Changing the standard of care for stage III melanoma surgery
Date:
March 4, 2022
Source:
University of Colorado Anschutz Medical Campus
Summary:
For years, surgery for patients with stage III melanoma -- melanoma
that has spread to the lymph nodes -- involved removing those lymph
nodes along with the primary tumor. Known as completion lymph node
dissection (CLND), the surgery was meant to ensure that no cancer
remained after surgery. More recently, however, cancer surgeons have
discovered that CLND has the potential to cause more problems than
it solves. In most cases, patients do better on immunotherapy alone
than they do when their surgery involves removal of the lymph nodes,
due to potential complications from lymph node surgery.
FULL STORY ==========================================================================
For years, surgery for patients with stage III melanoma -- melanoma that
has spread to the lymph nodes -- involved removing those lymph nodes along
with the primary tumor. Known as completion lymph node dissection (CLND),
the surgery was meant to ensure that no cancer remained after surgery.
==========================================================================
More recently, however, cancer surgeons have discovered that CLND has
the potential to cause more problems than it solves. In most cases,
patients do better on immunotherapy alone than they do when their surgery involves removal of the lymph nodes, due to potential complications from
lymph node surgery.
In a paper published in February in the Annals of Surgical Oncology,
University of Colorado (CU) Cancer Center members Martin McCarter, MD,
Camille Stewart, MD, Karl Lewis, MD, William Robinson, MD, Ana Gleisner,
MD, PhD, and Rene Gonzalez, MD -- along with CU School of Medicine
resident Robert Torphy, MD, PhD -- reviewed their patient data to
determine if immunotherapy alone resulted in better outcomes than CLND.
"In the few years prior to immunotherapy being available, some surgical
trials were done asking if regional node dissection by itself improves
overall survival for the patients," says McCarter, a professor of surgical oncology at the CU School of Medicine. "And the answer came back: no,
it did not improve survival. That had been the standard forever, because
we didn't have other effective therapies, but once the definitive trials
were done, we learned that CLND wasn't helping, it wasn't improving
survival. Subsequent trials demonstrated that immunotherapy can improve survival in metastatic melanoma." Better outcomes with immunotherapy
For the study, Torphy, working with McCarter and the other researchers,
looked at data on 90 patients who underwent sentinel lymph node biopsy
(a procedure to determine if a skin melanoma has spread microscopically)
only for stage III melanoma but did not undergo CLND. Of those patients,
56 received immunotherapy and 34 did not. Those who received immunotherapy
had better rates of distant metastasis-free survival, meaning their
cancer was less likely to come back.
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"As treatments for melanoma have evolved, the standard of care may
be evolving as well," McCarter says. "This study took a look at the
patients who had a sentinel lymph node biopsy, so we knew the patient
had a positive melanoma metastasis to their regional node. Those
folks historically used to go on and get the completion lymph node
dissection, but recently, people started to forego doing that lymph
node dissection, which did not improve survival, and instead moved
directly to immunotherapy, which did improve survival in other clinical
trials. We proved that this is acceptable, that we're not causing more
harm to patients by doing it, and that those who do go on to get the immunotherapy seem to benefit from it." The de-escalation movement
Forgoing CLND is part of a recent movement in cancer treatment known
as de- escalation (or de-implementation) -- giving patients only the
surgery absolutely necessary to treat their immediate disease. It's
especially important when it comes to lymph node surgery, McCarter says,
as on top of the risks inherent to all surgeries, CLND has a 20% to 30%
risk of permanent lymphedema, potentially harmful tissue swelling caused
by an accumulation of protein-rich fluid that's usually drained through
the body's lymphatic system.
"If you could avoid that complication and not compromise a patient's
survival, that would be beneficial," McCarter says. "That's what we
guessed was happening outside of definitive clinical trial evidence,
and that's what we were able to show. We know that we often overtreat
patients, and this fits in that paradigm of finding ways to de-escalate unnecessary therapies, which has been done in breast cancer and other
cancers as well." Changing course The CU researchers hope the study
begins to move the needle for cancer surgeons for whom CLND is still
routine, despite the earlier studies showing that the additional surgery
was not improving survival.
"Previous clinical trials with the use of adjuvant immunotherapy
for melanoma had required a CLND," McCarter says. "This study used
real-world data from our stage III melanoma patients who were treated
with immunotherapy without having a prior CLND.
"It takes years to change people's practice patterns. I still have conversations with community surgeons who treat melanoma, asking
me, 'Should I be doing these regional node dissections?' even
though this data has been out for five to 10 years now," McCarter
continues. "They're afraid to give up what they used to do, and they're
afraid that they are doing a disservice to the patients or not giving
them the best chance, when in reality, our understanding of cancer
biology has evolved. We now have effective immunotherapy, which is
overcoming some of the limitations of surgery while improving outcomes." ========================================================================== Story Source: Materials provided by University_of_Colorado_Anschutz_Medical_Campus. Original written by Greg Glasgow. Note: Content may be edited for style and length.
========================================================================== Journal Reference:
1. Robert J. Torphy, Chloe Friedman, Felix Ho, Laura D. Leonard, Daniel
Thieu, Karl D. Lewis, Theresa M. Medina, William A. Robinson,
Rene C.
Gonzalez, Camille L. Stewart, Nicole Kounalakis, Martin D. McCarter,
Ana Gleisner. Adjuvant Therapy for Stage III Melanoma Without
Immediate Completion Lymph Node Dissection. Annals of Surgical
Oncology, 2021; 29 (2): 806 DOI: 10.1245/s10434-021-10775-8 ==========================================================================
Link to news story:
https://www.sciencedaily.com/releases/2022/03/220304124017.htm
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