Role of surgery in patients with stage IV melanoma

Surgical treatment of melanoma metastases to the small bowel: A single cancer referral center real-life experience

INTRODUCTION

Treatment of metastatic melanoma has rapidly changed during the last years, and patients often require a multidisciplinary approach to achieve effective results. We aimed to assess the survival benefit achieved through surgical approach to patients with small bowel (SB) metastases from cutaneous melanoma, to emphasize the potential role of surgery in association with novel therapies.

METHODS

Ninety consecutive patients with cutaneous melanoma diagnosed as having resectable SB metastases from 1995 to 2015 were retrospectively investigated.

RESULTS

Median age at surgery of melanoma metastases was 53.4 years. Among 30 patients who had a curative-intent resection, the 5- and 10-year survival rates were 61% and 54%, respectively, while among 60 patients treated with a palliative surgery the corresponding rates were both 4%. Among 29 patients, for whom the interval time between the occurrence of SB metastases and the previous surgical event on GI tract was ≥36 months, the 5-year overall survival rate was 42%; for 56 patients who had an interval time <36 months the corresponding survival rate was 14%. Within the whole series, an absence of any residual disease after surgery (R0) was a factor affecting better survival, regardless of the evidence of metastases in other organs.

CONCLUSION

Our observational data showed that surgical treatment for patients with SB metastases from melanoma might increase survival, but further studies are needed to confirm this finding. In the age of novel available therapies, the increase in survival time given by surgery may offer important chances for patients to benefit from systemic therapies.

Prognostic significance of distant metastasis-free interval in patients with relapsed melanoma treated with BRAF with or without MEK inhibitors

This retrospective cohort study assessed the prognostic significance of distant metastasis-free interval (DMFI) in patients with relapsed BRAF-mutant melanoma treated with BRAF with or without MEK inhibitors (BRAFi ± MEKi). Patients with a DMFI of up to 24 months were compared with those with DMFI of more than 24 months, with regard to their postrelapse progression-free survival (PR-PFS) and overall survival (PR-OS). In total, 109 patients were included in the study. Median DMFI was 25.3 (range: 3.4-188.2) months. Median PR-PFS in patients with DMFI of more than 24 months was 7.9 months [95% confidence interval (CI): 6.2-9.7] compared with 5.4 (95% CI: 4.2-6.7) months of those with shorter DMFI (P = 0.016). Median PR-OS was 15.6 months (95% CI: 13.6-17.6) in patients with DMFI of more than 24 months and 12.0 months (95% CI: 9.0-15.0) with DMFI of up to 24 months (P = 0.289). Multivariate Cox regression analysis showed that DMFI was independently and strongly associated with improved PR-PFS (adjusted hazard ratio = 3.21, 95% CI: 1.78-5.77, ≤ 24 vs. > 24 months) and longer PR-OS (adjusted hazard ratio: 2.09, 95% CI: 1.15-3.80, ≤ 24 vs. > 24 months). The present cohort study is one of the first to confirm the association of DMFI of more than 24 months with an indolent disease course, as shown by longer PR-PFS and PR-OS, in patients with relapsed stage IV melanoma treated by BRAF inhibitor/MEK inhibitor.

Indications for the surgical resection of stage IV disease

Tumor biology and careful patient selection weigh heavily in determining the appropriate role of surgical resection in stage IV melanoma. Historically, surgical resection for highly selected patients with metastatic melanoma was the only treatment modality associated with improved long-term survival and the ability to provide palliation. With the new age of effective systemic therapies, the treatment of metastatic melanoma has become more intricate and future work is needed to better define the role for surgery within the current treatment paradigm.

Surveillance strategies in the follow-up of melanoma patients: too much or not enough?

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.

Recurrence and Survival Outcomes After Percutaneous Thermal Ablation of Oligometastatic Melanoma

OBJECTIVES

To evaluate focal treatment of melanoma metastases and to explore whether any potential extended survival benefit exists in a select patient population.

PATIENTS AND METHODS

All patients who underwent image-guided local thermal ablation of metastatic melanoma over an 11-year period (January 1, 2002, to December 31, 2013) were retrospectively identified using an internally maintained clinical registry. Only patients with oligometastatic stage IV disease amenable to complete ablation of all clinical disease at the time of ablation were included in the analysis. Overall survival and median progression-free survival periods were calculated.

RESULTS

Thirty-three patients with primary ocular or nonocular melanoma had 66 metastases treated in the lungs, liver, bones, or soft tissues. Eleven (33%) patients were on systemic medical therapy at the time of the procedure. The median survival time was 3.8 years (range, 0.5-10.5 years), with a 4-year estimated survival of 44.1% (95% CI, 28%-68%). Local recurrence at the ablation site developed in 15.1% (5 of 33) of the patients and 13.6% of the tumors (9 of 66). The median progression-free survival time was 4.4 months (95% CI, 1.4 months to 10.5 years), with an estimated 1-year progression-free survival of 30.3% (95% CI, 18%-51%). A subgroup analysis identified 11 patients with primary ocular melanoma and 22 with nonocular melanoma, with a median survival time of 3.9 years (range, 0.9-4.7 years) and 3.8 years (range, 0.5-10.5 years), respectively (P=.58). There were no major complications and no deaths within 30 days of the procedure.

CONCLUSION

Selective use of image-guided thermal ablation of oligometastatic melanoma may provide results similar to surgical resection in terms of technical effectiveness and oncologic outcomes with minimal risk.

"Unsteady gait": an uncommon presentation and course of malignant melanoma in terminal ileum-a case report and review of literature

Malignant melanoma within the gastrointestinal tract is an uncommon neoplasm that is usually metastatic in origin, with primary melanomas being relatively uncommon. Embryologically melanocytes normally exist in the esophagus, stomach, small bowel, and anorectum and this theory supports the primary melanoma of the gastrointestinal tract that has been confirmed for lesions occurring through several published reports. However, most patients with brain metastases from malignant melanoma are diagnosed after treatment for known extracranial metastases and have poor outcomes. Our case is unique in that we discuss an unusual case of 69-year-old female patient presented with unsteady gait as the first symptom of disease and where the presumed primary lesion later was found in the terminal ileum on colonoscopy. Treatment consisted of surgical removal of the terminal ileal lesion with chemotherapy, whole-brain radiotherapy, and cyberknife radiosurgical procedure. Patient was in remission for more than 14 months and later succumbed to disease. Despite the advances in therapeutic options, prognosis for patients with melanoma brain metastases remains poor with a median survival time of six months after diagnosis.

Optimal management of metastatic melanoma: current strategies and future directions

Melanoma is increasing in incidence and remains a major public health threat. Although the disease may be curable when identified early, advanced melanoma is characterized by widespread metastatic disease and a median survival of less than 10 months. In recent years, however, major advances in our understanding of the molecular nature of melanoma and the interaction of melanoma cells with the immune system have resulted in several new therapeutic strategies that are showing significant clinical benefit. Current therapeutic approaches include surgical resection of metastatic disease, chemotherapy, immunotherapy, and targeted therapy. Dacarbazine, interleukin-2, ipilimumab, and vemurafenib are now approved for the treatment of advanced melanoma. In addition, new combination chemotherapy regimens, monoclonal antibodies blocking the programmed death-1 (PD-1)/PD-ligand 1 pathway, and targeted therapy against CKIT, mitogen-activated protein/extracellular signal-regulated kinase (MEK), and other putative signaling pathways in melanoma are beginning to show promise in early-phase clinical trials. Further research on these modalities alone and in combination will likely be the focus of future clinical investigation and may impact the outcomes for patients with advanced melanoma.

Inoperable bulky melanoma responds to neoadjuvant therapy with vemurafenib

A patient with a bulky inoperable stage IIIC melanoma involving the left axilla and neck from a primary of the left medial elbow received vemurafenib as neo-adjuvant treatment. Based on the molecular analysis, BRAF V600E mutation was present. After 4 months of vemurafinib treatment, the tumours shrank to less than 50% of original clinical size and allowed the surgeons to perform a left modified radical neck dissection and left radical axillary dissection. Pathological analysis of specimen revealed viable metastatic cells only in 1 of 40 nodes resected in the neck and axillary dissection, accounting for over 98% pathological response. Other lymph nodes had a mixture of foamy histiocytic inflammatory reaction fibrosis and islands of necrotic tissues. After recovery from surgery, vemurafenib was resumed and continued for 6 months. He remained disease free 6 months after surgery.

A multicenter prospective evaluation of the clinical utility of F-18 FDG-PET/CT in patients with AJCC stage IIIB or IIIC extremity melanoma

OBJECTIVE/BACKGROUND

There is a high risk of relapse in stage IIIB/IIIC melanoma. The utility of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography integrated with computed tomography (FDG-PET/CT) in these patients to evaluate response to treatment or for surveillance after treatment is currently not well defined.

METHODS

Prospective data from 2 centers identified 97 patients with stage IIIB/IIIC extremity melanoma undergoing isolated limb infusion (ILI) who had whole body FDG-PET/CT scans before and every 3 months after treatment. Clinical response was determined at 3 months by Response Evaluation Criteria In Solid Tumors.

RESULTS

Complete response (CR) after ILI occurred in 33% (32/97) of patients. FDG-PET/CT accurately identified 59% of patients who were CRs (19/32), whereas 41% (13/32) had residual metabolic activity in the extremity that was histologically negative for melanoma. The 3-year disease-free rate was 62.2% (95% CI: 40.1%-96.4%) for those patients who were CRs by both clinical/pathologic examination and FDG-PET/CT (n = 19) compared to only 29.4% (95% CI: 9.9%-87.2%) of those CRs who still had residual FDG-PET/CT activity (n = 13). FDG-PET/CT was utilized for surveillance of disease recurrence outside the regional field of treatment. Fifty-two percent (51/97) of patients developed disease outside the extremity at a median time of 212 days from pre-ILI FDG-PET/CT. In 47% (29/62) of these cases, the recurrence was resected.

CONCLUSIONS

Although FDG-PET/CT does not appear to accurately identify patients who appear to be CRs to ILI, it does appear to identify a subgroup of patients whose regional progression-free survival is markedly worse. However, FDG-PET/CT appears to be an excellent method for surveillance in stage IIIB/IIIC patients after ILI with ability to identify surgically resectable recurrent disease in these high-risk patients.

Complete resection of pulmonary metastatic melanoma

BACKGROUND

The prognosis of melanoma metastasized to other organs is very poor. There have been many studies on metastatic melanoma in Western society, but there have been few studies done in Korea because of the small number of cases.

MATERIALS AND METHODS

A retrospective review of 7 patients who underwent complete resection of pulmonary metastases from melanoma from January 2005 to December 2009 was performed. When the primary lesion was controlled or simultaneously controllable and no other metastatic lesion was found, pulmonary resections were performed. We analyzed the clinical prognoses after the initial melanoma diagnosis.

RESULTS

Of the seven patients, one was male and six were female. The mean age was 58.2 years (range 45~71). Six patients had a single pulmonary lesion and one patient had three lesions confined to the same lobe. The mean disease-free interval was 43.5 months (0~146 months). Before pulmonary resection, 4 patients had received systemic therapy. After pulmonary resection, 6 patients received systemic therapy. Complete resection was confirmed histologically. The metastasectomy was performed by wedge resection (6 patients) or lobectomy (1 patient). There were no mortalities or complications. After pulmonary resection, 1 patient had recurrent multiple lesions in the lung and 4 patients had metastases to other organs. The organs were the liver, brain, pleura, and lymph nodes. The mean observation time was 31.6 months and 3 patients died during observation. The mean survival was 27.7 months (14~60 months) and the 1-year and 3-year survival rates were 100% and 42%, respectively.

CONCLUSION

When patients were selected carefully, the complete resection of pulmonary metastatic lesions was considered a major therapeutic tool.

Differential expression patterns of capping protein, protein phosphatase 1, and casein kinase 1 may serve as diagnostic markers for malignant melanoma

Early and accurate diagnosis of malignant melanoma is critical for patient survival. However, currently used diagnostic markers are insufficiently specific, which limits their utility. We aimed to identify molecular markers that are more specific to malignant melanoma, thereby aiding in melanoma diagnosis and treatment. A PCR-based suppression subtractive hybridization was used to identify capping protein Z-line α1, protein phosphatase 1 catalytic subunit β isoform (PP1CB), and casein kinase 1 α1 (CSNK1A1) as being differentially expressed between melanoma cells and normal melanocytes. Quantitative reverse transcription-PCR and western blot analysis confirmed that these genes were overexpressed in melanoma cells. In addition, immunohistochemical assays revealed that the expression of PP1CB and CSNK1A1 was significantly greater in human melanoma specimens than nevi (P<0.0001). Combined application of PP1CB and CSNK1A showed high sensitivity and specificity for melanoma. Thus, our data suggest that PP1CB and CSNK1A1 are potential biomarkers for distinguishing malignant melanoma from other melanocytic lesions. In addition, because capping protein Z-line α1, PP1CB, and CSNK1A1 are involved in cell motility, which underlies invasion and metastasis of human cancer; they may be novel targets for antimetastatic therapies as well.

Rationale for complete metastasectomy in patients with stage IV metastatic melanoma

Patients with stage IV melanoma have usually been treated with systemic therapies; however, the overall survival for patients with this approach is disappointing. A complete surgical resection of metastatic disease to stage IV sites offers the best chance to maximize survival. This review article will present data supporting the position that if a complete metastasectomy is technically feasible, then surgery should be strongly considered the first option for properly selected patients with stage IV melanoma.

Current and planned multicenter trials for patients with primary or metastatic melanoma

Multicenter clinical trials have established new standards of care in the surgical and medical management of malignant melanoma. They have led to the testing of new therapies and improved outcomes for patients with loco-regional and distant disease. Many pressing questions remain, however, and additional multicenter trials are currently underway to address them. The purpose of this review is to summarize relevant ongoing and planned multicenter trials that have and continue to define current melanoma management.

A phase 2 trial of complete resection for stage IV melanoma: results of Southwest Oncology Group Clinical Trial S9430

BACKGROUND

On the basis of retrospective experience at individual centers, it appears that patients with stage IV melanoma who undergo complete resection have a favorable outcome compared with patients with disseminated stage IV disease. The Southwest Oncology Group (SWOG) performed a prospective trial in patients with metastatic melanoma who were enrolled before complete resection of their metastatic disease and provided prospective outcomes in the cooperative group setting.

METHODS

Based on their physical examination and radiologic imaging studies, patients with a stage IV melanoma judged amenable to complete resection underwent surgery within 28 days of enrollment. All eligible patients were followed with scans (computed tomography or positron emission tomography) every 6 months until relapse and death.

RESULTS

Seventy-seven patients were enrolled from 18 different centers. Of those, 5 patients were ineligible; 2 had stage III disease alone; and 3 had no melanoma in their surgical specimen. In addition, 8 eligible patients had incompletely resected tumor. Therefore, the primary analysis included 64 completely resected patients. Twenty patients (31%) had visceral disease. With a median follow-up of 5 years, the median relapse-free survival was 5 months (95% CI, 3-7 months) whereas median overall survival was 21 months (95% CI, 16-34 months). Overall survivals at 3 and 4 years were 36% and 31%, respectively.

CONCLUSIONS

In a prospective multicenter setting, appropriately selected patients with stage IV melanoma achieved prolonged overall survival after complete surgical resection. Although median relapse-free survival was only 5 months, patients could still frequently undergo subsequent surgery for isolated recurrences. This patient population is appropriate for aggressive surgical therapy and for trials evaluating adjuvant therapy.

Surgical resection for bulky or recurrent axillary metastatic melanoma

INTRODUCTION

Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients.

METHODS

We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms.

RESULTS

Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001).

DISCUSSION

Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.

Immunotherapy for cutaneous malignancy

BACKGROUND

Immunotherapy for cutaneous malignancy involves manipulating the immune system to treat and prevent skin cancer. Although initial efforts were fraught with low success rates and technical challenges, more-recent endeavors have yielded response rates approaching 50% for treating metastatic melanoma. Many of these advances are a result of increasing knowledge of the immune system's intricacies and continued progress in laboratory techniques.

OBJECTIVE

To review our current understanding of the skin immune system and discuss how these factors contribute to the host response to malignancy and to report the current state of immunotherapeutic techniques.

MATERIALS AND METHODS

An extensive PubMed literature search was conducted in topics involving immunotherapy with specific relevance to cutaneous malignancy using the MeSH terms "immunotherapy" and "skin cancer."

RESULTS

Despite initially poor patient responses to these treatment modalities, recent gains in scientific knowledge and clinical intervention protocols have brought immunotherapy to the forefront of prospective skin cancer therapeutics, particularly for advanced melanoma.

CONCLUSIONS

Current treatment options for advanced cutaneous malignancies such as melanoma are low in efficacy. Immunotherapies have the potential to provide novel approaches to address this, particularly when used in combination. The authors have indicated no significant interest with commercial supporters.

Melanoma staging: facts and controversies

The value of staging examinations remains controversial for the initial staging in melanoma patients at the time of the primary diagnosis and for surveillance. Issues concerning tumor recurrences and progression must be discussed separately for different risk groups. For low-risk patients (stage IA; tumor thickness less than 1 mm), staging examinations like sentinel lymph node biopsy (SLNB), blood tests, or imaging can generally be abandoned. Baseline staging with simple techniques is at the discretion of the physician. In intermediate-risk patients (stages IB and IIA), an initial staging examination involving SLNB and computed tomography (CT) scans is recommended. Further follow-up may be restricted to physical examinations, blood tests of tumor marker protein S100beta, and to lymph node ultrasonography. If findings are suspicious, further imaging procedures may be involved. In high-risk patients (stages IIB to III), an initial staging examination with CT is recommended, and regular follow-up every 6 months with whole body imaging by CT or magnetic resonance imaging seems useful. Physical examinations, blood tests of tumor marker protein S100beta, and lymph node ultrasound imaging should be routine. This intense follow-up may enable surgical treatments with complete removal of all recognizable metastases in about 15% to 25% of patients and improve their prognosis. The risk of recurrence or tumor progression is very high in stage IV patients, and their management is individualized.

Surgical Metastasectomy in AJCC Stage IV M1c Melanoma Patients with Gastrointestinal and Liver Metastases

Introduction: Visceral metastases from melanoma represent the poorest prognosis based according to the revised version of the AJCC staging system that recognises both clinical and pathological features distinctive to melanoma. Given that systemic treatments in metastatic melanoma to date remains inadequate, we evaluated the efficacy of surgical metastasectomy on survival outcomes. Materials and Methods: Between year 2000 and 2009, 23 patients with visceral metastases from melanoma were evaluated for metastasectomy. Retrospective review was undertaken of the specific therapy administered following consensus meeting of a multidisciplinary team. Results: There were 16 males and 7 females. Seventeen patients (74%) had metachronous gastrointestinal/liver metastases following previous treatment of the primary tumour. The median time to development of gastrointestinal/liver metastases, otherwise known as disease-free interval, was 49 (range, 5 to 559) months. Overall median survival period was 9 months, with a 1- and 3-year survival percentages of 39% and 30%, respectively. Survival was influenced by the number of metastases (P = 0.05) and the treatment received (P = 0.03). The disease-free and overall survival periods after metastasectomy were 14 and 21 months, respectively. The 1- and 3-year survival percentages were 60% and 40%, respectively. Patients with single site of metastasis survived longer than patients with more than one site of metastasis (P= 0.005). Conclusion: Patients with visceral metastases from melanoma may derive survival benefit from metastasectomy over systemic therapy. Judicious selection of patients for metastasectomy is paramount for the success of treatment in this group of patients. Key Words: Melanoma, Metastasectomy, Liver metastasis, Surgery, Prognosis

Liver resection for metastatic melanoma with postoperative tumor-infiltrating lymphocyte therapy

BACKGROUND

Patients with metastatic melanoma to the liver (MML) have a median survival of 4 to 6 months. This study evaluated patients who underwent liver resection with intent to receive postoperative tumor-infiltrating lymphocyte (TIL) therapy.

METHODS

Retrospective analysis of a prospective database identified patients with MML who underwent liver resection from 1980 to 2008.

RESULTS

A total of 539 patients had MML, and 39% (204 of 539) had tumor collected for TIL. A total of 17% (35 of 204) underwent liver resection for TIL. The 3-year overall survival was 53%. Lack of extrahepatic disease (P = .026), negative margin (P = .056), and single hepatic metastasis (P = .04) predicted survival after univariate analysis. Only lack of extrahepatic disease remained a significant predictor of survival after multivariate analysis (P = .043). A total of 31% (11 of 35) underwent complete resection without TIL, and 69% (24 of 35) underwent resection with synchronous intrahepatic and extrahepatic disease with intent to receive TIL. For 9 of 11 patients (2 of 11 excluded for gene therapy), 3-year survival was 80%. A total of 4 (44%) of 9 experienced recurrence, with a median disease-free survival of 1.2 years. For 24 patients (69%) with residual disease, 3-year survival was 51% (2 of 24 excluded for gene therapy). A total of 63% (15 of 24) received postoperative TIL (3-year survival 65%), and 29% (7 of 24) did not. A total of 40% (6 of 15) had disease that partially responded to TIL; the disease of 67% (4 of 6) had not progressed at median follow-up of 55 months (range, 42-197+ months). The seven patients who did not receive TIL had a median survival of 4.6 months.

CONCLUSIONS

Resection of MML with TIL should be considered because it can result in prolonged survival in a highly selected group of patients.

Surgical management of melanoma

Melanoma is an increasing health care problem worldwide. Up to 80,000 cases of melanoma are diagnosed per year and it is the sixth leading cause of cancer death in the United States. The lifetime risk is estimated to be 1 in 75 individuals for the development of melanoma. Surgery remains the mainstay of treatment of melanoma, and in most cases it is curative. Several important surgical issues are discussed in this review, including the extent of surgical margins, Mohs micrographic surgery for melanoma in situ, the use of sentinel lymph node biopsy, the usefulness of lymphadenectomy, isolated limb perfusion, and the role of metastasectomy.

Novel therapeutics for the treatment of metastatic melanoma

Metastatic malignant melanoma is an incurable disease with a median survival of 8.5 months and a probability of surviving 5 years after the diagnosis of less than 5%. To date, no systemic therapy has meaningfully changed these survival end points. Currently, in the USA the FDA has approved three agents for the treatment of metastatic melanoma: hydroxyurea, dacarbazine and interleukin-2. None of these have demonstrated a meaningfully prolonged survival of patients with metastatic melanoma. Therefore, a number of innovative therapeutic strategies have been pursued to improve outcomes, including immune therapy, tyrosine kinase inhibitors and angiogenesis inhibitors. Herein, we review some of the recent advances in novel therapeutic developments for the treatment of metastatic melanoma.

Factors affecting the outcome after treatment for metastatic melanoma to the brain

BACKGROUND

Because of the difficulties inherent to the treatment of metastatic melanoma to the brain including high rates of disease progression and local treatment failure, we attempted to determine the prognostic factors that impacted the outcome of these patients, and reviewed patient outcome based on primary treatment with either surgical resection or SRS.

METHODS

A retrospective review identified 37 patients treated for metastatic melanoma between July 2002 and April 2007. Information was obtained documenting systemic disease, preoperative symptoms, tumor size and location, disease recurrence, primary and secondary treatments, and survival time.

RESULTS

Two patients were alive as of March 2008. The median survival time for patients primarily treated with surgical resection was 9.7 months compared to 7.9 months for patients initially treated with SRS. Solitary brain metastases and the absence of both preoperative hemorrhage and lung metastases served as prognostic factors increasing survival in both groups. Four patients undergoing primary treatment with SRS required subsequent surgical intervention secondary to radiation necrosis (3 patients) or local recurrence (1 patient). All 4 had lesions greater than 1.5 cm. For surgical patients, planned postoperative treatment with either radiosurgery or radiation therapy increased survival time to 12.3 months vs 7.3 months.

CONCLUSIONS

Patients with positive prognostic factors including solitary brain lesions, absence of hemorrhage preoperatively, and absence of lung disease are viable candidates for aggressive, surgical intervention followed by adjuvant therapy with radiosurgery or conventional radiation therapy. Other patients should be considered for more conservative treatment with radiosurgery or other palliative treatments.

Treatment Options for Limited or Symptomatic Metastatic Melanoma

Background

Patients who develop metastatic melanoma often have limited effective treatment options. However, a select group of patients will benefit from aggressive surgery or a multidisciplinary approach, depending on the site of metastasis.

Methods

The current literature was reviewed and summarized regarding the collective recommendations for staging and treating patients with metastatic melanoma.

Results

A thorough preoperative staging includes positron-emission tomography, MRI of the brain, and CT of the chest, abdomen, and pelvis. Tumor biology ultimately determines the success of intervention. A long disease-free interval is a good indicator of potential benefit from resection of metastatic disease. If surgery is performed, no less than a complete resection will affect the overall survival of the patient. Surgery and other multimodality treatment options can be used for symptomatic palliation but will not affect survival. Chemotherapy and radiation are often used to control the symptoms of brain and bony metastases but have limited if any impact on survival.

Conclusions

A select group of patients with metastatic melanoma will benefit from aggressive surgery. Identifying which patients will benefit from treatment requires good clinical judgment and a thorough radiologic evaluation to identify the true extent of disease.

Can surgeons improve survival in stage IV melanoma?

Successful systemic management of stage IV melanoma continues to be elusive because of the paucity of effective therapies. This has fueled the continued interest in surgical resection. Several single-institution studies and a current, large, multi-institutional phase III trial have demonstrated a survival benefit for patients who underwent surgical resection for melanoma metastases. Incorporating these results into new approaches using multimodality treatment may enhance survival in patients with stage IV melanoma.

Treatment of melanoma and nonmelanoma skin cancer

The incidence of skin cancer is increasing in Caucasian populations worldwide. Treatment approaches for Nonmelanoma skin cancer (NMSC) are predominantly curative and surgery can be regarded as standard of care. Nevertheless, novel and less invasive topical therapy modalities like photodynamic therapy or local immune modifiers are in progress. In contrast to NMSC, the mortality of melanoma has not changed considerably over the last years and decades. Melanoma survival mainly depends on primary tumor thickness underlining the importance of primary and secondary prevention by avoidance or early detection of the disease. The chance to cure melanoma patients is steadily decreasing with tumor stage. As the prognosis in distant metastatic disease is still poor, except for single situations therapy approaches are palliative and accompanied by an optimal supportive care of the patients concerned. Albeit removal of localized metastases is currently the most effective approach in metastatic melanoma, chemo- and chemoimmunotherapy has to be regarded as standard treatment in most of the cases. Novel and promising therapeutic options accrue from growing insights in tumor biology and immunology. Not only in melanoma, development and application of targeted therapies currently attract the most attention in the treatment of advanced tumors. First clinical experiences with those antiproliferative, antiangiogenic and proapoptotic agents reveal only moderate antitumoral activity in melanoma, so that future efforts aim at defining more effective combination strategies using chemo-, targeted and vaccination therapy approaches.

Surgery and adjuvant therapies in the treatment of stage IV melanoma: our experience in 84 patients

BACKGROUND AND AIMS

Survival rates of patients with stage IV melanoma are poor: Median survival is 7-8 months and 5-year survival rates about 5%. There is no agreement on the role of surgery at this stage. Most patients with metastatic melanoma are not able to undergo resection and usually are sent to systemic chemo- and immunotherapy.

PATIENTS AND METHODS

Eighty-four patients operated on for stage IV melanoma were evaluated. Of them, 61.9% were submitted to reiterative surgery with 168 operations and 182 surgical procedures overall. A total of 90.5% was submitted to adjuvant therapies according to aggressive and reiterated schedules: chemotherapy, immunotherapy, dendritic cells vaccine, infusion of tumor infiltrating lymphocytes, local therapies as electrochemotherapy.

RESULTS

The mean overall survival (Kaplan-Meier) was 56.7 months (1 year: 72.1%, 3 years: 46.5%, 5 years: 23.16%). The survival of reiterative surgery was significatively longer than single surgery (62.7 vs 42.4 months, median 50.9 vs 16.0), p = 0.03. Multivariated Cox analysis was performed for disease-free interval, repeated surgery, adjuvant therapies, and site of metastasis according to the American Joint Committee on Cancer: Reiterative surgery was shown as an independent prognostic factor (p < 0.05).

CONCLUSION

Metastatic resection associated with adjuvant therapy may improve overall survival and, in some instances, can provide long-term survival, whatever site and numbers of metastasis. In our series, reiterative surgery was more significatively efficient in improving survival than single-time surgery.

An uncommon presentation and course of metastatic malignant melanoma: a case report

Most patients with brain metastases from malignant melanoma are diagnosed after treatment for known extracranial metastases and have a poor outcome despite various local and systemic therapeutic approaches. Here we discuss an unusual case where a 45-year old patient presented with a brain metastasis as the first symptom of disease and where the presumed primary lesion later was found in the gastro-intestinal tract. Treatment consisted of sequential surgical removal of a total of 4 tumor sites (2 extracranially), whole-brain radiotherapy and two radiosurgery procedures within 13 months. Following her last treatment, the patient has now been in remission for 20 months. This case illustrates that some patients with multi-organ melanoma manifestations may benefit from the repeated use of effective local therapeutic approaches and may experience a quite favourable prognosis.

Selected patients with metastatic melanoma may benefit from liver resection

BACKGROUND

In the last few years there has been expanding use of hepatic resection for non-colorectal metastases. The purpose of this study is to evaluate the experience of liver resection for patients with metastatic melanoma.

METHODS

Eighteen patients with metastatic melanoma were explored for possible surgical resection. All patients fitted the following criteria: absence of extra-hepatic disease after evaluation with CT/MRI and FDG-PET scans; disease-free interval longer than 24 months after the resection of the primary melanoma; presumed completely resectable lesions; absence of clinical co-morbidities.

RESULTS

Liver resection was performed in 10 patients; 8 out of 18 presented with irresectable tumors and/or peritoneal metastases and were not operated. One patient presented with postoperative biliary fistula and was conservatively managed. No other complications or postoperative mortality were observed. After a mean follow-up of 25.4 months, 5 patients are alive and without evidence of recurrence. Overall median survival was 22 months; overall survival and disease-free survival were 70% and 50% respectively.

CONCLUSIONS

Resection of liver metastases from melanoma in a selected group of patients may increase survival. Exploratory laparoscopy should be included in the preoperative armamentarium of diagnostic tools.

Current surgical management of melanoma

The surgical management of melanoma has changed dramatically over the last few decades. Through the development and conduction of well-designed, prospective, randomized trials, we have been able to refine the way that we surgically manage patients with melanoma. Indeed, many important issues have been addressed through such trials: the proper surgical margins for the primary melanoma, utility of the elective lymph node dissection and the role for selective lymphadenectomy, to name a few. This review will also discuss what we have learned from past clinical trials and address several issues with regards to where we are going in the future.

Phase I Clinical Study With Multiple Peptide Vaccines in Combination With Tetanus Toxoid and GM-CSF in Advanced-stage HLA-A*0201-positive Melanoma Patients

Successful induction of functional tumor-specific T cells by peptide vaccination in animal models has resulted in many clinical trials to test this approach in advanced-stage melanoma patients. In this phase I clinical trial, 11 end-stage melanoma patients were vaccinated intradermally with 3 peptides: MART-1(26-35) E27L (ELAGIGILTV), tyrosinase(368-376) N375Q (YMDGTMSQV), and gp100(209-217) T210M (IMQVPFSV), admixed with tetanus toxoid and granulocyte-monocyte colony stimulating factor. The peptide vaccine was well tolerated at all tested doses, and led to grade 1-2 toxicity only. Although all patients did show a rise in antitetanus IgG titers, in only 3 patients peptide-specific CD8 T-cells were induced. In 2 cases, the response was directed against MART-1(26-35) and consisted of 0.2% and 3.3% of the CD8 population; however, in both instances these cells did not produce interferon-gamma on stimulation with the unmodified peptide. The third patient mounted a small (0.1%) response against gp100. In a fourth patient, a nonfunctional tyrosinase-specific response (0.6%) was found that was present before vaccination, but was not affected in size nor in function by the vaccine. None of the 11 patients responded clinically according to response evaluation criteria in solid tumors criteria. Although this study is a small scale phase I clinical trial, the efficacy that was observed was disappointingly low. In accordance with previously published peptide vaccination studies, these results add to the increasing evidence that peptide vaccination in itself is not potent enough as an effective melanoma immunotherapy in advanced-stage patients.

Survival after surgical resection of isolated pulmonary metastases from malignant melanoma

BACKGROUND

The overall prognosis for patients with metastatic malignant melanoma remains poor. However, careful staging and identification of patients with limited metastatic disease offers the opportunity for surgical salvage and improved survival for selected patients.

METHODS

We reviewed the experience over the last 17 years at our institute with isolated pulmonary metastasectomy in 86 patients with advanced malignant melanoma.

RESULTS

Our data demonstrate an overall median time to relapse of approximately 8.4 months and a median survival of 35 months. The 5-year survival rate is estimated at 33%, and 16% remain continuously free of disease after a median follow-up of 35 months. Resection of properly staged and evaluated patients with limited pulmonary metastases appears to convey a significant survival benefit. Patients with a single metastasis fare best.

CONCLUSIONS

These encouraging results offer a rationale for the careful follow-up of resected patients. One third of all relapses will be limited and additional surgery contributes to their overall survival.

Complete metastasectomy in patients with stage IV metastatic melanoma

Patients with stage IV melanoma have traditionally been managed with various systemic treatments; however, overall survival with this approach has been disappointing. Findings of many retrospective, single-institution, and multicentre studies suggest that participants treated with complete metastasectomy for stage IV metastases have enhanced overall 5-year survival. Complete surgical resection of metastatic disease to stage IV sites-including skin, soft tissue, distant lymph nodes, lungs, or other non-CNS visceral regions-offers the best chance for prolonged survival. This Review will present data lending support to the idea that if complete surgical metastasectomy is technically feasible, then surgery should be the first option for properly selected patients with stage IV melanoma.

The role of surgery in treatment of stage IV melanoma

The prognosis for patients with melanoma has not improved over the last 30 years. So far, almost without exception, clinical trials conducted with single or multiple agent chemotherapy, biological therapy (interferon-alpha, interleukin-2), and biochemotherapy have failed to demonstrate consistent survival benefit. Without effective alternate treatments, surgery must be considered the primary treatment of melanoma, independent of disease stage. Although surgery is clearly favored as the treatment of localized melanoma, consensus opinion and clinician preference become divided once melanoma progresses beyond its primary site. Many physicians will adopt an attitude of resignation and hesitancy when treating metastatic melanoma. As a result, patients with advanced disease are often treated with medications that produce little survival or palliative benefit at the expense of significant toxicity. Numerous studies have demonstrated clear and durable survival advantages for patients undergoing complete resection of metastatic melanoma. Further, surgical resection can produce an immediate decrease in tumor burden with minimal morbidity and mortality at a reasonable cost.

Therapie des metastasierten Melanoms

The incidence of malignant melanoma is steadily increasing worldwide. The most crucial requirement to cure the disease is early detection of thin primary tumors. At the stage of distant metastases, the treatment options are predominantly palliative. Resection of localized metastases is currently the most effective approach. Dacarbazine is considered as standard chemotherapy for inoperable metastatic disease showing remission rates of 5-20% without any noteworthy effect on overall survival. Quite recently, a large spectrum of innovative treatment approaches have been developed from an increasing insight into tumor biology. Along with improved vaccination strategies, targeted therapies have attracted the most attention in the treatment of advanced melanoma. Those anti-proliferative, anti-angiogenic and proapoptotic agents are directed against pathogenetically important pathways of the tumor cell. First clinical experiences are encouraging, but results from controlled trials have to be awaited.

Surgical management of distant metastases

Although the location of metastases is of prognostic importance in stage IV melanoma, as seen in the revised AJCC staging classification system and other studies, certain guiding principles apply to patients who have any stage IV disease. Close follow-up of any patient who has melanoma may identify surgically resectable metastatic disease, although this method is controversial. Components of this monitoring may include careful questioning to determine symptoms, such as cough, abdominal pain, or headaches; physical examination for evidence of skin, soft tissue, and lymph node metastases; and screening tools, such as radiographs and laboratory tests. Identifying patients who have metastatic disease at the earliest stage possible is crucial for surgical resection to be an option. Patients should also be thoughtfully evaluated for the possibility of a complete surgical re-section. Complete metastectomy, regardless of the anatomic site, confers survival advantages not seen with other treatment modalities. This aggressive surgical approach should be tempered with the knowledge that incomplete resections put patients at increased risk without any proven survival benefit, and should be reserved only for palliation of symptoms. Systemic adjuvant therapies for stage IV melanoma are evolving, but do not yet confer the survival advantage of complete surgical resection. Until novel drug therapies show efficacy and significantly prolong survival in patients who have stage IV disease, careful consideration should be given to a complete metastectomy if technically feasible.

The treatment of melanoma with an emphasis on immunotherapeutic strategies

Melanoma continues to be one of the most difficult to treat of all solid tumors. Many new advances have been made in the surgical management of melanoma, including new guidelines for margins of excision, as well as sentinel node biopsy for the diagnosis of lymph node micrometastases. The search continues for an effective adjuvant melanoma treatment that can prevent local and distant recurrences. Melanoma is one of the most immunogenic of all tumors, and several clinical trials testing the immunotherapy of melanoma have been conducted, including trials in interferon, interleukin-2, and melanoma vaccines. Here we discuss many of the recent clinical trials in the surgical management of melanoma, in addition to the advances that have been made in the field of immunotherapy. A new second-generation melanoma vaccine, DC-MelVac (patent # 11221/5), has recently been granted FDA approval for Phase I clinical trials and will be introduced in this review.

Early-Stage Melanoma: Staging Criteria and Prognostic Modeling

Accurate risk assessment is central to the process of making rational surgical and systemic treatment recommendations for melanoma patients and in establishing appropriate clinical trial stratification criteria. The current American Joint Commission on Cancer melanoma staging system incorporated relevant prognostic variables to provide a framework for the estimation of risk for recurrence; however, significant prognostic heterogeneity exists within the stage groupings. In the stage I/II group, survival rates range from 40% to 95% as defined by the combination of tumor thickness and ulceration. The use of novel prognostic factors, such as mitotic rate, sentinel node biopsy, and prognostic modeling using a variety of factors, can minimize this prognostic heterogeneity and provide a more accurate and individualized prognostic profile. Recent modifications in the stage III criteria include the number of positive nodes, whether the nodal disease is microscopic or clinically apparent, and the presence of an ulcerated primary. Through these factors, survival estimates can be provided, but like the stage I/II group, wide ranges in prognosis exist. The complexion of the stage III population is in evolution as a result of increasing numbers of patients being diagnosed as having microscopic sentinel node disease. Contemporary efforts are focused on defining the prognosis and natural history of this group. Through prognostic modeling using the number of nodes involved, ulceration status, and a measure of disease burden--disease in the sentinel node--relatively homogeneous subgroups can be identified. Long-term follow-up of patients staged with PCR molecular techniques on sentinel nodes shows conflicting value in assessing prognosis and therefore cannot be routinely used outside a clinical trial. The combination of genomic profiling using microarray analyses and the development of targeted therapy holds the future promise of individualizing prognosis and therapy.

Routine use of FDG-PET scans in melanoma patients with positive sentinel node biopsy

PURPOSE

Positron emission tomography (PET) scanning is an efficient and well-known diagnostic tool in various malignant disorders. However, the utility of PET as a clinical routine screening procedure for the detection of subclinical metastases in stage III melanoma patients has not yet been established.

METHODS

Thirty-three patients with cutaneous malignant melanoma and subclinical lymph node metastases diagnosed by sentinel node biopsy (SNB) were submitted to( 18)F-fluoro-2-deoxy-D: -glucose (FDG) whole-body PET scanning within 100 days after SNB and wide local excision. Before PET scanning, patients were screened conventionally and found to be without evidence of further dissemination. Positive PET scan findings were evaluated by computed tomography scanning, magnetic resonance imaging and ultrasonography. Biopsy was performed whenever possible. The median follow-up was 15 months (range 6-39 months).

RESULTS

Nine patients (27%) had a positive PET scan performed after SNB and WLE. On verification, four cases (12%) were found to be true positive for melanoma metastasis and were thus upgraded from stage III to stage IV. Furthermore, one patient (3%) had another primary malignancy (prostate carcinoma), and two (6%) were found to have non-malignant lesions. Two PET-positive patients (6%) refused further investigations. In one case (3%) the PET scan was false negative. Twenty-three (69%) PET scans were true negative.

CONCLUSION

In a number of stage III melanoma patients with positive SNB, postoperative whole-body FDG-PET scanning revealed further melanoma dissemination not found by conventional screening methods and thus identified these cases as stage IV. Relevant therapy can accordingly be instituted earlier on the basis of FDG-PET scanning.

New American Joint Commission on Cancer Staging System for Melanoma: Prognostic Impact and Future Directions

Accurate melanoma staging is critical in establishing management strategies and estimating disease relapse. Combined with assessment of comorbidities and understanding treatment toxicities, risk assessment is central to offering appropriate surgical or systemic therapies. The American Joint Commission on Cancer (AJCC) melanoma staging system provides survival estimates within anatomically defined disease categories. Newer prognostic factors and methods of prognostic analyses can augment predictions for the presence of micro-metastatic disease and further define the risk for relapse. This article highlights relevant changes, evidence supporting future incorporation of more recently defined prognostic variables, novel approaches used as adjuncts to the current staging system, and future directions of the AJCC staging committee.

Conduta para o melanoma cutâneo

A incidência do melanoma cutâneo vem aumentando significativamente de 1:1500 em 1935 para cerca de 1:75 no ano 2000. Contudo, atribuído a um diagnóstico cada vez mais precoce, têm-se observado uma melhora da sobrevida em cinco anos com diminuição da taxa de mortalidade geral entre 70 a 80% desde a década de 30. É o câncer mais prevalente na faixa etária entre 25 e 35 anos nos EUA. O Brasil ocupa a 15º posição com relação à incidência do tumor no mundo. O estadiamento inicial é baseado na pesquisa de sinais e sintomas que podem indicar doença metastática. Especial atenção deve ser dada à palpação de linfonodos regionais. A espessura e a ulceração são os principais fatores de risco independentes, em pacientes com melanoma primário com linfonodos livres. Já naqueles com metástases linfonodais, a presença de ulceração, de metástase detectada macroscopicamente e o número de linfonodos acometidos, são os principais índices de impacto na sobrevida. Pacientes com metástases para o pulmão possuem melhor prognóstico no primeiro ano de sobrevida em comparação àqueles com metástases para outros órgãos. A dosagem de DHL é fator prognóstico poderoso, sendo incluída no último estadiamento publicado, em pacientes com estádio IV da doença. A pesquisa do linfonodo sentinela já é técnica incorporada à conduta de pacientes com melanoma com reconhecido impacto no estadiamento, prognóstico e programação terapêutica. Devido à falta de padronização para o tratamento do melanoma, muitos pacientes ainda evoluem com um prognóstico reservado devido a uma conduta inicial inadequada. Os tratamentos vêm mudando significativamente e a proposta deste trabalho visa apresentar uma revisão com ênfase nas condutas preconizadas para o melanoma.