Adjuvant therapy of malignant melanoma and the role of sentinel node mapping

MicroRNA profiles discriminate among colon cancer metastasis

MicroRNAs are being exploited for diagnosis, prognosis and monitoring of cancer and other diseases. Their high tissue specificity and critical role in oncogenesis provide new biomarkers for the diagnosis and classification of cancer as well as predicting patients' outcomes. MicroRNAs signatures have been identified for many human tumors, including colorectal cancer (CRC). In most cases, metastatic disease is difficult to predict and to prevent with adequate therapies. The aim of our study was to identify a microRNA signature for metastatic CRC that could predict and differentiate metastatic target organ localization. Normal and cancer tissues of three different groups of CRC patients were analyzed. RNA microarray and TaqMan Array analysis were performed on 66 Italian patients with or without lymph nodes and/or liver recurrences. Data obtained with the two assays were analyzed separately and then intersected to identify a primary CRC metastatic signature. Five differentially expressed microRNAs (hsa-miR-21, -103, -93, -31 and -566) were validated by qRT-PCR on a second group of 16 American metastatic patients. In situ hybridization was performed on the 16 American patients as well as on three distinct commercial tissues microarray (TMA) containing normal adjacent colon, the primary adenocarcinoma, normal and metastatic lymph nodes and liver. Hsa-miRNA-21, -93, and -103 upregulation together with hsa-miR-566 downregulation defined the CRC metastatic signature, while in situ hybridization data identified a lymphonodal invasion profile. We provided the first microRNAs signature that could discriminate between colorectal recurrences to lymph nodes and liver and between colorectal liver metastasis and primary hepatic tumor.

Surgical management of melanoma: an EORTC Melanoma Group survey

Objectives:

The objective of the article is to explore the surgical practices and views in the treatment of melanoma within members and non-members of the EORTC Melanoma Group (MG) during the years 2003–2005.

Methods:

An e-mail questionnaire (see appendix) developed within the EORTC MG was sent to all melanoma units (MUs) of the EORTC (180) and to selected international centres between 2003 and 2005. The questionnaire investigated the different practices regarding surgical management of melanoma patients at all stages.

Results:

A total of 75 questionnaires were returned from centres in Europe (70), Israel (3), Australia (1) and the United States (1). Resection margins on primary melanoma vary according to AJCC 2002 staging. Sixty three of 75 MUs perform Sentinel node biopsy. Modified radical neck dissection is performed in 82% of MUs for macrometastases and in 80% of MUs for micrometastases. Most MUs surveyed perform all three levels of Berg axillary dissection whether for macrometastases (79%) or micrometastases (62%). An ilio inguinal-obturator dissection is proposed with macrometastases (41% of MUs), whereas 33% of MUs perform a pelvic dissection only if the Cloquet node is positive. Twenty five of 75 MUs perform an isolated limb perfusion with a therapeutic indication; three also as an adjuvant. The majority of MUs perform surgery for distant metastases including superficial (53 of 75 [71%]) or solitary visceral metastases (52 of 75[69%]) or for palliation (58 of 75[77%]).

Conclusion:

The adequacy of surgery appears to be the most important milestone in the therapeutic approach of melanoma. Even if surgery is fundamental in the different stages of the disease, there is quite a variability concerning the extension of the surgical treatment related to primary and lymphnodal disease. Phase III randomised trials have shown that wide margins, elective lymph node dissections, and prophylactic isolated limb perfusions have not improved survival and cannot be considered the standard of care in the routine management of primary melanoma. The surgical subgroup of the EORTC Melanoma Group is developing a new version of the surgical survey questionnaire including new treatment modalities like isolated limb infusion and electrochemotherapy, which were not frequently in use some years ago, to obtain new data to be compared to the nearly ten-year-old data.

Anal melanoma

Anal melanoma is rare and aggressive malignancy. Patients commonly present with advanced, even metastatic disease. Unlike cutaneous melanoma, anal melanoma has no known risk factors. Surgical excision remains the cornerstone of therapy. There are no long-term survivors of stage II or III disease; therefore, early diagnosis and treatment remain crucial. There are no trials definitively proving abdominal perineal resection (APR) or wide local excision (WLE) to yield superior long-term survival. APR may offer a higher rate of local control, whereas WLE offers a much less morbid operation. Adjuvant chemotherapy, interferon, and radiation may offer some benefit.

Adjuvant therapy of melanoma with interferon: lessons of the past decade

The effect of interferon alpha (IFNalpha2) given alone or in combination has been widely explored in clinical trials over the past 30 years. Despite the number of adjuvant studies that have been conducted, controversy remains in the oncology community regarding the role of this treatment. Recently an individual patient data (IPD) meta-analysis at longer follow-up was reported, showing a statistically significant benefit for IFN in relation to relapse-free survival, without any difference according to dosage (p = 0.2) or duration of IFN therapy (p = 0.5). Most interestingly, there was a statistically significant benefit of IFN upon overall survival (OS) that translates into an absolute benefit of at least 3% (CI 1-5%) at 5 years. Thus, both the individual trials and this meta-analysis provide evidence that adjuvant IFNalpha2 significantly reduces the risk of relapse and mortality of high-risk melanoma, albeit with a relatively small absolute improvement in survival in the overall population. We have surveyed the international literature from the meta-analysis (2006) to summarize and assimilate current biological evidence that indicates a potent impact of this molecule upon the tumor microenvironment and STAT signaling, as well as the immunological polarization of the tumor tissue in vivo. In conclusion, we argue that there is a compelling rationale for new research upon IFN, especially in the adjuvant setting where the most pronounced effects of this agent have been discovered. These efforts have already shed light upon the immunological and proinflammatory predictors of therapeutic benefit from this agent--that may allow practitioners to determine which patients may benefit from IFN therapy, and approaches that may enable us to overcome resistance or enhance the efficacy of IFN. Future efforts may well build toward patient-oriented therapy based upon the knowledge of the unique molecular features of this disease and the immune system of each melanoma patient.

Randomized adjuvant therapy trials in melanoma: surgical and systemic

The utility of adjuvant surgical procedures in the management of primary melanomas has been evaluated in a large number of phase III randomized trials. These trials have shown that wide margins, elective lymph node dissection, sentinel lymph node (SLN) biopsy, and prophylactic isolated limb perfusion (ILP) do not improve survival but may improve locoregional control. Based on the claim of providing a survival benefit, these surgical procedures cannot be considered standard of care in the routine management of primary melanoma. Regarding the role of SLN biopsy it must be stated that this procedure provides the best information on prognosis and provides us with an important tool to stratify for and study more homogeneous patient populations to evaluate adjuvant systemic therapies in randomized phase III trials. The utility of systemic adjuvant therapy remains marginal as a result of the fact that a lack of effective drugs in stage IV disease is reflected by a lack of effective adjuvant therapies in stage II-III melanoma. Thus far, chemotherapeutic drugs, immunostimulants, and various vaccines have all failed. Interferon (IFN) has an effect on relapse-free survival but not on overall survival. Thus its impact is judged by many to be too small to be considered standard of care. The population of patients that can benefit from IFN needs to be better defined by identifying new biomarkers by genomic and proteomic studies, which are ongoing.

Randomized Trials in Melanoma: An Update

No effective therapy for metastatic melanoma exists. Polychemotherapy or chemoimmunotherapy have not shown survival benefits. Vaccines have shown little activity in stage IV disease. To advance the identification of effective agents, new drugs can and should be offered as first-line treatment. Efforts must be made to improve understanding of the biology of malignant melanoma. Too many phase III trials have been conducted with a poor understanding of the mechanism of action of the involved drugs.

Adjuvant treatment of malignant melanoma: where are we?

To date, no standard adjuvant therapy have increased overall survival in patients with malignant melanoma (MM). The effect of interferon alpha as a single agent or in combination has been widely explored in clinical trials. Critical reading of the major international randomised trials showed that response to interferon (IFN) in terms of improvement of overall survival (OS) may not be strictly correlated with the used dosage and that duration of therapy may impact disease-free survival (DFS) but not OS. Patients' heterogeneity could be an explanation for the discordant data of the international literature. Indeed, majority of these studies started in late 1980s or early 1990s, when accurate staging procedure were not available yet. The adequate surgical treatment should be considered as an independent variable in the analysis of MM adjuvant protocols. Considering the treatment cost, which is the main goal: DFS, OS or quality of life? Answering these questions is difficult, but some considerations must be taken to put order in this field. Putting together data from all different studies, IFN therapy seems to protect MM patients from recurrences during the entire treatment period and a prolonged IFN therapy seems to improve DFS. The only positive result on OS was demonstrated for high-dose IFN (HD-IFN) in a single study (presenting a relatively short follow-up median) and not confirmed in a subsequent study from the same authors. Considering that low-dose interferon (LD-IFN) is tolerated much better than HD-IFN (about 10% versus more than 70% of cases with grade 3-4 toxicity, respectively), a prolonged LD-IFN (more than 2 years) may represent a reasonable opportunity for MM patients, also considering its advantageous cost-effectiveness. Conversely, considering the improvement of OS as the main target of MM adjuvant therapy, the "wait and watch" attitude remains the only approach to be pursued at present. It is a physician's choice.

Sentinel node biopsy procedures with an analysis of recurrence patterns and prognosis in melanoma patients: technical advantages using computer-assisted gamma probe with adjustable collimation

The purpose of this study was to investigate whether a computer-assisted gamma probe with adjustable collimation could aid in the detection of sentinel nodes (SNs) and to analyse the patterns of recurrence and prognosis in SN-positive and SN-negative cases. We analysed 385 SN biopsies. The SN identification rate was 87.2% using preoperative lymphoscintigraphy and blue dye, 93.9% using preoperative lymphoscintigraphy, blue dye and different probes, and 100% using preoperative lymphoscintigraphy, blue dye and a computer-assisted probe with adjustable collimation. The computer-assisted probe was particularly advantageous in cases where the melanoma was located very close to the SN and in cases of deep-seated nodes or nodes with low uptake, due to the possibility of changing the collimation during the procedure. The SN-positive rate according to the thickness of the primary melanoma was 1.7% for melanomas < or = 1 mm in thickness and 27.5% for melanomas > or = 1 mm. In 4.9% of cases we identified nodes outside the regional nodal basin. In one case we found a micrometastasis in a blue and hot interval node of the lateral abdominal wall. Analysing the node counts registered by the computer-assisted probe, we verified that the blue-positive node for tumour metastases was not the most radioactive node in the field in six out of 52 positive cases (11.5%). Distant metastases were present in 2.0% of SN-negative patients, and in 24% of SN-positive patients (P < 0.001). Highly statistically significant differences were found between SN-negative and SN-positive patients in both the 3 year disease-free survival (86.3% versus 49.2%) and the 3 year disease-specific survival (92.3% versus 77.1%) (P < 0.001).

Patients with lymphatic metastasis of cutaneous malignant melanoma benefit from sentinel lymphonodectomy and early excision of their nodal disease

Early versus delayed excision of lymph node metastases is still being assessed in malignant melanoma. In the present retrospective, multicentre study, the outcome of 314 patients with positive sentinel lymphonodectomy (SLNE) was compared with the outcome of 623 patients with delayed lymph node dissection (DLND) of clinically enlarged lymph node metastases. In order to avoid the lead-time bias, survival was generally calculated from the excision of the primary tumour. Survival curves were constructed using the Kaplan-Meier product-limit estimate. Cox's proportional hazards model was used to perform a multivariate analysis of factors related to overall survival. Compared with SLNE and early performed complete lymph node dissection, DLND yielded a significantly higher number of lymph node metastases. Median and mean tumour thickness were nearly identical in the two therapy groups. The estimated 3-year overall survival rate was 80.1+/-2.8% (+/-standard error of the mean (SEM)) in patients with positive SLNs, and 67.6+/-1.9% in patients with DLND (5-year survival rates 62.5+/-5.5 and 50.2+/-5.4%, respectively). The difference between the two survival curves was statistically significant (P=0.002). Using multifactorial analysis, SLNE (P=0.000052), American Joint Committee on Cancer (AJCC) Breslow thickness category (P<0.000001), age (P=0.01) and gender (P=0.028) were independent predictors of overall survival. The location of the primary tumour (P=0.59) was non-significant. Considering only those centres with sufficient data for epidermal ulceration, this risk factor was also significant. In cutaneous malignant melanoma, early excision of lymphatic metastases, directed by the sentinel node procedure, provides a highly significant overall survival benefit.

High-tech in radiation oncology: should there be a ceiling?

PURPOSE

To analyze some of the limitations to improvement of the outcome of radiotherapy (RT) expected from the introduction of sophisticated treatment planning and delivery technology.

METHODS AND MATERIALS

Several recent examples from the literature were analyzed in some detail. Mathematical modeling techniques were used to assess the likely clinical impact of new technologies or biologic principles. The findings of recent randomized controlled trials of RT for prostate, breast, and rectal cancer were analyzed from the perspective of cost-effectiveness and therapeutic gain.

RESULTS

The main findings of the analyses may be summarized as follows. Dosimetric precision should aim for a <2% patient-to-patient variability in the delivered dose. Imprecision in clinical target volume definition remains an obstacle for high-precision RT. Functional imaging and novel biologic assays may facilitate a move from a clinical target volume to the real target volume. Improved target volume coverage is mainly important if RT has high effectiveness. Radiation oncology is increasingly becoming evidence based. However, there is still a long way to go. Hypofractionation in adjuvant RT for breast cancer may represent a favorable balance between cost and benefit. Treatment complications are potentially associated with both suffering and high cost. The identification of high-risk patients would improve the cost-effectiveness of high-tech RT aimed at avoiding complications. Conformal RT may allow the introduction of hypofractionation, which, again, could potentially save resources. With improvement in surgery and more screening-detected cancer cases, the number needed to treat increases, and this will directly affect the cost-effectiveness of high-tech RT unless efficient patient selection can be developed.

CONCLUSION

Sustained technological refinement is only likely to be cost-effective if the clinical and biologic understanding of patient-to-patient variability in the risk of specific types of failure and the optimal multimodality approach to handle these risks is developed at the same time. Mathematical modeling together with methods from health technology assessment and health economics are useful complements to standard methods from evidence-based medicine. Progress in functional imaging and in basic and clinical cancer biology is likely to provide the tools required for individualized risk-adapted RT.

Review and evaluation of sentinel node procedures in 250 melanoma patients with a median follow-up of 6 years

BACKGROUND

The aim of this study was to evaluate the results of sentinel node biopsy in cutaneous melanoma at our institute.

METHODS

A total of 250 patients with cutaneous melanoma were studied prospectively. Preoperative lymphoscintigraphy was performed after injection of (99m)Tc-nanocolloid intradermally around the primary tumor or biopsy site (.32 mL, 65.5 MBq [1.8 mCi]). The sentinel node was surgically identified with the aid of patent blue dye and a gamma ray detection probe. The median follow-up was 72 months.

RESULTS

Lymphoscintigraphic visualization was 100%, and surgical identification was 99.6%. In 60 patients (24%), 1 or more sentinel nodes were tumor positive at initial pathology evaluation. Late complications after sentinel node biopsy of the remaining 190 patients were seen in 35 patients (18%). The false-negative rate was 9%. In-transit metastases were seen in 7% of sentinel node-negative and 23% of sentinel node-positive patients. The estimated 5-year overall survival rates were 89% and 64%, respectively (P <.001).

CONCLUSIONS

This study confirms that the status of the sentinel node is a strong independent prognostic factor. The false-negative rate and the incidence of in-transit metastases in sentinel node-positive patients are high and have to be weighed against the possible survival benefit of early removal of nodal metastases.

The role of preoperative ultrasound scan in detecting lymph node metastasis before sentinel node biopsy in melanoma patients

BACKGROUND AND OBJECTIVES

To evaluate the efficacy of preoperative ultrasound (US) scanning in identifying lymph node metastasis before sentinel node biopsy (SNB), we conducted a prospective study on 125 patients with primary cutaneous melanoma (CM).

METHODS

We prospectively enrolled 125 patients with >1 mm thick CM and candidate for SNB. Preoperatively, patients underwent US scanning of regional lymphatic basins and FNA of suspected lymph nodes (LN). All patients underwent lymphatic mapping and SNB.

RESULTS

Combined with fine-needle aspirate (FNA) of suspect LN, US scan allowed the correct preoperative detection of 12 out of 31 histologically positive lymphatic basins, specificity and sensitivity being 100 and 39%, respectively. The false negative rate (61%) was mainly linked to tumor deposits less than 2 mm in diameter, which can be considered the current spatial resolution limit of this technique.

CONCLUSIONS

Preoperative US scan could reduce the number of SNB, thus avoiding the stress of this surgical procedure in approximately 10% of patients and reducing health care costs. As a non-invasive and relatively inexpensive technique, lymph node US scan can be part of the preoperative staging process of patients' candidate for SNB in order to avoid unnecessary surgical procedures.

Surgical therapy for anorectal melanoma

BACKGROUND

Anorectal melanoma is a rare but highly lethal malignancy. Historically, radical resection was considered the "gold standard" for treatment of potentially curable anorectal melanoma. The dismal prognosis of this disease has prompted us to recommend wide local excision as the initial therapeutic approach. The purpose of this study was to review our results in patients who underwent wide local excision or radical surgery (abdominoperineal resection [APR]) for localized anorectal melanoma.

STUDY DESIGN

We reviewed the charts of all patients referred for resection of anorectal melanoma between 1988 and 2002. Endpoints included overall survival, disease-free survival, and local, regional, or systemic recurrence.

RESULTS

Fifteen patients underwent curative-intent surgery; four underwent APR and 11 underwent wide local excision. Eight patients (53%) are alive; 7 (47%) are disease-free (followup 6 months to 13 years). Of 12 patients who have been followed for more than 2 years, 4 are alive (33%) and 3 are disease-free (25%). Seven patients have been followed for more than 5 years and two are alive and disease-free (29%). All of the longterm survivors underwent local excision as the initial operation. There were no differences in local recurrence, systemic recurrence, disease-free survival, or overall survival between the APR group and the local excision group. Local recurrence occurred in 50% of the APR group and 18% of the local excision group; regional recurrence occurred in 25% versus 27%. Distant metastases were common (75% versus 36%).

CONCLUSION

In patients who have undergone resection with curative intent for anorectal melanoma, most recurrences occur systemically regardless of the initial surgical procedure. Local resection does not increase the risk of local or regional recurrence. APR offers no survival advantage over local excision. We advocate wide local excision as primary therapy for anorectal melanoma when technically feasible.

European approach to adjuvant treatment of intermediate- and high-risk malignant melanoma

Adjuvant therapies for patients with melanoma at high risk of relapse whether local, such as excision margins, elective regional lymph node dissection (ELND), and prophylactic isolated limb perfusion (ILP), or systemic, such as chemotherapy, immunotherapy, immunochemotherapy, or vaccination therapy, have little or no impact on survival when evaluated in randomized trials. The European approach to the treatment of each stage of malignant melanoma is characterized by thoughtful caution with particular attention being paid to the avoidance of unwarranted mutilation or toxicity because phase 3 studies have failed to demonstrate unequivocal benefits for a more aggressive approach. In Europe, there is no standard adjuvant systemic therapy; high-dose interferon (IFN) is used sporadically in individual patients by some physicians, but there is little enthusiasm for adopting this regimen as the standard of care because of its high toxicity profile and the lack of a clear beneficial impact on long-term survival. Less toxic lower-dose maintenance IFN regimens, antiangiogenic agents, and vaccine therapies are currently being explored.

Interferon alfa therapy for malignant melanoma: a systematic review of randomized controlled trials

PURPOSE

No standard systemic adjuvant therapy has been proven to increase overall survival in melanoma patients. The effect of interferon alfa (IFNalpha) as a single agent or in combination has been widely explored in clinical trials. The purpose of this study was to assess the benefit of IFNalpha therapy in malignant melanoma.

METHODS

We performed a systematic review of randomized controlled trials comparing regimens with or without IFNalpha adjuvant therapy in melanoma patients. We assessed the effect of IFNalpha therapy on overall survival (OS), disease-free survival (DFS), melanoma recurrences, and toxicity. The quality of each trial was systematically evaluated.

RESULTS

Nine randomized controlled trials (RCTs) of IFNalpha therapy in melanoma patients were identified. Eight were published and one was unpublished. Eight trials comprising 3,178 patients fulfilled our inclusion criteria and were analyzed. Quality assessment scores ranged from 22 to 71, with a mean score of 55.4 (95% confidence interval, 53.8 to 57.0). For OS, only one trial reported a statistically significant benefit for IFNalpha, but our analysis did not confirm it. Two trials reported statistically significant benefit in DFS for the patients treated with IFNalpha, but our analysis confirmed it in only one trial. There was a wide clinical heterogeneity between included trials, making meta-analysis inappropriate.

CONCLUSION

In our review, results from included RCTs demonstrated no clear benefit of IFNalpha therapy on OS in melanoma patients. A large RCT is required to answer whether a full regimen of IFNalpha therapy is effective and to identify the subgroups of patients who might benefit from IFNalpha treatment.

European approach to the treatment of malignant melanoma

The European approach to the treatment of each stage of malignant melanoma can be characterized as cautious, avoiding unwarranted mutilation or toxicity, because phase III trials have demonstrated that an aggressive approach in surgical management, adjuvant therapy, and treatment of stage IV disease has met with little success. Phase III trials have demonstrated that wide margins, elective lymph node dissections, and prophylactic isolated limb perfusions bring no survival benefit. Primary melanoma is excised with a margin of 1 cm to maximally 2 cm and primary closure as a rule. There is no standard adjuvant therapy. High-dose interferon treatment is practiced only sporadically in Europe because its high toxicity profile and an unclear long-term impact on survival are not popular. Long-term nontoxic lower-dose interferon regimens and vaccines are currently being explored. Phase III trials have shown that highly toxic polychemotherapy or biochemotherapy has not produced a survival benefit over simple treatment with dacarbazide alone. In Europe biochemotherapy is being abandoned and various less toxic or nontoxic approaches with vaccines and antiangiogenic agents are under study.

The EORTC Melanoma Group: a comprehensive melanoma research programme by clinicians and scientists. European Organisation for Research and Treatment of Cancer

The EORTC Melanoma Group (MG) was founded in 1969 by both clinicians and scientists from various disciplines and fields of research with a common interest in malignant melanoma. This collaborative approach has always been the foundation of the groups strength. With an interest in tumour biology and especially the immunological aspects of the disease, the group has always pursued a scientific approach to treatment development in malignant melanoma. Over the years, the group has performed many clinical trials, epidemiological studies, histopathological studies defining standards and guidelines, translational research regarding prognostic factors and various metastatic and immunological aspects of melanoma, and developed quality assurance programmes for immunological and molecular biological assays in laboratory networks. At present, the EORTC MG runs the worldwide largest clinical trial programme in stages II, III and IV melanoma involving some 140 cancer centres in and outside Europe. Each trial is associated with the appropriate translational research programmes.