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Koizumi S, Inozume T, Nakamura Y. Current surgical management for melanoma. J Dermatol 2024; 51:312-323. [PMID: 38149725 DOI: 10.1111/1346-8138.17086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/15/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023]
Abstract
Melanoma is a major malignant cutaneous neoplasm with a high mortality rate. In recent years, the treatment of melanoma has developed dramatically with the invention of new therapeutic agents, including immune checkpoint inhibitors and molecular-targeted agents. These agents are available as adjuvant therapies for postoperative patients with stage IIB, IIC, and III melanomas. Furthermore, neoadjuvant therapy has been studied in several global clinical trials and has demonstrated promising and favorable clinical efficacy, mainly in patients with palpable regional lymph nodes. A recent large phase III clinical trial investigating early lymph node dissection for sentinel lymph node metastases demonstrated no survival benefits. Based on these data, surgery should be reconsidered as an appropriate treatment modality for melanoma. The need for invasive surgical procedures will be reduced with the invention of effective adjuvant and neoadjuvant therapies and novel clinical trial data on regional lymph node dissection. However, surgery still plays an important role in treating early-stage melanoma, accurately determining the disease stage, and effective palliative treatment for advanced melanoma. In this article, we focus on surgery for primary tumors, regional lymph nodes, and metastatic sites in an era of remarkably revolutionary drug treatments for melanoma.
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Affiliation(s)
- Shigeru Koizumi
- Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center, Saitama, Japan
- Department of Dermatology, Chiba University, Chiba, Japan
| | | | - Yasuhiro Nakamura
- Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center, Saitama, Japan
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2
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Donahue MJ, Donahue PMC, Jones RS, Garza M, Lee C, Patel NJ, Cooper A, De Vis JB, Meszoely I, Crescenzi R. In vivo lymph node CEST-Dixon MRI in breast cancer patients with metastatic lymph node involvement. Magn Reson Med 2024; 91:670-680. [PMID: 37684712 DOI: 10.1002/mrm.29858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE Axillary lymph nodes (LNs) often present a reservoir for metastatic breast cancer, yet metastatic LN involvement cannot be discerned definitively using diagnostic imaging. This study investigated whether in vivo CEST may discriminate LNs with versus without metastatic involvement. METHODS 3T MRI was performed in patients with breast cancer before clinically-indicated mastectomy or lumpectomy with LN removal, after which LN metastasic involvement was determined using histological evaluation. Non-contrast anatomical imaging, as well as B0 and B1 field maps, were acquired in sequence with three-point CEST-Dixon (3D turbo-gradient-echo; factor = 25; TR/TE1/ΔTE = 851/1.35/1.1 ms; spatial-resolution = 2.5 × 2.5 × 6 mm; slices = 10; four sinc-gauss pulses with duty-cycle = 0.5, total saturation duration = 701.7 ms; B1 = 1.5 μT; saturation offsets = -5.5 to +5.5 ppm; stepsize = 0.2 ppm; scan duration = 6 min 30 s). The mean z-spectrum from LNs with (n = 20) versus without (n = 22) metastatic involvement were analyzed and a Wilcoxon rank-sum test (significance: p < 0.05) was applied to evaluate differences in B0, B1 , and magnetization transfer ratio (MTR) in differing spectral regions of known proton exchange (nuclear Overhauser effect [NOE], amide, amine, and hydroxyl) between cohorts. RESULTS No difference in axillary B1 (p = 0.634) or B0 (p = 0.689) was observed between cohorts. Elevated MTR was observed for the NOE (-1.7 ppm; MTR = 0.285 ± 0.075 vs. 0.248 ± 0.039; p = 0.048), amine (+2.5 ppm; MTR = 0.284 ± 0.067 vs. 0.234 ± 0.31; p = 0.005), and hydroxyl (+1 ppm; MTR = 0.394 ± 0.075 vs. 0.329 ± 0.055; p = 0.002) protons in LNs from participants with versus without metastatic involvement. CONCLUSIONS Findings are consistent with a unique metastatic LN microenvironment detectable by CEST-Dixon and suggest that CEST MRI may have potential for mapping LN metastasis non-invasively in vivo.
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Affiliation(s)
- Manus J Donahue
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paula M C Donahue
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Dayani Center for Health and Wellness, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - R Sky Jones
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Maria Garza
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chelsea Lee
- Department of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Niral J Patel
- Department of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jill B De Vis
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ingrid Meszoely
- Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rachelle Crescenzi
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
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Santamaria-Barria JA, Mammen JMV. Surgical Management of Melanoma: Advances and Updates. Curr Oncol Rep 2022; 24:1425-1432. [PMID: 35657482 DOI: 10.1007/s11912-022-01289-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To review and update surgeons about the evolving complexities in the surgical management of melanoma including lymph node staging and treatment. RECENT FINDINGS Primary resection with adequate margins continues to be the standard of care for localized cutaneous melanoma. Sentinel lymph node biopsy is confirmed to be a powerful tool due to its prognostic value and informative guidance for adjuvant treatments and surveillance. Due to the lack of benefit in melanoma-specific survival and distant metastasis-free survival, completion lymph node dissection is not performed routinely after a positive sentinel lymph node biopsy. Neoadjuvant systemic treatment approaches for advanced loco-regional disease show promise in phase I and II clinical trial data, and phase III studies. The surgical management of cutaneous melanoma continues to evolve with further de-escalation of the extent of excision of primary melanomas and the management of lymph node disease.
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Affiliation(s)
- Juan A Santamaria-Barria
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198-6880, USA
| | - Joshua M V Mammen
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198-6880, USA.
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Meints SM, Edwards RR, Gilligan C, Schreiber KL. Behavioral, Psychological, Neurophysiological, and Neuroanatomic Determinants of Pain. J Bone Joint Surg Am 2020; 102 Suppl 1:21-27. [PMID: 32251127 PMCID: PMC8272523 DOI: 10.2106/jbjs.20.00082] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Samantha M. Meints
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Gilligan
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kristin L. Schreiber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Covarelli P, Barberini F, Cannavicci D, Cirocchi R, Rulli A, Boselli C, De Giorgi V. Reduction of postoperative lymphorrhoea in patients undergoing radical lymphadenectomy for stage III melanoma: prospective study using collagen-fibrin patches. MINERVA CHIR 2019; 75:111-116. [PMID: 31820617 DOI: 10.23736/s0026-4733.19.08114-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Radical lymph nodes dissection (RLND) is the standard procedure for regional control of disease in patients with metastatic melanoma (stage III). Because of its aggressiveness, lymphorrhoea is a constant problem in postoperative. METHODS In this prospective nonrandomized study with a retrospective analysis of data, patients undergoing surgical treatment of axillary or iliac-inguinal RLND received standard treatment plus a collagen-fibrin sealant patch (TachoSil) (N.=50) or standard treatment alone (N.=50). The first endpoint was the comparison between the treated population and the control group, in terms of persistence of drainage and average daily volume of lymphorrhoea. The second aim was to relate patients' BMI, volume of lymphorrhoea and time of drainage in the two groups. RESULTS In the comparison between the two groups receiving or not the treatment with collagen-fibrin patch, we found an average difference both in the volume of daily lymphorrhoea (42.91±6.61 cc) and in the persistence of drainage (9.292±1.644 days) with P value <0.0001. Besides, the collagen-fibrin patch was actually effective in reducing lymphorrhoea and time of drainage, regardless of patients' BMI. CONCLUSIONS The results of this study confirm and support the starting thesis: TachoSil is an effective tissue sealant able to reduce lymphorrhoea and drainage removal times following a radical lymphadenectomy, independently from the BMI.
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Affiliation(s)
- Piero Covarelli
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy -
| | - Francesco Barberini
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Daniele Cannavicci
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Roberto Cirocchi
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Antonio Rulli
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Carlo Boselli
- Department of Oncologic Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Nandi M, Schreiber KL, Martel MO, Cornelius M, Campbell CM, Haythornthwaite JA, Smith MT, Wright J, Aglio LS, Strichartz G, Edwards RR. Sex differences in negative affect and postoperative pain in patients undergoing total knee arthroplasty. Biol Sex Differ 2019; 10:23. [PMID: 31060622 PMCID: PMC6501305 DOI: 10.1186/s13293-019-0237-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/10/2019] [Indexed: 12/28/2022] Open
Abstract
Background Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence in the developed world, and affects women to a greater degree than men. In the USA, the growth of knee OA has been paralleled by an increase in rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, postoperative trajectories of pain vary widely, with some patients reporting a complete absence of pain, but with a significant minority reporting worsening pain. Biopsychosocial factors, including anxiety and depression, are known to contribute importantly to the experience of joint pain, with women reporting a higher degree of negative affective symptoms. Methods This study investigated sex differences in TKA outcomes in age-matched groups of men and women at two academic medical centers. Pain and physical function were assessed in 100 patients (50 men and 50 women) during the perioperative period (preoperative visit—6 weeks postsurgical). The association of preoperative negative affect (anxiety and depression scores) to postoperative pain and function was evaluated, with specific attention to sex differences in this relationship. Results Overall, women reported more baseline pain-related physical dysfunction (although not higher baseline pain scores), as well as higher acute postoperative pain scores during the 2 weeks following TKA than their male counterparts. By 6 weeks postoperatively, sex differences in reported pain were no longer evident. Interestingly, although women reported higher preoperative levels of emotional distress than men, preoperative anxiety and depression scores were better predictors of severe postoperative pain among men than women, throughout the postoperative test period. Conclusions This study underlines the importance of considering sex and psychosocial factors, as well as their interaction, in understanding postsurgical pain trajectories.
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Affiliation(s)
- Meghna Nandi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA. .,Connors Center for Women's Health, Brigham and Women's Hospital, Boston, MA, USA. .,Brown University School of Medicine, Providence, RI, United States.
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Marc O Martel
- Faculties of Dentistry & Medicine, McGill University, Strathcona Anatomy & Dentistry building, 3640 University Street, Montreal, QC, H3A 2B2, Canada
| | - Marise Cornelius
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Ste 100, Baltimore, MD, 21224, USA
| | - Jennifer A Haythornthwaite
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Ste 100, Baltimore, MD, 21224, USA
| | - Michael T Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Ste 100, Baltimore, MD, 21224, USA
| | - John Wright
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Linda S Aglio
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Gary Strichartz
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.,Connors Center for Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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Stadler R, Leiter U, Garbe C. Kein Überlebensvorteil beim Sentinel-Lymphknoten-positiven Melanom mit sofortiger kompletter Lymphadenektomie - eine Übersicht. J Dtsch Dermatol Ges 2019; 17:7-14. [DOI: 10.1111/ddg.13707_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rudolf Stadler
- Universitätsklinik für Dermatologie; Klinikum Johannes Wesling in Minden; Universitätsklinikum Ruhr; Bochum
| | - Ulrike Leiter
- Zentrum für Dermatoonkologie; Universitäts-Hautklinik; Eberhard Karls Universität; Tübingen
| | - Claus Garbe
- Zentrum für Dermatoonkologie; Universitäts-Hautklinik; Eberhard Karls Universität; Tübingen
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Freeman R, Edwards R, Baron R, Bruehl S, Cruccu G, Dworkin RH, Haroutounian S. AAPT Diagnostic Criteria for Peripheral Neuropathic Pain: Focal and Segmental Disorders. THE JOURNAL OF PAIN 2018; 20:369-393. [PMID: 30527971 DOI: 10.1016/j.jpain.2018.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 12/19/2022]
Abstract
Peripheral neuropathic pain is among the most prevalent types of neuropathic pain. No comprehensive peripheral neuropathic pain classification system that incorporates contemporary clinical, diagnostic, biological, and psychological information exists. To address this need, this article covers the taxonomy for 4 focal or segmental peripheral neuropathic pain disorders, as part of the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership and the American Pain Society (APS) collaborative to develop a standardized, evidence-based taxonomy initiative: the ACTTION-APS Pain Taxonomy (AAPT). The disorders-postherpetic neuralgia, persistent posttraumatic neuropathic pain, complex regional pain disorder, and trigeminal neuralgia-were selected because of their clinical and clinical research relevance. The multidimensional features of the taxonomy are suitable for clinical trials and can also facilitate hypothesis-driven case-control and cohort epidemiologic studies. PERSPECTIVE: The AAPT peripheral neuropathic pain taxonomy subdivides the peripheral neuropathic pain disorders into those that are generalized and symmetric and those that are focal or segmental and asymmetric. In this article, we cover the focal and segmental disorders: postherpetic neuralgia, persistent posttraumatic neuropathic pain, complex regional pain disorder, and trigeminal neuralgia. The taxonomy is evidence-based and multidimensional, with the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.
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Affiliation(s)
- Roy Freeman
- Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Robert Edwards
- Department of Anesthesiology, Brigham & Women's Hospital, Harvard University School of Medicine, Boston, MA
| | - Ralf Baron
- University of Kiel, Division of Neurological Pain Research and Therapy, Department of Neurology, Kiel, Germany
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Giorgio Cruccu
- Department Human Neuroscience, Sapienza University, Rome, Italy
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Simon Haroutounian
- Department of Anesthesiology and Washington University Pain Center, Washington University School of Medicine, St Louis, MO
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Stadler R, Leiter U, Garbe C. Lack of survival benefit in sentinel lymph node-positive melanoma with immediate complete lymphadenectomy - a review. J Dtsch Dermatol Ges 2018; 17:7-13. [DOI: 10.1111/ddg.13707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rudolf Stadler
- University Hospital for Dermatology; Johannes Wesling Clinical Centre in Minden; Ruhr University Hospital; Bochum Germany
| | - Ulrike Leiter
- Centre for Dermato-oncology; University Department of Dermatology, Eberhard Karls University; Tübingen Germany
| | - Claus Garbe
- Centre for Dermato-oncology; University Department of Dermatology, Eberhard Karls University; Tübingen Germany
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Natural history of pain associated with melanoma surgery. Pain Rep 2018; 3:e689. [PMID: 30706034 PMCID: PMC6344134 DOI: 10.1097/pr9.0000000000000689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 07/25/2018] [Accepted: 08/20/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction After excision of a primary malignant melanoma (MM), treatment of stage IB or higher MM consists of sentinel lymph node biopsy (SLNB). If malignant cells are identified, a complete lymph node dissection (CLND) can be performed. Objective To determine the natural history of pain and sensory changes after MM surgery. Methods We prospectively followed 39 patients (29 SLNB-only, 2 CLND-only, and 8 CLND preceded by SLNB) from before inguinal or axillary surgery through 6 months after surgery on measures of pain intensity, sensory symptoms, allodynia, and questionnaires of anxiety, depression, and catastrophizing. Results No patient had pain preoperatively. Ten days after surgery, 35% had surgical site pain after SLNB-only compared with 90% after CLND (P < 0.003); clinically meaningful pain (Visual Analogue Scale ≥ 30 mm/100 mm) was reported by 3% of patients after SLNB-only compared with 40% after CLND (P < 0.001). At 6 months, all SLNB-only patients were pain-free. By contrast, 4 of 7 in the SLNB + CLND group still had pain (P < 0.002). At 6 months, symptoms of altered sensation or numbness were reported by 32% and 42% of SLNB-only patients, and by 67% and 67% of patients undergoing CLND surgery (both P > 0.05). Conclusion Acute pain is more common after CLND surgery. Undergoing SLNB followed by more invasive CLND surgery may increase the likelihood of pain at 6 months. Persistent sensory symptoms typical of those associated with nerve injury are more common after CLND. Surgery for MM is a good model for studying the natural history of postsurgical pain and sensory changes.
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Masoud SJ, Perone JA, Farrow NE, Mosca PJ, Tyler DS, Beasley GM. Sentinel Lymph Node Biopsy and Completion Lymph Node Dissection for Melanoma. Curr Treat Options Oncol 2018; 19:55. [PMID: 30232648 PMCID: PMC6684152 DOI: 10.1007/s11864-018-0575-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Sabran J Masoud
- Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Jennifer A Perone
- Department of Surgery, University Texas Medical Branch, Galveston, TX, USA
| | - Norma E Farrow
- Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Paul J Mosca
- Department of Surgery, Duke University, Durham, NC, 27710, USA
| | - Douglas S Tyler
- Department of Surgery, University Texas Medical Branch, Galveston, TX, USA
| | - Georgia M Beasley
- Department of Surgery, Duke University, Durham, NC, 27710, USA.
- Duke University Medical Center, DUMC Box 3118, Durham, NC, 27710, USA.
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Postlewait LM, Farley CR, Diller ML, Martin B, Hart Squires M, Russell MC, Rizzo M, Ogan K, Master V, Delman K. A Minimally Invasive Approach for Inguinal Lymphadenectomy in Melanoma and Genitourinary Malignancy: Long-Term Outcomes in an Attempted Randomized Control Trial. Ann Surg Oncol 2017; 24:3237-3244. [DOI: 10.1245/s10434-017-5971-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 12/15/2022]
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13
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Esposito M, Busam B, Hennersperger C, Rackerseder J, Navab N, Frisch B. Multimodal US-gamma imaging using collaborative robotics for cancer staging biopsies. Int J Comput Assist Radiol Surg 2016; 11:1561-71. [PMID: 27507282 DOI: 10.1007/s11548-016-1464-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/25/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The staging of female breast cancer requires detailed information about the level of cancer spread through the lymphatic system. Common practice to obtain this information for patients with early-stage cancer is sentinel lymph node (SLN) biopsy, where LNs are radioactively identified for surgical removal and subsequent histological analysis. Punch needle biopsy is a less invasive approach but suffers from the lack of combined anatomical and nuclear information. We present and evaluate a system that introduces live collaborative robotic 2D gamma imaging in addition to live 2D ultrasound to identify SLNs in the surrounding anatomy. METHODS The system consists of a robotic arm equipped with both a gamma camera and a stereoscopic tracking system that monitors the position of an ultrasound probe operated by the physician. The arm cooperatively places the gamma camera parallel to the ultrasound imaging plane to provide live multimodal visualization and guidance. We validate the system by evaluating the target registration errors between fused nuclear and US image data in a phantom consisting of two spheres, one of which is filled with radioactivity. Medical experts perform punch biopsies on agar-gelatine phantoms with complex configurations of hot and cold lesions to provide a qualitative and quantitative evaluation of the system. RESULTS The average point registration error for the overlay is [Formula: see text] mm. The time of the entire procedure was reduced by 36 %, with 80v of the biopsies being successful. The users' feedback was very positive, and the system was deemed to be very intuitive, with handling similar to classic US-guided needle biopsy. CONCLUSION We present and evaluate the first medical collaborative robotic imaging system. Feedback from potential users for SLN punch needle biopsy is encouraging. Ongoing work investigates the clinical feasibility with more complex and realistic phantoms.
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Affiliation(s)
- Marco Esposito
- Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany.
| | - Benjamin Busam
- Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany
- FRAMOS GmbH, Taufkirchen, Germany
| | | | - Julia Rackerseder
- Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany
| | - Nassir Navab
- Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, MD, US
| | - Benjamin Frisch
- Computer Aided Medical Procedures (CAMP), Technische Universität München, Munich, Germany
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Leiter U, Stadler R, Mauch C, Hohenberger W, Brockmeyer N, Berking C, Sunderkötter C, Kaatz M, Schulte KW, Lehmann P, Vogt T, Ulrich J, Herbst R, Gehring W, Simon JC, Keim U, Martus P, Garbe C. Complete lymph node dissection versus no dissection in patients with sentinel lymph node biopsy positive melanoma (DeCOG-SLT): a multicentre, randomised, phase 3 trial. Lancet Oncol 2016; 17:757-767. [PMID: 27161539 DOI: 10.1016/s1470-2045(16)00141-8] [Citation(s) in RCA: 456] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/01/2016] [Accepted: 02/18/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complete lymph node dissection is recommended in patients with positive sentinel lymph node biopsy results. To date, the effect of complete lymph node dissection on prognosis is controversial. In the DeCOG-SLT trial, we assessed whether complete lymph node dissection resulted in increased survival compared with observation. METHODS In this multicentre, randomised, phase 3 trial, we enrolled patients with cutaneous melanoma of the torso, arms, or legs from 41 German skin cancer centres. Patients with positive sentinel lymph node biopsy results were eligible. Patients were randomly assigned (1:1) to undergo complete lymph node dissection or observation with permuted blocks of variable size and stratified by primary tumour thickness, ulceration of primary tumour, and intended adjuvant interferon therapy. Treatment assignment was not masked. The primary endpoint was distant metastasis-free survival and analysed by intention to treat. All patients in the intention-to-treat population of the complete lymph node dissection group were included in the safety analysis. This trial is registered with ClinicalTrials.gov, number NCT02434107. Follow-up is ongoing, but the trial no longer recruiting patients. FINDINGS Between Jan 1, 2006, and Dec 1, 2014, 5547 patients were screened with sentinel lymph node biopsy and 1269 (23%) patients were positive for micrometastasis. Of these, 483 (39%) agreed to randomisation into the clinical trial; due to difficulties enrolling and a low event rate the trial closed early on Dec 1, 2014. 241 patients were randomly assigned to the observation group and 242 to the complete lymph node dissection group. Ten patients did not meet the inclusion criteria, so 233 patients were analysed in the observation group and 240 patients were analysed in the complete lymph node dissection group, as the intention-to-treat population. 311 (66%) patients (158 in the observation group and 153 in the dissection group) had sentinel lymph node metastases of 1 mm or less. Median follow-up was 35 months (IQR 20-54). Distant metastasis-free survival at 3 years was 77·0% (90% CI 71·9-82·1; 55 events) in the observation group and 74·9% (69·5-80·3; 54 events) in the complete lymph node dissection group. In the complete lymph node dissection group, grade 3 and 4 events occurred in 15 patients (6%) and 19 patients (8%) patients, respectively. Adverse events included lymph oedema (grade 3 in seven patients, grade 4 in 13 patients), lymph fistula (grade 3 in one patient, grade 4 in two patients), seroma (grade 3 in three patients, no grade 4), infection (grade 3 in three patients, no grade 4), and delayed wound healing (grade 3 in one patient, grade 4 in four patients); no serious adverse events were reported. INTERPRETATION Although we did not achieve the required number of events, leading to the trial being underpowered, our results showed no difference in survival in patients treated with complete lymph node dissection compared with observation only. Consequently, complete lymph node dissection should not be recommended in patients with melanoma with lymph node micrometastases of at least a diameter of 1 mm or smaller. FUNDING German Cancer Aid.
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Affiliation(s)
- Ulrike Leiter
- Centre for Dermatooncology, Department of Dermatology, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany.
| | - Rudolf Stadler
- Department of Dermatology, Medical Centre Minden, Minden, Germany
| | - Cornelia Mauch
- Department of Dermatology, University of Cologne, Cologne, Germany
| | | | | | - Carola Berking
- Department of Dermatology, Ludwig-Maximilians University of Munich, Munich, Germany
| | | | - Martin Kaatz
- Department of Dermatology, Gera and University of Jena, Jena, Germany
| | | | - Percy Lehmann
- Department of Dermatology, Medical Hospital, Wuppertal, Germany
| | - Thomas Vogt
- Department of Dermatology, Saarland University, Saarbrücken, Germany
| | - Jens Ulrich
- Department of Dermatology, University of Magdeburg, Magdeburg, Germany; Department of Dermatology, Medical Hospital of Quedlinburg, Quedlinburg, Germany
| | - Rudolf Herbst
- Department of Dermatology, Medical Hospital, Erfurt, Germany
| | | | | | - Ulrike Keim
- Centre for Dermatooncology, Department of Dermatology, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany
| | - Peter Martus
- Institute of Clinical Epidemiology and Applied Biostatistics, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany
| | - Claus Garbe
- Centre for Dermatooncology, Department of Dermatology, Eberhard-Karls-University of Tuebingen, Tuebingen, Germany
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Beiteke U, Bigge S, Reichenberger C, Gralow I. [Pain and pain management in dermatology]. J Dtsch Dermatol Ges 2015; 13:967-89. [PMID: 26408456 DOI: 10.1111/ddg.10_12822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Beiteke U, Bigge S, Reichenberger C, Gralow I. Pain and pain management in dermatology. J Dtsch Dermatol Ges 2015; 13:967-87. [DOI: 10.1111/ddg.12822] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Ingrid Gralow
- Department of Pain Medicine; Münster University Hospital
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