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Mellemgaard C, Christensen IJ, Salkus G, Wirenfeldt Staun P, Korsgaard N, Hein Lindahl K, Skaarup Larsen M, Klausen S, Lade-Keller J. Reducing workload in malignant melanoma sentinel node examination: a national study of pathology reports from 507 melanoma patients. J Clin Pathol 2024; 77:312-317. [PMID: 36737244 DOI: 10.1136/jcp-2022-208743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
AIMS Even though extensive melanoma sentinel node (SN) pathology protocols increase metastasis detection, there is a need for balancing high detection rates with reasonable workload. A newly tested Danish protocol recommended examining nodes at six levels 150 µm apart (six-level model) and using SOX10 and Melan-A immunohistochemistry (IHC). We explored if a protocol examining 3 levels 300 µm apart (three-level model) combined with IHC would compromise metastasis detection. The study aim was to optimise the protocol to reduce workload without compromising detection rate. METHODS 8 months after protocol implementation, we reviewed the pathology reports of SNs from 507 melanoma patients nationwide, including 117 SN-positive patients. Each report was reviewed to determine histopathological features, including detection of metastasis, exact levels with metastasis, exact levels with metastasis >1 mm in diameter and IHC results. RESULTS The six-level model detected metastases in 23% of patients, whereas the three-level model would have detected metastases in 22% of patients. The three-level model would have missed a few small metastases (n=4), measuring <0.1 mm, 0.1 mm, 0.4 mm and 0.1 mm, respectively. The six-level model detected metastases >1 mm in 7% of patients. One of these metastases (measuring 1.1 mm) would have been detected by the three-level model, but not as >1 mm. SOX10 and Melan-A had equal sensitivity. CONCLUSIONS Reducing the number of levels examined to three levels 300 µm apart combined with IHC does not have significant impact on metastasis detection rate, and we will therefore recommend that the future melanoma SN guideline takes this into consideration to reduce overall workload.
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Affiliation(s)
- Carina Mellemgaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
- Aarhus University, Aarhus, Denmark
| | - Ib Jarle Christensen
- Department of Pathology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Giedrius Salkus
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Niels Korsgaard
- Department of Pathology, Hospital South West Jutland, Esbjerg, Denmark
| | | | | | - Siri Klausen
- Department of Pathology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
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2
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Maher NG, Vergara IA, Long GV, Scolyer RA. Prognostic and predictive biomarkers in melanoma. Pathology 2024; 56:259-273. [PMID: 38245478 DOI: 10.1016/j.pathol.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/20/2023] [Indexed: 01/22/2024]
Abstract
Biomarkers help to inform the clinical management of patients with melanoma. For patients with clinically localised primary melanoma, biomarkers can help to predict post-surgical outcome (including via the use of risk prediction tools), better select patients for sentinel lymph node biopsy, and tailor catch-all follow-up protocols to the individual. Systemic drug treatments, including immune checkpoint inhibitor (ICI) therapies and BRAF-targeted therapies, have radically improved the prognosis of metastatic (stage III and IV) cutaneous melanoma patients, and also shown benefit in the earlier setting of stage IIB/C primary melanoma. Unfortunately, a response is far from guaranteed. Here, we review clinically relevant, established, and emerging, prognostic, and predictive pathological biomarkers that refine clinical decision-making in primary and metastatic melanoma patients. Gene expression profile assays and nomograms are emerging tools for prognostication and sentinel lymph node risk prediction in primary melanoma patients. Biomarkers incorporated into clinical practice guidelines include BRAF V600 mutations for the use of targeted therapies in metastatic cutaneous melanoma, and the HLA-A∗02:01 allele for the use of a bispecific fusion protein in metastatic uveal melanoma. Several predictive biomarkers have been proposed for ICI therapies but have not been incorporated into Australian clinical practice guidelines. Further research, validation, and assessment of clinical utility is required before more prognostic and predictive biomarkers are fluidly integrated into routine care.
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Affiliation(s)
- Nigel G Maher
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Ismael A Vergara
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia; Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia.
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3
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Hu T, Xu Y, Yan W, Wang C, Sun W, Kong Y, Chen Y. Prognostic value of the number of biopsied sentinel lymph nodes for Chinese patients with melanoma: A single-center retrospective study. Cancer Rep (Hoboken) 2023; 7:e1958. [PMID: 38148035 PMCID: PMC10849921 DOI: 10.1002/cnr2.1958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/10/2023] [Accepted: 12/01/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) helps to determine accurate pathological stages and facilitates strategies for regional disease control in melanoma. However, whether the number of biopsied sentinel lymph nodes (SLNs) influences the patients' survival is rarely investigated. METHODS Acral or cutaneous melanoma patients with no history of nodal disease who received SLNB in Fudan University Shanghai Cancer Center (FUSCC) from January 1, 2017, to December 31, 2021 were retrospectively enrolled. Clinicopathological variables including Breslow index, ulceration, number of positive SLNs, SLN/non-SLN status were analyzed. The pathologic nodal (pN) stage and pathological stage were defined. RESULTS A total of 381 eligible patients were enrolled in this study, of whom 132 (34.7%) patients were diagnosed with SLN-positive. The median number of biopsied SLNs was 2 (range: 1 to 20). Different numbers of biopsied SLNs did not influence the release-free survival (RFS) of the general patients. However, patients with >2 SLNs had a longer RFS than those with 1-2 SLNs in T4, N1a group and those who rejected complete lymph node dissection (CLND). CONCLUSIONS In patients with T4 melanomas, N1a melanomas and those that did not undergo a CLND, the prognosis of those with three or more SLNs retrieved seemed to be improved.
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Affiliation(s)
- Tu Hu
- Department of Musculoskeletal SurgeryFudan University Shanghai Cancer CenterShanghaiChina
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Yu Xu
- Department of Musculoskeletal SurgeryFudan University Shanghai Cancer CenterShanghaiChina
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Wangjun Yan
- Department of Musculoskeletal SurgeryFudan University Shanghai Cancer CenterShanghaiChina
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Chunmeng Wang
- Department of Musculoskeletal SurgeryFudan University Shanghai Cancer CenterShanghaiChina
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Wei Sun
- Department of Musculoskeletal SurgeryFudan University Shanghai Cancer CenterShanghaiChina
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
| | - Yunyi Kong
- Department of PathologyFudan University Shanghai Cancer Center, Fudan UniversityShanghaiChina
| | - Yong Chen
- Department of Musculoskeletal SurgeryFudan University Shanghai Cancer CenterShanghaiChina
- Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
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4
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Lin X, Sun W, Ren M, Xu Y, Wang C, Yan W, Kong Y, Balch CM, Chen Y. Prediction of nonsentinel lymph node metastasis in acral melanoma with positive sentinel lymph nodes. J Surg Oncol 2023; 128:1407-1415. [PMID: 37689989 DOI: 10.1002/jso.27438] [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: 02/05/2023] [Revised: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Metastasis in a nonsentinel lymph node (non-SLN) is an unfavorable independent prognostic factor in cutaneous melanoma (CM). Recent data did suggest potential value of completion lymph node dissection (CLND) in CM patients with non-SLN metastasis. Prediction of non-SLN metastasis assists clinicians in deciding on adjuvant therapy without CLND. We analyzed risk factors and developed a prediction model for non-SLN status in acral melanoma (AM). METHODS This retrospective study enrolled 656 cases of melanoma who underwent sentinel lymph node biopsy at Fudan University Shanghai Cancer Center from 2009 to 2017. We identified 81 SLN + AM patients who underwent CLND. Clinicopathologic data, including SLN tumor burden and non-SLN status were examined with Cox and Logistics regression models. RESULTS Ulceration, Clark level, number of deposits in the SLN (NumDep) and maximum size of deposits (MaxSize) are independent risk factors associated with non-SLN metastases. We developed a scoring system that combines ulceration, the cutoff values of Clark level V, MaxSize of 2 mm, and NumDep of 5 to predict non-SLN metastasis with an efficiency of 85.2% and 100% positive predictive value in the high-rank group (scores of 17-24). CONCLUSIONS A scoring system that included ulceration, Clark level, MaxSize, and NumDep is reliable and effective for predicting non-SLN metastasis in SLN-positive AM.
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Affiliation(s)
- XinYi Lin
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min Ren
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yu Xu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - ChunMeng Wang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - WangJun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - YunYi Kong
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Charles M Balch
- Department of Surgical Oncology, University of Texas MD Anderson Cancer center, Houston, Texas, USA
| | - Yong Chen
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Almeida PDDE, Lavareze L, Rangel CEDAS, Mariano FV, Rodrigues DVN, Baldasso TA, Fanni RV, Casarim ALM, Negro AD, Tincani AJ. Evaluation of tumor load in sentinel lymph node in patients with cutaneous melanoma. Rev Col Bras Cir 2023; 50:e20233521. [PMID: 37436282 PMCID: PMC10508682 DOI: 10.1590/0100-6991e-20233521-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/31/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION cutaneous melanoma (MC) is a malignant neoplasm derived from melanocytic cells with an aggressive behavior. It is usually associated with the multifactorial interaction of genetic susceptibility and environmental exposure, usually ultraviolet radiation. Despite advances in treatment, the disease remains relentless with poor prognosis. Sentinel lymph node (SLN) biopsy is a technique used to screen patients in need of lymph node dissection. OBJECTIVES to correlate the tumor burden in the SLN with the mortality of patients undergoing SLN biopsy. METHODOLOGY the medical records and histological slides of patients with MC who underwent SLN biopsy treated at HC-Unicamp from 2001 to 2021 were retrospectively analyzed. The positive SLN were measured according to the size of the tumor infiltration area, for analysis of the depth of invasion (DI), closest proximity to the capsule (CPC) and tumor burden (TB). For statistical analysis, associations between variables were analyzed using Fishers exact test, with post Bonferroni test and Wilcoxon test. RESULTS 105 records of patients who underwent SLN biopsy of MC were identified. Of these, nine (8.6%) had positive SLN and 81 (77.1%) had negative SLN. The performed lymphadenectomies resulted in 55.6% (n=5) affected, 22.2% (n=2) without disease and 22.2% (n=2) were not performed. Mean CPC, TB, and DI were 0.14mm, 32.10mm and 2.33mm, respectively. Patients with T2 and T3 tumors were more likely to show the SLN affected (p=0.022). No patient with positive SLN died during follow-up. CONCLUSION patients who presented T3 staging are the ones who most presented positive SLN.
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Affiliation(s)
- Pedro Deak DE Almeida
- - Universidade Estadual de Campinas, Departamento de Cirurgia Geral - Área de Cabeça e Pescoço - Campinas - SP - Brasil
| | - Luccas Lavareze
- - Universidade Estadual de Campinas, Departamento de Patologia - Campinas - SP - Brasil
| | | | | | | | - Tiago Antonio Baldasso
- - Universidade Estadual de Campinas, Departamento de Cirurgia Geral - Área de Cabeça e Pescoço - Campinas - SP - Brasil
| | - Renato Ventura Fanni
- - Universidade Estadual de Campinas, Departamento de Cirurgia Geral - Área de Cabeça e Pescoço - Campinas - SP - Brasil
| | - Andre Luis Maion Casarim
- - Universidade Estadual de Campinas, Departamento de Cirurgia Geral - Área de Cabeça e Pescoço - Campinas - SP - Brasil
| | - André Del Negro
- - Universidade Estadual de Campinas, Departamento de Cirurgia Geral - Área de Cabeça e Pescoço - Campinas - SP - Brasil
| | - Alfio José Tincani
- - Universidade Estadual de Campinas, Departamento de Cirurgia Geral - Área de Cabeça e Pescoço - Campinas - SP - Brasil
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Jansen P, Baguer DO, Duschner N, Arrastia JL, Schmidt M, Landsberg J, Wenzel J, Schadendorf D, Hadaschik E, Maass P, Schaller J, Griewank KG. Deep learning detection of melanoma metastases in lymph nodes. Eur J Cancer 2023; 188:161-170. [PMID: 37257277 DOI: 10.1016/j.ejca.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/20/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND In melanoma patients, surgical excision of the first draining lymph node, the sentinel lymph node (SLN), is a routine procedure to evaluate lymphogenic metastases. Metastasis detection by histopathological analysis assesses multiple tissue levels with hematoxylin and eosin and immunohistochemically stained glass slides. Considering the amount of tissue to analyze, the detection of metastasis can be highly time-consuming for pathologists. The application of artificial intelligence in the clinical routine has constantly increased over the past few years. METHODS In this multi-center study, a deep learning method was established on histological tissue sections of sentinel lymph nodes collected from the clinical routine. The algorithm was trained to highlight potential melanoma metastases for further review by pathologists, without relying on supplementary immunohistochemical stainings (e.g. anti-S100, anti-MelanA). RESULTS The established method was able to detect the existence of metastasis on individual tissue cuts with an area under the curve of 0.9630 and 0.9856 respectively on two test cohorts from different laboratories. The method was able to accurately identify tumour deposits>0.1 mm and, by automatic tumour diameter measurement, classify these into 0.1 mm to -1.0 mm and>1.0 mm groups, thus identifying and classifying metastasis currently relevant for assessing prognosis and stratifying treatment. CONCLUSIONS Our results demonstrate that AI-based SLN melanoma metastasis detection has great potential and could become a routinely applied aid for pathologists. Our current study focused on assessing established parameters; however, larger future AI-based studies could identify novel biomarkers potentially further improving SLN-based prognostic and therapeutic predictions for affected patients.
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Affiliation(s)
- Philipp Jansen
- Department of Dermatology, University Hospital Bonn, Bonn 53127, Germany
| | | | | | | | | | - Jennifer Landsberg
- Department of Dermatology, University Hospital Bonn, Bonn 53127, Germany
| | - Jörg Wenzel
- Department of Dermatology, University Hospital Bonn, Bonn 53127, Germany
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen 45147, Germany
| | - Eva Hadaschik
- Department of Dermatology, University Hospital Essen, Essen 45147, Germany
| | | | - Jörg Schaller
- Dermatopathologie Duisburg Essen GmbH, Essen 45329, Germany
| | - Klaus Georg Griewank
- Department of Dermatology, University Hospital Essen, Essen 45147, Germany; Dermatopathologie bei Mainz, Nieder-Olm 55268, Germany.
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7
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van Akkooi ACJ, Schadendorf D, Eggermont AMM. Alternatives and reduced need for sentinel lymph node biopsy (SLNB) staging for melanoma. Eur J Cancer 2023; 182:163-169. [PMID: 36681612 DOI: 10.1016/j.ejca.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
Sentinel lymph node biopsy (SLNB) has been introduced in the 1990s to identify patients who might benefit from completion lymph node dissection. Neither SLNB nor CLND improved survival, but SLNB staging did provide the best staging, above Breslow thickness and ulceration. The SLN status and SLN tumour burden were used in all trials until date looking at modern adjuvant systemic therapy with immune checkpoint inhibition (ICI) or targeted therapies (TT). Adjuvant ICI and TT are shifting towards stage II melanoma. The question is whether there is still role for SLNB in melanoma, in this day and age, and if so, how does the future look for SLNB staging? The SLN status and SLN tumour burden might be useful for a consultation to discuss the number needed to treat in a risk/benefit discussion. For stage IIB/C patients, it seems likely, however, that patients will forego a nuclear scan followed by the risk of surgical intervention and morbidity associated with SLNB if they opt to receive adjuvant therapy regardless of the SLNB result. For stage I/IIA, it is still required to detect high-risk patients who might benefit from adjuvant therapy. However, biomarkers are emerging, such as gene expression profilers (GEP), immunohistological signatures and liquid biopsies with ctDNA. There still is a role for SLNB staging in melanoma today, but we expect that the availability of therapeutic option independent of SLNB status as well as emergence of validated biomarkers to predict risk will reduce the need for SLNB staging in the upcoming decade to the point it will no longer be used.
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Affiliation(s)
- Alexander C J van Akkooi
- Melanoma Institute Australia, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia.
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer DKTK Consortium, Partner Site, Germany; Research Center One Health Ruhr, Research Alliance Ruhr, University Duisburg-Essen, Duisburg, Germany
| | - Alexander M M Eggermont
- Comprehensive Cancer Center München, Technical University München & Ludwig Maximiliaan University, München, Germany; University Medical Center Utrecht & Princess Maxima Center, Utrecht, the Netherlands
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8
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Hussain Z, Heaton MJ, Snelling AP, Nobes JP, Gray G, Garioch JJ, Moncrieff MD. Risk Stratification of Sentinel Node Metastasis Disease Burden and Phenotype in Stage III Melanoma Patients. Ann Surg Oncol 2023; 30:1808-1819. [PMID: 36445500 PMCID: PMC9908720 DOI: 10.1245/s10434-022-12804-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, all patients with American Joint Committee on Cancer (AJCC) pT2b-pT4b melanomas and a positive sentinel node biopsy are now considered for adjuvant systemic therapy without consideration of the burden of disease in the metastatic nodes. METHODS This was a retrospective cohort analysis of 1377 pT1-pT4b melanoma patients treated at an academic cancer center. Standard variables regarding patient, primary tumor, and sentinel node characteristics, in addition to sentinel node metastasis maximum tumor deposit size (MTDS) in millimeters and extracapsular spread (ECS) status, were analyzed for predicting disease-specific survival (DSS). RESULTS The incidence of SN+ was 17.3% (238/1377) and ECS was 10.5% (25/238). Increasing AJCC N stage was associated with worse DSS. There was no difference in DSS between the IIIB and IIIC groups. Subgroup analyses showed that the optimal MTDS cut-point was 0.7 mm for the pT1b-pT4a SN+ subgroups, but there was no cut-point for the pT4b SN+ subgroup. Patients with MTDS <0.7 mm and no ECS had similar survival outcomes as the N0 patients with the same T stage. Nodal risk categories were developed using the 0.7 mm MTDS cut-point and ECS status. The incidence of low-risk disease, according to the new nodal risk model, was 22.3% (53/238) in the stage III cohort, with 49% (26/53) in the pT2b-pT3a and pT3b-pT4a subgroups and none in the pT4b subgroup. Similar outcomes were observed for overall and distant metastasis-free survival. CONCLUSION We propose a more granular classification system, based on tumor burden and ECS status in the sentinel node, that identifies low-risk patients in the AJCC IIIB and IIIC subgroups who may otherwise be observed.
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Affiliation(s)
- Zahra Hussain
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Martin J Heaton
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Andrew P Snelling
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Jenny P Nobes
- Department of Oncology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gill Gray
- Department of Oncology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Jennifer J Garioch
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Marc D Moncrieff
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
- Norwich Medical School, University of East Anglia, Norwich, UK.
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Allard-Coutu A, Dobson V, Schmitz E, Shah H, Nessim C. The Evolution of the Sentinel Node Biopsy in Melanoma. Life (Basel) 2023; 13:life13020489. [PMID: 36836846 PMCID: PMC9966203 DOI: 10.3390/life13020489] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.
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Affiliation(s)
- Alexandra Allard-Coutu
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Correspondence:
| | | | - Erika Schmitz
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Hely Shah
- Department of Medical Oncology, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Carolyn Nessim
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Molecular Detection of Lymph Node Metastases in Lung Cancer Patients Using the One-Step Nucleic Acid Amplification Method:Clinical Significance and Prognostic Value. Cells 2022; 11:cells11244010. [PMID: 36552774 PMCID: PMC9776771 DOI: 10.3390/cells11244010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
The one-step nucleic acid amplification (OSNA) method allows for the quantitative evaluation of the tumor burden in resected lymph nodes (LNs) in patients with lung cancer. This technique enables to detect macro and micrometastases, facilitating the correct classification of patients for appropriate follow-up of the disease after surgery. Of 160 patients with resectable lung cancer whose LNs were examined by OSNA, H&E and CK19 IHC between July 2015 and December 2018, 110 patients with clinical stages from IA1 to IIIB were selected for follow-up. LN staging in lung cancer by pathological study led to understaging in 13.64% of the cases studied. OSNA allowed to quantify the tumor burden and establish a prognostic value. Patients with a total tumor load of ≥1650 cCP/uL were associated with a significantly increased likelihood of recurrence. Moreover, the survival of patients with <4405 cCP/uL was significantly higher than patients with ≥4405 cCP/uL. The OSNA assay is a rapid and accurate technique for quantifying the tumor burden in the LNs of lung cancer patients and OSNA quantitative data could allow to establish prognostic values for recurrence-free survival and overall survival in this type of malignancy.
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11
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Sharon CE, Straker RJ, Li EH, Karakousis GC, Miura JT. National Practice Patterns in the Management of the Regional Lymph Node Basin After Positive Sentinel Lymph Node Biopsy for Cutaneous Melanoma. Ann Surg Oncol 2022; 29:8456-8464. [PMID: 36006494 DOI: 10.1245/s10434-022-12364-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Immediate completion lymph node dissection (CLND) for patients with sentinel lymph node (SLN) metastasis from cutaneous melanoma has been replaced largely by ultrasound nodal surveillance since the publication of two landmark trials in 2016 and 2017. National practice patterns of CLND remain poorly characterized. METHODS Patients with a diagnosis of cutaneous melanoma in 2016 and 2018 without clinical nodal disease who underwent sentinel lymph node biopsy (SLNB) were identified from the National Cancer Database (NCDB). Characteristics associated with CLND were analyzed by uni- and multivariate logistic regression. Overall survival (OS) was estimated using Kaplan-Meier and Cox proportional hazards regression analyses. RESULTS Of the 3517 patients included in the study, 1405 had disease diagnosed in 2016. The patients with cutaneous melanoma diagnosed in 2016 had a median age of 60 years and a tumor thickness of 2.3 mm compared to 62 years and 2.4 mm, respectively, for the patients with cutaneous melanoma diagnosed in 2018. According to the NCDB, 40 % (n = 559) of the patients underwent CLND in 2016 compared with 6 % (n = 132) in 2018. The factors associated with receipt of CLND in 2018 included younger age (odds ratio [OR], 0.97; 95 % confidence interval [CI], 0.95-0.99; p = 0.001), rural residence (OR, 3.96; 95 % CI, 1.50-10.49; p = 0.006), head/neck tumor location (OR, 1.88; 95 % CI, 1.10-3.23; p = 0.021), and more than one positive SLN (OR, 1.80; 95 % CI, 1.17-2.76; p = 0.007). The 5-year OS did not differ between the patients who received SLNB only and those who underwent CLND (hazard ratio [HR], 0.93; p = 0.54). CONCLUSION The rates of CLND have decreased nationally. However, patients with head/neck primary tumors who live in rural locations are more likely to undergo CLND, highlighting populations for which treatment may be non-uniform with national practice patterns.
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Affiliation(s)
- Cimarron E Sharon
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4, Philadelphia, 19104, PA, USA.
| | - Richard J Straker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4, Philadelphia, 19104, PA, USA
| | - Eric H Li
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4, Philadelphia, 19104, PA, USA
| | - John T Miura
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4, Philadelphia, 19104, PA, USA
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12
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Loidi-Pascual L, Librero J, Córdoba-Iturriagagoitia A, Guarch-Troyas R, Montes-Díaz M, Ruiz de Azua-Ciria Y, Arozarena I, Goñi-Gironés E, Yanguas I. Sentinel node tumor burden in cutaneous melanoma. Survival with competing risk analysis and influence in relapses and non-sentinel node status: retrospective cohort study with long follow-up in a Spanish population. Arch Dermatol Res 2022; 314:369-378. [PMID: 33973061 DOI: 10.1007/s00403-021-02232-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 04/05/2021] [Accepted: 04/13/2021] [Indexed: 11/27/2022]
Abstract
Several authors have studied the potential of sentinel lymph node (SLN) tumor burden as prognostic factor but the microscopic classifications used in different study groups were variable. We examined the prognostic role of tumor burden in SLN on melanoma specific-survival and competing causes of death. We also analysed clinical and histological factors as predictors of disease relapses and additional non sentinel lymph node (NSLN) metastases. We included all patients with cutaneous melanoma that underwent SLN biopsy between 2002 and 2012 at Complejo Hospitalario de Navarra (Spain). The study end-points were death due to melanoma, melanoma relapse and involvement of NSLN. We used Fine-Gray test for competing risk analysis. A logistic regression model was performed to predict the risk of involvement of NSLN. Between 2002 and 2012, there were 348 patients who underwent SLN biopsy in our centre (308 were eligible for the study). 26.9% patients positive SLN. 88 patients died during the follow-up period and 66 (75%) died from melanoma. The 5-year cumulative incidence of melanoma death was 15.33% (95 % CI 15.25-15.42). The cumulative probability of death from melanoma was associated with gender, histological subtype, Breslow thickness, mitotic rate, ulceration and SLN tumor burden. In multivariable analysis, Breslow thickness and SLN tumor burden remained as independent prognostic factors. SLN tumor burden appears to be an important prognostic factor. It is very important reporting these characteristics in pathological reports. More prospective studies would be necessary to analyze these variables and to be able to make recommendations in management of melanoma patients.
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Affiliation(s)
- Leire Loidi-Pascual
- Dermatology Department of Complejo Hospitalario de Navarra, C/Irunlarrea., 31008, Pamplona, Navarra, Spain.
| | - Julián Librero
- Methodology Unit of Navarrabiomed Center-IDISNA, Pamplona, Spain
| | | | - Rosa Guarch-Troyas
- Pathology Department of Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Marta Montes-Díaz
- Pathology Department of Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | - Imanol Arozarena
- Navarrabiomed, Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Elena Goñi-Gironés
- Nuclear Medicine Department of Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Ignacio Yanguas
- Dermatology Department of Complejo Hospitalario de Navarra, C/Irunlarrea., 31008, Pamplona, Navarra, Spain
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13
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Cassell O, Harwood C, Hovey M, Payne M. Implications of systemic adjuvant melanoma treatments for U.K. melanoma services: Results of the U.K. Melanoma Adjuvant Pathway Survey. Eur J Cancer Care (Engl) 2022; 31:e13565. [DOI: 10.1111/ecc.13565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/19/2019] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Oliver Cassell
- Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry Queen Mary University of London; Barts Health NHS Trust London UK
| | | | - Miranda Payne
- Oxford University Hospitals NHS Foundation Trust Oxford UK
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14
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Witt RG, Erstad DJ, Wargo JA. Neoadjuvant therapy for melanoma: rationale for neoadjuvant therapy and pivotal clinical trials. Ther Adv Med Oncol 2022; 14:17588359221083052. [PMID: 35251322 PMCID: PMC8894940 DOI: 10.1177/17588359221083052] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/03/2022] [Indexed: 12/26/2022] Open
Abstract
The treatment of malignant melanoma has drastically changed over the past decade with the advent of immune checkpoint blockade, targeted therapy with BRAF/MEK inhibition, and other novel therapies such as oncolytic virus intralesional therapy. Despite improvements in patient response rates and survival with these new treatments, there exists a large portion of patients with surgically resectable disease that are high risk for relapse. Patients with high-risk resectable melanoma account for up to 20% of newly diagnosed cases. For this high-risk group of patients, neoadjuvant therapy has many purposed advantages over adjuvant therapy, including a more robust immune response due to abundant tumor antigens at treatment initiation, the ability to assess pathologic response to therapy, tumor downstaging leading to increased disease resectability, and a potential decreased need for extensive lymphadenectomies. These findings have been backed by preclinical models and multiple neoadjuvant trials are underway. In this review, we will discuss the trials that have set the foundation for the current treatment standards and discuss the role and rationale for neoadjuvant therapy for high-risk malignant melanomas.
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Affiliation(s)
- Russell G. Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Derek J. Erstad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer A. Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1484, Houston, TX 77030-4009, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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Eggermont AM, Ascierto PA, Khushalani NI, Schadendorf D, Boland G, Weber J, Lewis KD, Johnson D, Rivalland G, Khattak A, Majem M, Gogas H, Long GV, Currie SL, Chien D, Tagliaferri MA, Carlino MS, Diab A. PIVOT-12: a phase III study of adjuvant bempegaldesleukin plus nivolumab in resected stage III/IV melanoma at high risk for recurrence. Future Oncol 2022; 18:903-913. [PMID: 35073733 DOI: 10.2217/fon-2021-1286] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Bempegaldesleukin (BEMPEG: NKTR-214) is an immunostimulatory IL-2 cytokine prodrug engineered to deliver a controlled, sustained and preferential IL-2 pathway signal. Nivolumab (NIVO), a PD-1 inhibitor, has been shown to prolong survival in patients with advanced melanoma and recurrence-free survival in the adjuvant setting. PIVOT-02 showed that BEMPEG plus NIVO was well-tolerated and demonstrated clinical activity as first-line therapy in metastatic melanoma. PIVOT-12 is a randomized, phase III, global, multicenter, open-label study comparing adjuvant therapy with BEMPEG plus NIVO versus NIVO alone in adult and adolescent patients with completely resected cutaneous stage III/IV melanoma at high risk of recurrence. The primary objective is to compare the efficacy, as measured by recurrence-free survival, of BEMPEG plus NIVO versus NIVO.
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Affiliation(s)
- Alexander Mm Eggermont
- Princess Máxima Center for Pediatric Oncology & University Medical Center Utrecht, Utrecht, Netherlands
| | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione G Pascale, Naples, Italy
| | | | - Dirk Schadendorf
- West German Cancer Center at the University Hospital Essen, Essen, Germany
| | | | - Jeffrey Weber
- Perlmutter Cancer Center at NYU Langone Health, New York, NY 10016, USA
| | - Karl D Lewis
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | | | - Gareth Rivalland
- University of Auckland & Auckland City Hospital, Auckland, New Zealand
| | - Adnan Khattak
- Hollywood Private Hospital, Edith Cowan University, Perth, Australia
| | | | - Helen Gogas
- National & Kapodistrian University of Athens, Athens, Greece
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, & Royal North Shore & Mater Hospitals, Sydney, Australia
| | - Sue L Currie
- Nektar Therapeutics, San Francisco, CA 94158, USA
| | - David Chien
- Nektar Therapeutics, San Francisco, CA 94158, USA
| | | | - Matteo S Carlino
- Westmead & Blacktown Hospitals & Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - Adi Diab
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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16
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El Sharouni MA, Scolyer RA, van Gils CH, Ch'ng S, Nieweg OE, Pennington TE, Saw RP, Shannon K, Spillane A, Stretch J, Witkamp AJ, Sigurdsson V, Thompson JF, van Diest PJ, Lo SN. Effect of the time interval between melanoma diagnosis and sentinel node biopsy on the size of metastatic tumour deposits in node-positive patients. Eur J Cancer 2022; 167:133-141. [PMID: 35216870 DOI: 10.1016/j.ejca.2021.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/10/2021] [Accepted: 12/05/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This study sought to assess whether the interval between diagnostic excision-biopsy of a primary melanoma and definitive wide excision with sentinel node biopsy (SNB) influenced the size of SN metastatic deposits, which might have implications for management and prognosis. METHODS Data were collected for (i) a Dutch population-based cohort of patients treated between 2004 and 2014 who underwent SNB within 100 days of complete excision of their primary melanoma and who were SN-positive with known SN metastasis diameter (n = 1027) and (ii) a cohort from a large Australian melanoma treatment centre (n = 541) who presented in the same time period. The effects of SNB timing on the size of SN metastatic deposits were analysed. RESULTS Dutch patients whose SNB was performed in the second or third months after diagnosis had significantly larger SN metastasis diameters than patients who had their SNB in the first month (median increases of 17% (95%CI -14, 60%, p = 0.211) and 71% (95%CI 15, 119%, p = 0.004), respectively). No significant difference in tumour diameter for early and late SNB was found in the Australian cohort. CONCLUSIONS SN metastasis diameter became progressively greater with SN biopsy in the second and third months after primary melanoma diagnosis in the larger, population-based patient cohort. An increase in metastasis diameter was not observed in the smaller, institutional cohort, possibly due to detection of larger SN metastases by routine pre-operative ultrasound, with fine-needle biopsy confirmation. These patients did not proceed to SNB and were therefore not included in the study.
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Affiliation(s)
- Mary-Ann El Sharouni
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Department of Dermatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Tissue Oncology and Diagnostic Pathology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Carla H van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Sydney Ch'ng
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Omgo E Nieweg
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Thomas E Pennington
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Robyn Pm Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kerwin Shannon
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Breast and Melanoma Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jonathan Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Vigfús Sigurdsson
- Department of Dermatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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17
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Mulder EEAP, Smit L, Grünhagen DJ, Verhoef C, Sleijfer S, van der Veldt AAM, Uyl-de Groot CA. Cost-effectiveness of adjuvant systemic therapies for patients with high-risk melanoma in Europe: a model-based economic evaluation. ESMO Open 2021; 6:100303. [PMID: 34781194 PMCID: PMC8599106 DOI: 10.1016/j.esmoop.2021.100303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The introduction of adjuvant systemic treatment has significantly improved recurrence-free survival in patients with resectable high-risk melanoma. Adjuvant treatment with immune checkpoint inhibitors and targeted therapy, however, substantially impacts health care budgets, while the number of patients with melanoma who are treated in the adjuvant setting is still increasing. To evaluate the socioeconomic impact of the three adjuvant treatments, a cost-effectiveness analysis (CEA) was carried out. MATERIALS AND METHODS Data were obtained from the three pivotal registration phase III clinical trials on the adjuvant treatment of patients with resected high-risk stage III in melanoma (KEYNOTE-054, CheckMate 238, and COMBI-AD). For this CEA, a Markov model with three health states (no evidence of disease, recurrent/progressive disease, and death) was applied. From a societal perspective, different adjuvant strategies were compared according to total costs, life years (LYs), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. To evaluate model uncertainty, sensitivity analyses (deterministic and probabilistic) were carried out. RESULTS In the adjuvant setting, total costs (per patient) were €168 826 for nivolumab, €194 529 for pembrolizumab, and €211 110 for dabrafenib-trametinib. These costs were mainly determined by drug acquisition costs, whereas routine surveillance costs varied from €126 096 to €134 945. Compared with routine surveillance, LYs improved by approximately 1.41 for all therapies and QALYs improved by 2.02 for immune checkpoint inhibitors and 2.03 for targeted therapy. This resulted in incremental cost-effectiveness ratios of €21 153 (nivolumab), €33 878 (pembrolizumab), and €37 520 (dabrafenib-trametinib) per QALY gained. CONCLUSIONS This CEA compared the three EMA-approved adjuvant systemic therapies for resected stage III melanoma. Adjuvant treatment with nivolumab was the most cost-effective, followed by pembrolizumab. Combination therapy with dabrafenib-trametinib was the least cost-effective. With the increasing number of patients with high-risk melanoma who will be treated with adjuvant treatment, there is an urgent need to reduce drug costs while developing better prognostic and predictive tools to identify patients who will benefit from adjuvant treatment.
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Affiliation(s)
- E E A P Mulder
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - L Smit
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Sleijfer
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - A A M van der Veldt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - C A Uyl-de Groot
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
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18
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High-resolution three-dimensional imaging for precise staging in melanoma. Eur J Cancer 2021; 159:182-193. [PMID: 34773902 DOI: 10.1016/j.ejca.2021.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Many cancer guidelines include sentinel lymph node (SLN) staging to identify microscopic metastatic disease. Current SLN analysis of melanoma patients is effective but has the substantial drawback that only a small representative portion of the node is sampled, whereas most of the tissue is discarded. This might explain the high clinical false-negative rate of current SLN diagnosis in melanoma. Furthermore, the quantitative assessment of metastatic load and microanatomical localisation might yield prognosis with higher precision. Thus, methods to analyse entire SLNs with cellular resolution apart from tedious sequential physical sectioning are required. PATIENTS AND METHODS Eleven melanoma patients eligible to undergo SLN biopsy were included in this prospective study. SLNs were fixed, optically cleared, whole-mount stained and imaged using light sheet fluorescence microscopy (LSFM). Subsequently, compatible and unbiased gold standard histopathological assessment allowed regular patient staging. This enabled intrasample comparison of LSFM and histological findings. In addition, the development of an algorithm, RAYhance, enabled easy-to-handle display of LSFM data in a browsable histologic slide-like fashion. RESULTS We comprehensively quantify total tumour volume while simultaneously visualising cellular and anatomical hallmarks of the associated SLN architecture. In a first-in-human study of 21 SLN of melanoma patients, LSFM not only confirmed all metastases identified by routine histopathological assessment but also additionally revealed metastases not detected by routine histology alone. This already led to additional therapeutic options for one patient. CONCLUSION Our three-dimensional digital pathology approach can increase sensitivity and accuracy of SLN metastasis detection and potentially alleviate the need for conventional histopathological assessment in the future. GERMAN CLINICAL TRIALS REGISTER: (DRKS00015737).
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19
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Eggermont AM, Meshcheryakov A, Atkinson V, Blank CU, Mandala M, Long GV, Barrow C, Di Giacomo AM, Fisher R, Sandhu S, Kudchadkar R, Ortiz Romero PL, Svane IM, Larkin J, Puig S, Hersey P, Quaglino P, Queirolo P, Stroyakovskiy D, Bastholt L, Mohr P, Hernberg M, Chiarion-Sileni V, Strother M, Hauschild A, Yamazaki N, van Akkooi AC, Lorigan P, Krepler C, Ibrahim N, Marreaud S, Kicinski M, Suciu S, Robert C. Crossover and rechallenge with pembrolizumab in recurrent patients from the EORTC 1325-MG/Keynote-054 phase III trial, pembrolizumab versus placebo after complete resection of high-risk stage III melanoma. Eur J Cancer 2021; 158:156-168. [PMID: 34678677 DOI: 10.1016/j.ejca.2021.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the phase III double-blind European Organisation for Research and Treatment of Cancer 1325/KEYNOTE-054 trial, pembrolizumab improved recurrence-free and distant metastasis-free survival in patients with stage III cutaneous melanoma with complete resection of lymph nodes. In the pembrolizumab group, the incidence of grade I-V and of grade III-V immune-related adverse events (irAEs) was 37% and 7%, respectively. METHODS Patients were randomised to receive intravenous (i.v.) pembrolizumab 200 mg (N = 514) or placebo (N = 505) every 3 weeks, up to 1 year. On recurrence, patients could enter part 2 of the study: pembrolizumab 200 mg i.v. every 3 weeks up to 2 years, for crossover (those who received placebo) or rechallenge (those who had recurrence ≥6 months after completing 1-year adjuvant pembrolizumab therapy). For these patients, we present the safety profile and efficacy outcomes. RESULTS At the clinical cut-off (16-Oct-2020), in the placebo group, 298 patients had a disease recurrence, in which 155 (52%) crossed over ('crossover'). In the pembrolizumab group, 297 patients completed the 1-year treatment period; 47 had a recurrence ≥6 months later, in which 20 (43%) entered the rechallenge part 2 ('rechallenge'). In the crossover group, the median progression-free survival (PFS) was 8.5 months (95% confidence interval [CI] 5.7-15.2) and the 3-year PFS rate was 32% (95% CI 25-40%). Among 80 patients with stage IV evaluable disease, 31 (39%) had an objective response: 14 (18%) patients with complete response (CR) and 17 (21%) patients with partial response. The 2-year PFS rate from response was 69% (95% CI 48-83%). In the rechallenge group, the median PFS was 4.1 months (95% CI 2.6-NE). Among 9 patients with stage IV evaluable disease, 1 had an objective response (CR). Among the 175 patients, 51 (29%) had a grade I-IV irAE and 11 (6%) had a grade III-IV irAE. CONCLUSIONS Pembrolizumab treatment after crossover yielded an overall 3-year PFS rate of 32% and a 39% ORR in evaluable patients, but the efficacy (11% ORR) was lower in those rechallenged.
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Affiliation(s)
- Alexander Mm Eggermont
- Princess Máxima Center and University Medical Center Utrecht, Utrecht, 3584 CS, the Netherlands.
| | - Andrey Meshcheryakov
- Federal State Budgetary Institution "Russian Oncology Scientific Centre named after N.N. Blokhin RAMS", Moscow, Russia
| | - Victoria Atkinson
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Christian U Blank
- Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Mario Mandala
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Ospedale Santa Maria Della Misericordia, Perrugia, Italy
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Mater and Royal North Shore Hospitals, Sydney, Australia
| | | | - Anna Maria Di Giacomo
- Center for Immuno-Oncology, University Hospital of Siena, University of Siena, Siena, Italy
| | - Rosalie Fisher
- North Shore Hospital, Waitemata DHB, Takapuna, Auckland, New Zealand; Auckland City Hospital, Auckland, New Zealand
| | | | | | - Pablo Luis Ortiz Romero
- Hospital 12 de Octubre, Institute i+12, CIBERONC, Medical School, University Complutense, Madrid, Spain
| | | | - James Larkin
- Royal Marsden Hospital - Chelsea, London, United Kingdom
| | - Susana Puig
- Hospital Clinic Universitari de Barcelona, Barcelona, Spain
| | - Peter Hersey
- David Maddison Clinical Sciences, Gateshead, Australia
| | - Pietro Quaglino
- Azienda Ospedaliera Città della Salute e della Scienza di Torino, Ospedale San Lazzaro, Torino, Italy
| | - Paola Queirolo
- Istituto Nazionale Per La Ricerca Sul Cancro, Genova, Italy; European Institute of Oncology IRCCS, Milan, Italy
| | | | | | | | | | | | | | - Axel Hauschild
- Universitaetsklinikum Schleswig-Holstein, Campus Kiel - Klinik Dermatologie, Venerologie und Allergologie, Kiel, Germany
| | | | | | - Paul Lorigan
- The University of Manchester and Christie NHS Foundation Trust, Manchester, UK
| | | | | | | | | | | | - Caroline Robert
- Gustave Roussy Cancer Campus Grand Paris and University Paris-Saclay, Villejuif, France
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Maurichi A, Barretta F, Patuzzo R, Miceli R, Gallino G, Mattavelli I, Barbieri C, Leva A, Angi M, Lanza FB, Spadola G, Cossa M, Nesa F, Cortinovis U, Sala L, Di Guardo L, Cimminiello C, Del Vecchio M, Valeri B, Santinami M. Survival in Patients With Sentinel Node-Positive Melanoma With Extranodal Extension. J Natl Compr Canc Netw 2021; 19:1165-1173. [PMID: 34311443 DOI: 10.6004/jnccn.2020.7693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prognostic parameters in sentinel node (SN)-positive melanoma are important indicators to identify patients at high risk of recurrence who should be candidates for adjuvant therapy. We aimed to evaluate the presence of melanoma cells beyond the SN capsule-extranodal extension (ENE)-as a prognostic factor in patients with positive SNs. METHODS Data from 1,047 patients with melanoma and positive SNs treated from 2001 to 2020 at the Istituto Nazionale dei Tumori in Milano, Italy, were retrospectively investigated. Kaplan-Meier survival and crude cumulative incidence of recurrence curves were estimated. A multivariable logistic model was used to investigate the association between ENE and selected predictive factors. Cox models estimated the effect of the selected predictors on survival endpoints. RESULTS Median follow-up was 69 months. The 5-year overall survival rate was 62.5% and 71.7% for patients with positive SNs with and without ENE, respectively. The 5-year disease-free survival rate was 54.0% and 64.0% for patients with positive SNs with and without ENE, respectively. The multivariable logistic model showed that age, size of the main metastatic focus in the SN, and numbers of metastatic non-SNs were associated with ENE (all P<.0001). The multivariable Cox regression models showed the estimated prognostic effects of ENE associated with age, ulceration, size of the main metastatic focus in the SN, and number of metastatic non-SNs (all P<.0001) on disease-free survival and overall survival. CONCLUSIONS ENE was a significant prognostic factor in patients with positive-SN melanoma. This parameter may be useful in clinical practice as a selection criterion for adjuvant treatment in patients with stage IIIA disease with a tumor burden <1 mm in the SN. We recommend its inclusion as an independent prognostic determinant in future updates of melanoma guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Laura Sala
- 4Plastic and Reconstructive Surgical Unit, and
| | - Lorenza Di Guardo
- 5Melanoma Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Carolina Cimminiello
- 5Melanoma Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Michele Del Vecchio
- 5Melanoma Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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21
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Vuoristo M, Muhonen T, Koljonen V, Juteau S, Hernberg M, Ilmonen S, Jahkola T. Long-term prognostic value of sentinel lymph node tumor burden in survival of melanoma patients. Acta Oncol 2021; 60:803-807. [PMID: 33656957 DOI: 10.1080/0284186x.2021.1892820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Mikko Vuoristo
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Timo Muhonen
- Department of Oncology, University of Helsinki, Helsinki, Finland
| | - Virve Koljonen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Susanna Juteau
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Micaela Hernberg
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi Ilmonen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Jahkola
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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22
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Nebhan CA, Johnson DB. Pembrolizumab in the adjuvant treatment of melanoma: efficacy and safety. Expert Rev Anticancer Ther 2021; 21:583-590. [PMID: 33504219 PMCID: PMC8238788 DOI: 10.1080/14737140.2021.1882856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
Introduction: Regional or distant metastases from melanoma may be surgically resected but remain at high-risk of recurrence. Over the last few years, several treatments have been approved to mitigate this risk. These include anti-PD-1 agents, specifically pembrolizumab and nivolumab.Areas covered: Herein, we will discuss the landscape of pembrolizumab safety and efficacy used in the adjuvant setting for high-risk, resected melanoma. We place this in context with other available adjuvant therapies, and discuss subgroup analyses.Expert opinion: Anti-PD-1 therapy with either pembrolizumab or nivolumab has become a standard of care for patients with resected stage III or IV melanoma. In our practice, we generally offer these agents (which have comparable safety and efficacy profiles) to patients with resected stage IIIb-IV melanoma regardless of BRAF mutation status.
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Affiliation(s)
- Caroline A. Nebhan
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center
| | - Douglas B. Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center
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23
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Han D, van Akkooi ACJ, Straker RJ, Shannon AB, Karakousis GC, Wang L, Kim KB, Reintgen D. Current management of melanoma patients with nodal metastases. Clin Exp Metastasis 2021; 39:181-199. [PMID: 33961168 PMCID: PMC8102663 DOI: 10.1007/s10585-021-10099-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/22/2021] [Indexed: 12/26/2022]
Abstract
The management of melanoma patients with nodal metastases has undergone dramatic changes over the last decade. In the past, the standard of care for patients with a positive sentinel lymph node biopsy (SLNB) was a completion lymph node dissection (CLND), while patients with palpable macroscopic nodal disease underwent a therapeutic lymphadenectomy in cases with no evidence of systemic spread. However, studies have shown that SLN metastases present as a spectrum of disease, with certain SLN-based factors being prognostic of and correlated with outcomes. Furthermore, the results of key clinical trials demonstrate that CLND provides no survival benefit over nodal observation in positive SLN patients, while other clinical trials have shown that adjuvant immune checkpoint inhibitor therapy or targeted therapy after CLND is associated with a recurrence-free survival benefit. Given the efficacy of these systemic therapies in the adjuvant setting, these agents are now being evaluated and utilized as neoadjuvant treatments in patients with regionally-localized or resectable metastatic melanoma. Multiple options now exist to treat melanoma patients with nodal disease, and determining the best treatment course for a particular case requires an in-depth knowledge of current data and an informed discussion with the patient. This review will provide an overview of the various options for treating melanoma patients with nodal metastases and will discuss the data that supported the development of these treatment options.
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Affiliation(s)
- Dale Han
- Division of Surgical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L619, Portland, OR, 97239, USA.
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Richard J Straker
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Adrienne B Shannon
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Lin Wang
- California Pacific Medical Center and Research Institute, San Francisco, CA, USA
| | - Kevin B Kim
- California Pacific Medical Center and Research Institute, San Francisco, CA, USA
| | - Douglas Reintgen
- Department of Surgery, Morsani School of Medicine, University of South Florida, Tampa, FL, USA
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24
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Eggermont AMM, Blank CU, Mandalà M, Long GV, Atkinson VG, Dalle S, Haydon AM, Meshcheryakov A, Khattak A, Carlino MS, Sandhu S, Larkin J, Puig S, Ascierto PA, Rutkowski P, Schadendorf D, Koornstra R, Hernandez-Aya L, Di Giacomo AM, van den Eertwegh AJM, Grob JJ, Gutzmer R, Jamal R, Lorigan PC, van Akkooi ACJ, Krepler C, Ibrahim N, Marreaud S, Kicinski M, Suciu S, Robert C. Adjuvant pembrolizumab versus placebo in resected stage III melanoma (EORTC 1325-MG/KEYNOTE-054): distant metastasis-free survival results from a double-blind, randomised, controlled, phase 3 trial. Lancet Oncol 2021; 22:643-654. [PMID: 33857412 DOI: 10.1016/s1470-2045(21)00065-6] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The European Organisation for Research and Treatment of Cancer (EORTC) 1325/KEYNOTE-054 trial assessed pembrolizumab versus placebo in patients with resected high-risk stage III melanoma. At 15-month median follow-up, pembrolizumab improved recurrence-free survival (hazard ratio [HR] 0·57 [98·4% CI 0·43-0·74], p<0·0001) compared with placebo, leading to its approval in the USA and Europe. This report provides the final results for the secondary efficacy endpoint, distant metastasis-free survival and an update of the recurrence-free survival results. METHODS This double-blind, randomised, controlled, phase 3 trial was done at 123 academic centres and community hospitals across 23 countries. Patients aged 18 years or older with complete resection of cutaneous melanoma metastatic to lymph node, classified as American Joint Committee on Cancer staging system, seventh edition (AJCC-7) stage IIIA (at least one lymph node metastasis >1 mm), IIIB, or IIIC (without in-transit metastasis), and with an Eastern Cooperative Oncology Group performance status of 0 or 1 were eligible. Patients were randomly assigned (1:1) via a central interactive voice response system to receive intravenous pembrolizumab 200 mg or placebo every 3 weeks for up to 18 doses or until disease recurrence or unacceptable toxicity. Randomisation was stratified according to disease stage and region, using a minimisation technique, and clinical investigators, patients, and those collecting or analysing the data were masked to treatment assignment. The two coprimary endpoints were recurrence-free survival in the intention-to-treat (ITT) population and in patients with PD-L1-positive tumours. The secondary endpoint reported here was distant metastasis-free survival in the ITT and PD-L1-positive populations. This study is registered with ClinicalTrials.gov, NCT02362594, and EudraCT, 2014-004944-37. FINDINGS Between Aug 26, 2015, and Nov 14, 2016, 1019 patients were assigned to receive either pembrolizumab (n=514) or placebo (n=505). At an overall median follow-up of 42·3 months (IQR 40·5-45·9), 3·5-year distant metastasis-free survival was higher in the pembrolizumab group than in the placebo group in the ITT population (65·3% [95% CI 60·9-69·5] in the pembrolizumab group vs 49·4% [44·8-53·8] in the placebo group; HR 0·60 [95% CI 0·49-0·73]; p<0·0001). In the 853 patients with PD-L1-positive tumours, 3·5-year distant metastasis-free survival was 66·7% (95% CI 61·8-71·2) in the pembrolizumab group and 51·6% (46·6-56·4) in the placebo group (HR 0·61 [95% CI 0·49-0·76]; p<0·0001). Recurrence-free survival remained longer in the pembrolizumab group 59·8% (95% CI 55·3-64·1) than the placebo group 41·4% (37·0-45·8) at this 3·5-year follow-up in the ITT population (HR 0·59 [95% CI 0·49-0·70]) and in those with PD-L1-positive tumours 61·4% (56·3-66·1) in the pembrolizumab group and 44·1% (39·2-48·8) in the placebo group (HR 0·59 [95% CI 0·49-0·73]). INTERPRETATION Pembrolizumab adjuvant therapy provided a significant and clinically meaningful improvement in distant metastasis-free survival at a 3·5-year median follow-up, which was consistent with the improvement in recurrence-free survival. Therefore, the results of this trial support the indication to use adjuvant pembrolizumab therapy in patients with resected high risk stage III cutaneous melanoma. FUNDING Merck Sharp & Dohme.
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Affiliation(s)
- Alexander M M Eggermont
- Princess Máxima Center, Utrecht, Netherlands; University Medical Center Utrecht, Utrecht, Netherlands.
| | - Christian U Blank
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Mario Mandalà
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Georgina V Long
- Melanoma Institute Australia, the University of Sydney, and Mater and Royal North Shore Hospitals, Sydney, NSW, Australia
| | | | | | | | | | - Adnan Khattak
- Fiona Stanley Hospital & Edith Cowan University, Perth, WA, Australia
| | - Matteo S Carlino
- Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney, Sydney, NSW, Australia
| | | | | | - Susana Puig
- Hospital Clinic de Barcelona, Universitat de Barcelona, Spain & Centro de Investigación Biomédica en Red de Enfermedades Raras, Instituto de Salud Carlos III, Barcelona, Spain
| | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS "Fondazione G Pascale", Naples, Italy
| | - Piotr Rutkowski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Dirk Schadendorf
- University Hospital Essen, Essen and German Cancer Consortium, Heidelberg, Germany
| | - Rutger Koornstra
- Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | | | | | | | | | - Ralf Gutzmer
- Skin Cancer Center, Hannover Medical School, Hannover, Germany
| | - Rahima Jamal
- Centre Hospitalier de l'Université de Montréal (CHUM), Centre de recherche du CHUM, Montreal, QC, Canada
| | | | | | | | | | | | | | | | - Caroline Robert
- Gustave Roussy and Paris-Saclay University, Villejuif, France
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Tejera-Vaquerizo A, Fernández-Figueras M, Santos-Briz Á, Ríos-Martín J, Monteagudo C, Fernández-Flores Á, Requena C, Traves V, Descalzo-Gallego M, Rodríguez-Peralto J. Protocol for the Histologic Diagnosis of Cutaneous Melanoma: Consensus Statement of the Spanish Society of Pathology and the Spanish Academy of Dermatology and Venereology (AEDV) for the National Cutaneous Melanoma Registry. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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26
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Tejera-Vaquerizo A, Fernández-Figueras MT, Santos-Briz A, Ríos-Martín JJ, Monteagudo C, Fernández-Flores A, Requena C, Traves V, Descalzo-Gallego MA, Rodríguez-Peralto JL. Protocol for the Histologic Diagnosis of Cutaneous Melanoma: Consensus Statement of the Spanish Society of Pathology and the Spanish Academy of Dermatology and Venereology (AEDV) for the National Cutaneous Melanoma Registry. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:32-43. [PMID: 33038295 PMCID: PMC7540207 DOI: 10.1016/j.ad.2020.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/15/2020] [Accepted: 09/19/2020] [Indexed: 11/26/2022] Open
Abstract
This article describes a proposed protocol for the histologic diagnosis of cutaneous melanoma developed for the National Cutaneous Melanoma Registry managed by the Spanish Academy of Dermatology and Venereology (AEDV). Following a review of the literature, 36 variables relating to primary tumors, sentinel lymph nodes, and lymph node dissection were evaluated using the modified Delphi method by a panel of 8 specialists (including 7 pathologists). Consensus was reached on the 30 variables that should be included in all pathology reports for cutaneous melanoma and submitted to the Melanoma Registry. This list can also serve as a model to guide routine reporting in pathology departments.
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Affiliation(s)
- A Tejera-Vaquerizo
- Servicio de Dermatología, Instituto Dermatológico GlobalDerm, Palma del Río, Córdoba, España; Unidad de Oncología Cutánea, Hospital San Juan de Dios, Córdoba, España.
| | - M T Fernández-Figueras
- Servicio de Anatomía Patológica, Hospital Universitari General de Catalunya, Grupo Quironsalud, Sant Cugat del Vallès, Barcelona, España
| | - A Santos-Briz
- Servicio de Anatomía Patológica, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - J J Ríos-Martín
- Servicio de Anatomía Patológica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - C Monteagudo
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - A Fernández-Flores
- Servicio de Anatomía Patológica, Hospital del Bierzo, Ponferrada, León, España; Servicio de Anatomía Patológica, Hospital de la Reina, Ponferrada, León, España
| | - C Requena
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España
| | - V Traves
- Servicio de Anatomía Patológica, Instituto Valenciano de Oncología, Valencia, España
| | - M A Descalzo-Gallego
- Unidad de Investigación, Fundación Academia Española de Dermatología y Venereología, Madrid, España
| | - J L Rodríguez-Peralto
- Servicio de Anatomía Patológica, Hospital Universitario 12 de Octubre, Madrid, España
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Predictors of Nonsentinel Lymph Node Metastasis in Cutaneous Melanoma: A Systematic Review and Meta-Analysis. J Surg Res 2020; 260:506-515. [PMID: 33358194 DOI: 10.1016/j.jss.2020.11.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 09/05/2020] [Accepted: 11/01/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although completion lymph node dissection (CLND) is not routinely performed for a positive sentinel lymph node (SLN) anymore, adjuvant therapy depends on the risk factors available from SLN biopsy, including the risk of nonsentinel node metastases (NSNM). A systematic review and meta-analysis was performed in an attempt to identify risk factors that could be used to predict the risk of NSNM. MATERIALS AND METHODS Medline, Web of Science, Embase, and Cochrane were searched for articles discussing predictive factors for NSNM. PRISMA guidelines were followed, and RevMan software was used to calculate pooled odds ratios (OR) using the Mantel-Haenszel test. RESULTS Fifty publications were suitable for additional analysis. The clinical and primary tumor factors that were consistently identified as risk factors for NSNMs were: age >50, T stage 3 or 4, Clark level IV/V, ulceration, microsatellitosis, lymphovascular invasion, nodular histology, and extremity versus trunk primary tumor location. SLN factors that predicted NSNMs were >1 positive SLN, SLN micrometastatic tumor burden, diameter >2 mm, extracapsular extension, nonsubcapsular location (Dewar), and Rotterdam > 1 mm or ≥ 0.1 mm. CONCLUSIONS The findings in this study support that many clinical and pathologic risk factors that can be assessed with SLN biopsy alone can be used to predict the risk of NSNMs. The factors identified in this review should be evaluated in clinical prediction models to predict the risk of NSNMS, a prediction that may be used to select patients for adjuvant therapy in high-risk melanoma.
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Tejera-Vaquerizo A, Fernández-Figueras MT, Santos-Briz Á, Ríos-Martín JJ, Monteagudo C, Fernández-Flores Á, Requena C, Traves V, Descalzo-Gallego MÁ, Rodríguez-Peralto JL. [Protocol for the histologic diagnosis of cutaneous melanoma: consensus statement of the Spanish Society of Pathology and the Spanish Academy of Dermatology and Venereology (AEDV) for the National Cutaneous Melanoma Registry]. REVISTA ESPAÑOLA DE PATOLOGÍA : PUBLICACIÓN OFICIAL DE LA SOCIEDAD ESPAÑOLA DE ANATOMÍA PATOLÓGICA Y DE LA SOCIEDAD ESPAÑOLA DE CITOLOGÍA 2020; 54:29-40. [PMID: 33455691 DOI: 10.1016/j.patol.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 10/22/2022]
Abstract
This article describes a proposed protocol for the histologic diagnosis of cutaneous melanoma developed for the National Cutaneous Melanoma Registry managed by the Spanish Academy of Dermatology and Venereology (AEDV). Following a review of the literature, 36 variables relating to primary tumors, sentinel lymph nodes, and lymph node dissection were evaluated using the modified Delphi method by a panel of 8 specialists (including 7 pathologists). Consensus was reached on the 30 variables that should be included in all pathology reports for cutaneous melanoma and submitted to the Melanoma Registry. This list can also serve as a model to guide routine reporting in pathology departments.
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Affiliation(s)
- Antonio Tejera-Vaquerizo
- Servicio de Dermatología, Instituto Dermatológico GlobalDerm, Palma del Río, Córdoba, España; Unidad de Oncología Cutánea, Hospital San Juan de Dios, Córdoba, España.
| | - María Teresa Fernández-Figueras
- Servicio de Anatomía Patológica, Hospital Universitari General de Catalunya, Grupo Quironsalud, Sant Cugat del Vallès, Barcelona, España
| | - Ángel Santos-Briz
- Servicio de Anatomía Patológica, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Juan José Ríos-Martín
- Servicio de Anatomía Patológica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - Carlos Monteagudo
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - Ángel Fernández-Flores
- Servicio de Anatomía Patológica, Hospital del Bierzo, Ponferrada, León, España; Servicio de Anatomía Patológica, Hospital de la Reina, Ponferrada, León, España
| | - Celia Requena
- Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España
| | - Victor Traves
- Servicio de Anatomía Patológica, Instituto Valenciano de Oncología, Valencia, España
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29
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Deckers EA, Wj Louwman M, Kruijff S, Hoekstra HJ. Letter in reply: increase of sentinel lymph node melanoma staging in The Netherlands; still room and need for further improvement. Melanoma Manag 2020; 8:MMT53. [PMID: 33552469 PMCID: PMC7849923 DOI: 10.2217/mmt-2020-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Eric A Deckers
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke Wj Louwman
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Schelto Kruijff
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Harald J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Eggermont AMM, Blank CU, Mandala M, Long GV, Atkinson VG, Dalle S, Haydon AM, Meshcheryakov A, Khattak A, Carlino MS, Sandhu S, Larkin J, Puig S, Ascierto PA, Rutkowski P, Schadendorf D, Koornstra R, Hernandez-Aya L, Di Giacomo AM, van den Eertwegh AJM, Grob JJ, Gutzmer R, Jamal R, Lorigan PC, van Akkooi ACJ, Krepler C, Ibrahim N, Marreaud S, Kicinski M, Suciu S, Robert C. Longer Follow-Up Confirms Recurrence-Free Survival Benefit of Adjuvant Pembrolizumab in High-Risk Stage III Melanoma: Updated Results From the EORTC 1325-MG/KEYNOTE-054 Trial. J Clin Oncol 2020; 38:3925-3936. [PMID: 32946353 PMCID: PMC7676886 DOI: 10.1200/jco.20.02110] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE We conducted the phase III double-blind European Organisation for Research and Treatment of Cancer (EORTC) 1325/KEYNOTE-054 trial to evaluate pembrolizumab versus placebo in patients with resected high-risk stage III melanoma. On the basis of 351 recurrence-free survival (RFS) events at a 1.25-year median follow-up, pembrolizumab prolonged RFS (hazard ratio [HR], 0.57; P < .0001) compared with placebo. This led to the approval of pembrolizumab adjuvant treatment by the European Medicines Agency and US Food and Drug Administration. Here, we report an updated RFS analysis at the 3.05-year median follow-up. PATIENTS AND METHODS A total of 1,019 patients with complete lymph node dissection of American Joint Committee on Cancer Staging Manual (seventh edition; AJCC-7), stage IIIA (at least one lymph node metastasis > 1 mm), IIIB, or IIIC (without in-transit metastasis) cutaneous melanoma were randomly assigned to receive pembrolizumab at a flat dose of 200 mg (n = 514) or placebo (n = 505) every 3 weeks for 1 year or until disease recurrence or unacceptable toxicity. The two coprimary end points were RFS in the overall population and in those with programmed death-ligand 1 (PD-L1)-positive tumors. RESULTS Pembrolizumab (190 RFS events) compared with placebo (283 RFS events) resulted in prolonged RFS in the overall population (3-year RFS rate, 63.7% v 44.1% for pembrolizumab v placebo, respectively; HR, 0.56; 95% CI, 0.47 to 0.68) and in the PD-L1-positive tumor subgroup (HR, 0.57; 99% CI, 0.43 to 0.74). The impact of pembrolizumab on RFS was similar in subgroups, in particular according to AJCC-7 and AJCC-8 staging, and BRAF mutation status (HR, 0.51 [99% CI, 0.36 to 0.73] v 0.66 [99% CI, 0.46 to 0.95] for V600E/K v wild type). CONCLUSION In resected high-risk stage III melanoma, pembrolizumab adjuvant therapy provided a sustained and clinically meaningful improvement in RFS at 3-year median follow-up. This improvement was consistent across subgroups.
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Affiliation(s)
| | - Christian U. Blank
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Mario Mandala
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Georgina V. Long
- Melanoma Institute Australia, The University of Sydney, and Mater and Royal North Shore Hospitals, Sydney, New South Wales, Australia
| | | | | | | | | | - Adnan Khattak
- Fiona Stanley Hospital and Edith Cowan University, Perth, Western Australia, Australia
| | - Matteo S. Carlino
- Westmead and Blacktown Hospitals, Melanoma Institute Australia, and The University of Sydney, Sydney, New South Wales, Australia
| | - Shahneen Sandhu
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Susana Puig
- Hospital Clinic Universitari de Barcelona, Barcelona, Spain
| | - Paolo A. Ascierto
- Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale,” Naples, Italy
| | - Piotr Rutkowski
- Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Dirk Schadendorf
- University Hospital Essen, Essen, Germany
- German Cancer Consortium, Heidelberg, Germany
| | - Rutger Koornstra
- Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
| | | | | | | | | | - Ralf Gutzmer
- Skin Cancer Center, Hannover Medical School, Hanover, Germany
| | - Rahima Jamal
- Centre Hospitalier de l’Université de Montréal (CHUM), Centre de recherche du CHUM, Montreal, Quebec, Canada
| | | | | | | | | | - Sandrine Marreaud
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Michal Kicinski
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Stefan Suciu
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Caroline Robert
- Gustave Roussy and Paris-Saclay University, Villejuif, France
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Sun W, Xu Y, Yang J, Liao Z, Li T, Huang K, Patel P, Yan W, Chen Y. The prognostic significance of non-sentinel lymph node metastasis in cutaneous and acral melanoma patients-A multicenter retrospective study. Cancer Commun (Lond) 2020; 40:586-597. [PMID: 33025763 PMCID: PMC7668482 DOI: 10.1002/cac2.12101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 09/01/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023] Open
Abstract
Background Whether non‐sentinel lymph node (SLN)‐positive melanoma patients can benefit from completion lymph node dissection (CLND) is still unclear. The current study was performed to identify the prognostic role of non‐SLN status in SLN‐positive melanoma and to investigate the predictive factors of non‐SLN metastasis in acral and cutaneous melanoma patients. Methods The records of 328 SLN‐positive melanoma patients who underwent radical surgery at four cancer centers from September 2009 to August 2017 were reviewed. Clinicopathological data including age, gender, Clark level, Breslow index, ulceration, the number of positive SLNs, non‐SLN status, and adjuvant therapy were included for survival analyses. Patients were followed up until death or June 30, 2019. Multivariable logistic regression modeling was performed to identify factors associated with non‐SLN positivity. Log‐rank analysis and Cox regression analysis were used to identify the prognostic factors for disease‐free survival (DFS) and overall survival (OS). Results Among all enrolled patients, 220 (67.1%) had acral melanoma and 108 (32.9%) had cutaneous melanoma. The 5‐year DFS and OS rate of the entire cohort was 31.5% and 54.1%, respectively. More than 1 positive SLNs were found in 123 (37.5%) patients. Positive non‐SLNs were found in 99 (30.2%) patients. Patients with positive non‐SLNs had significantly worse DFS and OS (log‐rank P < 0.001). Non‐SLN status (P = 0.003), number of positive SLNs (P = 0.016), and adjuvant therapy (P = 0.025) were independent prognostic factors for DFS, while non‐SLN status (P = 0.002), the Breslow index (P = 0.027), Clark level (P = 0.006), ulceration (P = 0.004), number of positive SLNs (P = 0.001), and adjuvant therapy (P = 0.007) were independent prognostic factors for OS. The Breslow index (P = 0.020), Clark level (P = 0.012), and number of positive SLNs (P = 0.031) were independently related to positive non‐SLNs and could be used to develop more personalized surgical strategy. Conclusions Non‐SLN‐positive melanoma patients had worse DFS and OS even after immediate CLND than those with non‐SLN‐negative melanoma. The Breslow index, Clark level, and number of positive SLNs were independent predictive factors for non‐SLN status.
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Affiliation(s)
- Wei Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Yu Xu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - JiLong Yang
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, P. R. China
| | - ZhiChao Liao
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, China.,National Clinical Research Center for Cancer, Tianjin Medical University Cancer Hospital and Institute, Tianjin, 300060, P. R. China
| | - Tao Li
- Department of Bone and Soft-tissue Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, 310022, P. R. China
| | - Kai Huang
- Department of General Surgery, Brandon Regional Hospital, HCA West Florida Division, Brandon, 33511, USA
| | - Poulam Patel
- Academic Unit of Clinical Oncology, University of Nottingham, City Hospital Campus, Nottingham, NG5 1PB, UK
| | - WangJun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
| | - Yong Chen
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, P. R. China
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32
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Franke V, Madu MF, Bierman C, Klop WMC, van Houdt WJ, Wouters MWJM, van de Wiel BA, van Akkooi ACJ. Challenges in sentinel node pathology in the era of adjuvant treatment. J Surg Oncol 2020; 122:964-972. [PMID: 32602119 DOI: 10.1002/jso.26095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 05/24/2020] [Accepted: 06/18/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the approval of adjuvant therapy for stage III melanoma, accurate staging is more important than ever. Sentinel node biopsy (SNB) is an accurate staging tool, yet the presence of capsular nevi (CN) can lead to a false-positive diagnosis. PATIENTS AND METHODS Retrospective analysis of the American Joint Committee on Cancer 7th edition stage IIIA melanoma patients who were treated at our institute between 2000 and 2015. SNB slides were reviewed for this study by an expert melanoma pathologist. RESULTS Of 159 eligible patients, 14 originally diagnosed with metastatic melanoma merely had CN (8.8%). Another two merely had melanophages (1.3%). Thus, 10.1% of SNs were considered false positive after revision. In 12 patients, the SN tumor burden was originally reported as larger than 1 mm but turned out to be less than 1 mm. Four patients originally reported as SN tumor burden less than 1 mm before revision turned out to have larger than 1 mm. These patients might have been over- or undertreated in the current era of adjuvant therapy for stage III melanoma. CONCLUSIONS Distinguishing metastatic melanoma from benign CN and melanophages can be a diagnostic challenge. We plead for an expert pathologists' review, especially when using the SNB + results to determine treatment consequences.
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Affiliation(s)
- Viola Franke
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Max F Madu
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Carolien Bierman
- Division of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Willem M C Klop
- Department of Head and Neck Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Winan J van Houdt
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Michel W J M Wouters
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Bart A van de Wiel
- Division of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Alexander C J van Akkooi
- Departments of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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Testori AAE, Chiellino S, van Akkooi AC. Adjuvant Therapy for Melanoma: Past, Current, and Future Developments. Cancers (Basel) 2020; 12:cancers12071994. [PMID: 32708268 PMCID: PMC7409361 DOI: 10.3390/cancers12071994] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023] Open
Abstract
This review describes the progress that the concept of adjuvant therapies has undergone in the last 50 years and focuses on the most recent development where an adjuvant approach has been scientifically evaluated in melanoma clinical trials. Over the past decade the development of immunotherapies and targeted therapies has drastically changed the treatment of stage IV melanoma patients. These successes led to trials studying the same therapies in the adjuvant setting, in high risk resected stage III and IV melanoma patients. Adjuvant immune checkpoint blockade with anti-CTLA-4 antibody ipilimumab was the first drug to show an improvement in recurrence-free and overall survival but this was accompanied by high severe toxicity rates. Therefore, these results were bypassed by adjuvant treatment with anti-PD-1 agents nivolumab and pembrolizumab and BRAF-directed target therapy, which showed even better recurrence-free survival rates with more favorable toxicity rates. The whole concept of adjuvant therapy may be integrated with the new neoadjuvant approaches that are under investigation through several clinical trials. However, there is still no data available on whether the effective adjuvant therapy that patients finally have at their disposal could be offered to them while waiting for recurrence, sparing at least 50% of them a potentially long-term toxic side effect but with the same rate of overall survival (OS). Adjuvant therapy for melanoma has radically changed over the past few years—anti-PD-1 or BRAF-directed therapy is the new standard of care.
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Affiliation(s)
- Alessandro A. E. Testori
- Department of Dermatology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Correspondence: or
| | - Silvia Chiellino
- Department of Medical Oncology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Alexander C.J. van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute–Antoni van Leeuwenhoek, 1066cx Amsterdam, The Netherlands;
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Kantere D, Siarov J, De Lara S, Parhizkar S, Olofsson Bagge R, Wennberg Larkö A, Ericson MB. Label‐free laser scanning microscopy targeting sentinel lymph node diagnostics: A feasibility study ex vivo. TRANSLATIONAL BIOPHOTONICS 2020. [DOI: 10.1002/tbio.202000002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Despoina Kantere
- Department of Dermatology and Venereology, Institute of Clinical Sciences University of Gothenburg Gothenburg Sweden
| | - Jan Siarov
- Department of Pathology University of Gothenburg Gothenburg Sweden
| | - Shahin De Lara
- Department of Pathology University of Gothenburg Gothenburg Sweden
| | - Samad Parhizkar
- Department of Pathology University of Gothenburg Gothenburg Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences University of Gothenburg Gothenburg Sweden
| | - Ann‐Marie Wennberg Larkö
- Department of Dermatology and Venereology, Institute of Clinical Sciences University of Gothenburg Gothenburg Sweden
| | - Marica B. Ericson
- Biomedical photonics group, Department of Chemistry and Molecular Biology University of Gothenburg Gothenburg Sweden
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Wan JCM, Heider K, Gale D, Murphy S, Fisher E, Mouliere F, Ruiz-Valdepenas A, Santonja A, Morris J, Chandrananda D, Marshall A, Gill AB, Chan PY, Barker E, Young G, Cooper WN, Hudecova I, Marass F, Mair R, Brindle KM, Stewart GD, Abraham JE, Caldas C, Rassl DM, Rintoul RC, Alifrangis C, Middleton MR, Gallagher FA, Parkinson C, Durrani A, McDermott U, Smith CG, Massie C, Corrie PG, Rosenfeld N. ctDNA monitoring using patient-specific sequencing and integration of variant reads. Sci Transl Med 2020; 12:eaaz8084. [PMID: 32554709 DOI: 10.1126/scitranslmed.aaz8084] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/10/2020] [Accepted: 05/28/2020] [Indexed: 02/11/2024]
Abstract
Circulating tumor-derived DNA (ctDNA) can be used to monitor cancer dynamics noninvasively. Detection of ctDNA can be challenging in patients with low-volume or residual disease, where plasma contains very few tumor-derived DNA fragments. We show that sensitivity for ctDNA detection in plasma can be improved by analyzing hundreds to thousands of mutations that are first identified by tumor genotyping. We describe the INtegration of VAriant Reads (INVAR) pipeline, which combines custom error-suppression methods and signal-enrichment approaches based on biological features of ctDNA. With this approach, the detection limit in each sample can be estimated independently based on the number of informative reads sequenced across multiple patient-specific loci. We applied INVAR to custom hybrid-capture sequencing data from 176 plasma samples from 105 patients with melanoma, lung, renal, glioma, and breast cancer across both early and advanced disease. By integrating signal across a median of >105 informative reads, ctDNA was routinely quantified to 1 mutant molecule per 100,000, and in some cases with high tumor mutation burden and/or plasma input material, to parts per million. This resulted in median area under the curve (AUC) values of 0.98 in advanced cancers and 0.80 in early-stage and challenging settings for ctDNA detection. We generalized this method to whole-exome and whole-genome sequencing, showing that INVAR may be applied without requiring personalized sequencing panels so long as a tumor mutation list is available. As tumor sequencing becomes increasingly performed, such methods for personalized cancer monitoring may enhance the sensitivity of cancer liquid biopsies.
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Affiliation(s)
- Jonathan C M Wan
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Katrin Heider
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Davina Gale
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Suzanne Murphy
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Eyal Fisher
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Florent Mouliere
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pathology, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - Andrea Ruiz-Valdepenas
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Angela Santonja
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - James Morris
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Dineika Chandrananda
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Andrea Marshall
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Andrew B Gill
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Department of Radiology, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Pui Ying Chan
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Emily Barker
- Cambridge Clinical Trials Unit-Cancer Theme, Cambridge CB2 0QQ, UK
| | - Gemma Young
- Cambridge Clinical Trials Unit-Cancer Theme, Cambridge CB2 0QQ, UK
| | - Wendy N Cooper
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Irena Hudecova
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Francesco Marass
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Richard Mair
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Kevin M Brindle
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Department of Biochemistry, University of Cambridge, Cambridge CB2 1QW, UK
| | - Grant D Stewart
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Department of Surgery, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Jean E Abraham
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
- Department of Oncology, Centre for Cancer Genetic Epidemiology, University of Cambridge, Cambridge CB1 8RN, UK
| | - Carlos Caldas
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cambridge Breast Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Doris M Rassl
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
| | - Robert C Rintoul
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Royal Papworth Hospital NHS Foundation Trust, Cambridge CB2 0AY, UK
- Department of Oncology, University of Cambridge Hutchison-MRC Research Centre, Box 197, Cambridge Biomedical Campus, Cambridge CB2 0XZ, UK
| | | | - Mark R Middleton
- National Institute for Health Research Biomedical Research Centre, Oxford OX4 2PG, UK
| | - Ferdia A Gallagher
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pathology, Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | | | - Amer Durrani
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | | | - Christopher G Smith
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Charles Massie
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
- Department of Oncology, University of Cambridge Hutchison-MRC Research Centre, Box 197, Cambridge Biomedical Campus, Cambridge CB2 0XZ, UK
| | - Pippa G Corrie
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
| | - Nitzan Rosenfeld
- Cancer Research UK Cambridge Institute, University of Cambridge, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK.
- Cancer Research UK Major Centre-Cambridge, Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Robinson Way, Cambridge CB2 0RE, UK
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Franke V, van Akkooi ACJ. The extent of surgery for stage III melanoma: how much is appropriate? Lancet Oncol 2020; 20:e167-e174. [PMID: 30842060 DOI: 10.1016/s1470-2045(19)30099-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
Abstract
Since the first documented lymph node dissection in 1892, many trials have investigated the potential effect of this surgical procedure on survival in patients with melanoma. Two randomised controlled trials were unable to demonstrate improved survival with completion lymph node dissection versus nodal observation in patients with sentinel node-positive disease, although patients with larger sentinel node metastases (>1 mm) might benefit more from observation than from dissection, and could potentially be considered for adjuvant systemic therapy instead of complete dissection. Adjuvant immunotherapy with high-dose ipilimumab has led to improvements in overall survival, whereas therapy with nivolumab and pembrolizumab has improved relapse-free survival with greater safety. Furthermore, adjuvant-targeted therapy with dabrafenib and trametinib has improved survival outcomes in BRAFV600E and BRAFV600K-mutated melanomas. Three neoadjuvant trials have all shown high response rates, including complete responses, after short-term combination therapy with ipilimumab and nivolumab with no recurrences so far, although follow-up is still short. Despite the absence of a survival benefit with completion lymph node dissection in patients with sentinel node-positive or negative disease, the use of sentinel node staging will increase because of the introduction of effective adjuvant therapies. However, routine completion lymph node dissection for sentinel node-positive disease should be reconsidered. Accordingly, existing clinical guidelines are currently being revised. For palpable (macroscopic) nodal disease, the type and extent of surgery could be reduced if the index node can accurately predict the response and if studies show that lymph node dissection can be safely foregone in patients with a complete response. Overall, the appropriate type and extent of surgery for stage III melanoma is changing and becoming more personalised.
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Affiliation(s)
- Viola Franke
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, Netherlands.
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37
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Verver D, Rekkas A, Garbe C, van Klaveren D, van Akkooi ACJ, Rutkowski P, Powell BWEM, Robert C, Testori A, van Leeuwen BL, van der Veldt AAM, Keilholz U, Stadler R, Eggermont AMM, Verhoef C, Leiter U, Grünhagen DJ. The EORTC-DeCOG nomogram adequately predicts outcomes of patients with sentinel node-positive melanoma without the need for completion lymph node dissection. Eur J Cancer 2020; 134:9-18. [PMID: 32454396 DOI: 10.1016/j.ejca.2020.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Based on recent advances in the management of patients with sentinel node (SN)-positive melanoma, we aimed to develop prediction models for recurrence, distant metastasis (DM) and overall mortality (OM). METHODS The derivation cohort consisted of 1080 patients with SN-positive melanoma from nine European Organization for Research and Treatment of Cancer (EORTC) centres. Prognostic factors for recurrence, DM and OM were studied with Cox regression analysis. Significant factors were incorporated in the models. Performance was assessed by discrimination (c-index) and calibration in cross-validation across centres. The models were externally validated using a prospective cohort consisting of 705 German patients with SN-positive: 473 trial participants of the German Dermatologic Cooperative Oncology Group study (DeCOG-SLT) and 232 screened patients. A nomogram was developed for graphical presentation. RESULTS The final model for recurrence and the calibrated models for DM and OM included ulceration, age, SN tumour burden and Breslow thickness. The models showed reasonable calibration. The c-index for the recurrence, DM and OM model was 0.68, 0.70 and 0.70, respectively, and 0.70, 0.72 and 0.74, respectively, in external validation. The EORTC-DeCOG model identified a robust low-risk group, with all identified low-risk patients (approximately 4% of the entire population) having a 5-year recurrence probability of <25% and an overall 5-year recurrence rate of 13%. A model including information on completion lymph node dissection (CLND) showed only marginal improvement in model performance. CONCLUSIONS The EORTC-DeCOG nomogram provides an adequate prognostic tool for patients with SN-positive melanoma, without the need for CLND. It showed consistent results across validation. The nomogram could be used for patient counselling and might aid in adjuvant therapy decision-making.
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Affiliation(s)
- Daniëlle Verver
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
| | - A Rekkas
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Claus Garbe
- Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - David van Klaveren
- Department of Medical Statistics, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Alexander C J van Akkooi
- Department of Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Amsterdam, the Netherlands
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Institute - Oncological Center, Warsaw, Poland
| | | | - Caroline Robert
- Department of Dermatology and Allergology, Cancer Institute Gustave Roussy, Villejuif, France
| | | | - Barbara L van Leeuwen
- Department of Surgical Oncology, Groningen University, University Medical Centre Groningen, Groningen, the Netherlands
| | - Astrid A M van der Veldt
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Ulrich Keilholz
- Director of the Charité Comprehensive Cancer Center, Charité - University of Medicine Berlin, Berlin, Germany
| | - Rudolf Stadler
- Department of Dermatology, University Hospital Johannes Wesling Minden, Minden, Germany
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Ulrike Leiter
- Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Grassi T, Dell'Orto F, Jaconi M, Lamanna M, De Ponti E, Paderno M, Landoni F, Leone BE, Fruscio R, Buda A. Two ultrastaging protocols for the detection of lymph node metastases in early-stage cervical and endometrial cancers. Int J Gynecol Cancer 2020; 30:1404-1410. [PMID: 32376740 DOI: 10.1136/ijgc-2020-001298] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To date, there is no universal consensus on which is the optimal ultrastaging protocol for sentinel lymph node (SLN) evaluation in gynecologic malignancies. To estimate the impact of different ultrastaging methods of SLNs on the detection of patients with nodal metastases in early-stage cervical and endometrial cancers and to describe the incidence of low-volume metastases between two ultrastaging protocols. METHODS We retrospectively compared two ultrastaging protocols (ultrastaging-A vs ultrastaging-B) in patients with clinical stage I endometrial cancer or FIGO stage IA-IB1 cervical cancer who underwent primary surgery including SLN biopsy from October 2010 to December 2017 in our institution. The histologic subtypes and grades of the tumors were evaluated according to WHO criteria. Only SLNs underwent ultrastaging, while other lymph nodes were sectioned and examined by routine hematoxylin and eosin (H&E). RESULTS Overall 224 patients were reviewed (159 endometrial cancer and 65 cervical cancer). Lymph node involvement was noted in 15% of patients with endometrial cancer (24/159): 24% of patients (9/38) with the ultrastaging protocol A and 12% (15/121) with the ultrastaging protocol B (p=0.08); while for cervical cancer, SLN metastasis was detected in 14% of patients (9/65): 22% (4/18) in ultrastaging-A and 11% (5/47) in ultrastaging-B (p=0.20). Overall, macrometastasis and low-volume metastases were 50% and 50% for endometrial cancer and 78% and 22% for cervical cancer. Median size of nodal metastasis was 2 (range 0.9-8.5) mm for the ultrastaging-A and 1.2 (range 0.4-2.6) mm for the ultrastaging-B protocol in endometrial cancer (p=0.25); 4 (range 2.5-9.8) mm for ultrastaging-A and 4.4 (range 0.3-7.8) mm for ultrastaging-B protocol in cervical cancer (p=0.64). CONCLUSION In endometrial or cervical cancer patients, the incidence of SLN metastasis was not different between the two different types of ultrastaging protocol.
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Affiliation(s)
- Tommaso Grassi
- Obstetrics and Gynecology, Hospital San Gerardo, Monza, Lombardia, Italy
| | - Federica Dell'Orto
- Obstetrics and Gynecology, Hospital San Gerardo, Monza, Lombardia, Italy
| | - Marta Jaconi
- Pathology, Hospital San Gerardo, Monza, Lombardia, Italy
| | - Maria Lamanna
- Obstetrics and Gynecology, Hospital San Gerardo, Monza, Lombardia, Italy
| | - Elena De Ponti
- Physical Medicine, Hospital San Gerardo, Monza, Lombardia, Italy
| | | | - Fabio Landoni
- Obstetrics and Gynecology, University of Milan-Bicocca, Milano, Lombardia, Italy
| | | | - Robert Fruscio
- Obstetrics and Gynecology, University of Milan-Bicocca, Milano, Lombardia, Italy
| | - Alessandro Buda
- Obstetrics and Gynecology, Hospital San Gerardo, Monza, Lombardia, Italy
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Jenkins RW, Fisher DE. Treatment of Advanced Melanoma in 2020 and Beyond. J Invest Dermatol 2020; 141:23-31. [PMID: 32268150 DOI: 10.1016/j.jid.2020.03.943] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/16/2020] [Indexed: 01/22/2023]
Abstract
The melanoma field has seen an unprecedented set of clinical advances over the past decade. Therapeutic efficacy for advanced or metastatic melanoma went from being one of the most poorly responsive to one of the more responsive. Perhaps most strikingly, the advances that transformed management of the disease are based upon modern mechanism-based therapeutic strategies. The targeted approaches that primarily suppress the BRAF oncoprotein pathway have a high predictability of efficacy although less optimal depth or durability of response. Immunotherapy is primarily based on blockade of one or two immune checkpoints and has a lower predictability of response but higher fractions of durable remissions. This article reviews the clinical progress in management of advanced melanoma and also discusses the impact of the same therapies on earlier stage disease, where the agents have shown significant promise in treating resectable but high-risk clinical scenarios. Collectively, the progress in melanoma therapeutics has transformed the standard of care for patients, informed new approaches that are increasingly utilized for treatment of other malignancies, and suggest novel strategies to further boost efficacy for the many patients not yet receiving optimal benefit from these approaches.
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Affiliation(s)
- Russell W Jenkins
- Center for Cancer Research, Department of Medicine, MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Laboratory for Systems Pharmacology, Harvard Program in Therapeutic Sciences, Harvard Medical School, Boston, Massachusetts, USA
| | - David E Fisher
- Cutaneous Biology Research Center, Department of Dermatology and MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Madu MF, Franke V, Van de Wiel BA, Klop WM, Jóźwiak K, van Houdt WJ, Wouters MW, van Akkooi AC. External validation of the American Joint Committee on Cancer 8th edition melanoma staging system: who needs adjuvant treatment? Melanoma Res 2020; 30:185-192. [DOI: 10.1097/cmr.0000000000000643] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Michielin O, van Akkooi ACJ, Ascierto PA, Dummer R, Keilholz U. Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol 2019; 30:1884-1901. [PMID: 31566661 DOI: 10.1093/annonc/mdz411] [Citation(s) in RCA: 348] [Impact Index Per Article: 69.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- O Michielin
- Department of Oncology, University Hospital Lausanne, Lausanne, Switzerland
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - P A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Napoli, Italy
| | - R Dummer
- Department of Dermatology, Skin Cancer Centre, University Hospital Zürich, Zürich, Switzerland
| | - U Keilholz
- Charité Comprehensive Cancer Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Satzger I, Leiter U, Gräger N, Keim U, Garbe C, Gutzmer R. Melanoma-specific survival in patients with positive sentinel lymph nodes: Relevance of sentinel tumor burden. Eur J Cancer 2019; 123:83-91. [DOI: 10.1016/j.ejca.2019.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
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Fayne RA, Macedo FI, Rodgers SE, Möller MG. Evolving management of positive regional lymph nodes in melanoma: Past, present and future directions. Oncol Rev 2019; 13:433. [PMID: 31857858 PMCID: PMC6902307 DOI: 10.4081/oncol.2019.433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/20/2019] [Indexed: 12/29/2022] Open
Abstract
Sentinel lymph node (SLN) biopsy has become the standard of care for lymph node staging in melanoma and the most important predictor of survival in clinically node-negative disease. Previous guidelines recommend completion lymph node dissection (CLND) in cases of positive SLN; however, the lymph nodes recovered during CLND are only positive in a minority of these cases. Recent evidence suggests that conservative management (i.e. observation) has similar outcomes compared to CLND. We sought to review the most current literature regarding the management of SLN in metastatic melanoma and to discuss potential future directions.
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Affiliation(s)
- Rachel A Fayne
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Francisco I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Miami, FL, USA
| | - Steven E Rodgers
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Mecker G Möller
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
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van Akkooi ACJ, Hayes A. Recent developments in lymph node surgery for melanoma. Br J Dermatol 2019; 180:5-7. [PMID: 30604533 DOI: 10.1111/bjd.17143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121 - Room U2·38, 1066 CX, Amsterdam, the Netherlands
| | - A Hayes
- Melanoma Unit, Department of Academic Surgery, Royal Marsden NHS Trust, London, U.K
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Eggermont AMM, Blank CU, Mandala M, Long GV, Atkinson VG, Dalle S, Haydon A, Lichinitser M, Khattak A, Carlino MS, Sandhu S, Larkin J, Puig S, Ascierto PA, Rutkowski P, Schadendorf D, Koornstra R, Hernandez-Aya L, Di Giacomo AM, van den Eertwegh AJ, Grob JJ, Gutzmer R, Jamal R, Lorigan PC, Lupinacci R, Krepler C, Ibrahim N, Kicinski M, Marreaud S, van Akkooi AC, Suciu S, Robert C. Prognostic and predictive value of AJCC-8 staging in the phase III EORTC1325/KEYNOTE-054 trial of pembrolizumab vs placebo in resected high-risk stage III melanoma. Eur J Cancer 2019; 116:148-157. [PMID: 31200321 DOI: 10.1016/j.ejca.2019.05.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer-8 (AJCC) classification of melanoma was implemented in January 2018. It was based on data gathered when checkpoint inhibitors were not used as adjuvant therapy in stage III melanoma. The European Organization for Research and Treatment of Cancer (EORTC) 1325/KEYNOTE-054 double-blind phase III trial evaluated pembrolizumab vs placebo in AJCC-7 stage IIIA (excluding lymph node metastasis ≤1 mm), IIIB or IIIC (without in-transit metastasis) patients after complete lymphadenectomy. PATIENTS, METHODS AND RESULTS Patients (n = 1019) were randomised 1:1 to pembrolizumab 200 mg or placebo every 3 weeks (total of 18 doses, ∼1 year). At 1.25-year median follow-up, pembrolizumab prolonged relapse-free survival (RFS) in the total population (1-year RFS rate: 75.4% vs 61.0%; hazard ratio [HR] 0.57; logrank P < 0.0001) and consistently in the AJCC-7 subgroups. Prognostic and predictive values of AJCC-8 for RFS were evaluated in this study. Patient distribution according to the AJCC-8 stage subgroups was 8% (IIIA), 34.7% (IIIB), 49.7% (IIIC), 3.7% (IIID) and 3.8% (unknown). AJCC-8 classification was strongly associated with RFS (HRs for stage IIIB, IIIC and IIID vs IIIA were 4.0, 5.7 and 12.2, respectively) but showed no predictive importance for the treatment comparison regarding RFS (test for interaction: P = 0.68). The 1-year RFS rate for pembrolizumab vs placebo and the HRs (99% confidence interval) within each AJCC-8 subgroup were as follows: stage IIIA (92.7% vs 92.5%; 0.76 [0.11-5.43]), IIIB (79.0% vs 65.5%; 0.59 [0.35-0.99]), IIIC (73.6% vs 53.9%; 0.48 [0.33-0.70]) and IIID (50.0% vs 33.3%; 0.69 [0.24-2.00]). CONCLUSIONS AJCC-8 staging had a strong prognostic importance for RFS but no predictive importance: the RFS benefit of pembrolizumab was observed across AJCC-8 subgroups in resected high-risk stage III melanoma patients.
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Affiliation(s)
| | - Christian U Blank
- Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Mario Mandala
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, and Mater and Royal North Shore Hospitals, Sydney, NSW, Australia
| | | | | | | | | | - Adnan Khattak
- Fiona Stanley Hospital/University of Western Australia, Perth, WA, Australia
| | - Matteo S Carlino
- Westmead and Blacktown Hospitals, Melanoma Institute Australia and the University of Sydney, Sydney, NSW, Australia
| | | | | | - Susana Puig
- Hospital Clinic Universitari de Barcelona, Barcelona, Spain
| | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Piotr Rutkowski
- Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
| | | | - Rutger Koornstra
- Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
| | | | | | | | | | - Ralf Gutzmer
- Skin Cancer Center, Hannover Medical School, Hannover, Germany
| | - Rahima Jamal
- Centre Hospitalier de l'Université de Montréal (CHUM), Centre de recherche du CHUM, Montreal, QC, Canada
| | - Paul C Lorigan
- Christie NHS Foundation Trust, Manchester, United Kingdom
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Cai W, Ding X, Li J, Li Z. Methylation analysis highlights novel prognostic criteria in human-metastasized melanoma. J Cell Biochem 2019; 120:11990-12001. [PMID: 30861178 DOI: 10.1002/jcb.28484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 01/24/2023]
Abstract
Melanoma accounts for 90% of the deaths associated with cutaneous neoplasms, and the 5-year survival rate of patients with the advanced stage is about 20%. Many mechanisms are involved in melanoma progression, but dynamic epigenetic changes are likely to be critical contributors, especially for DNA methylation. However, we know little about the methylation events involved in melanoma lymph node metastasis (LNM), a deficit that is of particular concern because it has a growing incidence and mortality. To identify DNA methylated-associated changes involved in the formation of metastatic melanoma, we explored the different methylated genes (DMGs) between primary and LNM melanoma by Illumina Human Methylation 450 K BeadArray GSE44661. By integrating DNA methylation and messenger RNA expression data from The Cancer Genome Atlas database, we identified these DNA methylation biomarkers. Pathway analysis highlighted these DMGs, which were closely related to the carcinogenesis of melanoma, such as cell cycle regulation and RNA transcription process. Furthermore, according to the univariate and multivariate Cox regression analysis, we constructed a four-DMG prognostic signature model, which could precisely predict the outcome of melanoma in a more exact way. In summary, this four-DMG based risk score model successfully predicts the survival of melanoma. It is independent of other clinical characteristics and is good for prognosis prediction.
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Affiliation(s)
- Weiyang Cai
- Department of Oncology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoxia Ding
- Department of Dermatology and Venereology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jingjing Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhiming Li
- Department of Dermatology and Venereology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Abstract
PURPOSE OF REVIEW We review the results from relevant clinical trials and discuss current strategies in the melanoma adjuvant setting. RECENT FINDINGS The favorable therapeutic efficacy and the significant less toxicity of nivolumab compared with ipilimumab, fully substitutes today's approval of ipilimumab, regardless mutation status, whereas in BRAF-mutated patients, dabrafenib and trametinib seem to confirm their high efficacy also in adjuvant setting. The use of interferon is restricted to patients with ulcerated melanoma and countries with no access to the new drugs. SUMMARY Systemic adjuvant treatment after complete disease resection in high-risk melanoma patients aims to increase relapse-free survival (RFS) and overall survival (OS). According to the eighth edition of melanoma classification of American Joint Committee on Cancer (AJCC), the prognosis in stage III patients is heterogeneous and depends not only on N (nodal) but also on T (tumor thickness) category criteria. Recent data from randomized, phase-3 clinical trials analyzing the use of adjuvant anti-programmed death-1 and targeted therapies ultimately affect the standard of care and change the landscape of the adjuvant treatment.
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Enhancing the prognostic role of melanoma sentinel lymph nodes through microscopic tumour burden characterization: clinical usefulness in patients who do not undergo complete lymph node dissection. Melanoma Res 2019; 29:163-171. [DOI: 10.1097/cmr.0000000000000481] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Grob JJ, Garbe C, Ascierto P, Larkin J, Dummer R, Schadendorf D. Adjuvant melanoma therapy with new drugs: should physicians continue to focus on metastatic disease or use it earlier in primary melanoma? Lancet Oncol 2018; 19:e720-e725. [DOI: 10.1016/s1470-2045(18)30596-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 02/06/2023]
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