Current concepts in advanced sinonasal mucosal melanoma: a single institution experience

Sinonasal Mucosal Melanoma: A Contemporary Review

Sinonasal mucosal melanoma (SNMM) is a rare aggressive tumor often diagnosed at advanced stage. SNMM is associated with a greater than 50% rate of recurrence and a disease-specific 5 year survival rate of less than 25%. Sinonasal anatomy may contribute to difficulty in early detection; SNMM is usually asymptomatic until bulky and polypoidal. Presenting clinical symptoms are often nonspecific. The histopathologic features of SNMM are quite variable and immunohistochemical analysis is usually necessary for diagnosis. Mucosal melanomas lack ultraviolet signature, have low somatic mutational burden, and are reported to have more genomic instability manifested as structural variants, deletions, and amplifications.

Survival Outcomes in Sinonasal Mucosal Melanoma: Systematic Review and Meta-Analysis

Background/Objectives: Sinonasal mucosal melanomas (SNMMs) are rare and aggressive malignancies with poor survival outcomes. Our systematic review and meta-analysis aim to evaluate overall survival (OS) rates in patients with SNMM; Methods: We conducted a systematic search, following PRISMA guidelines across PubMed, Web of Science (WOS), and citation searching for studies reporting survival and prognosis outcomes for SNMMs. Inclusion criteria included studies with 5-year OS rates. Studies were excluded if they included tumor sites other than the paranasal sinuses or nasal cavity, were published in languages other than English and Spanish, or had a sample size of fewer than 15 patients. Two reviewers independently screened studies, extracted data, and assessed study quality using the Joanna Briggs Institute (JBI) critical appraisal checklist. Analyses of survival probabilities were conducted. Meta-analyses were performed using a random-effects model. PROSPERO ID CRD42024565137; Results: A total of 515 articles were identified after removing duplicates, and 99 reports were assessed for eligibility. Of these, 35 studies were included in the meta-analysis, encompassing a total of 2383 SNMM patients, of whom 1192 (50%) were female, with a weighted mean age of 65.4 years (SD = 5.4). Fifteen studies were from Europe (42.9%), six (17.1%) were from America, eleven (31.4%) were from Asia, two (5.7%) were from Australia, and one (2.9%) combined European, United Kingdom, and American populations. The 5-year OS was 34.8 [95% CI = 30.6-39.5], with the highest OS in America at 40.5 [95% CI = 34.1-48.1], followed by Europe at 36.6 [95% CI = 30.6-43.7], Australia at 32.3 [95% CI = 12.5-83.8], and Asia at 28.1 [95% CI = 19.5-40.7]. The age-standardized incidence rate (ASIR) for SNMM ranges was between 0.07 and 0.14 per 100,000 persons/year, with a slightly higher incidence in women than in men; Conclusions: This meta-analysis, one of the largest to date on SNMM, confirms the aggressive nature of this melanoma subtype with poor survival outcomes. Despite geographic differences in survival rates, the overall 5-year survival remains low, highlighting the urgent need for improved treatment strategies and more research to improve patient outcomes.

Immunotherapy in the Management of Sinonasal Mucosal Melanoma: A Systematic Review

OBJECTIVE

The aim of this work is to comprehensively review and synthesize the literature related to sinonasal mucosal melanoma (SNMM) treatment with immunotherapy, including potentially targetable genetic mutations, survival outcomes, and adverse events.

DATA SOURCES

Embase, Cochrane, Scopus, and Web of Science.

REVIEW METHODS

The study protocol was designed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Databases were searched from inception through May 23, 2023.

RESULTS

A total of 42 studies met inclusion criteria. Twenty-four of the included studies reported genetic mutations for a combined 787 patients with SNMM. 8.1% (95% confidence interval, CI: 7.6-8.6), 18.9% (95% CI: 18.1-19.8), and 8.5% (95% CI: 8.1-9.0) of reported patients were positive for BRAF, NRAS, and KIT mutations, respectively. The presence of brisk tumor-infiltrating lymphocytes was associated with improved recurrence-free survival and overall survival (OS). Six studies reported a combined 5-year OS after adjuvant immunotherapy treatment of 42.6% (95% CI: 39.4-45.8). Thirteen studies encompassing 117 patients reported adjuvant or salvage immune checkpoint inhibitor (ICI) immunotherapy response rates: 40.2% (95% CI: 36.8-43.6) had a positive response (tumor volume reduction or resolution). Eleven studies reported direct comparisons between SNMM patients treated with or without immunotherapy; the majority (7/11) reported survival benefit for their entire cohort or select subgroups of SNMM patients. With the transition to modern ICIs, there is a stronger trend toward survival improvement with adjuvant ICI. Tumors with Ki67 <40% may respond better to ICI's.

CONCLUSION

ICI therapy can be an effective in select SNMM patients, especially those with advanced/metastatic disease.

Sinonasal mucosal melanoma treatment response assessment to immune checkpoint inhibitors using hybrid positron emission tomography imaging

The purpose of this retrospective study was to investigate response of sinonasal mucosal melanoma (SMM) patients to treatment with immune checkpoint inhibitors (ICI), using hybrid PET imaging. Fifteen SMM patients underwent hybrid PET imaging before and three months after initiation of ICI. The disease-specific survival (DSS) was calculated. Quantitative PET parameters of the primary tumor and their association with DSS and therapy response were investigated. Nine of the fifteen (60%) patients responded to ICI therapy. Patients with therapy response depicted on hybrid PET imaging had better DSS than those without (p = 0.0058). Quantitative PET parameters of the initial PET harbored no association with DSS or therapy response. However, these findings lack of sufficient statistical power and must be interpreted with caution. The first restaging PET-imaging after ICI initiation can help stratify patients with regard to DSS.

PET/CT Imaging in Treatment Planning and Surveillance of Sinonasal Neoplasms

Sinonasal cancers are uncommon malignancies with a generally unfavorable prognosis, often presenting at an advanced stage. Their high rate of recurrence supports close imaging surveillance and the utilization of functional imaging techniques. Whole-body 18F-FDG PET/CT has very high sensitivity for the diagnosis of sinonasal malignancies and can also be used as a "metabolic biopsy" in the characterization of some of the more common subgroups of these tumors, though due to overlap in uptake, histological confirmation is still needed. For certain tumor types, radiotracers, such as 11C-choline, and radiolabeled somatostatin analogs, including 68Ga-DOTATATE/DOTATOC, have proven useful in treatment planning and surveillance. Although serial scans for posttreatment surveillance allow the detection of subclinical lesions, the optimal schedule and efficacy in terms of survival are yet to be determined. Pitfalls of 18F-FDG, such as post-surgical and post-radiotherapy crusting and inflammation, may cause false-positive hypermetabolism in the absence of relapse.

A nomogram for predicting overall survival of patients with sinonasal melanoma: A population-based study

Objective

Sinonasal melanoma (SMM) is a rare but aggressive malignancy with 5-year overall survival (OS) rates below 40% in published studies. However, the clinicopathological predictors of the prognosis of SMM remain undefined. We aimed to establish a model to predict the survival outcomes of SMM.

Methods

We searched the Surveillance, Epidemiology, and End Results (SEER) database for patients diagnosed with SMM between 1975 and 2016. Data on patient demographics, treatment modalities, and survival outcomes were retrieved. Risk factors for OS were evaluated by survival and Cox regression analyses. We also developed and validated a nomogram for OS, and compared its performance with that of conventional staging systems.

Results

Overall, 305 SMM patients were included in this population-based study. Multivariate Cox regression showed that primary site, American Joint Committee on Cancer stage, radiotherapy, and surgery were significant risk factors for survival. A nomogram was established using the regression model. The C-indices, areas under the receiver operating characteristic curves, calibration plots, and decision curve analysis demonstrated reliable performance of the nomogram.

Conclusion

The nomogram predicting survival outcomes of SMM patients based on clinical information showed good discriminative ability and prognostic accuracy compared with conventional stage classifications. Our nomogram could be used to predict the survival probabilities for SMM patients at different timepoints.

Level of Evidence

2b.

Sinonasal Mucosal Melanoma: Role of Tumor Proliferative Indices and Pathological Factors in Survival

OBJECTIVE

The objective of this study is to determine the association of proliferation indices and pathologic biomarkers on overall and recurrence/metastasis-free survival (OS and RMFS) in patients with sinonasal mucosal melanoma (SNMM) and to assess the genetic mutational landscape of SNMM.

METHODS

This is a retrospective cohort study of 45 SNMM patients without neoadjuvant therapy who underwent surgical therapy with curative intent and had tumor tissue available for histopathologic review, molecular analysis, and genetic mutational assessment. The OS and RMFS were assessed for associations with numerous tumor and patient-related factors.

RESULTS

Among proliferative indices, higher Ki67 and mitotic rates were associated with worsened OS and RMFS (Ki67: p = 0.0007 and p < 0.0001; mitotic rate: p = 0.005 and p = 0.0009, respectively). The presence of brisk tumor-infiltrating lymphocytes (TILs) was associated with improved RMFS (p = 0.007) and the presence of lymphovascular invasion was associated with worsened OS and RMFS (p = 0.02 and p = 0.04, respectively). Patients with amelanotic tumors were more likely to have higher T-stage (p = 0.046), less likely to have brisk TILs (p = 0.02) and had worsened RMFS (p = 0.03). Patients on immunotherapy with tumor Ki67 < 40% had better 3-year OS compared to those with higher Ki67 index (p = 0.004). Actionable genetic mutations such as BRAF V600E are rare and present in only 1 of 20 patients tested.

CONCLUSION

In SNMM patients, pathologic and proliferation markers such as Ki67, mitotic rate and brisk TILs are associated with survival and may be considered in future staging systems. Clinical response to immunotherapy appears to correlate with the Ki67 index. Given the distinct genetic profile of SNMM, targeted therapies against the MAPK kinase pathway have limited utility.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Multimodality Imaging and Genetics of Primary Mucosal Melanomas and Response to Treatment

Mucosal melanomas (MMs) are rare and aggressive tumors that arise from melanocytes in the mucosal tissues that line the respiratory, gastrointestinal, and urogenital tracts. Most MMs occur during the 6th and 7th decades of life. MMs may be asymptomatic but may also cause bleeding, pain, and itching, depending on the site of origin. Because of their asymptomatic or oligosymptomatic nature and the difficulty of visualizing them in some cases, they are often advanced tumors at patient presentation. MM staging varies depending on the site of the primary tumor. A simplified staging system allows classification of clinically localized disease as stage I, regional nodal involvement as stage II, and distant metastasis as stage III. MM differs genetically from its cutaneous counterparts. Common drivers in cutaneous melanoma such as B-raf proto-oncogene serine/threonine kinase (BRAF) have a lower mutation rate in MM, whereas mutations of other genes including the KIT proto-oncogene, receptor tyrosine kinase (KIT) and splicing factor 3b subunit 1 gene (SF3B1) are more common in MM. Complete resection is the best curative option. However, surgical intervention with wide local excision and negative margins may be difficult to attain because of the local anatomy and the extent of disease. In addition, despite aggressive surgical resection, most patients develop local recurrence and metastatic disease. Recent advances in the treatment of melanoma include immunotherapy and targeted therapy. Unfortunately, MMs have a relatively poor prognosis, with an overall 5-year survival rate of 25%. Online supplemental material is available for this article. ^©RSNA, 2021.

Whole-body hybrid positron emission tomography imaging yields clinically relevant information in the staging and restaging of sinonasal tumors

Background

Whole‐body hybrid positron emission tomography (PET) imaging is increasingly used for sinonasal tumors. However, only empirical data exist on the additional, clinically relevant information derived from these techniques.

Methods

This study included 96 regionalized magnetic resonance imaging (MRI) of the sinonasal tract/neck and separate hybrid FDG‐PET/CT or FDG‐PET/MRI in 74 patients. Additional radiological information (ARI) obtained from each hybrid examination was analyzed and its clinically relevance was determined. Clinically relevant information (CRI) was categorized with regard to primary tumor site, regional lymph node metastases, distant metastases, second primary tumors, and non‐neoplastic findings.

Results

A total of 45/96 (46.9%) hybrid PET examinations revealed ARI. CRI was found in 32/96 (33.3%) examinations and concerned the primary tumor site (6.1%), regional lymph node metastases (4.1%), distant metastases (14.3%), second primary tumors (7.3%), and non‐neoplastic findings (5.1%).

Conclusions

Hybrid PET imaging yields additional radiological information translating into clinically relevant information in a substantial proportion of patients with sinonasal tumors.

Adjuvant Therapy and Prognosticators of Survival in Head and Neck Mucosal Melanoma

OBJECTIVES/HYPOTHESIS

To identify prognosticators and determine the efficacies of surgery with adjuvant radiotherapy (SR) and surgery with immunotherapy (SI) of head and neck mucosal melanoma (HNMM).

STUDY DESIGN

Retrospective database study.

METHODS

The 2004 to 2017 National Cancer Database was queried for HNMM patients. Cox proportional hazards and Kaplan-Meier analyses evaluated prognosticators of mortality and survival benefits conferred by SR, SI, or surgery with adjuvant radiotherapy and immunotherapy (SRI). Logistic regression identified predictors of adjuvant radiotherapy or immunotherapy use.

RESULTS

Overall, 1,910 cases (845 surgery, 802 SR, 51 SI, 101 SRI) were analyzed, with 50.3% females and an average age of 68.6 ± 13.8 years. SI was associated with greater overall survival (OS) than surgery (hazard ratio [HR] 0.672; P = .036). SI (HR 0.425; P = .024) and SRI (HR 0.594; P = .045) were associated with superior OS than SR. Older age (HR 1.607; P < .001), female sex (HR 0.757; P = .006), paranasal sinus localization (HR 1.648; P < .001), T4 classification (HR 1.443; P < .001), N1 classification (HR 2.310; P < .001), M1 classification (HR 3.357; P < .001), and positive surgical margins (HR 1.454; P < .001) were survival prognosticators. Adjuvant radiotherapy use was negatively correlated with older age, oral cavity localization, and M0 or T3 tumors (all P < .05). Adjuvant immunotherapy use was positively correlated with younger age and M1 tumors (all P < .05).

CONCLUSIONS

Although SR did not confer survival benefits in HNMM patients, SI and SRI yielded greater OS than surgery alone. SRI was associated with superior survival outcomes than SR. Certain demographic and clinical factors were associated with increased mortality risk. Patient age and certain tumor characteristics were predictors of adjuvant radiotherapy or immunotherapy use.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Hybrid positron emission tomography imaging for initial staging of sinonasal tumors: Total lesion glycolysis as prognosticator of treatment response

BACKGROUND

To assess hybrid positron emission tomography (PET) imaging in the initial staging and outcome prediction of sinonasal malignancies.

METHODS

Retrospective study on patients with sinonasal malignancies undergoing hybrid PET imaging for initial staging.

RESULTS

Complete remission (CR) was achieved in 45 of 65 patients (69.2%). Overall sensitivity for detection of primaries using 18F-fluoro-deoxy-d-glucose PET (FDG-PET) was 95.4%, for lymph node metastases 100% and distant metastases (DM) 100%. On univariate analysis, PET parameter total lesion glycolysis (TLG) was associated with achieving CR after primary treatment (176.8 ± 157.2 vs 83.7 ± 110.8, P = .03). Multivariate logistic regression demonstrated that TLG adjusted for the T classification best predicted achievement of CR.

CONCLUSIONS

Hybrid PET imaging yields an excellent sensitivity in detecting primary tumors, lymph node metastases and DM in sinonasal malignancies. TLG of the primary tumor is an independent prognostic factor for achieving CR after initial treatment.

PET/MR in Head and Neck Cancer - An Update

In academic centers, PET/MR has taken the road to clinical nuclear medicine in the past 6 years since the last review on its applications in head and neck cancer patients in this journal. Meanwhile, older sequential PET + MR machines have largely vanished from clinical sites, being replaced by integrated simultaneous PET/MR scanners. Evidence from several studies suggests that PET/MR overall performs equally well as PET/CT in the staging and restaging of head and neck cancer and in radiation therapy planning. PET/MR appears to offer advantages in the characterization and prognostication of head and neck malignancies through multiparametric imaging, which demands an exact preparation and validation of imaging modalities, however. The majority of available clinical PET/MR studies today covers FDG imaging of squamous cell carcinoma arising from a broad spectrum of locations in the upper aerodigestive tract. In the future, specific PET/MR studies are desired that address specific histopathological tumor entities, nonepithelial malignancies, such as major salivary gland tumors, squamous cell carcinomas arising in specific locations, and malignancies imaged with non-FDG radiotracers. With the advent of digital PET/CT scanners, PET/MR is expected to partake in future technical developments, such as novel iterative reconstruction techniques and deviceless motion correction for respiration and gross movement in the head and neck region. Owing to the still comparably high costs of PET/MR scanners and facility requirements on the one hand, and the concentration of multidisciplinary head and neck cancer treatment mainly at academic centers on the other hand, a more widespread use of this imaging modality outside major hospitals is currently limited.

Predictive value of positron emission tomography for the prognosis of immune checkpoint inhibitors (ICIs) in malignant tumors

PURPOSE

This study aimed at investigating the value of applying positron emission tomography (PET) to early predict the effect of immune checkpoint inhibitors (ICIs) in malignant tumors.

METHODS

Electronic databases MEDLINE/PubMed, EMBASE, and Cochrane Library were searched to identify relevant trials. The primary endpoints were progression-free survival (PFS) and overall survival (OS). The results were analyzed utilizing Stata 12.0 statistical software. Subgroup analyses were implemented based on primary tumors, study designs, continents, type of ICIs, evaluation index of PET, and evaluated PET timing.

RESULTS

Fifteen studies incorporating 664 individuals were eligible. Compared with PET nonresponse group, PET response group displayed a significantly prolonged PFS (HR 0.27, 95% CI [0.16, 0.44]; P < 0.001) and OS (HR 0.56, 95% CI [0.48, 0.65]; P < 0.001). Analogical outcomes were obtained in subgroup analyses of PFS in non-small cell lung cancer, prospective, America, ipilimumab, nivolumab/pembrolizumab combined ipilimumab, PET Response Criteria in Solid Tumors (PERCIST), baseline PET and early PET timing arms without heterogeneity; so did OS in melanoma, retrospective, Europe, America, ipilimumab, nivolumab/pembrolizumab, PERCIST, baseline metabolic tissue volume, baseline standard uptake value, and baseline total lesion glycolysis, baseline PET timing, early PET timing and late PET timing arms.

CONCLUSION

Our study demonstrated that PET was a promising approach to early predict the prognosis of ICIs for malignancies.