Primary staging and follow-up in melanoma patients--monocenter evaluation of methods, costs and patient survival

Follow-up in patients with localised primary cutaneous melanoma

Follow-up services for patients with localised cutaneous melanoma are widely discussed but there is no international consensus. Our aim was to discuss frequency and duration of follow-up, type of health professional involved, optimum intensity of routine investigation, and patients' satisfaction with follow-up. Searches of the published work were directed at publications between January, 1985, and February, 2004 on recurrences, subsequent primary melanoma, routine tests, and patients' satisfaction. In a selection of 72 articles, 2142 (6.6%) recurrences were reported, 62% of which were detected by the patients themselves. 2.6% of patients developed a subsequent primary melanoma. Most investigators do not support high-intensity routine follow-up investigations. Of the various follow-up investigations requested by physicians, only medical history and physical examination seem to be cost effective. Lymph-node sonography seems to be a promising method for detection, although survival benefit remains to be proven. Patients were found to be anxious about follow-up visits, although other research showed that provision of information to patients was much appreciated. Published work on the follow-up of patients with cutaneous melanoma has mainly been retrospective and descriptive. Recommendations can be given with only a low grade of evidence. For meaningful guidelines to be developed, prospective, high-quality methodological research is needed.

Quantification of Melanoma Micrometastases in Sentinel Lymph Nodes Using Real-Time RT-PCR

Detection of micrometastases in the regional tumor-draining lymph nodes is critical for staging and prognosis in melanoma patients. We applied a quantitative multiple-marker RT-PCR assay to improve the detection of occult melanoma cells in the sentinel lymph node (SLN). From 139 patients with primary cutaneous melanoma who underwent sentinel lymphadenectomy, a total of 235 SLN were assessed for Melan-A and tyrosinase expression by real-time quantitative RT-PCR. Twenty-three patients (17%) were positive by histopathology and expressed messenger RNA of one or two markers. Of the patients with histopathologically negative SLN 39 (28%) were reclassified by positive RT-PCR. Patients were examined for tumor recurrences during a median follow-up period of 29 mo. Tumor recurrences were demonstrated in eight patients (35%) with histopathologically positive SLN, in four patients (10%) with submicroscopic tumor cells detected exclusively by real-time RT-PCR, and in none of the patients negative by both methods. The differences in recurrence rates were statistically significant (p=0.01). These data indicate that real-time quantitative RT-PCR for the detection of minimal residual melanoma in SLN improves the prediction of disease-free survival.

Evaluation of extensive initial staging procedure in intermediate/high-risk melanoma patients

INTRODUCTION

Early diagnosis and treatment of metastases have been shown to improve overall survival of melanoma patients. The purpose of this study was to evaluate the impact of extensive initial staging, including positron emission tomography (PET) scan on the management of melanoma patients.

PATIENTS AND METHODS

Forty-three patients with intermediate/poor prognosis primary melanoma benefited from complementary excision and sentinel lymph node biopsy (SLB) after clinical and paraclinical staging (computed tomography, nuclear magnetic resonance and whole body fluorodeoxyglucose PET scan).

RESULTS

No systemic metastases were demonstrated, while the SLB procedure emphasized the presence of regional lymph node metastases in 10 patients as suggested by the PET scan in four patients (sensitivity of the PET scan 40%). These 10 patients with early diagnosed lymph node involvement benefited from early surgery and were included in adjuvant treatment protocols. A secondary primary cancer was fortuitously diagnosed and treated early in two patients.

CONCLUSIONS

The development of new adjuvant therapies and therapeutic procedures (specific and non-specific immunotherapy, gamma-knife radiosurgery, etc.) now raises the relevance of extensive staging in intermediate/poor prognosis melanoma patients. We confirm in our series that PET scan is not useful to detect micrometastasis and cannot replace SLB in initial regional staging. However, we show in our study that 12 of 43 patients were treated early or were included early in treatment protocols thanks to the extensive staging procedure. Nevertheless, it seems important to evaluate through larger prospective trials the real impact of these early diagnoses and new treatments on overall survival before defining new diagnostic and therapeutic guidelines.

Is ultrasound lymph node examination superior to clinical examination in melanoma follow-up? A monocentre cohort study of 373 patients

BACKGROUND

There is still lack of consensus regarding the most effective follow-up for stage I and II melanoma patients although some consensus conferences have provided guidelines stating that clinical examination should be the standard.

OBJECTIVES

Our aim was to study the value of adding ultrasound lymph node examination (7.5 MHz) to the routine clinical examination recommended by French guidelines in melanoma follow-up.

METHODS

A cohort of melanoma patients was enrolled between 1 July 1995 and 1 July 2000 in a follow-up protocol including clinical examination performed four times a year for thick melanomas (Breslow index > or = 1.5 mm) and twice a year for thin melanomas (Breslow index < 1.5 mm) according to French guidelines, and ultrasound lymph node examination performed every 6 months for thick melanomas and every year for thin melanomas. Follow-up was continued up to 1 July 2003. When clinical or ultrasound examination indicated signs of node recurrence, surgical biopsy of the involved node was performed. When ultrasound examination was only suspicious, another ultrasound examination was performed within the following 3 months. The results of both clinical and ultrasound examinations were compared with histopathology examination when node biopsy was performed.

RESULTS

Ultrasound follow-up was performed for 373 patients (213 females and 160 males). Mean age at diagnosis of melanoma was 59 years (range 14-90, SD 15). In total, 1909 ultrasound examinations combined with clinical examination were analysed. Node biopsy was performed in 65 patients and demonstrated melanoma metastases in 54. Sensitivity of clinical examination and ultrasound examination was 71.4%[95% confidence interval (CI) 55.4-84.3] and 92.9 (95% CI 80.5-98.5), respectively, P = 0.02. Specificity of clinical examination and ultrasound examination was 99.6% (95% CI 99.2-99.8) and 97.8% (95% CI 97.0-98.4), respectively. Despite this apparent superiority of ultrasound examination over palpation, only 7.2% of the patients really benefited from ultrasound examination (earlier lymph node metastasis detection or avoidance of unnecessary surgery), while 5.9% had some deleterious effect from ultrasound examination (unnecessary stress caused by repetition of ultrasound examination for benign lymph nodes, useless removal of benign lymph node).

CONCLUSIONS

This study confirms the greater sensitivity of ultrasound examination to clinical examination in the diagnosis of node metastases from cutaneous melanoma. However, the place of ultrasound in routine follow-up is at least questionable as only a very small proportion of patients (1.3%) really benefited from adding ultrasound examination to clinical examination.

Ultrasonography or palpation for detection of melanoma nodal invasion: a meta-analysis

Because treatment of distant melanoma metastases is not very effective, nodal spread should be diagnosed early so that therapeutic lymphadenectomy can be started as early as possible. Physical examination alone often does not detect nodal metastases and palpable nodes cannot be clasified unambiguously. Whether lymph-node ultrasonography-an inexpensive procedure-improves detection of nodal invasion during the initial staging and follow-up of patients with melanoma is controversial. We used meta-analysis techniques for diagnostic tests to assess the merit of ultrasonography and palpation in detection of nodal invasion in patients with melanoma. Five databases were screened until December, 2003. 12 studies, including 6642 patients and 18?610 paired palpation and ultrasound examinations, were eligible. The main limitations were variations in the definition of false negatives, and verification bias. Ultrasonography had a higher discriminatory power (odds ratio 1755; 95% CI 726-4238) than did palpation (21 [4-111]; p=0.0001). Furthermore, positive-likelihood ratios were 41.9 (95% CI 29-75) for ultrasonography and 4.55 (2-18) for palpation; negative-likelihood ratios were 0.024 (0.01-0.03) and 0.22 (0.06-0.31), respectively. Our results showed clearly that ultrasonography detects lymph-node invasion more accurately than palpation, and should therefore probably be used routinely in patients with melanoma.

Evaluation of staging chest radiographs and serum lactate dehydrogenase for localized melanoma

BACKGROUND

Radiographic and laboratory evaluations are often routinely used in the initial work-up for melanoma.

PURPOSE

To examine the yield of a chest radiograph and serum lactate dehydrogenase (LDH), in the work-up for newly diagnosed localized melanoma.

METHODS

Patients with a new diagnosis of localized invasive melanoma were entered into a prospective database. The status of the chest radiograph, LDH, and sentinel lymph node (SLN) was assessed.

RESULTS

Two-hundred-twenty-four patients were entered into the study and 210 had chest radiograph data for analysis. The true positive chest radiograph rate, defined as the percent of chest radiographs interpreted as "positive or equivocal possibly melanoma related" with subsequent confirmed melanoma metastases, was 0%. The false positive chest radiograph rate, defined as the percent of chest radiographs interpreted as "positive or equivocal possibly melanoma related" with melanoma metastases excluded based on previous or subsequent studies or other known medical conditions, was 7%. Ninety-six patients (melanoma> or =1 mm) had LDH results for analysis. Elevations in LDH were found in 15% and did not lead to detection of occult disease in any patients. Seventy-seven patients underwent SLN biopsy. A positive SLN did not correlate with abnormal chest radiograph or LDH.

CONCLUSION

Low yield, high rate of false-positive tests and lack of significant impact of early detection of metastases on survival argue that chest radiographs and serum lactate dehydrogenase should probably not be accepted into routine clinical practice in patients with clinically localized melanoma in the absence of data supporting their use.

The history and future of melanoma staging

The evolution and progressive refinement of an internationally accepted melanoma staging system over the last 50 years has resulted in much greater accuracy and increased utility, but the staging process has become more complex and less intuitive. This raises the question of whether melanoma staging should continue to develop with ever-increasing levels of complexity, or whether attempts should be made to produce an alternative system that is simpler and more intuitive. The current, TNM-based American Joint Committee on Cancer (AJCC) staging system for melanoma incorporates only some of the prognostic factors of proven significance. However, the information that is now available about these and other, well-documented prognostic factors allows accurate prediction of an individual melanoma patient's prognosis using a computer-generated estimate. Thus an alternative staging strategy that could be considered in the future would be to use such an estimate to obtain a numerical score for each patient, based on all available information agreed to be of prognostic relevance. A stage grouping could then be assigned on the basis of that score, according to previously determined score ranges for each stage and substage. The advantages of such a system would be that it would allow more reliable comparison of treatment results within and between institutions, and would provide more equivalent stratification groups for patients entering clinical trials of new therapies and those entering adjuvant therapy trials. A further advantage would be that because there would be a direct link between staging and prognostic estimate, such a system would be more readily able to be understood in an intuitive fashion.

Die Wertigkeit der Melanomnachsorge aus der Patientenperspektive. Patients' view of melanoma follow-up

BACKGROUND

About 20% of melanoma patients develop progressive disease during follow-up. This is an alarming number for the patients. In view of new recommendations for melanoma follow-up, this study assesses the performance and quality of follow-up as perceived by the patients.

PATIENTS AND METHODS

A questionnaire was distributed to 462 patients with melanoma being followed in the skin cancer units of the universities of Cologne and Münster. Follow-up was based on recommendations published in 1994 by Malignant Melanoma Committee of the German Dermatological Society.

RESULTS

Follow-up was regularly performed. In Münster, 62% patients were seen in the university clinic, while in Cologne 53% of patients were followed jointly by the university clinic and practicing dermatologists. Radiological examinations were regularly repeated in 70% of the collective. 70% of patients reported performing self-examinations. 14% had developed progressive disease. 15% made use of psycho-social help.

CONCLUSIONS

The questionnaire reveals that the interdisciplinary follow-up and self-examinations proposed in the new recommendations are already well accepted. Based on latest standards, 90% of the patients felt that follow-up was reassuring. Psychosocial services should be offered more directly with emphasis on both social services and psychological support. Systematic patient inquiries can be used to establish quality standards for follow-up which are more patient-oriented.

Geographic and Patient Variation in Receipt of Surveillance Procedures After Local Excision of Cutaneous Melanoma11Tables 4, 6, and appendix can be found at http://www.blackwellpublishing.com/products/journals/suppmat/jid/jid22238/jid22238sm.htm

Little is known about variation in surveillance practices following the diagnosis of invasive melanoma. The objective of this study was to characterize geographic, patient, and tumor variation in the use of follow-up surveillance testing in patients with local or regional stage melanoma. A cohort of Medicare beneficiaries > or =65 y diagnosed with invasive melanoma during 1992 to 1996 living in a Surveillance, Epidemiology, and End Results registry area was studied. Outpatient and inpatient Medicare claims 3 mo following diagnosis were examined for up to 2 y for surveillance procedures of interest. Use of chest X-ray, chest computed tomography scan, abdominal and/or pelvic computed tomography scan, abdominal ultrasound, head computed tomography scan, head magnetic resonance imaging, laboratory testing, and skin examinations were compared between patient groups and geographic regions. A total of 3389 patients were identified for the analysis. Surveillance testing was relatively common, ranging from 13% for abdominal ultrasound to 80% for laboratory testing. Follow-up skin examinations were performed in 70% to 90% of patients. The use of most surveillance procedures was associated (p<0.01) with younger age, male gender, regional stage tumors, and geographical area, with up to 2-fold differences observed. In contrast, there was much less variability in the receipt of skin examinations. Further studies are needed to determine the etiology and impact of such disparities, and the influence of surveillance procedures on morbidity and mortality.

Vulvar Melanoma: Review of Diagnosis, Staging, and Therapy

OBJECTIVES

To update, assimilate, and bridge the contemporary literature on vulvar and cutaneous melanoma regarding diagnosis, staging, and therapy to provide a useful clinical reference for managing and counseling for affected patients.

MATERIALS AND METHODS

A computerized search for reports in the literature up to June 2003 was carried out using PubMed and MEDLINE databases. Multidisciplinary involvement was used in evaluating the available data and formulating conclusions.

RESULTS

More than 300 reports were reviewed. Diagnosis, staging, and therapy aspects of vulvar melanoma are summarized.

CONCLUSIONS

Vulvar melanoma represents a subtype of cutaneous melanoma, with similar prognostic and staging factors. The most recent American Joint Committee on Cancer staging system for cutaneous melanoma is applicable to vulvar melanoma. Sentinel lymph node biopsy is reliable for staging the regional lymph node basin for vulvar melanoma. Standardized documentation of clinical and histopathologic parameters is needed to standardize grouping of cases for future comparison studies.