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Dugan MM, Shannon AB, DePalo DK, Perez MC, Zager JS. Intralesional and Infusional Updates for Metastatic Melanoma. Cancers (Basel) 2024; 16:1957. [PMID: 38893078 PMCID: PMC11171204 DOI: 10.3390/cancers16111957] [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: 04/06/2024] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Locoregionally advanced and metastatic melanoma represent a challenging clinical problem, but in the era of immune checkpoint blockade and intralesional and infusional therapies, more options are available for use. Isolated limb infusion (ILI) was first introduced in the 1990s for the management of advanced melanoma, followed by the utilization of isolated extremity perfusion (ILP). Following this, intralesional oncolytic viruses, xanthene dyes, and cytokines were introduced for the management of in-transit metastases as well as unresectable, advanced melanoma. In 2015, the Food and Drug Administration (FDA) approved the first oncolytic intralesional therapy, talimogene laherparepvec (T-VEC), for the treatment of advanced melanoma. Additionally, immune checkpoint inhibition has demonstrated efficacy in the management of advanced melanomas, and this improvement in outcomes has been extrapolated to aid in the management of in-transit metastatic disease. Finally, percutaneous hepatic perfusion (PHP), also approved by the FDA, has been reported to have a significant impact on the treatment of hepatic disease in uveal melanoma. While some of these treatments have less utility due to inferior outcomes as well as higher toxicity profiles, there are selective patient profiles for which these therapies carry a role. This review highlights intralesional and infusional therapies for the management of metastatic melanoma.
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Affiliation(s)
- Michelle M. Dugan
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
| | - Adrienne B. Shannon
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
| | - Danielle K. DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
- Department of General Surgery, University of Massachusetts Chan Medical School, Boston, MA 01655, USA
| | - Matthew C. Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33602, USA
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Huibers A, DePalo DK, Perez MC, Zager JS, Olofsson Bagge R. Isolated hyperthermic perfusions for cutaneous melanoma in-transit metastasis of the limb and uveal melanoma metastasis to the liver. Clin Exp Metastasis 2023:10.1007/s10585-023-10234-6. [PMID: 37843790 DOI: 10.1007/s10585-023-10234-6] [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: 05/18/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Patients with cutaneous melanoma can develop in-transit metastases (ITM), most often localized to limbs. For patients with uveal melanoma that develop metastatic disease, the overall majority develop isolated liver metastases. For these types of metastases, regional cancer therapies have evolved as effective treatments. Isolated limb perfusion (ILP), isolated limb infusion (ILI), isolated hepatic perfusion (IHP) and percutaneous hepatic perfusion (PHP) achieve a high local concentration of chemotherapy with minimal systemic exposure. This review discusses the mechanism and available literature on locoregional treatment modalities in the era of modern immunotherapy.
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Affiliation(s)
- Anne Huibers
- Department of Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden
| | - Danielle K DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani, College of Medicine, Tampa, FL, USA
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden.
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3
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Effects of the Introduction of Modern Immunotherapy on the Outcome of Isolated Limb Perfusion for Melanoma In-Transit Metastases. Cancers (Basel) 2023; 15:cancers15020472. [PMID: 36672422 PMCID: PMC9856283 DOI: 10.3390/cancers15020472] [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: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Isolated limb perfusion (ILP) is an effective locoregional treatment for melanoma in-transit metastasis, but the advent of modern effective immunotherapy, such as ICI (immune checkpoint inhibitors), has changed the treatment landscape. The primary aims of this study were to compare the characteristics of the patient population receiving ILP before and after the introduction of modern systemic treatments and to assess if outcomes after ILP were influenced by previous immunotherapy treatment. A single-centre analysis of patients that underwent ILP for melanoma in-transit metastasis between 2010 and 2021 was conducted, with patients grouped and compared by treatment time period: pre-ICI era (2010-2014) and ICI era (2017-2021). 218 patients were included. Patients undergoing ILP in the ICI era were slightly older (median age 73 vs. 68 years) compared to the pre-ICI era, with no other difference found. The overall response rate (ORR) was 83% vs. 84% and the complete response (CR) rate was 52% vs. 47% for the pre-ICI era and the ICI era, respectively. For patients that had received and failed immunotherapy prior to ILP (n = 20), the ORR was 75% and the CR rate was 50%. Melanoma-specific survival has improved, with a 3-year survival rate of 54% in the pre-ICI era vs. 86% in the ICI era. The patient population undergoing ILP for in-transit melanoma is largely unchanged in the current era of effective systemic treatments. Response rates have not decreased, and prior ICI treatment did not affect response rates, making ILP still a valid treatment option for this patient group.
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Tumor Burden and Health-Related Quality of Life in Patients with Melanoma In-Transit Metastases. Cancers (Basel) 2022; 15:cancers15010161. [PMID: 36612157 PMCID: PMC9817978 DOI: 10.3390/cancers15010161] [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: 10/30/2022] [Revised: 12/14/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Few studies have investigated the health-related quality of life (HRQOL) in patients with melanoma in-transit metastases (ITM). The aim was to investigate the association between tumor burden and HRQOL, including disparities pertaining to sex and age, in treatment-naïve patients with ITM. METHODS Functional Assessment of Cancer Therapy-Melanoma (FACT-M) questionnaire was used to assess HRQOL Pairwise comparisons using t-tests between clinical cutoffs are presented and multiple linear regression analysis showing the unique associations of gender, age, number of tumors, tumor size, presence of lymph node metastases, and tumor localization. RESULTS A total of 95 patients, 47% females and 53% males (median age 72 years) were included between 2012 and 2021. Women scored significantly lower on emotional well-being (p = 0.038) and lower on FACT-M (p = 0.058). Patients who had ≥10 tumors scored significantly lower on FACT-M (p = 0.015), emotional- and functional well-being (p = 0.04, p = 0.004, respectively), melanoma scale (p = 0.005), and FACT-G (p = 0.027). There was no significant difference in HRQOL depending on age, size of tumors, localization, or presence of lymph node metastases. CONCLUSION For patients with melanoma ITMs, the female sex and higher tumor burden (i.e., number of tumors) were significantly correlated with lower HRQOL. However, these findings do not fully explain HRQOL for this patient population, and future research should consider the possibility that there are specific questions for patients with ITM where current instruments might fail to measure their discomfort to the full extent.
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5
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Bastrup FA, Vissing M, Gehl J. Electrochemotherapy with intravenous bleomycin for patients with cutaneous malignancies, across tumour histology: a systematic review. Acta Oncol 2022; 61:1093-1104. [DOI: 10.1080/0284186x.2022.2110385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Freya A. Bastrup
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mille Vissing
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Julie Gehl
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Bastrup FA, Vissing M, Gehl J. Electrochemotherapy for metastatic cutaneous melanoma. Acta Oncol 2022; 61:531-532. [PMID: 35484987 DOI: 10.1080/0284186x.2022.2057199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/20/2022] [Indexed: 12/21/2022]
Affiliation(s)
- Freya A Bastrup
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mille Vissing
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Julie Gehl
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Queiroz MM, Bertolli E, Belfort FA, Munhoz RR. Management of In-Transit Metastases. Curr Oncol Rep 2022; 24:573-583. [PMID: 35192119 DOI: 10.1007/s11912-022-01216-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW The purpose of this study is to discuss the current knowledge and future perspectives regarding the treatment options for in-transit metastases (ITM), along with the optimal algorithms for patients presenting with this adverse manifestation of melanoma. RECENT FINDINGS In addition to procedures historically accepted for the management of ITM, encompassing surgery and regional techniques, novel medications in the form of immune checkpoint inhibitors (ICI) and targeted therapies now represent standard options, allowing for the possibility of combined approaches, with an expanding role of systemic therapies. Melanoma in-transit metastases consist of intralymphatic neoplastic implants distributed between the primary site and the regional nodal basin, within the subepidermal and dermal lymphatics. Distinct risk factors may influence the development of ITM, and the clinical presentation can be highly heterogeneous, enhancing the complexity of the management of ITM. Surgical resection, when feasible, continues to represent a standard approach for patients with curative intent. Patients with extensive or unresectable disease may also benefit from regional approaches that include isolated limb perfusion or infusion, electrochemotherapy, and a wide variety of intralesional therapies. Over the past decade, regimens with ICI and BRAF/MEK inhibitors dramatically expanded the benefit of systemic treatments for patients with melanoma, both in the adjuvant setting and for those with advanced disease, and the combination of these modalities with regional treatments, as well as neoadjuvant approaches, may represent the future for the treatment of patients with ITM.
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Affiliation(s)
| | - Eduardo Bertolli
- Cutaneous Oncology and Sarcomas Group, Hospital Sírio Libanês, São Paulo, Brazil.,Skin Cancer Department, AC Camargo Cancer Center, São Paulo, Brazil.,Melanoma and Sarcoma Group, Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | | | - Rodrigo Ramella Munhoz
- Oncology Center, Hospital Sírio Libanês, São Paulo, Brazil. .,Cutaneous Oncology and Sarcomas Group, Hospital Sírio Libanês, São Paulo, Brazil.
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Knackstedt R, Smile T, Yu J, Gastman BR. Non-Operative Options for Loco-regional Melanoma. Clin Plast Surg 2021; 48:631-642. [PMID: 34503723 DOI: 10.1016/j.cps.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Malignant melanoma is the 5th most common cancer and stage IV melanoma accounts for approximately 4% of new melanoma diagnoses in the United States. The prognosis for regionally advanced disease is poor, but there have been numerous recent advances in the medical management of melanoma in-transit metastases. The goal of this paper is to review currently accepted treatment options for in-transit metastases and introduce emerging therapies. Therapies to be discussed include limb perfusion and infusion, immunotherapy, checkpoint inhibitors, and radiation therapy.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA
| | - Timothy Smile
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Jennifer Yu
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA.
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Patel A, Carr MJ, Sun J, Zager JS. In-transit metastatic cutaneous melanoma: current management and future directions. Clin Exp Metastasis 2021; 39:201-211. [PMID: 33999365 DOI: 10.1007/s10585-021-10100-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/22/2021] [Indexed: 12/22/2022]
Abstract
Management of in-transit melanoma encompasses a variety of possible treatment pathways and modalities. Depending on the location of disease, number of lesions, burden of disease and patient preference and characteristics, some treatments may be more beneficial than others. After full body radiographic staging is performed to rule out metastatic disease, curative therapy may be performed through surgical excision, intraarterial regional perfusion and infusion therapies, intralesional injections, systemic therapies or various combinations of any of these. While wide excision is limited in indication to superficial lesions that are few in number, the other listed therapies may be effective in treating unresectable disease. Where intraarterial perfusion based therapies have been shown to successfully treat extremity disease, injectable therapies can be used in lesions of the head and neck. Although systemic therapies for in-transit melanoma have limited specific data to support their primary use for in-transit disease, there are patients who may not be eligible for any of the other options, and current clinical trials are exploring the use of concurrent and sequential use of regional and systemic therapies with early results suggesting a synergistic benefit for oncologic response and outcomes.
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Affiliation(s)
- Ayushi Patel
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA.,Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Jonathan S Zager
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA. .,Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA.
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Anti-PD-1 checkpoint blockade improves the efficacy of a melphalan-based therapy in experimental melanoma. Eur J Surg Oncol 2021; 47:2460-2464. [PMID: 33980416 DOI: 10.1016/j.ejso.2021.04.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/24/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The induction of adaptive cellular immunity in patients with in-transit melanoma metastasis treated with hyperthermic isolated limb perfusion (ILP) with melphalan has been shown to contribute to the effectiveness of the therapy. Activated CD8+ T cells appear to be of particular importance for the efficacy of melphalan-based ILP therapy, as observed in both patients and animal models. In this study, we explored the possible synergistic effects of combining melphalan-based therapy with the checkpoint inhibitor anti-PD-1 on tumours in a mouse melanoma model. METHODS A murine vaccination model that utilized melphalan-exposed melanoma cells was used to mimic certain immunological features of melphalan-based ILP. The effects of the vaccine on tumour growth and PD-1 expression on CD8+ tumour-infiltrating T cells were analyzed. The melphalan-based vaccine was then combined with an anti-PD-1 antibody and tumour growth was assessed. RESULTS Treatment with melphalan-based therapy significantly induced the expression of PD-1 on CD8+ tumour-infiltrating lymphocytes. Combination therapy using melphalan-based therapy followed by treatment with PD-1 antibodies significantly reduced early-stage tumour growth relative to monotherapies and no treatment. CONCLUSIONS This study thus suggests that the addition of PD-1 blockade to melphalan-based therapies, such as ILP, may be therapeutically beneficial.
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Troiani T, De Falco V, Napolitano S, Trojaniello C, Ascierto PA. How we treat locoregional melanoma. ESMO Open 2021; 6:100136. [PMID: 33930656 PMCID: PMC8100625 DOI: 10.1016/j.esmoop.2021.100136] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/02/2021] [Indexed: 12/19/2022] Open
Abstract
Cutaneous melanoma is the most lethal form of skin cancer and its incidence has been increasing in the past 30 years. Although this is completely resectable in most cases, thicker melanoma and those with regional lymph-node involvement are at a high risk of relapse. In recent years, the management of locoregional disease has drastically changed. In particular, in the 8th Edition of the American Joint Committee on Cancer (AJCC), subgroup classification of TNM (tumor–node–metastasis) has been modified, with the addition of the IIID stage. Furthermore, in recent randomized trials, completion lymph node dissection in case of sentinel lymph node biopsy positivity has not been shown to offer any improvement in overall survival versus observation. Consequently, radical dissection has been recommended as the standard treatment, but only in patients with palpable nodal metastases. However, the major novelty in the treatment of locally advanced melanoma has been the introduction of drugs, already used for metastatic disease, that have also shown clinical efficacy in the adjuvant setting. In fact, immunotherapies and, in the case of BRAF V600E/K-mutated melanoma, combination treatment of BRAF and MEK inhibitors have improved recurrence-free survival in these patients. In this paper, we will describe the current management of a patient with radically resectable melanoma and discuss the key points in light of the latest scientific evidence. Melanoma is the deadliest of skin cancers, although most cases are resectable at diagnosis. Use of targeted therapies and immunotherapies as adjuvant treatment revolutionized the scenario in stage III melanoma. In this review, we summarize all current evidence about locoregional melanoma, including open issues and future directions.
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Affiliation(s)
- T Troiani
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania 'Luigi Vanvitelli', Napoli, Italy.
| | - V De Falco
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania 'Luigi Vanvitelli', Napoli, Italy
| | - S Napolitano
- Medical Oncology, Department of Precision Medicine, Università degli Studi della Campania 'Luigi Vanvitelli', Napoli, Italy
| | - C Trojaniello
- Melanoma, Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale dei Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - P A Ascierto
- Melanoma, Cancer Immunotherapy and Innovative Therapy Unit, Istituto Nazionale dei Tumori IRCCS Fondazione Pascale, Napoli, Italy.
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Singha TK, Dagar VK, Gulati P, Kumar S. Kinetic study and optimization of recombinant human tumor necrosis factor-alpha (rhTNF-α) production in Escherichia coli. Prep Biochem Biotechnol 2020; 51:267-276. [PMID: 32876507 DOI: 10.1080/10826068.2020.1815056] [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] [Indexed: 12/16/2022]
Abstract
Tumor necrosis factor-alpha (TNF-α) is an inflammatory cytokine that plays a major role in immune regulation, homeostatic function, and cellular organization. The present study was undertaken to overproduce recombinant human TNF-α (rhTNF-α) in Escherichia coli (E.coli) in high cell density culture. The use of a codon-optimized gene and strong promoter-based (T7) expression system, choice of Terrific Broth (TB) as medium, and subsequent optimization of culture conditions in shake flasks resulted in production of 0.95 g/L insoluble rhTNF-α comprising upto 50% of total cellular protein (TCP) The protein yield further increased upto 1.26 g/L in 1 L TB medium batch culture in bioreactor with the controlled temperature, pH, and dissolved oxygen. In a series of chemostats operated at dilution rates of 0.2 h-1, 0.3 h-1, 0.4 h-1 and 0.5 h-1 the specific growth rate (μ) positively correlated with specific yield (Yp/x) and a maximum yield of 164 mg/g DCW was obtained at μ = 0.4 h-1 within 4 h post-induction. A fed-batch cultivation in TB with an exponential feeding profile (μ = ∼0.4 h-1) of concentrated feed resulted in an accumulation of 5.5 g/L of rhTNF-α within 14 h of cultivation which accounted for ∼29% of TCP.
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Affiliation(s)
| | - Vikas Kumar Dagar
- Department of Microbiology, University of Delhi South Campus, New Delhi, India
| | - Pooja Gulati
- Department of Microbiology, Maharshi Dayanand University, Rohtak, India
| | - Sanjay Kumar
- Department of Microbiology, Maharshi Dayanand University, Rohtak, India
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Michielin O, van Akkooi A, Lorigan P, Ascierto PA, Dummer R, Robert C, Arance A, Blank CU, Chiarion Sileni V, Donia M, Faries MB, Gaudy-Marqueste C, Gogas H, Grob JJ, Guckenberger M, Haanen J, Hayes AJ, Hoeller C, Lebbé C, Lugowska I, Mandalà M, Márquez-Rodas I, Nathan P, Neyns B, Olofsson Bagge R, Puig S, Rutkowski P, Schilling B, Sondak VK, Tawbi H, Testori A, Keilholz U. ESMO consensus conference recommendations on the management of locoregional melanoma: under the auspices of the ESMO Guidelines Committee. Ann Oncol 2020; 31:1449-1461. [PMID: 32763452 DOI: 10.1016/j.annonc.2020.07.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 02/06/2023] Open
Abstract
The European Society for Medical Oncology (ESMO) held a consensus conference on melanoma on 5-7 September 2019 in Amsterdam, The Netherlands. The conference included a multidisciplinary panel of 32 leading experts in the management of melanoma. The aim of the conference was to develop recommendations on topics that are not covered in detail in the current ESMO Clinical Practice Guideline and where available evidence is either limited or conflicting. The main topics identified for discussion were: (i) the management of locoregional disease; (ii) targeted versus immunotherapies in the adjuvant setting; (iii) targeted versus immunotherapies for the first-line treatment of metastatic melanoma; (iv) when to stop immunotherapy or targeted therapy in the metastatic setting; and (v) systemic versus local treatment of brain metastases. The expert panel was divided into five working groups in order to each address questions relating to one of the five topics outlined above. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel for further discussion and amendment before voting. This manuscript presents the results relating to the management of locoregional melanoma, including findings from the expert panel discussions, consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.
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Affiliation(s)
- O Michielin
- Department of Oncology, University Hospital Lausanne, Lausanne, Switzerland.
| | - A van Akkooi
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - P Lorigan
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - P A Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - R Dummer
- Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
| | - C Robert
- Department of Medicine, Gustave Roussy, Villejuif, France; Paris-Saclay University, Le Kremlin-Bicêtre, Paris, France
| | - A Arance
- Department of Medical Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - C U Blank
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - V Chiarion Sileni
- Department of Experimental and Clinical Oncology, Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy
| | - M Donia
- National Center for Cancer Immune Therapy, Department of Oncology, Herlev and Gentofte Hospital, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - M B Faries
- Department of Surgery, The Angeles Clinic, Cedars Sinai Medical Center, Los Angeles, USA
| | - C Gaudy-Marqueste
- Department of Dermatology and Skin Cancer, Aix Marseille University, Hôpital Timone, Marseille, France
| | - H Gogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - J J Grob
- Department of Dermatology and Skin Cancer, Aix Marseille University, Hôpital Timone, Marseille, France
| | - M Guckenberger
- Department of Radio-Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - J Haanen
- Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A J Hayes
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - C Hoeller
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Lebbé
- AP-HP Dermatology, Université de Paris, Paris, France; INSERM U976, Hôpital Saint Louis, Paris, France
| | - I Lugowska
- Early Phase Clinical Trials Unit, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - M Mandalà
- Department of Oncology and Haematology, Papa Giovanni XXIII Cancer Center Hospital, Bergamo, Italy
| | - I Márquez-Rodas
- Department of Medical Oncology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - P Nathan
- Department of Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - B Neyns
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - R Olofsson Bagge
- Sahlgrenska Cancer Center, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - S Puig
- Dermatology Service, Hospital Clínic de Barcelona and University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August i Pi Sunyer, Barcelona, Spain; CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - B Schilling
- Department of Dermatology, University Hospital Würzburg, Würzburg, Germany
| | - V K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa
| | - H Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A Testori
- Department of Dermatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - U Keilholz
- Charité Comprehensive Cancer Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
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14
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Wright FC, Kellett S, Hong NJL, Sun AY, Hanna TP, Nessim C, Giacomantonio CA, Temple-Oberle CF, Song X, Petrella TM. Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline. Curr Oncol 2020; 27:e318-e325. [PMID: 32669939 PMCID: PMC7339852 DOI: 10.3747/co.27.6523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- F C Wright
- Department of General Surgery, Sunnybrook Health Sciences Centre/Odette Regional Cancer Centre, Toronto, ON
| | - S Kellett
- Program in Evidence-Based Care, Ontario Health (Cancer Care Ontario), and Department of Oncology, McMaster University, Hamilton, ON
| | - N J Look Hong
- Department of General Surgery, Division of Surgical Oncology, Sunnybrook Health Sciences Centre, and Department of Surgery, University of Toronto, Toronto, ON
| | - A Y Sun
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre, Toronto, ON
| | - T P Hanna
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, ON
| | - C Nessim
- Division of General Surgery, The Ottawa Hospital, and Department of Surgery, University of Ottawa, Ottawa, ON
| | - C A Giacomantonio
- Queen Elizabeth II Health Sciences Centre, Capital District Health, and Departments of Surgery and Pathology, Dalhousie University, Halifax, NS
| | - C F Temple-Oberle
- Departments of Oncology and Surgery, University of Calgary, Calgary, AB
| | - X Song
- Department of Internal Medicine, Division of Medical Oncology, University of Ottawa, and The Ottawa Hospital Cancer Centre, Ottawa, ON
| | - T M Petrella
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Toronto, ON
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15
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Beasley GM, Zager JS, Thompson JF. The Landmark Series: Regional Therapy of Recurrent Cutaneous Melanoma. Ann Surg Oncol 2020; 27:35-42. [PMID: 31471842 DOI: 10.1245/s10434-019-07760-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Indexed: 01/20/2023]
Abstract
In-transit melanoma represents a distinct disease pattern in which melanoma recurs as dermal or subcutaneous nodules between the primary melanoma site and the draining regional lymph node basin. The disease pattern is often not amenable to complete surgical resection. Since the 1950s, regional therapies have been explored for the treatment of this disease entity, with the goal of maximizing delivery of the therapeutic agent to the tumor while minimizing systemic toxicity. We reviewed landmark studies describing and evaluating regional chemotherapy and intralesional therapies for patients with in-transit melanoma metastases.
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Affiliation(s)
- Georgia M Beasley
- Department of Surgery, Duke University, Durham, NC, USA.
- Duke University Medical Center, Durham, NC, USA.
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Surgery, University of South Florida Morsani School of Medicine, Tampa, FL, USA
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia
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16
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Ekenberg M, Wesslau H, Olofsson Bagge R, Engström M. Patient experiences with isolated limb perfusion for malignant melanoma - A qualitative study. Eur J Oncol Nurs 2019; 43:101672. [PMID: 31614318 DOI: 10.1016/j.ejon.2019.101672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/26/2019] [Accepted: 10/02/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE In recent years, the incidence of malignant melanoma has rapidly increased worldwide. Among patients with recurrences, approximately 5% develop in-transit metastases, which can potentially be treated with isolated limb perfusion (ILP). However, little is known about patient experiences with this treatment. A more thorough understanding might guide future research and clinical care. In this study, we aimed to describe patients' experiences of ILP treatment. METHODS This study included eight patients who participated in a semi-structed interviewed, conducted at one occasion between 3 and 11 months after their ILP treatment. The mean interview duration was 26 min. Data were analyzed using qualitative inductive content analysis according to the methods of Elo-Kyngäs and Graneheim and Lundman. RESULTS Our analysis yielded three categories, each built on two subcategories: positive experiences after ILP treatment emerged from the sub-categories reduced tumor burden and living a less restricted life; negative experiences after ILP was built on the subcategories fear of relapse and complications and side effects; and experiences of healthcare was founded on the subcategories need for correct information and being viewed as sicker then experienced. CONCLUSION Participants showed greater focus on the healthy parts of their lives, even when negative symptoms occurred after ILP treatment. They also described how healthcare workers focused on their illness. Based on these findings, we suggest the following means of providing good nursing care to ILP patients: give correct information, strive to reduce patients' negative symptoms, support their daily living needs, and provide emotional support to reduce fear of recurrence.
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Affiliation(s)
- Monica Ekenberg
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanna Wesslau
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - My Engström
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Health and Care Science, Sahlgrenska Academy at the University of Gothenburg, Sweden; Department of Gastrosurgical research and education, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg, Sweden.
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17
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Wang T, Osborne N, Rechtenwald J, Kim A, Matusko N, Mayle R, Cohen MS. Improved durable responses regardless of age following cytoreduction and "no-tourniquet" hyperthermic isolated limb chemotherapy for in transit melanoma of the extremity. Am J Surg 2019; 218:1114-1121. [PMID: 31630826 PMCID: PMC6927738 DOI: 10.1016/j.amjsurg.2019.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 09/20/2019] [Accepted: 09/26/2019] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Ton Wang
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
| | - Nicholas Osborne
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
| | - John Rechtenwald
- University of Wisconsin, Department of Surgery, Madison, WI, USA
| | - Alex Kim
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
| | - Niki Matusko
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
| | - Rita Mayle
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA
| | - Mark S Cohen
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA; University of Michigan, Department of Pharmacology, Ann Arbor, MI, USA.
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18
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Gamboa AC, Lowe M, Yushak ML, Delman KA. Surgical Considerations and Systemic Therapy of Melanoma. Surg Clin North Am 2019; 100:141-159. [PMID: 31753109 DOI: 10.1016/j.suc.2019.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent advances in effective medical therapies have markedly improved the prognosis for patients with advanced melanoma. This article aims to highlight the current era of integrated multidisciplinary care of patients with advanced melanoma by outlining current approved therapies, including immunotherapy, targeted therapy, radiation therapy, and other strategies used in both the adjuvant and the neoadjuvant setting as well as the evolving role of surgical intervention in the changing landscape of advanced melanoma.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Emory University School of Medicine, 1365B Clifton Road Northeast, Suite B4000, Atlanta, GA 30322, USA
| | - Michael Lowe
- Division of Surgical Oncology, Emory University School of Medicine, 1365B Clifton Road Northeast, Suite B4000, Atlanta, GA 30322, USA
| | - Melinda L Yushak
- Division of Medical Oncology, Emory University School of Medicine, 1365B4 Clifton Road Northeast, Suite B4000, Atlanta, GA 30322, USA
| | - Keith A Delman
- Division of Surgical Oncology, Emory University School of Medicine, 1365B Clifton Road Northeast, Suite B4000, Atlanta, GA 30322, USA.
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19
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Abstract
Melanoma has a unique propensity for locoregional metastasis secondary to intralymphatic transit not seen in other cutaneous or soft tissue malignancies. Novel intralesional therapies using oncolytic immunotherapy exhibit increasing response rates with observed bystander effect. Intralesional modalities in combination with systemic immunotherapy are the subject of ongoing clinical trials. Regional therapy is used in isolated limb locoregional metastasis whereby chemotherapy is delivered to an isolated limb avoiding systemic side effects. Multimodal treatment strategy is imperative in the treatment of locoregionally advanced melanoma. One must be versed on these quickly evolving therapeutic options.
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Affiliation(s)
- David T Pointer
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 McKinley Drive, Tampa, FL, 33612; Department of Surgery, University of South Florida Morsani College of Medicine, 13220 USF Laurel Dr., Tampa, FL 33612
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 McKinley Drive, Tampa, FL, 33612; Department of Surgery, University of South Florida Morsani College of Medicine, 13220 USF Laurel Dr., Tampa, FL 33612.
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20
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Nan Tie E, Na LH, Hicks RJ, Spillane J, Speakman D, Henderson MA, Gyorki DE. The Prognosis and Natural History of In-Transit Melanoma Metastases at a High-Volume Centre. Ann Surg Oncol 2019; 26:4673-4680. [PMID: 31641949 DOI: 10.1245/s10434-019-07965-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with in-transit melanoma metastases (ITM) experience a diverse spectrum of clinical presentations and a highly variable disease course. There is no standardized treatment protocol for these patients due to the limited data comparing treatment modalities for ITM. This is the first study to describe the disease trajectory and natural history of a large cohort of patients with ITM. METHODS A retrospective study of patients treated for ITM between 2004 and 2018 at the Peter MacCallum Cancer Centre was performed. Clinical and pathological characteristics for primary and in-transit episodes were analyzed for predictors of relapse-free survival (RFS), distant metastasis-free survival (DMFS), and melanoma-specific survival. RESULTS A total of 109 patients with 303 episodes of ITM were identified: 52 (48%) females, median age 70.1 years (range 35-92). The median RFS for all episodes was 5 months (95% confidence interval [CI] 4.2-5.7). Eighty-seven percent of episodes involving isolated in-transit lesions underwent surgical excision, compared with 17% involving more than five in-transit lesions. A trend was seen between a greater number of lesions and shorter RFS (p = 0.055). The median DMFS was 34.8 months (95% CI 22.8-51.6). Factors associated with shorter DMFS included primary tumor thickness (hazard ratio [HR] 1.08, 95% CI 1.01-1.15; p = 0.026), site of primary tumor (p = 0.008), and BRAF mutation (HR 2.12, 95% CI 1.14-3.94; p = 0.018). CONCLUSIONS Locoregional relapse is common in patients with ITM regardless of treatment modality. Characteristics of the ITM may predict for RFS, while primary tumor characteristics remain important predictors of DMFS.
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Affiliation(s)
- Emilia Nan Tie
- Division of Cancer Surgery, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - Lumine H Na
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Rodney J Hicks
- Centre for Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Medicine/Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - John Spillane
- Division of Cancer Surgery, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - David Speakman
- Division of Cancer Surgery, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael A Henderson
- Division of Cancer Surgery, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - David E Gyorki
- Division of Cancer Surgery, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia. .,Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia. .,Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia.
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21
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Broman KK, Zager JS. Intra-arterial perfusion-based therapies for regionally metastatic cutaneous and uveal melanoma. Melanoma Manag 2019; 6:MMT26. [PMID: 31807277 PMCID: PMC6891941 DOI: 10.2217/mmt-2019-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Locoregional disease remains a challenging problem in cutaneous melanoma and uveal melanoma. Arterial-based chemoperfusion strategies enable regional therapy delivery with minimal systemic toxicity. Herein we discuss intra-arterial therapies for in-transit cutaneous melanoma of the extremity including hyperthermic-isolated limb perfusion and isolated limb infusion. We also discuss open (isolated hepatic perfusion) and percutaneous hepatic perfusion techniques for isolated liver metastases from uveal melanoma. We review the current state of knowledge with respect to indications, procedural techniques, outcomes and expected toxicities for intra-arterial chemoperfusion for locoregional melanoma metastases.
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Affiliation(s)
- Kristy K Broman
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
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22
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Song Y, Bruce AN, Fraker DL, Karakousis GC. Isolated limb perfusion and infusion in the treatment of melanoma and soft tissue sarcoma in the era of modern systemic therapies. J Surg Oncol 2019; 120:540-549. [DOI: 10.1002/jso.25600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/05/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Yun Song
- Department of SurgeryHospital of the University of Pennsylvania Philadelphia Pennsylvania
| | - Adrienne N. Bruce
- Department of SurgeryHospital of the University of Pennsylvania Philadelphia Pennsylvania
| | - Douglas L. Fraker
- Department of SurgeryHospital of the University of Pennsylvania Philadelphia Pennsylvania
| | - Giorgos C. Karakousis
- Department of SurgeryHospital of the University of Pennsylvania Philadelphia Pennsylvania
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23
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Vrielink OM, Kruijff S, van Leeuwen BL, Roodenburg JL. Application of CO 2 laser evaporation in locally advanced melanoma. Melanoma Manag 2019; 6:MMT14. [PMID: 31236206 PMCID: PMC6582456 DOI: 10.2217/mmt-2018-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/18/2019] [Indexed: 11/21/2022] Open
Abstract
Aim This study aims to investigate the role of CO2 laser evaporation in the treatment of melanoma patients with satellite or in-transit metastases. Materials & methods Patients who underwent CO2 laser evaporation were retrospectively included between November 2002 and August 2018. The Sharplan 40C CO2 laser was used with a high pulse wave mode. Data concerning patient and tumor characteristics, CO2 laser evaporation and subsequent therapies were collected. Results A total of 26 patients were included. Median duration of local control was 5.5 months. The median number of lesions evaporated per treatment was three (1-16); patients received a median of three (1-19) treatments. Conclusion In a selected group of melanoma patients with satellite or in-transit metastases, CO2 laser evaporation should be considered as treatment for local control.
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Affiliation(s)
- Otis M Vrielink
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Ln Roodenburg
- Department of Oral & Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Oral & Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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24
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Evaluation of the efficacy and toxicity of upper extremity isolated limb infusion chemotherapy for melanoma: An Australian multi-center study. Eur J Surg Oncol 2019; 45:832-837. [DOI: 10.1016/j.ejso.2019.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/20/2019] [Indexed: 01/20/2023] Open
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25
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Falk Delgado A, Zommorodi S, Falk Delgado A. Sentinel Lymph Node Biopsy and Complete Lymph Node Dissection for Melanoma. Curr Oncol Rep 2019; 21:54. [PMID: 31028497 PMCID: PMC6486528 DOI: 10.1007/s11912-019-0798-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The main surgical treatment for invasive malignant melanoma consists of wide surgical and examination of the sentinel node and in selected cases complete lymph node dissection. The aim of this review is to present data for the optimal surgical management of patients with malignant melanoma. RECENT FINDINGS A surgical excision margin of 1-2 cm is recommended for invasive melanoma depending on the thickness of the melanoma. Sentinel node biopsy may be considered for patients with at least T1b melanomas thickness 0.8 to 1.0 mm or less than 0.8 mm Breslow thickness with ulceration, classified as T1b lesion, per recent AJCC guidelines. Two randomized controlled trials have been published-DeCOG (German Dermatologic Cooperative Oncology Group Selective Lymphadenectomy) and MSLT-2 (Multicenter Selective Lymphadenectomy Trial) comparing the complete lymph node dissection (CLND) with observation after positive sentinel node biopsy. In the MSLT-2 study, the disease control rate was improved in the immediate CLND group compared with observation but there was no difference in 3-year melanoma specific survival (86% ± 1.3% and 86% ± 1.2%, respectively; p = 0.42). Isolated limb perfusion (ILP) or isolated limb infusion (ILI) with melphalan and actinomycin D is recommended for large and multiple in-transit metastases and satellite metastases in the extremities when local excision is considered ineffective or too extensive. In light of new adjuvant treatment options and new indications for checkpoint inhibitors, and the lack of survival benefit after CLND, we can expect open surgery to decrease in melanoma disease.
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Affiliation(s)
- Alberto Falk Delgado
- Department of Plastic Surgery, Uppsala University, Ing 85, Akademiska Sjukhuset, 75185, Uppsala, Sweden.
| | - Sayid Zommorodi
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Falk Delgado
- Clinical neurosciences, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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26
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Belgrano V, Pettersson J, Nilsson JA, Mattsson J, Katsarelias D, Olofsson Bagge R. Response and Toxicity of Repeated Isolated Limb Perfusion (re-ILP) for Patients With In-Transit Metastases of Malignant Melanoma. Ann Surg Oncol 2019; 26:1055-1062. [PMID: 30617871 PMCID: PMC6399180 DOI: 10.1245/s10434-018-07143-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a safe and well-established treatment for in-transit metastases of melanoma. In case of relapse or disease progression, ILP can be repeated (re-ILP). This study aimed retrospectively to analyze a large consecutive series of re-ILP and compare clinical outcomes with first-time ILP. METHOD Between 2001 and 2015, 290 consecutive patients underwent 380 ILPs. Of these, 90 were re-ILPs including 68 second ILPs, 16 third ILPs, 4 fourth ILPs, and two fifth ILPs. The study evaluated response (using World Health Organization [WHO] criteria), local toxicity (using the Wieberdink scale), and complications (using Clavien-Dindo). RESULTS The results were compared between the first ILP, the second ILP, and the third to fifth ILP. The overall response rate was respectively 83%, 80% and 68%, with a complete response (CR) rate of 60%, 41%, and 59%. In the re-ILP group, the patients with a CR after the first ILP had a 65% CR rate after the second ILP compared with 8% for the patients without a CR (p = 0.001). The risk for local toxicity or complications was not increased after re-ILP. The median overall survival periods were respectively 34, 41, and 93 months (p = 0.02). CONCLUSION As a therapeutic option, ILP can be repeated safely for in-transit metastases of melanoma, achieving similar high response rates without increasing complications or toxicity. Re-ILP is mainly indicated for patients who already had a CR after the first ILP, whereas other treatment options should be considered for primary non-responders.
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Affiliation(s)
- Valerio Belgrano
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.,Sahlgrenska Cancer Center, University of Gothenburg, 405 30, Gothenburg, Sweden
| | - Jessica Pettersson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Jonas A Nilsson
- Sahlgrenska Cancer Center, University of Gothenburg, 405 30, Gothenburg, Sweden
| | - Jan Mattsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
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27
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Racz JM, Block MS, Baum CL, Jakub JW. Management of local or regional non‐nodal disease. J Surg Oncol 2018; 119:187-199. [DOI: 10.1002/jso.25330] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/19/2018] [Indexed: 12/31/2022]
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Kroon HM, Thompson JF. Isolated Limb Infusion and Isolated Limb Perfusion for Melanoma: Can the Outcomes of these Procedures be Compared? Ann Surg Oncol 2018; 26:8-9. [DOI: 10.1245/s10434-018-7067-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Indexed: 11/18/2022]
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Olofsson Bagge R, Carlson P, Razzazian R, Hansson C, Hjärpe A, Mattsson J, Katsarelias D. Minimally invasive isolated limb perfusion – technical details and initial outcome of a new treatment method for limb malignancies. Int J Hyperthermia 2018; 35:667-673. [DOI: 10.1080/02656736.2018.1522000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Carlson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roya Razzazian
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christoffer Hansson
- Department of Thoracic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Hjärpe
- Department of Thoracic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Mattsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Nan Tie E, Henderson MA, Gyorki DE. Management of in-transit melanoma metastases: a review. ANZ J Surg 2018; 89:647-652. [PMID: 30414233 DOI: 10.1111/ans.14921] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 09/04/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
In-transit metastases (ITM) of cutaneous melanoma are locoregional recurrences confined to the superficial lymphatics that occur in 3.4-6.2% of patients diagnosed with melanoma. ITM are a heterogeneous disease that poses a therapeutic dilemma. Patients may have a prolonged disease trajectory involving multiple or repeat treatment modalities for frequent recurrences. The management of ITM has evolved without the development of a standardized protocol. Owing to the variability of the disease course there are few dedicated clinical trials, with a number of key trials in stage III melanoma excluding ITM patients. Thus, there is a paucity of quality data on the efficacy of the treatment modalities available for ITM and even fewer studies directly comparing modalities. At present the mainstay of ITM treatment is surgical resection, with intralesional therapies, isolated limb infusion and radiotherapy utilized as second-line measures. The developing role of targeted therapies and immunotherapy has yet to be explored completely in these patients. This review addresses the evidence base of the efficacy of the various treatment modalities available and those factors that have impacted their clinical uptake.
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Affiliation(s)
- Emilia Nan Tie
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael A Henderson
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - David E Gyorki
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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Miura JT, Zager JS. Intralesional therapy as a treatment for locoregionally metastatic melanoma. Expert Rev Anticancer Ther 2018; 18:399-408. [PMID: 29466885 DOI: 10.1080/14737140.2018.1444482] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The emergence of novel intralesional therapies have dramatically changed the treatment landscape for melanoma. The heterogeneous presentation of melanoma continues to pose challenges for clinicians, especially when dealing with advanced locoregional disease. Intralesional therapies have the benefit of causing local tumor destruction, while minimizing systemic toxicity. Moreover, the integration of immunotherapeutic agents into intralesional compounds has resulted in the additional benefit of a bystander effect, whereby untreated distant lesions also derive a benefit from treatment. Intralesional therapy has assumed an important role in the management of unresectable, locoregional disease for melanoma. Areas covered: Multiple intralesional agents have been studied over the years, with only a few demonstrating promising results. This review will provide an overview of the different intralesional agents for melanoma. Mechanisms of action, clinical efficacy, and side effects will be the primary focus. Expert commentary: Treatment options for advanced melanoma continue to evolve. Attractive new therapies delivered by an intralesional route has demonstrated promising results, with minimal side effects. The ideal treatment strategy for melanoma will remain a multimodal approach; intralesional therapy provides an additional tool in the treatment armamentarium for melanoma.
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Affiliation(s)
- John T Miura
- a Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center , University of South Florida School of Medicine , Tampa , FL , USA
| | - Jonathan S Zager
- a Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center , University of South Florida School of Medicine , Tampa , FL , USA
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O'Donoghue C, Perez MC, Mullinax JE, Hardman D, Sileno S, Naqvi SMH, Kim Y, Gonzalez RJ, Zager JS. Isolated Limb Infusion: A Single-Center Experience with Over 200 Infusions. Ann Surg Oncol 2017; 24:3842-3849. [PMID: 29019175 DOI: 10.1245/s10434-017-6107-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique for delivering regional chemotherapy to an extremity for patients with locally advanced cutaneous malignancies and sarcoma. METHODS A single-institution, prospectively collected database was analyzed for intention-to-treat with ILI. RESULTS From 2007 to 2016, 163 patients underwent 205 procedures (201 were successfully completed), and four malignancies were treated: melanoma (72.1% of all ILIs), sarcoma (23.4%), squamous cell carcinoma (SCC; 2.0%) and Merkel cell carcinoma (MCC; 2.5%). A median grade II regional Wieberdink toxicity score was observed, with 88.1% of patients experiencing grade II or less. Median follow-up was 21.8 months, and overall response rate (ORR) was 59.0% for melanoma, 48.9% for sarcoma, 50.0% for SCC, and 60.0% for MCC. A significant difference (p = 0.04) between upper (76.9%) and lower extremity (55.1%) ORR was observed in patients with melanoma. When comparing responders with nonresponders, patients with melanoma had significantly longer in-field progression-free survival (IPFS; 14.1 vs. 3.2 months, p < 0.001), distant metastatic-free survival (DMFS; not reached vs. 25.8 months, p = 0.006), and overall survival (OS; 56.0 vs. 26.7 months, p = 0.0004). Sarcoma responders had a significantly longer IPFS (13.0 vs. 2.7 months, p < 0.0001), but no significant distant metastatic or OS advantage. Over a median follow-up of 19.3 months, sarcoma patients had an overall limb salvage rate of 68.4%. CONCLUSION ILI is a well-tolerated procedure for patients with locally advanced melanoma, sarcoma, and other cutaneous malignancies. ILI responders had a significantly longer time to IPFS, while melanoma responders also had a DMFS and OS advantage.
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Affiliation(s)
| | - Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - John E Mullinax
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Danielle Hardman
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Sean Sileno
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | - Youngchul Kim
- Department of Biostatistics, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA.
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Isolated Limb Infusion as a Limb Salvage Strategy for Locally Advanced Extremity Sarcoma. J Am Coll Surg 2017; 224:635-642. [PMID: 28214556 DOI: 10.1016/j.jamcollsurg.2016.12.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Treatment-resistant, locally advanced soft tissue sarcomas often require amputation for complete tumor extirpation. Isolated limb infusion (ILI) selectively delivers high-dose chemotherapy to the extremity in an attempt to achieve limb salvage. The aim of this study was to report perioperative and oncologic outcomes after ILI in patients with extremity soft tissue sarcomas. STUDY DESIGN From 1994 to 2016, 77 patients underwent 84 ILIs at a total of 5 institutions. Melphalan and actinomycin D were circulated for 30 minutes after complete tourniquet occlusion of the limb, then actively washed out to prevent systemic exposure. RESULTS The procedure was performed in an upper extremity on 19 patients (21 infusions) and in a lower extremity on 58 patients (63 infusions). The 3-month overall response rate (ORR) for the entire cohort was 58%, and there was a statistically significant difference (p = 0.03) between upper (37%) and lower extremity (66%) ORR. With median follow-up of 20.6 months (range 0.6 to 146.1 months), the overall limb salvage rate was 77.9%. For those who underwent amputation due to progression of disease, the median time to amputation was 4.5 months. With a median follow-up of 20.6 months, the median overall survival for the entire cohort was 44.3 months. The distant metastatic-free survival was longer for responders than nonresponders (p = 0.01), though the disease-specific survival was not different for the same groups (p = 0.2). CONCLUSIONS Isolated limb infusion for extremity soft tissue sarcoma results in an objective response for half of the patients who are otherwise facing amputation, and offers prolonged limb salvage for the vast majority of patients. The procedure is well tolerated without serious complications.
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Madu MF, Deken MM, van der Hage JA, Jóźwiak K, Wouters MWJM, van Akkooi ACJ. Isolated Limb Perfusion for Melanoma is Safe and Effective in Elderly Patients. Ann Surg Oncol 2017; 24:1997-2005. [DOI: 10.1245/s10434-017-5803-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 11/18/2022]
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Testori A, Ribero S, Bataille V. Diagnosis and treatment of in-transit melanoma metastases. Eur J Surg Oncol 2016; 43:544-560. [PMID: 27923593 DOI: 10.1016/j.ejso.2016.10.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023] Open
Abstract
In transit metastases (ITM) from extremity or trunk melanomas are subcutaneous or cutaneous lymphatic deposits of melanoma cells, distant from the primary site but not reaching the draining nodal basin. Superficial ITM metastases develop in 5-10% of melanoma patients and are thought to be caused by cells spreading along lymphatics; ITM appear biologically different from distant cutaneous metastases, these probably due to a haematogenous dissemination. The diagnosis is usually clinical and by patients, but patients need to be adequately educated in the recognition of this clinical situation. Ultrasound or more sophisticated instrumental devices may be required if the disease develops more deeply in the soft tissues. According to AJCC 2009 staging classification, ITM are included in stages IIIb and IIIc, which are considered local advanced disease with quite poor 5-year survival rates and outcomes of 24-54% at 5 years.2 Loco-regional recurrence is in fact an important risk factor for distant metastatic disease, either synchronous or metachronous. Therapy for this pattern of recurrence is less standardised then in most other clinical situations and options vary based on the volume and site of the disease. Definitive surgical resection remains the preferred therapeutic approach. However, when surgery cannot be performed with a reasonable cosmetic and functional outcome, other options must be utilized.3-6 Treatment options are classified as local, regional or systemic. The choice of therapy depends on the number of lesions, their anatomic location, whether or not these are dermal or subcutaneous, the size and the presence or absence of extra-regional disease.
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Affiliation(s)
- A Testori
- Divisione di Chirurgia Dermatoncologica, Istituto Europeo di Oncologia, Milano, Italy.
| | - S Ribero
- Dermatologia, Dipartimentto di Scienze mediche, Università di Torino, Italy
| | - V Bataille
- West Herts NHS Trust, London, UK; Mount Vernon Cancer Centre, Northwood, UK
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