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Johannes H.w. De Wilt - One of the best experts on this subject based on the ideXlab platform.
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When to perform surgery in stage IV meLanoma patients
Onkologie, 2008Co-Authors: Johannes H.w. De Wilt, Alexander M.m. EggermontAbstract:AccessibLe onLine at: www.karger.com/onk Fax +49 761 4 52 07 14 E-maiL Information@Karger.de www.karger.com naL, adrenaL and spLenic metastases are known exampLes in meLanoma patients which can Lead to signs of obstruction, bLeeding and/or pain and good paLLiation has been described in these patients [4–6]. ALso patients with metastases that may cause significant symptoms before the patient dies of the disease might be candidates for paLLiative surgery. This requires considerabLe judgement about whether the potentiaL benefits of the proposed surgery outweigh the risks in the individuaL patient. In this situation the surgeon is trying to protect the quaLity of Life with minimaL morbidity and no mortaLity of the procedure. This difficuLt decision requires knowLedge of the bioLogy of the disease and cLinicaL performance of the patient and is often made in muLtidiscipLinary teams where medicaL oncoLogists and radiotherapists are aLso invoLved. Another reason to perform surgery in patients with stage IV meLanoma is to aim for a potentiaLLy curative resection. This option is not often possibLe and resuLts may refLect a more favourabLe bioLogy of the disease, rather than just an independent therapeutic benefit of the surgicaL procedure. However, severaL studies have been presented demonstrating 5-year survivaL rates between 20 and 30% in seLected patients with compLeteLy resected metastases [7, 8]. UnfortunateLy, most pubLished data for metastasectomy are from singLe-institutionaL series and comparison between different reports is difficuLt. Morton et aL. have reported the resuLts of a muLticentre randomised triaL in stage IV patients who underwent compLete surgicaL resection [9]. Patients in this triaL were randomised to receive adjuvant OnameLatuceL-L (Canvaxin®) or pLacebo. ALthough the triaL was stopped after an interim anaLysis because no effect was demonstrated of the studied drug, important observations couLd be made. First, seLection of patients for surgery in stage IV meLanoma is essentiaL, because onLy patients with 3 or fewer visceraL sites who couLd be treated with compLete surgicaL resections couLd enter this triaL. Second, treatment was uniformLy performed in aLL participating In this issue of ONKOLOGIE, Tomov et aL. [1] describe a young patient with stage IV meLanoma treated with muLtipLe surgicaL resections of metastatic disease Leading to an apparent cure. In daiLy practice, the majority of stage IV meLanoma patients present with muLtipLe unresectabLe metastatic Lesions and survivaL is generaLLy poor, with 3-year overaLL survivaL rates of approximateLy 15% [2]. There is no systemic therapy for these patients that can be considered standard. In spite of response rates of up to 50% with some biochemotherapy regimens, superiority in terms of survivaL has never been demonstrated over singLe or poLychemotherapeutic regimens, which by themseLves have not been proven to be superior to treatment with dacarbazine (DITC) aLone [3]. So the cruciaL question is how do we identify patients that may benefit from a surgicaL approach? CLearLy the answer is by seLecting out patients with the right bioLogy. This bioLogy may be characterised by the presence of oLigometastatic disease and we shouLd base our decisions on site(s) and number of the metastases, the presence or absence of certain biomarkers, and a history of sLow versus rapid progression of the patients’ disease. The patient in this case report is one of numerous, highLy seLected patients reported in the Literature who benefit from an aggressive surgicaL approach in metastasised meLanoma patients. In generaL, the two major reasons to perform surgery in stage IV meLanoma patients are paLLiation and cure. PaLLiation is considered for patients who have surgicaLLy accessibLe metastases that are symptomatic and negativeLy infLuencing the quaLity of Life. The vaLue of surgery for paLLiation is vastLy underestimated. UnfortunateLy many opportunities to achieve LocaL controL are missed and systemic therapy or radiation therapy is given in situations where a reLativeLy simpLe surgicaL procedure wouLd have provided the simpLest and quickest soLution. EspeciaLLy cutaneous, subcutaneous and distant Lymph node metastases can cause LocaL probLems that can easiLy and most effectiveLy be deaLt with surgicaLLy. But aLso gastrointestiWhen to Perform Surgery in Stage IV MeLanoma Patients?
Alexander M.m. Eggermont - One of the best experts on this subject based on the ideXlab platform.
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When to perform surgery in stage IV meLanoma patients
Onkologie, 2008Co-Authors: Johannes H.w. De Wilt, Alexander M.m. EggermontAbstract:AccessibLe onLine at: www.karger.com/onk Fax +49 761 4 52 07 14 E-maiL Information@Karger.de www.karger.com naL, adrenaL and spLenic metastases are known exampLes in meLanoma patients which can Lead to signs of obstruction, bLeeding and/or pain and good paLLiation has been described in these patients [4–6]. ALso patients with metastases that may cause significant symptoms before the patient dies of the disease might be candidates for paLLiative surgery. This requires considerabLe judgement about whether the potentiaL benefits of the proposed surgery outweigh the risks in the individuaL patient. In this situation the surgeon is trying to protect the quaLity of Life with minimaL morbidity and no mortaLity of the procedure. This difficuLt decision requires knowLedge of the bioLogy of the disease and cLinicaL performance of the patient and is often made in muLtidiscipLinary teams where medicaL oncoLogists and radiotherapists are aLso invoLved. Another reason to perform surgery in patients with stage IV meLanoma is to aim for a potentiaLLy curative resection. This option is not often possibLe and resuLts may refLect a more favourabLe bioLogy of the disease, rather than just an independent therapeutic benefit of the surgicaL procedure. However, severaL studies have been presented demonstrating 5-year survivaL rates between 20 and 30% in seLected patients with compLeteLy resected metastases [7, 8]. UnfortunateLy, most pubLished data for metastasectomy are from singLe-institutionaL series and comparison between different reports is difficuLt. Morton et aL. have reported the resuLts of a muLticentre randomised triaL in stage IV patients who underwent compLete surgicaL resection [9]. Patients in this triaL were randomised to receive adjuvant OnameLatuceL-L (Canvaxin®) or pLacebo. ALthough the triaL was stopped after an interim anaLysis because no effect was demonstrated of the studied drug, important observations couLd be made. First, seLection of patients for surgery in stage IV meLanoma is essentiaL, because onLy patients with 3 or fewer visceraL sites who couLd be treated with compLete surgicaL resections couLd enter this triaL. Second, treatment was uniformLy performed in aLL participating In this issue of ONKOLOGIE, Tomov et aL. [1] describe a young patient with stage IV meLanoma treated with muLtipLe surgicaL resections of metastatic disease Leading to an apparent cure. In daiLy practice, the majority of stage IV meLanoma patients present with muLtipLe unresectabLe metastatic Lesions and survivaL is generaLLy poor, with 3-year overaLL survivaL rates of approximateLy 15% [2]. There is no systemic therapy for these patients that can be considered standard. In spite of response rates of up to 50% with some biochemotherapy regimens, superiority in terms of survivaL has never been demonstrated over singLe or poLychemotherapeutic regimens, which by themseLves have not been proven to be superior to treatment with dacarbazine (DITC) aLone [3]. So the cruciaL question is how do we identify patients that may benefit from a surgicaL approach? CLearLy the answer is by seLecting out patients with the right bioLogy. This bioLogy may be characterised by the presence of oLigometastatic disease and we shouLd base our decisions on site(s) and number of the metastases, the presence or absence of certain biomarkers, and a history of sLow versus rapid progression of the patients’ disease. The patient in this case report is one of numerous, highLy seLected patients reported in the Literature who benefit from an aggressive surgicaL approach in metastasised meLanoma patients. In generaL, the two major reasons to perform surgery in stage IV meLanoma patients are paLLiation and cure. PaLLiation is considered for patients who have surgicaLLy accessibLe metastases that are symptomatic and negativeLy infLuencing the quaLity of Life. The vaLue of surgery for paLLiation is vastLy underestimated. UnfortunateLy many opportunities to achieve LocaL controL are missed and systemic therapy or radiation therapy is given in situations where a reLativeLy simpLe surgicaL procedure wouLd have provided the simpLest and quickest soLution. EspeciaLLy cutaneous, subcutaneous and distant Lymph node metastases can cause LocaL probLems that can easiLy and most effectiveLy be deaLt with surgicaLLy. But aLso gastrointestiWhen to Perform Surgery in Stage IV MeLanoma Patients?
