Selected patients with metastatic melanoma may benefit from liver resection

An Overview of Liver Directed Locoregional Therapies

An overview of all liver-directed locoregional therapies, including surgical resection for melanoma liver metastases (MLMs), is provided. MLM patients are divided by their primary melanoma location; cutaneous, uvea (eye), and mucosal melanoma. If patients with isolated cutaneous MLMs are considered for surgical resection, treatment with systemic therapy should be part of the treatment course. For uveal MLMs, complete surgical or ablative treatment of all MLMs suggests superior results compared with other liver-directed or systemic therapies, based on current evidence, no recommendations for any liver-directed regional therapy in the treatment of mucosal MLMs can be made.

Multimodal therapy with surgery and adjuvant nivolumab for late-onset multiple liver metastases of choroidal malignant melanoma: a case report

BACKGROUND

Choroidal malignant melanoma is the most common primary malignant tumor of the eye in adults. Prognosis after recurrence of this disease has been dismal because of the absence of an effective therapy. However, resection of recurrent foci and a subsequent treatment with immune-checkpoint inhibitor may improve the prognosis after recurrence of this disease. This study presents a case of late-onset liver metastases of choroidal malignant melanoma, successfully treated with hepatectomy and postoperative adjuvant nivolumab.

CASE PRESENTATION

A 53-year-old woman had undergone left ocular enucleation because of choroidal malignant melanoma 13 years prior to admission. She visited a nearby clinic with complaints of epigastric pain. She was referred to our hospital because a giant liver tumor was observed on abdominal ultrasonography. Enhanced computed tomography revealed multiple liver tumors in the right lobe, 49 mm in diameter with ring enhancement in subsegment (S) 5/6, and 14 and 8 mm without any enhancement in S7 and S5, respectively. On magnetic resonance imaging, the main tumor showed high intensity on T1-weighted with fat suppression, suggesting melanin deposition. Based on the diagnosis of multiple liver metastases of choroidal malignant melanoma, right hepatectomy and regional lymphadenectomy were performed. She was discharged without postoperative complications. Histological examination revealed that all tumors were metastatic malignant melanoma. She was treated with nivolumab postoperatively, and no recurrences were observed during 22 months of follow-up.

CONCLUSIONS

Aggressive surgery plus adjuvant nivolumab appears to be a promising treatment for choroidal malignant melanoma with late-onset liver metastases.

Surgical management of metastatic melanoma in the era of targeted systemic therapies

Treatment strategies for metastatic melanoma have changed markedly in recent times due to the advent of targeted systemic therapies. In addition to these developments, surgery remains a useful adjunct that can confer survival benefits in selected patients. In this review, we examine the current literature to highlight the role of surgical intervention in metastatic melanoma in the era of targeted systemic therapies.

The benefits of liver resection for non-colorectal, non-neuroendocrine liver metastases: a systematic review

PURPOSE

Defining the benefits of resection of isolated non-colorectal, non-neuroendocrine (NCRNNE) liver metastases is difficult. To better understand the survival benefit in this group of patients, we conducted a systematic review of the previous literature.

METHODS

Medline, Web of Knowledge, and manual searches were performed using search terms, such as "liver resection" and "primary tumor." Inclusion criteria were year>1990, >five patients, and median survival reported or derived. An expected median survival was calculated from weighted averages of median survivals, and differences were assessed using a permutation test.

RESULTS

A total of 7,857 references were identified. Overall 4,735 abstracts were reviewed; 120 manuscripts evaluated and of these, 73 met the study inclusion criteria. The final population consisted of 3,596 patients with renal (n=234), ovarian (n=119), testicular (n=153), adrenal (n=90), small bowel (n=28), gallbladder (n=21), duodenum (n=38), gastric (n=481), pancreatic (n=55), esophageal (n=23), head and neck (n=15), and lung (n=36) cancers, gastrointestinal stromal tumors (GISTs) (n=106), cholangiocarcinoma (n=13), sarcoma (n=189), and melanoma (n=643). The greatest expected median was 63 months for genitourinary (GU) primaries (n=549; range 5.4-142 months) followed by 44.4 months for breast cancer (n=1,013; range 8-74 months), 22.3 months for gastrointestinal cancer (n=549; range 5-58 months), and 23.7 months for other tumor types (n=1,082; range 10-72 months). Using a permutation test, we observed that survival was best for patients with GU primaries followed by that for breast cancer patients. Additionally, we also observed that survival was similar for those with cancer of the GI tract and other primary sites.

CONCLUSIONS

There appears to be a benefit to resection for patients with NCRNNE liver metastases. The degree of survival advantage is predicated by primary site.

First experience on laparoscopic near-infrared fluorescence imaging of hepatic uveal melanoma metastases using indocyanine green

BACKGROUND

Uveal melanoma is the most common primary intraocular tumor in adults, and up to 50% of patients will develop liver metastases. Complete surgical resection of these metastases can improve 5-year survival, but only a few patients are eligible for radical surgical treatment. The aim of this study was to introduce a near-infrared (NIR) fluorescence laparoscope during minimally invasive surgery for intraoperative identification of uveal melanoma hepatic metastases and to use it to provide guidance during resection.

METHODS

Three patients diagnosed with one solitary liver metastasis from uveal melanoma are presented. Patients received 10 mg indocyanine green (ICG) intravenously 24 hours before surgery. A NIR fluorescence laparoscope was used to detect malignant liver lesions.

RESULTS

In all 3 patients, laparoscopic NIR fluorescence imaging using ICG successfully identified uveal melanoma metastases. In 2 patients, multiple additional lesions were identified by inspection and NIR fluorescence imaging, which were not identified by preoperative conventional imaging. In one patient, one additional lesion, not identified by computed tomography, magnetic resonance imaging, laparoscopic ultrasonography, and inspection, was observed with NIR fluorescence imaging only. Importantly, NIR fluorescence imaging provided guidance during resection of these metastases.

CONCLUSIONS

We describe the successful use of laparoscopic identification and resection of uveal melanoma liver metastases using NIR fluorescence imaging and ICG. This procedure is minimally invasive and should be used as complementary to conventional techniques for the detection and resection of liver metastases.

The Liverpool uveal melanoma liver metastases pathway: outcome following liver resection

AIM

To determine the outcome of patients that underwent liver resection for metastases from uveal melanoma.

METHODS

Over a 9-year period, patients referred with uveal melanoma metastases were included. Following treatment of primary uveal melanoma, high-risk patients were offered to be enrolled into a 6-monthly non-contrast liver magnetic resonance imaging (MRI) surveillance. Following detection of liver metastases, patients were staged with a contrast-enhanced (Primovist(®)) liver MRI, computer tomography (CT) of the thorax and staging laparoscopy.

RESULTS

155 patients were referred with uveal melanoma liver metastases, of which 17 (11.0%) patients had liver resection and one patient was treated with percutaneous radio-frequency ablation. The majority of patients undergoing liver resection were treated with multiple metastectomies (n = 8) and three patients had major liver resections. The overall median survival for patients treated with surgery/ablation was 27 (14-90) months, and this was significantly better compared to patients treated palliatively [median = 8(1-30) months, P < 0.001]. Following surgery, 11 patients had recurrent disease [median = 13(6-36) months]. Patients who had undergone a major liver resection had a significantly poorer disease-free survival (P = 0.037).

CONCLUSIONS

Patients who can undergo surgical resection for metastatic uveal melanoma have a more favorable survival compared to those who do not.

Pure laparoscopic posterior sectionectomy for liver metastasis resulting from choroidal malignant melanoma: a case report

Liver metastases resulting from primary choroidal malignant melanomas occur frequently and have a poor prognosis. As a result of advancements in multidisciplinary approaches, life expectancy can be increased when R0 resection is possible. Herein we report the surgical outcomes of pure laparoscopic posterior sectionectomy (PLPS) in a patient with a solitary liver metastasis resulting from choroidal malignant melanoma. The subject was a 46-year-old Japanese man who had received radiotherapy for primary right choroidal malignant melanoma 2 years before presenting at our hospital; he subsequently underwent ophthalmectomy as a result of the relapse. During follow-up, CT revealed a metastatic lesion in the liver S7, and interventional treatments were performed sequentially. The lesion still showed a tendency to enlarge, so we performed PLPS. On postoperative day 7, the patient was discharged from the hospital, and he started to receive adjuvant chemotherapy 2 weeks after PLPS. Although PLPS is deemed to be difficult for lesions in the upper part or posterior segment of the liver, we performed this modality safely.

Liver resection for metastatic melanoma: equivalent survival for cutaneous and ocular primaries

BACKGROUND

The value of surgical resection in patients with hepatic metastases from melanoma is poorly documented in the literature. This study sought to determine the clinicopathologic and surgical factors predictive of outcome for melanoma patients who underwent resection of hepatic metastases.

METHODS

Thirty-three patients who underwent liver resection for melanoma metastases were identified from the Melanoma Institute Australia research database. Univariate and multivariate analyses were performed to identity factors predictive of recurrence and survival following liver resection for melanoma metastasis.

RESULTS

The actuarial 2- and 5-year survival rates were 59% and 42%, respectively, with a median survival of 29 months (range 1-139). The 5-year survival rates for cutaneous and ocular primary melanoma were 44% and 39%, respectively. Improved post-hepatic metastasectomy survival was observed in patients with microscopically clear resection margins (R0, 44 months; R1/2, 12 months; P = 0.04). Although major hepatic resection was associated with improved survival (major, 70 months; minor, 23 months; P = 0.07), major hepatectomies were performed almost exclusively in patients with isolated liver metastases.

CONCLUSIONS

Hepatic resection for metastatic melanoma is associated with improved survival in selected patients with both primary ocular and cutaneous melanoma. Surgical treatment of hepatic melanoma metastases should be considered when complete resection is feasible.

Systematic review and meta-analysis of liver resection for metastatic melanoma

Background

The multidisciplinary management of metastatic melanoma now occasionally includes major hepatic resection. The objective of this work was to conduct a systematic review of the literature on liver resection for metastatic melanoma.

Methods

MEDLINE, Embase, the Cochrane Library and Scopus were searched (1990 to December 2012). Studies with at least ten patients undergoing liver resection for metastatic melanoma were included. Data on the outcomes of overall survival (OS) and/or disease-free survival (DFS) were abstracted and synthesized. Hazard ratios (HRs) were derived from survival curves and subjected to meta-analysis using random-effects models.

Results

Twenty-two studies involving 579 patients (13 per cent weighted resection rate) who underwent liver resection were included. Study quality was poor to moderate. Median follow-up ranged from 9 to 59 months. Median DFS ranged from 8 to 23 months, and median OS ranged from 14 to 41 months (R0, 22–66 months, R2, 10–16 months; R0versus R1/R2: HR 0.52, 95 per cent confidence interval (c.i.) 0.37 to 0.73). The OS rate was 56–100 per cent at 1 year, 34–53 per cent at 3 years and 11–36 per cent at 5 years. Median OS with non-operative management ranged from 4 to 12 months. Comparison of OS with resection and non-operative management favoured resection (HR 0.32, 95 per cent c.i. 0.22 to 0.46).

Conclusion

Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results.

[Surgical treatment of melanoma liver metastases]

The appearance of liver metastases during the follow-up of a patient with a skin melanoma has classically been considered a sign of a very poor prognosis. There are limited therapeutic options, since these lesions are non-resectable and form part of a disseminated disease in several organs. In certain cases, in those where the disease is restricted to the liver or accompanied by a resectable extra-hepatic disease, hepatectomy can be useful, obtaining acceptable survivals of about 25% at 5 years, although hepatic or skin recurrence is usually early. The limited number of patient cases published, the absence of randomised studies, and the heterogeneity of the series, makes it difficult to reach conclusions to be able to recommend which patients may benefit from liver resection, with an acceptable level of scientific evidence, and thus define its real usefulness. There are also no action plans defined as to when and what type of adjuvant therapy we should use.

Debulking surgery in advanced melanoma

In general, patients with stage IV melanoma have poor survival. However, there are subsets of stage IV melanoma patients who are candidates for surgical debulking. There is a growing body of retrospective evidence about clinicians being able to better select patients who may benefit from surgical resection in isolated stage IV disease. In addition, palliative-type resections may improve quality of life in selected cases. In this article, we discuss how recent advances in effective systemic therapies for melanoma may impact the clinical use of debulking surgery in melanoma patients. We also review the available literature about the rationale, risks, benefits and selection of patients for these procedures.

Therapy for metastatic melanoma: the past, present, and future

Metastatic melanoma is the most aggressive form of skin cancer with a median overall survival of less than one year. Advancements in our understanding of how melanoma evades the immune system as well as the recognition that melanoma is a molecularly heterogeneous disease have led to major improvements in the treatment of patients with metastatic melanoma. In 2011, the US Food and Drug Administration (FDA) approved two novel therapies for advanced melanoma: a BRAF inhibitor, vemurafenib, and an immune stimulatory agent, ipilimumab. The success of these agents has injected excitement and hope into patients and clinicians and, while these therapies have their limitations, they will likely provide excellent building blocks for the next generation of therapies. In this review we will discuss the advantages and limitations of the two new approved agents, current clinical trials designed to overcome these limitations, and future clinical trials that we feel hold the most promise.

Outcome of patients following hepatic resection for metastatic cutaneous and ocular melanoma

BACKGROUND/PURPOSE

The aim of this study was to analyze the outcome of patients undergoing hepatic resection for melanoma liver metastases.

METHODS

Patients undergoing liver resection for melanoma metastases at the Hospital Vall d'Hebron and Hospital Clinic, Barcelona, were reviewed. Selection criteria were: good performance status, feasibly complete and safe resection, and absence of visceral extrahepatic metastases.

RESULTS

Between 1994 and 2007, 14 liver resections were performed for melanoma liver metastases. The primary tumor was cutaneous in 8 patients and ocular in 6. Two patients underwent urgent liver surgery due to tumor bleeding. In these patients, complete melanoma staging was not performed and extrahepatic metastases were found during surgery or during the postoperative course. Six of 13 patients (46.2%) developed liver recurrence during follow-up. One- and 3-year actuarial patient survivals were 77 and 49%, respectively. Excluding the patients who underwent urgent liver surgery, the 1- and 3-year actuarial patient survivals in those with primary ocular and cutaneous melanoma were 83 and 56% and 80 and 60%, respectively.

CONCLUSIONS

Liver resection may be considered as part of oncosurgical treatment in patients with melanoma liver metastases, since prolonged survival was observed, albeit with a high recurrence rate. Nevertheless, it should be taken into account that our study included only a small number of patients.

Treatment of cutaneous melanoma: current approaches and future prospects

Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.

Treatment of cutaneous melanoma: current approaches and future prospects

Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.

Liver resection for metastatic melanoma with postoperative tumor-infiltrating lymphocyte therapy

BACKGROUND

Patients with metastatic melanoma to the liver (MML) have a median survival of 4 to 6 months. This study evaluated patients who underwent liver resection with intent to receive postoperative tumor-infiltrating lymphocyte (TIL) therapy.

METHODS

Retrospective analysis of a prospective database identified patients with MML who underwent liver resection from 1980 to 2008.

RESULTS

A total of 539 patients had MML, and 39% (204 of 539) had tumor collected for TIL. A total of 17% (35 of 204) underwent liver resection for TIL. The 3-year overall survival was 53%. Lack of extrahepatic disease (P = .026), negative margin (P = .056), and single hepatic metastasis (P = .04) predicted survival after univariate analysis. Only lack of extrahepatic disease remained a significant predictor of survival after multivariate analysis (P = .043). A total of 31% (11 of 35) underwent complete resection without TIL, and 69% (24 of 35) underwent resection with synchronous intrahepatic and extrahepatic disease with intent to receive TIL. For 9 of 11 patients (2 of 11 excluded for gene therapy), 3-year survival was 80%. A total of 4 (44%) of 9 experienced recurrence, with a median disease-free survival of 1.2 years. For 24 patients (69%) with residual disease, 3-year survival was 51% (2 of 24 excluded for gene therapy). A total of 63% (15 of 24) received postoperative TIL (3-year survival 65%), and 29% (7 of 24) did not. A total of 40% (6 of 15) had disease that partially responded to TIL; the disease of 67% (4 of 6) had not progressed at median follow-up of 55 months (range, 42-197+ months). The seven patients who did not receive TIL had a median survival of 4.6 months.

CONCLUSIONS

Resection of MML with TIL should be considered because it can result in prolonged survival in a highly selected group of patients.

Metastatic Malignant Melanoma of the Gallbladder Presenting as Biliary Colic: A Case Report and Review of Literature

Malignant melanoma (MM) is the most common cancer to metastasize to the gastrointestinal tract. Autopsy reports estimate that up to 15 per cent of these patients also have gallbladder metastases, and MM accounts for up to 60 per cent of metastatic lesions to the gallbladder. However, despite its prevalence, MM to the gallbladder is reported only sparingly in the literature. This discordance may be explained by the fact that these lesions are seldom symptomatic. Abdominal ultrasound remains the modality of choice in studying gallbladder pathology and has the ability to define metastatic lesions. The effect of screening for gallbladder metastases on improving survival is not well defined, and thus its role remains controversial. Cholecystectomy for melanoma metastases to the gallbladder seems to be mostly palliative, although there have been isolated reports of excellent long-term survival outcomes. The role for immunotherapy and chemotherapy in this population is not well defined, and overall prognosis is poor. Recent reports have advocated laparoscopic cholecystectomy as the treatment of choice, though there remains a concern for peritoneal port site seeding. We present the case of a 48-year-old man with MM metastatic to the gallbladder and a brief review of the literature.