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Knackstedt R, Smile T, Yu J, Gastman BR. Non-Operative Options for Loco-regional Melanoma. Clin Plast Surg 2021; 48:631-642. [PMID: 34503723 DOI: 10.1016/j.cps.2021.05.007] [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: 10/21/2022]
Abstract
Malignant melanoma is the 5th most common cancer and stage IV melanoma accounts for approximately 4% of new melanoma diagnoses in the United States. The prognosis for regionally advanced disease is poor, but there have been numerous recent advances in the medical management of melanoma in-transit metastases. The goal of this paper is to review currently accepted treatment options for in-transit metastases and introduce emerging therapies. Therapies to be discussed include limb perfusion and infusion, immunotherapy, checkpoint inhibitors, and radiation therapy.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA
| | - Timothy Smile
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Jennifer Yu
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA.
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2
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Hendrickx A, Cozzio A, Plasswilm L, Panje CM. Radiotherapy for lentigo maligna and lentigo maligna melanoma - a systematic review. Radiat Oncol 2020; 15:174. [PMID: 32664998 PMCID: PMC7362499 DOI: 10.1186/s13014-020-01615-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/08/2020] [Indexed: 11/25/2022] Open
Abstract
Lentigo maligna (LM) is the most common subtype of in situ melanoma und occurs frequently in the sun-exposed head and neck region in elderly patients. The therapeutic “gold standard” is surgical excision, as there is the risk of progression to invasive (lentigo maligna) melanoma (LMM). However, surgery is not feasible in certain patients due to age, comorbidities or patient preference. Radiotherapy using Grenz rays or superficial X-rays has been established as non-invasive alternative for the treatment of LM and LMM. We performed a systematic literature search of MEDLINE and Embase databases in September 2019 and identified 14 patient series using radiotherapy for LM or LMM. No prospective trials were found. The 14 studies reported a total of 1243 lesions (1075 LM and 168 LMM) treated with radiotherapy. Local recurrence rates ranged from 0 to 31% and were comparable to surgical series in most of the reports on radiotherapy. Superficial radiotherapy was prescribed in 5–23 fractions with a total dose of 35–57 Gy. Grenz ray therapy was prescribed in 42–160 Gy in 3–13 fractions with single doses up to 20 Gy. Cosmetic results were reported as “good” to “excellent” for the majority of patients. In conclusion, the available low-level evidence suggests that radiotherapy may be a safe and effective treatment for LM and LMM. Data from prospective trials such as the phase 3 RADICAL trial are needed to confirm these promising findings and to compare radiotherapy to other non-surgical therapies and to surgery.
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Affiliation(s)
| | - Antonio Cozzio
- Department of Dermatology, Venerology and Allergology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Ludwig Plasswilm
- University of Bern, Bern, Switzerland.,Department of Radiation Oncology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Cédric M Panje
- Department of Radiation Oncology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
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Read T, Noonan C, David M, Wagels M, Foote M, Schaider H, Soyer HP, Smithers BM. A systematic review of non-surgical treatments for lentigo maligna. J Eur Acad Dermatol Venereol 2015; 30:748-53. [PMID: 26299846 DOI: 10.1111/jdv.13252] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/22/2015] [Indexed: 11/26/2022]
Abstract
Lentigo maligna (LM) is the most common melanocytic malignancy of the head and neck. If left untreated, LM can progress to lentigo maligna melanoma (LMM). Complete surgical excision is the gold standard for treatment, however, due to the location, size, and advanced age of patients, surgery is not always acceptable. As a result, there is ongoing interest in alternative, less invasive treatment modalities. The objective was to provide a structured review of key literature reporting the use of radiotherapy, imiquimod and laser therapy for the management of LM in patients where surgical resection is prohibited. An independent review was conducted following a comprehensive search of the National Library of Medicine using MEDLINE and PubMed, Embase, Scopus, ScienceDirect and Cochrane Library databases. Data were presented in tabular format, and crude data pooled to calculate mean recurrence rates for each therapy. 29 studies met the inclusion criteria: radiotherapy 10; topical imiquimod 10; laser therapies 9. Radiotherapy demostrated recurrence rates of up to 31% (mean 11.5%), with follow-up durations of 1-96 months. Topical imiquimod recurrence rates were up to 50% (mean 24.5%), with follow-up durations of 2-49 months. Laser therapy yielded recurrence rates of up to 100% (mean 34.4%), and follow-up durations of 8-78 months. in each of the treatment series the I(2) value measuring statistical heterogeneity exceeded the accepted threshold of 50% and as such a meta-analysis of included data were inappropriate. For non-surgical patients with LM, radiotherapy and topical imiquimod were efficacious treatments. Radiotherapy produced superior complete response rates and fewer recurrences than imiquimod although both are promising non-invasive modalities. There was no consistent body of evidence regarding laser therapy although response rates of up to 100% were reported in low quality studies. A prospective comparative trial is indicated and would provide accurate data on the long-term efficacy and overall utility of these treatments.
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Affiliation(s)
- T Read
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, QLD, Australia.,Discipline of Surgery, School of Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - C Noonan
- School of Medicine, Griffith University, Gold Coast, QLD, Australia.,Department of Radiation Oncology, Christchurch Hospital, Canterbury District Health, Christchurch, New Zealand
| | - M David
- Faculty of Medicine and Biomedical Sciences, School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - M Wagels
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, QLD, Australia.,Discipline of Surgery, School of Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - M Foote
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, QLD, Australia
| | - H Schaider
- Dermatology Research Centre, Translational Research Institute, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - H P Soyer
- Dermatology Research Centre, Translational Research Institute, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - B M Smithers
- Queensland Melanoma Project, Princess Alexandra Hospital, Queensland Health, Brisbane, QLD, Australia.,Discipline of Surgery, School of Medicine, The University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia
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Hibler BP, Connolly KL, Cordova M, Nehal KS, Rossi AM, Barker CA. Radiation therapy for synchronous basal cell carcinoma and lentigo maligna of the nose: Response assessment by clinical examination and reflectance confocal microscopy. Pract Radiat Oncol 2015; 5:e543-e547. [PMID: 26142026 DOI: 10.1016/j.prro.2015.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/19/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Brian P Hibler
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karen L Connolly
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel Cordova
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kishwer S Nehal
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York; Multidisciplinary Skin Cancer Management Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony M Rossi
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York; Multidisciplinary Skin Cancer Management Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher A Barker
- Multidisciplinary Skin Cancer Management Program, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Fogarty GB, Hong A, Scolyer RA, Lin E, Haydu L, Guitera P, Thompson J. Radiotherapy for lentigo maligna: a literature review and recommendations for treatment. Br J Dermatol 2015; 170:52-8. [PMID: 24032599 DOI: 10.1111/bjd.12611] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2013] [Indexed: 11/28/2022]
Abstract
Lentigo maligna (LM) incidence is increasing. LM frequently involves the face near critical anatomical structures and as a consequence clinical management is challenging. Nonsurgical therapies, including radiotherapy (RT), are increasingly used. Evidenced-based treatment guidelines are lacking. We conducted a review of previously published data analysing RT treatment of LM. A search of PubMed, Embase and Medline databases to June 2012 identified nine clinical studies that examined the use of RT for LM treatment in at least five patients. Nine studies described 537 patients with LM treated with definitive primary RT, between 1941 and 2009, with a median reported follow-up time of 3 years. Eight articles could be reviewed for oncological outcome data. There were 18 recurrences documented in a total of 349 assessable patients (5%). Salvage was successful in the majority of recurrent LM cases by using further RT, surgery or other therapies. Progression to LM melanoma (LMM) occurred in five patients (five out of 349, 1.4%) who all had poor outcomes. There were five marginal recurrences documented out of 123 assessable patients (4%). There were eight in-field recurrences documented with either LM (five) or LMM (three) out of 171 assessable patients (5%). A series of recommendations were then developed for RT parameters for treatment of LM. These parameters include treatment volume, dose, dose per fraction and outcome measures. These may be of use in prospective data collection.
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Affiliation(s)
- G B Fogarty
- Melanoma Institute Australia, Poche Centre, 40 Rocklands Road, North Sydney, NSW, 2060, Australia; Genesis Cancer Care, Mater Sydney Radiation Oncology Centre, Mater Hospital, 25 Rocklands Road, North Sydney, NSW, 2060, Australia
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Abstract
Radiation therapy is used infrequently for cutaneous melanoma, despite research suggesting benefit in certain clinical scenarios. This review presents data forming the highest level of evidence supporting the use of radiation therapy. Retrospective and prospective studies demonstrate radiation therapy for primary tumors is associated with high control rates. Two randomized trials have found improvements in regional control with adjuvant radiotherapy to regional lymphatics. Retrospective and prospective studies demonstrate radiation therapy is associated with palliative response and metastatic tumor control. Optimal care of melanoma patients involves radiation therapy; awareness of this is incumbent of clinicians caring for patients with this disease.
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Affiliation(s)
- Christopher A Barker
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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McLEOD MICHAEL, CHOUDHARY SONAL, GIANNAKAKIS GEORGIOS, NOURI KEYVAN. Surgical Treatments for Lentigo Maligna: A Review. Dermatol Surg 2011; 37:1210-28. [DOI: 10.1111/j.1524-4725.2011.02042.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Veness MJ. The important role of radiotherapy in patients with non-melanoma skin cancer and other cutaneous entities. J Med Imaging Radiat Oncol 2008; 52:278-86. [PMID: 18477123 DOI: 10.1111/j.1440-1673.2008.01956.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Non-melanoma skin cancer is the commonest malignancy worldwide and a significant public health issue. Although most non-melanoma skin cancers are small and easily excised or ablated, a recommendation of definitive radiotherapy is often made in patients where the outcome (cosmetic and/or functional) will probably be better with radiotherapy compared to surgery. The aim of adjuvant radiotherapy is to reduce the risk of loco-regional recurrence and the role of palliative radiotherapy is important in improving the quality of life in patients with advanced and/or incurable disease. The aim of this review article is to broadly discuss the various clinical settings in which a recommendation of radiotherapy may be made and also includes a discussion on less frequently encountered cutaneous entities (e.g. in situ squamous cell carcinoma, keratocanthoma, lentigo maligna, cutaneous lymphomas and malignant fibrous tumours).
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Affiliation(s)
- M J Veness
- Department of Radiation Oncology, Westmead Cancer Care Centre, Westmead Hospital, Sydney, New South Wales, Australia.
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Abstract
BACKGROUND Lentigo maligna (LM) is treated to prevent progression to lentigo maligna melanoma (LMM). Surgery remains the treatment of choice, although topical immunotherapy with imiquimod has recently become a popular alternative. OBJECTIVES In this review, we have analysed the published literature relating to the use of imiquimod for LM, in order to understand better the utility of this treatment. METHODS All English language studies relating to the use of imiquimod for LM were analysed up to January 2006. RESULTS Eleven case reports and four open-label studies were identified, comprising a total of 67 patients who completed treatment with imiquimod for LM. There was significant variability in treatment schedules and regimens. Eight patients failed to respond, with LMM developing in two of these. In certain cases there were discrepancies between clinical and histological response with some patients clearing clinically but not histologically, and vice versa. Follow-up periods were short, exceeding 12 months in only five cases. CONCLUSIONS Although imiquimod clearly has an effect on LM, this analysis of available studies has helped to identify concerns about its use. Without controlled evidence and prolonged follow up, the use of imiquimod for LM must still be considered experimental.
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Affiliation(s)
- S F Rajpar
- Skin Oncology Service, University Hospital Birmingham NHS Trust, Birmingham B29 6JD, UK.
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Abstract
The role of RT in the management of melanoma is complex and spans the entire course of the disease. To provide optimal management of patients who have melanoma, radiation oncologists are an integral part of a multidisciplinary team. Appropriate integration of radiation into the management plan can improve locoregional control and alleviate symptoms from meta-static disease. The specific role of RT in locoregional disease is being refined. It is likely that current developments in radiation treatment technology will be applicable to melanoma. These should improve the therapeutic ratio by enhancing the tumoricidal effects of RT without increasing toxicity.
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Affiliation(s)
- Graham Stevens
- Melanoma Foundation of New Zealand, Auckland, New Zealandd.
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Abstract
This article discusses that previously considered radioresistant, malignant melanomas clearly have been shown to respond either to conventional or high-dose-per-fraction radiation therapy. Approximately one fourth of palliatively irradiated malignant melanomas respond completely and another one third respond substantially. Some physicians have controlled small-volume macroscopic tumors by radiation therapy, but such treatment has not gained wide acceptance. Elective irradiation of anatomic sites considered likely to harbor microscopic-size tumor unquestionably decreases the risk of local-regional recurrence. The inability of available systemic therapies, however, to prevent the appearance of distant metastases limits the current impact of such treatment.
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Affiliation(s)
- Jay S Cooper
- New York University Medical Center, 560 First Avenue, New York, NY 10016, USA.
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Cooper JS. The evolution of the role of radiation therapy in the management of mucocutaneous malignant melanoma. Hematol Oncol Clin North Am 1998; 12:849-62, vii. [PMID: 9759583 DOI: 10.1016/s0889-8588(05)70027-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The role of radiation therapy in the treatment of malignant melanoma has evolved substantially over time. Years ago, malignant melanomas were generally considered radioresistant. Over time, the palliative value of radiation therapy was established. Most recently it also has become clear that judiciously applied therapy may be curative in either an adjuvant setting or for small-volume disease.
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Affiliation(s)
- J S Cooper
- Department of Radiation Oncology, New York University Medical Center, New York, USA
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