Management of Cutaneous Melanoma
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The excellent review by Tsao and colleagues on the management of cutaneous melanoma (Sept. 2 issue)1 makes no mention of dermoscopy,2 an in vivo, noninvasive technique that permits visualization of numerous morphologic features that are invisible to the naked eye, and thus enhances the clinical diagnosis of nearly all pigmented lesions. In our opinion, this method is particularly useful for patients at high risk for melanoma because of a genetic predisposition or multiple risk factors. Such patients often have many pigmented lesions, a cause of concern to them and their dermatologists. These patients frequently undergo many surgical excisions of histologically irrelevant pigmented lesions, with subsequent scarring and attendant psychological costs, as well as high costs to society. In our experience, the addition of dermoscopy to routine screening for melanoma is clinically relevant: lesions that appear suspicious to the naked eye can be classified more appropriately, thereby reducing false positive findings on clinical examination and, ultimately, reducing the number of superfluous surgical excisional biopsies.3,4 Consequently, we think that this method, described in more than 200 indexed articles in recent years, should be mentioned.
Vincenzo de Giorgi, M.D.
Paolo Carli, M.D.
Benvenuto Giannotti, M.D.
University of Florence
50121 Florence, Italy
dermoncologia@unifi.it
References
Tsao H, Atkins MB, Sober AJ. Management of cutaneous melanoma. N Engl J Med 2004;351:998-1012.
Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions -- a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001;2:443-449.
Carli P, De Giorgi V, Crocetti E, et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the `dermoscopy era': a retrospective study 1997-2001. Br J Dermatol 2004;150:687-692.
Carli P, de Giorgi V, Chiarugi A, et al. Addition of dermoscopy to conventional naked-eye examination in melanoma screening: a randomized study. J Am Acad Dermatol 2004;50:683-689.
To the Editor: Tsao et al. do not cite the work of Morton and colleagues, who showed that after patients with melanoma were vaccinated with a melanoma-associated antigen (TA-90), patients who had a response and a high serum titer of antigen–IgM immune complexes had a better prognosis than those with high titers of antigen–IgG immune complexes, who had a poor prognosis.1,2 Such results suggest that not only the intensity but also the quality of the immune response may have value in future therapies. Moreover, in our experience, some types of antitumor immune response are harmful, not because they favor tolerance but because they actually promote tumor progression.3,4,5
James W. Sampsel, M.D.
Emilio Barbera-Guillem, M.D., Ph.D.
Memorial Hospital of Union County
Marysville, OH 43040
ebarbera@sbcglobal.net
References
Euhus DM, Gupta RK, Morton DL. Characterization of a 90-100 kDa tumor-associated antigen in the sera of melanoma patients. Int J Cancer 1990;45:1065-1070.
Litvak DA, Gupta RK, Yee R, Wanek LA, Ye W, Morton DL. Endogenous immune response to early- and intermediate-stage melanoma is correlated with outcomes and is independent of locoregional relapse and standard prognostic factors. J Am Coll Surg 2004;198:27-35.
Barbera-Guillem E, Sampsel JW. Immune-promoted tumor cell invasion and metastasis. In: Llombart-Bosch A, Felipo V, eds. New trends in cancer for the 21st century. New York: Kluwer Academic, 2003:153-72.
Barbera-Guillem E, Nyhus JK, Wolford CC, Friece CR, Sampsel JW. Vascular endothelial growth factor secretion by tumor-infiltrating macrophages essentially supports tumor angiogenesis, and IgG immune complexes potentiate the process. Cancer Res 2002;62:7042-7049.
Nyhus JK, Wolford CC, Friece CR, Nelson MB, Sampsel JW, Barbera-Guillem E. IgG-recognizing shed tumor-associated antigens can promote tumor invasion and metastasis. Cancer Immunol Immunother 2001;50:361-372.
To the Editor: In their review on the management of cutaneous melanoma, Tsao et al. do not discuss the importance of radiography for staging in patients with node-positive disease. In their algorithm for the management of melanoma, the authors recommend computed tomography (CT) of the chest and pelvis, magnetic resonance imaging (MRI) of the head, and positron-emission tomography (PET) for all patients with stage III disease. This suggestion is consistent with the recommendations that were made for patients with palpable regional lymphadenopathy in the era before the sentinel lymph node.1 Today, with the widespread use of selective sentinel lymphadenectomy, patients with regional disease are at a different place in the natural progression of melanoma. It has been shown that for asymptomatic patients with positive sentinel lymph nodes, staging CT and MRI show true metastatic disease in less than 1 percent of cases, whereas the false positive rate is 14 percent.2 Management of these cases with false positive results is a source of increased cost and physical illness, as well as a source of potentially devastating mental anguish. It is time to reevaluate the standard approach of routine imaging for baseline staging and reserve it for patients with symptomatic stage III disease.
Edward P. Miranda, M.D.
University of California, San Francisco
San Francisco, CA 94143
edmiranda@gmail.com
References
Gershenwald JE, Buzaid AC, Ross MI. Classification and staging of melanoma. Hematol Oncol Clin North Am 1998;12:737-765.
Miranda EP, Gertner M, Wall J, et al. Routine imaging of asymptomatic melanoma patients with metastasis to sentinel lymph nodes rarely identifies systemic disease. Arch Surg 2004;139:831-837.
The authors reply: In response to Dr. de Giorgi and colleagues: we do believe that dermoscopy can be a useful aid to visual inspection in certain settings. Because of space constraints, we were not able to offer in our article an informative and balanced discussion of dermoscopy for the general practitioner. A recent survey of 456 physicians in the American Academy of Dermatology showed that less than 25 percent of dermatologists in the United States use dermoscopy regularly for pigmented lesions1; thus, even among specialists, it is used inconsistently. Moreover, in a recent meta-analysis, Kittler et al. concluded that although dermoscopy performed by skilled practitioners improves diagnostic accuracy, its use by untrained or less experienced examiners is no better than clinical inspection without dermoscopy.2
In response to Drs. Sampsel and Barbera-Guillem: we were not able to provide a thorough, in-depth review of melanoma immunotherapy because of space limitations.
In response to Dr. Miranda: we agree that techniques for examining the sentinel lymph node have changed and will continue to change the landscape of melanoma management. In our algorithm, we suggest possible staging tests that may be appropriate if the sentinel lymph node is found to be positive. In certain settings, these tests can include CT, PET, or MRI. It was not our intent to imply that all of these radiologic tests should be performed in every patient with sentinel-node involvement. The recommendations we make in our article are in line with those endorsed by the National Comprehensive Cancer Network (www.nccn.org/patients/patient_gls/_english/_melanoma/index.htm). We concur with Dr. Miranda that as more data about patients who have undergone selective lymphadenectomy become available, current best-practice guidelines will probably change and evolve into more evidence-based approaches.
Hensin Tsao, M.D., Ph.D.
Massachusetts General Hospital
Boston, MA 02114
Michael B. Atkins, M.D.
Beth Israel Deaconess Medical Center
Boston, MA 02215
Arthur J. Sober, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
Tripp JM, Kopf AW, Marghoob AA, Bart RS. Management of dysplastic nevi: a survey of fellows of the American Academy of Dermatology. J Am Acad Dermatol 2002;46:674-682.
Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159-165.
Vincenzo de Giorgi, M.D.
Paolo Carli, M.D.
Benvenuto Giannotti, M.D.
University of Florence
50121 Florence, Italy
dermoncologia@unifi.it
References
Tsao H, Atkins MB, Sober AJ. Management of cutaneous melanoma. N Engl J Med 2004;351:998-1012.
Argenziano G, Soyer HP. Dermoscopy of pigmented skin lesions -- a valuable tool for early diagnosis of melanoma. Lancet Oncol 2001;2:443-449.
Carli P, De Giorgi V, Crocetti E, et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the `dermoscopy era': a retrospective study 1997-2001. Br J Dermatol 2004;150:687-692.
Carli P, de Giorgi V, Chiarugi A, et al. Addition of dermoscopy to conventional naked-eye examination in melanoma screening: a randomized study. J Am Acad Dermatol 2004;50:683-689.
To the Editor: Tsao et al. do not cite the work of Morton and colleagues, who showed that after patients with melanoma were vaccinated with a melanoma-associated antigen (TA-90), patients who had a response and a high serum titer of antigen–IgM immune complexes had a better prognosis than those with high titers of antigen–IgG immune complexes, who had a poor prognosis.1,2 Such results suggest that not only the intensity but also the quality of the immune response may have value in future therapies. Moreover, in our experience, some types of antitumor immune response are harmful, not because they favor tolerance but because they actually promote tumor progression.3,4,5
James W. Sampsel, M.D.
Emilio Barbera-Guillem, M.D., Ph.D.
Memorial Hospital of Union County
Marysville, OH 43040
ebarbera@sbcglobal.net
References
Euhus DM, Gupta RK, Morton DL. Characterization of a 90-100 kDa tumor-associated antigen in the sera of melanoma patients. Int J Cancer 1990;45:1065-1070.
Litvak DA, Gupta RK, Yee R, Wanek LA, Ye W, Morton DL. Endogenous immune response to early- and intermediate-stage melanoma is correlated with outcomes and is independent of locoregional relapse and standard prognostic factors. J Am Coll Surg 2004;198:27-35.
Barbera-Guillem E, Sampsel JW. Immune-promoted tumor cell invasion and metastasis. In: Llombart-Bosch A, Felipo V, eds. New trends in cancer for the 21st century. New York: Kluwer Academic, 2003:153-72.
Barbera-Guillem E, Nyhus JK, Wolford CC, Friece CR, Sampsel JW. Vascular endothelial growth factor secretion by tumor-infiltrating macrophages essentially supports tumor angiogenesis, and IgG immune complexes potentiate the process. Cancer Res 2002;62:7042-7049.
Nyhus JK, Wolford CC, Friece CR, Nelson MB, Sampsel JW, Barbera-Guillem E. IgG-recognizing shed tumor-associated antigens can promote tumor invasion and metastasis. Cancer Immunol Immunother 2001;50:361-372.
To the Editor: In their review on the management of cutaneous melanoma, Tsao et al. do not discuss the importance of radiography for staging in patients with node-positive disease. In their algorithm for the management of melanoma, the authors recommend computed tomography (CT) of the chest and pelvis, magnetic resonance imaging (MRI) of the head, and positron-emission tomography (PET) for all patients with stage III disease. This suggestion is consistent with the recommendations that were made for patients with palpable regional lymphadenopathy in the era before the sentinel lymph node.1 Today, with the widespread use of selective sentinel lymphadenectomy, patients with regional disease are at a different place in the natural progression of melanoma. It has been shown that for asymptomatic patients with positive sentinel lymph nodes, staging CT and MRI show true metastatic disease in less than 1 percent of cases, whereas the false positive rate is 14 percent.2 Management of these cases with false positive results is a source of increased cost and physical illness, as well as a source of potentially devastating mental anguish. It is time to reevaluate the standard approach of routine imaging for baseline staging and reserve it for patients with symptomatic stage III disease.
Edward P. Miranda, M.D.
University of California, San Francisco
San Francisco, CA 94143
edmiranda@gmail.com
References
Gershenwald JE, Buzaid AC, Ross MI. Classification and staging of melanoma. Hematol Oncol Clin North Am 1998;12:737-765.
Miranda EP, Gertner M, Wall J, et al. Routine imaging of asymptomatic melanoma patients with metastasis to sentinel lymph nodes rarely identifies systemic disease. Arch Surg 2004;139:831-837.
The authors reply: In response to Dr. de Giorgi and colleagues: we do believe that dermoscopy can be a useful aid to visual inspection in certain settings. Because of space constraints, we were not able to offer in our article an informative and balanced discussion of dermoscopy for the general practitioner. A recent survey of 456 physicians in the American Academy of Dermatology showed that less than 25 percent of dermatologists in the United States use dermoscopy regularly for pigmented lesions1; thus, even among specialists, it is used inconsistently. Moreover, in a recent meta-analysis, Kittler et al. concluded that although dermoscopy performed by skilled practitioners improves diagnostic accuracy, its use by untrained or less experienced examiners is no better than clinical inspection without dermoscopy.2
In response to Drs. Sampsel and Barbera-Guillem: we were not able to provide a thorough, in-depth review of melanoma immunotherapy because of space limitations.
In response to Dr. Miranda: we agree that techniques for examining the sentinel lymph node have changed and will continue to change the landscape of melanoma management. In our algorithm, we suggest possible staging tests that may be appropriate if the sentinel lymph node is found to be positive. In certain settings, these tests can include CT, PET, or MRI. It was not our intent to imply that all of these radiologic tests should be performed in every patient with sentinel-node involvement. The recommendations we make in our article are in line with those endorsed by the National Comprehensive Cancer Network (www.nccn.org/patients/patient_gls/_english/_melanoma/index.htm). We concur with Dr. Miranda that as more data about patients who have undergone selective lymphadenectomy become available, current best-practice guidelines will probably change and evolve into more evidence-based approaches.
Hensin Tsao, M.D., Ph.D.
Massachusetts General Hospital
Boston, MA 02114
Michael B. Atkins, M.D.
Beth Israel Deaconess Medical Center
Boston, MA 02215
Arthur J. Sober, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
Tripp JM, Kopf AW, Marghoob AA, Bart RS. Management of dysplastic nevi: a survey of fellows of the American Academy of Dermatology. J Am Acad Dermatol 2002;46:674-682.
Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159-165.