Clinical and oncological outcomes of surgery in Anorectal melanoma in Asian population: A 15 year analysis at a tertiary cancer institute

Multidisciplinary Management of Anorectal Melanoma: a Retrospective Analysis of Surgical and Systemic Therapies from the National Cancer Database

PURPOSE

Anorectal melanoma (ARM) represents a problematic scenario due to a 5-year overall survival (OS) rate below 20% and its increasing incidence. Due to its comparable OS, local surgery (LS) has replaced radical surgery (RS). Adjuvant chemotherapy (Adj-CHT) and adjuvant immunotherapy (Adj-IT) are common treatments for ARM, while neoadjuvant immunotherapy (Neo-IT) has not been investigated yet. This study aimed to determine the best treatment to improve the OS.

METHODS

Patients with non-metastatic ARM in the National Cancer 1Database (2011-2021) who underwent surgery and received Neo-IT, Adj-IT, or Adj-CHT were included. Two cohorts were created based on the surgical approach (LS or RS). In their respective cohorts, patients receiving Neo-IT, Adj-IT, or Adj-CHT were matched 1:1:1 based on age, tumor size and location, lymphovascular invasion, and nodal disease. Kaplan-Meier analyses compared the different groups' influence on the 3-year OS.

RESULTS

Sixty patients were included in the LS cohort. Among them, there was no difference in the 3-year OS at the Kaplan-Meier analysis (Neo-IT 61%, Adj-IT 47.1%, and Adj-CHT 44%). Thirty-six patients were included in the RS cohort. Kaplan-Meier analysis for this group revealed that Neo-IT was a protective factor for 3-year OS (Neo-IT 71%, Adj-IT 11%, Adj-CHT 8%; p-value = 0.002).

CONCLUSION

Neo-IT + RS seems to improve the 3-year OS compared to the other common treatments for ARM. Neo-IT + RS can be considered a valuable treatment since prospective trials are challenging for rare diseases. When RS is not feasible, Neo-IT + LS may be beneficial as the 3-year OS reaches 61%.

A 22-year experience of surgical management of anorectal melanoma: risk factors for recurrence and death

PURPOSE

Anorectal melanoma (ARM) poses a significant challenge due to the lack of established guidelines and a 5-year overall survival rate of less than 20%. The only recognized death risk factors are positive lymph nodes and positive surgical margins. This study aimed to identify the risk factors for local/distant recurrences and death in a 22-year multi-institutional experience.

METHODS

All patients who underwent curative surgical resection or were referred to after resection at the Mayo Clinic for non-metastatic ARM (2002-2024) were included. Risk factors for local/distant recurrences, and deaths were assessed through multivariable Cox regression.

RESULTS

Eighty-eight patients were included in the study. Seventy-eight percent of patients had anal melanoma and 22% rectal melanoma. Nineteen percent had clinically positive lymph nodes. The surgical margins were positive in 62% of local surgeries, while they were positive in 13% of radical surgery cases. The first recurrence was often a local recurrence (67%), followed by distant metastasis (21%), with an overall comparable overall survival between the two. Radiotherapy administration, radical surgery, and negative margins were associated with less local recurrence. Clinically positive lymph nodes and local recurrences increased the risk of developing distant metastasis over time. Clinically negative lymph nodes, radiotherapy administration, radical surgery, and negative margins all contributed to a reduced death risk.

CONCLUSION

Local recurrences in ARM may influence distant metastasis and death more than what was previously believed. Positive surgical margins in local surgery were remarkably high, reaching 62%. Protective factors for local recurrence and death included radical surgery, negative surgical margins, and radiotherapy.

Survival Outcomes in Patients Undergoing Pelvic Exenteration for Pelvic Mucosal Melanomas: Retrospective Single Institution Australian Study

BACKGROUND

Pelvic mucosal melanomas, including anorectal and urogenital melanomas, are rare and aggressive, with a median overall survival of up to 20 months. Pelvic mucosal melanomas behave differently from their cutaneous counterparts and present late with locoregional disease, making pelvic exenteration its only curative surgical option.

OBJECTIVE

This study aimed to evaluate the survival outcomes after pelvic exenteration in pelvic mucosal melanomas at Royal Prince Alfred Hospital.

DESIGN

Retrospective case series from a prospectively collected pelvic exenteration database from October 1994 to November 2023.

SETTING

Royal Prince Alfred Hospital (quaternary institution), Camperdown, New South Wales, Australia.

PATIENTS

Seven patients undergoing pelvic exenteration for pelvic mucosal melanoma.

MAIN OUTCOME MEASURES

Overall survival, disease-free survival, and complication rates.

RESULTS

Of the 7 patients, most were women (n = 5; 71.4%) and had a median age of 65 years (range, 36-79). Five patients (71.4%) underwent pelvic exenteration for primary pelvic mucosal melanoma, 3 of which were anorectal and 2 vaginal melanomas. Two patients (28.6%) had recurrent anorectal melanoma and received neoadjuvant radiotherapy after an initial wide local excision. Three patients (42.9%) required total pelvic exenteration, whereas 2 required a central pelvic exenteration (28.6%). The remaining procedures included central and lateral pelvic exenteration and anterior, central, and lateral pelvic exenteration. The median length of hospital stay was 19.7 days. Five patients had postoperative complications with 1 major complication (Clavien-Dindo grade IIIa). At the completion of the study, there were 4 mortalities. Mean survival was 23.6 months (range, 2-100) with a recurrence rate of 83%. The median time to recurrence was 3 months, despite 6 patients (85.7%) having R0 resections. Distant recurrence, specifically to bone, the lungs, and the liver, was most common.

LIMITATIONS

Small study cohort due to rarity of disease, limiting generalizability.

CONCLUSIONS

Pelvic exenteration for pelvic mucosal melanoma appears to help control local disease as recurrence is most commonly distant or regional. See Video Abstract .

RESULTADOS DE SUPERVIVENCIA EN PACIENTES SOMETIDOS A EXENTERACIN PLVICA POR MELANOMAS DE LA MUCOSA PLVICA ESTUDIO RETROSPECTIVO AUSTRALIANO DE UNA SOLA INSTITUCIN

ANTECEDENTES:Los melanomas de la mucosa pélvica (MM), incluidos los melanomas anorrectales y urogenitales, son raros y agresivos, con una supervivencia global media de hasta 20 meses. Los melanomas de la mucosa pélvica se comportan de manera diferente a sus contrapartes cutáneas y se presentan tardíamente con enfermedad locoregional, lo que hace que la exenteración pélvica (EP) sea su única opción quirúrgica curativa.OBJETIVO:Este estudio tuvo como objetivo evaluar los resultados de supervivencia tras la exenteración pélvica en melanomas de la mucosa pélvica en el Royal Prince Alfred Hospital.DISEÑO:Serie de casos retrospectivos de una base de datos de exenteración pélvica recopilada prospectivamente desde octubre de 1994 hasta noviembre de 2023.ESCENARIO:Royal Prince Alfred Hospital (institución cuaternaria), Camperdown, Nueva Gales del Sur, Australia.PACIENTES:Siete pacientes sometidos a exenteración pélvica por melanoma de la mucosa pélvica.PRINCIPALES MEDIDAS DE RESULTADOS:Supervivencia general, supervivencia libre de enfermedad y tasas de complicaciones.RESULTADOS:De los siete pacientes, la mayoría fueron mujeres (n = 5, 71,4%) y tenían una edad media de 65 años (rango 36-79). Cinco pacientes (71,4%) fueron sometidos a una exenteración pélvica por melanoma primario de la mucosa pélvica; tres de los cuales eran melanomas anorrectales y dos vaginales. Dos pacientes (28,6%) tuvieron melanoma anorrectal recurrente y recibieron radioterapia neoadyuvante después de una escisión local amplia inicial.Tres pacientes (42,9%) requirieron una exenteración pélvica total, mientras que dos requirieron una exenteración pélvica central (28,6%). Los procedimientos restantes fueron una exenteración pélvica central y lateral; junto con una exenteración pélvica anterior, central y lateral. La duración media de la estancia hospitalaria fue de 19,7 días. Cinco pacientes tuvieron complicaciones postoperatorias con una complicación mayor (Clavien-Dindo IIIa). Al finalizar el estudio, hubo cuatro muertes. La supervivencia media fue de 23,6 meses (rango 2-100) con una tasa de recurrencia del 83%. El tiempo medio hasta la recurrencia fue de tres meses, a pesar de que seis pacientes (85,7%) tuvieron resecciones R0. La recurrencia distante, es decir, en hueso, pulmón e hígado fueron la más comúnes.LIMITACIONES:Cohorte de estudio pequeña debido a la rareza de la enfermedad, lo que limita la generalización.CONCLUSIÓN:La exenteración pélvica para el melanoma de la mucosa pélvica parece ayudar a controlar la enfermedad local, ya que la recurrencia es más comúnmente distante o regional. (Traducción-Dr Osvaldo Gauto ).

Uncommon Anal Cancers

Anal cancer is by itself a rare entity. Even rarer are the uncommon anal tumors described in this article. Diagnosis of these lesions can be challenging as some of these have no symptoms in their initial stages and only cause symptoms once they have progressed to advanced stages. Further, it can be difficult for even the trained eye to make a diagnosis as some of these pathologies mimic benign disease or the more common anal malignancy, squamous cell carcinoma. More data are needed to establish consensus for the management of these unusual pathologies.

Reducing the positive margins rate for anal melanoma in the modern era: a national propensity score matched study

Anal Melanoma (AM) is a rare and aggressive disease lacking standardized treatment protocols. Despite advancements in medical oncology, the 5-year overall survival (OS) remains at 20%. Local surgery (LS) has gained popularity over radical surgery (RS) due to its comparable OS when negative margins are achieved. Neoadjuvant chemotherapy and radiotherapy do not improve margins status, while neoadjuvant immunotherapy (Neo-IT) has not been studied on AM margins status. Patients diagnosed with AM in the National Cancer Database (2011-2021) who received Neo-IT were retrospectively identified and divided into two cohorts based on the surgical approach (LS or RS). In each cohort, patients were matched in a 1:1 ratio to those who did not receive Neo-IT based on age and tumor size. Univariate analyses were performed to compare Neo-IT influence on surgical margins in both cohorts. Thirty patients were included in the LS cohort, with 56.7% of positive margins. Univariate analysis revealed that Neo-IT did not improve surgical margins in LS in AM (p value = 0.713). However, the 22 RS (31.8% positive margins) patient cohort's univariate analysis revealed that Neo-IT significantly improved surgical margins in AM (p value = 0.022). Achieving negative margins is crucial to increase OS in anal melanoma. Neo-IT appears to improve negative surgical margin status in RS for anal melanoma. However, Neo-IT did not improve margins in LS. This opportunity to improve margin suggests a potential to increase the 5-year OS of 20%. Future work is needed to determine the impact to OS and confirm the IT role in LS.

Endoscopic ultrasound features of rectal melanoma: A case report and review of literature

BACKGROUND

Rectal mucosal melanoma is a rare and highly aggressive disease. Common symptoms include anal pain, an anal mass, or bleeding. As such, the disease is usually detected on rectal examination of patients with other suspected anorectal diseases. However, due to its rarity and nonspecific symptoms, melanoma of the rectal mucosa is easily misdiagnosed.

CASE SUMMARY

This report describes the case of a 58-year-old female patient who presented with a history of blood in her stool for the prior one or two months, without any identifiable cause. During colonoscopy, a bulge of approximately 2.2 cm × 2.0 cm was identified. Subsequently, the patient underwent endoscopic ultrasound (EUS) to characterize the depth of invasion of the lesions. EUS suggested a hypoechoic mucosal mass with involvement of the submucosal layer and heterogeneity of the internal echoes. Following surgical intervention, the excised tissue samples were examined and confirmed to be rectal malignant melanoma. The patient recovered well with no evidence of recurrence during follow-up.

CONCLUSION

This case shows that colonoscopy with EUS and pathological examination can accurately diagnose rare cases of rectal mucosal melanoma.

[Anorectal melanoma : Update on clinical presentation, diagnosis and treatment]

Anorectal melanomas are a rare malignant type of cancer and pose a diagnostic challenge due to their hidden anatomical location. They are associated with nonspecific clinical symptoms and are therefore often misinterpreted as benign disease. The result is delayed diagnosis in the locally advanced or metastasized stage and an unfavorable prognosis. Given the overall low incidence of the tumor, no consensus guidelines for diagnosis or therapy are established either internationally or nationally at present. The present work intends to provide a comprehensive overview of the clinical aspects, diagnostics, and therapeutic approaches of anorectal melanoma based on the currently available literature.

Anorectal melanoma

Anorectal melanoma is an aggressive mucosal melanoma subtype with a poor prognosis. Although recent advancements have been seen for cutaneous melanoma, the optimal treatment paradigm for management of anorectal melanoma is evolving. In this review, we highlight differences in the pathogenesis of mucosal versus cutaneous melanoma, new concepts of staging for mucosal melanoma, updates to surgical management of anorectal melanoma, and current data for adjuvant radiation and systemic therapy in this unique patient population.

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.