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Robert C, Gastman B, Gogas H, Rutkowski P, Long GV, Chaney MF, Joshi H, Lin YL, Snyder W, Chesney JA. Open-label, phase II study of talimogene laherparepvec plus pembrolizumab for the treatment of advanced melanoma that progressed on prior anti-PD-1 therapy: MASTERKEY-115. Eur J Cancer 2024; 207:114120. [PMID: 38870745 DOI: 10.1016/j.ejca.2024.114120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/29/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Treatment options for immunotherapy-refractory melanoma are an unmet need. The MASTERKEY-115 phase II, open-label, multicenter trial evaluated talimogene laherparepvec (T-VEC) plus pembrolizumab in advanced melanoma that progressed on prior programmed cell death protein-1 (PD-1) inhibitors. METHODS Cohorts 1 and 2 comprised patients (unresectable/metastatic melanoma) who had primary or acquired resistance, respectively, and disease progression within 12 weeks of their last anti-PD-1 dose. Cohorts 3 and 4 comprised patients (resectable disease) who underwent complete surgery, received adjuvant anti-PD-1, and experienced recurrence. Cohort 3 were disease-free for < 6 months and cohort 4 for ≥ 6 months after starting the adjuvant anti-PD-1 therapy and before confirmed recurrence. The primary endpoint was objective response rate (ORR) per RECIST v1.1. Secondary endpoints included complete response rate (CRR), disease control rate (DCR) and progression-free survival (PFS) per RECIST v1.1 and irRC-RECIST, and safety. RESULTS Of the 72 enrolled patients, 71 were treated. The ORR (95% CI) was 0%, 6.7% (0.2-32.0), 40.0% (16.3-67.7), and 46.7% (21.3-73.4) in cohorts 1-4, respectively; iORR was 3.8% (0.1-19.6), 6.7% (0.2-32.0), 53.3% (26.6-78.7), and 46.7% (21.3-73.4). iCRR was 0%, 0%, 13.3%, and 13.3%. Median iPFS (months) was 5.5, 8.2, not estimable [NE], and NE for cohorts 1-4, respectively; iDCR was 50.0%, 40.0%, 73.3%, and 86.7%. Treatment-related adverse events (TRAEs), grade ≥ 3 TRAEs, serious AEs, and fatal AEs occurred in 54 (76.1%), 9 (12.7%), 24 (33.8%), and 10 (14.1%) patients, respectively. CONCLUSION T-VEC-pembrolizumab demonstrated antitumor activity and tolerability in PD-1-refractory melanoma, specifically in patients with disease recurrence on or after adjuvant anti-PD-1. TRIAL REGISTRATION ClinicalTrials.gov identifier - NCT04068181.
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Affiliation(s)
- Caroline Robert
- Gustave Roussy and Paris-Saclay University, Villejuif, France
| | - Brian Gastman
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Helen Gogas
- National and Kapodistrian University of Athens, Athens, Greece
| | - Piotr Rutkowski
- Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, and Royal North Shore and Mater Hospitals, New South Wales, Australia
| | | | | | | | | | - Jason A Chesney
- UofL Health - Brown Cancer Center, University of Louisville, Louisville, KY, USA.
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Huibers A, DePalo DK, Perez MC, Zager JS, Olofsson Bagge R. Isolated hyperthermic perfusions for cutaneous melanoma in-transit metastasis of the limb and uveal melanoma metastasis to the liver. Clin Exp Metastasis 2023:10.1007/s10585-023-10234-6. [PMID: 37843790 DOI: 10.1007/s10585-023-10234-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Patients with cutaneous melanoma can develop in-transit metastases (ITM), most often localized to limbs. For patients with uveal melanoma that develop metastatic disease, the overall majority develop isolated liver metastases. For these types of metastases, regional cancer therapies have evolved as effective treatments. Isolated limb perfusion (ILP), isolated limb infusion (ILI), isolated hepatic perfusion (IHP) and percutaneous hepatic perfusion (PHP) achieve a high local concentration of chemotherapy with minimal systemic exposure. This review discusses the mechanism and available literature on locoregional treatment modalities in the era of modern immunotherapy.
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Affiliation(s)
- Anne Huibers
- Department of Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden
| | - Danielle K DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani, College of Medicine, Tampa, FL, USA
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden.
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DePalo DK, Perez MC, Huibers A, Olofsson Bagge R, Zager JS. Oncolytic intralesional therapy for metastatic melanoma. Clin Exp Metastasis 2023:10.1007/s10585-023-10228-4. [PMID: 37556092 DOI: 10.1007/s10585-023-10228-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/28/2023] [Indexed: 08/10/2023]
Abstract
In-transit metastasis (ITM) develop in approximately 1 in 10 patients with melanoma and the disease course can vary widely. Surgical resection is the gold-standard treatment; however, ITM are often surgically unresectable due to size, distribution, and/or anatomic involvement. Oncolytic viral therapies are one category of non-surgical treatment options available for ITM. They induce tumor cell lysis and systemic anti-tumor activity through selective infection of tumor cells by naturally occurring or genetically modified factors. While there are numerous oncolytic viral therapies in various stages of development for the treatment of ITM, this discussion focuses on the mechanism and available literature for the two most established herpes virus-based therapies.
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Affiliation(s)
- Danielle K DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 McKinley Drive Room 4123, Tampa, FL, USA
| | - Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 McKinley Drive Room 4123, Tampa, FL, USA
| | - Anne Huibers
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 McKinley Drive Room 4123, Tampa, FL, USA.
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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Song EH, Lee SY, Lee S, Jung JY, Shin SH, Chung YG, Jung CK. Diagnosis of Local Recurrence of Malignant Soft Tissue Tumors after Reconstructive Surgery on MRI. J Clin Med 2023; 12:4369. [PMID: 37445404 DOI: 10.3390/jcm12134369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
PURPOSE Magnetic resonance imaging (MRI) is useful in the diagnosis of local recurrence, but few studies have explored recurrence in MRI in patients after reconstructive surgery. The purpose of this study was to analyze MRI findings of locoregional recurrence following reconstructive surgery after malignant soft tissue tumor resection. METHOD Fifty-three postoperative MRIs from 37 patients who underwent reconstructive surgery after malignant soft tissue tumor resection were retrospectively reviewed. A total of 76 enhancing lesions, including 40 locoregional recurrences and 36 postoperative changes, were analyzed regarding morphology (location on the transplanted tissue, border, and shape) and the signals on T1- and T2-weighted imaging (T1WI, T2WI), fat-suppressed (FS) T2WI, and contrast-enhanced FS T1WI. Diffusion-weighted imaging with an apparent diffusion coefficient was assessed. A chi-squared test and Fisher's exact test were used for statistical analysis. RESULTS The most common site of recurrent tumors and postoperative changes was the peripheral margin on transplanted tissue (63% and 61%, respectively p = 0.907). Recurrent tumors commonly appeared with well-defined borders (75%) as well as nodular appearance (98%), hyperintensity on T2WI (85%) and FS-T2WI (95%), isointensity on T1WI (65%), impeded water diffusion (55%), and intense (50%) or moderate (45%) enhancement. Postoperative changes showed ill-defined borders (75%), nodular appearance (56%), facilitated water diffusion (69%), and moderate (86%) enhancement, which were significantly different from those of recurrent tumors (p ≤ 0.020). CONCLUSIONS Common and partitioning MRI features of locoregional recurrence were well-defined borders, nodular shape, impeded water diffusion, and intense enhancement. Peripheral margins on transplanted tissue were common sites in both recurrent tumors and postoperative changes.
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Affiliation(s)
- Eun-Hee Song
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Republic of Korea
| | - So-Yeon Lee
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Seungeun Lee
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Joon-Yong Jung
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Seung-Han Shin
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Yang-Guk Chung
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Chan-Kwon Jung
- Department of Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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de Meza MM, Blokx WAM, Bonenkamp HJ, Blank CU, Aarts MJB, van den Berkmortel FWPJ, Boers-Sonderen MJ, de Groot JWB, Haanen JB, Hospers GAP, Kapiteijn EW, van Not OJ, Piersma D, van Rijn RS, Stevense-Den Boer MA, van der Veldt AAM, Vreugdenhil G, van den Eertwegh AJM, Suijkerbuijk KPM, Wouters MWJM. Adjuvant treatment of in-transit melanoma: Narrowing the knowledge gap left by clinical trials. Int J Cancer 2023; 153:389-398. [PMID: 36843260 DOI: 10.1002/ijc.34485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 02/28/2023]
Abstract
Few clinical trials address efficacy of adjuvant systemic treatment in patients with in-transit melanoma (ITM). This study describes adjuvant systemic therapy of ITM patients beyond clinical trials. In this study, we included stage III adjuvant-treated melanoma patients registered in the nationwide Dutch Melanoma Treatment Registry between July 2018 and December 2020. Patients were divided into three groups: nodal disease only, ITM only and ITM and nodal disease. Recurrence patterns, recurrence-free survival (RFS) and overall survival (OS) at 12-months were analyzed. In our study population of 1037 patients, 66.8% had nodal disease only, 16.7% had ITM only and 16.2% had ITM with nodal disease. RFS at 12-months was comparable in the nodal only and ITM only group (72.2% vs70.1%, P = .97) but lower in ITM and nodal disease patients (57.8%; P = .01, P < .01). Locoregional metastases occurred as first recurrence in 38.9% nodal disease only, 71.9% of ITM-only and 44.0% of ITM and nodal disease patients. Distant recurrences occurred in 42.3%, 18.8% and 36.0%, respectively (P = .02). 12-months OS was not significantly different for nodal disease only patients compared with ITM-only (94.4% vs 97.6%, P = .06) but was significantly higher for ITM-only compared with ITM and nodal disease patients (97.6% vs 91.0%, P < .01). In conclusion, we showed that in the adjuvant setting, RFS rates in ITM-only patients are similar to non-ITM, though better than in ITM and nodal disease patients. Adjuvant-treated ITM-only patients less often experience distant recurrences and have a superior OS compared with ITM and nodal disease patients.
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Affiliation(s)
- Melissa M de Meza
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Willeke A M Blokx
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Han J Bonenkamp
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cristian U Blank
- Department of Medical Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maureen J B Aarts
- Department of Medical Oncology, GROW-School for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Marye J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - John B Haanen
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ellen W Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier J van Not
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Djura Piersma
- Department of Internal Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Rozemarijn S van Rijn
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Astrid A M van der Veldt
- Departments of Medical Oncology and Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gerard Vreugdenhil
- Department of Internal Medicine, Maxima Medical Center, Eindhoven, The Netherlands
| | - Alfons J M van den Eertwegh
- Department of Medical Oncology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Czarnecka AM, Ostaszewski K, Borkowska A, Szumera-Ciećkiewicz A, Kozak K, Świtaj T, Rogala P, Kalinowska I, Koseła-Paterczyk H, Zaborowski K, Teterycz P, Tysarowski A, Makuła D, Rutkowski P. Efficacy of Neoadjuvant Targeted Therapy for Borderline Resectable III B-D or IV Stage BRAF V600 Mutation-Positive Melanoma. Cancers (Basel) 2021; 14:cancers14010110. [PMID: 35008274 PMCID: PMC8744603 DOI: 10.3390/cancers14010110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Neoadjuvant therapy for locally advanced disease or potentially resectable metastatic melanoma is expected to improve operability and clinical outcomes over upfront surgery. 46 patients were treated with BRAFi/MEKi or BRAFi before surgery with 78% R0 resection. In patients with a major pathological response with no, or less than 10%, viable cells in the tumor, median DFS and PFS were significantly longer than in patients with a minor pathological response. Abstract Neoadjuvant therapy for locally advanced disease or potentially resectable metastatic melanoma is expected to improve operability and clinical outcomes over upfront surgery and adjuvant treatment as it is for sarcoma, breast, rectal, esophageal, or gastric cancers. Patients with locoregional recurrence after initial surgery and those with advanced regional lymphatic metastases are at a high risk of relapse and melanoma-related death. There is an unmet clinical need to improve the outcomes for such patients. Patients with resectable bulky stage III or resectable stage IV histologically confirmed melanoma were enrolled and received standard-dose BRAFi/MEKi for at least 12 weeks before feasible resection of the pre-therapy target and then received at least for the next 40 weeks further BRAFi/MEKi. Of these patients, 37 were treated with dabrafenib and trametinib, three were treated with vemurafenib and cobimetinib, five with vemurafenib, and one with dabrafenib alone. All patients underwent surgery with 78% microscopically margin-negative resection (R0) resection. Ten patients achieved a complete pathological response. In patients with a major pathological response with no, or less than 10%, viable cells in the tumor, median disease free survival and progression free survival were significantly longer than in patients with a minor pathological response. No patient discontinued neoadjuvant BRAFi/MEKi due to toxicity. BRAFi/MEKi pre-treatment did not result in any new specific complications of surgery. Fourteen patients experienced disease recurrence or progression during post-operative treatment. We confirmed that BRAFi/MEKi combination is an effective and safe regimen in the perioperative treatment of melanoma. Pathological response to neoadjuvant treatment may be considered as a surrogate biomarker of disease recurrence.
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Affiliation(s)
- Anna M. Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
- Correspondence: or ; Tel.: +48-22-546-24-55; Fax: +48-22-643-93-75
| | - Krzysztof Ostaszewski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Aneta Borkowska
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Anna Szumera-Ciećkiewicz
- Department of Pathology and Laboratory Medicine, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (A.S.-C.); (A.T.)
| | - Katarzyna Kozak
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Tomasz Świtaj
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Paweł Rogala
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Iwona Kalinowska
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Hanna Koseła-Paterczyk
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Konrad Zaborowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Paweł Teterycz
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
| | - Andrzej Tysarowski
- Department of Pathology and Laboratory Medicine, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (A.S.-C.); (A.T.)
- Department of Molecular and Translational Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Donata Makuła
- Department of Radiology I, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland;
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland; (K.O.); (A.B.); (K.K.); (T.Ś.); (P.R.); (I.K.); (H.K.-P.); (K.Z.); (P.T.); (P.R.)
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Current approaches in managing in-transit metastasis of malignant melanoma: a comprehensive review and proposal of an algorithm. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01875-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fujimoto N, Dieterich LC. Mechanisms and Clinical Significance of Tumor Lymphatic Invasion. Cells 2021; 10:cells10102585. [PMID: 34685565 PMCID: PMC8533989 DOI: 10.3390/cells10102585] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 12/17/2022] Open
Abstract
Tumor-associated lymphatic vessels play an important role in tumor progression, mediating lymphatic dissemination of malignant cells to tumor-draining lymph nodes and regulating tumor immunity. An early, necessary step in the lymphatic metastasis cascade is the invasion of lymphatic vessels by tumor cell clusters or single tumor cells. In this review, we discuss our current understanding of the underlying cellular and molecular mechanisms, which include tumor-specific as well as normal, developmental and immunological processes “hijacked” by tumor cells to gain access to the lymphatic system. Furthermore, we summarize the prognostic value of lymphatic invasion, discuss its relationship with local recurrence, lymph node and distant metastasis, and highlight potential therapeutic options and challenges.
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Affiliation(s)
- Noriki Fujimoto
- Department of Dermatology, Shiga University of Medical Science, Otsu 520-2192, Japan;
| | - Lothar C. Dieterich
- Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology (ETH) Zurich, Vladimir-Prelog-Weg 1-5/10, 8093 Zurich, Switzerland
- Correspondence:
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Knackstedt R, Smile T, Yu J, Gastman BR. Non-Operative Options for Loco-regional Melanoma. Clin Plast Surg 2021; 48:631-642. [PMID: 34503723 DOI: 10.1016/j.cps.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Malignant melanoma is the 5th most common cancer and stage IV melanoma accounts for approximately 4% of new melanoma diagnoses in the United States. The prognosis for regionally advanced disease is poor, but there have been numerous recent advances in the medical management of melanoma in-transit metastases. The goal of this paper is to review currently accepted treatment options for in-transit metastases and introduce emerging therapies. Therapies to be discussed include limb perfusion and infusion, immunotherapy, checkpoint inhibitors, and radiation therapy.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA
| | - Timothy Smile
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Jennifer Yu
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA.
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10
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Khoury S, Knapp GC, Fyfe A, Monzon J, Temple-Oberle C, McKinnon GJ. Durability of Complete Response to Intralesional Interleukin-2 for In-Transit Melanoma. J Cutan Med Surg 2021; 25:364-370. [PMID: 33529083 PMCID: PMC8311908 DOI: 10.1177/1203475420988862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intralesional injection of interleukin-2 (IL-2) for in-transit melanoma (ITM) is associated with a high rate of complete response. However, there is a paucity of data on treatment durability and long-term outcomes. Objectives To provide long-term data on patients with a complete response to IL-2 therapy for ITM. Methods Consecutive patients with ITM, treated with intralesional IL-2 therapy, at the Tom Baker Cancer Center were identified from April 2009 to August 2019. All patients received at least 4 cycles (every 2 weeks) of IL-2 (5 MIU/mL). Complete response was defined as sustained (ie, 3 months) clinical complete remission of all known in-transit disease. Results Sixty-five patients were treated with curative intent for in-transit disease with intralesional IL-2. Complete clinical response was identified in 44.6% (29/65). In this subset of patients, the median number of lesions per patient was 9 (range 1-40). The median total dose of IL-2 was 0.8 mL (IQR 0.4-1.5) per lesion. One patient received isolated limb infusion and 13.8% (4/29) received systemic immunotherapy as part of their initial management. At a median follow-up of 27 months (IQR 16-59), 34.5% (10/29) developed recurrent disease. Of these patients, 50.0% (5/10) presented with synchronous in-transit and distant metastases. The median time to recurrence was 10.5 months (IQR 5.8-16.3). Conclusion With long-term follow-up, 65.5% of complete responders have a durable response to intralesional IL-2 therapy. In this cohort of patients, local in-transit recurrence is most likely to occur within 12 months and is often associated with concomitant distant disease.
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Affiliation(s)
- Sami Khoury
- 70401 Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gregory C Knapp
- 2129 Department of Oncology, Division of Surgical Oncology, University of Calgary, Calgary, AB, Canada
| | - Allison Fyfe
- 3146 Alberta Health Services, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Jose Monzon
- Department of Oncology, Division of Medical Oncology, University of Calgary, Calgary, AB, Canada
| | - Claire Temple-Oberle
- Department of Surgery, Division of Plastic Surgery and Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Gregory J McKinnon
- 2129 Department of Oncology, Division of Surgical Oncology, University of Calgary, Calgary, AB, Canada
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Jojoa Acosta MF, Caballero Tovar LY, Garcia-Zapirain MB, Percybrooks WS. Melanoma diagnosis using deep learning techniques on dermatoscopic images. BMC Med Imaging 2021; 21:6. [PMID: 33407213 PMCID: PMC7789790 DOI: 10.1186/s12880-020-00534-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 12/08/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Melanoma has become more widespread over the past 30 years and early detection is a major factor in reducing mortality rates associated with this type of skin cancer. Therefore, having access to an automatic, reliable system that is able to detect the presence of melanoma via a dermatoscopic image of lesions and/or skin pigmentation can be a very useful tool in the area of medical diagnosis. METHODS Among state-of-the-art methods used for automated or computer assisted medical diagnosis, attention should be drawn to Deep Learning based on Convolutional Neural Networks, wherewith segmentation, classification and detection systems for several diseases have been implemented. The method proposed in this paper involves an initial stage that automatically crops the region of interest within a dermatoscopic image using the Mask and Region-based Convolutional Neural Network technique, and a second stage based on a ResNet152 structure, which classifies lesions as either "benign" or "malignant". RESULTS Training, validation and testing of the proposed model was carried out using the database associated to the challenge set out at the 2017 International Symposium on Biomedical Imaging. On the test data set, the proposed model achieves an increase in accuracy and balanced accuracy of 3.66% and 9.96%, respectively, with respect to the best accuracy and the best sensitivity/specificity ratio reported to date for melanoma detection in this challenge. Additionally, unlike previous models, the specificity and sensitivity achieve a high score (greater than 0.8) simultaneously, which indicates that the model is good for accurate discrimination between benign and malignant lesion, not biased towards any of those classes. CONCLUSIONS The results achieved with the proposed model suggest a significant improvement over the results obtained in the state of the art as far as performance of skin lesion classifiers (malignant/benign) is concerned.
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Affiliation(s)
| | | | | | - Winston Spencer Percybrooks
- Department of Electrical and Electronics Engineering, Universidad del Norte, Km.5 Vía Puerto Colombia, Barranquilla, Colombia
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12
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Tran AD, Fogarty G, Nowak AK, Diaby V, Hong A, Watts C, Morton RL. Cost-Effectiveness of Subsequent Whole-Brain Radiotherapy or Hippocampal-Avoidant Whole-Brain Radiotherapy Versus Stereotactic Radiosurgery or Surgery Alone for Treatment of Melanoma Brain Metastases. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:679-687. [PMID: 32157631 DOI: 10.1007/s40258-020-00560-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND A randomized phase III trial comparing whole-brain radiotherapy (WBRT) to observation following definitive local treatment of intracranial melanoma metastases with neurosurgery and/or stereotactic surgery (SRS) is underway. OBJECTIVE We sought to assess the pre-trial cost-effectiveness of WBRT, hippocampal-avoidant WBRT (HA-WBRT), and observation (SRS or surgery alone) for this population to guide trial data collection efforts and reduce decision uncertainty. METHODS: A time-dependent Markov model followed patients treated with neurosurgery or SRS who received subsequent WBRT, HA-WBRT or observation over a 5-year time horizon. Model inputs were sourced from published literature and results tested for robustness using probabilistic sensitivity analysis. Value of information (VOI) analysis was undertaken to guide data collection for the randomized trial. RESULTS Over 5 years, the WBRT strategy produced 1.74 QALYs (2.38 life-years) at a mean cost of $40,128 (costs in 2017 Australian dollars); HA-WBRT produced 1.88 QALYs (2.38 life-years) and cost $42,977; and SRS/surgery alone produced 1.65 QALYs (2.13 life-years) at a cost of $46,281. Probabilistic sensitivity analysis showed HA-WBRT was the preferred strategy in 77% of simulations. Cost-effectiveness results were most sensitive to utilities of the controlled-disease health state in the WBRT group, and costs of HA-WBRT. The EVPI for a randomized trial was estimated at $6,888 per person. CONCLUSIONS HA-WBRT may be cost-effective for the treatment of melanoma brain metastases. The results predicted in our model can be validated with prospective trial data when available.
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Affiliation(s)
- Anh Dam Tran
- Health Economics, National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King street, Sydney, NSW, 2031, Australia.
| | - Gerald Fogarty
- St Vincent's Department of Radiotherapy, St Vincent's Hospital, Darlinghurst, NSW, 2010, Australia
| | - Anna K Nowak
- Medical School, University of Western Australia, Crawley, WA, 6009, Australia
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Vakaramoko Diaby
- Health Economics and Outcomes Research, Department of Pharmaceutical Outcomes and Policy (POP), College of Pharmacy, University of Florida, 1225 Center Drive, Gainesville, FL, 32610, USA
| | - Angela Hong
- Melanoma Institute Australia, University of Sydney, North Sydney, NSW, Australia
| | - Caroline Watts
- Melanoma Institute Australia, University of Sydney, North Sydney, NSW, Australia
- Kirby Institute, UNSW, Sydney, NSW, 2052, Australia
| | - Rachael L Morton
- Health Economics, National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King street, Sydney, NSW, 2031, Australia
- Melanoma Institute Australia, University of Sydney, North Sydney, NSW, Australia
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Biomarkers Predictive of Survival and Response to Immune Checkpoint Inhibitors in Melanoma. Am J Clin Dermatol 2020; 21:1-11. [PMID: 31602560 DOI: 10.1007/s40257-019-00475-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Immunotherapy has revolutionized the treatment of melanoma. Targeting of the immune checkpoints cytotoxic T-lymphocyte-associated protein 4 and programmed cell death protein 1 has led to improved survival in a subset of patients. Unfortunately, the use of immune checkpoint inhibitors is associated with significant side effects and many patients do not respond to treatment. Thus, there is an urgent need both for prognostic biomarkers to estimate risk and for predictive biomarkers to determine which patients are likely to respond to therapy. In this review, prognostic and predictive biomarkers that are an active area of research are outlined. Of note, certain transcriptomic signatures are already used in the clinic, albeit not routinely, to prognosticate patients. In the predictive setting, programmed cell death protein ligand 1 expression has been shown to correlate with benefit but is not precise enough to be used as an exclusionary biomarker. Future investigation will need to focus on biomarkers that are easily reproducible, cost effective, and accurate. The use of readily available clinical material, such as serum or hematoxylin and eosin-stained images, may offer one such path forward.
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Local and Recurrent Regional Metastases of Melanoma. CUTANEOUS MELANOMA 2020. [PMCID: PMC7123735 DOI: 10.1007/978-3-030-05070-2_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Up to 10% of patients with cutaneous melanoma will develop recurrent locoregional disease. While surgical resection remains the mainstay of treatment for isolated recurrences, locoregional melanoma can often present as bulky, unresectable disease and can pose a significant therapeutic challenge. This chapter focuses on the natural history of local and regionally recurrent metastases and the multiple treatment modalities which exist for advanced locoregional melanoma, including regional perfusion procedures such as hyperthermic isolated limb perfusion and isolated limb infusion, intralesional therapies, and neo-adjuvant systemic therapy strategies for borderline resectable regional disease. Hyperthermic limb perfusion (HILP) and isolated limb infusion (ILI) are generally well-tolerated and have shown overall response rates between 44% and 90%. Intralesional therapies also appear to be well-tolerated as adverse events are usually limited to the site of injection and minor transient flu-like symptoms. Systemic targeted therapies have shown to have response rates up to 85% when used as neoadjuvant therapy in patients with borderline resectable disease. While combination immunotherapy in the neoadjuvant setting has also shown promising results, this data has not yet matured.
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15
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Louie RJ, Perez MC, Jajja MR, Sun J, Collichio F, Delman KA, Lowe M, Sarnaik AA, Zager JS, Ollila DW. Real-World Outcomes of Talimogene Laherparepvec Therapy: A Multi-Institutional Experience. J Am Coll Surg 2019; 228:644-649. [PMID: 30690076 DOI: 10.1016/j.jamcollsurg.2018.12.027] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Talimogene laherparepvec (TVEC) is an FDA-approved oncolytic herpes virus used to treat unresectable stage IIIB to IV metastatic melanoma via intralesional injection. This study aims to characterize the efficacy TVEC in patients with unresectable stage IIIB to IV melanoma. METHODS We performed a multi-institutional, IRB-approved review of all patients who received TVEC at 3 centers from October 2015 to October 2018. Clinicopathologic characteristics, TVEC treatment data, and outcomes were assessed. RESULTS One hundred and twenty-one patients received TVEC, of which 80 patients had available treatment response data with at least 3-month follow-up. Anatomic sites treated were 19 (24%) head and neck, 9 (11%) upper extremity, 12 (15%) torso, and 40 (50%) lower extremity. Thirty-four (42.5%) patients did not receive therapy before TVEC. Side effects were mild and self-limited, most commonly flu-like symptoms seen in 22 (28%) patients. Median follow-up was 9 months (range 3 to 28 months), with complete local response in 31 (39%) and partial response in 14 (18%) patients. Of complete responders, 29 (37%) had no evidence of disease at last follow-up and received a median of 6 (range 2 to 12) cycles of therapy. CONCLUSIONS Talimogene laherparepvec is a well-tolerated, durable treatment option for patients with unresectable locoregional melanoma, particularly in stage IIIB/C disease. Additionally, we found that TVEC can be administered safely across anatomic sites that are otherwise not amenable to other local therapies.
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Affiliation(s)
- Raphael J Louie
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - Mohammad Raheel Jajja
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - Frances Collichio
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Keith A Delman
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Michael Lowe
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Amod A Sarnaik
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Perez MC, Miura JT, Naqvi SMH, Kim Y, Holstein A, Lee D, Sarnaik AA, Zager JS. Talimogene Laherparepvec (TVEC) for the Treatment of Advanced Melanoma: A Single-Institution Experience. Ann Surg Oncol 2018; 25:3960-3965. [PMID: 30298318 DOI: 10.1245/s10434-018-6803-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Talimogene laherparepvec (TVEC) is an oncolytic herpes virus used as intralesional therapy for patients with unresectable stage IIIB through IV melanoma. We reviewed the standard of care treatment of TVEC at a single institution. METHODS All patients treated with TVEC for advanced melanoma were retrospectively evaluated from 2015 to 2018. Patient demographics, clinicopathologic characteristics, treatment response, and toxicity were reviewed. RESULTS Twenty-seven patients underwent therapy with TVEC. Median age was 75 years, and 63% of patients were female. Seventeen (63.0%) patients underwent injections on the lower extremity, four (14.8%) on the upper extremity, four (14.8%) on the head and neck, and two (7.4%) on the trunk. Median number of injections was five. Median follow-up was 8.6 months. Of the 27 patients, 23 patients met the criteria for response analysis with at least 8 weeks follow-up. Ten (43.5%) patients experienced a complete response (CR), three (13.1%) experienced a partial response (PR), and five (21.7%) had stable disease (SD) for an overall response rate of 56.5% (CR + PR) and a disease control rate of 78.3% (CR + PR + SD). Adverse events were mostly limited to mild constitutional symptoms within 48 h of injection. Two patients developed cellulitis treated with oral antibiotics, and one patient underwent excision of a lesion for ulceration and bleeding during therapy. DISCUSSION TVEC is an effective and well-tolerated intralesional therapy for patients with unresectable stage IIIB through IV melanoma. A CR was achieved in almost half of patients treated. Disease control is seen in the vast majority.
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Affiliation(s)
- Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - John T Miura
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | | | - Youngchul Kim
- Department of Biostatistics, Moffitt Cancer Center, Tampa, FL, USA
| | - Amanda Holstein
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - Daniel Lee
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - Amod A Sarnaik
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA.
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17
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Zenga J, Nussenbaum B, Cornelius LA, Linette GP, Desai SC. Management Controversies in Head and Neck Melanoma. JAMA FACIAL PLAST SU 2017; 19:53-62. [DOI: 10.1001/jamafacial.2016.1038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Joseph Zenga
- Department of Otolaryngology–Head & Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Brian Nussenbaum
- Department of Otolaryngology–Head & Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Lynn A. Cornelius
- Department of Dermatology, Washington University School of Medicine, St Louis, Missouri
| | - Gerald P. Linette
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Shaun C. Desai
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins University School of Medicine, Bethesda, Maryland
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Alexander M, Acosta Gonzalez G, Malerba S, Hochman T, Goldberg JD, Darvishian F. Multifocal Invasive Ductal Cancer: Distinguishing Independent Tumor Foci From Multiple Satellites. Int J Surg Pathol 2016; 25:298-303. [PMID: 27831532 DOI: 10.1177/1066896916676586] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with multifocal breast cancers (MBCs) have a poorer prognosis than patients with unifocal breast cancers. Studies have attributed this to tumor size underestimation in MBC. An alternative hypothesis is that some MBCs behave in a fashion analogous to the "satellite" and "in-transit metastasis" observed in melanoma and, thereby, are more clinically aggressive. We identified 79 cases of MBC, which we classified into 2 groups: study cases defined as ≥2 morphologically similar tumor foci with ≥1 focus without in situ carcinoma (n = 21); and a control group defined as ≥2 morphologically similar or dissimilar foci with associated in situ carcinoma in all foci (n = 58). The odds of being a study case is 1.86 (95% confidence interval [CI] 1.26-2.74) times greater per unit increase in number of tumor foci (median of 4 tumor foci; P = .002). Study cases were 73.33 (95% CI = 8.91-603.16) times more likely to have lymphovascular invasion (LVI) and 14.72 (95% CI = 4.37-49.61) times more likely to have nodal metastases. Grade I/II tumors were 0.20 (95% CI = 0.07-0.59) times less likely to be study cases. There was a significant positive interaction ( P < 0.001) indicated by the relationship of LVI status and nodal status with the study case and control group. We conclude that there is a subset of MBC that presents with more numerous tumor foci and a higher rate of nodal metastasis. The aggressive behavior of these cases may be attributed to their proclivity for LVI.
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19
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Sloot S, Speijers M, Bastiaannet E, Hoekstra H. Is there a relation between type of primary melanoma treatment and the development of intralymphatic metastasis? A review of the literature. Cancer Treat Rev 2016; 45:120-8. [DOI: 10.1016/j.ctrv.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/19/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
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20
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Moncrieff M, Fadhil M, Garioch J. Topical diphencyprone for the treatment of locoregional intralymphatic melanoma metastases of the skin; the 5-year Norwich experience. Br J Dermatol 2016; 174:1141-2. [PMID: 26598951 DOI: 10.1111/bjd.14314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Moncrieff
- Skin Tumour Unit, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, U.K
| | - M Fadhil
- Skin Tumour Unit, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, U.K
| | - J Garioch
- Skin Tumour Unit, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, U.K
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Hassan S, Petrella TM, Zhang T, Kamel-Reid S, Nordio F, Baccarelli A, Sade S, Naert K, Habeeb AA, Ghazarian D, Wright FC. Pathologic complete response to intralesional interleukin-2 therapy associated with improved survival in melanoma patients with in-transit disease. Ann Surg Oncol 2014; 22:1950-8. [PMID: 25366584 DOI: 10.1245/s10434-014-4199-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Melanoma patients with in-transit disease have a high mortality rate despite various treatment strategies. The aim of this study was to validate the role of intralesional interleukin (IL)-2, to understand its mechanism of action, and to better understand factors that may influence its response. METHODS We retrospectively collected the clinicopathological data of 31 consecutive patients who presented to a tertiary care cancer center for treatment of in-transit melanoma with intralesional IL-2. Kaplan-Meier survival curves and multivariable Cox regression analysis were performed. Immunohistochemistry (IHC) was used to better understand the immune response to localized IL-2 therapy. Targeted next-generation sequencing was performed to genomically characterize the tumors. RESULTS Ten patients (10/31, 32 %) achieved a pathologic complete response (pCR), 17/21 (55 %) had a partial response, and 4/21 (19 %) had progressive disease on treatment. pCR to IL-2 therapy was associated with overall survival (log-rank p = 0.004) and improved progression-free survival (PFS) [adjusted hazard ratio (HR) 0.11; 95 % CI 0.02-0.47; p = 0.003). A higher CD8+ T cell infiltrate was identified in in-transit lesions with a pCR compared with the other lesions (mean IHC score 3.78 vs. 2.61; p = 0.01). Patients with an elevated CD8+ infiltrate demonstrated an improved PFS (unadjusted HR 0.08; 95 % CI 0.01-0.52; p = 0.008). CONCLUSIONS Thirty-two percent of patients achieved pCR with intralesional IL-2 therapy and had a significantly improved PFS compared with the rest of the cohort, which may be explained by a systemic CD8+ T-cell response.
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Affiliation(s)
- Saima Hassan
- Division of Surgical Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, ON, Canada
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22
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Costa J, Ortiz-Ibañez K, Salerni G, Borges V, Carrera C, Puig S, Malvehy J. Dermoscopic patterns of melanoma metastases: interobserver consistency and accuracy for metastasis recognition. Br J Dermatol 2014; 169:91-9. [PMID: 23495915 DOI: 10.1111/bjd.12314] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cutaneous metastases of malignant melanoma (CMMM) can be confused with other skin lesions. Dermoscopy could be helpful in the differential diagnosis. OBJECTIVES To describe distinctive dermoscopic patterns that are reproducible and accurate in the identification of CMMM. METHODS A retrospective study of 146 dermoscopic images of CMMM from 42 patients attending a melanoma unit between 2002 and 2009 was performed. Firstly, two investigators established six dermoscopic patterns for CMMM. The correlation of 73 dermoscopic images with their distinctive patterns was assessed by four independent dermatologists to evaluate the reproducibility in the identification of the patterns. Finally, 163 dermoscopic images, including CMMM and nonmetastatic lesions, were evaluated by the same four dermatologists to calculate the accuracy of the patterns in the recognition of CMMM. RESULTS Five CMMM dermoscopic patterns had a good interobserver agreement (blue naevus-like, naevus-like, angioma-like, vascular and unspecific). When CMMM were classified according to these patterns, correlation between the investigators and the four dermatologists ranged from κ = 0.56 to κ = 0.7. In total, 71 CMMM, 16 angiomas, 22 blue naevi, 15 malignant melanomas, 11 seborrhoeic keratoses, 15 melanocytic naevi with a globular pattern and 13 pink lesions with a vascular pattern were evaluated according to the previously described CMMM dermoscopy patterns, showing an overall sensitivity of 67.9% (range 54.9-76%) and a specificity of 79.9% (range 68.5-93.5%) for the diagnosis of CMMM. CONCLUSIONS Five dermoscopic patterns of CMMM with good interobserver agreement obtained a high sensitivity and specificity in the diagnosis of metastasis, with the accuracy varying according to the experience of the observer.
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Affiliation(s)
- J Costa
- Hospital Clínic i Provincial de Barcelona, Unitat de Melanoma, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
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23
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Hoekstra HJ, Veerman K, van Ginkel RJ. Isolated limb perfusion for in-transit melanoma metastases: Melphalan or TNF-melphalan perfusion? J Surg Oncol 2014; 109:338-47. [DOI: 10.1002/jso.23552] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 12/05/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Harald J. Hoekstra
- Department of Surgical Oncology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - Kelly Veerman
- Department of Surgical Oncology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - Robert J. van Ginkel
- Department of Surgical Oncology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
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Bartlett EK, Gupta M, Datta J, Gimotty PA, Guerry D, Xu X, Elder DE, Czerniecki BJ, Fraker DL, Karakousis GC. Prognosis of patients with melanoma and microsatellitosis undergoing sentinel lymph node biopsy. Ann Surg Oncol 2013; 21:1016-23. [PMID: 24258854 DOI: 10.1245/s10434-013-3388-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Melanoma microsatellitosis is classified as stage IIIB/C disease and is associated with a poor prognosis. Prognostic factors within this group, however, have not been well characterized. METHODS We performed a retrospective analysis of 1,621 patients undergoing sentinel lymph node (SLN) biopsy at our institution (1996-2011) to compare patients with (n = 98) and patients without (n = 1,523) microsatellites. Univariate and multivariate logistic and Cox regression analyses were used to identify factors associated with SLN positivity and melanoma-specific survival (MSS) in patients with microsatellites. RESULTS Patients with microsatellites were older and had lesions with higher Clark level and greater thickness that more frequently had mitoses, ulceration, and lymphovascular invasion (LVI) (all p < 0.0001). In microsatellite patients, the SLN positivity rate was 43 %. Lesional ulceration (odds ratio [OR] = 2.9, 95 % confidence interval [CI] 1.5-8.6), absent tumor infiltrating lymphocytes (OR = 2.8, 95 % CI 1.1-7.1), and LVI (OR = 3.3, 95 % CI 1.7-10) were significantly associated with SLN positivity by multivariate analysis. With a median follow-up of 4.5 years in survivors, ulceration (hazards ratio [HR] = 3.4, 95 % CI 1.5-7.8) and >1 metastatic LN (HR = 2.7, 95 % CI 1.1-6.6) were significantly associated with decreased MSS by multivariate analysis. In patients without these prognostic factors, the 5-year MSS was 90 % (n = 49) compared with 50 % (n = 23) among patients with ulceration only, 51 % (n = 12) in those with >1 metastatic LN only, or 25 % in those with both (n = 14, p < 0.01). DISCUSSION Microsatellitosis was frequently associated with multiple adverse pathologic features. In the absence of ulceration and >1 metastatic LN; however, the outcome for patients with microsatellites compared favorably to stage IIIB patients overall.
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Affiliation(s)
- Edmund K Bartlett
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA,
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Risk Factors for the Development of Locoregional Cutaneous Metastases as the Sole Form of Recurrence in Patients With Melanoma. ACTAS DERMO-SIFILIOGRAFICAS 2013. [DOI: 10.1016/j.adengl.2012.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Risk factors for the development of locoregional cutaneous metastases as the sole form of recurrence in patients with melanoma. ACTAS DERMO-SIFILIOGRAFICAS 2012; 104:53-60. [PMID: 23010018 DOI: 10.1016/j.ad.2012.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 05/07/2012] [Accepted: 05/13/2012] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND While locoregional cutaneous metastases (in transit and satellite) in melanoma have received little attention from researchers to date, they have pathogenic and prognostic features that distinguish them from other forms of locoregional recurrence. Identifying predictors of these metastases would be of great value for their prevention, early diagnosis, and treatment. The aim of this study was to identify the risk factors associated with locoregional cutaneous metastases as the first form of recurrence in the metastatic progression of melanoma. MATERIAL AND METHODS Between 2000 and 2010, we prospectively collected the data of 1327 patients diagnosed with stage I and II melanoma. During follow up, 112 patients (8.4%) developed metastases. Of these, 36 had exclusively locoregional cutaneous metastases. The clinical and histological characteristics of this subgroup were evaluated. RESULTS In the univariate analysis, significant predictors were patient age, primary tumor thickness, site, ulceration, mitotic index, and histological type. After multivariate analysis, the independent risk factors were tumor thickness (risk ratio [RR] 5.6; 95% CI: 2.7-11.5) and the location of the primary tumor on the lower limbs (RR 3.4; 95% CI: 1.0-11.5), on the head or neck (RR 4.8; 95% IC: 1.7-13.5), or in acral sites (RR 6.7; 95% IC: 2.2-20.8). CONCLUSION Patients who have melanomas with a Breslow thickness of more than 2mm located on the lower limbs, head, neck, or acral sites have a higher risk of developing locoregional cutaneous metastases. These findings could be useful in the design of future guidelines for the monitoring and management of melanoma.
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Messeguer F, Agustí-Mejías A, Traves V, Requena C, Alegre V, Guillén C, Oliver V, Nagore E. Mitotic rate and subcutaneous involvement are prognostic factors for survival after recurrence in patients with only locoregional skin metastasis as the first site of recurrence from cutaneous melanoma. J Eur Acad Dermatol Venereol 2012; 27:436-41. [DOI: 10.1111/j.1468-3083.2012.04454.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Marcoval J, Ferreres J, Penín R, Piulats J, Caminal J, Fabra À. Descriptive Analysis of Cutaneous Recurrence Patterns in Patients with Melanoma. ACTAS DERMO-SIFILIOGRAFICAS 2011. [DOI: 10.1016/j.adengl.2012.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Egger ME, Gilbert JE, Burton AL, Mcmasters KM, Callender GG, Quillo AR, Brown RE, Hill CRS, Hagendoorn L, Martin RCG, Stromberg AJ, Scoggins CR. Lymphovascular Invasion as a Prognostic Factor in Melanoma. Am Surg 2011. [DOI: 10.1177/000313481107700816] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The prognostic significance of lymphovascular invasion (LVI) in melanoma remains controversial. Clinicopathologic data from a prospective trial of patients with melanoma were analyzed with respect to LVI. Disease-free survival and overall survival (OS) were evaluated by Kaplan-Meier (KM) analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive sentinel nodes (SLN) and survival. A total of 2183 patients were included in this analysis; 171 (7.8%) had LVI. Median follow-up was 68 months. Factors associated with LVI included tumor thickness, ulceration, and histologic subtype ( P < 0.05). LVI was associated with a greater risk of SLN metastasis ( P < 0.05). By KM analysis, LVI was associated with worse OS ( P = 0.0009). On multivariate analysis, age, gender, thickness, ulceration, anatomic location, and SLN status were predictors of OS; however, LVI was not an independent predictor of OS. Among patients with regression, the 5-year OS rate was 49.4 per cent for patients with LVI versus 81.1 per cent for those with no LVI ( P < 0.0001). LVI is associated with a greater risk of SLN metastasis. Although LVI is not an independent predictor of OS in general, it is a powerful predictor of worse OS among patients who have evidence of regression of the primary tumor.
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Affiliation(s)
- Michael E. Egger
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | | | - Alison L. Burton
- University of Louisville School of Medicine, Louisville, Kentucky
| | | | | | - Amy R. Quillo
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Russell E. Brown
- Department of Surgery, University of Louisville, Louisville, Kentucky
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Marcoval J, Ferreres JR, Penín RM, Piulats JM, Caminal JM, Fabra A. [Descriptive analysis of cutaneous recurrence patterns in patients with melanoma]. ACTAS DERMO-SIFILIOGRAFICAS 2011; 102:791-6. [PMID: 21658662 DOI: 10.1016/j.ad.2011.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 03/22/2011] [Accepted: 04/03/2011] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Few studies have addressed cutaneous recurrence of melanoma. The aim of this retrospective study was to analyze the characteristics and prognostic significance of the different patterns of cutaneous recurrence. MATERIAL AND METHODS Patients diagnosed with melanoma between 1988 and 2008 at Hospital de Bellvitge, Barcelona, Spain and for whom data were available for at least 2 years of follow-up were included in the study. Local recurrence was defined as melanoma invasion of the skin adjacent to the scar left by excision of the primary tumor, regional metastasis or recurrence as metastasis restricted to the area drained by a regional lymph node station, and distant cutaneous metastasis as metastasis occurring outside this area. The relationship between cutaneous recurrence pattern and age, sex, primary tumor site, tumor subtype, Breslow depth, and ulceration was assessed. RESULTS Eighty-five out of 1,080 patients (7.87%) had cutaneous recurrence. In 71 of those patients (83.53%; 27 men and 44 women; mean age, 60.68 years), this was the first indication of melanoma recurrence. Thirty-two patients had local recurrence, 32 regional metastasis, and 7 distant metastasis. Significant differences were observed in survival time from diagnosis of the primary tumor (P=.044) and from diagnosis of cutaneous recurrence (P<.001) according to the type of recurrence. CONCLUSIONS Our results suggest that the pattern of cutaneous recurrence is prognostically significant and related to the site of the primary tumor given that the majority of local and regional recurrences occurred in primary tumors located on the lower limbs and head.
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Affiliation(s)
- J Marcoval
- Servicio de Dermatología, IDIBELL, Hospital Universitari de Bellvitge, Barcelona, España.
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Leong SPL, Gershenwald JE, Soong SJ, Schadendorf D, Tarhini AA, Agarwala S, Hauschild A, Soon CWM, Daud A, Kashani-Sabet M. Cutaneous melanoma: a model to study cancer metastasis. J Surg Oncol 2011; 103:538-49. [PMID: 21480247 DOI: 10.1002/jso.21816] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nodal status in melanoma is a critically important prognostic factor for patient outcome. The survival rate drops to <10% when melanoma has spread beyond the regional lymph nodes and includes visceral involvement. In general, the process of melanoma metastasis is progressive in that dissemination of melanoma from the primary site to the regional lymph nodes occurs prior to systemic disease. The goal of this review article is to describe melanoma as a clinical model to study cancer metastasis. A future challenge is to develop a molecular taxonomy to subgroup melanoma patients at various stages of tumor progression for more accurate targeted treatment.
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Affiliation(s)
- Stanley P L Leong
- Center for Melanoma Research and Treatment and Department of Surgery, California Pacific Medical Center and Research Institute, San Francisco, California 94115, USA.
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Grotz TE, Markovic SN, Erickson LA, Harmsen WS, Huebner M, Farley DR, Pockaj BA, Donohue JH, Sim FH, Grant CS, Bagaria SP, Shives TC, Balch CM, Jakub JW. Mayo Clinic consensus recommendations for the depth of excision in primary cutaneous melanoma. Mayo Clin Proc 2011; 86:522-8. [PMID: 21628616 PMCID: PMC3104911 DOI: 10.4065/mcp.2011.0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Currently, no data from randomized controlled clinical trials are available to guide the depth of resection for intermediate-thickness primary cutaneous melanoma. Thus, we hypothesized that substantial variability exists in this aspect of surgical care. We have summarized the literature regarding depth of resection and report the results of our survey of surgeons who treat melanoma. Most of the 320 respondents resected down to, but did not include, the muscular fascia (extremity, 71%; trunk, 66%; and head and neck, 62%). However, significant variation exists. We identified variability in our own practice and have elected to standardize this common aspect of routine surgical care across our institution. In light of the lack of evidence to support resection of the deep muscular fascia, we have elected to preserve the muscular fascia as a matter of routine, except when a deep primary melanoma or thin subcutaneous tissue dictates otherwise.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - James W. Jakub
- Individual reprints of this article are not available. Address correspondence to James W. Jakub, MD, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Petersson F, Diwan AH, Ivan D, Gershenwald JE, Johnson MM, Harrell R, Prieto VG. Immunohistochemical detection of lymphovascular invasion with D2-40 in melanoma correlates with sentinel lymph node status, metastasis and survival. J Cutan Pathol 2009; 36:1157-63. [DOI: 10.1111/j.1600-0560.2008.01242.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Santillan AA, Delman KA, Beasley GM, Mosca PJ, Hochwald SN, Grobmyer SR, Andtbacka RH, Noyes RD, Kane JM, Ross MI, Tyler DS, Zager JS. Predictive factors of regional toxicity and serum creatine phosphokinase levels after isolated limb infusion for melanoma: a multi-institutional analysis. Ann Surg Oncol 2009; 16:2570-8. [PMID: 19543771 DOI: 10.1245/s10434-009-0563-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 04/08/2009] [Accepted: 05/05/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique delivering regional chemotherapy to treat in-transit extremity melanoma. Determining perioperative factors that could predict toxicity is important to optimize strategies to improve clinical outcomes after regional chemotherapy in melanoma. METHODS Perioperative factors from 171 ILI patients performed at eight centers from 2001 to 2008 were reviewed. The Wieberdink limb toxicity scale and creatine phosphokinase (CK) levels were used to measure toxicity. Logistic regression analysis was used to estimate the association between toxicity and perioperative parameters. RESULTS Mild (grades I-II) and severe (grades >or=III) limb toxicity developed in 68% and 32% of patients, respectively. Melphalan adjusted for ideal body weight (aIBW) and papaverine were used in 47% and 63% of patients, respectively. Median peak CK for all patients was 563 U/l, and median peak occurred at postoperative day 4. On univariate analysis, papaverine and high CK levels (>563 U/l) were significantly associated with higher toxicity. On the contrary, aIBW was significantly associated with a lower risk of severe toxicity. Perfusate blood gas at 30 min [pH, PaO(2), and base excess (BE) ], limb temperature, and ischemia time were not predictive of limb toxicity. On multivariate analysis, severe toxicity was associated with female sex (P = 0.01), papaverine (P = 0.01), and high peak CK levels (P < 0.01). Independent predictors of high CK levels included younger age, unadjusted melphalan dose, and low PaO(2) at 30 min. CONCLUSIONS ILI can be performed with an acceptable morbidity. Papaverine use, female gender, and high peak CK were associated with higher limb toxicity. CK levels can be diminished significantly with aIBW.
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Affiliation(s)
- Alfredo A Santillan
- Division of Cutaneous Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Uludag M, Citgez B, Ozkaya O, Sakiz D. In-transit metastasis of the breast region from malignant melanoma of the trunk. BMJ Case Rep 2009; 2009:bcr07.2008.0433. [PMID: 21686814 DOI: 10.1136/bcr.07.2008.0433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Extramammarian cancer metastases to the breast are rare. Melanoma is one of the malignancies that can metastasise to the breast. The distinction between a primary breast carcinoma and a metastatic neoplasm is crucial because surgical and therapeutic treatment options will vary accordingly. The present report concerns a case of breast metastasis from melanoma of the trunk. A 50-year-old man with a self-detected left breast lump who had previously undergone wide local excision and axillary dissection for melanoma was admitted to our department. Ultrasonography showed an 0.8 cm hypoechoic nodule with silent margins. The palpable mass was excised. Surgical pathology revealed metastatic melanoma.
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Affiliation(s)
- Mehmet Uludag
- Sisli Etfal Training and Research Hospital, 2nd General Surgery, Etfal Sok. No. 1, Istanbul, 34360, Turkey
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Doeden K, Ma Z, Narasimhan B, Swetter SM, Detmar M, Dadras SS. Lymphatic invasion in cutaneous melanoma is associated with sentinel lymph node metastasis. J Cutan Pathol 2008; 36:772-80. [PMID: 19032379 DOI: 10.1111/j.1600-0560.2008.01166.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) metastasis is a major determinant for staging, prognostication and clinical management of patients with cutaneous melanoma. However, the role of lymphatic vs. vascular invasion (VI) for SLN spread remains unclear. METHODS We compared the frequency of lymphatic invasion (LI) vs. VI in melanoma sections from 94 patients with a mean three-year clinical follow up using immunostains for the lymphatic endothelial markers D2-40 (podoplanin) and LYVE-1 and the panvascular marker CD31. RESULTS LI occurred more frequently than VI (16 vs. 3%, respectively, p = 0.001) and correlated with higher American Joint Committee on Cancer stage at diagnosis (p = 0.0004). In a univariate analysis, LI was strongly associated with SLN metastasis (p = 0.008), independent of tumor thickness. In a multivariate analysis, LI was not a significant risk factor for SLN metastasis. The presence of intratumoral lymphatics (ITLs) was associated with distant metastasis, whereas VI was rare and did not correlate with SLN or distant metastasis. A combination of LI and ITL had higher positive and negative predictive values for the risk of developing SLN metastasis compared with routine histology and VI. CONCLUSION Detection of LI in the primary tumor may aid in identifying melanoma patients with the propensity to develop SLN metastasis.
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Affiliation(s)
- Katie Doeden
- Department of Pathology, Stanford University Medical Center, Stanford, CA 94305-5324, USA
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Angiotropism is an independent predictor of local recurrence and in-transit metastasis in primary cutaneous melanoma. Am J Surg Pathol 2008; 32:1396-403. [PMID: 18670348 DOI: 10.1097/pas.0b013e3181753a8e] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The migration of melanoma cells along the external surface of blood vessels (angiotropism) has recently been proposed as a mechanism for melanoma metastasis (termed extravascular migratory metastasis). To determine whether the presence of angiotropism, as seen in the routine hematoxylin and eosin sections of primary cutaneous melanomas (PCMs), predicts the development of local or in-transit melanoma recurrence, 32 patients with a PCM who developed local or in-transit recurrence were matched for Breslow thickness with 59 "control" patients with a PCM who did not. The slides from both groups of patients were analyzed in a "blinded" manner for evidence of angiotropism. Other histologic and clinical variables were also assessed. Angiotropism was found more often in patients who developed local or in-transit recurrence (cases) compared with those patients who did not (controls) (P=0.02). Variables that showed a statistically significant association with angiotropism on univariate analysis were: increasing Breslow thickness (P<0.0001), greater Clark level (P<0.001), increasing mitotic index (P<0.0001), presence of ulceration (P<0.01), and absence of regression (P<0.05). The median disease-free survival was 72 months for patients with angiotropism and 104 months for those without (P=0.02). On multivariate analysis the presence of angiotropism was an independent predictor of decreased disease-free survival (P=0.02). This is the first reported study to identify a statistically significant association between the development of local or in-transit recurrence of PCM and the histologic presence of angiotropism and that angiotropism is an independent predictor of decreased disease-free survival, as far as we are aware. Our findings support the hypothesis that angiotropism represents a pathogenic mechanism for metastasis in patients with PCM.
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Abstract
The biological behavior of melanoma is unpredictable. Three to five per cent of melanoma patients will develop in-transit lesions and the median time to recurrence ranges between 13-16 months. At the time of recurrence the risk of occult nodal metastasis, with clinically negative regional lymph nodes, is as high as 50%. The risk of in-transit lesions depends on the tumor biology and not on the surgical approach to the regional lymph nodes. The high incidence of in-transit lesions at the lower limb may be caused by the gravity and delayed lymphatic drainage. The treatment of limited disease is local excision, laser ablation, cryosurgery, while multiple in-transit lesions or bulky disease located in a limb can be successfully treated with regional chemotherapy, a therapeutic isolated limb perfusion or infusion with melphalan or a combination of melphalan and tumor necrosis factor (TNF) alpha. If local regional treatment or systemic dacarbazine based systemic treatment fails, novel systemic treatment strategies with vaccines, antibodies and gene therapy are currently investigated.
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Affiliation(s)
- H J Hoekstra
- Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
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Kretschmer L, Beckmann I, Thoms KM, Mitteldorf C, Bertsch HP, Neumann C. Factors Predicting the Risk of In-Transit Recurrence After Sentinel Lymphonodectomy in Patients With Cutaneous Malignant Melanoma. Ann Surg Oncol 2006; 13:1105-12. [PMID: 16865591 DOI: 10.1245/aso.2006.07.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Accepted: 02/21/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND In-transit metastasis is an important morbidity factor after sentinel lymphonodectomy (SLNE). So far, factors posing an increased risk after SLNE have not been adequately analyzed. METHODS Using Kaplan-Meier estimations and the Cox proportional hazards model, we analyzed the risk of developing in-transit metastases after SLNE for 328 consecutive patients (median tumor thickness, 2.0 mm; median follow-up period, 40 months). RESULTS The 5-year probability of developing in-transit metastases as a first recurrence was 11.2%. After negative and positive SLNE, the probabilities were 6.3% and 24%, respectively. Patients in whom satellite metastases were excised concurrently with the primary tumor had a probability of recurrence with in-transit metastases of 41%. In sentinel lymph node (SLN)-negative patients with primary tumors having a thickness of more than 4 mm, the probability was 22.1%. Among the group of SLN-positive patients, significantly increased in-transit probabilities were observed in those with primary tumors that were thicker than 4 mm (41.8%), with tumors located on the distal extremities (42.1%), and with penetration of the nodal metastasis of >1 mm into the SLN (36%) and in patients with capsular breakthrough (63.3%). By using multifactorial analysis, the SLN status (P = .005), Breslow thickness (P = .0009), and extremity location of the primary melanoma (P = .005) significantly predicted the risk of in-transit recurrence. Satellite metastasis (P < .089), Clark level, and ulceration did not reach significance. CONCLUSIONS Subgroups of patients can be identified who seem to have an increased risk of developing in-transit metastases as a first recurrence after SLNE. Individualized therapeutic strategies should be developed for these patients.
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Affiliation(s)
- Lutz Kretschmer
- Department of Dermatology, Georg-August-University Göttingen, v. Siebold-Str. 3, D-37075 Göttingen, Germany.
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Yonemura Y, Endou Y, Tabachi K, Kawamura T, Yun HY, Kameya T, Hayashi I, Bandou E, Sasaki T, Miura M. Evaluation of lymphatic invasion in primary gastric cancer by a new monoclonal antibody, D2-40. Hum Pathol 2006; 37:1193-9. [PMID: 16938525 DOI: 10.1016/j.humpath.2006.04.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2005] [Revised: 04/12/2006] [Accepted: 04/18/2006] [Indexed: 12/12/2022]
Abstract
Lymphatic invasion is known as an independent predictor of lymph node metastasis in gastric cancer. However, the diagnosis of lymphatic invasion is sometimes difficult by hematoxylin-eosin (H&E) staining. Immunostaining using D2-40 was performed to study the distribution of lymphatic vessel and lymphatic invasion in a series of 78 primary gastric cancers. D2-40 showed specific staining for the lymphatic vessels, but not for blood vessels. The lymphatic invasion was most frequently found in the upper half of submucosal layer. Positive rate of lymphatic invasion by H&E staining was 27% (21/78), and that by D2-40 was 44% (34/78). Lymphatic invasion on H&E staining was diagnosed as false negative in 17 (21.8%) of 78 primary gastric cancers and false positive in 4 (5.1%) of 78 primary gastric cancers. Sensitivity for lymph node metastasis by the lymphatic invasion diagnosed by D2-40 was significantly higher (89%, 24/27) than by H&E staining (41%, 11/27). These results suggest that the diagnosis of lymphatic invasion by D2-40 is more sensitive than H&E staining. Sensitivity for the prediction of lymph node metastasis from the lymphatic invasion status in primary tumor by D2-40 was significantly higher than by H&E staining. Based on our results, we recommend the use of D2-40 immunoreactions for the routine evaluation of lymphatic invasion in gastric cancer.
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Affiliation(s)
- Yutaka Yonemura
- Gastric Surgery Division, Shizuoka Cancer Center, Shizuoka 411-8777, Japan.
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Cerovac S, Mashhadi SA, Williams AM, Allan RA, Stanley PRW, Powell BWEM. Is there increased risk of local and in-transit recurrence following sentinel lymph node biopsy? J Plast Reconstr Aesthet Surg 2006; 59:487-93. [PMID: 16631558 DOI: 10.1016/j.bjps.2005.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 12/14/2005] [Indexed: 12/20/2022]
Abstract
Recent publications have suggested that sentinel lymph node biopsy (SLNB) and completion lymphadenectomy (CLND) increase the rate of local and in-transit disease up to 23% in sentinel node positive group of patients with cutaneous melanoma. This retrospective study combined the data from two national centres on local and in-transit disease in 972 melanoma patients who underwent SLNB procedure over 6.5 years period. In total, 77 patients (7.9%) developed loco-regional recurrence: 41 (4.2%) local recurrence only and 36 patients (3.7%) in-transit metastases during a mean follow-up of 42 months. Patients with positive sentinel lymph node were three times more likely to develop loco-regional metastases than those with no nodal disease (17 vs. 5.6%). Over one third of all recurrences developed following excision of thick (Breslow thickness over 4mm) primary tumours. In both centres age and Breslow thickness were found to be significantly higher in the recurrence group (p<0.001 for both). This study revealed a strong association between increased risk of loco-regional metastases and aggressive tumour biology and adverse patients factors. No conclusive evidence was found to support an increased incidence in patients undergoing SLNB and CLND compared to that published for patients undergoing wide local excision alone.
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Abstract
The role of RT in the management of melanoma is complex and spans the entire course of the disease. To provide optimal management of patients who have melanoma, radiation oncologists are an integral part of a multidisciplinary team. Appropriate integration of radiation into the management plan can improve locoregional control and alleviate symptoms from meta-static disease. The specific role of RT in locoregional disease is being refined. It is likely that current developments in radiation treatment technology will be applicable to melanoma. These should improve the therapeutic ratio by enhancing the tumoricidal effects of RT without increasing toxicity.
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Affiliation(s)
- Graham Stevens
- Melanoma Foundation of New Zealand, Auckland, New Zealandd.
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Elder DE, Gimotty PA, Guerry D. Cutaneous melanoma: estimating survival and recurrence risk based on histopathologic features. Dermatol Ther 2005; 18:369-85. [PMID: 16297012 DOI: 10.1111/j.1529-8019.2005.00044.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The prognosis of melanoma is best understood in terms of a model of tumor progression, in which most melanomas may evolve through two major phases of progression: from a lesion that is nontumorigenic and has little or no capacity for metastasis; to a more advanced lesion that is tumorigenic and may have capacity for metastasis. The likelihood of metastasis varies with a number of attributes of the primary melanoma, including the phase of progression, the Breslow tumor thickness, mitotic rate, and host response to the tumorigenic compartment of the lesion, Clark's level of invasion, and other factors. When distant metastasis has occurred, the prognosis for the patient is very poor. In this monograph, the focus will be the discussion of factors related to the prognosis of melanomas that at diagnosis are clinically localized to the primary site.
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Affiliation(s)
- David E Elder
- Melanoma Program of the Abramson Cancer Center, Divison of Anatomic Pathology, Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, 19104, USA.
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Pawlik TM, Ross MI, Thompson JF, Eggermont AMM, Gershenwald JE. The Risk of In-Transit Melanoma Metastasis Depends on Tumor Biology and Not the Surgical Approach to Regional Lymph Nodes. J Clin Oncol 2005; 23:4588-90. [PMID: 16034040 DOI: 10.1200/jco.2005.12.245] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Timothy M Pawlik
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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van Poll D, Thompson JF, Colman MH, McKinnon JG, Saw RPM, Stretch JR, Scolyer RA, Uren RF. A Sentinel Node Biopsy Does Not Increase the Incidence of In-Transit Metastasis in Patients With Primary Cutaneous Melanoma. Ann Surg Oncol 2005; 12:597-608. [PMID: 16021534 DOI: 10.1245/aso.2005.08.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Accepted: 02/10/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND It has been suggested that performing a sentinel node biopsy (SNB) in patients with cutaneous melanoma increases the incidence of in-transit metastasis (ITM). METHODS ITM rates for 2018 patients with primary melanomas > or =1.0 mm thick treated at a single institution between 1991 and 2000 according to 3 protocols were compared: wide local excision (WLE) only (n = 1035), WLE plus SNB (n = 754), and WLE plus elective lymph node dissection (n = 229). RESULTS The incidence of ITM for the three protocols was 4.9%, 3.6%, and 5.7%, respectively (not significant), and as a first site of recurrent disease the incidence was 2.5%, 2.4%, and 4.4%, respectively (not significant). The subset of patients who were node positive after SNB and after elective lymph node dissection also had similar ITM rates (10.8% and 7.1%, respectively; P = .11). On multivariate analysis, primary tumor thickness and patient age predicted ITM as a first recurrence, but type of treatment did not. Patients who underwent WLE only and who had a subsequent therapeutic lymph node dissection (n = 149) had an ITM rate of 24.2%, compared with 10.8% in patients with a tumor-positive sentinel node treated with immediate dissection (n = 102; P = .03). CONCLUSIONS Performing an SNB in patients with melanoma treated by WLE does not increase the incidence of ITM.
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Affiliation(s)
- Daan van Poll
- Sydney Melanoma Unit, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Australia
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Pawlik TM, Ross MI, Johnson MM, Schacherer CW, McClain DM, Mansfield PF, Lee JE, Cormier JN, Gershenwald JE. Predictors and Natural History of In-Transit Melanoma After Sentinel Lymphadenectomy. Ann Surg Oncol 2005; 12:587-96. [PMID: 16021533 DOI: 10.1245/aso.2005.05.025] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2004] [Accepted: 11/19/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND In-transit recurrence is a unique and uncommon pattern of treatment failure in patients with melanoma. Little information exists concerning the incidence, predictors, and natural history of in-transit disease since the introduction of sentinel lymph node biopsy (SLNB). METHODS Between 1991 and 2001, 1395 patients with primary melanoma underwent SLNB. Univariate and multivariate logistic regression analyses were performed to examine the association among known clinicopathologic factors, in-transit recurrence, and distant metastatic failure after the development of in-transit disease. RESULTS With a median follow-up of 3.9 years, 241 patients (17.3%) experienced disease recurrence, including 91 (6.6%) who developed in-transit recurrence. Independent predictors of in-transit recurrence included age >50 years, a lower extremity location of the primary tumor, Breslow depth, ulceration, and sentinel lymph node (SLN) status. Of the 69 patients who presented with in-transit disease as the sole site of first recurrence, 39 developed distant disease. By univariate analysis, predictors of distant failure among patients with in-transit disease included SLN status, largest metastatic focus in the SLN >2.5 mm2, subcutaneous location of in-transit disease, in-transit tumor size > or = 2 cm, and a disease-free interval before in-transit recurrence of <12 months. In-transit tumor size remained a significant predictor of distant metastasis by multivariate analysis (odds ratio, 9.69). CONCLUSIONS The overall incidence of in-transit metastases in patients undergoing SLNB is low and does not seem to have increased since the introduction of the SLNB technique. In-transit recurrence, as well as subsequent distant metastatic failure, can be predicted on the basis of adverse tumor factors and SLN status.
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Affiliation(s)
- Timothy M Pawlik
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Unit 444, PO Box 301402, Houston, Texas 77230-1402, USA
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Kretschmer L, Beckmann I, Thoms KM, Haenssle H, Bertsch HP, Neumann C. Sentinel lymphonodectomy does not increase the risk of loco-regional cutaneous metastases of malignant melanomas. Eur J Cancer 2005; 41:531-8. [PMID: 15737557 DOI: 10.1016/j.ejca.2004.11.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Revised: 10/29/2004] [Accepted: 11/30/2004] [Indexed: 10/26/2022]
Abstract
With regard to malignant melanoma, the impact of lymph node surgery on the development of loco-regional cutaneous metastases (LCM) has not yet been adequately addressed. However, this aspect is of interest, since sentinel lymphonodectomy (SLNE) has been suspected of causing LCM by inducing entrapment of melanoma cells. We analysed 244 patients with SLNE and compared the data with 199 patients treated with delayed lymph node dissection (DLND) for clinically palpable metastases. Analysis of both groups commenced at the time of excision of the primary tumour, using the Kaplan-Meier method. LCM that appeared as a first recurrence, as well as the overall probability of developing LCM, were recorded. For sentinel-negative patients with a primary melanoma >1mm thick, the 5-year probability of developing LCM as a first recurrence was 6.9 +/- 0.02% (+/-standard error of the mean (SEM)). The probability was 17.6 +/- 0.03% in the DLND group. Comparing the two node-positive subgroups, the probability of developing LCM as a first recurrence was significantly higher in patients with positive SLNE (27.3 +/- 0.05%, P = 0.03). However, the 5-year overall probability of developing LCM did not differ significantly in the node-positive groups (33.3% in the DLND group vs. 33.7% in patients with positive sentinel lymph nodes (SLNs)). Since early excision of lymphatic metastases by SLNE avoids nodal recurrences, thereby prolonging the recurrence-free interval, the chance of LCM to manifest as a first recurrence should inevitably increase. However, the overall in-transit probability is not increased after SLNE.
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Affiliation(s)
- L Kretschmer
- Department of Dermatology, Georg August University of Göttingen, v. Siebold-Str. 3, D-37075, Göttingen, Germany.
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