Does complete resection of melanoma metastatic to solid intra-abdominal organs improve survival?

Surgical Utilization and Outcomes for Patients with Stage IV Melanoma in the Modern Immunotherapy Era

BACKGROUND

The benefit of surgery for patients with stage IV melanoma in the modern era of effective immunotherapy is unclear. This study aimed to evaluate trends and outcomes after surgical resection of stage IV melanoma in the modern immunotherapy era.

METHODS

Patients with stage IV melanoma who received surgery, immunotherapy, or both from 2012 to 2017 were identified from the National Cancer Database (NCDB). Demographics, facility-level characteristics, and use of immunotherapy were compared between patients who received surgery and those who did not. Multivariate Poisson regression modeling, Kaplan-Meier survival analysis, and Cox regression analysis were performed.

RESULTS

The study identified 9800 patients with stage IV melanoma, and 2160 of these patients (22 %) underwent surgery. The patients who received surgery were more likely to be younger (P < 0.001), to have private insurance (P < 0.001), to have a higher median income (P = 0.008), and to receive treatment at academic/research programs (P < 0.001), whereas they were less likely to receive immunotherapy (33.7 % vs 36.6 %; P = 0.013). The patients who received immunotherapy had a lower likelihood of undergoing surgery (relative risk [RR], 0.82; 95 % confidence interval [CI[, 0.75-0.88; P < 0.001). The patients who received both surgery and immunotherapy had a better overall survival rate (hazard ratio [HR], 0.41; 95 % CI, 0.36-0.46; P < 0.01) than the patients who received neither immunotherapy nor surgery.

CONCLUSIONS

The use of immunotherapy was associated with a lower use of surgery for patients with stage IV melanoma. The patients with stage IV disease who received both surgery and immunotherapy had the highest overall survival rates.

Local therapy in advanced melanoma after immune checkpoint inhibitors aiming to achieve complete response

Background and Objectives

New scenarios for local therapy have arisen after starting immune checkpoint inhibitors (ICIs) to treat advanced melanoma (AM). The aim of this study is to examine the role of local therapies with curative intention for patients with AM that have been on ICI.

Methods

This was a single institution, retrospective analysis of unresectable stage III or IV melanoma patients on treatment with anti-PD1 ± anti-CTLA-4 who underwent local therapy with curative intention with no other remaining sites of disease (NRD).

Results

Of the 170 patients treated with ICI, 19 (11.2%) met the criteria of curative intention. The median time on ICI before local therapy was 16.6 months (range: 0.92-43.2). At the time of the local treatment, the disease was controlled in 16 (84.25%) and progressing in 3 patients (15.75%); 14 patients (73.7%) treated a single lesion and 5 (26.3%) treated 2 to 3 lesions. In a median follow-up of 17 months (range: 1.51-38.2) after the local therapy and 9.8 months after the last ICI cycle (range: 0.56-31), only 2 (10.5%) out of 19 patients relapsed.

Conclusions

Patients with AM on treatment with ICI were able to achieve NRD after local treatment and may benefit from long-term disease control without systemic treatment.

The role of resection for melanoma metastases to the pancreas

BACKGROUND

Among patients with distant metastatic melanoma, the site of metastases is the most significant predictor of survival and visceral-nonpulmonary metastases hold the highest risk of poor outcomes. However, studies demonstrate that a significant percentage of patients may be considered candidates for resection with improved survival over nonsurgical therapeutic modalities. We aimed at analyzing the results of resection in patients with melanoma metastasis to the pancreas by assessing the available evidence.

METHODS

The PubMed/MEDLINE, WoS, and Embase electronic databases were systematically searched for articles reporting on the surgical treatment of pancreatic metastases from melanoma. Relevant data from included studies were assessed and analyzed. Overall survival was the primary endpoint of interest. Surgical details and oncological outcomes were also appraised.

RESULTS

A total of 109 patients treated surgically for pancreatic metastases were included across 72 articles and considered for data extraction. Overall, patients had a mean age of 51.8 years at diagnosis of pancreatic disease. The cumulative survival was 71%, 38%, and 26% at 1, 3 and 5 years after pancreatectomy, with an estimated median survival of 24 months. Incomplete resection and concomitant extrapancreatic metastasis were the only factors which significantly affected survival. Patients in whom the pancreas was the only metastatic site who received curative resection exhibited significantly longer survival, with a 1-year, 3-year, and 5-year survival rates of 76%, 43%, and 41%, respectively.

CONCLUSION

Within the limitations of a review of non-randomized reports, curative surgical resection confers a survival benefit in carefully selected patients with pancreatic dissemination of melanoma.

Surgery for liver metastases from primary melanoma: a systematic review and meta-analysis

BACKGROUND

Historically , liver metastases due to melanoma have been associated with dismal prognosis. Moreover, the actual survival benefit from the treatment of melanoma liver metastases is still controversial. Hence, this study aims to evaluate the difference in surgical versus non-surgical options for melanoma liver metastases.

METHODS

Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to July 17, 2022. Studies were included if they compared outcomes between surgical and non-surgical treatment for patients with liver metastases from resectable melanoma. Meta-analyses were performed for the outcomes of 1-year, 2-year, 3-year and 5-year OS. Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity. To account for possible moderators that might contribute to statistical heterogeneity, univariate meta-regression with mixed-effects models and subgroup analyses were conducted for the outcome of 2-year OS.

RESULTS

The search yielded 6610 articles; 13 studies were included in our analysis. Meta-analyses showed that survival outcomes were in favour of patients undergoing surgery as compared to non-surgery: 1-year OS (HR = 0.29, 95%CI 0.19-0.44, p < 0.00001), 2-year OS (HR = 0.19, 95%CI 0.09-0.38, p < 0.00001), 3-year OS (HR = 0.07, 95%CI 0.03-0.19, p < 0.00001) and 5-year OS (HR = 0.07, 95%CI 0.02-0.22, p < 0.00001). All included studies were of high quality. There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses. Subgroup analyses and univariate meta-regression revealed neoadjuvant therapy and age as statistically significant subgroup and moderator respectively.

CONCLUSIONS

This study suggests that surgical treatment of melanoma liver metastases could offer better OS outcomes compared with non-surgical treatment.

Intra-Abdominal Malignant Melanoma: Challenging Aspects of Epidemiology, Clinical and Paraclinical Diagnosis and Optimal Treatment—A Literature Review

According to European consensus-based interdisciplinary guidelines for melanoma, cutaneous melanoma (CM) is the most deadly form of dermatological malignancy, accounting for 90% of the deaths of skin cancer patients. In addition to cutaneous melanoma, mucosal melanoma occurs in four major anatomical sites, including the upper respiratory tract, the conjunctiva, the anorectal region, and the urogenital area. As this cancer type metastasizes, a classification used in the current medical literature is the distinction between secondary lesions and primary malignant melanoma of the abdominal cavity. Given that malignant melanoma is the most common cancer that spreads to the gastrointestinal tract, different imaging modalities compete to diagnose the phenomenon correctly and to measure its extension. Treatment is primarily surgery-based, supported by immunotherapy, and prolongs survival, even when performed at stage IV illness. In the end, special forms of malignant melanoma are discussed, such as melanoma of the genito-urinary tract and amelanotic/achromic melanoma. The importance of this present literature review relies on yielding and grouping consistent and relevant, updated information on the many aspects and challenges that a clinician might encounter during the diagnosis and treatment of a patient with intra-abdominal melanoma.

Outcomes After Curative Metastasectomy for Patients with Malignant Melanoma: A Systematic Review and Meta-analysis

BACKGROUND

Evidence on the role of curative metastasectomy (CM) for malignant melanoma (MM) patients is limited, especially in the current era of effective systemic therapy. A systematic review and meta-analysis were performed to ascertain the role of CM compared with incomplete or nonsurgical treatment for patients with MM.

METHODS

Medline, Embase, and Scopus databases were searched for studies investigating CM for MM until 30 September 2021. The review included studies that compared CM with no-CM and reported a hazard ratio (HR) after multivariate analysis for overall survival. A random-effects model with inverse variance was used to calculate pooled HR. The Newcastle-Ottawa Scale was used to assess the risk of bias.

RESULTS

For the final analysis, 40 studies including 31,282 patients (CM, 9958; no-CM, 21,324) were considered. Compared with no-CM, CM was associated with a significantly lower risk of death (HR, 0.42; 95% confidence interval [CI], 0.38-0.47; p < 0.00001). Subgroup analysis showed that the outcome was independent of the effective systemic therapy and anatomic location of metastasis. An unfavorable prognosis was associated with advancing age, elevated lactate dehydrogenase (LDH), male gender, prior stage 3 disease, multiple metastases and organ sites, and shorter disease-free interval.

CONCLUSION

Curative metastasectomy for MM is associated with a lower risk of death than non-curative treatment methods. Selection bias and underlying weakness of studies reduced the strength of evidence in this review. However, CM should be a part of the multimodality treatment of MM whenever technically feasible.

Robotic Extended Ultrasound-Guided Distal Pancreatectomy for Pancreatic Metastases from Uveal Melanoma

BACKGROUND

Isolated pancreatic metastasis from melanoma is extremely uncommon and accounts for approximately only 2% of visceral disseminations of melanoma.^1-3 Interestingly, pancreatic localizations disproportionately derive from primary ocular melanoma.^1,2 Despite the currently available evidence on this argument being scarce, the survival outcomes of patients receiving resection for visceral melanoma metastases are reported to be superior than those managed by non-surgical modalities.^4,5 CASE PRESENTATION: A 59-year-old female with a history of uveal melanoma presented with surveillance-detected metastatic disease confined to the pancreas. Computed tomography demonstrated one lesion located in the body of the pancreas and one further lesion in the head. The presented video illustrates the details of an extended, ultrasound-guided, robotic distal pancreatectomy.

DISCUSSION

Metastatic ocular melanoma has a highly variable natural history, which ranges from a fulminant course to prolonged stable disease.⁶ In contrast to cutaneous melanoma derivation, metastases mostly occur via hematogenous spread, in the absence of lymphatic drainage of the eye.^6,7 Liver is the most common site of secondary localization and is not involved by metastatic disease in <10% of cases. Interestingly, patients with extrahepatic metastases tend to have significantly better survival rates than those with hepatic disease.^6,7 Fewer than 100 cases of pancreatic metastasis from malignant melanoma are reported in the medical literature, including a relatively high percentage of primary ocular malignancies.^1,5 Furthermore, the prognosis of these patients is essentially unknown, although metastatic melanoma of both cutaneous and ocular origin generally indicates poor survival.^1,5,6 Although no robust evidence is available, a number of reports suggest that pancreatic resection may improve survival in these patients.^1-4 A large retrospective review investigating the association between treatment modalities and survival of patients with abdominal visceral melanoma metastases showed that patients receiving resection had a superior median survival compared with patients treated medically. Although patients with metastases of the gastrointestinal tract showed the best outcomes following surgery, patients with pancreas metastasis (of both cutaneous and ocular origin) undergoing resection also exhibited a significant survival advantage compared with those treated non-surgically.⁵ Minimally invasive pancreatectomy is gaining momentum.⁸ In fact, in selected patients there are distinct advantages compared with conventional surgery owing to reduced postoperative morbidity and earlier return to daily activities, while maintaining the oncological tenets of resection.^8-10 Recent reports suggest that the application of robots may provide some advantages over conventional laparoscopy, especially for patients necessitating technically challenging surgeries.^8,11 Such benefits are mainly in relation to the rate of conversion, length of postoperative hospital stay, and number of cases necessary to surmount the learning curve and reach optimal performance; however, no definitive conclusions can be drawn due to the lack of high-level evidence.^8,10.

Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.

Isolated metastatic melanoma to the pancreas in the context of myeloproliferative neoplasm: a rare occurrence

Isolated metastatic melanoma to the pancreas is a rare occurrence, representing less than 1 per cent of metastatic melanoma. This case describes the clinical presentation and course of illness of a patient who was diagnosed with a solitary metastasis to the pancreas 11 months after a clear margin resection of a pT1b, stage IB melanoma. Her melanoma metastasis was diagnosed on Endoscopic Ultrasound-Fine Needle Biopsy (EUS-FNB). This patient was found to have a concurrent myeloproliferative neoplasm (MPN) at the time of diagnosis. This case importantly highlights the course of a rare finding in isolated metastatic melanoma to the pancreas that may have been accelerated by the patient's immunocompromised state with concurrent MPN. A high index of suspicion must be raised in patients with abdominal symptoms and melanoma history as the therapeutic window for these patients is quite narrow.

Partial splenectomy after preoperative embolization in a patient with metastatic melanoma – A case report

Introduction and importance

There is lack of evidence regarding the best treatment option for metastatic melanoma. In patients with a single splenic metastasis, preoperative superselective embolization followed by partial splenectomy (PS) could be a feasible treatment strategy to preserve splenic function and hopefully reduce the risk of postoperative bleeding. To our knowledge, this two-step procedure has yet not been published in patients with splenic metastasis.

Case presentation

We present the case of a 73-year-old man with stage IV melanoma consisting of a single splenic metastasis located at the lower pole. Four days prior to surgery, the patient underwent percutaneous superselective embolization of the segmental arteries going to the lower splenic pole. Subsequent, PS was performed using an upper midline laparotomy were a clearly visible tumor was found at the devascularized lower third of the spleen. The splenic parenchyma was divided using an energy device and hemostasis was secured with diathermia and a hemostatic patch. The patient had an uncomplicated recovery and was discharged home on postoperative day 8. Histology revealed an 8 mm, partly necrotic metastasis from a melanoma. There were no signs of recurrency at his last control four months postoperative.

Clinical discussion

There are no guidelines on how splenic metastasis from melanoma are to be removed, nor any literature on postoperative splenic function or survival after PS.

Conclusion

Superselective embolization followed by PS for metastatic melanoma could be a feasible treatment approach in highly selective patients where there is a strong desire to preserve splenic function.

•

Total splenectomy is associated with an increased risk of infections, thromboembolism and certain malignancies

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Partial splenectomy (PS) may be considered to preserve splenic function in cases where a splenic lesion is to be removed

•

Preoperative superselective arterial embolization can be used to devascularize the relevant splenic segment prior to PS

•

To our knowledge, superselective splenic embolization followed by PS has not been published in patients with splenic metastasis

Nonsurgical Approach to Isolated Pancreatic Metastatic Malignant Melanoma: A Case Report and Review of the Literature

Isolated pancreatic metastases from melanoma are rare with high mortality rate and account for less than 1% of metastatic melanomas. Treatment options are limited with highest overall survival reported in those with complete surgical resection. Of cases reported in the literature with nonsurgical management, highest length of survival was reported to be 10 months. We report a case of malignant melanoma with isolated pancreatic metastasis treated with interferon therapy and immunotherapy, with evidence of progressive tumor shrinkage and survival at 38 months.

Biliary tract melanoma metastasis mimicking hilar cholangiocarcinoma: a case report

Malignant melanoma is the 19th leading cause of cancer worldwide. It is an aggressive neoplastic disease in which pathophysiological understanding and management has been in constant evolution in recent decades. The primary site is the skin, uvea and mucous membranes and has the capacity to metastasize to any organ. There are few reports of primary or secondary involvement of the biliary tract. We present the case of a 73-year-old woman with a bile duct lesion suggestive of cholangiocarcinoma and a final diagnosis of a single melanoma metastasis. Surgical treatment was performed due to oligometastatic stage IV melanoma with possibility of R0 resection followed by immune checkpoint therapy.

A case of laparoscopic partial hepatic S7 resection for postoperative liver metastasis of rectal malignant melanoma

Background

Anorectal malignant melanoma (ARMM) has an extremely poor prognosis, and there is no report of resection of liver metastases so far. We report herein a rare case of postoperative laparoscopic partial hepatic S7 resection for rectal malignant melanoma.

Case presentation

A 51-year-old female patient with a diagnosis of an ARMM underwent a laparoscopic rectal amputation. Eleven months later, computed tomography (CT) revealed a 14-mm nodule in liver segment 7 (S7), which was diagnosed as a hepatic recurrence of the ARMM. Because no other recurrences were found, a laparoscopic partial resection of S7 was performed. Pathological analysis found intracellular melanin deposition, and immunostaining was S-100 (+), HMB-45 (+), and SOX-10 (+). Based on these findings, a liver metastasis of malignant melanoma was diagnosed. The patient is alive 7 months after the second surgery and has so far experienced no recurrences.

Conclusion

We reported an extremely rare case of a laparoscopic resection of a liver metastasis following surgery for ARMM.

Utility of CT to Differentiate Pancreatic Parenchymal Metastasis from Pancreatic Ductal Adenocarcinoma

Simple Summary

The purpose of this retrospective study was to report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and PDAC. At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47–29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13–33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.51–34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27–49.91) were independently associated with PPM. A nomogram based on CT features identified at multivariable analysis yielded an AUC of 0.92 (95% CI: 0.85–0.98) for the diagnosis of PPM vs. PDAC.

Abstract

Purpose: To report the computed tomography (CT) features of pancreatic parenchymal metastasis (PPM) and identify CT features that may help discriminate between PPM and pancreatic ductal adenocarcinoma (PDAC). Materials and methods: Thirty-four patients (24 men, 12 women; mean age, 63.3 ± 10.2 [SD] years) with CT and histopathologically proven PPM were analyzed by two independent readers and compared to 34 patients with PDAC. Diagnosis performances of each variable for the diagnosis of PPM against PDAC were calculated. Univariable and multivariable analyses were performed. A nomogram was developed to diagnose PPM against PDAC. Results: PPM mostly presented as single (34/34; 100%), enhancing (34/34; 100%), solid (27/34; 79%) pancreatic lesion without visible associated lymph nodes (24/34; 71%) and no Wirsung duct enlargement (29/34; 85%). At multivariable analysis, well-defined margins (OR, 6.64; 95% CI: 1.47–29.93; p = 0.014), maximal enhancement during arterial phase (OR, 6.15; 95% CI: 1.13–33.51; p = 0.036), no vessel involvement (OR, 7.19; 95% CI: 1.512–34.14) and no Wirsung duct dilatation (OR, 10.63; 95% CI: 2.27–49.91) were independently associated with PPM. The nomogram yielded an AUC of 0.92 (95% CI: 0.85–0.98) for the diagnosis of PPM vs. PDAC. Conclusion: CT findings may help discriminate between PPM and PDAC.

CT, MRI and PET/CT features of abdominal manifestations of cutaneous melanoma: a review of current concepts in the era of tumor-specific therapies

Abdominal manifestations in patients with cutaneous melanoma include involvement due to metastatic spread and immune checkpoint inhibitor induced adverse events. The purpose of this review is to provide a critical overview of abdominal manifestations in patients with cutaneous melanoma and highlight the current imaging challenges in the era of tumor-specific therapies. Immune checkpoint inhibitors represent a treatment with demonstrated efficacy in the treatment of advanced cutaneous melanoma but are associated with several abdominal adverse events that must be recognized. CT has a role in the identification of colitis, enteritis and pancreatitis, whereas MRI has an important role in the diagnosis of autoimmune pancreatitis. Current evidence demonstrates that MRI should be the preferred imaging technique for the detection and characterization of hepatic and splenic metastases from cutaneous melanoma. The role of ¹⁸F-FDG-PET/CT should be further evaluated but current literature suggests an efficacy in the detection of pancreatic metastases not seen on CT and MRI.

Image-guided Raman spectroscopy probe-tracking for tumor margin delineation

SIGNIFICANCE

Tumor detection and margin delineation are essential for successful tumor resection. However, postsurgical positive margin rates remain high for many cancers. Raman spectroscopy has shown promise as a highly accurate clinical spectroscopic diagnostic modality, but its margin delineation capabilities are severely limited by the need for pointwise application.

AIM

We aim to extend Raman spectroscopic diagnostics and develop a multimodal computer vision-based diagnostic system capable of both the detection and identification of suspicious lesions and the precise delineation of disease margins.

APPROACH

We first apply visual tracking of a Raman spectroscopic probe to achieve real-time tumor margin delineation. We then combine this system with protoporphyrin IX fluorescence imaging to achieve fluorescence-guided Raman spectroscopic margin delineation.

RESULTS

Our system enables real-time Raman spectroscopic tumor margin delineation for both ex vivo human tumor biopsies and an in vivo tumor xenograft mouse model. We then further demonstrate that the addition of protoporphyrin IX fluorescence imaging enables fluorescence-guided Raman spectroscopic margin delineation in a tissue phantom model.

CONCLUSIONS

Our image-guided Raman spectroscopic probe-tracking system enables tumor margin delineation and is compatible with both white light and fluorescence image guidance, demonstrating the potential for our system to be developed toward clinical tumor resection surgeries.

Isolated Pancreatic Metastasis From Choroidal Melanoma After 10 Years of Enucleation Mimicking Neuroendocine Tumor on 68Ga-DOTANOC PET/CT

Isolated pancreatic metastasis from choroidal melanoma is a rare phenomenon. We describe a case of a 38-year-old woman who underwent enucleation surgery for right choroidal melanoma and subsequently developed lesions in the pancreas 10 years after enucleation, which were depicted on Ga-DOTANOC PET/CT and confirmed to be metastasis from choroidal melanoma on surgical histopathology.

Melanoma of unknown primary in the pancreas: should it be considered primary?

Background

Malignant melanoma is characterized as highly malignant due to its rapid growth and early metastasis. Metastatic melanoma from occult primary is rare. Melanoma of unknown primary in pancreas are even rear. But it is a biologically ill-defined and clinically understudied concept.

Case presentation

In this report, a 43-year-old man was diagnosed with pancreatic carcinoma. Extended total pancreatectomy together with portal vein reconstruction and extensive lymphadenectomy were performed in our hospital. The patient was diagnosed with pancreatic malignant melanoma after pathological examination. He was still alive 20 months after the operation without any evidence of recurrence.

Conclusion

The described case highlights the possibility of primary pancreatic malignant melanoma and the treatment strategies of this rare carcinoma.

Use of immunotherapy and surgery for stage IV melanoma

BACKGROUND

Immunotherapy for stage IV melanoma has dramatically changed the overall prognosis and treatment strategies. The aim of this study was to evaluate whether changes in systemic immunotherapy options have significantly altered surgical resection rates for patients with stage IV melanoma.

METHODS

The National Cancer Database (2004-2015) was used to perform a difference-in-difference analysis to evaluate whether the rate of surgical resection of metastatic disease for stage IV melanoma differed with the use of immunotherapy in the checkpoint inhibitor era in comparison with the use of immunotherapy in the pre-checkpoint inhibitor era. An adjusted difference-in-difference analysis stratified by facility type was performed. An adjusted Poisson regression analysis evaluated predictors of surgical resection in patients with stage IV melanoma who received immunotherapy.

RESULTS

There were 14,433 patients with stage IV melanoma (median age, 66 years [interquartile range, 56-76 years]; female, 31.7%), and of all patients in the checkpoint inhibitor era (n = 7,524), 25% (n = 1,879) received immunotherapy. Patients with stage IV disease who received immunotherapy in the checkpoint inhibitor era were more likely to be younger, be healthier, have private insurance, come from upper income quartiles, and be treated at academic programs. A difference-in-difference analysis revealed similar rates of surgical resection of metastatic disease with the use of immunotherapy in the checkpoint inhibitor era and the pre-checkpoint inhibitor era, regardless of facility type.

CONCLUSIONS

The distribution of immunotherapy was unequal among patients with stage IV melanoma. Across all facilities, the rates of surgical resection of metastatic disease for stage IV melanoma did not differ with the use of immunotherapy between the checkpoint inhibitor era and the pre-checkpoint inhibitor era.

Survival Outcomes After Metastasectomy in Melanoma Patients Categorized by Response to Checkpoint Blockade

INTRODUCTION

Checkpoint inhibitors have improved outcomes in metastatic melanoma, with 4-year overall survival (OS) of 46% for anti-PD-1 alone or 53% in combination with anti-CTLA-4. However, the median progression free survival is 6.9 and 11.5 months, respectively. Many who progress have gone on to alternative treatments, including surgery, yet the outcome of patients selected for surgery after checkpoint blockade remains unclear.

METHODS

Patients who were treated with checkpoint blockade from 2003 to 2017, followed by metastasectomy, were identified from a prospectively maintained institutional melanoma database. Response to immunotherapy was assessed at the time of surgery. Patients were categorized as having responding, isolated progressing, or multiple progressing lesions.

RESULTS

Of the 237 total patients identified, 208 (88%) had stage IV disease, and 29 (12%) had unresectable stage III disease at the start of immunotherapy. Median OS following first resection was 21 months. Median follow-up among survivors was 23 months. Complete resection at the first operation (n = 87, 37%) was associated with improved survival compared with patients with incomplete resection (n = 150, 63%) [median OS not reached (NR) vs. 10.8 months, respectively; 95% CI: 7.3, 14.8; p < 0.0001]. Patients resected for an isolated progressing or responding tumor had a longer median survival compared with those with multiple progressing lesions (NR vs. 7.8 months, 95% CI: 6.2, 11.2; p < 0.0001).

CONCLUSIONS

Patients selected for surgical resection following checkpoint blockade have a relatively favorable survival, especially if they had a response to immunotherapy and undergo complete resection of isolated progressing or responding disease.

Isolated pancreatic metastasis from malignant melanoma: a case report and literature review

Isolated pancreatic metastasis from malignant melanoma is rare. Pancreatic metastasis is difficult to diagnose in patients with unknown primary malignant melanoma. Endoscopic ultrasound-guided fine-needle aspiration plays an important role in confirming the diagnosis. A 67-year-old woman was referred to our institution because of a mass in her pancreas. Computed tomography and magnetic resonance imaging revealed a 35-mm mass localized on the pancreatic tail, with low attenuation, surrounded by a high-attenuation rim. Endoscopic ultrasonography revealed a hypoechoic mass with central anechoic areas. Endoscopic ultrasound-guided fine-needle aspiration of the mass was performed, and the pathological diagnosis was malignant melanoma. Intense fluorodeoxyglucose uptake was observed in the pancreatic tail on positron emission tomography-computed tomography. No other malignant melanoma was found. Distal pancreatectomy was performed. Six months postoperatively, positron emission tomography-computed tomography revealed high uptake in the left nasal cavity, and biopsy revealed the mass to be a malignant melanoma, indicating that the primary site of the malignant melanoma was the left nasal cavity and that the pancreatic mass and peritoneal lesion were metastases. The patient had survived > 2 years after the distal pancreatectomy. Pancreatic resection of isolated pancreatic metastasis can possibly prolong survival; however, metastatic melanoma usually has poor prognosis.

Surgically resected pancreatic metastasis from nasal malignant melanoma: case report and literature review

A 13-mm mass was observed in the pancreatic head of a 70-year-old woman who had undergone melanoma resection in the nasal cavity 10 years earlier. Endoscopic ultrasonography (EUS) showed that the mass consisted of multiple hypoechoic nodules. EUS-guided fine needle aspiration and pancreatic juice cytologies revealed neoplastic cells positive for HMB45 and melan-A staining with a few melanin granules, indicating the presence of a metastatic malignant melanoma. These additional stainings were evaluated after surgery. In the surgically resected specimen, the mass had multiple nodule-like structures, some of which were brown colored. Immunocytochemistry and electronic microscopy findings confirmed the diagnosis of malignant melanoma. Microscopic findings were similar to the nasal specimen; therefore, the pancreatic lesion was considered to be a metastasis from the nasal cavity.

Indications for the surgical resection of stage IV disease

Tumor biology and careful patient selection weigh heavily in determining the appropriate role of surgical resection in stage IV melanoma. Historically, surgical resection for highly selected patients with metastatic melanoma was the only treatment modality associated with improved long-term survival and the ability to provide palliation. With the new age of effective systemic therapies, the treatment of metastatic melanoma has become more intricate and future work is needed to better define the role for surgery within the current treatment paradigm.

Case report on the role of radiofrequency-assisted spleen-preserving surgery for splenic metastasis in the era of check-point inhibitors

RATIONALE

An isolated splenic metastasis is a rare phenomenon noted in advanced stage melanoma. We report the role of radiofrequency (RF) -based splenic-preserving splenectomy in a patient with a solitary splenic metastasis from advanced stage melanoma that was managed with checkpoint inhibitors.

PATIENT CONCERNS

We report a case of a 60-year-old man who presented with multiple lung metastases and a solitary splenic metastasis with advanced stage melanoma following excision of primary from his trunk 2.3 years back.

DIAGNOSIS

Considering the diagnosis of advanced stage melanoma with multiple lung metastases and a solitary splenic metastasis, and its ongoing progressive nature. This case was discussed in the tumour board meeting.

INTERVENTIONS

A decision was made to commence treatment with immunotherapy in the form of PD-1 inhibitor (programmed cell death 1 receptor) pembrolizumab. Follow-up restaging computer tomography (CT) scan of the abdomen and chest showed a significant reduction in the lung and chest wall lesions, but the splenic lesion remained unchanged. Given the lack of response to treatment in the splenic metastasis and the significant decrease in lung metastases, the multidisciplinary team decided that a partial splenectomy combined with continued immunotherapy treatment would be appropriate as the success of immunotherapy was imminent within the splenic preservation.

OUTCOMES

The postoperative recovery was smooth and the patient was discharged from hospital on the sixth postoperative day with normal platelets and white blood cells. The histopathological analysis of the resected specimen showed a metastatic melanoma with negative margins.At 10-month follow-up after the splenic resection the patient had not experienced further tumour recurrences.

LESSONS

Spleen-preserving resection for an isolated, solitary splenic metastasis of melanoma is a feasible approach as it not only preserves the ongoing efficacy of checkpoint inhibitors by preserving the physiological T cell milieu, but the immunomodulation properties of RF can produce potentially additional therapeutic benefit.

Association of Surgical Treatment, Systemic Therapy, and Survival in Patients With Abdominal Visceral Melanoma Metastases, 1965-2014: Relevance of Surgical Cure in the Era of Modern Systemic Therapy

Importance

Systemic therapy for metastatic melanoma has evolved rapidly during the last decade, and patient treatment has become more complex.

Objective

To evaluate the survival benefit achieved through surgical resection of melanoma metastatic to the abdominal viscera in patients treated in the modern treatment environment.

Design, Setting, and Participants

This retrospective review of the institutional melanoma database from the John Wayne Cancer Institute at Providence St Johns Health Center, a tertiary-level melanoma referral center, included 1623 patients with melanoma diagnosed as having potentially resectable abdominal metastases before (1969-2003) and after (2004-2014) advances in systemic therapy.

Main Outcomes and Measures

Overall survival (OS).

Results

Of the 1623 patients identified in the database with abdominal melanoma metastases, 1097 were men (67.6%), and the mean (SD) age was 54.6 (14.6) years. Of the patients with metastatic melanoma, 1623 (320 [19.7%] in the 2004-2014 period) had abdominal metastases, including 336 (20.7%) with metastases in the gastrointestinal tract, 697 (42.9%) in the liver, 138 (8.5%) in the adrenal glands, 38 (2.3%) in the pancreas, 109 (6.7%) in the spleen, and 305 (18.8%) with multiple sites. Median OS was superior in surgical (n = 392; 18.0 months) vs nonsurgical (n = 1231; 7.0 months) patients (P < .001). The most favorable 1-year and 2-year OS was seen after surgery for gastrointestinal tract (52% and 41%) and liver (51% and 38%) metastases, respectively. Multivariable analysis found increasing age (hazard ratio [HR], 1.01; 95% CI, 1.00-1.01; P = .02) and the presence of ulceration (HR, 1.21; 95% CI, 1.01-1.45; P = .04) were associated with a worse OS. Alternatively, treatment with metastasectomy (HR, 0.59; 95% CI, 0.46-0.74; P < .001) and metastases involving the gastrointestinal tract (HR, 0.65; 95% CI, 0.48-0.87; P = .004) were associated with a better OS. The systemic treatment era did not significantly affect outcomes (HR, 0.82; 95% CI, 0.67-1.02; P = .15). Overall, patients with gastrointestinal tract metastases undergoing complete, curative resection derived the greatest benefit, with a median OS of 64 months.

Conclusions and Relevance

To our knowledge, this series is the largest single-institution experience with abdominal melanoma metastases, demonstrating that surgical resection remains an important treatment consideration even in the systemic treatment era.

Resection of Gastrointestinal Metastases in Stage IV Melanoma: Correlation with Outcomes

The prognosis of patients with gastrointestinal (GI) melanoma metastases is poor. Surgery renders select patients disease free and/or palliates symptoms. We reviewed our single-institution experience of resection with GI melanoma metastases. A retrospective review was performed on patients who underwent surgery for GI melanoma metastases from 2007 to 2013. Fifty-four patients were identified and separated based on completeness of resection into curative 13 (24%) and palliative 41 (75.9%) groups. Thiry-six (63.2%) were symptomatic preoperatively with bleeding and/or obstruction/pain with 91.7 per cent achieving objective symptom relief. Thirty-day operative mortality was 0 per cent. The most common complication was wound infection (n = 5); major complications like anastomotic leak (n = 1) were uncommon. With a median follow-up of 9.5 months (range 0.2–75.8), median overall survival was not reached (curative) versus 9.53 months (palliative group). Median recurrence-free and progression-free survival after resection were 18.89 and 1.97 months in the curative versus palliative groups, respectively. On multivariate analysis, resection to no clinical evidence of disease (P = 0.012) and presence of single metastases (P = 0.031) were associated with improved overall survival. Surgery for GI metastases from melanoma provides symptomatic relief without major morbidity. Fewer metastases and curative resection were associated with improved survival.

Recurrence and Survival Outcomes After Percutaneous Thermal Ablation of Oligometastatic Melanoma

OBJECTIVES

To evaluate focal treatment of melanoma metastases and to explore whether any potential extended survival benefit exists in a select patient population.

PATIENTS AND METHODS

All patients who underwent image-guided local thermal ablation of metastatic melanoma over an 11-year period (January 1, 2002, to December 31, 2013) were retrospectively identified using an internally maintained clinical registry. Only patients with oligometastatic stage IV disease amenable to complete ablation of all clinical disease at the time of ablation were included in the analysis. Overall survival and median progression-free survival periods were calculated.

RESULTS

Thirty-three patients with primary ocular or nonocular melanoma had 66 metastases treated in the lungs, liver, bones, or soft tissues. Eleven (33%) patients were on systemic medical therapy at the time of the procedure. The median survival time was 3.8 years (range, 0.5-10.5 years), with a 4-year estimated survival of 44.1% (95% CI, 28%-68%). Local recurrence at the ablation site developed in 15.1% (5 of 33) of the patients and 13.6% of the tumors (9 of 66). The median progression-free survival time was 4.4 months (95% CI, 1.4 months to 10.5 years), with an estimated 1-year progression-free survival of 30.3% (95% CI, 18%-51%). A subgroup analysis identified 11 patients with primary ocular melanoma and 22 with nonocular melanoma, with a median survival time of 3.9 years (range, 0.9-4.7 years) and 3.8 years (range, 0.5-10.5 years), respectively (P=.58). There were no major complications and no deaths within 30 days of the procedure.

CONCLUSION

Selective use of image-guided thermal ablation of oligometastatic melanoma may provide results similar to surgical resection in terms of technical effectiveness and oncologic outcomes with minimal risk.

Adrenalectomy for Metastatic Melanoma: Current Role in the Age of Nonsurgical Treatments

Surgical resection of metastases to the adrenal gland can improve overall survival of patients with stage IV melanoma, but its relative value with respect to current nonsurgical therapies is unknown. We hypothesized that surgery remains an optimal first-line treatment approach for resectable adrenal metastases. A search of our institution's prospectively collected melanoma database identified stage IV patients treated for adrenal metastases between January 1, 2000, and August 11, 2014. The 91 study patients had a mean age of 60.3 years at diagnosis of adrenal metastasis and 24 had undergone adrenalectomy. Improved survival was associated with an unknown primary lesion, surgical resection, and nonsurgical therapies. Median overall survival from diagnosis of adrenal metastases was 29.2 months with adrenalectomy versus 9.4 months with nonoperative treatment. Adrenalectomy, either as complete metastasectomy or targeted to lesions resistant to systemic therapy, is associated with improved long-term survival in metastatic melanoma.

Liver resection and ablation for metastatic melanoma: A single center experience

BACKGROUND

The median survival for patients with stage IV metastatic melanoma is usually limited to approximately 1 year. In the case of liver metastasis, resection and ablation can achieve long-term survival. This study aimed to describe the outcomes after liver resection or ablation for metastatic melanoma to the liver and identify preoperative prognostic factors.

METHODS

Forty eight patients who underwent liver resection (n = 32) or percutaneous ablation (n = 16) were identified from the 1,523 patients with melanoma liver metastases evaluated between January1993 and January 2013.

RESULTS

Median OS was 25.9 months. Median OS was not different after ablation (18 months) and resection (26 months; P > 0.2). Patients in the ablation group more often presented with extrahepatic disease (EHD) (P = 0.008) and received more frequently systemic therapy before ablation (P = 0.005). Patients without EHD tended to have longer OS (26.5 vs. 12 months; P = 0.076) and PFS (13 vs. 5 months; P = 0.11) in the whole cohort. EHD was significantly associated with a worse OS in the resection group (P = 0.034).

CONCLUSION

Liver resection is associated to prolonged survival over 24 months and should be considered only in selected patients with metastatic disease confined to the liver. In patients not candidate for surgery, tumor ablation can be considered.

Metastasectomy for stage IV melanoma

Metastatic melanoma has an unpredictable natural history but a predictably high mortality. Despite recent advances in systemic therapy, many patients do not respond, or develop resistance to drug therapy. Surgery has consistently shown good outcomes in appropriately selected patients. It is likely to be even more successful in the era of more effective medical treatment. Surgery should remain a strongly considered option for metastatic melanoma.

Overview and a meta-analysis of pancreatic melanoma based on case reports

AIM: To investigate the clinical characteristics of pancreatic malignant melanoma.

METHODS: Here we report a case of pancreatic malignant melanoma and present a meta-analysis of pancreatic melanoma based on data from well-documented case reports.

RESULTS: A 32-year-old male presented with abdominal pain and jaundice. Computed tomography showed a non-discrete mass in the head of the pancreas. A pancreatoduodenectomy was performed. Histology revealed pancreatic malignant melanoma. Immunostaining showed that the neoplastic cells were positive for Melan A and S100, and that they expressed HMB-45. A review of 13 publications reporting 15 cases identified main clinical symptoms as abdominal pain (nine cases) and jaundice (three cases). Nine patients had a history of extra-abdominal malignant melanoma. The overall median survival time was 10 mo.

CONCLUSION: Pancreatic malignant melanoma is not typified by any special clinical presentation. The diagnosis depends on biopsy or specimen histology. Surgical resection remains the best treatment choice.

Isolated pancreatic metastasis from malignant melanoma: is pancreatectomy worthwile?

Isolated pancreatic metastasis from malignant melanoma (IPMMM) is rare because most melanoma patients already have a widespread disease at diagnosis. No adjuvant systemic treatment is known to be efficient in this setting. Experience with pancreatic resection for IPMMM is limited and controversial. We report here the case of an IPMMM patient successfully treated by pancreaticoduodenectomy with a prolonged survival of 6 years.

Biomarkers in melanoma: Stage III and IV disease

The prognosis associated with Stage III melanoma is variable (17-65% 5-year survival) and primarily influenced by the number of lymph nodes involved, the presence of ulceration in a primary lesion, and the tumor burden present in each lymph node. In patients with metastatic (Stage IV) melanoma, the prognosis remains dismal (6-18% 5-year survival) and is influenced primarily by the sites (and extent) of metastatic involvement. Serum lactate dehydrogenase is the only prognostic biomarker useful in metastatic melanoma and it has been incorporated into the 2002 American Joint Committee on Cancer tumor, node, metastasis staging system. In this review, the known prognostic factors in Stage III and IV melanoma are reviewed. Selected investigational therapies and associated biomarkers are also discussed.

[Acute abdomen as initial manifestation of metastatic melanoma]

The malignant melanoma is a relatively common neoplasia, with origin generally in the melanocytics cells in the skin, but with presentation of other possible primary lesions, being presented in this, a case witnessed of liver and mesentery metastases with unknown primary sites.

[Not Available]

We report a case of minimally invasive surgery in the management of metastasis to the spleen. A 67-year-old male patient with possible splenic soft tissue melanoma metastasis was referred to our hospital. He had a history of an excised soft tissue melanoma from his back eight months earlier, and the control abdominal computer tomography (CT) scan revealed a hypodense spleen lesion. The patient underwent laparoscopic surgery to diagnose and treat the splenic lesion. The splenectomy was performed and the histological examination revealed a melanoma. The patient had a good postoperative course and was discharged on the second postoperative day. On his 12-month follow-up there was no sign of recurrence. The laparoscopic approach is a safe and effective alternative for treatment of splenic metastases.

Systematic review and meta-analysis of liver resection for metastatic melanoma

Background

The multidisciplinary management of metastatic melanoma now occasionally includes major hepatic resection. The objective of this work was to conduct a systematic review of the literature on liver resection for metastatic melanoma.

Methods

MEDLINE, Embase, the Cochrane Library and Scopus were searched (1990 to December 2012). Studies with at least ten patients undergoing liver resection for metastatic melanoma were included. Data on the outcomes of overall survival (OS) and/or disease-free survival (DFS) were abstracted and synthesized. Hazard ratios (HRs) were derived from survival curves and subjected to meta-analysis using random-effects models.

Results

Twenty-two studies involving 579 patients (13 per cent weighted resection rate) who underwent liver resection were included. Study quality was poor to moderate. Median follow-up ranged from 9 to 59 months. Median DFS ranged from 8 to 23 months, and median OS ranged from 14 to 41 months (R0, 22–66 months, R2, 10–16 months; R0versus R1/R2: HR 0.52, 95 per cent confidence interval (c.i.) 0.37 to 0.73). The OS rate was 56–100 per cent at 1 year, 34–53 per cent at 3 years and 11–36 per cent at 5 years. Median OS with non-operative management ranged from 4 to 12 months. Comparison of OS with resection and non-operative management favoured resection (HR 0.32, 95 per cent c.i. 0.22 to 0.46).

Conclusion

Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results.

Stage IV melanoma: completely resectable patients are scarce

BACKGROUND

In melanoma, about 1 in 5 patients develops distant metastases and suffers a very poor prognosis. Common treatment options comprise surgery, systemic medical therapy, and radiotherapy, depending on the number, the location, and the resectability of distant metastases. Previous studies suggested that surgery should be the first choice of treatment whenever complete surgical removal is feasible. However, the proportion of patients that are candidates for this approach is not clear. The aim of the present study was to evaluate the extent of disease and resectability in melanoma patients presenting with stage IV disease at our institute.

METHODS

All melanoma patients diagnosed with stage IV between January 2011 and August 2012 were assessed for extent and resectability of their disease.

RESULTS

About half of 70 assessed patients had 7 or more metastases at diagnosis, whereas 13 patients had only 1 metastasis. The vast majority (n = 55, 78.6 %) was ineligible for complete surgical resection. Six patients did receive complete surgery as initial stage IV treatment and in 9 patients incomplete surgery was performed. Widespread disease (n = 44) and unresectable metastasis (n = 11) were the most common reasons for refraining from complete surgery.

CONCLUSION

The results of the present study show that only a small proportion of patients diagnosed with stage IV melanoma are candidates for complete surgical resection with curative intent in our institution.

Surgical resection of malignant melanoma metastatic to the pancreas: case series and review of literature

BACKGROUND

Malignant melanoma only rarely metastasizes to the pancreas. As such, there is limited medical literature on the clinical course and outcomes for patients who have undergone surgical management of these tumors. The aim of our study was to review our experience with the surgical resection of melanoma metastatic to the pancreas.

METHODS

The records of five patients (four females, one male) with surgically resected melanoma metastatic to the pancreas were retrospectively reviewed. Tumor characteristics, patient presentation, operative details, and follow-up data were evaluated.

RESULTS

The primary site of melanoma was known in three cases and unknown in two cases. Four patients were symptomatic at presentation, including abdominal pain (n = 3), jaundice (n = 2), abdominal distension (n = 1), bleeding metastases (n = 1), and fatigue (n = 1). In one patient, the metastasis was an incidental discovery. Surgical resection was accomplished by pylorus-preserving pancreaticoduodenectomy in four patients and distal pancreatectomy in one patient. Single-site resection was done in two patients while the other three underwent synchronous multiple-site resections. Complications developed post-operatively in three patients. Two patients had progression of disease in the form of new metastatic lesions and received subsequent chemotherapy. The median survival was 11.4 months (range, 3-26 months).

CONCLUSIONS

Aggressive surgical management of pancreatic metastases provides palliative relief of symptoms and may be considered in appropriately selected candidates.

Solitary metachronous splenic metastasis from cutaneous melanoma

Melanoma has been found to metastasise to the spleen, usually in cases of disseminated disease. Solitary splenic metastasis from cutaneous melanoma is very rare. Herein we report the case of a 43-year-old man who developed solitary splenic metastasis from cutaneous melanoma. The patient was operated for T(4b) N(1a) Mo superficial spreading melanoma of the anterior thoracic wall. He subsequently underwent left axillary lymph node dissection due to a positive sentinel lymph node. The 33 retrieved lymph nodes were negative for metastasis. The patient received adjuvant therapy with high-dose interferon α-2b. After 27 months and during the follow-up visit an increasing lactate dehydrogenase serum level was observed. Furthermore, CT of the whole body revealed a solitary hypodense tumour of the spleen 9 cm×6 cm. Curative splenectomy was performed and the histopathological report confirmed metastatic melanoma to the spleen.

Metastatic malignant melanoma of the small bowel--report of two cases

CASE REPORT

We report two cases of malignant melanoma metastasizing to the ileum and jejunum in a 48-year-old female and 62-year-old male, respectively. The female patient was a known case of vaginal melanoma who on follow-up developed pain abdomen 4 years after excision of the primary, whereas the male patient who was initially referred as pleomorphic spindle cell sarcoma of the groin presented with complaints of bleeding per rectum and melena 6 years later.

RESULTS

After preliminary investigations both underwent laparotomy and resection of segments of ileum and jejunum with tumor. Histopathological examination with immunohistochemistry showed features suggestive of metastatic malignant melanoma.

DISCUSSION

Metastasis should be suspected in patients with malignant melanoma who develop gastrointestinal symptoms such as abdominal pain, anemia, melena, fatigue, constipation, small bowel obstruction, or perforation. This helps in avoiding a delay in the diagnosis and complications that arise due to metastatic disease.

CONCLUSION

Our first patient with primary vaginal melanoma died of multiple metastases 11 months following surgery for the ileal metastasis while the second patient with jejunal metastasis developed recurrent disease in the small bowel and iliac lymph nodes 10 months after surgery. However, in a patient with isolated gastrointestinal metastasis, diagnosed early, with good general condition surgical management should be encouraged when a complete resection of the disease is feasible as no other treatment option is as good for relief of symptoms and prolongation of life.

Surgery for distant melanoma metastasis

Traditionally, distant metastatic melanoma has a poor prognosis owing to lack of efficacious, U.S. Food and Drug Administration-approved systemic therapy and the limited use of surgical resection as a therapeutic option. More recently, new biological therapies such as vemurafenib (Zelboraf) and ipilimumab (Yervoy) have shown strong promise and dramatically improved the landscape of stage IV melanoma therapy. Although there are numerous single-institution studies advocating the role for therapeutic surgical intervention, many remain skeptical of nonpalliative surgery for metastatic melanoma. Surgical resection of advanced melanoma has been proven to be effective as long as all disease is removed (R0). Patient selection is paramount. The combination of newer systemic therapies and surgical resection is currently under investigation. Understanding the tumor biology of melanoma and its mechanism of metastatic spread is essential to developing the most efficacious treatment strategy.

Serum markers lactate dehydrogenase and S100B predict independently disease outcome in melanoma patients with distant metastasis

Background:

Established prognostic factors are of limited value to predict long-term survival and benefit from metastasectomy in advanced melanoma. This study aimed to identify prognostic factors in patients with distant metastasis.

Methods:

We analysed overall survival of 855 institutional melanoma patients with distant metastasis by bivariate Kaplan–Meier survival probabilities and multivariate Cox hazard regression analysis.

Results:

Serum lactate dehydrogenases (LDH), S100B, the interval between initial diagnosis and occurrence of distant metastasis, the site of distant metastases, and the number of involved distant sites were significant independent prognostic factors in both bivariate and multivariate analyses. Visceral metastases other than lung (hazard ratio (HR) 1.8), elevated S100B (HR 1.7) and elevated LDH (HR 1.6) had the highest negative impact on survival. Complete metastasectomy was likewise an independent prognostic factor in multivariate analysis. This treatment was associated with favourable survival for patients with normal LDH and S100B values (5-year survival, 37.2%).

Conclusion:

The serum markers LDH and S100B were both found to be prognostic factors in melanoma patients with distant metastasis. Furthermore, complete metastasectomy had an independent favourable prognostic impact in particular for the patient subgroup with normal LDH and S100B values.