Long-term survival in 2,505 patients with melanoma with regional lymph node metastasis

Enhancements in Radiological Detection of Metastatic Lymph Nodes Utilizing AI-Assisted Ultrasound Imaging Data and the Lymph Node Reporting and Data System Scale

The paper presents a novel approach for the automatic detection of neoplastic lesions in lymph nodes (LNs). It leverages the latest advances in machine learning (ML) with the LN Reporting and Data System (LN-RADS) scale. By integrating diverse datasets and network structures, the research investigates the effectiveness of ML algorithms in improving diagnostic accuracy and automation potential. Both Multinominal Logistic Regression (MLR)-integrated and fully connected neuron layers are included in the analysis. The methods were trained using three variants of combinations of histopathological data and LN-RADS scale labels to assess their utility. The findings demonstrate that the LN-RADS scale improves prediction accuracy. MLR integration is shown to achieve higher accuracy, while the fully connected neuron approach excels in AUC performance. All of the above suggests a possibility for significant improvement in the early detection and prognosis of cancer using AI techniques. The study underlines the importance of further exploration into combined datasets and network architectures, which could potentially lead to even greater improvements in the diagnostic process.

Risk factors and novel predictive model for metastatic cutaneous squamous cell carcinoma: a population-based analysis

Cutaneous squamous cell carcinoma (cSCC) is one of the most common skin malignancies. Patients with metastatic cSCC (mcSCC) tended to have unfavorable prognosis. However, there is no available models to evaluate the survival outcomes for these patients. This study retrospectively collected mcSCC cases identified from The Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2018. All patients were randomly divided into the training and validation cohorts. The independent factors which predicted the cancer-specific survival (CSS) were identified by Cox proportional hazard regression analysis, and were used to build nomogram. he discrimination ability of nomograms was evaluated using the concordance index (C-index). The receiver operating characteristic (ROC) curve and the corresponding area under the curve (AUC) at 1, 3, and 5 years were calculated to estimate the predictive accuracy. The performance of this nomogram was evaluated by the calibration curves. The decision curve analyses (DCAs) were conducted to assess the clinical usefulness of the models. Based on the novel nomograms, all patients were classified into low- and high-risk groups. Kaplan-Meier curves were plotted to compare the survival outcomes of two groups. All analyses were conducted by R software (Version 4.1.3). A total of 916 patients were included. Age, marital status, location of the primary sites, number of metastases, T stage, N stage, surgical resection of the primary sites, radiotherapy of the primary sites, and chemotherapy were significantly associated with CSS. A nomogram predicting CSS was built based on these parameters. C-index and ROC curves of nomogram showed promising discriminating and predicting ability for CSS. Survival analysis showed that patients in the low-risk group had significant superior CSS time than those in the high-risk group (median CSS time: 15.0 vs. 5.0 months, p < 0.001). In conclusion, we developed and validated a novel nomogram predicting the CSS in metastatic cSCC patients. This nomogram could be used to assess the prognosis of metastatic cSCC patients, and help clinicians evaluating optimal treatment options for individual patient.

A Step Toward Personalized Surgical Decision Making: Machine Learning Predicts 1 Versus Numerous Melanoma Lymph Node Metastases Using RNA-sequencing

OBJECTIVE

Develop a predictive model to identify patients with 1 pathologic lymph node (pLN) versus >1 pLN using machine learning applied to gene expression profiles and clinical data as input variables.

BACKGROUND

Standard management for clinically detected melanoma lymph node metastases is complete therapeutic LN dissection (TLND). However, >40% of patients with a clinically detected melanoma lymph node will only have 1 pLN on final review. Recent data suggest that targeted excision of just the single enlarged LN may provide excellent regional control, with less morbidity than TLND. The selection of patients for less morbid surgery requires accurate identification of those with only 1 pLN.

METHODS

The Cancer Genome Atlas database was used to identify patients who underwent TLND for melanoma. Pathology reports in The Cancer Genome Atlas were reviewed to identify the number of pLNs. Patients were included for machine learning analyses if RNA sequencing data were available from a pLN. After feature selection, the top 20 gene expression and clinical input features were used to train a ridge logistic regression model to predict patients with 1 pLN versus >1 pLN using 10-fold cross-validation on 80% of samples. The model was then tested on the remaining holdout samples.

RESULTS

A total of 153 patients met inclusion criteria: 64 with one pLN (42%) and 89 with >1 pLNs (58%). Feature selection identified 1 clinical (extranodal extension) and 19 gene expression variables used to predict patients with 1 pLN versus >1 pLN. The ridge logistic regression model identified patient groups with an accuracy of 90% and an area under the receiver operating characteristic curve of 0.97.

CONCLUSIONS

Gene expression profiles together with clinical variables can distinguish melanoma metastasis patients with 1 pLN versus >1 pLN. Future models trained using positron emission tomography/computed tomography imaging, gene expression, and relevant clinical variables may further improve accuracy and may predict patients who can be managed with a targeted LN excision rather than a complete TLND.

A prognostic nomogram for the cancer-specific survival of white patients with invasive melanoma at BANS sites based on the Surveillance, Epidemiology, and End Results database

Objective

The purpose of this study was to develop a comprehensive nomogram for the cancer-specific survival (CSS) of white patients with invasive melanoma at back, posterior arm, posterior neck, and posterior scalp (BANS) sites and to determine the validity of the nomogram by comparing it with the conventional American Joint Committee on Cancer (AJCC) staging system.

Methods

This study analyzed the patients with invasive melanoma in the Surveillance, Epidemiology, and End Results (SEER) database. R software was used to randomly divide the patients into training and validation cohorts at a ratio of 7:3. Multivariable Cox regression was used to identify predictive variables. The new survival nomogram was compared with the AJCC prognosis model using the concordance index (C-index), area under the receiver operating characteristic (ROC) curve (AUC), net reclassification index (NRI), integrated discrimination index (IDI), calibration plotting, and decision-curve analysis (DCA).

Results

A novel nomogram was established to determine the 3-, 5-, and 8-year CSS probabilities of patients with invasive melanoma. According to the nomogram, the Age at Diagnosis had the greatest influence on CSS in invasive melanoma, followed by Bone Metastasis, AJCC, Stage, Liver Metastasis, Histologic Subtype, Brain Metastasis, Ulceration, and Primary Site. The nomogram had a higher C-index than the AJCC staging system in both the training (0.850 versus 0.799) and validation (0.829 versus 0.783) cohorts. Calibration plotting demonstrated that the model had good calibration ability. The nomogram outperformed the AJCC staging system in terms of AUC, NRI, IDI, and DCA.

Conclusion

This was the first study to develop and evaluate a comprehensive nomogram for the CSS of white patients with invasive melanoma at BANS sites using the SEER database. The novel nomogram can assist clinical staff in predicting the 3-, 5-, and 8-year CSS probabilities of patients with invasive melanoma more accurately than can the AJCC staging system.

Modeling lymphangiogenesis: Pairing in vitro and in vivo metrics

Lymphangiogenesis is the mechanism by which the lymphatic system develops and expands new vessels facilitating fluid drainage and immune cell trafficking. Models to study lymphangiogenesis are necessary for a better understanding of the underlying mechanisms and to identify or test new therapeutic agents that target lymphangiogenesis. Across the lymphatic literature, multiple models have been developed to study lymphangiogenesis in vitro and in vivo. In vitro, lymphangiogenesis can be modeled with varying complexity, from monolayers to hydrogels to explants, with common metrics for characterizing proliferation, migration, and sprouting of lymphatic endothelial cells (LECs) and vessels. In comparison, in vivo models of lymphangiogenesis often use genetically modified zebrafish and mice, with in situ mouse models in the ear, cornea, hind leg, and tail. In vivo metrics, such as activation of LECs, number of new lymphatic vessels, and sprouting, mirror those most used in vitro, with the addition of lymphatic vessel hyperplasia and drainage. The impacts of lymphangiogenesis vary by context of tissue and pathology. Therapeutic targeting of lymphangiogenesis can have paradoxical effects depending on the pathology including lymphedema, cancer, organ transplant, and inflammation. In this review, we describe and compare lymphangiogenic outcomes and metrics between in vitro and in vivo studies, specifically reviewing only those publications in which both testing formats are used. We find that in vitro studies correlate well with in vivo in wound healing and development, but not in the reproductive tract or the complex tumor microenvironment. Considerations for improving in vitro models are to increase complexity with perfusable microfluidic devices, co-cultures with tissue-specific support cells, the inclusion of fluid flow, and pairing in vitro models of differing complexities. We believe that these changes would strengthen the correlation between in vitro and in vivo outcomes, giving more insight into lymphangiogenesis in healthy and pathological states.

Adjuvant nodal field radiation in resected Stage III melanoma: A single-centre retrospective study in Christchurch, New Zealand

INTRODUCTION

Stage III melanoma is associated with poor outcomes. We studied the characteristics and outcomes of patients with resected Stage III melanoma before the routine use of adjuvant immunotherapy. Some of these patients received adjuvant nodal radiation with modern radiation techniques.

METHODS

We retrieved data of patients with resected Stage III melanoma treated in Christchurch over 10 years. Overall survival (OS), melanoma-specific survival (MSS), recurrence-free survival (RFS) and nodal recurrence-free rate (NRFR) were determined, and the association of these outcomes with tumour and treatment factors was investigated.

RESULTS

We identified 178 patients (110 male and 68 female), of whom 61 received adjuvant radiation. The median age was 66.6 years, and the median follow-up was 2.7 years. First recurrences occurred in 108 (61%) patients. There were 42 (24%) nodal field relapses and 103 (58%) distant relapses. One-half of nodal relapses in patients treated with adjuvant radiation were infield. The 5-year OS, RFS, MSS and NRFR were 46.4%, 26.8%, 53.7% and 69.6%, respectively. Adjuvant radiation was associated with improved RFS and no OS benefit. T4 disease and extranodal spread were associated with poorer OS, while extranodal spread and >3 involved nodes were associated with worse RFS.

CONCLUSION

Patients treated with adjuvant radiation remain at moderate risk of regional and high risk of distant relapse, despite the use of modern radiation techniques. Adjuvant radiation was associated with improved local control but infield recurrence rates remained a problem. The role of combined adjuvant radiation and immunotherapy in improving these outcomes requires further investigation.

Insights Into Vascular Anomalies, Cancer, and Fibroproliferative Conditions: The Role of Stem Cells and the Renin-Angiotensin System

Cells exhibiting embryonic stem cell (ESC) characteristics have been demonstrated in vascular anomalies (VAs), cancer, and fibroproliferative conditions, which are commonly managed by plastic surgeons and remain largely unsolved. The efficacy of the mTOR inhibitor sirolimus, and targeted therapies that block the Ras/BRAF/MEK/ERK1/2 and PI3KCA/AKT/mTOR pathways in many types of cancer and VAs, further supports the critical role of ESC-like cells in the pathogenesis of these conditions. ESC-like cells in VAs, cancer, and fibroproliferative conditions express components of the renin-angiotensin system (RAS) – a homeostatic endocrine signaling cascade that regulates cells with ESC characteristics. ESC-like cells are influenced by the Ras/BRAF/MEK/ERK1/2 and PI3KCA/AKT/mTOR pathways, which directly regulate cellular proliferation and stemness, and interact with the RAS at multiple points. Gain-of-function mutations affecting these pathways have been identified in many types of cancer and VAs, that have been treated with targeted therapies with some success. In cancer, the RAS promotes tumor progression, treatment resistance, recurrence, and metastasis. The RAS modulates cellular invasion, migration, proliferation, and angiogenesis. It also indirectly regulates ESC-like cells via its direct influence on the tissue microenvironment and by its interaction with the immune system. In vitro studies show that RAS inhibition suppresses the hallmarks of cancer in different experimental models. Numerous epidemiological studies show a reduced incidence of cancer and improved survival outcomes in patients taking RAS inhibitors, although some studies have shown no such effect. The discovery of ESC-like cells that express RAS components in infantile hemangioma (IH) underscores the paradigm shift in the understanding of its programmed biologic behavior and accelerated involution induced by β-blockers and angiotensin-converting enzyme inhibitors. The findings of SOX18 inhibition by R-propranolol suggests the possibility of targeting ESC-like cells in IH without β-adrenergic blockade, and its associated side effects. This article provides an overview of the current knowledge of ESC-like cells and the RAS in VAs, cancer, and fibroproliferative conditions. It also highlights new lines of research and potential novel therapeutic approaches for these unsolved problems in plastic surgery, by targeting the ESC-like cells through manipulation of the RAS, its bypass loops and converging signaling pathways using existing low-cost, commonly available, and safe oral medications.

[Plantar melanoma: A wolf in sheep's clothing]

BACKGROUND AND FINDINGS

 Amelanotic melanoma (AM) is a subtype of melanoma characterized by a diminished or lacking melanin synthesis. AM, especially ulcerated variants of the plantar region (AMP), are often clinically misdiagnosed, leading to a delay in treatment initiation.

THERAPY AND FURTHER DEVELOPMENT

 We present a case series of 4 AMP and give a detailed overview about clinical features and the subsequent medical history of this severe disease.

CONCLUSIONS

 AMP shows a variety of clinical presentations and particularly elderly patients with many accompanying medical conditions are in danger of incorrect clinical diagnoses. Therefore, we recommend to biopsy any amelanotic plantar ulcer or tumor that does not respond to treatment within 6 weeks to rule out AM.

OUP accepted manuscript

Background

Methods

Results

Conclusions

BRAF mutation correlates with worse local-regional control following radiation therapy in patients with stage III melanoma

Background

In patients with stage III melanoma, the use of adjuvant radiation therapy (RT) after lymph node dissection (LND) may be currently considered in selected high-risk patients to improve tumor control. Melanomas harbor BRAF mutations (BRAF+) in 40–50% of cases, the majority of which are on the V600E residue. This study sought to compare the clinical outcomes after RT between patients with BRAF+ and BRAF− melanoma.

Methods

This was a retrospective review of 105 Stage III melanoma patients treated at our institution with LND followed by adjuvant RT from 2006 to 2019. BRAF mutational status was determined on the primary skin or nodal tissue samples from all patients. We compared characteristics of the BRAF+ and BRAF− groups using Fisher’s exact test and Wilcoxon rank sum test and performed univariate and multivariate analysis using Kaplan–Meier estimates, log-rank tests, and Cox proportional hazards modeling with the clinical outcomes of local–regional lymph node control, distant metastasis-free survival (DMFS), recurrence-free survival (RFS), and overall survival (OS).

Results

Fifty-three (50%) patients harbored a BRAF mutation (92%, pV600E). BRAF+ patients were younger and had primary tumors more commonly found in the trunk vs head and neck compared to BRAF- patients (p < 0.05). The 5 year local–regional control in the BRAF + patients was 60% compared to 81% in the BRAF- patients (HR 4.5, 95% CI 1.3–15.5, p = 0.02). There were no significant differences in 5-year DMFS, RFS, and OS rates between the two BRAF patient groups. The presence of 4 or more positive LNs remained a significant prognostic factor for local–regional lymph node control, RFS, and OS in multivariate analysis.

Conclusions

Stage III melanoma patients with BRAF mutation treated with adjuvant RT had > 4 times increased risk of local recurrence or regional lymph node recurrence. These results could be useful for adjuvant RT consideration in lymph node positive melanoma patients and supports other data that BRAF mutation confers radiation resistance.

Computational pan-cancer characterization of model-based quantitative transcription regulations dysregulated in regional lymph node metastasis

Cancer is one of the major causes of mortality worldwide. Regional lymph node metastasis is an important mechanism during the spread of human cancers, in which transcription regulation plays an essential role. This study formulated a regression-model-based quantitative transcription regulation (mqTrans) between one mRNA gene and multiple transcription factors (TFs). Computational pan-cancer screening was carried out to detect the quantitative dysregulation of transcription regulation in the regional lymph node metastasis of 18 cancer types. Only a few metastasis-dysregulated mqTrans models were shared among the cancer types. The mRNA genes of the metastasis-dysregulated mqTrans models were not differentially expressed in regional lymph node metastasis. The experimental data suggested that mqTrans technology provided a complementary approach to the evaluation of transcription regulation mechanisms and may facilitate its quantitative investigation in other phenotypes.

Resistance to Molecularly Targeted Therapies in Melanoma

Malignant melanoma is the most aggressive type of skin cancer with invasive growth patterns. In 2021, 106,110 patients are projected to be diagnosed with melanoma, out of which 7180 are expected to die. Traditional methods like surgery, radiation therapy, and chemotherapy are not effective in the treatment of metastatic and advanced melanoma. Recent approaches to treat melanoma have focused on biomarkers that play significant roles in cell growth, proliferation, migration, and survival. Several FDA-approved molecular targeted therapies such as tyrosine kinase inhibitors (TKIs) have been developed against genetic biomarkers whose overexpression is implicated in tumorigenesis. The use of targeted therapies as an alternative or supplement to immunotherapy has revolutionized the management of metastatic melanoma. Although this treatment strategy is more efficacious and less toxic in comparison to traditional therapies, targeted therapies are less effective after prolonged treatment due to acquired resistance caused by mutations and activation of alternative mechanisms in melanoma tumors. Recent studies focus on understanding the mechanisms of acquired resistance to these current therapies. Further research is needed for the development of better approaches to improve prognosis in melanoma patients. In this article, various melanoma biomarkers including BRAF, MEK, RAS, c-KIT, VEGFR, c-MET and PI3K are described, and their potential mechanisms for drug resistance are discussed.

Outcomes of patients with metastatic cutaneous squamous cell carcinoma to the axilla: a multicentre cohort study

BACKGROUND

Metastatic cutaneous squamous cell carcinoma to the axilla is uncommon, with limited data to guide management. We sought to assess the outcomes of patients with this condition after surgery and radiotherapy.

METHODS

A retrospective cohort study of patients treated at two Australian hospitals from 1994 through 2016 was performed.

RESULTS

A total of 74 patients were identified, including 48 treated curatively with surgery-plus-radiotherapy and 15 with surgery alone. Compared with patients treated with surgery alone, a higher proportion of patients treated with surgery-plus-radiotherapy had lymph nodes larger than 6 cm (53% versus 8%, P = 0.012) and multiple adverse histopathological features (75% versus 47%, P = 0.04). The groups had similar 5-year disease-free survival (45% versus 46%) and overall survival (51% versus 48%). Presence of multiple positive lymph nodes was associated with reduced disease-free survival (hazard ratio 4.57, P = 0.01) and overall survival (hazard ratio 3.53, P = 0.02). Regional recurrence was higher in patients treated with surgery alone (38% versus 22%, P = 0.22) and patients with lymph nodes larger than 6 cm (34% versus 10%, P = 0.03). All recurrences occurred within 2 years following treatment.

CONCLUSION

Combined-modality therapy for metastatic cutaneous squamous cell carcinoma to the axilla is recommended for high-risk patients, although outcomes remain modest. The key period for recurrence is within 2 years following treatment.

Cancer immunotherapy: a promising dawn in cancer research

Cancer is a highly proliferative disease, which is caused due to the loss of regulation of cell cycle and apoptosis, DNA damage, faulty repair system etc. The cancer microenvironment plays a pivotal role in disease progression as they contain different types of innate and adaptive immune cells. The most important molecules that establish a correlation between inflammation, innate immunity, adaptive immunity, and cancer are the molecules released by inflammatory cells in cancer microenvironment. These molecules secreted by the immune cells, which might activate a pro-tumorigenic and anti-tumorigenic response in cancer. In inflammatory microenvironment, the equilibrium state of immunosuppressive and immunostimulatory signals are important in tumor suppression. The immunotherapeutic approaches could be more effective in cancer treatment. However, advancement in immunobiology and cancer are improving the prospects of immunotherapy alone and/or in combination with the conventional therapies. Thus, the review attempts to highlight a promising and futuristic immunotherapeutic approach in combination with conventional treatment modalities.

Vascular endothelial growth factor/semaphorin-3A ratio and SEMA3A expression in cutaneous malignant melanoma

Breslow thickness and Clark level are still important factors for cutaneous melanoma, but do not provide a precise prognosis in all cases. It is necessary to find new factors capable of a more accurate prediction of the tumor course. Angiogenesis is essential for tumor development and progression and is regulated by vascular endothelial growth factor A (VEGF-A) and semaphorins (SEMA), in particular, SEMA3A inhibits angiogenesis by affecting VEGF signaling. However, the prognostic role of angiogenetic factors remains unclear. To date, no information is available on SEMA3A in human melanoma. Microvessel density, immunohistochemical and mRNA VEGF and SEMA3A expression level in 60 thin (Breslow thickness ≤ 1.0 mm), 60 intermediate (1.1-4.0 mm) and 50 thick (>4.0 mm) primary human cutaneous melanomas were investigated and related to clinical/pathological parameters and disease-specific survival. No positive association between Breslow thickness, Clark level, metastasis presence and survival was identified; Clark level was poorly related to survival. VEGF and microvessel density were significantly higher in intermediate and thick melanomas and related to Breslow thickness and Clark level but not to metastasis status and survival. On the contrary, SEMA3A was significantly reduced in intermediate and thick melanomas and associated to metastasis and poor survival. VEGF/SEMA3A ratio was higher in the worst prognosis, resulting the most closely related factor with metastasis and survival. SEMA3A expression and VEGF/SEMA3A ratio turned out to be valuable prognostic biomarkers in patients affected by cutaneous melanoma, in particular with Breslow thickness >1 mm. SEMA3A might serve as a candidate tumor suppressor in cutaneous melanoma therapy.

Regional Node Basin Recurrence in Melanoma Patients: More Common After Node Dissection for Macroscopic Rather than Clinically Occult Nodal Disease

BACKGROUND

Recommended treatment for patients with sentinel lymph node (SLN)-positive melanoma has recently changed. Randomized trials demonstrated equivalent survival with close observation versus completion lymph node dissection (CLND), but increased regional node recurrence. We evaluated factors related to in-basin nodal recurrence after lymphadenectomy (LND) for SLN-positive or macroscopic nodal metastases.

METHODS

An institutional database and the first Multicenter Selective Lymphadenectomy Trial (MSLT-I) were analyzed independently. Exclusions were multiple primaries, multi-basin involvement, or in-transit metastases. Patient demographics, primary tumor thickness and ulceration, lymph nodes retrieved, and use of adjuvant radiotherapy were analyzed. Multivariate analyses were performed to determine factors predicting in-basin nodal recurrence (significance p ≤ 0.05).

RESULTS

The retrospective cohort (577 patients) showed an in-basin failure rate of 6.6% after CLND for a positive SLN and 13.1% after LND for palpable disease (p = 0.001). This recurrence risk persisted after adjustment for patient, tumor, and LND factors [hazard ratio (HR) 2.32; p = 0.004]. In the MSLT-I cohort (326 patients), the failure rate after CLND following SLNB was 6.2%, but 10.1% after LND for palpable recurrence in observation patients. After adjustment for other factors, macroscopic disease was associated with an increased risk of recurrence after LND (HR 2.24; p = 0.05).

CONCLUSION

After LND for melanoma, in-basin recurrence is infrequent, but a clinically significant fraction will fail. Failure is less likely if dissection is performed for clinically occult disease. Further research is warranted to evaluate the long-term regional control and quality of life associated with nodal basin observation, which has now become standard practice.

Characteristics Associated with Pathologic Nodal Burden in Patients Presenting with Clinical Melanoma Nodal Metastasis

BACKGROUND

Nodal observation is safe for patients with microscopic melanoma metastasis in a sentinel lymph node (LN). Complete LN dissection (CLND) remains the standard of care for patients with clinically evident LN (cLN) metastases, even though about 40% have only one pathologic LN (pLN). We sought to identify clinical features associated with having one pLN among patients with cLNs.

METHODS

Patients at three melanoma centers who underwent CLND for cLNs were identified. Clinicopathologic and imaging characteristics associated with one pLN were determined by multivariable logistic regression and classification tree analysis.

RESULTS

Of 190 patients, 90 (47.4%) had one pLN and 100 (52.6%) had more than one pLN. By multivariable logistic regression, extremity versus truncal primary (odds ratio [OR] 2.15, p = 0.012), axillary versus superficial inguinal location (OR 3.89, p = 0.009), and preoperative cross-sectional imaging demonstrating more than one versus one cLN (OR 17.1, p < 0.001) were associated with more than one pLN. The negative predictive value for additional pathologic nodal disease of preoperative imaging was 70.9%, increasing to 74.4% for positron emission tomography/computed tomography. In the subgroup of patients with one cLN, the classification tree identified two groups with < 10% risk of additional pLNs: (1) Breslow thickness > 6.55 mm (n = 17); and (2) if unknown primary or Breslow thickness ≤ 6.55 mm, then LN diameter > 1.8 cm in the inguinal location (n = 22).

CONCLUSION

The majority of patients with one cLN from melanoma by preoperative imaging will harbor no additional pathologic nodes on CLND. Safety of nodal observation after clinical nodal excision in these patients, particularly in an era of effective adjuvant therapies, deserves prospective evaluation.

Prediction and Analysis of Skin Cancer Progression using Genomics Profiles of Patients

The metastatic Skin Cutaneous Melanoma (SKCM) has been associated with diminished survival rates and high mortality rates worldwide. Thus, segregating metastatic melanoma from the primary tumors is crucial to employ an optimal therapeutic strategy for the prolonged survival of patients. The SKCM mRNA, miRNA and methylation data of TCGA is comprehensively analysed to recognize key genomic features that can segregate metastatic and primary tumors. Further, machine learning models have been developed using selected features to distinguish the same. The Support Vector Classification with Weight (SVC-W) model developed using the expression of 17 mRNAs achieved Area under the Receiver Operating Characteristic (AUROC) curve of 0.95 and an accuracy of 89.47% on an independent validation dataset. This study reveals the genes C7, MMP3, KRT14, LOC642587, CASP7, S100A7 and miRNAs hsa-mir-205 and hsa-mir-203b as the key genomic features that may substantially contribute to the oncogenesis of melanoma. Our study also proposes genes ESM1, NFATC3, C7orf4, CDK14, ZNF827, and ZSWIM7 as novel putative markers for cutaneous melanoma metastasis. The major prediction models and analysis modules to predict metastatic and primary tumor samples of SKCM are available from a webserver, CancerSPP ( http://webs.iiitd.edu.in/raghava/cancerspp/ ).

Survival Outcomes of Patients with Clinical Stage III Melanoma in the Era of Novel Systemic Therapies

BACKGROUND

Immune checkpoint and BRAF-targeted inhibitors have demonstrated significant survival benefits for advanced melanoma patients within the context of clinical trials. We sought to determine their impact on overall survival (OS) at a population level in order to better understand the current landscape for patients diagnosed with clinical stage III melanoma.

METHODS

A retrospective study was performed using the National Cancer Database. Patients diagnosed with clinical stage III melanoma were categorized by diagnosis year into two cohorts preceding the advent of novel therapies (P1: 2004-2005, P2: 2008-2009) and a contemporary group (P3: 2012-2013). OS was estimated using standard time-to-event statistical methods.

RESULTS

Of 3720 patients, 525 (14%) were diagnosed in P1, 1375 (37%) in P2, and 1820 (49%) in P3. Median age at diagnosis increased over time (58, 59, and 61 years in P1, P2, and P3, respectively, P = 0.004). OS increased between P2 (median 49.3 months) and P3 (median 58.2 months, Bonferroni-corrected log-rank P < 0.001) but did not differ between P1 (median 50.5 months) and P2 (Bonferroni-corrected log-rank P > 0.99). These differences persisted on multivariable analysis. OS improved for patients diagnosed in P3 compared with P1 [hazard ratio (HR) 0.76, P < 0.001] but not P2 compared with P1 (HR 0.96, P = 0.52).

CONCLUSIONS

OS has significantly improved nationally for patients newly diagnosed with clinical stage III melanoma in the era of novel melanoma therapies. OS outcomes will likely continue to evolve as these agents are increasingly utilized in the adjuvant setting. These data may help to better inform affected patients with respect to prognosis.

Patterns of recurrence and retreatment outcomes among clinical stage I and II head and neck melanoma patients

BACKGROUND

The objective of this study was to determine survival outcomes in patients who underwent retreatment of recurrent cases of cutaneous melanoma of the head and neck (CMHN).

METHODS

Retrospective review of all patients who were treated for primary clinical stage I or II CMHN between January 1, 2000 and December 31, 2015.

RESULTS

Twenty percent (33/168) of the patients developed a recurrence. Sixty-six percent (4/6) of patients who developed local recurrence first and 50% (3/6) of patients who developed regional recurrence first were alive without evidence (NED) of disease at last follow-up, while 0% (0/21) of patients who developed distant or simultaneous recurrences first were NED at last follow-up. Among the 7 patients who were NED, the mean time from recurrence to last follow-up was 735 days.

CONCLUSIONS

Of patients with isolated local or regional recurrences, 58% (7/12) obtained durable curative treatment for recurrent melanoma.

Targeting Lymph Node Sinus Macrophages to Inhibit Lymph Node Metastasis

Lymph nodes are important peripheral immune organs in which numerous important immune responses occur. During the process of lymphatic metastasis, lymph nodes are also sites through which tumor cells must pass. Therefore, it is essential to develop a drug delivery system that can specifically transfer immunostimulatory medicine into lymph nodes to block lymphatic metastasis. Here, we developed a nucleic acid drug delivery system containing cationic agarose (C-agarose) and CpG oligodeoxynucleotides. C-agarose has a high affinity for Siglec-1 on the surface of lymph node sinus macrophages, which have a high specificity for targeting lymph nodes. Subcutaneous implantation of C-agarose+CpG gel caused the accumulation of CpG in the lymph node sinus macrophages and generated antitumor immune responses in the lymph node. C-agarose+CpG gel treatment decreased the metastasis size in the tumor-draining lymph node (TDLN) and lung metastatic nodules and suppressed tumor growth in both a mouse 4T1 breast cancer model and a B16F10 melanoma model. On this basis, this study proposes a nonsurgical invasive lymph node targeting immunotherapy concept that may provide a new approach for antitumor metastasis.

Lymphatic changes in cancer and drug delivery to the lymphatics in solid tumors

Although many solid tumors use the lymphatic system to metastasize, there are few treatment options that directly target cancer present in the lymphatic system, and those that do are highly invasive, uncomfortable, and/or have limitations. In this review we provide a brief overview of lymphatic function and anatomy, discusses changes that befall the lymphatics in cancer and the mechanisms by which these changes occur, and highlight limitations of lymphatic drug delivery. We then go on to summarize relevant techniques and new research for targeting cancer populations in the lymphatics and enhancing drug delivery intralymphatically, including intralymphatic injections, isolated limb perfusion, passive nano drug delivery systems, and actively targeted nanomedicine.

Re-examining the role of adjuvant radiation therapy

Previously important roles for adjuvant radiotherapy (RT) in melanoma patients included improved regional control after resection of high-risk nodal disease, to reduce local recurrence for desmoplastic, and other subtypes of melanoma with neurotropism, reducing in-brain relapse of brain metastases after surgery and other situations on a case-by-case basis. This review evaluates the integration of adjuvant RT into clinical practice at this time of rapidly evolving knowledge and improving outcomes from effective systemic therapy.

Malignant melanoma: Claims and controversies

Malignant melanoma is a common cancer in young people and its incidence is rising in the UK. The management of the disease is evolving, with new approaches to the treatment of locally advanced and systemic disease in particular being rapidly developed. Sentinel node biopsy is a valuable treatment option for the staging of melanoma, and completion lymphadenectomy in node-positive patients improves local disease control. However, early clearance of occult microscopic nodal disease has not been proven to confer a melanoma-specific survival advantage. Delays in the diagnosis and treatment of melanoma lead to claims being brought in negligence, but establishing causation in such cases can be difficult.

Minimizing Post-operative Complications of Groin Dissection Using Modified Skin Bridge Technique: A Single-Centre Descriptive Study Showing Post-operative and Early Oncological Outcomes

INTRODUCTION

Historically, groin dissections are associated with high morbidity. Various modifications have been described in the literature with inconsistent outcomes. The aim of this paper is to highlight modified skin bridge technique to minimize all post-operative complications of groin dissection without compromising early oncological outcomes.

METHODS

A retrospective descriptive study of the computerized cancer database was performed to retrieve details of all the cancer patients who had undergone groin dissections during January 2012 to September 2016. Data pertaining to clinical profile including demographics, clinical and histopathological details, treatment profile, procedure-related morbidity and relapse patterns were extracted and analysed.

RESULTS

A total of 75 patients underwent 105 groin dissections during this period. Out of 105 groin dissections, 43 were inguinal lymph node dissection (ILND) and 62 were combined ilio-inguinal lymph node dissection (IILND). The most common diagnosis was carcinoma penis (25%) followed by malignant melanoma (14.6%) and squamous cell carcinoma (13.33%) of lower extremities. Overall, the most common complications were seroma (14.28%) and skin edge necrosis (7.61%) followed by surgical site infection (4.76%). After a median follow-up of 17.64 months (IQR 5-61.53), a total of 18 patients (24%) developed recurrence.

CONCLUSION

Groin dissection still remains an important diagnostic as well as therapeutic procedure justifying its potential of morbidity. Modified skin bridge technique is a very effective method to minimize all post-operative complications with optimal early oncological outcomes.

Sentinel Lymph Node Biopsy and Completion Lymph Node Dissection for Melanoma

OPINION STATEMENT

This review critically evaluates recent trials which have challenged the practice of completion lymph node dissection (CLND) for melanoma patients diagnosed with regional metastasis by positive sentinel lymph node biopsy (SLNB). Two trials in the last 2 years, DeCOG-SLT and MSLT-II, found no significant differences in melanoma-specific survival between patients, whether they received immediate CLND or observation after positive SLNB, despite decreases in nodal recurrence achieved by dissection. These trials together disfavor routine CLND in most patients after positive SLNB. However, their conclusions are limited by study populations which overall harbored a lower burden of SLN disease. Special attention needs to be given to patients who do have higher risk disease, with SLN tumor burdens exceeding 1 mm in diameter, for whom CLND may remain both prognostic and therapeutic. Current guidelines thus recommend either CLND or careful observation after positive SLNB after appropriate risk stratification of patients. While a decline in CLND is inevitable, treatment of stage III melanoma is witnessing the concurrent rise of effective adjuvant therapies. PD-1 inhibitors such as nivolumab, or combination BRAF/MEK inhibitors for V600E or K mutant melanoma, which were previously available to only trial patients with completely resected stage III disease, are now approved for use in patients with positive SLNB alone. Providers are better equipped than ever to treat clinically occult, regional metastatic disease with SLNB followed by adjuvant therapy for most patients, but should take steps to avoid undertreatment of high-risk patients who may proceed to disease relapse or progression.

Superselective Drug Delivery Using Doxorubicin-Encapsulated Liposomes and Ultrasound in a Mouse Model of Lung Metastasis Activation

Conventional treatment of lymph node metastasis involves dissection of the tumor and regional lymph nodes, but this may cause activation of latent metastatic tumor cells. However, there are few reports on animal models regarding the activation of latent metastatic tumor cells and effective methods of treating activated tumor cells. Here, we report the use of a superselective drug delivery system in a mouse model of lung metastasis in which activated tumor cells are treated with doxorubicin-encapsulated liposomes (DOX-LP) and ultrasound. The axillary lymph node was injected with DOX-LP and exposed to ultrasound so that the released DOX would be delivered from the axillary lymph node to the metastatic lung via the subclavian vein, heart and pulmonary artery. The size of the DOX-LP was optimized to a diameter of 460 nm using indocyanine green-encapsulated liposomes, and the ultrasound intensity was 0.5 W/cm². We found that compared with DOX or DOX-LP alone, the superselective drug delivery system was effective in the treatment of metastasis in both the lung and axillary lymph node. We anticipate that this superselective drug delivery system will be a starting point for the development of new techniques for treating lung metastasis in the clinical setting. Furthermore, the superselective drug delivery system may be used to screen novel drugs for the treatment of lung cancer and investigate the mechanisms of tumor cell activation after resection of a primary tumor or lymph nodes.

Impact of extended lymphadenectomy on morbidity and regional recurrence-free survival in melanoma patients

Introdurction: Current guidelines for malignant melanoma do not set a concrete cutoff limit for the number of lymph nodes to be resected during regional lymph node dissection (LND). Here, we investigate if extended LND (ext-LND) has an impact on surgical morbidity and oncological outcome in melanoma patients.

MATERIAL AND METHODS

A total of 245 melanoma patients receiving axillary or inguinal LND in curative intention were investigated retrospectively. Ext-LND was defined as axillary LND with 20 or more and inguinal LND with 10 or more resected lymph nodes. Surgical morbidity and regional recurrence-free survival were investigated.

RESULTS

Ext-LND did not lead to increased surgical morbidity in the overall study collective. After ext-LND, 55.4% of the patients experienced one of the investigated complications compared to 46.2% in the limited LND group (p = .2113). There was no difference in the occurrence of lymphatic fistula, wound infection, severe bleeding or neurological complications. In addition, patients with positive lymph node status showed improved regional recurrence-free survival following ext-LND (p = .0425).

CONCLUSION

Ext-LND can be considered a quality marker of LND in melanoma patients.

Tumor Microenvironment on a Chip: The Progress and Future Perspective

Tumors develop in intricate microenvironments required for their sustained growth, invasion, and metastasis. The tumor microenvironment plays a critical role in the malignant or drug resistant nature of tumors, becoming a promising therapeutic target. Microengineered physiological systems capable of mimicking tumor environments are one emerging platform that allows for quantitative and reproducible characterization of tumor responses with pathophysiological relevance. This review highlights the recent advancements of engineered tumor microenvironment systems that enable the unprecedented mechanistic examination of cancer progression and metastasis. We discuss the progress and future perspective of these microengineered biomimetic approaches for anticancer drug prescreening applications.

Morbidity and oncologic outcome after saphenous vein-sparing inguinal lymphadenectomy in melanoma patients

BACKGROUND

Inguinal lymph node dissection (LND) is a surgical procedure with a high morbidity rate. Variations in surgical procedure, such as sparing of the saphenous vein, have been proposed to reduce surgical morbidity. While sparing of the saphenous vein has shown promising results in earlier studies, data for this procedure in melanoma patients are rare. In this retrospective study, we report 10-year findings on the effects of saphenous vein-sparing LND on surgical morbidity and oncologic outcomes in melanoma patients.

METHODS

A retrospective analysis of melanoma patients receiving inguinal LND in our facility between 2003 and 2013 was performed. Patients were divided into two groups: the saphenous vein resection group and the vein sparing group. Surgical morbidity, including wound infection, lymphatic fistula, severe bleeding, neurological complications, and chronic lymphedema, as well as regional recurrence-free survival were investigated.

RESULTS

A total of 106 patients were included in this study; of these, the saphenous vein was spared in 41 patients (38.7%). The rate of lymphatic fistula was 51.6 vs. 48.8%, wound infection occurred in 31.3 vs. 24.4%, and patients suffered from chronic lymphedema in 30.0 vs. 26.5% in V. saphena magna resection vs. sparing group. Differences observed, however, were not significant. No difference in regional recurrence-free survival between the two study groups was detected.

CONCLUSIONS

The results of our retrospective analysis could not confirm the promising results reported in earlier studies. Thus, sparing of the saphenous vein appears to be optional.

Human Melanoma-Derived Extracellular Vesicles Regulate Dendritic Cell Maturation

Evolution of melanoma from a primary tumor to widespread metastasis is crucially dependent on lymphatic spread. The mechanisms regulating the initial step in metastatic dissemination via regional lymph nodes remain largely unknown; however, evidence supporting the establishment of a pre-metastatic niche is evolving. We have previously described a dysfunctional immune profile including reduced expression of dendritic cell (DC) maturation markers in the first node draining from the primary tumor, the sentinel lymph node (SLN). Importantly, this phenotype is present prior to evidence of nodal metastasis. Herein, we evaluate melanoma-derived extracellular vesicles (EVs) as potential mediators of the premetastatic niche through cargo-specific polarization of DCs. DCs matured in vitro in the presence of melanoma EVs demonstrated significantly impaired expression of CD83 and CD86 as well as decreased expression of Th1 polarizing chemokines Flt3L and IL15 and migration chemokines MIP-1α and MIP-1β compared to liposome-treated DCs. Profiling of melanoma EV cargo identified shared proteomic and RNA signatures including S100A8 and S100A9 protein cargo, which in vitro compromised DC maturation similar to melanoma EVs. Early evidence demonstrates that similar EVs can be isolated from human afferent lymphatic fluid ex vivo. Taken together, here, we propose melanoma EV cargo as a mechanism by which DC maturation is compromised warranting further study to consider this as a potential mechanism enabled by the primary tumor to establish the premetastatic niche in tumor-draining SLNs of patients.

Therapeutic implications of cellular and molecular biology of cancer stem cells in melanoma

Melanoma is a form of cancer that initiates in melanocytes. Melanoma has multiple phenotypically distinct subpopulation of cells, some of them have embryonic like plasticity which are involved in self-renewal, tumor initiation, metastasis and progression and provide reservoir of therapeutically resistant cells. Cancer stem cells (CSCs) can be identified and characterized based on various unique cell surface and intracellular markers. CSCs exhibit different molecular pattern with respect to non-CSCs. They maintain their stemness and chemoresistant features through specific signaling cascades. CSCs are weak in immunogenicity and act as immunosupressor in the host system. Melanoma treatment becomes difficult and survival is greatly reduced when the patient develop metastasis. Standard conventional oncology treatments such as chemotherapy, radiotherapy and surgical resection are only responsible for shrinking the bulk of the tumor mass and tumor tends to relapse. Thus, targeting CSCs and their microenvironment niche addresses the alternative of traditional cancer therapy. Combined use of CSCs targeted and traditional therapies may kill the bulk tumor and CSCs and offer a promising therapeutic strategy for the management of melanoma.

Adjuvant external beam radiotherapy after therapeutic groin lymphadenectomy for patients with melanoma: a dosimetric comparison of three-dimensional conformal and intensity-modulated radiotherapy techniques

Radiotherapy after lymph node dissection is recommended in high-risk melanoma cases. The aim of this study is to assess whether intensity-modulated radiotherapy (IMRT) offers advantages over three-dimensional conformal radiotherapy (3DCRT) in the groin nodal basin. Fifteen consecutively treated patients (5 3DCRT and 10 IMRT) were selected. Optimized theoretical plans using the other modality were created - enabling direct comparisons of 3DCRT and IMRT. Target volume and organs at risk constraints were assessed as achieved or as having minor (≤5%) or major (>5%) deviations. The Wilcoxon signed-rank test was used to compare the dose received from each patient plan (3DCRT vs. IMRT), whereas the Mann-Whitney U-test was used to compare clinical plans with theoretical plans. Fisher's exact test was used to compare categorical data. Target coverage was achievable in most patients (major deviations - 1 IMRT and 3 3DCRT). Conformity index improved with IMRT - median 0.65, range 0.48-0.81, versus median 0.44, range 0.29-0.60 for 3DCRT; P value less than 0.001. All 3DCRT plans had major deviations for femoral head/neck constraints. Twelve and 13 IMRT plans achieved the high (V42<5%) and low (V36<35%) constraints; P value less than 0.001. IMRT delivered statistically significant lower doses to small bowel volumes up to 40 ml. There were no differences in beam numbers used nor dosimetric endpoints measured when clinical plans were compared with theoretical plans. IMRT appears to allow superior conformity of dose to the target volume while relatively sparing the adjacent the bowel and femoral head/neck. This may reduce toxicity while maintaining control rates.

Impact of gender and primary tumor location on outcome of patients with cutaneous melanoma

Background. The survival of patients with cutaneous malignant melanoma (MM) depends on multiple factors whose role is continuously updated, as the molecular mechanisms underlying the disease progression are understood. This study intended to assess whether the patient's gender and tumor location affect the disease outcome. Methods. Between 2008 and 2012, 155 patients with cutaneous MM underwent various types of surgeries in our clinic. Patients were staged according to the 2009 TNM classification. There were 90 women and 65 men. Primary tumors were located as it follows head and neck region - 4.5%, limbs - 50.7% and trunk - 44.8%. The disease free and overall survival rates (DFS, OS) were estimated by using the Kaplan-Meier method. Results. Metastases developed in 52.3% of the males and 31.1% of the females (p=0.008). In univariate analysis, distant metastasis risk was significantly higher in men (p = 0.0472 for stage II patients and p = 0.0288 for stage III). In multivariate analysis, male gender almost doubled the risk of relapse (p = 0.044) and death (p = 0.022). Consequently, DFS and OS were significantly higher among females. Primary tumor location seemed to influence the melanoma spreading ability. Half of the trunk MM developed metastases while only a third of limbs MM did. The association between MM location and the recurrence risk was not random (p = 0.033). Conclusions. The patient gender represents an independent prognostic factor for both relapse and death. Although trunk MM had a significantly higher risk of metastasis than limbs MM, the location per se was not an independent prognostic factor for survival (p = 0.078). Abbreviations: MM = malignant melanoma, DFS = disease free survival, OS = overall survival, p = p value, AJCC = American Joint Commission on Cancer, CI = confidence interval.

Videoscopic ilioinguinal lymphadenectomy for groin lymph node metastases from melanoma

BACKGROUND

Groin lymph node dissection for melanoma is burdened by high postoperative morbidity. Videoscopic lymphadenectomy may lower the incidence of complications, including infection, dehiscence and lymphoedema. This pilot study aimed to investigate the feasibility and postoperative outcomes of videoscopic ilioinguinal lymphadenectomy in patients with inguinal nodal melanoma metastases.

METHODS

Patients with inguinal nodal metastases, with either a positive sentinel lymph node biopsy or clinically positive nodes from melanoma, were enrolled. Inguinal dissection was performed via three ports. Iliac dissection was obtained through a preperitoneal access. Intraoperative and postoperative data were collected.

RESULTS

Of 23 patients selected for 24 procedures, four needed conversion to an open procedure. Median duration of surgery was 270 (i.q.r. 245-300) min. Wound-related postoperative complications occurred in four patients, although only one needed further intervention. The median number of excised lymph nodes was 21 (i.q.r. 15-25). After a median follow-up of 18 months, regional lymph node recurrence was observed in two patients.

CONCLUSION

Videoscopic ilioinguinal lymphadenectomy for melanoma groin lymph node metastases is technically feasible, safe, and associated with acceptable morbidity and oncological outcome.

Role of radiation therapy in melanomas: Systematic review and best practice in 2016

Radiotherapy has been used for skin cancers since early after the discovery of X-rays. The introduction of sophisticated surgery techniques and information of the general population on potential late radiation-induced toxicity and carcinogenesis have led to limiting indications in the dermatologist community. However, radiotherapy (RT) has undergone considerable developments, essentially including technological advances, to sculpt radiation delivery, with demonstration of the benefit either alone or after adding concomitant cytotoxic agents or targeted therapies. Although side effects due to high doses and/or the use of old RT techniques have been significantly decreased, the risk of atrophic scars, ulcerations or secondary cancers persist. In this systematic review, we aim to discuss indications for RT in melanomas with focus on new advances that may lead to rehabilitating this treatment option according to the tumor radiosensitivity and clinical benefit/risk ratio. Melanomas have been considered as radioresistant tumors for many years.

Vesicular trafficking mechanisms in endothelial cells as modulators of the tumor vasculature and targets of antiangiogenic therapies

A common feature of solid tumors is their ability to incite the formation of new blood and lymph vessels trough the processes of angiogenesis and lymphangiogenesis, respectively, to support tumor growth and favor metastatic dissemination. As a result of the lack of feedback regulatory control mechanisms or due to the exacerbated presence of pro-angiogenic signals within the tumor microenvironment, the tumor endothelium receives continuous signals to sprout and develop, generating vessels that are structurally and functionally abnormal. An emerging mechanism playing a central role in shaping the tumor vasculature is the endothelial-vesicular network that regulates trafficking/export and degradation of key signaling proteins and membrane receptors, including the vascular endothelial growth-factor receptor-2/3 and members of the Notch pathway. Here we will discuss recent evidence highlighting how vesicular trafficking mechanisms in endothelial cells contribute to pathological angiogenesis/lymphangiogenesis and can provide novel and exploitable targets in antiangiogenic therapies.

Treatment Outcome and Prognostic Factors for Malignant Skin Melanoma Treated with Radical Surgery

AIM

To assess the treatment outcome in patients with malignant skin melanoma and prognostic factors for distant metastases (DM), disease-free survival (DFS) and overall survival (OS).

MATERIALS AND METHODS

A retrospective analysis was conducted on 113 patients with malignant skin melanoma (60 females, 53 males, average age-55 years) who were treated surgically. Primary treatment consisted of local excision. In 12 cases, it was accompanied by lymph node excision. In 93 (82%) cases, radicalization was necessary, which was either local only (19 cases) or accompanied by lymph node surgery/biopsy (74 cases). Possible prognostic factors such as Clark's stage and Breslow's depth of invasion, ulceration, average tumor dimensions, lymph nodes metastases (pN+), gender, tumor location and primary excision margins were considered.

RESULTS

In 51 (45%) cases, treatment failure occurred. The 5-year DM rate was 47%, the 5-year DFS was 38%, and the 5-year OS was 56%. In the univariate analysis, the important factors with respect to at least one endpoint included Clark's stage, Breslow's depth of invasion, ulceration, average tumor dimensions, lymph nodes metastases, gender and primary tumor localization. The presence of metastasic nodes was the most important prognostic factor, with a 5-year DM rates of 30% for pN(-) and 76% for pN(+) and a 5-year DFS and OS of 56% and 76% for pN(-) and 13% and 24% for pN(+), respectively. The average tumor dimension was independently significant for DFS and OS, with 5-year rates of 69% and 80% for ≤1 cm, 28% and 53% for 1-2 cm, and 18% and 30% for >2 cm, respectively. Tumor location was also significant for DM and OS, with 5-year rates of 69% vs 33% and 41% vs 66% for trunk vs other locations, respectively.

CONCLUSIONS

The natural course of a malignant skin melanoma treated radically is disadvantageous, with unsuccessful outcome in nearly half of the cases. Common clinical factors, such as Clark's tumor stage, Breslow's depth of invasion and the presence of metastatic nodes, have high prognostic significance. The size and location of the primary lesion may be considered independent prognostic factors. The most important negative prognostic factor is the presence of metastatic regional lymph nodes. Only one quarter of patients with metastases in lymph nodes survive 5 years from primary surgery.

The use of interferon in melanoma patients: a systematic review

Interferon (IFN) and PEG-IFN are the only drugs approved as adjuvant therapy in patients with melanoma at high-risk of recurrence after surgical resection. Several clinical trials of adjuvant IFN, using different doses and durations of therapy, have been conducted in these patients. Results generally suggest relapse-free survival and overall survival benefits; however, questions over the optimal dose and duration of treatment and concerns over toxicity have limited its use. IFN exerts its biological activity in melanoma via multiple mechanisms of action, most of which can be considered as indirect immunomodulatory effects. As such, IFN may also be of benefit in the neoadjuvant setting, where it may have a role in melanoma patients with locally advanced disease for whom immediate surgical excision is not possible. However, this has not been well studied. The use of IFN in patients with metastatic melanoma is controversial, with limited data and no convincing evidence of a survival benefit. However, IFN therapy combined with novel biological and immunotherapies offers the potential for a synergistic effect and improved clinical outcomes. Predictive and prognostic factors to better select melanoma patients for IFN treatment have been identified (e.g. disease stage, ulceration, various cytokines) and may also enhance its therapeutic efficacy, but their incorporation into the clinical decision-making process requires validation in prospective trials. In conclusion, the modest efficacy of IFN shown in clinical trials is largely a reflection of differences in response between patients. Despite advancements in the understanding of its biological mechanisms of action, the huge potential of IFN remains to be fully explored and utilized in patients with melanoma.

BRAF mutation status is an independent prognostic factor for resected stage IIIB and IIIC melanoma: implications for melanoma staging and adjuvant therapy

BACKGROUND

5-year survival for melanoma metastasis to regional lymph nodes (American Joint Committee on Cancer stage III) is <50%. Knowledge of outcomes following therapeutic lymphadenectomy for stage III melanoma related to BRAF status may guide adjuvant use of BRAF/MEK inhibitors along with established and future therapies.

AIMS

To determine patterns of melanoma recurrence and survival following therapeutic lymph node dissection (TLND) associated with oncogenic mutations.

METHODS

DNA was obtained from patients who underwent TLND and had ⩾2 positive nodes, largest node >3cm or extracapsular invasion. Mutations were detected using an extended Sequenom MelaCARTA panel.

RESULTS

Mutations were most commonly detected in BRAF (57/124 [46%] patients) and NRAS (26/124 [21%] patients). Patients with BRAF mutations had higher 3-year recurrence rate (77%) versus 54% for BRAF wild-type patients (hazard ratio (HR) 1.8, p=0.008). The only prognostically significant mutations occurred in BRAF: median recurrence-free (RFS) and disease-specific survival (DSS) for BRAF mutation patients was 7 months and 16 months, versus 19 months and not reached for BRAF wild-type patients, respectively. Multivariate analysis identified BRAF mutant status and number of positive lymph nodes as the only independent prognostic factors for RFS and DSS.

CONCLUSIONS

Patients with BRAF mutations experienced rapid progression of metastatic disease with locoregional recurrence rarely seen in isolation, supporting incorporation of BRAF status into melanoma staging and use of BRAF/MEK inhibitors post-TLND.