Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline

Objective

The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastasis (itm) from melanoma.

Methods

The guideline was developed by the Program in Evidence-Based Care (pebc) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group. Recommendations were drafted by a Working Group based on a systematic review of publications in the medline and embase databases. The document underwent patient- and caregiver-specific consultation and was circulated to the Melanoma Disease Site Group and the pebc Report Approval Panel for internal review; the revised document underwent external review.

Recommendations

"Minimal itm" is defined as lesions in a location with limited spread (generally 1-4 lesions); the lesions are generally superficial, often clustered together, and surgically resectable. "Moderate itm" is defined as more than 5 lesions covering a wider area, or the rapid development (within weeks) of new in-transit lesions. "Maximal itm" is defined as large-volume disease with multiple (>15-20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area.■ In patients presenting with minimal itm, complete surgical excision with negative pathologic margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered.■ In patients presenting with moderate unresectable itm, consider using this approach for localized treatment: intralesional interleukin 2 or talimogene laherparepvec as 1st choice, topical diphenylcyclopropenone as 2nd choice, or radiation therapy as 3rd choice. Evidence is insufficient to recommend intralesional bacille Calmette- Guérin or CO2 laser ablation outside of a research setting.■ In patients presenting with maximal itm confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference.■ In cases in which local, regional, or surgical treatments for itm might be ineffective or unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered.

Improved durable responses regardless of age following cytoreduction and "no-tourniquet" hyperthermic isolated limb chemotherapy for in transit melanoma of the extremity

BACKGROUND

In-transit metastatic melanoma of the extremity is a clinically aggressive disease. For patients with disease confined to the limb, regional chemotherapy remains an effective option. However, no studies thus far have included cytoreduction or perfusion/infusion without using a limb tourniquet as part of the operative procedure. We hypothesize that combining cytoreduction with no-tourniquet HILP/HILI is safe in patients of all ages and results in durable responses.

METHODS

A retrospective analysis was performed of a prospectively collected database of patients with in-transit malignant melanoma who underwent cytoreduction and HILP/HILI between 2013 and 2017. The primary endpoint was RECIST response at 3-12 months. Secondary endpoints included length of hospital stay, adverse effects, overall survival, and time to recurrence. A subgroup analysis was performed in patients ≥80 years old.

RESULTS

HILP patients had significantly higher disease burdens than HILI patients. Complete response rates for HILP and HILI were 95% and 75%, respectively at 3 months and 47% and 50%, respectively at 1 year (50% for patients >80) with 100% 1-year survival rates for both HILP and HILI patients. Three-year survival rates were 57% (HILP), 52% (HILI) and 68% (patients >80 years old). The average length of stay for all patients was 3.6 ± 1.4 days.

CONCLUSION

Combining cytoreduction with no-tourniquet HILP/HILI for in-transit metastatic melanoma of the extremity resulted in 100% survival regardless of age at 1 year and 68% 3-year survival in patients over 80 without any increase in adverse events.

A web platform for the network analysis of high-throughput data in melanoma and its use to investigate mechanisms of resistance to anti-PD1 immunotherapy

Cellular phenotypes are established and controlled by complex and precisely orchestrated molecular networks. In cancer, mutations and dysregulations of multiple molecular factors perturb the regulation of these networks and lead to malignant transformation. High-throughput technologies are a valuable source of information to establish the complex molecular relationships behind the emergence of malignancy, but full exploitation of this massive amount of data requires bioinformatics tools that rely on network-based analyses. In this report we present the Virtual Melanoma Cell, an online tool developed to facilitate the mining and interpretation of high-throughput data on melanoma by biomedical researches. The platform is based on a comprehensive, manually generated and expert-validated regulatory map composed of signaling pathways important in malignant melanoma. The Virtual Melanoma Cell is a tool designed to accept, visualize and analyze user-generated datasets. It is available at: https://www.vcells.net/melanoma. To illustrate the utilization of the web platform and the regulatory map, we have analyzed a large publicly available dataset accounting for anti-PD1 immunotherapy treatment of malignant melanoma patients.

Surgical management and minimally invasive approaches for the treatment of metastatic sarcoma

Soft tissue sarcomas describe a very heterogeneous group of soft tissue tumors mainly arising in the lower extremities. If diagnosed at an early stage and a complete resection of the primary tumor is achieved, the patients' prognosis is excellent. However, metastatic tumor spread is common with only limited treatment possibilities. Despite an improved insight into tumor biology of sarcomas, no notable improvement has been gained in the last 20 years regarding prognosis of patients. Metastatic lung disease has long been the preserve of systemic treatments, local treatments being considered in a purely palliative intention. Several studies have objectified benefit to the local treatment of metastases, especially in an oligometastatic state. The development of techniques for stereotactic radiotherapy on the one hand and the refusal or contraindication for surgery on the other hand inaugurated studies in this direction. Besides surgery and radiotherapy, other local modalities have been investigated in the last few years such as thermal therapy (radiofrequency and laser ablation) or combined modalities (isolated limb perfusion and deep-wave hyperthermia plus chemotherapy) to help patients with metastatic soft tissue sarcoma. Minimally invasive, image-guided therapies such as thermal ablation should be considered particularly in patients who are not suitable surgical candidates or may have exhausted all other viable surgical options. Some of these techniques will be reviewed in this article, and their value for the patients will be evaluated in the light of indication from tumor biology and technical feasibility. These highly selected and specific procedures should only be performed after decision making in an interdisciplinary sarcoma-board.

The Role of Regional Therapies for in-Transit Melanoma in the Era of Improved Systemic Options

The incidence of melanoma has been increasing at a rapid rate, with 4%–11% of all melanoma recurrences presenting as in-transit disease. Treatments for in-transit melanoma of the extremity are varied and include surgical excision, lesional injection, regional techniques and systemic therapies. Excision to clear margins is preferred; however, in cases of widespread disease, this may not be practical. Historically, intralesional therapies were generally not curative and were often used for palliation or as adjuncts to other therapies, but recent advances in oncolytic viruses may change this paradigm. Radiation as a regional therapy can be quite locally toxic and is typically relegated to disease control and symptom relief in patients with limited treatment options. Regional therapies such as isolated limb perfusion and isolated limb infusion are older therapies, but offer the ability to treat bulky disease for curative intent with a high response rate. These techniques have their associated toxicities and can be technically challenging. Historically, systemic therapy with chemotherapies and biochemotherapies were relatively ineffective and highly toxic. With the advent of novel immunotherapeutic and targeted small molecule agents for the treatment of metastatic melanoma, the armamentarium against in-transit disease has expanded. Given the multitude of options, many different combinations and sequences of therapies can be offered to patients with in-transit extremity melanoma in the contemporary era. Reported response and survival rates of the varied treatments may offer valuable information regarding treatment decisions for patients with in-transit melanoma and provide rationale for these decisions.

Regional therapies for in-transit disease

In-transit melanoma is an uncommon pattern of recurrence, but presents unique management challenges and opportunities for treatment. The clinical presentation usually involves from 1 to more than 100 small subcutaneous or cutaneous nodules, ranging from submillimeter to multiple centimeters in diameter. Regional chemotherapy techniques are a mainstay of treatment of patients without systemic disease spread. Future applications of regional therapy are likely to involve combination therapy with cytotoxic agents and novel immune modulators. Regional therapy provides distinct opportunities for the treatment of unresectable disease, and offers a unique platform for investigation of novel therapeutics in early-stage clinical trials.

Subcutaneous metastases from melanoma: a discussion of clinical experience

SUMMARY 

The majority of locoregional relapses of cutaneous melanoma occur as subcutaneous local recurrences/in-transit metastases; subcutaneous metastases (SMs) are also common in distant metastases. SM therapy is challenging and depends on the number, site, depth, size, clinical behavior and presence of other metastases. Isolated, resectable SMs should be treated surgically. In multiple/unresectable lesions, several local modalities are used: carbon dioxide laser ablation, radiotherapy, cryotherapy, intralesional injections and electrochemotherapy. Hyperthermic isolated limb perfusion is the preferred method of treating multiple, bulky in-transit metastases in extremities, allowing for high response rates and long-lasting remission. Electrochemotherapy is a simple method for the fast ablation of SMs that are not feasible for hyperthermic isolated limb perfusion. Recent advances in systemic therapy of melanoma, including immunotherapy (anti-CTLA4/anti-PD-1) and targeted therapy (BRAF/MEK inhibitors), have significantly impacted on SM treatment. We present our own SM cases treated with different modalities. The future of SM therapy will rely on a combination of different local, locoregional and systemic modalities, and we can expect major improvements in long-term outcomes.

Immunotherapy following regional chemotherapy treatment of advanced extremity melanoma

PURPOSE

Following regional chemotherapy (RC) for melanoma, approximately 75 % of patients will progress. The role of immunotherapy after RC has not been well established.

METHODS

A prospective, single-institution database of 243 patients with in-transit melanoma (1995-2013) was queried for patients who had progression of disease after RC with melphalan and subsequently received systemic immunotherapy. Fifteen patients received IL-2 only, 12 received ipilimumab only, and 6 received IL-2 followed by ipilimumab. Fisher's exact test was used to determine if there was a difference in number of complete responders after immunotherapy.

RESULTS

With IL-2 alone, all patients progressed. After ipilimumab alone, three patients had a complete response and nine had progressive disease. Six additional patients received IL-2 first then ipilimumab. All six progressed on IL-2 but three went on to have a complete response to ipilimumab while three progressed. The use of ipilimumab at any time in patients who progressed after RC was associated with higher rate of complete response compared to use of IL-2 alone (33 vs. 0 %; p = 0.021).

CONCLUSIONS

Patients with progression after regional therapy for melanoma may benefit from immunologic therapy. In this group of patients, immune checkpoint blockade with ipilimumab has a higher complete response rate than T cell stimulation with IL-2, with no complete responders in the IL-2 only group. Furthermore, the complete response rate for ipilimumab in our cohort is higher than reported response rates in the literature for ipilimumab alone, suggesting that the effects of immunotherapy may be bolstered by previous regional treatment.

Efficacy of repeat sentinel lymph node biopsy in patients who develop recurrent melanoma

BACKGROUND

Even after negative sentinel lymph node biopsy (SLNB) for primary melanoma, patients who develop in-transit (IT) melanoma or local recurrences (LR) can have subclinical regional lymph node involvement.

STUDY DESIGN

A prospective database identified 33 patients with IT melanoma/LR who underwent technetium 99m sulfur colloid lymphoscintigraphy alone (n = 15) or in conjunction with lymphazurin dye (n = 18) administered only if the IT melanoma/LR was concurrently excised.

RESULTS

Seventy-nine percent (26 of 33) of patients undergoing SLNB in this study had earlier removal of lymph nodes in the same lymph node basin as the expected drainage of the IT melanoma or LR at the time of diagnosis of their primary melanoma. Lymphoscintography at time of presentation with IT melanoma/LR was successful in 94% (31 of 33) cases, and at least 1 sentinel lymph node was found intraoperatively in 97% (30 of 31) cases. The SLNB was positive in 33% (10 of 30) of these cases. Completion lymph node dissection was performed in 90% (9 of 10) of patients. Nine patients with negative SLNB and IT melanoma underwent regional chemotherapy. Patients in this study with a positive sentinel lymph node at the time the IT/LR was mapped had a considerably shorter time to development of distant metastatic disease compared with those with negative sentinel lymph nodes.

CONCLUSIONS

In this study, we demonstrate the technical feasibility and clinical use of repeat SLNB for recurrent melanoma. Performing SLNB cannot only optimize local, regional, and systemic treatment strategies for patients with LR or IT melanoma, but also appears to provide important prognostic information.

Resection of residual disease after isolated limb infusion (ILI) is equivalent to a complete response after ILI-alone in advanced extremity melanoma

BACKGROUND

Isolated limb infusion (ILI) is a limb-preserving treatment for in-transit extremity melanoma. The benefit of resecting residual disease after ILI is unclear.

METHODS

A multi-institutional experience was analyzed comparing patients who underwent ILI plus resection of residual disease (ILI + RES) versus ILI-alone.

RESULTS

A total of 176 patients were included, 154 with ILI-alone and 22 with ILI + RES. There were no differences between the groups with respect to gender, age, extremity affected, or time from diagnosis to ILI. All surgical resections were performed as an outpatient procedure, separate from the ILI. Within the ILI + RES group, 15 (68%) had a partial response (PR), 2 (9%) stable disease (SD), and 5 (23%) progressive disease (PD). The ILI-alone group had 52 (34%) CR, 30 (19%) PR, 15 (10%) SD, and 46 (30%) PD. Eleven (7%) ILI-alone patients did not have 3-month response available for review. Evaluating overall survival (OS) from date of ILI, the ILI-alone group had a median OS of 30.9 months, whereas the ILI + RES group had not reached median OS, p = 0.304. Although the ILI + RES group had a slightly longer disease-free survival (DFS) compared to those with a CR after ILI-alone (12.4 vs. 9.6), this was not statistically significant, p = 0.978. Within the ILI + RES group, those with an initial PR after ILI had improved DFS versus those with SD or PD after ILI, p < 0.0001.

CONCLUSIONS

Resection of residual disease after ILI offers a DFS and OS similar to those who have a CR after ILI-alone. It may offer a treatment strategy that benefits patients undergoing ILI.

Predicting disease progression after regional therapy for in-transit melanoma

IMPORTANCE

Although approximately 30% to 50% of patients experience a complete response after regional chemotherapy for in-transit melanoma, a subset of patients will develop rapidly progressive disease. In the current era of an expanding armamentarium, including both regional and systemic options for treating advanced melanoma, identifying perioperative factors that predict disease progression may obviate unnecessary morbidity associated with regional therapy and avoid delays in systemic therapy.

OBJECTIVE

To identify patient-related clinical and pathological variables, as well as procedural factors, that correlate with disease progression.

DESIGN

Using a prospectively maintained database, we identified patients who either underwent first-time melphalan-based isolated limb infusion (ILI) or first-time hyperthermic isolated limb perfusion (HILP) for in-transit melanoma. Response was defined using modified Response Evaluation Criteria in Solid Tumors for cutaneous disease at 3 months after treatment. Survival analyses were performed using the Kaplan-Meier method, with the differences in survival curves compared using a log-rank test. Potential preoperative and procedural predictors of in-field progressive disease were analyzed using logistic regression.

PARTICIPANTS

Of the 258 patients included in the database, 215 were identified as having undergone first-time regional therapy. Of these 215 patients, 134 underwent ILI, and 81 underwent HILP.

EXPOSURE

Regional therapy (ILI or HILP).

MAIN OUTCOMES AND MEASURES

Complete response or progressive disease.

RESULTS

Of 134 patients who underwent ILI, 43 (32.1%) experienced in-field progressive disease. Of 81 patients who underwent HILP, 9 (11.1%) experienced in-field progressive disease. The median survival for patients with in-field progressive disease was 20.3 months for the ILI cohort and 15.0 months for the HILP cohort. In general, patients with progressive disease were younger, with advanced-stage melanoma and increased tumor burden. Compared with patients who experienced a complete response, patients with in-field progressive disease after ILI were younger (odds ratio, 1.06 [95% CI, 0.90-0.98]; P = .002). For patients who underwent HILP, no clinically relevant preoperative predictors of in-field progressive disease were identified. Procedural variables, including chemotherapeutic dosing, degree of acidosis or base deficit achieved, and peak temperature attained, were not predictors of in-field progressive disease after ILI or HILP.

CONCLUSIONS AND RELEVANCE

Patient, clinical, and procedural factors are unreliable predictors of in-field progressive disease after regional therapy in patients with in-transit melanoma. Defining the potential utility of molecular markers in predicting response or failure of regional therapy should be the focus of future research efforts.

Bevacizumab-induced alterations in vascular permeability and drug delivery: a novel approach to augment regional chemotherapy for in-transit melanoma

PURPOSE

To investigate whether the systemically administered anti-VEGF monoclonal antibody bevacizumab could improve regional chemotherapy treatment of advanced extremity melanoma by enhancing delivery and tumor uptake of regionally infused melphalan (LPAM).

EXPERIMENTAL DESIGN

After treatment with systemic bevacizumab or saline, changes in vascular permeability were determined by spectrophotometric analysis of tumors infused with Evan's blue dye. Changes in vascular structure and tumor hemoglobin-oxygen saturation HbO(2) were determined by intravital microscopy and diffuse reflectance spectroscopy, respectively. Rats bearing the low-VEGF secreting DM738 and the high-VEGF secreting DM443 melanoma xenografts underwent isolated limb infusion (ILI) with melphalan (LPAM) or saline via the femoral vessels. The effect of bevacizumab on terminal drug delivery was determined by immunohistochemical analysis of LPAM-DNA adducts in tumor tissues.

RESULTS

Single-dose bevacizumab given three days before ILI with LPAM significantly decreased vascular permeability (50.3% in DM443, P < 0.01 and 35% in DM738, P < 0.01) and interstitial fluid pressure (57% in DM443, P < 0.01 and 50% in DM738, P = 0.01). HbO(2) decreased from baseline in mice following treatment with bevacizumab. Systemic bevacizumab significantly enhanced tumor response to ILI with LPAM in two melanoma xenografts, DM443 and DM738, increasing quadrupling time 37% and 113%, respectively (P = 0.03). Immunohistochemical analyses of tumor specimens showed that pretreatment with systemic bevacizumab markedly increased LPAM-DNA adduct formation.

CONCLUSIONS

Systemic treatment with bevacizumab before regional chemotherapy increases delivery of LPAM to tumor cells and represents a novel way to augment response to regional therapy for advanced extremity melanoma.