Is head and neck melanoma different from trunk and extremity melanomas with respect to sentinel lymph node status and clinical outcome?

Benefits of initial CT staging before sentinel lymph node biopsy in patients with head and neck cutaneous melanoma

BACKGROUND

The value of CT at the time of diagnosis for patients with cutaneous head and neck melanoma clinically asymptomatic for metastatic disease is unclear.

METHODS

A retrospective medical chart review was performed on 198 consecutive patients identified with primary T1b-T4b head and neck melanoma clinically asymptomatic for metastatic disease referred for sentinel lymph node biopsy procedures between 2004 and 2014.

RESULTS

Initial CTs identified clinically occult melanoma metastases in 8.1% and advanced second primary tumors in 3.5% of patients. CT findings were false-negative in 1% and false-positive in 6% of patients. Overall survival (OS) for patients with true-positive CT findings was lower than for the other patients (P < .001).

CONCLUSION

CT imaging when staging patients with head and neck melanoma seems to identify more metastases than has been reported for melanoma at other sites. Preoperative CTs decreased the number of sentinel lymph node biopsy (SLNBs), thus avoiding the stress and cost of this surgical procedure in 12% of patients.

Prognostic factors in head and neck melanoma according to facial aesthetic units

BACKGROUND

Head and neck melanoma is a clinical challenge. Indeed, cutaneous head and neck melanoma shows a worse prognosis in comparison to melanomas of other body sites. Although the emphasis on facial cosmetic preservation plays a pivotal role in comparison to other body areas, specific Facial Aesthetic Units (FAU) could also play a key role in the prognostic evaluation of the malignancy.

METHODS

The aim of the current study was to evaluate the general outcome and clinicopathological features of head and neck melanoma and to detect prognostic differences according to each FAU. The Kaplan-Meier product was used to calculate survival curves, while Cox proportional-hazard regression was performed to evaluate the predictive value of each FAU.

RESULTS

A total of 221 head and neck melanoma patients was included in our analysis. In the nasal FAU, we found a high rate of local recurrence, which affected significantly disease-free survival. The worse prognosis was observed in melanoma of the scalp, which showed a greater tendency to skip metastases in internal organs. Moreover, we found that scalp showed a low incidence of non-melanoma skin cancers, if compared to other FAU, highlighting that the scalp local milieu might play a more prominent role in melanoma biology than chronic UV exposition.

CONCLUSIONS

Although FAUs have an aesthetic function, they could also play a role in the evaluation and follow-up of melanoma.

A retrospective analysis of the role of adjuvant radiotherapy in the treatment of cutaneous melanoma

Melanoma is a significant clinical problem, with rising rates of incidence. Surgery is the mainstay of treatment. The role of adjuvant radiotherapy in the control of locoregionally advanced cutaneous melanoma is controversial. A retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database was performed. Patients with locoregionally confined cutaneous melanoma treated surgically between 2004 and 2009 were evaluated, with cancer-specific and all-cause mortality as primary end points. Propensity score matching was used to match 319 radiotherapy patients with 319 non-radiotherapy controls, stratifying by head and neck (HN) and non-head and neck (NHN) primary. Surgery was primarily by wide excision in both the radiotherapy (51.72%) and non-radiotherapy (53.91%) groups. The majority had nodal disease (82.13% vs. 82.44%). White (91.22% vs. 90.59%) males (70.21% vs. 68.96%) predominated. Average ages at diagnosis were 62.27 (SD 15.93) and 63.02 (SD 16.03). Using Cox proportional hazards models, radiation conferred decreased survival in all-cause (HR 1.44, p < 0.0003), and cancer specific mortality (HR 1.57, p < 0.0002) in combined analysis. The NHN group showed significantly decreased 6-year cancer specific survival (HR 2.05, p < 0.0001) for radiated patients. The HN group showed a non-significant hazard with radiotherapy (HR 1.19, p = 0.307). Meaningful differences not captured in the SEER database may exist between cohorts. Based on available SEER data, routine use of adjuvant radiotherapy should be viewed with caution and reserved for high-risk patients. Future trials evaluating patient quality of life may clarify the benefit of adjuvant radiotherapy in high-risk melanoma populations.

Clinical and biological determinants of melanoma progression: Should all be considered for clinical management?

Cutaneous melanoma is a heterogeneous disease affecting the regulation of multiple genes and proteins that contribute to melanoma progression. Survival for patients with locally invasive disease varies greatly, even within tumour stages based on current prognostic criteria. This has prompted investigations into the value of additional clinical or biological parameters predicting survival. In particular, the improved knowledge of tumour biology has fed the hope that the outcome may be predicted at the molecular level. The prognostic value of numerous potential biomarkers has therefore been evaluated in protein and gene expression studies, and genomic associations with melanoma prognosis are beginning to emerge. These potential biomarkers interrogate key tumour and host processes important for tumour development and progression, such as proliferation, invasion and migration through epithelial mesenchymal transition or the host immune or vascular responses. This research may allow more individualised information on prognosis if the challenges regarding the quality and validation of studies are overcome.

Cutaneous head and neck melanoma in OPTiM, a randomized phase 3 trial of talimogene laherparepvec versus granulocyte-macrophage colony-stimulating factor for the treatment of unresected stage IIIB/IIIC/IV melanoma

Background

Cutaneous head and neck melanoma has poor outcomes and limited treatment options. In OPTiM, a phase 3 study in patients with unresectable stage IIIB/IIIC/IV melanoma, intralesional administration of the oncolytic virus talimogene laherparepvec improved durable response rate (DRR; continuous response ≥6 months) compared with subcutaneous granulocyte‐macrophage colony‐stimulating factor (GM‐CSF).

Methods

Retrospective review of OPTiM identified patients with cutaneous head and neck melanoma given talimogene laherparepvec (n = 61) or GM‐CSF (n = 26). Outcomes were compared between talimogene laherparepvec and GM‐CSF treated patients with cutaneous head and neck melanoma.

Results

DRR was higher for talimogene laherparepvec–treated patients than for GM‐CSF treated patients (36.1% vs 3.8%; p = .001). A total of 29.5% of patients had a complete response with talimogene laherparepvec versus 0% with GM‐CSF. Among talimogene laherparepvec–treated patients with a response, the probability of still being in response after 12 months was 73%. Median overall survival (OS) was 25.2 months for GM‐CSF and had not been reached with talimogene laherparepvec.

Conclusion

Treatment with talimogene laherparepvec was associated with improved response and survival compared with GM‐CSF in patients with cutaneous head and neck melanoma. © 2016 Wiley Periodicals, Inc. Head Neck38: 1752–1758, 2016

Clinical utilities and biological characteristics of melanoma sentinel lymph nodes

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.

Dermoscopic and clinical features of head and neck melanoma

BACKGROUND

The dermoscopic criteria of extrafacial melanomas are well-known.

OBJECTIVE

To determine the frequency of dermatoscopic findings in head and neck melanomas (HNM) and to assess the distinguishing dermoscopic criteria of facial and extrafacial melanoma.

METHODS

This observational study included 108 patients with HNM (63% male, mean age 64 years). Participants underwent individual dermoscopic imaging of clinically melanoma. All lesions were excised, and histopathological examination was performed on all specimens.

RESULTS

Drawing on histopathological analysis, lentigo maligna melanoma or lentigo maligna was diagnosed in 60 lesions, superficial spreading melanoma in 18, nodular in 10, desmoplastic in 8, superficial spreading melanoma in situ in 12. The most frequent location for head and neck melanoma was the cheek (60 patients, 55.6%). Eight prominent dermatoscopic features were observed in facial melanoma: annular-granular pattern (18%); rhomboidal structures (29%); pseudonetwork (29%); asymmetrical, pigmented, follicular openings (51%); obliterated hair follicles (8%); red rhomboidal structures (18%); increased density of the vascular network (32%); scar-like depigmentation (59%).

CONCLUSIONS

HNM has specific dermoscopic features, and classical extrafacial dermoscopic rules are less useful for diagnosis of facial melanoma. In our study, further characteristic dermatoscopic findings were detected in facial melanoma such as low frequencies of irregular dots, 2 or fewer colors in lesions, the presence of pseudonetwork, increased density of the vascular network, red rhomboidal structures, in addition to dermatoscopic findings of extrafacial melanoma. Thus, it is concluded that the prediction and identification of HNM may be evident with the help of these signs.

Current staging and prognostic factors in melanoma

The current American Joint Commission for Cancer staging system for melanoma includes thickness, ulceration, and mitotic index as primary tumor factors for patients with stage I and II disease. Number and size of nodal metastases, presence of satellitosis and in-transit disease, and tumor ulceration status categorize patients with stage III disease. Presence and location of distant metastatic disease and increased lactate dehydrogenase level stratify prognosis in patients with stage IV disease. Factors predictive of sentinel lymph node positivity are also studied, particularly in patients with T1 melanomas, but are not always congruent with those predictive of survival.

Lymphatic and blood vasculature in primary cutaneous melanomas of the scalp and neck

BACKGROUND

Scalp/neck melanomas have a poor prognosis, possibly because of a rich vascular supply that prompts tumor cells' dissemination.

METHODS

We compared the accuracy of immunohistochemical (IHC) staining with morphology for the identification of lymphovascular invasion in 156 scalp/neck melanomas. We then analyzed the association of vessel invasion and density with pathological features and survival.

RESULTS

IHC-detected lymphatic vessel invasion (LVI) and blood vessel invasion (BVI) were identified in 34.6% and 13.5% of cases, respectively. IHC increased the LVI/BVI detection compared to morphology (40.4% vs 16.6%; p < .001). The degree of peritumoral and intratumoral blood vessel density (BVD) was greater than lymphatic vessel density (LVD). Ulceration was the only factor independently associated with intratumoral (p = .029) and peritumoral (p = .047) BVD. Tumor thickness was the only independent predictor of survival (p = .002).

CONCLUSION

IHC allows accurate assessment of lymphovascular invasion in scalp/neck melanomas. In these tumors, we observed a high incidence of BVI, which deserves further investigations.

Completion Lymph Node Dissection Based on Risk of Nonsentinel Metastasis in Cutaneous Melanoma of the Head and Neck

Objective

Theoretically, completion lymph node dissection (CNLD) should have the lowest benefit in the absence of nonsentinel lymph node (NSLN) metastases. For this reason, substantial research efforts have attempted to define specific criteria that are associated with a low-enough risk of NSLN positivity so that CLND can be deferred. Our objectives were (1) to identify features associated with low risk of NSLN positivity in sentinel lymph node–positive cutaneous melanoma of the head and neck (CMHN) and (2) to analyze the effect of CLND on 5-year disease-specific survival (DSS) among subgroups stratified by risk of NSLN metastasis.

Study Design

Retrospective analysis of population-based data.

Setting

SEER database.

Subjects and Methods

Patients with sentinel lymph node–positive CMHN were categorized according to lymph node treatment following sentinel lymph node biopsy (SLNB): 210 underwent CLND and 140 deferred. Clinicopathologic characteristics and survival were compared between SLNB+CLND and SLNB-only groups. Survival analyses were stratified by age and characteristics associated with NSLN positivity.

Results

Minimal tumor thickness and nonulceration were associated with lowest risk of positive NSLN ( P < .025). In the subgroup with the lowest risk of metastasis, patients aged <60 years who underwent CLND+SLNB had markedly better DSS than those receiving SLNB only (>90% vs <25%; P < .0025). Paradoxically, in subgroups with a higher risk of NSLN metastasis, DSS was similar whether CLND was performed or not ( P > .25).

Conclusions

Selecting patients for CLND according to risk of NSLN metastasis may be a suboptimal strategy for improving DSS. We believe that CLND should not be withheld on the basis of “low risk” features in CMHN.

[Malignant head and neck melanoma: Part 2: Therapy]

Resection margins of melanomas in the head and neck region often have to be adapted according anatomical circumstances. In the case of thicker primary tumors or after complete resection of locoregional lymph node metastases, adjuvant therapy with interferon-α can be performed; in some cases, adjuvant radiotherapy may also be indicated. In the case of inoperable lymph node or distant metastases, systemic treatment is required. Beside well-established mono- or polychemotherapy regimens, newer targeted therapies with BRAF inhibitors (vemurafenib, dabrafenib), mitogenic-activated protein kinase (MEK) inhibitors (trametinib, binimetinib, and cobimetinib), and kinase inhibitors (imatinib, sunitinib, nilotinib, dasatinib) are also available.

Association of sentinel lymph node biopsy with survival for head and neck melanoma: survival analysis using the SEER database

IMPORTANCE

Sentinel lymph node biopsy (SLNB) provides prognostic information for melanoma; however, a survival benefit has not been demonstrated.

OBJECTIVE

To assess the association of SLNB with survival for melanoma arising in head and neck subsites (HNM).

DESIGN, SETTING, AND PARTICIPANTS

Propensity score-matched retrospective cohort study using the Surveillance Epidemiology and End Results (SEER) database to compare US patients with HNM meeting current recommendations for SLNB, treated from 2004 to 2011 with either (1) SLNB with or without neck dissection, or (2) no SLNB or neck dissection.

INTERVENTIONS

SLNB with or without neck dissection.

MAIN OUTCOMES AND MEASURES

Disease-specific survival (DSS) estimates based on the Kaplan-Meier method, and Cox proportional hazards modeling to compare survival outcomes between matched pair cohorts.

RESULTS

A total of 7266 patients with HNM meeting study criteria were identified from the SEER database. Matching of treatment cohorts was performed using propensity scores modeled on 10 covariates known to be associated with SLNB treatment or melanoma survival. Cohorts were stratified by tumor thickness (thin, >0.75-1.00 mm Breslow thickness; intermediate, >1.00-4.00 mm; and thick, >4.00 mm) and exactly matched within 5 age categories. In the intermediate-thickness cohort, 2808 patients with HNM were matched and balanced by propensity score for SLNB treatment; the 5-year DSS estimate for those treated by SLNB was 89% vs 88% for nodal observation (log-rank P = .30). The hazard ratio for melanoma-specific death was 0.87 for those undergoing SLNB (95% CI, 0.66-1.14; P = .31). In each of the other cohorts analyzed, including those with thin and thick melanomas, and cohorts with melanoma overall, no significant difference in DSS was demonstrated.

CONCLUSIONS AND RELEVANCE

This SEER cohort analysis demonstrates no significant association between SLNB and improved disease-specific survival for patients with HNM.

Red meat and fruit intake is prognostic among patients with localized cutaneous melanomas more than 1mm thick

BACKGROUND

As the 10-year mortality for localized cutaneous melanoma more than 1.00 mm thick approaches 40% following complete resection, non-therapeutic interventions that can supplement recommended active surveillance are needed. Although guidelines recommending nutrition, physical activity and tobacco cessation for cancer survivors have been published, data describing their associations with melanoma survivorship are lacking.

METHODS

Analysis of modifiable lifestyle behaviors collected on the 249 cases with melanomas more than 1.00 mm thick enrolled in the Connecticut Case-Control Study of Skin Self-Examination study was conducted. Independent associations with melanoma-specific survival were evaluated through Cox proportional hazards modeling adjusting for age, gender, Breslow thickness, ulceration and the presence of microsatellites. Independently significant variables were then combined into a single model and backwards elimination was employed until all remaining variables were significant at p<0.05.

RESULTS

Following adjustment for age, Breslow thickness and anatomic site of the index melanoma, daily fruit consumption was associated with improved melanoma-specific survival (HR=0.54; 95% CI: 0.34-0.86) whereas at least weekly red meat consumption was associated with worse outcomes (HR=1.84; 95% CI: 1.02-3.30). Natural red (HR=0.44; 95% CI: 0.22-0.88) or blond (HR=0.52; 95% CI: 0.29-0.94) hair were also favorably prognostic. Higher fish consumption was of borderline significance for improved survival only when considered independently (HR=0.65; 95% CI: 0.40-1.05); no association was seen following adjustment for red meat and fruit consumption (p>0.10).

CONCLUSIONS

Dietary choices at the time of diagnosis are associated with melanoma-specific survival in patients with melanomas more than 1.00 mm thick. Further validation of our findings in larger cohorts with repeated post-diagnostic measures is warranted to further evaluate whether dietary modification during the survivorship period can improve melanoma-specific survival.

The influence of sentinel lymph node biopsy on survival for intermediate-thickness melanoma

BACKGROUND

The Multicenter Selective Lymphadenectomy Trial-1 (MSLT-1) failed to demonstrate a survival advantage for sentinel lymph node biopsy (SNB) in melanoma. This may have been secondary to inadequate statistical power. This study was designed to determine the impact of SNB on melanoma-specific survival (MSS) in a larger patient cohort.

METHODS

From 2003-2008, patients with tumors 1-4 mm in thickness and clinically negative nodes were identified within the SEER registry. Propensity score was used to create two matched cohorts: those who underwent a wide excision with SNB or wide excision alone.

RESULT

A total of 15,274 met inclusion criteria and 7,910 comprised the match cohort. Average age was 67.4 years. The majority were male (62.3 %) and white (97.2 %). Primary tumors were most frequently nonulcerated (77.1 %), located on the extremity (42.3 %), and T2 (64.1 %). There were 3,955 patients in both the SNB and observation groups. There was no significant difference in gender, ethnicity, ulceration status, primary site, or T-classification between the groups. Improved 5-year MSS was associated with SNB (85.7 vs. 84.0 %), female gender (88.3 vs. 82.7 %), absence of ulceration (87.5 vs. 75.7 %), extremity location (87.4 %), T2 disease (88.6 vs. 77.9 %), and a negative SNB (88.9 vs. 64.8 %). The relationships between observation [hazard ratio (HR) 1.18], male gender (HR 1.33), ulceration (HR 1.77), head-and-neck location (HR 1.34), and T3 disease (HR 1.82) persisted on multivariate analysis.

CONCLUSIONS

Status of the sentinel node is the strongest predictor of survival in patients with intermediate thickness melanoma. SNB compared with observation was associated with a modest survival advantage.

The role of sentinel lymph node biopsy for thin cutaneous melanomas of the head and neck

From 18% to 35% of cutaneous melanomas are located in the head and neck, and nearly 70% are thin (Breslow thickness ≤ 1 mm). Sentinel lymph node biopsy (SLNB) has an established role in staging of intermediate-thickness melanomas, however its use in thin melanomas remains controversial. In this article, we review the literature regarding risk factors for occult nodal metastasis in thin cutaneous melanoma of the head and neck (CMHN). Based on the current literature, we recommend SLNB for all lesions with Breslow thickness ≥ 0.75 mm, particularly when accompanied by adverse features including mitotic rate ≥ 1 per mm(2), ulceration, and extensive regression. SLNB should also be strongly considered in younger patients (e.g. < 40 years old), especially in the presence of additional adverse features. All patients who do not proceed with sentinel lymph node biopsy must be carefully followed to monitor for regional relapse.

Management of regional metastatic disease in head and neck cutaneous malignancy. 2. Cutaneous malignant melanoma

This is the second of 2 articles giving an overview of the current evidence for management of the neck and parotid in cutaneous cancers of the head and neck. We discuss cutaneous malignant melanoma and review the latest evidence for management of the regional nodes.

Age as a predictor of sentinel node metastasis among patients with localized melanoma: an inverse correlation of melanoma mortality and incidence of sentinel node metastasis among young and old patients

PURPOSE

We have previously reported that older patients with clinical stage I and II primary cutaneous. Melanoma had lower survival rates compared to younger patients. We postulated that the incidence of nodal metastasis would therefore be higher among older melanoma patients.

METHODS

The expanded American Joint Committee on Cancer melanoma staging database contains a cohort of 7,756 melanoma patients who presented without clinical evidence of regional lymph node or distant metastasis and who underwent a sentinel node biopsy procedure as a component of their staging assessment.

RESULTS

Although older patients had primary melanoma features associated with more aggressive biology, we paradoxically observed a significant decrease in the incidence of sentinel node metastasis as patient age increased. Overall, the highest incidence of sentinel node metastasis was 25.8 % in patients under 20 years of age, compared to 15.5 % in patients 80 years and older (p < 0.001). In contrast, 5-year mortality rates for clinical stage II patients ranged from a low of 20 % for those 20-40 years of age up to 38 % for those over 70 years of age. Patient age was an independent predictor of sentinel node metastasis in a multifactorial analysis (p < 0.001).

CONCLUSIONS

Patients with clinical stage I and II melanoma under 20 years of age had a higher incidence of sentinel lymph node metastasis but, paradoxically, a more favorable survival outcome compared to all other age groups. In contrast, patients >70 years had the most aggressive primary melanoma features and a higher mortality rate compared to all other age groups but a lower incidence of sentinel lymph node metastasis.