A long-term analysis of 620 patients with malignant melanoma at a major referral center

Novel Therapies for Metastatic Melanoma: An Update on Their Use in Older Patients

Cutaneous melanoma is the most aggressive form of skin cancer. With age as a risk factor, melanoma is projected to become a substantial healthcare burden. The clinical course of melanoma in older patients is different from that in middle-aged and younger patients: melanomas are thicker, have higher mitotic rates and are more likely to be ulcerated. Older patients also have a higher mortality rate, yet, paradoxically, have a lower rate of lymph node metastases. After decades of no significant progress in the treatment of this devastating disease, novel insights into the mechanisms underlying the pathophysiology of metastatic melanoma have led to new and remarkably efficient therapeutic opportunities. The discovery that about half of all melanomas carry BRAF mutations led to the introduction of targeted therapy with significant improvements in clinical outcomes. Although these drugs appear to be equally effective in older patients, specific considerations regarding adverse events are required. Besides targeted therapy, immunotherapy has emerged as an alternative therapeutic option. Antibodies that block cytotoxic T-lymphocyte antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1) can induce responses with high durability. Despite an aging immune system, older patients seem to benefit to the same degree from these treatments, apparently without increased toxicity. In this review, we focus on the epidemiology, clinicopathological features, and recent developments of systemic treatment in cutaneous melanoma with regard to older patients.

Malignant melanoma in elderly patients: biological, surgical and medical issues

Malignant melanoma is an aggressive tumor with a poor prognosis for patients with advanced disease. Over the last decades, its incidence and mortality has increased in elderly population, impacting significantly on healthcare costs, considering the increase in average age of the world population. Older age is recognized as an independent poor prognostic factor for melanoma, but the scientific community now is wondering if elderly melanoma patients have worse outcome because they are not receiving the same treatment as their younger counterparts. This article summarizes current data on elderly melanoma prevention and early detection and its subsequent management, underling the differences observed between older and younger patients. It also describes age-associated alterations in immunity and how these may impact on anti-melanoma response.

Metastatic melanoma in the older patient: special considerations

Cancer is a disease of older age where genomic instability, impaired DNA repair, and weakened immune surveillance against cancer are recognized to play a causative role. Because the incidence of melanoma is increasing at a very fast pace in the elderly and there is a rapid expansion of the aging population, a large number of elderly patients with metastatic melanoma will be encountered in clinical practice. As a result, significant burden is expected to be placed on health care resources as effective treatment of this condition is sought. Because melanoma is an immunogenic tumor and promising immune-based treatments have acquired approval for treatment of metastatic melanoma, their successful use in elderly patients will require knowledge about aging and associated alterations in immune function. The spotlight will likely remain on antitumor immunity, its regulation and quality, and the profiles of the cytokines that shape the tumor microenvironment.

Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8,033 cases

PURPOSE

To evaluate clinical features and life prognosis of uveal melanoma based on age at presentation.

DESIGN

Retrospective, nonrandomized, interventional case series.

RESULTS

Of 8,033 eyes with uveal melanoma, 106 (1%) were in young patients (≤20 years), 4,287 (53%) in mid adults (21-60 years), and 3,640 (45%) in older adults (>60 years). Based on age (young, mid adults, and older adults) at presentation, tumor epicenter was located in iris (21, 4, 2%; P < 0.0001), ciliary body (8, 5, and 7%; P = 0.0225), or choroid (71, 91, and 90%; P < 0.0001). Mean tumor diameter (10.2, 10.8, 11.5 mm; P < 0.0001), mean tumor thickness (5.0, 5.3, 5.7 mm; P < 0.0001), and extraocular extension (1, 2, and 4%; P = 0.0004) increased with age. Kaplan-Meier estimates of tumor-related metastasis at 3, 5, 10, and 20 years were 2%, 9%, 9%, and 20% in young patients (P < 0.011); 6%, 12%, 23%, and 34% in mid adults (P < 0.0001); and 11%, 19%, 28%, and 39% in older adults. Kaplan-Meier estimate of tumor-related death at 3, 5, 10, and 20 years were 0%, 2%, 5%, and 17% in young patients (P = 0.08); 3%, 6%, 11%, and 17% in mid adults (P < 0.001); and 7%, 11%, 16%, and 20% in older adults.

CONCLUSION

Compared with mid adults and older adults, young patients manifested a higher proportion of iris melanoma. Compared with older adults, young and mid adults showed smaller melanoma basal dimension and lower tumor-related metastasis and death.

Is primary melanoma ulceration a factor of good response to adoptive immunotherapy?

BACKGROUND

Primary melanoma ulceration is a factor of poor prognosis at the local and regional stage. The physiopathological mechanisms which explain its prognostic impact are still little known. However, two recent studies suggest that it could be a predictive factor of good response to a non-specific immunotherapy (interferon-alpha) and to an active immunotherapy (vaccine).

OBJECTIVE

The aim of this study was to determine whether ulceration could be a factor of good prognosis in the context of an adoptive immunotherapy with tumour infiltrating lymphocytes (TIL) in stage III regional lymph node metastatic melanoma (sixth American Joint Committee on Cancer staging system) and whether it was associated with an improvement in the effectiveness of this treatment compared with the control group.

METHODS

We have included all the patients treated in open prospective randomized TIL vs. control protocols in our unit from 1997 to 2009. Clinical data were derived retrospectively from patient files. Statistical analysis was performed using log-rank tests, Cox models and tests for interaction.

RESULTS

A total of 144 patients were included. In the group of 80 patients treated with TIL, primary melanoma ulceration remained a pejorative factor for relapse-free and overall survival in univariate and multivariate analysis. The presence of ulceration did not change the effectiveness of TIL treatment in comparison with the control group with regards to relapse-free and overall survival.

CONCLUSION

Our study demonstrates that primary melanoma ulceration does not have any impact on the response to TIL adoptive immunotherapy and thus does not confirm its positive prognostic value suggested by two other immunotherapy approaches.

Detection of melanoma nodal metastases; differences in detection between elderly and younger patients do not affect survival

BACKGROUND

Melanoma lymph nodes metastases may be detected by patients or by physicians. Understanding the outcomes of self-detection or physician detection is essential for the design of follow-up studies. We evaluated the role of the method of detection in nodal disease in the prognosis of melanoma patients who underwent therapeutic lymph node dissection (TLND).

MATERIALS AND METHODS

All melanoma patients with palpable lymph nodes were included in a prospective database (n = 98), and the method of detection was recorded. Detection of lymph node metastases compared with pathological findings in the TLND was assessed by multivariate logistic regression. Disease-free survival (DFS) and disease-specific survival (DSS) were assessed by univariate and multivariate Cox proportional hazard analysis.

RESULTS

Nodal metastases were detected by physicians in 45% and by patients in 55% (P < 0.001). Age was significantly associated with method of detection. Patients ≤60 years detected 69% their lymph node metastases as opposed to 32% of patients >60 years (odds ratio [OR] 0.3; P = 0.007). However, this was not associated with prognostic findings in TLND, number of positive nodes, tumor size, or extranodal spread. Method of detection or age at the time of nodal metastases was not significantly associated with 2-year DFS or DSS.

CONCLUSIONS

45% of all lymph node metastases in stage I-II melanoma patients are physician detected. Younger patients detect their own lymph node metastases significantly more often than elderly patients. However, neither the method of detection nor age correlates with DSS. More frequent follow-up would not alter DFS and DSS significantly.

Malignant Melanoma in Turkey: A Single Institution's Experience on 475 Cases

BACKGROUND

This study was performed to determine the characteristics and the clinical outcomes of patients with cutaneous melanoma in Turkey.

METHODS

The medical records of patients between 1991 and 2003 at Institute of Oncology were retrieved from the cancer registry.

RESULTS

Of the 475 adult cases with complete staging procedure, the incidence of localized (stages I-II) disease was 301 (63.4%), and followed by node involved (stage III) and metastatic (stage IV) disease with the incidence of 117 (24.6%) and 57 (12.0%), respectively. The median age of patients was 50 years (17-104 years) and male/female ratio was 1.1. Of 206 patients (43.4%) the diseases were located on extremities, 150 (31.6%) on the trunk, and 102 (21.5%) on the head and neck region. In cases with early/node negative stage, stage distribution was identical. The superficial spreading type was the commonest histology (52.2%). The Breslow thickness distributed equally, whereas tumor invasion aggregated mainly at Clark level III and IV. Half of the lesions were ulcerated and with low mitotic potential. In cases with the node involved stage, the majority of patients had only one lymph node involved. In metastatic patients, two thirds had distant metastases including lung metastases and half of them had single metastatic region. With the median follow-up of all patients of 5.2 years, the median overall survival of all patients was 62.2 months and the 5-year overall survival was 50.5%. Overall survival was significantly negatively correlated with male (P<0.001), advanced stages (P<0.001) and old ages (P=0.005). The five-year survival rates of patients with stages I-II and III disease were 63.6% and 36.6%, respectively. Nodular histology subtype, deeper Breslow tumor depth, extensive invasion, presence of ulceration, advanced stage, presence of relapse, being male and elderly patient, presence of visceral recurrence, and high mitotic activity were found to be associated with poor prognosis for overall survival in localized disease. The median survival of metastatic patients was 9.9 months and 1-year overall survival rate was 32.7%. Unresponsiveness to chemotherapy, visceral metastasis, multiple metastases and not given chemotherapy were the poor prognostic factors for overall survival.

CONCLUSION

The descriptive and prognostic factors in Turkey are similar to those in Western countries.

Sentinel and nonsentinel node status in stage IB and II melanoma patients: two-step prognostic indicators of survival

PURPOSE

To evaluate the prognostic significance of sentinel node biopsy in the management of stage IB and II melanoma patients, and to evaluate the status of nonsentinel nodes as a "second step key factor" to assess the prognosis of these patients.

PATIENTS AND METHODS

We conducted an analysis of data collected in a prospective database.

RESULTS

From February 1994 to June 2005, 1,108 consecutive patients with stage IB and II melanoma were submitted to sentinel node biopsy; 176 patients (15.9%) had occult node metastases. The frequency of positive nodes increased with increasing Breslow's thickness. The largest diameter of metastatic foci and their localization within the lymph node were associated with the risk of nonsentinel node metastases only. The 5-year survival of patients with positive sentinel nodes was 81.4% in patients with one positive node and 39.6% in patients with two positive nodes (P = .056). Multivariate analysis indicated that status of sentinel nodes is a key factor and that sex and Breslow's thickness maintain statistically significant relevance. Ulceration, which was associated with survival when considered as single factor (P < .001) had no impact on survival in the multivariate analysis (P = .10). To evaluate the relevance of metastases to nonsentinel nodes, we identified four groups of patients.

CONCLUSION

Evaluation of the sentinel node is a useful procedure to identify patients to be submitted for complete lymph node dissection. The procedure makes it possible to assess the best prognosis of patients.

A long-term analysis of 1018 patients with melanoma by classic Cox regression and tree-structured survival analysis at a major referral center: Implications on the future of cancer staging

BACKGROUND

Traditional statistical analysis of 2 surgeons' experiences with resectable malignant melanoma during a 30-year period (November 1970-July 2000) was compared with new tree-structured recursive partitioning regression analysis.

METHODS

A total of 1018 consecutive patients were registered and 983 patients were evaluable. Disease-free survival (DFS) and melanoma survival (MS) were calculated by Kaplan-Meier method for stage, thickness, ulceration, site, lymph node involvement, age, sex, and type; and compared with log-rank tests. Cox proportional hazards model was used for multivariate analysis. Multivariate predictors were used to analyze DFS and MS with a classification and regression tree model that partitioned patients into progressively more homogenous prognostic groups with significantly different Kaplan-Meier curves.

RESULTS

Multivariate correlations were with thickness (millimeters), ulceration, age (per year), type, and sex in predicting DFS (relative risk = 1.18, 2.10, 1.05, 1.71, and 1.71, respectively). Thickness, ulceration, age, and type remained significant predictors of MS (relative risk = 1.14, 3.02, 1.02, and 2.30, respectively). Classification and regression tree analysis showed thickness, age, ulceration, and sex affected DFS. Only thickness and ulceration were significant in predicting MS.

CONCLUSION

The Cox model is an important tool for analysis of clinical data but has flaws. New statistical technology to predict outcome should be considered. Classification and regression tree analysis of larger published series may reveal new predictors useful for staging, prognosis, and guiding clinical decisions.

Prognostic factors

The American Joint Committee on Cancer has recently revised the staging system for melanoma. In this article, prognostic factors for melanoma are discussed in order of significance as outlined by the new staging system. In addition, other historically relevant prognostic factors are reviewed. The article concludes with a discussion of new technology, which may aid in the future staging of melanoma patients.

Pathologic staging of melanoma

The American Joint Committee on Cancer (AJCC) recently launched a new staging system for cutaneous melanoma that was based on clinical experience with a large number of patients treated in major centers worldwide. As this system includes various histopathologic parameters of the primary melanoma and of melanoma metastasis, including micrometastases in the sentinel lymph node (SLN), they are discussed here. Special attention is given to ulceration of the primary tumor, because it remains a dominant prognostic parameter in addition to tumor thickness. Molecular markers that may reflect aggressive behavior of the primary melanoma also are described. Finally, pathologic examination of SLNs is addressed with emphasis on the efficacy of various microstaging approaches.

Testing a new staging system for cutaneous melanoma proposed by the American Joint Committee on Cancer

The American Joint Committee on Cancer (AJCC) recently proposed a new staging system for cutaneous melanoma. We tested its practicability and its prognostic value was compared with the currently used TNM classification. The data of 1976 melanoma patients were used for the testing. 1218 patients (61.6%) could be assigned to the proposed pT classification, 136 patients (90.1%) with lymph node metastases and/or in-transit metastases to the proposed pN classification and all 14 patients with distant metastases to the proposed pM classification. Proposed pathological staging was possible for 971 patients (49%). The number of pT1 patients (399 versus 230) and stage I patients (544 versus 393) was distinctly higher in the proposed classification. In proposed stage II and III groups, subgroups with different prognosis could be identified. The new staging system includes more detailed information on clinical and pathohistological findings. Nevertheless, it is practicable and enables more patients with excellent prognosis to be identified.

Prognostic factors in invasive cutaneous malignant melanoma: a population-based study and review

A population-based study from Sweden identified 711 patients with cutaneous malignant melanoma diagnosed in 1965, 1975, 1985 and 1989. Prognostic factors were evaluated and a review of the literature was performed. On univariate analysis, thick tumours (> 0.8 mm) (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.6-2.1), increasing Clark level (OR 1.8, 95% CI 1.6-2.0), ulceration (OR 1.8, 95% CI 1.6-2.0), nodular melanoma (OR 1.5, 95% CI 1.3-1.6) and increasing age (continuous variable, P < 0.0001) were associated with a shorter survival. Location on extremities (OR 0.8, 95% CI 0.7-0.9), inflammation (OR 0.8, 95% CI 0.7-0.9) and female gender (OR 0.8, 95% CI 0.8-0.9) were associated with improved survival. On multivariate analysis, thick tumours (> 0.8 mm) (OR 1.5, 95% CI 1.2-1.7) and ulceration (OR 1.4, 95% CI 1.2-1.6) were independently related to a poor prognosis, while location on extremities (OR 0.8, 95% CI 0.7-0.9), inflammation (OR 0.8, 95% CI 0.7-0.9) and female gender (OR 0.8, 95% CI 0.8-1.0) were associated with improved survival. No difference in mean tumour thickness was seen over time, but there was a significant increase in the percentage of thin melanomas (< 0.8 mm) in 1985 (P = 0.01) and 1989 (P = 0.002) compared with 1965. The incidence of melanomas with inflammation increased significantly (P = 0.04), as did age at diagnosis (P = 0.005).

Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma

PURPOSE

To revise the staging system for cutaneous melanoma under the auspices of the American Joint Committee on Cancer (AJCC).

MATERIALS AND METHODS

The prognostic factors analysis described in the companion publication (this issue), as well as evidence from the published literature, was used to assemble the tumor-node-metastasis criteria and stage grouping for the melanoma staging system.

RESULTS

Major changes include (1) melanoma thickness and ulceration but not level of invasion to be used in the T category (except for T1 melanomas); (2) the number of metastatic lymph nodes rather than their gross dimensions and the delineation of clinically occult (ie, microscopic) versus clinically apparent (ie, macroscopic) nodal metastases to be used in the N category; (3) the site of distant metastases and the presence of elevated serum lactic dehydrogenase to be used in the M category; (4) an upstaging of all patients with stage I, II, and III disease when a primary melanoma is ulcerated; (5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into stage III disease; and (6) a new convention for defining clinical and pathologic staging so as to take into account the staging information gained from intraoperative lymphatic mapping and sentinel node biopsy.

CONCLUSION

This revision will become official with publication of the sixth edition of the AJCC Cancer Staging Manual in the year 2002.

Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system

PURPOSE

The American Joint Committee on Cancer (AJCC) recently proposed major revisions of the tumor-node-metastases (TNM) categories and stage groupings for cutaneous melanoma. Thirteen cancer centers and cancer cooperative groups contributed staging and survival data from a total of 30,450 melanoma patients from their databases in order to validate this staging proposal.

PATIENTS AND METHODS

There were 17,600 melanoma patients with complete clinical, pathologic, and follow-up information. Factors predicting melanoma-specific survival rates were analyzed using the Cox proportional hazards regression model. Follow-up survival data for 5 years or longer were available for 73% of the patients.

RESULTS

This analysis demonstrated that (1) in the T category, tumor thickness and ulceration were the most powerful predictors of survival, and the level of invasion had a significant impact only within the subgroup of thin (< or = 1 mm) melanomas; (2) in the N category, the following three independent factors were identified: the number of metastatic nodes, whether nodal metastases were clinically occult or clinically apparent, and the presence or absence of primary tumor ulceration; and (3) in the M category, nonvisceral metastases was associated with a better survival compared with visceral metastases. A marked diversity in the natural history of pathologic stage III melanoma was demonstrated by five-fold differences in 5-year survival rates for defined subgroups. This analysis also demonstrated that large and complex data sets could be used effectively to examine prognosis and survival outcome in melanoma patients.

CONCLUSION

The results of this evidence-based methodology were incorporated into the AJCC melanoma staging as described in the companion publication.

Using a continuous transformation of the Breslow thickness for prognosis in cutaneous melanoma

Although the Breslow thickness provides the most important histologic information for prognosis in cutaneous melanoma, controversies and uncertainty remain about how best to use thickness. It is unclear whether cut points should be used, or, if they are used, which are optimal. We studied new data collected from more than 1,000 patients followed up for a relatively long period. From Cox proportional hazards models of survival we learned that more cut points provide more prognostic information than using, for example, just 1 cut point at 1.7 mm. Nevertheless, a continuous transformation provides an effective alternative that captures the information that thickness provides, and it avoids the pitfalls of using multiple cut points. In a multivariate model, this transformation provided strong prognostic information, and the result produced a prognostic score for cutaneous melanoma. This score provides a practical way that Cox model results can be used, and we believe it consolidates the prognostic information provided by traditional histologic and clinical variables. When newer prognostic variables are introduced, we suggest that they be used with this continuous transformation of thickness rather than with cut points in thickness.

A new American Joint Committee on Cancer staging system for cutaneous melanoma

The Melanoma Staging Committee of the AJCC has proposed major revisions of the melanoma TNM and stage grouping criteria. The committee members represent most of the major cooperative groups and cancer centers worldwide with a special interest in melanoma; the committee also collectively has had clinical experience with over 40,000 patients. The new staging system better reflects independent prognostic factors that are used in clinical trials and in reporting the outcomes of various melanoma treatment modalities. Major revisions include 1) melanoma thickness and ulceration, but not level of invasion, to be used in the T classification; 2) the number of metastatic lymph nodes, rather than their gross dimensions, the delineation of microscopic versus macroscopic lymph node metastases, and presence of ulceration of the primary melanoma to be used in the N classification; 3) the site of distant metastases and the presence of elevated serum LDH, to be used in the M classification; 4) an upstaging of all patients with Stage I,II, and III disease when a primary melanoma is ulcerated; 5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into Stage III disease; and 6) a new convention for defining clinical and pathologic staging so as to take into account the new staging information gained from intraoperative lymphatic mapping and sentinel lymph node biopsy. The AJC Melanoma Staging Committee invites comments and suggestions regarding this proposed staging system before a final recommendation is made.

Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial

BACKGROUND

Ten- to 15-year survival results were analyzed from a prospective multi-institutional randomized surgical trial that involved 740 stages I and II melanoma patients with intermediate thickness melanomas (1.0 to 4.0 mm) and compared elective (immediate) lymph node dissection (ELND) with clinical observation of the lymph nodes as well as prognostic factors that independently predict outcomes.

METHODS

Eligible patients were stratified according to tumor thickness, anatomical site, and ulceration, and then prerandomized to either ELND or nodal observation. By using Cox stepwise multivariate regression analysis, the independent predictors of outcome were tumor thickness (P < .001), the presence of tumor ulceration (P < .001), trunk site (P = .003), and patient age more than 60 years (P = .01).

RESULTS

Overall 10-year survival was not significantly different for patients who received ELND or nodal observation (77% vs. 73%; P = .12). Among the prospectively stratified subgroups of patients, 10-year survival rates favored those patients with ELND, with a 30% reduction in mortality rate for the 543 patients with nonulcerated melanomas (84% vs. 77%; P = .03), a 30% reduction in mortality rate for the 446 patients with tumor thickness of 1.0 to 2.0 mm (86% vs. 80%; P = .03), and a 27% reduction in mortality rate for 385 patients with limb melanomas (84% vs. 78%; P = .05). Of these subgroups, the presence or absence of ulceration should be the key factor for making treatment recommendations with regard to ELND for patients with intermediate thickness melanomas.

CONCLUSIONS

These long-term survival rates from patients treated at 77 institutions demonstrate that ulceration and tumor thickness are dominant predictive factors that should be used in the staging of stages I and II melanomas, and confer a survival advantage for these subgroups of prospectively defined melanoma patients.