Management of recurrent cutaneous melanoma

Translational Research in Oncology: Implications for Palliative Care

The label "translational research" (TR) has become ever more popular in the biomedical domain in recent years. It is usually presented as an attempt to bridge a supposed gap between knowledge produced at the laboratory bench and its use at the clinical bedside. This is claimed to help society harvest the benefits of its investments in scientific research. The past decade has witnessed a remarkable acceleration in the pace of translational cancer medicine - genome sequencing of various human cancers has been broadly deployed in drug discovery programs, diagnostic tests have been developed to predict molecularly targeted anticancer agents, advent of cancer immunotherapies, an enhanced appreciation of the complex interactions that exist between tumor cells and their microenvironment have revolutionized the management of cancers. Treatment for cancer and palliative care (PC) go hand in hand and the role of TR in PC can no longer be ignored. This paper discusses about the scientific discourse of TR in cancer care and its implications for the practice of PC. It starts with a brief reconstruction of the history of the concept and subsequently unravels how the label is used in clinical/research practice. In conclusion, TR seems to be driven by a changed relationship between science and society. "Translation" has become important because society is thought to deserve a tangible return in terms of health and quality of life on its investment in basic biomedical science.

Beyond bench and bedside: disentangling the concept of translational research

The label 'Translational Research' (TR) has become ever more popular in the biomedical domain in recent years. It is usually presented as an attempt to bridge a supposed gap between knowledge produced at the lab bench and its use at the clinical bedside. This is claimed to help society harvest the benefits of its investments in scientific research. The rhetorical as well as moral force of the label TR obscure, however, that it is actually used in very different ways. In this paper, we analyse the scientific discourse on TR, with the aim to disentangle and critically evaluate the different meanings of the label. We start with a brief reconstruction of the history of the concept. Subsequently, we unravel how the label is actually used in a sample of scientific publications on TR and examine the presuppositions implied by different views of TR. We argue that it is useful to distinguish different views of TR on the basis of three dimensions, related to (1) the construction of the 'translational gap'; (2) the model of the translational process; and (3) the cause of the perceived translational gap. We conclude that the motive to make society benefit from its investments in biomedical science may be laudable, but that it is doubtful whether the dominant views of TR will contribute to this end.

Immediate local and regional recurrence after the excision of a polypoid melanoma: tumor dormancy or tumor activation?

Recurrent melanoma occurs in approximately one third of the patients who are treated for cutaneous melanoma. Although the majority of recurrences occur within the first few years of primary therapy, a significant number remain at risk beyond 10 years. Tumor dormancy provides the conceptual framework to explain a prolonged quiescent state in which tumor cells are present, but tumor progression is not clinically apparent. Surgery, or other perturbing factors, might modulate the transition of dormant cancer cells to rapidly growing ones. These may be due to a perturbation of the mechanisms of tumor regulation such as local immunity or angiogenesis. Here, the case of a woman is discussed in whom the surgical removal of a polypoid melanoma was followed, in less than a month, by local recurrence and locoregional lymph nodal metastases, which were previously clinically absent.

Detection of circulating melanoma cells in peripheral blood by a two-marker RT-PCR assay

The aim of this study was to develop a highly sensitive two-marker assay for the detection of circulating melanoma cells in patients' blood using a reverse transcriptase-polymerase chain reaction (RT-PCR). We analysed the usefulness of two different sets of markers: tyrosinase and MUC-18 (TYR/MUC-18), and tyrosinase and MART 1 (TYR/MART 1). Total cellular RNA was isolated from 337 blood samples from 80 melanoma patients at different stages of the disease. All patients had undergone primary surgery. Assay sensitivity and specificity were confirmed using three different melanoma cell lines and two different fibroblast lines. In addition, blood from 47 healthy subjects and 10 patients with non-melanoma cancer was used as a negative control. We found that two-marker analysis is more accurate than the single tyrosinase assay. The frequency of melanoma cell detection in patients' blood was about 10% higher when the TYR/MART 1 two-marker assay was used. Using this assay we did not find any statistical correlation between the molecular markers and the UICC stage of disease or the Breslow thickness or Clark level of the primary melanoma. The frequency of melanoma cell detection with the TYR/MUC-18 two-marker assay was even higher than the TYR/MART 1 assay, but unfortunately the MUC-18 transcript was also present in about 20% of healthy subjects. Therefore we do not recommend the use of MUC-18 as a standard value marker.

Clinical applications of electrochemotherapy

Electrochemotherapy is a novel treatment which consists of a combination of a chemotherapeutic agent and pulsed electric fields. This relatively new treatment modality relies on the physical effects of locally applied electric fields to temporarily destabilize cell membranes in the presence of a drug to allow increased uptake of the agent into the cytosol. Electrochemotherapy has been used effectively in preclinical and clinical studies. The therapy was shown to be effective regardless of histologic type of tumor including head and neck squamous cell carcinoma, melanoma, basal cell carcinoma, adenocarcinoma and Kaposi's sarcoma. Objective response rates ranging from 72 percent to 100 percent have been reported from these trials. These responses were obtained with minimal adverse side effects. A review of the clinical data for this novel drug delivery method is presented.

Effective treatment of cutaneous and subcutaneous malignant tumours by electrochemotherapy

Electrochemotherapy (ECT) enhances the effectiveness of chemotherapeutic agents by administering the drug in combination with short intense electric pulses. ECT is effective because electric pulses permeabilize tumour cell membranes and allow non-permeant drugs, such as bleomycin, to enter the cells. The aim of this study was to demonstrate the anti-tumour effectiveness of ECT with bleomycin on cutaneous and subcutaneous tumours. This article summarizes results obtained in independent clinical trials performed by five cancer centres. A total of 291 cutaneous or subcutaneous tumours of basal cell carcinoma (32), malignant melanoma (142), adenocarcinoma (30) and head and neck squamous cell carcinoma (87) were treated in 50 patients. Short and intense electric pulses were applied to tumours percutaneously after intravenous or intratumour administration of bleomycin. The tumours were measured and the response to the treatment evaluated 30 days after the treatment. Objective responses were obtained in 233 (85.3%) of the 273 evaluable tumours that were treated with ECT. Clinical complete responses were achieved in 154 (56.4%) tumours, and partial responses were observed in 79 (28.9%) tumours. The application of electric pulses to the patients was safe and well tolerated. An instantaneous contraction of the underlying muscles was noticed. Minimal adverse side-effects were observed. ECT was shown to be an effective local treatment. ECT was effective regardless of the histological type of the tumour. Therefore, ECT offers an approach to the treatment of cutaneous and subcutaneous tumours in patients with minimal adverse side-effects and with a high response rate.

Factors affecting survival following local, regional, or distant recurrence from localized melanoma

BACKGROUND AND OBJECTIVES

Approximately one third of all melanoma patients will experience disease recurrence. Factors that affect patient survival following local, regional, or distant first recurrences of localized melanoma are the subject of this investigation.

METHODS

Survival times for a total of 1,085 first recurrences from 4,568 localized melanoma patients were examined in relationship to patient and disease factors by Cox regression. Nearly half (48.8%) of all first recurrences were regional, 21.8% were local, and 29.4% were distant recurrences.

RESULTS

Survival following recurrence differed significantly by site of recurrence (local, regional, or distant; P < 0.0001). Within each site, the median survival time did not differ by time of recurrence following diagnosis. Significant tumor factors for survival following local recurrence included tumor thickness (P = 0.0263) and lesion location (P < 0.0001). For regional recurrences, survival was significantly related to ulceration (P = 0.0105) and whether the recurrence was combined with a local recurrence (P = 0.0429). Survival following distant metastasis was related to number of distant sites (P < 0.0001) and whether a visceral site was involved (P < 0.0001).

CONCLUSIONS

Patient and tumor characteristics predict survival following recurrence. Regardless of disease-free interval, long-term follow-up of melanoma patients is necessary. Patients experiencing distant metastasis have the shortest median survival time compared to patients experiencing local or regional recurrences.

Phase I/II trial for the treatment of cutaneous and subcutaneous tumors using electrochemotherapy

BACKGROUND

Electroporation is a process that causes a transient increase in the permeability of cell membranes. It can be used to increase the intracellular concentration of chemotherapeutic agents in tumor cells (electrochemotherapy; ECT). A clinical study was initiated to determine if this mode of treatment would be effective against certain primary and metastatic cutaneous malignancies. A group of six patients, three with malignant melanoma, two with basal cell carcinoma, and one with metastatic adenocarcinoma, were enrolled in the study. the treatment was administered in a two-step process.

METHODS

Each patient received a 10 unit/m2 dose of bleomycin administered intravenously at 1 to 1.5 units/minute. This was followed by eight 99 microsecond pulses at an amplitude of 1.3 kV/cm administered directly to the tumors 5 to 15 minutes after the bleomycin was completely infused. Pulses were administered after the injection of 1% lidocaine solution around the treatment site.

RESULTS

Two of three melanoma patients had objective responses. In these two patients, five of six treated tumors decreased in size, and three completely responded. Untreated tumors displayed continued growth. Objective responses were observed in both basal cell carcinoma (BCC) patients. One patient had partial responses in both treated tumors. The other patient had one of four primary BCCs respond completely, and the remaining three respond partially. Patients with metastatic breast adenocarcinoma showed complete responses in both treated nodules after ECT. All patients tolerated the treatment well with no residual effects from the electric pulses.

CONCLUSIONS

ECT was an effective local treatment in the majority of nodules treated. The results thus far are very encouraging and the study is being continued.