Factors affecting survival following local, regional, or distant recurrence from localized melanoma

Development and validation of time-to-event models to predict metastatic recurrence of localized cutaneous melanoma

BACKGROUND

The recent expansion of immunotherapy for stage IIB/IIC melanoma highlights a growing clinical need to identify patients at high risk of metastatic recurrence and, therefore, most likely to benefit from this therapeutic modality.

OBJECTIVE

To develop time-to-event risk prediction models for melanoma metastatic recurrence.

METHODS

Patients diagnosed with stage I/II primary cutaneous melanoma between 2000 and 2020 at Mass General Brigham and Dana-Farber Cancer Institute were included. Melanoma recurrence date and type were determined by chart review. Thirty clinicopathologic factors were extracted from electronic health records. Three types of time-to-event machine-learning models were evaluated internally and externally in the distant versus locoregional/nonrecurrence prediction.

RESULTS

This study included 954 melanomas (155 distant, 163 locoregional, and 636 1:2 matched nonrecurrences). Distant recurrences were associated with worse survival compared to locoregional/nonrecurrences (HR: 6.21, P < .001) and to locoregional recurrences only (HR: 5.79, P < .001). The Gradient Boosting Survival model achieved the best performance (concordance index: 0.816; time-dependent AUC: 0.842; Brier score: 0.103) in the external validation.

LIMITATIONS

Retrospective nature and cohort from one geography.

CONCLUSIONS

These results suggest that time-to-event machine-learning models can reliably predict the metastatic recurrence from localized melanoma and help identify high-risk patients who are most likely to benefit from immunotherapy.

Risk factors for lymphatic and hematogenous metastasis after diagnosis of cutaneous Melanoma in Taiwan

BACKGROUND

Risk factors of lymphatic and hematogenous metastasis in cutaneous melanoma remained unclear in Asian population. This study aimed to identify clinical and histopathological factors to predict metastatic pathways in cutaneous melanoma in Taiwan.

METHODS

A total of 247 patients diagnosed as stage I and II melanoma, followed at National Taiwan University Hospital were included in this retrospective study from 1980 to 2020. Kaplan-Meier curves and Cox proportional hazards regression were utilized to identify risk factors.

RESULTS

During a median follow-up of 143 months, 48 (19.4%) and 62 (25.1%) patients developed lymphatic and hematogenous metastasis respectively. In the univariate analysis, age> 70 years, greater Breslow thickness, ulceration, neurotropism, and NRAS mutation were significant risk factors for lymphatic metastasis in all subtypes of melanoma. Age >70 years, head and neck location, thickness, ulceration, higher mitotic rate, neurotropism, and NRAS mutation were significant predictors of hematogenous metastasis in all subtypes. In the multivariate analysis, greater thickness (HR for 2.0-4.0 mm, 4.5; p = .009 and HR for >4.0 mm, 5.7; p = .003) retained its significance as an independent risk factor for lymphatic metastasis in all subtypes of melanoma. Thickness (HR for >4.0 mm, 5.7; p < .001) and ulceration (HR, 2.5; p = .001) were independent risk factors for hematogenous metastasis.

CONCLUSION

Risk factors of metastasis not only differ between lymphatic and hematogenous pathways, but also differ between ethnics and melanoma subtypes. Better understanding the behavior of cutaneous melanoma may help guide further treatments and follow-up plans.

Risk factors for cardiovascular mortality and melanoma-specific mortality among patients with melanoma: a SEER based study

OBJECTIVE

This study aims to identify the risk factors for cardiovascular mortality in melanoma patients.

METHODS

Data of melanoma patients were obtained from the Surveillance, Epidemiology, and End Results database. We used Person's chi-square test to assess the relationships between categorical variables. We used Kaplan-Meier test in the univariate analysis and Cox regression test for the multivariate analysis. Analyses were conducted using the SPSS software.

RESULTS

We analyzed data of 194 503 melanoma patients. Among them, 28 818 (14.8 %) died due to cardiovascular diseases. Cardiovascular-specific survival was higher in younger patients, women, married, localized disease, superficial spreading melanoma and in patients who had surgery. It was lower in patients who received chemotherapy or radiotherapy. The multivariate analysis revealed a higher risk of cardiovascular mortality in patients aged 50-64 years [hazard ratio (HR), 7.297; 95% confidence interval (CI), 6.68-7.97], patients aged ≥65 years (HR, 43.309; 95% CI, 39.706-47.240), men (HR, 1.535; 95% CI, 1.475-1.597), Blacks (HR, 1.29; 95% CI, 1.044-1.594), separated (HR, 1.286; 95% CI, 1.058-1.562), widowed (HR, 1.829; 95% CI, 1.706-1.961), patients with no or unknown history of chemotherapy (HR, 1.302; 95% CI, 1.071-1.583) or radiotherapy (HR, 1.477; 95% CI, 1.217-1.793) and patients with no surgery (HR, 1.468; 95% CI, 1.264-1.706).

CONCLUSIONS

In patients with melanoma, the risk of cardiovascular death is higher in older patients, men, Blacks, separated, widowed and patients with nodular or lentigo maligna melanoma. The risk is lower in married, patients with superficial spreading or acral lentiginous melanoma, and patients who had chemotherapy, radiotherapy or surgery.

Regression in melanoma is significantly associated with a lower regional recurrence rate and better recurrence-free survival

BACKGROUND AND OBJECTIVES

The prognostic significance of regression in predicting melanoma recurrences is unknown. We present a large multicenter study correlating regression with recurrence.

METHODS

The Sentinel Lymph Node Working Group database was queried from 1993 to 2018 for cases with regression data. Clinicopathologic factors were correlated with overall and first-site of recurrence and with recurrence-free survival (RFS).

RESULTS

There were 4790 patients and the median follow-up was 39.6 months. Regression and recurrences were seen in 1081 (22.6%) and 773 (16.1%) cases, respectively. First-site locoregional and distant recurrences were seen in 412 (8.6%) and 352 (7.3%) patients, respectively. Regression was seen in 15.8% and 24.7% of all cases with and without recurrences (p < 0.0001), respectively, while regression was seen in 14.3% and 17.9% of first-site locoregional and distant recurrent cases, respectively, compared with 23.3% and 22.9% of patients with regression and without first-site locoregional and distant recurrences, respectively (p = 0.29). On multivariable analysis, after controlling for age, gender, thickness, ulceration, lymphovascular invasion, and sentinel lymph node status, regression significantly predicted improved RFS (p = 0.004) and fewer first-site regional recurrences (p = 0.017).

CONCLUSION

Our data suggest that regression is a favorable prognostic marker in melanoma and predicts significantly better RFS and decreased first-site regional recurrences.

Early time to recurrence predicts worse survival in patients with localized or regionally advanced cutaneous melanoma

To investigate the prognostic significance of time to recurrence (TTR) for overall survival (OS) and survival after recurrence (SAR) in patients with localized or regionally advanced cutaneous melanoma. A total of 731 cutaneous melanoma patients with an initial diagnosis of 8th American Joint Committee on Cancer (AJCC) clinical stage I‐III were included in this study. The prognostic factors associated with OS and SAR were estimated through Kaplan‐Meier and Cox regression analysis. Of the total cohort, 329 patients (45%) died, and 418 patients (57%) experienced recurrence. The median follow‐up and TTR were 55.6 months and 9.6 months, respectively. A total of 141 patients (19%) experienced recurrence in <6 months, and 277 patients (38%) experienced recurrence in ≥6 months. Patients with stage III and positive lymph node dissection (LND) were more common in the early TTR group than in the late TTR group. Both the OS and SAR rates at 5 years and 10 years in the early TTR group were significantly poorer than those in the late TTR group (P < .001 and P = .008, respectively). Furthermore, early TTR, along with truncal tumor, higher TNM stage and therapeutic variables (extended resection, LND and adjuvant therapy), were significant independent predictors of worse OS and SAR in multivariate analysis (all P < .05). Early TTR predicts worse survival and could be considered an independent prognostic factor for patients with localized or regionally advanced cutaneous melanoma. TTR should be evaluated in all patients with recurrence to guide post‐recurrence risk stratification and follow‐up schedules.

UVR-sensor wearable device intervention to improve sun behaviors and reduce sunburns in melanoma survivors: study protocol of a parallel-group randomized controlled trial

Background

Individuals who have been diagnosed with melanoma have more than a 9-fold increased risk of developing another melanoma. Ultraviolet radiation (UVR) exposure following a melanoma diagnosis can be modified to reduce risk of a new melanoma diagnosis. Yet research shows that many melanoma survivors do not report optimal sun protection practices. The objective of this study is to evaluate the effectiveness of a UVR-sensor wearable device to improve sun protection behaviors and reduce sunburns in a randomized controlled trial (RCT) in melanoma survivors.

Methods

We will conduct an RCT among 368 melanoma survivors in two waves (Summer 2020, Summer 2021). This approach allows for adequate recruitment of the required sample and potential improvements to recruitment, compliance, and retention strategies between waves. The intervention includes an informational brochure about sun protection behaviors and a commercially available UVR-sensor wearable device (Shade), which accurately measures UVR. The device, along with its associated mobile application, measures and stores UVR exposure. As UVR exposure accumulates, the device provides notifications to increase sun protection action. Survivors in the control group receive the device and a separate mobile application that does not provide notifications or summary UVR exposure data. Participants will be asked to wear the device for 12 weeks. They will complete surveys about their sun behaviors at study entry, every 4 weeks during the intervention, and 1 year later. At the end of the intervention period, intervention and control groups will be compared for differences in a summary measure of sun protection habits and experience of a sunburn. We will also measure self-reported physical activity, depression, and anxiety to examine potential unintended negative consequences of the intervention.

Discussion

The study intervention will be completed Fall 2021, with anticipated results available in 2022. If this intervention improves sun protection behaviors in melanoma survivors, these findings would support expanding the use of this technology with other populations at high risk for melanoma.

Trial registration

ClinicalTrials.gov NCT03927742. Registered on April 15, 2019.

Study of cutaneous melanoma recurrences after sentinel node biopsy: Patterns of dissemination and use of complementary test in follow-up

OBJECTIVES

To investigate the patterns of melanoma recurrence in the local population, including factors that may influence in this event and timing of relapse, and to determine the mode of detection of them.

METHODS

This is a retrospective cohort study of patients with melanoma who underwent sentinel lymph node biopsy at the Complejo Hospitalario de Navarra (Spain) from 2002 to 2012. The following data were collected of each patient: age, gender, date of diagnosis, location of melanoma, histological subtype, Breslow thickness, ulceration, mitosis, sentinel node status, AJCC 8th edition stage, site of first diagnosed metastasis, mode of relapse, date of first relapse and time of death.

RESULTS

Of 308 patients, 30% people suffered metastasis. The mean follow-up time was 68.63 months. 51.1% of relapses were locoregional and 48.9% haemato-visceral. Sentinel node status was the only variable associated with higher risk of haemato-visceral metastasis (p < 0.001). The mean time between diagnosis of melanoma and recurrence was 2.7 years. Most recurrences were detected by the patient himself or had any type of symptoms and were consequently selected for a complementary test.

CONCLUSION

It is important to follow-up all patients with diagnosis of cutaneous melanoma, essentially during the first 5 years after diagnosis.

Loss of prdm1a accelerates melanoma onset and progression

Melanoma is an aggressive, deadly skin cancer derived from melanocytes, a neural crest cell derivative. Melanoma cells mirror the developmental program of neural crest cells in that they exhibit the same gene expression patterns and utilize similar cellular mechanisms, including increased cell proliferation, epithelial-mesenchymal transition, and migration. Here we studied the role of neural crest regulator PRDM1 in melanoma onset and progression. In development, Prdm1a functions to promote neural crest progenitor fate, and in melanoma, we found that PRDM1 has reduced copy number and is recurrently deleted in both zebrafish and humans. When examining expression of neural crest and melanocyte development genes, we show that sox10 progenitor expression is high in prdm1a-/- mutants, while more differentiated melanocyte markers are reduced, suggesting that normally Prdm1a is required for differentiation. Data mining of human melanoma datasets indicates that high PRDM1 expression in human melanoma is correlated with better patient survival and decreased PRDM1 expression is common in metastatic tumors. When one copy of prdm1a is lost in the zebrafish melanoma model Tg(mitfa:BRAFV600E );p53-/- ;prdm1a+/- , melanoma onset occurs more quickly, and the tumors that form have a larger area with increased expression of sox10. These data demonstrate a novel role for PRDM1 as a tumor suppressor in melanoma.

Clinicopathological Characteristics and Short-Term Survival Analyses of Cutaneous Malignant Melanoma

Objective

Cutaneous malignant melanoma (CMM) arises from melanocytes, which are pigment-producing cells in the skin. CMM constitutes less than 5% of all cutaneous malignancies worldwide but is associated with the highest mortality rate among all skin cancers. The objective of this study was to examine the profile of clinicopathological factors, survival analyses, recurrence rate, metastatic rates, and the management of CMM at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) in Lahore, Pakistan.

Methodology

All patients with a diagnosis of CMM treated at our institute from 2014 to 2017 were included in the study. Demographic variables and clinicopathological characteristics were collected and short-term oncological outcomes were recorded. All data were entered and analyzed in SPSS Statistics version 21 (IBM, Armonk, NY).

Results

A total of 28 patients were included in the study. The median age of the patients was 46.5 ±15.9 years. There were 16 male and 12 female patients. A family history of melanoma was present in 7.1% (n=2) of the patients. All patients had a mean survival of 13.43 ±9.09 months. The lower limb was the most common site of tumor among all patients, accounting for 46.4% (n=13) of the cases. On histopathological analyses, ulceration was seen in 53.6% (n=15) of the patients. Unclassified tumor type was present in 75% (n=21) of the patients, followed by nodular in 21.4% (n=6), and superficial spreading in 3.5% (n=1). Clark level IV was the most common presentation, constituting 46.4% (n=13) of the cases. Metastasis was seen in 50% (n=14) of the patients. Local recurrence was observed in 60.7% (n=17) of the patients; 64.3% (n=18) of the patients were alive after one year of treatment.

Conclusion

CMM is a disease with very high fatality rates. Although it is a disease commonly associated with fair-skinned populations, the incidence of CMM is rising in our part of the world as well. Early diagnosis and prompt management of the disease are crucial in its treatment. However, the mortality rate associated with this disease is still not favorable.

Thiol antioxidants sensitize malabaricone C induced cancer cell death via reprogramming redox sensitive p53 and NF-κB proteins in vitro and in vivo

Specific focus on "redox cancer therapy" by targeting drugs to redox homeostasis of the cancer cells is growing rapidly. Recent clinical studies showed that N-acetyl cysteine (NAC) treatment significantly decreased the metabolic heterogeneity and reduced Ki67 (a proliferation marker) with simultaneous enhancement in apoptosis of tumor cells in patients. However, it is not yet precisely known how thiol antioxidants enhance killing of cancer cells in a context dependent manner. To this end, we showed that a dietary compound, malabaricone C (mal C) generated copious amounts of reactive oxygen species (ROS) and also reduced GSH level in lung cancer cells. Paradoxically, although antioxidants supplementation reduced mal C-induced ROS, thiol-antioxidants (NAC/GSH) restored intracellular GSH level but enhanced DNA DSBs and apoptotic cell death induced by mal C. Our results unraveled two tightly coupled biochemical mechanisms attributing this sensitization process by thiol antioxidants. Firstly, thiol antioxidants enable the "catechol-quinone redox cycle" of mal C and ameliorate ROS generation and bio-molecular damage (DNA and protein). Secondly, thiol antioxidants cause rapid glutathionylation of transcription factors [p53, p65 (NF-κB) etc.], oxidized by mal C, and abrogates their nuclear sequestration and transcription of the anti-apoptotic genes. Furthermore, analyses of the mitochondrial fractions of p53 expressing and silenced cells revealed that cytoplasmic accumulation of glutathionylated p53 (p53-SSG) triggers a robust mitochondrial death process. Interestingly, mutation of redox sensitive cysteine residues at 124, 141 and 182 position in p53 significantly reduces mal C plus NAC mediated sensitization of cancer cells. The preclinical results, in two different tumor models in mice, provides further support our conclusion that NAC is able to sensitize mal C induced suppression of tumor growth in vivo.

Survival between synchronous and non-synchronous multiple primary cutaneous melanomas-a SEER database analysis

Background

There is no criterion to distinguish synchronous and non-synchronous multiple primary cutaneous melanomas (MPMs). This study aimed to distinguish synchronous and non-synchronous MPMs and compare the survivals of them using the Surveillance, Epidemiology, and End Results database.

Methods

Synchronous and non-synchronous MPMs were distinguished by fitting the double log transformed distribution of the time interval between the first and second primary cutaneous melanomas (TIFtS) through a piecewise linear regression. The overall and melanoma-specific survivals were compared by the Kaplan-Meier method and Cox proportional hazard model through modeling the occurrence of synchronous MPMs as a time-dependent variable.

Results

The distribution of TIFtS was composed by three power-law distributions. According to its first inflection point, synchronous MPMs were defined as tumors that occurred within 2 months. The Kaplain-Meier plot revealed a significant inferior survival for synchronous MPMs than non-synchronous MPMs (P < 0.0001), and the occurrence of synchronous MPM was a risk factor for overall survival of cutaneous melanoma (CM) (hazard ratio: 2.213; (95% CI [2.087-2.346]); P < 0.0001).

Conclusions

This study provided data analysis evidences for using 2 months to distinguish synchronous MPMs and non-synchronous MPMs. Furthermore, the occurrence of synchronous MPM was a risk factor for prognosis of patients with CM.

Early and late relapses of cutaneous melanoma patients

OBJECTIVES

Recurrence may most likely develop during the course of the disease in patients presented with early stage melanoma at initial diagnosis. The specific risk factors for early and late recurrences following definitive surgical excision have yet to be determined. The aim of this study was to analyze the early and late relapses in stage I-III cutaneous melanoma patients.

METHODS

Of 365 patients with relapses, 189 developed within the first 18 months following surgical intervention (early relapse [ER]) and the remaining 176 occurred later (late relapse [LR]) were analyzed.

RESULTS

ER patients were found to have thicker and ulcerated lesions with higher mitotic rates and lymphovascular invasion, and they were found to be more significantly associated with node involvements. Nearly half of the first recurrences were locoregional (49.9%) that were followed by distant metastases alone (26.6%). The distribution of the initial relapse patterns was similar between the ER and the LR groups. The lung was the most frequently metastasized site (43.1%), and it was followed by bone (21.0%), liver (20.7%) and brain (15.1%). On multivariate analysis risk factors in association with both ER and LR were found as follows: ulcerated lesions, high mitotic rate, and node-positive disease; however nodular histopathological subtype and lymphovascular invasion were found to have impact merely on ER, and male gender merely on LR.

CONCLUSION

The current study has detected potential risk factors for relapse of patients who developed ER and LR. These indicators may be useful for rational follow-up programs of the patients.

Approach to Patients with Malignant Melanoma of Unknown Primary Origin

Objectives:

Although malignant melanoma accounts for 3% of skin cancers, it is responsible for 75% of deaths associated with skin cancer. In our study, all melanoma cases diagnosed and treated at our clinic were retrospectively reviewed, and the cases of unknown primary origin among them were examined in detail in terms of diagnosis and treatment.

Methods:

The patients with malignant melanoma treated at the inpatient services of our clinic between January 1991 and April 2017 were retrospectively screened in the records. These patients were evaluated for age, sex, tumor type, Breslow depth, metastasis, and treatment. Among these patients, four cases of unknown primary origin were examined in detail.

Results:

During January 1991 and April 2017, 173 patients received inpatient care for malignant melanoma at our clinic. As regards to the melanoma subtypes, nodular type in 45 patients, acral lentiginous type in 43 patients, superficial spreading type in 63 patients, lentigo maligna melanoma in 15 patients, subungual type in 7 patients, and either unidentified melanoma or other subtypes in 10 patients were identified.

Conclusion:

The ideal treatment of a patient with melanoma is multidisciplinary, with plastic surgery having a central role.

Satellite and In-Transit Metastatic Disease in Melanoma Skin Cancer: A Retrospective Review of Disease Presentation, Treatment, and Outcomes

BACKGROUND

Satellitosis and in-transit metastases (SITM) are uncommon in cutaneous melanoma and are associated with poor prognosis. However, the disease- and treatment-specific variables that predict outcomes among patients with SITM are poorly defined.

OBJECTIVE

To identify factors that predict prognosis among patients with SITM.

MATERIALS AND METHODS

Retrospective chart review of patients treated for melanoma at a large academic medical center in central Pennsylvania between 2000 and 2012. Patients with pathology reports containing "satellite lesions" or "in-transit metastases" were selected for analysis. Data were collected regarding tumor stage, the timing of SITM discovery, treatment, recurrence-free survival after SITM discovery, and overall survival (OS).

RESULTS

We identified SITM in 32 (1.9%) of 1,650 patients with pathology-diagnosed melanoma over the study period. Reduced recurrence-free survival after SITM discovery was associated with higher pathologic stage, metastatic disease, lymph node dissection, and use of adjuvant chemotherapy. Reduced OS was associated with higher T, N, M, and overall prognostic stage; positive surgical margins; disease recurrence; and SITM on initial presentation.

CONCLUSION

Our data support previous findings that higher stage disease confers a worse prognosis among patients with SITM. Patients with SITM on initial presentation had worse outcomes, suggesting SITM is indicative of more aggressive disease.

Relapse patterns in patients with local and regional cutaneous melanoma

BACKGROUND

The differences in features and risk factors for recurrence after definitive surgical excision are yet to be determined. The aim of this study was to understand these factors influencing recurrence patterns with local and regional disease in these patients.

METHODS

A total of 365 relapsed patients, of whom 196 presented with local disease (stage I-II) and 169 with regional disease (stage III), were investigated in this retrospective study.

RESULTS

The median time to initial recurrence for stage I-II and stage III patients was 22.3 and 13.4 months, respectively. Stage III patients were found to have higher Clark levels (p = 0.0001) and thicker lesions (p = 0.0001), and they were more significantly associated with the absence of tumor-infiltrating lymphocytes (p = 0.02) than stage I-II patients. Stage III patients were more significantly associated with recurrences compared to the stage I-II patients (p = 0.0001). Locoregional relapses were significantly associated with stage I-II melanomas, whereas majority of the distant metastases occurred in stage III patients (p = 0.01). Pulmonary metastasis was most frequently observed and the distribution of the sites for distant metastases was similar in both groups of the patients. On univariate analysis, male sex, increased tumor depth, presence of ulceration, nodular histopathology, higher Clark level, higher mitotic rate, and presence of lymphovascular invasions were found to predict shorter time to relapse for stage I-II patients; whereas only nodular pathology, presence of ulceration, and high mitotic rate were found to be associated with poor relapse-free survival in stage III patients. However, on multivariate analysis, only mitotic rate maintained its significance for both clinical staging groups.

CONCLUSION

Potential differences among early-stage melanoma patients, who developed recurrence, were noted and mitotic rate was found as the single significant prognostic factor for recurrence in both stage I-II and III patients.

Metabolomic identification of diagnostic serum-based biomarkers for advanced stage melanoma

INTRODUCTION

Melanoma is a highly aggressive malignancy and is currently one of the fastest growing cancers worldwide. While early stage (I and II) disease is highly curable with excellent prognosis, mortality rates rise dramatically after distant spread. We sought to identify differences in the metabolome of melanoma patients to further elucidate the pathophysiology of melanoma and identify potential biomarkers to aid in earlier detection of recurrence.

METHODS

Using ¹H NMR and DI-LC-MS/MS, we profiled serum samples from 26 patients with stage III (nodal metastasis) or stage IV (distant metastasis) melanoma and compared their biochemical profiles with 46 age- and gender-matched controls.

RESULTS

We accurately quantified 181 metabolites in serum using a combination of ¹H NMR and DI-LC-MS/MS. We observed significant separation between cases and controls in the PLS-DA scores plot (permutation test p-value = 0.002). Using the concentrations of PC-aa-C40:3, DL-carnitine, octanoyl-L-carnitine, ethanol, and methylmalonyl-L-carnitine we developed a diagnostic algorithm with an AUC (95% CI) = 0.822 (0.665-0.979) with sensitivity and specificity of 100 and 56%, respectively. Furthermore, we identified arginine, proline, tryptophan, glutamine, glutamate, glutathione and ornithine metabolism to be significantly perturbed due to disease (p < 0.05).

CONCLUSION

Targeted metabolomic analysis demonstrated significant differences in metabolic profiles of advanced stage (III and IV) melanoma patients as compared to controls. These differences may represent a potential avenue for the development of multi-marker serum-based assays for earlier detection of recurrences, allow for newer, more effective targeted therapy when tumor burden is less, and further elucidate the pathophysiologic changes that occur in melanoma.

Local Adjuvant Treatment with Low-Dose CpG-B Offers Durable Protection against Disease Recurrence in Clinical Stage I-II Melanoma: Data from Two Randomized Phase II Trials

Purpose: Although risk of recurrence after surgical removal of clinical stage I-II melanoma is considerable, there is no adjuvant therapy with proven efficacy. Here, we provide clinical evidence that a local conditioning regimen, aimed at immunologic arming of the tumor-draining lymph nodes, may provide durable protection against disease recurrence (median follow-up, 88.8 months).Experimental Design: In two randomized phase II trials, patients, diagnosed with stage I-II melanoma after excision of the primary tumor, received local injections at the primary tumor excision site within 7 days preceding re-excision and sentinel lymph node (SLN) biopsy of either a saline placebo (n = 22) or low-dose CpG type B (CpG-B) with (n = 9) or without (n = 21) low-dose GM-CSF.Results: CpG-B treatment was shown to be safe, to boost locoregional and systemic immunity, to be associated with lower rates of tumor-involved SLN (10% vs. 36% in controls, P = 0.04), and, at a median follow-up of 88.8 months, to profoundly improve recurrence-free survival (P = 0.008), even for patients with histologically confirmed (i.e., pathologic) stage I-II disease (P = 0.02).Conclusions: Potentially offering durable protection, local low-dose CpG-B administration in early-stage melanoma provides an adjuvant treatment option for a large group of patients currently going untreated despite being at considerable risk for disease recurrence. Once validated in a larger randomized phase III trial, this nontoxic immunopotentiating regimen may prove clinically transformative. Clin Cancer Res; 23(19); 5679-86. ©2017 AACR.

Targeting cholesterol transport in circulating melanoma cells to inhibit metastasis

Despite recent breakthroughs in targeted- and immune-based therapies, rapid development of drug resistance remains a hurdle for the long-term treatment of patients with melanoma. Targeting metastatically spreading circulating tumor cells (CTCs) may provide an additional approach to manage melanoma. This study investigates whether targeting cholesterol transport in melanoma CTCs can retard metastasis development. Nanolipolee-007, the liposomal form of leelamine, reduced melanoma metastasis in both a novel in vitro flow system mimicking the circulating system and in experimental as well as spontaneous animal metastasis models, irrespective of the BRAF mutational status of the CTCs. Leelamine led to cholesterol trapping in lysosomes, which subsequently shut down receptor-mediated endocytosis, endosome trafficking, and inhibited the major oncogenic signaling cascades important for survival such as the AKT pathway. As pAKT is important in CTC survival, inhibition by targeting cholesterol metabolism led to apoptosis, suggesting this approach might be particularly effective for those CTCs having high levels of pAKT to aid survival in the circulation system.

Tumour mutation status and sites of metastasis in patients with cutaneous melanoma

Background:

Cutaneous melanoma can metastasise haematogenously and/or lymphogenously to form satellite/in-transit, lymph node or distant metastasis. This study aimed to determine if BRAF and NRAS mutant and wild-type tumours differ in their site of first tumour metastasis and anatomical metastatic pathway.

Methods:

Prospective cohort of patients with a histologically confirmed primary cutaneous melanoma at three tertiary referral centres in Melbourne, Australia from 2010 to 2015. Multinomial regression determined clinical, histological and mutational factors associated with the site of first metastasis and metastatic pathway.

Results:

Of 1048 patients, 306 (29%) developed metastasis over a median 4.7 year follow-up period. 73 (24%), 192 (63%) and 41 (13%) developed distant, regional lymph node and satellite/in-transit metastasis as the first site of metastasis, respectively. BRAF mutation was associated with lymph node metastasis (adjusted RRR 2.46 95% CI 1.07–5.69, P=0.04) and sentinel lymph node positivity (adjusted odds ratio [aOR] OR 1.55, 95% CI 1.14–2.10, P=0.005). BRAF mutation and NRAS mutation were associated with increased odds of developing liver metastasis (aOR 3.09, 95% CI 1.49–6.42, P=0.003; aOR 3.17, 95% CI 1.32–7.58, P=0.01) and central nervous system (CNS) metastasis (aOR 4.65, 95% CI 2.23–9.69, P<0.001; aOR 4.03, 95% CI 1.72–9.44, P=0.001). NRAS mutation was associated with lung metastasis (aOR 2.44, 95% CI 1.21–4.93, P=0.01).

Conclusions:

BRAF mutation was found to be associated with lymph node metastasis as first metastasis and sentinel lymph node positivity. BRAF and NRAS mutations were associated with CNS and liver metastasis and NRAS mutation with lung metastasis. If these findings are validated in additional prospective studies, a role for heightened visceral organ surveillance may be warranted in patients with tumours harbouring these somatic mutations.

Melanoma patient imaging in the era of effective systemic therapies

Imaging plays a critical role in the current multi-disciplinary management of patients with melanoma. It is used for primary disease staging, surgical planning, and surveillance in high-risk patients, and for monitoring the effects of systemic or loco-regional therapies. Several different imaging modalities have been utilised in the past. Contemporary imaging practises vary geographically depending on clinical guidelines, physician preferences, availability and cost. Targeted therapies and immunotherapies have revolutionised the treatment of patients with metastatic melanoma over the last few years. With this have come new patterns of disease that were not observed after conventional therapies, and new criteria to assess therapeutic responses. In this article we review the role of imaging for patients with melanoma in the era of effective systemic therapies and discuss likely future developments.

Metastatic pathways in patients with cutaneous melanoma

Metastasis represents the end product of an elaborate biological process, which is determined by a complex interplay between metastatic tumour cells, host factors and homoeostatic mechanisms. Cutaneous melanoma can metastasize haematogenously or lymphogenously. The three predominant models that endeavour to explain the patterns of melanoma progression are the stepwise spread model, the simultaneous spread model and the model of differential spread. The time course to the development of metastases differs between the different metastatic routes. There are several clinical and histopathological risk factors for the different metastatic pathways. In particular, patient sex and the anatomical location of the primary tumour influence patterns of disease progression. There is limited existing evidence regarding the relationship between tumour mutation status, other diagnostic and prognostic biomarkers and the metastatic pathways of primary cutaneous melanoma. This knowledge gap needs to be addressed to better identify patients at high risk of disease recurrence and personalize surveillance strategies.

Sentinel node biopsy in patients with primary cutaneous melanoma of any thickness: A cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of the sentinel node biopsy with lymphadenectomy for nodal metastases (SNB) in patients with primary cutaneous melanoma (CM) of different Breslow thickness (intermediate, thick, thin).

METHODS

Decision tree models were constructed to compare two different strategies of management of patients with CM, wide excision of the primary lesion and SNB and wide excision only (WE). Tree models were created for every Breslow thickness over 1-, 5- and 10-year time horizons. Mean and total direct healthcare costs, life years saved (LYSs), quality-adjusted life years (QALYs), cost effectiveness ratio (CER), and incremental cost effectiveness ratio (ICER) were estimated. Every model was considered as a base case, and its results tested with sensitivity analyses.

RESULTS

Base case analyses showed that the best results were obtained for intermediate CM over 10-year time horizon. In this case, ICER for SNB was 130,508€/QALY, well over the threshold of acceptance (30,000€/QALY). In patients with intermediate CM over 1 and 5 years, and for those with thick and thin CM at any time horizon, negative ICER values were estimated since SNB was proved to be more expensive and less effective than WE. Sensitivity analyses confirmed the robustness of our results.

CONCLUSIONS

SNB caused no improvement in health outcomes in terms of LYSs and QALYs in patients with thick and thin CM, and only a slight benefit in those with intermediate CM. WE was more cost-effective compared with SNB for any CM thickness over any time horizon up to 10 years.

Pregnancy and melanoma: a European-wide survey to assess current management and a critical literature overview

BACKGROUND

Management of melanoma during pregnancy can be extremely challenging. The reported incidence of melanoma in pregnancy ranges from 2.8 to 5.0 per 100 000 pregnancies. There are no guidelines for the management of melanoma during pregnancy.

METHODS

The survey was designed to investigate the opinions of melanoma physicians on decision making in relation to pregnancy and melanoma. A clinical scenario-based survey on management of pregnancy in melanoma was distributed all over Europe via the membership of the EORTC and other European melanoma societies.

RESULTS

A total of 290 questionnaires were returned with a larger participation from southern Europe. A large heterogeneity was found for the answers given in the different clinical scenarios with 50% of the answers showing discordance, especially regarding sentinel lymph node biopsy during pregnancy. Discordant answers were also found for the counselling of women about a potential delay in getting pregnant after a high-risk melanoma (35% for a 2 year wait minimum vs. 57% no waiting needed), while for thin melanomas, as expected, there was more concordance with 70% of the physicians recommending no delay. Fifteen per cent of physicians recommended an abortion in stage II melanoma during the third month of pregnancy. Twenty per cent of the responders advised against hormonal replacement therapy in melanoma patients.

CONCLUSIONS

The management of melanoma during pregnancy varies widely in Europe. At present, there is a lack of consensus in Europe, which may lead to very important decisions in women with melanoma, and guidelines are needed.

An unusual presentation of recurring metastatic melanoma

A 53-year-old non-distressed Caucasian female complains of dyspnea and palpitations for 5 days. Past medical history includes Stage IV melanoma with adequate resection 23 years prior. The patient suddenly became increasingly tachycardic in mild respiratory distress while maintaining hemodynamic stability. TTE depicted 10.5 × 7.5 × 9.5 cm³ mass within her left ventricle and a large volume of pericardial effusion, which progressed to cardiac tamponade. Pericardial window was performed. Metastatic involvement should be ruled out for all symptomatic patients with a history of melanoma.

Differentiation of cutaneous melanoma from surrounding skin using laser-induced breakdown spectroscopy

Laser-induced breakdown spectroscopy (LIBS) has the potential to be used as a surgical tool for simultaneous tissue ablation and elemental analysis of the ablated tissue. LIBS may be used to distinguish melanoma lesions from the surrounding dermis based on the quantitative difference of elements within melanoma lesions. Here, we measured the elements in homogenized pellets and real tissues from excised skin samples of melanoma-implanted mice. In addition, statistical analysis of LIBS spectra using principal component analysis and linear discriminant analysis was performed. Our results showed that this method had high detection sensitivity, highlighting the potential of this tool in clinical applications.

Long-term follow-up for melanoma patients: is there any evidence of a benefit?

As the incidence of melanoma and the number of melanoma survivors continues to rise, optimal surveillance strategies are needed that balance the risks and benefits of screening in the context of contemporary resource use. Detection of recurrences has important implications for clinical management. Most current surveillance recommendations for melanoma survivors are based on low-level evidence with wide variations in practice patterns and an unknown clinical impact for the melanoma survivor.

Budget impact analysis of a novel gene expression assay for the diagnosis of malignant melanoma

BACKGROUND

Traditional pathology techniques alone can be insufficient to reliably distinguish between malignant melanoma, dysplastic nevi, and benign nevi in biopsies of suspicious pigmented lesions. Numerous studies have shown high rates of ambiguity when assessing such samples. A novel gene expression assay has been developed to objectively differentiate malignant melanoma from benign nevi.

OBJECTIVE

The purpose of this study was to quantify the economic impact of the gene expression assay on a US commercial health plan.

METHODS

The clinical paradigm of care was modeled for a hypothetical cohort of patients with suspicious pigmented lesions that are difficult-to-diagnose. Costs were assigned to each unit of care provided based on 2013 Medicare fee-for-service rates. Patients were followed for 10 years and were modeled to progress according to the natural history of their disease. The total cost of care was calculated for two scenarios: a Reference Scenario, representing current clinical practice, and a Test Scenario, in which each lesion was tested with the gene expression assay and diagnosed. Total cost of care was compared between the two scenarios to determine overall budget impact. Sensitivity analyses were performed to test the robustness of the model.

RESULTS

The gene expression assay reduces costs by $1268 per patient tested over 10 years, a decrease of 8.3%, after accounting for the cost of the assay. For a health plan with 10 million members, this would translate to over $8 million in savings. The largest portion of this saving comes from reducing the number of missed melanomas, which would otherwise progress to advanced disease. In sensitivity analyses, no single model input changed within a reasonable range of values caused the model to show that the assay was not cost-saving.

CONCLUSION

In addition to improving the diagnosis of melanoma, this gene expression assay would likely reduce costs for health plans that choose to cover it.

Predictive factors for loco regional recurrence and distant metastasis following primary surgical treatment of cutaneous melanoma

Background:

Cutaneous melanoma (CM) has a high propensity for regional and systemic spread. This is one of the largest series of CM reported from India.

Aims:

To predict factors for loco regional recurrence (LRR) and distant metastasis in patients with CM primarily treated with surgery.

Study Design:

Retrospective analysis of patient database at a tertiary care cancer center with evaluation of factors for LRR and distant metastasis for CM.

Materials and Methods:

Data from 68 patients treated for CM between January 2006 and December 2010 were reviewed. Data recorded included age, sex, symptoms, investigations, treatment given, histopathology, recurrence and follow-up. Patient factors, tumor factors, pathologic variables, and adjuvant treatment were investigated as predictors’ of LRR and distant metastasis.

Results:

Mean age of patients was 54 years. Melanoma was more common in males (44). Tumor thickness > 4 mm was found in 43 patients. Lymph node involvement was found in 43 patients. Adjuvant radiotherapy was given in seven patients. At mean follow-up of 16.5 months, LRR was seen in 34 patients and distant metastasis in 28 patients. LRR and distant metastasis were more commonly found in females, age > 40 years, Clark's level IV and V, Breslow's depth > 4 mm, patients with lymph node involvement and extra-capsular spread.

Conclusion:

The age, sex, site, thickness of lesion, involvement of lymph node, and extra-capsular spread were important factors in predicting LRR and distant metastasis. Distant metastasis was also more commonly found in patients with LRR.

Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies

OBJECTIVE

To guide resource utilization, we aimed to determine the impact of routine surveillance imaging for the detection of melanoma recurrences amenable to surgical resection with curative intent.

BACKGROUND

The National Comprehensive Cancer Network guidelines for melanoma surveillance are largely consensus based.

METHODS

Using single-institution, patient-level data (n = 1600), transition probabilities were calculated for a Markov model simulating the natural history of patients with stage I-III melanoma. As a base estimate, imaging was assumed to detect regional and distant recurrences of which 80% and 20% could be surgically treated with curative intent, respectively. Sensitivity analyses were conducted for all point estimates. For each disease stage, we calculated the number of surgically treatable regional or distant recurrence detected during 5 years per 10,000 patients undergoing computed tomography (CT) or positron emission tomography (PET)/CT scans at 6- or 12-month intervals. The associated positive and negative predictive values and life expectancy were also calculated and compared with clinical examination alone.

RESULTS

At 5-year follow-up, CT or PET/CT at 6-month intervals detected surgically treatable regional or distant recurrence in 6.4% of patients with stage I, 18.5% of stage II, and 33.1% of stage III disease; 12-month intervals decreased the rates to 3.0%, 7.9%, and 13.0%, respectively. The high false-positive rates of CT (20%) and PET/CT (9%) resulted in overall low positive predictive values. However, both CT and PET/CT effectively predicted absence of disease. Life-expectancy gains were minimal (≤ 2 months) for all groups.

CONCLUSIONS

The effectiveness of routine surveillance imaging for detecting treatable melanoma recurrences is limited. Even in patients with stage III disease, only minimal gains in life expectancy were achieved.

Defining the role of CD2 in disease progression and overall survival among patients with completely resected stage-II to -III cutaneous melanoma

BACKGROUND

Accurate assessment of prognosis remains clinically challenging in stage II to III cutaneous melanoma. Studies have implicated CD2 in immune surveillance, T-cell activation, and antitumor immunity, but its role in melanoma progression warrants further investigation.

OBJECTIVE

We sought to investigate the prognostic role of CD2 in primary cutaneous melanoma.

METHODS

Patients with American Joint Committee on Cancer stage II and III cutaneous melanoma were identified by retrospective review of dermatopathology databases from 2001 to 2010 at Mount Sinai Medical Center and Geisinger Medical Center. Additional patients were provided by New York University Medical Center based on retrospective review and tissue availability. Immunohistochemistry was performed on tumors from 90 patients with known recurrence status and documented follow-up.

RESULTS

Primary tumors from patients who developed recurrent disease had fewer CD2(+) cells (P = .0003). In multivariable analyses including standard clinicopathologic predictors, CD2 was an independent predictor of disease recurrence (P = .008) and overall survival (P = .007). CD2 count correlated with characterization of tumor-infiltrating lymphocytes (P = .0004). Among the intermediate prognosis group of patients with nonbrisk tumor-infiltrating lymphocytes, CD2 count was predictive of disease recurrence (P = .0006) and overall survival (P = .0318).

LIMITATIONS

Our retrospective design may have resulted in incomplete representation of patients lacking documented follow-up.

CONCLUSIONS

CD2 may be an independent predictor of disease recurrence and overall survival among patients with primary cutaneous melanoma.

Latest advances in chemotherapeutic, targeted, and immune approaches in the treatment of metastatic melanoma

Melanoma is the most dangerous form of skin cancer owing to its metastatic potential and is an important public health concern. The melanoma incidence has been increasing worldwide. Although potentially curable when diagnosed early, metastatic melanoma carries a poor prognosis. Until recently, systemic therapy for metastatic melanoma was ineffective, but the recent successes in the development of new therapies for metastatic melanoma, such as mitogen-activated protein kinase (MAPK) pathway inhibitors, anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), and programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) pathway blocking antibodies, as well as combination strategies of cytotoxic chemotherapy and inhibitors of angiogenesis, have all yielded promising results, changing the continually evolving landscape of therapeutic options for patients with this disease. The aim of this review was to summarize the evolution of and recent advances in the treatment of metastatic melanoma. Therefore, we conducted a comprehensive PubMed search between January 1, 1960, and February 1, 2014, using the search term melanoma or metastatic melanoma combined with terms such as chemotherapy, immunotherapy, CTLA-4, PD-1, PD-L1, adoptive T cell, targeted therapy, MAPK, molecular biology, and survival.

Early development of PAT-SM6 for the treatment of melanoma

Despite the recent development of novel therapies for patients with metastatic melanoma, this disease remains fatal in the majority of those who develop a relapse. Here, we report the preclinical and early clinical development of a novel IgM antibody PAT-SM6 that specifically binds to a cancer-specific isoform of glucose-regulated protein 78 (GRP78) and low-density lipoprotein. Finding a GRP78 cancer-specific form on the surface of cancer cells, but not normal cells in vivo, presents an opportunity for cancer-specific targeting. PAT-SM6 binding to the cell surface induces apoptosis in a variety of tumors, including melanoma. Recent studies show the specificity of PAT-SM6 binding to the surface of melanoma cells and primary tissue but not to normal tissue. They also confirm, for the first time, cell proliferation inhibition and apoptosis through classical apoptotic pathways as well as induction of lipid accumulation in melanoma cells. These in-vitro data are supported by positive in-vivo data using PAT-SM6 in a xenograft C8161 model. Furthermore, PAT-SM6 was well tolerated in pharmacokinetic/toxicology studies in monkeys. On the basis of these preclinical observations, a clinical study of PAT-SM6 was carried out in patients with 'in-transit' melanoma. Even with microdosing, histological analyses of tumor biopsies detected the presence of PAT-SM6 as well as apoptosis. Although there are many small molecules and monoclonal antibodies currently in clinical development for patients with melanoma, PAT-SM6 is the only therapeutic targeting the cancer-specific isoform of GRP78. These PAT-SM6 preclinical data and positive findings from the phase 1 safety study provide strong support for the further development of this novel antibody.

Current concepts of metastasis in melanoma

The main cause of death in melanoma patients is widespread metastases. Staging of melanoma is based on the primary tumor thickness, ulceration, lymph node and distant metastases. Metastases develop in regional lymph nodes, as satellite or in-transit lesions, or in distant organs. Lymph flow and chemotaxis is responsible for the homing of melanoma cells to different sites. Standard pathologic evaluation of sentinel lymph nodes fails to find occult melanoma in a significant proportion of cases. Detection of small numbers of malignant melanoma cells in these and other sites, such as adjacent to the primary site, bone marrow or the systemic circulation, may be enhanced by immunohistochemistry, reverse transcription PCR, evaluation of lymphatic vessel invasion and proteomics. In the organs to which melanoma cells metastasize, extravasation of melanoma cells is regulated by adhesion molecules, matrix metalloproteases, chemokines and growth factors. Melanoma cells may travel along external vessel lattices. After settling in the metastatic sites, melanoma cells develop mechanisms that protect them against the attack of the immune system. It is thought that one of the reasons why melanoma cells are especially resistant to killing is the fact that melanocytes (cells from which melanoma cells derive) are resistant to such noxious factors as ultraviolet light and reactive oxygen species. Targeted melanoma therapies are, so far, largely unsuccessful, and new ones, such as adjuvant inhibition of melanogenesis, are under development.

Comparison of outcomes for malignant melanoma of the face treated using Mohs micrographic surgery and wide local excision

BACKGROUND

Mohs micrographic surgery (MMS) is an accepted treatment for nonmelanoma skin cancer and has an evolving role in melanoma.

OBJECTIVE

To review oncologic outcomes of MMS and wide local excision (WLE) treatments for facial melanoma.

METHODS AND MATERIALS

A retrospective review of patients with invasive melanoma of the face between 1997 and 2007 identified from the Alberta Cancer Registry (Canada) was performed. Outcome measures were local recurrence (recurrence <2 cm from excision scar), distant recurrence (regional or systemic), and disease-specific survival.

RESULTS

One hundred fifty-one patients were available for analysis (60 MMS, 91 WLE). Median follow-up time was 48 months. The groups differed in tumor location and mitotic rate. Overall, there was no significant difference in 5-year local recurrence (7.9% WLE vs 6.2% MMS, p = .58), regional or systemic recurrence (18.8% vs 8.8%, p = 0.37) or disease-specific survival (82.8% vs 92.4%, p = .59). Breslow thickness was the only consistent predictor of local recurrence or other recurrence and disease-specific survival on multivariate analysis. Subset analysis of tumors with Breslow thickness less than 2 mm did not reveal any difference in outcomes.

CONCLUSION

Mohs micrographic surgery has oncologic outcomes of local recurrence, distant recurrence and overall survival similar to those of WLE for invasive facial melanoma.

Outcome of clinical stage III melanoma patients with FDG-PET and whole-body CT added to the diagnostic workup

BACKGROUND

Combined whole-body FDG-PET and CT provide the most comprehensive staging of melanoma patients with palpable lymph node metastases (LNM). The aim of this study is to analyze survival of FDG-PET and CT negative or positive melanoma patients and to assess which factors have independent prognostic impact on survival of these patients.

METHODS

Patients with palpable and histologically or cytologically proven LNM of melanoma, referred to participating hospitals for examination with FDG-PET and CT, were selected from a previous study. Melanoma-specific survival (MSS) and disease-free period (DFP) were analyzed for FDG-PET and CT positive and negative patients using the Kaplan-Meier method. Cox-regression analysis was performed to analyze which patient or melanoma characteristics had significant impact on MSS or DFP.

RESULTS

For all 252 patients 5-year MSS was 38.2%. For FDG-PET and CT negative and positive patients 5-year MSS was 47.6 and 16.9%, respectively. Disease-free period for FDG-PET and CT negative patients was 46.0% after 5 years. Gender, a positive FDG-PET and CT, LNM in axilla compared to head or neck, and presence of extranodal growth were independent factors for worse MSS in all patients. Positive FDG-PET and CT was the most important prognostic factor for MSS with a hazard ratio of 2.54 (95% CI, 1.55-4.17, P<0.001).

CONCLUSIONS

Staging melanoma patients with palpable LNM is more accurate when whole-body FDG-PET and CT is added to the diagnostic workup. Hence, FDG-PET and CT, preferably combined, are indicated in the staging of clinical stage III melanoma patients.

Melanoma patients with unknown primary site or nodal recurrence after initial diagnosis have a favourable survival compared to those with synchronous lymph node metastasis and primary tumour

Background

A direct comparison of prognosis between patients with regional lymph node metastases (LNM) detected synchronously with the primary melanoma (primary LNM), patients who developed their first LNM subsequently (secondary LNM) and those with initial LNM in melanoma with unknown primary site (MUP) is missing thus far.

Patients and Methods

Survival of 498 patients was calculated from the time point of the first macroscopic LNM using Kaplan Meier and multivariate Cox hazard regression analysis.

Results

Patients with secondary LNM (HR = 0.67; p = 0.009) and those with initial LNM in MUP (HR = 0.45; p = 0.008) had a better prognosis compared to patients with primary LNM (median survival time 52 and 65 vs. 24 months, respectively). A high number of involved nodes, the presence of in-transit/satellite metastases and male gender had an additional independent unfavourable effect.

Conclusions

Survival of patients with LNM in MUP and with secondary LNM is similar and considerably more favourable compared to those with primary LNM. This difference needs to be considered during patient counselling and for stratification purposes in clinical trials. The assumption of an immune privilege of patients with MUP which is responsible for rejection of the primary melanoma, and results in a favourable prognosis is not supported by our data.

Cost-effectiveness of a FISH assay for the diagnosis of melanoma in the USA

OBJECTIVE

The authors evaluated the cost-effectiveness of a FISH assay in melanoma diagnosis in the USA.

METHOD

A model was developed simulating the addition of FISH to the diagnosis of suspected melanoma. A decision analytic module simulated diagnosis using microscopic assessment alone versus addition of FISH (sensitivity: 92%; specificity: 94%). The authors simulated a clinical setting in which an initial excisional biopsy microscopic assessment (sensitivity: 73%; specificity: 78%) was followed by dermatopathologist assessment (sensitivity: 89%; specificity: 79%) for inconclusive results. Diagnostic strategies 1 and 2 added FISH to the initial and dermatopathologist assessments, respectively. A Markov outcomes module simulated patients' remaining lifetime, including treatment.

RESULTS

In diagnostic strategies 1 and 2, the cost per quality-adjusted life year gained was US$14,930 and 43,925, respectively, versus no FISH. Cost per misdiagnosis avoided was US$3292 and 3759, respectively. Sensitivity and specificity without FISH were both ≥88%; however, addition of FISH exceeded US$100,000/quality-adjusted life year.

CONCLUSION

In specific clinical settings, FISH could be cost effective for melanoma diagnosis.

Prognostic factors of melanoma patients with satellite or in-transit metastasis at the time of stage III diagnosis

BACKGROUND

Prognosis of patients with loco-regional skin metastases has not been analyzed in detail and the presence or absence of concurrent lymph node metastasis represents the only established prognostic factor thus far. Most studies were limited to patients already presenting with skin lesions at the time of initial diagnosis. We aimed to analyze the impact of a broad penal of prognostic factors in patients with skin metastases at the time of first metastatic spread, including patients with synchronous lesions already present at the time of initial diagnosis, stage I/II patients with loco-regional recurrence and patients initially presenting with skin metastasis but unknown primary melanoma.

PATIENTS AND METHODS

We investigated disease-specific survival of 380 patients treated at our department between 1996 and 2010 using Kaplan Meier survival probabilities and Cox-proportional hazard analysis.

RESULTS

Five-year survival probability was 60.1% for patients with skin metastases only and 36.3% for those with synchronous nodal metastases. The number of involved nodes and a tumor thickness of at least 3 mm had independent negative impact on prognosis. A strong relationship was identified between the risk of death and the number of involved nodes. Neither ulceration nor the timing of the first occurrence of metastases as either in stage I/II patients, at the time of excision of the primary melanoma or initially in patients with unknown primary tumor, had additional effects on survival.

CONCLUSION

Lymph node involvement was confirmed as the most important prognostic factor for melanoma patients with loco-regional skin metastasis including those with unknown primary tumor and stage I/II patients with skin recurrence. Consideration of the tumor thickness and of the number of involved lymph nodes instead of the exclusive differentiation into presence vs. absence of nodal disease may allow a more accurate prediction of prognosis for patients with satellite or in-transit metastases.

Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review

There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. There are significant intercountry and interspecialty variations in the surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.

Surgical resection plus biotherapy/chemotherapy improves survival of hepatic metastatic melanoma

AIM

To analyze the correlation of treatment method with the outcome of all the hepatic metastatic melanoma (HMM) patients from our hospital.

METHODS

There were altogether nine cases of HMM that had been treated in the PUMCH hospital during the past 25 years, from December 1984 to February 2010. All of the cases developed hepatic metastasis from primary cutaneous melanoma. A retrospective review was performed on all the cases in order to draw informative conclusion on diagnosis and treatment in correlation with the prognosis. Clinical features including symptoms, signs, blood test results, B-ultrasound and computed tomography (CT) imaging characteristics, and pathological data were analyzed in each case individually. A simple comparison was made on case by case basis instead of performing statistical analysis since the case numbers are low and patients were much diversified in each item that has been analyzed. Literatures on this subject were reviewed in order to draw a safe conclusion and found to be supportive to our finding in a much broad scope.

RESULTS

There are six males and three females whose ages ranged 39-74 years old with an average of 58.8. Patients were either with or without symptoms at the time of diagnosis. The liver function and tumor marker exam were normal in all but one patient. The incidence of HMM does not affect liver function and was not related to virus infection status in the liver. Most of these HMM patients were also accompanied by the metastases of other locations, including lung, abdominal cavity, and cervical lymph nodes. Ultrasound examinations showed lesions ranging 2-12 cm in diameter, with no- or low-echo peripheral areola. Doppler showed blood flow appeared inside some tumors as well as in the surrounding area. CT image demonstrated low density without uniformed lesions, characterized with calcification in periphery, and enhanced in the arterial phase. Contrast phase showed heterogeneous enhancement, with a density higher than normal liver tissue, which was especially apparent at the edge. Patients were treated differently with following procedures: patients #1, #6 and #8 were operated with hepatectomy with or without removal of primary lesion, and followed by comprehensive biotherapy/chemotherapy; patient #9 received hepatectomy only; patient #2 received bacille calmette-guerin treatment only; patient #7 had Mile's surgery but no hepatectomy; and patients #3, #4 and #5 had supportive treatment without specific measurement. The patients who had resections of metastatic lesions followed by post-operative comprehensive therapy have an average survival time of 30.7 mo, which is much longer than those did not receive surgery treatment (4.6 mo). Even for the patient receiving a resection of HMM only, the post-operative survival time was 18 mo at the time we reviewed the data. This patient and the patient #6 are still alive currently and subjected to continue following up.

CONCLUSION

Surgical operation should be first choice for HMM treatment, and together with biotherapy/chemotherapy, hepatectomy is likely to bring better prognosis.

Metastatic behavior in melanoma: timing, pattern, survival, and influencing factors

Metastatic melanoma (MM) is a fatal disease with a rapid systemic dissemination. This study was conducted to investigate the metastatic behavior, timing, patterns, survival, and influencing factors in MM. 214 patients with MM were evaluated retrospectively. Distant metastases (82%) were the most frequent for patients initially metastatic. The median and 1-year survival rates of initially MM patients were 10 months and 41%, respectively. The median time to metastasis for patients with localized disease was 28 months. The timing of appearance of metastases varied minimally; however, times to metastases for distant organs varied greatly. For the first metastatic pathway, more than half of the primary metastases were M1A (57%). These findings were in contrast to the results compared with those with metastatic in diagnosis (P < 0.001). The median and 1-year survival rates of all patients were 12 months and 49%, respectively. Outcome was higher in M1A than visceral metastases (P < 0.001). In conclusion, the fact that over half of all recurrences/metastases occurred within 3 years urges us to concentrate follow-up in the early time periods following diagnosis. Because the clinical behavior of MM is variable, the factors for survival consisting of site and number of metastases should be emphasized.