New TNM melanoma staging system: linking biology and natural history to clinical outcomes

Does the morphology of cutaneous melanoma help to explain the international differences in survival? Results from 1 578 482 adults diagnosed during 2000-2014 in 59 countries (CONCORD-3)

BACKGROUND

CONCORD-3 highlighted wide disparities in population-based 5-year net survival for cutaneous melanoma during 2000-2014. Clinical evidence suggests marked international differences in the proportion of lethal acral and nodular subtypes of cutaneous melanoma.

OBJECTIVES

We aimed to assess whether the differences in morphology may explain global variation in survival.

METHODS

Patients with melanoma were grouped into the following seven morphological categories: malignant melanoma, not otherwise specified (International Classification of Diseases for Oncology, third revision morphology code 8720), superficial spreading melanoma (8743), lentigo maligna melanoma (8742), nodular melanoma (8721), acral lentiginous melanoma (8744), desmoplastic melanoma (8745) and other morphologies (8722-8723, 8726-8727, 8730, 8740-8741, 8746, 8761, 8770-8774, 8780). We estimated net survival using the nonparametric Pohar Perme estimator, correcting for background mortality by single year of age, sex and calendar year in each country or region. All-ages survival estimates were standardized using the International Cancer Survival Standard weights. We fitted a flexible parametric model to estimate the effect of morphology on the hazard of death.

RESULTS

Worldwide, the proportion of nodular melanoma ranged between 7% and 13%. Acral lentiginous melanoma accounted for less than 2% of all registrations but was more common in Asia (6%) and Central and South America (7%). Overall, 36% of tumours were classified as superficial spreading melanoma. During 2010-2014, age-standardized 5-year net survival for superficial spreading melanoma was 95% or higher in Oceania, North America and most European countries, but was only 71% in Taiwan. Survival for acral lentiginous melanoma ranged between 66% and 95%. Nodular melanoma had the poorest prognosis in all countries. The multivariable analysis of data from registries with complete information on stage and morphology found that sex, age and stage at diagnosis only partially explain the higher risk of death for nodular and acral lentiginous subtypes.

CONCLUSIONS

This study provides the broadest picture of distribution and population-based survival trends for the main morphological subtypes of cutaneous melanoma in 59 countries. The poorer prognosis for nodular and acral lentiginous melanomas, more frequent in Asia and Latin America, suggests the need for health policies aimed at specific populations to improve awareness, early diagnosis and access to treatment. What is already known about this topic? The histopathological features of cutaneous melanoma vary markedly worldwide. The proportion of melanomas with the more aggressive acral lentiginous or nodular histological subtypes is higher in populations with predominantly dark skin than in populations with predominantly fair skin. What does this study add? We aimed to assess the extent to which these differences in morphology may explain international variation in survival when all histological subtypes are combined. This study provides, for the first time, international comparisons of population-based survival at 5 years for the main histological subtypes of melanoma for over 1.5 million adults diagnosed during 2000-2014. This study highlights the less favourable distribution of histological subtypes in Asia and Central and South America, and the poorer prognosis for nodular and acral lentiginous melanomas. We found that later stage at diagnosis does not fully explain the higher excess risk of death for nodular and acral lentiginous melanoma compared with superficial spreading melanoma.

The Interplay between Tumour Microenvironment Components in Malignant Melanoma

Malignant melanoma has shown an increasing incidence during the last two decades, exhibiting a large spectrum of locations and clinicopathological characteristics. Although current histopathological, biochemical, immunohistochemical, and molecular methods provide a deep insight into its biological behaviour and outcome, melanoma is still an unpredictable disease, with poor outcome. This review of the literature is aimed at updating the knowledge regarding melanoma’s clinicopathological and molecular hallmarks, including its heterogeneity and plasticity, involving cancer stem cells population. A special focus is given on the interplay between different cellular components and their secretion products in melanoma, considering its contribution to tumour progression, invasion, metastasis, recurrences, and resistance to classical therapy. Furthermore, the influences of the specific tumour microenvironment or “inflammasome”, its association with adipose tissue products, including the release of “extracellular vesicles”, and distinct microbiota are currently studied, considering their influences on diagnosis and prognosis. An insight into melanoma’s particular features may reveal new molecular pathways which may be exploited in order to develop innovative therapeutic approaches or tailored therapy.

Prognosis for Cutaneous Melanoma by Clinical and Pathological Profile: A Population-Based Study

Introduction

Among white people, the incidence of cutaneous malignant melanoma (CMM) has been increasing steadily for several decades. Meanwhile, there has also been a significant improvement in 5-year survival among patients with melanoma. This population-based cohort study investigates the five-year melanoma-specific survival (MSS) for all melanoma cases recorded in 2015 in the Veneto Tumor Registry (North-Est Italian Region), taking both demographic and clinical-pathological variables into consideration.

Methods

The cumulative melanoma-specific survival probabilities were calculated with the Kaplan-Meier method, applying different sociodemographic and clinical-pathological variables. Cox’s proportional hazards model was fitted to the data to assess the association between independent variables and MSS, and also overall survival (OS), calculating the hazard ratios (HR) relative to a reference condition, and adjusting for sex, age, site of tumor, histotype, melanoma ulceration, mitotic count, tumor-infiltrating lymphocytes (TIL), and stage at diagnosis.

Results

Compared with stage I melanoma, the risk of death was increased for stage II (HR 3.31, 95% CI: 0.94-11.76, p=0.064), almost ten times higher for stage III (HR 10.51, 95% CI: 3.16-35.02, p<0.001), and more than a hundred times higher for stage IV (HR 117.17, 95% CI: 25.30-542.62, p<0.001). Among the other variables included in the model, the presence of mitoses and histological subtype emerged as independent risk factors for death.

Conclusions

The multivariable analysis disclosed that older age, tumor site, histotype, mitotic count, and tumor stage were independently associated with a higher risk of death. Data on survival by clinical and morphological characteristics could be useful in modelling, planning, and managing the most appropriate treatment and follow-up for patients with CMM.

Five-year survival in patients with nodular and superficial spreading melanomas in the US population

BACKGROUND

Although superficial spreading melanomas (SSM) are diagnosed as thinner lesions, nodular melanomas (NM) have a more rapid growth rate and are biologically more aggressive compared with other histologic subtypes.

OBJECTIVE

To determine the difference in 5-year relative survival in patients with NM and SSM at the same Breslow depth and TNM stage.

METHODS

A population-based cross-sectional analysis compared the 5-year relative survival of patients with NM and SSM using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)∗Stat software (version 8.2.1-8.3.5). Chi-square tests compared the proportions, and Kaplan-Meier method with Z-score compared 5-year relative survival.

RESULTS

For patients receiving a diagnosis between 2004 and 2009, 5-year relative survival was lower in NM compared with SSM (53.7% vs 87.3%; Z score, -41.35; P < .001). Similarly, for patients receiving a diagnosis between 2010 and 2015, 5-year relative survival was lower in NM compared with SSM (61.5% vs 89.7%; Z score, -2.7078; P < .01). Subgroup analyses showed inferior survival in NM in T1b, and survival differences remained significant after excluding patients with nodal or distant metastases.

CONCLUSIONS

Five-year relative survival is worse in NM compared with SSM especially in T1b, T2a, and T2b melanomas. Melanoma subtype should be taken into consideration when making treatment recommendations.

Primary Melanoma Histologic Subtype: Impact on Survival and Response to Therapy

BACKGROUND

Two primary histologic subtypes, superficial spreading melanoma (SSM) and nodular melanoma (NM), comprise the majority of all cutaneous melanomas. NM is associated with worse outcomes, which have been attributed to increased thickness at presentation, and it is widely expected that NM and SSM would exhibit similar behavior once metastasized. Herein, we tested the hypothesis that primary histologic subtype is an independent predictor of survival and may impact response to treatment in the metastatic setting.

METHODS

We examined the most recent Surveillance, Epidemiology, and End Results (SEER) cohort (n = 118 508) and the New York University (NYU) cohort (n = 1621) with available protocol-driven follow-up. Outcomes specified by primary histology were studied in both the primary and metastatic settings with respect to BRAF-targeted therapy and immunotherapy. We characterized known driver mutations and examined a 140-gene panel in a subset of NM and SSM cases using next-generation sequencing. All statistical tests were two-sided.

RESULTS

NM was an independent risk factor for death in both the SEER (hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.41 to 1.70, P < .001) and NYU (HR = 1.47, 95% CI = 1.05, 2.07, P = .03) cohorts, controlling for thickness, ulceration, stage, and other variables. In the metastatic setting, NM remained an independent risk factor for death upon treatment with BRAF-targeted therapy (HR = 3.33, 95% CI = 1.06 to 10.47, P = .04) but showed no statistically significant difference with immune checkpoint inhibition. NM was associated with a higher rate of NRAS mutation (P < .001), and high-throughput sequencing revealed NM-specific genomic alterations in NOTCH4, ANK3, and ZNF560, which were independently validated.

CONCLUSIONS

Our data reveal distinct clinical and biological differences between NM and SSM that support revisiting the prognostic and predictive impact of primary histology subtype in the management of cutaneous melanoma.

Multiple antigen-engineered DC vaccines with or without IFNα to promote antitumor immunity in melanoma

Background

Cancer vaccines are designed to promote systemic antitumor immunity and tumor eradication. Cancer vaccination may be more efficacious in combination with additional interventions that may build on or amplify their effects.

Methods

Based on our previous clinical and in vitro studies, we designed an antigen-engineered DC vaccine trial to promote a polyclonal CD8⁺ and CD4⁺ T cell response against three shared melanoma antigens. The 35 vaccine recipients were then randomized to receive one month of high-dose IFNα or observation.

Results

The resulting clinical outcomes were 2 partial responses, 8 stable disease and 14 progressive disease among patients with measurable disease using RECIST 1.1, and, of 11 surgically treated patients with no evidence of disease (NED), 4 remain NED at a median follow-up of 3 years. The majority of vaccinated patients showed an increase in vaccine antigen-specific CD8⁺ and CD4⁺ T cell responses. The addition of IFNα did not appear to improve immune or clinical responses in this trial. Examination of the DC vaccine profiles showed that IL-12p70 secretion did not correlate with immune or clinical responses. In depth immune biomarker studies support the importance of circulating Treg and MDSC for development of antigen-specific T cell responses, and of circulating CD8⁺ and CD4⁺ T cell subsets in clinical responses.

Conclusions

DC vaccines are a safe and reliable platform for promoting antitumor immunity. This combination with one month of high dose IFNα did not improve outcomes. Immune biomarker analysis in the blood identified several predictive and prognostic biomarkers for further analysis, including MDSC.

Trial registration

NCT01622933.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0552-x) contains supplementary material, which is available to authorized users.

FAK inhibition reduces metastasis of α4 integrin-expressing melanoma to lymph nodes by targeting lymphatic VCAM-1 expression

Malignant melanoma typically metastasizes to lymph nodes (LNs) as a primary or in-transit lesion before secondary metastasis occurs, and LN biopsy is a common procedure to diagnose melanoma progression. Since cancer metastasis is a complex process where various interactions between tumor cells and the stroma play key roles in establishing metastatic lesions, the exact mechanisms underlying melanoma metastasis to LNs remains unknown. It has been known that focal adhesion kinase (FAK) activity promotes the expression of proinflammatory vascular cell adhesion molecule-1 (VCAM-1). As VCAM-1 is a major receptor for α4 integrin and plays a key role in leukocyte recruitment, we reasoned that inhibition of FAK activity may reduce VCAM-1 expression within LNs and thus reduce metastasis of α4 integrin-expressing melanoma to LNs. First, we found that a pharmacological FAK inhibitor, PF-271, blocked tumor necrosis factor-α (TNF-α)-mediated VCAM-1 expression on human dermal lymphatic endothelial cells (HDLECs). In vitro, PF-271 significantly decreased B16F10 melanoma adhesion to and transmigration through HDLECs compared to TNF-α treated cells. Furthermore, in vivo FAK inhibition by oral PF-271 administration reduced VCAM-1 expression in inguinal, cervical, and popliteal LNs compared to vehicle treated mice. Finally, in a footpad metastasis model, B16F10 melanoma cells were injected into the right footpad of C57BL/6 mice, and PF-271 (50 mg/kg, twice daily for 6 days) was orally administrated after 1 week of tumor transplantation. While untreated mice exhibited significant metastatic melanoma lesions in popliteal LNs, PF-271 treated mice showed only marginal melanoma metastasis. These results support the possibility that FAK inhibitors may be a novel preventative option in melanoma metastasis by blocking VCAM-1 expression in LNs.

Malignant adnexal tumors of the skin: a single institution experience

BACKGROUND

Malignant adnexal tumors of the skin (MATS) are rare. We aimed to measure the survival of patients with MATS and identify predictors of improved survival.

METHODS

A retrospective review of MATS treated at our institution from 1990 to 2012.

RESULTS

There were 50 patients within the time period. Median age was 59.5 years (range 22-95); primary site was the head and neck (52%); most common histologic subtypes were skin appendage carcinoma (20%) and eccrine adenocarcinoma (20%); and the vast majority were T1 (44%). Most patients (98%) underwent surgical treatment. Chemotherapy and radiation were administered to 8 and 14% of patients, respectively. Recurrence rate was 12%. Median OS was 158 months (95% CI, 52-255). OS and recurrence-free survival at 5 years were 62.4 and 47.4% and at 10 years 56.7 and 41.5%, respectively. Five-year and 10-year disease-specific survival (DSS) was 62.9%. Age > 60 years was an unfavorable predictor of OS (HR 12.9, P < .0008) and recurrence-free survival (RFS) (HR 12.53, P < .0003). Nodal metastasis was a negative predictor of RFS (HR 2.37, P < 0.04) and DSS (HR 7.2, P < 0.03) while treatment with chemotherapy was predictive of poor DSS (HR 14.21, P < 0.03).

CONCLUSIONS

Younger patients had better OS and RFS. Absence of nodal metastasis translated to better RFS and DSS. Lymph node basin staging is worth considering in the workup and treatment.

Focus on cutaneous and uveal melanoma specificities

Cutaneous melanoma (CM) and uveal melanoma (UM) derive from cutaneous and uveal melanocytes that share the same embryonic origin and display the same cellular function. However, the etiopathogenesis and biological behaviors of these melanomas are very different. CM and UM display distinct landscapes of genetic alterations and show different metastatic routes and tropisms. Hence, therapeutic improvements achieved in the last few years for the treatment of CM have failed to ameliorate the clinical outcomes of patients with UM. The scope of this review is to discuss the differences in tumorigenic processes (etiologic factors and genetic alterations) and tumor biology (gene expression and signaling pathways) between CM and UM. We develop hypotheses to explain these differences, which might provide important clues for research avenues and the identification of actionable vulnerabilities suitable for the development of new therapeutic strategies for metastatic UM.

Timing of completion lymphadenectomy after positive sentinel node biopsy in patients with melanoma

Background

Nodal staging with sentinel node biopsy (SNB) and completion lymph node dissection (CLND) provides prognostic information to patients with melanoma and their physicians. It is not known whether the timing of CLND is associated with survival outcome and/or CLND tumour load. This study investigated whether CLND timing is associated with CLND tumour load, disease-free survival (DFS) and/or melanoma-specific survival (MSS).

Methods

A retrospective cohort of patients with SNB-positive melanoma from nine European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group centres undergoing surgery between 1993 and 2009 were examined. Patients were selected based on availability of CLND and follow-up data. The CLND interval was defined as the number of days between diagnosis and CLND. Patient and tumour characteristics were collected. Five-year DFS and MSS rates were calculated. Cox and logistic regression analysis were performed, adjusting for known prognostic/predictive indicators.

Results

A total of 784 patients were included in the study. Their median age was 51 (i.q.r. 40–62) years, and 418 patients (53·3 per cent) were men. Median Breslow thickness was 3·0 (i.q.r. 2·0–5·0) mm, and 148 patients (18·9 per cent) had a residual tumour load. Median CLND interval was 84 (i.q.r. 65–105) days. Five-year DFS and MSS rates were not significantly different for patients operated on with a median CLND interval of less than 84 days and those with an interval of at least 84 days (DFS: 54·2 versus 53·3 per cent respectively; MSS: 66·9 versus 65·1 per cent). In a multivariable Cox model, CLND interval was not a significant prognostic indicator. CLND interval was negatively correlated with identification of positive non-sentinel nodes, but following adjustment for known risk factors this effect was no longer found.

Conclusion

The time interval between diagnosis of melanoma and CLND did not influence CLND tumour load, DFS or MSS.

Implementation of the 7th edition AJCC staging system: Effects on staging and survival for pT1 melanoma. A Dutch population based study

In the 7^th edition of the AJCC staging system, the mitotic rate criterion replaced Clark level to increase correct classification of high-risk thin melanoma patients (pT1B). Additionally, sentinel node biopsy (SNB) was recommended for nodal staging of pT1B melanomas. The aim of this article was to evaluate the effects on pT1 substaging and clinical implications in the national pT1 melanoma population. All pT1 melanomas diagnosed in the Netherlands between 2003 and 2014 were selected from the Netherlands Cancer Registry (IKNL). Patients were stratified by cohort according to AJCC edition: (1) 2003-2009 (6^th ) and (2) 2010-2014 (7^th ). Relative survival was calculated to estimate melanoma-specific survival. A total of 29.546 pT1 melanoma patients were included. The pT1b proportion increased from 10.1% in Cohort 1 to 21.5% in Cohort 2. The proportion of performed SNBs per cohort increased: for pT1b melanomas alone from 4.5% to 13.0%. SNB positivity rate decreased from 10.5% to 8.8% for the entire pT1 population, and for pT1b melanomas from 11.3% to 8.6%. At 5 years, the relative survival rate was similar for pT1a and pT1b in both cohorts, namely, pT1a 100% vs pT1b 97% (Cohort 1), and pT1a 100% vs pT1b 98% (Cohort 2). The 7^th edition of the AJCC staging system has caused an increased number of patients to undergo SNB, without an increase in SNB positivity rate. Survival between pT1 subgroups remains similar. The mitotic rate criterion for pT1b classification and the recommendation to perform SNB for pT1b melanomas should be reconsidered.

Serum calcium, albumin and tumor stage in cutaneous malignant melanoma

AIM

Assess the relationship of serum calcium and serum albumin to tumor stage and other clinical characteristics in patients with cutaneous malignant melanoma (MM).

PATIENTS & METHODS

A cross-sectional study to evaluate serum calcium as a marker of disease progression (n = 644) in MM.

RESULTS

Serum albumin was significantly lower among men (p < 0.01) and among patients with stage 4 disease (p < 0.05). In a multivariable regression model adjusted for age, gender and site, albumin-corrected calcium was positively associated with disease stage (odds ratio: 1.46; 95% CI: 1.02-2.07; p = 0.04). The odds of higher stage increased 60% for each 1.0 mg/dl increase in albumin-corrected calcium.

CONCLUSION

Higher albumin-corrected serum calcium may be a marker of disease progression in MM.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Integrin α5 promotes tumor progression and is an independent unfavorable prognostic factor in esophageal squamous cell carcinoma

The integrin family plays a major role in complex biological events such as differentiation, development, wound healing, and the altered adhesive and invasive properties of tumor cells. The expression and function of integrin α5 in esophageal squamous cell carcinoma (ESCC) are not clear. Here, by using tissue microarrays and immunohistochemical method, integrin α5 expression was retrospectively evaluated in 147 samples of human ESCC. Results showed that expression of integrin α5 was heterogeneous and varied from negative to intense expression in a membrane and cytoplasmic distribution manner. High expression of integrin α5 was significantly correlated with lymph node metastasis (P = .042) and tumor size (P = .042). Kaplan-Meier analysis revealed that high expression of integrin α5 was related to poor overall survival of ESCC patients (P = .018). Multivariate analysis suggested that integrin α5 expression status was an independent prognostic factor for ESCC (P = .003). Moreover, integrin α5 expression was associated with the survival of patients with lymph node metastasis (P = .020), but did not influence the survival of patients without lymph node metastasis. Finally, we found that RNAi-mediated knockdown of integrin α5 led to decreased growth, migration, and invasion of ESCC cells. Combined, integrin α5 might play important roles in the progression of ESCC. Integrin α5 is a novel biomarker to predict the prognosis of ESCC patients.

Oral malignant melanoma: A case report with review of literature

Oral mucosal melanoma is a rare malignancy with the tendency to metastasize and locally invade tissues more readily than other malignant tumor of the oral cavity. It occurs approximately four times more frequently in the oral mucosa of the upper jaw usually on the palate or alveolar gingiva. The chameleonic presentation of malignant melanoma, its asymptomatic condition, rarity of the lesion, poor prognosis and the necessity of a highly specialized treatment are factors that should be seriously considered by the involved health care provider. Herein we report a rare and interesting case of oral malignant melanoma of the maxillary anterior gingiva, which was clinically and histopathologically diagnosed with a brief review of literature, has been discussed.

Anti-melanoma activity of Cynanchi atrati Radix is mediated by regulation of NF-kappa B activity and pro-apoptotic proteins

ETHNOPHARMACOLOGICAL RELEVANCE

Cynanchi atrati Radix has been traditionally prescribed for patients with inflammatory fever or chronic tumoral disorders. Melanoma is one of the most devastating cancer types, in which overexpression of nuclear factor kappa B (NF-κB) enables the cancer to survive without apoptosis. To identify a potential anti-melanoma candidate, we evaluated the apoptotic activity of an ethanol extract of Cynanchi atrati Radix (CAE) on melanoma and its underlying mechanisms.

MATERIALS AND METHODS

Sixty C57BL/6N mice with melanoma were orally administrated CAE (100 or 200mg/kg) or distilled water for 10 days. Survival, tumor weight and volume were monitored and measured. Intratumoral apoptotic change was measured using terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining. To confirm the pro-apoptotic activity of CAE (10, 50 or 100μg/mL) compared to positive drug (10μg/mL of IKK-2 inhibitor IV), cell proliferation, caspase-3/7 activity, flow cytometric analysis, TUNEL and DAPI staining, immunoblotting and gene expression analyses for apoptosis-associated genes were conducted using B16F10 cell line.

RESULTS

CAE administration remarkably improved survivability with a significant reduction in tumor weight (p<0.01) and volume (p<0.01), as well as increased apoptotic bodies in melanoma tissue. The CAE treatment significantly inhibited proliferation of B16F10 cells (p<0.001), but increased caspase-3/7 activity (p<0.01 or 0.001) and apoptotic population. The CAE partially blocked nuclear translocation of NF-κB but activated the p53-associated apoptotic pathway.

CONCLUSION

These results indicate that the CAE has anti-melanoma potential, and the underlying mechanisms involve inhibition of the activities of NF-κB and its target proteins as well as promoting the activities of pro-apoptotic proteins.

Metastatic melanoma to the upper aerodigestive tract: a systematic review of the literature

This study is a systematic review of the literature that was performed to clarify the natural history and treatment outcomes of upper aerodigestive tract metastases from cutaneous melanoma. A search of the MEDLINE database was undertaken from 1950 to 2013 to identify relevant manuscripts for this review. Article inclusion required cases with documentation of previous cutaneous melanoma primary lesions, adequate survival data, and description of metastatic treatment. Individual patient data were extracted from source articles for analysis of survival outcomes. A systematic search revealed 34 relevant articles with 37 cases for inclusion. Metastases were identified throughout the upper aerodigestive tract with a predilection for the oropharynx, larynx, and oral cavity. Treatment outcomes were estimated with the Kaplan-Meier method, with survival of 37% and 16% at 1 and 5 years, respectively. As expected from previous reports, 73% presented with disseminated disease burden with almost universally poor prognosis despite locoregional or systemic therapy. Conversely, a group of patients with limited metastatic burden had improved treatment response with a 1-year survival of 90%, denoting a hazard ratio of 9.7332 (95% confidence interval, 4.5-21.1) for disseminated disease in comparison. Upper aerodigestive tract metastases of melanoma thus are rare clinical entities that in general present in the setting of disseminated disease and evidently necessitate a focus on palliation. In contrast, for those with a limited metastatic burden, aggressive multimodality therapy including complete metastectomy can produce a significant survival advantage.

Epidermotropic metastatic melanoma with perilesional depigmentation in an Indian male

Melanoma is a rare form of cutaneous malignancy encountered in the dark skin population. Epidermotropic metastatic melanoma is a rare form of cutaneous metastatic melanoma which can mimic primary melanoma on histopathology. Hence its differentiation is of immense prognostic importance. The occurrence of rim of depigmentation around the primary cutaneous melanoma has previously been reported to portend a bad prognosis. The occurrence of vitiligo like lesions in patients with metastatic melanoma in comparison has a better prognosis. However the occurrence of depigmentation around the secondaries is rare and its importance is not well known. Hence we wish to report a case of epidermotropic metastatic melanoma with perilesional depigmentation in a 78 year old Indian male.

Phase I-II study of plitidepsin and dacarbazine as first-line therapy for advanced melanoma

BACKGROUND

This phase I-II trial compared plitidepsin 1-h infusion alone or combined with dacarbazine (DTIC) 1-h infusion as front-line therapy for advanced melanoma.

METHODS

The recommended dose (RD) for plitidepsin/DTIC was defined in the first stage. In the second stage, patients were randomised to receive single-agent plitidepsin 3.2 mg m(-2) (n = 20) on days 1, 8 and 15 every 4 weeks (q4wk) or plitidepsin 2.4 mg m(-2) on days 1, 8 and 15 q4wk combined with DTIC 800 mg m(-2) q4wk (n = 38).

RESULTS

The overall response rate with plitidepsin/DTIC was 21.4%; all responders had normal serum lactate dehydrogenase (LDH) levels and performance status ≤ 1 at baseline. Median progression-free survival (PFS) with plitidepsin/DTIC was 3.3 months in all patients, and 4.3 months in those with baseline normal LDH. No responses occurred with single-agent plitidepsin and median PFS was 1.5 months. Both regimens were well tolerated. Haematological abnormalities were more common and transaminase increases more severe with plitidepsin/DTIC. Treatment-related transaminase increases leading to infusion omission on day 8 were relatively common. No drug-drug pharmacokinetic interactions were found.

CONCLUSION

This plitidepsin/DTIC schedule has antitumour activity and manageable toxicity in advanced melanoma. Further evaluation of plitidepsin 2.4 mg m(-2) fortnightly and DTIC 800 mg m(-2) q4wk is recommended.

Sentinel lymph node biopsy for cutaneous melanoma: results of 10 years' experience in two regional training hospitals in the Netherlands

BACKGROUND AND OBJECTIVE

The Multicenter Selective Lymphadenectomy Trial (MSLT-I) demonstrated that the sentinel node (SN) status in cutaneous melanoma affects prognosis and that completion lymphadenectomy in SN-positive patients may improve survival. Our objective was to evaluate sentinel lymph node biopsy (SLNB) in two regional hospitals in the Netherlands.

METHODS

Patients with localized melanoma were planned for wide excision and SLNB. Completion lymphadenectomy was recommended for positive SN status. Data were compared with the MSLT-I.

RESULTS

A median of 2 (1-7) SNs were identified in 305 patients and complications occurred in 11%. Fifty-four patients (18%) demonstrated SN metastases and 45 underwent completion lymphadenectomy (20% additional metastases). Six patients with initially negative SN developed lymph node metastases (sensitivity 90%). Overall disease-free survival was 83% (SN-negative 91% vs. SN-positive 41%; p < 0.001) and melanoma-specific survival was 93% (SN-negative 97% vs. SN-positive 62%; p < 0.001). Multivariate regression analysis revealed the SN status to be the most significant predictor for recurrence and melanoma-related death.

CONCLUSION

Our results of SLNB are comparable to data from high-volume centers participating in MSLT-I. From a patient perspective, the false-negative SN rate of 10% and complication rate of 11% should be weighed against being informed about prognosis and having a possible therapeutic benefit from completion lymphadenectomy.

Patient follow-up after participating in a beach-based skin cancer screening program

Many skin cancer screenings occur in non-traditional community settings, with the beach being an important setting due to beachgoers being at high risk for skin cancer. This study is a secondary analysis of data from a randomized trial of a skin cancer intervention in which participants (n = 312) had a full-body skin examination by a clinician and received a presumptive diagnosis (abnormal finding, no abnormal finding). Participants’ pursuit of follow-up was assessed post-intervention (n = 283). Analyses examined: (1) participant’s recall of screening results; and (2) whether cognitive and behavioral variables were associated with follow-up being as advised. Just 12% of participants (36/312) did not correctly recall the results of their skin examination. One-third (33%, 93/283) of participants’ follow-up was classified as being not as advised (recommend follow-up not pursued, unadvised follow-up pursued). Among participants whose follow-up was not as advised, 71% (66/93) did not seek recommended care. None of the measured behavioral and cognitive variables were significantly associated with recall of screening examination results or whether follow-up was as advised. Research is needed to determine what factors are associated with follow-up being as advised and to develop messages that increase receipt of advised follow-up care.

Transferred melanoma-specific CD8+ T cells persist, mediate tumor regression, and acquire central memory phenotype

Adoptively transferred tumor-specific T cells offer the potential for non-cross-resistant therapy and long-term immunoprotection. Strategies to enhance in vivo persistence of transferred T cells can lead to improved antitumor efficacy. However, the extrinsic (patient conditioning) and intrinsic (effector cell) factors contributing to long-term in vivo persistence are not well-defined. As a means to enhance persistence of infused T cells in vivo and limit toxicity, 11 patients with refractory, progressive metastatic melanoma received cyclophosphamide alone as conditioning before the infusion of peripheral blood mononuclear cell-derived, antigen-specific, CD8(+) cytotoxic T-lymphocyte (CTL) clones followed by low-dose or high-dose IL-2. No life-threatening toxicities occurred with low-dose IL-2. Five of 10 evaluable patients had stable disease at 8 wk, and 1 of 11 had a complete remission that continued for longer than 3 y. On-target autoimmune events with the early appearance of skin rashes were observed in patients with stable disease or complete remission at 4 wk or longer. In vivo tracking revealed that the conditioning regimen provided a favorable milieu that enabled CTL proliferation early after transfer and localization to nonvascular compartments, such as skin and lymph nodes. CTL clones, on infusion, were characterized by an effector memory phenotype, and CTL that persisted long term acquired phenotypic and/or functional qualities of central memory type CTLs in vivo. The use of a T-cell product composed of a clonal population of antigen-specific CTLs afforded the opportunity to demonstrate phenotypic and/or functional conversion to a central memory type with the potential for sustained clinical benefit.

Tamoxifen vs. non-tamoxifen treatment for advanced melanoma: a meta-analysis

Although tamoxifen (TAM) is routinely used in advanced melanoma, it is still uncertain whether evidence exists to support this practice. This review assesses the benefits and harms of systemic therapy with TAM vs. without TAM on response and mortality in patients with advanced melanoma. MEDLINE, The Cochrane Database of Systemic Reviews, The Cochrane Central Register of Controlled Trials, EMBASE and LILACS were searched for randomized controlled trials comparing chemotherapy using and not using TAM in any dose, in patients of any age with advanced melanoma. References lists, databases of ongoing trials and conference proceedings were hand-searched. All included trials were evaluated for quality assessment. Primary outcomes were response and mortality. Secondary outcomes were hematologic and non hematologic toxicity, treatment-related mortality and quality of life. A meta-analysis was performed and results were presented as relative risk with 95% confidence interval. Nine randomized controlled trials met the inclusion criteria. Patients treated with TAM were more likely to respond, with a relative risk 1.36 (95% CI: 1.04-1.77, P = 0.02). However, there was no improvement in 1-year mortality. The incidence of hematologic toxicity was higher in the TAM group. Subgroup analyses showed that female patients were more likely to respond. Chemotherapies with TAM improve overall and partial response, but do not improve mortality in 1 year in advanced melanoma. Further use of TAM in melanoma should be done only in the context of clinical trials.

Quantitative detection of melanoma-associated antigens by multimarker real-time RT-PCR for molecular staging: results of a 5 years study

INTRODUCTION

Monitoring of circulating melanoma cells in the peripheral blood is a promising method for identifying a subgroup of patients with minimal residual disease.

OBJECTIVES

To evaluate the prognostic impact of melanoma-associated antigens by multimarker real-time RT-PCR for disease-specific survival time.

METHODS

Five melanoma markers: Melan-A, gp 100, MAGE-3, MIA and tyrosinase were detected by a quantitative multimarker real-time reverse transcription-PCR (RT-PCR). We included 65 patients with resected melanoma in stage II-III. Peripheral blood samples were examined every 3 months for 2 years. The expression of melanoma markers in 2925 RT-PCR assays was correlated with clinical staging results in total of 5 years.

RESULTS

Twenty-seven patients relapsed during the study period and 26 of them revealed positive markers. MAGE-3 was the most sensitive progression marker in single occurrence or in combination with MIA and gp 100. The time distribution of metastases during the screened period was as follows: progression in the first year was observed in 40.7% patients, second year in 25.9%, third year in 18.6%, fourth and fifth year in 7.4% equally.

CONCLUSIONS

Statistically significant tumor marker elevation during the first 2 years after the surgical treatment correlates with a worse prognosis of patients. In contrast, the group showing negative real-time RT-PCR results in 24 months serial blood testing was associated with prolonged 5-year disease-specific survival. Therefore, quantitative detection of melanoma-specific molecular markers in the presented setting represents a useful tool for selecting patients in a higher risk of disease recurrence.

Malignant melanoma of the mandibular gingiva

Oral malignant melanoma is an infrequent neoplasia making up less than 1% of all melanomas, which exhibits much more aggressive behavior than those found on the skin. We present an aggressive case of oral malignant melanoma located on the mandibular gingiva in a 24-year-old male patient, who developed metastases to not only the regional lymph nodes but also the lungs and liver. The advanced stage of the disease contraindicated any surgical intervention and palliative chemotherapy was planned.

Old and new serological biomarkers in melanoma: where we are in 2009

Biomarkers play an important role in the diagnosis and prognostic classification of various cancers and can be useful in monitoring the patient's clinical course of disease and response to therapy. Generally, biomarkers are proteins and their expressions are associated with malignant disease. In the majority of cases, the marker molecules are expressed by the tumour cells themselves or by the tumour microenvironment cells. Thus, most biomarkers can primarily be found in malignant tissues, but after active secretion or passive release at tumour destruction, they become detectable in body fluids such as blood. Besides morphological and histopathological biomarkers (anatomic site, type of the primary tumour, tumour size, invasion depth, vascular invasion and ulceration), an increasing variety of serological markers have been identified, providing the possibility of a more detailed diagnostic and prognostic subgrouping of tumour entities, up to and even changing existing classification systems. The goal of this review is to provide an overview of old and more recent serological biomarkers in malignant melanoma. We will first focus on confirmed and nonconfirmed serum tumour markers, followed by proteomic profiling, an innovative approach to identify new and better serological biomarkers in melanoma, and ending with the predictive factors for treatments in this pathology.

Genetics of uveal melanoma and cutaneous melanoma: two of a kind?

Cutaneous melanoma and uveal melanoma both derive from melanocytes but show remarkable differences in tumorigenesis, mode of metastatic spread, genetic alterations, and therapeutic response. In this review we discuss the differences and similarities along with the genetic research techniques available and the contribution to our current understanding of melanoma. The several chromosomal aberrations already identified prove to be very strong predictors of decreased survival in CM and UM patients. Especially in UM, where the overall risk of metastasis is high (45%), genetic research might aid clinicians in selecting high-risk patients for future systemic adjuvant therapies.

Constitutive expression of the alpha4 integrin correlates with tumorigenicity and lymph node metastasis of the B16 murine melanoma

The lymphatic system plays a critical role in melanoma metastasis, and yet, virtually no information exists regarding the cellular and molecular mechanisms that take place between melanoma cells and the lymphatic vasculature. Here, we generated B16-F1 melanoma cells that expressed high (B16alpha(4)+) and negligible (B16alpha(4)-) levels of alpha(4) integrin to determine how the expression of alpha(4) integrins affects tumor cell interactions with lymphatic endothelial cells in vitro and how it impacts lymphatic metastasis in vivo. We found a direct correlation between alpha(4) integrin expression on B16-F1 melanoma cells and their ability to form adhesive interactions with monolayers of lymphatic endothelial cells. Adhesion of B16-F1 melanoma cells to lymphatic endothelial cells was mediated by the melanoma cell alpha(4) integrin binding to its counterreceptor, vascular cell adhesion molecule 1 (VCAM-1), that was constitutively expressed on the lymphatic endothelial cells. VCAM-1 was also expressed on the tumor-associated lymphatic vessels of B16-F1 and B16alpha(4)+ tumors growing in the subcutaneous space of C57BL/6J mice. B16-F1 tumors metastasized to lymph nodes in 30% of mice, whereas B16alpha(4)+ tumors generated lymph node metastases in 80% of mice. B16-F1 melanoma cells that were deficient in alpha(4) integrins (B16alpha(4)-) were nontumorigenic. Collectively, these data show that the alpha(4) integrin expressed by melanoma cells contributes to tumorigenesis and may also facilitate metastasis to regional lymph nodes by promoting stable adhesion of melanoma cells to the lymphatic vasculature.

Presence of tumor-infiltrating lymphocytes and a dominant nodule within primary melanoma are prognostic factors for relapse-free survival of patients with thick (t4) primary melanoma: pathologic analysis of the e1690 and e1694 intergroup trials

Lymphocytic infiltration of primary cutaneous melanoma has been demonstrated to be of prognostic significance. Tumor infiltrating lymphocytes (TILs) were evaluated on histologic sections of pT4 primary cutaneous melanoma from 293 patients, accrued in protocols 1690 and 1694 of the Eastern Cooperative Oncology Group. Data for the 60-month follow-up were available. Statistical analysis of the pathologic data evaluated the correlation of regional lymph node metastasis and response to interferon therapy, overall survival, and relapse-free survival. In multivariate analysis, there was significant correlation of the presence of TILs and improved survival. The presence of TILs did not affect the survival of patients treated with interferon alfa-2b. Presence of a localized dominant tumor nodule within the primary tumor had an adverse effect on relapse-free survival (P = .044) that was also marginally present for overall survival (P = .112). The presence of TILs has prognostic but not predictive value, and the presence of a dominant nodule in the primary lesion represents a new adverse prognostic factor that should be incorporated in the evaluation of primary melanoma. This study confirmed the importance of tumor ulceration and the number of positive lymph nodes on outcome.

Presence of tumor-infiltrating lymphocytes and a dominant nodule within primary melanoma are prognostic factors for relapse-free survival of patients with thick (t4) primary melanoma: pathologic analysis of the e1690 and e1694 intergroup trials

Lymphocytic infiltration of primary cutaneous melanoma has been demonstrated to be of prognostic significance. Tumor infiltrating lymphocytes (TILs) were evaluated on histologic sections of pT4 primary cutaneous melanoma from 293 patients, accrued in protocols 1690 and 1694 of the Eastern Cooperative Oncology Group. Data for the 60-month follow-up were available. Statistical analysis of the pathologic data evaluated the correlation of regional lymph node metastasis and response to interferon therapy, overall survival, and relapse-free survival. In multivariate analysis, there was significant correlation of the presence of TILs and improved survival. The presence of TILs did not affect the survival of patients treated with interferon alfa-2b. Presence of a localized dominant tumor nodule within the primary tumor had an adverse effect on relapse-free survival (P = .044) that was also marginally present for overall survival (P = .112). The presence of TILs has prognostic but not predictive value, and the presence of a dominant nodule in the primary lesion represents a new adverse prognostic factor that should be incorporated in the evaluation of primary melanoma. This study confirmed the importance of tumor ulceration and the number of positive lymph nodes on outcome.

Pre-operative ultrasound with a 12-15 MHz linear probe reliably differentiates between melanoma thicker and thinner than 1 mm

BACKGROUND

Pre-operative determination of primary melanoma thickness could be a tool to identify those patients who could be treated with radical primary tumour excision and sentinel lymph node biopsy in a single procedure. An excellent correlation between sonographic and histological measurement of maximal tumour thickness has been achieved using 20-MHz transducers.

OBJECTIVE

To show that widely available high resolution ultrasound with 12-15 MHz linear probe could also reliably assess the thickness of primary melanoma.

METHODS

Sixty-nine patients underwent ultrasound evaluation of 70 clinically and dermoscopically suspicious pigmented skin lesions before surgical excision.

RESULTS

The sensitivity, specificity, positive and negative predictive values of ultrasound to detect melanoma > 1 mm were 92%, 92%, 95% and 81% respectively. The correlation between ultrasound and histological tumour thickness was very good [Pearson's correlating index 0.823 (P < 0.001)]. Mean difference between sonographic and histological measurements was 0.045 mm with limits of agreement estimated at -1.4 and +1.49, and a bias between two methods 45 microm.

CONCLUSION

Ultrasound examination with a 12-15 MHz linear transducer can reliably differentiate primary melanoma > 1 mm from those <or= 1 mm.

Surgical treatment of advanced melanoma

Primary surgical treatment should be considered for patients with metastatic melanoma. Because of the poor response of melanoma to chemotherapy or radiation therapy, surgery can be the best approach to quickly eliminate detectable disease and return the patient to normal activities. In properly selected patients, surgery can lead to significant palliation and prolongation of survival. This article reviews the principles of patient selection and the potential benefits of surgical management of melanoma metastatic to various sites. Novel adjuvant therapies are being developed to augment the benefits of surgical treatment of advanced melanoma in the future.

Surgical excision margins for primary cutaneous melanoma

BACKGROUND

Cutaneous melanoma accounts for 75% of skin cancer deaths. Standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. The purpose of the safety margin is to remove both the complete primary tumour and any melanoma cells that might have spread into the surrounding skin.Excision margins are important because there could be trade-off between a better cosmetic result but poorer long-term survival if margins become too narrow. The optimal width of excision margins remains unclear. This uncertainty warrants systematic review.

OBJECTIVES

To assess the effects of different excision margins for primary cutaneous melanoma.

SEARCH STRATEGY

In August 2009 we searched for relevant randomised trials in the Cochrane Skin Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 3, 2009), MEDLINE, EMBASE, LILACS, and other databases including Ongoing Trials Registers.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) of surgical excision of melanoma comparing different width excision margins.

DATA COLLECTION AND ANALYSIS

We assessed trial quality, and extracted and analysed data on survival and recurrence. We collected adverse effects information from included trials.

MAIN RESULTS

We identified five trials. There were 1633 participants in the narrow excision margin group and 1664 in the wide excision margin group. Narrow margin definition ranged from 1 to 2 cm; wide margins ranged from 3 to 5 cm. Median follow-up ranged from 5 to 16 years.

AUTHORS' CONCLUSIONS

This systematic review summarises the evidence regarding width of excision margins for primary cutaneous melanoma. None of the five published trials, nor our meta-analysis, showed a statistically significant difference in overall survival between narrow or wide excision.The summary estimate for overall survival favoured wide excision by a small degree [Hazard Ratio 1.04; 95% confidence interval 0.95 to 1.15; P = 0.40], but the result was not significantly different. This result is compatible with both a 5% relative reduction in overall mortality favouring narrower excision and a 15% relative reduction in overall mortality favouring wider excision. Therefore, a small (but potentially important) difference in overall survival between wide and narrow excision margins cannot be confidently ruled out.The summary estimate for recurrence free survival favoured wide excision [Hazard Ratio 1.13; P = 0.06; 95% confidence interval 0.99 to 1.28] but again the result did not reach statistical significance (P < 0.05 level).Current randomised trial evidence is insufficient to address optimal excision margins for primary cutaneous melanoma.

TNM: therapeutically not mandatory

Cancer survival may be inversely related to the speed at which a primary tumour grows and disseminates. Assessment of prognosis using surgical and/or radiological definition of disease extent, i.e. staging, has thus become a standard intervention in newly diagnosed patients, with the most popular framework being the tumour-node-metastasis (TNM) system. However, increasing use of biomarkers--non-TNM factors that predict therapeutic benefit, rather than adverse disease outcome--has weakened the decision-making dominance of TNM. This shift from risk-led to benefit-led practice is now starting to blur the time-honoured qualitative distinction between curable (M(0), early stage, adjuvant) and incurable (M(1), early metastatic, palliative) disease treatment strategies; the same biologic drug strategy may improve average survival outcomes by similar increments for two patients, one of whom is 'adjuvant' and the other 'metastatic'. Plausibly, then, biomarker-positive patients presenting with high-TNM (M(1)) disease may enjoy the same, if not more, disease-free and/or overall survival benefit as conventional low-TNM (M(0)) patients when treated with standard adjuvant interventions. Conversely, M(0) patients concerned by quality-of-life issues such as alopecia may in future be able to choose better-tolerated personalized drug regimens similar to those now used with survival benefit in palliative settings, even if such adjuvant regimens have not yet been validated by level 1 data. To these ends, a modernised decision-oriented disease staging system called METS (molecular/extra-primary/tumour/symptoms) is presented here.

Microscopic satellitosis in patients with primary cutaneous melanoma: implications for nodal basin staging

BACKGROUND

Microscopic satellitosis in melanoma is uncommon. The role of regional basin staging/therapy in patients with this high-risk feature has not been well defined.

METHODS

Patients presenting from 1996 to 2005 with clinically localized melanoma containing microscopic satellitosis were identified from a prospective, single-institution database. Multiple factors were analyzed to determine their predictive value for recurrence. The management of the draining nodal basin was evaluated to determine its impact on recurrence and survival.

RESULTS

Thirty-eight patients presented to our institution during this time period with clinically localized melanoma containing microscopic satellitosis. The 5-year overall and disease-free survivals in these patients were 34% and 18%, respectively. Sixty-eight percent had pathologically involved regional nodal metastases. With median follow-up of 21 months, 68% recurred, with a median time to recurrence of 9 months. Lymphovascular invasion (LVI) (p = 0.01), tumor regression (p = 0.04), and positive regional lymph nodes (p = 0.02) were associated with an increased risk of recurrence. Of the 31 patients who underwent sentinel lymph node (SLN) biopsy, 22 had metastasis in the SLN (71%). Fifteen of these patients underwent completion lymphadenectomy (CLND) and seven were observed. There was no difference in disease-free survival (DFS), disease-specific survival (DSS), or overall survival (OS) between these groups (p = 0.42).

CONCLUSIONS

Pathological lymph node metastases were more prevalent (68%) than in any group previously defined. Regional nodal status predicted recurrence but not nodal recurrence. In SLN-positive patients, CLND did not improve DFS, DSS, or OS, although the number of patients was small. Further studies are needed to determine the utility of regional nodal staging/therapy in these high-risk patients.

One-day or two-day procedure for sentinel node biopsy in melanoma?

PURPOSE

We compared the outcome of a 1-day and a 2-day sentinel node (SN) biopsy procedure, evaluated in terms of lymphoscintigraphic, surgical and pathological findings.

METHODS

We studied 476 patients with melanoma from two melanoma centres using static scintigraphy and blue dye. A proportional odds model was used for statistical analysis.

RESULTS

The number of SNs visualized at scintigraphy increased significantly with time from injection to scintigraphy and activity left in the patient at scintigraphy, and depended on the melanoma location. The number of SNs removed at surgery increased with the number of SNs visualized at scintigraphy and time from injection to surgery. The frequency of nodal metastasis increased with increasing thickness and Clark level of the melanoma, and was highest for two SNs visualized at scintigraphy.

CONCLUSION

This study showed that early vs. late imaging and surgery do make a difference on the outcome of the SN procedure and confirmed the importance of the scintigraphic visualization of all true SNs.

Intraoperative application of fibrin sealant does not reduce the duration of closed suction drainage following radical axillary lymph node dissection in melanoma patients: a prospective randomized trial in 58 patients

BACKGROUND

Patients suffering from malignant melanoma often require radical lymph node dissection of the axillary nodal basin. The effects of intraoperative application of fibrin sealant following radical axillary lymph node dissection (RALND) on the incidence of postoperative lymphatic secretion are discussed. To study the effect of intraoperatively applied fibrin sealant following RALND a randomized patient-blinded trial was carried out.

METHODS

Fifty-eight patients with axillary lymph node metastases of malignant melanoma underwent therapeutic RALND and were randomized into two groups: 29 patients received 2 cc of fibrin glue intraoperatively and 29 patients were only irrigated with 0.9% saline. The amount of drainage was recorded every 24 h. The main outcome criterion was the duration of drain placement in the wound. Minor criteria were the total amount of fluid and the length of hospital stay. Statistical analysis was performed using Spearman's log-rank correlation and paired t-test.

RESULTS

There was no significant difference between the nonfibrin group 5 days (range = 3.6-5.7 days) and the fibrin group 5 days (range = 4.1-8.5 days) (p = 0.701). The total amount of fluid for the nonfibrin group (410 cc, range = 362-727 cc) and that for the fibrin group (503 cc, range = 369-1098 cc) (p = 0.605) and the length of postoperative hospital stay of 6 days (range = 5.4-7) vs. 7 days (range = 5.9-10.7), respectively, were not different between both groups (p = 0.387).

CONCLUSION

Considering our study results, we cannot recommend the use of 2 cc of fibrin glue intraoperatively in the prevention of lymphatic secretion in patients undergoing RALND for metastatic melanoma.

Sentinel node in melanoma patients: triple negativity with routine techniques and PCR as positive prognostic factor for survival

Lymph node mapping and sentinel lymph node biopsy are currently used to stage patients with cutaneous malignant melanoma. Immunohistochemical stains contribute to the detection of micrometastases; however, molecular biology techniques are associated with better diagnostic sensitivity. Sixty sentinel lymph nodes were included in this study. The primary lesions were malignant melanoma stage I or II, with a follow-up of longer than 2 years. Sentinel lymph nodes were studied with hematoxylin-eosin, immunohistochemistry for S-100 and HMB-45, and molecular biology techniques (reverse transcription (RT)-PCR) for the detection of tyrosinase messenger RNA. In 15 of 60 cases (25%), tyrosinase was detected by RT-PCR; three of these cases were also positive by immunohistochemistry. The population was divided into three groups: (i) hematoxylin-eosin-/immunohistochemistry+/molecular biology techniques+ (3 cases); (ii) hematoxylin-eosin-/immunohistochemistry-/molecular biology techniques+ (12 cases); (iii) hematoxylin-eosin-/immunohistochemistry-/molecular biology techniques- (45 cases). Correlation of the groups with overall survival showed the following: (i) 2 of 3 patients died (67%); (ii) 5 of 12 died (42%), and (iii) all 45 patients are alive, with no lymphadenectomy and a median follow-up of 84 months. The inclusion of molecular biology techniques appears to be of great value for the detection of sentinel lymph node micrometastases in patients with cutaneous malignant melanoma. In our series, those patients who showed negativity with all the three methods had a null recurrence rate. Therefore, this triple negativity could be a positive prognostic factor for overall survival. Our findings suggest the possibility of molecular oncological staging, which would allow the selection of patients with submicroscopic metastases for a complete treatment.

Targeted combined anti-inflammatory and angiostatic therapy in advanced melanoma: a randomized phase II trial

An angiostatic approach was used to assess the impact of anti-inflammatory therapy in combination with metronomic low-dose chemotherapy. A randomized multi-institutional phase II trial was designed to select metronomic chemotherapy (arm A: trofosfamide 50 mg orally three times daily, day 1+) or combined anti-inflammatory/angiostatic treatment (arm B: trofosfamide as above mentioned plus rofecoxib 25 mg orally, day 1+, and pioglitazone 60 mg orally, day 1+) for further evaluation. A total of 76 patients, mostly (>60%) refractory to at least one previous chemotherapy with maximum tolerated doses, and progression of metastatic melanoma were included. The estimated progression-free survival (PFS) rates at one year were 0% for metronomic chemotherapy (A), but 9% for additional anti-inflammatory therapy (B). Vice versa the hazard ratio for the intent-to-treat analysis of A versus B was 1.9 (P=0.008). By Cox analysis, the impact of anti-inflammatory therapy on PFS achieved significance (P=0.016) as well as C-reactive protein response on overall survival (P=0.045). WHO grade 3 (no grade 4) toxicities were reported in arm A/B in 19 and 28%, respectively. In conclusion, control of tumour-associated inflammatory processes (C-reactive protein response) is associated with longer PFS than achieved with metronomic chemotherapy alone in metastatic melanoma.