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Abstract
In this article we provide a critical review of the evidence available for surgical management of the nodal basin in melanoma, with an aim to ensure an understanding of risks and benefits for all lymph node surgery offered to patients, and alternatives to surgical management where appropriate.
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Affiliation(s)
- Rogeh Habashi
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada
| | - Valerie Francescutti
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, 6 North, Hamilton, Ontario L8L 2X2, Canada.
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Śniegocka M, Podgórska E, Płonka PM, Elas M, Romanowska-Dixon B, Szczygieł M, Żmijewski MA, Cichorek M, Markiewicz A, Brożyna AA, Słominski AT, Urbańska K. Transplantable Melanomas in Hamsters and Gerbils as Models for Human Melanoma. Sensitization in Melanoma Radiotherapy-From Animal Models to Clinical Trials. Int J Mol Sci 2018; 19:E1048. [PMID: 29614755 PMCID: PMC5979283 DOI: 10.3390/ijms19041048] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 12/18/2022] Open
Abstract
The focus of the present review is to investigate the role of melanin in the radioprotection of melanoma and attempts to sensitize tumors to radiation by inhibiting melanogenesis. Early studies showed radical scavenging, oxygen consumption and adsorption as mechanisms of melanin radioprotection. Experimental models of melanoma in hamsters and in gerbils are described as well as their use in biochemical and radiobiological studies, including a spontaneously metastasizing ocular model. Some results from in vitro studies on the inhibition of melanogenesis are presented as well as radio-chelation therapy in experimental and clinical settings. In contrast to cutaneous melanoma, uveal melanoma is very successfully treated with radiation, both using photon and proton beams. We point out that the presence or lack of melanin pigmentation should be considered, when choosing therapeutic options, and that both the experimental and clinical data suggest that melanin could be a target for radiosensitizing melanoma cells to increase efficacy of radiotherapy against melanoma.
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Affiliation(s)
- Martyna Śniegocka
- Department of Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Ewa Podgórska
- Department of Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Przemysław M Płonka
- Department of Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Martyna Elas
- Department of Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Bożena Romanowska-Dixon
- Department of Ophthalmology and Ocular Oncology, Medical College of Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Małgorzata Szczygieł
- Department of Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Michał A Żmijewski
- Department of Histology, Medical University of Gdansk, 80-210 Gdańsk, Poland.
| | - Mirosława Cichorek
- Department of Embryology, Medical University of Gdansk, 80-210 Gdańsk, Poland.
| | - Anna Markiewicz
- Department of Ophthalmology and Ocular Oncology, Medical College of Jagiellonian University in Kraków, 31-007 Kraków, Poland.
| | - Anna A Brożyna
- Department of Tumor Pathology and Pathomorphology, Faculty of Health Sciences, Nicolaus Copernicus University Collegium Medicum in Bydgoszcz, Oncology Centre-Prof. Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland.
- Department of Dermatology, Comprehensive Cancer Center Cancer Chemoprevention Program, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Andrzej T Słominski
- Department of Dermatology, Comprehensive Cancer Center Cancer Chemoprevention Program, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
- VA Medical Center, Birmingham, AL 35294, USA.
| | - Krystyna Urbańska
- Department of Biophysics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University in Kraków, 31-007 Kraków, Poland.
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3
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Jakub JW, Racz JM, Hieken TJ, Gonzalez AB, Kottschade LA, Markovic SN, Yan Y, Block MS. Neoadjuvant systemic therapy for regionally advanced melanoma. J Surg Oncol 2017; 117:1164-1169. [PMID: 29228467 DOI: 10.1002/jso.24939] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/02/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with regionally advanced melanoma are at high risk of distant failure and unlikely to be cured by surgery alone. Neoadjuvant therapy may provide benefit in these patients. OBJECTIVES To evaluate our experience with neoadjuvant systemic therapy in high-risk stage III patients. METHODS Retrospective review of patients with advanced stage III disease who received neoadjuvant therapy between August 2009 and August 2016 at Mayo Clinic Rochester. RESULTS Twenty-three cases met our inclusion criteria, 16 with resectable disease and 7 with unresectable disease. No patients with resectable disease and one patient with borderline resectable disease progressed regionally, prohibiting surgical resection. Five of seven patients with unresectable disease were down-staged to a resectable state. Six of twenty-three (26%) had a CR and five are alive at last follow-up. Fifteen of twenty three patients (65%) progressed with a median progression free survival of 11 months; however, the 5 year overall survival estimate was 84%. CONCLUSIONS Neoadjuvant systemic therapy is a reasonable approach for patients with advanced but resectable/borderline resectable disease and the risk of losing regional control is low. Our data also suggest some patients with unresectable disease will be converted to resectable and a complete clinical response to treatment can be obtained in approximately one quater of patients.
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Affiliation(s)
- James W Jakub
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Yiyi Yan
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mathew S Block
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota
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Read T, Webber S, Tan J, Wagels M, Schaider H, Soyer HP, Smithers BM. Diphenylcyclopropenone for the treatment of cutaneous in-transit melanoma metastases - results of a prospective, non-randomized, single-centre study. J Eur Acad Dermatol Venereol 2017. [PMID: 28626861 DOI: 10.1111/jdv.14422] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Current treatments for in-transit melanoma (ITM) metastases are frequently invasive and do not improve overall survival. Recently, there has been increasing investigation into the use of topical agents. Diphenylcyclopropenone or diphencyprone (DPCP) is a novel, topical therapy that has been reported to have immune-sensitizing properties useful in the treatment of ITM. OBJECTIVE To assess the clinical outcomes of patients treated within a prospective, non-randomized, non-comparative study using DPCP for cutaneous ITM metastases. METHODS A review was conducted assessing the outcomes of 58 patients prospectively treated using DPCP. Patients had satellite or in-transit disease (stage IIIB+), with all lesion morphology types included. The patients were treated through a single, specialized clinic with regular outpatient follow-up. DPCP was topically applied as an aqueous cream in 0.005-1% concentrations once to twice per week for up to 24-48 h of duration. To assess variables associated with response, a per-protocol statistical analysis was performed. RESULTS Fifty-four patients were treated who satisfied eligibility criteria for analysis. The overall response rates were as follows: complete response 22%, partial response 39%, stable disease 24% and progressive disease 15%. The mean time to complete response was 10.5 months, mean duration (disease-free interval) 12.3 months and recurrence rate in complete responders 41%. Lesion morphology was predictive of clinical benefit with a higher response in epidermotropic disease (P < 0.05). CONCLUSIONS DPCP provided a well-tolerated, convenient and efficacious treatment for cutaneous ITM metastases. Identifying patterns of response may assist treatment selection and improve patient-rated outcomes.
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Affiliation(s)
- T Read
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia.,Discipline of Surgery, School of Medicine, The University of Queensland, Brisbane, Qld, Australia.,School of Medicine, Griffith University, Gold Coast, Qld, Australia
| | - S Webber
- Department of Dermatology, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia
| | - J Tan
- Department of Dermatology, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia
| | - M Wagels
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia.,Discipline of Surgery, School of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - H Schaider
- Department of Dermatology, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia.,Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Qld, Australia
| | - H P Soyer
- Department of Dermatology, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia.,Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Qld, Australia
| | - B M Smithers
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, Qld, Australia.,Discipline of Surgery, School of Medicine, The University of Queensland, Brisbane, Qld, Australia
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Samstein RM, Carvajal RD, Postow MA, Callahan MK, Shoushtari AN, Patel SG, Lee NY, Barker CA. Localized sinonasal mucosal melanoma: Outcomes and associations with stage, radiotherapy, and positron emission tomography response. Head Neck 2016; 38:1310-7. [PMID: 27043023 DOI: 10.1002/hed.24435] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Sinonasal mucosal melanoma is a rare neoplasm with a poor prognosis. METHODS Retrospective analysis was conducted on 78 patients with localized sinonasal mucosal melanoma treated at Memorial Sloan Kettering Cancer Center (MSKCC from 1998-2013). Demographic, tumor, imaging, and treatment factors were recorded and survival and disease-control outcomes were analyzed. RESULTS Median overall survival (OS) and disease-specific survival (DSS) were 32 and 50 months, respectively. Median locoregional recurrence-free survival (LRFS) and distant recurrence-free survival (DRFS) were 43 and 12 months, respectively. Multivariate analysis demonstrated greater OS in nasal cavity tumors and earlier T classification. Radiotherapy (RT) was associated with significantly greater LRFS (5-years; 35% vs 59%; p = .01), but no difference in OS. Post-RT positron emission tomography (PET) response was associated with greater OS. CONCLUSION Distant metastasis is the predominant mode of recurrence in sinonasal mucosal melanoma, but local recurrence remains common. RT is associated with improved local control, but no survival benefit. The prognostic value of post-RT PET imaging warrants further investigation. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1310-1317, 2016.
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Affiliation(s)
- Robert M Samstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard D Carvajal
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Michael A Postow
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Margaret K Callahan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Snehal G Patel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Induction vemurafenib followed by consolidative radiation therapy for surgically incurable melanoma. Melanoma Res 2016; 25:246-51. [PMID: 25746037 DOI: 10.1097/cmr.0000000000000154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Approximately half of melanomas are driven by a point mutation in the BRAF kinase gene, targetable with vemurafenib. However, the chief limitation of continuous BRAF inhibition is that the majority of patients develop resistance within 8 months, including those with surgically unresectable stage III melanoma. Researchers retrospectively reviewed medical records of all patients at our institution with surgically incurable BRAF V600E mutated stage III or limited stage IV melanoma treated with induction vemurafenib, stopped electively during ongoing response, followed by consolidative radiation therapy with or without intervening surgery to debulk nodal metastases. In our six-patient cohort, the median duration of vemurafenib was 5.8 months and the median radiation dose was 57 Gy using conventional fractionation. This algorithm produced 100% locoregional control at 29+ months following radiation and a median progression-free survival of 32.5+ months. Three of six patients remained progression free, and three relapsed in a single organ and achieved ongoing complete response to subsequent therapy. Outcomes greatly exceeding those reported with either BRAF inhibition or radiation alone suggest unanticipated synergies with this therapeutic sequence for both in-field and distant melanoma control, which may be mediated by radiosensitization and immune activation, respectively. In patients with surgically incurable melanoma encompassed within a radiation field, induction vemurafenib and consolidative radiation therapy, rather than continuing vemurafenib until progression, also limit the duration of vemurafenib toxicity and preserve sensitivity to future BRAF inhibition.
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Gorayski P, Burmeister B, Foote M. Radiotherapy for cutaneous melanoma: current and future applications. Future Oncol 2015; 11:525-34. [PMID: 25675130 DOI: 10.2217/fon.14.300] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Cutaneous malignant melanoma remains a significant health burden worldwide despite advances in the management of locoregionally advanced and metastatic disease. Historically, the efficacy of radiation therapy (RT) has been questioned due to the perceived radioresistance of melanoma cancer cells in vitro. Nowadays, RT has limited indications for primary disease, but is used for high-risk nodal disease and in the palliative setting. This review article outlines the current role of RT for melanoma and its expanding role in oligometastatic disease scenarios as an alternative approach to surgery and highlights potential future applications to harness RT interaction with immunomodulatory targeted therapies.
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Affiliation(s)
- Peter Gorayski
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Abstract
Although melanoma was historically thought to be radiation resistant, there are limited data to support the use of adjuvant radiation therapy for certain situations at increased risk for locoregional recurrence. High-risk primary tumor features include thickness, ulceration, certain anatomic locations, satellitosis, desmoplastic/neurotropic features, and head and neck mucosal and anorectal melanoma. Lentigo maligna can be effectively treated with either adjuvant or definitive radiation therapy. Some retrospective and prospective randomized studies support the use of adjuvant radiation to improve regional control after lymph node dissection for high-risk nodal metastatic disease. Consensus on the optimal radiation doses and fractionation is lacking.
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Affiliation(s)
- Jacqueline Oxenberg
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - John M Kane
- Melanoma-Sarcoma Service, Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
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La Greca M, Grasso G, Antonelli G, Russo AE, Bartolotta S, D'Angelo A, Vitale FV, Ferraù F. Neoadjuvant therapy for locally advanced melanoma: new strategies with targeted therapies. Onco Targets Ther 2014; 7:1115-21. [PMID: 24971022 PMCID: PMC4069135 DOI: 10.2147/ott.s62699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Neoadjuvant chemotherapy has been successfully tested in several bulky solid tumors, but it has not been utilized in advanced cutaneous melanoma, primarily because effective medical treatments for this disease have been lacking. However, with the development of new immunotherapies (monoclonal antibodies specific for cytotoxic T lymphocyte-associated antigen 4 [anti-CTLA-4] and programmed death protein-1 [anti-PD1]) and small molecules interfering with intracellular pathways (anti-BRAF and mitogen-activated protein kinase kinase [anti- MEK]) the use of this approach is becoming a viable treatment strategy for locally advanced melanoma. The neoadjuvant setting provides a double opportunity for a better knowledge of these drugs: a short-term evaluation of their intrinsic activity, and a deeper analysis of their action and resistance-induction mechanisms. BRAF inhibitors seem to be ideal candidates for the neoadjuvant setting, because of their prompt, repeatedly confirmed response in V600E BRAF-mutant metastatic melanoma. In this report we summarize studies focused on the neoadjuvant use of traditional medical treatments in advanced melanoma and anecdotal cases of this approach with the use of biologic therapies. Moreover, we discuss our experience with neoadjuvant targeted therapy as a priming for radical surgery in a patient with BRAF V600E mutation-positive advanced melanoma.
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Affiliation(s)
- Michele La Greca
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Giuseppe Grasso
- Pathology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Giovanna Antonelli
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Alessia Erika Russo
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | | | - Alessandro D'Angelo
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Felice Vito Vitale
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
| | - Francesco Ferraù
- Medical Oncology Department, San Vincenzo Hospital, Taormina, Messina, Italy
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Laks S, Brueske KA, Hsueh EC. Neoadjuvant treatment of melanoma: case reports and review. Exp Hematol Oncol 2013; 2:30. [PMID: 24499550 PMCID: PMC3832230 DOI: 10.1186/2162-3619-2-30] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/04/2013] [Indexed: 01/06/2023] Open
Abstract
Neoadjuvant therapy is an under-utilized regimen for the treatment of metastatic melanoma. The use of this approach has been increasing in other tumor types. Neoadjuvant therapy may reduce occult circulating tumor cell burden in the face of bulky disease and afford a real time evaluation of treatment effectiveness. Neoadjuvant approach can also provide preoperative histologic and molecular analysis of treated tissue that may guide the postoperative treatment planning in patients with resectable metastatic melanoma lesions. The putative benefits of better margin control and clearance of occult systemic disease would theoretically improve surgical outcome. With the advent of effective agents against metastatic melanoma, this common approach to the treatment of rectal cancer, metastatic colon cancer, and breast cancer should also be evaluated as a viable treatment strategy for advanced stage melanoma.
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Affiliation(s)
| | | | - Eddy C Hsueh
- Department of Surgery, Saint Louis University, 3635 Vista at Grand Blvd,, St, Louis, Missouri 63110, USA.
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Teulings HE, Tjin EPM, Willemsen KJ, Krebbers G, van Noesel CJ, Kemp EH, Nieuweboer-Krobotova L, van der Veen JPW, Luiten RM. Radiation-induced melanoma-associated leucoderma, systemic antimelanoma immunity and disease-free survival in a patient with advanced-stage melanoma: a case report and immunological analysis. Br J Dermatol 2013; 168:733-8. [PMID: 23421690 DOI: 10.1111/bjd.12136] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Melanoma is an immunogenic tumour. The development of skin depigmentation or melanoma-associated leucoderma (MAL) has been associated with favourable clinical outcome in patients with metastatic melanoma, especially after immunotherapy. Evidence for clinically meaningful enhancement of melanoma-directed autoimmunity, as indicated by MAL, after radiotherapy without immunotherapy has not yet been published. OBJECTIVES We investigated whether a patient with stage IV melanoma, who developed leucoderma in the irradiated skin areas following radiotherapy and experienced exceptional disease-free survival of 3 years despite brain metastasis, possessed antimelanoma immunity that could be linked to the favourable disease course. METHODS A detailed immunological analysis was performed consisting of immunohistochemistry of several melanoma tissues, and analyses of T cells isolated from the blood and MAL skin tissue for melanocyte/melanoma specificity and functionality, as well as the presence of a melanoma-specific antibody response. RESULTS Immunological analyses showed the presence of CD8+ T cells and antibody responses directed against melanocyte differentiation antigens expressed in the primary tumour, lymph node and brain metastasis, indicating adequate tumour recognition by activated T cells. CONCLUSION The immune responses found in this patient, probably enhanced by radiotherapy, are thought to have contributed to his favourable clinical course. Radiotherapy may act as local immunotherapy in patients with melanoma by destroying melanocytes, leading to the induction, or enhancement, of already existent antimelanoma immunity. As in patients treated with immunotherapy, this may lead to MAL, also at distant sites from the treated area. This patient is a clear example of the positive prognostic value of MAL, which is possibly induced by radiotherapy, for patients with melanoma.
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Affiliation(s)
- H E Teulings
- Department of Dermatology and the Netherlands Institute for Pigment Disorders, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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