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Kibel S, Kuehne N, Ribeiro MF, Muniz TP, Ye XY, Spreafico A, Saibil SD, Sun A, Mak DY, Gray D, Jones B, Wong P, Butler MO. The Role of Adjuvant Radiotherapy for the Treatment of Resected High-Risk Stage III Cutaneous Melanoma in the Era of Modern Systemic Therapies. Cancers (Basel) 2023; 15:5867. [PMID: 38136412 PMCID: PMC10741555 DOI: 10.3390/cancers15245867] [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: 11/12/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Modern adjuvant systemic therapies (STs) have revolutionized the management of stage III melanoma. Currently, the role of adjuvant radiotherapy (RT) remains unclear. In this single-center retrospective study, patients with clinically detectable stage III melanoma with high-risk features for lymph node basin (LNB) recurrence and whose tumors were fully resected with complete lymphadenectomy (CLD) between 2010 and 2019 were assessed. We determined the cumulative incidence (CIF) of LNB recurrence and any disease recurrence or progression using competing risk analysis. A total of 108 patients were identified; the median age was 59 years (24-92), and 74 (69%) were men. A total of 51 (42%) received adjuvant RT, 22 (20%) received adjuvant ST, and 35 (32%) received no adjuvant therapy. The advent of ST changed clinical practice, with a significant increase in the use of adjuvant ST and a decrease in the use of RT when comparing practice patterns before and after 2015 (p < 0.001). The 3-year CIF of LNB recurrence was similar in patients treated with adjuvant RT (6.3%) and adjuvant ST (9.8%). The 3-year CIF of any disease recurrence or progression was lower in patients receiving adjuvant ST (24%) compared to those receiving adjuvant RT (52%) or no adjuvant therapy (55%, p = 0.06). Three-year overall survival (OS) was not significantly different in patients treated with ST compared to those not treated with any ST (p = 0.118). Despite ST replacing RT as the dominant adjuvant treatment modality, this change in practice has not resulted in increased LNB recurrence for patients at high risk of LNB recurrence following CLD.
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Affiliation(s)
- Seth Kibel
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Nathan Kuehne
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Mauricio Fernando Ribeiro
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Thiago P. Muniz
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Xiang Y. Ye
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Anna Spreafico
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Samuel D. Saibil
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Alexander Sun
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - David Y. Mak
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Diana Gray
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Bailie Jones
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Philip Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Marcus O. Butler
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
- Department of Immunology, University of Toronto, Toronto, ON M5S 3H2, Canada
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Meneveau MO, Vavolizza RD, Mohammad A, Kumar P, Manderfield JT, Callahan C, Lynch KT, Abbas T, Slingluff CL, Bekiranov S. A Step Toward Personalized Surgical Decision Making: Machine Learning Predicts 1 Versus Numerous Melanoma Lymph Node Metastases Using RNA-sequencing. Ann Surg 2023; 278:e589-e597. [PMID: 36538614 PMCID: PMC10209351 DOI: 10.1097/sla.0000000000005761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Develop a predictive model to identify patients with 1 pathologic lymph node (pLN) versus >1 pLN using machine learning applied to gene expression profiles and clinical data as input variables. BACKGROUND Standard management for clinically detected melanoma lymph node metastases is complete therapeutic LN dissection (TLND). However, >40% of patients with a clinically detected melanoma lymph node will only have 1 pLN on final review. Recent data suggest that targeted excision of just the single enlarged LN may provide excellent regional control, with less morbidity than TLND. The selection of patients for less morbid surgery requires accurate identification of those with only 1 pLN. METHODS The Cancer Genome Atlas database was used to identify patients who underwent TLND for melanoma. Pathology reports in The Cancer Genome Atlas were reviewed to identify the number of pLNs. Patients were included for machine learning analyses if RNA sequencing data were available from a pLN. After feature selection, the top 20 gene expression and clinical input features were used to train a ridge logistic regression model to predict patients with 1 pLN versus >1 pLN using 10-fold cross-validation on 80% of samples. The model was then tested on the remaining holdout samples. RESULTS A total of 153 patients met inclusion criteria: 64 with one pLN (42%) and 89 with >1 pLNs (58%). Feature selection identified 1 clinical (extranodal extension) and 19 gene expression variables used to predict patients with 1 pLN versus >1 pLN. The ridge logistic regression model identified patient groups with an accuracy of 90% and an area under the receiver operating characteristic curve of 0.97. CONCLUSIONS Gene expression profiles together with clinical variables can distinguish melanoma metastasis patients with 1 pLN versus >1 pLN. Future models trained using positron emission tomography/computed tomography imaging, gene expression, and relevant clinical variables may further improve accuracy and may predict patients who can be managed with a targeted LN excision rather than a complete TLND.
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Affiliation(s)
- Max O. Meneveau
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Rick D. Vavolizza
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Anwaruddin Mohammad
- Bioinformatics Core, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Pankaj Kumar
- Bioinformatics Core, University of Virginia School of Medicine, Charlottesville, VA, USA
- Department of Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, VA, USA
| | | | - Colleen Callahan
- University of Virginia, School of Data Science, Charlottesville, VA, USA
| | - Kevin T. Lynch
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Tarek Abbas
- Department of Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, VA, USA
| | - Craig L. Slingluff
- Department of Surgery/Division of Surgical Oncology and the Human Immune Therapy Center, Cancer Center, University of Virginia, Charlottesville, VA, USA
| | - Stefan Bekiranov
- Department of Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, VA, USA
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Current Controversies in Melanoma Treatment. Plast Reconstr Surg 2023; 151:495e-505e. [PMID: 36821575 DOI: 10.1097/prs.0000000000009936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
LEARNING OBJECTIVES After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. SUMMARY Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.
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King ALO, Lee V, Yu B, Mirza FN, Zogg CK, Yang DX, Tran T, Leventhal J, An Y. Factors associated with the use of adjuvant radiation therapy in stage III melanoma. Front Oncol 2023; 13:1005930. [PMID: 36816935 PMCID: PMC9929351 DOI: 10.3389/fonc.2023.1005930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023] Open
Abstract
Objective The role of radiation therapy (RT) in melanoma has historically been limited to palliative care, with surgery as the primary treatment modality. However, adjuvant RT can be a powerful tool in certain cases and its application in melanoma has been increasingly explored in recent years. The aim of this study is to explore national patterns of care and associations surrounding the use of adjuvant RT for stage III melanoma. Methods The National Cancer Data Base (NCDB) was used to identify patients who were diagnosed with stage III melanoma between 2004 and 2014. Exclusion criteria included those with distant metastatic disease, in-situ histology, no confirmed positive nodes, palliative intent therapy, and dosing regimens inconsistent with National Comprehensive Cancer Network (NCCN) guidelines for adjuvant RT in melanoma. Patients treated with and without adjuvant RT were compared and factors associated with use of adjuvant RT were identified using multivariable logistic regression analyses. Results A total of 7,758 cases of stage III melanoma were analyzed, of which 11.7% received adjuvant RT. The mean age of the overall cohort was 58.5 years, and the majority of patients were male (64.7%), white (96.6%), on private insurance (51.3%), and presented to a non-high-volume facility (90.3%). Multivariable regression analyses revealed that patients who present to the hospital in 2009-2014 as compared to 2004-2008 (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.36-1.92), had 4 or more positive nodes (OR 4.30, 95% CI 3.67-5.04), and had microscopic residual tumor (OR 2.11, 95% CI 1.46-3.04) were more likely to receive adjuvant RT. Factors that were negatively associated with receiving adjuvant RT included female gender (OR 0.72, 95% CI 0.61-0.85) and median income of at least $63,000 (OR 0.66, 95% CI 0.52-0.83). Conclusions This study demonstrates the rising use of RT for stage III melanoma in recent years and identifies demographic, social, clinical, and hospital-specific factors associated with patients receiving adjuvant RT. Further investigation is needed to explore disease benefits to improve guidance on the utilization of RT in melanoma.
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Affiliation(s)
- Amber L. O. King
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Victor Lee
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Beverly Yu
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Fatima N. Mirza
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Daniel X. Yang
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Thuy Tran
- Department of Medicine (Medical Oncology), Yale School of Medicine, New Haven, CT, United States
| | - Jonathan Leventhal
- Department of Dermatology, Yale School of Medicine, New Haven, CT, United States
| | - Yi An
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, United States
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Rossi E, Schinzari G, Cellini F, Balducci M, Pasqualoni M, Maiorano BA, Fionda B, Longo S, Deodato F, Di Stefani A, Peris K, Gambacorta MA, Tortora G. Dabrafenib-Trametinib and Radiotherapy for Oligoprogressive BRAF Mutant Advanced Melanoma. Biomedicines 2023; 11:biomedicines11020394. [PMID: 36830931 PMCID: PMC9953646 DOI: 10.3390/biomedicines11020394] [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: 12/30/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
The clinical management of metastatic melanoma has been changed by BRAF (BRAFi) and MEK inhibitors (MEKi), which represent a standard treatment for BRAF-mutant melanoma. In oligoprogressive melanoma patients with BRAF mutations, target therapy can be combined with loco-regional radiotherapy (RT). However, the association of BRAF/MEK inhibitors and RT needs to be carefully monitored for potential increased toxicity. Despite the availability of some reports regarding the tolerability of RT + target therapy, data on simultaneous RT and BRAFi/MEKi are limited and mostly focused on the BRAFi vemurafenib. Here, we report a series of metastatic melanoma patients who received fractioned RT regimens for oligoprogressive disease in combination with the BRAFi dabrafenib and the MEKi trametinib, which have continued beyond progression. None of the cases developed relevant adverse events while receiving RT or interrupted dabrafenib and trametinib administration. These cases suggest that a long period of dabrafenib/trametinib interruption during radiotherapy for oligoprogressive disease can be avoided. Prospective trials are warranted to assess the efficacy and safety of the contemporary administration of BRAF/MEK inhibitors and radiotherapy for oligoprogressive disease.
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Affiliation(s)
- Ernesto Rossi
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: or
| | - Giovanni Schinzari
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Medical Oncology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Cellini
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Mario Balducci
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | | | - Brigida Anna Maiorano
- Oncology Unit, IRCCS Foundation Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Bruno Fionda
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Silvia Longo
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Deodato
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- UOC Radioterapia Oncologica Molise ART, Gemelli Molise Hospital, 86100 Campobasso, Italy
| | - Alessandro Di Stefani
- Dermatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Ketty Peris
- Dermatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dermatology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Antonietta Gambacorta
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giampaolo Tortora
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Medical Oncology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Sondak VK, Neves RI, Wuthrick EJ, Messina JL, Khushalani NI. Current and future approaches in the surgical management of T3b/T4 primary and locoregionally advanced melanoma. Cancer 2022; 128:3764-3771. [PMID: 36066835 DOI: 10.1002/cncr.34449] [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: 05/19/2022] [Revised: 06/25/2022] [Accepted: 07/14/2022] [Indexed: 11/08/2022]
Abstract
Currently accepted principles of surgical management-margin width, use of sentinel node biopsy, performance of radical node dissections for node-positive cases-and some aspects of postoperative management (use of radiation for desmoplastic melanoma primaries and for clinically node-positive disease) will change in the future with the potential widespread adoption of adjuvant and neoadjuvant therapies.
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Affiliation(s)
- Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Rogerio I Neves
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Reconstructive and Plastic Surgery Program, Moffitt Cancer Center, Tampa, Florida, USA
| | - Evan J Wuthrick
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jane L Messina
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Anatomic Pathology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Nikhil I Khushalani
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Mansour J, Asarkar A, Pang J, Nathan CAO. What Is the Role of Adjuvant Radiotherapy in Head and Neck Melanoma in the Era of Systemic Therapy? Laryngoscope 2022; 132:2085-2086. [PMID: 35147220 DOI: 10.1002/lary.30048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/21/2022] [Accepted: 01/27/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Jobran Mansour
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A
| | - Ameya Asarkar
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A.,Surgical Service, Otolaryngology Section, Overton Brooks VA Medical Center, Shreveport, Louisiana, U.S.A
| | - John Pang
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A
| | - Cherie-Ann O Nathan
- Department of Otolaryngology/Head Neck Surgery, LSU Health, Shreveport, Louisiana, U.S.A.,Surgical Service, Otolaryngology Section, Overton Brooks VA Medical Center, Shreveport, Louisiana, U.S.A
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