New diagnostic techniques in staging in the surgical treatment of cutaneous malignant melanoma

[18F]FLT-PET in oncology: current status and opportunities

In recent years, [18F]-fluoro-3'-deoxy-3'-L: -fluorothymidine ([18F]FLT) has been developed as a proliferation tracer. Imaging and measurement of proliferation with PET could provide us with a non-invasive staging tool and a tool to monitor the response to anticancer treatment. In this review, the basis of [18F]FLT as a proliferation tracer is discussed. Furthermore, an overview of the current status of [18F]FLT-PET research is given. The results of this research show that although [18F]FLT is a tracer that visualises cellular proliferation, it also has certain limitations. In comparison with the most widely used PET tracer, [18F]FDG, [18F]FLT uptake is lower in most cases. Furthermore, [18F]FLT uptake does not always reflect the tumour cell proliferation rate, for example during or shortly after certain chemotherapy regimens. The opportunities provided by, and the limitations of, [18F]FLT as a proliferation tracer are addressed in this review, and directions are given for further research, taking into account the strong and weak points of the new tracer.

Role of surgery in patients with stage IV melanoma

PURPOSE OF REVIEW

The purpose of this brief review is to highlight recent advances in the surgical treatment of metastatic melanoma; to review factors important in the decision-making process of selecting the most appropriate patients for resection; and to discuss the current literature in the context of site of recurrence.

RECENT FINDINGS

While there are relatively few new findings on the surgical treatment of metastatic melanoma, recent reports do support prior observations in the field. The recently revised staging system for melanoma groups metastatic disease according to prognostic features. There is currently a great deal of interest in the use of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to more accurately evaluate metastatic disease. The use stereotactic radiosurgery for brain metastases has expanded recently and adds to local treatment options. When procedures are performed with palliative intent, treatment goals must be clearly defined and communicated among the patient, family and surgeon. Improved understanding of the goals of palliative surgery may be facilitated by the concept of a palliative triangle, which helps define the decision making process among the patient, family members, and surgeon.

SUMMARY

Metastatic melanoma is usually associated with a dismal prognosis. When a procedure is performed with palliative intent, appropriately selected patients usually experience reliable relief of symptoms and improved quality of life. Improved survival after a complete resection with curative intent is often predicted by good performance status, longer disease-free interval, limited extent of metastatic disease, and less aggressive tumor biology.

Melanoma in children and adolescents

Childhood and adolescent melanoma is rare, accounting for only 1.3% for all cases of cancer in patients under the age of 20 years. However, in 15-19 year olds, melanoma accounts for up to 7% of all cancers. Review of reported cases in this age group reveals that predisposing 'paediatric' conditions such as a giant congenital melanocytic naevi or xeroderma pigmentosum are rarely present. Furthermore, inactivating germ-line mutations of the gene CDKN2A have only been reported in 1.5% of cases of early onset melanoma. Epidemiological studies suggest that interactions between solar exposure, development of naevi, pigmentary traits, and a family history of melanoma are the main determinants of melanoma development during the first 20 years of life. As yet, there are no available staging or treatment strategies for this group of patients so treatment recommendations are based on the adult experience. To improve our understanding of the natural history of melanoma and to identify the most appropriate therapies for young patients with this disease, practising physicians are encouraged to enroll their patients, especially those with advanced stage disease, in cooperative group trials which incorporate newer staging systems and promising therapies.

Fluorodeoxyglucose-positron emission tomography and sentinel lymph node biopsy in staging primary cutaneous melanoma

AIM

We report the value of sentinel lymph node (SLN) biopsy and fluorodeoxyglucose-positron emission tomography (FDG-PET) in relation to SLN biopsy in staging primary cutaneous melanoma.

METHODS

Fifty-five patients with primary cutaneous melanoma >1.0 mm. Breslow thickness and no palpable regional lymph nodes underwent a FDG-PET scan before SLN biopsy.

RESULTS

SLN's were retrieved in 53 patients. Melanoma metastases were found in the SLN of 13 patients. FDG-PET detected the lymph node metastases in two of the 13 patients with SLN metastases. In five patients FDG accumulation was recorded in a regional lymph node basin, while no tumour positive SLN was found. In eight patients FDG-PET showed increased activity at a site of possible distant metastasis. Metastatic disease was confirmed in one patient. No explanation for the positive FDG-PET result could be found in five cases.

CONCLUSION

FDG-PET should not be considered in this group. SLN biopsy reveals regional metastases that are too small to be detected by FDG-PET. The prevalence of distant metastases is too small to justify routine use of FDG-PET.