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Reshko LB, Baliga S, Crandley EF, Harry Lomas IV, Richardson MK, Spencer K, Bennion N, Mikdachi HE, Irvin W, Kersh CR. Stereotactic body radiation therapy (SBRT) in recurrent, persistent or oligometastatic gynecological cancers. Gynecol Oncol 2020; 159:611-617. [PMID: 33059914 DOI: 10.1016/j.ygyno.2020.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/03/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE SBRT is a well-tolerated technique and provides local-regional control in a variety of metastatic and recurrent tumor types. The role of SBRT in extracranial recurrent, persistent, or oligometastatic gynecological tumors is not well-studied. We therefore retrospectively analyzed a sizeable number of patients in this setting. METHODS We performed a retrospective review of 86 patients with 209 tumors treated at our institution with SBRT for recurrent, persistent, or oligometastatic extracranial gynecological tumors. The median follow-up was 20 months (range 1-91). The median SBRT dose was 24 Gy (range 10-50) delivered in a median of 4 fractions (range 1-6). The Kaplan-Meier curves and log rank tests were used to assess local control (LC) and overall survival (OS). Cox proportional hazards model was used to evaluate for covariates associated with LC and OS. RESULTS The 1- and 3-year LC were 80% and 68% respectively. The 1- and 3-year OS were 70% and 39%. 32% of the lesions demonstrated complete response, 23% partial response and 20% stable disease. SBRT achieved better local control in smaller tumors. Toxicity was typically mild with grade 1 gastrointestinal toxicity and fatigue being the most common. Only 4.3% of treatments resulted in grade 2 or greater toxicity. There was only one case of grade 3 and no grade 4 or 5 toxicities. CONCLUSIONS SBRT offers a high rate of local control with low incidence of toxicity, mainly grade 1 GI toxicity and fatigue, and provides effective salvage therapy for oligometastatic extracranial pelvic and extra-pelvic gynecological tumors.
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Affiliation(s)
- Leonid B Reshko
- University of Louisville, Department of Radiation Oncology, KY, United States.
| | - Sujith Baliga
- The Ohio State University Comprehensive Cancer Center, OH, United States
| | | | | | - Martin K Richardson
- University of Louisville, Department of Radiation Oncology, KY, United States
| | - Kelly Spencer
- University of Louisville, Department of Radiation Oncology, KY, United States
| | | | | | - William Irvin
- University of Louisville, Department of Radiation Oncology, KY, United States
| | - Charles R Kersh
- UVA/Riverside Radiosurgery Center, Newport News, VA, United States
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Guzha BT, Ngxola N, Adams T, Rogers L, Mbatani N, Wu HT, Fakie N, Muzenda V, Denny LA. Synchronous oligometastases in cervical cancer: a case report. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2018. [DOI: 10.1080/20742835.2018.1491139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- BT Guzha
- Division of Gynaecology Oncology, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - N Ngxola
- Division of Gynaecology Oncology, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - T Adams
- Division of Gynaecology Oncology, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - L Rogers
- Division of Gynaecology Oncology, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - N Mbatani
- Division of Gynaecology Oncology, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
| | - H-T Wu
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
- Division of Anatomical Pathology, Groote Schuur Hospital, National Health Laboratory Service, Cape Town, South Africa
| | - N Fakie
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
- Department of Radiation Oncology, Groote Schuur Hospital, Cape Town, South Africa
| | - V Muzenda
- Department of Radiology, Groote Schuur Hospital, Cape Town, South Africa
| | - LA Denny
- Division of Gynaecology Oncology, Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, South Africa
- South African Medical Research Council (SAMRC)/University of Cape Town (UCT) Gynaecological Cancer Research Centre, Cape Town, South Africa
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Ning MS, Ahobila V, Jhingran A, Stecklein SR, Frumovitz M, Schmeler KM, Eifel PJ, Klopp AH. Outcomes and patterns of relapse after definitive radiation therapy for oligometastatic cervical cancer. Gynecol Oncol 2018; 148:132-138. [DOI: 10.1016/j.ygyno.2017.10.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
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Abstract
INTRODUCTION Intralesional therapy for metastatic melanoma has some advantages over systemic therapy. Local drug administration allows for delivery of an increased concentration of the agent and reduced systemic exposure, thereby increasing local efficacy and limiting toxicity. Moreover, since in vivo tumor nodules contain the tumor antigens, this tumor tissue may serve as an autologous vaccine to induce systemic immunity. This so-called 'bystander effect', where uninjected distant lesions exhibit a response, has been reported in select intralesional therapy trials. AREAS COVERED This review will give an overview of the working mechanisms, clinical evidence and side effects for available intralesional and topical therapies and summarize the most recent developments in this field. EXPERT OPINION The ideal treatment approach for locoregionally advanced melanoma should be multidisciplinary and tailored to the patient, taking into consideration patient-related, tumor-related factors (such as location, tumor burden, mutation status) and previous treatments received. It will likely not be a single therapy, but rather a combination of injectable treatments, regional perfusions and systemic therapies.
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Affiliation(s)
- Sarah Sloot
- University Medical Center Groningen , Groningen , Netherlands
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Hersey P, Kakavand H, Wilmott J, van der Westhuizen A, Gallagher S, Gowrishankar K, Scolyer R. How anti-PD1 treatments are changing the management of melanoma. Melanoma Manag 2014; 1:165-172. [PMID: 30190821 PMCID: PMC6094707 DOI: 10.2217/mmt.14.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The introduction of immunotherapy based on the blockade of the PD1/PD-L1 checkpoints has been associated with high response rates and durable remissions of disease in patients with metastatic melanoma, to the extent that it is now considered the standard of care for a wide range of patients, irrespective of their BRAF or NRAS mutation status. In addition, more frequent follow-up of patients who are at high risk of recurrence after surgical treatment appears to be justified, as does neoadjuvant treatments in order to render patients treatable by surgery. The limitations of this treatment include failure of some patients to respond, a low rate of complete responses and relapses of the disease during treatment. New initiatives in order to overcome these limitations include the identification of biomarkers for the selection responders and evaluations of treatment combinations that will increase responses and their durability. The latter includes combinations with antibodies against other checkpoints on T cells and cotreatments with inhibitors of resistance pathways in melanoma.
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Affiliation(s)
- Peter Hersey
- Kolling Institute, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Melanoma Institute of Australia, Rocklands Road, North Sydney, NSW, Australia
| | - Hojabr Kakavand
- Melanoma Institute of Australia, Rocklands Road, North Sydney, NSW, Australia
- Department of Anatomical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - James Wilmott
- Melanoma Institute of Australia, Rocklands Road, North Sydney, NSW, Australia
- Department of Anatomical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | | | - Stuart Gallagher
- Kolling Institute, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | | | - Richard Scolyer
- Melanoma Institute of Australia, Rocklands Road, North Sydney, NSW, Australia
- Department of Anatomical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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La Greca M, Grasso G, Antonelli G, Russo AE, Bartolotta S, D'Angelo A, Vitale FV, Ferraù F. Neoadjuvant therapy for locally advanced melanoma: new strategies with targeted therapies. Onco Targets Ther 2014; 7:1115-21. [PMID: 24971022 PMCID: PMC4069135 DOI: 10.2147/ott.s62699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Neoadjuvant chemotherapy has been successfully tested in several bulky solid tumors, but it has not been utilized in advanced cutaneous melanoma, primarily because effective medical treatments for this disease have been lacking. However, with the development of new immunotherapies (monoclonal antibodies specific for cytotoxic T lymphocyte-associated antigen 4 [anti-CTLA-4] and programmed death protein-1 [anti-PD1]) and small molecules interfering with intracellular pathways (anti-BRAF and mitogen-activated protein kinase kinase [anti- MEK]) the use of this approach is becoming a viable treatment strategy for locally advanced melanoma. The neoadjuvant setting provides a double opportunity for a better knowledge of these drugs: a short-term evaluation of their intrinsic activity, and a deeper analysis of their action and resistance-induction mechanisms. BRAF inhibitors seem to be ideal candidates for the neoadjuvant setting, because of their prompt, repeatedly confirmed response in V600E BRAF-mutant metastatic melanoma. In this report we summarize studies focused on the neoadjuvant use of traditional medical treatments in advanced melanoma and anecdotal cases of this approach with the use of biologic therapies. Moreover, we discuss our experience with neoadjuvant targeted therapy as a priming for radical surgery in a patient with BRAF V600E mutation-positive advanced melanoma.
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Affiliation(s)
- Michele La Greca
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Giuseppe Grasso
- Pathology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Giovanna Antonelli
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Alessia Erika Russo
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | | | - Alessandro D'Angelo
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Felice Vito Vitale
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Francesco Ferraù
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
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7
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Gutman H, Ben-Ami E, Shapira-Frommer R, Schachter J. Multidisciplinary management of very advanced stage III and IV melanoma: Proof-of-principle. Oncol Lett 2012; 4:307-310. [PMID: 22844375 DOI: 10.3892/ol.2012.712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 03/19/2012] [Indexed: 11/06/2022] Open
Abstract
Patients with potentially resectable advanced stage III and IV melanoma are a selected subgroup that gain maximal advantage if treated in a melanoma center. Surgery combined with chemo/chemobiotherapy may yield durable remission and long-term palliation. Thirty-seven non-randomly selected patients underwent systemic therapy with the aim of consolidating treatment by surgery. Data were collected prospectively, and analyzed retrospectively. The median follow-up from diagnosis was 50 (3-307) months and 15 (1-156) months when calculated from the last intervention. Twenty-two males and 15 females, with a median age at diagnosis of 44 (20-71) years, with 13 trunk, 13 extremity, 3 head and neck and 8 unknown primary melanomas were included. There were 17 stage III and 20 stage IV patients with a median Breslow thickness of 3.7 (0.45-26) mm. Chemo/chemobiotherapy achieved 7 clinical complete responses (cCRs), 28 partial responses (PRs) and 2 instances of stable disease. Six of the 7 cCRs were operated on, securing pathological complete response in 5 and PR in one. Four of these five and the PR patient still have no evidence of disease (NED). Twenty-one of 30 PR patients were rendered NED by surgery; 14 of these 21 patients succumbed to melanoma, and one is alive with stable disease. Overall, 11 of 37 patients have not succumbed to melanoma, with a median of 72 (14-156) months survival following the last intervention. Of the eight patients with unknown primary melanomas, five have not succumbed to melanoma, with a median of 89 (30-156) months survival following the last intervention. Patients with marginally resectable stage III and IV melanoma have a significant 30% chance, according to this series, for durable remission if treated by a multidisciplinary team in a melanoma center using induction chemobiotherapy and surgery. Results are more favorable for patients with an unknown primary lesion. In view of the currently approved new effective treatments for melanoma, this study may be considered a proof-of-principle investigation, enabling long-term remissions by combining induction therapy and surgery.
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Affiliation(s)
- Haim Gutman
- Department of Surgery, Rabin Medical Center, Beilinson Campus, Israel
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8
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Shada AL, Walters DM, Tierney SN, Slingluff CL. Surgical resection for bulky or recurrent axillary metastatic melanoma. J Surg Oncol 2011; 105:21-5. [PMID: 21826672 DOI: 10.1002/jso.22058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Accepted: 07/18/2011] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients. METHODS We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms. RESULTS Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001). DISCUSSION Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.
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Affiliation(s)
- Amber L Shada
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
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Testori A, Rutkowski P, Marsden J, Bastholt L, Chiarion-Sileni V, Hauschild A, Eggermont AMM. Surgery and radiotherapy in the treatment of cutaneous melanoma. Ann Oncol 2009; 20 Suppl 6:vi22-9. [PMID: 19617294 PMCID: PMC2712595 DOI: 10.1093/annonc/mdp257] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Adequate surgical management of primary melanoma and regional lymph node metastasis, and rarely distant metastasis, is the only established curative treatment. Surgical management of primary melanomas consists of excisions with 1–2 cm margins and primary closure. The recommended method of biopsy is excisional biopsy with a 2 mm margin and a small amount of subcutaneous fat. In specific situations (very large lesions or certain anatomical areas), full-thickness incisional or punch biopsy may be acceptable. Sentinel lymph node biopsy provides accurate staging information for patients with clinically unaffected regional nodes and without distant metastases, although survival benefit has not been proved. In cases of positive sentinel node biopsy or clinically detected regional nodal metastases (palpable, positive cytology or histopathology), radical removal of lymph nodes of the involved basin is indicated. For resectable local/in-transit recurrences, excision with a clear margin is recommended. For numerous or unresectable in-transit metastases of the extremities, isolated limb perfusion or infusion with melphalan should be considered. Decisions about surgery of distant metastases should be based on individual circumstances. Radiotherapy is indicated as a treatment option in select patients with lentigo maligna melanoma and as an adjuvant in select patients with regional metastatic disease. Radiotherapy is also indicated for palliation, especially in bone and brain metastases.
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Affiliation(s)
- A Testori
- European Institute of Oncology, Division of Melanoma, Milan, Italy.
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