1
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King ALO, Lee V, Yu B, Mirza FN, Zogg CK, Yang DX, Tran T, Leventhal J, An Y. Factors associated with the use of adjuvant radiation therapy in stage III melanoma. Front Oncol 2023; 13:1005930. [PMID: 36816935 PMCID: PMC9929351 DOI: 10.3389/fonc.2023.1005930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023] Open
Abstract
Objective The role of radiation therapy (RT) in melanoma has historically been limited to palliative care, with surgery as the primary treatment modality. However, adjuvant RT can be a powerful tool in certain cases and its application in melanoma has been increasingly explored in recent years. The aim of this study is to explore national patterns of care and associations surrounding the use of adjuvant RT for stage III melanoma. Methods The National Cancer Data Base (NCDB) was used to identify patients who were diagnosed with stage III melanoma between 2004 and 2014. Exclusion criteria included those with distant metastatic disease, in-situ histology, no confirmed positive nodes, palliative intent therapy, and dosing regimens inconsistent with National Comprehensive Cancer Network (NCCN) guidelines for adjuvant RT in melanoma. Patients treated with and without adjuvant RT were compared and factors associated with use of adjuvant RT were identified using multivariable logistic regression analyses. Results A total of 7,758 cases of stage III melanoma were analyzed, of which 11.7% received adjuvant RT. The mean age of the overall cohort was 58.5 years, and the majority of patients were male (64.7%), white (96.6%), on private insurance (51.3%), and presented to a non-high-volume facility (90.3%). Multivariable regression analyses revealed that patients who present to the hospital in 2009-2014 as compared to 2004-2008 (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.36-1.92), had 4 or more positive nodes (OR 4.30, 95% CI 3.67-5.04), and had microscopic residual tumor (OR 2.11, 95% CI 1.46-3.04) were more likely to receive adjuvant RT. Factors that were negatively associated with receiving adjuvant RT included female gender (OR 0.72, 95% CI 0.61-0.85) and median income of at least $63,000 (OR 0.66, 95% CI 0.52-0.83). Conclusions This study demonstrates the rising use of RT for stage III melanoma in recent years and identifies demographic, social, clinical, and hospital-specific factors associated with patients receiving adjuvant RT. Further investigation is needed to explore disease benefits to improve guidance on the utilization of RT in melanoma.
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Affiliation(s)
- Amber L. O. King
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Victor Lee
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Beverly Yu
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Fatima N. Mirza
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Daniel X. Yang
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Thuy Tran
- Department of Medicine (Medical Oncology), Yale School of Medicine, New Haven, CT, United States
| | - Jonathan Leventhal
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Yi An
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
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2
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Mansour J, Asarkar A, Pang J, Nathan CAO. What Is the Role of Adjuvant Radiotherapy in Head and Neck Melanoma in the Era of Systemic Therapy? Laryngoscope 2022; 132:2085-2086. [PMID: 35147220 DOI: 10.1002/lary.30048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/21/2022] [Accepted: 01/27/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Jobran Mansour
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A
| | - Ameya Asarkar
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A.,Surgical Service, Otolaryngology Section, Overton Brooks VA Medical Center, Shreveport, Louisiana, U.S.A
| | - John Pang
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A
| | - Cherie-Ann O Nathan
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A.,Surgical Service, Otolaryngology Section, Overton Brooks VA Medical Center, Shreveport, Louisiana, U.S.A
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3
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Drescher NR, Amdur RJ, Morris CG, Shaw CM, Dziegielewski PT, Mendenhall WM. Postoperative Radiotherapy for Cutaneous Melanoma in Patients at High Risk of Local-Regional Recurrence after Surgery Alone. Cancer Invest 2022; 40:348-353. [PMID: 35100059 DOI: 10.1080/07357907.2022.2033986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
We evaluated outcomes in 131 patients with cutaneous melanoma (median follow-up, 3.6 years) considered at high risk of recurrence after surgery alone treated with surgery and postoperative radiotherapy. Eligible patients had one or more of the following: recurrence after surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, or in-transit metastases. 102 patients received hypofractionated radiotherapy and 29 had conventional fractionation. 10-year outcomes were: in-field local-regional control, 87%; local regional control, 72%; distant metastasis-free survival, 48%; cause-specific survival, 44%; and overall survival, 31%. Three patients experienced acute toxicities while 6 experienced late toxicities.
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Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peter T Dziegielewski
- Department of Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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Abstract
Mucosal melanoma is a rare but aggressive cancer arising in mucosal surfaces most commonly in the head and neck. The clinical presentation is often nonspecific and differs in relation to the site of origin so often diagnosis is delayed resulting in poor prognosis. Mucosal melanoma has a 5-year survival of only 25%. Surgery with negative margins is the mainstay of treatment but dependent on several variables including anatomic location, involved structures, and size of tumor. Although not well defined given the rarity of mucosal melanoma, there is a role for radiation and systemic therapy in the treatment of this disease.
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Affiliation(s)
- Danielle Olla
- Institute for Plastic Surgery, Southern Illinois University, 747 N Rutledge Street #3, Springfield, IL 62702, USA.
| | - Michael W Neumeister
- Department of Surgery, The Elvin G Zook Endowed Chair - Institute for Plastic Surgery, Southern Illinois University, 747 N Rutledge Street #3, Springfield, IL 62702, USA
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5
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Knackstedt R, Smile T, Yu J, Gastman BR. Non-Operative Options for Loco-regional Melanoma. Clin Plast Surg 2021; 48:631-642. [PMID: 34503723 DOI: 10.1016/j.cps.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Malignant melanoma is the 5th most common cancer and stage IV melanoma accounts for approximately 4% of new melanoma diagnoses in the United States. The prognosis for regionally advanced disease is poor, but there have been numerous recent advances in the medical management of melanoma in-transit metastases. The goal of this paper is to review currently accepted treatment options for in-transit metastases and introduce emerging therapies. Therapies to be discussed include limb perfusion and infusion, immunotherapy, checkpoint inhibitors, and radiation therapy.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA
| | - Timothy Smile
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Jennifer Yu
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA.
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6
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Studer G, Glanzmann C. [Radiation Oncology - Recent Status]. PRAXIS 2021; 110:733-742. [PMID: 34583545 DOI: 10.1024/1661-8157/a003729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Radiation Oncology - Recent Status Abstract. We summarize the most important developments and innovations in the field over the past years and illustrate resulting external radiation treatment schedules and related treatment tolerance, focusing on hypofractionation.
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7
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North LM, Harvey E, Vanle B, Shreenivas A, Shukla M, Wong S, Awan M, Zenga J. Frequent omission of radiation after flap reconstruction of head and neck cancer: Are we dooming patients to failure? Oral Oncol 2021; 119:105225. [PMID: 33612388 DOI: 10.1016/j.oraloncology.2021.105225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Lauren M North
- Department of Otolaryngology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Erin Harvey
- Department of Otolaryngology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Brigitte Vanle
- Department of Otolaryngology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Aditya Shreenivas
- Department of Medicine-Oncology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Monica Shukla
- Department of Radiation Oncology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Stuart Wong
- Department of Medicine-Oncology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Joseph Zenga
- Department of Otolaryngology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
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8
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Fiorentino A, Gregucci F, Desideri I, Fiore M, Marino L, Errico A, Di Rito A, Borghetti P, Franco P, Greto D, Donato V. Radiation treatment for adult rare cancers: Oldest and newest indication. Crit Rev Oncol Hematol 2021; 159:103228. [PMID: 33508447 DOI: 10.1016/j.critrevonc.2021.103228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022] Open
Abstract
AIM Aim of this analysis is to review the role of RT in the management of several rare tumors for adult patients. METHODS Collection data regarding RT and rare tumors was made by Pubmed. RESULTS For mucosal melanomas, RT is prescribed, being associated with lower local recurrence rate. For trachea tumors, RT was used as adjuvant or salvage treatment for unresectable disease. For pNET, RT can be a suitable option for post-surgical or unresectable/borderline. For bronchopulmonary neuroendocrine tumors the role of adjuvant treatments is uncertain. For hepatobiliary and ovarian malignancy, stereotactic body RT (SBRT) is a promising approach. For soft tissue sarcoma, perioperative treatments are indicated, and a growing role of SBRT in oligometastatic disease is recognized. For endocrine tumors, adjuvant RT has demonstrated benefits through reducing recurrence risk. CONCLUSION The radiotherapy is a frequent indication in adult rare cancers; thus the role of Radiation Oncologist must not be neglected.
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Affiliation(s)
- Alba Fiorentino
- Radiation Oncology Department, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Radiation Oncology Department, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy.
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Lorenza Marino
- Radiation Oncology Department, Humanitas Istituto Clinico Catanese, Misterbianco, Catania, Italy
| | - Angelo Errico
- Radiotherapy Oncology Department, R. Dimiccoli Hospital, Barletta, Italy
| | - Alessia Di Rito
- Radiotherapy Oncology Department, IRCCS "Giovanni Paolo II", Bari, Italy
| | - Paolo Borghetti
- Radiation Oncology Department University and Spedali Civili, Brescia, Italy
| | | | - Daniela Greto
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Vittorio Donato
- Radiation Oncology Department, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
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9
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Straker RJ, Song Y, Sun J, Shannon AB, Cohen LS, Muradova E, Daou H, Krause K, Li S, Frederick DT, Rhodin KE, Brizel DM, Boland GM, Beasley GM, Wuthrick EJ, Sondak VK, Zager JS, Lin A, Lukens JN, Karakousis GC. Adjuvant Radiation Therapy for Clinical Stage III Melanoma in the Modern Therapeutic Era. Ann Surg Oncol 2020; 28:3512-3521. [PMID: 33230747 DOI: 10.1245/s10434-020-09384-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adjuvant radiation therapy (RT) can decrease lymph node basin (LNB) recurrences in patients with clinically evident melanoma lymph node (LN) metastases following lymphadenectomy, but its role in the era of modern systemic therapies (ST), immune checkpoint or BRAF/MEK inhibitors, is unclear. PATIENTS AND METHODS Patients at four institutions who underwent lymphadenectomy (1/1/2010-12/31/2019) for clinically evident melanoma LN metastases and received neoadjuvant and/or adjuvant ST with RT, or ST alone, but met indications for RT, were identified. Comparisons were made between ST alone and ST/RT groups. The primary outcome was 3-year cumulative incidence (CI) of LNB recurrence. Secondary outcomes included 3-year incidences of in-transit/distant recurrence and survival estimates. RESULTS Of 98 patients, 76 received ST alone and 22 received ST/RT. Median follow-up time for patients alive at last follow-up was 44.6 months. The ST/RT group had fewer inguinal node metastases (ST 36.8% versus ST/RT 9.1%; P = 0.04), and more extranodal extension (ST 50% versus ST/RT 77.3%; P = 0.02) and positive lymphadenectomy margins (ST 2.6% versus ST/RT 13.6%; P = 0.04). The 3-year CI of LNB recurrences was lower for the ST/RT group compared with the ST group (13.9% versus 25.2%), but this reduction was not statistically significant (P = 0.36). Groups did not differ significantly in in-transit/distant recurrences (P = 0.24), disease-free survival (P = 0.14), or melanoma-specific survival (P = 0.20). CONCLUSIONS In the era of modern ST, RT may still have value in reducing LNB recurrences in melanoma with clinical LN metastases. Further research should focus on whether select patient populations derive benefit from combination therapy, and optimizing indications for RT following neoadjuvant ST.
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Affiliation(s)
- Richard J Straker
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Adrienne B Shannon
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Leah S Cohen
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Elnara Muradova
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Hala Daou
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kate Krause
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Siming Li
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennie T Frederick
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - David M Brizel
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Genevieve M Boland
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Evan J Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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10
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Goepfert RP, Myers JN, Gershenwald JE. Updates in the evidence-based management of cutaneous melanoma. Head Neck 2020; 42:3396-3404. [PMID: 33463835 DOI: 10.1002/hed.26398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 06/02/2020] [Accepted: 07/14/2020] [Indexed: 11/11/2022] Open
Abstract
Treatment of cutaneous melanoma is changing with significant developments over the past several years that promise to reshape the field of melanoma surgical oncology. Modifications to the staging system based on analysis of a large international dataset, the timing and extent of regional lymphadenectomy, the emergence of effective systemic therapies in the neoadjuvant and adjuvant setting, and the role of adjuvant radiation are all undergoing a data-driven evolution. Surgeon engagement in multidisciplinary decision making remains an essential component of contemporary management for patients across all stages of melanoma and demands specific involvement of head and neck surgical oncologists.
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Affiliation(s)
- Ryan P Goepfert
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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11
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Saaiq M, Zalaudek I, Rao B, Lee Y, Rudnicka L, Czuwara J, Giuffrida R, Wollina U, Jafferany M, Lotti T, Grabbe S, Goldust M. A brief synopsis on scalp melanoma. Dermatol Ther 2020; 33:e13795. [PMID: 32520414 DOI: 10.1111/dth.13795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Melanoma constitutes one of the most sinister and troublesome malignancies encountered by humanity. Generally, the diagnosis of advanced melanoma connotes a grave prognosis, prompting a sense of looming threat of death, however, the early-stage detected disease responds well to robust treatment resulting in reasonable survivorship. Scalp melanomas are even more troublesome, because they typically exhibit more aggressive biologic behavior and are often diagnosed at a late stage. This review tries to comprehensively highlight the various diagnostic, therapeutic, and outcome aspects of scalp melanomas. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included.
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Affiliation(s)
- Muhammad Saaiq
- Department of Plastic Surgery and Orthopedics, National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan
| | - Iris Zalaudek
- Dermatology Clinic, University of Trieste, Maggiore Hospital, Trieste, Italy
| | - Babar Rao
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, New Jersey, USA.,Department of Dermatology, Weill Cornell Medical Center, New York, New York, USA
| | - Young Lee
- Department of Dermatology, Chungnam National University, Daejeon, South Korea
| | - Lidia Rudnicka
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Czuwara
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - Roberta Giuffrida
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Mohammad Jafferany
- College of Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Torello Lotti
- Department of Dermatology, University of Studies Guglielmo Marconi, Rome, Italy
| | - Stephan Grabbe
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Mohamad Goldust
- Department of Dermatology, University of Rome G. Marconi, Rome, Italy.,Department of Dermatology, University Medical Center Mainz, Mainz, Germany.,Department of Dermatology, University Hospital Basel, Basel, Switzerland
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12
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Fayne RA, Macedo FI, Rodgers SE, Möller MG. Evolving management of positive regional lymph nodes in melanoma: Past, present and future directions. Oncol Rev 2019; 13:433. [PMID: 31857858 PMCID: PMC6902307 DOI: 10.4081/oncol.2019.433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/20/2019] [Indexed: 12/29/2022] Open
Abstract
Sentinel lymph node (SLN) biopsy has become the standard of care for lymph node staging in melanoma and the most important predictor of survival in clinically node-negative disease. Previous guidelines recommend completion lymph node dissection (CLND) in cases of positive SLN; however, the lymph nodes recovered during CLND are only positive in a minority of these cases. Recent evidence suggests that conservative management (i.e. observation) has similar outcomes compared to CLND. We sought to review the most current literature regarding the management of SLN in metastatic melanoma and to discuss potential future directions.
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Affiliation(s)
- Rachel A Fayne
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Francisco I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Miami, FL, USA
| | - Steven E Rodgers
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Mecker G Möller
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
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13
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Wuthrick EJ, Chablani P. Do Not Forget About the Importance of Loco-Regional Therapy in Melanoma Management. Semin Radiat Oncol 2019; 29:166-170. [PMID: 30827455 DOI: 10.1016/j.semradonc.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Immunotherapy agents have significantly changed the landscape of melanoma treatment over the past decade. Paradigm shifts in treatment require reanalysis of the treatment algorithms in melanoma. Despite surgical excision, certain high risk patients with desmoplastic melanoma remain at high risk for local recurrence and retrospective data suggests improvement in local control with adjuvant radiation therapy. Likewise, despite surgical excision and effective systemic therapy agents, patients with extracapsular extension and other high risk features are at substantial risk of nodal basin (regional) recurrence. Adjuvant radiation therapy has been demonstrated to reduce the local recurrence risk. Despite these benefits, adjuvant radiation therapy in melanoma remains controversial in part because its use has not been definitively demonstrated to improve overall or disease-free survival in a randomized prospective study.
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Affiliation(s)
- Evan J Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL.
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14
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Torabi SJ, Benchetrit L, Spock T, Cheraghlou S, Judson BL. Clinically node-negative head and neck mucosal melanoma: An analysis of current treatment guidelines & outcomes. Oral Oncol 2019; 92:67-76. [PMID: 31010627 DOI: 10.1016/j.oraloncology.2019.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/11/2019] [Accepted: 03/23/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To analyze head and neck mucosal melanoma (MM) treatment patterns, and their association with survival, relative to National Comprehensive Cancer Network (NCCN) guidelines. MATERIAL & METHODS Adult head and neck MM patients with clinically-staged T3/4aN0 disease were identified in a retrospective analysis of the National Cancer Database (2010-2014) and stratified into sinonasal cavity (SN) and oral cavity, oropharynx, larynx, or hypopharynx (non-SN) cohorts. RESULTS We identified 353 SN and 79 non-SN MM cases. The majority of patients were treated with surgery (SN: 92.4%; non-SN 84.8%), within NCCN guidelines. Treatment within the non-SN MM NCCN recommendation of elective neck dissection (END) was approximately 26.6%. END is not recommended for SN MM and was not performed in 91.5% of cases. Radiotherapy (RT) is recommended in both SN and non-SN MM and was utilized in 63.5% of SN patients and 46.8% of non-SN patients. END was not independently associated with OS compared to surgery alone (SN HR: 1.350 [95% CI: 0.733-2.485]; non-SN HR: 3.460 [95% CI: 0.912-13.125]). RT was independently associated with improved OS in SN MM cases (HR: 0.679 [95% CI: 0.479-0.963]), but not in non-SN MM cases (HR: 0.824 [95% CI: 0.331-2.051]). CONCLUSION The majority of patients with head and neck MM are not treated within NCCN guidelines. The use of recommended END in non-SN patients is low. Similarly, adjuvant RT utilization is low. Our analysis shows that while greater use of RT may increase survival rates in this disease, the utility of END is unclear.
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Affiliation(s)
- Sina J Torabi
- Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, 800 Howard Ave, 4th Floor, New Haven, CT 0519, United States.
| | - Liliya Benchetrit
- Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, 800 Howard Ave, 4th Floor, New Haven, CT 0519, United States.
| | - Todd Spock
- Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, 800 Howard Ave, 4th Floor, New Haven, CT 0519, United States.
| | - Shayan Cheraghlou
- Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, 800 Howard Ave, 4th Floor, New Haven, CT 0519, United States.
| | - Benjamin L Judson
- Department of Surgery (Section of Otolaryngology), Yale University School of Medicine, 800 Howard Ave, 4th Floor, New Haven, CT 0519, United States; Yale Cancer Center, PO Box 208028, New Haven, CT 06520-8028, United States.
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Spillane A, Hong A, Fogarty G. Re-examining the role of adjuvant radiation therapy. J Surg Oncol 2018; 119:242-248. [PMID: 30554414 DOI: 10.1002/jso.25329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/23/2018] [Indexed: 11/08/2022]
Abstract
Previously important roles for adjuvant radiotherapy (RT) in melanoma patients included improved regional control after resection of high-risk nodal disease, to reduce local recurrence for desmoplastic, and other subtypes of melanoma with neurotropism, reducing in-brain relapse of brain metastases after surgery and other situations on a case-by-case basis. This review evaluates the integration of adjuvant RT into clinical practice at this time of rapidly evolving knowledge and improving outcomes from effective systemic therapy.
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Affiliation(s)
- Andrew Spillane
- Surgical Oncology, Northern Clinical School, The University of Sydney, Sydney, Australia.,Melanoma Institute Australia, Sydney, Australia.,Melanoma Unit, Mater Hospital, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Angela Hong
- Surgical Oncology, Northern Clinical School, The University of Sydney, Sydney, Australia.,Melanoma Institute Australia, Sydney, Australia.,Melanoma Unit, Mater Hospital, Sydney, Australia.,Radiation Oncology, Royal Prince Alfred Hospital, Sydney, Australia.,Radiation Oncology, GenesisCare, Mater Radiation Oncology, Sydney, Australia
| | - Gerald Fogarty
- Surgical Oncology, Northern Clinical School, The University of Sydney, Sydney, Australia.,Melanoma Institute Australia, Sydney, Australia.,Melanoma Unit, Mater Hospital, Sydney, Australia.,Radiation Oncology, St Vincents Hospital, Sydney, Australia.,Radiation Oncology, GenesisCare, Mater Radiation Oncology, Sydney, Australia
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Metastatic malignant melanoma of parotid gland: A case report and review of literature. OTOLARYNGOLOGY CASE REPORTS 2017. [DOI: 10.1016/j.xocr.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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17
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Hayashi T, Furukawa H, Kitamura T, Shichinohe R, Murao N, Oyama A, Funayama E, Maeda T, Yamamoto Y. Review and proposal of regional surgical management for melanoma: revisiting of integumentectomy and incontinuity dissection in treatment of skin melanoma. Int J Clin Oncol 2017; 22:569-576. [PMID: 28064397 DOI: 10.1007/s10147-016-1085-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Past studies showed that integumentectomy and incontinuity could be effective procedures in the surgical management of melanoma patients. The present study reports on the historical background of these procedures. In addition, we analyze the ICG assisted integumentectomy and incontinuity techniques and algorithms that we had created when performing this procedure. METHOD In accordance with our algorithm, we performed ICG assisted integumentectomy/incontinuity procedures on 17 patients with stage III melanomas between 2008 and 2016. We also investigated the locoregional recurrence rate in a control group comprising 60 patients at stage III without using the algorithm. RESULTS The former group exhibited a tendency of locoregional recurrence rate suppression. Melanoma cells in the dissected intervening tissue were microscopically identified in 2 out of 17 cases. CONCLUSIONS Our ICG assisted integumentectomy or incontinuity procedures could be effective in controlling locoregional recurrence rates in melanoma cases. Moreover, our method can be generally applied because the dissection is only performed within the lymphatic pathway region identified using indocyanine green.
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Affiliation(s)
- Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
- Department of Oral and Maxillofacial Surgery, Graduate School of Dental Medicine, Hokkaido University, Kita 13, Nishi 7, Kita-ku, Sapporo, 060-8586, Japan.
| | - Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takashi Kitamura
- Department of Plastic and Reconstructive Surgery, Obihiro-Kosei General Hospital, Nishi 6, Minami 8, Obihiro, 080-0016, Japan
| | - Ryuji Shichinohe
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Akihiko Oyama
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
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Abstract
Systemic adjuvant therapy for surgically resected cutaneous melanoma that is at high risk for disease recurrence and death targets residual micrometastatic disease which is the source of future local or distant relapse. Interferon-alfa (IFNα) has been the most extensively studied in regimens that varied by dosage, route of administration, formulation, and duration of therapy. Most regimens have demonstrated improvements in relapse-free survival (RFS), while the regimen administered at high dosage (HDI) showed improvements in overall survival (OS) in two out of three RCTs. HDI benefits as measured by the hazard ratios (HR) in E1684 (vs. observation), E1690 (vs. observation), and E1694 (vs. vaccine) trials were estimated at 0.61, 0.78, and 0.67 (RFS) and 0.67, 1.0, and 0.72 (OS) when first reported with lesser estimates on later updates. Pegylated IFNα (peg-IFN) as studied in the European Organisation for Research and Treatment of Cancer (EORTC) 18991 trial in patients with stage III melanoma significantly reduced the risk of relapse (HR 0.87) with no impact on OS. More recently (EORTC 18071), ipilimumab at the high dose of 10 mg/kg was shown to significantly improve RFS (HR 0.76) and OS (HR 0.72) of stage III melanoma patients but at a significant cost in terms of immune-related toxicities. Ongoing adjuvant studies are testing ipilimumab at 3 or 10 mg/kg versus HDI (E1609) and the anti-PD-1 antibodies nivolumab (CheckMate 238) and pembrolizumab (KEYNOTE-054 and S1404).
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Mendenhall WM, Amdur RJ, Morris CG, Kirwan J, Shaw C, Dziegielewski PT. Adjuvant postoperative radiotherapy for cutaneous melanoma. Acta Oncol 2017; 56:495-496. [PMID: 28256960 DOI: 10.1080/0284186x.2017.1295168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- William M. Mendenhall
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert J. Amdur
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher G. Morris
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jessica Kirwan
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana Shaw
- Departments of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peter T. Dziegielewski
- Departments of Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
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20
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Keenan LG, O'Sullivan S, Glynn A, Higgins M, Flavin A, Brennan S. Clinical review of treatment outcomes and patterns of failure with adjuvant radiotherapy in node-positive malignant melanoma. J Med Imaging Radiat Oncol 2016; 61:258-262. [PMID: 27667733 DOI: 10.1111/1754-9485.12536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/20/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Adjuvant radiotherapy is proven to prevent lymph node field relapse after therapeutic lymphadenectomy for melanoma, but does not improve overall survival based on current data. There remains a high rate of distant relapse. This study reports patterns of failure in patients treated with adjuvant radiotherapy, looking at factors associated with distant metastasis and comparing this to recent literature. METHODS This retrospective study included patients treated with adjuvant nodal irradiation after lymphadenectomy between June 2012 and March 2015. RESULTS Twenty-one patients were treated during this period. Median follow-up was 13.5 months. There were no lymph node field recurrences. Distant metastasis (DM) rate was 48%. DM rate was significantly higher (P = 0.027) in patients with extracapsular extension (ECE) (71%) than those without ECE (0%). DM rate was higher in those with a maximum tumour size of >3 cm (71%) than those with tumour size <3 cm (30%) (P = 0.160). Number of nodes, BRAF status or nodal site did not correlate with rate of DM. The median time to DM was 16 weeks after completion of radiotherapy. CONCLUSION Radiotherapy is well tolerated and effective in regional control. However, patients are at risk of early distant relapse, particularly those with ECE or large tumour size. There are currently no useful prognostic markers to differentiate the risk of regional versus distant recurrence, and the optimal treatment paradigm remains undefined. Research on adjuvant systemic therapies and abscopal effects of radiotherapy have shown improved management of distant metastasis; creating an even greater need for effective regional control strategies.
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Affiliation(s)
| | | | - Aisling Glynn
- St Lukes Radiation Oncology Network, Dublin, Ireland
| | | | - Aileen Flavin
- Cork University Hospital, Wilton, Co., Cork, Ireland
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21
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Scott JF, Thompson CL, Vyas R, Honda K, Zender C, Rezaee R, Lavertu P, Koon H, Cooper KD, Gerstenblith MR. Parotid melanoma of unknown primary. J Cancer Res Clin Oncol 2016; 142:1529-37. [DOI: 10.1007/s00432-016-2156-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/04/2016] [Indexed: 12/01/2022]
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22
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Makino J, Cabral H, Miura Y, Matsumoto Y, Wang M, Kinoh H, Mochida Y, Nishiyama N, Kataoka K. cRGD-installed polymeric micelles loading platinum anticancer drugs enable cooperative treatment against lymph node metastasis. J Control Release 2015; 220:783-91. [PMID: 26474676 DOI: 10.1016/j.jconrel.2015.10.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/05/2015] [Accepted: 10/09/2015] [Indexed: 01/11/2023]
Abstract
Lymph node metastasis (LNM) is correlated with decreased survival, indicating high tumor malignancy and being a potential source for subsequent fatal metastases. Targeted therapies inhibiting the formation of LNM, while eliminating established metastatic foci, could provide synergistic effects by reducing the incidence and growth of metastasis. Based on the inhibitory activity of cRGD peptide against the development of metastasis, and the LNM targeting ability of systemically injected drug-loaded polymeric micelles, herein, we studied the capability of cRGD-installed polymeric micelles incorporating the platinum anticancer drug (1,2-diaminocylohexane)platinum(II) (DACHPt) for cooperatively inhibiting the formation and progression of LNM. As cRGD-installed DACHPt-loaded micelles (cRGD-DACHPt/m) presented similar size, drug loading and surface charge to non-conjugated micelles (MeO-DACHPt/m), the differences in the biological performance of the micelles were endorsed to the effect of the ligand. In a syngeneic melanoma model, both MeO-DACHPt/m and cRGD-DACHPt/m showed comparable antitumor activity against the primary tumors and the established metastatic foci in lymph nodes. However, cRGD-DACHPt/m significantly enhanced the efficacy against LNM draining from primary tumors through the effective inhibition of the spreading of cancer cells. This improved inhibition was associated with the ability of cRGD-DACHPt/m to reduce the migration of melanoma cells, which was higher than that of MeO-DACHPt/m, free cRGD and their combination. These results support our strategy of using cRGD-installed micelles for attaining cooperative therapies against LNM exploiting the inhibitory function of the peptide and the cytotoxic effect of the micelles.
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Affiliation(s)
- Jun Makino
- Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Horacio Cabral
- Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan.
| | - Yutaka Miura
- Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Yu Matsumoto
- Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Ming Wang
- Department of Materials Engineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan
| | - Hiroaki Kinoh
- The Innovation Center of Nanomedicine, 66-20 Horikawa-cho, Saiwai-ku, Kawasaki 212-0013, Japan
| | - Yuki Mochida
- The Innovation Center of Nanomedicine, 66-20 Horikawa-cho, Saiwai-ku, Kawasaki 212-0013, Japan
| | - Nobuhiro Nishiyama
- Polymer Chemistry Division, Chemical Resources Laboratory, Tokyo Institute of Technology, R1-11, 4259 Nagatsuta, Midori-ku, Yokohama 226-8503, Japan
| | - Kazunori Kataoka
- Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan; Department of Materials Engineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan; The Innovation Center of Nanomedicine, 66-20 Horikawa-cho, Saiwai-ku, Kawasaki 212-0013, Japan.
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23
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Henderson MA, Burmeister BH, Ainslie J, Fisher R, Di Iulio J, Smithers BM, Hong A, Shannon K, Scolyer RA, Carruthers S, Coventry BJ, Babington S, Duprat J, Hoekstra HJ, Thompson JF. Adjuvant lymph-node field radiotherapy versus observation only in patients with melanoma at high risk of further lymph-node field relapse after lymphadenectomy (ANZMTG 01.02/TROG 02.01): 6-year follow-up of a phase 3, randomised controlled trial. Lancet Oncol 2015. [PMID: 26206146 DOI: 10.1016/s1470-2045(15)00187-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Adjuvant radiotherapy is recommended for patients with melanoma after lymphadenectomy. We previously showed this treatment reduced risk of repeat lymph-node field cancer in patients with a high risk of recurrence but had no effect on overall survival. Here, we aim to update the relapse and survival data from that trial and assess quality of life and toxic effects. METHODS In the ANZMTG 01.02/TROG 02.01 randomised controlled trial, we enrolled patients who had undergone lymphadenectomy for a palpable lymph-node field relapse and were at high risk of recurrence at 16 hospitals (11 in Australia, three in New Zealand, one in Netherlands, and one in Brazil). We randomly assigned patients (1:1) to adjuvant radiotherapy (48 Gy in 20 fractions, given over a maximum of 30 days) or observation, stratified by institution, areas of lymph-node field (parotid and cervical, axilla, or groin), number of involved nodes (≤3 vs >3), maximum involved node diameter (≤4 cm vs >4 cm), and extent of extracapsular extension (none, limited, or extensive). Participants, those giving treatment, and those assessing outcomes were not masked to treatment allocation, but participants were unaware of each other's treatment allocation. In this follow-up, we assessed outcomes every 3 months from randomisation for the first 2 years, then every 6 months up to 5 years, then annually. The primary endpoint was lymph-node field relapse as a first relapse, assessed in patients without major eligibility infringements (determined by an independent data monitoring committee). We assessed late adverse effects (occurring >90 days after surgery or start of radiotherapy) with standard criteria in the as-treated population. This study is registered with ClinicalTrials.gov, number NCT00287196. FINDINGS Between March 21, 2003, and Nov 15, 2007, we randomly assigned 123 patients to adjuvant radiotherapy (109 eligible for efficacy assessments) and 127 to observation (108 eligible). The final follow-up date was Nov 15, 2011. Median follow-up was 73 months (IQR 61-91). 23 (21%) relapses occurred in the adjuvant radiotherapy group compared with 39 (36%) in the observation group (adjusted hazard ratio [HR] 0·52 [95% CI 0·31-0·88], p=0·023). Overall survival (HR 1·27 [95% CI 0·89-1·79], p=0·21) and relapse-free survival (0·89 [0·65-1·22], p=0·51) did not differ between groups. Minor, long-term toxic effects from radiotherapy (predominantly pain, and fibrosis of the skin or subcutaneous tissue) were common, and 20 (22%) of 90 patients receiving adjuvant radiotherapy developed grade 3-4 toxic effects. 18 (20%) of 90 patients had grade 3 toxic effects, mainly affecting skin (nine [10%] patients) and subcutaneous tissue (six [7%] patients). Over 5 years, a significant increase in lower limb volumes was noted after adjuvant radiotherapy (mean volume ratio 15·0%) compared with observation (7·7%; difference 7·3% [95% CI 1·5-13·1], p=0·014). No significant differences in upper limb volume were noted between groups. INTERPRETATION Long-term follow-up supports our previous findings. Adjuvant radiotherapy could be useful for patients for whom lymph-node field control is a major issue, but entry to an adjuvant systemic therapy trial might be a preferable first option. Alternatively, observation, reserving surgery and radiotherapy for a further recurrence, might be an acceptable strategy. FUNDING National Health and Medical Research Council of Australia, Cancer Council Australia, Melanoma Institute Australia, and the Cancer Council South Australia.
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Affiliation(s)
- Michael A Henderson
- Division of Cancer Surgery, University of Melbourne Department of Surgery, East Melbourne, VIC, Australia; University of Melbourne, East Melbourne, VIC, Australia.
| | - Bryan H Burmeister
- Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Jill Ainslie
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Richard Fisher
- Centre for Biostatistics and Clinical Trials, East Melbourne, VIC, Australia
| | - Juliana Di Iulio
- Centre for Biostatistics and Clinical Trials, East Melbourne, VIC, Australia
| | - B Mark Smithers
- Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Angela Hong
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
| | - Kerwin Shannon
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
| | - Scott Carruthers
- Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Brendon J Coventry
- Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | | | | | | | - John F Thompson
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
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Abstract
Adjuvant therapy targets melanoma micrometastases in patients with surgically resected disease that carry a high risk of death from melanoma recurrence. In this setting, adjuvant therapy provides the greatest opportunity for cure before progression into advanced inoperable stages. In randomized clinical trials, interferon-alfa has been shown to have a significant impact on relapse-free survival and, at high dosage, on overall survival compared with observation (E1684) and the GMK vaccine (E1694). This article reviews melanoma adjuvant therapy along with the ongoing and planned clinical trials.
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Affiliation(s)
- Ahmad A Tarhini
- Department of Medicine, Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, UPMC Cancer Pavilion, 5150 Centre Avenue (555), Pittsburgh, PA 15232, USA.
| | - Prashanth M Thalanayar
- Department of Internal Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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25
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Abstract
Although melanoma is generally considered a relative radioresistant tumor, radiation therapy (RT) remains a valid and effective treatment option in definitive, adjuvant, and palliative settings. Definitive RT is generally only used in inoperable patients. Despite a high-quality clinical trial showing adjuvant RT following lymphadenectomy in node-positive melanoma patients prevents local and regional recurrence, the role of adjuvant RT in the treatment of melanoma remains controversial and is underused. RT is highly effective in providing symptom palliation for metastatic melanoma. RT combined with new systemic options, such as immunotherapy, holds promise and is being actively evaluated.
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Affiliation(s)
- Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, 111 South 11th Street, Suite G301, Philadelphia, PA 19107, USA.
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27
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Abstract
Although melanoma was historically thought to be radiation resistant, there are limited data to support the use of adjuvant radiation therapy for certain situations at increased risk for locoregional recurrence. High-risk primary tumor features include thickness, ulceration, certain anatomic locations, satellitosis, desmoplastic/neurotropic features, and head and neck mucosal and anorectal melanoma. Lentigo maligna can be effectively treated with either adjuvant or definitive radiation therapy. Some retrospective and prospective randomized studies support the use of adjuvant radiation to improve regional control after lymph node dissection for high-risk nodal metastatic disease. Consensus on the optimal radiation doses and fractionation is lacking.
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Affiliation(s)
- Jacqueline Oxenberg
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - John M Kane
- Melanoma-Sarcoma Service, Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
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28
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A large retrospective multicenter study of vaginal melanomas: implications for new management. Melanoma Res 2014; 23:138-46. [PMID: 23449321 DOI: 10.1097/cmr.0b013e32835e590e] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The outcome of patients presenting with vaginal melanoma has been assessed in a large multicentric retrospective study. The databases of 12 French institutions were searched for primary vaginal melanomas managed between 1990 and 2007. Among the 54 patients recorded, 46 were managed with a curative intent and included in the study. The clinical characteristics, treatments, and detection of c-KIT protein expression have been studied. The median age of the patients was 63.5 years (42-88). Twenty-eight patients were classified as International Federation of Gynecology and Obstetrics (FIGO) stage I, five as stage II, six as stage III, and one as stage IVA. c-KIT protein was overexpressed in 80% of the patients. Forty-two patients underwent surgical resection of the tumor, nine patients received local adjuvant treatment, and 10 received systemic adjuvant therapy. The median relapse-free survival was 10.9 months. c-KIT-negative status (P=0.01) and stage I (P=0.02) were associated with locoregional recurrence. The rate of metastasis was increased for advanced FIGO stages (P<0.01). The median overall survival (OS) was 28.4 months. The finding of lymph node metastasis adversely affected OS (P<0.01). Conservative surgery and radiotherapy were associated with a decrease in metastasis-free and OS (P<0.01) compared with surgery alone, this group of patients presenting with advanced FIGO stages (P=0.02). Despite the use of limited data, conservative surgery combined with a sentinel lymph node procedure, followed by adjuvant radiotherapy could be proposed to patients with early FIGO stage in the absence of validated management. c-KIT negativity by immunochemistry appears to be a poor prognosis marker in terms of locoregional recurrences but not for metastatic spread nor survival. Further assessment of the role of c-KIT expression in this disease is thus mandatory to select patients for targeted therapy.
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Abstract
Malignant melanoma is increasing in incidence worldwide, and many patients remain at a significant risk of recurrence following surgical resection. Over the past 30 years, interferon-alpha has been the only agent approved for adjuvant therapy of melanoma. This review summarizes the rationale for adjuvant therapy, and discusses the roles of interferon, immunotherapy, chemotherapy and radiation therapy in the adjuvant setting. New approaches and novel combinations that appear promising for the adjuvant therapy of malignant melanoma are also outlined.
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Affiliation(s)
- John P Stoutenburg
- Division of Medical Oncology, Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, New York 10032, USA
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Mendenhall WM, Shaw C, Amdur RJ, Kirwan J, Morris CG, Werning JW. Surgery and adjuvant radiotherapy for cutaneous melanoma considered high-risk for local-regional recurrence. Am J Otolaryngol 2013; 34:320-2. [PMID: 23375588 DOI: 10.1016/j.amjoto.2012.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 12/17/2012] [Accepted: 12/28/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the efficacy of postoperative radiotherapy (RT) in the treatment of cutaneous melanoma. MATERIALS Between August 1981 and December 2009, 82 patients were treated with surgery and postoperative RT for cutaneous melanoma. Patients were thought to be high risk for local-regional recurrence after surgery alone because of the presence of one or more risk factors including recurrence after prior surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, and in-transit metastases. The primary site was located in the head and neck in 64 patients and elsewhere in the remainder. Forty-two patients (47%) were treated with hypofractionated RT and the remainder with conventional fractionation. Median age was 62 years (range, 21 to >89 years). Median follow-up overall and for survivors was 3.0 years (range, 0.1 to 17.4 years) and 6.4 years (1.6 to 17.4 years), respectively. RESULTS The 5-year outcomes were: in-field local-regional control 82%; local-regional control, 76%; distant metastasis-free survival, 48%; cause-specific survival, 56%; and overall survival, 43%. In-field local-regional control at 5 years was 87% after hypofractionated RT and 78% after conventionally fractionated RT. CONCLUSIONS Postoperative adjuvant RT likely reduces the risk of local-regional recurrence after surgery for patients with high risk cutaneous melanoma. Hypofractionated RT is as effective as conventional fractionation and is logistically advantageous, particularly for patients with a relatively poor prognosis. The risk of RT complications is low.
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Salama JK, Kirkpatrick JP, Yin FF. Stereotactic body radiotherapy treatment of extracranial metastases. Nat Rev Clin Oncol 2012; 9:654-65. [PMID: 23007273 DOI: 10.1038/nrclinonc.2012.166] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Radiotherapy is an integral treatment for patients with metastatic cancer, although it is usually reserved for palliation of pain, dyspnoea, oedema, bleeding and neurological symptoms. However, the administration of high-precision radiotherapy, termed stereotactic body radiotherapy (SBRT), has the potential to significantly affect the disease course for some patients with metastatic cancer by delivering high doses of radiation to the secondary tumours with limited high-dose delivery to adjacent healthy tissues. Indeed, such accurate delivery has been firmly established as a therapy for medically inoperable early-stage non-small-cell lung cancer. To date, the technique has demonstrated improvements in controlling metastasis and, in some cases, improved palliation compared with conventionally fractionated radiotherapy. Active areas of research in SBRT include patient selection for curative intent, optimization of SBRT planning techniques, dosing schema and integration of SBRT into systemic therapies. Given the improvements in cytotoxic and targeted therapies over the past decade, studies testing the careful integration of SBRT into standard systemic therapy regimens are needed. Further investigations are also needed to understand the basic biological mechanisms underlying SBRT because they are likely to be different to those mechanisms in conventional radiotherapy.
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Affiliation(s)
- Joseph K Salama
- Department of Radiation Oncology, Box 3085, Duke Cancer Institute, Durham, NC 27710, USA
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Hallemeier CL, Garces YI, Neben-Wittich MA, Olivier KR, Shon W, García JJ, Brown PD, Foote RL. Adjuvant hypofractionated intensity modulated radiation therapy after resection of regional lymph node metastases in patients with cutaneous malignant melanoma of the head and neck. Pract Radiat Oncol 2012; 3:e71-7. [PMID: 24674323 DOI: 10.1016/j.prro.2012.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/08/2012] [Accepted: 06/10/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate outcomes in patients with malignant melanoma of the head and neck with resected regional lymph node (LN) metastases treated with adjuvant hypofractionated intensity modulated radiation therapy (IMRT). METHODS AND MATERIALS A retrospective review was performed of 46 patients with malignant melanoma of the head and neck with regional LN metastases treated with lymphadenectomy and adjuvant IMRT. Patients underwent neck dissection (n = 42) or local excision (n = 4) for regional metastases at initial diagnosis (n = 19) or recurrence (n = 27). Adjuvant IMRT was delivered twice per week over 2.5 weeks for a total dose of 30 Gray (Gy) in 5 fractions. Acute and late adverse events were recorded using the Common Toxicity Criteria for Adverse Events version 4. Site of first recurrence was defined as local-regional (LR, above the clavicles) or distant. Overall survival, disease-free survival, and disease recurrence risks were determined using Kaplan-Meier estimates. RESULTS The median follow-up in living patients was 2.8 years (range, 0.2-6.9). Most patients experienced acute grade 1-2 dermatitis (80%) and mucositis (85%). One patient (2%) experienced an acute grade 3 adverse event. Seven patients (16%) experienced late grade 2 adverse events. No patient experienced grade 3 or higher late adverse events. Site of first recurrence was LR alone (n = 5), both LR and distant (n = 1), and distant alone (n = 25). Five of the 6 LR recurrences were inside the IMRT planning target volume (PTV). In-PTV and total LR control at 3 years were 85% and 76%, respectively. Overall survival and disease-free survival at 3 years were 63% and 25%, respectively. CONCLUSIONS Adjuvant hypofractionated IMRT (30 Gy in 5 fractions) was associated with a high rate of in-PTV control and a low risk of serious adverse events.
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Affiliation(s)
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Wonwoo Shon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joaquín J García
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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Burmeister BH, Henderson MA, Ainslie J, Fisher R, Di Iulio J, Smithers BM, Hong A, Shannon K, Scolyer RA, Carruthers S, Coventry BJ, Babington S, Duprat J, Hoekstra HJ, Thompson JF. Adjuvant radiotherapy versus observation alone for patients at risk of lymph-node field relapse after therapeutic lymphadenectomy for melanoma: a randomised trial. Lancet Oncol 2012; 13:589-97. [PMID: 22575589 DOI: 10.1016/s1470-2045(12)70138-9] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The use of radiotherapy after therapeutic lymphadenectomy for patients with melanoma at high risk of further lymph-node field and distant recurrence is controversial. Decisions for radiotherapy in this setting are made on the basis of retrospective, non-randomised studies. We did this randomised trial to assess the effect of adjuvant radiotherapy on lymph-node field control in patients who had undergone therapeutic lymphadenectomy for metastatic melanoma in regional lymph nodes. METHODS This randomised controlled trial included patients from 16 hospitals in Australia, New Zealand, the Netherlands, and Brazil. To be eligible for this trial, patients had to be at high risk of lymph-node field relapse, judged on the basis of number of nodes involved, extranodal spread, and maximum size of involved nodes. After lymphadenectomy, randomisation was done centrally by computer and patients assigned by telephone in a ratio of 1:1 to receive adjuvant radiotherapy of 48 Gy in 20 fractions or observation, with institution, lymph-node field, number of involved nodes, maximum node diameter, and extent of extranodal spread as minimisation factors. Participants, those giving treatment, and those assessing outcomes were not masked to treatment allocation. The primary endpoint was lymph-node field relapse (as a first relapse), analysed for all eligible patients. The study is registered at ClinicalTrials.gov, number NCT00287196. The trial is now closed and follow-up discontinued. FINDINGS 123 patients were randomly allocated to the adjuvant radiotherapy group and 127 to the observation group between March 20, 2002, and Sept 21, 2007. Two patients withdrew consent and 31 had a major eligibility infringement as decided by the independent data monitoring committee, resulting in 217 eligible for the primary analysis (109 in the adjuvant radiotherapy group and 108 in the observation group). Median follow-up was 40 months (IQR 27-55). Risk of lymph-node field relapse was significantly reduced in the adjuvant radiotherapy group compared with the observation group (20 relapses in the radiotherapy group vs 34 in the observation group, hazard ratio [HR] 0·56, 95% CI 0·32-0·98; p=0·041), but no differences were noted for relapse-free survival (70 vs 73 events, HR 0·91, 95% CI 0·65-1·26; p=0·56) or overall survival (59 vs 47 deaths, HR 1·37, 95% CI 0·94-2·01; p=0·12). The most common grade 3 and 4 adverse events were seroma (nine in the radiotherapy group vs 11 in the observation group), radiation dermatitis (19 in the radiotherapy group), and wound infection (three in the radiotherapy group vs seven in the observation group). INTERPRETATION Adjuvant radiotherapy improves lymph-node field control in patients at high risk of lymph-node field relapse after therapeutic lymphadenectomy for metastatic melanoma. Adjuvant radiotherapy should be discussed with patients at high risk of relapse after lymphadenectomy. FUNDING National Health and Medical Research Council of Australia, Cancer Australia, Melanoma Institute Australia, Cancer Council of South Australia.
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Affiliation(s)
- Bryan H Burmeister
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia.
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Shashanka R, Smitha BR. Head and neck melanoma. ISRN SURGERY 2012; 2012:948302. [PMID: 22570796 PMCID: PMC3337483 DOI: 10.5402/2012/948302] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 01/24/2012] [Indexed: 12/02/2022]
Abstract
The incidence of malignant melanoma appears to be increasing at an alarming rate throughout the world over the past 30–40 years and continues to increase in the United States, Canada, Australia, Asia, and Europe. The behavior of head and neck melanoma is aggressive, and it has an overall poorer prognosis than that of other skin sites. The authors review the published literature and text books, intending to give an overall picture of malignant melanomas of the head and neck and a special emphasis on treatment considerations with controversies in treatment including biopsy, radiation therapy, sentinel node biopsy, and nodal dissection.
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Affiliation(s)
- R Shashanka
- Department of General Surgery, Hassan Institute of Medical Sciences, Karnataka, Hassan 573201, India
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Kelly P, Zagars GK, Cormier JN, Ross MI, Guadagnolo BA. Sphincter-sparing local excision and hypofractionated radiation therapy for anorectal melanoma: a 20-year experience. Cancer 2011; 117:4747-55. [PMID: 21446049 DOI: 10.1002/cncr.26088] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/03/2011] [Accepted: 02/02/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anorectal melanoma is a rare disease with a poor prognosis. Because survival is determined by distant failure, many centers have adopted sphincter-sparing excision for primary tumor control. However, this approach is associated with high rates of local failure (∼50%). In this study, the authors report their 20-year experience with sphincter-sparing excision combined with radiation therapy (RT) for the treatment of localized anorectal melanoma. METHODS The authors reviewed the records of 54 patients with localized anorectal melanoma who were treated at the University of Texas MD Anderson Cancer Center from 1989 to 2008. All patients underwent definitive local excision with or without sentinel lymph node biopsy or lymph node dissection. RT (25-36 grays in 5-6 fractions) was delivered to extended fields that targeted the primary site and draining pelvic/inguinal lymphatics in 39 patients and to limited fields that targeted only the primary site in 15 patients. RESULTS The 5-year rates of local control (LC), lymph node control (NC), and sphincter preservation were 82%, 88%, and 96%, respectively. However, because of the high rate of distant metastasis, the overall survival (OS) rate at 5 years was only 30%. Although there were no significant differences in LC, NC, or OS based on RT field extent, patients who received extended-field RT had higher rates of lymphedema than patients who received limited-field RT. CONCLUSIONS The current results indicated that combined sphincter-sparing local excision and RT is a well tolerated approach that provides effective LC for patients with anorectal melanoma. Inclusion of the inguinal lymph node basins in the RT fields did not improve outcomes and was associated with an increased risk of lymphedema.
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Affiliation(s)
- Patrick Kelly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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Bibault JE, Dewas S, Mirabel X, Mortier L, Penel N, Vanseymortier L, Lartigau E. Adjuvant radiation therapy in metastatic lymph nodes from melanoma. Radiat Oncol 2011; 6:12. [PMID: 21294913 PMCID: PMC3041681 DOI: 10.1186/1748-717x-6-12] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 02/06/2011] [Indexed: 11/26/2022] Open
Abstract
Purpose To analyze the outcome after adjuvant radiation therapy with standard fractionation regimen in metastatic lymph nodes (LN) from cutaneous melanoma. Patients and methods 86 successive patients (57 men) were treated for locally advanced melanoma in our institution. 60 patients (69%) underwent LN dissection followed by radiation therapy (RT), while 26 patients (31%) had no radiotherapy. Results The median number of resected LN was 12 (1 to 36) with 2 metastases (1 to 28). Median survival after the first relapse was 31.8 months. Extracapsular extension was a significant prognostic factor for regional control (p = 0.019). Median total dose was 50 Gy (30 to 70 Gy). A standard fractionation regimen was used (2 Gy/fraction). Median number of fractions was 25 (10 to 44 fractions). Patients were treated with five fractions/week. Patients with extracapsular extension treated with surgery followed by RT (total dose ≥50 Gy) had a better regional control than patients treated by surgery followed by RT with a total dose <50 Gy (80% vs. 35% at 5-year follow-up; p = 0.004). Conclusion Adjuvant radiotherapy was able to increase regional control in targeted sub-population (LN with extracapsular extension).
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Affiliation(s)
- Jean-Emmanuel Bibault
- Academic Radiotherapy Departement, CLCC Oscar Lambret Comprehensive Cancer Center, Lille-Nord de France University, Lille, France.
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Strojan P, Jančar B, Čemažar M, Perme MP, Hočevar M. Melanoma Metastases to the Neck Nodes: Role of Adjuvant Irradiation. Int J Radiat Oncol Biol Phys 2010; 77:1039-45. [DOI: 10.1016/j.ijrobp.2009.06.071] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Revised: 06/10/2009] [Accepted: 06/11/2009] [Indexed: 10/20/2022]
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Abstract
BACKGROUND In melanoma, radiotherapy has generally been considered as a palliative treatment option indicated only for advanced cases or disseminated disease. In the 70s of the previous century, the technological advances in radiotherapy, linked to rapid development of computer sciences, resulted in restored interest for radiotherapy in melanoma management. Although a fundamental lack of well designed prospective and/or randomized clinical trials critically influenced the integration of radiotherapy into treatment strategies in melanoma, radiotherapy was recently recognized as an indispensable part in the multidisciplinary management of patients with melanoma. Altogether, approximately 23% of melanoma patients should receive at least one course of radiotherapy during the course of the disease. In this review, radiobiological properties of melanoma that govern the decisions for the fractionation patterns used in the treatment of this disease are described. Moreover, the indications for irradiation and the results of pertinent clinical studies from the literature, creating a rationale for the use of radiotherapy in the management of this disease, are reviewed and a brief description of radiotherapy techniques is given. CONCLUSIONS Basic treatment modality in melanoma is surgery. However, whenever surgery is not radical or there are adverse prognostic factors identified on histopathological examination of resected tissue specimen, it needs to be supplemented. Also, in patients with unresectable disease or in those not being suitable for major surgery or who refuse proposed surgical intervention, other effective mode(s) of therapy need to be implemented. From this perspective, supported by clinical experiences and literature results, radiotherapy is a valuable option: it is effective and safe, in curative and palliative setting.
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Shuff JH, Siker ML, Daly MD, Schultz CJ. Role of radiation therapy in cutaneous melanoma. Clin Plast Surg 2010; 37:147-60. [PMID: 19914465 DOI: 10.1016/j.cps.2009.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cutaneous melanoma is a disease that often has an aggressive and unpredictable course. It was historically thought to be a radioresistant neoplasm; however, substantial radiobiologic and clinical evidence has emerged to refute this notion. Improved local control has been demonstrated with the use of adjuvant radiation therapy delivered to the primary site or regional lymphatics in patients with high-risk clinical or pathologic features. Despite improved local control, high-risk cutaneous melanoma often spreads systemically, leading to poor survival. In the setting of systemic progression, radiation therapy can frequently palliate symptomatic sites of metastatic disease.
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Affiliation(s)
- Jaime H Shuff
- Department of Radiation Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Agrawal S, Kane JM, Guadagnolo BA, Kraybill WG, Ballo MT. The benefits of adjuvant radiation therapy after therapeutic lymphadenectomy for clinically advanced, high-risk, lymph node-metastatic melanoma. Cancer 2009; 115:5836-44. [DOI: 10.1002/cncr.24627] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Loco-regional control after postoperative radiotherapy for patients with regional nodal metastases from melanoma. Clin Transl Oncol 2009; 11:688-93. [DOI: 10.1007/s12094-009-0425-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Guadagnolo BA, Zagars GK. Adjuvant radiation therapy for high-risk nodal metastases from cutaneous melanoma. Lancet Oncol 2009; 10:409-16. [DOI: 10.1016/s1470-2045(09)70043-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Cutaneous Malignant Melanoma. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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45
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Moncrieff MD, Martin R, O’Brien CJ, Shannon KF, Clark JR, Gao K, McCarthy WM, Thompson JF. Adjuvant Postoperative Radiotherapy to the Cervical Lymph Nodes in Cutaneous Melanoma: Is There Any Benefit for High-Risk Patients? Ann Surg Oncol 2008; 15:3022-7. [DOI: 10.1245/s10434-008-0087-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 07/11/2008] [Accepted: 07/12/2008] [Indexed: 11/18/2022]
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Abstract
Extracutaneous malignant melanomas are rare tumors with vexing clinical presentation and grim prognosis. Only 4%-5% of all primary melanomas do not arise from the skin. These tumors are almost uniformly fatal, even in 2006. Although a fairly good number of these lesions were reported in the literature, the lack of a side-by-side analysis of these studies has resulted in tentative conclusions that merely offer a first glimpse at the clinicopathologic diversity of these lesions. To remedy this issue, this article took an aim at presenting a literature review concerning extracutaneous malignant melanomas. It also reports several cases of extracutaneous melanomas, which I came across in my 15 years of surgical and molecular pathology practice. The study raises several notions. Extracutaneous malignant melanomas are rare but extremely aggressive lesions with a grim outcome. They include ocular, metastatic, anorectal, mucosal, nail beds, conjunctival, vaginal, urogenital, orbital, esophageal, and leptomeningial malignant melanomas. The development of these lesions lacks an association with sun damage, family history, or precursor nevi. These lesions cause considerable diagnostic consternation and their distinction from other types of tumors (such as undifferentiated carcinomas, high-grade sarcomas, and lymphomas) is critical both from a diagnostic and prognostic point of view. In the proper clinical, histological, and cytological context, immunopositivity for S100 protein, HMB45, and vimentin allows the distinction of these malignant melanomas from other histologically similar malignancies. To conclude, extracutaneous melanoma should be considered while undifferentiated neoplasms, especially those displaying prominent eosinophilic nucleoli, and the coexistence of epithelioid and spindle cells. Special staining and immunohistochemistry should be resorted to establish the diagnosis.
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Affiliation(s)
- Mahmoud R Hussein
- Department of Pathology, Faculty of Medicine, Assuit University Hospitals, Assuit, Egypt.
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Berk LB. Radiation Therapy as Primary and Adjuvant Treatment for Local and Regional Melanoma. Cancer Control 2008; 15:233-8. [DOI: 10.1177/107327480801500306] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background The role of radiation therapy as primary and adjuvant therapy for localized or locally advanced melanoma is controversial. Methods To develop evidence-based guidelines, PubMed was searched using the keywords melanoma AND (radiation OR radiotherapy). These references were reviewed and the relevant articles selected. The articles were then reviewed for further references. Because of the paucity of prospective or randomized trials, no attempt was made to classify the quality of the results. Results No phase III trials of nodal irradiation for prevention of regional recurrence are available. A phase III trial is being completed by the Tasman Radiation Oncology Group. A phase II trial has been completed by the group. Multiple retrospective series have been published. The available data appear to confirm that nodal radiation therapy is effective in preventing nodal recurrence. No dose response or fraction size response was found. According to generally accepted guidelines, radiation therapy should be offered for patients who have nodes greater than 3 cm, more than 3 involved nodes, or extracapsular extension. For radiation therapy for the treatment of metastatic disease, a phase III trial showed that 50 Gy in 2.5-Gy fractions was as effective as 32 Gy in 8-Gy fractions, with 25% complete remission and 35% partial remission. In contrast, the retrospective studies support that larger fraction sizes, at least 4 Gy, are more effective. Conclusions Adjuvant nodal irradiation appears to be effective for the prevention of nodal recurrence. Radiation therapy can also be effective for treatment of local disease, if surgery is not an option.
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Affiliation(s)
- Lawrence B. Berk
- Radiation Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Mendenhall WM, Amdur RJ, Grobmyer SR, George TJ, Werning JW, Hochwald SN, Mendenhall NP. Adjuvant radiotherapy for cutaneous melanoma. Cancer 2008; 112:1189-96. [DOI: 10.1002/cncr.23306] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lalami Y, Vereecken P, Dequanter D, Lothaire P, Awada A. Salivary gland carcinomas, paranasal sinus cancers and melanoma of the head and neck: an update about rare but challenging tumors. Curr Opin Oncol 2008; 18:258-65. [PMID: 16552238 DOI: 10.1097/01.cco.0000219255.30220.90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW This is a review about recent clinical developments in rare cancers of the head and neck. RECENT FINDINGS Progress in molecular biology techniques has allowed the identification of new prognostic factors, and potential molecular-targeted therapies. This is of importance since chemotherapy continues to play a role but is still limited in this group of malignancies. New techniques of irradiation such as intensity-modulated radiotherapy and three-dimensional conformal radiotherapy appear to improve the locoregional control of these tumors. Surgery continues to be the cornerstone of treatment, with a growing interest in the technique of sentinel lymph node biopsy. SUMMARY As salivary gland carcinomas, paranasal sinus cancers and melanoma of the head and neck are rare malignancies, these tumors must be treated in specialized anticancer centers with access to the latest surgical and irradiation techniques. Moreover, clinical studies with translational research are needed to identify strong prognostic and predictive factors, and effective molecular-targeted therapies.
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Affiliation(s)
- Yassine Lalami
- Jules Bordet Institute, Department of Internal Medicine, Medical Oncology Clinic, Brussels, Belgium.
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Markovic SN, Erickson LA, Rao RD, Weenig RH, Pockaj BA, Bardia A, Vachon CM, Schild SE, McWilliams RR, Hand JL, Laman SD, Kottschade LA, Maples WJ, Pittelkow MR, Pulido JS, Cameron JD, Creagan ET. Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment. Mayo Clin Proc 2007; 82:490-513. [PMID: 17418079 DOI: 10.4065/82.4.490] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.
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Affiliation(s)
- Svetomir N Markovic
- Division of Hematology, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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