The Impact of Surgical Delay in Primary Cutaneous Melanoma: A Systematic Review

BACKGROUND AND OBJECTIVES

The prognosis of patients diagnosed with melanoma is highly dependent on staging, early detection, and early intervention. In this systematic review, the authors aimed to investigate the impact of surgical delay (time between diagnostic biopsy and definitive surgical excision) on melanoma-specific outcomes.

MATERIAL AND METHODS

A systematic review was conducted from Embase (1974-present), MEDLINE (1946-present), Cochrane Central Register of Controlled Trials (2005-present), Scopus, and Web of Science. A total of 977 studies were included for review after removal of duplicates. A total of 10 studies were included for final analysis.

RESULTS

In total, 70% (7/10) of the studies found that longer wait times between initial biopsy and surgical intervention are correlated with lower overall survival. Among the 9 studies that reported overall survival as a percentage, the median and SD overall survival was 82% ± 5.87.

CONCLUSION

There is evidence that prolonged surgical delay in patients diagnosed with Stage I cutaneous melanoma is associated with worsened overall mortality, whereas the effect of surgical delay on overall mortality in Stages II and III melanomas is uncertain. Future prospective studies and randomized clinical trials are needed to better define the appropriate surgical wait times between biopsy and surgical treatment.

[Nuclear medicine procedure guideline for sentinel lymph node localization]

The authors present a procedure guideline for scintigraphic detection of sentinel lymph nodes in malignant melanoma, in breast cancer, in penile and vulva tumors, in head and neck cancer, and in prostate carcinoma. Important goals of sentinel lymph node scintigraphy comprise reduction of the extent of surgery, lower postoperative morbidity and optimization of histopathological examination focussing on relevant lymph nodes. Sentinel lymph node scintigraphy itself does not diagnose tumorous lymph node involvement and is not indicated when lymph node or distant metastases have been definitely diagnosed before sentinel lymph node scintigraphy. Procedures are compiled with the aim to reliably localise sentinel lymph nodes with a high detection rate typically in early tumour stages. New aspects in this guideline are new radiopharmaceuticals such as tilmanocept and Tc-99m-PSMA and SPECT/CT allowing an easier anatomical orientation. Initial dynamic lymphoscintigraphy in breast cancer is of little significance nowadays. Radiation exposure is low so that pregnancy is not a contraindication for sentinel lymph node scintigraphy. A one-day protocol should preferentially be used. Even with high volumes of scintigraphic sentinel lymph node procedures surgeons, theatre staff and pathologists receive a radiation exposure < 1 mSv/year so that they do not require occupational radiation surveillance. Aspects of quality control were included (scintigraphy, quality control of gamma probe, 6 h SLN course for surgeons, certified breast centers, medical surveillance center).

The effect of surgical timing in nonmetastatic melanoma

BACKGROUND AND OBJECTIVES

There is no consensus guidelines on the best timing to perform Sentinel lymph node biopsy (SLNB) in high-risk melanoma patients. We aimed to understand the impact of surgical timing on nodal upstaging in patients with cutaneous melanoma.

METHODS

We queried the National Cancer Database from 2004 to 2018 for patients with T2-T4, N0, M0 melanomas, who underwent melanoma excision and nodal surgery. We included patients who underwent surgery within 2-19 weeks postdiagnosis. We aimed to determine the association of surgical delay (weeks) with nodal positivity.

RESULTS

A total of 53 355 patients were included, of whom 20.9% had positive lymph nodes. Patients underwent surgery at a median of 5 (4-7) weeks after diagnosis. The rate of positive nodes increased with increased weeks to surgery (line of best-fit slope = 0.38). Multivariable regression analysis identified an association between time to surgery and nodal positivity (2.4% increased risk per week, p < 0.05). Our analysis showed significantly increased likelihood of nodal positivity beginning 9 weeks after diagnosis (odds ratio [OR] = 1.3, p < 0.05). Furthermore, patients with T2-3 tumors had a significant increase in nodal positivity with increased time to surgery (OR = 1.03 per week, p < 0.001). However, no significant trend in nodal positivity was identified for patients with T4 melanomas (OR = 1.01 per week, p = 0.596).

CONCLUSION

Surgery within 9 weeks of melanoma diagnosis was not associated with increased likelihood of nodal positivity. These data can guide clinical conversations regarding the importance of surgical timing for melanoma.

Association between surgical delay and outcomes among patients with invasive cutaneous melanoma

BACKGROUND

The relationship between surgical delay and outcomes for patients with cutaneous melanoma is understudied. The objectives of this study were to determine the impact of surgical delay on regional nodal involvement and mortality in patients with cutaneous melanoma.

METHODS

Retrospective study of patients diagnosed with clinically node-negative invasive cutaneous melanoma from 2004 to 2018. Outcomes included regional lymph node disease and overall survival. Multivariable logistic regression and Cox proportional-hazards models were constructed to adjust for pertinent clinical factors.

RESULTS

Of 423,001 patients, 21.8% experienced a surgical delay (≥45 days). These patients were more likely to have nodal involvement (OR1.09; P ​= ​0.01). Surgical delay (HR1.14; P ​< ​0.001), Black race (HR1.34; P ​= ​0.002), and Medicaid (HR1.92; P ​< ​0.001) were associated with lower survival. Patients treated at academic/research (HR0.87; P ​< ​0.001) or integrated network cancer programs (HR0.89; P ​= ​0.001) had improve survival.

CONCLUSIONS

Surgical delay was frequent and resulted in higher rates of lymph node involvement and decreased overall survival.

Regulators CDCA8 as potential targets and biomarkers for the prognosis of human skin cutaneous melanoma

Cutaneous melanoma (CM) is considered as the most malignant skin tumor with high distant metastasis and poor prognosis. Cell division cycle-associated protein (CDCA) family has a role in regulating cell proliferation and modulating immune cell and tumor cell proliferation in the tumor microenvironment to regulate tumor oncogenesis, development and affect patient outcomes. However, the differential expression pattern and prognostic value of CDCA factors (CDCAs) have not been clarified. In this study, the role of CDCAs in CM was analyzed by using bioinformatics and found that the transcriptional expressions of CDCA1/2/3/5/6/8 were upregulating in CM samples than in normal compares. CM patients with downregulated of CDCA1/3/4/5/6/8 and high transcriptional levels of CDCA7 suggest a significantly better prognosis. Furthermore, the significant correlations among the expression of CDCAs and the infiltration of immune cells. In terms of the protein level, we found CDCA8 was upregulated in CM patients. In conclusion, CDCA8 is a powerful prognostic biomarker for CM and can be a novel target for immunotherapy.

Time-to-treatment initiation for cutaneous melanoma reflects disparities in healthcare access in Brazil: a retrospective study

OBJECTIVES

This study aimed at identifying the sociodemographic and first treatment characteristics affecting time-to-treatment initiation (TTI) of patients with cutaneous melanoma assisted by the Brazilian Unified Health System (SUS).

STUDY DESIGN

Retrospective observational study using cutaneous melanoma cases recorded in the Brazilian Hospital-Based Cancer Registries (HBCR).

METHODS

A total of 12,783 cutaneous melanoma cases were included in the analysis. Based on the legislation, TTI in Brazil is 60 days; therefore, the cohort was dichotomized into TTI within 60 days and over. The association among variables was evaluated through the Chi-squared test. Kaplan-Meier method and log-rank hypothesis test were used to determine the probability of initiating treatment within 60 days. Cox proportional hazards regression model was used for multivariate analysis.

RESULTS

Median TTI was 28 days (95% CI, 25-29). First treatment in SUS provided more than 60 days after diagnosis (34.8%) was associated with females; low level of formal education; living or getting treatment in northern Brazil; being diagnosed in SUS and treated at different healthcare facilities, in addition to starting treatment with radiotherapy or systemic therapy. There were no significant differences in access to health care before and after the enactment of the 60-day law.

CONCLUSION

Increased TTI for cutaneous melanoma is associated with sociodemographic and first treatment characteristics in Brazil; approximately one-third of cases did not have access to first treatment within the period established by law. Receiving the diagnosis and treatment at different healthcare facilities (transitions in care) is the main independent factor associated with TTI longer than 60 days.

Current Challenges in Access to Melanoma Care: A Multidisciplinary Perspective

A diagnosis of melanoma requires multidisciplinary specialized care across all stages of disease. Although many important advances have been made for the treatment of melanoma for local and advanced disease, barriers to optimal care remain for many patients who live in areas without ready access to the expertise of a specialized melanoma center. In this article, we review some of the recent advances in the treatment of melanoma and the persistent challenges around the world that prevent the delivery of the best standard of care to patients living in the community. With the therapeutic landscape continuing to evolve and newer more complex drug therapies soon to be approved, it is important to recognize the many challenges that patients face and attempt to identify tools and policies that will help to improve treatment outcomes for their melanoma.

Surgery vs non-surgery in cutaneous melanoma based on SEER database: A cross-sectional study

ABSTRACT

This study was to assess the survival outcome of cutaneous melanoma (CM) patients with surgery vs non-surgery through inverse probability of treatment weighting (IPTW) using the propensity score. Patients diagnosed as CM were selected from the Surveillance, Epidemiology, and End Results Program (SEER) database. The survival outcome was estimated and compared by IPTW using the propensity score. Totally 2203 CM patients were identified, in which 1921 cases received surgical treatment (surgery group), while 282 cases didn't (non-surgery group). The median survival time of surgery and non-surgery groups was respectively 150 months and 15 months (unmatched cohort), 70 months and 40 months (matched cohort) and 130 months vs. 75 months (IPTW-weighted cohort). Compared with the non-surgery group, the surgery group had a lower risk of death in unmatched [hazard ratio (HR): 0.647, 95% confidence interval (CI): 0.509-0.821, P < .001] and matched (HR: 0.636, 95%CI: 0.459-0.882, P < .01) cohorts. In multivariate Cox model of IPTW-weighted cohort, the risk of death in the surgery group decreased notably than the non-surgery group (HR: 0.423, 95%CI: 0.383-0.468, P < .001). In conclusion, CM patients receiving surgical treatment are associated with a better survival outcome compared with those without surgical treatment through IPTW using the propensity score.

MicroRNA-365 promotes apoptosis in human melanoma cell A375 treated with hydatid cyst fluid of Echinococcus granulosus sensu stricto

Hydatid cyst fluid (HCF)-based therapeutics has experimentally targeted approaches for treating human cancer cell lines. MicroRNA-365 (miR-365) has been reported to be an important tumor suppressor miRNA in cancers. However, it remains unknown, how miR-365 plays a pivotal role in inducing apoptosis in HCF-treated cancer cells in vitro. The fertile/infertile HCF was aspirated from liver of infected sheep and in terms of molecular taxonomy was identified as G1 genotype of Echinococcus granulosus sensu stricto. A375 human melanoma cancer cells were cultured into two groups: fertile and infertile HCF-treated A375 cells. To assess the cytotoxicity of various concentrations of HCF on melanoma cells, cell viability was determined by using MTT assay. The IC50 value of HCF on A375 cells was determined 85 μg/mL. Caspase-3 enzymatic activity was evaluated by fluorometric assay in the HCF-treated melanoma cells. In addition, the mRNA expression of Bax, Bcl-2, Caspase-9 and miR-365 were determined by qRT-PCR. Findings of MTT assay showed that concentrations 85 μg/mL to 100 μg/mL of fertile HCF have the highest mortality (50%-52%) on A375 cells during 24 h. The fold change of Bax/Bcl-2 ratio, Caspase-9, miR-365 and Caspase-3 activity was higher in the fertile HCF-treated melanoma cells compared to infertile fluid treated A375 cells and human normal epithelial cell (as control cell). In conclusion, we over-expressed the miR-365 in melanoma A375 cells, via treatment of fertile HCF. Our findings suggested that inducing high expression of miR-365 might be a negative regulator of melanoma growth through activation of pro-apoptotic Bax, Caspase-9 and Caspase-3 that are essential to intrinsic apoptotic pathway. These findings provide new insights into the use of Echinococcus HCF-derived metabolites in the design of drug therapies and in vivo tumor cell vaccine to combat melanoma progression.

Does very early timing of lymph node surgery after resection of the primary tumour improve the clinical outcome of patients with melanoma?

BACKGROUND

In patients with cutaneous melanoma (CM), the time span between resection of the primary tumour and sentinel lymph node biopsy (SLNB) as well as the subsequent interval between SLNB and complete lymph node dissection (CLND) varies greatly.

AIM

To determine whether very early timing of SLNB after resection of the primary tumour, or timing of CLND after SLNB affect the clinical outcome of patients with CM, compared with longer time intervals.

METHODS

We compared the time spans between complete resection of the primary tumour and SLNB, and the interval between SLNB and CLND in a cohort of 896 patients with melanoma who had undergone SLNB. An interval between primary resection and SLNB or between SLNB and CLND of up to 7 days was classified as very early (VE-SLNB and VE-CLND, respectively). This time span was compared with intervals of > 7 days. Univariate and multivariate statistics were performed.

RESULTS

VE-SLNB was significantly associated with the presence of micrometastases. However, this was probably due to tumour thickness being significantly higher in patients with VE-SLNB compared with patients with later SLNB. Importantly, VE-SLNB was not significantly associated with disease relapse and VE-CLND was not associated with melanoma-specific death.

CONCLUSIONS

VE-SLNB and VE-CLND neither improved nor worsened the clinical outcome of patients. Thus, timing of SLNB and CLND has no influence on the overall clinical outcome of patients with melanoma. Our findings support the rational planning of lymph node surgery after resection of the primary tumour and provide help for effective patient counselling.

Development and validation of a Brazilian nomogram to assess sentinel node biopsy positivity in melanoma

BACKGROUND

Although well-established, sentinel node biopsy (SNB) for melanoma is not free from controversies and sometimes it can be questionable if SNB should be considered even for patients who meet the criteria for the procedure. Mathematical tools such as nomograms can be helpful and give more precise answers for both clinicians and patients. We present a nomogram for SNB positivity that has been internally validated.

METHODS

Retrospective analysis of patients who underwent SNB from 2000 to 2015 in a single institution. Single logistic regressions were used to identify variables that were associated to SNB positivity. All variables with a p value < 0.05 were included in the final model. Overall performance, calibration, and discriminatory power of the final multiple logistic regression model were all assessed. Internal validation of the multiple logistic regression model was performed via bootstrap analysis based on 1000 replications.

RESULTS

Site of primary lesion, Breslow thickness, mitotic rate, histologic regression, lymphatic invasion, and Clark level were statistically related to SNB positivity. After internal validation, a good performance was observed as well as an adequate power of discrimination (area under the curve 0.751).

CONCLUSIONS

We have presented a nomogram that can be helpful and easily used in daily practice for assessing SNB positivity.

Timing of sentinel node biopsy independently predicts disease-free and overall survival in clinical stage I-II melanoma patients: A multicentre study of the Italian Melanoma Intergroup (IMI)

Background

Sentinel lymph node biopsy (SNB) still remains a key procedure to appropriately stage melanoma patients and to select those who are candidate to novel treatments with immunotherapy and targeted therapy in the adjuvant setting. The impact of timing of SNB on disease-free survival (DFS) and overall survival (OS) is still unclear.

Material and methods

The study was conducted at 6 Italian Melanoma Intergroup (IMI) centres and included 8953 consecutive clinical stage I-II melanoma patients who were diagnosed, treated, and followed up between November 1997 and March 2018. All patients were prospectively included in dedicated IMI database. Multivariable Cox regression analyses were performed to investigate how baseline characteristics and time interval until SNB are related to DFS and OS.

Results

Considering the whole population, at multivariable analysis, after adjusting for age, gender, Breslow thickness, site, ulceration, and the SNB status, a delay in the timing of SNB was associated with a better DFS (adjusted hazard ratio [aHR, delayed versus early SNB] 0.98, 95% confidence interval [CI] 0.97–0.99, p < 0.001) and OS (aHR 0.98, 95% CI 0.97–0.99, p = 0.001). Specifically, in patients with a negative SNB status, a beneficial impact of delayed SNB (i.e. at least 32 days after primary excision) was confirmed for DFS (aHR 0.70, 95%CI 0.63–0.79, p < 0.001) and OS (aHR 0.69, 95%CI 0.61–0.78, p < 0.001), whereas in those with a positive SNB status, DFS (aHR 0.96, 95%CI 0.84–1.09, p = 0.534) and OS (aHR 0.94 95%CI 0.81–1.08, p = 0.374) were not significantly different in patients with early or delayed SNB.

Conclusions

Our study does not support a strict time interval for SNB. These results may be useful for national guidelines, for counselling patients and reducing the number of high urgency referrals.

Malignant Melanoma: Diagnostic and Management Update

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Summarize the changes to the American Joint Committee on Cancer Eighth Edition Melanoma Staging System. 2. List advances in genetic, molecular, and histopathologic melanoma diagnosis and prognostication. 3. Recommend sentinel lymph node biopsy and appropriate surgical margins based on individualized patient needs. 4. Recognize the currently available treatments for in-transit metastasis and advanced melanoma. 5. Describe current and future therapies for melanoma with distant visceral or brain metastases.

SUMMARY

Strides in melanoma surveillance, detection, and treatment continue to be made. The American Joint Committee on Cancer Eighth Edition Cancer Staging System has improved risk stratification of patients, introduced new staging categories, and resulted in stage migration of patients with improved outcomes. This review summarizes melanoma advances of the recent years with an emphasis on the surgical advances, including techniques and utility of sentinel node biopsy, controversies in melanoma margin selection, and the survival impact of time-to-treatment metrics. Once a disease manageable only with surgery, a therapeutic paradigm shift has given a more promising outlook to melanoma patients at any stage. Indeed, a myriad of novel, survival-improving immunotherapies have been introduced for metastatic melanoma and more recently in the high-risk adjuvant setting.

MicroRNA-365 Inhibits Cell Growth and Promotes Apoptosis in Melanoma by Targeting BCL2 and Cyclin D1 (CCND1)

BACKGROUND MicroRNA-365 (miR-365) is involved in the development of a variety of cancers. However, it remains largely unknown if and how miRNAs-365 plays a role in melanoma development. MATERIAL AND METHODS In this study, we overexpressed miR-365 in melanoma cell lines A375 and A2058, via transfection of miR-365 mimics oligos. We then investigated alterations in a series of cancer-related phenotypes, including cell viability, cell cycle, apoptosis, colony formation, and migration and invasion capacities. We also validated cyclin D1 (CCND1) and BCL2 apoptosis regulator (BCL2) as direct target genes of miR-365 by luciferase reporter assay and investigated their roles in miR-365 caused phenotypic changes. To get a more general view of miR-365's biological functions, candidate target genes of miR-365 were retrieved via searching online databases, which were analyzed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses for potential biological functions. We then analyzed The Cancer Genome Atlas (TCGA) Skin Cutaneous Melanoma (SKCM) dataset for correlation between miR-365 level and clinicopathological features of patients, and for survival of patients with high and low miR-365 levels. RESULTS We found that miR-365 was downregulated in melanoma cells. Overexpression of miR-365 remarkably suppressed cell proliferation, induced cell cycle arrest and apoptosis, and compromised the migration and invasion capacities in A375 and A2058 cell lines. We also found that the phenotypic alterations by miR-365 were partially due to downregulation of CCND1 and BCL2 oncogenes. The bioinformatics analysis revealed that predicted targets of miR-365 were widely involved in transcriptional regulation and cancer-related signaling pathways. However, analysis of SKCM dataset failed to find differences in miR-365 level among melanoma patients at different clinicopathologic stages. The Kaplan-Meier analysis also failed to discover significant differences in overall survival and disease-free survival between patients with high and low miR-365 levels. CONCLUSIONS Our findings suggested that miR-365 might be an important novel regulator for melanoma formation and development, however, the in vivo roles in melanoma developments need further investigation.