1
|
Liu ZF, Sylivris A, Wu J, Tan D, Hong S, Lin L, Wang M, Chew C. Ultrasound Surveillance in Melanoma Management: Bridging Diagnostic Promise with Real-World Adherence: A Systematic Review and Meta-Analysis. Am J Clin Dermatol 2024; 25:513-525. [PMID: 38635019 DOI: 10.1007/s40257-024-00862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Ultrasound surveillance has become the new standard of care in stage III melanoma after the 2017 Multicenter Selective Lymphadenectomy Trial II (MSLT-II) demonstrated non-inferior 3-year survival compared with complete lymph node dissection. OBJECTIVE We aimed to quantify diagnostic performance and adherence rates of ultrasound surveillance for melanoma locoregional metastasis, offering insights into real-world applicability. METHODS Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases from inception until 11 October 2023. All primary studies that reported data on the diagnostic performance or adherence rates to ultrasound surveillance in melanoma were included. R statistical software was used for data synthesis and analysis. Sensitivity and specificity were aggregated across studies using the meta-analytic method for diagnostic tests outlined by Rutter and Gatsonis. Adherence rates were calculated as the ratio of patients fully compliant to planned follow-up to those who were not. RESULTS A total of 36 studies including 18,273 patients were analysed, with a mean age of 56.6 years and a male-to-female ratio of 1:1.11. The median follow-up duration and frequency was 36 and 4 months, respectively. The pooled sensitivity of ultrasound examination was 0.879 (95% confidence interval [CI] 0.878-0.879) and specificity was 0.969 (95% CI 0.968-0.970), representing a diagnostic odds ratio of 224.5 (95% CI 223.1-225.9). Ultrasound examination demonstrated a substantial improvement in absolute sensitivity over clinical examination alone, with a number needed to screen (NNS) of 2.95. The overall adherence rate was 77.0% (95% CI 76.0-78.1%), with significantly lower rates in the United States [US] (p < 0.001) and retrospective studies (p < 0.001). CONCLUSION Ultrasound is a powerful diagnostic tool for locoregional melanoma metastasis. However, the real applicability to surveillance programmes is limited by low adherence rates, especially in the US. Further studies should seek to address this adherence gap.
Collapse
Affiliation(s)
- Zhao Feng Liu
- Department of Dermatology, Alfred Health, Melbourne, VIC, Australia
| | | | - Johnny Wu
- Monash Health, Clayton, VIC, Australia
| | - Darren Tan
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| | | | - Lawrence Lin
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Wang
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Christopher Chew
- Department of Dermatology, Alfred Health, Melbourne, VIC, Australia
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| |
Collapse
|
2
|
Koizumi S, Inozume T, Nakamura Y. Current surgical management for melanoma. J Dermatol 2024; 51:312-323. [PMID: 38149725 DOI: 10.1111/1346-8138.17086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/15/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023]
Abstract
Melanoma is a major malignant cutaneous neoplasm with a high mortality rate. In recent years, the treatment of melanoma has developed dramatically with the invention of new therapeutic agents, including immune checkpoint inhibitors and molecular-targeted agents. These agents are available as adjuvant therapies for postoperative patients with stage IIB, IIC, and III melanomas. Furthermore, neoadjuvant therapy has been studied in several global clinical trials and has demonstrated promising and favorable clinical efficacy, mainly in patients with palpable regional lymph nodes. A recent large phase III clinical trial investigating early lymph node dissection for sentinel lymph node metastases demonstrated no survival benefits. Based on these data, surgery should be reconsidered as an appropriate treatment modality for melanoma. The need for invasive surgical procedures will be reduced with the invention of effective adjuvant and neoadjuvant therapies and novel clinical trial data on regional lymph node dissection. However, surgery still plays an important role in treating early-stage melanoma, accurately determining the disease stage, and effective palliative treatment for advanced melanoma. In this article, we focus on surgery for primary tumors, regional lymph nodes, and metastatic sites in an era of remarkably revolutionary drug treatments for melanoma.
Collapse
Affiliation(s)
- Shigeru Koizumi
- Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center, Saitama, Japan
- Department of Dermatology, Chiba University, Chiba, Japan
| | | | - Yasuhiro Nakamura
- Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center, Saitama, Japan
| |
Collapse
|
3
|
Toprak Celenay S, Bayramoglu Demirdogen E, Barut O, Cigdem Karacay B, Ozer Kaya D. Postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer: A case-control study. Eur J Oncol Nurs 2023; 67:102416. [PMID: 37879191 DOI: 10.1016/j.ejon.2023.102416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/07/2023] [Accepted: 09/07/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE To compare postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer with a matched control group. METHODS Twenty-seven women with unilateral lower extremity lymphedema (lymphedema group, age: 54.14 ± 5.80 years) and 30 healthy women (control group, age: 51.90 ± 6.54 years) were included. The lymphedema severity was evaluated with circumferential measurements. Postural stability with the Biodex Balance System SD and the spinal alignment, mobility, and postural competency with the Spinal Mouse device were assessed. RESULTS In the lymphedema group, it was found that 3.7% of the women had mild lymphedema, 7.4% had moderate lymphedema, and 88.9% had severe lymphedema. Static eyes open (EO) (overall, medio-lateral and antero-posterior) and eyes closed (EC) (antero-posterior) stability scores and dynamic EO and EC stability scores (overall and antero-posterior) were detected to be higher in the lymphedema group than in the controls (p < 0.05). Spinal mobility and postural competency scores were lower in the lymphedema group than in the control group (p < 0.05). In other parameters, there were no significant differences between the groups (p > 0.05). CONCLUSION Decreased postural stability, spinal mobility, and postural competency were detected in women with unilateral lower extremity lymphedema; however, no difference was seen in spinal alignment. These changes should be taken into account in the assessment and the treatment of unilateral lower extremity lymphedema.
Collapse
Affiliation(s)
- Seyda Toprak Celenay
- Ankara Yildirim Beyazit University, Health Sciences Faculty, Department of Physiotherapy and Rehabilitation, Ankara, Turkey.
| | | | - Ozge Barut
- Kirsehir Ahi Evran University, Rectorship, Pilot University Coordinatorship of Health, Kirsehir, Turkey
| | - Basak Cigdem Karacay
- Kirsehir Ahi Evran University, Faculty of Medicine, Department of Physical Therapy and Rehabilitation, Kirsehir, Turkey
| | - Derya Ozer Kaya
- Izmir Katip Celebi University, Health Sciences Faculty, Department of Physiotherapy and Rehabilitation, Izmir, Turkey
| |
Collapse
|
4
|
Lin X, Sun W, Ren M, Xu Y, Wang C, Yan W, Kong Y, Balch CM, Chen Y. Prediction of nonsentinel lymph node metastasis in acral melanoma with positive sentinel lymph nodes. J Surg Oncol 2023; 128:1407-1415. [PMID: 37689989 DOI: 10.1002/jso.27438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Metastasis in a nonsentinel lymph node (non-SLN) is an unfavorable independent prognostic factor in cutaneous melanoma (CM). Recent data did suggest potential value of completion lymph node dissection (CLND) in CM patients with non-SLN metastasis. Prediction of non-SLN metastasis assists clinicians in deciding on adjuvant therapy without CLND. We analyzed risk factors and developed a prediction model for non-SLN status in acral melanoma (AM). METHODS This retrospective study enrolled 656 cases of melanoma who underwent sentinel lymph node biopsy at Fudan University Shanghai Cancer Center from 2009 to 2017. We identified 81 SLN + AM patients who underwent CLND. Clinicopathologic data, including SLN tumor burden and non-SLN status were examined with Cox and Logistics regression models. RESULTS Ulceration, Clark level, number of deposits in the SLN (NumDep) and maximum size of deposits (MaxSize) are independent risk factors associated with non-SLN metastases. We developed a scoring system that combines ulceration, the cutoff values of Clark level V, MaxSize of 2 mm, and NumDep of 5 to predict non-SLN metastasis with an efficiency of 85.2% and 100% positive predictive value in the high-rank group (scores of 17-24). CONCLUSIONS A scoring system that included ulceration, Clark level, MaxSize, and NumDep is reliable and effective for predicting non-SLN metastasis in SLN-positive AM.
Collapse
Affiliation(s)
- XinYi Lin
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min Ren
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu Xu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - ChunMeng Wang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - WangJun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - YunYi Kong
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Charles M Balch
- Department of Surgical Oncology, University of Texas MD Anderson Cancer center, Houston, Texas, USA
| | - Yong Chen
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
5
|
Lucas MW, Versluis JM, Rozeman EA, Blank CU. Personalizing neoadjuvant immune-checkpoint inhibition in patients with melanoma. Nat Rev Clin Oncol 2023; 20:408-422. [PMID: 37147419 DOI: 10.1038/s41571-023-00760-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/07/2023]
Abstract
Neoadjuvant immune-checkpoint inhibition is a promising emerging treatment approach for patients with surgically resectable macroscopic stage III melanoma. The neoadjuvant setting provides an ideal platform for personalized therapy owing to the very homogeneous nature of the patient population and the opportunity for pathological response assessments within several weeks of starting treatment, thereby facilitating the efficient identification of novel biomarkers. A pathological response to immune-checkpoint inhibitors has been shown to be a strong surrogate marker of both recurrence-free survival and overall survival, enabling timely analyses of the efficacy of novel therapies in patients with early stage disease. Patients with a major pathological response (defined as the presence of ≤10% viable tumour cells) have a very low risk of recurrence, which offers an opportunity to adjust the extent of surgery and any subsequent adjuvant therapy and follow-up monitoring. Conversely, patients who have only a partial pathological response or who do not respond to neoadjuvant therapy still might benefit from therapy escalation and/or class switch during adjuvant therapy. In this Review, we outline the concept of a fully personalized neoadjuvant treatment approach exemplified by the current developments in neoadjuvant therapy for patients with resectable melanoma, which could provide a template for the development of similar approaches for patients with other immune-responsive cancers in the near future.
Collapse
Affiliation(s)
- Minke W Lucas
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Judith M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Elisa A Rozeman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Christian U Blank
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands.
- Department of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands.
- Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands.
| |
Collapse
|
6
|
Khan M, Kelley J, Wright GP. Starting a minimally invasive inguinal lymphadenectomy program: Initial learning experience and outcomes. Surgery 2023; 173:633-639. [PMID: 36379745 DOI: 10.1016/j.surg.2022.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is promising data on minimally invasive inguinal lymphadenectomy indicating decreased wound complications compared with the standard open approach. We examined our institutional experience with starting a minimally invasive inguinal lymphadenectomy program. METHODS This is a retrospective case series of consecutive patients undergoing videoscopic minimally invasive inguinal lymphadenectomy from August 2017 to March 2022 by a single surgeon. Patients meeting criteria for inguinal lymphadenectomy were considered for minimally invasive inguinal lymphadenectomy unless there was skin involvement by tumor or bulky disease. Data collected included patient characteristics, primary cancer, surgery, and postoperative complications. RESULTS There were 26 patients included. The mean age was 60.6 ± 16.2 years. Most patients were female (n = 17, 65.4%), and the primary diagnosis was melanoma (n = 21, 19.2%). In 6 cases (23.1%), minimally invasive inguinal lymphadenectomy was combined with deep pelvic node dissection, but most patients did not have a concurrent procedure (n = 15, 57.7%). The median operative time was 119.0 minutes (range, 89.0-160.0), or 130.5 minutes (range, 89.0-345.0) when including concurrent procedures. The mean number of nodes retrieved was 9.8 ± 3.7, with a positive node identified in 19 patients (73.1%) during minimally invasive inguinal lymphadenectomy. There were 12 (46.2%) patients experiencing at least one postoperative complication within 30 days of surgery, the most common being infection (n = 4, 15.4%). One patient required reoperation for infected hematoma washout. Postoperative intervention for seroma was undertaken in 3 patients (11.5%). CONCLUSION Minimally invasive inguinal lymphadenectomy is a safe approach to inguinal lymph node dissection, in terms of node retrieval and postoperative complications, and can feasibly be adopted into practice with minimal learning curve.
Collapse
Affiliation(s)
- Mariam Khan
- Spectrum Health General Surgery Residency, Grand Rapids, MI.
| | - Jesse Kelley
- Spectrum Health Surgical Oncology, Grand Rapids, MI
| | | |
Collapse
|
7
|
Hoerig C, Wallace K, Wu M, Mamou J. Classification of Metastatic Lymph Nodes In Vivo Using Quantitative Ultrasound at Clinical Frequencies. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:787-801. [PMID: 36470739 DOI: 10.1016/j.ultrasmedbio.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/28/2022] [Accepted: 10/30/2022] [Indexed: 06/17/2023]
Abstract
Quantitative ultrasound (QUS) methods characterizing the backscattered echo signal have been of use in assessing tissue microstructure. High-frequency (30 MHz) QUS methods have been successful in detecting metastases in surgically excised lymph nodes (LNs), but limited evidence exists regarding the efficacy of QUS for evaluating LNs in vivo at clinical frequencies (2-10 MHz). In this study, a clinical scanner and 10-MHz linear probe were used to collect radiofrequency (RF) echo data of LNs in vivo from 19 cancer patients. QUS methods were applied to estimate parameters derived from the backscatter coefficient (BSC) and statistics of the envelope-detected RF signal. QUS parameters were used to train classifiers based on linear discriminant analysis (LDA) and support vector machines (SVMs). Two BSC-based parameters, scatterer diameter and acoustic concentration, were the most effective for accurately detecting metastatic LNs, with both LDA and SVMs achieving areas under the receiver operating characteristic (AUROC) curve ≥0.94. A strategy of classifying LNs based on the echo frame with the highest cancer probability improved performance to 88% specificity at 100% sensitivity (AUROC = 0.99). These results provide encouraging evidence that QUS applied at clinical frequencies may be effective at accurately identifying metastatic LNs in vivo, helping in diagnosis while reducing unnecessary biopsies and surgical treatments.
Collapse
Affiliation(s)
- Cameron Hoerig
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA.
| | | | - Maoxin Wu
- Department of Pathology, Stony Brook University, Stony Brook, New York, USA
| | - Jonathan Mamou
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
8
|
Versluis JM, Menzies AM, Sikorska K, Rozeman EA, Saw RPM, van Houdt WJ, Eriksson H, Klop WMC, Ch'ng S, van Thienen JV, Mallo H, Gonzalez M, Torres Acosta A, Grijpink-Ongering LG, van der Wal A, Bruining A, van de Wiel BA, Scolyer RA, Haanen JBAG, Schumacher TN, van Akkooi ACJ, Long GV, Blank CU. Survival update of neoadjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma in the OpACIN and OpACIN-neo trials. Ann Oncol 2023; 34:420-430. [PMID: 36681299 DOI: 10.1016/j.annonc.2023.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/20/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Neoadjuvant ipilimumab plus nivolumab has yielded high response rates in patients with macroscopic stage III melanoma. These response rates translated to high short-term survival rates. However, data on long-term survival and disease recurrence are lacking. PATIENTS AND METHODS In OpACIN, 20 patients with macroscopic stage III melanoma were randomized to ipilimumab 3 mg/kg plus nivolumab 1 mg/kg q3w four cycles of adjuvant or split two cycles of neoadjuvant and two adjuvant. In OpACIN-neo, 86 patients with macroscopic stage III melanoma were randomized to arm A (2× ipilimumab 3 mg/kg plus nivolumab 1 mg/kg q3w; n = 30), arm B (2× ipilimumab 1 mg/kg plus nivolumab 3 mg/kg q3w; n = 30), or arm C (2× ipilimumab 3 mg/kg q3w plus 2× nivolumab 3 mg/kg q2w; n = 26) followed by surgery. RESULTS The median recurrence-free survival (RFS) and overall survival (OS) were not reached in either trial. After a median follow-up of 69 months for OpACIN, 1/7 patients with a pathologic response to neoadjuvant therapy had disease recurrence. The estimated 5-year RFS and OS rates for the neoadjuvant arm were 70% and 90% versus 60% and 70% for the adjuvant arm. After a median follow-up of 47 months for OpACIN-neo, the estimated 3-year RFS and OS rates were 82% and 92%, respectively. The estimated 3-year RFS rate for OpACIN-neo was 95% for patients with a pathologic response versus 37% for patients without a pathologic response (P < 0.001). In multiple regression analyses, pathologic response was the strongest predictor of disease recurrence. Of the 12 patients with distant disease recurrence after neoadjuvant therapy, 5 responded to subsequent anti-PD-1 and 8 to targeted therapy, although 7 patients showed progression after the initial response. CONCLUSIONS Updated data confirm the high survival rates after neoadjuvant combination checkpoint inhibition in macroscopic stage III melanoma, especially for patients with a pathologic response. Pathologic response is the strongest surrogate marker for long-term outcome.
Collapse
Affiliation(s)
- J M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney; Faculty of Medicine and Health, The University of Sydney, Sydney; Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - K Sikorska
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - E A Rozeman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney; Faculty of Medicine and Health, The University of Sydney, Sydney; Department of Surgery, Mater Hospital, Sydney; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - W J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - H Eriksson
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm; Department of Oncology/Skin Cancer Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - W M C Klop
- Departments of, Head and Neck Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - S Ch'ng
- Melanoma Institute Australia, The University of Sydney, Sydney; Department of Surgery, Mater Hospital, Sydney; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - J V van Thienen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - H Mallo
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M Gonzalez
- Melanoma Institute Australia, The University of Sydney, Sydney
| | - A Torres Acosta
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - A van der Wal
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A Bruining
- Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - B A van de Wiel
- Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney; Faculty of Medicine and Health, The University of Sydney, Sydney; Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney; Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - J B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam
| | - T N Schumacher
- Department of Hematology, Leiden University Medical Center, Leiden; Division of Molecular Oncology and Immunology, Oncode Institute, Netherlands Cancer Institute, Amsterdam
| | - A C J van Akkooi
- Melanoma Institute Australia, The University of Sydney, Sydney; Faculty of Medicine and Health, The University of Sydney, Sydney; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - G V Long
- Melanoma Institute Australia, The University of Sydney, Sydney; Faculty of Medicine and Health, The University of Sydney, Sydney; Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, Australia; Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - C U Blank
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam; Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|
9
|
Chungsiriwattana W, Kongkunnavat N, Kamnerdnakta S, Hayashi A, Tonaree W. Immediate inguinal lymphaticovenous anastomosis following lymphadenectomy in skin cancer of lower extremities. Asian J Surg 2023; 46:299-305. [PMID: 35414452 DOI: 10.1016/j.asjsur.2022.03.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/24/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Secondary lymphedema following inguinal lymph node dissection in lower extremities skin cancer reduce the patients' quality of life. Immediate lymphaticovenous anastomosis (LVA) at groin is a procedure intended to prevent secondary lymphedema. The data regarding the long-term efficacy and safety of this procedure was limited. Therefore, we evaluated the long-term outcomes of immediate LVA in patients with melanoma and non-melanoma skin cancer of the lower extremities. METHODS The retrospective data review of patients with melanoma or squamous cell carcinoma of the lower extremities underwent oncologic tumor resection with groin node dissection between December 2013 and December 2016 was performed. Seven patients underwent immediate LVA (intervention) at groin after node dissection and 22 acted as controls. The occurrence of lymphedema and oncologic outcomes were followed up to 7 years. RESULTS Fifteen patients (51.7%) developed postoperative lymphedema, which were three patients in the intervention group and twelve patients in the control group (p = 0.68). The intervention group had significant lower 2-year (57.1% versus 77.3%) and 5-year overall survival (14.3% versus 54.5%) (p = 0.035). The intervention group had reduced 2-year (28.6% versus 86.4%) and 5-year (28.6% versus 68.2%) Recurrence Free Survival (RFS) (p = 0.013). The intervention group also had reduced 2-year (0% versus 90%) and 5-year (0% versus 70%) Metastasis Free Survival (MFS) (p = 0.003). CONCLUSION Immediate inguinal LVA following groin node dissection in lower extremity skin cancer patients did not reduce the incidence of lymphedema. Unfortunately, it was associated with lower overall survival and an increase in tumor recurrence and metastasis.
Collapse
Affiliation(s)
- Wanchalerm Chungsiriwattana
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natthapong Kongkunnavat
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirichai Kamnerdnakta
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Warangkana Tonaree
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
10
|
Lattimore CM, Meneveau MO, Marsh KM, Shada AL, Slingluff CL, Dengel LT. A Novel Fascial Flap Technique After Inguinal Complete Lymph Node Dissection for Melanoma. J Surg Res 2022; 278:356-363. [PMID: 35671681 DOI: 10.1016/j.jss.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/07/2022] [Accepted: 04/13/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Inguinal complete lymph node dissection (CLND) for metastatic melanoma exposes the femoral vein and artery. To protect femoral vessels while preserving the sartorius muscle, we developed a novel sartorius and adductor fascial flap (SAFF) technique for coverage. METHODS The SAFF technique includes dissection of fascia off sartorius and/or adductor muscles, rotation over femoral vasculature, and suturing into place. Patients who underwent inguinal CLND with SAFF for melanoma at our institution were identified retrospectively from a prospectively-collected database. Patient characteristics and post-operative outcomes were obtained. Multivariate logistic regression assessed associations of palpable and non-palpable disease with wound complications. RESULTS From 2008 to 2019, 51 patients underwent CLND with SAFF. Median age was 62 years, and 59% were female. Thirty-one (61%) patients were presented with palpable disease and 20 (39%) had non-palpable disease. Fifty-five percent (95% confidence interval CI: 40%-69%) experienced at least one wound complication: wound infection was most common (45%; 95% CI: 31%-60%), while bleeding was the least (2%; 95% CI: 0.05%-11%). Complications were similar, with and without palpable disease. CONCLUSIONS The SAFF procedure covers femoral vessels, minimizes bleeding, preserves the sartorius muscle, and uses standard surgical techniques easily adoptable by surgeons who perform inguinal CLND.
Collapse
Affiliation(s)
- Courtney M Lattimore
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Max O Meneveau
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Katherine M Marsh
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Amber L Shada
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Craig L Slingluff
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Lynn T Dengel
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
| |
Collapse
|
11
|
van Akkooi ACJ, Hieken TJ, Burton EM, Ariyan C, Ascierto PA, Asero SVMA, Blank CU, Block MS, Boland GM, Caraco C, Chng S, Davidson BS, Duprat Neto JP, Faries MB, Gershenwald JE, Grunhagen DJ, Gyorki DE, Han D, Hayes AJ, van Houdt WJ, Karakousis GC, Klop WMC, Long GV, Lowe MC, Menzies AM, Olofsson Bagge R, Pennington TE, Rutkowski P, Saw RPM, Scolyer RA, Shannon KF, Sondak VK, Tawbi H, Testori AAE, Tetzlaff MT, Thompson JF, Zager JS, Zuur CL, Wargo JA, Spillane AJ, Ross MI. Neoadjuvant Systemic Therapy (NAST) in Patients with Melanoma: Surgical Considerations by the International Neoadjuvant Melanoma Consortium (INMC). Ann Surg Oncol 2022; 29:3694-3708. [PMID: 35089452 DOI: 10.1245/s10434-021-11236-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022]
Abstract
Exciting advances in melanoma systemic therapies have presented the opportunity for surgical oncologists and their multidisciplinary colleagues to test the neoadjuvant systemic treatment approach in high-risk, resectable metastatic melanomas. Here we describe the state of the science of neoadjuvant systemic therapy (NAST) for melanoma, focusing on the surgical aspects and the key role of the surgical oncologist in this treatment paradigm. This paper summarizes the past decade of developments in melanoma treatment and the current evidence for NAST in stage III melanoma specifically. Issues of surgical relevance are discussed, including the risk of progression on NAST prior to surgery. Technical aspects, such as the definition of resectability for melanoma and the extent and scope of routine surgery are presented. Other important issues, such as the utility of radiographic response evaluation and method of pathologic response evaluation, are addressed. Surgical complications and perioperative management of NAST related adverse events are considered. The International Neoadjuvant Melanoma Consortium has the goal of harmonizing NAST trials in melanoma to facilitate rapid advances with new approaches, and facilitating the comparison of results across trials evaluating different treatment regimens. Our ultimate goals are to provide definitive proof of the safety and efficacy of NAST in melanoma, sufficient for NAST to become an acceptable standard of care, and to leverage this platform to allow more personalized, biomarker-driven, tailored approaches to subsequent treatment and surveillance.
Collapse
Affiliation(s)
| | | | | | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | | | - Christian U Blank
- Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | | | - Corrado Caraco
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Sydney Chng
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | | | - Mark B Faries
- The Angeles Clinic, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - David E Gyorki
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Dale Han
- Oregon Health and Science University, Portland, Oregon, USA
| | | | - Winan J van Houdt
- Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - Willem M C Klop
- Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal North Shore Hospital, St. Leonards, NSW, Australia
- The Mater Hospital, North Sydney, NSW, Australia
| | - Michael C Lowe
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal North Shore Hospital, St. Leonards, NSW, Australia
- The Mater Hospital, North Sydney, NSW, Australia
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas E Pennington
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Kerwin F Shannon
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Hussein Tawbi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mike T Tetzlaff
- University of California San Francisco (UCSF), San Francisco, CA, USA
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- The Mater Hospital, North Sydney, NSW, Australia
| | | | - Charlotte L Zuur
- Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Otorhinolaryngology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jennifer A Wargo
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal North Shore Hospital, St. Leonards, NSW, Australia
- The Mater Hospital, North Sydney, NSW, Australia
| | - Merrick I Ross
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
12
|
Reijers ILM, Menzies AM, van Akkooi ACJ, Versluis JM, van den Heuvel NMJ, Saw RPM, Pennington TE, Kapiteijn E, van der Veldt AAM, Suijkerbuijk KPM, Hospers GAP, Rozeman EA, Klop WMC, van Houdt WJ, Sikorska K, van der Hage JA, Grünhagen DJ, Wouters MW, Witkamp AJ, Zuur CL, Lijnsvelt JM, Torres Acosta A, Grijpink-Ongering LG, Gonzalez M, Jóźwiak K, Bierman C, Shannon KF, Ch'ng S, Colebatch AJ, Spillane AJ, Haanen JBAG, Rawson RV, van de Wiel BA, van de Poll-Franse LV, Scolyer RA, Boekhout AH, Long GV, Blank CU. Personalized response-directed surgery and adjuvant therapy after neoadjuvant ipilimumab and nivolumab in high-risk stage III melanoma: the PRADO trial. Nat Med 2022; 28:1178-1188. [PMID: 35661157 DOI: 10.1038/s41591-022-01851-x] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/29/2022] [Indexed: 02/06/2023]
Abstract
Neoadjuvant ipilimumab and nivolumab induces high pathologic response rates (pRRs) in clinical stage III nodal melanoma, and pathologic response is strongly associated with prolonged relapse-free survival (RFS). The PRADO extension cohort of the OpACIN-neo trial ( NCT02977052 ) addressed the feasibility and effect on clinical outcome of using pathologic response after neoadjuvant ipilimumab and nivolumab as a criterion for further treatment personalization. In total, 99 patients with clinical stage IIIb-d nodal melanoma were included and treated with 6 weeks of neoadjuvant ipilimumab 1 mg kg-1 and nivolumab 3 mg kg-1. In patients achieving major pathologic response (MPR, ≤10% viable tumor) in their index lymph node (ILN, the largest lymph node metastasis at baseline), therapeutic lymph node dissection (TLND) and adjuvant therapy were omitted. Patients with pathologic partial response (pPR; >10 to ≤50% viable tumor) underwent TLND only, whereas patients with pathologic non-response (pNR; >50% viable tumor) underwent TLND and adjuvant systemic therapy ± synchronous radiotherapy. Primary objectives were confirmation of pRR (ILN, at week 6) of the winner neoadjuvant combination scheme identified in OpACIN-neo; to investigate whether TLND can be safely omitted in patients achieving MPR; and to investigate whether RFS at 24 months can be improved for patients achieving pNR. ILN resection and ILN-response-tailored treatment were feasible. The pRR was 72%, including 61% MPR. Grade 3-4 toxicity within the first 12 weeks was observed in 22 (22%) patients. TLND was omitted in 59 of 60 patients with MPR, resulting in significantly lower surgical morbidity and better quality of life. The 24-month relapse-free survival and distant metastasis-free survival rates were 93% and 98% in patients with MPR, 64% and 64% in patients with pPR, and 71% and 76% in patients with pNR, respectively. These findings provide a strong rationale for randomized clinical trials testing response-directed treatment personalization after neoadjuvant ipilimumab and nivolumab.
Collapse
Affiliation(s)
- Irene L M Reijers
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alexander M Menzies
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Alexander C J van Akkooi
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Judith M Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Noëlle M J van den Heuvel
- Department of Psychosocial research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Robyn P M Saw
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Thomas E Pennington
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Astrid A M van der Veldt
- Departments of Medical Oncology and Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisa A Rozeman
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Willem M C Klop
- Department of Head and Neck Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Karolina Sikorska
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jos A van der Hage
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Michel W Wouters
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Charlotte L Zuur
- Department of Head and Neck Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Otorhinolaryngology Head Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith M Lijnsvelt
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | - Maria Gonzalez
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - Katarzyna Jóźwiak
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Carolien Bierman
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Kerwin F Shannon
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - Sydney Ch'ng
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J Colebatch
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
| | - Andrew J Spillane
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Breast and Melanoma Surgery, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - John B A G Haanen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Robert V Rawson
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
| | - Bart A van de Wiel
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Psychosocial research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disorders (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Richard A Scolyer
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Annelies H Boekhout
- Department of Psychosocial research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Georgina V Long
- Melanoma Institute of Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Christian U Blank
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands.
- Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
| |
Collapse
|
13
|
Kaptein P, Jacoberger-Foissac C, Dimitriadis P, Voabil P, de Bruijn M, Brokamp S, Reijers I, Versluis J, Nallan G, Triscott H, McDonald E, Tay J, Long GV, Blank CU, Thommen DS, Teng MWL. Addition of interleukin-2 overcomes resistance to neoadjuvant CTLA4 and PD1 blockade in ex vivo patient tumors. Sci Transl Med 2022; 14:eabj9779. [PMID: 35476594 DOI: 10.1126/scitranslmed.abj9779] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neoadjuvant immunotherapy with anti-cytotoxic T lymphocyte-associated protein 4 (CTLA4) + anti-programmed cell death protein 1 (PD1) monoclonal antibodies has demonstrated remarkable pathological responses and relapse-free survival in ~80% of patients with clinically detectable stage III melanoma. However, about 20% of the treated patients do not respond. In pretreatment biopsies of patients with melanoma, we found that resistance to neoadjuvant CTLA4 + PD1 blockade was associated with a low CD4/interleukin-2 (IL-2) gene signature. Ex vivo, addition of IL-2 to CTLA4 + PD1 blockade induced T cell activation and deep immunological responses in anti-CTLA4 + anti-PD1-resistant human tumor specimens. In the 4T1.2 breast cancer mouse model of neoadjuvant immunotherapy, triple combination of anti-CTLA4 + anti-PD1 + IL-2 cured almost twice as many mice as compared with dual checkpoint inhibitor therapy. This improved efficacy was due to the expansion of tumor-specific CD8+ T cells and improved proinflammatory cytokine polyfunctionality of both CD4+ and CD8+ T effector cells and regulatory T cells. Depletion studies suggested that CD4+ T cells were critical for priming of CD8+ T cell immunity against 4T1.2 and helped in the expansion of tumor-specific CD8+ T cells early after neoadjuvant triple immunotherapy. Our results suggest that the addition of IL-2 can overcome resistance to neoadjuvant anti-CTLA4 + anti-PD1, providing the rationale for testing this combination as a neoadjuvant therapy in patients with early-stage cancer.
Collapse
Affiliation(s)
- Paulien Kaptein
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | | | - Petros Dimitriadis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Paula Voabil
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Marjolein de Bruijn
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Simone Brokamp
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Irene Reijers
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Judith Versluis
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Gahyathiri Nallan
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia
| | - Hannah Triscott
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia.,School of Medicine, University of Queensland, Herston, Queensland 4006, Australia
| | - Elizabeth McDonald
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia
| | - Joshua Tay
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia
| | - Georgina V Long
- Melanoma Institute Australia, University of Sydney, Sydney 2006, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia.,Royal North Shore and Mater Hospitals, Sydney 2065, Australia
| | - Christian U Blank
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Daniela S Thommen
- Division of Molecular Oncology and Immunology, Netherlands Cancer Institute, Amsterdam 1066 CX, Netherlands
| | - Michele W L Teng
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland 4006, Australia.,School of Medicine, University of Queensland, Herston, Queensland 4006, Australia
| |
Collapse
|
14
|
Reijers ILM, Rawson RV, Colebatch AJ, Rozeman EA, Menzies AM, van Akkooi ACJ, Shannon KF, Wouters MW, Saw RPM, van Houdt WJ, Zuur CL, Nieweg OE, Ch’ng S, Klop WMC, Spillane AJ, Long GV, Scolyer RA, van de Wiel BA, Blank CU. Representativeness of the Index Lymph Node for Total Nodal Basin in Pathologic Response Assessment After Neoadjuvant Checkpoint Inhibitor Therapy in Patients With Stage III Melanoma. JAMA Surg 2022; 157:335-342. [PMID: 35138335 PMCID: PMC8829746 DOI: 10.1001/jamasurg.2021.7554] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/28/2021] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Neoadjuvant checkpoint inhibition in patients with high-risk stage III melanoma shows high pathologic response rates associated with a durable relapse-free survival. Whether a therapeutic lymph node dissection (TLND) can be safely omitted when a major pathologic response in the largest lymph node metastasis at baseline (index lymph node; ILN) is obtained is currently being investigated. A previous small pilot study (n = 12) showed that the response in the ILN may be representative of the pathologic response in the entire TLND specimen. OBJECTIVE To assess the concordance of response between the ILN and the total lymph node bed in a larger clinical trial population. DESIGN, SETTING, AND PARTICIPANTS Retrospective pathologic response analysis of a multicenter clinical trial population of patients from the randomized Study to Identify the Optimal Adjuvant Combination Scheme of Ipilimumab and Nivolumab in Melanoma Patients (OpACIN) and Optimal Neo-Adjuvant Combination Scheme of Ipilimumab and Nivolumab (OpACIN-neo) trials. Included patients were treated with 6 weeks neoadjuvant ipilimumab plus nivolumab. Patient inclusion into the trials was conducted from August 12, 2015, to October 24, 2016 (OpACIN), and November 24, 2016, and June 28, 2018 (OpACIN-neo). Data were analyzed from April 1, 2020, to August 31, 2021. MAIN OUTCOMES AND MEASURES Concordance of the pathologic response between the ILN and the TLND tumor bed. The pathologic response of the ILN was retrospectively assessed according to the International Neoadjuvant Melanoma Consortium criteria and compared with the pathologic response of the entire TLND specimen. RESULTS A total of 82 patients treated with neoadjuvant ipilimumab and nivolumab followed by TLND (48 [59%] were male; median age, 58.5 [range, 18-80] years) were included. The pathologic response in the ILN was concordant with the entire TLND specimen response in 81 of 82 patients (99%) and in 79 of 82 patients (96%) concordant when comparing the ILN response with the response in every individual lymph node. In the single patient with a discordant response, the ILN response (20% viable tumor, partial pathologic response) underestimated the entire TLND specimen response (5% viable, near-complete pathologic response). Two other patients each had 1 small nonindex node that contained 80% viable tumor (pathologic nonresponse) whereas all other lymph nodes (including the ILN) showed a partial pathologic response. In these 2 patients, the risk of regional relapse might potentially have been increased if TLND had been omitted. CONCLUSIONS AND RELEVANCE The results of this study suggest that the pathologic response of the ILN may be considered a reliable indicator of the entire TLND specimen response and may support the ILN response-directed omission of TLND in a prospective trial.
Collapse
Affiliation(s)
- Irene L. M. Reijers
- Department of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Robert V. Rawson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Tissue Pathology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
| | - Andrew J. Colebatch
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Tissue Pathology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
- Department of Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
| | - Elisa A. Rozeman
- Department of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Alex M. Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Oncology Department, Royal North Shore Hospital, Sydney, Australia
- Oncology Department, Mater Hospital, Sydney, New South Wales, Australia
| | | | - Kerwin F. Shannon
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michel W. Wouters
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Robyn P. M. Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Winan J. van Houdt
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Charlotte L. Zuur
- Department of Head and Neck Surgery, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Otorhinolaryngology, Leiden University Medical Center, Leiden, the Netherlands
| | - Omgo E. Nieweg
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sydney Ch’ng
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - W. Martin C. Klop
- Department of Head and Neck Surgery, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Andrew J. Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Oncology Department, Royal North Shore Hospital, Sydney, Australia
- Oncology Department, Mater Hospital, Sydney, New South Wales, Australia
| | - Georgina V. Long
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Oncology Department, Royal North Shore Hospital, Sydney, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard A. Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Tissue Pathology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, New South Wales, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Bart A. van de Wiel
- Department of Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Christian U. Blank
- Department of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
- Division of Molecular Oncology & Immunology, the Netherlands Cancer Institute, Amsterdam
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
15
|
Monteiro MGCT, de Morais Gouveia GP. Physiotherapy in the management of gynecological cancer patient: A systematic review. J Bodyw Mov Ther 2021; 28:354-361. [PMID: 34776164 DOI: 10.1016/j.jbmt.2021.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 01/05/2023]
Abstract
AIM to evaluate the effectiveness of physiotherapy as an adjunct treatment in patients with gynecological cancer. METHOD systematic review carried out in the PubMed, MEDLINE, via VHL, Cochrane and SciELO, in the last ten years. A search strategy was based on the PICO method and the PRISMA flowchart using Boolean descriptors and operators: "gynecological cancer or neoplasms of female genital organs" and "physiotherapy or physiotherapy modalities" and "rehabilitation or quality of life" in languages Portuguese, English, and Spanish. RESULTS 405 articles were found, and after eligibility criteria, only 5 studies were selected for review. Evidence of a monitored physical exercise, photobiomodulation and pelvic floor rehabilitation program as physiotherapeutic resources in the management of gynecological cancer. CONCLUSION Physiotherapy dominates techniques and appears to be beneficial for the main complications arising from the treatment or post-treatment of gynecological cancer and has sought to accompany the knowledge and care of the patient, through scientific research.
Collapse
|
16
|
Abstract
Regional nodal melanoma management has changed substantially over the past 2 decades alongside advances in systemic therapy. Significant data from retrospective studies and from 2 randomized controlled trials show no survival benefit to completion lymph node dissection compared with observation in sentinel lymph node-positive melanoma patients. Observation is becoming the standard recommendation in these patients, whereas patients with clinically detected lymph nodes are still recommended to undergo lymph node dissection. Promising early results from a neoadjuvant approach inform the ongoing evolution of melanoma management. Recruiting patients to clinical trials is paramount to attaining evidence-based practice changes in melanoma.
Collapse
|
17
|
Cutaneous Malignancies of the Head and Neck. Hematol Oncol Clin North Am 2021; 35:991-1008. [PMID: 34281755 DOI: 10.1016/j.hoc.2021.05.008] [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: 11/21/2022]
Abstract
Cutaneous malignancies (CMs), or skin cancers, are the most common cancer worldwide, with a quarter million cases diagnosed annually in the United States alone. The best described risk factor for CM is ultraviolet radiation from sunlight, and therefore most of these cancers develop in sun-exposed skin, including the head and neck. Beginning with melanoma, immunotherapy has increasingly been used over the past decade for treatment of unresectable CM, and immune checkpoint inhibitors are now Food and Drug Administration-approved for first-line treatment of unresectable melanoma, Merkel cell carcinoma, and cutaneous squamous cell carcinoma, and second-line for basal cell carcinoma.
Collapse
|
18
|
Inguinal Lymph Node Dissection for Advanced Stages of Plantar Melanoma in a Low-Income Country. J Skin Cancer 2020; 2020:8854460. [PMID: 33381319 PMCID: PMC7749766 DOI: 10.1155/2020/8854460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022] Open
Abstract
Background Advanced stages of plantar acral lentiginous melanoma are common in Africa. Inguinal lymph node dissection (ILND) in these cases plays a critical role in disease-free and overall survival. Our study aims to share our experience in ILND for advanced plantar melanomas. Methods and Study Design. Four-year prospective study. Patients. We included all documented cases of advanced stage plantar melanoma with clinically detectable inguinal lymph node metastasis. Twenty-two of 27 patients identified—with mean age 56 years—underwent ILND. Studied Variables. Tumor patterns and stage, surgery, morbidity, oncologic pathology, and evolution were studied. Statistical software assessed the overall survival (OS). Results Plantar lesions were all excised with a cancer-free margin (3 cm). ILND was performed for 22 patients with visible (n = 11), palpable (n = 7), and ulcerous (n = 4) lymphadenopathies. It was performed through an S-shaped (n = 11) or ellipse-shaped skin incision (n = 11). The tumors were AJCC stage III (n = 18) and IV (n = 2). We found high Breslow index tumor thickness (>3 mm) and an advanced Clark IV stage (n = 20). All operative wounds healed within 46 days (21–90). Wound healing was delayed by suture failure (n = 16), lymphorrhoea (n = 22), and infection (n = 18). After 29 months, three patients had complete remissions, seven had recurrences, and twelve patients had died. The overall survival (OS) at one year was 56%. In two patients with AJCC stage III disease, the OS was better (22 months). Conclusion In low-income countries, ILND in advanced stages of plantar foot melanoma is a valuable surgical treatment option. Alongside ILND adjuvants, treatment must be available and accessible to improve survival.
Collapse
|
19
|
Dargan D, Hindocha S, Hadlett M, Wright R, Beck D, McConville S, Hartley-Large D, Mortimer K, Brackley P. Groin dissections in skin cancer: Effect of a change in prophylactic antibiotic protocol. J Plast Reconstr Aesthet Surg 2020; 74:1553-1561. [PMID: 33551360 DOI: 10.1016/j.bjps.2020.11.035] [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: 12/20/2019] [Revised: 09/14/2020] [Accepted: 11/22/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether groin dissection surgical site infection (SSI) incidence changed with shorter post-operative antibiotic prophylaxis. BACKGROUND Post-operative prophylaxis changed due to antimicrobial stewardship, from regular oral antibiotics until drain removal, to three intravenous doses. Both groups had a single intravenous dose at induction. METHODS A prospective database of groin dissections for metastatic skin cancer was retrospectively reviewed for SSI according to Public Health England criteria. Eighty groin dissections in 79 consecutive patients were included: 40 had oral antibiotics until drain removal [mean 26±7 (range 19-36) days] and 39 had three post-operative intravenous doses. RESULTS Longer prophylaxis was associated with lower SSI incidence [10 (25%) versus 21 (54%), odds ratio (OR) 3.50, 95% confidence interval (CI) 1.34-9.08, p = 0.009], fewer deep infections [5 (13%) versus 16 (41%), OR 4.89, 95% CI 1.57-15.13, p = 0.004], fewer readmissions for infection [5 (13%) versus 15 (38%), OR 4.38, 95% CI 1.40-13.65, p = 0.008], but similar seroma incidence [18 (45%) versus 16 (41%), OR 0.85, 95% CI 0.35-2.07, p = 0.72] and wound dehiscence [7 (18%) versus 5 (13%), OR 0.69, 95% CI 0.20-2.40, p = 0.56]. BMI ≥30 (n = 21) was associated with SSI, occurring in 13 of 21 (62%) (OR 3.859, 95% CI 1.34-11.10, p = 0.01). Median infection onset was 22 days (IQR 12-27) versus 17 (IQR 13-22), (p = 0.53). Multiple organisms were cultured in 21 of 31 (68%) patients with positive microbiological samples. CONCLUSIONS SSI rates doubled with shorter prophylaxis; deep infections and readmissions for infection tripled. Obesity was independently associated with infection. Seroma and wound dehiscence incidence were unchanged. Infections mainly occurred in the third week after surgery and were polymicrobial.
Collapse
Affiliation(s)
- Dallan Dargan
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom.
| | - Sandip Hindocha
- Plastic Surgery & Laser Centre, Bedford Hospital NHS Trust, Kempston Road, Bedford MK42 9DJ, United Kingdom
| | - Max Hadlett
- School of Medicine, University of Liverpool, Cedar House, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - Rosanna Wright
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Deborah Beck
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Sarah McConville
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - David Hartley-Large
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Kalani Mortimer
- Departments of Microbiology and Infection Prevention, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| | - Philip Brackley
- Mersey Regional Burns and Plastic Surgery Centre, St. Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Warrington Road, Prescot L35 5DR, United Kingdom
| |
Collapse
|
20
|
Gullestad HP, Haugen G, Fosså SD. Late arm and shoulder problems after axillary therapeutic lymph node dissection in patients with melanoma. J Plast Surg Hand Surg 2020; 55:127-131. [PMID: 33176535 DOI: 10.1080/2000656x.2020.1842746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Lymphedema is exempted, only a few studies have dealt with the late adverse effects in melanoma patients who have undergone axillary therapeutic lymph node dissection (ATLND) for the clinical nodal disease. We evaluated the data on late arm/shoulder problems (ASPs) reported by the patients and daily life impairment after ATLND and identified the risk factors. MATERIAL AND METHODS Between 2008 and 2014, 82 patients underwent full en bloc Level I-III ATLND. After a median of 56 months (range 34-104), 76 patients (compliance: 93%) rated their ASPs and daily life dysfunction in a questionnaire, leading to the calculation of individual a Symptom/Problem Summary Score and a Function Summary Score. Multivariate analyses identified risk factors. RESULTS Two groups of patients were identified. Group 1: no or mild ASPs, n = 56 (74%). Group 2: at least one moderate, severe and very severe ASP, n = 20 (26%). Overall, lymphedema, numbness and restricted arm movements represented the most frequent ASPs. Based on the distribution of the summary scores, about 60% of the patients reported no or only mild symptoms/problems and no or mild dysfunction. More than mild impairment of daily life was reported by five patients. On multivariate analyses, increasing tumor size and decreasing age were identified as risk factors. CONCLUSION Our sample shows that ATLND in melanoma patients with the clinically detectable disease can be performed without a major risk of late ASPs and impaired daily life. Increasing tumor size and decreasing age at the surgery are risk factors for developing ASP-related dysfunction.
Collapse
Affiliation(s)
- Hans P Gullestad
- Division of Plastic Surgery, Department of Surgical Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.,Division of Oncoplastic Surgery, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Gro Haugen
- Section for Cancer Rehabilitation, Department of Clinical Service, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Sophie D Fosså
- Department of Clinical Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
21
|
Sun W, Xu Y, Yang J, Liao Z, Li T, Huang K, Patel P, Yan W, Chen Y. The prognostic significance of non-sentinel lymph node metastasis in cutaneous and acral melanoma patients-A multicenter retrospective study. Cancer Commun (Lond) 2020; 40:586-597. [PMID: 33025763 PMCID: PMC7668482 DOI: 10.1002/cac2.12101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/01/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023] Open
Abstract
Background Whether non‐sentinel lymph node (SLN)‐positive melanoma patients can benefit from completion lymph node dissection (CLND) is still unclear. The current study was performed to identify the prognostic role of non‐SLN status in SLN‐positive melanoma and to investigate the predictive factors of non‐SLN metastasis in acral and cutaneous melanoma patients. Methods The records of 328 SLN‐positive melanoma patients who underwent radical surgery at four cancer centers from September 2009 to August 2017 were reviewed. Clinicopathological data including age, gender, Clark level, Breslow index, ulceration, the number of positive SLNs, non‐SLN status, and adjuvant therapy were included for survival analyses. Patients were followed up until death or June 30, 2019. Multivariable logistic regression modeling was performed to identify factors associated with non‐SLN positivity. Log‐rank analysis and Cox regression analysis were used to identify the prognostic factors for disease‐free survival (DFS) and overall survival (OS). Results Among all enrolled patients, 220 (67.1%) had acral melanoma and 108 (32.9%) had cutaneous melanoma. The 5‐year DFS and OS rate of the entire cohort was 31.5% and 54.1%, respectively. More than 1 positive SLNs were found in 123 (37.5%) patients. Positive non‐SLNs were found in 99 (30.2%) patients. Patients with positive non‐SLNs had significantly worse DFS and OS (log‐rank P < 0.001). Non‐SLN status (P = 0.003), number of positive SLNs (P = 0.016), and adjuvant therapy (P = 0.025) were independent prognostic factors for DFS, while non‐SLN status (P = 0.002), the Breslow index (P = 0.027), Clark level (P = 0.006), ulceration (P = 0.004), number of positive SLNs (P = 0.001), and adjuvant therapy (P = 0.007) were independent prognostic factors for OS. The Breslow index (P = 0.020), Clark level (P = 0.012), and number of positive SLNs (P = 0.031) were independently related to positive non‐SLNs and could be used to develop more personalized surgical strategy. Conclusions Non‐SLN‐positive melanoma patients had worse DFS and OS even after immediate CLND than those with non‐SLN‐negative melanoma. The Breslow index, Clark level, and number of positive SLNs were independent predictive factors for non‐SLN status.
Collapse
Affiliation(s)
- Wei Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Yu Xu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - JiLong Yang
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, P. R. China
| | - ZhiChao Liao
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, P. R. China
| | - Tao Li
- Department of Bone and Soft-tissue Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, P. R. China
| | - Kai Huang
- Department of General Surgery, Brandon Regional Hospital, HCA West Florida Division, Brandon, 33511, USA
| | - Poulam Patel
- Academic Unit of Clinical Oncology, University of Nottingham, City Hospital Campus, Nottingham, NG5 1PB, UK
| | - WangJun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Yong Chen
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| |
Collapse
|
22
|
Leiter U, Stadler R, Mauch C, Hohenberger W, Brockmeyer NH, Berking C, Sunderkötter C, Kaatz M, Schatton K, Lehmann P, Vogt T, Ulrich J, Herbst R, Gehring W, Simon JC, Keim U, Verver D, Martus P, Garbe C. Final Analysis of DeCOG-SLT Trial: No Survival Benefit for Complete Lymph Node Dissection in Patients With Melanoma With Positive Sentinel Node. J Clin Oncol 2019; 37:3000-3008. [PMID: 31557067 DOI: 10.1200/jco.18.02306] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 12/17/2023] Open
Abstract
PURPOSE We have previously reported on the 3-year results of the phase III German Dermatologic Cooperative Oncology Group trial (DeCOG; ClinicalTrials.gov identifier: NCT02434107) comparing distant metastasis-free survival (DMFS), recurrence-free survival (RFS), and overall survival (OS) in patients with positive sentinel lymph-node biopsy who were randomly assigned to complete lymph node dissection (CLND) or observation. Here, we report the final analysis with 72 months of median follow up. PATIENTS AND METHODS The multicenter randomized phase III trial included patients with cutaneous melanoma of the trunk and extremities who were randomly assigned (1:1) to undergo CLND or observation. DMFS was analyzed as the primary end point, and RFS, OS, and recurrences in the regional lymph node basin were secondary end points. The analysis was by intention to treat. Disease and survival information were collected quarterly. RESULTS From January 2006 to December 2014, 5,547 patients were screened to identify 1,256 with metastases in the sentinel lymph node (SLN). Of these, 483 (39%) were included: 241 in the observation arm and 242 in the CLND arm. In the final analysis, median follow up was 72 months (interquartile range, 67-77 months). No significant treatment-related difference was seen in the 5-year DMFS between the observation and CLND arms (67.6% v 64.9%, respectively; hazard ratio [HR], 1.08; P = .87). The 5-year RFS and OS also showed no difference (HR, 1.01 and 0.99, respectively). Grade 3 and 4 adverse effects occurred in 32 patients (13%) in the CLND arm; lymphedema (n = 20) and delayed wound healing (n = 5) were most common and no serious adverse events were reported. CONCLUSION The final results of the German Dermatologic Cooperative Oncology Group trial with a median follow up of 72 months showed higher event rates, but similar HRs compared with those at the 3-year analysis. These results confirm that immediate CLND in SLN-positive patients is not superior to observation in terms of DMFS, RFS, or OS and support not recommending CLND in patients with SLN metastasis.
Collapse
Affiliation(s)
- Ulrike Leiter
- Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | | | | | | | | | - Cord Sunderkötter
- University of Munster, Munster, Germany
- University Hospital Halle, Halle, Germany
| | - Martin Kaatz
- SRH Wald-Klinikum Gera, Gera, Germany
- University of Jena, Jena, Germany
| | | | | | | | - Jens Ulrich
- University of Magdeburg, Quedlinburg, Germany
| | | | | | | | - Ulrike Keim
- Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | - Peter Martus
- Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Claus Garbe
- Eberhard Karls University of Tübingen, Tübingen, Germany
| |
Collapse
|
23
|
Testori AAE, Blankenstein SA, van Akkooi ACJ. Surgery for Metastatic Melanoma: an Evolving Concept. Curr Oncol Rep 2019; 21:98. [DOI: 10.1007/s11912-019-0847-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
24
|
Enhancing the prognostic role of melanoma sentinel lymph nodes through microscopic tumour burden characterization: clinical usefulness in patients who do not undergo complete lymph node dissection. Melanoma Res 2019; 29:163-171. [DOI: 10.1097/cmr.0000000000000481] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
25
|
Bloemendal M, van Willigen WW, Bol KF, Boers-Sonderen MJ, Bonenkamp JJ, Werner JEM, Aarntzen EHJG, Koornstra RHT, de Groot JWB, de Vries IJM, van der Hoeven JJM, Gerritsen WR, de Wilt JHW. Early Recurrence in Completely Resected IIIB and IIIC Melanoma Warrants Restaging Prior to Adjuvant Therapy. Ann Surg Oncol 2019; 26:3945-3952. [PMID: 30830540 PMCID: PMC6787294 DOI: 10.1245/s10434-019-07274-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 11/30/2022]
Abstract
Purpose To evaluate the results of restaging completely resected stage IIIB/C melanoma prior to start of adjuvant therapy. Patients and Methods One hundred twenty patients with stage IIIB or IIIC (AJCC 2009) melanoma who underwent complete surgical resection were screened for inclusion in our trial investigating adjuvant dendritic cell therapy (NCT02993315). All patients underwent imaging to exclude local relapse or metastasis before entering the trial. The frequency of recurrent disease within 12 weeks after resection and the method of detection were investigated. Results Sixty-nine (58%) stage IIIB and 51 (43%) stage IIIC melanoma patients were screened. Median age was 54 (range 27–79) years. Twenty-two (18%) of 120 patients with completely resected stage IIIB/C melanoma had evidence of early recurrent disease, despite exclusion thereof by prior imaging. Median interval between resection and detection of relapse was 7.4 (range 4.3–10.7) weeks. Recurrence was asymptomatic in 17 (77%) patients, but metastasis was noticed by the patient or physician in 5 (23%). Eight patients with local relapse received local treatment with curative intent, and one was treated with systemic therapy. The remaining patients had distant metastasis, 1 of whom underwent resection of a solitary liver metastasis while 12 patients received systemic treatment. Conclusions Patients with completely resected stage IIIB/C melanoma have high risk of early recurrence before start of adjuvant therapy. Restaging should be considered for high-risk melanoma patients before start of adjuvant therapy.
Collapse
Affiliation(s)
- Martine Bloemendal
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Wouter W van Willigen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Kalijn F Bol
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Marye J Boers-Sonderen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes J Bonenkamp
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J E M Werner
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik H J G Aarntzen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rutger H T Koornstra
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - I Jolanda M de Vries
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | | | - Winald R Gerritsen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| |
Collapse
|
26
|
Stadler R, Leiter U, Garbe C. Kein Überlebensvorteil beim Sentinel-Lymphknoten-positiven Melanom mit sofortiger kompletter Lymphadenektomie - eine Übersicht. J Dtsch Dermatol Ges 2019; 17:7-14. [DOI: 10.1111/ddg.13707_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rudolf Stadler
- Universitätsklinik für Dermatologie; Klinikum Johannes Wesling in Minden; Universitätsklinikum Ruhr; Bochum
| | - Ulrike Leiter
- Zentrum für Dermatoonkologie; Universitäts-Hautklinik; Eberhard Karls Universität; Tübingen
| | - Claus Garbe
- Zentrum für Dermatoonkologie; Universitäts-Hautklinik; Eberhard Karls Universität; Tübingen
| |
Collapse
|
27
|
Stadler R, Leiter U, Garbe C. Lack of survival benefit in sentinel lymph node-positive melanoma with immediate complete lymphadenectomy - a review. J Dtsch Dermatol Ges 2018; 17:7-13. [DOI: 10.1111/ddg.13707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rudolf Stadler
- University Hospital for Dermatology; Johannes Wesling Clinical Centre in Minden; Ruhr University Hospital; Bochum Germany
| | - Ulrike Leiter
- Centre for Dermato-oncology; University Department of Dermatology, Eberhard Karls University; Tübingen Germany
| | - Claus Garbe
- Centre for Dermato-oncology; University Department of Dermatology, Eberhard Karls University; Tübingen Germany
| |
Collapse
|
28
|
Faut M, Kruijff S, Hoekstra HJ, van Ginkel RJ, Been LB, van Leeuwen BL. Pelvic lymph node dissection in metastatic melanoma to the groin should not be abandoned yet. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1779-1785. [PMID: 30054111 DOI: 10.1016/j.ejso.2018.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/02/2018] [Accepted: 06/27/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND In recent years there has been a plea to abandon the pelvic lymph node dissection in the treatment of patients with metastatic melanoma to the groin. A trend towards a conservative surgical treatment is already evolving in several European countries. The purpose of this study is to identify factors associated with pelvic nodal involvement, in order to improve selection of patients whom might benefit from a pelvic nodal dissection. METHODS A retrospective analysis was performed on prospectively collected data concerning patients who underwent an inguinal lymph node dissection (ILND) with pelvic lymph node dissection for metastatic melanoma at the University Medical Center Groningen. Multivariable logistic regression analysis was performed to determine factors associated with pelvic nodal involvement. Diagnostic accuracy was calculated for 18F-FDG PET + contrast enhanced CT-scan and 18F-FDG PET + low dose CT-scan. RESULTS Two-hundred-and-twenty-six ILND's were performed in 223 patients. The most common histologic subtype was superficial spreading melanoma (42.6%). In patients with micrometastatic disease, 15.7% had pelvic nodal involvement vs 28.2% in patients with macrometastatic disease (p: 0.030). None of the characteristics known prior to the ILND, were associated with pelvic nodal involvement. Imaging methods were unable to accurately predict pelvic nodal involvement. Negative predictive value was 78% for 18F-FDG PET + low dose CT-scan and 86% for an 18F-FDG PET + contrast enhanced CT-scan. CONCLUSION There are no patient- or tumor characteristics available that can predict pelvic nodal involvement in patients with melanoma metastasis to the groin. As no imaging technique is able to predict pelvic nodal involvement it seems unjust to abandon the pelvic lymph node dissection.
Collapse
Affiliation(s)
- M Faut
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - S Kruijff
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - H J Hoekstra
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - R J van Ginkel
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - L B Been
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - B L van Leeuwen
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| |
Collapse
|
29
|
Kroon HM, van der Bol WD, Tonks KT, Hong AM, Hruby G, Thompson JF. Treatment of Clinically Positive Cervical Lymph Nodes by Limited Local Node Excision and Adjuvant Radiotherapy in Melanoma Patients with Major Comorbidities. Ann Surg Oncol 2018; 25:3476-3482. [PMID: 30116948 DOI: 10.1245/s10434-018-6692-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION When cervical lymph nodes are clinically positive for metastatic melanoma, surgeons may be hesitant to recommend a therapeutic complete lymph node dissection if the patient is elderly or has major comorbidities. A limited local node excision of the clinically positive nodes only, followed by adjuvant radiotherapy to the entire node field, may be an effective alternative in such patients. METHODS All patients who had presented with a primary head and neck melanoma or an unknown primary site and had subsequently undergone limited local node excision and adjuvant radiotherapy for macroscopically involved cervical nodes between 1993 and 2010 at a tertiary referral center were selected for study. RESULTS Twenty-eight patients were identified, with a median age of 78 years and a median of 2 major comorbidities. The 5-year regional control, disease-free survival, and overall survival rates were 69%, 44%, and 50%, respectively. At the time of data analysis, seven patients were alive without evidence of disease. Twenty-one patients had died: 11 of melanoma (4 with neck recurrence) and 10 of other causes (2 with neck recurrence). CONCLUSIONS Excision of clinically positive metastatic cervical lymph nodes followed by radiotherapy provides satisfactory regional disease control without risking serious morbidity or mortality in melanoma patients whose general condition is considered a contraindication for therapeutic complete lymph node dissection.
Collapse
Affiliation(s)
- Hidde M Kroon
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Wendy D van der Bol
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | | | - Angela M Hong
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Department of Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - George Hruby
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Department of Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia. .,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| |
Collapse
|
30
|
Do JH, Choi KH, Ahn JS, Jeon JY. Effects of a complex rehabilitation program on edema status, physical function, and quality of life in lower-limb lymphedema after gynecological cancer surgery. Gynecol Oncol 2017; 147:450-455. [DOI: 10.1016/j.ygyno.2017.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/02/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
|
31
|
Postlewait LM, Farley CR, Diller ML, Martin B, Hart Squires M, Russell MC, Rizzo M, Ogan K, Master V, Delman K. A Minimally Invasive Approach for Inguinal Lymphadenectomy in Melanoma and Genitourinary Malignancy: Long-Term Outcomes in an Attempted Randomized Control Trial. Ann Surg Oncol 2017; 24:3237-3244. [DOI: 10.1245/s10434-017-5971-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 12/15/2022]
|
32
|
Moody JA, Botham SJ, Dahill KE, Wallace DL, Hardwicke JT. Complications following completion lymphadenectomy versus therapeutic lymphadenectomy for melanoma - A systematic review of the literature. Eur J Surg Oncol 2017; 43:1760-1767. [PMID: 28756017 DOI: 10.1016/j.ejso.2017.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/24/2017] [Accepted: 07/11/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Completion lymph node dissection (CLND) following a positive sentinel lymph node biopsy (SLNB) has been reported to be less morbid than lymphadenectomy for palpable disease (therapeutic lymph node dissection; TLND). The reporting of morbidity data can be heterogeneous, and hence no 'average' surgical complication rates of these procedures has been reported. This review aims to determine complications rates to inform patients undergoing surgery for metastatic melanoma. METHODS A systematic review of English-language literature from 2000 to 2017, reporting morbidity information about CLND and TLND for melanoma, was performed. The methodological quality of the included studies was performed using the methodological index for non-randomised studies (MINORS) instrument and Detsky score. Pooled proportions of post-operative complications were constructed using a random effects statistical model. RESULTS After application of inclusion and exclusion criteria, 18 articles progressed to the final analysis. In relation to TLND (1627 patients), the overall incidence of surgical complications was 39.3% (95% CI 32.6-46.2); including wound infection/breakdown 25.4% (95% CI: 20.9-30.3); lymphoedema 20.9% (95% CI: 13.8-29.1); and seroma 20.4% (95% CI: 15.9-25.2). For CLND (1929 patients), the overall incidence of surgical complications was 37.2% (95% CI 27.6-47.4); including wound infection/breakdown 21.6% (95% CI: 13.8-30.6); lymphoedema 18% (95% CI: 12.5-24.2); and seroma 17.9% (95% CI: 10.3-27). The complication rate was marginally lower for CLND but not to statistical significance. DISCUSSION This study provides information about the incidence of complications after CLND and TLND. It can be used to counsel patients about the procedures and it sets a benchmark against which surgeons can audit their practice.
Collapse
Affiliation(s)
- J A Moody
- GKT School of Medical Education, King's College London, Great Maze Pond, London, SE1 9RT, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - S J Botham
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - K E Dahill
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - D L Wallace
- Department of Plastic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom
| | - J T Hardwicke
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom; Department of Plastic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
| |
Collapse
|
33
|
Rios-Cantu A, Lu Y, Melendez-Elizondo V, Chen M, Gutierrez-Range A, Fadaki N, Thummala S, West-Coffee C, Cleaver J, Kashani-Sabet M, Leong SPL. Is the non-sentinel lymph node compartment the next site for melanoma progression from the sentinel lymph node compartment in the regional nodal basin? Clin Exp Metastasis 2017; 34:345-350. [PMID: 28699042 DOI: 10.1007/s10585-017-9854-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/28/2017] [Indexed: 01/12/2023]
Abstract
Melanoma patients with additional positive lymph nodes in the completion lymph node dissection (CLND) following a positive sentinel lymph node (SLN) biopsy would have a poorer prognosis than patients with no additional positive lymph nodes. We hypothesize that the progression of disease from the SLN to the non-SLN compartment is orderly and is associated with the worsening of the disease status. Thus, the SLN and non-SLN compartments are biologically different in that cancer cells, in general, arrive in the SLN compartment before spreading to the non-SLN compartment. To validate this concept, we used a large cohort of melanoma patients from our prospective SLN database in an academic tertiary medical center. Adult cutaneous melanoma patients (n = 291) undergoing CLND after a positive SLN biopsy from 1994 to 2009 were analyzed. Comparison of 5-year disease-free survival and 5-year overall survival between positive (n = 66) and negative (n = 225) CLND groups was made. The 5-year disease-free survival rates were 55% (95% CI 49-62%) for patients with no additional LN on CLND versus 14% (95% CI 8-26%) in patients with positive LN on CLND (p < 0.0001, log-rank test). The median disease-free survival time was 7.4 years with negative CLND (95% CI 4.4-15+ years) and 1.2 years with positive CLND (95% CI 1.0-1.8 years). The 5-year overall survival rates were 67% (95% CI 61-74%) for negative CLND versus 38% (95% CI 28-52%) for positive CLND (p < 0.0001, log-rank test). The median overall survival time was 12.1 years for negative CLND (95% CI 9.3-15+ years) and 2.5 years for positive CLND (95% CI 2.2-5.7 years). This study shows that CLND status is a significant prognostic factor for patients with positive SLNs undergoing CLND. Also, it suggests an orderly progression of metastasis from the SLN to the non-SLN compartment. Thus, the SLN in the regional nodal basin draining the primary melanoma may serve as an important gateway for metastasis to the non-SLN compartment and beyond to the systemic sites.
Collapse
Affiliation(s)
- Andrei Rios-Cantu
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.,Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Consorcio de Universidades Mexicanas (CuMEX), Pachuca, Mexico
| | - Ying Lu
- Departments of Biomedical Data Science, Health Research and Policy, and Radiology, The Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Victor Melendez-Elizondo
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.,Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Consorcio de Universidades Mexicanas (CuMEX), Pachuca, Mexico
| | - Michael Chen
- Departments of Biomedical Data Science, Health Research and Policy, and Radiology, The Stanford Cancer Institute, Stanford University, Stanford, CA, USA.,University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Alejandra Gutierrez-Range
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.,Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Consorcio de Universidades Mexicanas (CuMEX), Pachuca, Mexico
| | - Niloofar Fadaki
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - Suresh Thummala
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - Carla West-Coffee
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - James Cleaver
- Department of Dermatology, University of California, San Francisco, CA, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA
| | - Stanley P L Leong
- Center for Melanoma Research & Treatment, California Pacific Medical Center, 2340 Clay Street, 2nd Floor, San Francisco, CA, 94115, USA.
| |
Collapse
|
34
|
Theodore JE, Frankel AJ, Thomas JM, Barbour AP, Bayley GJ, Allan CP, Wagels M, Smithers BM. Assessment of morbidity following regional nodal dissection in the axilla and groin for metastatic melanoma. ANZ J Surg 2017; 87:44-48. [PMID: 27102082 DOI: 10.1111/ans.13526] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study assessed and compared the morbidity of nodal dissection in the axilla and groin including sentinel lymph node biopsy (SLNB), completion lymph node dissection for a positive SLNB (CLND) and therapeutic lymph node dissection (TLND) with and without adjuvant radiotherapy (RT). METHODS Patients who had nodal dissection in the axilla or groin for cutaneous melanoma over an 18-year period (1995-2013) were prospectively documented on a database. The median follow-up was nearly 3 years. Early complications and clinically relevant lymphoedema were retrospectively analysed to assess the incidence and differences between the region and type of nodal surgery. RESULTS Included were 1521 patients following nodal dissection in the axilla (916 patients) and groin (605 patients). Less early complications occurred following SLNB in the axilla compared with the groin (5% versus 14%, P = 0.0001). Early complications were similar for CLND and TLND in the groin (49% versus 43%, P = 0.879) and axilla (28% versus 33%, P = 0.607). Moderate to severe lymphoedema rates were similar following axillary SLNB and CLND (6% versus 8%, P = 0.407). The lymphoedema rate for groin SLNB was lower than CLND (10% versus 20%, P = 0.063). No significant difference in lymphoedema rates followed CLND and TLND in each region. Following TLND, RT increased lymphoedema rates. CONCLUSIONS Morbidity may occur following SLNB with the groin having a higher rate of early complications and lymphoedema compared with the axilla. The morbidity following CLND and TLND were similar. Lymphoedema rates were increased following RT.
Collapse
Affiliation(s)
- Jane E Theodore
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The University of Queensland, Mater Health Services, Brisbane, Queensland, Australia
| | - Adam J Frankel
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Janine M Thomas
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Mater Research Institute, Mater Health Services, Brisbane, Queensland, Australia
| | - Andrew P Barbour
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
| | - Gerard J Bayley
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Christopher P Allan
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The University of Queensland, Mater Health Services, Brisbane, Queensland, Australia
| | - Michael Wagels
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
| | - B Mark Smithers
- The Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
- Mater Research Institute, Mater Health Services, Brisbane, Queensland, Australia
| |
Collapse
|
35
|
Faut M, Heidema RM, Hoekstra HJ, van Ginkel RJ, Been SLB, Kruijff S, van Leeuwen BL. Morbidity After Inguinal Lymph Node Dissections: It Is Time for a Change. Ann Surg Oncol 2016; 24:330-339. [PMID: 27519351 PMCID: PMC5215190 DOI: 10.1245/s10434-016-5461-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Inguinal lymph node dissection (ILND) for stage 3 melanoma is accompanied by high wound complication rates. During the past decades, several changes in perioperative care have been instituted to decrease the incidence of these complications. This study aimed to evaluate the effect of these different care protocols on wound complications after ILND. METHODS A retrospective analysis of prospectively collected data was performed with 240 patients who underwent an ILND in the University Medical Center Groningen between 1989 and 2014. Four groups with different treatment protocols were analyzed: A (≥10 days of bed rest with a Bohler Braun splint), B (10 days of bed rest without a splint), C (5 days of bed rest), and D (1 day of bed rest). The effect of early mobilization, abolishment of the Bohler Braun splint and postural restrictions, and the introduction of prophylactic antibiotics were analyzed. RESULTS One or more wound complications occurred in 51.2 % of the patients including wound infection (29.8 %), seroma (21.5 %), wound necrosis (13.6 %), and hematoma (5 %). In consecutive periods, respectively 44.4, 60.3, 44.9 and 55.2 % of the patients experienced wound complications. None of the instituted changes in protocols led to a decrease in wound complications. CONCLUSION Changes in perioperative care protocols did not affect the rate of wound complications. Perhaps a change in the surgical procedure itself can lead to the necessary reduction of wound complications after ILND.
Collapse
Affiliation(s)
- Marloes Faut
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Rianne M Heidema
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Harald J Hoekstra
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Robert J van Ginkel
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - S Lukas B Been
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgical Oncology, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
| |
Collapse
|
36
|
Boudewijns S, Bloemendal M, Gerritsen WR, de Vries IJM, Schreibelt G. Dendritic cell vaccination in melanoma patients: From promising results to future perspectives. Hum Vaccin Immunother 2016; 12:2523-2528. [PMID: 27322496 DOI: 10.1080/21645515.2016.1197453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Dendritic cells (DCs) play an important role in the induction of antitumor immunity. Therefore, they are used as anti-cancer vaccines in clinical studies in various types of cancer. DC vaccines are generally well tolerated and able to induce antigen-specific T cell responses in melanoma patients. After DC vaccinations, functional tumor-specific T cells are more frequently detected in stage III melanoma patients, as compared to patients with advanced melanoma, indicating that the tumor load influences immunological responses. Furthermore, long-lasting clinical responses were rarely seen in metastatic melanoma patients after DC vaccination. Since more potent treatment options are available, e.g. immune checkpoint inhibitors and targeted therapy, DC vaccination as monotherapy may not be preferred in the treatment of advanced melanoma. However, encouraging results of DC vaccines combined with ipilimumab have been reported in advanced melanoma patients with an objective response rate of 38%. DC vaccines show promising clinical results in stage III patients, although clinical efficacy still needs to be proven in a phase 3 trial. The clinical and immunological results of DC vaccination in stage III melanoma patients might be further improved by using naturally circulating DCs (myeloid DCs and plasmacytoid DCs) and neoantigens to load DCs.
Collapse
Affiliation(s)
- Steve Boudewijns
- a Department of Medical Oncology , Radboud University Medical Center , Nijmegen , The Netherlands.,b Department of Tumor Immunology , Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen , The Netherlands
| | - Martine Bloemendal
- a Department of Medical Oncology , Radboud University Medical Center , Nijmegen , The Netherlands.,b Department of Tumor Immunology , Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen , The Netherlands
| | - Winald R Gerritsen
- a Department of Medical Oncology , Radboud University Medical Center , Nijmegen , The Netherlands
| | - I Jolanda M de Vries
- b Department of Tumor Immunology , Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen , The Netherlands
| | - Gerty Schreibelt
- b Department of Tumor Immunology , Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen , The Netherlands
| |
Collapse
|
37
|
Boudewijns S, Bol KF, Schreibelt G, Westdorp H, Textor JC, van Rossum MM, Scharenborg NM, de Boer AJ, van de Rakt MWMM, Pots JM, van Oorschot TGM, Duiveman-de Boer T, Olde Nordkamp MA, van Meeteren WSEC, van der Graaf WTA, Bonenkamp JJ, de Wilt JHW, Aarntzen EHJG, Punt CJA, Gerritsen WR, Figdor CG, de Vries IJM. Adjuvant dendritic cell vaccination induces tumor-specific immune responses in the majority of stage III melanoma patients. Oncoimmunology 2016; 5:e1191732. [PMID: 27622047 PMCID: PMC5006921 DOI: 10.1080/2162402x.2016.1191732] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/13/2016] [Accepted: 05/15/2016] [Indexed: 01/16/2023] Open
Abstract
Purpose: To determine the effectiveness of adjuvant dendritic cell (DC) vaccination to induce tumor-specific immunological responses in stage III melanoma patients. Experimental design: Retrospective analysis of stage III melanoma patients, vaccinated with autologous monocyte-derived DC loaded with tumor-associated antigens (TAA) gp100 and tyrosinase after radical lymph node dissection. Skin-test infiltrating lymphocytes (SKILs) obtained from delayed-type hypersensitivity skin-test biopsies were analyzed for the presence of TAA-specific CD8+ T cells by tetrameric MHC-peptide complexes and by functional TAA-specific T cell assays, defined by peptide-recognition (T2 cells) and/or tumor-recognition (BLM and/or MEL624) with specific production of Th1 cytokines and no Th2 cytokines. Results: Ninety-seven patients were analyzed: 21 with stage IIIA, 34 with stage IIIB, and 42 had stage IIIC disease. Tetramer-positive CD8+ T cells were present in 68 patients (70%), and 24 of them showed a response against all 3 epitopes tested (gp100:154–162, gp100:280–288, and tyrosinase:369–377) at any point during vaccinations. A functional T cell response was found in 62 patients (64%). Rates of peptide-recognition of gp100:154–162, gp100:280–288, and tyrosinase:369–377 were 40%, 29%, and 45%, respectively. Median recurrence-free survival and distant metastasis-free survival of the whole study population were 23.0 mo and 36.8 mo, respectively. Conclusions: DC vaccination induces a functional TAA-specific T cell response in the majority of stage III melanoma patients, indicating it is more effective in stage III than in stage IV melanoma patients. Furthermore, performing multiple cycles of vaccinations enhances the chance of a broader immune response.
Collapse
Affiliation(s)
- Steve Boudewijns
- Department of Medical Oncology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands; Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Kalijn F Bol
- Department of Medical Oncology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands; Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Gerty Schreibelt
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Harm Westdorp
- Department of Medical Oncology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands; Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Johannes C Textor
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Michelle M van Rossum
- Department of Dermatology, Radboud University Medical Center , Nijmegen, the Netherlands
| | - Nicole M Scharenborg
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Annemiek J de Boer
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Mandy W M M van de Rakt
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Jeanne M Pots
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Tom G M van Oorschot
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Tjitske Duiveman-de Boer
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - Michel A Olde Nordkamp
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | | | - Winette T A van der Graaf
- Department of Medical Oncology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands; The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Johannes J Bonenkamp
- Department of Surgical Oncology, Radboud University Medical Center , Nijmegen, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgical Oncology, Radboud University Medical Center , Nijmegen, the Netherlands
| | - Erik H J G Aarntzen
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center , Amsterdam, the Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, Radboud University Medical Center Nijmegen , Nijmegen, the Netherlands
| | - Carl G Figdor
- Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences , Nijmegen, the Netherlands
| | - I Jolanda M de Vries
- Department of Medical Oncology, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands; Department of Tumor Immunology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| |
Collapse
|
38
|
Sánchez A, Sotelo R, Rodriguez O, Sánchez R, Rosciano J, Medina L, Vegas L. Robot-assisted video endoscopic inguinal lymphadenectomy for melanoma. J Robot Surg 2016; 10:369-372. [PMID: 27173971 DOI: 10.1007/s11701-016-0599-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/26/2016] [Indexed: 11/24/2022]
Abstract
Inguinal lymphadenectomy is the indicated procedure in the regional lymph node management for patients with lower limb melanoma and positive nodes. This procedure is commonly associated with surgical site complications. Video endoscopic inguinal lymphadenectomy is a minimally invasive alternative with oncological principles and lower wound-related morbidity. Incorporation of robotic surgery with optimal vision and great maneuverability would offer great advantages. A 42-year-old male patient was diagnosed with acral lentiginous melanoma and palpable inguinal nodes T2 N1 M0. The patient was scheduled for robot-assisted left inguinal video endoscopic lymphadenectomy. The working space is created using blunt-finger dissection and then extended with the endoscope by sweeping with the lens. Two 8-mm robotic trocars and a 10-mm trocar for assistant are placed. The lymphadenectomy is carried out with Maryland and scissors. The operative time was 130 min, estimated blood loss 70 ml and hospital stay 2 days. The robot-assisted inguinal video endoscopic lymphadenectomy is a safe and feasible procedure for lower limb melanoma treatment. The incorporation of the robotic system to this approach where there is a limited working space would offer advantages to the technique.
Collapse
Affiliation(s)
- Alexis Sánchez
- Robotic Surgery Program, Medicine Faculty, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela
- Robotic and Minimally Invasive Surgery (UNIC), Caracas, Venezuela
| | - Rene Sotelo
- University of Southern California, Los Angeles, USA
| | - Omaira Rodriguez
- Robotic Surgery Program, Medicine Faculty, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela.
- Robotic and Minimally Invasive Surgery (UNIC), Caracas, Venezuela.
| | - Renata Sánchez
- Robotic Surgery Program, Medicine Faculty, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela
- Robotic and Minimally Invasive Surgery (UNIC), Caracas, Venezuela
| | - José Rosciano
- Robotic Surgery Program, Medicine Faculty, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela
| | - Luis Medina
- Robotic Surgery Program, Medicine Faculty, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela
| | - Liumariel Vegas
- Robotic Surgery Program, Medicine Faculty, University Hospital of Caracas, Central University of Venezuela, Caracas, Venezuela
| |
Collapse
|
39
|
Leiter U, Stadler R, Mauch C, Hohenberger W, Brockmeyer N, Berking C, Sunderkötter C, Kaatz M, Schulte KW, Lehmann P, Vogt T, Ulrich J, Herbst R, Gehring W, Simon JC, Keim U, Martus P, Garbe C. Complete lymph node dissection versus no dissection in patients with sentinel lymph node biopsy positive melanoma (DeCOG-SLT): a multicentre, randomised, phase 3 trial. Lancet Oncol 2016; 17:757-767. [PMID: 27161539 DOI: 10.1016/s1470-2045(16)00141-8] [Citation(s) in RCA: 465] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/01/2016] [Accepted: 02/18/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complete lymph node dissection is recommended in patients with positive sentinel lymph node biopsy results. To date, the effect of complete lymph node dissection on prognosis is controversial. In the DeCOG-SLT trial, we assessed whether complete lymph node dissection resulted in increased survival compared with observation. METHODS In this multicentre, randomised, phase 3 trial, we enrolled patients with cutaneous melanoma of the torso, arms, or legs from 41 German skin cancer centres. Patients with positive sentinel lymph node biopsy results were eligible. Patients were randomly assigned (1:1) to undergo complete lymph node dissection or observation with permuted blocks of variable size and stratified by primary tumour thickness, ulceration of primary tumour, and intended adjuvant interferon therapy. Treatment assignment was not masked. The primary endpoint was distant metastasis-free survival and analysed by intention to treat. All patients in the intention-to-treat population of the complete lymph node dissection group were included in the safety analysis. This trial is registered with ClinicalTrials.gov, number NCT02434107. Follow-up is ongoing, but the trial no longer recruiting patients. FINDINGS Between Jan 1, 2006, and Dec 1, 2014, 5547 patients were screened with sentinel lymph node biopsy and 1269 (23%) patients were positive for micrometastasis. Of these, 483 (39%) agreed to randomisation into the clinical trial; due to difficulties enrolling and a low event rate the trial closed early on Dec 1, 2014. 241 patients were randomly assigned to the observation group and 242 to the complete lymph node dissection group. Ten patients did not meet the inclusion criteria, so 233 patients were analysed in the observation group and 240 patients were analysed in the complete lymph node dissection group, as the intention-to-treat population. 311 (66%) patients (158 in the observation group and 153 in the dissection group) had sentinel lymph node metastases of 1 mm or less. Median follow-up was 35 months (IQR 20-54). Distant metastasis-free survival at 3 years was 77·0% (90% CI 71·9-82·1; 55 events) in the observation group and 74·9% (69·5-80·3; 54 events) in the complete lymph node dissection group. In the complete lymph node dissection group, grade 3 and 4 events occurred in 15 patients (6%) and 19 patients (8%) patients, respectively. Adverse events included lymph oedema (grade 3 in seven patients, grade 4 in 13 patients), lymph fistula (grade 3 in one patient, grade 4 in two patients), seroma (grade 3 in three patients, no grade 4), infection (grade 3 in three patients, no grade 4), and delayed wound healing (grade 3 in one patient, grade 4 in four patients); no serious adverse events were reported. INTERPRETATION Although we did not achieve the required number of events, leading to the trial being underpowered, our results showed no difference in survival in patients treated with complete lymph node dissection compared with observation only. Consequently, complete lymph node dissection should not be recommended in patients with melanoma with lymph node micrometastases of at least a diameter of 1 mm or smaller. FUNDING German Cancer Aid.
Collapse
Affiliation(s)
- Ulrike Leiter
- Centre for Dermatooncology, Department of Dermatology, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany.
| | - Rudolf Stadler
- Department of Dermatology, Medical Centre Minden, Minden, Germany
| | - Cornelia Mauch
- Department of Dermatology, University of Cologne, Cologne, Germany
| | | | | | - Carola Berking
- Department of Dermatology, Ludwig-Maximilians University of Munich, Munich, Germany
| | | | - Martin Kaatz
- Department of Dermatology, Gera and University of Jena, Jena, Germany
| | | | - Percy Lehmann
- Department of Dermatology, Medical Hospital, Wuppertal, Germany
| | - Thomas Vogt
- Department of Dermatology, Saarland University, Saarbrücken, Germany
| | - Jens Ulrich
- Department of Dermatology, University of Magdeburg, Magdeburg, Germany; Department of Dermatology, Medical Hospital of Quedlinburg, Quedlinburg, Germany
| | - Rudolf Herbst
- Department of Dermatology, Medical Hospital, Erfurt, Germany
| | | | | | - Ulrike Keim
- Centre for Dermatooncology, Department of Dermatology, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany
| | - Peter Martus
- Institute of Clinical Epidemiology and Applied Biostatistics, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany
| | - Claus Garbe
- Centre for Dermatooncology, Department of Dermatology, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany
| | | |
Collapse
|
40
|
Abstract
Although now commonplace in contemporary cancer care, the systematic approach to classification of disease-specific cancers into a formalized staging system is a relatively modern concept. Overall, the goals of cancer staging are to characterize the status of cancer at a specific moment in time, risk stratify, facilitate prognostication, and inform clinical decision making. The revisions to the American Joint Committee on Cancer (AJCC) melanoma staging system over time reflect changes in our understanding of the biology of the disease. Since the 1st edition, where tumor thickness was defined anatomically by its relationship to the reticular or papillary dermis (Clark level) as well as tumor thickness (Breslow thickness), there have been significant strides in our use of clinicopathological variables to stratify low- versus high-risk patients. Management of the regional nodal basin has also changed dramatically over time, impacted by techniques such as lymphatic mapping and sentinel lymph node biopsy (SLNB) and changes in pathological evaluation of the regional lymph nodes. Additionally, stratification of distant metastases has evolved as survival outcomes have been shown to vary based upon anatomic site of metastases and serum lactate dehydrogenase levels. The variables in use in the current (7th edition) AJCC staging system are surrogate markers of biology with validated impact of survival outcomes. Going forward, it is likely that these and additional clinicopathological factors will be integrated with molecular and other correlates of melanoma tumor biology to further refine and personalize melanoma staging.
Collapse
|
41
|
Holtkamp LHJ, Wang S, Wilmott JS, Madore J, Vilain R, Thompson JF, Nieweg OE, Scolyer RA. Detailed pathological examination of completion node dissection specimens and outcome in melanoma patients with minimal (<0.1 mm) sentinel lymph node metastases. Ann Surg Oncol 2015; 22:2972-7. [PMID: 25990968 DOI: 10.1245/s10434-015-4615-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nonsentinel lymph nodes (NSLNs) are rarely involved in patients with minimal volume melanoma metastases in sentinel lymph nodes (SLNs). Therefore, it has been suggested that completion lymph node dissection (CLND) is not required. However, the lack of routine immunohistochemical staining and multiple sectioning may have led to failure to identify additional positive nodes. The present study sought to more reliably determine the tumor status of NSLNs in patients with minimally involved SLNs and their clinical outcome. METHODS A total of 21 tumor-negative CLND specimens from 20 patients with SLN metastases of <0.1 mm in diameter treated between 1991 and 2013 were examined with a more detailed pathologic protocol (five new sections stained with/for H&E, S-100, HMB45, Melan-A, and H&E). Clinical follow-up data were also obtained. RESULTS Of the 343 examined NSLNs, 1 was found to harbor a 0.18-mm subcapsular sinus metastasis. No metastases were identified in the other NSLNs. Median follow-up was 48 months (range 17-130 months). Six patients (30 %) developed a recurrence. At the end of follow-up, 15 patients (75 %) were alive without sign of melanoma recurrence and 5 patients (25 %) had died of melanoma. Estimated 5-year melanoma-specific survival was 64 %. The patient with the additional positive NSLN remains without recurrence after 130 months follow-up. CONCLUSIONS Although the risk of additional nodal involvement is low, detailed pathologic examination may identify NSLN metastases not identified using routine protocols. Therefore, nodal clearance appears to be the safest option for these patients, pending the results of prospective trials.
Collapse
|
42
|
Sentinel lymph node biopsy for eyelid and conjunctival tumors: what is the evidence? Int Ophthalmol Clin 2015; 55:123-36. [PMID: 25436498 DOI: 10.1097/iio.0000000000000051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
43
|
Bol KF, Aarntzen EHJG, Hout FEMI', Schreibelt G, Creemers JHA, Lesterhuis WJ, Gerritsen WR, Grunhagen DJ, Verhoef C, Punt CJA, Bonenkamp JJ, de Wilt JHW, Figdor CG, de Vries IJM. Favorable overall survival in stage III melanoma patients after adjuvant dendritic cell vaccination. Oncoimmunology 2015; 5:e1057673. [PMID: 26942068 DOI: 10.1080/2162402x.2015.1057673] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 05/28/2015] [Accepted: 05/28/2015] [Indexed: 12/11/2022] Open
Abstract
Melanoma patients with regional metastatic disease are at high risk for recurrence and metastatic disease, despite radical lymph node dissection (RLND). We investigated the immunologic response and clinical outcome to adjuvant dendritic cell (DC) vaccination in melanoma patients with regional metastatic disease who underwent RLND with curative intent. In this retrospective study, 78 melanoma patients with regional lymph node metastasis who underwent RLND received autologous DCs loaded with gp100 and tyrosinase and were analyzed for functional tumor-specific T cell responses in skin-test infiltrating lymphocytes. The study shows that adjuvant DC vaccination in melanoma patients with regional lymph node metastasis is safe and induced functional tumor-specific T cell responses in 71% of the patients. The presence of functional tumor-specific T cells was correlated with a better 2-year overall survival (OS) rate. OS was significantly higher after adjuvant DC vaccination compared to 209 matched controls who underwent RLND without adjuvant DC vaccination, 63.6 mo vs. 31.0 mo (p = 0.018; hazard ratio 0.59; 95%CI 0.42-0.84). Five-year survival rate increased from 38% to 53% (p < 0.01). In summary, in melanoma patients with regional metastatic disease, who are at high risk for recurrence and metastatic disease after RLND, adjuvant DC vaccination is well tolerated. It induced functional tumor-specific immune responses in the majority of patients and these were related to clinical outcome. OS was significantly higher compared to matched controls. A randomized clinical trial is needed to prospectively validate the efficacy of DC vaccination in the adjuvant setting.
Collapse
Affiliation(s)
- Kalijn F Bol
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center; Nijmegen, The Netherlands; Department of Medical Oncology; Radboud University Medical Center; Nijmegen, The Netherlands
| | - Erik H J G Aarntzen
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center; Nijmegen, The Netherlands; Department of Medical Oncology; Radboud University Medical Center; Nijmegen, The Netherlands; Department of Radiology and Nuclear Medicine; Radboud University Medical Center; Nijmegen, The Netherlands
| | - Florentien E M In 't Hout
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center; Nijmegen, The Netherlands; Department of Surgical Oncology; Radboud University Medical Center; Nijmegen, The Netherlands
| | - Gerty Schreibelt
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center ; Nijmegen, The Netherlands
| | - Jeroen H A Creemers
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center ; Nijmegen, The Netherlands
| | - W Joost Lesterhuis
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center; Nijmegen, The Netherlands; Department of Medicine and Pharmacology; University of Western Australia; Crawley, Australia
| | - Winald R Gerritsen
- Department of Medical Oncology; Radboud University Medical Center ; Nijmegen, The Netherlands
| | - Dirk J Grunhagen
- Department Surgical Oncology; Erasmus MC Cancer Institute ; Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department Surgical Oncology; Erasmus MC Cancer Institute ; Rotterdam, The Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology; Academic Medical Center ; Amsterdam, The Netherlands
| | - Johannes J Bonenkamp
- Department of Surgical Oncology; Radboud University Medical Center ; Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgical Oncology; Radboud University Medical Center ; Nijmegen, The Netherlands
| | - Carl G Figdor
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center ; Nijmegen, The Netherlands
| | - I Jolanda M de Vries
- Department of Tumor Immunology; Radboud Institute for Molecular Life Sciences; Radboud University Medical Center; Nijmegen, The Netherlands; Department of Medical Oncology; Radboud University Medical Center; Nijmegen, The Netherlands
| |
Collapse
|
44
|
Yakymchuk OM, Perepelytsina OM, Dobrydnev AV, Sydorenko MV. Effect of single-walled carbon nanotubes on tumor cells viability and formation of multicellular tumor spheroids. NANOSCALE RESEARCH LETTERS 2015; 10:150. [PMID: 25852438 PMCID: PMC4385323 DOI: 10.1186/s11671-015-0858-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/11/2015] [Indexed: 05/31/2023]
Abstract
ABSTRACT This paper describes the impact of different concentrations of single-walled carbon nanotubes (SWCNTs) on cell viability of breast adenocarcinoma, MCF-7 line, and formation of multicellular tumor spheroids (MTS). Chemical composition and purity of nanotubes is controlled by Fourier transform infrared spectroscopy. The strength and direction of the influence of SWCNTs on the tumor cell population was assessed by cell counting and measurement of the volume of multicellular tumor spheroids. Effect of SWCNTs on the formation of multicellular spheroids was compared with the results obtained by culturing tumor cells with ultra dispersed diamonds (UDDs). Our results demonstrated that SWCNTs at concentrations ranging from 12.5 to 50 μg/ml did not have cytotoxic influence on tumor cells; instead, they had weak cytostatic effect. The increasing of SWCNTs concentration to 100 to 200 μg/ml stimulated proliferation of tumor cells, especially in suspension fractions. The result of this influence was in formation of more MTS in cell culture with SWCNTs compared with UDDs and control samples. In result, the median volume of MTS after cultivation with SWCNTs at 100 to 200 μg/ml concentrations is 3 to 5 times greater than that in samples which were incubated with the UDDs and is 2.5 times greater than that in control cultures. So, if SWCNTs reduced cell adhesion to substrate and stimulated formation of tumor cell aggregates volume near 7 · 10(-3) mm(3), at the same time, UDDs reduced adhesion and cohesive ability of cells and stimulated generation of cell spheroids volume no more than 4 · 10(-3) mm(3). Our results could be useful for the control of cell growth in three-dimensional culture. PACS 61. 46 + w; 61.48 + c; 61.48De; 87.15-v; 87.64-t.
Collapse
Affiliation(s)
- Olena M Yakymchuk
- />Department for Biotechnical Problems of Diagnostic, Institute for Problems of Cryobiology and Cryomedicine of NAS Ukraine, 42/1 Nauky str., 03028 Kiev, Ukraine
| | - Olena M Perepelytsina
- />Department for Biotechnical Problems of Diagnostic, Institute for Problems of Cryobiology and Cryomedicine of NAS Ukraine, 42/1 Nauky str., 03028 Kiev, Ukraine
| | - Alexey V Dobrydnev
- />Department of Chemistry, Taras Shevchenko’ National University of Kiev, 60 Volodymyrska str., 01033 Kiev, Ukraine
| | - Mychailo V Sydorenko
- />Department for Biotechnical Problems of Diagnostic, Institute for Problems of Cryobiology and Cryomedicine of NAS Ukraine, 42/1 Nauky str., 03028 Kiev, Ukraine
| |
Collapse
|
45
|
Campanholi LL, Duprat Neto JP, Fregnani JHTG. Evaluation of inter-rater reliability of subjective and objective criteria for diagnosis of lymphedema in upper and lower limbs. J Vasc Bras 2015. [DOI: 10.1590/1677-5449.20140037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: The diagnosis of lymphedema can be obtained objectively by measurement methods, and also by subjective methods, based on the patient's complaint. OBJECTIVE: To evaluate inter-rater reliability of objective and subjective criteria used for diagnosis of lymphedema and to propose a lymphedema cut-off for differences in volume between affected and control limbs. METHODS: We studied 84 patients who had undergone lymphadenectomy for treatment of cutaneous melanoma. Physical measures were obtained by manual perimetry (MP). The subjective criteria analyzed were clinical diagnosis of lymphedema in patients' medical records and self-report of feelings of heaviness and/or increase in volume in the affected limb. RESULTS: For upper limbs, the subjective criteria clinical observation (k 0.754, P<0.001) and heaviness and swelling (k 0.689, P<0.001) both exhibited strong agreement with MP results and there was moderate agreement between MP results and swelling (k 0.483 P<0.001), heaviness (k 0.576, P<0.001) and heaviness or swelling (k 0.412, P=0.001). For lower limbs there was moderate agreement between MP results and clinical observation (k 0.423, P=0.003) and regular agreement between MP and self-report of swelling (k 0.383, P=0.003). Cut-off values for diagnosing lymphedema were defined as a 9.7% difference between an affected upper limb and control upper limb and a 5.7% difference between lower limbs. CONCLUSION: Manual perimetry, medical criteria, and self-report of heaviness and/or swelling exhibited better agreement for upper limbs than for lower limbs for diagnosis of lymphedema.
Collapse
|
46
|
Bertheuil N, Sulpice L, Levi Sandri G, Lavoué V, Watier E, Meunier B. Inguinal lymphadenectomy for stage III melanoma: A comparative study of two surgical approaches at the onset of lymphoedema. Eur J Surg Oncol 2015; 41:215-9. [DOI: 10.1016/j.ejso.2014.10.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/26/2014] [Accepted: 10/24/2014] [Indexed: 11/28/2022] Open
|
47
|
Perepelytsina O, Gergeliuk T, Sydorenko M. Effects of T-lymphocytes and interferon-γ on different stages of development of multicellular tumor spheroids in vitro. CYTOL GENET+ 2014. [DOI: 10.3103/s0095452714050065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
48
|
Stuiver M, Westerduin E, ter Meulen S, Vincent A, Nieweg O, Wouters M. Surgical wound complications after groin dissection in melanoma patients – A historical cohort study and risk factor analysis. Eur J Surg Oncol 2014; 40:1284-90. [DOI: 10.1016/j.ejso.2014.01.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 12/30/2013] [Accepted: 01/27/2014] [Indexed: 11/26/2022] Open
|
49
|
|
50
|
Niebling MG, Wevers KP, Hoekstra HJ. The prognostic significance ofBRAFmutation status in stage IIIB–C melanoma. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.12.80] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|