Prevention of local recurrence after surgical debulking of nodal and subcutaneous melanoma deposits by hypofractionated radiation

The Role of Regional Therapies for in-Transit Melanoma in the Era of Improved Systemic Options

The incidence of melanoma has been increasing at a rapid rate, with 4%–11% of all melanoma recurrences presenting as in-transit disease. Treatments for in-transit melanoma of the extremity are varied and include surgical excision, lesional injection, regional techniques and systemic therapies. Excision to clear margins is preferred; however, in cases of widespread disease, this may not be practical. Historically, intralesional therapies were generally not curative and were often used for palliation or as adjuncts to other therapies, but recent advances in oncolytic viruses may change this paradigm. Radiation as a regional therapy can be quite locally toxic and is typically relegated to disease control and symptom relief in patients with limited treatment options. Regional therapies such as isolated limb perfusion and isolated limb infusion are older therapies, but offer the ability to treat bulky disease for curative intent with a high response rate. These techniques have their associated toxicities and can be technically challenging. Historically, systemic therapy with chemotherapies and biochemotherapies were relatively ineffective and highly toxic. With the advent of novel immunotherapeutic and targeted small molecule agents for the treatment of metastatic melanoma, the armamentarium against in-transit disease has expanded. Given the multitude of options, many different combinations and sequences of therapies can be offered to patients with in-transit extremity melanoma in the contemporary era. Reported response and survival rates of the varied treatments may offer valuable information regarding treatment decisions for patients with in-transit melanoma and provide rationale for these decisions.

Adjuvant hypofractionated intensity modulated radiation therapy after resection of regional lymph node metastases in patients with cutaneous malignant melanoma of the head and neck

PURPOSE

To evaluate outcomes in patients with malignant melanoma of the head and neck with resected regional lymph node (LN) metastases treated with adjuvant hypofractionated intensity modulated radiation therapy (IMRT).

METHODS AND MATERIALS

A retrospective review was performed of 46 patients with malignant melanoma of the head and neck with regional LN metastases treated with lymphadenectomy and adjuvant IMRT. Patients underwent neck dissection (n = 42) or local excision (n = 4) for regional metastases at initial diagnosis (n = 19) or recurrence (n = 27). Adjuvant IMRT was delivered twice per week over 2.5 weeks for a total dose of 30 Gray (Gy) in 5 fractions. Acute and late adverse events were recorded using the Common Toxicity Criteria for Adverse Events version 4. Site of first recurrence was defined as local-regional (LR, above the clavicles) or distant. Overall survival, disease-free survival, and disease recurrence risks were determined using Kaplan-Meier estimates.

RESULTS

The median follow-up in living patients was 2.8 years (range, 0.2-6.9). Most patients experienced acute grade 1-2 dermatitis (80%) and mucositis (85%). One patient (2%) experienced an acute grade 3 adverse event. Seven patients (16%) experienced late grade 2 adverse events. No patient experienced grade 3 or higher late adverse events. Site of first recurrence was LR alone (n = 5), both LR and distant (n = 1), and distant alone (n = 25). Five of the 6 LR recurrences were inside the IMRT planning target volume (PTV). In-PTV and total LR control at 3 years were 85% and 76%, respectively. Overall survival and disease-free survival at 3 years were 63% and 25%, respectively.

CONCLUSIONS

Adjuvant hypofractionated IMRT (30 Gy in 5 fractions) was associated with a high rate of in-PTV control and a low risk of serious adverse events.

Surgical resection for bulky or recurrent axillary metastatic melanoma

INTRODUCTION

Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients.

METHODS

We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms.

RESULTS

Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001).

DISCUSSION

Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.

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.

Surgical management of melanoma

Melanoma is an increasing health care problem worldwide. Up to 80,000 cases of melanoma are diagnosed per year and it is the sixth leading cause of cancer death in the United States. The lifetime risk is estimated to be 1 in 75 individuals for the development of melanoma. Surgery remains the mainstay of treatment of melanoma, and in most cases it is curative. Several important surgical issues are discussed in this review, including the extent of surgical margins, Mohs micrographic surgery for melanoma in situ, the use of sentinel lymph node biopsy, the usefulness of lymphadenectomy, isolated limb perfusion, and the role of metastasectomy.

Radiation Therapy as Primary and Adjuvant Treatment for Local and Regional Melanoma

Background

The role of radiation therapy as primary and adjuvant therapy for localized or locally advanced melanoma is controversial.

Methods

To develop evidence-based guidelines, PubMed was searched using the keywords melanoma AND (radiation OR radiotherapy). These references were reviewed and the relevant articles selected. The articles were then reviewed for further references. Because of the paucity of prospective or randomized trials, no attempt was made to classify the quality of the results.

Results

No phase III trials of nodal irradiation for prevention of regional recurrence are available. A phase III trial is being completed by the Tasman Radiation Oncology Group. A phase II trial has been completed by the group. Multiple retrospective series have been published. The available data appear to confirm that nodal radiation therapy is effective in preventing nodal recurrence. No dose response or fraction size response was found. According to generally accepted guidelines, radiation therapy should be offered for patients who have nodes greater than 3 cm, more than 3 involved nodes, or extracapsular extension. For radiation therapy for the treatment of metastatic disease, a phase III trial showed that 50 Gy in 2.5-Gy fractions was as effective as 32 Gy in 8-Gy fractions, with 25% complete remission and 35% partial remission. In contrast, the retrospective studies support that larger fraction sizes, at least 4 Gy, are more effective.

Conclusions

Adjuvant nodal irradiation appears to be effective for the prevention of nodal recurrence. Radiation therapy can also be effective for treatment of local disease, if surgery is not an option.

Multidisciplinary management of special melanoma situations: oligometastatic disease and bulky nodal sites

Potentially resectable, advanced stage melanoma in the form of extensive palpable adenopathy or limited systemic metastases presents a significant challenge but also offers the prospect of long-term disease control. Although surgical resection is the mainstay of therapy, involvement of a multidisciplinary team is required for optimal management of these special situations. These patients need to be evaluated preoperatively by the team, discussed at a multidisciplinary conference, and treated by experienced physicians with access to the full spectrum of modern surgical and oncologic therapy. Surgical resection is generally extensive and may require en bloc resection of important anatomic structures. Adjuvant radiation or systemic therapy is required in many patients to help achieve durable regional and systemic control of disease. In addition, novel therapies, such as neoadjuvant chemotherapy, targeted therapies, or investigational intralesional therapies, may ultimately play a role in the management of these difficult clinical situations and require further evaluation, as preliminary studies show some encouraging results.

Mise au point sur la prise en charge chirurgicale du mélanome malin cutané. Revue de la littérature

Nowadays managing a cutaneous malignant melanoma can concern different kind of physicians: dermatologists, general or plastic surgeons The primary surgical procedure is a major step of the treatment. Biopsy must be total to properly determine the thickness of the tumor in case of malignancy. Wide local excision of the scar is often necessary to decrease the local and general recurrence rates. Wide local excision must be performed conforming to its own surgical rules. Managing tumor located on the face or limb extremities is a matter of plastic surgery. Sentinel node biopsy has succeeded to elective lymph node dissection. This procedure allows research of lymphatic spreading of the disease. Practice of sentinel node biopsy must be achieved in a protocolar way. Topography of the lesion can modified achievement and results of this procedure. Prognosis benefit of sentinel biopsy is now clear. Elective lymph node dissection is only performed in case of invaded sentinel node or clinically invaded lymph nodes. Local or locoregional recurrences mainly respond to surgical treatment using wide excision. However, alternative solutions are being evaluated (isolated limb perfusion).

Reconstruction following Radical Resection of Recurrent Metastatic Axillary Melanoma

BACKGROUND

Recurrent axillary metastasis following axillary lymphadenectomy for melanoma is associated with a poor prognosis. Radical resection of such axillary recurrences with concomitant reconstruction may not only yield significant palliation of symptoms but also improve disease-free survival. The purpose of this study was to evaluate the outcomes of this radical surgical approach and help determine the risks and benefits for this patient population.

METHODS

A retrospective review of all patients who underwent axillary reexcision and reconstruction for metastatic melanoma between 1990 and 2000 was conducted at The University of Texas M. D. Anderson Cancer Center. Nine patients were identified who underwent flap reconstruction following radical excision of axillary recurrence after a previous lymphadenectomy.

RESULTS

A total of 14 flaps were performed on the nine patients (five free flaps and nine pedicled muscle or myocutaneous flaps). Indications for surgery included pain, bleeding, and infection. Seven of the nine patients received perioperative radiation therapy. Palliation of symptoms was achieved in all patients. Free flap survival was 100 percent. Complications occurred in four of nine patients and included seroma, lymphedema, and wound dehiscence. Three patients had second local recurrences necessitating reresection and reconstruction; the mean time to rerecurrence was 6.7 months (range, 2 to 12 months). Four of nine patients were alive with no evidence of disease at the end of the follow-up period, with a mean disease-free interval of 41 months (range, 5 to 77 months). One patient was alive with distant metastasis, and four patients had died of distant metastases. The mean disease-free interval following original lymphedema for the nine patients was 11 months (range, 2 to 40 months).

CONCLUSIONS

Aggressive resection of axillary recurrence following lymphadenectomy can palliate symptoms in select individuals and may result in long-term disease-free survival. Critical to this evolving surgical strategy is the use of vascularized soft tissue in the form of pedicled or free flaps to provide durable coverage of the resulting resection defect.

Radiation Therapy in the Management of Cutaneous Melanoma

The role of RT in the management of melanoma is complex and spans the entire course of the disease. To provide optimal management of patients who have melanoma, radiation oncologists are an integral part of a multidisciplinary team. Appropriate integration of radiation into the management plan can improve locoregional control and alleviate symptoms from meta-static disease. The specific role of RT in locoregional disease is being refined. It is likely that current developments in radiation treatment technology will be applicable to melanoma. These should improve the therapeutic ratio by enhancing the tumoricidal effects of RT without increasing toxicity.

Combined-modality therapy for patients with regional nodal metastases from melanoma

PURPOSE

To evaluate the outcome and patterns of failure for patients with nodal metastases from melanoma treated with combined-modality therapy.

METHODS AND MATERIALS

Between 1983 and 2003, 466 patients with nodal metastases from melanoma were managed with lymphadenectomy and radiation, with or without systemic therapy. Surgery was a therapeutic procedure for clinically apparent nodal disease in 434 patients (regionally advanced nodal disease). Adjuvant radiation was generally delivered with a hypofractionated regimen. Adjuvant systemic therapy was delivered to 154 patients.

RESULTS

With a median follow-up of 4.2 years, 252 patients relapsed and 203 patients died of progressive disease. The actuarial 5-year disease-specific, disease-free, and distant metastasis-free survival rates were 49%, 42%, and 44%, respectively. By multivariate analysis, increasing number of involved lymph nodes and primary ulceration were associated with an inferior 5-year actuarial disease-specific and distant metastasis-free survival. Also, the number of involved lymph nodes was associated with the development of brain metastases, whereas thickness was associated with lung metastases, and primary ulceration was associated with liver metastases. The actuarial 5-year regional (in-basin) control rate for all patients was 89%, and on multivariate analysis there were no patient or disease characteristics associated with inferior regional control. The risk of lymphedema was highest for those patients with groin lymph node metastases.

CONCLUSIONS

Although regional nodal disease can be satisfactorily controlled with lymphadenectomy and radiation, the risk of distant metastases and melanoma death remains high. A management approach to these patients that accounts for the competing risks of distant metastases, regional failure, and long-term toxicity is needed.

The impact of whole-brain radiation therapy on the long-term control and morbidity of patients surviving more than one year after gamma knife radiosurgery for brain metastases

PURPOSE

To better analyze how whole-brain radiotherapy (WBXRT) affects long-term tumor control and toxicity from the initial stereotactic radiosurgery (SRS) for brain metastases, we studied these outcomes in patients who had survived at least 1 year from SRS.

METHODS AND MATERIALS

We evaluated the results of gamma knife radiosurgery for 160 brain metastases in 110 patients who were followed for a median of 18 months (range, 12-122 months) after SRS. Eighty-two patients had a solitary brain metastasis and 28 patients had multiple metastases. Seventy patients (116 tumors) were treated with initial radiosurgery and WBXRT, whereas 40 patients (44 lesions) initially received radiosurgery alone. Median treatment volume was 1.9 cc in the entire group, 2.3 cc in the WBXRT group, and 1.6 cc in the SRS alone group. Median tumor dose was 16 Gy (range, 12-21 Gy).

RESULTS

At 1, 3, and 5 years, local tumor control was 84.1% +/- 5.5%, 68.6% +/- 8.7%, and 68.6% +/- 8.7% with SRS alone compared with 93.1% +/- 2.4%, 87.7% +/- 4.9%, and 65.7% +/- 10.2%. with concurrent WBXRT and SRS (p = 0.0228, univariate). We found that WBXRT improved local control in patient subsets tumor volume > or =2 cc, peripheral dose < or =16 Gy, single metastases, nonradioresistant tumors, and lung cancer metastases (p = 0.0069, 0.0080, 0.0083, 0.0184, and 0.0348). Distal intracranial failure developed at 1, 3, and 5 years in 26.0% +/- 7.1%, 74.5% +/- 9.4%, and 74.5% +/- 9.4% with SRS alone compared with 20.7% +/- 4.9%, 49.0% +/- 8.7%, and 61.8% +/- 12.8% with concurrent WBXRT and SRS (p = 0.0657). We found a trend for improved distal intracranial control with WBXRT for only nonradioresistant tumors (p = 0.054). Postradiosurgery complications developed in 2.8% +/- 1.2% and 10.7% +/- 3.5% at 1 and 3-5 years and was unaffected by WBXRT (p = 0.7721). WBXRT did not improve survival in the entire series (p = 0.5027) or in any subsets.

CONCLUSIONS

In this retrospective study of 1-year survivors of SRS for brain metastases, the addition of concurrent WBXRT to SRS was associated with an improved local control rate in patient subsets with tumor volume > or =2 cc, peripheral dose < or =16 Gy, single metastases, nonradioresistant tumors, and specifically lung cancer metastases. A trend was noted for improved distal intracranial control for patients having nonradioresistant tumors. Distant intracranial relapse >1 year posttreatment is a significant problem with or without initial WBXRT.

Surgical treatment of stage IV melanoma

Surgical therapy plays an important role in the management of selected patients with metastatic melanoma. Patients are frequently symptomatic from metastatic lesions, have few effective therapeutic options, and are faced with dismal outcomes. Surgical resection may provide successful palliation of symptomatic lesions with low morbidity and operative mortality. In carefully selected patients, resections performed with curative intent may result in improved survival if a pattern of disease recurrence suggestive of favorable tumor biology is present, and if complete resection of tumor is achieved. Because the majority of post-surgical metastatic patients eventually relapse and succumb to distant disease, adjuvant immunotherapeutic strategies are currently being evaluated.

A Critical Assessment of Adjuvant Radiotherapy for Inguinal Lymph Node Metastases from Melanoma

BACKGROUND

Although patients with inguinal or pelvic lymph node (LN) metastases from melanoma may develop regional recurrence after dissection, the role of adjuvant radiotherapy remains controversial.

METHODS

The medical records of 40 patients with inguinal and/or pelvic lymph node metastases from melanoma were reviewed retrospectively. Indications for adjuvant radiotherapy included the following nodal characteristics: extracapsular extension, LNs > or =3 cm in diameter, > or =4 involved LNs, and LN recurrence after prior nodal surgery. Thirty-seven of 40 patients underwent formal LN dissection. Three patients had only local excision of gross disease for recurrence after prior dissection. All patients received radiation to a median dose of 30 Gy at six Gy/fraction delivered twice weekly.

RESULTS

With a median follow-up time of 22.5 months, the 3-year actuarial distant metastasis-free and overall survival rates were 35% and 38%, respectively. The 3-year regional control rate was 74%. Univariate analyses of patient, tumor, and treatment characteristics failed to reveal any association with distant metastasis-free survival, overall survival, or regional control. Regional failures occurred in nine patients; seven of these were isolated dermal failures within the field of irradiation. Only two patients (5%) had LN basin recurrences; one of these patients also developed dermal recurrence. Fifteen of 40 patients developed lymphedema; in seven of these, lymphedema was present before initiation of radiation therapy.

CONCLUSIONS

Radiation may prevent recurrence of nodal disease in patients at high risk for regional failure, but in-field dermal recurrences may sometimes occur (8 of 40, 20%). Treatment-related lymphedema and death from metastatic melanoma were common.

Radiation therapy following lymph node dissection in melanoma patients: treatment, outcome and complications

Adjuvant radiation treatment following lymph node dissection in the melanoma patient has been suggested and investigated in an attempt to gain regional control and improve survival. In this review we discussed the treatment, the loco-regional control, disease-free and survival rates and complications. Historically melanoma has been thought of as a relatively radioresistant tumour. Nowadays, radiation delivered according to the hypofractionated schedule is the most used, although there are no data to confirm that this schedule improves the therapeutic impact. Almost all the reviewed studies were retrospective, which could have led to an underestimation of the true incidence of the treatment toxicity and morbidity. Adjuvant radiotherapy after lymph node dissection for metastases of melanoma seems to improve loco-regional control without improving overall survival. The available data indicate the need for improved regional control rates in patients with extranodal extension, multiple involved nodes (more than three) and patients with large involved nodes (larger than 3 cm). The complications seem manageable and consist mainly of fibrosis and edema.

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.

Concurrent interferon-alpha and radiation for head and neck melanoma

Melanoma cells are resistant to radiation in part due to their capacity to repair sublethal damage. A large fraction dose is therefore often utilized. However, if the tumour is located close to critical structures with modest tolerance, high fraction doses increase the risk for late complications compared with standard fractionation, but using the latter alone risks the desired outcome. Concurrent systemic biotherapy with standard radiation fractions may therefore represent an acceptable compromise. The outcome of concurrent systemic interferon-alpha (IFNalpha) and radiation in three patients with head and neck melanoma was evaluated. Standard radiation fractions were used because of the radiosensitizing properties of IFNalpha. Acute toxicity was significant and required treatment interruptions. However, all side effects subsided following treatment. All three patients achieved local control at follow-up periods of 24, 18 and 19 months, respectively. One patient developed widespread distant metastases. The combination of IFNalpha with radiation is considered feasible in terms of outcome and should be investigated with a larger cohort of patients. Toxicity is significant, and the addition of radioprotectors could be desirable.

Current concepts in the management of patients with melanoma

Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.

The clinical behavior of desmoplastic melanoma

BACKGROUND

Desmoplastic melanoma (DM) is a rare variant of malignant melanoma. A better understanding of the clinical course of DM will impact on its treatment.

METHODS

We reviewed the medical records of 59 patients with DM seen at the Mayo Clinics Scottsdale and Rochester since 1985.

RESULTS

Thirty-seven (63%) patients were male with a mean age of 62.8 years. The mean DM thickness was 6.5 mm. A total of 23 patients (39%) experienced local recurrence (LR). LR correlated with positive, unknown, or <1 cm margins. Fifty percent of patients who locally recurred subsequently developed metastatic disease. No patients were found to have positive nodal disease during ELND (16) or SLN biopsy (12). Only 1 patient (2%) developed delayed regional node metastases. Sixteen patients developed metastatic disease. The most common site was the lungs (81%).

CONCLUSIONS

LR is a significant problem and correlates with an increased risk of systemic metastatic disease. With the rare occurrence of lymphatic spread, we recommend patients undergo SLN biopsy only. DM appears to preferentially metastasize to the lungs and should be targeted when evaluating the patient for metastatic disease.