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Montgomery KB, Duncan ZN, Holder AM, Burgan CM, Galgano SJ, Broman KK. Interdisciplinary Implementation of a Synoptic Reporting Template for Melanoma Nodal Surveillance Ultrasound. Ann Surg Oncol 2024:10.1245/s10434-024-15630-0. [PMID: 38954095 DOI: 10.1245/s10434-024-15630-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/04/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND With nodal surveillance increasingly used for sentinel lymph node-positive (SLN+) melanoma following the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II), high-quality nodal ultrasonography (U/S) has become a critical need. Previous work has demonstrated low utilization of MSLT-II U/S criteria to define abnormal lymph nodes requiring intervention or biopsy. To address this gap, an evidence-based synoptic template was designed and implemented in this single-center study. METHODS Sentinel lymph node-positive patients undergoing nodal surveillance at a tertiary cancer center from July 2017 to June 2023 were identified retrospectively. Ultrasound reporting language was analyzed for MSLT-II criteria reported and clinically actionable recommendations (e.g., normal, abnormal with recommendation for biopsy). Following a multidisciplinary design process, the synoptic template was implemented in January 2023. Postimplementation outcomes were evaluated by using U/S reports and provider surveys. RESULTS A total of 337 U/S studies were performed on 94 SLN+ patients, with a median of 3 U/S per patient (range 1-12). Among 42 synoptic-eligible U/S performed postimplementation, 32 U/S (76.0%) were reported synoptically. Significant increases were seen in the number of MSLT-II criteria reported (Pre 0.5 ± 0.8 vs. Post 2.5 ± 1.0, p < 0.001), and clinically actionable recommendations for abnormal findings (Pre 64.0% vs. Post 93.0%, p = 0.04). Nearly all surgeon and radiologist survey respondents were "very" or "completely" satisfied with the clinical utility of the synoptic template (90.0%). CONCLUSIONS Following implementation of a synoptic template, U/S reports were significantly more likely to document MSLT-II criteria and provide an actionable recommendation, increasing usefulness to providers. Efforts to disseminate this synoptic template to other centers are ongoing.
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Affiliation(s)
- Kelsey B Montgomery
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Zoey N Duncan
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley M Holder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Constantine M Burgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samuel J Galgano
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristy K Broman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Liu ZF, Sylivris A, Wu J, Tan D, Hong S, Lin L, Wang M, Chew C. Ultrasound Surveillance in Melanoma Management: Bridging Diagnostic Promise with Real-World Adherence: A Systematic Review and Meta-Analysis. Am J Clin Dermatol 2024; 25:513-525. [PMID: 38635019 DOI: 10.1007/s40257-024-00862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Ultrasound surveillance has become the new standard of care in stage III melanoma after the 2017 Multicenter Selective Lymphadenectomy Trial II (MSLT-II) demonstrated non-inferior 3-year survival compared with complete lymph node dissection. OBJECTIVE We aimed to quantify diagnostic performance and adherence rates of ultrasound surveillance for melanoma locoregional metastasis, offering insights into real-world applicability. METHODS Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases from inception until 11 October 2023. All primary studies that reported data on the diagnostic performance or adherence rates to ultrasound surveillance in melanoma were included. R statistical software was used for data synthesis and analysis. Sensitivity and specificity were aggregated across studies using the meta-analytic method for diagnostic tests outlined by Rutter and Gatsonis. Adherence rates were calculated as the ratio of patients fully compliant to planned follow-up to those who were not. RESULTS A total of 36 studies including 18,273 patients were analysed, with a mean age of 56.6 years and a male-to-female ratio of 1:1.11. The median follow-up duration and frequency was 36 and 4 months, respectively. The pooled sensitivity of ultrasound examination was 0.879 (95% confidence interval [CI] 0.878-0.879) and specificity was 0.969 (95% CI 0.968-0.970), representing a diagnostic odds ratio of 224.5 (95% CI 223.1-225.9). Ultrasound examination demonstrated a substantial improvement in absolute sensitivity over clinical examination alone, with a number needed to screen (NNS) of 2.95. The overall adherence rate was 77.0% (95% CI 76.0-78.1%), with significantly lower rates in the United States [US] (p < 0.001) and retrospective studies (p < 0.001). CONCLUSION Ultrasound is a powerful diagnostic tool for locoregional melanoma metastasis. However, the real applicability to surveillance programmes is limited by low adherence rates, especially in the US. Further studies should seek to address this adherence gap.
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Affiliation(s)
- Zhao Feng Liu
- Department of Dermatology, Alfred Health, Melbourne, VIC, Australia
| | | | - Johnny Wu
- Monash Health, Clayton, VIC, Australia
| | - Darren Tan
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| | | | - Lawrence Lin
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Wang
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Christopher Chew
- Department of Dermatology, Alfred Health, Melbourne, VIC, Australia
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
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Novis E, van Akkooi ACJ. Management of Localized Melanoma in the Anti-PD-1 Era. Curr Oncol Rep 2024:10.1007/s11912-024-01556-z. [PMID: 38842606 DOI: 10.1007/s11912-024-01556-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The management of cutaneous melanoma has rapidly progressed over the past decade following the introduction of effective systemic therapies. Given the large number of recent clinical trials which have dramatically altered the management of these patients, an updated review of the current evidence regarding the management of localized melanoma is needed. RECENT FINDINGS The role of effective systemic therapies in earlier stages (I-III) melanoma, both in adjuvant and neoadjuvant settings is rapidly changing the role of surgery in the management cutaneous melanoma, particularly regarding surgical safety margins for wide local excision (WLE), the role of sentinel lymph node biopsy (SLNB) and the extent of lymph node dissections. The randomized phase 2 SWOG1801 trial has demonstrated superiority of neoadjuvant-adjuvant anti-PD1 therapy in improving event-free survival by 23% at 2-years over adjuvant anti-PD-1 therapy only. Furthermore, the PRADO trial has suggested a more tailored approach both the extent of surgery as well as adjuvant therapy can safely and effectively be done, depending on the response to initial neoadjuvant immunotherapy. These results await validation and it is expected that in 2024 the phase 3 Nadina trial (NCT04949113) will definitively establish neo-adjuvant combination immunotherapy as the novel standard. This will further redefine the management of localized melanoma. The use of effective systemic therapies will continue to evolve in the next decade and, together with new emerging diagnostic and surveillance techniques, will likely reduce the extent of routine surgery for stage I-III melanoma.
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Affiliation(s)
- Elan Novis
- Melanoma Institute Australia, 40 Rocklands Road, Wollstonecraft, North Sydney, Sydney, NSW, 2060, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Alexander C J van Akkooi
- Melanoma Institute Australia, 40 Rocklands Road, Wollstonecraft, North Sydney, Sydney, NSW, 2060, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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Downey J, Hamm J, Baliski C. Impact of extra-nodal extension and AJCC lymph node staging in predicting recurrence following lymphadenectomy in patients with melanoma. Am J Surg 2024; 231:120-124. [PMID: 38320886 DOI: 10.1016/j.amjsurg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/01/2024] [Accepted: 01/24/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Regional lymphadenectomy (RL) has traditionally been recommended in patients with melanoma found to have clinical lymphadenopathy or a positive sentinel lymph node biopsy (SLNB). Regional control of disease is still a relevant issue for patients, even after undergoing lymphadenectomy. The goal of this study was to identify the clinicopathologic characteristics that predict locoregional recurrence in patients who have undergone either therapeutic lymph node dissection (TLND) or completion lymph node dissection (CLND) following SLNB. METHODS Retrospective review of population-based cohort of patients with melanoma lymph node metastasis from the years 2005-2015. Multivariate, proportional hazards regression analysis was performed to determine factors predicting nodal recurrence. RESULTS 586 patients underwent a RL, with a median follow up of 35 months. Overall, in-basin recurrence rates in the axilla, groin, and head/neck were 7.7 %, 8.7 % and 9.2 %, respectively. Higher unadjusted recurrence rates occurred following CLND than TLND of the groin (12.8 % vs 4.5 %) and neck (10.0 % vs 4.7 %) but not the axilla (7.5 % vs 8.0 %). Upon multivariate analysis, ENE (HR 2.77; p=<0.0001) and the AJCC lymph node stage (N3 vs N1) (HR 2.51; p = 0.025) were predictive of regional recurrence. CONCLUSION The AJCC nodal stage and the presence of extranodal extension were the only variables impacting regional recurrence following regional lymphadenectomy for melanoma. When considering regional disease control, they should be factored into treatment decisions, and surveillance strategies.
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Affiliation(s)
- Julia Downey
- BC Cancer-Sindi Ahluwalia Hawkins Centre, Dept. of Surgical Oncology, Kelowna, BC, Canada.
| | - Jeremy Hamm
- Cancer Surveillance and Outcomes, BC Cancer, Vancouver, BC, Canada
| | - Christopher Baliski
- BC Cancer-Sindi Ahluwalia Hawkins Centre, Dept. of Surgical Oncology, Kelowna, BC, Canada; Department of Surgery, Kelowna General Hospital, Kelowna, BC, Canada
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Gyurdzhyan S, Muralidharan V, Liu LY, Sunwoo JB, Zaba LC, Swetter SM. Nodal ultrasound for regional recurrence detection in sentinel lymph node biopsy-positive cutaneous melanoma patients undergoing cross-sectional imaging. SKIN HEALTH AND DISEASE 2024; 4:e305. [PMID: 38312253 PMCID: PMC10831564 DOI: 10.1002/ski2.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Affiliation(s)
- Samvel Gyurdzhyan
- Department of DermatologyPigmented Lesion and Melanoma ProgramStanford University Medical Center and Cancer InstituteStanfordCaliforniaUSA
- Stanford University School of MedicineStanfordCaliforniaUSA
| | - Vijaytha Muralidharan
- Department of DermatologyPigmented Lesion and Melanoma ProgramStanford University Medical Center and Cancer InstituteStanfordCaliforniaUSA
| | - Lucy Y. Liu
- Department of DermatologyPigmented Lesion and Melanoma ProgramStanford University Medical Center and Cancer InstituteStanfordCaliforniaUSA
| | - John B. Sunwoo
- Department of Otolaryngology – Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Lisa C. Zaba
- Department of DermatologyPigmented Lesion and Melanoma ProgramStanford University Medical Center and Cancer InstituteStanfordCaliforniaUSA
| | - Susan M. Swetter
- Department of DermatologyPigmented Lesion and Melanoma ProgramStanford University Medical Center and Cancer InstituteStanfordCaliforniaUSA
- Dermatology ServiceVeterans Affairs Palo Alto Health Care SystemPalo AltoCaliforniaUSA
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de Menezes JN, Arra DASM, Lôbo MM, Pinto CAL, Lima JPSN, Silva MJB, Duprat Neto JP, Bertolli E. Recurrence Patterns and Clinical Management after a Positive Sentinel Node Biopsy in Melanoma Patients. Cancer Invest 2023; 41:830-836. [PMID: 37962565 DOI: 10.1080/07357907.2023.2283459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 11/09/2023] [Indexed: 11/15/2023]
Abstract
Introduction melanoma patients who become stage III after a positive sentinel node biopsy (SNB) may have several patterns of recurrence patients and methods retrospective analysis of melanoma patients who have undergone SNB in a single institution from 2000 to 2015. Results There were 111 recurrences (45.1%) among 246 (20.3%) SNB positive patients and median DRFS was 77.7 months. After initial treatment, further recurrences occurred in 68 (77.3%) patients, regardless the site of initial recurrence conclusions multimodal strategies are recommended to achieve better results when managing stage III melanoma patients after a positive SNB.
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Affiliation(s)
| | - Dante A S M Arra
- Surgical Oncology Residence Program, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Matheus M Lôbo
- Skin Cancer Department, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
| | | | | | | | - João P Duprat Neto
- Skin Cancer Department, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Eduardo Bertolli
- Skin Cancer Department, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
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Montgomery KB, Holder AM, Burgan CM, Galgano SJ, Broman KK. Is it Time for Synoptic Reporting in Melanoma Nodal Surveillance Ultrasonography? Ann Surg Oncol 2023; 30:5327-5328. [PMID: 37326810 PMCID: PMC10527281 DOI: 10.1245/s10434-023-13749-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/04/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Kelsey B Montgomery
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Ashley M Holder
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Constantine M Burgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samuel J Galgano
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristy K Broman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
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Long GV, Swetter SM, Menzies AM, Gershenwald JE, Scolyer RA. Cutaneous melanoma. Lancet 2023:S0140-6736(23)00821-8. [PMID: 37499671 DOI: 10.1016/s0140-6736(23)00821-8] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/17/2023] [Accepted: 04/19/2023] [Indexed: 07/29/2023]
Abstract
Cutaneous melanoma is a malignancy arising from melanocytes of the skin. Incidence rates are rising, particularly in White populations. Cutaneous melanoma is typically driven by exposure to ultraviolet radiation from natural sunlight and indoor tanning, although there are several subtypes that are not related to ultraviolet radiation exposure. Primary melanomas are often darkly pigmented, but can be amelanotic, with diagnosis based on a combination of clinical and histopathological findings. Primary melanoma is treated with wide excision, with margins determined by tumour thickness. Further treatment depends on the disease stage (following histopathological examination and, where appropriate, sentinel lymph node biopsy) and can include surgery, checkpoint immunotherapy, targeted therapy, or radiotherapy. Systemic drug therapies are recommended as an adjunct to surgery in patients with resectable locoregional metastases and are the mainstay of treatment in advanced melanoma. Management of advanced melanoma is complex, particularly in those with cerebral metastasis. Multidisciplinary care is essential. Systemic drug therapies, particularly immune checkpoint inhibitors, have substantially increased melanoma survival following a series of landmark approvals from 2011 onward.
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Affiliation(s)
- Georgina V Long
- Melanoma Institute Australia, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Department of Medical Oncology, Mater Hospital, Sydney, NSW, Australia.
| | - Susan M Swetter
- Department of Dermatology and Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, Stanford, CA, USA; Department of Dermatology, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alexander M Menzies
- Melanoma Institute Australia, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Department of Medical Oncology, Mater Hospital, Sydney, NSW, Australia
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology and Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard A Scolyer
- Melanoma Institute Australia, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia
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Broman KK, Hughes TM, Bredbeck BC, Sun J, Kirichenko D, Carr MJ, Sharma A, Bartlett EK, Nijhuis AAG, Thompson JF, Hieken TJ, Kottschade L, Downs J, Gyorki DE, Stahlie E, van Akkooi A, Ollila DW, O'shea K, Song Y, Karakousis G, Moncrieff M, Nobes J, Vetto J, Han D, Hotz M, Farma JM, Deneve JL, Fleming MD, Perez M, Baecher K, Lowe M, Bagge RO, Mattsson J, Lee AY, Berman RS, Chai H, Kroon HM, Teras J, Teras RM, Farrow NE, Beasley GM, Hui JYC, Been L, Kruijff S, Sinco B, Sarnaik AA, Sondak VK, Zager JS, Dossett LA. International Center-Level Variation in Utilization of Completion Lymph Node Dissection and Adjuvant Systemic Therapy for Sentinel Lymph Node-Positive Melanoma at Major Referral Centers. Ann Surg 2023; 277:e1106-e1115. [PMID: 35129464 PMCID: PMC10097464 DOI: 10.1097/sla.0000000000005370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. SUMMARY BACKGROUND DATA Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. METHODS We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. RESULTS Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. CONCLUSIONS There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.
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Affiliation(s)
- Kristy K Broman
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | | | - Amanda A G Nijhuis
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | | | - Emma Stahlie
- Netherlands Cancer institute, Amsterdam, The Netherlands
| | | | | | | | - Yun Song
- University of Gothenburg, Gothenburg, Sweden
| | | | - Marc Moncrieff
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Jenny Nobes
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - John Vetto
- Oregon Health & Science University, Portland, OR
| | - Dale Han
- Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | | | | | | | - Jan Mattsson
- University Medical Center, Groningen, Netherlands
| | | | | | - Harvey Chai
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Hidde M Kroon
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Juri Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Roland M Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | | | | | | | | | | | | | - Amod A Sarnaik
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Vernon K Sondak
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Jonathan S Zager
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
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Pérez-Morales J, Broman KK, Bettampadi D, Haver MK, Zager JS, Schabath MB. Recurrence Patterns for Regionally Metastatic Melanoma Treated in the Era of Adjuvant Therapy: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2023; 30:2364-2374. [PMID: 36479663 DOI: 10.1245/s10434-022-12866-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this systematic review was to examine the timing and patterns of recurrence for patients with regionally metastatic melanoma on the basis of nodal management and receipt of adjuvant therapy. METHODS We identified randomized controlled trials and non-randomized studies published between 2010 and 2020 that reported timing and/or patterns of recurrence. We evaluated recurrence-free survival (RFS), location of recurrence, and surveillance strategy on the basis of receipt of adjuvant systemic therapy and nodal management with observation versus completion dissection. We compared differences in patterns of recurrence across studies using RevMan. RFS was evaluated graphically using point estimates and confidence intervals. RESULTS Among the 19 publications, there was wide variation in study populations, imaging surveillance regimens, and format of recurrence reporting. Patterns of disease recurrence did not differ between adjuvant and placebo/observation groups. A total of 11 studies reported RFS at variable time intervals, which ranged in adjuvant therapy groups (38-88% at 1 year, 29-67% at 2 years, 33-58% at 3 years, and 34-53% at 5 years) and placebo/observation groups (47-63% at 1 year, 39-47% at 2 years, 33-68% at 3 years, and 57% at 5 years). Anti-PD-1 immune therapy and BRAF/MEK inhibitor therapy were superior to placebo at year 1. DISCUSSION We found that adjuvant treatment improved RFS but did not alter the patterns of disease recurrence compared with patients managed without adjuvant systemic treatment. Future studies should separately report sites of disease recurrence on the basis of specific adjuvant systemic treatment and surveillance practices to better advise patients about their patterns and risk of recurrence.
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Affiliation(s)
- Jaileene Pérez-Morales
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
| | - Kristy K Broman
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Deepti Bettampadi
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Mary Katherine Haver
- Moffitt Biomedical Library, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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11
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Senders ZJ, Bartlett EK, Mouw TJ, McMasters KM, Egger ME. Does Stage Migration Occur as a Consequence of Omitting Completion Lymph Node Dissection for Melanoma? Ann Surg Oncol 2023; 30:3648-3654. [PMID: 36934378 DOI: 10.1245/s10434-023-13342-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 02/19/2023] [Indexed: 03/20/2023]
Abstract
INTRODUCTION Completion lymph node dissection (CLND) is no longer recommended routinely in the treatment of melanoma. CLND omission may understage patients for whom the distinction between stage IIIA and IIIB-C could alter adjuvant therapy recommendations. The aim of this study is to determine if stage migration has occurred with the declining use of CLND. METHODS Patients with clinically node-negative ≥ T1b cutaneous melanoma were identified from the National Cancer Database (NCDB) from 2012 to 2018. CLND utilization and changes in AJCC staging were analyzed. Patients undergoing sentinel lymph node biopsy (SLNB) alone were compared with those undergoing SLNB + CLND. RESULTS Overall, 68,933 patients met inclusion criteria and 60,536 underwent SLNB, of which 9031 (14.9%) were tumor positive. CLND was performed in 3776 (41.8%). Patients undergoing CLND were younger (58 versus 62 years, p < 0.0001) and more likely male (61.5% versus 57.9%, p = 0.0005). Patients were more likely to have an N classification >N1a if they received SLNB + CLND (36.8%) versus SLNB alone (19.3%), p < 0.0001. This translated to a small difference in stage IIIA patients between groups (SLNB alone 34.0%, SLNB + CLND 31.8%, p < 0.0001). Of the patients with T1b/T2a tumors who would be upstaged from IIIA to IIIC with identification of additional positive nodes, IIIC incidence was only slightly higher after SLNB + CLND compared with SLNB alone (4.4% versus 1.1%, p < 0.0001). CLND utilization dramatically decreased from 59% in 2012 to 12.6% in 2018, p < 0.0001. However, the incidence of stage IIIA disease for all patients remained stable over the 7-year study period. CONCLUSIONS While the utilization of CLND after positive SLNB has declined dramatically in the last 7 years, stage migration that may affect adjuvant therapy decisions has not occurred to a clinically meaningful degree.
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Affiliation(s)
- Zachary J Senders
- Division of Surgical Oncology, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY, USA.
| | - Edmund K Bartlett
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tyler J Mouw
- Division of Surgical Oncology, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Michael E Egger
- Division of Surgical Oncology, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY, USA
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12
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Berania I, Tzelnick S, de Almeida JR, McKinnon G, Goldstein DP. Practice patterns for positive sentinel lymph node in head and neck melanoma. Head Neck 2023; 45:555-560. [PMID: 36513594 DOI: 10.1002/hed.27262] [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: 04/02/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND An international survey was conducted to investigate the preferences for completion lymph node dissection (CLND) in head and neck melanomas. METHODS A questionnaire was sent through the American Society of Head & Neck Surgery (AHNS) and Canadian Society of Otolaryngology-Head and Neck Surgery (CSO). RESULTS Hundred and forty-nine surgeons completed the survey. Response rate was 6.3% and 9.7% from AHNS and CSO members, respectively. When presented the scenario of a 47-year-old male with a clinical T3bN0 cheek melanoma, with 1/1 positive sentinel lymph node (SLN) with nodal deposit <2 mm, 72 of respondents (48.3%) would perform a CLND. Reasons for CLND included multiples positive SLN (64.1%), size of nodal deposits (54.2%), and perceived lack of compliance to follow-up (54.2%). Surgeons with access to immunotherapy treatment were less likely to recommend CLND (p = 0.025). CONCLUSIONS Following SLN biopsy, nearly half of the surveyed head and neck surgeons would recommend CLND, which contrasts with the current melanoma practice patterns in other anatomic locations. However, compared with an earlier study in the literature it does seem that there has been a shift away from completion neck dissection. Further investigation into understanding practice variations is warranted.
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Affiliation(s)
- Ilyes Berania
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sharon Tzelnick
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory McKinnon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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13
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Current Controversies in Melanoma Treatment. Plast Reconstr Surg 2023; 151:495e-505e. [PMID: 36821575 DOI: 10.1097/prs.0000000000009936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
LEARNING OBJECTIVES After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. SUMMARY Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.
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14
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Allard-Coutu A, Dobson V, Schmitz E, Shah H, Nessim C. The Evolution of the Sentinel Node Biopsy in Melanoma. Life (Basel) 2023; 13:life13020489. [PMID: 36836846 PMCID: PMC9966203 DOI: 10.3390/life13020489] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.
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Affiliation(s)
- Alexandra Allard-Coutu
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Correspondence:
| | | | - Erika Schmitz
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Hely Shah
- Department of Medical Oncology, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Carolyn Nessim
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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15
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Keller J, Stern S, Chang SC, Marcus R, Weiss J, Nassoiy S, Christopher W, Fischer T, Essner R. Predicting Regional Lymph Node Recurrence in the Modern Age of Tumor-Positive Sentinel Node Melanoma: The Role of the First Postoperative Ultrasound. Ann Surg Oncol 2022; 29:8469-8477. [PMID: 35989390 DOI: 10.1245/s10434-022-12345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Multicenter Selective Lymphadenectomy Trial II (MSLT-II) led to a change in the management of tumor-positive sentinel lymph nodes (SLNs) from completion node dissection (CLND) to nodal observation. This study aimed to evaluate prognostic factors for predicting sentinel node basin recurrence (SNBR) using data from MSLT-II trial participants. METHODS In MSLT-II, 1076 patients were treated with observation. Patients were included in the current study if they had undergone a post-sentinel node basin ultrasound (PSNB-US) within 4 months after surgery. The study excluded patients with positive SLN by reverse transcription-polymerase chain reaction (RT-PCR) or incomplete SLN pathologic data. Primary tumor, patient, PSNB-US, and SLN characteristics were evaluated. Multivariable regression analyses were performed to determine independent prognostic factors associated with SNBR. RESULTS The study enrolled 737 patients: 193 (26.2%) patients with SNBR and 73 (9.9%) patients with first abnormal US. The patients with an abnormal first US were more likely to experience SNBR (23.8 vs. 5.0%). In the multivariable analyses, increased risk of SNBR was associated with male gender (adjusted hazard ratio [aHR], 1.38; 95% confidence interval [CI], 1.00-1.9; p = 0.049), increasing Breslow thickness (aHR, 1.10; 95% CI, 1.01-1.2; p = 0.038), presence of ulceration (aHR, 1.93; 95% CI, 1.42-2.6; p < 0.001), sentinel node tumor burden greater than 1 mm (aHR, 1.91; 95% CI, 1.10-3.3; p = 0.022), lymphovascular invasion (aHR, 1.53; 95% CI, 1.00-2.3; p = 0.048), and presence of abnormal PSNB-US (aHR, 4.29; 95% CI, 3.02-6.1; p < 0.001). CONCLUSIONS The first postoperative US together with clinical and pathologic factors may play an important role in predicting SNBR.
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Affiliation(s)
- Jennifer Keller
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Stacey Stern
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA
| | | | - Rebecca Marcus
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Jessica Weiss
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Sean Nassoiy
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA
| | | | - Trevan Fischer
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Richard Essner
- Providence Saint John's Cancer Institute, Santa Monica, CA, USA.
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16
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Ziętek M, Wierzbicki J, Pawlak E, Maciejczyk A, Matkowski R. Introduction of a pilot program to measure and improve the clinical care of melanoma patients in the Lower Silesian Voivodeship in Poland: a report of 20 months experience. BMC Cancer 2022; 22:1207. [PMID: 36419046 PMCID: PMC9684787 DOI: 10.1186/s12885-022-10253-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In recent years, benchmarking and assessment methods to improve the quality of care have become increasingly important. Such approaches allow for a uniform assessment, comparisons between centers or over time, and the identification of weaknesses. In this study, the results of a 20-month pilot program to assess, monitor and improve the quality of care in melanoma patients primarily treated surgically are presented. METHODS The pilot program started in May 2020 at the Lower Silesian Oncology, Pulmonology and Hematology Center (LSOPHC) in Wroclaw, Poland (Lower Silesian Voivodeship, southwestern province of Poland with a population of 2,9 million). The program involved the introduction of a synoptic histopathological protocol, medical coordinators, and a set of measures to assess oncological care. In total, 11 Skin Cancer Unit (SCU) measures were introduced to analyze clinical outcomes, diagnostic quality, and duration. Data from 352 patients covered by the program were analyzed. In addition, the completeness of diagnostics from external sites was compared to our own results. Furthermore, the timeliness of the initial diagnostic tests and in-depth diagnostics were assessed and compared to the timeliness before implementation of the pilot program. RESULTS The introduced measures assessed the mortality related to oncological treatment, the rate of complications, advanced stages of melanoma, the completeness and duration of diagnostics, the involved nodes after lymphadenectomy, and melanoma screening. During the study period, the timeliness of the initial diagnostics was maintained at 87.8%, and the timeliness of the in-depth diagnostics at 89.5%. Compared to a similar period before the program, these values were 36.1% and 67.5%, respectively. CONCLUSION The introduced measures seem to be effective and practical tools for benchmarking clinical and diagnostic aspects. They also allowed for a sensitive assessment of individual issues and indicated sensitive points. Furthermore, the actions undertaken in this pilot program allowed for a shortening of the duration of diagnostics.
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Affiliation(s)
- Marcin Ziętek
- grid.4495.c0000 0001 1090 049XDepartment of Oncology, Wrocław Medical University, 12 Hirszfeld Square, 53-413 Wrocław, Poland ,grid.500476.00000 0004 0620 4055Dolnośląskie Centrum Onkologii, Pulmonologii i Hematologii (Lower Silesian Oncology, Pulmonology and Hematology Center), 12 Hirszfeld Square, 53-413 Wrocław, Poland
| | - Jędrzej Wierzbicki
- grid.500476.00000 0004 0620 4055Dolnośląskie Centrum Onkologii, Pulmonologii i Hematologii (Lower Silesian Oncology, Pulmonology and Hematology Center), 12 Hirszfeld Square, 53-413 Wrocław, Poland ,grid.413454.30000 0001 1958 0162Laboratory of Immunopathology, Department of Experimental Therapy, Hirszfeld Institute of Immunology & Experimental Therapy, Polish Academy of Sciences, Rudolf Weigl 12 Street, 53-413 Wroclaw, Poland
| | - Edyta Pawlak
- grid.413454.30000 0001 1958 0162Laboratory of Immunopathology, Department of Experimental Therapy, Hirszfeld Institute of Immunology & Experimental Therapy, Polish Academy of Sciences, Rudolf Weigl 12 Street, 53-413 Wroclaw, Poland
| | - Adam Maciejczyk
- grid.4495.c0000 0001 1090 049XDepartment of Oncology, Wrocław Medical University, 12 Hirszfeld Square, 53-413 Wrocław, Poland ,grid.500476.00000 0004 0620 4055Dolnośląskie Centrum Onkologii, Pulmonologii i Hematologii (Lower Silesian Oncology, Pulmonology and Hematology Center), 12 Hirszfeld Square, 53-413 Wrocław, Poland
| | - Rafał Matkowski
- grid.4495.c0000 0001 1090 049XDepartment of Oncology, Wrocław Medical University, 12 Hirszfeld Square, 53-413 Wrocław, Poland ,grid.500476.00000 0004 0620 4055Dolnośląskie Centrum Onkologii, Pulmonologii i Hematologii (Lower Silesian Oncology, Pulmonology and Hematology Center), 12 Hirszfeld Square, 53-413 Wrocław, Poland
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17
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Santamaria-Barria JA, Mammen JMV. Surgical Management of Melanoma: Advances and Updates. Curr Oncol Rep 2022; 24:1425-1432. [PMID: 35657482 DOI: 10.1007/s11912-022-01289-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To review and update surgeons about the evolving complexities in the surgical management of melanoma including lymph node staging and treatment. RECENT FINDINGS Primary resection with adequate margins continues to be the standard of care for localized cutaneous melanoma. Sentinel lymph node biopsy is confirmed to be a powerful tool due to its prognostic value and informative guidance for adjuvant treatments and surveillance. Due to the lack of benefit in melanoma-specific survival and distant metastasis-free survival, completion lymph node dissection is not performed routinely after a positive sentinel lymph node biopsy. Neoadjuvant systemic treatment approaches for advanced loco-regional disease show promise in phase I and II clinical trial data, and phase III studies. The surgical management of cutaneous melanoma continues to evolve with further de-escalation of the extent of excision of primary melanomas and the management of lymph node disease.
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Affiliation(s)
- Juan A Santamaria-Barria
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198-6880, USA
| | - Joshua M V Mammen
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198-6880, USA.
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18
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Intermediate-thickness melanoma: A population-based study of surgical quality metrics. Surgery 2022. [PMID: 37534705 DOI: 10.1016/j.surg.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Variability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists. METHODS T2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates. RESULTS Of 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001). CONCLUSIONS Despite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.
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19
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Sondak VK, Neves RI, Wuthrick EJ, Messina JL, Khushalani NI. Current and future approaches in the surgical management of T3b/T4 primary and locoregionally advanced melanoma. Cancer 2022; 128:3764-3771. [PMID: 36066835 DOI: 10.1002/cncr.34449] [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: 05/19/2022] [Revised: 06/25/2022] [Accepted: 07/14/2022] [Indexed: 11/08/2022]
Abstract
Currently accepted principles of surgical management-margin width, use of sentinel node biopsy, performance of radical node dissections for node-positive cases-and some aspects of postoperative management (use of radiation for desmoplastic melanoma primaries and for clinically node-positive disease) will change in the future with the potential widespread adoption of adjuvant and neoadjuvant therapies.
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Affiliation(s)
- Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Rogerio I Neves
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Reconstructive and Plastic Surgery Program, Moffitt Cancer Center, Tampa, Florida, USA
| | - Evan J Wuthrick
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jane L Messina
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Anatomic Pathology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Nikhil I Khushalani
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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20
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Montgomery KB, Broman KK. ASO Author Reflections: Challenges to Achieving Consistent Nodal Surveillance with Ultrasound in Melanoma. Ann Surg Oncol 2022; 29:5969-5970. [PMID: 35532829 PMCID: PMC11216219 DOI: 10.1245/s10434-022-11883-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Kelsey B Montgomery
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Kristy K Broman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
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21
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Montgomery KB, Correya TA, Broman KK. Real-World Adherence to Nodal Surveillance for Sentinel Lymph Node-Positive Melanoma. Ann Surg Oncol 2022; 29:5961-5968. [PMID: 35608800 PMCID: PMC10827327 DOI: 10.1245/s10434-022-11839-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/19/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with sentinel lymph node-positive (SLN+) melanoma are increasingly undergoing active nodal surveillance over completion lymph node dissection (CLND) since the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II). Adherence to nodal surveillance in real-world practice remains unknown. METHODS In a retrospective cohort of SLN+ melanoma patients who underwent nodal surveillance at a single institution from July 2017 through April 2021, this study evaluated adherence to nodal surveillance ultrasound (US). Adherence to nodal US was compared with adherence to other surveillance methods based on receipt of adjuvant therapy. Early recurrence data were reported using descriptive statistics. RESULTS Among 109 SLN+ patients, 37 (34%) received US surveillance at recommended intervals. Of the 72 (66%) non-adherent patients, 16 were lost to follow-up, and 33 had planned follow-up at an outside institution without available records. More patients had a minimum of bi-annual clinic visits (83%) and cross-sectional imaging (53%) compared to those who were adherent with nodal US. The patients who received adjuvant therapy (60%) had fewer ultrasounds (p < 0.01) but more exams (p < 0.01) and a trend toward more cross-sectional imaging (p = 0.06). Of the overall cohort, 26 patients (24%) experienced recurrence at a median follow-up period of 15 months. Of these recurrences, 10 were limited to the SLN basin, and all of these isolated nodal recurrences were resectable. CONCLUSIONS Pragmatic challenges to real-world delivery of nodal surveillance remain after MSLT-II, and adjuvant therapy appears to be associated with a decreased likelihood of US adherence. Understanding US utility alongside cross-sectional imaging will be critical as increasingly more patients undergo nodal surveillance and adjuvant therapy.
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Affiliation(s)
- Kelsey B Montgomery
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Tanya A Correya
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristy K Broman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
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22
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Eroglu Z, Broman KK, Thompson JF, Nijhuis A, Hieken TJ, Kottschade L, Farma JM, Hotz M, Deneve J, Fleming M, Bartlett EK, Sharma A, Dossett L, Hughes T, Gyorki DE, Downs J, Karakousis G, Song Y, Lee A, Berman RS, van Akkooi A, Stahlie E, Han D, Vetto J, Beasley G, Farrow NE, Hui JYC, Moncrieff M, Nobes J, Baecher K, Perez M, Lowe M, Ollila DW, Collichio FA, Bagge RO, Mattsson J, Kroon HM, Chai H, Teras J, Sun J, Carr MJ, Tandon A, Babacan NA, Kim Y, Naqvi M, Zager J, Khushalani NI. Outcomes with adjuvant anti-PD-1 therapy in patients with sentinel lymph node-positive melanoma without completion lymph node dissection. J Immunother Cancer 2022; 10:jitc-2021-004417. [PMID: 36002183 PMCID: PMC9413295 DOI: 10.1136/jitc-2021-004417] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/08/2022] Open
Abstract
Until recently, most patients with sentinel lymph node-positive (SLN+) melanoma underwent a completion lymph node dissection (CLND), as mandated in published trials of adjuvant systemic therapies. Following multicenter selective lymphadenectomy trial-II, most patients with SLN+ melanoma no longer undergo a CLND prior to adjuvant systemic therapy. A retrospective analysis of clinical outcomes in SLN+ melanoma patients treated with adjuvant systemic therapy after July 2017 was performed in 21 international cancer centers. Of 462 patients who received systemic adjuvant therapy, 326 patients received adjuvant anti-PD-1 without prior immediate (IM) CLND, while 60 underwent IM CLND. With median follow-up of 21 months, 24-month relapse-free survival (RFS) was 67% (95% CI 62% to 73%) in the 326 patients. When the patient subgroups who would have been eligible for the two adjuvant anti-PD-1 clinical trials mandating IM CLND were analyzed separately, 24-month RFS rates were 64%, very similar to the RFS rates from those studies. Of these no-CLND patients, those with SLN tumor deposit >1 mm, stage IIIC/D and ulcerated primary had worse RFS. Of the patients who relapsed on adjuvant anti-PD-1, those without IM CLND had a higher rate of relapse in the regional nodal basin than those with IM CLND (46% vs 11%). Therefore, 55% of patients who relapsed without prior CLND underwent surgery including therapeutic lymph node dissection (TLND), with 30% relapsing a second time; there was no difference in subsequent relapse between patients who received observation vs secondary adjuvant therapy. Despite the increased frequency of nodal relapses, adjuvant anti-PD-1 therapy may be as effective in SLN+ pts who forego IM CLND and salvage surgery with TLND at relapse may be a viable option for these patients.
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Affiliation(s)
- Zeynep Eroglu
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA .,University of South Florida, Tampa, Florida, USA
| | - Kristy K Broman
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA,University of South Florida, Tampa, Florida, USA
| | - John F Thompson
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
| | - Amanda Nijhuis
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
| | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, New York, USA
| | - Lisa Kottschade
- Department of Surgery, Mayo Clinic, Rochester, New York, USA
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Meghan Hotz
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jeremiah Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Martin Fleming
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Edmund K Bartlett
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Avinash Sharma
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lesly Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Tasha Hughes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - David E Gyorki
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jennifer Downs
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Giorgos Karakousis
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yun Song
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Lee
- Department of Surgery, New York University, New York, New York, USA
| | - Russell S Berman
- Department of Surgery, New York University, New York, New York, USA
| | - Alexander van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emma Stahlie
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dale Han
- Division of Surgical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - John Vetto
- Division of Surgical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - Georgia Beasley
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Norma E Farrow
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | | | | | - Jenny Nobes
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Kirsten Baecher
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Matthew Perez
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Michael Lowe
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - David W Ollila
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Frances A Collichio
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska Center for Cancer Research, University of Gothenburg, Gothenburg, Sweden
| | - Jan Mattsson
- Department of Surgery, Sahlgrenska Center for Cancer Research, University of Gothenburg, Gothenburg, Sweden
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Harvey Chai
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Jyri Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Nalan Akgul Babacan
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Younchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida, USA
| | - Mahrukh Naqvi
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jonathan Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA,University of South Florida, Tampa, Florida, USA
| | - Nikhil I Khushalani
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA,University of South Florida, Tampa, Florida, USA
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Ulrich J, Maschke J, Winkelmann A, Schwürzer-Voit M, Jenderka KV. [Conventional ultrasound diagnostics in dermatology]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 73:563-574. [PMID: 35925205 DOI: 10.1007/s00105-022-05012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 06/15/2023]
Abstract
The imaging of changes to the skin, the subcutis and especially the regional lymph nodes by high-resolution ultrasound is an integral part of routine dermatological diagnostics. This is mainly done with electronic scanners operating at frequencies between 7.5 and 20 MHz (conventional ultrasound diagnostics). In addition, there are very high-frequency ultrasound systems (frequencies up to 100 MHz) that are used for special scientific questions. Ultrasound diagnostics has a number of advantages over other cross-sectional imaging techniques but is more dependent than these on the individual experience of the examiner. Structured training and continuing education are therefore essential for ultrasound diagnostics, also in dermatology. The following overview describes the most important indications for conventional sonography in dermatology in addition to the physical, technical and administrative principles.
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Affiliation(s)
- Jens Ulrich
- Klinik für Dermatologie und Allergologie, Hautkrebszentrum Harz, Harzklinikum Dorothea Christiane Erxleben, Ditfurter Weg 24, 06484, Quedlinburg, Deutschland.
| | | | | | | | - Klaus-Vitold Jenderka
- Fachbereich Ingenieur- und Naturwissenschaften, Hochschule Merseburg, Merseburg, Deutschland
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24
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Ascierto PA, Warner AB, Blank C, Caracò C, Demaria S, Gershenwald JE, Khushalani NI, Long GV, Luke JJ, Mehnert JM, Robert C, Rutkowski P, Tawbi HA, Osman I, Puzanov I. The "Great Debate" at Melanoma Bridge 2021, December 2nd-4th, 2021. J Transl Med 2022; 20:200. [PMID: 35538491 PMCID: PMC9087170 DOI: 10.1186/s12967-022-03406-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022] Open
Abstract
The Great Debate session at the 2021 Melanoma Bridge virtual congress (December 2-4) featured counterpoint views from experts on seven important issues in melanoma. The debates considered the use of adoptive cell therapy versus use of bispecific antibodies, mitogen-activated protein kinase (MAPK) inhibitors versus immunotherapy in the adjuvant setting, whether the use of corticosteroids for the management of side effects have an impact on outcomes, the choice of programmed death (PD)-1 combination therapy with cytotoxic T-lymphocyte-associated antigen (CTLA)-4 or lymphocyte-activation gene (LAG)-3, whether radiation is needed for brain metastases, when lymphadenectomy should be integrated into the treatment plan and then the last debate, telemedicine versus face-to-face. As with previous Bridge congresses, the debates were assigned by meeting Chairs and positions taken by experts during the debates may not have necessarily reflected their respective personal view. Audiences voted both before and after each debate.
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Affiliation(s)
- Paolo A Ascierto
- Department of Melanoma, Cancer Immunotherapy and Innovative Therapy, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy.
| | | | | | - Corrado Caracò
- Division of Surgery of Melanoma and Skin Cancer, Istituto Nazionale Tumori "Fondazione Pascale" IRCCS, Naples, Italy
| | - Sandra Demaria
- Department of Radiation Oncology, Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia.,Faculty of Medicine & Health, The University of Sydney, Sydney, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Jason J Luke
- University of Pittsburgh Medical Center, UPMC) Hillman Cancer Center, Pittsburgh, PA, USA
| | - Janice M Mehnert
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Caroline Robert
- Institut de Cancérologie Gustave Roussy Et Université Paris-Saclay, Villejuif, France
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Hussein A Tawbi
- Melanoma Medical Oncology, Investigational Cancer Therapeutics, Division of Cancer Medicine, MD Anderson Brain Metastasis Clinic, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Iman Osman
- New York University Langone Medical Center, New York, NY, USA
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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25
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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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26
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Broman KK, Richman J, Bhatia S. Evidence and implementation gaps in management of sentinel node-positive melanoma in the United States. Surgery 2022; 172:226-233. [PMID: 35120732 DOI: 10.1016/j.surg.2021.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/25/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Melanoma clinical trials demonstrated that completion lymph node dissection is low value for most sentinel lymph node-positive patients. Contemporaneous trials of adjuvant systemic immunotherapy and BRAF/MEK targeted therapy showed improved recurrence-free survival in high-risk sentinel lymph node-positive patients. To better understand how oncologic evidence is incorporated into practice (implementation), we evaluated factors associated with discontinuation of completion lymph node dissection and adoption of systemic treatment at United States Commission on Cancer-accredited centers. METHODS In a retrospective cohort study of adults with sentinel lymph node-positive melanoma treated from 2012 to 2017 using the National Cancer Database, we evaluated use of completion lymph node dissection and adjuvant systemic treatment using mixed-effects logistic regression, reporting results as odds ratios with 95% confidence intervals. RESULTS Among 10,240 sentinel lymph node-positive melanoma patients, performance of completion lymph node dissection declined from 60% to 27%. Adjuvant systemic treatment increased from 29% to 43% (37% in stage IIIA patients, 46% in IIIB-C). Completion lymph node dissection was less common with lower extremity tumors (odds ratio = 0.53, 95% confidence interval = 0.44-0.64) and more common with multiple positive sentinel lymph nodes (odds ratio = 2.36, 95% confidence interval = 2.08-2.67), treatment at a high- or moderate-volume center (odds ratiohigh = 1.49, 95% confidence interval = 1.05-2.12; odds ratiomoderate = 1.32, 95% confidence interval = 1.05-1.64), and receipt of systemic therapy (odds ratio = 1.44, 95% confidence interval = 1.27-1.63). The increased likelihood of completion lymph node dissection in patients receiving adjuvant systemic treatment persisted in the most recent study years and in patients with a single positive sentinel lymph node. CONCLUSION At a population level, completion lymph node dissection declined and adjuvant systemic treatment increased, reflecting evidence-responsive care. Variation in persistent use of completion lymph node dissection and in provision of adjuvant treatment for lower risk patients highlights residual gaps in both evidence and implementation.
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Affiliation(s)
- Kristy K Broman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL.
| | - Joshua Richman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL
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Risk Factors for Lower Extremity Lymphedema after Inguinal Lymphadenectomy in Melanoma Patients: A Retrospective Cohort Study. Surg Open Sci 2022; 8:33-39. [PMID: 35280121 PMCID: PMC8914217 DOI: 10.1016/j.sopen.2022.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/26/2022] [Accepted: 02/04/2022] [Indexed: 01/25/2023] Open
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28
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Lindqvist Bagge AS, Wesslau H, Cizek R, Holmberg CJ, Moncrieff M, Katsarelias D, Carlander A, Olofsson Bagge R. Health-related quality of life using the FACT-M questionnaire in patients with malignant melanoma: A systematic review. Eur J Surg Oncol 2021; 48:312-319. [PMID: 34600786 DOI: 10.1016/j.ejso.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/20/2021] [Accepted: 09/16/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Since there are no formal definition of health-related quality of life (HRQOL) there may be a lack of coherence and understanding of how to interpret HRQOL-data. The aim of this study is to summarize HRQOL-results that have used the FACT-M questionnaire in patients with melanoma, and specifically to summarize FACT-M between tumor stage. METHODS This review was conducted in accordance with the PRISMA guidelines. INCLUSION CRITERIA original studies on cutaneous melanoma between 2005 and 2020, written in English, containing "Functional Assessment of Cancer Therapy Melanoma" OR "Functional Assessment of Cancer Therapy M" OR FACT-M OR FACT/M OR FACTM OR "FACT M" OR FACT-melanoma OR "FACT Melanoma" together with FACT-M numbered data and basic patient characteristics, using the databases Scopus, Web of Science, PubMed and PsycINFO. RESULTS 16 articles describing 14 patient cohorts published 2008-2020 were included. The majority of the studies did not report subscale scores in accordance with FACT-M guidelines. The results did indicate that FACT-M total scores were inversely correlated with AJCC stage. Subscale analysis demonstrated varying degrees of correlation with AJCC stage. The Melanoma Surgery Subscale score was lowest in stage III patients, probably reflecting more advanced surgical procedures in this group of patients. CONCLUSIONS Though this review is based on a questionnaire limited to the assessment of melanoma patients, it highlights the universal need for clinical studies to describe their selected HRQOL-questionnaires, its definition of HRQOL and its dimensions, as well as comply with the questionnaire's guidelines when reporting HRQOL-data.
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Affiliation(s)
- Ann-Sophie Lindqvist Bagge
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Psychology, Gothenburg University, Gothenburg, Sweden.
| | - Hanna Wesslau
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Roza Cizek
- Department of Psychology, Gothenburg University, Gothenburg, Sweden
| | - Carl Jacob Holmberg
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Marc Moncrieff
- Department of Plastic & Reconstructive Surgery, Norfolk & Norwich University Hospital, Norwich, UK
| | - Dimitrios Katsarelias
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Anders Carlander
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden; SOM Institute. University of Gothenburg, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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29
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Torphy RJ, Friedman C, Ho F, Leonard LD, Thieu D, Lewis KD, Medina TM, Robinson WA, Gonzalez RC, Stewart CL, Kounalakis N, McCarter MD, Gleisner A. Adjuvant Therapy for Stage III Melanoma Without Immediate Completion Lymph Node Dissection. Ann Surg Oncol 2021; 29:806-815. [PMID: 34537899 DOI: 10.1245/s10434-021-10775-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/23/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION For patients with stage III melanoma with occult lymph node metastasis, the use of adjuvant therapy is increasing, and completion lymph node dissection (CLND) is decreasing. We sought to evaluate the use of modern adjuvant therapy and outcomes for patients with stage III melanoma who did not undergo CLND. METHODS Patients with a positive SLNB from 2015 to 2020 who did not undergo CLND were evaluated retrospectively. Nodal recurrence, recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and melanoma-specific survival were evaluated. RESULTS Among 90 patients, 56 (62%) received adjuvant therapy and 34 (38%) underwent observation alone. Patients who received adjuvant therapy were younger (mean age: 53 vs. 65, p < 0.001) and had higher overall stage (Stage IIIb/c 75% vs. 54%, p = 0.041). Disease recurred in 12 of 34 patients (35%) in the observation group and 11 of 56 patients (20%) in the adjuvant therapy group. The most common first site of recurrence was distant recurrence alone (5/34 patients) in the observation group and nodal recurrence alone (8/90 patients) in the adjuvant therapy group. Despite more adverse nodal features in the adjuvant therapy group, 24-month nodal recurrence rate and RFS were not significantly different between the adjuvant and observation cohorts (nodal recurrence rate: 26% vs. 20%, p = 0.68; RFS: 75% vs. 61%, p = 0.39). Among patients with stage IIIb/c disease, adjuvant therapy was associated with a significantly improved 24-month DMFS (86% vs. 59%, p = 0.04). CONCLUSIONS In this early report, modern adjuvant therapy in patients who forego CLND is associated with longer DMFS among patients with stage IIIb/c disease.
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Affiliation(s)
- Robert J Torphy
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Chloe Friedman
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Felix Ho
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura D Leonard
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel Thieu
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Karl D Lewis
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Theresa M Medina
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William A Robinson
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rene C Gonzalez
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicole Kounalakis
- Melanoma Sarcoma Specialists of Georgia, Northside Cancer Institute, Atlanta, GA, USA
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ana Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Downs JS, Subramaniam S, Henderson MA, Paton E, Spillane AJ, Mathy JA, Gyorki DE. A survey of surgical management of the sentinel node positive melanoma patient in the post-MSLT2 era. J Surg Oncol 2021; 124:1544-1550. [PMID: 34406652 DOI: 10.1002/jso.26641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/06/2021] [Accepted: 07/15/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND The evidence-based management of melanoma patients with a positive sentinel lymph node biopsy (SLNB) has undergone a dramatic shift following publication of practice-changing surgical trials demonstrating no melanoma-specific survival advantage for completion lymph node dissection (CLND) in this scenario. We aimed to survey how surgeons' clinical practice had shifted in response to new evidence from these trials, and at a time when there was starting to become available systemic adjuvant treatments for AJCC Stage III melanoma patients. METHODS A web-based survey consisting of practice-based questions and hypothetical clinical scenarios about current melanoma practice with regard to positive sentinel node biopsy was developed and sent to the surgical members of a Melanoma and Skin Cancer (MASC) Trials group in December 2018. Responses were analysed using descriptive statistics. RESULTS There were 212 invitations sent and 65 respondents (31%). Respondents were from 17 countries, 94% of whom practice in specialist melanoma centres or at referral centres. Of these 97% were familiar with the MSLT2 and DeCOG-SLT clinical trials. At survey, 5% of respondents reported routinely recommending CLND and 55% recommend CLND in selected cases. Respondents were most likely to recommend CLND when multiple SLNs were positive. Important factors for surgical decision-making mentioned included size of SLN deposit, number of positive SLNs and likely compliance with the recommended surveillance regimen. CONCLUSION In line with rapid adoption of published evidence, surgical management of Stage III melanoma has altered significantly, with few surgeons within the cohort now performing routine CLNDs after positive SLNB.
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Affiliation(s)
| | | | - Michael A Henderson
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Paton
- Melanoma and Skin Cancer Trials Ltd, Monash University, Melbourne, Victoria, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Royal North Shore Hospital, St Leonards, Sydney, New South Wales, Australia.,Mater Hospital, Wollstonecraft, Sydney, New South Wales, Australia
| | - Jon A Mathy
- Auckland Regional Plastic Surgery Unit, Auckland, New Zealand.,University of Auckland, Auckland, Australia
| | - David E Gyorki
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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31
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Thompson JF. In Sentinel Node-Positive Melanoma Patients, Does Omission of Completion Lymph Node Dissection Make More Intensive Follow-Up Necessary, and Does Adjuvant Systemic Therapy Permit Less Intensive Follow-Up? Ann Surg Oncol 2021; 28:6915-6917. [PMID: 34365560 PMCID: PMC8519943 DOI: 10.1245/s10434-021-10572-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/18/2022]
Affiliation(s)
- John F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, NSW, Australia. .,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. .,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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32
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Broman KK, Bettampadi D, Pérez-Morales J, Sun J, Kirichenko D, Carr MJ, Eroglu Z, Tarhini AA, Khushalani N, Schabath MB, Sarnaik A, Sondak VK, Zager JS. Surveillance of Sentinel Node-Positive Melanoma Patients Who Receive Adjuvant Therapy Without Undergoing Completion Lymph Node Dissection. Ann Surg Oncol 2021; 28:6978-6985. [PMID: 34363118 DOI: 10.1245/s10434-021-10570-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Adjuvant therapy trials required completion lymph node dissection (CLND) for sentinel lymph node (SLN)-positive melanoma prior to systemic treatment, but nodal surveillance without CLND is now common. For patients receiving adjuvant therapy without CLND, patterns of recurrence are unknown and the value of regional nodal ultrasound alongside cross-sectional imaging is not well-defined. METHODS In a retrospective cohort of SLN-positive melanoma patients managed with nodal surveillance from June 2014 to June 2019, we evaluated the association between adjuvant treatment and location of first recurrence (locoregional, nodal, distant, or multisite) using Chi-square tests. We compared methods of recurrence detection and cost by surveillance intensity using Chi-square and Dunn's tests. RESULTS Among 177 nodal surveillance patients, 66 (37%) received adjuvant therapy. Median follow-up was 24 months, during which 48 patients (27%) recurred. Adjuvant treatment did not alter patterns of initial recurrence (p = 0.76). Adjuvant therapy recipients more often had both nodal ultrasound and cross-sectional imaging surveillance (p < 0.01). Among 13 isolated nodal recurrences, 85% were within the first year and 85% were detected by examination and/or ultrasound. Increasing surveillance intensity was not associated with recurrence detection rates but increased overall cost and cost per detected recurrence. CONCLUSION Regardless of adjuvant treatment, most nodal recurrences occurred in the first year and were initially detected clinically or by ultrasound. Findings support continued use of examination and nodal basin ultrasound in addition to any planned cross-sectional imaging surveillance.
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Affiliation(s)
- Kristy K Broman
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA. .,University of South Florida Morsani College of Medicine, Tampa, FL, USA. .,University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | | | - James Sun
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Dennis Kirichenko
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael J Carr
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Zeynep Eroglu
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Ahmad A Tarhini
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Nikhil Khushalani
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Matthew B Schabath
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Amod Sarnaik
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Vernon K Sondak
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jonathan S Zager
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,University of South Florida Morsani College of Medicine, Tampa, FL, USA
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33
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Gershenwald JE. Active surveillance of patients who have melanoma with a positive sentinel node in an era of effective adjuvant therapy: Early lessons learned … and still learning. Cancer 2021; 127:2177-2180. [PMID: 33826746 DOI: 10.1002/cncr.33484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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