1
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Sun J, Wang M, Kan Z. Diagnostic and prognostic risk factors analysis for distant metastasis in melanoma: a population-based study. Eur J Cancer Prev 2024; 33:461-474. [PMID: 38251671 DOI: 10.1097/cej.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND We aimed to develop tools that could predict the occurrence of distant metastases in melanoma and its prognosis based on clinical and pathological characteristics. MATERIALS AND METHODS We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database of melanoma patients diagnosed between 2010 and 2019. Logistic analyses were performed to identify independent risk factors associated with distant metastasis. Additionally, multivariate Cox analyses were conducted to determine independent prognostic factors for patients with distant metastasis. Two nomograms were established and evaluated with the receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Furthermore, we performed a retrospective analysis of melanoma with distant metastasis from our institute between March 2018 and June 2022. RESULTS Of the total 19 396 melanoma patients, 352 (1.8%) had distant metastases at the time of diagnosis. The following clinical and pathological characteristics were identified as independent risk factors for distant metastasis in melanoma: N stage, tumor size, ulceration, mitosis, primary tumor site, and pathological subtype. Furthermore, tumor size, pathological subtype, and radiotherapy were identified as independent prognostic factors. The results of the training and validation cohorts' ROC curves, calibration, DCA, and Kaplan-Meier survival curves demonstrate the effectiveness of the two nomograms. The retrospective study results from our center supported the results from the SEER database. CONCLUSION The clinical and pathological characteristics of melanoma can predict a patient's risk of metastasis and prognosis, and the two nomograms are expected to be effective tools to guide therapy decisions.
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Affiliation(s)
- Junwei Sun
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Mingyu Wang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Zhisheng Kan
- Department of Neurosurgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College
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2
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Guadagnolo BA, Baldini EH. Are We Ready for Life in the Fast Lane? A Critical Review of Preoperative Hypofractionated Radiotherapy for Localized Soft Tissue Sarcoma. Semin Radiat Oncol 2024; 34:180-194. [PMID: 38508783 DOI: 10.1016/j.semradonc.2023.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
This critical review aims to summarize the relevant published data regarding hypofractionation regimens for preoperative radiation therapy (RT) prior to surgery for soft tissue sarcoma (STS) of the extremity or superficial trunk. We identified peer-reviewed publications using a PubMed search on the MeSH headings of "soft tissue sarcoma" AND "hypofractionated radiation therapy." To obtain complication data on similar anatomical radiotherapeutic scenarios we also searched "hypofractionated radiation therapy" AND "melanoma" as well as "hypofractionated radiation therapy" AND "breast cancer." We then used reference lists from relevant articles to obtain additional pertinent publications. We also incorporated relevant abstracts presented at international sarcoma meetings and relevant clinical trials as listed on the ClinicalTrials.gov website. Detailed data are presented and contextualized for ultra-hypofractionated and moderately hypofractionated regimens with respect to local control, wound complications, and amputation rates. Comparative data are also presented for late toxicities including: fibrosis, joint limitation, edema, skin integrity, and bone fracture or necrosis. These data are compared to a standard regimen of 50 Gy in 25 daily fractions delivered over 5 weeks. This analysis supports the continued use of a standard regimen for preoperative RT for STS of 25 × 2 Gy over 5 weeks without concurrent chemotherapy. Use of concurrent chemotherapy with preoperative RT for STS should be reserved for well-designed clinical trials. A randomized trial of ultra-hypofractionated and moderately hypofractionated pre op RT for STS is warranted, but it is critical for the primary endpoint (or co-primary endpoint) to be late toxicity to: bone, soft tissue, joint, and skin.
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Affiliation(s)
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Dana Farber/Brigham Women's Hospital, Boston, MA
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3
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Holtkamp LHJ, Lo SN, Thompson JF, Spillane AJ, Stretch JR, Saw RPM, Shannon KF, Nieweg OE, Hong AM. Adjuvant radiotherapy after salvage surgery for melanoma recurrence in a node field following a previous lymph node dissection. J Surg Oncol 2023; 128:97-104. [PMID: 36971691 PMCID: PMC10952220 DOI: 10.1002/jso.27245] [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: 08/29/2022] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Adjuvant radiotherapy (RT) can be given to melanoma patients following salvage surgery for node field recurrence after a previous regional node dissection, but the value of this treatment strategy is poorly documented. This study evaluated long-term node field control and survival of patients treated in this way in an era before effective adjuvant systemic therapy became available. METHODS Data for 76 patients treated between 1990 and 2011 were extracted from an institutional database. Baseline patient characteristics, treatment details and oncological outcomes were analysed. RESULTS Adjuvant RT with conventional fractionation (median dose 48 Gy in 20 fractions) was given to 43 patients (57%) and hypofractionated RT (median dose 33 Gy in 6 fractions) to 33 patients (43%). The 5-year node field control rate was 70%, 5-year recurrence-free survival 17%, 5-year melanoma-specific survival 26% and 5-year overall survival 25%. CONCLUSIONS Salvage surgery with adjuvant RT achieved node field control in 70% of melanoma patients with node field recurrence following a prior node dissection. However, disease progression at distant sites was common and survival outcomes were poor. Prospective data will be required to assess outcomes for contemporary combinations of surgery, adjuvant RT and systemic therapy.
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Affiliation(s)
- Lodewijka H. J. Holtkamp
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Department of Surgical OncologyUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Serigne N. Lo
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - John F. Thompson
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Melanoma and Surgical OncologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Andrew J. Spillane
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of SurgeryRoyal North Shore HospitalSydneyNew South WalesAustralia
| | - Jonathan R. Stretch
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Melanoma and Surgical OncologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Robyn P. M. Saw
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Melanoma and Surgical OncologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Kerwin F. Shannon
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Melanoma and Surgical OncologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Omgo E. Nieweg
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Melanoma and Surgical OncologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Angela M. Hong
- Melanoma Institute AustraliaThe University of SydneyNorth SydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of Radiation OncologyChris O'Brien LifehouseSydneyNew South WalesAustralia
- GenesisCare Radiation OncologyMater HospitalSydneyNew South WalesAustralia
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4
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Holtkamp LHJ, Lo S, Drummond M, Thompson JF, Nieweg OE, Hong AM. Hypofractionated or Conventionally Fractionated Adjuvant Radiotherapy After Regional Lymph Node Dissection for High-Risk Stage III Melanoma. Clin Oncol (R Coll Radiol) 2023; 35:e85-e93. [PMID: 35851490 DOI: 10.1016/j.clon.2022.06.012] [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: 11/22/2021] [Revised: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/04/2023]
Abstract
AIMS Adjuvant radiotherapy can be beneficial after regional lymph node dissection for high-risk stage III melanoma, as it has been shown to reduce the risk of recurrence in the node field. However, the optimal fractionation schedule is unknown and both hypofractionated and conventionally fractionated adjuvant radiotherapy are used. The present study examined the oncological outcomes of these two approaches in patients treated in an era before effective systemic immunotherapy became available. MATERIALS AND METHODS This retrospective cohort study involved 335 patients with stage III melanoma who received adjuvant radiotherapy after therapeutic regional lymph node dissection for metastatic melanoma between 1990 and 2011. Information on tumour characteristics, radiotherapy doses and fractionation schedules and patient outcomes was retrieved from the institution's database and patients' medical records. RESULTS Hypofractionated radiotherapy (median dose 33 Gy in six fractions over 3 weeks) was given to 95 patients (28%) and conventionally fractionated radiotherapy (median dose 48 Gy in 20 fractions over 4 weeks) to 240 patients (72%). Five-year lymph node field control rates were 86.0% (95% confidence interval 78.4-94.4%) for the hypofractionated group and 85.5% (95% confidence interval 80.5-90.7%) for the conventional fractionation group (P = 0.87). There were no significant differences in recurrence-free survival (RFS) (41.7%, 95% confidence interval 32.5-53.5 versus 31.9%, 95% confidence interval 26.1-38.9; P = 0.18) or overall survival (41.2%, 95% confidence interval 32.1-52.8 versus 45.0%, 95% confidence interval 38.7-52.4; P = 0.77). On multivariate analysis, extranodal spread was associated with decreased RFS (P = 0.04) and the number of resected lymph nodes containing metastatic melanoma was associated with decreased RFS (P = 0.0006) and overall survival (P = 0.01). CONCLUSION Lymph node field control rates, RFS and overall survival were similar after hypofractionated and conventionally fractionated adjuvant radiotherapy. The presence of extranodal spread and an increasing number of positive lymph nodes were predictive of an unfavourable outcome.
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Affiliation(s)
- L H J Holtkamp
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Department of Surgical Oncology, University Medical Centre Groningen, Groningen, the Netherlands.
| | - S Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - M Drummond
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - J F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - O E Nieweg
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - A M Hong
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia; GenesisCare, Radiation Oncology, Mater Sydney Hospital, Sydney, NSW, Australia
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5
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Glaun MDE, Feng Z, Lango M. Management of Regional Lymph Nodes in Head and Neck Melanoma. Oral Maxillofac Surg Clin North Am 2022; 34:273-281. [PMID: 35400571 DOI: 10.1016/j.coms.2021.11.001] [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] [Indexed: 11/21/2022]
Abstract
The utilization of sentinel lymph node (SLN) biopsy has transformed the workup and staging of intermediate-thickness cutaneous melanomas. SLN biopsy, performed at the time of primary tumor excision, accurately maps lymph nodes at risk of harboring occult metastatic deposits from head and neck cutaneous melanomas and represents the current standard of care. Completion lymphadenectomy identifies additional tumor in 12% to 24% of SLN biopsy positive cases but does not affect melanoma-specific survival.
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Affiliation(s)
- Mica D E Glaun
- Department of Otolaryngology, Baylor College of Medicine, 1977 Butler Boulevard, Suite E5.200, Houston, TX 77030, USA; Department of Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Zipei Feng
- Department of Otolaryngology, Baylor College of Medicine, 1977 Butler Boulevard, Suite E5.200, Houston, TX 77030, USA; Department of Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Miriam Lango
- Department of Head and Neck Surgery, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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6
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Dabestani PJ, Dawson AJ, Neumeister MW, Bradbury CM. Radiation Therapy for Local Cutaneous Melanoma. Clin Plast Surg 2021; 48:643-649. [PMID: 34503724 DOI: 10.1016/j.cps.2021.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While primary treatment for melanoma consists of surgical resection and chemotherapeutics, radiation can be used as either definitive or adjuvant therapy in certain clinical scenarios. This chapter aims to explore the indications for primary definitive radiotherapy as well as adjuvant treatment following resection. Delivery, dose, fractionation, and toxicity of radiation treatment will be discussed. As our understanding of melanoma tumor biology increases, the role of radiotherapy may expand for more effective treatment of oligometastatic disease.
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Affiliation(s)
- Parinaz J Dabestani
- Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | | | - Michael W Neumeister
- Southern Illinois University School of Medicine, Institute for Plastic Surgery, 747 N. Rutledge St #3, Springfield, IL 62702, USA
| | - C Matthew Bradbury
- Springfield Clinic Cancer Center and Southern Illinois University School of Medicine, 900 N. 1st Street, Springfield, IL 62702, USA
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7
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Sezen D, Patel RR, Tang C, Onstad M, Nagarajan P, Patel SP, Welsh JW, Lin LL. Immunotherapy combined with high- and low-dose radiation to all sites leads to complete clearance of disease in a patient with metastatic vaginal melanoma. Gynecol Oncol 2021; 161:645-652. [PMID: 33795130 DOI: 10.1016/j.ygyno.2021.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 73-year-old woman with metastatic vaginal mucosal melanoma that had progressed on ipilimumab and nivolumab experienced clinical and radiographic complete response to dual checkpoint inhibitor immunotherapy given in combination with high-dose plus low-dose radiation. General characteristics and treatment options in this disease are highlighted.
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Affiliation(s)
- Duygu Sezen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, Koc University School of Medicine, Istanbul, Turkey
| | - Roshal R Patel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Albany Medical College, Albany, NY, USA
| | - Christine Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA
| | - Michaela Onstad
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priyadharsini Nagarajan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sapna P Patel
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James W Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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8
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Keung EZ, Gershenwald JE. Clinicopathological Features, Staging, and Current Approaches to Treatment in High-Risk Resectable Melanoma. J Natl Cancer Inst 2020; 112:875-885. [PMID: 32061122 PMCID: PMC7492771 DOI: 10.1093/jnci/djaa012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/06/2019] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
The incidence of melanoma in the United States has been increasing over the past several decades. Prognosis largely depends on disease stage, with 5-year melanoma-specific survival ranging from as high as 99% in patients with stage I disease to less than 10% for some patients with stage IV (distant metastatic) disease. Fortunately, in the last 5-10 years, there have been remarkable treatment advances for patients with high-risk resectable melanoma, including approval of targeted and immune checkpoint blockade therapies. In addition, results of recent clinical trials have confirmed the importance of sentinel lymph node biopsy and continue to refine the approach to regional lymph node basin management. Lastly, the melanoma staging system was revised in the eighth edition AJCC Cancer Staging Manual, which was implemented on January 1, 2018. Here we discuss these changes and the clinicopathological features that confer high risk for locoregional and distant disease relapse and poor survival. Implications regarding the management of melanoma in the metastatic and adjuvant settings are discussed, as are future directions for neoadjuvant therapies.
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Affiliation(s)
- Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Melanoma and Skin Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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9
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Goepfert RP, Myers JN, Gershenwald JE. Updates in the evidence-based management of cutaneous melanoma. Head Neck 2020; 42:3396-3404. [PMID: 33463835 DOI: 10.1002/hed.26398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 06/02/2020] [Accepted: 07/14/2020] [Indexed: 11/11/2022] Open
Abstract
Treatment of cutaneous melanoma is changing with significant developments over the past several years that promise to reshape the field of melanoma surgical oncology. Modifications to the staging system based on analysis of a large international dataset, the timing and extent of regional lymphadenectomy, the emergence of effective systemic therapies in the neoadjuvant and adjuvant setting, and the role of adjuvant radiation are all undergoing a data-driven evolution. Surgeon engagement in multidisciplinary decision making remains an essential component of contemporary management for patients across all stages of melanoma and demands specific involvement of head and neck surgical oncologists.
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Affiliation(s)
- Ryan P Goepfert
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Abstract
OPINION STATEMENT With greater understanding of underlying biology and development of effective BRAF-targeted therapy and immunotherapy, along with remarkable advances in local treatment such as stereotactic radiosurgery, melanoma brain metastasis (MBM) is witnessing continually improving outcome, with 1-year overall survival rate approaching 85%. Given disease complexity and myriad treatment options, all patients with MBM should ideally be evaluated in a multidisciplinary setting to allow an individualized treatment approach based on prognostic groups, molecular classification, number and size of brain metastasis, and performance status. With improving outcome, pendulum has now swayed to focus more on effective treatment modalities with minimal neurological toxicity while maintaining quality of life. Surgery is usually considered in symptomatic and large MBMs, while stereotactic radiosurgery considered in 1-4 lesions, and now also being explored for up to 15 brain metastases for improved local control. The role of whole brain radiotherapy is diminishing given its neurocognitive toxicities and is reserved for patients with diffuse brain involvement. Cytotoxic chemotherapy has largely been ineffective without evidence for survival benefit. Immune checkpoint inhibitors have become the cornerstone of management for melanoma brain metastasis with durable intracranial tumor control and excellent toxicity profile. For patients with asymptomatic MBMs, ipilimumab and nivolumab have shown intracranial response near 60% and provides comparable clinical benefit in MBMs as for extracranial metastases. For patients with driver BRAF mutation, BRAFi-/MEKi-targeted agents are proven to be effective in MBM with high rate intracranial responses (44-59%). However, the durability of intracranial responses induced by BRAFi/MEKi seems to be shorter than that of extracranial disease. Emerging data support novel combination of systemic therapy and stereotactic radiosurgery, which appears to be safe and effective; however, potential benefits and risks should be evaluated prospectively. Promising ongoing trials will further expand therapeutic evidence in MBM, and patients should be encouraged to participate in clinical trials.
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Affiliation(s)
- Anupam Rishi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA
| | - Hsiang-Hsuan Michael Yu
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA.
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11
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Read RL, Thompson JF. Managing in-transit melanoma metastases in the new era of effective systemic therapies for melanoma. Expert Rev Clin Pharmacol 2019; 12:1107-1119. [DOI: 10.1080/17512433.2019.1689121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Rebecca L Read
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Department of General Surgery, Calvary Health Care, Canberra, Australia
- School of Medicine, Australian National University, Canberra, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia
- Discipline of Surgery, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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12
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Alshedoukhy A, Cahusac P, Kashir J, Alkhawaja FH, Tulbah AMM, Anwar K. A retrospective study of malignant melanoma from a tertiary care centre in Saudi Arabia from 2004 to 2016. Clin Transl Oncol 2019; 22:663-669. [PMID: 31256363 DOI: 10.1007/s12094-019-02169-w] [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: 03/14/2019] [Accepted: 06/19/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Malignant melanoma is a well-known and commonly lethal tumour yet there exists scarce published information available from Saudi Arabia. MATERIALS AND METHODS This study examined the demographic, clinical, and histopathological profile of melanoma in a sample of Saudi patients over a period of 13 years. Medical records of 98 patients from 2004 to 2016 were retrieved from the Department of Pathology and Laboratory Medicine at King Faisal Specialist Hospital (KFSH), Riyadh, Saudi Arabia. RESULTS Forty two males and fifty six females (median age of 58 years) were analysed. Most cases were diagnosed in patients aged 50 years or above. The most common sites of occurrence were the extremities, especially the feet, followed by the head and neck, and then mucosal regions. Most mucosal melanomas were located in the mouth. The most common histopathological form was nodular melanoma (38 cases) followed by acral lentiginous melanoma (27 cases). Most of the cases were diagnosed in late diagnostic stages III and IV (59 cases) and most had higher Clark's level and stage V Breslow thickness. The cases with preceding history of xeroderma pigmentosum and dysplastic nevi tended to be diagnosed earlier. The most common mode of treatment was surgical resection. Patients on palliative treatment were older. Only 27/40 patients were confirmed to be alive and the rest were lost to follow-up. CONCLUSION Our data contrast with previously published studies from other parts of the world. Further work is needed to confirm our findings of female preponderance, common histological subtypes of nodular and acral melanomas, and the high involvement of oral mucosa in our Saudi patients.
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Affiliation(s)
- A Alshedoukhy
- Department of Pathology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - P Cahusac
- Department of Pharmacology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Department of Comparative Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - J Kashir
- Department of Comparative Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Anatomy, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,School of Biosciences, Cardiff University, Cardiff, UK
| | - F H Alkhawaja
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - A M M Tulbah
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - K Anwar
- Department of Pathology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
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13
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The influence of postoperative lymph node radiation therapy on overall survival of patients with stage III melanoma, a National Cancer Database analysis. Melanoma Res 2018; 26:595-603. [PMID: 27575390 DOI: 10.1097/cmr.0000000000000292] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recently, TROG 02.01 results showed that in stage III melanoma patients with nodal metastasis, adjuvant radiation to lymph node basin after nodal dissection improves lymph node field relapse without an overall survival (OS) benefit. However, this trial was neither designed nor powered to detect an OS difference. In the present study, we analyzed patients in the National Cancer Database (NCDB) with stage III melanoma with pathologically involved nodes and compared survival outcomes of adjuvant radiation and no-radiation cohorts. Inclusion criteria were as follows: age at least 18 years; diagnosed 2003-2011; surgery to regional lymph nodes; pathologically involved lymph nodes; and American Joint Committee on Cancer stage (IIIA-C). We used propensity score matching analysis to compare the OS of patients with similar baseline demographic, clinical, and pathologic characteristics who received adjuvant radiation and no adjuvant radiation. Overall, 912 patients were analyzed with an average age at diagnosis of 54.4 years and a median follow-up time of 5.5 years. In this cohort, the 5-year OS was 69.0, 51.1, and 30.6% for stage IIIA, IIIB, and IIIC, respectively. On propensity score-adjusted multivariate analysis, we found that adjuvant radiation had no statistically significant impact on OS (hazard ratio: 1.09, 95% confidence interval: 0.75-1.58, P=0.640). Furthermore, age older than 60 years, number of nodes, increasing pathologic stage, and absence of immunotherapy correlated with worse OS. In this NCDB analysis, we found that the adjuvant radiotherapy for node-positive, stage III melanoma patients did not improve OS. This is consistent with TROG 02.01; however, there may be patient selection bias not accounted for by the NCDB.
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14
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Kan CE, Mansur DB. The role of radiation therapy in the management of cutaneous melanoma. Melanoma Manag 2016; 3:61-72. [PMID: 30190873 DOI: 10.2217/mmt.15.41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/06/2015] [Indexed: 02/05/2023] Open
Abstract
The local treatment of cutaneous melanoma with surgical excision is well-established; however, the role of adjuvant radiation is not well-defined. Characteristics of the primary melanoma can indicate a higher local recurrence risk and thus warrant consideration of adjuvant treatment to the primary site. Management of the lymph node regions has been studied in some recent clinical trials, especially with the advent of sentinel lymph node procedures. We will review the indications for radiation to the primary site as well as lymph node regions based on the available data.
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Affiliation(s)
- Charlene E Kan
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, University Hospitals, Seidman Cancer Center, 11100 Euclid Avenue, Lerner Tower B-141, Cleveland, OH 44106, USA
| | - David B Mansur
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, University Hospitals, Seidman Cancer Center, 11100 Euclid Avenue, Lerner Tower B-141, Cleveland, OH 44106, USA
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Yu LJ, Wall BA, Wangari-Talbot J, Chen S. Metabotropic glutamate receptors in cancer. Neuropharmacology 2016; 115:193-202. [PMID: 26896755 DOI: 10.1016/j.neuropharm.2016.02.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 01/31/2023]
Abstract
Metabotropic glutamate receptors (mGluRs) are widely known for their roles in synaptic signaling. However, accumulating evidence suggests roles of mGluRs in human malignancies in addition to synaptic transmission. Somatic cell homeostasis presents intriguing possibilities of mGluRs and glutamate signaling as novel targets for human cancers. More recently, aberrant glutamate signaling has been shown to participate in the transformation and maintenance of various cancer types, including glioma, melanoma skin cancer, breast cancer, and prostate cancer, indicating that genes encoding mGluRs, GRMs, can function as oncogenes. Here, we provide a review on the interactions of mGluRs and their ligand, glutamate, in processes that promote the growth of tumors of neuronal and non-neuronal origins. Further, we discuss the evolution of riluzole, a glutamate release inhibitor approved for amyotrophic lateral sclerosis (ALS), but now fashioned as an mGluR1 inhibitor for melanoma therapy and as a radio-sensitizer for tumors that have metastasized to the brain. With the success of riluzole, it is not far-fetched to believe that other drugs that may act directly or indirectly on other mGluRs can be beneficial for multiple applications. This article is part of the Special Issue entitled 'Metabotropic Glutamate Receptors, 5 years on'.
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Affiliation(s)
- Lumeng J Yu
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University, NJ, USA
| | - Brian A Wall
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University, NJ, USA; Global Product Safety, Colgate-Palmolive Company, Piscataway, NJ, USA
| | - Janet Wangari-Talbot
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University, NJ, USA
| | - Suzie Chen
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University, NJ, USA; The Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08903, USA.
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Abstract
The discovery of the BRAFV600 mutation and the development of targeted therapies directed against this mutation as well as effective immunotherapies with durable benefits have revolutionized the treatment of patients with melanoma. Nonetheless, the frequent occurrence of brain metastases in patients with advanced melanoma represents a significant obstacle to long-term, high quality survival. The application of stereotactic radiation therapy has provided an opportunity to control brain metastases in the majority of patients with metastatic melanoma reducing the impact of these lesions on morbidity and mortality and enabling patients to receive and potentially benefit from these novel systemic treatments. Encouragingly, several of these novel new therapies have shown antitumor activity against CNS metastases that approach that seen against extracranial disease. As a consequence, several effective treatment options are now available for patients with melanoma brain metastases. With these tools in hand, it is anticipated that further investigation into the optimal sequence and/or combination of systemic therapies and local therapies along with multidisciplinary team practice will continue to improve the outcome of patients with this previously life-limiting disease complication.
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Affiliation(s)
- Sekwon Jang
- Georgetown Lombardi Comprehensive Cancer Center, Washington, D.C., USA
| | - Michael B Atkins
- Georgetown Lombardi Comprehensive Cancer Center, Washington, D.C., USA.
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Henderson MA, Burmeister BH, Ainslie J, Fisher R, Di Iulio J, Smithers BM, Hong A, Shannon K, Scolyer RA, Carruthers S, Coventry BJ, Babington S, Duprat J, Hoekstra HJ, Thompson JF. Adjuvant lymph-node field radiotherapy versus observation only in patients with melanoma at high risk of further lymph-node field relapse after lymphadenectomy (ANZMTG 01.02/TROG 02.01): 6-year follow-up of a phase 3, randomised controlled trial. Lancet Oncol 2015. [PMID: 26206146 DOI: 10.1016/s1470-2045(15)00187-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Adjuvant radiotherapy is recommended for patients with melanoma after lymphadenectomy. We previously showed this treatment reduced risk of repeat lymph-node field cancer in patients with a high risk of recurrence but had no effect on overall survival. Here, we aim to update the relapse and survival data from that trial and assess quality of life and toxic effects. METHODS In the ANZMTG 01.02/TROG 02.01 randomised controlled trial, we enrolled patients who had undergone lymphadenectomy for a palpable lymph-node field relapse and were at high risk of recurrence at 16 hospitals (11 in Australia, three in New Zealand, one in Netherlands, and one in Brazil). We randomly assigned patients (1:1) to adjuvant radiotherapy (48 Gy in 20 fractions, given over a maximum of 30 days) or observation, stratified by institution, areas of lymph-node field (parotid and cervical, axilla, or groin), number of involved nodes (≤3 vs >3), maximum involved node diameter (≤4 cm vs >4 cm), and extent of extracapsular extension (none, limited, or extensive). Participants, those giving treatment, and those assessing outcomes were not masked to treatment allocation, but participants were unaware of each other's treatment allocation. In this follow-up, we assessed outcomes every 3 months from randomisation for the first 2 years, then every 6 months up to 5 years, then annually. The primary endpoint was lymph-node field relapse as a first relapse, assessed in patients without major eligibility infringements (determined by an independent data monitoring committee). We assessed late adverse effects (occurring >90 days after surgery or start of radiotherapy) with standard criteria in the as-treated population. This study is registered with ClinicalTrials.gov, number NCT00287196. FINDINGS Between March 21, 2003, and Nov 15, 2007, we randomly assigned 123 patients to adjuvant radiotherapy (109 eligible for efficacy assessments) and 127 to observation (108 eligible). The final follow-up date was Nov 15, 2011. Median follow-up was 73 months (IQR 61-91). 23 (21%) relapses occurred in the adjuvant radiotherapy group compared with 39 (36%) in the observation group (adjusted hazard ratio [HR] 0·52 [95% CI 0·31-0·88], p=0·023). Overall survival (HR 1·27 [95% CI 0·89-1·79], p=0·21) and relapse-free survival (0·89 [0·65-1·22], p=0·51) did not differ between groups. Minor, long-term toxic effects from radiotherapy (predominantly pain, and fibrosis of the skin or subcutaneous tissue) were common, and 20 (22%) of 90 patients receiving adjuvant radiotherapy developed grade 3-4 toxic effects. 18 (20%) of 90 patients had grade 3 toxic effects, mainly affecting skin (nine [10%] patients) and subcutaneous tissue (six [7%] patients). Over 5 years, a significant increase in lower limb volumes was noted after adjuvant radiotherapy (mean volume ratio 15·0%) compared with observation (7·7%; difference 7·3% [95% CI 1·5-13·1], p=0·014). No significant differences in upper limb volume were noted between groups. INTERPRETATION Long-term follow-up supports our previous findings. Adjuvant radiotherapy could be useful for patients for whom lymph-node field control is a major issue, but entry to an adjuvant systemic therapy trial might be a preferable first option. Alternatively, observation, reserving surgery and radiotherapy for a further recurrence, might be an acceptable strategy. FUNDING National Health and Medical Research Council of Australia, Cancer Council Australia, Melanoma Institute Australia, and the Cancer Council South Australia.
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Affiliation(s)
- Michael A Henderson
- Division of Cancer Surgery, University of Melbourne Department of Surgery, East Melbourne, VIC, Australia; University of Melbourne, East Melbourne, VIC, Australia.
| | - Bryan H Burmeister
- Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Jill Ainslie
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Richard Fisher
- Centre for Biostatistics and Clinical Trials, East Melbourne, VIC, Australia
| | - Juliana Di Iulio
- Centre for Biostatistics and Clinical Trials, East Melbourne, VIC, Australia
| | - B Mark Smithers
- Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Angela Hong
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
| | - Kerwin Shannon
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
| | - Scott Carruthers
- Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Brendon J Coventry
- Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | | | | | | | - John F Thompson
- Melanoma Institute of Australia, University of Sydney, Sydney, NSW, Australia
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Yu LJ, Wall BA, Chen S. The current management of brain metastasis in melanoma: a focus on riluzole. Expert Rev Neurother 2015; 15:779-92. [PMID: 26092602 DOI: 10.1586/14737175.2015.1055321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Brain metastasis is a common endpoint in human malignant melanoma, and the prognosis for patients remains poor despite advancements in therapy. Current treatment for melanoma metastatic to the brain is grouped into those providing symptomatic relief such as corticosteroids and antiepileptic agents, to those that are disease modifying. Related to the latter group, recent studies have demonstrated that aberrant glutamate signaling plays a role in the transformation and maintenance of various cancer types, including melanoma. Glutamate secretion from these and surrounding cells have been found to stimulate regulatory pathways that control tumor growth, proliferation and survival in vitro and in vivo. The antiglutamatergic actions of an inhibitor of glutamate release, riluzole, have been detected by its ability to clear glutamate from the synapse, and it has been shown to inhibit glutamate release rather than directly inhibiting glutamate receptors. Preclinical studies have demonstrated the ability of riluzole to act as a radiosensitizing agent in melanoma. The effect of riluzole on downstream glutamatergic signaling has pointed to cross talk between the metabotropic G-protein-coupled glutamate receptors implicated in a subset of human melanomas with other signaling pathways, including apoptotic, angiogenic, ROS and cell invasion mechanisms, thus establishing its potential to be further explored in combination therapy regimens for both primary human melanoma and melanoma metastatic to the brain.
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Affiliation(s)
- Lumeng J Yu
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers, the State University, Piscataway, NJ, 08854, USA
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Abstract
Adjuvant therapy targets melanoma micrometastases in patients with surgically resected disease that carry a high risk of death from melanoma recurrence. In this setting, adjuvant therapy provides the greatest opportunity for cure before progression into advanced inoperable stages. In randomized clinical trials, interferon-alfa has been shown to have a significant impact on relapse-free survival and, at high dosage, on overall survival compared with observation (E1684) and the GMK vaccine (E1694). This article reviews melanoma adjuvant therapy along with the ongoing and planned clinical trials.
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Affiliation(s)
- Ahmad A Tarhini
- Department of Medicine, Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, UPMC Cancer Pavilion, 5150 Centre Avenue (555), Pittsburgh, PA 15232, USA.
| | - Prashanth M Thalanayar
- Department of Internal Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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Wall BA, Yu LJ, Khan A, Haffty B, Goydos JS, Chen S. Riluzole is a radio-sensitizing agent in an in vivo model of brain metastasis derived from GRM1 expressing human melanoma cells. Pigment Cell Melanoma Res 2014; 28:105-9. [PMID: 25363352 DOI: 10.1111/pcmr.12327] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/29/2014] [Indexed: 11/29/2022]
Abstract
Approximately 50% of patients having metastatic melanoma develop brain metastases during the course of their illness. Evidence exists that melanoma cells have increased aptitude for the repair of sublethal DNA damage caused by ionizing radiation therapy. To address the radio-resistance of melanoma, many groups adopted radiotherapy schedules that deliver larger daily fractions of radiation, but due to the risk of neurotoxicity, these large fractions cannot be delivered to the whole brain for patients with brain metastases. Here, we used orthotopic implanted GRM1 expressing human melanoma cell xenografts in mice, to demonstrate that animals receiving concurrent glutamate signaling blockade (riluzole) and radiation led to a decrease in intracranial tumor growth compared to either modality alone. These preclinical results suggest riluzole may cause radio-sensitization that offers enhanced efficacy for a subset of human melanoma patients undergoing radiotherapy for brain metastasis.
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Affiliation(s)
- Brian A Wall
- Susan Lehman Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers, The State University, Piscataway, NJ, USA; Joint Graduate Program of Toxicology and Pharmacology, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
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Abstract
Although melanoma was historically thought to be radiation resistant, there are limited data to support the use of adjuvant radiation therapy for certain situations at increased risk for locoregional recurrence. High-risk primary tumor features include thickness, ulceration, certain anatomic locations, satellitosis, desmoplastic/neurotropic features, and head and neck mucosal and anorectal melanoma. Lentigo maligna can be effectively treated with either adjuvant or definitive radiation therapy. Some retrospective and prospective randomized studies support the use of adjuvant radiation to improve regional control after lymph node dissection for high-risk nodal metastatic disease. Consensus on the optimal radiation doses and fractionation is lacking.
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Affiliation(s)
- Jacqueline Oxenberg
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - John M Kane
- Melanoma-Sarcoma Service, Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
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Gumusay O, Coskun U, Akman T, Ekinci AS, Kocar M, Erceleb ÖB, Yazıcı O, Kaplan MA, Berk V, Cetin B, Taskoylu BY, Yildiz A, Goksel G, Alacacioglu A, Demirci U, Algin E, Uysal M, Oztop I, Oksuzoglu B, Dane F, Gumus M, Buyukberber S. Predictive factors for the development of brain metastases in patients with malignant melanoma: a study by the Anatolian society of medical oncology. J Cancer Res Clin Oncol 2013; 140:151-7. [DOI: 10.1007/s00432-013-1553-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/14/2013] [Indexed: 10/26/2022]
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Chiarion-Sileni V, Guida M, Romanini A, Bernengo MG, Ascierto P, Queirolo P, Mandalà M, Maio M, Ferraresi V, Stanganelli I, Testori A, Ridolfi R. Diagnostic and therapeutic approaches in Italian hospitals: adjuvant and metastatic therapy in melanoma. Dermatology 2013; 226 Suppl 1:22-7. [PMID: 23736267 DOI: 10.1159/000348870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Melanoma incidence and mortality rates are rising in Italy, indicating that more effective treatments are required both in the adjuvant and metastatic settings. We analyzed clinical practices in the adjuvant and metastatic settings by conducting a nationwide survey of clinicians responsible for managing melanoma treatment and follow-up in a representative sample of Italian hospitals. 95% of participating hospitals completed the panel of questions on adjuvant and metastatic treatment, making it likely that these results give a realistic picture of treatment and follow-up of melanoma patients in Italy. In low-volume hospitals (<25 new melanoma diagnoses yearly) adjuvant therapy was significantly more used than in large-volume hospitals for patients in stage III and IV (82 versus 66% and 56 versus 30%, respectively), and only 11% of patients were enrolled in clinical trials. In the metastatic setting dacarbazine was the preferred first-line treatment (32%) followed by polychemotherapy (23%); 12% of patients were enrolled in clinical trials and less than 10% received interleukin-2, usually subcutaneously. The information provided by this study was used by the Italian Melanoma Intergroup to improve the quality of care and to redirect financial resources.
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Affiliation(s)
- Vanna Chiarion-Sileni
- Melanoma and Skin Cancer Unit, Veneto Oncology Institute, IRCCS, Padua, Italy. mgaliz @ tiscali.it
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Metastatic Melanoma from Unknown Primary Presenting as Dorsal Midbrain Syndrome. Optom Vis Sci 2012; 89:e112-7. [DOI: 10.1097/opx.0b013e3182771698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Burmeister B, Henderson M, Thompson J. Adjuvant nodal irradiation in melanoma – Authors' reply. Lancet Oncol 2012. [DOI: 10.1016/s1470-2045(12)70330-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Burmeister BH, Henderson MA, Ainslie J, Fisher R, Di Iulio J, Smithers BM, Hong A, Shannon K, Scolyer RA, Carruthers S, Coventry BJ, Babington S, Duprat J, Hoekstra HJ, Thompson JF. Adjuvant radiotherapy versus observation alone for patients at risk of lymph-node field relapse after therapeutic lymphadenectomy for melanoma: a randomised trial. Lancet Oncol 2012; 13:589-97. [PMID: 22575589 DOI: 10.1016/s1470-2045(12)70138-9] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The use of radiotherapy after therapeutic lymphadenectomy for patients with melanoma at high risk of further lymph-node field and distant recurrence is controversial. Decisions for radiotherapy in this setting are made on the basis of retrospective, non-randomised studies. We did this randomised trial to assess the effect of adjuvant radiotherapy on lymph-node field control in patients who had undergone therapeutic lymphadenectomy for metastatic melanoma in regional lymph nodes. METHODS This randomised controlled trial included patients from 16 hospitals in Australia, New Zealand, the Netherlands, and Brazil. To be eligible for this trial, patients had to be at high risk of lymph-node field relapse, judged on the basis of number of nodes involved, extranodal spread, and maximum size of involved nodes. After lymphadenectomy, randomisation was done centrally by computer and patients assigned by telephone in a ratio of 1:1 to receive adjuvant radiotherapy of 48 Gy in 20 fractions or observation, with institution, lymph-node field, number of involved nodes, maximum node diameter, and extent of extranodal spread as minimisation factors. Participants, those giving treatment, and those assessing outcomes were not masked to treatment allocation. The primary endpoint was lymph-node field relapse (as a first relapse), analysed for all eligible patients. The study is registered at ClinicalTrials.gov, number NCT00287196. The trial is now closed and follow-up discontinued. FINDINGS 123 patients were randomly allocated to the adjuvant radiotherapy group and 127 to the observation group between March 20, 2002, and Sept 21, 2007. Two patients withdrew consent and 31 had a major eligibility infringement as decided by the independent data monitoring committee, resulting in 217 eligible for the primary analysis (109 in the adjuvant radiotherapy group and 108 in the observation group). Median follow-up was 40 months (IQR 27-55). Risk of lymph-node field relapse was significantly reduced in the adjuvant radiotherapy group compared with the observation group (20 relapses in the radiotherapy group vs 34 in the observation group, hazard ratio [HR] 0·56, 95% CI 0·32-0·98; p=0·041), but no differences were noted for relapse-free survival (70 vs 73 events, HR 0·91, 95% CI 0·65-1·26; p=0·56) or overall survival (59 vs 47 deaths, HR 1·37, 95% CI 0·94-2·01; p=0·12). The most common grade 3 and 4 adverse events were seroma (nine in the radiotherapy group vs 11 in the observation group), radiation dermatitis (19 in the radiotherapy group), and wound infection (three in the radiotherapy group vs seven in the observation group). INTERPRETATION Adjuvant radiotherapy improves lymph-node field control in patients at high risk of lymph-node field relapse after therapeutic lymphadenectomy for metastatic melanoma. Adjuvant radiotherapy should be discussed with patients at high risk of relapse after lymphadenectomy. FUNDING National Health and Medical Research Council of Australia, Cancer Australia, Melanoma Institute Australia, Cancer Council of South Australia.
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Affiliation(s)
- Bryan H Burmeister
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia.
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Gojkovič-Horvat A, Jančar B, Blas M, Zumer B, Karner K, Hočevar M, Strojan P. Adjuvant radiotherapy for palpable melanoma metastases to the groin: when to irradiate? Int J Radiat Oncol Biol Phys 2011; 83:310-6. [PMID: 22035662 DOI: 10.1016/j.ijrobp.2011.06.1979] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/21/2011] [Accepted: 06/24/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the efficacy of and criteria for postoperative radiotherapy (PORT) in patients with palpable melanoma metastases to the groin. METHODS AND MATERIALS Patients with palpable metastases to the groin who were treated with therapeutic nodal dissection during 2000 to 2006 were identified in a prospective institutional database. RESULTS In 101 patients, 103 therapeutic nodal dissections were performed; 37 of these were treated with PORT to a median equivalent dose (eqTD(2)) of 50.6 Gy (range, 50-72 Gy). In the surgery-only and PORT groups, 2-year regional control rates were 86% (95% confidence interval [CI] 76-95%) and 91% (95% CI, 81-100%), respectively (p = 0.395). Of five recurrences in radiation-treated patients, four were of dermal type, and in three of these cases, no bolus over the operative scar was used. PORT improved 2-year regional control (46% [95% CI, 11-82%] vs. 82% [95% CI, 63-100%], p = 0.022) among patients in which the sum of risk factors present (i.e., risk factor score) was ≥2. In multivariate analysis, risk-factor score (<2 vs. ≥2: HR, 2.93; 95% CI, 1.00-8.56; p < 0.0001) and PORT (yes vs. no: HR, 7.81; 95% CI, 2.83-21.74; p = 0.050) was predictive for regional control and on logistic-regression testing, number of involved lymph nodes was predictive for systemic dissemination (p = 0.011). CONCLUSIONS PORT should follow therapeutic nodal dissection in cases with two or more adverse factors. More conventional fractionation (≤2.5 Gy), cumulative eqTD(2) <60 Gy and use of bolus over the operative scar are recommended.
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Khan MK, Khan N, Almasan A, Macklis R. Future of radiation therapy for malignant melanoma in an era of newer, more effective biological agents. Onco Targets Ther 2011; 4:137-48. [PMID: 21949607 PMCID: PMC3176173 DOI: 10.2147/ott.s20257] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The incidence of melanoma is rising. The primary initial treatment for melanoma continues to be wide local excision of the primary tumor and affected lymph nodes. Exceptions to wide local excision include cases where surgical excision may be cosmetically disfiguring or associated with increased morbidity and mortality. The role of definitive or adjuvant radiotherapy has largely been relegated to palliative measures because melanoma has been viewed as a prototypical radiotherapy-resistant cancer. However, the emerging clinical and radiobiological data summarized here suggests that many types of effective radiation therapy, such as radiosurgery for melanoma brain metastases, plaque brachytherapy for uveal melanoma, intensity modulated radiotherapy for melanoma of the head and neck, and adjuvant radiotherapy for selected high-risk, node-positive patients can improve outcomes. Similarly, although certain chemotherapeutic agents and biologics have shown limited responses, long-term control for unresectable tumors or disseminated metastatic disease has been rather disappointing. Recently, several powerful new biologics and treatment combinations have yielded new hope for this patient group. The recent identification of several clinically linked melanoma gene mutations involved in mitogen-activated protein kinase (MAPK) pathway such as BRAF, NRAS, and cKIT has breathed new life into the drive to develop more effective therapies. Some of these new therapeutic approaches relate to DNA damage repair inhibitors, cellular immune system activation, and pharmacological cell cycle checkpoint manipulation. Others relate to the investigation of more effective targeting and dosing schedules for underutilized therapeutics, such as radiotherapy. This paper summarizes some of these new findings and attempts to give some context to the renaissance in melanoma therapeutics and the potential role for multimodality regimens, which include certain types of radiotherapy as aids to locoregional control in sensitive tissues.
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Affiliation(s)
- Mohammad K Khan
- Taussig Cancer Institute, Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
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31
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Shada AL, Walters DM, Tierney SN, Slingluff CL. Surgical resection for bulky or recurrent axillary metastatic melanoma. J Surg Oncol 2011; 105:21-5. [PMID: 21826672 DOI: 10.1002/jso.22058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Accepted: 07/18/2011] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients. METHODS We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms. RESULTS Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001). DISCUSSION Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.
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Affiliation(s)
- Amber L Shada
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
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Chaudhuri A, De-Groot C, Seel M, Jolly M, Cameron T. Treatment of regional cutaneous nodular metastases from melanoma using high-dose rate mould brachytherapy. J Med Imaging Radiat Oncol 2011; 55:206-12. [DOI: 10.1111/j.1754-9485.2011.02253.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Khan N, Khan MK, Almasan A, Singh AD, Macklis R. The evolving role of radiation therapy in the management of malignant melanoma. Int J Radiat Oncol Biol Phys 2011; 80:645-54. [PMID: 21489712 DOI: 10.1016/j.ijrobp.2010.12.071] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 12/19/2010] [Accepted: 12/26/2010] [Indexed: 02/01/2023]
Abstract
The incidence of melanoma is rising in the United States, leading to an estimated 68,720 new diagnoses and 8,650 deaths annually. The natural history involves metastases to lymph nodes, lung, liver, brain, and often to other sites. Primary treatment for melanoma is surgical excision of the primary tumor and affected lymph nodes. The role of adjuvant or definitive radiation therapy in the treatment of melanoma remains controversial, because melanoma has traditionally been viewed as a prototypical radioresistant cancer. However, recent studies suggest that under certain clinical circumstances, there may be a significant role for radiation therapy in melanoma treatment. Stereotactic radiosurgery for brain metastases has shown effective local control. High dose per fraction radiation therapy has been associated with a lower rate of locoregional recurrence of sinonasal melanoma. Plaque brachytherapy has evolved into a promising alternative to enucleation at the expense of moderate reduction in visual acuity. Adjuvant radiation therapy following lymphadenectomy in node-positive melanoma prevents local and regional recurrence. The newer clinical data along with emerging radiobiological data indicate that radiotherapy is likely to play a greater role in melanoma management and should be considered as a treatment option.
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Affiliation(s)
- Niloufer Khan
- Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
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Carvalho TC, Carvalho SR, McConville JT. Formulations for Pulmonary Administration of Anticancer Agents to Treat Lung Malignancies. J Aerosol Med Pulm Drug Deliv 2011; 24:61-80. [DOI: 10.1089/jamp.2009.0794] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Kelly P, Zagars GK, Cormier JN, Ross MI, Guadagnolo BA. Sphincter-sparing local excision and hypofractionated radiation therapy for anorectal melanoma: a 20-year experience. Cancer 2011; 117:4747-55. [PMID: 21446049 DOI: 10.1002/cncr.26088] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/03/2011] [Accepted: 02/02/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anorectal melanoma is a rare disease with a poor prognosis. Because survival is determined by distant failure, many centers have adopted sphincter-sparing excision for primary tumor control. However, this approach is associated with high rates of local failure (∼50%). In this study, the authors report their 20-year experience with sphincter-sparing excision combined with radiation therapy (RT) for the treatment of localized anorectal melanoma. METHODS The authors reviewed the records of 54 patients with localized anorectal melanoma who were treated at the University of Texas MD Anderson Cancer Center from 1989 to 2008. All patients underwent definitive local excision with or without sentinel lymph node biopsy or lymph node dissection. RT (25-36 grays in 5-6 fractions) was delivered to extended fields that targeted the primary site and draining pelvic/inguinal lymphatics in 39 patients and to limited fields that targeted only the primary site in 15 patients. RESULTS The 5-year rates of local control (LC), lymph node control (NC), and sphincter preservation were 82%, 88%, and 96%, respectively. However, because of the high rate of distant metastasis, the overall survival (OS) rate at 5 years was only 30%. Although there were no significant differences in LC, NC, or OS based on RT field extent, patients who received extended-field RT had higher rates of lymphedema than patients who received limited-field RT. CONCLUSIONS The current results indicated that combined sphincter-sparing local excision and RT is a well tolerated approach that provides effective LC for patients with anorectal melanoma. Inclusion of the inguinal lymph node basins in the RT fields did not improve outcomes and was associated with an increased risk of lymphedema.
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Affiliation(s)
- Patrick Kelly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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Bibault JE, Dewas S, Mirabel X, Mortier L, Penel N, Vanseymortier L, Lartigau E. Adjuvant radiation therapy in metastatic lymph nodes from melanoma. Radiat Oncol 2011; 6:12. [PMID: 21294913 PMCID: PMC3041681 DOI: 10.1186/1748-717x-6-12] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 02/06/2011] [Indexed: 11/26/2022] Open
Abstract
Purpose To analyze the outcome after adjuvant radiation therapy with standard fractionation regimen in metastatic lymph nodes (LN) from cutaneous melanoma. Patients and methods 86 successive patients (57 men) were treated for locally advanced melanoma in our institution. 60 patients (69%) underwent LN dissection followed by radiation therapy (RT), while 26 patients (31%) had no radiotherapy. Results The median number of resected LN was 12 (1 to 36) with 2 metastases (1 to 28). Median survival after the first relapse was 31.8 months. Extracapsular extension was a significant prognostic factor for regional control (p = 0.019). Median total dose was 50 Gy (30 to 70 Gy). A standard fractionation regimen was used (2 Gy/fraction). Median number of fractions was 25 (10 to 44 fractions). Patients were treated with five fractions/week. Patients with extracapsular extension treated with surgery followed by RT (total dose ≥50 Gy) had a better regional control than patients treated by surgery followed by RT with a total dose <50 Gy (80% vs. 35% at 5-year follow-up; p = 0.004). Conclusion Adjuvant radiotherapy was able to increase regional control in targeted sub-population (LN with extracapsular extension).
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Affiliation(s)
- Jean-Emmanuel Bibault
- Academic Radiotherapy Departement, CLCC Oscar Lambret Comprehensive Cancer Center, Lille-Nord de France University, Lille, France.
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Campanholi L, Duprat Neto J, Fregnani J. Mathematical model to predict risk for lymphoedema after treatment of cutaneous melanoma. Int J Surg 2011; 9:306-9. [DOI: 10.1016/j.ijsu.2011.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 01/19/2011] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
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Guadagnolo BA, Myers JN, Zagars GK. Role of postoperative irradiation for patients with bilateral cervical nodal metastases from cutaneous melanoma: a critical assessment. Head Neck 2010; 32:708-13. [PMID: 19787786 DOI: 10.1002/hed.21238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the role of regional nodal radiation therapy (RT) for patients with bilateral cervical nodal metastases from melanoma. METHODS Between 1998 and 2008, 16 patients with bilateral cervical metastases without distant metastases were treated with postoperative RT (30 Gy in 5 fractions delivered twice weekly). RESULTS Median follow-up was 5 months (range, 1-34 months). Median survival was 9 months (95% confidence interval [CI], 0-23 months). Overall survival was 68%, 50%, and 27% at 6, 12, and 24 months, respectively. Regional nodal control was 74% and 64% at 6 and 12 months, respectively. Rates of development of distant metastasis were 60%, 70%, and 90% at 6, 12, and 18 months, respectively. The actuarial rate of RT-related complications was 49% at 12 months. CONCLUSION The limited life expectancy of patients observed with this disease combined with the high rate of RT-related complications argue against the routine use of adjuvant RT for regional nodal disease in this setting.
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Affiliation(s)
- B Ashleigh Guadagnolo
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Bowles TL, Xing Y, Hu CY, Mungovan KS, Askew RL, Chang GJ, Gershenwald JE, Lee JE, Mansfield PF, Ross MI, Cormier JN. Conditional survival estimates improve over 5 years for melanoma survivors with node-positive disease. Ann Surg Oncol 2010; 17:2015-23. [PMID: 20369298 DOI: 10.1245/s10434-010-1051-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND Conditional survival estimates provide useful prognostic information for cancer survivors. The objective of this study was to determine conditional survival estimates for melanoma patients with substages of stage III disease. MATERIALS AND METHODS A retrospective analysis of 760 patients who underwent lymphadenectomy for node-positive melanoma was conducted, and patients were stratified into substages: IIIA, IIIB, and IIIC. The 5-year conditional disease-free survival (DFS) and disease-specific survival (DSS) were calculated following lymphadenectomy using the methods of Kaplan and Meier and were reassessed for survivors on an annual basis. Multivariate Cox regression models were used to calculate adjusted conditional DFS and DSS accounting for age, gender, tumor histology, and extracapsular extension. RESULTS For patients with IIIA, IIIB, and IIIC disease, 5-year conditional DSS from treatment to year 5 improved from 78% to 90%, 54% to 79%, and 39% to 78%, respectively. For 5-year conditional DFS over the same period, the estimates increased from 65% to 79%, 37% to 81%, and 26% to 92%, respectively. Male patients experienced decreased 5-year conditional DSS and DFS across all substages, with the most pronounced effect on DSS in stage IIIC. Multivariate analysis demonstrated that survival differences among stage IIIC patients based on histologic subtype and extracapsular extension decreased over time. CONCLUSIONS Conditional survival estimates are more optimistic and realistic for cancer survivors than traditional survival estimates over time. For node-positive melanoma survivors, 5-year conditional DFS and DSS improve significantly over time. These estimates are critical to treatment decisions and non-treatment-related planning for both clinicians and patients.
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Affiliation(s)
- Tawnya L Bowles
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Strojan P, Jančar B, Čemažar M, Perme MP, Hočevar M. Melanoma Metastases to the Neck Nodes: Role of Adjuvant Irradiation. Int J Radiat Oncol Biol Phys 2010; 77:1039-45. [DOI: 10.1016/j.ijrobp.2009.06.071] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Revised: 06/10/2009] [Accepted: 06/11/2009] [Indexed: 10/20/2022]
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Abstract
BACKGROUND In melanoma, radiotherapy has generally been considered as a palliative treatment option indicated only for advanced cases or disseminated disease. In the 70s of the previous century, the technological advances in radiotherapy, linked to rapid development of computer sciences, resulted in restored interest for radiotherapy in melanoma management. Although a fundamental lack of well designed prospective and/or randomized clinical trials critically influenced the integration of radiotherapy into treatment strategies in melanoma, radiotherapy was recently recognized as an indispensable part in the multidisciplinary management of patients with melanoma. Altogether, approximately 23% of melanoma patients should receive at least one course of radiotherapy during the course of the disease. In this review, radiobiological properties of melanoma that govern the decisions for the fractionation patterns used in the treatment of this disease are described. Moreover, the indications for irradiation and the results of pertinent clinical studies from the literature, creating a rationale for the use of radiotherapy in the management of this disease, are reviewed and a brief description of radiotherapy techniques is given. CONCLUSIONS Basic treatment modality in melanoma is surgery. However, whenever surgery is not radical or there are adverse prognostic factors identified on histopathological examination of resected tissue specimen, it needs to be supplemented. Also, in patients with unresectable disease or in those not being suitable for major surgery or who refuse proposed surgical intervention, other effective mode(s) of therapy need to be implemented. From this perspective, supported by clinical experiences and literature results, radiotherapy is a valuable option: it is effective and safe, in curative and palliative setting.
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Agrawal S, Kane JM, Guadagnolo BA, Kraybill WG, Ballo MT. The benefits of adjuvant radiation therapy after therapeutic lymphadenectomy for clinically advanced, high-risk, lymph node-metastatic melanoma. Cancer 2009; 115:5836-44. [DOI: 10.1002/cncr.24627] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Loco-regional control after postoperative radiotherapy for patients with regional nodal metastases from melanoma. Clin Transl Oncol 2009; 11:688-93. [DOI: 10.1007/s12094-009-0425-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Testori A, Rutkowski P, Marsden J, Bastholt L, Chiarion-Sileni V, Hauschild A, Eggermont AMM. Surgery and radiotherapy in the treatment of cutaneous melanoma. Ann Oncol 2009; 20 Suppl 6:vi22-9. [PMID: 19617294 PMCID: PMC2712595 DOI: 10.1093/annonc/mdp257] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Adequate surgical management of primary melanoma and regional lymph node metastasis, and rarely distant metastasis, is the only established curative treatment. Surgical management of primary melanomas consists of excisions with 1–2 cm margins and primary closure. The recommended method of biopsy is excisional biopsy with a 2 mm margin and a small amount of subcutaneous fat. In specific situations (very large lesions or certain anatomical areas), full-thickness incisional or punch biopsy may be acceptable. Sentinel lymph node biopsy provides accurate staging information for patients with clinically unaffected regional nodes and without distant metastases, although survival benefit has not been proved. In cases of positive sentinel node biopsy or clinically detected regional nodal metastases (palpable, positive cytology or histopathology), radical removal of lymph nodes of the involved basin is indicated. For resectable local/in-transit recurrences, excision with a clear margin is recommended. For numerous or unresectable in-transit metastases of the extremities, isolated limb perfusion or infusion with melphalan should be considered. Decisions about surgery of distant metastases should be based on individual circumstances. Radiotherapy is indicated as a treatment option in select patients with lentigo maligna melanoma and as an adjuvant in select patients with regional metastatic disease. Radiotherapy is also indicated for palliation, especially in bone and brain metastases.
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Affiliation(s)
- A Testori
- European Institute of Oncology, Division of Melanoma, Milan, Italy.
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Guadagnolo BA, Zagars GK. Adjuvant radiation therapy for high-risk nodal metastases from cutaneous melanoma. Lancet Oncol 2009; 10:409-16. [DOI: 10.1016/s1470-2045(09)70043-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Berk LB. Radiation Therapy as Primary and Adjuvant Treatment for Local and Regional Melanoma. Cancer Control 2008; 15:233-8. [DOI: 10.1177/107327480801500306] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background The role of radiation therapy as primary and adjuvant therapy for localized or locally advanced melanoma is controversial. Methods To develop evidence-based guidelines, PubMed was searched using the keywords melanoma AND (radiation OR radiotherapy). These references were reviewed and the relevant articles selected. The articles were then reviewed for further references. Because of the paucity of prospective or randomized trials, no attempt was made to classify the quality of the results. Results No phase III trials of nodal irradiation for prevention of regional recurrence are available. A phase III trial is being completed by the Tasman Radiation Oncology Group. A phase II trial has been completed by the group. Multiple retrospective series have been published. The available data appear to confirm that nodal radiation therapy is effective in preventing nodal recurrence. No dose response or fraction size response was found. According to generally accepted guidelines, radiation therapy should be offered for patients who have nodes greater than 3 cm, more than 3 involved nodes, or extracapsular extension. For radiation therapy for the treatment of metastatic disease, a phase III trial showed that 50 Gy in 2.5-Gy fractions was as effective as 32 Gy in 8-Gy fractions, with 25% complete remission and 35% partial remission. In contrast, the retrospective studies support that larger fraction sizes, at least 4 Gy, are more effective. Conclusions Adjuvant nodal irradiation appears to be effective for the prevention of nodal recurrence. Radiation therapy can also be effective for treatment of local disease, if surgery is not an option.
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Affiliation(s)
- Lawrence B. Berk
- Radiation Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Mcloughlin JM, Zager JS, Sondak VK, Berk LB. Treatment Options for Limited or Symptomatic Metastatic Melanoma. Cancer Control 2008; 15:239-47. [DOI: 10.1177/107327480801500307] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Patients who develop metastatic melanoma often have limited effective treatment options. However, a select group of patients will benefit from aggressive surgery or a multidisciplinary approach, depending on the site of metastasis. Methods The current literature was reviewed and summarized regarding the collective recommendations for staging and treating patients with metastatic melanoma. Results A thorough preoperative staging includes positron-emission tomography, MRI of the brain, and CT of the chest, abdomen, and pelvis. Tumor biology ultimately determines the success of intervention. A long disease-free interval is a good indicator of potential benefit from resection of metastatic disease. If surgery is performed, no less than a complete resection will affect the overall survival of the patient. Surgery and other multimodality treatment options can be used for symptomatic palliation but will not affect survival. Chemotherapy and radiation are often used to control the symptoms of brain and bony metastases but have limited if any impact on survival. Conclusions A select group of patients with metastatic melanoma will benefit from aggressive surgery. Identifying which patients will benefit from treatment requires good clinical judgment and a thorough radiologic evaluation to identify the true extent of disease.
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Affiliation(s)
| | - Jonathan S. Zager
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Vernon K. Sondak
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Immunology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Lawrence B. Berk
- Radiation Oncology Programs at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Sarnaik AA, Zager JS, Sondak VK. Multidisciplinary management of special melanoma situations: oligometastatic disease and bulky nodal sites. Curr Oncol Rep 2007; 9:417-27. [PMID: 17706171 DOI: 10.1007/s11912-007-0057-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Potentially resectable, advanced stage melanoma in the form of extensive palpable adenopathy or limited systemic metastases presents a significant challenge but also offers the prospect of long-term disease control. Although surgical resection is the mainstay of therapy, involvement of a multidisciplinary team is required for optimal management of these special situations. These patients need to be evaluated preoperatively by the team, discussed at a multidisciplinary conference, and treated by experienced physicians with access to the full spectrum of modern surgical and oncologic therapy. Surgical resection is generally extensive and may require en bloc resection of important anatomic structures. Adjuvant radiation or systemic therapy is required in many patients to help achieve durable regional and systemic control of disease. In addition, novel therapies, such as neoadjuvant chemotherapy, targeted therapies, or investigational intralesional therapies, may ultimately play a role in the management of these difficult clinical situations and require further evaluation, as preliminary studies show some encouraging results.
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Affiliation(s)
- Amod A Sarnaik
- Division of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Department of Interdisciplinary Oncology, University of South Florida College of Medicine, 12902 Magnolia Drive, Tampa, FL 33612, USA
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Markovic SN, Erickson LA, Rao RD, Weenig RH, Pockaj BA, Bardia A, Vachon CM, Schild SE, McWilliams RR, Hand JL, Laman SD, Kottschade LA, Maples WJ, Pittelkow MR, Pulido JS, Cameron JD, Creagan ET. Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment. Mayo Clin Proc 2007; 82:490-513. [PMID: 17418079 DOI: 10.4065/82.4.490] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.
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Affiliation(s)
- Svetomir N Markovic
- Division of Hematology, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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