1
|
Di Raimondo C, Lozzi F, Di Domenico PP, Campione E, Bianchi L. The Diagnosis and Management of Cutaneous Metastases from Melanoma. Int J Mol Sci 2023; 24:14535. [PMID: 37833981 PMCID: PMC10572973 DOI: 10.3390/ijms241914535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Melanoma is one of the deadliest skin tumors, accounting for almost 90% of skin cancer mortality. Although immune therapy and targeted therapy have dramatically changed the prognosis of metastatic melanoma, many patients experience disease progression despite the currently available new treatments. Skin metastases from melanoma represent a relatively common event as first sign of advanced disease or a sign of recurrence. Skin metastases are usually asymptomatic, although in advanced stages, they can present with ulceration, bleeding, and superinfection; furthermore, they can cause symptoms related to compression on nearby tissues. Treatments vary from simple surgery resections to topical or intralesional local injections, or a combination of these techniques with the most recent systemic immune or target therapies. New research and studies should focus on the pathogenesis and molecular mechanisms of the cutaneous metastases of melanoma in order to shed light on the mechanisms underlying the different behavior and prognoses of different patients.
Collapse
Affiliation(s)
- Cosimo Di Raimondo
- Department of Dermatology, University of Roma Tor Vergata, 00133 Rome, Italy; (F.L.); (P.P.D.D.); (E.C.); (L.B.)
| | | | | | | | | |
Collapse
|
2
|
DePalo DK, Zager JS. Isolated Limb Infusion for Limb-Threatening, Unresectable Sarcoma: Past Progress, Current Applications, and Future Directions. J Clin Med 2023; 12:4036. [PMID: 37373729 DOI: 10.3390/jcm12124036] [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: 04/20/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Treatment of soft tissue sarcomas (STSs) is complicated by disease heterogeneity. Further, it has not benefitted much from the recent therapeutic advances in other soft tissue malignancies. Surgical resection remains the gold standard in resectable disease, but unresectable, locally advanced STS requires alternative and multimodal approaches. Isolated limb infusion (ILI) provides regional chemotherapy to extremity STS and offers the potential for limb salvage. Despite being in use for nearly 3 decades, there is limited literature on ILI in STS. This review provides an overview of patient eligibility, the procedure, significant publications in this field, and opportunities for further progress.
Collapse
Affiliation(s)
- Danielle K DePalo
- Department of Cutaneous Oncology, Moffitt Canter, Tampa, FL 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Canter, Tampa, FL 33612, USA
| |
Collapse
|
3
|
Diagnosis and treatment of Merkel cell carcinoma: European consensus-based interdisciplinary guideline - Update 2022. Eur J Cancer 2022; 171:203-231. [PMID: 35732101 DOI: 10.1016/j.ejca.2022.03.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 11/22/2022]
Abstract
Merkel cell carcinoma (MCC) is a rare skin cancer, accounting for less than 1% of all cutaneous malignancies. It is found predominantly in white populations and risk factors include advanced age, ultraviolet exposure, male sex, immunosuppression, such as AIDS/HIV infection, haematological malignancies or solid organ transplantation, and Merkel cell polyomavirus infection. MCC is an aggressive tumour with 26% of cases presenting lymph node involvement at diagnosis and 8% with distant metastases. Five-year overall survival rates range between 48% and 63%. Two subsets of MCC have been characterised with distinct molecular pathogenetic pathways: ultraviolet-induced MCC versus virus-positive MCC, which carries a better prognosis. In both subtypes, there are alterations in the retinoblastoma protein and p53 gene structure and function. MCC typically manifests as a red nodule or plaque with fast growth, most commonly on sun exposed areas. Histopathology (small-cell neuroendocrine appearance) and immunohistochemistry (CK20 positivity and TTF-1 negativity) confirm the diagnosis. The current staging systems are the American Joint Committee on Cancer/Union for international Cancer control 8th edition. Baseline whole body imaging is encouraged to rule out regional and distant metastasis. For localised MCC, first-line treatment is surgical excision with postoperative margin assessment followed by adjuvant radiation therapy (RT). Sentinel lymph node biopsy is recommended in all patients with MCC without clinically detectable lymph nodes or distant metastasis. Adjuvant RT alone, eventually combined with complete lymph nodes dissection is proposed in case of micrometastatic nodal involvement. In case of macroscopic nodal involvement, the standard of care is complete lymph nodes dissection potentially followed by post-operative RT. Immunotherapy with anti-PD-(L)1 antibodies should be offered as first-line systemic treatment in advanced MCC. Chemotherapy can be used when patients fail to respond or are intolerant for anti-PD-(L)1 immunotherapy or clinical trials.
Collapse
|
4
|
Elleson KM, DePalo DK, Zager JS. An update on local and systemic therapies for non-melanoma skin cancer. Expert Rev Anticancer Ther 2022; 22:479-489. [PMID: 35412413 DOI: 10.1080/14737140.2022.2065987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Nonmelanoma skin cancers (NMSC) as a group exceed the incidence of all other malignancies combined. NMSC includes basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma. As the incidence continues to rise, it is important to appreciate the available treatment options. AREAS COVERED This article discusses the treatment of NMSC though surgical, topical, regional, and systemic modalities. EXPERT OPINION As there are many treatment options available for these diseases, selection of the appropriate method can be difficult. With time, we expect treatment decisions to become even more complex and personalized. The role of systemic immunotherapies and neoadjuvant therapies in the treatment of NMSC is still not well defined. Local treatment with intralesional injections and isolated limb infusion may prove to be promising alternative therapies.
Collapse
Affiliation(s)
- Kelly M Elleson
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | | | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
An Aggressive Tumoral Metastasis to Groin Arising from Perianal Squamous Cell Carcinoma: Management of a Unique Case. Indian J Surg Oncol 2020; 11:90-92. [PMID: 33088138 DOI: 10.1007/s13193-020-01063-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/27/2020] [Indexed: 10/24/2022] Open
|
9
|
Carr MJ, Sun J, Kroon HM, Miura JT, Beasley GM, Farrow NE, Mosca PJ, Lowe MC, Farley CR, Kim Y, Naqvi SMH, Kirichenko DA, Potdar A, Daou H, Mullen D, Farma JM, Henderson MA, Speakman D, Serpell J, Delman KA, Smithers BM, Coventry BJ, Tyler DS, Thompson JF, Zager JS. Oncologic Outcomes After Isolated Limb Infusion for Advanced Melanoma: An International Comparison of the Procedure and Outcomes Between the United States and Australia. Ann Surg Oncol 2020; 27:5107-5118. [PMID: 32918177 DOI: 10.1245/s10434-020-09051-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/13/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive procedure for delivering high-dose chemotherapy to extremities affected by locally advanced or in-transit melanoma. This study compared the outcomes of melanoma patients treated with ILI in the United States of America (USA) and Australia (AUS). METHODS Patients with locally recurrent in-transit melanoma treated with ILI at USA or AUS centers between 1992 and 2018 were identified. Demographic and clinicopathologic characteristics were collected. Primary outcomes of treatment response, in-field progression-free survival (IPFS), distant progression-free survival (DPFS), and overall survival (OS) were evaluated by the Kaplan-Meier method. Multivariable analysis evaluated whether availability of new systemic therapies affected outcomes. RESULTS More ILIs were performed in AUS (n = 411, 60 %) than in the USA (n = 276, 40 %). In AUS, more ILIs were performed for stage 3B disease than in the USA (62 % vs 46 %; p < 0.001). The reported complete response rates were similar (AUS 30 % vs USA 29 %). Among the stage 3B patients, AUS patients had better IPFS (p = 0.001), whereas DPFS and OS were similar between the two countries. Among the stage 3C patients, the USA patients had better OS (p < 0.001), whereas IPFS and DPFS were similar. Availability of new systemic therapies did not affect IPFS or DPFS in either country. However, the USA patients who received ILI after ipilimumab approval in 2011 had significantly improved OS (hazard ratio, 0.62; p = 0.013). CONCLUSIONS AUS patients were treated at an earlier disease stage than the USA patients with better IPFS for stage 3B disease. The USA patients treated after the availability of new systemic therapies had a better OS.
Collapse
Affiliation(s)
- Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - John T Miura
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania Perelman, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Paul J Mosca
- Department of Surgery, Duke University, Durham, NC, USA
| | - Michael C Lowe
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Clara R Farley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Dennis A Kirichenko
- University of South Florida Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Aishwarya Potdar
- University of South Florida Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Hala Daou
- University of South Florida Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Dean Mullen
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Michael A Henderson
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - David Speakman
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Jonathan Serpell
- Discipline of Surgery, The Alfred Hospital, Melbourne, VIC, Australia
| | - Keith A Delman
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - B Mark Smithers
- Queensland Melanoma Project, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Brendon J Coventry
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, 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
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA. .,Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| |
Collapse
|
10
|
Carr MJ, Kroon HM, Zager JS. ASO Author Reflections: Return to Isolated Limb Infusion for In-Transit Melanoma. Ann Surg Oncol 2020; 27:5119-5120. [PMID: 32918180 DOI: 10.1245/s10434-020-09113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 08/26/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA. .,Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| |
Collapse
|
11
|
Carr MJ, Sun J, Zager JS. Isolated limb infusion: Institutional protocol and implementation. J Surg Oncol 2020; 122:99-105. [PMID: 32162353 DOI: 10.1002/jso.25886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/25/2020] [Indexed: 01/20/2023]
Abstract
Patients with unresectable cutaneous and soft tissue malignancies confined to a limb have many treatment options. Isolated limb infusion (ILI) is one therapeutic option whereby the extremity is isolated and perfused with high-dose chemotherapy through a percutaneously placed catheter-based procedure. A detailed description of the ILI protocol at the Moffitt Cancer Center is given. We have shown that ILI is a safe and effective treatment strategy for malignancies confined to an extremity.
Collapse
Affiliation(s)
- Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Local and Recurrent Regional Metastases of Melanoma. CUTANEOUS MELANOMA 2020. [PMCID: PMC7123735 DOI: 10.1007/978-3-030-05070-2_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Up to 10% of patients with cutaneous melanoma will develop recurrent locoregional disease. While surgical resection remains the mainstay of treatment for isolated recurrences, locoregional melanoma can often present as bulky, unresectable disease and can pose a significant therapeutic challenge. This chapter focuses on the natural history of local and regionally recurrent metastases and the multiple treatment modalities which exist for advanced locoregional melanoma, including regional perfusion procedures such as hyperthermic isolated limb perfusion and isolated limb infusion, intralesional therapies, and neo-adjuvant systemic therapy strategies for borderline resectable regional disease. Hyperthermic limb perfusion (HILP) and isolated limb infusion (ILI) are generally well-tolerated and have shown overall response rates between 44% and 90%. Intralesional therapies also appear to be well-tolerated as adverse events are usually limited to the site of injection and minor transient flu-like symptoms. Systemic targeted therapies have shown to have response rates up to 85% when used as neoadjuvant therapy in patients with borderline resectable disease. While combination immunotherapy in the neoadjuvant setting has also shown promising results, this data has not yet matured.
Collapse
|
14
|
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.
Collapse
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.
| |
Collapse
|
15
|
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] [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.
Collapse
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
| |
Collapse
|
16
|
Miura JT, Kroon HM, Beasley GM, Mullen D, Farrow NE, Mosca PJ, Lowe MC, Farley CR, Kim Y, Naqvi SMH, Potdar A, Daou H, Sun J, Farma JM, Henderson MA, Speakman D, Serpell J, Delman KA, Mark Smithers B, Coventry BJ, Tyler DS, Thompson JF, Zager JS. Long-Term Oncologic Outcomes After Isolated Limb Infusion for Locoregionally Metastatic Melanoma: An International Multicenter Analysis. Ann Surg Oncol 2019; 26:2486-2494. [PMID: 30911949 PMCID: PMC7771312 DOI: 10.1245/s10434-019-07288-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive procedure for delivering high-dose regional chemotherapy to patients with locally advanced or in-transit melanoma located on a limb. The current international multicenter study evaluated the perioperative and long-term oncologic outcomes for patients who underwent ILI for stage 3B or 3C melanoma. METHODS Patients undergoing a first-time ILI for stage 3B or 3C melanoma (American Joint Committee on Cancer [AJCC] 7th ed) between 1992 and 2018 at five Australian and four United States of America (USA) tertiary referral centers were identified. The primary outcome measures included treatment response, in-field (IPFS) and distant progression-free survival (DPFS), and overall survival (OS). RESULTS A total of 687 first-time ILIs were performed (stage 3B: n = 383, 56%; stage 3C; n = 304, 44%). Significant limb toxicity (Wieberdink grade 4) developed in 27 patients (3.9%). No amputations (grade 5) were performed. The overall response rate was 64.1% (complete response [CR], 28.9%; partial response [PR], 35.2%). Stable disease (SD) occurred in 14.5% and progressive disease (PD) in 19.8% of the patients. The median follow-up period was 47 months, with a median OS of 38.2 months. When stratified by response, the patients with a CR or PR had a significantly longer median IPFS (21.9 vs 3.0 months; p < 0.0001), DPFS (53.6 vs 12.7 months; p < 0.0001), and OS (46.5 vs 24.4 months; p < 0.0001) than the nonresponders (SD + PD). CONCLUSION This study is the largest to date reporting long-term outcomes of ILI for locoregionally metastatic melanoma. The findings demonstrate that ILI is effective and safe for patients with stage 3B or 3C melanoma confined to a limb. A favorable response to ILI is associated with significantly longer IFPS, DPFS, and OS.
Collapse
Affiliation(s)
- John T Miura
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | | | - Dean Mullen
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | | | - Paul J Mosca
- Department of Surgery, Duke University, Durham, NC, USA
| | - Michael C Lowe
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Clara R Farley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Youngchul Kim
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Aishwarya Potdar
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hala Daou
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Michael A Henderson
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - David Speakman
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Jonathan Serpell
- Discipline of Surgery, The Alfred Hospital, Melbourne, VIC, Australia
| | - Keith A Delman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - B Mark Smithers
- Queensland Melanoma Project, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Brendon J Coventry
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Douglas S Tyler
- Department of Surgery, University Texas Medical Branch, Galveston, TX, 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
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
- University of South Florida Morsani School of Medicine, Tampa, USA.
| |
Collapse
|
17
|
Miura JT, Kroon HM, Zager JS. ASO Author Reflections: International Experience of Isolated Limb Infusion for Melanoma Shows Durable Response. Ann Surg Oncol 2019; 26:2495-2496. [PMID: 31087177 DOI: 10.1245/s10434-019-07435-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Indexed: 11/18/2022]
Affiliation(s)
- John T Miura
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
| |
Collapse
|
18
|
Read T, Lonne M, Sparks DS, David M, Wagels M, Schaider H, Soyer HP, Smithers BM. A systematic review and meta‐analysis of locoregional treatments for in‐transit melanoma. J Surg Oncol 2019; 119:887-896. [DOI: 10.1002/jso.25400] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/13/2019] [Accepted: 01/19/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Tavis Read
- Queensland Melanoma Project, Princess Alexandra HospitalBrisbane Queensland Australia
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
- Griffith University, School of MedicineGold Coast Queensland Australia
| | - Michael Lonne
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| | - David S. Sparks
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| | - Michael David
- The University of Queensland, School of Health and Rehabilitation SciencesBrisbane Queensland Australia
- The University of Newcastle, School of Medicine and Public HealthNewcastle New South Wales Australia
| | - Michael Wagels
- Queensland Melanoma Project, Princess Alexandra HospitalBrisbane Queensland Australia
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| | - Helmut Schaider
- The University of Queensland, Dermatology Research CentreBrisbane Queensland Australia
| | - H. Peter Soyer
- The University of Queensland, Dermatology Research CentreBrisbane Queensland Australia
| | - B. Mark Smithers
- Queensland Melanoma Project, Princess Alexandra HospitalBrisbane Queensland Australia
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| |
Collapse
|
19
|
Read T, Fayers W, Thomas J, Wagels M, Barbour A, Mark Smithers B. Patients with in‐transit melanoma metastases have comparable survival outcomes following isolated limb infusion or intralesional PV‐10—A propensity score matched, single center study. J Surg Oncol 2019; 119:717-727. [DOI: 10.1002/jso.25373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 01/02/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Tavis Read
- Queensland Melanoma ProjectPrincess Alexandra HospitalQueensland HealthBrisbane Queensland Australia
- Faculty of Medicine, The University of Queensland, Southern Clinical School, Princess Alexandra HospitalBrisbane Australia
| | - Warren Fayers
- Queensland Melanoma ProjectPrincess Alexandra HospitalQueensland HealthBrisbane Queensland Australia
| | - Janine Thomas
- Queensland Melanoma ProjectPrincess Alexandra HospitalQueensland HealthBrisbane Queensland Australia
| | - Michael Wagels
- Queensland Melanoma ProjectPrincess Alexandra HospitalQueensland HealthBrisbane Queensland Australia
- Faculty of Medicine, The University of Queensland, Southern Clinical School, Princess Alexandra HospitalBrisbane Australia
| | - Andrew Barbour
- Queensland Melanoma ProjectPrincess Alexandra HospitalQueensland HealthBrisbane Queensland Australia
- Faculty of Medicine, The University of Queensland, Southern Clinical School, Princess Alexandra HospitalBrisbane Australia
| | - B. Mark Smithers
- Queensland Melanoma ProjectPrincess Alexandra HospitalQueensland HealthBrisbane Queensland Australia
- Faculty of Medicine, The University of Queensland, Southern Clinical School, Princess Alexandra HospitalBrisbane Australia
| |
Collapse
|
20
|
Perez MC, Miura JT, Naqvi SMH, Kim Y, Holstein A, Lee D, Sarnaik AA, Zager JS. Talimogene Laherparepvec (TVEC) for the Treatment of Advanced Melanoma: A Single-Institution Experience. Ann Surg Oncol 2018; 25:3960-3965. [PMID: 30298318 DOI: 10.1245/s10434-018-6803-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Talimogene laherparepvec (TVEC) is an oncolytic herpes virus used as intralesional therapy for patients with unresectable stage IIIB through IV melanoma. We reviewed the standard of care treatment of TVEC at a single institution. METHODS All patients treated with TVEC for advanced melanoma were retrospectively evaluated from 2015 to 2018. Patient demographics, clinicopathologic characteristics, treatment response, and toxicity were reviewed. RESULTS Twenty-seven patients underwent therapy with TVEC. Median age was 75 years, and 63% of patients were female. Seventeen (63.0%) patients underwent injections on the lower extremity, four (14.8%) on the upper extremity, four (14.8%) on the head and neck, and two (7.4%) on the trunk. Median number of injections was five. Median follow-up was 8.6 months. Of the 27 patients, 23 patients met the criteria for response analysis with at least 8 weeks follow-up. Ten (43.5%) patients experienced a complete response (CR), three (13.1%) experienced a partial response (PR), and five (21.7%) had stable disease (SD) for an overall response rate of 56.5% (CR + PR) and a disease control rate of 78.3% (CR + PR + SD). Adverse events were mostly limited to mild constitutional symptoms within 48 h of injection. Two patients developed cellulitis treated with oral antibiotics, and one patient underwent excision of a lesion for ulceration and bleeding during therapy. DISCUSSION TVEC is an effective and well-tolerated intralesional therapy for patients with unresectable stage IIIB through IV melanoma. A CR was achieved in almost half of patients treated. Disease control is seen in the vast majority.
Collapse
Affiliation(s)
- Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - John T Miura
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | | | - Youngchul Kim
- Department of Biostatistics, Moffitt Cancer Center, Tampa, FL, USA
| | - Amanda Holstein
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - Daniel Lee
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - Amod A Sarnaik
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA.
| |
Collapse
|
21
|
Turaga KK, Clark Gamblin T, Richard Alexander H, Edwards R, Bartlett DL. Together We Make a Difference. Ann Surg Oncol 2018; 25:1794-1796. [PMID: 29766390 DOI: 10.1245/s10434-018-6338-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Kiran K Turaga
- Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - T Clark Gamblin
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - H Richard Alexander
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, Piscataway Township, NJ, USA
| | - Robert Edwards
- Department of Obstetrics/Gynecology, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
22
|
Regional therapies for locoregionally advanced and unresectable melanoma. Clin Exp Metastasis 2018; 35:495-502. [DOI: 10.1007/s10585-018-9890-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/16/2018] [Indexed: 02/04/2023]
|
23
|
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.
Collapse
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
| |
Collapse
|