The John Wayne Clinical Research Lecture. Surgical management of melanoma: results of prospective randomized trials

Acral lentiginous melanoma-Population, treatment, and survival using the NCDB from 2004 to 2015

Acral lentiginous melanoma (ALM) is a rare histological subtype of cutaneous malignant melanoma that typically presents on the palms and soles. To characterize the demographic and treatment characteristics of ALM, we used the National Cancer Database (NCDB) to describe a large multi-institutional cohort of ALM patients, consisting of 4,796 ALM patients from 2004 to 2015. ALM was more likely to be diagnosed at a later stage overall compared with non-ALM cutaneous melanomas, and more likely to be thicker, ulcerated, lymph node positive, and have lymphovascular invasion and positive margins. When stratified by stage, ALM had worse survival compared with non-ALM patients, most notably in stage III patients with 5-year survival of 47.5% versus 56.7%, respectively (p < .001). In ALM patients, older age, male sex, higher comorbidity burden, increased tumor thickness and ulceration, positive lymph nodes, and positive metastasis were independently associated with lower 5-year survival. Multimodality therapy, defined as surgery in addition to systemic therapy and/or radiation therapy, was associated with higher survival in stage III patients but not in other stages. These results call for further investigation into possible treatment intensification in the ALM population in the future.

National trials involving lymphatic mapping for melanoma: the multicenter selective lymphadenectomy trial, the sunbelt melanoma trial, and the florida melanoma trial

Radioguided surgery and lymphatic mapping provide more accurate staging and a less morbid operation for the patient with malignant melanoma. It has rapidly become the standard of care for the nodal staging of this disease. Regional and national trials have been designed to address various questions that concern the application of this technique. The Multicenter Selective Lymphadenectomy Trial (MSLT), being performed by Donald Morton at the John Wayne Cancer Institute, is a national trial that will address whether this surgical strategy provides a survival benefit for patients. The national, industry-sponsored SunBelt Melanoma Trial (SBMT), with Kelly McMasters from the University of Louiville as the principle investigator, will determine the role of molecular staging in patients who undergo sentinel lymph node (SLN) harvest. In another arm of the study, the role of adjuvant interferon alfa (IFN) will be examined in patients with minimal disease in the regional basin, those patients with just one microscopically positive SLN. Finally, the Florida Melanoma Trial (FMT), with the central office and laboratory located at the Lakeland Regional Cancer Center, is a regional, industry-sponsored trial that will determine whether all patients with a positive SLN need to undergo a complete lymph node dissection (CLND) of the affected basin. Clinicians await the results of these three trials to help to determine the final role of radioguided surgery in patients with malignant melanoma.

J, Lewin S, Marone MMS. Pesquisa do linfonodo sentinela em pacientes com melanoma: experiência com fitato marcado com Tecnécio-99m e revisão da literatura

FUNDAMENTOS: A progressão linfática do melanoma maligno habitualmente se inicia pelo linfonodo sentinela (LNS), cuja análise histopatológica permite predizer o acometimento de toda a cadeia. OBJETIVO: O trabalho tem por objetivo descrever a utilização do 99mTc-Fitato na detecção do LNS em pacientes com melanoma maligno, revisando as indicações e informações fornecidas por sua biópsia. MÉTODO: A pesquisa de LNS foi realizada por meio da linfocintilografia com 99mTc-Fitato em 92 pacientes com melanoma (54,0±14,3 anos). Após 18-24 horas, 88 pacientes foram submetidos à localização intra-operatória com detector portátil, seguida da ressecção e análise histopatológica do LNS. RESULTADOS: A linfocintilografia permitiu a identificação do LNS em todos os estudos, havendo detecção intra-operatória em 98,8% dos casos. O LNS estava acometido em 23 pacientes (26%). O valor preditivo negativo foi de 100% e não se observaram reações adversas pelo uso do 99mTc-Fitato. CONCLUSÃO: A detecção do LNS pode ser realizada com diferentes radiofármacos, incluindo o 99mTc-Fitato, que apresenta vantagens de custo e disponibilidade no Brasil. A pesquisa de LNS resulta em maior acurácia e menor morbidade no estadiamento de pacientes com melanoma maligno

Elective, therapeutic, and delayed lymph node dissection for malignant melanoma of the head and neck: analysis of 1444 patients from 1970 to 1998

OBJECTIVE

The purpose of this article is to evaluate the effects on survival, disease-free interval, and recurrence patterns for patients undergoing elective, therapeutic, and delayed lymph node dissection for malignant melanoma of the head and neck.

STUDY DESIGN AND METHODS

A retrospective computer-aided analysis was performed comparing 1444 patients treated from 1970 to 1998 at Duke University Medical Center. A total of 446 of the 1444 (32%) of patients with head and neck melanoma underwent some form of lymph node dissection. Survival, disease-free interval, and recurrence rates for patients having 1) no initial lymph node dissection (no LND), 2) elective lymph node dissection (ELND) within 2 months of date of diagnosis, 3) therapeutic lymph node dissection (TLND) for metastatic regional disease at diagnosis, or 4) delayed lymph node dissection (DLND) for patients developing regional lymph node metastasis later than 3 months from the date of diagnosis were compared.

RESULTS

A total of 246 patients undergoing ELND demonstrated 11% with occult disease. DLND for regional lymph node recurrence was reported at a median time interval of 1.2 years from diagnosis. Multivariate analysis indicated a significant improvement in survival for DLND when compared with patients undergoing ELND plus sign in circle or TLND (P =.01). Distant metastasis was the site of first recurrence in 12% of patients undergoing no initial LND. Five-year survival after DLND and TLND was 56% and 36%, respectively.

CONCLUSION

Patients undergoing DLND had an overall better survival than patients undergoing TLND or ELND with positive nodes. The progression of metastatic disease following regional node disease occurred in 35% to 45% of cases, underscoring the need for effective adjunctive therapy.

The changing role of the surgical oncologist

It is increasingly important for the surgical oncologist and surgeons to have a thorough understanding of the advantages and limitations of adjuvant systemic chemotherapy, hormonal therapy, and adjuvant radiotherapy in various resectable cancers. Justification for the field of surgical oncology should include the fact that enough knowledge has been acquired about these adjunctive treatments for patients with cancer that they can be integrated into overall management. Too often in the recent past, surgeons, after the technical surgical resection, turned over the entire management of patients to the medical oncologist or the radiotherapist. Comprehensive management for surgeons and surgical oncologists should maintain their voice in management policy so that the patients can be served best by the application of adjuvant treatment or by the avoidance of adjuvant treatment, systemic or local, when it is not appropriate or significantly helpful. The overall justification for the field of surgical oncology is that the surgeon not only knows how to use medical treatments in advanced cancers, but also knows how to select minimal surgical procedures in early cancers and how to manage and direct the application of adjuvant treatments, regionally and systemically.

Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial

BACKGROUND

Ten- to 15-year survival results were analyzed from a prospective multi-institutional randomized surgical trial that involved 740 stages I and II melanoma patients with intermediate thickness melanomas (1.0 to 4.0 mm) and compared elective (immediate) lymph node dissection (ELND) with clinical observation of the lymph nodes as well as prognostic factors that independently predict outcomes.

METHODS

Eligible patients were stratified according to tumor thickness, anatomical site, and ulceration, and then prerandomized to either ELND or nodal observation. By using Cox stepwise multivariate regression analysis, the independent predictors of outcome were tumor thickness (P < .001), the presence of tumor ulceration (P < .001), trunk site (P = .003), and patient age more than 60 years (P = .01).

RESULTS

Overall 10-year survival was not significantly different for patients who received ELND or nodal observation (77% vs. 73%; P = .12). Among the prospectively stratified subgroups of patients, 10-year survival rates favored those patients with ELND, with a 30% reduction in mortality rate for the 543 patients with nonulcerated melanomas (84% vs. 77%; P = .03), a 30% reduction in mortality rate for the 446 patients with tumor thickness of 1.0 to 2.0 mm (86% vs. 80%; P = .03), and a 27% reduction in mortality rate for 385 patients with limb melanomas (84% vs. 78%; P = .05). Of these subgroups, the presence or absence of ulceration should be the key factor for making treatment recommendations with regard to ELND for patients with intermediate thickness melanomas.

CONCLUSIONS

These long-term survival rates from patients treated at 77 institutions demonstrate that ulceration and tumor thickness are dominant predictive factors that should be used in the staging of stages I and II melanomas, and confer a survival advantage for these subgroups of prospectively defined melanoma patients.