Routine Imaging of Asymptomatic Melanoma Patients With Metastasis to Sentinel Lymph Nodes Rarely Identifies Systemic Disease

Classification and Staging of Melanoma in the Head and Neck

The rates of melanoma continue to rise, with recent estimates have shown that 18% to 22% of new melanoma cases occur within the head and neck in the United States each year. The mainstay of treatment of nonmetastatic primary melanomas of the head and neck includes the surgical resection and management of regional disease as indicated. Thorough knowledge of the classification and staging of melanoma is paramount to evaluate prognosis, determine the appropriate surgical intervention, and assess eligibility for adjuvant therapy and clinic trials. The traditional clinicopathologic classification of melanoma is based on morphologic aspects of the growth phase and distinguishes 4 of the most common subtypes as defined by the World Health Organization: superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. The data used to derive the AJCC TNM Categories are based on superficial spreading melanoma and nodular subtypes. Melanoma is diagnosed histopathologically following initial biopsy that will assist with classifying the tumor to guide treatment. Classification is based on tumor thickness and ulceration (T stage, Breslow Staging), Regional Lymph Node Involvement (N Stage), and presence of metastasis (M Stage). Tumor thickness (Breslow thickness) and ulceration are 2 independent prognostic factors that have been shown to be the strongest predictors of survival and outcome. Clark level of invasion and mitotic rate are no longer incorporated into the current AJCC staging system, but still have shown to be important prognostic factors for cutaneous melanoma. For patients with metastatic (Stage IV) disease Lactate Dehydrogenase remains an independent predictor of survival. The Maxillofacial surgeon must remain up to date on the most current management strategies in this patient population. Classification systems and staging provide the foundation for clinical decision making and prognostication for the Maxillofacial surgeon when caring for these patients.

Preoperative Screening CT and PET/CT Scanning for Acral Melanoma: Is it Necessary?

The efficacy of preoperative imaging for acral melanoma (AM) has not been fully evaluated. We examined the accuracy of imaging modalities in the detection of nodal and distant metastases in patients with AM. A retrospective review of 109 patients with AM was performed. All patients had no clinical signs suggestive of distant metastases, and underwent preoperative screening computed tomography (CT) and positron emission tomography (PET)/CT scans. Of 100 patients without lymphadenopathy, 17 patients were suspected of having nodal metastasis in CT and PET/CT, but only two of them were confirmed on histopathological analysis. On the other hand, 12 out of 83 negatively imaged patients showed histopathological signs of nodal metastasis; thus, the sensitivity and specificity of nodal detection were 14.3% and 82.6%, respectively. Regard to the detection of distant metastases, four patients were suspected of having metastasis, but this was later ruled out. The remaining 96 negatively imaged patients were confirmed to have no metastasis at the time of CT and PET/CT by the follow-up. In contrast, distant metastases were found by CT and PET/CT in four of nine patients (44.4%) with lymphadenopathy. Routine preoperative CT and PET/CT for AM patients without lymphadenopathy may not be warranted because of low sensitivity and specificity, but it can be considered for those with lymphadenopathy.

The utility of initial staging PET-CT as a baseline scan for surveillance imaging in stage II and III melanoma

BACKGROUND

This study evaluates the utility of whole-body PET-CT for the initial staging and subsequent surveillance imaging of patients with completely resected stage II and stage III melanoma.

METHODS

A single-center, retrospective review of patients who received perioperative whole-body PET-CT from January 1, 2005 to December 1, 2019 within three months of initial melanoma diagnosis was performed.

RESULTS

Of 258 total patients with completely resected melanoma who had a PET-CT within 3 months after their melanoma diagnosis, 113 had stage II and 145 had stage III melanoma. PET-CT detected distant metastasis in 3 (2.7%) of 113 stage II patients and 7 (4.8%) of 145 stage III patients. 179 of 258 patients had adequate follow-up time to determine whether they received surveillance cross-sectional imaging and whether they had a melanoma recurrence. 143 (79.9%) received subsequent surveillance imaging, 74 of whom developed a recurrence. In 64 (86.5%) of 74 cases, recurrence was detected by routine surveillance. 26 (34.2%) of 76 stage II and 65 (63.1%) of 103 stage III patients developed a recurrence. The median time to recurrence among the 179 patients for stage II and III was 16.3 and 13.0 months, respectively.

CONCLUSIONS

These findings indicate that baseline staging with whole-body PET-CT rarely provides information that changes initial management. Rather, the value of the initial PET-CT is as a baseline for subsequent surveillance scans. Therefore, it may be premature to discourage cross-sectional imaging for patients with stage II and III melanoma without supportive evidence or a reliable biomarker of recurrent disease.

Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma

BACKGROUND

Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used.

OBJECTIVES

Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity.

MAIN RESULTS

We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT.

AUTHORS' CONCLUSIONS

Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.

Guidelines of care for the management of primary cutaneous melanoma

The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.

Futility of imaging to stage melanoma patients with a positive sentinel lymph node

The use of staging imaging in melanoma patients with a positive sentinel lymph node (SLN) has been reported to be of limited value. Improved accuracy resulting from the development of time-of-flight positron emission tomography (PET) and ongoing image quality improvement of computed tomography (CT) may challenge this statement. Our retrospective study assessed the clinical value of routine staging CT and PET/CT imaging in a recent cohort of asymptomatic SLN-positive patients. Between January 2011 and April 2014, 143 patients with a positive SLN were routinely staged using CT of various parts of the body or whole-body PET/CT. Scores were assigned for level of certainty for regional or distant metastases and incidental second primary malignancies. Diagnostic test performance was assessed, as well as the number and nature of ensuing additional diagnostic actions. CT was performed in 102 of 143 (71%) patients and PET/CT in 41 (29%) patients. The use of PET/CT increased over the study period. Metastases were found in two of the 143 patients (true-positive yield 1.4%). Sensitivity, specificity and positive predictive value were 11, 73 and 4% for CT and 17, 57 and 6%, respectively, for PET/CT. None of the 143 patients had a change in AJCC stage. Two other primary malignancies were found. Twenty-one (15%) patients were subjected to 37 additional investigations, referrals or procedures. Routine staging imaging with CT or PET/CT in SLN-positive patients is not useful. The yield is low and the results are often false positive, leading to unnecessary additional tests, most of which are costly and some potentially morbid.

Benefits of initial CT staging before sentinel lymph node biopsy in patients with head and neck cutaneous melanoma

BACKGROUND

The value of CT at the time of diagnosis for patients with cutaneous head and neck melanoma clinically asymptomatic for metastatic disease is unclear.

METHODS

A retrospective medical chart review was performed on 198 consecutive patients identified with primary T1b-T4b head and neck melanoma clinically asymptomatic for metastatic disease referred for sentinel lymph node biopsy procedures between 2004 and 2014.

RESULTS

Initial CTs identified clinically occult melanoma metastases in 8.1% and advanced second primary tumors in 3.5% of patients. CT findings were false-negative in 1% and false-positive in 6% of patients. Overall survival (OS) for patients with true-positive CT findings was lower than for the other patients (P < .001).

CONCLUSION

CT imaging when staging patients with head and neck melanoma seems to identify more metastases than has been reported for melanoma at other sites. Preoperative CTs decreased the number of sentinel lymph node biopsy (SLNBs), thus avoiding the stress and cost of this surgical procedure in 12% of patients.

Melanoma patient imaging in the era of effective systemic therapies

Imaging plays a critical role in the current multi-disciplinary management of patients with melanoma. It is used for primary disease staging, surgical planning, and surveillance in high-risk patients, and for monitoring the effects of systemic or loco-regional therapies. Several different imaging modalities have been utilised in the past. Contemporary imaging practises vary geographically depending on clinical guidelines, physician preferences, availability and cost. Targeted therapies and immunotherapies have revolutionised the treatment of patients with metastatic melanoma over the last few years. With this have come new patterns of disease that were not observed after conventional therapies, and new criteria to assess therapeutic responses. In this article we review the role of imaging for patients with melanoma in the era of effective systemic therapies and discuss likely future developments.

Melanoma and pregnancy

Melanoma is the most common cancer in women during their reproductive years and kills more young Australians than any other single cancer. Care of women whose pregnancy is complicated by a diagnosis of malignancy is complex. The risk of delaying treatment to the mother, the short-term and long-term risks of premature delivery to the child, and the immediate risks to the foetus and long-term risks to the child of maternal treatment with surgery, radiotherapy or medical therapies must be considered.

Detection of Metastases in Patients with Cutaneous Melanoma Using FDG-PET/CT

This study aimed to detect metastases in patients with stage III or IV cutaneous melanoma by 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT). Thirty-nine patients with clinically evident stage III or IV melanoma underwent whole-body FDG-PET/CT scans for metastatic disease and these results were compared with those of biopsy. Scans for 38 of the patients were evaluated; one patient's scan could not be evaluated. There were 11 true-positive, two false-positive, 24 true-negative and one false-negative scans for the detection of melanoma metastases, with sensitivity 91%, specificity 92%, accuracy 92%, and positive and negative predictive values 84% and 96%, respectively. False-positive FDG-PET/CT scans were due to sarcoidosis in the lung and infected cyst in the liver. It is concluded that FDG-PET/CT scanning has high sensitivity and specificity for detecting stage III or IV metastatic melanoma.

Staging studies for cutaneous melanoma in the United States: a population-based analysis

BACKGROUND

Routine cross-sectional imaging for staging of early-stage cutaneous melanoma is not recommended. This study sought to investigate the use of imaging for staging of cutaneous melanoma in the United States.

METHODS

Patients with nonmetastatic cutaneous melanoma newly diagnosed between 2000 and 2007 were identified from the Surveillance Epidemiology End Results-Medicare registry. Any imaging study performed within 90 days after diagnosis was considered a staging study.

RESULTS

The study identified 25,643 patients, 3,116 (12.2 %) of whom underwent cross-sectional imaging: positron emission tomography (PET) (7.2 %), computed tomography (CT) (5.9 %), and magnetic resonance imaging (MRI) (0.6 %). From 2000 to 2007, the use of cross-sectional imaging increased from 8.7 to 16.1 % (p < 0.001), driven predominantly by increased usage of PET (4.2-12.1 %). Stratification by T and N classification showed that cross-sectional imaging was used for 8.6 % of T1, 14.3 % of T2, 18.6 % of T3, and 26.7 % of T4 tumors (p < 0.001) and for 33.3 % of node-positive patients versus 11.1 % of node-negative patients (p < 0.001). Factors predictive of cross-sectional imaging included T classification [odds ratio (OR) for T4 vs T1, 2.66; 95 % confidence interval (CI) 2.33-3.03], node positivity (OR 2.70; 95 % CI 2.36-3.10), more recent year of diagnosis (OR 2.05 for 2007 vs 2000; 95 % CI 1.74-2.42), atypical histology, and non-Caucasian race (OR 1.32; 95 % CI 1.02-1.73).

CONCLUSIONS

The use of cross-sectional imaging for staging of early-stage cutaneous melanoma is increasing in the Medicare population. Better dissemination of guidelines and judicious use of imaging should be encouraged.

Lymph node dissection for stage III melanoma

Locoregional spread of melanoma to its draining lymph node basin is the strongest negative prognostic factor for patients. Exclusive of clinical trials, patients with sentinel lymph node-positive (microscopic) or clinically palpable (macroscopic) nodal disease should undergo lymphadenectomy. This article reviews the management and technical aspects of surgical care for regional metastases. Adjunct therapies (immunotherapy, targeted therapy, and radiation) may supplement lymphadenectomy in certain patient populations. Surgical morbidity after lymphadenectomy can be substantial, creating opportunities for improvement via minimally invasive techniques or refined patient selection.

Comparative effectiveness in melanoma

The worldwide incidence of melanoma continues to rise. It is a leading cause of cancer death and the second leading cause of loss of productive years of life. Although the diagnosis of melanoma is straightforward, there remain many controversies regarding treatment and surveillance. This chapter addresses important questions in melanoma treatment such as sentinel lymph node biopsy, what to do with a positive sentinel lymph node, margins of resection for melanoma, radiation for primary, nodal and metastatic melanoma, and routine use imaging. Through this chapter, the evidence for these controversial subjects and the barriers to resolution will be elucidated.

Is sentinel lymph node biopsy the standard of care for cutaneous head and neck melanoma?

OBJECTIVES/HYPOTHESIS

Sentinel lymph node biopsy (SLNB) is considered one of the most important melanoma advancements to date. Since its inception in 1992, a plethora of data and associated controversies has emerged leading to the question: Is SLNB considered the standard of care for head and neck (HN) cutaneous melanoma?

STUDY DESIGN

English literature (1990-2014) review.

METHODS

The PubMed database search was conducted using key terms "melanoma" and "sentinel node." This review included both dedicated HN SLNB studies and larger prospective SLNB studies, in which HN patients were included among the cohort. Bibliography cross-referencing was conducted to ensure a comprehensive search.

RESULTS

SLNB is safe and accurate in the HN region. Review of large prospective SLNB trials identified the pathologic status of the SLN as the most important prognostic factor for recurrence and survival. Early lymphadenectomy following a positive SLNB imparts a survival benefit.

CONCLUSIONS

Our review of the current literature suggests that SLNB is the standard of care for selected cases of HN cutaneous melanoma. It is now incorporated into the American Joint Committee on Cancer staging system, the National Comprehensive Cancer Network practice guidelines, and numerous national and international consensus statements.

Preoperative imaging for early-stage cutaneous melanoma: predictors, usage, and utility at a single institution

BACKGROUND

Preoperative imaging for early-stage cutaneous melanoma is not recommended by current guidelines. Our goal was to investigate our institutional usage and utility.

METHODS

Patients with clinically node-negative cutaneous melanoma undergoing surgery with sentinel lymph node biopsy were identified retrospectively. Any melanoma-related imaging after diagnosis and before surgery was considered a staging study.

RESULTS

Five hundred fifteen studies were performed in 409 of 546 (75%) patients. Chest x-rays was performed in 70% and advanced imaging in 14% (computed tomography imaging, magnetic resonance imaging, ultrasound, and positron-emission computed tomography imaging). No metastatic lesions were identified. A Breslow thickness greater than 4 mm (odds ratio = 6.46 vs <1 mm; 95% confidence interval, 2.07 to 20.15) and male sex (odds ratio = 2.62 vs female; 95% confidence interval, 1.26 to 5.46) were associated with an increased likelihood of advanced imaging.

CONCLUSIONS

Preoperative imaging was performed in the majority of patients with node-negative melanoma, with 14% undergoing advanced studies. No metastatic lesions were identified, confirming the limited utility in this setting.

Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors

Background

The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases.

Methods

Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases.

Results

The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001).

Conclusions

Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further.

Dermatology of the head and neck: skin cancer and benign skin lesions

Skin lesions are extremely common, and early detection of dangerous lesions makes skin cancer one of the most highly curable malignancies. By simply becoming aware of common lesions and their phenotypic presentation, dental professionals are empowered to detect suspicious dermatologic lesions in unaware patients. This article serves as an introduction to skin cancer and benign skin lesions for dental professionals.

Preoperative FDG-PET/CT Is an Important Tool in the Management of Patients with Thick (T4) Melanoma

The yield of preoperative PET/CT (PET/CT) for regional and distant metastases for thin/intermediate thickness melanoma is low. Objective of this study is to determine if PET/CT performed for T4 melanomas helps guide management and alter treatment plans. Methods. Retrospective cohort of 216 patients with T4 melanomas treated at two tertiary institutions. Fifty-six patients met our inclusion criteria (T4 lesion, PET/CT and no clinical evidence of metastatic disease). Results. Fifty-six patients (M: 32, F: 24) with median tumor thickness of 6 mm were identified. PET/CT recognized twelve with regional and four patients with metastatic disease. Melanoma-related treatment plan was altered in 11% of the cases based on PET/CT findings. PET/CT was negative 60% of the time, in 35% of the cases; it identified incidental findings that required further evaluation. Conclusion. Patients with T4 lesions, PET/CT changed the treatment plan 18% of the time. Regional findings changed the surgical treatment plan in 11% and the adjuvant plan in 7% of our cases due to the finding of metastatic disease. Additionally 20 patients had incidental findings that required further workup. In this subset of patients, we feel there is a benefit to PET/CT, and further studies should be performed to validate our findings.

PET/CT in the management of patients with stage IIIC and IV metastatic melanoma considered candidates for surgery: evaluation of the additive value after conventional imaging

OBJECTIVE

The purpose of this article is to determine how often unexpected (18)F-FDG PET/CT findings result in a change in management for patients with stage IV and clinically evident stage III melanoma with resectable disease according to conventional imaging.

SUBJECTS AND METHODS

Thirty-two patients with oligometastatic stage IV and clinically evident stage III melanoma were identified by surgical oncologists according to the results of conventional imaging, which included contrast-enhanced CT of the chest, abdomen, and pelvis and MRI of the brain. The surgical plan included resection of known metastases or isolated limb perfusion with chemotherapy. Thirty-three FDG PET/CT scans were performed within 36 days of their contrast-enhanced CT. The impact of PET/CT was defined as the percentage of cases in which a change in the surgical plan resulted from the unanticipated PET/CT findings.

RESULTS

PET/CT revealed unexpected melanoma metastases in 12% of scans (4/33). As a result, the surgery was canceled for two patients, and the planned approach was altered for another two patients to address the unexpected sites. In 6% of scans (2/33), the unexpected metastases were detected in the extremities, which were not included in conventional imaging. Three scans (9%) showed false-positive FDG-avid findings that proved to be benign by subsequent stability or resolution with no therapy.

CONCLUSION

In patients with surgically treatable metastatic melanoma, FDG PET/CT can detect unexpected metastases that are missed or not imaged with conventional imaging, and can be considered as part of preoperative workup.

Head and neck melanoma

The incidence of malignant melanoma appears to be increasing at an alarming rate throughout the world over the past 30–40 years and continues to increase in the United States, Canada, Australia, Asia, and Europe. The behavior of head and neck melanoma is aggressive, and it has an overall poorer prognosis than that of other skin sites. The authors review the published literature and text books, intending to give an overall picture of malignant melanomas of the head and neck and a special emphasis on treatment considerations with controversies in treatment including biopsy, radiation therapy, sentinel node biopsy, and nodal dissection.

Cutaneous malignancies of the upper extremity

Cutaneous malignancies are the most common primary malignancies of the hand. The hand surgeon may be the first physician to see these patients or may have the patients referred to them because of expertise in this anatomical region. This article reviews diagnosis and treatment, including margin of resection and need for sentinel lymph node biopsy, for the 3 most common cutaneous malignancies: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma.

Outcomes for lymph node-positive cutaneous melanoma over two decades

BACKGROUND

Our aim was to demonstrate that, despite advances in treatment and surveillance of node-positive cutaneous melanoma, rates of overall survival (OS) and melanoma-specific survival (MSS) have not changed over the last two decades.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute to identify patients with node-positive cutaneous melanoma. Patients were categorized by treatment era; the first era encompassed patients diagnosed from 1988 to 1999 and the second era 2000 to 2006. Multivariate Cox proportional hazards models compared rates of OS and MSS between treatment eras while controlling for known prognostic factors. We reported risks of death as hazard ratios (HR) with 95% confidence intervals (CI) and set significance at P≤0.05.

RESULTS

Entrance criteria were met by 6,868 patients, 1,631 (23.8%) treated in era I and 5,237 (76.3%) treated in era II. On multivariate analysis, era II patients did not demonstrate a significantly different risk of death from any cause (HR 0.89, CI 0.79-1.01; P<0.08), but they did have a lower risk of melanoma-specific mortality (HR 0.81, CI 0.71-0.93; P=0.003) relative to their era I counterparts.

CONCLUSIONS

Over nearly two decades, MSS but not OS has improved for AJCC stage III melanoma patients. Stage migration is likely responsible for any improvement in MSS among patients in the most recently diagnosed era.

Guidelines for lymphoscintigraphy and F18 FDG PET scans in melanoma

Melanoma has a high potential to develop metastases. Accurate staging is essential for appropriate management. Sentinel node (SN) status is a powerful prognostic factor in early stage melanoma. Staging is assisted by SN biopsy after lymphoscintigraphy to locate all true SNs prior to biopsy. PET using F18-FDG can detect metastases and is used to restage patients with AJCC Stages III and IV disease before planning surgery with curative intent.

Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology

The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.

Utility of 3-year torso computed tomography and head imaging in asymptomatic patients with high-risk melanoma

There is no general consensus regarding the optimal follow-up strategy for patients with melanoma. We sought to determine the utility and cost effectiveness of radiological restaging of patients with stage IIB-IIIC melanoma at the 3-year follow-up time point. A retrospective review of 210 patients diagnosed with stage IIB-IIIC melanoma seen in the Cutaneous Oncology Program at Beth Israel Deaconess Medical Center between January, 2001 and July, 2006 was conducted. Fifty-two patients were asymptomatic and continuously disease free and underwent restaging head computed tomography (CT) or MRI and torso CT scans 3 years after completion of local-regional therapy or initiation of adjuvant treatment. True positive, false positive and normal scans were identified and the cost per diagnosis calculated. Fifty-five percent of patients developed melanoma recurrences: 88% before 3 years (median time to recurrence 12 months, 95% confidence interval: 10-16 months). The majority of patients (69%) recurred with disease symptoms. Twenty-five head CT scans, 27 head MRIs, and 52 torso CTs were performed. One false-positive head CT and five abnormal torso CT scans (three false positive, two true positive) were identified. The total cost per diagnosis was $312,990. Extensive 3-year restaging imaging seems to be of limited value for symptomatic and continuously disease-free patients with stage IIB-IIIC melanoma. Furthermore, given the low risk of recurrence beyond 3 years, it is likely that subsequent routine imaging would have similarly low utility.

Office management of melanoma patients

As the incidence of melanoma continues to increase, so does the role of the dermatologist as both medical and surgical oncologist for these patients. The dermatologist holds a key role in all phases of care, including prevention, diagnosis, treatment, and follow-up. The dermatologist is best trained to complete a full and thorough skin examination and is best able to recognize a melanoma in its early stages of growth. Dermatologists have a unique opportunity to prevent melanoma through appropriate patient education concerning sun protection, self skin examinations, and the ABCDEs of melanoma recognition (ie, asymmetry, border irregularity, color variations, dimension and evolution). The dermatologist is well trained to obtain an appropriate full-thickness skin biopsy and is knowledgeable to interpret the pathologist report and understand the significance of the various histologic prognostic indexes. Most patients present with localized disease and with thinner Breslow depth and thus can be skillfully treated in an outpatient setting under local anesthesia by a dermatologist.

Treatment of cutaneous melanoma: current approaches and future prospects

Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.

Treatment of cutaneous melanoma: current approaches and future prospects

Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.

Staging of cutaneous melanoma

The American Joint Committee on Cancer (AJCC) staging of cutaneous melanoma is a continuously evolving system. The identification of increasingly more accurate prognostic factors has led to major changes in melanoma staging over the years, and the current system described in this review will likely be modified in the near future. Likewise, application of new imaging techniques has also changed the staging work-up of patients with cutaneous melanoma. Chest and abdominal computed tomography (CT) scanning is most commonly used for evaluation of potential metastatic sites in the lungs, lymph nodes and liver, and is indicated in patients with new symptoms, anaemia, elevated lactate dehydrogenase or a chest X-ray abnormality. CT scans should be restricted to patients with high-risk melanoma (stage IIC, IIIB, IIIC and stage IIIA with a macroscopic sentinel lymph node). Magnetic resonance imaging (MRI) of the brain is a mandatory test in patients with stage IV, optional in stage III and not used in patients with stage I and II disease. Positron emission tomography (PET)/CT is more accurate than CT or MRI alone in the diagnosis of metastases and should complement conventional CT/MRI imaging in the staging work-up of patients who have solitary or oligometastatic disease where surgical resection is most relevant.

Role of radiologic imaging at the time of initial diagnosis of stage T1b-T3b melanoma

BACKGROUND

In patients with T1b-T3b cutaneous melanoma the utility of radiologic imaging at the time of diagnosis is unclear. Whether initial imaging led to a change in stage or treatment plan was investigated.

METHODS

The melanoma database was searched for patients with T1b-T3b primary lesions, clinically N0, and asymptomatic for metastatic disease. Radiologic studies conducted before wide local excision +/- sentinel lymph node biopsy as well as all further imaging and investigations were analyzed. Outcome measures included upstaging, change in initial surgical management, true-positive, false-positive, true-negative, and false-negative rates of each imaging modality.

RESULTS

In all, 344 preoperative imaging studies (chest x-ray [CXR], computed tomography [CT], positron emission tomography [PET]/CT) were performed on 158 patients, resulting in 49 findings suspicious for metastatic melanoma and 134 findings suggestive of nonmelanoma pathology. Only 1 of 344 (0.3%) studies, a PET/CT, correlated with confirmed metastatic melanoma. The false-positive rates were CXR 5 of 7 (71.4%), chest CT 21 of 24 (87.5%), abdomen/pelvis CT 10 of 11 (90.9%), head CT 2 of 2 (100.0%), PET/CT 3 of 5 (60.0%). No patient was upstaged or had a change in initial surgical management based on preoperative imaging. The cost of all initial imaging and imaging to follow-up abnormal findings was estimated as $555,308 for the 158 patients studied.

CONCLUSIONS

Imaging at the time of initial diagnosis of T1b-T3b, clinically N0, M0 melanoma was of low yield with a high false-positive rate, and did not lead to upstaging or change in initial surgical management. These findings suggest that imaging of asymptomatic patients at the time of diagnosis may not be warranted.

Yield and Predictors of Radiologic Studies for Identifying Distant Metastases in Melanoma Patients with a Positive Sentinel Lymph Node Biopsy

BACKGROUND

It is common to obtain radiological studies around the time of a positive sentinel lymph node biopsy (SLNB) to exclude patients with distant metastases from completion lymph node dissection. The yield of such a work-up is unknown.

METHODS

Patients were identified from a prospectively maintained database. Medical records were reviewed.

RESULTS

Over an 8-year period, 181 patients had a positive SLNB. At least one study (computed tomography or magnetic resonance imaging of the brain; chest x-ray; computed tomography of the thorax, abdomen, or pelvis; positron-emission tomography scan; or bone scan) was obtained around the time of SLNB in 178 patients (98%). Studies were obtained after SLNB in 107 patients (59%). Studies ordered after SLNB resulted in indeterminate findings in 51 patients (48% of those studied). Among patients tested after SLNB, four were found to have metastatic disease (positive rate 3.7%). All of these patients had both a thick melanoma and macrometastasis within the SLN. The number of patients with indeterminate findings would be decreased and the yield of the work-up increased by 4 fold, by restricting the work-up to those with thick melanoma and macrometastasis.

CONCLUSIONS

Radiological studies obtained after a positive SLN produce indeterminate findings in about half of the patients and identify distant disease in 3.7%. Restricting work-up to patients with thick melanoma and macrometastasis on SLNB would spare patients from indeterminate findings and increase the yield of the evaluation.

Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment

Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.

Imaging Studies in Patients with Melanoma

The incidence of malignant cutaneous melanoma is rising. Imaging studies represent a major component of the staging work-up and follow-up of melanoma patients and are used to facilitate preoperative planning and intraoperative management. Study benefits are not clear, and evidence does not support any particular protocol for their use. The National Comprehensive Cancer Network's updated guidelines for use of imaging studies in melanoma patients represent a consensus based on lower level evidence, including clinical experience. The utility of individual imaging studies in melanoma patients depends on disease stage. Chest radiography, CT, MRI, lymphoscintigraphy, ultrasonography, PET, and PET/CT have specific roles in patient evaluation. Clinicians must use available evidence to guide decisions regarding which imaging modalities are appropriate for a given indication.