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Wolfe AR, Chablani P, Siedow MR, Miller ED, Walston S, Kendra KL, Wuthrick E, Williams TM. BRAF mutation correlates with worse local-regional control following radiation therapy in patients with stage III melanoma. Radiat Oncol 2021; 16:181. [PMID: 34537078 PMCID: PMC8449455 DOI: 10.1186/s13014-021-01903-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/30/2021] [Indexed: 11/26/2022] Open
Abstract
Background In patients with stage III melanoma, the use of adjuvant radiation therapy (RT) after lymph node dissection (LND) may be currently considered in selected high-risk patients to improve tumor control. Melanomas harbor BRAF mutations (BRAF+) in 40–50% of cases, the majority of which are on the V600E residue. This study sought to compare the clinical outcomes after RT between patients with BRAF+ and BRAF− melanoma. Methods This was a retrospective review of 105 Stage III melanoma patients treated at our institution with LND followed by adjuvant RT from 2006 to 2019. BRAF mutational status was determined on the primary skin or nodal tissue samples from all patients. We compared characteristics of the BRAF+ and BRAF− groups using Fisher’s exact test and Wilcoxon rank sum test and performed univariate and multivariate analysis using Kaplan–Meier estimates, log-rank tests, and Cox proportional hazards modeling with the clinical outcomes of local–regional lymph node control, distant metastasis-free survival (DMFS), recurrence-free survival (RFS), and overall survival (OS). Results Fifty-three (50%) patients harbored a BRAF mutation (92%, pV600E). BRAF+ patients were younger and had primary tumors more commonly found in the trunk vs head and neck compared to BRAF- patients (p < 0.05). The 5 year local–regional control in the BRAF + patients was 60% compared to 81% in the BRAF- patients (HR 4.5, 95% CI 1.3–15.5, p = 0.02). There were no significant differences in 5-year DMFS, RFS, and OS rates between the two BRAF patient groups. The presence of 4 or more positive LNs remained a significant prognostic factor for local–regional lymph node control, RFS, and OS in multivariate analysis. Conclusions Stage III melanoma patients with BRAF mutation treated with adjuvant RT had > 4 times increased risk of local recurrence or regional lymph node recurrence. These results could be useful for adjuvant RT consideration in lymph node positive melanoma patients and supports other data that BRAF mutation confers radiation resistance.
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Affiliation(s)
- Adam R Wolfe
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Priyanka Chablani
- Division of Hematology-Oncology, Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Michael R Siedow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric D Miller
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Steve Walston
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kari L Kendra
- Division of Hematology-Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Evan Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Terence M Williams
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
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2
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Cornelius LA, Fields RC, Tarhini A. Multidisciplinary Care of BRAF-Mutant Stage III Melanoma: A Physicians Perspective Review. Oncologist 2021; 26:e1644-e1651. [PMID: 34080754 PMCID: PMC8417868 DOI: 10.1002/onco.13852] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 05/21/2021] [Indexed: 11/19/2022] Open
Abstract
Prognosis among patients with stage III melanoma can vary widely depending on the risk of disease relapse. Therefore, it is vital to optimize patient care through accurate diagnosis and staging as well as thoughtful treatment planning. A multidisciplinary team (MDT) approach, which involves active collaboration among physician specialists across a patient's disease journey, has been increasingly adopted as the standard of care for treatment of a variety of cancers, including melanoma. This review provides an overview of MDT care principles for patients with BRAF‐mutant–positive, stage III cutaneous melanoma and summarizes current literature, clinical experiences, and institutional best practices. Therapeutic goals from dermatologic, surgical, and medical oncologist perspectives regarding MDT care throughout a patient's disease course are discussed. Additionally, the role of each specialty's involvement in testing for predictive biomarkers at relevant time points to facilitate informed treatment decisions is discussed. Last, instances of successful MDT treatment of other cancers and key lessons to optimize MDT patient care in cutaneous melanoma are provided. Several aspects of MDT patient care are considered vital, such as the importance of staging via pathological examination and imaging, biomarker testing, and interdisciplinary physician and patient engagement throughout the course of treatment. Use of MDTs has the potential to improve patient care in cutaneous melanoma by improving the speed and accuracy of diagnosis, implementing a personalized treatment plan early on, and being proactive in adverse event management. Physician perspectives described in this review may lead to better outcomes, quality of life, and overall patient satisfaction. A multidisciplinary team (MDT) approach has been increasingly adopted as the standard of care for treatment of a variety of cancers, including melanoma. This review provides an overview of MDT care principles for patients with BRAF‐mutant–positive, stage III cutaneous melanoma and summarizes current literature, clinical experiences, and institutional best practices.
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Affiliation(s)
- Lynn A Cornelius
- Division of Dermatology, Department of Medicine, Alvin J. Siteman Cancer Center, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan C Fields
- Department of Surgery, Alvin J. Siteman Cancer Center, Barnes-Jewish Hospital and Washington University School of Medicine, St Louis, Missouri, USA
| | - Ahmad Tarhini
- Departments of Cutaneous Oncology and Immunology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.,University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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3
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Tarhini AA. Adjuvant Therapy of Melanoma. Hematol Oncol Clin North Am 2021; 35:73-84. [PMID: 33759774 DOI: 10.1016/j.hoc.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
as adjuvant therapy for high-risk melanoma was extensively studied in regimens that varied by dosage, route of administration, formulation, and therapy duration. The high-dose regimen (HDI) showed significant improvements in relapse-free survival (RFS) in 3 trials and overall survival (OS) in 2. Ipilimumab at 3 mg/kg demonstrated significant OS benefits compared with HDI and less toxicity compared with ipilimumab at 10 mg/kg. More recently, the standard of care has changed in favor of nivolumab and pembrolizumab and BRAF-MEK inhibitors dabrafenib plus trametinib (for BRAF mutated melanoma), based on significant RFS benefits and more favorable toxicity profiles.
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Affiliation(s)
- Ahmad A Tarhini
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, 10920 McKinley Drive, Tampa, FL 33612, USA; Department of Immunology, Moffitt Cancer Center and Research Institute, 10902 USF Magnolia Drive, Tampa, FL 33612, USA.
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4
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Claro G, Meyer N, Meresse T, Gangloff D, Grolleau JL, Chaput B. Does needle biopsy cause an increased risk of extracapsular extension in the diagnosis of metastatic lymph node in melanoma? Int J Dermatol 2018; 57:410-416. [PMID: 29430630 DOI: 10.1111/ijd.13936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 11/16/2017] [Accepted: 01/09/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Needle biopsy is a rapid, reliable, and reproducible procedure for histological confirmation of metastatic melanoma localization. Nonetheless, this procedure presents a theoretical risk of a mechanical weakening of the lymph node capsule with perinodal tumor seeding. The objective of the study was to evaluate the incidence of extracapsular extension after needle biopsy in comparison with surgical adenectomy in patients suspected of metastatic lymph node of melanoma. METHODS We conducted a retrospective study of 1056 patients who underwent lymphadenectomy for melanoma between 2000 and 2016 in our unit. Sixty-nine patients were clinically and/or radiologically suspected of metastatic lymph node of melanoma. Patients were divided according to external lymph node biopsy or surgical adenectomy before lymphadenectomy. The primary endpoint was the histopathological identification of extracapsular extension in analyzed lymph nodes. RESULTS The two populations were comparable except for the mitotic index, which was more frequently > 1/mm2 in the group with surgical adenectomy (P = 0.005). The proportion of extracapsular extension was significantly greater in the needle biopsy group (28/37) than in patients who underwent surgical adenectomy (14/32) (P = 0.0067; OR = 4 [95% CI: 1.4-11]). CONCLUSION Our results suggest an increased risk of extracapsular extension after external lymph node biopsy in cases of suspicion of metastatic lymph node of melanoma. Thus, this encourages us to prefer surgical adenectomy in patients with suspected adenopathy accessible surgically. In other cases, needle biopsy should be carried out under radiological guidance using devices limiting tumor seeding.
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Affiliation(s)
- Gilles Claro
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil Hospital, Toulouse, France.,Department of Surgical Oncology, Cancer University Institute of Toulouse Oncopole, Toulouse Cedex 09, France
| | - Nicolas Meyer
- Department of Dermatology, Cancer University Institute of Toulouse Oncopole, Toulouse Cedex 09, France
| | - Thomas Meresse
- Department of Surgical Oncology, Cancer University Institute of Toulouse Oncopole, Toulouse Cedex 09, France
| | - Dimitri Gangloff
- Department of Surgical Oncology, Cancer University Institute of Toulouse Oncopole, Toulouse Cedex 09, France
| | - Jean-Louis Grolleau
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil Hospital, Toulouse, France
| | - Benoit Chaput
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rangueil Hospital, Toulouse, France.,Department of Surgical Oncology, Cancer University Institute of Toulouse Oncopole, Toulouse Cedex 09, France
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5
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Eigentler TK, Mühlenbein C, Follmann M, Schadendorf D, Garbe C. S3-Leitlinie Diagnostik, Therapie und Nachsorge des Melanoms - Update 2015/2016, Kurzversion 2.0. J Dtsch Dermatol Ges 2017; 15:e1-e41. [DOI: 10.1111/ddg.13247] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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6
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Abstract
Systemic adjuvant therapy for surgically resected cutaneous melanoma that is at high risk for disease recurrence and death targets residual micrometastatic disease which is the source of future local or distant relapse. Interferon-alfa (IFNα) has been the most extensively studied in regimens that varied by dosage, route of administration, formulation, and duration of therapy. Most regimens have demonstrated improvements in relapse-free survival (RFS), while the regimen administered at high dosage (HDI) showed improvements in overall survival (OS) in two out of three RCTs. HDI benefits as measured by the hazard ratios (HR) in E1684 (vs. observation), E1690 (vs. observation), and E1694 (vs. vaccine) trials were estimated at 0.61, 0.78, and 0.67 (RFS) and 0.67, 1.0, and 0.72 (OS) when first reported with lesser estimates on later updates. Pegylated IFNα (peg-IFN) as studied in the European Organisation for Research and Treatment of Cancer (EORTC) 18991 trial in patients with stage III melanoma significantly reduced the risk of relapse (HR 0.87) with no impact on OS. More recently (EORTC 18071), ipilimumab at the high dose of 10 mg/kg was shown to significantly improve RFS (HR 0.76) and OS (HR 0.72) of stage III melanoma patients but at a significant cost in terms of immune-related toxicities. Ongoing adjuvant studies are testing ipilimumab at 3 or 10 mg/kg versus HDI (E1609) and the anti-PD-1 antibodies nivolumab (CheckMate 238) and pembrolizumab (KEYNOTE-054 and S1404).
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7
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Baker A, Camacho F, Andrews G, Mackley H. A retrospective analysis of the role of adjuvant radiotherapy in the treatment of cutaneous melanoma. Cancer Biol Ther 2016; 17:1030-1034. [PMID: 27636187 DOI: 10.1080/15384047.2016.1219811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Melanoma is a significant clinical problem, with rising rates of incidence. Surgery is the mainstay of treatment. The role of adjuvant radiotherapy in the control of locoregionally advanced cutaneous melanoma is controversial. A retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database was performed. Patients with locoregionally confined cutaneous melanoma treated surgically between 2004 and 2009 were evaluated, with cancer-specific and all-cause mortality as primary end points. Propensity score matching was used to match 319 radiotherapy patients with 319 non-radiotherapy controls, stratifying by head and neck (HN) and non-head and neck (NHN) primary. Surgery was primarily by wide excision in both the radiotherapy (51.72%) and non-radiotherapy (53.91%) groups. The majority had nodal disease (82.13% vs. 82.44%). White (91.22% vs. 90.59%) males (70.21% vs. 68.96%) predominated. Average ages at diagnosis were 62.27 (SD 15.93) and 63.02 (SD 16.03). Using Cox proportional hazards models, radiation conferred decreased survival in all-cause (HR 1.44, p < 0.0003), and cancer specific mortality (HR 1.57, p < 0.0002) in combined analysis. The NHN group showed significantly decreased 6-year cancer specific survival (HR 2.05, p < 0.0001) for radiated patients. The HN group showed a non-significant hazard with radiotherapy (HR 1.19, p = 0.307). Meaningful differences not captured in the SEER database may exist between cohorts. Based on available SEER data, routine use of adjuvant radiotherapy should be viewed with caution and reserved for high-risk patients. Future trials evaluating patient quality of life may clarify the benefit of adjuvant radiotherapy in high-risk melanoma populations.
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Affiliation(s)
- Aaron Baker
- a The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Fabian Camacho
- b University of Virginia , Department of Public Health Sciences Administration , Charlottesville , VA , USA
| | - Genevieve Andrews
- a The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Heath Mackley
- a The Pennsylvania State University, College of Medicine , Hershey , PA , USA
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8
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Pföhler C, Vogt T, Müller CSL. [Malignant head and neck melanoma: Part 2: Therapy]. HNO 2015. [PMID: 26219523 DOI: 10.1007/s00106-015-0034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Resection margins of melanomas in the head and neck region often have to be adapted according anatomical circumstances. In the case of thicker primary tumors or after complete resection of locoregional lymph node metastases, adjuvant therapy with interferon-α can be performed; in some cases, adjuvant radiotherapy may also be indicated. In the case of inoperable lymph node or distant metastases, systemic treatment is required. Beside well-established mono- or polychemotherapy regimens, newer targeted therapies with BRAF inhibitors (vemurafenib, dabrafenib), mitogenic-activated protein kinase (MEK) inhibitors (trametinib, binimetinib, and cobimetinib), and kinase inhibitors (imatinib, sunitinib, nilotinib, dasatinib) are also available.
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Affiliation(s)
- C Pföhler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Kirrbergerstrasse, 66421, Homburg/Saar, Deutschland,
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9
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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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10
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López F, Rodrigo JP, Cardesa A, Triantafyllou A, Devaney KO, Mendenhall WM, Haigentz M, Strojan P, Pellitteri PK, Bradford CR, Shaha AR, Hunt JL, de Bree R, Takes RP, Rinaldo A, Ferlito A. Update on primary head and neck mucosal melanoma. Head Neck 2015; 38:147-55. [PMID: 25242350 DOI: 10.1002/hed.23872] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2014] [Indexed: 12/19/2022] Open
Abstract
Primary mucosal melanomas (PMMs) of the head and neck are uncommon malignancies that arise mainly in the nasal cavity and paranasal sinuses, followed by the oral cavity. The mainstay of treatment is radical surgical resection followed by adjuvant radiotherapy in selected patients with high-risk features. Multimodality therapy has not been well studied and is not standardized. Adjuvant radiotherapy seems to improve locoregional control but does not improve overall survival (OS). Elective neck dissection is advocated in patients with oral PMM. Systemic therapy should be considered only for patients with metastatic or unresectable locoregional disease. Despite improvements in the field of surgery, radiotherapy, and systemic therapy, patients with PMM still face a very unfavorable prognosis (5-year disease-free survival [DFS] <20%) with high rates of locoregional recurrence and distant metastasis. The present review aims to summarize the current state of knowledge on the molecular biology, pathological diagnosis, and management of this disease.
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Affiliation(s)
- Fernando López
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain
| | - Antonio Cardesa
- Department of Anatomic Pathology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Asterios Triantafyllou
- Department of Oral Pathology, School of Dentistry, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Missak Haigentz
- Department of Medicine, Division of Oncology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Phillip K Pellitteri
- Department of Otolaryngology-Head and Neck Surgery, Guthrie Health System, Sayre, Pennsylvania
| | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jennifer L Hunt
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Remco de Bree
- Department of Otolaryngology-Head and Neck Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert P Takes
- Department of Otolaryngology-Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Alfio Ferlito
- University of Udine School of Medicine, Udine, Italy
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11
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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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12
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Abstract
Although melanoma is generally considered a relative radioresistant tumor, radiation therapy (RT) remains a valid and effective treatment option in definitive, adjuvant, and palliative settings. Definitive RT is generally only used in inoperable patients. Despite a high-quality clinical trial showing adjuvant RT following lymphadenectomy in node-positive melanoma patients prevents local and regional recurrence, the role of adjuvant RT in the treatment of melanoma remains controversial and is underused. RT is highly effective in providing symptom palliation for metastatic melanoma. RT combined with new systemic options, such as immunotherapy, holds promise and is being actively evaluated.
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Affiliation(s)
- Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, 111 South 11th Street, Suite G301, Philadelphia, PA 19107, USA.
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13
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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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14
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Supriya M, Narasimhan V, Henderson MA, Sizeland A. Managing regional metastasis in patients with cutaneous head and neck melanoma - is selective neck dissection appropriate? Am J Otolaryngol 2014; 35:610-6. [PMID: 25080830 DOI: 10.1016/j.amjoto.2014.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 06/21/2014] [Accepted: 06/27/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection. METHODS Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND). RESULTS There was no difference in LR, OS and PFS between CND (n=18) and SND groups (n=79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR. CONCLUSION Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.
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Affiliation(s)
| | | | - Michael A Henderson
- Division of Cancer Surgery, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Andrew Sizeland
- Division of Head and Neck Surgery, Peter MacCallum Cancer Center, Melbourne, Australia
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Pflugfelder A, Kochs C, Blum A, Capellaro M, Czeschik C, Dettenborn T, Dill D, Dippel E, Eigentler T, Feyer P, Follmann M, Frerich B, Ganten MK, Gärtner J, Gutzmer R, Hassel J, Hauschild A, Hohenberger P, Hübner J, Kaatz M, Kleeberg UR, Kölbl O, Kortmann RD, Krause-Bergmann A, Kurschat P, Leiter U, Link H, Loquai C, Löser C, Mackensen A, Meier F, Mohr P, Möhrle M, Nashan D, Reske S, Rose C, Sander C, Satzger I, Schiller M, Schlemmer HP, Strittmatter G, Sunderkötter C, Swoboda L, Trefzer U, Voltz R, Vordermark D, Weichenthal M, Werner A, Wesselmann S, Weyergraf AJ, Wick W, Garbe C, Schadendorf D. S3-guideline "diagnosis, therapy and follow-up of melanoma" -- short version. J Dtsch Dermatol Ges 2014; 11:563-602. [PMID: 23721604 DOI: 10.1111/ddg.12044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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16
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Follmann M, Schadendorf D, Kochs C, Buchberger B, Winter A, Wesselmann S. Quality assurance for care of melanoma patients based on guideline-derived quality indicators and certification. J Dtsch Dermatol Ges 2013; 12:139-47. [PMID: 24238575 DOI: 10.1111/ddg.12238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/19/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES In 2013 the first German S-3 guidelines on the diagnosis, treatment, and follow-up of melanoma were published in the framework of the German Guideline Program on Oncology. Quality indicators were developed at the same time as the guideline development process in order to implement the guideline recommendations. PATIENTS AND METHODS A multidisciplinary, interprofessional working group developed quality indicators following a standardized process. RESULTS Twelve quality indicators directly linked to guideline recommendations were generated and agreed on by consensus. They were integrated into the catalogue of requirements for dermato-oncological centers certified by the German Cancer Society. CONCLUSIONS The close cooperation between the guideline group and commission for certification allowed the guideline contents to be implemented in the form of quality indicators in everyday clinical practice. Adherence to the guidelines is required and continuously evaluated as part of certification.
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Hallemeier CL, Garces YI, Neben-Wittich MA, Olivier KR, Shon W, García JJ, Brown PD, Foote RL. Adjuvant hypofractionated intensity modulated radiation therapy after resection of regional lymph node metastases in patients with cutaneous malignant melanoma of the head and neck. Pract Radiat Oncol 2012; 3:e71-7. [PMID: 24674323 DOI: 10.1016/j.prro.2012.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/08/2012] [Accepted: 06/10/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate outcomes in patients with malignant melanoma of the head and neck with resected regional lymph node (LN) metastases treated with adjuvant hypofractionated intensity modulated radiation therapy (IMRT). METHODS AND MATERIALS A retrospective review was performed of 46 patients with malignant melanoma of the head and neck with regional LN metastases treated with lymphadenectomy and adjuvant IMRT. Patients underwent neck dissection (n = 42) or local excision (n = 4) for regional metastases at initial diagnosis (n = 19) or recurrence (n = 27). Adjuvant IMRT was delivered twice per week over 2.5 weeks for a total dose of 30 Gray (Gy) in 5 fractions. Acute and late adverse events were recorded using the Common Toxicity Criteria for Adverse Events version 4. Site of first recurrence was defined as local-regional (LR, above the clavicles) or distant. Overall survival, disease-free survival, and disease recurrence risks were determined using Kaplan-Meier estimates. RESULTS The median follow-up in living patients was 2.8 years (range, 0.2-6.9). Most patients experienced acute grade 1-2 dermatitis (80%) and mucositis (85%). One patient (2%) experienced an acute grade 3 adverse event. Seven patients (16%) experienced late grade 2 adverse events. No patient experienced grade 3 or higher late adverse events. Site of first recurrence was LR alone (n = 5), both LR and distant (n = 1), and distant alone (n = 25). Five of the 6 LR recurrences were inside the IMRT planning target volume (PTV). In-PTV and total LR control at 3 years were 85% and 76%, respectively. Overall survival and disease-free survival at 3 years were 63% and 25%, respectively. CONCLUSIONS Adjuvant hypofractionated IMRT (30 Gy in 5 fractions) was associated with a high rate of in-PTV control and a low risk of serious adverse events.
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Affiliation(s)
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Wonwoo Shon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joaquín J García
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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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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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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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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