Management of Noncutaneous Melanomas

Challenges in managing anorectal melanoma, a rare malignancy

INTRODUCTION AND IMPORTANCE

Anorectal melanoma is a rare and aggressive malignancy that can be difficult to diagnose due to its nonspecific presentation.

CASE PRESENTATION

We present a case of a 69-year-old woman who presented with painful defecation, bleeding per rectum, and a mass coming out of her anal opening. The initial differential diagnosis included hemorrhoids, rectal polyp, or a malignant lesion of the rectum. However, histopathological evaluation following transanal excision of the rectal mass revealed mucosal melanoma in the anorectal region. Further investigation showed no evidence of locoregional or distant metastasis.

CLINICAL DISCUSSION

Surgery remains the primary treatment option for anorectal melanoma, but complete resection is often not feasible, leading to high rates of local recurrence and distant metastasis. The incidence of metastatic disease at the time of presentation is high, and a multidisciplinary approach is necessary to manage these patients. Currently, standard systemic therapies used for cutaneous melanoma are the mainstay of treatment for metastatic anorectal melanoma, but there is a need for further research to develop tailored treatment strategies.

CONCLUSION

Our case report highlights the importance of considering anorectal melanoma in the differential diagnosis of patients presenting with anorectal symptoms. It emphasizes the need for a multidisciplinary approach to managing this rare malignancy. Early diagnosis, a multidisciplinary approach, and ongoing research into more effective treatments are crucial for improving outcomes for patients with anorectal melanoma.

Outcomes of radical surgical resections for nonmetastatic anorectal melanomas: Experience from a tertiary care centre

AIM

The outcome of radical surgery in nonmetastatic anorectal melanoma (AM) patients is studied infrequently. Here, we aimed to explore the stage-wise outcomes and the impact of radical resections in these patients.

METHODS

In this single-centre retrospective study, data of 154 eligible patients were recorded and analysed. Data were obtained from November 2010 to September 2019 with follow-up until November 2020. Overall survival (OS) and disease-free survival (DFS) was calculated by Kaplan Meir method and univariate analysis of prognostic factors by Cox regression.

RESULTS

Of 154 patients, 110 were metastatic (stage III) and 44 were nonmetastatic (stage I:22, stage II:22) and underwent curative resections. Median follow-up was 48 months (14-119 months). A total of 39 patients underwent total mesorectal excisions (TME) and five transanal excision (TAE) were performed. Seven patients underwent extended resections. Stage I and II patients had 3- and 5-year OS of 40% and 36%; and DFS of 45% and 33.2%, respectively. Median OS and DFS were 31 and 24 months, respectively. Stage II (node-positive) patients had better median OS compared to stage III (21 vs. 4 months; p = 0.000), and 54.5% patients had recurrences, most commonly both systemic and nodal (45.83%). Median OS of patients without recurrence was 34 months.

CONCLUSION

In this large surgical series of AMs, outcome in stage I and II patients was significantly better than stage III and patients with stage II disease can have acceptable oncological outcomes. Radical surgical resections with or without lymphadenectomy could be considered in these patients. The role of adjuvant systemic therapy and radiation needs to be explored as part of multimodality treatment.

Current Status and Prospects of Immunotherapy for Gynecologic Melanoma

Gynecologic melanomas are rare and have a poor prognosis. Although immunotherapy (immune checkpoint inhibitors) and targeted therapy has greatly improved the systemic treatment of cutaneous melanoma (CM) in recent years, its efficacy in gynecologic melanomas remains uncertain because of the rarity of this malignancy and its scarce literature. This review aimed to evaluate the literature of gynecologic melanomas treated with immunotherapy and targeted therapy through a PubMed search. We identified one study focusing on the overall survival of gynecologic melanomas separately and five case series and nine case reports concentrating on gynecologic melanomas treated with an immune checkpoint inhibitor and/or targeted therapy. Furthermore, the KIT mutation has the highest rate among all mutations in mucosal melanoma types. The KIT inhibitors (Tyrosine kinase inhibitors: TKIs) imatinib and nilotinib could be the treatment options. Moreover, immune checkpoint inhibitors combined with KIT inhibitors may potentially treat cases of resistance to immune checkpoint inhibitors. However, because of the different conditions and a small number of cases, it is difficult to evaluate the efficacy of immunotherapy and targeted therapy for gynecologic melanoma rigorously at this time. Further prospective cohort or randomized trials of gynecologic melanoma alone are needed to assess the treatment with solid evidence.

Evaluation of treatment, prognostic factors, and survival in 198 vulvar melanoma patients: Implications for clinical practice

OBJECTIVE

To identify clinicopathological characteristics, treatment patterns, clinical outcomes and prognostic factors in patients with vulvar melanoma (VM).

MATERIALS & METHODS

This retrospective multicentre cohort study included 198 women with VM treated in eight cancer centres in the Netherlands and UK between 1990 and 2017. Clinicopathological features, treatment, recurrence, and survival data were collected. Overall and recurrence-free survival was estimated with the Kaplan-Meier method. Prognostic parameters were identified with multivariable Cox regression analysis.

RESULTS

The majority of patients (75.8%) had localized disease at diagnosis. VM was significantly associated with high-risk clinicopathological features, including age, tumour thickness, ulceration, positive resection margins and involved lymph nodes. Overall survival was 48% (95% CI 40-56%) and 31% (95% CI 23-39%) after 2 and 5 years respectively and did not improve in patients diagnosed after 2010 compared to patients diagnosed between 1990 and 2009. Recurrence occurred in 66.7% of patients, of which two-third was non-local. In multivariable analysis, age and tumour size were independent prognostic factors for worse survival. Prognostic factors for recurrence were tumour size and tumour type. Only the minority of patients were treated with immuno- or targeted therapy.

CONCLUSION

Our results show that even clinically early-stage VM is an aggressive disease associated with poor clinical outcome due to distant metastases. Further investigation into the genomic landscape and the immune microenvironment in VM may pave the way to novel therapies to improve clinical outcomes in these aggressive tumours. Clinical trials with immunotherapy or targeted therapy in patients with high-risk, advanced or metastatic disease are highly needed.

Epidemiology and survival outcomes of primary gastrointestinal melanoma: a SEER-based population study

PURPOSE

Primary melanoma arising in the gastrointestinal (GI) tract is rare and poorly characterized. We sought to describe the epidemiology and survival outcomes of primary GI melanoma.

PATIENTS AND METHODS

GI melanoma cases were extracted from the Surveillance, Epidemiology, and End Results (SEER) database by tumor site and histology codes. We calculated age-adjusted incidence, and analyzed demographics, clinical characteristics, as well as overall survival (OS) and cancer-specific survival (CSS) of GI melanoma.

RESULTS

A total of 1080 histologically confirmed cases of primary GI melanoma were identified, with a median age of 71 years (IQR: 59-80). 49.9% of the cases originated from anus, 30.8% had distant disease at diagnosis, and 61.5% received cancer-directed surgery. The distribution of gender and age was varied in GI melanoma subtypes. The incidence of GI melanoma was 0.58 cases per million, and increased remarkably over age, especially in patients aged 60 years or older. The median OS and CSS of the whole cohort was 14 months (95% CI 12.7-15.3) and 22 months (95% CI 18.8-25.2), respectively. Anal melanoma patients had prolonged survival, while those with gastric melanoma had the poorest OS (18 and 4 months, respectively). Multivariate analysis showed that decreased survival was associated with age older than 80 years, gastric and esophageal origin, advanced-stage disease, lymph node metastasis, and without surgery of primary site.

CONCLUSION

Patients with primary GI melanoma trended to present with advanced-stage disease. Overall, GI melanoma had a poor prognosis, but the outcome differed according to the primary sites.