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Bliley R, Avant A, Medina TM, Lanning RM. Radiation and Melanoma: Where Are We Now? Curr Oncol Rep 2024:10.1007/s11912-024-01557-y. [PMID: 38822928 DOI: 10.1007/s11912-024-01557-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE OF REVIEW This review summarizes the current role of radiotherapy for the treatment of cutaneous melanoma in the definitive, adjuvant, and palliative settings, and combinations with immunotherapy and targeted therapies. RECENT FINDINGS Definitive radiotherapy may be considered for lentigo maligna if surgery would be disfiguring. High risk, resected melanoma may be treated with adjuvant radiotherapy, but the role is poorly defined since the advent of effective systemic therapies. For patients with metastatic disease, immunotherapy and targeted therapies can be delivered safely in tandem with radiotherapy to improve outcomes. Radiotherapy and modern systemic therapies act in concert to improve outcomes, especially in the metastatic setting. Further prospective data is needed to guide the use of definitive radiotherapy for lentigo maligna and adjuvant radiotherapy for high-risk melanoma in the immunotherapy era. Current evidence does not support an abscopal response or at least identify the conditions necessary to reliably produce one with combinations of radiation and immunotherapy.
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Affiliation(s)
- Roy Bliley
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam Avant
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Theresa M Medina
- Department of Medical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan M Lanning
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA.
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Kibel S, Kuehne N, Ribeiro MF, Muniz TP, Ye XY, Spreafico A, Saibil SD, Sun A, Mak DY, Gray D, Jones B, Wong P, Butler MO. The Role of Adjuvant Radiotherapy for the Treatment of Resected High-Risk Stage III Cutaneous Melanoma in the Era of Modern Systemic Therapies. Cancers (Basel) 2023; 15:5867. [PMID: 38136412 PMCID: PMC10741555 DOI: 10.3390/cancers15245867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Modern adjuvant systemic therapies (STs) have revolutionized the management of stage III melanoma. Currently, the role of adjuvant radiotherapy (RT) remains unclear. In this single-center retrospective study, patients with clinically detectable stage III melanoma with high-risk features for lymph node basin (LNB) recurrence and whose tumors were fully resected with complete lymphadenectomy (CLD) between 2010 and 2019 were assessed. We determined the cumulative incidence (CIF) of LNB recurrence and any disease recurrence or progression using competing risk analysis. A total of 108 patients were identified; the median age was 59 years (24-92), and 74 (69%) were men. A total of 51 (42%) received adjuvant RT, 22 (20%) received adjuvant ST, and 35 (32%) received no adjuvant therapy. The advent of ST changed clinical practice, with a significant increase in the use of adjuvant ST and a decrease in the use of RT when comparing practice patterns before and after 2015 (p < 0.001). The 3-year CIF of LNB recurrence was similar in patients treated with adjuvant RT (6.3%) and adjuvant ST (9.8%). The 3-year CIF of any disease recurrence or progression was lower in patients receiving adjuvant ST (24%) compared to those receiving adjuvant RT (52%) or no adjuvant therapy (55%, p = 0.06). Three-year overall survival (OS) was not significantly different in patients treated with ST compared to those not treated with any ST (p = 0.118). Despite ST replacing RT as the dominant adjuvant treatment modality, this change in practice has not resulted in increased LNB recurrence for patients at high risk of LNB recurrence following CLD.
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Affiliation(s)
- Seth Kibel
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Nathan Kuehne
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Mauricio Fernando Ribeiro
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Thiago P. Muniz
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Xiang Y. Ye
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Anna Spreafico
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Samuel D. Saibil
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Alexander Sun
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - David Y. Mak
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Diana Gray
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Bailie Jones
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Philip Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Marcus O. Butler
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada; (S.K.); (N.K.)
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
- Department of Immunology, University of Toronto, Toronto, ON M5S 3H2, Canada
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Allard-Coutu A, Dobson V, Schmitz E, Shah H, Nessim C. The Evolution of the Sentinel Node Biopsy in Melanoma. Life (Basel) 2023; 13:life13020489. [PMID: 36836846 PMCID: PMC9966203 DOI: 10.3390/life13020489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.
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Affiliation(s)
- Alexandra Allard-Coutu
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Correspondence:
| | | | - Erika Schmitz
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Hely Shah
- Department of Medical Oncology, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Carolyn Nessim
- Department of General Surgery, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Drescher NR, Amdur RJ, Morris CG, Shaw CM, Dziegielewski PT, Mendenhall WM. Postoperative Radiotherapy for Cutaneous Melanoma in Patients at High Risk of Local-Regional Recurrence after Surgery Alone. Cancer Invest 2022; 40:348-353. [PMID: 35100059 DOI: 10.1080/07357907.2022.2033986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
We evaluated outcomes in 131 patients with cutaneous melanoma (median follow-up, 3.6 years) considered at high risk of recurrence after surgery alone treated with surgery and postoperative radiotherapy. Eligible patients had one or more of the following: recurrence after surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, or in-transit metastases. 102 patients received hypofractionated radiotherapy and 29 had conventional fractionation. 10-year outcomes were: in-field local-regional control, 87%; local regional control, 72%; distant metastasis-free survival, 48%; cause-specific survival, 44%; and overall survival, 31%. Three patients experienced acute toxicities while 6 experienced late toxicities.
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Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peter T Dziegielewski
- Department of Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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Sadurní MB, Meves A. Breslow thickness 2.0: Why gene expression profiling is a step toward better patient selection for sentinel lymph node biopsies. Mod Pathol 2022; 35:1509-1514. [PMID: 35654998 PMCID: PMC9162102 DOI: 10.1038/s41379-022-01101-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/23/2022] [Accepted: 05/05/2022] [Indexed: 12/20/2022]
Abstract
Risk-stratification of cutaneous melanoma is important. Patients want to know what to expect after diagnosis, and physicians need to decide on a treatment plan. Historically, melanoma that had spread beyond the skin and regional lymph nodes was largely incurable, and the only approach to preventing a bad outcome was surgery. Through the seminal work of Alexander Breslow and Donald Morton, a system was devised to carefully escalate surgery based on primary tumor thickness and sentinel lymph node status. Today, we know that prophylactic lymph node dissections do not improve survival, but we continue to appreciate the prognostic implications of a positive sentinel node and the benefits of removing nodal metastases, which facilitates locoregional disease control. However, the question arises whether we can better select patients for sentinel lymph node biopsies (SLNB) as, currently, 85% of these procedures are negative and non-therapeutic. Here, we argue that gene expression profiling (GEP) of the diagnostic biopsy is a valuable step toward better patient selection when combined with reliable clinicopathologic (CP) information such as patient age and Breslow thickness. Recently, a CP-GEP-based classifier of nodal metastasis risk, the Merlin Assay, has become commercially available. While CP-GEP is still being validated in prospective studies, preliminary data suggest that it is an independent predictor of nodal metastasis, outperforming clinicopathological variables. The hunt is on for Breslow thickness 2.0.
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Affiliation(s)
- Mariana B. Sadurní
- grid.66875.3a0000 0004 0459 167XDepartment of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Alexander Meves
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Ollek S, Wen D, Ong I, Anderson W, Harman R, Martin R. Proposed Quality Performance Indicators (QPI's) for axillary lymphadenectomy in metastatic cutaneous melanoma. Eur J Surg Oncol 2021; 47:3011-3019. [PMID: 34489121 DOI: 10.1016/j.ejso.2021.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Axillary lymph node clearance (ALNC) continues to play a central role in the management of melanoma. However, what defines an adequate lymphadenectomy remains unclear. We aimed to propose Quality Performance Indicators (QPIs) for ALNC and to determine if the number of lymph nodes (LNs) removed impacts survival. METHODS We reviewed patients who underwent ALNC for melanoma at the Waitemata District Health Board and Melanoma Unit between February 2005 and October 2019, performed by two surgeons with standardized technique and surveillance. RESULTS 105 patients with stage III melanoma were included, of which 73 had clinically evident disease and 32 had clinically occult disease. The mean total number of LNs excised was 29 (SD 10.90, range 10-76). On multivariate analysis, lymph node ratio (HR 4.48, 95% CI 1.55-12.93, p = 0.006), extracapsular spread (HR 2.53, 95% CI 1.06-6.05, p = 0.036) and distant recurrence (HR 11.24, 95% CI 3.79-33.31, p < 0.001) were significant predictors of mortality. The number of LNs removed did not predict survival outcomes, while the lymph node ratio did significantly predict survival outcomes. The regional recurrence rate was 3.8%. DISCUSSION We propose that QPIs for ALNC in melanoma include a 90th percentile LN yield of greater than 15, a mean LN yield of 20, a regional recurrence rate of less than 10%, and an overall complication rate of less than 50%. CONCLUSION The establishment of QPIs can help ensure that surgical oncology patients receive the highest quality of care.
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Affiliation(s)
- Sita Ollek
- Surgical Oncology Fellow, University of British Columbia, Canada.
| | - Daniel Wen
- House Officer, North Shore Hospital, University of Auckland, New Zealand
| | - Ian Ong
- Surgical Registrar, North Shore Hospital, University of Auckland, New Zealand
| | - William Anderson
- Surgical Registrar, North Shore Hospital, University of Auckland, New Zealand
| | - Richard Harman
- Director General Surgery, Melanoma Unit, North Shore Hospital, University of Auckland, New Zealand
| | - Richard Martin
- Cutaneous Surgical Oncologist, Head/Neck and General Surgeon, Melanoma Unit, Waitemata District Health Board, University of Auckland, New Zealand
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Mitra D, Ologun G, Keung EZ, Goepfert RP, Amaria RN, Ross MI, Gershenwald JE, Lucci A, Fisher SB, Davies MA, Lee JE, Bishop AJ, Farooqi AS, Wargo J, Guadagnolo BA. Nodal Recurrence is a Primary Driver of Early Relapse for Patients with Sentinel Lymph Node-Positive Melanoma in the Modern Therapeutic Era. Ann Surg Oncol 2021; 28:3480-3489. [PMID: 33856603 DOI: 10.1245/s10434-021-09804-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/23/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Management of patients with sentinel lymph node (SLN)-positive melanoma has changed dramatically over the last few years such that completion lymph node dissection (CLND) has become uncommon, and many patients receive adjuvant immunotherapy or targeted therapy. This study seeks to characterize patterns and predictors of early recurrence in this setting. PATIENTS AND METHODS All patients with primary cutaneous melanoma undergoing sentinel lymph node biopsy (SLNB) between 3/2016 and 12/2019 were identified. The subset with a positive SLN who did not undergo CLND were examined for further analysis of outcomes and predictors of recurrence. RESULTS Overall, 215 patients with SLN-positive melanoma who did not have CLND were identified. Adjuvant systemic therapy was administered to 102 (47%), with 93% of this subset receiving immunotherapy (n = 95). Median follow-up from SLNB was 20 months (IQR 12-28.5 months), and 57 patients (27%) recurred during this time. The SLN basin was the most common site of recurrence (n = 38, 67% of recurrence), with isolated nodal recurrence being the most common first site of recurrent disease (n = 22, 39% of recurrence). On multivariable analysis, lymphovascular invasion (LVI) of the primary tumor, two or more involved nodes, and > 1 mm nodal deposit were independently associated with higher rates of nodal relapse. CONCLUSIONS Nodal recurrence is a primary driver of early disease relapse for patients with SLN-positive melanoma who do not undergo CLND in the era of effective adjuvant systemic therapy. LVI, ≥ 2 nodes, or > 1 mm nodal disease identifies patients at particularly high risk of nodal relapse.
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Affiliation(s)
- Devarati Mitra
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Gabriel Ologun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rodabe N Amaria
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Merrick I Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah B Fisher
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael A Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahsan S Farooqi
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B Ashleigh Guadagnolo
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Straker RJ, Song Y, Sun J, Shannon AB, Cohen LS, Muradova E, Daou H, Krause K, Li S, Frederick DT, Rhodin KE, Brizel DM, Boland GM, Beasley GM, Wuthrick EJ, Sondak VK, Zager JS, Lin A, Lukens JN, Karakousis GC. Adjuvant Radiation Therapy for Clinical Stage III Melanoma in the Modern Therapeutic Era. Ann Surg Oncol 2020; 28:3512-3521. [PMID: 33230747 DOI: 10.1245/s10434-020-09384-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adjuvant radiation therapy (RT) can decrease lymph node basin (LNB) recurrences in patients with clinically evident melanoma lymph node (LN) metastases following lymphadenectomy, but its role in the era of modern systemic therapies (ST), immune checkpoint or BRAF/MEK inhibitors, is unclear. PATIENTS AND METHODS Patients at four institutions who underwent lymphadenectomy (1/1/2010-12/31/2019) for clinically evident melanoma LN metastases and received neoadjuvant and/or adjuvant ST with RT, or ST alone, but met indications for RT, were identified. Comparisons were made between ST alone and ST/RT groups. The primary outcome was 3-year cumulative incidence (CI) of LNB recurrence. Secondary outcomes included 3-year incidences of in-transit/distant recurrence and survival estimates. RESULTS Of 98 patients, 76 received ST alone and 22 received ST/RT. Median follow-up time for patients alive at last follow-up was 44.6 months. The ST/RT group had fewer inguinal node metastases (ST 36.8% versus ST/RT 9.1%; P = 0.04), and more extranodal extension (ST 50% versus ST/RT 77.3%; P = 0.02) and positive lymphadenectomy margins (ST 2.6% versus ST/RT 13.6%; P = 0.04). The 3-year CI of LNB recurrences was lower for the ST/RT group compared with the ST group (13.9% versus 25.2%), but this reduction was not statistically significant (P = 0.36). Groups did not differ significantly in in-transit/distant recurrences (P = 0.24), disease-free survival (P = 0.14), or melanoma-specific survival (P = 0.20). CONCLUSIONS In the era of modern ST, RT may still have value in reducing LNB recurrences in melanoma with clinical LN metastases. Further research should focus on whether select patient populations derive benefit from combination therapy, and optimizing indications for RT following neoadjuvant ST.
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Affiliation(s)
- Richard J Straker
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Adrienne B Shannon
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Leah S Cohen
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Elnara Muradova
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Hala Daou
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kate Krause
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Siming Li
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennie T Frederick
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - David M Brizel
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Genevieve M Boland
- Division of Surgical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Evan J Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - John N Lukens
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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Lo M, Peach H, Moncrieff M. ASO Author Reflections: Extracapsular Spread in Melanoma Lymphadenopathy: Prognostic Implications, Classification, and Management. Ann Surg Oncol 2020; 28:1654-1655. [PMID: 33083908 PMCID: PMC7892679 DOI: 10.1245/s10434-020-09197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Michelle Lo
- Plastic and Reconstructive Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Howard Peach
- Plastic Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Marc Moncrieff
- Plastic and Reconstructive Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK. .,Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.
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10
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Lo M, Robinson A, Wade R, Peach H, Dewar D, Heaton M, Moncrieff M. Extracapsular Spread in Melanoma Lymphadenopathy: Prognostic Implications, Classification, and Management. Ann Surg Oncol 2020; 28:1642-1653. [PMID: 32944786 DOI: 10.1245/s10434-020-09099-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 08/15/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extracapsular spread (ECS) is recognized to be a high-risk factor in melanoma patients with macrometastatic (N+) nodal disease; however, ECS risk in sentinel lymph node (SLN) biopsy, micrometastatic stage III disease is ambiguous. OBJECTIVE The aim of this study was to examine ECS incidence and its prognostic significance. METHODS A two-center, retrospective analysis of all patients with micro/macrometastatic lymphadenopathy undergoing nodal surgery from 2008 to 2014 was performed. Patient demographics, tumor characteristics, nodal ECS status, and patient outcomes were collected. RESULTS Overall, 515 patients with nodal disease were identified (males/females = 277/238); median age was 63 years (range 17-94). There was an increased frequency of ECS disease in N+ disease compared with SLN+ disease (52.4% vs. 16.2%; p < 0.0001). The absolute disease-specific survival (DSS) difference for SLN+ patients was approximately 30% at 10 years (66.2% vs. 37.2%; p < 0.0001), and the prognosis of SLN+/ECS+ patients was identical to N+/ECS- patients. Multivariate analysis demonstrated that ECS status was an independent prognostic indicator for DSS (hazard ratio 2.47, 95% confidence interval 1.87-3.26; p < 0.0001) in patients with SLN+ disease. There were significant differences in nodal burden according to ECS status between the SLN+ and N+ subgroups suggestive of differing biology in ECS+ tumors. CONCLUSION We found that ECS is a significant DSS, progression-free survival, and overall survival indicator in SLN+ and N+ disease. We demonstrated that ECS upstages stage III disease, similar to ulceration in primary melanoma (stage I/II disease). A simplified staging system substituting ECS for N stage accurately stages patients according to prognosis.
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Affiliation(s)
- Michelle Lo
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
| | - Alyss Robinson
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Ryckie Wade
- Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Howard Peach
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Donald Dewar
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Martin Heaton
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Marc Moncrieff
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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11
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Keung EZ, Gershenwald JE. Clinicopathological Features, Staging, and Current Approaches to Treatment in High-Risk Resectable Melanoma. J Natl Cancer Inst 2020; 112:875-885. [PMID: 32061122 PMCID: PMC7492771 DOI: 10.1093/jnci/djaa012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/06/2019] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
The incidence of melanoma in the United States has been increasing over the past several decades. Prognosis largely depends on disease stage, with 5-year melanoma-specific survival ranging from as high as 99% in patients with stage I disease to less than 10% for some patients with stage IV (distant metastatic) disease. Fortunately, in the last 5-10 years, there have been remarkable treatment advances for patients with high-risk resectable melanoma, including approval of targeted and immune checkpoint blockade therapies. In addition, results of recent clinical trials have confirmed the importance of sentinel lymph node biopsy and continue to refine the approach to regional lymph node basin management. Lastly, the melanoma staging system was revised in the eighth edition AJCC Cancer Staging Manual, which was implemented on January 1, 2018. Here we discuss these changes and the clinicopathological features that confer high risk for locoregional and distant disease relapse and poor survival. Implications regarding the management of melanoma in the metastatic and adjuvant settings are discussed, as are future directions for neoadjuvant therapies.
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Affiliation(s)
- Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Melanoma and Skin Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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Knackstedt R, Couto RA, Ko J, Cakmakoglu C, Wu D, Gastman B. Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy for Sentinel Node Biopsy in Melanoma: Increasing the Sentinel Lymph Node-Positive Rate. Ann Surg Oncol 2019; 26:3550-3560. [PMID: 31313036 DOI: 10.1245/s10434-019-07617-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 12/17/2023]
Abstract
INTRODUCTION The goal of this study was to analyze patients who underwent a sentinel lymph node biopsy (SLNB) in melanoma with the combination of radioisotope lymphoscintigraphy and indocyanine green (ICG) fluorescence imaging to compare our true positive (TP) rate, a means to perform immediate analysis of the SLNB, with that of the literature. METHODS Consecutive cutaneous melanoma patients who underwent SLNB with lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (BG) from 2012 to 2018 were prospectively enrolled. The average expected SLN-positive rate per T stage was calculated based on three studies and compared with our SLN-positive rate. RESULTS Overall, 574 consecutive patients were analyzed. Average Breslow thickness was 1.9 mm. A total of 1754 sentinel nodes were sampled; 1497 were identified by gamma probe signaling and ICG, 241 were identified by gamma probe signaling only, and 16 were identified by ICG only. There were 123 (21.4%) patients with at least one positive SLN; 113 (91.9%) had at least one positive node identified with both gamma probe signaling and ICG, 8 (6.5%) had positive node(s) identified with gamma probe signaling only, and 2 (1.6%) had positive node(s) identified with ICG only. There was an overall 21.4% SLN-positive rate, with 8% T1, 18.5% T2, 41.1% T3, and 52.4% T4, which is higher than the predicted rates for each stage. CONCLUSIONS With the largest cohort of patients reported who underwent a melanoma SLNB with lymphoscintigraphy and ICG, we demonstrated that this technique results in higher SLN-positive rates than predicted. Patients are being followed but, given the TP data, knowledge of our results may foster the use of this modality to improve staging and treatment options.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rafael A Couto
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jennifer Ko
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cagri Cakmakoglu
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daisy Wu
- University of Toledo Medical School, Toledo, OH, USA
| | - Brian Gastman
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
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13
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Wuthrick EJ, Chablani P. Do Not Forget About the Importance of Loco-Regional Therapy in Melanoma Management. Semin Radiat Oncol 2019; 29:166-170. [PMID: 30827455 DOI: 10.1016/j.semradonc.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Immunotherapy agents have significantly changed the landscape of melanoma treatment over the past decade. Paradigm shifts in treatment require reanalysis of the treatment algorithms in melanoma. Despite surgical excision, certain high risk patients with desmoplastic melanoma remain at high risk for local recurrence and retrospective data suggests improvement in local control with adjuvant radiation therapy. Likewise, despite surgical excision and effective systemic therapy agents, patients with extracapsular extension and other high risk features are at substantial risk of nodal basin (regional) recurrence. Adjuvant radiation therapy has been demonstrated to reduce the local recurrence risk. Despite these benefits, adjuvant radiation therapy in melanoma remains controversial in part because its use has not been definitively demonstrated to improve overall or disease-free survival in a randomized prospective study.
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Affiliation(s)
- Evan J Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL.
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14
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Spillane A, Hong A, Fogarty G. Re-examining the role of adjuvant radiation therapy. J Surg Oncol 2018; 119:242-248. [PMID: 30554414 DOI: 10.1002/jso.25329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/23/2018] [Indexed: 11/08/2022]
Abstract
Previously important roles for adjuvant radiotherapy (RT) in melanoma patients included improved regional control after resection of high-risk nodal disease, to reduce local recurrence for desmoplastic, and other subtypes of melanoma with neurotropism, reducing in-brain relapse of brain metastases after surgery and other situations on a case-by-case basis. This review evaluates the integration of adjuvant RT into clinical practice at this time of rapidly evolving knowledge and improving outcomes from effective systemic therapy.
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Affiliation(s)
- Andrew Spillane
- Surgical Oncology, Northern Clinical School, The University of Sydney, Sydney, Australia.,Melanoma Institute Australia, Sydney, Australia.,Melanoma Unit, Mater Hospital, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Angela Hong
- Surgical Oncology, Northern Clinical School, The University of Sydney, Sydney, Australia.,Melanoma Institute Australia, Sydney, Australia.,Melanoma Unit, Mater Hospital, Sydney, Australia.,Radiation Oncology, Royal Prince Alfred Hospital, Sydney, Australia.,Radiation Oncology, GenesisCare, Mater Radiation Oncology, Sydney, Australia
| | - Gerald Fogarty
- Surgical Oncology, Northern Clinical School, The University of Sydney, Sydney, Australia.,Melanoma Institute Australia, Sydney, Australia.,Melanoma Unit, Mater Hospital, Sydney, Australia.,Radiation Oncology, St Vincents Hospital, Sydney, Australia.,Radiation Oncology, GenesisCare, Mater Radiation Oncology, Sydney, Australia
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15
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Indocyanine green fluorescence imaging with lymphoscintigraphy for sentinel node biopsy in head and neck melanoma. J Surg Res 2018; 228:77-83. [DOI: 10.1016/j.jss.2018.02.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/11/2017] [Accepted: 02/27/2018] [Indexed: 02/05/2023]
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16
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The influence of postoperative lymph node radiation therapy on overall survival of patients with stage III melanoma, a National Cancer Database analysis. Melanoma Res 2018; 26:595-603. [PMID: 27575390 DOI: 10.1097/cmr.0000000000000292] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recently, TROG 02.01 results showed that in stage III melanoma patients with nodal metastasis, adjuvant radiation to lymph node basin after nodal dissection improves lymph node field relapse without an overall survival (OS) benefit. However, this trial was neither designed nor powered to detect an OS difference. In the present study, we analyzed patients in the National Cancer Database (NCDB) with stage III melanoma with pathologically involved nodes and compared survival outcomes of adjuvant radiation and no-radiation cohorts. Inclusion criteria were as follows: age at least 18 years; diagnosed 2003-2011; surgery to regional lymph nodes; pathologically involved lymph nodes; and American Joint Committee on Cancer stage (IIIA-C). We used propensity score matching analysis to compare the OS of patients with similar baseline demographic, clinical, and pathologic characteristics who received adjuvant radiation and no adjuvant radiation. Overall, 912 patients were analyzed with an average age at diagnosis of 54.4 years and a median follow-up time of 5.5 years. In this cohort, the 5-year OS was 69.0, 51.1, and 30.6% for stage IIIA, IIIB, and IIIC, respectively. On propensity score-adjusted multivariate analysis, we found that adjuvant radiation had no statistically significant impact on OS (hazard ratio: 1.09, 95% confidence interval: 0.75-1.58, P=0.640). Furthermore, age older than 60 years, number of nodes, increasing pathologic stage, and absence of immunotherapy correlated with worse OS. In this NCDB analysis, we found that the adjuvant radiotherapy for node-positive, stage III melanoma patients did not improve OS. This is consistent with TROG 02.01; however, there may be patient selection bias not accounted for by the NCDB.
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17
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Nieweg OE, Cooper A, Thompson JF. Role of sentinel lymph node biopsy as a staging procedure in patients with melanoma: A critical appraisal. Australas J Dermatol 2017; 58:268-273. [PMID: 28707391 DOI: 10.1111/ajd.12655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 02/11/2017] [Indexed: 11/29/2022]
Abstract
Worldwide, sentinel node (SN) biopsy for accurate staging is now part of the standard work-up of patients with melanomas ≥1.0 mm Breslow thickness, as it is for staging patients with breast cancer. Nuclear medicine imaging and surgical techniques have evolved to such a degree that a SN can be identified and removed in virtually every patient. Nevertheless, some opposition to a routine SN biopsy remains, perhaps due to a failure to appreciate the serious implications of incomplete or inaccurate staging. Guided by a critical appraisal of the available evidence, this review elucidates the definition of an SN, discusses the sensitivity and specificity of the information it provides, emphasises that it is a minor staging procedure that can lead to improved survival when followed by appropriate therapy, and explains the necessarily unconventional and complex design of the only randomised trial that addresses this subject. It also describes other benefits and risks of an SN biopsy and outlines its role in current melanoma management.
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Affiliation(s)
- Omgo E Nieweg
- Melanoma Institute Australia, University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Alan Cooper
- Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School - Northern, University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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18
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Strom T, Torres-Roca JF, Parekh A, Naghavi AO, Caudell JJ, Oliver DE, Messina JL, Khushalani NI, Zager JS, Sarnaik A, Mulé JJ, Trotti AM, Eschrich SA, Sondak VK, Harrison LB. Regional Radiation Therapy Impacts Outcome for Node-Positive Cutaneous Melanoma. J Natl Compr Canc Netw 2017; 15:473-482. [PMID: 28404758 PMCID: PMC7771284 DOI: 10.6004/jnccn.2017.0047] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/01/2016] [Indexed: 01/14/2023]
Abstract
Background: Regional radiation therapy (RT) has been shown to reduce the risk of regional recurrence with node-positive cutaneous melanoma. However, risk factors for regional recurrence, especially in the era of sentinel lymph node biopsy (SLNB), are less clear. Our goals were to identify risk factors associated with regional recurrence and to determine whether a radiosensitivity index (RSI) gene expression signature (GES) could identify patients who experience a survival benefit with regional RT. Methods: A single-institution, Institutional Review Board-approved study was performed including 410 patients treated with either SLNB with or without completion lymph node dissection (LND; n=270) or therapeutic LND (n=91). Postoperative regional RT was delivered to the involved nodal basin in 83 cases (20.2%), to a median dose of 54 Gy (range, 30-60 Gy) in 27 fractions (range, 5-30). Primary outcomes were regional control and overall survival by RSI GES status. Results: Median follow-up was 69 months (range, 13-180). Postoperative regional RT was associated with a reduced risk of regional recurrence among all patients on univariate (5-year estimate: 95.0% vs 83.3%; P=.036) and multivariate analysis (hazard ratio[HR], 0.15; 95% CI, 0.05-0.43; P<.001). Among higher-risk subgroups, regional RT was associated with a lower risk of regional recurrence among patients with clinically detected lymph nodes (n=175; 5-year regional control: 94.1% vs 69.5%; P=.003) and extracapsular extension (ECE) present (n=138; 5-year regional control: 96.7% vs 62.2%; P<.001). Among a subset of radiated patients with gene expression data available, a low RSI GES (radiosensitive) tumor status was associated with improved survival compared with a high RSI GES (5-year: 75% vs 0%; HR, 10.68; 95% CI, 1.24-92.14). Conclusions: Regional RT was associated with a reduced risk of regional recurrence among patients with ECE and clinically detected nodal disease. Gene expression data show promise for better predicting radiocurable patients in the future. In the era of increasingly effective systemic therapies, the value of improved regional control potentially takes on greater significance.
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Affiliation(s)
- Tobin Strom
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Javier F. Torres-Roca
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Akash Parekh
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Arash O. Naghavi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jimmy J. Caudell
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Daniel E. Oliver
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jane L. Messina
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Pathology & Cell Biology and Dermatology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Nikhil I. Khushalani
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jonathan S. Zager
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Amod Sarnaik
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - James J. Mulé
- Center for Translational Research, Moffitt Cancer Center, Tampa, Florida
| | - Andy M. Trotti
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Steven A. Eschrich
- Department of Biomedical Informatics, Moffitt Cancer Center, Tampa, Florida
| | - Vernon K. Sondak
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Pathology & Cell Biology and Dermatology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Louis B. Harrison
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
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19
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Mendenhall WM, Amdur RJ, Morris CG, Kirwan J, Shaw C, Dziegielewski PT. Adjuvant postoperative radiotherapy for cutaneous melanoma. Acta Oncol 2017; 56:495-496. [PMID: 28256960 DOI: 10.1080/0284186x.2017.1295168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- William M. Mendenhall
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert J. Amdur
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher G. Morris
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jessica Kirwan
- Departments of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana Shaw
- Departments of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peter T. Dziegielewski
- Departments of Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
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20
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Crookes TR, Scolyer RA, Lo S, Drummond M, Spillane AJ. Extranodal Spread is Associated with Recurrence and Poor Survival in Stage III Cutaneous Melanoma Patients. Ann Surg Oncol 2017; 24:1378-1385. [PMID: 28130620 DOI: 10.1245/s10434-016-5723-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Inconsistent data suggests extranodal spread (ENS) is an adverse prognostic factor in Stage III melanoma patients but it remains contentious. By rigorously matching cohorts, this study sought to clarify associations with recurrence and survival. METHODS Melanoma patients with lymph node metastases (AJCC Stage III), with or without ENS, sub-classified on the basis of known (MKP) or unknown primary (MUP), were identified from a single institution prospective database. Of 725 ENS patients identified, 567 were able to be precisely matched 1:1 with a non-ENS cohort. Clinicopathologic factors were analyzed for associations with outcome. RESULTS There were 481 MKP and 86 MUP patients in each cohort. ENS, compared to non-ENS, was an independent predictor of worse melanoma specific survival (MSS) (HR = 1.71, 95% CI = 1.39-2.11, P < 0.0001) with median MSS 56.4 versus 175.2 months, P < 0.001; worse disease free survival (DFS) (HR = 1.16, 95%CI = 1.00-1.34, P = 0.044) with median DFS 15.6 versus 21.5 months, P = 0.009; and worse post-recurrence survival (PRS) (HR = 1.66, 95%CI = 1.37-2.02, P < 0.0001) with median PRS 20.1 versus 51.1 months, P < 0.001. ENS was also associated with reduced time to distant recurrence (Distant Disease Free Survival [DDFS]) (HR = 2.00, 95% CI = 1.24-3.24, P = 0.0047), however median time to distant recurrence not reached within the study time period. CONCLUSIONS ENS represents a significant independent predictor of worse MSS, DFS, PRS and DDFS in Stage III melanoma patients. ENS should be considered in the stratification of patients in adjuvant therapy trials.
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Affiliation(s)
- Thomas R Crookes
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia.,School of Medicine Sydney, The University of Notre Dame, Sydney, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Serigne Lo
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia
| | - Martin Drummond
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, 40 Rockland Roads, North Sydney, NSW, 2060, Australia. .,Sydney Medical School, The University of Sydney, Sydney, Australia.
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21
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Baker A, Camacho F, Andrews G, Mackley H. A retrospective analysis of the role of adjuvant radiotherapy in the treatment of cutaneous melanoma. Cancer Biol Ther 2016; 17:1030-1034. [PMID: 27636187 DOI: 10.1080/15384047.2016.1219811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Melanoma is a significant clinical problem, with rising rates of incidence. Surgery is the mainstay of treatment. The role of adjuvant radiotherapy in the control of locoregionally advanced cutaneous melanoma is controversial. A retrospective study of the Surveillance, Epidemiology, and End Results (SEER) database was performed. Patients with locoregionally confined cutaneous melanoma treated surgically between 2004 and 2009 were evaluated, with cancer-specific and all-cause mortality as primary end points. Propensity score matching was used to match 319 radiotherapy patients with 319 non-radiotherapy controls, stratifying by head and neck (HN) and non-head and neck (NHN) primary. Surgery was primarily by wide excision in both the radiotherapy (51.72%) and non-radiotherapy (53.91%) groups. The majority had nodal disease (82.13% vs. 82.44%). White (91.22% vs. 90.59%) males (70.21% vs. 68.96%) predominated. Average ages at diagnosis were 62.27 (SD 15.93) and 63.02 (SD 16.03). Using Cox proportional hazards models, radiation conferred decreased survival in all-cause (HR 1.44, p < 0.0003), and cancer specific mortality (HR 1.57, p < 0.0002) in combined analysis. The NHN group showed significantly decreased 6-year cancer specific survival (HR 2.05, p < 0.0001) for radiated patients. The HN group showed a non-significant hazard with radiotherapy (HR 1.19, p = 0.307). Meaningful differences not captured in the SEER database may exist between cohorts. Based on available SEER data, routine use of adjuvant radiotherapy should be viewed with caution and reserved for high-risk patients. Future trials evaluating patient quality of life may clarify the benefit of adjuvant radiotherapy in high-risk melanoma populations.
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Affiliation(s)
- Aaron Baker
- a The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Fabian Camacho
- b University of Virginia , Department of Public Health Sciences Administration , Charlottesville , VA , USA
| | - Genevieve Andrews
- a The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Heath Mackley
- a The Pennsylvania State University, College of Medicine , Hershey , PA , USA
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22
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Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Discuss the initial management of cutaneous malignant melanoma with regard to diagnostic biopsy and currently accepted resection margins. 2. Be familiar with the management options for melanoma in specific situations such as subungual melanoma, auricular melanoma, and melanoma in the pregnant patient. 3. Discuss the differentiating characteristics of desmoplastic melanoma and its treatment options. 4. List the indications for sentinel lymph node biopsy and be aware of the ongoing trials and current literature. 5. Discuss the medical therapies available to patients with metastatic melanoma. SUMMARY Management of the melanoma patient is a complex and evolving subject. Plastic surgeons should be aware of the recent changes in the field. Excisional biopsy remains the gold standard for diagnosis, although there is no evidence that use of other biopsy types alters survival or recurrence. Wide local excisions should be carried out with margins as recommended by National Comprehensive Cancer Network guidelines according to lesion Breslow depth, with sentinel lymph node biopsy being offered to all medically suitable candidates with intermediate thickness melanomas (1.0 to 4.0 mm), and with sentinel lymph node biopsy being considered for high-risk lesions (ulceration and/or high mitotic figures) with melanomas of 0.75 to 1.0 mm. Melanomas diagnosed during pregnancy can be treated with preoperative lymphoscintigraphy and wide local excision under local anesthesia, with sentinel lymph node biopsy under general anesthesia delayed until after delivery. Management of desmoplastic melanoma is currently controversial with regard to the indications for sentinel lymph node biopsy and the efficacy of postoperative radiation therapy. Subungual and auricular melanoma have evolved from being treated by amputation of the involved appendage to less radical procedures-ear reconstruction is now attempted in the absence of gross invasion into the perichondrium, and subungual melanomas may be treated with wide local excision down to and including the periosteum, with immediate full-thickness skin grafting over bone. Although surgical treatment remains the current gold standard, recent advances in immunotherapy and targeted molecular therapy for metastatic melanoma show great promise for the development of medical therapies for melanoma.
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Affiliation(s)
- Sabrina N Pavri
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
| | - James Clune
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
| | - Stephan Ariyan
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
| | - Deepak Narayan
- New Haven, Conn
- From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine
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23
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Rule WG, Allred JB, Pockaj BA, Markovic SN, DiCaudo DJ, Erickson LA, Deming RL, Schild SE. Results of NCCTG N0275 (Alliance) - a phase II trial evaluating resection followed by adjuvant radiation therapy for patients with desmoplastic melanoma. Cancer Med 2016; 5:1890-6. [PMID: 27368067 PMCID: PMC4971918 DOI: 10.1002/cam4.783] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 03/07/2016] [Accepted: 04/23/2016] [Indexed: 11/06/2022] Open
Abstract
To examine, in a prospective fashion, the utilization and efficacy of adjuvant radiation therapy (RT) in patients with resected desmoplastic melanoma (DM). Adult patients with resected, margin‐negative, and nonmetastatic DM were eligible for this single‐arm prospective phase II study. Patients were to receive postoperative RT, 30 Gy in five fractions, to the operative bed with 2‐ to 3‐cm margins (depending on the tumor location). Nodal basin RT was not allowed. The primary study endpoint was the 2‐year local recurrence rate (LRR). Secondary endpoints included the incidence of regional and distant metastatic disease, progression‐free survival, overall survival (OS), and treatment‐related toxicity. Twenty patients with a single de novo DM lesion meeting trial eligibility criteria were enrolled and treated. The 2‐year LRR was 10%, with two patients demonstrating a LR within 2 years of completion of protocol therapy. No regional or distant failures occurred. OS at 2 and 5 years was 95 and 77%, respectively. There were no grade 3 or higher acute or late adverse events that were related to the protocol therapy. Adjuvant RT after wide local excision (WLE) for DM is efficacious and well tolerated. It should be considered for DM patients after margin‐negative WLE. Additional study is needed to further refine low‐risk patient populations that can potentially have adjuvant RT omitted as part of the treatment plan.
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Affiliation(s)
- William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jacob B Allred
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | | | | | - David J DiCaudo
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Lori A Erickson
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota
| | - Richard L Deming
- Department of Radiation Oncology, Mercy Cancer Center, Des Moines, Iowa
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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24
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Kan CE, Mansur DB. The role of radiation therapy in the management of cutaneous melanoma. Melanoma Manag 2016; 3:61-72. [PMID: 30190873 DOI: 10.2217/mmt.15.41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/06/2015] [Indexed: 02/05/2023] Open
Abstract
The local treatment of cutaneous melanoma with surgical excision is well-established; however, the role of adjuvant radiation is not well-defined. Characteristics of the primary melanoma can indicate a higher local recurrence risk and thus warrant consideration of adjuvant treatment to the primary site. Management of the lymph node regions has been studied in some recent clinical trials, especially with the advent of sentinel lymph node procedures. We will review the indications for radiation to the primary site as well as lymph node regions based on the available data.
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Affiliation(s)
- Charlene E Kan
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, University Hospitals, Seidman Cancer Center, 11100 Euclid Avenue, Lerner Tower B-141, Cleveland, OH 44106, USA
| | - David B Mansur
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, University Hospitals, Seidman Cancer Center, 11100 Euclid Avenue, Lerner Tower B-141, Cleveland, OH 44106, USA
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Bradbury MS, Pauliah M, Zanzonico P, Wiesner U, Patel S. Intraoperative mapping of sentinel lymph node metastases using a clinically translated ultrasmall silica nanoparticle. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2015; 8:535-53. [PMID: 26663853 DOI: 10.1002/wnan.1380] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 09/29/2015] [Accepted: 10/12/2015] [Indexed: 12/22/2022]
Abstract
The management of regional lymph nodes in patients with melanoma has undergone a significant paradigm shift over the past several decades, transitioning from the use of more aggressive surgical approaches, such as lymph node basin dissection, to the application of minimally invasive sentinel lymph node (SLN) biopsy methods to detect the presence of nodal micrometastases. SLN biopsy has enabled reliable, highly accurate, and low-morbidity staging of regional lymph nodes in early stage melanoma as a means of guiding treatment decisions and improving patient outcomes. The accurate identification and staging of lymph nodes is an important prognostic factor, identifying those patients for whom the expected benefits of nodal resection outweigh attendant surgical risks. However, currently used standard-of-care technologies for SLN detection are associated with significant limitations. This has fueled the development of clinically promising platforms that can serve as intraoperative visualization tools to aid accurate and specific determination of tumor-bearing lymph nodes, map cancer-promoting biological properties at the cellular/molecular levels, and delineate nodes from adjacent critical structures. Among a number of promising cancer-imaging probes that might facilitate achievement of these ends is a first-in-kind ultrasmall tumor-targeting inorganic (silica) nanoparticle, designed to overcome translational challenges. The rationale driving these considerations and the application of this platform as an intraoperative treatment tool for guiding resection of cancerous lymph nodes is discussed and presented within the context of alternative imaging technologies. WIREs Nanomed Nanobiotechnol 2016, 8:535-553. doi: 10.1002/wnan.1380 For further resources related to this article, please visit the WIREs website.
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Affiliation(s)
- Michelle S Bradbury
- Department of Radiology, Sloan Kettering Institute for Cancer Research, New York, NY, USA.,Department of Molecular Pharmacology and Chemistry Program, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Mohan Pauliah
- Department of Radiology, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Pat Zanzonico
- Department of Medical Physics, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Ulrich Wiesner
- Department of Material Science & Engineering, Cornell University, Ithaca, NY, USA
| | - Snehal Patel
- Department of Surgery, Sloan Kettering Institute for Cancer Research, New York, NY, USA
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Kretschmer L, Bertsch HP, Zapf A, Mitteldorf C, Satzger I, Thoms KM, Völker B, Schön MP, Gutzmer R, Starz H. Nodal Basin Recurrence After Sentinel Lymph Node Biopsy for Melanoma: A Retrospective Multicenter Study in 2653 Patients. Medicine (Baltimore) 2015; 94:e1433. [PMID: 26356697 PMCID: PMC4616624 DOI: 10.1097/md.0000000000001433] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
UNLABELLED The objective of this study was to analyze different types of nodal basin recurrence after sentinel lymph node biopsy (SLNB) for melanoma. PATIENTS AND METHODS Kaplan-Meier estimates and the Cox proportional hazards model were used to study 2653 patients from 3 German melanoma centers retrospectively.The estimated 5-year negative predictive value of SLNB was 96.4%. The estimated false-negative (FN) rates after 1, 2, 3, 5, and 10 years were 2.5%, 4.6%, 6.4%, 8.7%, and 12.6%, respectively. Independent factors associated with false negativity were older age, fewer SLNs excised, and head or neck location of the primary tumor. Compared with SLN-positive patients, the FNs had a significantly lower survival. In SLN-positive patients undergoing completion lymphadenectomy (CLND), the 5-year nodal basin recurrence rate was 18.3%. The recurrence rates for axilla, groin, and neck were 17.2%, 15.5%, and 44.1%, respectively. Significant factors predicting local relapse after CLND were older age, head, or neck location of the primary tumor, ulceration, deeper penetration of the metastasis into the SLN, tumor-positive CLND, and >2 lymph node metastases. All kinds of nodal relapse were associated with a higher prevalence of in-transit metastases.The FN rate after SLNB steadily increases over the observation period and should, therefore, be estimated by the Kaplan-Meier method. False-negativity is associated with fewer SLNs excised. The beneficial effect of CLND on nodal basin disease control varies considerably across different risk groups. This should be kept in mind about SLN-positive patients when individual decisions on prophylactic CLND are taken.
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Affiliation(s)
- Lutz Kretschmer
- From the Department of Dermatology, Venereology and Allergology, Georg August University of Göttingen, Robert-Koch-Str. 40, D-37075 Göttingen (LK, HPB, KMT, MPS); Department of Medical Statistics, Georg August University of Göttingen, Humboldtallee 32 37073 Göttingen (AZ); Department of Dermatology and Allergy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany (IS, BV, RG); Department of Dermatology, Venereology and Allergology, Klinikum Hildesheim GmbH, Senator-Braun-Allee 33, 31135 Hildesheim, Germany (CM); and Department of Dermatology and Allergology, Klinikum Augsburg, Germany, Sauerbruchstr. 6, D-86179 Augsburg (HS)
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Bañuelos-Andrío L, Rodríguez-Caravaca G, López-Estebaranz JL, Rueda-Orgaz JA, Pinedo-Moraleda F. [Sentinel lymph node biopsy in melanoma: our experience over 8 years in a universitary hospital]. CIR CIR 2015; 83:378-85. [PMID: 26141108 DOI: 10.1016/j.circir.2015.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/19/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since the introduction of sentinel lymph node biopsy, its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. Our experience of sentinel lymph node biopsy for melanoma is presented and evaluated. MATERIAL AND METHODS A cohort study was conducted on 69 patients with a primary cutaneous melanoma and with no clinical evidence of metastasis, who had sentinel lymph node biopsy from October-2005 to December-2013. Sentinel lymph node biopsy was identified using preoperative lymphoscintigraphy and subsequent intraoperative detection with gamma probe. RESULTS The sentinel lymph node biopsy identification rate was 98.5%. The sentinel lymph node biopsy was positive for metastases in 23 patients (33.8%). Postoperative complications after sentinel lymph node biopsy were observed in 4.4% compared to 38% of complications in patients who had complete lymphadenectomy. CONCLUSION The sentinel lymph node biopsy in melanoma offers useful information about the lymphatic dissemination of melanoma and allows an approximation to the regional staging, sparing the secondary effects of lymphadenectomy. More studies with larger number of patients and long term follow-up will be necessary to confirm the validity of sentinel lymph node biopsy in melanoma patients, and especially of lymphadenectomy in patients with positive sentinel lymph node biopsy.
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Affiliation(s)
- Luis Bañuelos-Andrío
- Unidad de Medicina Nuclear, Hospital Universitario Fundación Alcorcón, Madrid, España.
| | - Gil Rodríguez-Caravaca
- Servicio de Medicina Preventiva, Hospital Universitario Fundación Alcorcón, Madrid, España
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Abstract
The worldwide incidence of melanoma continues to rise. It is a leading cause of cancer death and the second leading cause of loss of productive years of life. Although the diagnosis of melanoma is straightforward, there remain many controversies regarding treatment and surveillance. This chapter addresses important questions in melanoma treatment such as sentinel lymph node biopsy, what to do with a positive sentinel lymph node, margins of resection for melanoma, radiation for primary, nodal and metastatic melanoma, and routine use imaging. Through this chapter, the evidence for these controversial subjects and the barriers to resolution will be elucidated.
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Affiliation(s)
- Maria C Russel
- Department of Surgery, Emory University, Atlanta, GA, USA,
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Gorayski P, Burmeister B, Foote M. Radiotherapy for cutaneous melanoma: current and future applications. Future Oncol 2015; 11:525-34. [PMID: 25675130 DOI: 10.2217/fon.14.300] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Cutaneous malignant melanoma remains a significant health burden worldwide despite advances in the management of locoregionally advanced and metastatic disease. Historically, the efficacy of radiation therapy (RT) has been questioned due to the perceived radioresistance of melanoma cancer cells in vitro. Nowadays, RT has limited indications for primary disease, but is used for high-risk nodal disease and in the palliative setting. This review article outlines the current role of RT for melanoma and its expanding role in oligometastatic disease scenarios as an alternative approach to surgery and highlights potential future applications to harness RT interaction with immunomodulatory targeted therapies.
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Affiliation(s)
- Peter Gorayski
- Department of Radiation Oncology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Abstract
Although melanoma was historically thought to be radiation resistant, there are limited data to support the use of adjuvant radiation therapy for certain situations at increased risk for locoregional recurrence. High-risk primary tumor features include thickness, ulceration, certain anatomic locations, satellitosis, desmoplastic/neurotropic features, and head and neck mucosal and anorectal melanoma. Lentigo maligna can be effectively treated with either adjuvant or definitive radiation therapy. Some retrospective and prospective randomized studies support the use of adjuvant radiation to improve regional control after lymph node dissection for high-risk nodal metastatic disease. Consensus on the optimal radiation doses and fractionation is lacking.
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Affiliation(s)
- Jacqueline Oxenberg
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - John M Kane
- Melanoma-Sarcoma Service, Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
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Supriya M, Narasimhan V, Henderson MA, Sizeland A. Managing regional metastasis in patients with cutaneous head and neck melanoma - is selective neck dissection appropriate? Am J Otolaryngol 2014; 35:610-6. [PMID: 25080830 DOI: 10.1016/j.amjoto.2014.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 06/21/2014] [Accepted: 06/27/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection. METHODS Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND). RESULTS There was no difference in LR, OS and PFS between CND (n=18) and SND groups (n=79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR. CONCLUSION Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.
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Affiliation(s)
| | | | - Michael A Henderson
- Division of Cancer Surgery, Peter MacCallum Cancer Center, Melbourne, Australia
| | - Andrew Sizeland
- Division of Head and Neck Surgery, Peter MacCallum Cancer Center, Melbourne, Australia
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Barbour AP, Tang YH, Armour N, Dutton-Regester K, Krause L, Loffler KA, Lambie D, Burmeister B, Thomas J, Smithers BM, Hayward NK. BRAF mutation status is an independent prognostic factor for resected stage IIIB and IIIC melanoma: implications for melanoma staging and adjuvant therapy. Eur J Cancer 2014; 50:2668-76. [PMID: 25070294 DOI: 10.1016/j.ejca.2014.06.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/13/2014] [Accepted: 06/13/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND 5-year survival for melanoma metastasis to regional lymph nodes (American Joint Committee on Cancer stage III) is <50%. Knowledge of outcomes following therapeutic lymphadenectomy for stage III melanoma related to BRAF status may guide adjuvant use of BRAF/MEK inhibitors along with established and future therapies. AIMS To determine patterns of melanoma recurrence and survival following therapeutic lymph node dissection (TLND) associated with oncogenic mutations. METHODS DNA was obtained from patients who underwent TLND and had ⩾2 positive nodes, largest node >3cm or extracapsular invasion. Mutations were detected using an extended Sequenom MelaCARTA panel. RESULTS Mutations were most commonly detected in BRAF (57/124 [46%] patients) and NRAS (26/124 [21%] patients). Patients with BRAF mutations had higher 3-year recurrence rate (77%) versus 54% for BRAF wild-type patients (hazard ratio (HR) 1.8, p=0.008). The only prognostically significant mutations occurred in BRAF: median recurrence-free (RFS) and disease-specific survival (DSS) for BRAF mutation patients was 7 months and 16 months, versus 19 months and not reached for BRAF wild-type patients, respectively. Multivariate analysis identified BRAF mutant status and number of positive lymph nodes as the only independent prognostic factors for RFS and DSS. CONCLUSIONS Patients with BRAF mutations experienced rapid progression of metastatic disease with locoregional recurrence rarely seen in isolation, supporting incorporation of BRAF status into melanoma staging and use of BRAF/MEK inhibitors post-TLND.
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Affiliation(s)
- Andrew P Barbour
- Surgical Oncology Group, School of Medicine, The University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia; Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
| | - Yue Hang Tang
- Surgical Oncology Group, School of Medicine, The University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Nicola Armour
- Surgical Oncology Group, School of Medicine, The University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Ken Dutton-Regester
- QIMR Berghofer Medical Research Institute, Oncogenomics Laboratory, Brisbane, QLD, Australia
| | - Lutz Krause
- QIMR Berghofer Medical Research Institute, Oncogenomics Laboratory, Brisbane, QLD, Australia
| | - Kelly A Loffler
- Surgical Oncology Group, School of Medicine, The University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Duncan Lambie
- Department of Pathology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Bryan Burmeister
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Janine Thomas
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - B Mark Smithers
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Nicholas K Hayward
- QIMR Berghofer Medical Research Institute, Oncogenomics Laboratory, Brisbane, QLD, Australia
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He Y, Mou J, Luo D, Gao B, Wen Y. Primary malignant melanoma of the breast: A case report and review of the literature. Oncol Lett 2014; 8:238-240. [PMID: 24959253 PMCID: PMC4063568 DOI: 10.3892/ol.2014.2120] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 04/10/2014] [Indexed: 01/20/2023] Open
Abstract
Malignant melanoma predominantly occurs in the skin and mucous membranes, thus, malignant melanoma of the breast is particularly rare. In the current study, a case of a 26-year-old female with a malignant melanoma of the breast is presented. On diagnosis of the patient, extensive metastasis had occurred. The patient refused any treatment and succumbed two months after the initial diagnosis. The prognosis for patients with this rare tumour of the breast is somewhat poor. Early diagnosis, correct surgical resection and comprehensive adjuvant therapy are the key procedures that may improve the patient survival rate. The current case report aims to increase the awareness of uncommon tumours of the breast.
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Affiliation(s)
- Yujun He
- Department of General Surgery, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing 400042, P.R. China
| | - Jianghong Mou
- Department of Pathology, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing 400042, P.R. China
| | - Donglin Luo
- Department of General Surgery, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing 400042, P.R. China
| | - Bo Gao
- Department of General Surgery, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing 400042, P.R. China
| | - Yayuan Wen
- Department of General Surgery, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing 400042, P.R. China
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Biswas A, Goyal S, Jain A, Suri V, Mathur S, Julka PK, Rath GK. Primary amelanotic melanoma of the breast: combating a rare cancer. Breast Cancer 2014; 21:236-40. [PMID: 20978954 DOI: 10.1007/s12282-010-0231-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Accepted: 09/16/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Malignant melanoma is the foremost cause of metastasis to the breast from extramammary solid neoplasm. However primary melanoma of the breast is a distinct rarity. Primary melanoma involves the skin and less commonly the glandular parenchyma of the breast. METHOD We herein describe a case of primary amelanotic melanoma of the breast parenchyma in a 32-year-old female managed with a combination of surgery, adjuvant radiotherapy and immunotherapy. CONCLUSION This case report aims to increase awareness of unusual neoplasms of the breast which might require a different surgical and adjuvant therapeutic approach.
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Affiliation(s)
- Ahitagni Biswas
- Department of Radiotherapy and Oncology, All India Institute of Medical Sciences, New Delhi, India,
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Forschner A, Heinrich V, Pflugfelder A, Meier F, Garbe C. The role of radiotherapy in the overall treatment of melanoma. Clin Dermatol 2013; 31:282-9. [PMID: 23608447 DOI: 10.1016/j.clindermatol.2012.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Radiotherapy has become an effective treatment in the management of melanoma patients. It has its place beneath surgical treatment options in a tumor entity that has only limited response to systemic medical therapies. New therapies, such as ipilimumab and vemurafenib, may prolong survival for several months but will cure only a few patients. Radiotherapy will still be required in adjuvant settings to reduce the local recurrence rate and in palliative situations, particularly in brain and bone metastasis. We review several indications for radiotherapy in the management of malignant melanoma with an effect on the guidelines in our clinical practice.
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Affiliation(s)
- Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
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Stage III Melanoma in the Axilla: Patterns of Regional Recurrence After Surgery With and Without Adjuvant Radiation Therapy. Int J Radiat Oncol Biol Phys 2013; 86:702-8. [DOI: 10.1016/j.ijrobp.2013.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 03/15/2013] [Accepted: 03/18/2013] [Indexed: 11/22/2022]
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Ross MI, Gershenwald JE. Sentinel lymph node biopsy for melanoma: A critical update for dermatologists after two decades of experience. Clin Dermatol 2013; 31:298-310. [DOI: 10.1016/j.clindermatol.2012.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Is superficial inguinal node dissection adequate for regional control of malignant melanoma in patients with N1 disease? J Plast Reconstr Aesthet Surg 2013; 66:472-7. [DOI: 10.1016/j.bjps.2012.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 11/03/2012] [Accepted: 12/18/2012] [Indexed: 11/22/2022]
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Biver-Dalle C, Puzenat E, Puyraveau M, Delroeux D, Boulahdour H, Sheppard F, Pelletier F, Humbert P, Aubin F. Sentinel lymph node biopsy in melanoma: our 8-year clinical experience in a single French institute (2002-2009). BMC DERMATOLOGY 2012; 12:21. [PMID: 23228015 PMCID: PMC3538072 DOI: 10.1186/1471-5945-12-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/28/2012] [Indexed: 02/05/2023]
Abstract
Background Since the introduction of sentinel lymph node biopsy (SLNB), its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. We wished to evaluate our experience of SLNB for melanoma. Methods A single center observational cohort of 203 melanoma patients with a primary cutaneous melanoma (tumour thickness > 1 mm) and without clinical evidence of metastasis was investigated from 2002 to 2009. Head and neck melanoma were excluded. SLN was identified following preoperative lymphoscintigraphy and intraoperative gamma probe interrogation. Results The SLN identification rate was 97%. The SLN was tumor positive in 44 patients (22%). Positive SLN was significantly associated with primary tumor thickness and microscopic ulceration. The median follow-up was 39.5 (5–97) months. Disease progression was significantly more frequent in SLN positive patients (32% vs 13%, p = 0.002). Five-year DFS and OS of the entire cohort were 79.6% and 84.6%, respectively, with a statistical significant difference between SLN positive (58.7% and 69.7%) and SLN negative (85% and 90.3%) patients (p = 0.0006 and p = 0.0096 respectively). Postoperative complications after SLNB were observed in 12% of patients. Conclusion Our data confirm previous studies and support the clinical usefulness of SLNB as a reliable and accurate staging method in patients with cutaneous melanoma. However, the benefit of additional CLND in patients with positive SLN remains to be demonstrated.
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A multicenter prospective evaluation of the clinical utility of F-18 FDG-PET/CT in patients with AJCC stage IIIB or IIIC extremity melanoma. Ann Surg 2012; 256:350-6. [PMID: 22691370 DOI: 10.1097/sla.0b013e318256d1f5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE/BACKGROUND There is a high risk of relapse in stage IIIB/IIIC melanoma. The utility of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography integrated with computed tomography (FDG-PET/CT) in these patients to evaluate response to treatment or for surveillance after treatment is currently not well defined. METHODS Prospective data from 2 centers identified 97 patients with stage IIIB/IIIC extremity melanoma undergoing isolated limb infusion (ILI) who had whole body FDG-PET/CT scans before and every 3 months after treatment. Clinical response was determined at 3 months by Response Evaluation Criteria In Solid Tumors. RESULTS Complete response (CR) after ILI occurred in 33% (32/97) of patients. FDG-PET/CT accurately identified 59% of patients who were CRs (19/32), whereas 41% (13/32) had residual metabolic activity in the extremity that was histologically negative for melanoma. The 3-year disease-free rate was 62.2% (95% CI: 40.1%-96.4%) for those patients who were CRs by both clinical/pathologic examination and FDG-PET/CT (n = 19) compared to only 29.4% (95% CI: 9.9%-87.2%) of those CRs who still had residual FDG-PET/CT activity (n = 13). FDG-PET/CT was utilized for surveillance of disease recurrence outside the regional field of treatment. Fifty-two percent (51/97) of patients developed disease outside the extremity at a median time of 212 days from pre-ILI FDG-PET/CT. In 47% (29/62) of these cases, the recurrence was resected. CONCLUSIONS Although FDG-PET/CT does not appear to accurately identify patients who appear to be CRs to ILI, it does appear to identify a subgroup of patients whose regional progression-free survival is markedly worse. However, FDG-PET/CT appears to be an excellent method for surveillance in stage IIIB/IIIC patients after ILI with ability to identify surgically resectable recurrent disease in these high-risk patients.
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Hallemeier CL, Garces YI, Neben-Wittich MA, Olivier KR, Shon W, García JJ, Brown PD, Foote RL. Adjuvant hypofractionated intensity modulated radiation therapy after resection of regional lymph node metastases in patients with cutaneous malignant melanoma of the head and neck. Pract Radiat Oncol 2012; 3:e71-7. [PMID: 24674323 DOI: 10.1016/j.prro.2012.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/08/2012] [Accepted: 06/10/2012] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Wonwoo Shon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joaquín J García
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
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Suton P, Lukšić I, Müller D, Virag M. Lymphatic drainage patterns of head and neck cutaneous melanoma: does primary melanoma site correlate with anatomic distribution of pathologically involved lymph nodes? Int J Oral Maxillofac Surg 2012; 41:413-20. [DOI: 10.1016/j.ijom.2011.12.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 10/19/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
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Murthy V, Gopinath KS. Reconstruction of groin defects following radical inguinal lymphadenectomy: an evidence based review. Indian J Surg Oncol 2012; 3:130-8. [PMID: 23730102 DOI: 10.1007/s13193-012-0145-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022] Open
Abstract
Inguinal lymph node involvement is an important prognostic and predictive factor in various neoplasms of the genitalia and lower limb. As part of the multimodality approach, these patients undergo surgery and adjuvant radiotherapy. Morbidity of inguinal lymphadenectomy includes lymphedema, lymphorrhea and infection; however the most common distressing complication is skin necrosis. Myocutaneous flaps have been the most popular form of primary or delayed groin reconstruction. This paper aims to critically review the different myocutaneous flaps used in groin reconstruction, discuss evidence based data on the versatility and utility of these flaps and discuss ways in which modifications maybe incorporated in treatment and radiation planning following groin reconstruction. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to groin reconstruction. The search focused specifically on current management, technique, safety and complications of these procedures. Keywords searched included "inguinal lymphadenectomy", "primary reconstruction", "musculocutaneus flap", "myocutaneous flap", "tensor fascia lata flap", "anterolateral thigh flap", "rectus abdominis flap". Low to middle income countries witness a huge burden of locally advanced genital malignancies and melanoma of the lower extremity. Higher tumor burden both at the primary site as well as the inguinal basin requires surgery as the primary modality of treatment. Groin reconstruction is required not only to prevent femoral blowouts but also for early administration of adjuvant radiation. The versatility of tensor fascia lata, anterolateral thigh, and rectus abdominis flaps is useful to cover the defect, provide radiation, eradicate pain and achieve good palliation. Assessment of aesthetic and functional outcomes of one flap over the other and the "ideal" form of reconstruction for groin defects needs additional investigation.
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Affiliation(s)
- Vijayashree Murthy
- Department of Surgical Oncology, Bangalore Institute of Oncology, Bangalore, India ; Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Rd., Livingston, NJ 07039 USA
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Shashanka R, Smitha BR. Head and neck melanoma. ISRN SURGERY 2012; 2012:948302. [PMID: 22570796 PMCID: PMC3337483 DOI: 10.5402/2012/948302] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 01/24/2012] [Indexed: 12/02/2022]
Abstract
The incidence of malignant melanoma appears to be increasing at an alarming rate throughout the world over the past 30–40 years and continues to increase in the United States, Canada, Australia, Asia, and Europe. The behavior of head and neck melanoma is aggressive, and it has an overall poorer prognosis than that of other skin sites. The authors review the published literature and text books, intending to give an overall picture of malignant melanomas of the head and neck and a special emphasis on treatment considerations with controversies in treatment including biopsy, radiation therapy, sentinel node biopsy, and nodal dissection.
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Affiliation(s)
- R Shashanka
- Department of General Surgery, Hassan Institute of Medical Sciences, Karnataka, Hassan 573201, India
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Gojkovič-Horvat A, Jančar B, Blas M, Zumer B, Karner K, Hočevar M, Strojan P. Adjuvant radiotherapy for palpable melanoma metastases to the groin: when to irradiate? Int J Radiat Oncol Biol Phys 2011; 83:310-6. [PMID: 22035662 DOI: 10.1016/j.ijrobp.2011.06.1979] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/21/2011] [Accepted: 06/24/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the efficacy of and criteria for postoperative radiotherapy (PORT) in patients with palpable melanoma metastases to the groin. METHODS AND MATERIALS Patients with palpable metastases to the groin who were treated with therapeutic nodal dissection during 2000 to 2006 were identified in a prospective institutional database. RESULTS In 101 patients, 103 therapeutic nodal dissections were performed; 37 of these were treated with PORT to a median equivalent dose (eqTD(2)) of 50.6 Gy (range, 50-72 Gy). In the surgery-only and PORT groups, 2-year regional control rates were 86% (95% confidence interval [CI] 76-95%) and 91% (95% CI, 81-100%), respectively (p = 0.395). Of five recurrences in radiation-treated patients, four were of dermal type, and in three of these cases, no bolus over the operative scar was used. PORT improved 2-year regional control (46% [95% CI, 11-82%] vs. 82% [95% CI, 63-100%], p = 0.022) among patients in which the sum of risk factors present (i.e., risk factor score) was ≥2. In multivariate analysis, risk-factor score (<2 vs. ≥2: HR, 2.93; 95% CI, 1.00-8.56; p < 0.0001) and PORT (yes vs. no: HR, 7.81; 95% CI, 2.83-21.74; p = 0.050) was predictive for regional control and on logistic-regression testing, number of involved lymph nodes was predictive for systemic dissemination (p = 0.011). CONCLUSIONS PORT should follow therapeutic nodal dissection in cases with two or more adverse factors. More conventional fractionation (≤2.5 Gy), cumulative eqTD(2) <60 Gy and use of bolus over the operative scar are recommended.
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Shah PK, Shah KK, Karakousis GC, Reinke CE, Kelz RR, Fraker DL. Regional Recurrence after Lymphadenectomy for Clinically Evident Lymph Node Metastases from Papillary Thyroid Cancer: A Cohort Study. Ann Surg Oncol 2011; 19:1453-9. [DOI: 10.1245/s10434-011-1890-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Indexed: 01/22/2023]
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Ross MI, Gershenwald JE. Evidence-based treatment of early-stage melanoma. J Surg Oncol 2011; 104:341-53. [DOI: 10.1002/jso.21962] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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