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Liu ZF, Sylivris A, Wu J, Tan D, Hong S, Lin L, Wang M, Chew C. Ultrasound Surveillance in Melanoma Management: Bridging Diagnostic Promise with Real-World Adherence: A Systematic Review and Meta-Analysis. Am J Clin Dermatol 2024; 25:513-525. [PMID: 38635019 DOI: 10.1007/s40257-024-00862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Ultrasound surveillance has become the new standard of care in stage III melanoma after the 2017 Multicenter Selective Lymphadenectomy Trial II (MSLT-II) demonstrated non-inferior 3-year survival compared with complete lymph node dissection. OBJECTIVE We aimed to quantify diagnostic performance and adherence rates of ultrasound surveillance for melanoma locoregional metastasis, offering insights into real-world applicability. METHODS Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the Medline, Embase, Cochrane Library, CINAHL, Scopus, and Web of Science databases from inception until 11 October 2023. All primary studies that reported data on the diagnostic performance or adherence rates to ultrasound surveillance in melanoma were included. R statistical software was used for data synthesis and analysis. Sensitivity and specificity were aggregated across studies using the meta-analytic method for diagnostic tests outlined by Rutter and Gatsonis. Adherence rates were calculated as the ratio of patients fully compliant to planned follow-up to those who were not. RESULTS A total of 36 studies including 18,273 patients were analysed, with a mean age of 56.6 years and a male-to-female ratio of 1:1.11. The median follow-up duration and frequency was 36 and 4 months, respectively. The pooled sensitivity of ultrasound examination was 0.879 (95% confidence interval [CI] 0.878-0.879) and specificity was 0.969 (95% CI 0.968-0.970), representing a diagnostic odds ratio of 224.5 (95% CI 223.1-225.9). Ultrasound examination demonstrated a substantial improvement in absolute sensitivity over clinical examination alone, with a number needed to screen (NNS) of 2.95. The overall adherence rate was 77.0% (95% CI 76.0-78.1%), with significantly lower rates in the United States [US] (p < 0.001) and retrospective studies (p < 0.001). CONCLUSION Ultrasound is a powerful diagnostic tool for locoregional melanoma metastasis. However, the real applicability to surveillance programmes is limited by low adherence rates, especially in the US. Further studies should seek to address this adherence gap.
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Affiliation(s)
- Zhao Feng Liu
- Department of Dermatology, Alfred Health, Melbourne, VIC, Australia
| | | | - Johnny Wu
- Monash Health, Clayton, VIC, Australia
| | - Darren Tan
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| | | | - Lawrence Lin
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Wang
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Christopher Chew
- Department of Dermatology, Alfred Health, Melbourne, VIC, Australia
- Faculty of Medicine, Monash University, Clayton, VIC, Australia
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Zhang S, Bensimon AG, Xu R, Jiang R, Greatsinger A, Zhang A, Fukunaga-Kalabis M, Krepler C. Cost-Effectiveness Analysis of Pembrolizumab as an Adjuvant Treatment of Resected Stage IIB or IIC Melanoma in the United States. Adv Ther 2023; 40:3038-3055. [PMID: 37191852 PMCID: PMC10271902 DOI: 10.1007/s12325-023-02525-x] [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: 03/29/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Pembrolizumab was approved in the US as adjuvant treatment of patients with stage IIB or IIC melanoma post-complete resection, based on prolonged recurrence-free survival vs. placebo in the Phase 3 KEYNOTE-716 trial. This study aimed to evaluate the cost-effectiveness of pembrolizumab vs. observation as adjuvant treatment of stage IIB or IIC melanoma from a US health sector perspective. METHODS A Markov cohort model was constructed to simulate patient transitions among recurrence-free, locoregional recurrence, distant metastasis, and death. Transition probabilities from recurrence-free and locoregional recurrence were estimated via multistate parametric modeling based on patient-level data from an interim analysis (data cutoff date: 04-Jan-2022). Transition probabilities from distant metastasis were based on KEYNOTE-006 data and network meta-analysis. Costs were estimated in 2022 US dollars. Utilities were based on applying US value set to EQ-5D-5L data collected in trial and literature. RESULTS Compared to observation, pembrolizumab increased total costs by $80,423 and provided gains of 1.17 quality-adjusted life years (QALYs) and 1.24 life years (LYs) over lifetime, resulting in incremental cost-effectiveness ratios of $68,736/QALY and $65,059/LY. The higher upfront costs of adjuvant treatment were largely offset by reductions in costs of subsequent treatment, downstream disease management, and terminal care, reflecting the lower risk of recurrence with pembrolizumab. Results were robust in one-way sensitivity and scenario analyses. At a $150,000/QALY threshold, pembrolizumab was cost-effective vs. observation in 73.9% of probabilistic simulations that considered parameter uncertainty. CONCLUSION As an adjuvant treatment of stage IIB or IIC melanoma, pembrolizumab was estimated to reduce recurrence, extend patients' life and QALYs, and be cost-effective versus observation at a US willingness-to-pay threshold.
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Affiliation(s)
- Shujing Zhang
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA.
| | | | - Ruifeng Xu
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA
| | - Ruixuan Jiang
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA
| | | | | | | | - Clemens Krepler
- Merck & Co., Inc., 126 East Lincoln Ave., P.O. Box 2000, Rahway, NJ, 07065, USA
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Evaluating the effect of detection modalities in the Danish clinical follow-up program of cutaneous melanoma—a retrospective cohort study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-022-01997-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Tran AD, Hong AM, Nguyen MTH, Fogarty G, Steel V, Paton E, Morton RL. Cost Analysis of Adjuvant Whole-Brain Radiotherapy Treatment Versus No Whole-Brain Radiotherapy After Stereotactic Radiosurgery and/or Surgery Among Adults with One to Three Melanoma Brain Metastases: Results from a Randomized Trial. PHARMACOECONOMICS - OPEN 2022; 6:587-594. [PMID: 35513735 PMCID: PMC9283614 DOI: 10.1007/s41669-022-00332-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE We aimed to compare Australian health system costs at 12 months for adjuvant whole-brain radiotherapy (WBRT) treatment after stereotactic radiosurgery (SRS) and/or surgery versus observation among adults with one to three melanoma brain metastases. We hypothesized that treatment with adjuvant WBRT and subsequent healthcare would be more expensive than SRS/surgery alone. METHODS The analysis was conducted alongside a multicentre, randomized phase III trial. A bespoke cost questionnaire was used to measure healthcare use, including hospitalizations, specialist and primary care visits, imaging, and medicines over 12 months. Mean per-patient costs were calculated based on the quantity of resources used and unit costs, reported in Australian dollars ($AU), year 2018 values. Skewness of cost data was determined using normality tests and censor-adjusted costs reported using the Kaplan-Meier sample average method. The analysis of difference in mean costs at each 2-month time point and at 12 months was performed and checked using Kruskal-Wallis, generalized linear models with gamma distribution and log link, modified Park test, ordinary least squares, and non-parametric bootstrapping. RESULTS In total, 89 patients with similar characteristics at baseline were included in the cost analysis (n = 43 WBRT; n = 46 observation). Hospitalization cost was the main cost, ranging from 63 to 89% of total healthcare costs. The unadjusted 12-monthly cost for WBRT was $AU71,138 ± standard deviation 41,475 and for observation $AU69,848 ± 33,233; p = 0.7426. The censor-adjusted 12-monthly cost for WBRT was $AU90,277 ± 36,274 and $AU82,080 ± 34,411 for observation. There was no significant difference in 2-monthly costs between groups (p > 0.30 for all models). CONCLUSIONS Most costs were related to inpatient hospitalizations associated with disease recurrence. Adding WBRT after local SRS/surgery for patients with one to three melanoma brain metastases did not significantly increase health system costs during the first 12 months. TRIAL REGISTRATION ACTRN12607000512426, prospectively registered 14 September 2007.
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Affiliation(s)
- Anh Dam Tran
- National Drug and Alcohol Research Centre, UNSW, Sydney, Australia.
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Angela M Hong
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Mai T H Nguyen
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Gerald Fogarty
- Genesis Cancer Care, St Vincent's Clinic, Darlinghurst, NSW, Australia
| | - Victoria Steel
- Melanoma and Skin Cancer Trials, Monash University, Melbourne, Australia
| | - Elizabeth Paton
- Melanoma and Skin Cancer Trials, Monash University, Melbourne, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia
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Newcomer K, Robbins KJ, Perone J, Hinojosa FL, Chen D, Jones S, Kaufman CK, Weiser R, Fields RC, Tyler DS. Malignant melanoma: evolving practice management in an era of increasingly effective systemic therapies. Curr Probl Surg 2022; 59:101030. [PMID: 35033317 PMCID: PMC9798450 DOI: 10.1016/j.cpsurg.2021.101030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/12/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Ken Newcomer
- Department of Surgery, Barnes-Jewish Hospital, Washington University, St. Louis, MO
| | | | - Jennifer Perone
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - David Chen
- e. Department of Medicine, Washington University, St. Louis, MO
| | - Susan Jones
- f. Department of Pediatrics, Washington University, St. Louis, MO
| | | | - Roi Weiser
- University of Texas Medical Branch, Galveston, TX
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, MO
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, TX.
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Vale L, Kunonga P, Coughlan D, Kontogiannis V, Astin M, Beyer F, Richmond C, Wilson D, Bajwa D, Javanbakht M, Bryant A, Akor W, Craig D, Lovat P, Labus M, Nasr B, Cunliffe T, Hinde H, Shawgi M, Saleh D, Royle P, Steward P, Lucas R, Ellis R. Optimal surveillance strategies for patients with stage 1 cutaneous melanoma post primary tumour excision: three systematic reviews and an economic model. Health Technol Assess 2021; 25:1-178. [PMID: 34792018 DOI: 10.3310/hta25640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Malignant melanoma is the fifth most common cancer in the UK, with rates continuing to rise, resulting in considerable burden to patients and the NHS. OBJECTIVES The objectives were to evaluate the effectiveness and cost-effectiveness of current and alternative follow-up strategies for stage IA and IB melanoma. REVIEW METHODS Three systematic reviews were conducted. (1) The effectiveness of surveillance strategies. Outcomes were detection of new primaries, recurrences, metastases and survival. Risk of bias was assessed using the Cochrane Collaboration's Risk-of-Bias 2.0 tool. (2) Prediction models to stratify by risk of recurrence, metastases and survival. Model performance was assessed by study-reported measures of discrimination (e.g. D-statistic, Harrel's c-statistic), calibration (e.g. the Hosmer-Lemeshow 'goodness-of-fit' test) or overall performance (e.g. Brier score, R 2). Risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). (3) Diagnostic test accuracy of fine-needle biopsy and ultrasonography. Outcomes were detection of new primaries, recurrences, metastases and overall survival. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Review data and data from elsewhere were used to model the cost-effectiveness of alternative surveillance strategies and the value of further research. RESULTS (1) The surveillance review included one randomised controlled trial. There was no evidence of a difference in new primary or recurrence detected (risk ratio 0.75, 95% confidence interval 0.43 to 1.31). Risk of bias was considered to be of some concern. Certainty of the evidence was low. (2) Eleven risk prediction models were identified. Discrimination measures were reported for six models, with the area under the operating curve ranging from 0.59 to 0.88. Three models reported calibration measures, with coefficients of ≥ 0.88. Overall performance was reported by two models. In one, the Brier score was slightly better than the American Joint Committee on Cancer scheme score. The other reported an R 2 of 0.47 (95% confidence interval 0.45 to 0.49). All studies were judged to have a high risk of bias. (3) The diagnostic test accuracy review identified two studies. One study considered fine-needle biopsy and the other considered ultrasonography. The sensitivity and specificity for fine-needle biopsy were 0.94 (95% confidence interval 0.90 to 0.97) and 0.95 (95% confidence interval 0.90 to 0.97), respectively. For ultrasonography, sensitivity and specificity were 1.00 (95% confidence interval 0.03 to 1.00) and 0.99 (95% confidence interval 0.96 to 0.99), respectively. For the reference standards and flow and timing domains, the risk of bias was rated as being high for both studies. The cost-effectiveness results suggest that, over a lifetime, less intensive surveillance than recommended by the National Institute for Health and Care Excellence might be worthwhile. There was considerable uncertainty. Improving the diagnostic performance of cancer nurse specialists and introducing a risk prediction tool could be promising. Further research on transition probabilities between different stages of melanoma and on improving diagnostic accuracy would be of most value. LIMITATIONS Overall, few data of limited quality were available, and these related to earlier versions of the American Joint Committee on Cancer staging. Consequently, there was considerable uncertainty in the economic evaluation. CONCLUSIONS Despite adoption of rigorous methods, too few data are available to justify changes to the National Institute for Health and Care Excellence recommendations on surveillance. However, alternative strategies warrant further research, specifically on improving estimates of incidence, progression of recurrent disease; diagnostic accuracy and health-related quality of life; developing and evaluating risk stratification tools; and understanding patient preferences. STUDY REGISTRATION This study is registered as PROSPERO CRD42018086784. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol 25, No. 64. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Patience Kunonga
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Diarmuid Coughlan
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Margaret Astin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Beyer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Richmond
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dor Wilson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dalvir Bajwa
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Mehdi Javanbakht
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Wanwuri Akor
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Dawn Craig
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Penny Lovat
- Institute of Translation and Clinical Studies, Newcastle University, Newcastle upon Tyne, UK
| | - Marie Labus
- Business Development and Enterprise, Newcastle University, Newcastle upon Tyne, UK
| | - Batoul Nasr
- Dermatological Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Timothy Cunliffe
- Dermatology Department, James Cook University Hospital, Middlesbrough, UK
| | - Helena Hinde
- Dermatology Department, James Cook University Hospital, Middlesbrough, UK
| | - Mohamed Shawgi
- Radiology Department, James Cook University Hospital, Middlesbrough, UK
| | - Daniel Saleh
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Pam Royle
- Patient representative, ITV Tyne Tees, Gateshead, UK
| | - Paul Steward
- Patient representative, Dermatology Department, James Cook University Hospital, Middlesbrough, UK
| | - Rachel Lucas
- Patient representative, Dermatology Department, James Cook University Hospital, Middlesbrough, UK
| | - Robert Ellis
- Institute of Translation and Clinical Studies, Newcastle University, Newcastle upon Tyne, UK.,South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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Papageorgiou C, Apalla Z, Manoli SM, Lallas K, Vakirlis E, Lallas A. Melanoma: Staging and Follow-Up. Dermatol Pract Concept 2021; 11:e2021162S. [PMID: 34447611 DOI: 10.5826/dpc.11s1a162s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
Cancer staging is the process determining to which extent a cancer has spread and where it is located in the body. A thorough staging is of utmost importance, not only because it provides the most accurate prognostic estimation, but also because several crucial decisions, such as the treatment choice and the follow-up strategy, vary according to the tumor's stage. The current staging system for melanoma is based on the 8th edition of TNM classification issued by the American Joint Committee on Cancer (AJCC) in 2017. It includes a clinical and a pathological staging, both consisting of 5 stages (0-IV). The stage of a melanoma is determined by several factors, among which the Breslow thickness, the pathological presence or absence of ulceration in the primary tumor, the presence and the number of tumor-involved regional lymph nodes, the presence or absence of in-transit, satellite and/or microsatellite metastases, and the presence of distant metastases. Following melanoma diagnosis, an accurate medical workup, in line with the stage and the physical examination, should be performed. A continuous patient monitoring is fundamental to detect a potential relapse or a second primary melanoma and should be lifelong. However, there is still no universally adopted follow-up strategy program and different follow-up schemes have been suggested. Future prospective studies are needed to evaluate different follow-up protocols according to the adopted therapy, as novel recent therapies (targeted and immunotherapies) are being increasingly used. Key MessagesProper staging is of utmost importance because it provides accurate prognostic estimation. Several crucial decisions, such as the treatment choice and the follow up strategy, are based on the tumor stage.Physical examination during staging procedure and follow-up visits are important to avoid unnecessary imaging and laboratory tests that could increase the patients' anxiety. A personalized approach taking into consideration the patient's risk factors, is strongly recommended.Melanoma patients should be kept under surveillance lifelong due to an increased risk of developing a second primary melanoma and the risk of recurrence. Higher intensity follow-up strategies during the first 5 years are recommended due to higher rates of regional or distant relapse.
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Affiliation(s)
- Chryssoula Papageorgiou
- Second Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Zoe Apalla
- Second Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Sofia-Magdalini Manoli
- First Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Konstantinos Lallas
- First Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Efstratios Vakirlis
- First Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Aimilios Lallas
- First Dermatology Department, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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8
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Michaeli T, Michaeli D. Prostate cancer follow-up costs in Germany from 2000 to 2015. J Cancer Surviv 2021; 16:86-94. [PMID: 33646503 PMCID: PMC8881276 DOI: 10.1007/s11764-021-01006-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/12/2021] [Indexed: 12/30/2022]
Abstract
Purpose The main objective of this study is to estimate and evaluate 10-year follow-up costs after prostate cancer treatment with curative (surgery, radiotherapy) and non-curative intent (hormone, androgen deprivation) per patient in Germany in 2000, 2008, and 2015. Methods Prostate cancer follow-up recommendations were extracted from the European Association of Urology guidelines from 2000 to 2015. Per patient costs were calculated with a detailed micro-costing approach considering direct and indirect medical expenses. Input parameters were derived from expert interviews, literature research, and official scales of tariffs. Costs for insurers, providers, and payers were included to estimate societal costs. Results Mean 10-year follow-up costs per patient after treatment with curative intent amounted to EUR 4415 in 2000, EUR 4224 in 2008 (p < 0.001), and EUR 5159 in 2015 (p < 0.001). Costs after hormone therapy with metastasis cumulated to EUR 10,846 in 2000, EUR 9818 in 2008 (p < 0.001), and EUR 11,978 in 2015 (p < 0.001). While insurers covered 37% of costs in 2000 (EUR 1664), only 23% of costs were reimbursed in 2015 (EUR 1195; p < 0.001). Cost sources mainly included consultations (55%), transportation (18%), and imaging (27%). Conclusion Early detection and advances in prostate cancer treatment increased 10-year survival rates beyond 80% in Germany, ultimately expanding the number of survivors requiring follow-up. Statutory insurers reacted by decreasing the reimbursement rates to reduce per patient cost by up to 46%. Consequently, the economic burden was mainly shifted to payers and providers. Implications for Cancer Survivors Equitable and effective follow-up schedules covered by insurance funds are necessary to care for prostate cancer patients.
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Affiliation(s)
- Thomas Michaeli
- Fifth Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Michaeli
- Fifth Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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9
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Howard MD. Melanoma Radiological Surveillance: A Review of Current Evidence and Clinical Challenges. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2020; 93:207-213. [PMID: 32226349 PMCID: PMC7087071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Melanoma is a common cancer in both young and older populations in many western countries. Rates of melanoma diagnosis worldwide are increasing. With the introduction of both targeted and immunotherapies there have been dramatic improvements in the care of patients with metastatic melanoma. With these new therapies being increasingly offered to patients with stage III metastatic melanoma and stage IV disease, radiological surveillance of melanoma has become a widely used method of monitoring melanoma patients for early locoregional and distant metastasis. However, concerns have been raised about risk of false positive results, which patients to consider radiological surveillance for, and at what intervals to do so. To date, there are no published review articles on the topic of radiological surveillance in melanoma patients identified in the MEDLINE database. A comprehensive literature review was performed by searching the MEDLINE database to review all published works on this topic. This article aims to present an extensive review of literature surrounding radiological surveillance in melanoma patients, a discussion of controversies, and recommendations for surveillance modalities.
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Affiliation(s)
- Matthew David Howard
- Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Dermatology, Monash Health, Clayton, Victoria, Australia
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10
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Lewin J, Sayers L, Kee D, Walpole I, Sanelli A, Te Marvelde L, Herschtal A, Spillane J, Gyorki D, Speakman D, Estall V, Donahoe S, Pohl M, Pope K, Chua M, Sandhu S, McArthur GA, McCormack CJ, Henderson M, Hicks RJ, Shackleton M. Surveillance imaging with FDG-PET/CT in the post-operative follow-up of stage 3 melanoma. Ann Oncol 2019; 29:1569-1574. [PMID: 29659679 DOI: 10.1093/annonc/mdy124] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background As early detection of recurrent melanoma maximizes treatment options, patients usually undergo post-operative imaging surveillance, increasingly with FDG-PET/CT (PET). To assess this, we evaluated stage 3 melanoma patients who underwent prospectively applied and sub-stage-specific schedules of PET surveillance. Patients and methods From 2009, patients with stage 3 melanoma routinely underwent PET +/- MRI brain scans via defined schedules based on sub-stage-specific relapse probabilities. Data were collected regarding patient characteristics and outcomes. Contingency analyses were carried out of imaging outcomes. Results One hundred and seventy patients (stage 3A: 34; 3B: 93; 3C: 43) underwent radiological surveillance. Relapses were identified in 65 (38%) patients, of which 45 (69%) were asymptomatic. False-positive imaging findings occurred in 7%, and 6% had treatable second (non-melanoma) malignancies. Positive predictive values (PPV) of individual scans were 56%-83%. Negative scans had predictive values of 89%-96% for true non-recurrence [negative predictive values (NPV)] until the next scan. A negative PET at 18 months had NPVs of 80%-84% for true non-recurrence at any time in the 47-month (median) follow-up period. Sensitivity and specificity of the overall approach of sub-stage-specific PET surveillance were 70% and 87%, respectively. Of relapsed patients, 33 (52%) underwent potentially curative resection and 10 (16%) remained disease-free after 24 months (median). Conclusions Application of sub-stage-specific PET in stage 3 melanoma enables asymptomatic detection of most recurrences, has high NPVs that may provide patient reassurance, and is associated with a high rate of detection of resectable and potentially curable disease at relapse.
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Affiliation(s)
- J Lewin
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia; Princess Margaret Cancer Centre, Toronto, Canada
| | - L Sayers
- Cancer Treatment and Development Laboratory, Peter MacCallum Cancer Centre, Victoria, Australia
| | - D Kee
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia
| | - I Walpole
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia
| | - A Sanelli
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia
| | - L Te Marvelde
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Victoria, Australia
| | - A Herschtal
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Victoria, Australia
| | - J Spillane
- Department of Surgery, Peter MacCallum Cancer Centre, Victoria, Australia
| | - D Gyorki
- Department of Surgery, Peter MacCallum Cancer Centre, Victoria, Australia; Department of Surgery, St Vincent's Hospital, Victoria, Australia
| | - D Speakman
- Department of Surgery, Peter MacCallum Cancer Centre, Victoria, Australia
| | - V Estall
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - S Donahoe
- Department of Surgery, Peter MacCallum Cancer Centre, Victoria, Australia
| | - M Pohl
- Department of Surgery, Peter MacCallum Cancer Centre, Victoria, Australia
| | - K Pope
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - M Chua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - S Sandhu
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia
| | - G A McArthur
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - C J McCormack
- Department of Dermatology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - M Henderson
- Department of Surgery, Peter MacCallum Cancer Centre, Victoria, Australia; Department of Surgery, St Vincent's Hospital, Victoria, Australia
| | - R J Hicks
- Department of Surgery, St Vincent's Hospital, Victoria, Australia; Department of Cancer Imaging, Peter MacCallum Cancer Centre, Victoria, Australia
| | - M Shackleton
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, Victoria, Australia; Cancer Treatment and Development Laboratory, Peter MacCallum Cancer Centre, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia; Department of Pathology, The University of Melbourne, Victoria, Australia; Department of Oncology, Alfred Health, Victoria, Australia; Central Clinical School, Faculty of Medicine, Nursing and Allied Health, Monash University, Victoria, Australia.
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11
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Abstract
Primary cutaneous melanoma describes any primary melanoma lesion of the skin that does not have evidence of metastatic disease. This article reviews the current workup, treatment, and follow-up recommendations for primary cutaneous melanoma (stages 0, I, and II). Specific attention is focused on recent updates with regard to staging, sentinel lymph node biopsy, and surgical modalities.
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12
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Dinnes J, Ferrante di Ruffano L, Takwoingi Y, Cheung ST, Nathan P, Matin RN, Chuchu N, Chan SA, Durack A, Bayliss SE, Gulati A, Patel L, Davenport C, Godfrey K, Subesinghe M, Traill Z, Deeks JJ, Williams HC. Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma. Cochrane Database Syst Rev 2019; 7:CD012806. [PMID: 31260100 PMCID: PMC6601698 DOI: 10.1002/14651858.cd012806.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used. OBJECTIVES Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles. SELECTION CRITERIA We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity. MAIN RESULTS We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT. AUTHORS' CONCLUSIONS Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | | | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Seau Tak Cheung
- Dudley Hospitals Foundation Trust, Corbett HospitalDepartment of DermatologyWicarage RoadStourbridgeUKDY8 4JB
| | - Paul Nathan
- Mount Vernon HospitalMount Vernon Cancer CentreRickmansworth RoadNorthwoodUKHA6 2RN
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Sue Ann Chan
- City HospitalBirmingham Skin CentreDudley RdBirminghamUKB18 7QH
| | - Alana Durack
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation TrustDermatologyHills RoadCambridgeUKCB2 0QQ
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Abha Gulati
- Barts Health NHS TrustDepartment of DermatologyWhitechapelLondonUKE11BB
| | - Lopa Patel
- Royal Stoke HospitalPlastic SurgeryStoke‐on‐TrentStaffordshireUKST4 6QG
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Manil Subesinghe
- King's College LondonCancer Imaging, School of Biomedical Engineering & Imaging SciencesLondonUK
| | - Zoe Traill
- Oxford University Hospitals NHS TrustChurchill Hospital Radiology DepartmentOxfordUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Brooks WC, Votanopoulos KI, Russell GB, Shen P, Levine EA. Evaluation of Chest Radiographs and Laboratory Testing during Melanoma Staging Procedures. Am Surg 2019; 85:505-510. [PMID: 31126364 PMCID: PMC6743493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Chest radiographs (CXRs) and laboratory testing have historically been performed as a part of low-risk melanoma (clinical stage 1/2) workup. This study evaluates the utility of routine CXRs and laboratory testing during the staging of clinical stage 1 and 2 melanoma patients. This study was approved by the Institutional Review Board at Wake Forest University. A database of sentinel lymph node biopsies performed for clinical stage 1 or 2 melanoma was used to identify early-stage melanoma patients. The medical records of patients with melanoma were reviewed and preoperative workup procedures were recorded. Four hundred sixty-three patients were reviewed. A total of 315 patients underwent a preoperative CXR, whereas 309 received some laboratory testing. After sentinel node biopsies, 168 patients had pathologic stage 1 disease, 103 stage 2, and 44 stage 3. None of the CXRs (0%) correctly identified metastatic melanoma. Suspicious locations on CXRs and laboratory testing did not lead to metastatic findings in any patient within a year. Metastatic melanoma was not found in any patient by screening with CXRs or laboratory testing during preoperative workup. We recommend not conducting CXRs or laboratory testing during workup for surgical melanoma patients because of charges and anxiety these tests can cause. CXRs, blood tests, and metabolic panels have historically been ordered for early melanoma patients, although debate remains on their efficacy. Surgical patient records were retrospectively reviewed for these tests and no benefit was found.
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14
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Brooks WC, Votanopoulos KI, Russell GB, Shen P, Levine EA. Evaluation of Chest Radiographs and Laboratory Testing during Melanoma Staging Procedures. Am Surg 2019. [DOI: 10.1177/000313481908500528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Chest radiographs (CXRs) and laboratory testing have historically been performed as a part of low-risk melanoma (clinical stage 1/2) workup. This study evaluates the utility of routine CXRs and laboratory testing during the staging of clinical stage 1 and 2 melanoma patients. This study was approved by the Institutional Review Board at Wake Forest University. A database of sentinel lymph node biopsies performed for clinical stage 1 or 2 melanoma was used to identify early-stage melanoma patients. The medical records of patients with melanoma were reviewed and pre-operative workup procedures were recorded. Four hundred sixty-three patients were reviewed. A total of 315 patients underwent a preoperative CXR, whereas 309 received some laboratory testing. After sentinel node biopsies, 168 patients had pathologic stage 1 disease, 103 stage 2, and 44 stage 3. None of the CXRs (0%) correctly identified metastatic melanoma. Suspicious locations on CXRs and laboratory testing did not lead to metastatic findings in any patient within a year. Metastatic melanoma was not found in any patient by screening with CXRs or laboratory testing during preoperative workup. We recommend not conducting CXRs or laboratory testing during workup for surgical melanoma patients because of charges and anxiety these tests can cause. CXRs, blood tests, and metabolic panels have historically been ordered for early melanoma patients, although debate remains on their efficacy. Surgical patient records were retrospectively reviewed for these tests and no benefit was found.
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Affiliation(s)
- Wilson C. Brooks
- Surgical Oncology Service, Departments of General Surgery and Surgical Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Konstantinos I. Votanopoulos
- Surgical Oncology Service, Departments of General Surgery and Surgical Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Gregory B. Russell
- Surgical Oncology Service, Departments of General Surgery and Surgical Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Perry Shen
- Surgical Oncology Service, Departments of General Surgery and Surgical Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Edward A. Levine
- Surgical Oncology Service, Departments of General Surgery and Surgical Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
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15
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Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol 2018; 80:208-250. [PMID: 30392755 DOI: 10.1016/j.jaad.2018.08.055] [Citation(s) in RCA: 328] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/12/2022]
Abstract
The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.
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Affiliation(s)
- Susan M Swetter
- Department of Dermatology, Stanford University Medical Center and Cancer Institute, Stanford, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
| | - Hensin Tsao
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Wellman Center for Photomedicine, Boston, Massachusetts
| | - Christopher K Bichakjian
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan; Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Clara Curiel-Lewandrowski
- Division of Dermatology, University of Arizona, Tucson, Arizona; University of Arizona Cancer Center, Tucson, Arizona
| | - David E Elder
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; Department of Cancer Biology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Pathology, University of Connecticut Health Center, Farmington, Connecticut; Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut
| | - Allan C Halpern
- Department of Dermatology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy M Johnson
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan; Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Arthur J Sober
- Department of Dermatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - John A Thompson
- Division of Oncology, University of Washington, Seattle, Washington; Seattle Cancer Care Alliance, Seattle, Washington
| | - Oliver J Wisco
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | | | - Shasa Hu
- Department of Dermatology, University of Miami Health System, Miami, Florida
| | - Toyin Lamina
- American Academy of Dermatology, Rosemont, Illinois
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16
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Podlipnik S, Moreno-Ramírez D, Carrera C, Barreiro A, Manubens E, Ferrandiz-Pulido L, Sánchez M, Vidal-Sicart S, Malvehy J, Puig S. Cost-effectiveness analysis of imaging strategy for an intensive follow-up of patients with American Joint Committee on Cancer stage IIB, IIC and III malignant melanoma. Br J Dermatol 2018; 180:1190-1197. [PMID: 29876940 DOI: 10.1111/bjd.16833] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Many follow-up guidelines for patients with high-risk melanoma include expensive imaging studies, serum biomarkers and regular visits to the dermatologist, with little attention to cost-effectiveness. OBJECTIVES To establish the cost-effectiveness of chest-abdomen-pelvis computed tomography (CT) and brain magnetic resonance imaging (MRI) in a follow-up protocol for patients at high risk of relapse. METHODS This was a prospective single-centre cohort study of 290 patients with clinicopathological American Joint Committee on Cancer (AJCC) stage IIB, IIC and III melanoma. Patients had a body CT scan and brain MRI every 6 months and were withdrawn from the study after completing a 5-year follow-up or when metastases were detected. A cost-effectiveness analysis for each follow-up radiological procedure was performed. RESULTS Patients underwent 1805 body CT scans and 1683 brain MRIs. Seventy-six metastases (26·2%) were identified by CT or MRI. CT scan was cost-effective in the first 4 years (cost-effectiveness ratio €4710·70-€14 437·10/patient with metastasis); brain MRI was cost-effective during the first year (cost-effectiveness ratio €14 090·60/patient with metastasis). Limitations included lack of survival analysis and comparisons with willingness-to-pay thresholds. CONCLUSIONS Six-monthly CT scan of the chest, abdomen and pelvis is a cost-effective technique for the early detection of metastases in the first 4 years of follow-up in patients with AJCC stage IIC and III melanoma, and in the first 3 years in patients with AJCC stage IIB melanoma. In addition, brain MRI has been shown to be cost-effective only in the first year of follow-up in patients with AJCC stage IIC and III melanoma.
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Affiliation(s)
- S Podlipnik
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - D Moreno-Ramírez
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - C Carrera
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,CIBER on Rare Diseases, Instituto de Salud Carlos III, Barcelona, Spain
| | - A Barreiro
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - E Manubens
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - L Ferrandiz-Pulido
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - M Sánchez
- Department of Radiology, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - S Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clinic of Barcelona, University of Barcelona, Spain
| | - J Malvehy
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,CIBER on Rare Diseases, Instituto de Salud Carlos III, Barcelona, Spain
| | - S Puig
- Department of Dermatology , Hospital Clinic of Barcelona, University of Barcelona, Spain.,Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,CIBER on Rare Diseases, Instituto de Salud Carlos III, Barcelona, Spain
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Velazquez-Campoy A, Vega S, Sanchez-Gracia O, Lanas A, Rodrigo A, Kaliappan A, Hall MB, Nguyen TQ, Brock GN, Chesney JA, Garbett NC, Abian O. Thermal liquid biopsy for monitoring melanoma patients under surveillance during treatment: A pilot study. Biochim Biophys Acta Gen Subj 2018; 1862:1701-1710. [PMID: 29705200 PMCID: PMC6483604 DOI: 10.1016/j.bbagen.2018.04.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/13/2018] [Accepted: 04/24/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Differential Scanning Calorimetry (DSC) is a technique traditionally used to study thermally induced macromolecular transitions, and it has recently been proposed as a novel approach for diagnosis and monitoring of several diseases. We report a pilot study applying Thermal Liquid Biopsy (TLB, DSC thermograms of plasma samples) as a new clinical approach for diagnostic assessment of melanoma patients. METHODS Multiparametric analysis of DSC thermograms of patient plasma samples collected during treatment and surveillance (63 samples from 10 patients) were compared with clinical and diagnostic imaging assessment to determine the utility of thermograms for diagnostic assessment in melanoma. Nine of the ten patients were stage 2 or 3 melanoma subjects receiving adjuvant therapy after surgical resection of their melanomas. The other patient had unresectable stage 4 melanoma and was treated with immunotherapy. Two reference groups were used: (A) 36 healthy subjects and (B) 13 samples from 8 melanoma patients who had completed successful surgical management of their disease and were determined by continued clinical assessment to have no evidence of disease. RESULTS Plasma thermogram analysis applied to melanoma patients generally agrees with clinical evaluation determined by physical assessment or diagnostic imaging (~80% agreement). No false negatives were obtained from DSC thermograms. Importantly, this methodology was able to detect changes in disease status before it was identified clinically. CONCLUSIONS Thermal Liquid Biopsy could be used in combination with current clinical assessment for the earlier detection of melanoma recurrence and metastasis. GENERAL SIGNIFICANCE TLB offers advantages over current diagnostic techniques (PET/CT imaging), limited in frequency by radiation burden and expense, in providing a minimally-invasive, low-risk, low-cost clinical test for more frequent personalized patient monitoring to assess recurrence and facilitate clinical decision-making.
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Affiliation(s)
- Adrian Velazquez-Campoy
- Institute of Biocomputation and Physics of Complex Systems (BIFI), Joint Units IQFR-CSIC-BIFI, and GBsC-CSIC-BIFI, Universidad de Zaragoza, Zaragoza 50018, Spain; Department of Biochemistry and Molecular and Cell Biology, Universidad de Zaragoza, Zaragoza 50009, Spain; Aragon Institute for Health Research (IIS Aragon), Zaragoza, 50009, Spain; Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Fundacion ARAID, Government of Aragon, Zaragoza 50018, Spain.
| | - Sonia Vega
- Institute of Biocomputation and Physics of Complex Systems (BIFI), Joint Units IQFR-CSIC-BIFI, and GBsC-CSIC-BIFI, Universidad de Zaragoza, Zaragoza 50018, Spain
| | | | - Angel Lanas
- Aragon Institute for Health Research (IIS Aragon), Zaragoza, 50009, Spain; Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, 50009, Spain; Department of Medicine, University of Zaragoza, Spain
| | | | - Alagammai Kaliappan
- James Graham Brown Cancer Center, Department of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Melissa Barousse Hall
- James Graham Brown Cancer Center, Department of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Taylor Q Nguyen
- James Graham Brown Cancer Center, Department of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Guy N Brock
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Jason A Chesney
- James Graham Brown Cancer Center, Department of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Nichola C Garbett
- James Graham Brown Cancer Center, Department of Medicine, University of Louisville, Louisville, KY 40202, USA.
| | - Olga Abian
- Institute of Biocomputation and Physics of Complex Systems (BIFI), Joint Units IQFR-CSIC-BIFI, and GBsC-CSIC-BIFI, Universidad de Zaragoza, Zaragoza 50018, Spain; Department of Biochemistry and Molecular and Cell Biology, Universidad de Zaragoza, Zaragoza 50009, Spain; Aragon Institute for Health Research (IIS Aragon), Zaragoza, 50009, Spain; Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto Aragonés de Ciencias de la Salud (IACS), Zaragoza 50009, Spain.
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18
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Lim WY, Turner RM, Morton RL, Jenkins MC, Irwig L, Webster AC, Dieng M, Saw RPM, Guitera P, Low D, Low C, Bell KJL. Use of shared care and routine tests in follow-up after treatment for localised cutaneous melanoma. BMC Health Serv Res 2018; 18:477. [PMID: 29925350 PMCID: PMC6011416 DOI: 10.1186/s12913-018-3291-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/11/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients may decide to undertake shared care with a general practitioner (GP) during follow-up after treatment for localised melanoma. Routine imaging tests for surveillance may be commonly used despite no evidence of clinical utility. This study describes the frequency of shared care and routine tests during follow-up after treatment for localised melanoma. METHODS We randomly sampled 351 people with localised melanoma [American Joint Cancer Committee (AJCC) substages 0 - II] who had not had recurrent or new primary melanoma diagnosed from a total of 902 people diagnosed and treated for localised melanoma at a specialist centre in 2014. We interviewed participants by telephone about their experience of follow-up in the past year, and documented the proportion of patients who were undertaking shared care follow-up with a GP. We also recorded the frequency and type of investigations during follow-up. We calculated weighted estimates that are representative of the full inception cohort. RESULTS Of the 351 people who were invited to participate, 230 (66%) people consented to the telephone interview. The majority undertook shared care follow-up with a GP (61%). People who choose to have shared care follow-up with a GP are more likely to be male (p = 0.006), have lower AJCC stage (p for trend = 0.02), reside in more remote areas (p for trend< 0.001), and are less likely to have completed secondary school (p < 0.001). Few people saw a non-doctor health practitioner as part of their follow-up (9%). Many people report undergoing tests for melanoma, much of which may be routine tests for surveillance (37%). CONCLUSIONS The majority of people treated for a first primary localised melanoma at a specialist centre, without recurrent or new melanoma, choose to undertake shared care follow-up with a GP. Many appear to have routine diagnostic imaging as part of their melanoma surveillance.
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Affiliation(s)
- Wei-Yin Lim
- Clinical Research Centre Perak, Ministry of Health Malaysia, Ipoh, Perak Malaysia
- School of Public Health, The University of Sydney, Sydney, NSW Australia
| | - Robin M. Turner
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Rachael L. Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW Australia
| | - Marisa C. Jenkins
- School of Public Health, The University of Sydney, Sydney, NSW Australia
| | - Les Irwig
- School of Public Health, The University of Sydney, Sydney, NSW Australia
| | - Angela C. Webster
- School of Public Health, The University of Sydney, Sydney, NSW Australia
| | - Mbathio Dieng
- School of Public Health, The University of Sydney, Sydney, NSW Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW Australia
| | - Robyn P. M. Saw
- Melanoma Institute Australia, Sydney, NSW Australia
- Discipline of Surgery, The University of Sydney, Sydney, NSW Australia
- Division of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW Australia
| | - Pascale Guitera
- Melanoma Institute Australia, Sydney, NSW Australia
- Discipline of Dermatology, The University of Sydney, Sydney, NSW Australia
- The Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Camperdown, NSW Australia
| | - Donald Low
- Cancer Voices NSW, Sydney, NSW Australia
| | | | - Katy J. L. Bell
- School of Public Health, The University of Sydney, Sydney, NSW Australia
- Centre for Evidence Based Practice, Bond University, Gold Coast, QLD Australia
- The University of Sydney, Rm 333 Edward Ford Building (A27), Sydney, NSW 2006 Australia
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Barbieri M, Richardson G, Paisley S. The cost-effectiveness of follow-up strategies after cancer treatment: a systematic literature review. Br Med Bull 2018; 126:85-100. [PMID: 29659715 DOI: 10.1093/bmb/ldy011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/18/2018] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The cost of treatment and follow-up of cancer patients in the UK is substantial. In a budget-constrained system such as the NHS, it is necessary to consider the cost-effectiveness of the range of management strategies at different points on cancer patients' care pathways to ensure that they provide adequate value for money. SOURCES OF DATA We conducted a systematic literature review to explore the cost-effectiveness of follow-up strategies of patients previously treated for cancer with the aim of informing UK policy. All papers that were considered to be economic evaluations in the subject areas described above were extracted. AREAS OF AGREEMENT The existing literature suggests that intensive follow-up of patients with colorectal disease is likely to be cost-effective, but the opposite holds for breast cancer. AREAS OF CONTROVERSY Interventions and strategies for follow-up in cancer patients were variable across type of cancer and setting. Drawing general conclusions about the cost-effectiveness of these interventions/strategies is difficult. GROWING POINTS The search identified 2036 references but applying inclusion/exclusion criteria a total of 44 articles were included in the analysis. Breast cancer was the most common (n = 11) cancer type followed by colorectal (n = 10) cancer. In general, there were relatively few studies of cost-effectiveness of follow-up that could influence UK guidance. Where there was evidence, in the most part, NICE guidance broadly reflected this evidence. AREAS TIMELY TO DEVELOP RESEARCH In terms of future research around the timing, frequency and composition of follow-ups, this is dependent on the type of cancer being considered. Nevertheless, across most cancers, the possibility of remote follow-up (or testing) by health professionals other than hospital consultants in other settings appears to warrant further work.
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Affiliation(s)
- M Barbieri
- Centre for Health Economics, University of York, Heslington, York, UK
| | - G Richardson
- Centre for Health Economics, University of York, Heslington, York, UK
| | - S Paisley
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, UK
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20
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Kukar M, Gabriel E, May R, Cho E, Lichtenthal M, Groman A, Skitzki J, Francescutti V, Kane JM. Conditional Survival-Based “Abbreviated” Routine Cancer Surveillance for Pathologic Stage IB Melanoma. Am Surg 2017. [DOI: 10.1177/000313481708301128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A negative sentinel lymph node biopsy (SLNB) for stage IB (T1b/T2a N0) melanoma would predict an excellent long-term prognosis. Combined with the concept of conditional survival, an “abbreviated” cancer surveillance strategy was implemented to reduce the number of visits and total length of follow-up. Retrospective review of all pathologic stage IB melanoma patients (negative SLNB) at a single institution between 2006 and 2008 after implementation of an “abbreviated” cancer surveillance; clinic visits every six months for five years followed by one annual visit (total follow-up six years). Patient demographics, tumor characteristics, and information regarding recurrences were obtained. Recurrence-free, disease-specific, and overall survival were calculated. Eighty-seven patients underwent the “abbreviated” cancer surveillance. Median age was 55.4 years and 50.6 per cent were male. Median Breslow thickness was 1.1 mm (range 0.5–2.0 mm) and 1.1 per cent were ulcerated. Primary tumor site was 49 per cent extremities, 39 per cent trunk, and 12 per cent head/ neck. Median follow-up was 68.6 months. Five-year recurrence-free, disease-specific, and overall survivals were 89, 95, and 88 per cent, respectively. During surveillance, 10 patients had concerning symptoms or physical findings prompting subsequent workup, all of which were negative for recurrence/metastases. There were only three true melanoma recurrences; all were distant metastases and presented symptomatically between scheduled follow-up visits. In light of the excellent prognosis for pathologic (SLNB negative) stage IB melanoma, an “abbreviated” cancer surveillance schedule based on conditional survival would reduce both direct and indirect costs in this cohort. The few recurrences were symptomatic and unlikely to have changed with more intensive surveillance.
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Affiliation(s)
- Moshim Kukar
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Emmanuel Gabriel
- Department of Surgery, Section of Surgical Oncology, Mayo Clinic Florida, Jacksonville, Florida; and the
| | - Rebecca May
- Department of Surgery, State University of New York, Buffalo, New York
| | - Edward Cho
- Department of Surgery, State University of New York, Buffalo, New York
| | - Michelle Lichtenthal
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Adrienne Groman
- Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, New York
| | - Joseph Skitzki
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Valerie Francescutti
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - John M. Kane
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
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21
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Rubio-Rodríguez D, De Diego Blanco S, Pérez M, Rubio-Terrés C. Cost-Effectiveness of Drug Treatments for Advanced Melanoma: A Systematic Literature Review. PHARMACOECONOMICS 2017; 35:879-893. [PMID: 28551858 DOI: 10.1007/s40273-017-0517-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Until recently, advanced melanoma (unresectable and metastatic) has had a poor prognosis and has been treated with chemotherapy. The introduction of new treatments (BRAF and MEK inhibitors and immunotherapy) has improved overall survival and progression-free survival of some patients. OBJECTIVE The objective of this study was to review the published evidence on the cost-effectiveness of pharmacological treatments for advanced melanoma. METHODS A systematic literature search was conducted, without date or language restrictions, in PubMed, EMBASE, Scopus, the Cochrane Library, the UK National Institute for Health and Care Excellence databases and the Health Technology Assessment journal. Internet searches were also made to identify possible grey literature. Main study characteristics, methods and outcomes were extracted and critically assessed. The quality of health economic studies was assessed by the Quality Assessment of Economic Evaluation in Health Care checklist. RESULTS The search identified nine full-text pharmacoeconomic analyses of advanced melanoma treatments. According to the economic analyses published in the articles, the new treatments have been shown to be more effective (with more life-years and quality-adjusted life-years) than chemotherapy, although generally the cost per quality-adjusted life-year gained was above the commonly accepted threshold. Because of the variability of the available analyses comparing the new treatments, we cannot determine which treatment is the most cost-effective. CONCLUSIONS From the available data, it cannot be concluded that the new drugs (BRAF and MEK inhibitors and immunotherapy) are cost effective compared with chemotherapy or which is the most cost-effective new treatment.
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Affiliation(s)
| | | | - Maite Pérez
- Medical Department, AstraZeneca Farmacéutica Spain, Barcelona, Spain
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22
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Zitzelsberger T, Eigentler TK, Krumm P, Nikolaou K, Garbe C, Gawaz M, Klumpp B. Imaging characteristics of cardiac metastases in patients with malignant melanoma. Cancer Imaging 2017; 17:19. [PMID: 28666473 PMCID: PMC5493885 DOI: 10.1186/s40644-017-0122-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/26/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Due to prolonged survival and technical advances in CT imaging, cardiac metastases in patients with malignant melanoma are observed more frequently nowadays. The aim of the present study was to assess the anatomic distribution as well as the morphologic and histologic appearance of cardiac metastases from malignant melanoma. METHODS Twenty five patients with known metastasized melanoma and with incidental finding of cardiac metastases during routine staging CT were retrospectively included in this study. CT images were assessed for the presence, localization and extent of cardiac metastases. Histological results, mutational analysis and tumor markers were reviewed. RESULTS Fourteen out of 25 patients presented with singular cardiac mass (56%), whereas ten patients (40%) presented with multifocal and one patient with disseminated cardiac metastases. Twelve patients presented with endocardial (48%), eight with myocardial and two with pericardial metastases. Most frequent site involved in endocardial metastases was the right atrium (67%) followed by the right ventricle (33%). There seems to be a correlation between histological subtype and location of cardiac metastasis. Median survival after diagnosis of cardiac metastases was 8 months, with no significant difference regarding the localization of metastases within the heart. CONCLUSION Cardiac metastases can involve every part of the heart possibly in dependence of histological subtype. The awareness of different types of cardiac metastases and their characteristic appearance on CT images is necessary for further investigations and might contribute to targeted therapy.
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Affiliation(s)
- Tanja Zitzelsberger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Thomas K. Eigentler
- Eberhard-Karls-University Tuebingen, Center for Dermatooncology, Liebermeisterstr. 25, 72076 Tuebingen, Germany
| | - Patrick Krumm
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Claus Garbe
- Eberhard-Karls-University Tuebingen, Center for Dermatooncology, Liebermeisterstr. 25, 72076 Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Bernhard Klumpp
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
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23
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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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24
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Stodell M, Thompson JF, Emmett L, Uren RF, Kapoor R, Saw RPM. Melanoma patient imaging in the era of effective systemic therapies. Eur J Surg Oncol 2017. [PMID: 28625798 DOI: 10.1016/j.ejso.2017.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Imaging plays a critical role in the current multi-disciplinary management of patients with melanoma. It is used for primary disease staging, surgical planning, and surveillance in high-risk patients, and for monitoring the effects of systemic or loco-regional therapies. Several different imaging modalities have been utilised in the past. Contemporary imaging practises vary geographically depending on clinical guidelines, physician preferences, availability and cost. Targeted therapies and immunotherapies have revolutionised the treatment of patients with metastatic melanoma over the last few years. With this have come new patterns of disease that were not observed after conventional therapies, and new criteria to assess therapeutic responses. In this article we review the role of imaging for patients with melanoma in the era of effective systemic therapies and discuss likely future developments.
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Affiliation(s)
- M Stodell
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - J F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia; Division of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - L Emmett
- Garvan Institute of Medical Research, Discipline of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - R F Uren
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Alfred Nuclear Medicine and Ultrasound, Newtown, NSW, Australia
| | - R Kapoor
- Mater Imaging, The Mater Hospital Sydney, North Sydney, NSW, Australia
| | - R P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia; Division of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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25
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Park TS, Phan GQ, Yang JC, Kammula U, Hughes MS, Trebska-McGowan K, Morton KE, White DE, Rosenberg SA, Sherry RM. Routine Computer Tomography Imaging for the Detection of Recurrences in High-Risk Melanoma Patients. Ann Surg Oncol 2017; 24:947-951. [PMID: 28144760 PMCID: PMC5339323 DOI: 10.1245/s10434-017-5768-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND The use of routine CT imaging for surveillance in asymptomatic patients with cutaneous melanoma is controversial. We report our experience using a surveillance strategy that included CT imaging for a cohort of patients with high-risk melanoma. METHODS A total of 466 patients with high-risk cutaneous melanoma enrolled in adjuvant immunotherapy trials were followed for tumor progression by physical examination, labs, and CT imaging as defined by protocol. Evaluations were obtained at least every 6 months for year 1, every 6 months for year 2, and then annually for the remainder of the 5-year study. Time to tumor progression, sites of recurrence, and the method of relapse detection were identified. RESULTS The patient cohort consisted of 115 stage II patients, 328 stage III patients, and 23 patients with resected stage IV melanoma. The medium time to progression for the 225 patients who developed tumor progression was 7 months. Tumor progression was detected by patients, physician examination or routine labs, or by CT imaging alone in 27, 14, and 59% of cases respectively. Melanoma recurrences were noted to be locoregional in 36% of cases and systemic in 64% of cases. Thirty percent of patients with locoregional relapse and 75% of patients with systemic relapse were detected solely by CT imaging. CONCLUSIONS CT imaging alone detected the majority of sites of disease progression in our patients with high-risk cutaneous melanoma. This disease was not heralded by symptoms, physical examination, or blood work. Although the benefit of the early detection of advanced melanoma is unknown, this experience is relevant because of the rapid development and availability of potentially curative immunotherapies.
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Affiliation(s)
- Tristen S Park
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Giao Q Phan
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James C Yang
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Udai Kammula
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marybeth S Hughes
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kasia Trebska-McGowan
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kathleen E Morton
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Donald E White
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Steven A Rosenberg
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Richard M Sherry
- Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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Abstract
BACKGROUND After appropriate initial therapy for patients with stage II-III melanoma, there is no consensus regarding surveillance. Thus, follow-up is highly variable among institutions and individual providers. The National Comprehensive Cancer Network recommends routine clinical examination and consideration of imaging for stage IIB-IIIC every 3-12 mo with no distinction between stages. Detection of recurrence is important as novel systemic therapies and surgical resection of recurrence may provide survival benefits. METHODS We retrospectively reviewed 369 patients with stage II and III melanoma treated at Ohio State University from 2009-2015, who underwent surgery as primary therapy. Two hundred forty-seven patients who were followed for a minimum of 6 mo after surgical resection to achieve no evidence of disease status (NED) were included in this analysis. One hundred twenty-two were lost to follow-up after surgery and were excluded. RESULTS The rate of recurrence for stage IIA/IIB patients was 11% (14/125). Eleven of the 14 (79%) recurrences were detected by clinical symptoms or physical examination. Thirty-nine percent (49/125) of stage IIA or IIB patients were followed by clinical examination only, whereas 61% (76/125) were followed with at least two serial chest x-rays. The median time to first chest x-ray after NED status was 4.7 mo (n = 76), median time to second chest x-ray after NED status was 12.7 mo (n = 76), and 66% (50/76) continued to have additional serial chest x-rays. At median follow-up of 35 mo for the 125 patients with stage IIA/IIB, there was no difference in survival between those followed clinically (95% [95% CI: 0.88-0.99]) versus those followed with at least two serial x-rays (96% [95% CI: 0.89-0.98]). For stage IIC/IIIA-C patients, recurrence was detected in 23% (28/122) at median follow-up 31.2 mo. Fifty percent of recurrences were detected by imaging in asymptomatic patients, whereas 50% (14/28) had recurrence detected on imaging associated clinical findings. Eighty-seven percent (106/122) of stage IIC/IIIA-C patients were followed with at least two serial whole body positron emission tomography/computed tomography (CT) scans or whole body CT scans plus brain magnetic resonance imaging; median time between NED status and second scan was 10.3 mo. Of stage IIC/IIIA-C patients with recurrence, 57% (16/28) went on to surgical resection of the recurrence, whereas 11 (39%) patients received B-RAF inhibitor therapy, immune blockade therapy, or combination therapy. CONCLUSIONS For stage IIA and IIB melanoma, surveillance chest x-rays did not improve survival compared to physical examination alone. However, for stage IIC and IIIA-C melanoma, where the recurrence rates are higher, routine whole body imaging detected 50% of recurrences leading to additional surgery and/or treatment with novel systemic therapies for the majority of patients. Detection of melanoma recurrence is important and specific substage should be used to stratify risk and define appropriate follow-up.
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Lee AY, Droppelmann N, Panageas KS, Zhou Q, Ariyan CE, Brady MS, Chapman PB, Coit DG. Patterns and Timing of Initial Relapse in Pathologic Stage II Melanoma Patients. Ann Surg Oncol 2016; 24:939-946. [PMID: 27804026 DOI: 10.1245/s10434-016-5642-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Indexed: 01/26/2023]
Abstract
PURPOSE Pathologic stage II melanoma patients have variable outcomes when divided by substage. We hypothesized that an understanding of the patterns of initial relapse by substage will better inform follow-up guidelines. METHODS We performed a retrospective review of 738 adult patients with pathologic stage II cutaneous melanoma treated at Memorial Sloan Kettering Cancer Center between 1993 and 2013. Clinical records were reviewed to determine time, location, and method of detection of initial relapse. RESULTS At a median follow-up of 52 months, 219 patients relapsed. Relapses were detected more frequently in higher substages. Initial relapses were most commonly local/in-transit for IIA and IIB and systemic for IIC. Lung and brain were the most frequent sites of systemic relapse. Patient-detection was the most common method of relapse detection (59%) in all substages. The 5-year cumulative incidence for patient-detected relapse was 13.6% for IIA, 18.9% for IIB, and 23.3% for IIC and for image-detected relapse was 3.4, 7.9, and 16.6%, respectively. The 5-year cumulative incidence for physician-detected relapse was less than 10% across all substages and leveled off at 3 years for stage IIA and IIB and 2 years for stage IIC. CONCLUSIONS Relapses were most frequently patient-detected in all stage II substages, highlighting the importance of patient education and self-examination. The highest yield for routine imaging is in stage IIC patients during the first 4 years. Physician examination is unlikely to detect relapses beyond 3 years for stage IIA and IIB and beyond 2 years for stage IIC patients.
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Affiliation(s)
- Ann Y Lee
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,New York University School of Medicine, New York, NY, USA
| | - Nicolas Droppelmann
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Catholic University of Chile School of Medicine, Santiago, Chile
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charlotte E Ariyan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary S Brady
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Chapman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel G Coit
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Ipenburg NA, Nieweg OE, Uren RF, Thompson JF. Outcome of Melanoma Patients Who Did Not Proceed to Sentinel Node Biopsy After Preoperative Lymphoscintigraphy. Ann Surg Oncol 2016; 24:117-126. [PMID: 27480356 DOI: 10.1245/s10434-016-5458-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND At our institution, a planned sentinel node biopsy (SNB) procedure is occasionally canceled after preoperative lymphoscintigraphy. This study reports the frequency of this, the reasons, and the management and outcomes of these patients. METHODS All patients with clinically localized cutaneous melanoma treated at Melanoma Institute Australia between 2000 and 2009 whose planned SNB procedure was not undertaken after lymphoscintigraphy were included in this retrospective study. RESULTS Of the 3148 patients in whom the procedure had been planned, 203 patients (6.4 %) did not have a SNB. The main reason for not proceeding with SNB (in 84 % of cases) was the lymphoscintigraphic demonstration of multiple drainage fields and/or multiple sentinel nodes (SNs). Patients who did not proceed to SNB were significantly older than those who did, more often had melanomas of the head or neck, and had more SNs and more nodal drainage fields. Of the 203 patients, 181 (89 %) were followed with high-resolution ultrasound of their SNs, which identified 33 % of the nodal recurrences before they were clinically apparent. Patients whose SNB was canceled had significantly worse recurrence-free survival and regional node disease-free survival, but melanoma-specific survival was similar. Compared to SN-positive patients, node-positive patients without SNB had significantly more involved nodes when a delayed lymphadenectomy was performed, but melanoma-specific survival was not significantly different after a median follow-up of 42 months. CONCLUSIONS Lymphoscintigraphy with ultrasound follow-up of previously identified SNs is an acceptable management strategy for patients in whom a SNB procedure is likely to be challenging.
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Affiliation(s)
| | - Omgo E Nieweg
- Melanoma Institute Australia, North Sydney, NSW, Australia. .,Central Medical School, The University of Sydney, Sydney, NSW, Australia. .,The Mater Hospital, North Sydney and Royal Prince Alfred Hospital, Camperdown, Australia.
| | - Roger F Uren
- Central Medical School, The University of Sydney, Sydney, NSW, Australia.,Alfred Nuclear Medicine and Ultrasound, RPAH Medical Centre, Newtown, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, North Sydney, NSW, Australia.,Central Medical School, The University of Sydney, Sydney, NSW, Australia.,The Mater Hospital, North Sydney and Royal Prince Alfred Hospital, Camperdown, Australia
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Somda SM, Leconte E, Boher JM, Asselain B, Kramar A, Filleron T. Optimal scheduling of post-therapeutic follow-up of patients treated for cancer for early detection of relapses. Stat Methods Med Res 2016; 25:2457-2471. [DOI: 10.1177/0962280214524178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Post-therapeutic surveillance is one important component of cancer care. However, there still is no evidence-based strategies to schedule patients’ follow-up examinations. Our approach is based on the modeling of the probability of the onset of relapse at an early asymptotic or preclinical stage and its transition to a clinical stage. For that we consider a multistate homogeneous Markov model, which includes the natural history of relapse. The model also handles separately the different types of possible relapses. The optimal schedule is provided by the calendar visit that maximizes a utility function. The methodology has been applied to laryngeal cancer. The different follow-up strategies revealed to be more efficient than those proposed by different scientific societies.
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Affiliation(s)
- Serge Ma Somda
- Cellule de Biostatistique, Institut Claudius Regaud, Toulouse, France.,Centre MURAZ, Bobo Dioulasso, Burkina Faso
| | - Eve Leconte
- TSE (GREMAQ), Université Toulouse 1 Capitole, Toulouse, France
| | - Jean-Marie Boher
- Bureau des Etudes Cliniques, Institut Paoli Calmettes, Marseille, France
| | | | - Andrew Kramar
- Centre Oscar Lambret, Unité de Méthodologie et Biostatistique, Lille, France
| | - Thomas Filleron
- Cellule de Biostatistique, Institut Claudius Regaud, Toulouse, France
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30
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CT imaging of bone and bone marrow infiltration in malignant melanoma—Challenges and limitations for clinical staging in comparison to 18FDG-PET/CT. Eur J Radiol 2016; 85:732-8. [DOI: 10.1016/j.ejrad.2016.01.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/16/2016] [Indexed: 11/19/2022]
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31
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Barmpari ME, Savvidis C, Dede AD, Markogiannakis H, Dikoglou C, Xekouki P, Stratakis CA, Andreas M, Malaktari-Skarantavou S. Adrenal malignant melanoma masquerading as a pheochromocytoma in a patient with a history of a multifocal papillary and medullary thyroid carcinoma. Hormones (Athens) 2016; 15:283-290. [PMID: 27376430 PMCID: PMC6354246 DOI: 10.14310/horm.2002.1653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Adrenal masses usually represent benign and nonfunctional adrenal adenomas; however, primary or metastatic malignancy should also be considered. Discovery of an adrenal mass needs further evaluation in order to exclude malignancy and hormonal secretion. We present a rare case of a possibly primary adrenal malignant melanoma with imaging and biochemical features of a pheochromocytoma. CASE REPORT A 61-year-old male farmer was referred for evaluation of a mass in the right supraclavicular region and a left adrenal lesion. The patient had a history of a multifocal papillary and medullary thyroid carcinoma. Laboratory tests revealed increased 24hour urinary dopamine and also increased serum calcitonin and neuron specific enolase. A pathology report of the resected right supraclavicular mass and left adrenal showed a malignant melanoma. CONCLUSION This is a case of a possibly primary adrenal malignant melanoma with imaging and biochemical features of a pheochromocytoma. Although this case is very rare and there are rigid diagnostic criteria for the diagnosis of primary adrenal melanoma, it underlines the fact that the differential diagnosis of a dopamine secreting adrenal mass should include primary or metastatic malignant melanoma in order to determine the best diagnostic approach for the patient and select the most appropriate surgical management.
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Affiliation(s)
- Maria E Barmpari
- Department of Endocrinology and Metabolism, Hippokration Hospital, Athens, Greece.
| | - Christos Savvidis
- Department of Endocrinology and Metabolism, Hippokration Hospital, Athens, Greece
| | - Anastasia D Dede
- Department of Endocrinology and Metabolism, Hippokration Hospital, Athens, Greece
| | - Haridimos Markogiannakis
- Department of Endocrine Surgery, First Department of Propaedeutic Surgery, Hippokration Hospital, Athens Medical School, University of Athens, Athens, Greece
| | | | - Paraskevi Xekouki
- Section of Endocrinology and Genetics, Program on Developmental Endocrinology Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section of Endocrinology and Genetics, Program on Developmental Endocrinology Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Manouras Andreas
- Department of Endocrine Surgery, First Department of Propaedeutic Surgery, Hippokration Hospital, Athens Medical School, University of Athens, Athens, Greece
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Breitenbauch MTW, Holm J, Rødgaard JC, Stolle LB. Utility of chest X-ray and abdominal ultrasound for stage III cutaneous malignant melanoma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2015. [DOI: 10.1007/s00238-014-1059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Livingstone E, Eigentler TK, Windemuth-Kieselbach C, Hauschild A, Rompel R, Trefzer U, Nashan D, Kilian K, Debus D, Kähler KC, Mauerer A, Möllenhoff K, Dippel E, Schadendorf D. Actual practice of melanoma follow-up and treatment in Germany: results of a prospective, longitudinal cohort study. Br J Dermatol 2015; 172:1646-1650. [PMID: 25495472 DOI: 10.1111/bjd.13612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- E Livingstone
- Department of Dermatology, University Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - T K Eigentler
- Department of Dermatology, University Tübingen, Liebermeisterstr. 25, 72076, Tübingen, Germany
| | | | - A Hauschild
- Department of Dermatology, University Hopsital Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 7, 24105, Kiel, Germany
| | - R Rompel
- Department of Dermatology Kassel, Clinical Centre Kassel, Mönchebergstr. 41, 34125, Kassel, Germany
| | - U Trefzer
- Department of Dermatology, Charité Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - D Nashan
- Department of Dermatology, University Freiburg, Hauptstr. 7, 79104, Freiburg, Germany.,Department of Dermatology, Clinical Centre Mitte, Beurhausstraße 40, 44137, Dortmund, Germany
| | - K Kilian
- Department of Dermatology, Ludwig-Maximilians University Munich, Frauenlobstrasse 9-11, 80337, München, Germany
| | - D Debus
- Department of Dermatology, University Nürnberg, Prof.-Ernst-Nathan-Straße 1, 90419, Nürnberg, Germany
| | - K C Kähler
- Department of Dermatology, University Hopsital Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 7, 24105, Kiel, Germany
| | - A Mauerer
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - K Möllenhoff
- Department of Dermatology, Ruhr-University Bochum, Gudrunstr. 56, 44791, Bochum, Germany
| | - E Dippel
- Department of Dermatology, Clinical Centre Ludwigshafen, Bremserstr. 79, 67073, Ludwigshafen, Germany
| | - D Schadendorf
- Department of Dermatology, University Essen, Hufelandstr. 55, 45122, Essen, Germany
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Livingstone E, Krajewski C, Eigentler TK, Windemuth-Kieselbach C, Benson S, Elsenbruch S, Hauschild A, Rompel R, Meiss F, Mauerer A, Kähler KC, Dippel E, Möllenhoff K, Kilian K, Mohr P, Utikal J, Schadendorf D. Prospective evaluation of follow-up in melanoma patients in Germany - results of a multicentre and longitudinal study. Eur J Cancer 2015; 51:653-67. [PMID: 25638778 DOI: 10.1016/j.ejca.2015.01.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/05/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patient numbers requiring long-term melanoma surveillance are constantly rising. Surveillance is costly and guideline recommendations vary substantially. METHODS In this German nationwide study, information on surveillance and treatment of patients diagnosed with melanoma and melanoma in situ (MMis) between April and June 2008 was prospectively collected over four years. Additionally, patient self-report questionnaires were evaluated to assess anxiety, depression, health-related quality of life, socio-demographic information and use of disease specific health information sources at year 4 after primary diagnosis. RESULTS Complete data was available for 668 patients from 67 centres, of whom 96.0% were in regular melanoma surveillance. In year 3-4 of surveillance, only 55.6% of locoregionary metastases were detected during surveillance visits. Only 33.3% were self-detected by the patient even though 69.4% were documented as being clinically visible or palpable. Costs of 4year surveillance of 550 patients without tumour recurrence (stage I-IIC and MMis) accumulated to 228,155.75 €. Guideline-adherence for follow-up frequency, lymph node ultrasound, S100 serum level tests and diagnostic imaging recommendations was approximately 60% in year 3-4 of surveillance. Multivariate regression analysis showed that certain patient/tumour characteristics and regional differences were significantly associated with guideline deviations. The percentage of patients who exceeded published cut-off scores indicating clinically relevant symptoms of anxiety and depression were significantly increased. Patients frequently reported lack of psychosocial support and education but ascribed great importance to these. CONCLUSIONS We recommend further reduction of melanoma follow-up in low-risk melanoma patients and improvement of psycho-social support and patient education for all melanoma patients.
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Affiliation(s)
- E Livingstone
- Dept. of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Hufelandstr. 55, 45122 Essen, Germany.
| | - C Krajewski
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45122 Essen, Germany
| | - T K Eigentler
- Dept. of Dermatology, University Tübingen, Liebermeisterstr. 25, 72076 Tübingen, Germany
| | | | - S Benson
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45122 Essen, Germany
| | - S Elsenbruch
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45122 Essen, Germany
| | - A Hauschild
- Dept. of Dermatology, University Hospital Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 7, 24105 Kiel, Germany
| | - R Rompel
- Dept. of Dermatology Kassel, Clinical Centre Kassel, Mönchebergstr. 41, 34125 Kassel, Germany
| | - F Meiss
- Dept. of Dermatology, University Medical Centre Freiburg, Hauptstr. 7, 79104 Freiburg, Germany
| | - A Mauerer
- Dept. of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - K C Kähler
- Dept. of Dermatology, University Hospital Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 7, 24105 Kiel, Germany
| | - E Dippel
- Dept. of Dermatology, Clinical Centre Ludwigshafen, Bremserstr. 79, 67073 Ludwigshafen, Germany
| | - K Möllenhoff
- Dept. of Dermatology, Ruhr-University Bochum, Gudrunstr. 56, 44791 Bochum, Germany
| | - K Kilian
- Dept. of Dermatology, Ludwig-Maximilians University Munich, Frauenlobstrasse 9-11, 80337 München, Germany
| | - P Mohr
- Dept. of Dermatology, Elbekliniken Stade-Buxtehude GmbH, Am Krankenhaus 1, 21614 Buxtehude, Germany
| | - J Utikal
- Skin Cancer Unit, German Cancer Research Centre (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Department of Dermatology, Venereology and Allergology, University Medical Centre Mannheim, Ruprecht-Karl University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - D Schadendorf
- Dept. of Dermatology, University Hospital Essen, University of Duisburg-Essen, Essen, Hufelandstr. 55, 45122 Essen, Germany
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Rueth NM, Cromwell KD, Cormier JN. Long-term follow-up for melanoma patients: is there any evidence of a benefit? Surg Oncol Clin N Am 2015; 24:359-77. [PMID: 25769718 DOI: 10.1016/j.soc.2014.12.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
As the incidence of melanoma and the number of melanoma survivors continues to rise, optimal surveillance strategies are needed that balance the risks and benefits of screening in the context of contemporary resource use. Detection of recurrences has important implications for clinical management. Most current surveillance recommendations for melanoma survivors are based on low-level evidence with wide variations in practice patterns and an unknown clinical impact for the melanoma survivor.
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Affiliation(s)
- Natasha M Rueth
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1484, 1400 Holcombe Boulevard, Houston, TX 77230-1402, USA
| | - Kate D Cromwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1484, 1400 Holcombe Boulevard, Houston, TX 77230-1402, USA
| | - Janice N Cormier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Unit 1484, 1400 Holcombe Boulevard, Houston, TX 77230-1402, USA.
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Leiter U, Eigentler T, Garbe C. Follow-up in patients with low-risk cutaneous melanoma: is it worth it? Melanoma Manag 2014; 1:115-125. [PMID: 30190817 PMCID: PMC6094616 DOI: 10.2217/mmt.14.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Follow-up examinations in melanoma aim to detect recurrences or secondary melanomas in an early phase of development. Follow-up guidelines that have been developed in many European countries, the USA and Australia show varying recommendations and are controversial, especially in patients with melanomas of 1.0 mm tumor thickness or less. This group contains 50-70% of all melanoma patients and the majority is unlikely to develop recurrences. On the other hand, within this entity, subgroups at higher risk for recurrences can be defined who require a more intense follow-up. This article discusses recommendations for the frequency, duration and costs of follow-up in low-risk melanoma patients. Patient preferences are addressed and a risk-adapted follow-up scheme is proposed.
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Affiliation(s)
- Ulrike Leiter
- Center of Dermato-Oncology, Department of Dermatology, University of Tuebingen, Liebermeisterstr. 25, 72076 Tuebingen, Germany
| | - Thomas Eigentler
- Center of Dermato-Oncology, Department of Dermatology, University of Tuebingen, Liebermeisterstr. 25, 72076 Tuebingen, Germany
| | - Claus Garbe
- Center of Dermato-Oncology, Department of Dermatology, University of Tuebingen, Liebermeisterstr. 25, 72076 Tuebingen, Germany
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Ferreres J, Marcoval J, Fodge K, de Olza MO, Viñals A, Fabra A. The utility of ancillary tests in monitoring cutaneous melanoma patients to detect visceral metastasis. J Eur Acad Dermatol Venereol 2014; 29:2493-5. [DOI: 10.1111/jdv.12602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J.R. Ferreres
- Department of Dermatology; Bellvitge Hospital; IDIBELL; Barcelona University; Barcelona Spain
| | - J. Marcoval
- Department of Dermatology; Bellvitge Hospital; IDIBELL; Barcelona University; Barcelona Spain
| | - K. Fodge
- Department of Dermatology; Bellvitge Hospital; IDIBELL; Barcelona University; Barcelona Spain
| | - M. Ochoa de Olza
- Department of Medical Oncology; Hospital Duran i Reynals; Institut Català Oncologia; Barcelona Spain
| | - A. Viñals
- Molecular Oncology Laboratory; IDIBELL; Barcelona University; Barcelona Spain
| | - A. Fabra
- Molecular Oncology Laboratory; IDIBELL; Barcelona University; Barcelona Spain
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Rueth NM, Xing Y, Chiang YJ, Cromwell KD, Ross MI, Lee JE, Gershenwald JE, Royal RE, Cormier JN. Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies. Ann Surg 2014; 259:1215-22. [PMID: 24096759 DOI: 10.1097/sla.0000000000000233] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To guide resource utilization, we aimed to determine the impact of routine surveillance imaging for the detection of melanoma recurrences amenable to surgical resection with curative intent. BACKGROUND The National Comprehensive Cancer Network guidelines for melanoma surveillance are largely consensus based. METHODS Using single-institution, patient-level data (n = 1600), transition probabilities were calculated for a Markov model simulating the natural history of patients with stage I-III melanoma. As a base estimate, imaging was assumed to detect regional and distant recurrences of which 80% and 20% could be surgically treated with curative intent, respectively. Sensitivity analyses were conducted for all point estimates. For each disease stage, we calculated the number of surgically treatable regional or distant recurrence detected during 5 years per 10,000 patients undergoing computed tomography (CT) or positron emission tomography (PET)/CT scans at 6- or 12-month intervals. The associated positive and negative predictive values and life expectancy were also calculated and compared with clinical examination alone. RESULTS At 5-year follow-up, CT or PET/CT at 6-month intervals detected surgically treatable regional or distant recurrence in 6.4% of patients with stage I, 18.5% of stage II, and 33.1% of stage III disease; 12-month intervals decreased the rates to 3.0%, 7.9%, and 13.0%, respectively. The high false-positive rates of CT (20%) and PET/CT (9%) resulted in overall low positive predictive values. However, both CT and PET/CT effectively predicted absence of disease. Life-expectancy gains were minimal (≤ 2 months) for all groups. CONCLUSIONS The effectiveness of routine surveillance imaging for detecting treatable melanoma recurrences is limited. Even in patients with stage III disease, only minimal gains in life expectancy were achieved.
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Affiliation(s)
- Natasha M Rueth
- *Department of Surgical Oncology †Institute of Cancer Care Excellence ‡Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Marciano NJ, Merlin TL, Bessen T, Street JM. To what extent are current guidelines for cutaneous melanoma follow up based on scientific evidence? Int J Clin Pract 2014; 68:761-70. [PMID: 24548269 PMCID: PMC4238419 DOI: 10.1111/ijcp.12393] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Clinical practice guidelines should aim to assist clinicians in making evidence-based choices in the care of their patients. This review attempts to determine the extent of evidence-based support for clinical practice guideline recommendations concerning cutaneous melanoma follow up and to evaluate the methodological quality of these guidelines. METHODS Current guidelines providing graded recommendations regarding patient follow up were identified through a systematic literature review. The authors reviewed the evidence base used to formulate recommendations in each of the guidelines and appraised the quality of the guidelines using the AGREE II (Appraisal of Guidelines for Research and Evaluation) instrument. RESULTS Most guideline recommendations concerning the frequency of routine skin examinations by a clinician and the use of imaging and diagnostic tests in the follow up of melanoma patients were based on low-level evidence or consensus expert opinion. Melanoma follow-up guidelines are of variable methodological quality, with some guidelines not recommended by the appraisers for use in clinical practice. CONCLUSION Clinicians should be aware of how scant the evidence base is for many recommended courses of action. As a consequence of the paucity of evidence in the field of melanoma follow up, there is considerable variability in the guidance provided. The variable methodological quality of guidelines for melanoma follow up could be improved by attention to the criteria described in AGREE II.
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Affiliation(s)
- N J Marciano
- School of Population Health, University of Adelaide, Adelaide, Australia
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Routine restaging PET/CT and detection of initial recurrence in sentinel lymph node positive stage III melanoma. Am J Surg 2014; 207:549-54. [DOI: 10.1016/j.amjsurg.2013.04.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 04/02/2013] [Accepted: 04/02/2013] [Indexed: 12/13/2022]
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The role of ultrasound and ultrasound-guided fine needle aspiration biopsy of lymph nodes in patients with skin tumours. Radiol Oncol 2014; 48:29-34. [PMID: 24587776 PMCID: PMC3908844 DOI: 10.2478/raon-2013-0084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 09/03/2013] [Indexed: 11/21/2022] Open
Abstract
Background The primary aim of this study was to evaluate the diagnostic accuracy of ultrasound (US) in the study of superficial lymph nodes during the follow-up of patients surgically treated for skin tumours. The secondary objective was to compare positive cytological results with histological reports. Patients and methods From 2004 to 2011, 480 patients (male/female: 285/195; median age 57 years; prevalent skin tumour: melanoma) underwent US-guided fine-needle aspiration biopsy (FNAB) of suspicious recurrent lymph nodes. An expert radiologist first performed US testing of the lymph nodes, expressing either a negative or positive outcome of the test. Subsequently, US-guided FNAB was performed. FNAB positive patients were subjected to lymphadenectomy; the patients who tested negative underwent the follow-up. Results The size of lymph nodes was ≤ 2 cm in 90% of cases. Out of the 336 (70%) US “positive” patients, 231 (68.8%) were FNAB positives. Out of the 144 (30%) US “negatives”, 132 (91.7%) were FNAB negatives. The sensitivity and specificity of the US were 95% and 55.7%, respectively; the negative predictive value was 91.7% and the positive predictive value was 68.8%. Definitive histological results confirmed FNAB positivity in 97.5% of lymphadenectomies. Conclusions US is a sensitive method in the evaluation of superficial lymph nodes during the follow-up of patients with skin tumours. High positive predictive value of cytology was confirmed.
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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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Ulrich J, van Akkooi AJC, Eggermont AMM, Voit C. New developments in melanoma: utility of ultrasound imaging (initial staging, follow-up and pre-SLNB). Expert Rev Anticancer Ther 2014; 11:1693-701. [DOI: 10.1586/era.11.115] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Speijers MJ, Francken AB, Hoekstra-Weebers JEHM, Bastiaannet E, Kruijff S, Hoekstra HJ. Optimal follow-up for melanoma. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.10.38] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Haddad D, Garvey EM, Mihalik L, Pockaj BA, Gray RJ, Wasif N. Preoperative imaging for early-stage cutaneous melanoma: predictors, usage, and utility at a single institution. Am J Surg 2013; 206:979-85; discussion 985-6. [PMID: 24124660 DOI: 10.1016/j.amjsurg.2013.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preoperative imaging for early-stage cutaneous melanoma is not recommended by current guidelines. Our goal was to investigate our institutional usage and utility. METHODS Patients with clinically node-negative cutaneous melanoma undergoing surgery with sentinel lymph node biopsy were identified retrospectively. Any melanoma-related imaging after diagnosis and before surgery was considered a staging study. RESULTS Five hundred fifteen studies were performed in 409 of 546 (75%) patients. Chest x-rays was performed in 70% and advanced imaging in 14% (computed tomography imaging, magnetic resonance imaging, ultrasound, and positron-emission computed tomography imaging). No metastatic lesions were identified. A Breslow thickness greater than 4 mm (odds ratio = 6.46 vs <1 mm; 95% confidence interval, 2.07 to 20.15) and male sex (odds ratio = 2.62 vs female; 95% confidence interval, 1.26 to 5.46) were associated with an increased likelihood of advanced imaging. CONCLUSIONS Preoperative imaging was performed in the majority of patients with node-negative melanoma, with 14% undergoing advanced studies. No metastatic lesions were identified, confirming the limited utility in this setting.
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Affiliation(s)
- Dana Haddad
- Department of Surgery, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Scottsdale, AZ 85250, USA
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Scally CP, Wong SL. Intensity of follow-up after melanoma surgery. Ann Surg Oncol 2013; 21:752-7. [PMID: 24114053 DOI: 10.1245/s10434-013-3295-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Indexed: 11/18/2022]
Abstract
This contemporary review of melanoma surveillance strategies seeks to help practitioners examine and improve their surveillance protocols based on the currently available data. In general, there is no definitive benefit from increased screening or more aggressive use of interval imaging. Low-intensity surveillance strategies do not appear to adversely affect patient outcomes and should be the preferred approach compared with high-intensity strategies for most melanoma patients. All surveillance programs should emphasize education in order to maximize the effectiveness of patient-based detection of recurrent disease.
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Trotter SC, Sroa N, Winkelmann RR, Olencki T, Bechtel M. A Global Review of Melanoma Follow-up Guidelines. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2013; 6:18-26. [PMID: 24062870 PMCID: PMC3780800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Early detection of a melanoma recurrence is a major concern for the clinician. However, the follow-up care of melanoma patients lacks a uniform approach. Different dermatological and oncological organizations have developed their own strategies of follow-up management that vary by specialty and methods of screening for recurrence. Some areas of controversy in the follow-up care of melanoma patients include providers of care, use of staging versus Breslow depth to determine follow-up, the role of imaging and laboratory tests, frequency and duration of physical exams, and psychological well-being. Studies have evaluated these aspects of follow-up management, but no consensus exists. However, it is essential for clinicians to collaborate between specialties for an effective, evidence-based approach to melanoma clinical follow-up care.
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Affiliation(s)
- Shannon C Trotter
- The Ohio State University Wexner Medical Center, Division of Dermatology, Columbus, Ohio
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Tafreshi NK, Silva A, Estrella VC, McCardle TW, Chen T, Jeune-Smith Y, Lloyd MC, Enkemann SA, Smalley KSM, Sondak VK, Vagner J, Morse DL. In vivo and in silico pharmacokinetics and biodistribution of a melanocortin receptor 1 targeted agent in preclinical models of melanoma. Mol Pharm 2013; 10:3175-85. [PMID: 23763620 DOI: 10.1021/mp400222j] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The melanocortin 1 receptor (MC1R) is overexpressed in most melanoma metastases, making it a promising target for imaging of melanomas. In this study, the expression of MC1R in a large fraction of patients with melanoma was confirmed using mRNA and tissue microarray. Here, we have characterized the in vivo tumor and tissue distribution and pharmacokinetics (PK) of uptake and clearance of a MC1R specific peptidomimetic ligand conjugated to a near-infrared fluorescent dye. We propose an interdisciplinary framework to bridge the different time and space scales of ligand-tumor-host interactions: intravital fluorescence microscopy to quantify probe internalization at the cellular level, a xenograft tumor model for whole body pharmacokinetics, and a computational pharmacokinetic model for integration and interpretation of experimental data. Administration of the probe into mice bearing tumors with high and low MC1R expression demonstrated normalized image intensities that correlated with expression levels (p < 0.05). The biodistribution study showed high kidney uptake as early as 30 min postinjection. The PK computational model predicted the presence of receptors in the kidneys with a lower affinity, but at higher numbers than in the tumors. As the mouse kidney is known to express the MC5R, this hypothesis was confirmed by both coinjection of a ligand with higher MC5R affinity compared to MC1R and by injection of lower probe concentrations (e.g., 1 nmol/kg), both leading to decreased kidney accumulation of the MC1R ligand. In addition, through this interdisciplinary approach we could predict the rates of ligand accumulation and clearance into and from organs and tumors, and the amount of injected ligand required to have maximum specific retention in tumors. These predictions have potential to aid in the translation of a targeted agent from lab to the clinic. In conclusion, the characterized MC1R-specific probe has excellent potential for in vivo detection of melanoma metastases. The process of cell-surface marker validation, targeted imaging probe development, and in vitro, in vivo, and in silico characterization described in this study can be generally applied to preclinical development of targeted agents.
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Affiliation(s)
- Narges K Tafreshi
- Department of Cancer Imaging and Metabolism, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, United States
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Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review. Melanoma Res 2013; 22:376-85. [PMID: 22914178 DOI: 10.1097/cmr.0b013e328357d796] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. There are significant intercountry and interspecialty variations in the surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.
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