In-transit Melanoma Metastases: Incidence, Prognosis, and the Role of Lymphadenectomy

Abstract

In this issue of Annals of Surgical Oncology, Read and colleagues describe a cohort analysis of the incidence, prognosis, and role of lymphadenectomy for in-transit (IT) melanoma. The study contributes to the large volume of clinical research this group has contributed to IT melanoma specifically and melanoma in general. The data they describe from a large prospectively maintained melanoma database can help clinicians understand this unusual presentation of stage 3 disease and also can be used to optimize treatment strategies for this patient population.In their study, the incidence of IT disease was 7.8 % (n = 483/6211) among patients with primary melanomas ([1 mm) and 0.4 % (n = 22/5288) among patients with primary melanoma (\1 mm). These numbers generally are consistent with previous estimates of IT disease development, which range from 2 to 10 %. 1 The median interval between the primary diagnosis and IT disease was 17.9 months. Additionally, for 54 % of patients, IT disease was the only site of recurrence, whereas 36 % had IT disease plus nodal involvement, and only 10 % presented concurrently with metastatic disease.The aforementioned data also are consistent with those reported from other studies. Not surprisingly, sentinel node (SN) status and primary tumor ulceration were associated with higher incidences of IT disease in this study. The rate of IT diseases was 4.7 % among SN-negative patients and 21.6 % among SN-positive patients. The latter rate, which suggests that IT disease will develop in nearly one fourth (21 %) of patients with SN-positive disease, highlights the critical need for effective management strategies for IT disease.Patients who present with IT disease should undergo restaging including physical exam, whole-body imaging, and possibly SN biopsy. Evaluation of the nodal basin is essential to guide therapeutic options and for prognosis. At the time of primary melanoma diagnosis, 145 patients who experienced IT disease development in the current study were initially SN negative. However, 31 % subsequently experienced clinical regional nodal disease. Thus, even if a patient presenting with IT disease has a negative SN at the time of primary diagnosis, 30 % may harbor nodal disease. Elective lymph node dissection for patients presenting with IT failed to show a survival benefit in this study and should not be routinely recommended.We have previously reported the role of SN biopsy for patients presenting with IT disease and have found SN to be positive in 33 % of patients with IT disease, a vast majority of whom had a negative SN at the time of primary melanoma.2 The distinction between patients with and those without nodal disease may be helpful for therapy decisions (especially clinical trials) and prognosis.In the current study, those with no regional nodal disease had a 5-year survival rate of 59 % (stage 3B) compared with a survival rate of 19 % (stage 3C) for those with evidence of nodal disease. Conversely, the American Joint Committee on Cancer (AJCC) database suggests a 5-year survi...

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