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Bunnell AM, Nedrud SM, Fernandes RP. Classification and Staging of Melanoma in the Head and Neck. Oral Maxillofac Surg Clin North Am 2022; 34:221-234. [PMID: 35491079 DOI: 10.1016/j.coms.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The rates of melanoma continue to rise, with recent estimates have shown that 18% to 22% of new melanoma cases occur within the head and neck in the United States each year. The mainstay of treatment of nonmetastatic primary melanomas of the head and neck includes the surgical resection and management of regional disease as indicated. Thorough knowledge of the classification and staging of melanoma is paramount to evaluate prognosis, determine the appropriate surgical intervention, and assess eligibility for adjuvant therapy and clinic trials. The traditional clinicopathologic classification of melanoma is based on morphologic aspects of the growth phase and distinguishes 4 of the most common subtypes as defined by the World Health Organization: superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. The data used to derive the AJCC TNM Categories are based on superficial spreading melanoma and nodular subtypes. Melanoma is diagnosed histopathologically following initial biopsy that will assist with classifying the tumor to guide treatment. Classification is based on tumor thickness and ulceration (T stage, Breslow Staging), Regional Lymph Node Involvement (N Stage), and presence of metastasis (M Stage). Tumor thickness (Breslow thickness) and ulceration are 2 independent prognostic factors that have been shown to be the strongest predictors of survival and outcome. Clark level of invasion and mitotic rate are no longer incorporated into the current AJCC staging system, but still have shown to be important prognostic factors for cutaneous melanoma. For patients with metastatic (Stage IV) disease Lactate Dehydrogenase remains an independent predictor of survival. The Maxillofacial surgeon must remain up to date on the most current management strategies in this patient population. Classification systems and staging provide the foundation for clinical decision making and prognostication for the Maxillofacial surgeon when caring for these patients.
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Affiliation(s)
- Anthony M Bunnell
- Division of Head and Neck Surgery, Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine,- Jacksonville 653-1 West 8th, Street, Jacksonville, FL 32209, USA.
| | - Stacey M Nedrud
- Division of Head and Neck Surgery, Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine,- Jacksonville 653-1 West 8th, Street, Jacksonville, FL 32209, USA
| | - Rui P Fernandes
- Division of Head and Neck Surgery, Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine,- Jacksonville 653-1 West 8th, Street, Jacksonville, FL 32209, USA
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Kaleem A, Patel N, Chandra SR, Vijayaraghavan R. Imaging and Laboratory Workup for Melanoma. Oral Maxillofac Surg Clin North Am 2022; 34:235-250. [DOI: 10.1016/j.coms.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Patel A, Carr MJ, Sun J, Zager JS. In-transit metastatic cutaneous melanoma: current management and future directions. Clin Exp Metastasis 2021; 39:201-211. [PMID: 33999365 DOI: 10.1007/s10585-021-10100-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/22/2021] [Indexed: 12/22/2022]
Abstract
Management of in-transit melanoma encompasses a variety of possible treatment pathways and modalities. Depending on the location of disease, number of lesions, burden of disease and patient preference and characteristics, some treatments may be more beneficial than others. After full body radiographic staging is performed to rule out metastatic disease, curative therapy may be performed through surgical excision, intraarterial regional perfusion and infusion therapies, intralesional injections, systemic therapies or various combinations of any of these. While wide excision is limited in indication to superficial lesions that are few in number, the other listed therapies may be effective in treating unresectable disease. Where intraarterial perfusion based therapies have been shown to successfully treat extremity disease, injectable therapies can be used in lesions of the head and neck. Although systemic therapies for in-transit melanoma have limited specific data to support their primary use for in-transit disease, there are patients who may not be eligible for any of the other options, and current clinical trials are exploring the use of concurrent and sequential use of regional and systemic therapies with early results suggesting a synergistic benefit for oncologic response and outcomes.
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Affiliation(s)
- Ayushi Patel
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA.,Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Jonathan S Zager
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL, 33612, USA. .,Department of Cutaneous Oncology, Moffitt Cancer Center, 10920 North McKinley Drive, Tampa, FL, 33612, USA.
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Singh N, Alexander NA, Lachance K, Lewis CW, McEvoy A, Akaike G, Byrd D, Behnia S, Bhatia S, Paulson KG, Nghiem P. Clinical benefit of baseline imaging in Merkel cell carcinoma: Analysis of 584 patients. J Am Acad Dermatol 2021; 84:330-339. [PMID: 32707254 PMCID: PMC7854967 DOI: 10.1016/j.jaad.2020.07.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) guidelines derive from melanoma and do not recommend baseline cross-sectional imaging for most patients. However, MCC is more likely to have metastasized at diagnosis than melanoma. OBJECTIVE To determine how often baseline imaging identifies clinically occult MCC in patients with newly diagnosed disease with and without palpable nodal involvement. METHODS Analysis of 584 patients with MCC with a cutaneous primary tumor, baseline imaging, no evident distant metastases, and sufficient staging data. RESULTS Among 492 patients with clinically uninvolved regional nodes, 13.2% had disease upstaged by imaging (8.9% in regional nodes, 4.3% in distant sites). Among 92 patients with clinically involved regional nodes, 10.8% had disease upstaged to distant metastatic disease. Large (>4 cm) and small (<1 cm) primary tumors were both frequently upstaged (29.4% and 7.8%, respectively). Patients who underwent positron emission tomography-computed tomography more often had disease upstaged (16.8% of 352), than those with computed tomography alone (6.9% of 231; P = .0006). LIMITATIONS This was a retrospective study. CONCLUSIONS In patients with clinically node-negative disease, baseline imaging showed occult metastatic MCC at a higher rate than reported for melanoma (13.2% vs <1%). Although imaging is already recommended for patients with clinically node-positive MCC, these data suggest that baseline imaging is also indicated for patients with clinically node-negative MCC because upstaging is frequent and markedly alters management and prognosis.
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Affiliation(s)
- Neha Singh
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Nora A Alexander
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Kristina Lachance
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Christopher W Lewis
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington; Department of Physical Medicine and Rehabilitation, Northwestern University, Evanston, Illinois
| | - Aubriana McEvoy
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington; Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Gensuke Akaike
- Department of Radiology, Division of Nuclear Medicine, University of Washington, Seattle, Washington
| | - David Byrd
- Department of Surgery, Section of Surgical Oncology, University of Washington, Seattle, Washington
| | - Sanaz Behnia
- Department of Radiology, Division of Nuclear Medicine, University of Washington, Seattle, Washington
| | - Shailender Bhatia
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Paul Nghiem
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, Washington.
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Dinnes J, Ferrante di Ruffano L, Takwoingi Y, Cheung ST, Nathan P, Matin RN, Chuchu N, Chan SA, Durack A, Bayliss SE, Gulati A, Patel L, Davenport C, Godfrey K, Subesinghe M, Traill Z, Deeks JJ, Williams HC. Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma. Cochrane Database Syst Rev 2019; 7:CD012806. [PMID: 31260100 PMCID: PMC6601698 DOI: 10.1002/14651858.cd012806.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used. OBJECTIVES Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site. SEARCH METHODS We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles. SELECTION CRITERIA We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants. DATA COLLECTION AND ANALYSIS Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity. MAIN RESULTS We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT. AUTHORS' CONCLUSIONS Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | | | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Seau Tak Cheung
- Dudley Hospitals Foundation Trust, Corbett HospitalDepartment of DermatologyWicarage RoadStourbridgeUKDY8 4JB
| | - Paul Nathan
- Mount Vernon HospitalMount Vernon Cancer CentreRickmansworth RoadNorthwoodUKHA6 2RN
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Sue Ann Chan
- City HospitalBirmingham Skin CentreDudley RdBirminghamUKB18 7QH
| | - Alana Durack
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation TrustDermatologyHills RoadCambridgeUKCB2 0QQ
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Abha Gulati
- Barts Health NHS TrustDepartment of DermatologyWhitechapelLondonUKE11BB
| | - Lopa Patel
- Royal Stoke HospitalPlastic SurgeryStoke‐on‐TrentStaffordshireUKST4 6QG
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Manil Subesinghe
- King's College LondonCancer Imaging, School of Biomedical Engineering & Imaging SciencesLondonUK
| | - Zoe Traill
- Oxford University Hospitals NHS TrustChurchill Hospital Radiology DepartmentOxfordUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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Stodell M, Thompson JF, Emmett L, Uren RF, Kapoor R, Saw RPM. Melanoma patient imaging in the era of effective systemic therapies. Eur J Surg Oncol 2017. [PMID: 28625798 DOI: 10.1016/j.ejso.2017.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Imaging plays a critical role in the current multi-disciplinary management of patients with melanoma. It is used for primary disease staging, surgical planning, and surveillance in high-risk patients, and for monitoring the effects of systemic or loco-regional therapies. Several different imaging modalities have been utilised in the past. Contemporary imaging practises vary geographically depending on clinical guidelines, physician preferences, availability and cost. Targeted therapies and immunotherapies have revolutionised the treatment of patients with metastatic melanoma over the last few years. With this have come new patterns of disease that were not observed after conventional therapies, and new criteria to assess therapeutic responses. In this article we review the role of imaging for patients with melanoma in the era of effective systemic therapies and discuss likely future developments.
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Affiliation(s)
- M Stodell
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - J F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia; Division of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - L Emmett
- Garvan Institute of Medical Research, Discipline of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - R F Uren
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Alfred Nuclear Medicine and Ultrasound, Newtown, NSW, Australia
| | - R Kapoor
- Mater Imaging, The Mater Hospital Sydney, North Sydney, NSW, Australia
| | - R P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia; Division of Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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Choi WS, Park CM, Song YS, Lee SM, Wi JY, Goo JM. Transient subsolid nodules in patients with extrapulmonary malignancies: their frequency and differential features. Acta Radiol 2015; 56:428-37. [PMID: 24615419 DOI: 10.1177/0284185114528325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND For pulmonary subsolid nodules (SSNs) in patients with extrapulmonary malignancies, it is still unclear what proportion of SSNs is transient and how we can more accurately diagnose these transient SSNs. PURPOSE To investigate the frequency of transient SSNs and their differentiating clinical and thin-section computed tomography (CT) features in patients with extrapulmonary malignancies. MATERIAL AND METHODS From January 2005 to February 2012, 78 SSNs in 63 individuals (30 men and 33 women; mean age, 55.1 years ± 15.5) with extrapulmonary malignancies were identified. Their clinical and thin-section CT characteristics were reviewed and compared between transient and persistent SSNs. Differentiating factors and their performance were also measured. RESULTS Thirty-six of the 78 SSNs (46.2%) were transient. Between transient and persistent SSNs, there were significant differences in patients' age, sex, detection mode, and the presence of eosinophilia, lesion multiplicity, lesion margin, and pleural retraction (P < 0.05). Multivariate analysis revealed that follow-up detected SSNs (adjusted odds ratio [OR], 38.88), multiple lesions (OR, 7.64), and an ill-defined nodular margin (OR, 11.93) were significant discriminators of transient SSNs (P < 0.05). Discrimination of transient SSNs was significantly better upon incorporating both clinical and thin-section CT features than using clinical features alone (P < 0.05). CONCLUSION Approximately half of the SSNs detected in patients with extrapulmonary malignancies were transient. Transient SSNs in these patients can be very accurately differentiated using their thin-section CT and clinical features.
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Affiliation(s)
- Won Seok Choi
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Chang Min Park
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Yong Sub Song
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Sang Min Lee
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jae Yeon Wi
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jin Mo Goo
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
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Suki D, Khoury Abdulla R, Ding M, Khatua S, Sawaya R. Brain metastases in patients diagnosed with a solid primary cancer during childhood: experience from a single referral cancer center. J Neurosurg Pediatr 2014; 14:372-85. [PMID: 25127097 DOI: 10.3171/2014.7.peds13318] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Metastasis to the brain is frequent in adult cancer patients but rare among children. Advances in primary tumor treatment and the associated prolonged survival are said to have increased the frequency of brain metastasis in children. The authors present a series of cases of brain metastases in children diagnosed with a solid primary cancer, evaluate brain metastasis trends, and describe tumor type, patterns of occurrence, and prognosis. METHODS Patients with brain metastases whose primary cancer was diagnosed during childhood were identified in the 1990-2012 Tumor Registry at The University of Texas M.D. Anderson Cancer Center. A review of their hospital records provided demographic data, history, and clinical data, including primary cancer sites, number and location of brain metastases, sites of extracranial metastases, treatments, and outcomes. RESULTS Fifty-four pediatric patients (1.4%) had a brain metastasis from a solid primary tumor. Sarcomas were the most common (54%), followed by melanoma (15%). The patients' median ages at diagnosis of the primary cancer and the brain metastasis were 11.37 years and 15.03 years, respectively. The primary cancer was localized at diagnosis in 48% of patients and disseminated regionally in only 14%. The primary tumor and brain metastasis presented synchronously in 15% of patients, and other extracranial metastases were present when the primary cancer was diagnosed. The remaining patients were diagnosed with brain metastasis after initiation of primary cancer treatment, with a median presentation interval of 17 months after primary cancer diagnosis (range 2-77 months). At the time of diagnosis, the brain metastasis was the first site of systemic metastasis in only 4 (8%) of the 51 patients for whom data were available. Up to 70% of patients had lung metastases when brain metastases were found. Symptoms led to the brain metastasis diagnosis in 65% of cases. Brain metastases were single in 60% of cases and multiple in 35%; 6% had only leptomeningeal disease. The median Kaplan-Meier estimates of survival after diagnoses of primary cancer and brain metastasis were 29 months (95% CI 24-34 months) and 9 months (95% CI 6-11 months), respectively. Untreated patients survived for a median of 0.9 months after brain metastasis diagnosis (95% CI 0.3-1.5 months). Those receiving treatment survived for a median of 8 months after initiation of therapy (95% CI 6-11 months). CONCLUSIONS The results of this study challenge the current notion of an increased incidence of brain metastases among children with a solid primary cancer. The earlier diagnosis of the primary cancer, prior to its dissemination to distant sites (especially the brain), and initiation of presumably more effective treatments may support such an observation. However, although the actual number of cases may not be increasing, the prognosis after the diagnosis of a brain metastasis remains poor regardless of the management strategy.
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Rodriguez Rivera AM, Alabbas H, Ramjaun A, Meguerditchian AN. Value of positron emission tomography scan in stage III cutaneous melanoma: A systematic review and meta-analysis. Surg Oncol 2014; 23:11-6. [DOI: 10.1016/j.suronc.2014.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
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Surveillance for brain metastases in patients receiving systemic therapy for advanced melanoma. Melanoma Res 2014; 24:54-60. [PMID: 24121189 DOI: 10.1097/cmr.0000000000000022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The objectives of this study were to determine the cumulative incidence and timing of new brain metastases over the course of systemic therapy for metastatic melanoma and to identify prognostic factors for brain metastases. Chemo-naive patients underwent computed tomography or MRI of the brain every 6 weeks. The cumulative incidence of confirmed brain metastases was calculated at 12-week intervals. Univariable and multivariable competing risk regression models were used to assess the association between the development of brain metastases and potential risk factors of interest. Cumulative incidence with competing risk and competing risk regression was used to assess the brain metastasis-free interval from the time of diagnosis of stage IV disease. The clinical characteristics of the 315 patients with brain metastases were compared with those of 370 brain metastasis-free patients. Among patients with brain metastases, a significantly higher proportion had stage M1b and M1c disease at diagnosis compared with stage M1a and a greater proportion had metastatic disease in three or more visceral sites. Significantly shorter brain metastasis-free intervals were found in these patients compared with patients with M1a disease and those with no visceral metastases. More than 80% of the 230 patients who developed brain metastases during systemic therapy had their brain metastases confirmed within 60 weeks from the onset of advanced melanoma. Imaging studies at 12-week intervals for 60 weeks after the diagnosis of advanced melanoma will detect brain metastases in most of the patients who will eventually develop them.
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Speijers MJ, Francken AB, Hoekstra-Weebers JEHM, Bastiaannet E, Kruijff S, Hoekstra HJ. Optimal follow-up for melanoma. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.10.38] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Haddad D, Garvey EM, Mihalik L, Pockaj BA, Gray RJ, Wasif N. Preoperative imaging for early-stage cutaneous melanoma: predictors, usage, and utility at a single institution. Am J Surg 2013; 206:979-85; discussion 985-6. [PMID: 24124660 DOI: 10.1016/j.amjsurg.2013.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preoperative imaging for early-stage cutaneous melanoma is not recommended by current guidelines. Our goal was to investigate our institutional usage and utility. METHODS Patients with clinically node-negative cutaneous melanoma undergoing surgery with sentinel lymph node biopsy were identified retrospectively. Any melanoma-related imaging after diagnosis and before surgery was considered a staging study. RESULTS Five hundred fifteen studies were performed in 409 of 546 (75%) patients. Chest x-rays was performed in 70% and advanced imaging in 14% (computed tomography imaging, magnetic resonance imaging, ultrasound, and positron-emission computed tomography imaging). No metastatic lesions were identified. A Breslow thickness greater than 4 mm (odds ratio = 6.46 vs <1 mm; 95% confidence interval, 2.07 to 20.15) and male sex (odds ratio = 2.62 vs female; 95% confidence interval, 1.26 to 5.46) were associated with an increased likelihood of advanced imaging. CONCLUSIONS Preoperative imaging was performed in the majority of patients with node-negative melanoma, with 14% undergoing advanced studies. No metastatic lesions were identified, confirming the limited utility in this setting.
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Affiliation(s)
- Dana Haddad
- Department of Surgery, Mayo Clinic in Arizona, 5777 East Mayo Boulevard, Scottsdale, AZ 85250, USA
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Trout AT, Rabinowitz RS, Platt JF, Elsayes KM. Melanoma metastases in the abdomen and pelvis: Frequency and patterns of spread. World J Radiol 2013; 5:25-32. [PMID: 23494131 PMCID: PMC3596608 DOI: 10.4329/wjr.v5.i2.25] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 08/30/2012] [Accepted: 01/31/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the frequency, typical and atypical locations and patterns of melanoma metastases identifiable by computed tomography (CT) in the abdomen and pelvis.
METHODS: We performed a retrospective review of index CT examinations of the abdomen and pelvis in patients with melanoma and recorded all findings suggestive of metastatic disease.
RESULTS: Metastases were present on 36% (181/508) of the index examinations and most commonly involved the liver (47%) and pelvic lymph nodes (27%). Lower extremity primaries had the highest rate of metastasis (52%). Ocular and head and neck melanomas have a predilection to metastasize to the liver (hepatic involvement in 70% and 63%, respectively, of patients with metastatic disease) and metastases from lower extremity primaries most commonly involve pelvic lymph nodes (54% of patients with metastatic disease). Metastases to atypical locations were present in 14% of patients and most commonly occurred in the subcutaneous tissue and spleen. Primary tumors of the lower extremity, back and head and neck were most commonly associated with atypical metastases. Pelvic metastases are more common with lower extremity primaries (accounting for 70% of cases with pelvic metastases) but 5% of patients with supraumbilical primaries also had pelvic metastases.
CONCLUSION: The distribution of metastatic melanoma in the abdomen and pelvis that we have defined should help guide the interpretation of CT exams in these patients.
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Martinez SR, Tseng WH, Young SE. Outcomes for lymph node-positive cutaneous melanoma over two decades. World J Surg 2011; 35:1567-72. [PMID: 21559997 PMCID: PMC3109242 DOI: 10.1007/s00268-010-0903-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our aim was to demonstrate that, despite advances in treatment and surveillance of node-positive cutaneous melanoma, rates of overall survival (OS) and melanoma-specific survival (MSS) have not changed over the last two decades. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute to identify patients with node-positive cutaneous melanoma. Patients were categorized by treatment era; the first era encompassed patients diagnosed from 1988 to 1999 and the second era 2000 to 2006. Multivariate Cox proportional hazards models compared rates of OS and MSS between treatment eras while controlling for known prognostic factors. We reported risks of death as hazard ratios (HR) with 95% confidence intervals (CI) and set significance at P≤0.05. RESULTS Entrance criteria were met by 6,868 patients, 1,631 (23.8%) treated in era I and 5,237 (76.3%) treated in era II. On multivariate analysis, era II patients did not demonstrate a significantly different risk of death from any cause (HR 0.89, CI 0.79-1.01; P<0.08), but they did have a lower risk of melanoma-specific mortality (HR 0.81, CI 0.71-0.93; P=0.003) relative to their era I counterparts. CONCLUSIONS Over nearly two decades, MSS but not OS has improved for AJCC stage III melanoma patients. Stage migration is likely responsible for any improvement in MSS among patients in the most recently diagnosed era.
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Affiliation(s)
- Steve R Martinez
- Department of Surgery, Division of Surgical Oncology Sacramento, University of California at Davis, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA.
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15
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Bichakjian CK, Halpern AC, Johnson TM, Foote Hood A, Grichnik JM, Swetter SM, Tsao H, Barbosa VH, Chuang TY, Duvic M, Ho VC, Sober AJ, Beutner KR, Bhushan R, Smith Begolka W. Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology. J Am Acad Dermatol 2011; 65:1032-47. [PMID: 21868127 DOI: 10.1016/j.jaad.2011.04.031] [Citation(s) in RCA: 243] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 04/16/2011] [Accepted: 04/20/2011] [Indexed: 12/29/2022]
Abstract
The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.
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Affiliation(s)
- Christopher K Bichakjian
- Department of Dermatology, University of Michigan Health System and Comprehensive Cancer Center, Ann Arbor, Michigan, USA
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16
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DeRose ER, Pleet A, Wang W, Seery VJ, Lee MY, Renzi S, Sullivan RJ, Atkins MB. Utility of 3-year torso computed tomography and head imaging in asymptomatic patients with high-risk melanoma. Melanoma Res 2011; 21:364-9. [PMID: 21540750 PMCID: PMC3131441 DOI: 10.1097/cmr.0b013e3283471086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is no general consensus regarding the optimal follow-up strategy for patients with melanoma. We sought to determine the utility and cost effectiveness of radiological restaging of patients with stage IIB-IIIC melanoma at the 3-year follow-up time point. A retrospective review of 210 patients diagnosed with stage IIB-IIIC melanoma seen in the Cutaneous Oncology Program at Beth Israel Deaconess Medical Center between January, 2001 and July, 2006 was conducted. Fifty-two patients were asymptomatic and continuously disease free and underwent restaging head computed tomography (CT) or MRI and torso CT scans 3 years after completion of local-regional therapy or initiation of adjuvant treatment. True positive, false positive and normal scans were identified and the cost per diagnosis calculated. Fifty-five percent of patients developed melanoma recurrences: 88% before 3 years (median time to recurrence 12 months, 95% confidence interval: 10-16 months). The majority of patients (69%) recurred with disease symptoms. Twenty-five head CT scans, 27 head MRIs, and 52 torso CTs were performed. One false-positive head CT and five abnormal torso CT scans (three false positive, two true positive) were identified. The total cost per diagnosis was $312,990. Extensive 3-year restaging imaging seems to be of limited value for symptomatic and continuously disease-free patients with stage IIB-IIIC melanoma. Furthermore, given the low risk of recurrence beyond 3 years, it is likely that subsequent routine imaging would have similarly low utility.
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Affiliation(s)
- Erin R DeRose
- The Cutaneous Oncology Program, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Vermeeren L, van der Ent FW, Hulsewé KW. Is There an Indication for Routine Chest X-Ray in Initial Staging of Melanoma? J Surg Res 2011; 166:114-9. [DOI: 10.1016/j.jss.2009.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 04/21/2009] [Accepted: 05/01/2009] [Indexed: 11/16/2022]
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Pfluger T, Melzer HI, Schneider V, La Fougere C, Coppenrath E, Berking C, Bartenstein P, Weiss M. PET/CT in malignant melanoma: contrast-enhanced CT versus plain low-dose CT. Eur J Nucl Med Mol Imaging 2011; 38:822-31. [DOI: 10.1007/s00259-010-1702-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 12/02/2010] [Indexed: 01/11/2023]
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Abstract
This chapter discusses the value of FDG-PET and combined FDG-PET/CT in staging and follow-up of melanoma patients. For melanoma patients, the presence or absence of regional lymph node metastases is one of the most important prognostic factors; the recent development of sentinel lymph node biopsy offers a highly sensitive staging method. FDG-PET has shown a limited sensitivity to detect microscopic lymph node metastases in this selected group of patients with stages I and II melanoma. However, for the detection of distant metastases, FDG-PET is frequently used. Although there is no consensus, some surgeons pursue surgical excision of metastatic disease if only one or a few sites of disease are apparent. Precise identification of the location and number of metastatic lesions could therefore be important for surgical planning. Even though patients with metastatic melanoma generally have a poor prognosis (5-year survival 3-16%), there is still a need for accurate staging. Firstly, to identify those patients who may benefit from a surgical procedure, while avoiding these potentially harmful surgical procedures for patients with multiple distant metastases. Secondly, accurate staging is important to improve the efficiency of clinical trials, and thirdly, to provide patients with detailed information about their prognosis. Taking the published literature together, and reasoning that FDG-PET/CT is the current standard in PET imaging, there may be a case for the combined PET/CT in the setting of metastatic melanoma. However, further research is needed as the benefit of the combined FDG-PET/CT vs. FDG-PET alone seems to be less than reported for other tumor entities, which may be due to the high avidity of melanoma for FDG, so that many of the metastases are detected with FDG-PET and the additional CT does not increase the sensitivity.
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Affiliation(s)
- Esther Bastiaannet
- Department of Surgical Oncology, University Medical Centre, Groningen, The Netherlands.
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20
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Xing Y, Bronstein Y, Ross MI, Askew RL, Lee JE, Gershenwald JE, Royal R, Cormier JN. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis. J Natl Cancer Inst 2010; 103:129-42. [PMID: 21081714 DOI: 10.1093/jnci/djq455] [Citation(s) in RCA: 210] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Meta-analyses were performed to examine the utility of ultrasonography, computed tomography (CT), positron emission tomography (PET), and a combination of both (PET-CT) for the staging and surveillance of melanoma patients. METHOD Patient-level data from 74 studies containing 10,528 patients (between January 1, 1990, and June, 30, 2009) were used to derive characteristics of the diagnostic tests used. Meta-analyses were conducted by use of Bayesian bivariate binomial models to estimate sensitivity and specificity. Diagnostic odds ratios [ie, true-positive results/false-negative results)/(false-positive results/true-negative results)] and their 95% credible intervals (CrIs) and positive predictive values were used as indicators of test performance. RESULTS Among the four imaging methods examined for the staging of regional lymph nodes, ultrasonography had the highest sensitivity (60%, 95% CrI = 33% to 83%), specificity (97%, 95% CrI = 88% to 99%), and diagnostic odds ratio (42, 95% CrI = 8.08 to 249.8). For staging of distant metastases, PET-CT had the highest sensitivity (80%, 95% CrI = 53% to 93%), specificity (87%, 95% CrI = 54% to 97%), and diagnostic odds ratio (25, 95% CrI = 3.58 to 198.7). Similar trends were observed for melanoma surveillance of lymph node involvement, with ultrasonography having the highest sensitivity (96%, 95% CrI = 85% to 99%), specificity (99%, 95% CrI = 95% to 100%), and diagnostic odds ratio (1675, 95% CrI = 226.6 to 15,920). For distant metastases, PET-CT had the highest sensitivity (86%, 95% CrI = 76% to 93%), specificity (91%, 95% CrI = 79% to 97%), and diagnostic odds ratio (67, 95% CrI = 20.42 to 229.7). Positive predictive values were likewise highest for ultrasonography in lymph node staging and for PET-CT in detecting distant metastases. CONCLUSION Among the compared modalities, ultrasonography was superior for detecting lymph node metastases, and PET-CT was superior for the detection of distant metastases in both the staging and surveillance of melanoma patients.
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Affiliation(s)
- Yan Xing
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030-4009, USA
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21
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Pandalai PK, Dominguez FJ, Michaelson J, Tanabe KK. Clinical Value of Radiographic Staging in Patients Diagnosed With AJCC Stage III Melanoma. Ann Surg Oncol 2010; 18:506-13. [DOI: 10.1245/s10434-010-1272-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Indexed: 11/18/2022]
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22
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Algazi AP, Soon CW, Daud AI. Treatment of cutaneous melanoma: current approaches and future prospects. Cancer Manag Res 2010. [PMID: 21188111 DOI: 10.2147/cmar.s6073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.
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Affiliation(s)
- Alain P Algazi
- Department of Medicine, Division of Hematology and Oncology
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23
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Algazi AP, Soon CW, Daud AI. Treatment of cutaneous melanoma: current approaches and future prospects. Cancer Manag Res 2010; 2:197-211. [PMID: 21188111 PMCID: PMC3004577 DOI: 10.2147/cmr.s6073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Indexed: 12/22/2022] Open
Abstract
Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.
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Affiliation(s)
- Alain P Algazi
- Department of Medicine, Division of Hematology and Oncology
| | - Christopher W Soon
- Department of Dermatology, University of California, San Francisco San Francisco, CA, USA
| | - Adil I Daud
- Department of Medicine, Division of Hematology and Oncology
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Valoración inicial, diagnóstico, estadificación, tratamiento y seguimiento de los pacientes con melanoma maligno primario de la piel. Documento de consenso de la “Xarxa de Centres de Melanoma de Catalunya i Balears”. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/j.ad.2009.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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25
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Mangas C, Paradelo C, Puig S, Gallardo F, Marcoval J, Azon A, Bartralot R, Bel S, Bigatà X, Curcó N, Dalmau J, del Pozo L, Ferrándiz C, Formigón M, González A, Just M, Llambrich A, Llistosella E, Malvehy J, Martí R, Nogués M, Pedragosa R, Rocamora V, Sàbat M, Salleras M. Initial Evaluation, Diagnosis, Staging, Treatment, and Follow-up of Patients with Primary Cutaneous Malignant Melanoma. Consensus Statement of the Network of Catalan and Balearic Melanoma Centers. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/s1578-2190(10)70599-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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26
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Bastiaannet E, Wobbes T, Hoekstra OS, van der Jagt EJ, Brouwers AH, Koelemij R, de Klerk JM, Oyen WJ, Meijer S, Hoekstra HJ. Prospective Comparison of [18F]Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography in Patients With Melanoma With Palpable Lymph Node Metastases: Diagnostic Accuracy and Impact on Treatment. J Clin Oncol 2009; 27:4774-80. [DOI: 10.1200/jco.2008.20.1822] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients with melanoma with potentially resectable lymph node metastases require accurate staging to prevent unnecessary surgery. [18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is attractive for this because melanoma typically is FDG avid. The aim of this prospective multicenter study was to perform a head-to-head comparison of FDG-PET and computed tomography (CT) in staging of patients with melanoma with palpable lymph node metastases in terms of diagnostic accuracy and impact on treatment. Patients and Methods All consecutive patients with palpable, proven lymph node metastases of melanoma between mid 2003 and 2007 were prospectively included. The number/site of distant metastases detected with FDG-PET and CT were recorded. Histology/cytology or 6 months follow-up were the reference standard. Intended and performed treatment was recorded. Results Distant metastases were suspected by FDG-PET in 32% of the 251 patients and by CT in 29% (P = .26). Upstaging was correct in 27% by FDG-PET and in 24% by CT (P = .18). FDG-PET detected more metastatic sites (133 v 112, P = .03), detecting significantly more bone and subcutaneous metastases. Treatment changed in 19% of patients; in 79% as a result of both scans, in 17% exclusively by FDG-PET, and in 4% exclusively by CT. In 34 patients (14%), FDG-PET had an additional value over spiral CT, and in 23 patients (9%), CT had additional value over FDG-PET. Conclusion As a result of FDG-PET and CT, 27% of patients were upstaged, and treatment changed in one of five patients. FDG-PET and CT are equivalent in upstaging; however, FDG-PET detected more metastatic sites, especially bone and subcutaneous. FDG-PET and/or CT are indicated in the staging of patients with melanoma with palpable lymph node metastases.
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Affiliation(s)
- Esther Bastiaannet
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Theo Wobbes
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Otto S. Hoekstra
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Eric J. van der Jagt
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Adrienne H. Brouwers
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Ron Koelemij
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - John M.H. de Klerk
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Wim J.G. Oyen
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Sybren Meijer
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
| | - Harald J. Hoekstra
- From the Departments of Surgical Oncology, Radiology, and Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen; Departments of Surgical Oncology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen; Departments of Nuclear Medicine and PET Research and Surgical Oncology, VU University Medical Centre Amsterdam, Amsterdam; Department of Surgery, St Antonius Hospital Nieuwegein, Nieuwegein; and Department of Nuclear Medicine,
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Abstract
The American Joint Committee on Cancer (AJCC) staging of cutaneous melanoma is a continuously evolving system. The identification of increasingly more accurate prognostic factors has led to major changes in melanoma staging over the years, and the current system described in this review will likely be modified in the near future. Likewise, application of new imaging techniques has also changed the staging work-up of patients with cutaneous melanoma. Chest and abdominal computed tomography (CT) scanning is most commonly used for evaluation of potential metastatic sites in the lungs, lymph nodes and liver, and is indicated in patients with new symptoms, anaemia, elevated lactate dehydrogenase or a chest X-ray abnormality. CT scans should be restricted to patients with high-risk melanoma (stage IIC, IIIB, IIIC and stage IIIA with a macroscopic sentinel lymph node). Magnetic resonance imaging (MRI) of the brain is a mandatory test in patients with stage IV, optional in stage III and not used in patients with stage I and II disease. Positron emission tomography (PET)/CT is more accurate than CT or MRI alone in the diagnosis of metastases and should complement conventional CT/MRI imaging in the staging work-up of patients who have solitary or oligometastatic disease where surgical resection is most relevant.
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Affiliation(s)
- P Mohr
- Elbekliniken, Buxtehude, Germany.
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28
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Sawyer A, McGoldrick R, Mackey S, Allan R, Powell B. Does staging computered tomography change management in thick malignant melanoma? J Plast Reconstr Aesthet Surg 2009; 62:453-6. [DOI: 10.1016/j.bjps.2007.11.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Accepted: 11/20/2007] [Indexed: 11/30/2022]
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29
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Abstract
Cutaneous melanoma (CM) is a common malignancy and imaging, particularly lymphoscintigraphy (LS), positron-emission tomography with 2-fluoro-2-deoxyglucose (FDG-PET), ultrasound, radiography computed tomography (CT) and magnetic resonance imaging have important roles in staging and restaging, surgical guidance, surveillance and assessment of recurrent disease. This review aims to summarize the available data regarding these and other imaging modalities in CM and provide the basis for subsequent formulation of guidelines regarding the use of imaging in CM. PubMed and Medline searches were performed and reference lists from publications were also searched. The published data were reviewed and tabulated. There is level I evidence supporting the use of LS and sentinel lymph node biopsy in nodal staging for CM. There is level III evidence demonstrating the superiority of ultrasound to palpation in the assessment of lymph nodes in CM. There is level IV evidence supporting FDG-PET in American Joint Committee on Cancer stage III/IV and recurrent CM and that FDG-PET/CT may be superior to FDG-PET. Level IV evidence also supports the use of CT in the same group of patients and the role of CT appears to be complementary to FDG-PET. Various imaging modalities, especially LS/sentinel lymph node biopsy and FDG-PET/CT, add incremental information in the management of CM and the various modalities have complementary roles depending on the clinical situation.
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Cutaneous Malignant Melanoma. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Dancey A, Mahon B, Rayatt S. A review of diagnostic imaging in melanoma. J Plast Reconstr Aesthet Surg 2008; 61:1275-83. [DOI: 10.1016/j.bjps.2008.04.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Revised: 03/25/2008] [Accepted: 04/15/2008] [Indexed: 11/26/2022]
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Newton-Dunn E, Kok-Hao Hong M, Kok-Yee Hong M, Stone C. What is the role of CT staging in the management of patients with clinical stage 1 and 2 malignant melanoma? EUROPEAN JOURNAL OF PLASTIC SURGERY 2007. [DOI: 10.1007/s00238-007-0127-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gold JS, Jaques DP, Busam KJ, Brady MS, Coit DG. Yield and Predictors of Radiologic Studies for Identifying Distant Metastases in Melanoma Patients with a Positive Sentinel Lymph Node Biopsy. Ann Surg Oncol 2007; 14:2133-40. [PMID: 17453294 DOI: 10.1245/s10434-007-9399-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/02/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND It is common to obtain radiological studies around the time of a positive sentinel lymph node biopsy (SLNB) to exclude patients with distant metastases from completion lymph node dissection. The yield of such a work-up is unknown. METHODS Patients were identified from a prospectively maintained database. Medical records were reviewed. RESULTS Over an 8-year period, 181 patients had a positive SLNB. At least one study (computed tomography or magnetic resonance imaging of the brain; chest x-ray; computed tomography of the thorax, abdomen, or pelvis; positron-emission tomography scan; or bone scan) was obtained around the time of SLNB in 178 patients (98%). Studies were obtained after SLNB in 107 patients (59%). Studies ordered after SLNB resulted in indeterminate findings in 51 patients (48% of those studied). Among patients tested after SLNB, four were found to have metastatic disease (positive rate 3.7%). All of these patients had both a thick melanoma and macrometastasis within the SLN. The number of patients with indeterminate findings would be decreased and the yield of the work-up increased by 4 fold, by restricting the work-up to those with thick melanoma and macrometastasis. CONCLUSIONS Radiological studies obtained after a positive SLN produce indeterminate findings in about half of the patients and identify distant disease in 3.7%. Restricting work-up to patients with thick melanoma and macrometastasis on SLNB would spare patients from indeterminate findings and increase the yield of the evaluation.
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Affiliation(s)
- Jason S Gold
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Abstract
The incidence of malignant cutaneous melanoma is rising. Imaging studies represent a major component of the staging work-up and follow-up of melanoma patients and are used to facilitate preoperative planning and intraoperative management. Study benefits are not clear, and evidence does not support any particular protocol for their use. The National Comprehensive Cancer Network's updated guidelines for use of imaging studies in melanoma patients represent a consensus based on lower level evidence, including clinical experience. The utility of individual imaging studies in melanoma patients depends on disease stage. Chest radiography, CT, MRI, lymphoscintigraphy, ultrasonography, PET, and PET/CT have specific roles in patient evaluation. Clinicians must use available evidence to guide decisions regarding which imaging modalities are appropriate for a given indication.
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Affiliation(s)
- Eugene A Choi
- Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
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Aloia TA, Gershenwald JE, Andtbacka RH, Johnson MM, Schacherer CW, Ng CS, Cormier JN, Lee JE, Ross MI, Mansfield PF. Utility of Computed Tomography and Magnetic Resonance Imaging Staging Before Completion Lymphadenectomy in Patients With Sentinel Lymph Node–Positive Melanoma. J Clin Oncol 2006; 24:2858-65. [PMID: 16782925 DOI: 10.1200/jco.2006.05.6176] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose Although melanoma patients with regional nodal metastases are frequently imaged with computed tomography (CT) and magnetic resonance imaging (MRI) scans, the efficacy of routine radiologic staging in asymptomatic patients with microscopic nodal involvement has not been established. To determine the utility of this approach, we analyzed the incidence of synchronous distant metastases (SDM) detected by CT or MRI of the head, chest, and abdomen in a large group of patients with sentinel lymph node (SLN) –positive melanoma. Patients and Methods Positive SLNs were identified in 314 (16.2%) of the 1,934 melanoma patients who underwent sentinel lymphadenectomy at our institution from 1996 to 2003. Within 3 months of sentinel lymphadenectomy, 270 (86.0%) of the 314 SLN-positive patients were radiologically staged. To determine which prognostic factors were associated with SDM, associations between final staging outcomes and clinicopathologic variables, including SLN tumor burden, were analyzed. Results CT and/or MRI scans identified lesions that were suspicious for SDM in 23 (8.6%) of the 270 patients who underwent staging. In eight of these patients, further diagnostic studies determined that these abnormalities were benign. The remaining 15 suspicious lesions were percutaneously biopsied (10 negative and five positive), yielding a radiologically detectable SDM rate of 1.9%. Detection of SDM was associated with primary tumor thickness (P = .011), ulceration (P = .018), and SLN tumor burden (P = .018). Conclusion These data suggest that the vast majority of asymptomatic patients with a new diagnosis of microscopic SLN-positive melanoma do not harbor radiologically detectable SDM and can proceed to completion lymph node dissection without immediate CT or MRI staging.
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Affiliation(s)
- Thomas A Aloia
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030-4009, USA
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Reynolds SR, Vergilis IJ, Szarek M, Ferrone S, Bystryn JC. Cytoplasmic melanoma-associated antigen (CYT-MAA) serum level in patients with melanoma: a potential marker of response to immunotherapy? Int J Cancer 2006; 119:157-61. [PMID: 16450373 DOI: 10.1002/ijc.21820] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Simple, noninvasive methods are needed to follow effectiveness of new treatments in patients with melanoma. In our study, we examined cytoplasmic melanoma-associated antigen (CYT-MAA) serum level in melanoma patients during immunotherapy. Sera of 117 patients were assayed for CYT-MAA by double-sandwich ELISA before and during treatment with a polyvalent, shed antigen, melanoma vaccine. Vaccine-treated patients included 30 with American Joint Committee on Cancer (AJCC) stage IIb or IIIa, 30 with stage IIc, IIIb or IIIc, 30 with resected stage IV and 27 with measurable stage IV disease. Prior to vaccine therapy, 63% of patients had elevated serum CYT-MAA with high levels of antigen in all disease stages. After initiation of therapy, the level declined in more than 90% of the positive patients and fell below the positive cut-off in 56% of these patients within 5 months. By contrast, there was no decline in CYT-MAA serum level in 11 patients who served as untreated controls with melanoma. Multivariate analysis of the treated patients using accelerated failure time Weibull models adjusted for stage and age showed that patients whose CYT-MAA serum level remained elevated during treatment were approximately 3 times more likely to recur or progress than patients who were consistently below the positive cut-off (hazard ratio = 3.42, 95% CI [1.38, 8.47], p = 0.0079). Measurement of CYT-MAA serum level appears to show potential as an early marker of prognosis in patients with stages IIb to IV melanoma. Measurement of CYT-MAA serum level during therapy could provide an intermediate marker of response in these patients.
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Affiliation(s)
- Sandra R Reynolds
- Department of Dermatology, New York University School of Medicine, New York, NY 10016, USA.
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Fogarty GB, Tartaguia C. The Utility of Magnetic Resonance Imaging in the Detection of Brain Metastases in the Staging of Cutaneous Melanoma. Clin Oncol (R Coll Radiol) 2006; 18:360-2. [PMID: 16703756 DOI: 10.1016/j.clon.2006.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To retrospectively evaluate the use of brain magnetic resonance imaging (MRI) in the initial staging of patients with cutaneous melanoma in our melanoma unit. MATERIALS AND METHODS The radiology request forms for brain MRI for melanoma staging for 193 consecutive patients were reviewed. Patient hospital records were also retrospectively reviewed. Patients with no histological confirmation of a cutaneous primary or patients whose scan was to primarily investigate their neurological symptoms were excluded. Records were also searched for incidental symptoms that may have been associated with brain metastases. RESULTS One hundred patients were eligible. No patients were upstaged by MRI. Of a total of 33 patients already graded as stage IV by prior staging, 11 (33%) were found to have brain metastases. No patients graded less than stage IV were found to have brain metastases on MRI. Six out of 12 patients with incidental symptoms had metastases. Five patients graded as stage IV had asymptomatic brain metastases. CONCLUSION We recommend brain MRI only for patients with stage IV disease and for other patients with melanoma contemplating further adjuvant therapy where brain metastases would change management.
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Affiliation(s)
- G B Fogarty
- Radiation Oncology, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia.
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38
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Abstract
Numerous laboratory tests and imaging methods are available that can be used in patients who are diagnosed with cutaneous melanoma. The downside risks related to testing are cost and patient anxiety. Therefore, it must be critically considered which examinations are useful and feasible. After a diagnosis of primary cutaneous melanoma, many physicians in Germany perform lymph node ultrasound to detect occult regional metastasis. Whole-body imaging techniques, except the physical examination, are unlikely to detect distant occult metastasis. In tumors that have an intermediate or high risk of recurrence (> 1 mm tumor thickness), baseline whole-body imaging may serve as a reference for ongoing evaluation. During follow-up care, physical examination alone is appropriate when there is a low risk for recurrence (up to 1-mm tumor thickness). In patients whose tumors are > 1 mm thickness, regular lymph node ultrasound examinations and determination of serum tumor marker S-100beta protein are commonly used by physicians in Germany. Whole-body imaging techniques are useful in patients who have locoregional and/or distant metastasis. For consideration of surgical resections in stage IV disease, more advanced examinations techniques such as positron emission tomography-computed tomography or whole body magnetic resonance imaging may be used. Early detection of limited disease using these methods may be helpful for patients who have locoregional metastases and for 10-20% of patients who have distant metastases and whose limited disease may be amenable to surgical resection.
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Affiliation(s)
- Claus Garbe
- Division of Dermato-Oncology, Department of Dermatology, University of Tübingen, Germany.
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Affiliation(s)
- Edward L Lain
- Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA
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Spanknebel K, Coit DG, Bieligk SC, Gonen M, Rosai J, Klimstra DS. Characterization of micrometastatic disease in melanoma sentinel lymph nodes by enhanced pathology: recommendations for standardizing pathologic analysis. Am J Surg Pathol 2005; 29:305-17. [PMID: 15725798 DOI: 10.1097/01.pas.0000152134.36030.b7] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Lymphatic mapping and sentinel lymph node (SLN) biopsy are widely used as a staging technique for patients with cutaneous malignant melanoma who are at risk for metastases. SLN status has been shown to be a strong predictor of prognosis, and a variety of techniques have been used to identify minimal metastatic disease in SLNs. However, there is no validated consensus method for the optimal histologic analysis of SLNs harvested from melanoma patients. This study was conducted: 1) to assess the yield of metastatic melanoma detected in SLNs deemed negative by initial routine pathologic analysis (RPA) by subjecting them (after review of the original slides) to enhanced pathologic analysis (EPA) that included complete step-sectioning and immunohistochemistry (IHC); 2) to characterize the distribution of metastatic melanoma deposits within the SLNs; 3) to determine a preferred method of pathologic analysis applicable to daily practice; and 4) to attempt to assess the clinical significance of disease detected by EPA. A total of 105 SLNs were harvested from 49 patients who underwent successful SLN biopsy procedures during the period of study. Ten SLNs from 10 patients were positive on initial RPA and were not analyzed further. Ninety-five SLNs from the remaining 39 patients were reviewed and processed with additional hematoxylin and eosin, S-100 protein, and HMB-45 stains at 50-microm intervals for 20 levels or until the SLN tissue was exhausted. A single pathologist reviewed all sections without knowledge of the results of the other stains. Overall, metastatic melanoma was discovered in SLNs from 20 of the 39 patients: SLNs from 6 patients were found to have melanoma on review of the original hematoxylin and eosin slides, and SLNs from 14 patients were positive only after EPA. Twenty-one individual positive SLNs from these 14 patients were detected by EPA; of these, 10 positive SLNs were identified solely by IHC, representing 12% of the patient cohort and 10% of all SLNs studied by EPA. Detection rates were significantly associated with the staining method and the number of levels performed (P < 0.01). S-100 protein staining resulted in the highest yield of SLN positivity (86%), followed by HMB-45 (81%) and hematoxylin and eosin (52%). No single method detected all of the micrometastases. A detailed topographic mapping of metastatic deposits in SLNs was carried out. When using all three staining techniques, all 20 levels were required to identify 100% of the micrometastases; 95% of positive SLNs were identified with 17 levels, 90% with 15 levels, 75% with 10 levels, and 42% with 3 levels. Projected rates of detection for various different sectioning strategies were determined, with alteration of either the number of levels examined, the interval between the levels, or both. Detection of SLN positivity can be increased to 71% by performing three levels at 250-mum intervals, each level being composed of a set of three sections stained with hematoxylin and eosin, S-100 protein, and HMB-45, respectively. Therefore, this is the methodology we propose for the study of SLNs in melanoma patients. After a median follow-up of 87 months (range, 9-134 months), patients with EPA-detected disease and those with negative SLNs by EPA demonstrated improved recurrence-free and disease-specific survival compared with patients with RPA-detected disease in SLNs. Sampling error introduced by variations in pathologic processing should be addressed by standardization of pathologic methods, and the clinical significance of minimal SLN disease should be addressed in prospective studies of homogeneously staged patients.
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Affiliation(s)
- Kathryn Spanknebel
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Wang TS, Johnson TM, Cascade PN, Redman BG, Sondak VK, Schwartz JL. Evaluation of staging chest radiographs and serum lactate dehydrogenase for localized melanoma. J Am Acad Dermatol 2004; 51:399-405. [PMID: 15337983 DOI: 10.1016/j.jaad.2004.02.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Radiographic and laboratory evaluations are often routinely used in the initial work-up for melanoma. PURPOSE To examine the yield of a chest radiograph and serum lactate dehydrogenase (LDH), in the work-up for newly diagnosed localized melanoma. METHODS Patients with a new diagnosis of localized invasive melanoma were entered into a prospective database. The status of the chest radiograph, LDH, and sentinel lymph node (SLN) was assessed. RESULTS Two-hundred-twenty-four patients were entered into the study and 210 had chest radiograph data for analysis. The true positive chest radiograph rate, defined as the percent of chest radiographs interpreted as "positive or equivocal possibly melanoma related" with subsequent confirmed melanoma metastases, was 0%. The false positive chest radiograph rate, defined as the percent of chest radiographs interpreted as "positive or equivocal possibly melanoma related" with melanoma metastases excluded based on previous or subsequent studies or other known medical conditions, was 7%. Ninety-six patients (melanoma> or =1 mm) had LDH results for analysis. Elevations in LDH were found in 15% and did not lead to detection of occult disease in any patients. Seventy-seven patients underwent SLN biopsy. A positive SLN did not correlate with abnormal chest radiograph or LDH. CONCLUSION Low yield, high rate of false-positive tests and lack of significant impact of early detection of metastases on survival argue that chest radiographs and serum lactate dehydrogenase should probably not be accepted into routine clinical practice in patients with clinically localized melanoma in the absence of data supporting their use.
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Affiliation(s)
- Timothy S Wang
- Department of Dermatology, University of Michigan Health System, University of Michigan Comprehensive Cancer Center, USA
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42
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Abstract
The evolution and progressive refinement of an internationally accepted melanoma staging system over the last 50 years has resulted in much greater accuracy and increased utility, but the staging process has become more complex and less intuitive. This raises the question of whether melanoma staging should continue to develop with ever-increasing levels of complexity, or whether attempts should be made to produce an alternative system that is simpler and more intuitive. The current, TNM-based American Joint Committee on Cancer (AJCC) staging system for melanoma incorporates only some of the prognostic factors of proven significance. However, the information that is now available about these and other, well-documented prognostic factors allows accurate prediction of an individual melanoma patient's prognosis using a computer-generated estimate. Thus an alternative staging strategy that could be considered in the future would be to use such an estimate to obtain a numerical score for each patient, based on all available information agreed to be of prognostic relevance. A stage grouping could then be assigned on the basis of that score, according to previously determined score ranges for each stage and substage. The advantages of such a system would be that it would allow more reliable comparison of treatment results within and between institutions, and would provide more equivalent stratification groups for patients entering clinical trials of new therapies and those entering adjuvant therapy trials. A further advantage would be that because there would be a direct link between staging and prognostic estimate, such a system would be more readily able to be understood in an intuitive fashion.
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Affiliation(s)
- John F Thompson
- Sydney Melanoma Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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Affiliation(s)
- Elizabeth A Grasee
- Division of Plastic and Reconstructive Surgery, Indiana University School of Medicine, Emerson Hall, 545 Barnhill Drive, Indianapolis, IN 46202, USA
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Garbe C, Paul A, Kohler-Späth H, Ellwanger U, Stroebel W, Schwarz M, Schlagenhauff B, Meier F, Schittek B, Blaheta HJ, Blum A, Rassner G. Prospective evaluation of a follow-up schedule in cutaneous melanoma patients: recommendations for an effective follow-up strategy. J Clin Oncol 2003; 21:520-9. [PMID: 12560444 DOI: 10.1200/jco.2003.01.091] [Citation(s) in RCA: 180] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To prospectively examine and evaluate the results of follow-up procedures in a large cohort of cutaneous melanoma patients. PATIENTS AND METHODS This was a prospective study in 2,008 consecutive patients with stage I to IV cutaneous melanoma from 1996 to 1998 on the yield of stage-appropriate follow-up examinations according to the German guidelines. Documentation of patient and follow-up data comprised patient demography, primary tumor specifics, and any clinical and technical examinations performed. The detection of metastasis was classified as early or late, and the means of their detection and the resulting overall survival probabilities were examined. RESULTS A total of 3,800 clinical examinations and 12,398 imaging techniques were documented. Sixty-two second primary melanomas in 46 patients and 233 disease recurrences in 112 patients were detected during this time. In stage I to III disease, physical examination was responsible for the discovery of 50% of all recurrences. In the primary tumor stages, 21% of all recurrences were discovered by lymph node sonography, with the majority being classified as early detection. Forty-eight percent of the recurrences were classified as early detection, and these patients had a significant benefit of overall survival probability. CONCLUSION The results of our study suggest that an elaborated follow-up schedule in cutaneous melanoma is suitable for the early detection of second primary melanomas and early recurrences. The intensity of clinical and technical examinations can be reduced during follow-up of patients in the primary tumor stages and may be intensified in locoregional disease. Recommendations for an effective follow-up strategy are outlined.
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Affiliation(s)
- Claus Garbe
- Department of Dermatology, Skin Cancer Program, Eberhard-Karls-University of Tuebingen, Germany.
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Zalaudek I, Ferrara G, Argenziano G, Ruocco V, Soyer HP. Diagnosis and treatment of cutaneous melanoma: a practical guide. Skinmed 2003; 2:20-31; quiz 32-3. [PMID: 14673321 DOI: 10.1111/j.1540-9740.2003.01761.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
During the past decades, a number of new scientific evidences have been provided allowing a better understanding of the nature of cutaneous melanoma. New scientific methods, such as dermoscopy, have been shown to improve the diagnostic accuracy of pigmented skin lesions and early recognition of melanoma. Aggressive approaches for the surgical treatment of melanoma have been shown to be useless and have been replaced by more conservative surgical protocols and by sentinel lymph node biopsy. In the advanced stage of melanoma, new chemotherapy protocols and immunotherapy have been proposed, whereas the role of vaccines is still under investigation. In this review, the authors present an up-to-date overview of the epidemiologic, clinical, histopathologic, and therapeutic aspects of melanoma that can be used as a practical guide for the management of this tumor.
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Affiliation(s)
- Iris Zalaudek
- Department of Dermatology, University of Graz, Graz, Austria
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46
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Abstract
There are no generally accepted guidelines for the follow-up of cutaneous melanoma (CM), and there is an ongoing debate about the value of follow-up examinations. Some authors doubt whether early detection has any beneficial effect on patient survival and suggest that it may only prolong the patient's period of suffering from the knowledge of having metastasis. A systematic review of the literature on early detection and resection of CM metastasis shows the following picture: (1) In in-transit metastasis and in regional node metastasis, the tumour volume of the metastatic nodules at the time of diagnosis is prognostically significant. Either the number of nodes involved in regional metastasis or the diameter of the largest node showed prognostic impact in different studies. Therefore, early detection seems to affect the cure rate in this stage of disease. (2) In distant metastasis, surgical resection of all recognisable metastases prolongs survival. This is true as long as only one organ system is involved and particularly if complete resection of all metastases can be achieved. Therefore, early detection contributes to prolongation of survival. We performed a follow-up study in 2008 prospectively documented consecutive patients with stage I-III cutaneous melanoma who presented for follow-up examination at the Department of Dermatology of the University of Tübingen from August 1996 to August 1998. Stage-appropriate follow-up examinations were carried out according to the German Society of Dermatology guidelines. A total of 3,800 clinical examinations and 12,398 imaging techniques were documented: 62 second primary melanomas were detected in 46 patients and 233 disease recurrences in 112 patients during this time. Physical examination was responsible for the discovery of 50% of all recurrences, with the patient initially detecting the metastasis on self-examination in 17% of these cases. Technical examinations were responsible for the detection of the remaining 50%. In the primary tumour stages, 21% of all recurrences were discovered by lymph node sonography, the majority being classified as early detection. Among the recurrences, 48% were classified as early detection, and these patients had a significantly more favourable probability of recurrence-free survival than those with recurrences classified as late detection. The results of our study suggest that a follow-up schedule elaborated for cutaneous melanoma is suitable for the early detection of second primary melanomas and of early recurrences in approximately 5% of patients during a 2-year follow-up period.
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Affiliation(s)
- Claus Garbe
- Department of Dermatology, Eberhard Karls University, Tübingen, Germany
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Shoaib T, Dunn R, Soutar D. UK guidelines for the management of cutaneous melanoma. BRITISH JOURNAL OF PLASTIC SURGERY 2002; 55:706-7. [PMID: 12550141 DOI: 10.1054/bjps.2002.3944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Shoaib T, Dunn R, Soutar DS. Staging investigations and the U.K. guidelines for cutaneous melanoma. Br J Dermatol 2002; 147:837-8; author reply 838. [PMID: 12366459 DOI: 10.1046/j.1365-2133.2002.505122.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Stas M, Stroobants S, Dupont P, Gysen M, Hoe LV, Garmyn M, Mortelmans L, Wever ID. 18-FDG PET scan in the staging of recurrent melanoma: additional value and therapeutic impact. Melanoma Res 2002; 12:479-90. [PMID: 12394190 DOI: 10.1097/00008390-200209000-00010] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Staging of melanoma patients by means of whole body functional imaging in a single evaluation session using positron emission tomography (PET) with fluorine-18- labelled deoxy-d-glucose (FDG) as a metabolic tracer has created much interest over the last decade. After enthusiastic pilot studies, more attention has been paid to the false-negative and false-positive results of this technique than to its true therapeutic impact. This study aimed to evaluate (1) the sensitivity and specificity of this technique at a single lesion level compared with conventional screening procedures (CSP) - both of these accompanied by careful clinical examination; and (2) the additional value of the PET scan at the level of the individual patient and its therapeutic impact for different types of melanoma recurrence. A consecutive series of 100 PET scans performed on 84 melanoma patients with regional or distant recurrence according to CSP (89 PET scans) or suspicion of recurrence, i.e. inconclusive CSP (11 PET scans), were retrospectively analysed and compared with the CSP results. At the single lesion level, PET scan and CSP showed a sensitivity of 85 and 81%, a specificity of 90 and 87% and an accuracy of 88 and 84%, respectively. PET provided false-negative results for small skin metastases and brain involvement; false-positive results were associated with unrelated benign or malignant tumours and peripheral soft tissue and bone uptake. PET scan showed an additional value over and above CSP at the individual patient's level by true upstaging in 10 cases, true downstaging in 24 cases and depiction of more lesions within the same stage of disease in 15 cases. The overall therapeutic impact reached 26%: 17 out of 71 (24%) cases with regional recurrence, one out of 18 cases (5.5%) with distant metastasis and eight out of 11 cases (73%) with suspicion of recurrence where CSP remained doubtful. However, in 19 cases comparison between CSP and PET resulted in discordant findings, suggesting upstaging in one area and downstaging at another site within the same patient. In conclusion, PET scan has an additional value in the staging of recurrent melanoma, providing it is accompanied by careful clinical examination and specific brain imaging. However, in the absence of evidence of metastasis or unrelated conditions at the same site on CSP, PET spots may represent false-positive images, which would falsely upgrade a patient to an incurable state, or they may be early true-positive findings, which will become evident during close follow-up.
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Affiliation(s)
- M Stas
- Department of Surgical Oncology, University Hospitals, Catholic University Leuven, Belgium.
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50
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Kanzler MH, Mraz-Gernhard S. Primary cutaneous malignant melanoma and its precursor lesions: diagnostic and therapeutic overview. J Am Acad Dermatol 2001; 45:260-76. [PMID: 11464189 DOI: 10.1067/mjd.2001.116239] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During the past few decades, scientific data relating to melanoma have flourished. New information regarding acquired nevi, dysplastic nevi (atypical nevi), and congenital nevi has given us a better understanding of these precursor lesions and their relationships to malignant melanoma. The roles of laboratory testing, photography, and newer diagnostic tools (eg, epiluminescence) to evaluate patients for melanoma or precursor lesions have fallen under close scrutiny. Traditional surgical therapeutic interventions continue to be replaced by less aggressive protocols based on prospective randomized studies. Many new interventions such as sentinel lymph node procedures are currently being evaluated at research/referral centers around the world. We present clinicians with an evidence-based summary of the current literature with regard to primary cutaneous melanoma, its diagnosis, precursor lesions, and therapy.
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Affiliation(s)
- M H Kanzler
- Division of Dermatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA.
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