses, then every 3 months for up to 3 years or until disease recurrence or an unacceptable level of toxic effects occurred. Recurrence-free survival was the primary end point. Secondary end points included overall survival, distant metastasis-free survival, and safety. RESULTS At a median follow-up of 5.3 years, the 5-year rate of recurrence-free survival was 40.8% in the ipilimumab group, as compared with 30.3% in the placebo group (hazard ratio for recurrence or death, 0.76; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). The rate of overall survival at 5 years was 65.4% in the ipilimumab group, as compared with 54.4% in the placebo group (hazard ratio for death, 0.72; 95.1% CI, 0.58 to 0.88; P=0.001). The rate of distant metastasis-free survival at 5 years was 48.3% in the ipilimumab group, as compared with 38.9% in the placebo group (hazard ratio for death or distant metastasis, 0.76; 95.8% CI, 0.64 to 0.92; P=0.002). Adverse events of grade 3 or 4 occurred in 54.1% of the patients in the ipilimumab group and in 26.2% of those in the placebo group. Immune-related adverse events of grade 3 or 4 occurred in 41.6% of the patients in the ipilimumab group and in 2.7% of those in the placebo group. In the ipilimumab group, 5 patients (1.1%) died owing to immune-related adverse events. CONCLUSIONS As adjuvant therapy for high-risk stage III melanoma, ipilimumab at a dose of 10 mg per kilogram resulted in significantly higher rates of recurrence-free survival, overall survival, and distant metastasis-free survival than placebo. There were more immune-related adverse events with ipilimumab than with placebo. (Funded by Bristol-Myers Squibb; ClinicalTrials.gov number, NCT00636168 , and EudraCT number, 2007-001974-10 .).
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Affiliation(s)
- Alexander M M Eggermont
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Vanna Chiarion-Sileni
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Jean-Jacques Grob
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Reinhard Dummer
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Jedd D Wolchok
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Henrik Schmidt
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Omid Hamid
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Caroline Robert
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Paolo A Ascierto
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Jon M Richards
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Céleste Lebbé
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Virginia Ferraresi
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Michael Smylie
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Jeffrey S Weber
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Michele Maio
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Lars Bastholt
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Laurent Mortier
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Luc Thomas
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Saad Tahir
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Axel Hauschild
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Jessica C Hassel
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - F Stephen Hodi
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Corina Taitt
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Veerle de Pril
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Gaetan de Schaetzen
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Stefan Suciu
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
| | - Alessandro Testori
- From Gustave Roussy Cancer Campus Grand Paris, Villejuif (A.M.M.E., C.R.), Aix-Marseille University, Hôpital de La Timone, Marseille (J.-J.G.), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris (C.L.), University Lille, INSERM Unité-1189, Centre Hospitalier Universitaire (CHU) Lille, Service de Dermatologie, Lille (L.M.), and CHU Lyon, Lyon (L.T.) - all in France; the Oncology Institute of Veneto-Istituto di Ricovero e Cura a Carattere Scientifico, Padua (V.C.-S.), Istituto Nazionale Tumori Fondazione G. Pascale, Naples (P.A.A.), Istituti Fisioterapici Ospitalieri, Rome (V.F.), University Hospital of Siena, Istituto Toscano Tumori, Siena (M.M.), and the European Institute of Oncology, Milan (A.T.) - all in Italy; University of Zurich Hospital, Zurich, Switzerland (R.D.); Memorial Sloan Kettering Cancer Center, New York (J.D.W.); Aarhus University Hospital, Aarhus (H.S.), and Odense University Hospital, Odense (L.B.) - both in Denmark; the Angeles Clinic and Research Institute, Los Angeles (O.H.); Oncology Specialists, Park Ridge, IL (J.M.R.); Cross Cancer Institute, Edmonton, AB, Canada (M.S.); H. Lee Moffitt Cancer Center, Tampa, FL (J.S.W.); Broomfield Hospital, Chelmsford, United Kingdom (S.T.); Universitätsklinikum Schleswig-Holstein, Kiel (A.H.), and University Hospital Heidelberg, Heidelberg (J.C.H.) - both in Germany; Dana-Farber Cancer Institute, Boston (F.S.H.); Bristol-Myers Squibb, Princeton, NJ (C.T., V.P.); and the European Organization for Research and Treatment of Cancer, Brussels (G.S., S.S.)
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Mosquera C, Vora HS, Vohra N, Fitzgerald TL. Population-Based Analysis of Completion Lymphadenectomy in Intermediate-Thickness Melanoma. Ann Surg Oncol 2016; 24:127-134. [PMID: 27464609 DOI: 10.1245/s10434-016-5460-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Multicenter selective lymphadenectomy trial 1 (MSLT-I) defined the prognostic and potential therapeutic values of sentinel lymph node biopsy (SLNB) for intermediate-thickness melanoma. The role of completion lymphadenectomy (CLND) is, however, unclear and the subject of the ongoing MSLT-II trial. METHODS From 2003 to 2012, patients with tumors 1-4 mm thick with positive SLNB were identified in the Surveillance Epidemiology and End Results Program registry. The patients were divided into two groups: group 1 (CLND) and group 2 (observation). RESULTS The study enrolled 2172 patients, the majority of whom were white and male with extremity primaries, no ulceration, Clark level 4 invasion, and nodes 2.01-4.0 mm deep. In the univariate analysis, CLND was associated with lower mean age, male gender, primary site, number of positive nodes, and geographic region (p < 0.05). In the multivariate analysis, male gender [odds ratio (OR), 1.27] and geographic area (Michigan OR, 2.31; Iowa OR, 1.69) were associated with CLND (p < 0.05). In the survival analysis, male gender, primary site, ulceration, Clark level, and depth and number of positive nodes were associated with survival (p < 0.05), but CLND was not (p = 0.83). In the Cox regression analysis, the relationship between male gender [hazard ratio (HR), 1.14], primary site trunk versus extremity (HR, 1.3), ulceration (HR, 1.79), Clark level (2 vs. 4 HR, 3.51; 2 vs. 5 HR, 6.48), depth (HR, 1.43) and number of nodes (1 vs. 2: HR, 1.23; 1 vs. ≥3: HR, 2.52) persisted (p < 0.05). However, when CLND was included in this model, it was not associated with improved survival. CONCLUSIONS Age, gender, and geographic area predict the likelihood of CLND. In this retrospective study, CLND did not add survival benefit.
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Affiliation(s)
- Catalina Mosquera
- Division of Surgical Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Haily S Vora
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Nasreen Vohra
- Division of Surgical Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Timothy L Fitzgerald
- Division of Surgical Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA.
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Ribero S, Longo C, Glass D, Nathan P, Bataille V. What Is New in Melanoma Genetics and Treatment? Dermatology 2016; 232:259-64. [PMID: 27173969 DOI: 10.1159/000445767] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/16/2016] [Indexed: 11/19/2022] Open
Abstract
New therapies for advanced melanoma have led to major advances, which, for the first time, showed improved survival for patients with this very challenging neoplasm. These new treatments are based on gene-targeted therapies or stimulation of immune responses. However, these treatments are not without challenges in terms of resistance and toxicity. Physicians should be aware of these side effects as prompt treatment may save lives. Melanoma genetics is also unravelling new genetic risk factors involving telomere genes as well as new gene pathways at the somatic level which may soon become therapeutic targets. It is also shedding new light onto the pathology of this tumour with links to neural diseases and longevity.
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Affiliation(s)
- Simone Ribero
- Twin Research and Genetic Epidemiology Unit, King's College London, London, UK
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Han D, Thomas DC, Zager JS, Pockaj B, White RL, Leong SPL. Clinical utilities and biological characteristics of melanoma sentinel lymph nodes. World J Clin Oncol 2016; 7:174-188. [PMID: 27081640 PMCID: PMC4826963 DOI: 10.5306/wjco.v7.i2.174] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/05/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
An estimated 73870 people will be diagnosed with melanoma in the United States in 2015, resulting in 9940 deaths. The majority of patients with cutaneous melanomas are cured with wide local excision. However, current evidence supports the use of sentinel lymph node biopsy (SLNB) given the 15%-20% of patients who harbor regional node metastasis. More importantly, the presence or absence of nodal micrometastases has been found to be the most important prognostic factor in early-stage melanoma, particularly in intermediate thickness melanoma. This review examines the development of SLNB for melanoma as a means to determine a patient’s nodal status, the efficacy of SLNB in patients with melanoma, and the biology of melanoma metastatic to sentinel lymph nodes. Prospective randomized trials have guided the development of practice guidelines for use of SLNB for melanoma and have shown the prognostic value of SLNB. Given the rapidly advancing molecular and surgical technologies, the technical aspects of diagnosis, identification, and management of regional lymph nodes in melanoma continues to evolve and to improve. Additionally, there is ongoing research examining both the role of SLNB for specific clinical scenarios and the ways to identify patients who may benefit from completion lymphadenectomy for a positive SLN. Until further data provides sufficient evidence to alter national consensus-based guidelines, SLNB with completion lymphadenectomy remains the standard of care for clinically node-negative patients found to have a positive SLN.
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Eriksson H, Lyth J, Andersson TML. The proportion cured of patients diagnosed with Stage III-IV cutaneous malignant melanoma in Sweden 1990-2007: A population-based study. Int J Cancer 2016; 138:2829-36. [PMID: 26815934 DOI: 10.1002/ijc.30023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 12/30/2015] [Accepted: 01/15/2016] [Indexed: 02/03/2023]
Abstract
The survival in cutaneous malignant melanoma (CMM) is highly dependent on the stage of the disease. Stage III-IV CMM patients are at high risk of relapse with a heterogeneous outcome, but not all experience excess mortality due to their disease. This group is referred to as the cure proportion representing the proportion of patients who experience the same mortality rate as the general population. The aim of this study was to estimate the cure proportion of patients diagnosed with Stage III-IV CMM in Sweden. From the population-based Swedish Melanoma Register, we included 856 patients diagnosed with primary Stage III-IV CMM, 1990-2007, followed-up through 2013. We used flexible parametric cure models to estimate cure proportions and median survival times (MSTs) of uncured by sex, age, tumor site, ulceration status (in Stage III patients) and disease stage. The standardized (over sex, age and site) cure proportion was lower in Stage IV CMMs (0.15, 95% CI 0.09-0.22) than non-ulcerated Stage III CMMs (0.48, 95% CI 0.41-0.55) with a statistically significant difference of 0.33 (95% CI = 0.24-0.41). Ulcerated Stage III CMMs had a cure proportion of 0.27 (95% CI 0.21-0.32) with a statistically significant difference compared to non-ulcerated Stage III CMMs (difference 0.21; 95% CI = 0.13-0.30). The standardized MST of uncured was approximately 9-10 months longer for non-ulcerated versus ulcerated Stage III CMMs. We could demonstrate a significantly better outcome in patients diagnosed with non-ulcerated Stage III CMMs compared to ulcerated Stage III CMMs and Stage IV disease after adjusting for age, sex and tumor site.
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Affiliation(s)
- Hanna Eriksson
- Department of Oncology-Pathology, Karolinska Institutet, and Deptartment of Oncology, Karolinska University Hospital, SE-17176 Stockholm, Sweden
| | - Johan Lyth
- Unit of Research and Development in Local Health Care, County of Östergötland, Linköping, Sweden
| | - Therese M-L Andersson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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93
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Metastatic area ratio can help predict nonsentinel node positivity in melanoma patients. Melanoma Res 2016; 26:42-5. [DOI: 10.1097/cmr.0000000000000202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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94
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Eggermont AMM, Suciu S, Rutkowski P, Kruit WH, Punt CJ, Dummer R, Salès F, Keilholz U, de Schaetzen G, Testori A. Long term follow up of the EORTC 18952 trial of adjuvant therapy in resected stage IIB-III cutaneous melanoma patients comparing intermediate doses of interferon-alpha-2b (IFN) with observation: Ulceration of primary is key determinant for IFN-sensitivity. Eur J Cancer 2016; 55:111-21. [PMID: 26790144 DOI: 10.1016/j.ejca.2015.11.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND We report on the long term outcome of the EORTC 18952 adjuvant interferon (IFN) trial in 1388 resected stage IIB/III melanoma patients and identify key predictive factors for outcome. METHODS We analysed outcome of the EORTC 18952 trial (4 weeks of IFN, 10 MU, 5 times/week for 4 weeks followed by 12 months IFN at 10 MU, 3 times/week versus followed by 24 months IFN at 5 MU 3 times/week versus observation) regarding relapse-free survival (RFS), distant metastasis-free interval/survival (DMFI/DMFS), and overall survival (OS), and analysed potential predictive factors of outcome. FINDINGS At a median follow-up of 11 years, the comparison of IFN 13 months versus IFN 25 months versus observation yielded estimated hazard ratios (HR) for RFS of 0.94 versus 0.84 (p = 0.06); for DMFI 0.95 versus 0.82 (p = 0.027); for DMFS 0.95 versus 0.84 (p = 0.07); and for OS 0·95 versus 0.84 (p = 0.08), respectively. The impact of treatment was greatest in the ulceration group, whereas in patients with non-ulcerated primaries the impact was null (HR ≥ 1.0). In patients with ulcerated melanoma the HR for IFN 13 months versus 25 months versus observation were for: RFS 0.82 (p = 0.16) versus 0.61 (p = 0.0008); DMFS 0.76 (p = 0.06) versus 0.57 (p = 0.0003); OS 0.80 (p = 0.13) versus 0.59 (p = 0.0007). In stage IIB/III-N1 (microscopic nodal involvement only) patients with ulcerated melanoma the HR estimates were for: RFS 0.85 versus 0.62; DMFS 0.80 versus 0.56; OS 0.77 versus 0.54. CONCLUSIONS This long term report of the EORTC 18952 trial demonstrates the superiority of the 25-month IFN schedule and defines ulceration of the primary as the overriding predictive factor for IFN-sensitivity.
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Affiliation(s)
| | | | - Piotr Rutkowski
- Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland
| | - Willem H Kruit
- Erasmus MC Cancer Institute - Location Daniel den Hoed, Rotterdam, The Netherlands
| | - Cornelis J Punt
- Academisch Medisch Centrum - Universiteit van Amsterdam, Amsterdam, The Netherlands
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95
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Association of TIMP3 expression with vessel density, macrophage infiltration and prognosis in human malignant melanoma. Eur J Cancer 2015; 53:135-43. [PMID: 26707830 DOI: 10.1016/j.ejca.2015.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/17/2015] [Indexed: 12/29/2022]
Abstract
AIMS Several anti-tumour properties have been ascribed to the tissue inhibitor of matrix metalloproteinases-3 (TIMP3) gene, including inhibition of neovascularisation in tumour xenografts. Reduced protein expression has been linked to promoter hypermethylation and allelic loss of heterozygosity in various human malignancies. In melanoma-positive lymph nodes from patients, we evaluated the association between TIMP3 expression, vessel density, macrophage infiltration and potential correlations with disease-free survival (DFS) and overall survival (OS). PATIENTS AND METHODS TIMP3 expression was analysed by immunohistochemistry (IHC) in melanoma lymph node biopsies of stage III melanoma patients (n = 43). Blood vessel density and macrophage infiltration were quantitatively assessed and correlation with TIMP3 expression was investigated. Methylation status of the gene promoter was determined using methylation-specific polymerase chain reaction (MSP). Protein expression and promoter methylation status were investigated for associations with DFS and OS. RESULTS Reduced expression of TIMP3, as determined by IHC, was observed in 74% of the cases (32 in 43). A significant inverse correlation was observed between TIMP3 expression and vessel density (p = 0.031). Correlation between TIMP3 expression and macrophage infiltration was not statistically significant (p = 0.369). MSP analysis revealed methylation of the gene promoter in 18% (7 in 38) of the analysed cases. No differences in OS and DFS were observed between cases with high and low TIMP3 expression. Gene promoter methylation was significantly associated with both poor 5-year DFS (p = 0.024) and OS (p = 0.034). CONCLUSIONS Our data indicate that TIMP3 is a dominant negative regulator of angiogenesis in cutaneous melanoma and gene silencing by promoter methylation is associated with poor outcome.
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96
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Rutkowski P, Szydłowski K, Nowecki ZI, Sałamacha M, Goryń T, Mitręga-Korab B, Pieńkowski A, Dziewirski W, Zdzienicki M. The long-term results and prognostic significance of cutaneous melanoma surgery using sentinel node biopsy with triple technique. World J Surg Oncol 2015; 13:299. [PMID: 26462471 PMCID: PMC4603583 DOI: 10.1186/s12957-015-0701-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 09/03/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The sentinel lymph node biopsy (SLN) is a basic staging method in all primary cutaneous melanomas ≥pT1b. The standard technique is a triple technique consisting of preoperative lymphoscintigraphy, intraoperative blue-dye lymphography, and gamma-probe assessment. We performed the analysis of long-term results in a very large one-institution series of cutaneous melanoma patients. METHODS We have analyzed treatment results of a group of 1764 consecutive patients with cutaneous melanoma, who underwent SLN biopsy between 1997 and 2008 in one tertiary center. Additionally, we have analyzed the outcomes of a group of 473 patients with positive SLN biopsy undergoing completion lymph node dissection (CLND). Median follow-up time was 5.3 years. RESULTS Metastases to SLN (SLN+) were found in 19.9%. Eight-year overall survival (OS) rate in the entire group was 73.5%, 80% without SLN metastases (SLN-) and 50% in group with SLN+ (p < 0.001). Independent prognostic factors for OS were as follows: presence of metastases to SLN, primary tumor ulceration, and higher mitotic index (>5/mm(2)) of primary tumor. The nodal recurrences in the biopsied lymphatic basin were 5.4%. The metastases to non-sentinel lymph nodes (NSLN found in 27% of patients with SLN+) correlated (on multivariable logistic regression analysis) with primary tumor thickness >4 mm, SLN metastatic deposit size >1 mm, and extracapsular involvement of SLN. In an additionally analyzed SLN+ group, the NSLN involvement was related to poorer prognosis (8-year OS rate NSLN- vs NSLN+: 59.6 vs. 34.7%, respectively). The independent prognostic factors for OS in the SLN+ group were a higher Breslow thickness and ulceration of primary tumor, metastases to more than 1 lymph nodes. CONCLUSIONS The long-term results confirm crucial prognostic significance of SLN biopsy in cutaneous melanoma. We identified factors related to NSLN involvement, which in the future may limit indications for CLND.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | | | - Zbigniew I Nowecki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Maciej Sałamacha
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Tomasz Goryń
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Beata Mitręga-Korab
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Andrzej Pieńkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Wirginiusz Dziewirski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Marcin Zdzienicki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland.
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Holtkamp LHJ, Wang S, Wilmott JS, Madore J, Vilain R, Thompson JF, Nieweg OE, Scolyer RA. Detailed pathological examination of completion node dissection specimens and outcome in melanoma patients with minimal (<0.1 mm) sentinel lymph node metastases. Ann Surg Oncol 2015; 22:2972-7. [PMID: 25990968 DOI: 10.1245/s10434-015-4615-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nonsentinel lymph nodes (NSLNs) are rarely involved in patients with minimal volume melanoma metastases in sentinel lymph nodes (SLNs). Therefore, it has been suggested that completion lymph node dissection (CLND) is not required. However, the lack of routine immunohistochemical staining and multiple sectioning may have led to failure to identify additional positive nodes. The present study sought to more reliably determine the tumor status of NSLNs in patients with minimally involved SLNs and their clinical outcome. METHODS A total of 21 tumor-negative CLND specimens from 20 patients with SLN metastases of <0.1 mm in diameter treated between 1991 and 2013 were examined with a more detailed pathologic protocol (five new sections stained with/for H&E, S-100, HMB45, Melan-A, and H&E). Clinical follow-up data were also obtained. RESULTS Of the 343 examined NSLNs, 1 was found to harbor a 0.18-mm subcapsular sinus metastasis. No metastases were identified in the other NSLNs. Median follow-up was 48 months (range 17-130 months). Six patients (30 %) developed a recurrence. At the end of follow-up, 15 patients (75 %) were alive without sign of melanoma recurrence and 5 patients (25 %) had died of melanoma. Estimated 5-year melanoma-specific survival was 64 %. The patient with the additional positive NSLN remains without recurrence after 130 months follow-up. CONCLUSIONS Although the risk of additional nodal involvement is low, detailed pathologic examination may identify NSLN metastases not identified using routine protocols. Therefore, nodal clearance appears to be the safest option for these patients, pending the results of prospective trials.
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Yélamos O, Gerami P. Predicting the outcome of melanoma: can we tell the future of a patient's melanoma? Melanoma Manag 2015; 2:217-224. [PMID: 30190851 PMCID: PMC6094684 DOI: 10.2217/mmt.15.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cutaneous melanoma is responsible for the greatest number of skin cancer related deaths. For many years there were few therapeutic options. However, in the last years a number of new therapeutic options have emerged showing improved survival rates for advanced melanoma patients. A significant question based on these findings is whether identification and treatment of patients with biologically aggressive melanomas at an earlier clinical stage offer an opportunity for even greater improvement in overall survival. In this review, we will discuss the recent advancements in molecular strategies beyond traditional staging to identify biologically aggressive melanomas, and which are their implications in terms of predicting the prognosis of patients with melanoma.
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Affiliation(s)
- Oriol Yélamos
- Department of Dermatology, Feinberg School of Medicine, The Robert H Lurie Cancer Center, Northwestern University, 676 N. St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Pedram Gerami
- Department of Dermatology, Feinberg School of Medicine, The Robert H Lurie Cancer Center, Northwestern University, 676 N. St Clair Street, Suite 1765, Chicago, IL 60611, USA
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Cochran AJ. Identification, Clinical Significance, and Management of Very Small Melanoma Metastases in Sentinel Lymph Nodes. Ann Surg Oncol 2015; 22:2812-4. [DOI: 10.1245/s10434-015-4625-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Indexed: 11/18/2022]
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100
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Adjuvant ipilimumab versus placebo after complete resection of high-risk stage III melanoma (EORTC 18071): a randomised, double-blind, phase 3 trial. Lancet Oncol 2015; 16:522-30. [PMID: 25840693 DOI: 10.1016/s1470-2045(15)70122-1] [Citation(s) in RCA: 909] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ipilimumab is an approved treatment for patients with advanced melanoma. We aimed to assess ipilimumab as adjuvant therapy for patients with completely resected stage III melanoma at high risk of recurrence. METHODS We did a double-blind, phase 3 trial in patients with stage III cutaneous melanoma (excluding lymph node metastasis ≤1 mm or in-transit metastasis) with adequate resection of lymph nodes (ie, the primary cutaneous melanoma must have been completely excised with adequate surgical margins) who had not received previous systemic therapy for melanoma from 91 hospitals located in 19 countries. Patients were randomly assigned (1:1), centrally by an interactive voice response system, to receive intravenous infusions of 10 mg/kg ipilimumab or placebo every 3 weeks for four doses, then every 3 months for up to 3 years. Using a minimisation technique, randomisation was stratified by disease stage and geographical region. The primary endpoint was recurrence-free survival, assessed by an independent review committee, and analysed by intention to treat. Enrollment is complete but the study is ongoing for follow-up for analysis of secondary endpoints. This trial is registered with EudraCT, number 2007-001974-10, and ClinicalTrials.gov, number NCT00636168. FINDINGS Between July 10, 2008, and Aug 1, 2011, 951 patients were randomly assigned to ipilimumab (n=475) or placebo (n=476), all of whom were included in the intention-to-treat analyses. At a median follow-up of 2·74 years (IQR 2·28-3·22), there were 528 recurrence-free survival events (234 in the ipilimumab group vs 294 in the placebo group). Median recurrence-free survival was 26·1 months (95% CI 19·3-39·3) in the ipilimumab group versus 17·1 months (95% CI 13·4-21·6) in the placebo group (hazard ratio 0·75; 95% CI 0·64-0·90; p=0·0013); 3-year recurrence-free survival was 46·5% (95% CI 41·5-51·3) in the ipilimumab group versus 34·8% (30·1-39·5) in the placebo group. The most common grade 3-4 immune-related adverse events in the ipilimumab group were gastrointestinal (75 [16%] vs four [<1%] in the placebo group), hepatic (50 [11%] vs one [<1%]), and endocrine (40 [8%] vs none). Adverse events led to discontinuation of treatment in 245 (52%) of 471 patients who started ipilimumab (182 [39%] during the initial treatment period of four doses). Five patients (1%) died due to drug-related adverse events. Five (1%) participants died because of drug-related adverse events in the ipilimumab group; three patients died because of colitis (two with gastrointestinal perforation), one patient because of myocarditis, and one patient because of multiorgan failure with Guillain-Barré syndrome. INTERPRETATION Adjuvant ipilimumab significantly improved recurrence-free survival for patients with completely resected high-risk stage III melanoma. The adverse event profile was consistent with that observed in advanced melanoma, but at higher incidences in particular for endocrinopathies. The risk-benefit ratio of adjuvant ipilimumab at this dose and schedule requires additional assessment based on distant metastasis-free survival and overall survival endpoints to define its definitive value. FUNDING Bristol-Myers Squibb.
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