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Zheng DX, Soldozy S, Mulligan KM, Levoska MA, Cohn EF, Finberg A, Alsaloum P, Cwalina TB, Hanft SJ, Scott JF, Rothermel LD, Nambudiri VE. Epidemiology, management, and treatment outcomes of metastatic spinal melanoma. World Neurosurg X 2023; 18:100156. [PMID: 36875322 PMCID: PMC9976572 DOI: 10.1016/j.wnsx.2023.100156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/29/2022] [Accepted: 01/19/2023] [Indexed: 01/22/2023] Open
Abstract
Metastatic spinal melanoma is a rare and aggressive disease process with poor prognosis. We review the literature on metastatic spinal melanoma, focusing on its epidemiology, management, and treatment outcomes. Demographics of metastatic spinal melanoma are similar to those for cutaneous melanoma, and cutaneous primary tumors tend to be most common. Decompressive surgical intervention and radiotherapy have traditionally been considered mainstays of treatment, and stereotactic radiosurgery has emerged as a promising approach in the operative management of metastatic spinal melanoma. While survival outcomes for metastatic spinal melanoma remain poor, they have improved in recent years with the advent of immune checkpoint inhibition, used in conjunction with surgery and radiotherapy. New treatment options remain under investigation, especially for patients with disease refractory to immunotherapy. We additionally explore several of these promising future directions. Nevertheless, further investigation of treatment outcomes, ideally incorporating high-quality prospective data from randomized controlled trials, is needed to identify optimal management of metastatic spinal melanoma.
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Affiliation(s)
- David X Zheng
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States.,Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Miami, Miami, FL, United States.,Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Kathleen M Mulligan
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Melissa A Levoska
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Erin F Cohn
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Ariel Finberg
- Department of Neurological Surgery, University of Miami, Miami, FL, United States
| | - Peter Alsaloum
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Thomas B Cwalina
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States
| | - Jeffrey F Scott
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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Gouveia AG, Chan DCW, Hoskin PJ, Marta GN, Trippa F, Maranzano E, Chow E, Silva MF. Advances in radiotherapy in bone metastases in the context of new target therapies and ablative alternatives: A critical review. Radiother Oncol 2021; 163:55-67. [PMID: 34333087 DOI: 10.1016/j.radonc.2021.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
In patients with bone metastases (BM), radiotherapy (RT) is used to alleviate symptoms, reduce the risk of fracture, and improve quality of life (QoL). However, with the emergence of concepts like oligometastases, minimal invasive surgery, ablative therapies such as stereotactic ablative RT (SABR), radiosurgery (SRS), thermal ablation, and new systemic anticancer therapies, there have been a paradigm shift in the multidisciplinary approach to BM with the aim of preserving mobility and function survival. Despite guidelines on using single-dose RT in uncomplicated BM, its use remains relatively low. In uncomplicated BM, single-fraction RT produces similar overall and complete response rates to RT with multiple fractions, although it is associated with a higher retreatment rate of 20% versus 8%. Complicated BM can be characterised as the presence of impending or existing pathologic fracture, a major soft tissue component, existing spinal cord or cauda equina compression and neuropathic pain. The rate of complicated BM is around 35%. Unfortunately, there is a lack of prospective trials on RT in complicated BM and the best dose/fractionation regimen is not yet established. There are contradictory outcomes in studies reporting BM pain control rates and time to pain reduction when comparing SABR with Conventional RT. While some studies showed that SABR produces a faster reduction in pain and higher pain control rates than conventional RT, other studies did not show differences. Moreover, the local control rate for BM treated with SABR is higher than 80% in most studies, and the rate of grade 3 or 4 toxicity is very low. The use of SABR may be preferred in three circumstances: reirradiation, oligometastatic disease, and radioresistant tumours. Local ablative therapies like SABR can delay change or use of systemic therapy, preserve patients' Qol, and improve disease-free survival, progression-free survival and overall survival. Moreover, despite the potential benefit of SABR in oligometastatic disease, there is a need to establish the optial indication, RT dose fractionation, prognostic factors and optimal timing in combination with systemic therapies for SABR. This review evaluates the role of RT in BM considering these recent treatment advances. We consider the definition of complicated BM, use of single and multiple fractions RT for both complicated and uncomplicated BM, reirradiation, new treatment paradigms including local ablative treatments, oligometastatic disease, systemic therapy, physical activity and rehabilitation.
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Affiliation(s)
- André G Gouveia
- Radiation Oncology Department, Américas Centro de Oncologia Integrado, Rio de Janeiro, Brazil; Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Dominic C W Chan
- Department of Oncology, Princess Margaret Hospital, Hong Kong, China
| | - Peter J Hoskin
- Mount Vernon Cancer Centre, London, United Kingdom; Radiation Oncology Department, University of Manchester, United Kingdom
| | - Gustavo N Marta
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Department, Hospital Sírio Libanês, São Paulo, Brazil
| | - Fabio Trippa
- Radiation Oncology Center, Santa Maria Hospital, Terni, Italy
| | | | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Mauricio F Silva
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Radiation Oncology Unit, Santa Maria Federal University, Santa Maria, Brazil; Clínica de Radioterapia de Santa Maria, Brazil.
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Spencer KL, van der Velden JM, Wong E, Seravalli E, Sahgal A, Chow E, Verlaan JJ, Verkooijen HM, van der Linden YM. Systematic Review of the Role of Stereotactic Radiotherapy for Bone Metastases. J Natl Cancer Inst 2020; 111:1023-1032. [PMID: 31119273 PMCID: PMC6792073 DOI: 10.1093/jnci/djz101] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/07/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background Stereotactic radiotherapy (SBRT) might improve pain and local control in patients with bone metastases compared to conventional radiotherapy, although an overall estimate of these outcomes is currently unknown. Methods A systematic review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Embase, and Cochrane databases were systematically searched to identify studies reporting pain response and local control among patients with bone metastases from solid-organ tumors who underwent SBRT in 1–6 fractions. All studies prior to April 15, 2017, were included. Study quality was assessed by predefined criteria, and pain response and local control rates were extracted. Results A total of 2619 studies were screened; 57 were included (reporting outcomes for 3995 patients) of which 38 reported pain response and 45 local control rates. Local control rates were high with pain response rates above those previously reported for conventional radiotherapy. Marked heterogeneity in study populations and delivered treatments were identified such that quantitative synthesis was not appropriate. Reported toxicity was limited. Of the pain response studies, 73.7% used a retrospective cohort design and only 10.5% used the international consensus endpoint definitions of pain response. The median survival within the included studies ranged from 8 to 30.4 months, suggesting a high risk of selection bias in the included observational studies. Conclusions This review demonstrates the potential benefit of SBRT over conventional palliative radiotherapy in improving pain due to bone metastases. Given the methodological limitations of the published literature, however, large randomized trials are now urgently required to better quantify this benefit.
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Affiliation(s)
- Katie L Spencer
- Correspondence to: Katie Spencer, MB, BChir, FRCR, Cancer Epidemiology Group, Level 11 Worsley Building, Clarendon Way, University of Leeds, Leeds LS2 9NL, West Yorkshire, UK (e-mail: )
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Bagshaw HP, Ly D, Suneja G, Jensen RL, Shrieve DC. Local control of melanoma brain metastases treated with stereotactic radiosurgery. JOURNAL OF RADIOSURGERY AND SBRT 2016; 4:181-190. [PMID: 29296443 PMCID: PMC5658801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/22/2016] [Indexed: 06/07/2023]
Abstract
PURPOSE To examine the effectiveness of stereotactic radiosurgery (SRS) for melanoma brain metastases, as the optimal management is unknown. MATERIALS AND METHODS Patients with melanoma brain metastases treated between 1999 and 2013 with SRS as initial management were reviewed. Local control (LC), intracranial progression free survival, and overall survival were evaluated using the Kaplan Meier analysis and logistic regression. RESULTS 185 patients were identified with 435 treated brain metastases. 76% of metastases were controlled, with a median freedom from local failure of 23.4 months. Higher SRS dose (p=0.001) and smaller tumor volume (p=0.0007) were associated with improved LC on univariate analysis, but on multivariate analysis only smaller tumor volume remained significant (p=0.047). At analysis, 7.6% of patients were alive and the median time to death after SRS was 7.8 months. CONCLUSIONS SRS is an effective primary treatment for melanoma brain metastases. There was no benefit combining SRS and surgery or whole brain radiotherapy.
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Affiliation(s)
- Hilary P. Bagshaw
- University of Utah Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112, USA
| | - David Ly
- University of Utah Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112, USA
| | - Gita Suneja
- University of Utah Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112, USA
| | - Randy L. Jensen
- University of Utah Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112, USA
- University of Utah Neurosurgery, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Dennis C. Shrieve
- University of Utah Radiation Oncology, 1950 Circle of Hope, Room 1570, Salt Lake City, UT 84112, USA
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Caruso JP, Cohen-Inbar O, Bilsky MH, Gerszten PC, Sheehan JP. Stereotactic radiosurgery and immunotherapy for metastatic spinal melanoma. Neurosurg Focus 2015; 38:E6. [PMID: 25727228 DOI: 10.3171/2014.11.focus14716] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of metastatic spinal melanoma involves maximizing local control, preventing recurrence, and minimizing treatment-associated toxicity and spinal cord damage. Additionally, therapeutic measures should promote mechanical stability, facilitate rehabilitation, and promote quality of life. These objectives prove difficult to achieve given melanoma's elusive nature, radioresistant and chemoresistant histology, vascular character, and tendency for rapid and early metastasis. Different therapeutic modalities exist for metastatic spinal melanoma treatment, including resection (definitive, debulking, or stabilization procedures), stereotactic radiosurgery, and immunotherapeutic techniques, but no single treatment modality has proven fully effective. The authors present a conceptual overview and critique of these techniques, assessing their effectiveness, separately and combined, in the treatment of metastatic spinal melanoma. They provide an up-to-date guide for multidisciplinary treatment strategies. Protocols that incorporate specific, goal-defined surgery, immunotherapy, and stereotactic radiosurgery would be beneficial in efforts to maximize local control and minimize toxicity.
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Zappasodi R, Merghoub T. Alphavirus-based vaccines in melanoma: rationale and potential improvements in immunotherapeutic combinations. Immunotherapy 2015; 7:981-97. [DOI: 10.2217/imt.15.64] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Immune checkpoint blockade has formally demonstrated the clinical benefit of immunotherapy against melanoma. New immunotherapeutic modalities are currently explored to improve the management of relapsing/refractory patients. Potent antitumor vaccines would have the advantage to promote long-lasting tumor control while limiting autoimmunity. Alphavirus vectors and nonreplicating particles offer versatile platforms to deliver antigen expression and immunize against cancer. They have shown promising preclinical results and initial proof of clinical activity in melanoma. The growing number of clinically available immunomodulatory agents provides a tremendous opportunity to exploit and revisit anticancer vaccines in the setting of powerful immunotherapeutic combinations. Accelerating the evaluation of alphavirus-based vaccines in patients with immune sensitive, but still very deadly malignancies, such as melanoma, is thus extremely important.
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Affiliation(s)
- Roberta Zappasodi
- Ludwig Collaborative & Swim Across America Laboratory, New York, NY, USA
| | - Taha Merghoub
- Ludwig Collaborative & Swim Across America Laboratory, New York, NY, USA
- Melanoma & Immunotherapeutics Service MSKCC, New York, NY, USA
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Ly D, Bagshaw HP, Anker CJ, Tward JD, Grossmann KF, Jensen RL, Shrieve DC. Local control after stereotactic radiosurgery for brain metastases in patients with melanoma with and without BRAF mutation and treatment. J Neurosurg 2015; 123:395-401. [PMID: 25768829 DOI: 10.3171/2014.9.jns141425] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECT BRAF inhibitors improve progression-free and overall survival in patients with metastatic melanoma. Brain metastases are common, and stereotactic radiosurgery (SRS) has been used, resulting in excellent local control. Because BRAF inhibitors are associated with intracranial responses, the authors hypothesized that BRAF inhibitors would improve local control in patients with melanoma who are receiving SRS for brain metastases. METHODS The authors retrospectively identified patients with metastatic melanoma who had been tested for BRAF mutation and treated with SRS for brain metastases. Patients with previous resection, multiple brain metastases, or multiple courses of SRS were eligible. SRS was delivered in a single fraction to a median dose of 2000 cGy. Patients with a BRAF mutation were treated with a BRAF inhibitor on the basis of physician preference. RESULTS The authors identified 52 patients who were treated in 82 treatment sessions for 185 brain metastases and 13 tumor beds. At a median follow-up of 10.5 months, the 1-year local control rate was 69.2%. At 1 year, the local control rate for brain metastases in patients with BRAF mutation with BRAF treatment was 85.0%, and the local control rate for brain metastases in those without BRAF treatment was 51.5% (p = 0.0077). The rates of distant brain failure, freedom from whole-brain radiation, and overall survival were not different on the basis of BRAF mutation status or inhibitor therapy. The number of new intratumoral hemorrhages after SRS was increased significantly in patients with BRAF treatment. CONCLUSIONS Treatment with BRAF inhibitors was associated with improved local control after SRS in patients with melanoma and brain metastases. An increased number of intratumoral hemorrhages was associated with BRAF inhibitor therapy.
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Affiliation(s)
- David Ly
- Department of Radiation Oncology and
| | | | - Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont
| | | | | | - Randy L Jensen
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah; and
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Radiation necrosis mimicking rapid intracranial progression of melanoma metastasis in two patients treated with vemurafenib. Melanoma Res 2014; 24:172-6. [PMID: 24407165 DOI: 10.1097/cmr.0000000000000044] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Optimal treatment of metastases to the central nervous system (CNS) in patients with malignant melanoma remains a clinical challenge. In particular, for patients with BRAF-mutant melanoma and CNS metastases, much remains unknown about the safety and efficacy of the novel BRAF-targeted agents when administered in close sequence with radiation. We report two cases of rapid development of CNS radiation necrosis in patients with metastatic melanoma treated with the BRAF inhibitor, vemurafenib, closely sequenced with stereotactic radiosurgery or fractionated stereotactic radiation therapy. In the absence of prospective safety data from clinical trials, we advise vigilance in monitoring patients with BRAF-mutant melanoma whose treatment plan includes CNS radiation and vemurafenib and caution when assessing treatment response within the CNS in these patients.
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Soma PF, Pettinato A, Agnone AM, Donia C, Improta G, Fraggetta F. Oral malignant melanoma: A report of two cases with BRAF molecular analysis. Oncol Lett 2014; 8:1283-1286. [PMID: 25120707 PMCID: PMC4114621 DOI: 10.3892/ol.2014.2314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 06/05/2014] [Indexed: 11/26/2022] Open
Abstract
Primary oral malignant melanoma is a rare condition, accounting for 1.3–1.4% of all melanomas, usually presenting with an aggressive clinical behavior. The present study reports the clinicopathological findings of two cases of oral malignant melanoma and discusses the epidemiology, diagnosis and current therapeutic approaches for this uncommon condition. In the first case the patient presented with a pigmented lesion located on the lower mucosal lip. The patient showed no nodal metastases and therefore, underwent a wedge resection. After seven months, the patient presented with neck lymph nodes and multiple visceral metastases. Molecular analysis of BRAF, using a pyrosequencing approach, revealed the presence of BRAF V600E mutation. The patient developed multiple visceral metastases, but refused treatment and was lost to follow-up. In the second case, no BRAF V600E mutation was found, but the patient exhibited a pigmented patch in the lower gingival mucosa, which was excised by surgical treatment. The patient was followed up by an oncologist, but did not undergo an additional therapy and is currently alive with no evidence of visceral metastases at one year following the diagnosis.
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Affiliation(s)
| | | | | | - Claudio Donia
- Unit of Plastic Surgery, Vittorio Emanuele II Hospital, Castelvetrano (TP) 91022, Italy
| | - Giuseppina Improta
- Laboratory of Clinical Research and Advanced Diagnostics, IRCCS-CROB, Rionero in Vulture (PZ) 85028, Italy
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Bowden PJ, See AW, Dally MJ, Bittar RG. Stereotactic radiosurgery for brain and spine metastases. J Clin Neurosci 2013; 21:731-4. [PMID: 24373817 DOI: 10.1016/j.jocn.2013.07.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 06/16/2013] [Accepted: 07/20/2013] [Indexed: 11/15/2022]
Abstract
Metastases to the brain and spine are common and difficult to treat. Stereotactic radiosurgery (SRS) is a non-invasive treatment option for some individuals, and may obviate the need for open surgery and/or whole brain radiotherapy. Over the past decade there has been an increased number of patients undergoing SRS for the treatment of metastatic disease, and multiple published studies show favourable results in terms of local disease control. We review the available literature pertaining to the application of SRS for the treatment of brain and spine metastases, together with its limitations and outcomes.
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Affiliation(s)
- Patrick J Bowden
- Epworth Healthcare, Melbourne, VIC, Australia; Brain and Spine Tumour Clinic, Melbourne, VIC, Australia
| | - Andrew W See
- Epworth Healthcare, Melbourne, VIC, Australia; Brain and Spine Tumour Clinic, Melbourne, VIC, Australia
| | - Michael J Dally
- Epworth Healthcare, Melbourne, VIC, Australia; Monash University, Clayton, Melbourne, VIC, Australia
| | - Richard G Bittar
- Epworth Healthcare, Melbourne, VIC, Australia; Brain and Spine Tumour Clinic, Melbourne, VIC, Australia; Department of Neurosurgery, Royal Melbourne Hospital, Grattan Street, Parkville, Melbourne, VIC, Australia; Faculty of Health, Deakin University, Burwood, Melbourne, VIC, Australia.
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