Estudio descriptivo del patrón de diseminación visceral del melanoma cutáneo

Primary Melanoma Characteristics of Metastatic Disease: A Nationwide Cancer Registry Study

Simple Summary

Melanoma of the skin is the most lethal form of skin cancer. Almost 40% of the patients who die of metastatic melanoma did not have metastases at first diagnosis. More knowledge about patient and tumour characteristics as well as patterns of disease progression is needed. We described the characteristics and disease patterns of early-stage melanomas that progress into metastatic disease. We observed that more than half of the patients with metastases were initially diagnosed with early-stage disease. Additionally, we found that melanomas in some specific body sites were likely to metastasize to certain organs. Our finding that a substantial proportion of patients with metastases were initially diagnosed with early-stage disease highlights the need to investigate who these high-risk patients are.

Abstract

The characteristics and disease patterns of primary stage I and II cutaneous melanomas that progress to stage III or IV disease were investigated based on data from the Netherlands Cancer Registry (NCR). Data on stage III or IV melanomas at first diagnosis or during follow-up between 2017 and 2019 were retrieved. Patient and primary tumour characteristics were investigated in relation to time to disease progression and the number of organ sites with metastatic disease using regression models. In total, 2763 patients were included, of whom 1613 were diagnosed with stage IV disease. Among the patients with stage IV disease, 60% (n = 963) were initially diagnosed with stage I or II disease. The proportion of patients who received a sentinel lymph node biopsy increased after the introduction of adjuvant therapy in 2019 from 61% to 87%. Among all patients with stage III disease who were eligible for adjuvant systemic therapy (n = 453) after 2019, 37% were not treated with this therapy. Among patients with stage IV disease, lung metastases were most often detected as the first metastatic site and females presented with more metastatic sites than males. Most patient and primary tumour characteristics were not associated with the distant metastatic organ site, except melanoma localisation in the lower extremities and the head or neck. Our observation that most stage IV patients were initially diagnosed with early-stage disease highlights the need for more accurate risk prediction models.

Study of cutaneous melanoma recurrences after sentinel node biopsy: Patterns of dissemination and use of complementary test in follow-up

OBJECTIVES

To investigate the patterns of melanoma recurrence in the local population, including factors that may influence in this event and timing of relapse, and to determine the mode of detection of them.

METHODS

This is a retrospective cohort study of patients with melanoma who underwent sentinel lymph node biopsy at the Complejo Hospitalario de Navarra (Spain) from 2002 to 2012. The following data were collected of each patient: age, gender, date of diagnosis, location of melanoma, histological subtype, Breslow thickness, ulceration, mitosis, sentinel node status, AJCC 8th edition stage, site of first diagnosed metastasis, mode of relapse, date of first relapse and time of death.

RESULTS

Of 308 patients, 30% people suffered metastasis. The mean follow-up time was 68.63 months. 51.1% of relapses were locoregional and 48.9% haemato-visceral. Sentinel node status was the only variable associated with higher risk of haemato-visceral metastasis (p < 0.001). The mean time between diagnosis of melanoma and recurrence was 2.7 years. Most recurrences were detected by the patient himself or had any type of symptoms and were consequently selected for a complementary test.

CONCLUSION

It is important to follow-up all patients with diagnosis of cutaneous melanoma, essentially during the first 5 years after diagnosis.

Replacement and desmoplastic histopathological growth patterns in cutaneous melanoma liver metastases: frequency, characteristics, and robust prognostic value

Among visceral metastatic sites, cutaneous melanoma (CM) metastasises initially to the liver in ~14-20% of cases. Liver metastases in CM patients are associated with both poor prognosis and poor response to immunotherapy. Histopathological growth patterns (HGPs) of liver metastases of the replacement and desmoplastic type, particularly from colorectal cancer and uveal melanoma (UM), may impart valuable biological and prognostic information. Here, we have studied HGP in 43 CM liver metastases resected from 42 CM patients along with other prognostic factors from three institutions. The HGPs (replacement, desmoplastic, pushing) were scored at the metastasis-liver interface with two algorithms: (1) 100% desmoplastic growth pattern (dHGP) and any (≥1%) replacement pattern (any-rHGP) and (2) >50% dHGP, >50% rHGP or mixed (<50% dHGP and/or rHGP, pushing HGP). For 1 patient with 2 metastases, an average was taken to obtain 1 final HGP yielding 42 observations from 42 patients. 22 cases (52%) had 100% dHGP whereas 20 (48%) had any replacement. Cases with rHGP demonstrated vascular co-option/angiotropism. With the development of liver metastasis, only rHGP (both algorithms), male gender and positive resection margins predicted diminished overall survival (p = 0.00099 and p = 0.0015; p = 0.034 and p = 0.024 respectively). On multivariate analysis, only HGP remained significant. 7 of 42 (17%) patients were alive with disease and 21 (50%) died with follow-up after liver metastases ranging from 1.8 to 42.2 months (mean: 20.4 months, median: 19.0 months). 14 (33%) patients with previously-treated metastatic disease had no evidence of disease at last follow up. In conclusion, we report for the first time replacement and desmoplastic HGPs in CM liver metastases and their prognostic value, as in UM and other solid cancers. Of particular importance, any rHGP significantly predicted diminished overall survival while 100% dHGP correlated with increased survival. These results contribute to a better understanding of the biology of CM liver metastases and potentially may be utilised in managing patients with these metastases.

The course of stage III melanoma in accordance with the severity of node involvement

Objectives: Pathological stage III melanoma patients have variable clinical presentation and outcome when divided by substages, and the number of metastatic lymph nodes is the most significant independent factor. We aimed to determine the clinical features and natural course of node positive melanoma, such as first relapse and final outcome, and other factors influencing them. Methods: A total of 362 node positive melanoma patients were included in the study and reviewed retrospectively. Results: Cases were as follows: N1 (56.6%); N2 (27.1%); and N3 (16.3%). Lymphovascular invasion was found significant among node positive subtypes; it was predominant in patients with involvement of two or more nodes (p < .05). The majority of the relapses were locoregional alone (43.4%) and distant alone (31.3%). The lung/pleura was the most frequently metastasized site (32.1%). Time to relapse was the longest for N1 (20.8 months) (p < .05). Five and 10 year relapse-free survival (RFS) rates were 40% and 38%, respectively. Nodular histopathology, ulcerated lesion and higher mitotic rates carried worse RFS for all patients and also for N1. Five- and 10 year overall survival (OS) rates were 49% and 40%, respectively. Older age, nodular histopathology, higher mitotic rates and relapse of disease (p = .001) were the independent variables that were inversely correlated with OS for all patients. Conclusion: Comparative analyses of node positive melanoma suggested that there was not only a remarkable heterogeneity in the recurrence and survival rates but also a distinctive pattern among independent prognostic indicators in accordance with the severity of nodal involvement.

Early and late relapses of cutaneous melanoma patients

OBJECTIVES

Recurrence may most likely develop during the course of the disease in patients presented with early stage melanoma at initial diagnosis. The specific risk factors for early and late recurrences following definitive surgical excision have yet to be determined. The aim of this study was to analyze the early and late relapses in stage I-III cutaneous melanoma patients.

METHODS

Of 365 patients with relapses, 189 developed within the first 18 months following surgical intervention (early relapse [ER]) and the remaining 176 occurred later (late relapse [LR]) were analyzed.

RESULTS

ER patients were found to have thicker and ulcerated lesions with higher mitotic rates and lymphovascular invasion, and they were found to be more significantly associated with node involvements. Nearly half of the first recurrences were locoregional (49.9%) that were followed by distant metastases alone (26.6%). The distribution of the initial relapse patterns was similar between the ER and the LR groups. The lung was the most frequently metastasized site (43.1%), and it was followed by bone (21.0%), liver (20.7%) and brain (15.1%). On multivariate analysis risk factors in association with both ER and LR were found as follows: ulcerated lesions, high mitotic rate, and node-positive disease; however nodular histopathological subtype and lymphovascular invasion were found to have impact merely on ER, and male gender merely on LR.

CONCLUSION

The current study has detected potential risk factors for relapse of patients who developed ER and LR. These indicators may be useful for rational follow-up programs of the patients.

Small bowel obstruction due to intraluminal metastasis from malignant melanoma

The most common form of presentation of malignant melanoma is cutaneous. However, it is important to notice that it can occur in any part of the body, mostly from metastatic route. Gastrointestinal forms of symptomatic metastasis are rare, making it sometimes difficult to diagnose. We present a rare case of an 84-year-old female with a small bowel obstruction due to melanoma metastasis. She was treated with an enterectomy, with no surgical or post-operative complications. Although surgery should be reserved from symptomatic patients, some authors refer to it as a palliative treatment with improvement in long-term survival.

Relapse patterns in patients with local and regional cutaneous melanoma

BACKGROUND

The differences in features and risk factors for recurrence after definitive surgical excision are yet to be determined. The aim of this study was to understand these factors influencing recurrence patterns with local and regional disease in these patients.

METHODS

A total of 365 relapsed patients, of whom 196 presented with local disease (stage I-II) and 169 with regional disease (stage III), were investigated in this retrospective study.

RESULTS

The median time to initial recurrence for stage I-II and stage III patients was 22.3 and 13.4 months, respectively. Stage III patients were found to have higher Clark levels (p = 0.0001) and thicker lesions (p = 0.0001), and they were more significantly associated with the absence of tumor-infiltrating lymphocytes (p = 0.02) than stage I-II patients. Stage III patients were more significantly associated with recurrences compared to the stage I-II patients (p = 0.0001). Locoregional relapses were significantly associated with stage I-II melanomas, whereas majority of the distant metastases occurred in stage III patients (p = 0.01). Pulmonary metastasis was most frequently observed and the distribution of the sites for distant metastases was similar in both groups of the patients. On univariate analysis, male sex, increased tumor depth, presence of ulceration, nodular histopathology, higher Clark level, higher mitotic rate, and presence of lymphovascular invasions were found to predict shorter time to relapse for stage I-II patients; whereas only nodular pathology, presence of ulceration, and high mitotic rate were found to be associated with poor relapse-free survival in stage III patients. However, on multivariate analysis, only mitotic rate maintained its significance for both clinical staging groups.

CONCLUSION

Potential differences among early-stage melanoma patients, who developed recurrence, were noted and mitotic rate was found as the single significant prognostic factor for recurrence in both stage I-II and III patients.

Clinical relevance of 18F-FDG PET/CT lower-limb imaging in patients with malignant cutaneous melanoma

OBJECTIVE

The aim of this study was to assess the clinical relevance of imaging the lower limbs when using 2-(F)-fluoro-2-deoxy-D-glucose (F-FDG) positron emission tomography with computed tomography (PET/CT) for malignant cutaneous melanoma in patients without previously known or suspected primary or metastatic melanoma lesions in the lower limbs.

PATIENTS AND METHODS

We retrospectively assessed 880 consecutive F-FDG PET/CT scans performed for adult patients in a context of suspected melanoma spanning a period of 5 years. All scans were correlated with the associated patient records (clinical history, physical examinations, and pathology reports), as well as follow-up imaging examinations, up until at least 6 months after the end of the study.

RESULTS

Among the 461 whole-body scans included for analysis, 109 reported unusual activity in the lower limbs, but with at most 21 scans showing lower-limb lesions attributed to melanoma on follow-up. No scan showed melanoma lesions exclusively in the lower limbs, and in no case did imaging the lower limbs upstage a patient. Imaging the lower limbs changed the actual clinical management of the melanoma for only one patient, with precautionary local radiation therapy administered following the detection of an asymptomatic distal femur bone metastasis in an otherwise plurimetastatic patient headed for palliative care.

CONCLUSION

Our study, the largest of its kind, confirms that, when using F-FDG PET/CT for staging, restaging, or surveillance of malignant cutaneous melanoma in patients without previously known or suspected lower-limb melanoma lesions, imaging the lower extremities offers little additional clinically relevant information and stopping the scan at the proximal thighs has essentially no clinical impact.

New insights in melanoma biomarkers: long-noncoding RNAs

Melanoma is one of the leading cancers worldwide, distinguished for its malignancy and low survival rates. Although the poor outcome could improve with an early diagnosis and a good monitoring of the disease, current melanoma biomarkers display several limitations which make them useless. Interestingly, long-noncoding RNAs are secreted into the bloodstream inside exosomes by a wide range of malignant cells, and several of them have been validated as promising circulating molecular signatures of other tumors, but not melanoma. In this review we propose to explore the booming field of long-noncoding RNAs in order to find potential candidates to be tested as novel melanoma biomarkers, with the ultimate goal of improving melanoma detection, diagnosis and prognosis.