Role of Surgery in Stage IV Melanoma

Role of Surgery in Metastatic Melanoma and Review of Melanoma Molecular Characteristics

We aimed to review the molecular characteristics of metastatic melanoma and the role of surgery in metastasectomy for metastatic melanoma. We performed a systematic literature search on PubMed to identify relevant studies focusing on several mutations, including NRAS, BRAF, NF1, MITF, PTEN, TP53, CDKN2A, TERT, TMB, EGFR, and c-KIT. This was performed in the context of metastatic melanoma and the role of metastasectomy in the metastatic melanoma population. A comprehensive review of these molecular characteristics is presented with a focus on their prognosis and role in surgical metastasectomy.

Cost items in melanoma patients by clinical characteristics and time from diagnosis

Background

Costs related to the care of melanoma patients have been rising over the past few years due to increased disease incidence as well as the introduction of innovative treatments. The aim of this study is to analyse CMM cost items based on stage at diagnosis, together with other diagnostic and prognostic characteristics of the melanoma.

Methods

Analyses were performed on 2,647 incident cases of invasive CMM that were registered in 2015 and 2017 in the Veneto Cancer Registry (RTV). Direct melanoma-related costs per patient were calculated for each year ranging from 2 years before diagnosis to 4 years after, and were stratified by cost items such as outpatient services, inpatient drug prescriptions, hospital admissions, hospice admissions, and emergency room treatment. Average yearly costs per patient were compared according to available clinical-pathological characteristics. Lastly, log-linear multivariable analysis was performed to investigate potential cost drivers among these clinical-pathological characteristics.

Findings

Overall, the average direct costs related to melanoma are highest in the first year after diagnosis (€2,903) and then decrease over time. Hospitalization costs are 8 to 16 times higher in the first year than in subsequent years, while the costs of outpatient services and inpatient drugs decrease gradually over time. When stratified by stage it is observed that the higher expenditure associated with more advanced stages of CMM is mainly due to inpatient drug use.

Conclusion

The results of the present study show that grouping patients according to tumour characteristics can improve our understanding of the different cost items associated with cutaneous malignant melanoma. CMM patients experience higher costs in the first year after diagnosis due to higher hospitalization and outpatient services. Policy makers should consider overall and stage-specific annual costs when allocating resources for the management of CMM patients.

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.

The Identification and Validation of a Robust Immune-Associated Gene Signature in Cutaneous Melanoma

BACKGROUND

Cutaneous melanoma is defined as one of the most aggressive skin tumors in the world. An increasing body of evidence suggested an indispensable association between immune-associated gene (IAG) signature and melanoma. This article is aimed at formulating an IAG signature to estimate prognosis of melanoma.

METHODS

434 melanoma patients were extracted from The Cancer Genome Atlas (TCGA) database, and 1811 IAGs were downloaded from the ImmPort database in our retrospective study. The Cox regression analysis and LASSO regression analysis were utilized to establish a prognostic IAG signature. The Kaplan-Meier (KM) survival analysis was performed, and the time-dependent receiver operating characteristic curve (ROC) analysis was further applied to assess the predictive value. Besides, the propensity score algorithm was utilized to balance the confounding clinical factors between the high- and low-risk groups.

RESULTS

A total of six prognostic IAGs comprising of INHA, NDRG1, IFITM1, LHB, GBP2, and CCL8 were eventually filtered out. According to the KM survival analysis, the results displayed a shorter overall survival (OS) in the high-risk group compared to the low-risk group. In the multivariate Cox model, the gene signature was testified as a remarkable prognostic factor (HR = 45.423, P < 0.001). Additionally, the ROC curve analyses were performed which demonstrated our IAG signature was superior to four known biomarkers mentioned in the study. Moreover, the IAG signature was significantly related to immunotherapy-related biomarkers.

CONCLUSION

Our study demonstrated that the six IAG signature played a critical role in the prognosis and immunotherapy of melanoma, which might help clinicians predict patients' survival and provide individualized treatment.

A Novel Nomogram and Risk Classification System Predicting the Cancer-Specific Mortality of Patients with Initially Diagnosed Metastatic Cutaneous Melanoma

BACKGROUND

Cutaneous melanoma and distant organ metastasis has varying outcomes. Considering all prognostic indicators in a prediction model might assist in selecting cases who could benefit from a personalized therapy strategy.

OBJECTIVE

This study aimed to develop and validate a prognostic model for patients with metastatic melanoma.

METHODS

A total of 1535 cases diagnosed with metastatic cutaneous melanoma (stage IV) were identified from the Surveillance, Epidemiology, and End Results database. Patients were randomly divided into the training (n = 1023) and validation (n = 512) cohorts. A prognostic nomogram was established based predominantly on results from the competing-risk regression model for predicting cancer-specific death (CSD). The area under the time-dependent receiver operating characteristic curve (AUC), calibration curves, and decision curve analyses (DCAs) were used to evaluate the nomogram.

RESULTS

No significant differences were observed in the clinical characteristics between the training and validation cohorts. In the training cohort, patient-, tumor-, and treatment-related predictors of CSD for metastatic melanoma included age, sex, race, marital status, insurance, American Joint Committee on Cancer T and N stage, number of metastatic organs, surgical treatment, and chemotherapy. All these factors were used for nomogram construction. The time-dependent AUC values of the training and validation cohorts suggested a favorable performance and discrimination of the nomogram. The 6-, 12-, and 18-month AUC values were 0.706, 0.700, and 0.706 in the training cohort, and 0.702, 0.670, and 0.656 in the validation cohort, respectively. The calibration curves for the probability of death at 6, 12, and 18 months showed acceptable agreement between the values predicted by the nomogram and the observed outcomes in both cohorts. DCA curves showed good positive net benefits in the prognostic model among most of the threshold probabilities at different time points (death at 6, 12, and 18 months). Based on the total nomogram scores of each case, all patients were divided into the low-risk (n = 511), intermediate-risk (n = 512), and high-risk (n = 512) groups, and the risk classification could identify cases with a high risk of death in both cohorts.

CONCLUSIONS

A predictive nomogram and a corresponding risk classification system for CSD in patients with metastatic melanoma were developed in this study, which may assist in patient counseling and in guiding clinical decision making for cases with metastatic melanoma.