One Step Melanoma Surgery for Patient with Thick Primary Melanomas: "To Break the Rules, You Must First Master Them!"

Daphnoretin induces reactive oxygen species-mediated apoptosis in melanoma cells

Research suggests that daphnoretin exhibits a diverse array of antitumor mechanisms and pharmacological activities. However, there is no definitive explanation for the antitumor mechanisms of daphnoretin in malignant melanoma. In the present study, MTT and colony formation assays demonstrated that daphnoretin significantly inhibited the proliferation of melanoma A375 and B16 cells. Following treatment with daphnoretin, apoptotic bodies were observed in A375 and B16 cells via Hoechst 33258 staining. Furthermore, western blot analysis revealed that the apoptosis-related proteins cleaved caspase-3, cleaved caspase-9, Bax, cytochrome c and apoptotic protease-activating factor 1 were significantly upregulated, while the expression levels of caspase-3, caspase-9 and Bcl-2 were downregulated in A375 and B16 cells. Flow cytometry and fluorescence microscopy revealed that daphnoretin induced higher levels of reactive oxygen species (ROS). Therefore, the results of the present study indicated that daphnoretin induced ROS-mediated mitochondria apoptosis in human (A375) and murine (B16) malignant melanoma cells.

The Future of Personalized Medicine: One Step Melanoma Surgery

The divergent, personalized approach in the surgical treatment of cutaneous melanoma is the one in which the treatment of the neoplasm differs from that proposed within the generally accepted standards or guidelines. According to their presumption, guidelines are not obligatory for the treatment of a certain type of disease and cannot replace the judgment of the clinician. Which to a large extent determines the freedom (or possible one) of the clinician‘s action regarding the „personalization“ in the choice of a new, divergent therapy. It is interesting, for example, that the occurrence of locoregional recurrences in patients with melanoma after guideline therapy insures clinicians against both criticism of treatment choice and the end results. However, the lack of recurrences after innovative/personalized surgical treatment of cutaneous melanoma is accompanied for unknown reasons by a serious dose of unwarranted criticism. The fact is that a personalized surgical approach in the treatment of skin melanomas and the recommended by AJCC guidelines approach lead to exactly the same end results and that should not be ignored. The difference lies in the fact that this end result can be achieved by one step melanoma surgery (OSMS), for example, which is carried out in a single surgical session. Several advantages of OSMS can be noted: 1) it provides high efficiency in a short time, even in the initial stage of the disease, 2) it is cost-effective, and 3) according to initial clinical observations we have a much lower to no propensity for locoregional relapses.

Mechanisms of JAK-STAT signaling pathway mediated by CXCL8 gene silencing on epithelial-mesenchymal transition of human cutaneous melanoma cells

Effect of CXCL8 gene silencing-mediated JAK-STAT signaling pathway on epithelial-mesenchymal transition (EMT) of human cutaneous melanoma cells was explored. Eighty patients with cutaneous melanoma were enrolled in the study. Cells were transfected accordingly and divided into five groups: The blank group (human cutaneous melanoma cells), NC group (human cutaneous melanoma cells + blank vector plasmid transfection), CXCL8 siRNA group (human cutaneous melanoma cells + CXCL8 silent expression vector plasmid transfection), AG490 group (human cutaneous melanoma cells + JAK-STAT signal pathway inhibitor transfection), CXCL8 siRNA + AG490 group (human cutaneous melanoma cells + JAK-STAT signaling pathway inhibitor + CXCL8 silent expression vector plasmid transfection). The expression levels of CXCL8, JAK2, STAT3, epithelial cadherin (E-cadherin), neurotrophic cadherin (N-cadherin) and vimentin in tissues and cells were detected by RT-qPCR and western blot analysis. CCK-8 and flow cytometry were used to detect cell proliferation and apoptosis. Compared with adjacent normal tissues, the expression of E-cadherin in human cutaneous melanoma tissues was significantly decreased, whereas the expression of CXCL8, JAK2, STAT3, vimentin and N-cadherin was significantly increased (P<0.05). Compared with the blank group, CXCL8 siRNA group and CXCL8 siRNA + AG490 group had significantly lower expression of CXCL8 (P<0.05). Compared with the blank group, the expression levels of JAK2, STAT3, vimentin and N-cadherin in CXCL8 siRNA group, AG490 group and CXCL8 siRNA + AG490 group were decreased, the expression of E-cadherin was increased, the cell proliferation ability was decreased and apoptosis was increased (P<0.05). Compared with CXCL8 siRNA group, the expression of JAK2, STAT3, vimentin and N-cadherin in CXCL8 siRNA + AG490 group were significantly decreased, the expression of E-cadherin was significantly increased, cell proliferation ability was decreased and apoptosis was increased (P<0.05). In conclusion, CXCL8 gene expression silencing may inhibit EMT and cell proliferation while promoting cell apoptosis of human cutaneous melanoma cells by inhibiting the activation of JAK-STAT signaling pathway.

A novel surgical margin (1 cm) might be from benefit for patients with dysplastic nevi, thin melanomas, and melanoma in situ: Analysis based on clinical cases

Malignant melanoma is an oncologic disease, whose current management among others includes surgical and immunological therapy. According to the current recommendations of the American Joint Committee on Cancer, the surgical excision of the primary tumor should be performed in two operative sessions, which has several consequences. The following paper will present and discuss six cases of pigmented lesions and the advantages of the one-step melanoma surgery in their management.

Comparative Analysis of the "Scholastic" Recommendations of the AJCC From 2011 for the Surgical Treatment of Cutaneous Melanoma with the Newly Suggested Guidelines for OSMS From the Bulgarian Society For Dermatologic Surgery!

BACKGROUND:

The American Joint Committee on Cancer (AJCC) offers a two-stage, often insufficient or so-called variable model of cutaneous melanoma treatment. This model starts with primary excision and an initial operational safety margin of 0.5 cm in all directions, followed by a re-excision with an additional field of operational security, determined by histologically established tumor thickness (with or without removal of SLN). We present a brand new method of melanoma surgery, the so-called One Step melanoma surgery (OSMS), in which cutaneous melanomas (regardless of their thickness) could be removed by single surgical intervention.

CASE REPORT:

We describe a case of a patient with cutaneous melanoma, with postoperatively established Breslow’s tumor thickness of 6 mm, operated on the AJCC model within two surgical sessions. The usual primary excision was performed with a surgical safety margin of 0.5 cm in all directions, followed by a secondary excision with an additional surgical security field of 1.2 cm in all directions (due to the patient’s wish for the optimal cosmetic result, agreed and approved by the dermatosurgeon performing the manipulation).

CONCLUSION:

The two-stage method for the treatment of melanomas is often insufficient due to: 1) the inability (in this case) secondary excision in the face area to be conducted with an additional recommended operational security field of 1.5 cm in all directions; and 2) the patient’s wish for a better cosmetic result, which should be achieved with less surgical security field, resulting in a compromise solution for re-excision with an additional surgical field of 1.2 cm in all directions.

Multiple Primary Cutaneous Melanomas in a Bulgarian Patient: The Possible Role of One Step Melanoma Surgery (OSMS) As the Most Adequate Treatment Approach!

BACKGROUND:

Simultaneous occurrence of multiple primary melanomas is a rare, however possible phenomenon, and it is believed that older, male, white, Atypical Mole Syndrome carriers (sporadic and familial) are part of the possible risk factors for its occurrence. In these patients, it is possible to observe involutional changes or (partial/complete) regression of melanocytic lesions, which are likely to be caused by the generation of a spontaneous immune reaction against specific tumour antigens.

CASE REPORT:

A 58-year-old male patient is presented with two melanocytic lesions located in the right clavicle (subclavicular area) and left the scapular area that meets clinically and dermatoscopically the requirements for malignant melanoma. The lesions were removed by a radical excision with 0.5 cm surgical safety margin in all directions. During the subsequent histological verification it was established it was melanoma with a tumour thickness of 1 mm that in one case, and the other 2 mm. A week later, according to the recommendations of the current guidelines, a re-excision was performed with a surgical safety margin of 1.5 cm in all directions. Considering the complications that are possible during the parallel removal of a draining lymph node recommended for these tumour thicknesses, the patient definitively refused its detection and removal.

CONCLUSION:

A rare case of a Bulgarian patient with multiple primary, however partially involutional melanomas existing for over 20 years, is described. The individual recommendations of dermato-oncologists for the patient (according to AJCC) were not in favour of radicality but of a more sparing, individualised approach, appropriate for that patient. Unfortunately, the approach we used, in this case, was inconsistent with the AJCC or OSMS guidelines. The reason for individualising the approach in the case we have described is due to the variability of the recommendations for surgical treatment of melanomas laid down in the AJCC.

The Novel Surgical Margin for One Step Melanoma Surgery (OSMS) (Without Using Ultrasonography Preoperatively): The End of Conformity! "Vivere militare est!"

BACKGROUND:

Innovations in medicine are often due to the simplicity of a certain activity, interaction, even counteraction, or a mistake leading to a subsequent final optimal outcome. Innovations could also be due to conclusions based on targeted clinical or sporadic, as well as completely random observations. The genius of an approach or statement is often based on the “iron logic”, which in turn is based on irrefutable data or facts. These are often observations or results from actions that happen right before our eyes and provide advantages or prerequisites for the better future development of things (in this case, disease) concerning certain groups of people (in these case-patients). When the clinical results achieved following an inevitable introduction of certain methods or innovations speak eloquently of a number of advantages in terms of 1) spearing effect on the patients, 2) better control or prevention of possible local and/or distant metastatic spread 3) better financial balance for the health institutions and patients, …, then even the “Gods of certain latitudes” should be silenced. We at this moment present a completely new method or approach for surgical treatment of cutaneous melanoma that once again proves the effectiveness of one-step melanoma surgery, which was successfully first officialised in the world literature again by the Bulgarian Society of Dermatologic Surgery, (BULSDS). In some cases, this method does not even require the preoperative use of a high-frequency ultrasound for determining the tumour thickness.

CASE REPORT:

In patients with advanced stage of cutaneous melanoma, removal of a primary draining lymph node and/or locoregional lymph nodes is often performed simultaneously. However, it remains unclear why in patients with early-stage (or intermediate, with moderately thick melanomas) disease high-frequency ultrasound is not applied as a routine method of determination of tumour thickness? Meanwhile, re-excision is required following histopathological verification? Is it necessary to have 2 surgical interventions? The two surgical interventions are a burden for the patients and create prerequisites for contradicting opinions, statements, and subsequent results, which ultimately slows down the patient’s staging and the introducing more precise treatments. Based on the logic (and further aided by the clinical picture and dermatoscopy), we decided to operate selected cases of patients with cutaneous melanomas with a field of surgical security of 1cm in all directions when clinical, and dermatoscopic data are indicative of melanoma in situ or thin melanomas (less than 1 cm). Optimal results were achieved, with one surgical intervention and subsequent rehospitalisation spared for the patient.

CONCLUSIONS:

An answer to the question whether it is better not to follow the guidelines strictly (since, as a rule, they are generally recommended and somewhat misleading in certain circles of specialists, and as we have already found, also lead to unjustified logical secondary excisions), or update them at least annually when data for better tumor control is available (using a new method such as the one we mentioned above), should be searched for. This is a method not derived from AJCC/USA or other similar/equal or equivalent organisation’s “recesses”! Acceptability of innovations depends to a large extent on the latitude or territory where they originated?! Something that should be changed! Or in other words, something that has already been changed! The End of Conformity, and the beginning of a New Era!

One Step Melanoma Surgery (OSMS) Without Using Ultrasonography for Preoperative Tumour Thickness Measurement? - "A Question that Sometimes Drives Me Hazy: Am I or Are the Others Crazy!"

BACKGROUND:

One step melanoma surgery is a new surgical approach by which specific groups of patients with cutaneous melanoma may be operated only by or within a single surgical session. Until now, the Bulgarian Society for Dermatologic Surgery (BULSDS) has presented models of clinical behaviour, in which preoperative measurement of tumour thickness in combination with echographic measurement of the locoregional lymph nodes could lead to the conduct of the so-called one-step melanoma surgery. Although this one step surgery currently does not fit in the recommended guidelines, it ensures compliance of the recommended boundaries of operational security while saving patients a repeated excision and relieves the healthcare institutions or the patients themselves financially.

CASE REPORT:

We at this moment present another case from the Bulgarian Society for Dermatologic Surgery (BULSDS) of one step melanoma surgery with a perfect end result, where the tumour thickness was not preoperatively determined by high-frequency echography. Preoperative assessment of tumour thickness was performed based on the clinical picture and dermatoscopy. The histologically established tumour thickness was identical to the preoperative assessment, i.e. <1 mm. Removal of the melanocytic lesion was performed with operational security field of 1cm in all directions, where, as a rule, no further removal of the draining lymph nodes is required.

CONCLUSION:

One step melanoma surgery has two significant advantages: 1) it saves a re-excision in certain groups of patients, which in turn is 2) significantly more favourable from a financial point of view. Its applicability in the appropriate groups of patients and the postoperative (although in a limited number of patients) results achieved indicate the need to optimise the current algorithms and direct them individually to each patient. Guidelines may not and should not be unified or set strict limits given the fact that they show a significant level of variability themselves regarding some key moments in the initial surgical treatment of melanoma. More than 10% of the primary melanoma cases refer to thin melanomas, and dermatoscopy and clinics are a sufficient method of optimising the planned surgical excision.