Letters to the Editor
Case of advanced melanoma who died from meningitis carcinomatosa after carboplatin and paclitaxel with good response Dear Editor, Melanoma is a highly aggressive tumor with a poor prognosis in the metastatic stage. The combination of carboplatin and paclitaxel (CP) has never been compared with single-agent chemotherapy in a randomized trial in patients with melanoma, but it has been included in the treatment guidelines of the National Comprehensive Cancer Network (NCCN) as “other active regimens” (category 2B).1 A 47-year-old Japanese man was diagnosed with mucosal malignant melanoma of the nasal cavity in October 2009 at another hospital. The patient was treated with proton beam therapy with a total dose of 60 Gy between November and December 2009. The patient was referred to us in April 2011, because of metastases in multiple lesions including lung, skin and the intraperitoneal cavity. We started the patient on dacarbazine 1000 mg/m2 on day 1 every 4 weeks. But after two cycles, the performance status of the patient deteriorated rapidly with increasing abdominal and right knee pain, and positron emission tomography/computed tomography (PET-CT) showed severe disease progression at all metastatic sites (Fig. 1a). Laboratory examination showed increased serum lactate dehydrogenase (LDH) at 1541 U/L. We started chemotherapy by CP in September 2011. The dosing regimen of CP was paclitaxel 200 mg/m2 i.v. and carboplatin at area under the curve 6 each 21–28-day cycle. After two cycles of CP, PET-CT showed surprising partial response in all most lesions (Fig. 1b). The patient did not complain of pain and his general condition was improved significantly. LDH was also decreased into the normal range of 149 U/L. However, in December 2011, he suffered from headache, nausea and loss of appetite. CT scan did not showed any fresh lesions, but magnetic resonance imaging revealed abnormal meningeal enhancement which suggested meningitis carcinomatosa (Fig. 1c,d). It was conceivable that the drugs could not pass through the blood–brain barrier.2 Intrathecal chemotherapy and radiation was not possible due to the poor condition of the patient. According to the results of an extensive autopsy study, the incidence of meningitis carcinomatosa was 5–8% in cancer patients.3 The treatment for meningitis carcinomatosa is limited to a palliative therapy. As a result, the patient died 3 weeks later, but he spent the period in a good condition after CP therapy. In the recently reported phase III trial of 413 cases, the response rate of CP therapy was 18.2% (complete response, 1.2%; partial response, 17.0%; stable disease, 38.7%; progressive disease, 28.8%), median progression-free survival of 4.1 months and median overall survival of 11.3 months.4 From the clinical efficacy observed in our
(a)
(b)
(c)
(d)
Figure 1. (a) Positron emission tomography/computed tomography (PET-CT) image. Before carboplatin and paclitaxel (CP) therapy, multiple 18F-fluorodeoxyglucose (FDG) uptake was detected in the whole body including lung, skin, bone and intraperitoneal cavity. (b) PET-CT image. After two cycles of CP therapy, almost all FDG uptake except right cervical lymph node was lost. (c) Magnetic resonance imaging (MR) of the brain showed enhancement at the brain surface. (d) MRI of the spine showed enhancement at the spine surface. patients, CP therapy should be still selected as the second-line therapy for metastatic melanoma.
CONFLICT OF INTEREST:
None.
Junji KATO,1 Arata TSUTSUMIDA,2 Kenjiro NAMIKAWA,2 Ryota TANAKA,2 Naoya YAMAZAKI2 1
Department of Dermatology, Sapporo Medical University, and 2Department of Dermatology and Dermatologic Oncology National Cancer Center Hospital, Tokyo, Japan doi: 10.1111/1346-8138.12535
Correspondence: Junji Kato, M.D., Department of Dermatology, Sapporo Medical University, South 1 West 16, Chuo-ku, Sapporo 060-8556, Japan. Email: [email protected]
654
© 2014 Japanese Dermatological Association
Letters to the Editor
REFERENCES 1 NCCN: Clinical practice guidelines in oncology-melanoma 2014 (http://www.nccn.org). 2 Turunen BJ, Ge H, Oyetunji J et al. Paclitaxel succinate analogs: anionic and amide introduction as a strategy to impart blood-brain barrier permeability. Bioorg Med Chem Lett 2008; 18: 5971–5974.
3 Pentheroudakis G, Pavlidis N. Management of leptomeningeal malignancy. Expert Opin Pharmacother 2005; 6: 1115–1125. 4 Flaherty KT, Lee SJ, Zhao F et al. Phase III trial of carboplatin and paclitaxel with or without sorafenib in metastatic melanoma. J Clin Oncol 2013; 20: 373–379.
Sentinel lymph node mapping of melanoma using technetium-99m phytate by a hybrid single-photon emission computed tomography/computed tomography Dear Editor, Sentinel lymph node (SLN) biopsy has become a widely accepted method of staging regional lymph nodes for patients with melanoma. Recently, a hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) was introduced to enable gamma cameras to capture precise anatomical structures on CT images. Technetium-99m phytate (99mTc-phytate) has been approved for lymph mapping in Japan. However, there have been few reports of its use. The aim of this study was to evaluate a lymphoscintigraphy protocol involving 99mTc-phytate by SPECT/CT. The study population comprised 10 patients. Six patients had a primary lesion on the trunk, two on the head and neck and two on an extremity. The number of SLNs identified per image by the early dynamic, delayed static (3-h late phase) and SPECT/CT techniques was compared by ANOVA, followed by Tukey’s test and Bonferroni correction. Assuming that the number of SLNs biopsied (n = 27) using a combination of blue dye, radioisotope and fluorescence methods was optimum, the SPECT/CT accuracy rate was 96% (28 SLNs). Furthermore, SPECT/CT imaging successfully depicted SLNs very close to the injection sites by masking them to minimize their influence (Fig. 1). Seventeen SLNs were detected on dynamic imaging and two types of TACs were observed. Those of 11 SLNs (one in each regional basin) shared common characteristics: a bi-exponential clearance model of high radioactivity. Those of the other six SLNs remained steady at low level.
(a)
(b)
(c)
Figure 1. Sensitivity of delayed static imaging and singlephoton emission computed tomography/computed tomography (SPECT/CT) for sentinel lymph node (SLN) detection in the cervical region. (a) Delayed static image showing no SLN owing to the high radioactivity at the injection sites. (b) Non-processed SPECT/CT image with only the injections sites identified. (c) SPECT/CT image with masking of the injection sites. A SLN is clearly depicted in the lateral cervix (indicated by an arrow).
Correspondence: Yuzuru Kono, Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. Email: [email protected]
© 2014 Japanese Dermatological Association
655
Case of advanced melanoma who died from meningitis carcinomatosa after carboplatin and paclitaxel with good response Dear Editor, Melanoma is a highly aggressive tumor with a poor prognosis in the metastatic stage. The combination of carboplatin and paclitaxel (CP) has never been compared with single-agent chemotherapy in a randomized trial in patients with melanoma, but it has been included in the treatment guidelines of the National Comprehensive Cancer Network (NCCN) as “other active regimens” (category 2B).1 A 47-year-old Japanese man was diagnosed with mucosal malignant melanoma of the nasal cavity in October 2009 at another hospital. The patient was treated with proton beam therapy with a total dose of 60 Gy between November and December 2009. The patient was referred to us in April 2011, because of metastases in multiple lesions including lung, skin and the intraperitoneal cavity. We started the patient on dacarbazine 1000 mg/m2 on day 1 every 4 weeks. But after two cycles, the performance status of the patient deteriorated rapidly with increasing abdominal and right knee pain, and positron emission tomography/computed tomography (PET-CT) showed severe disease progression at all metastatic sites (Fig. 1a). Laboratory examination showed increased serum lactate dehydrogenase (LDH) at 1541 U/L. We started chemotherapy by CP in September 2011. The dosing regimen of CP was paclitaxel 200 mg/m2 i.v. and carboplatin at area under the curve 6 each 21–28-day cycle. After two cycles of CP, PET-CT showed surprising partial response in all most lesions (Fig. 1b). The patient did not complain of pain and his general condition was improved significantly. LDH was also decreased into the normal range of 149 U/L. However, in December 2011, he suffered from headache, nausea and loss of appetite. CT scan did not showed any fresh lesions, but magnetic resonance imaging revealed abnormal meningeal enhancement which suggested meningitis carcinomatosa (Fig. 1c,d). It was conceivable that the drugs could not pass through the blood–brain barrier.2 Intrathecal chemotherapy and radiation was not possible due to the poor condition of the patient. According to the results of an extensive autopsy study, the incidence of meningitis carcinomatosa was 5–8% in cancer patients.3 The treatment for meningitis carcinomatosa is limited to a palliative therapy. As a result, the patient died 3 weeks later, but he spent the period in a good condition after CP therapy. In the recently reported phase III trial of 413 cases, the response rate of CP therapy was 18.2% (complete response, 1.2%; partial response, 17.0%; stable disease, 38.7%; progressive disease, 28.8%), median progression-free survival of 4.1 months and median overall survival of 11.3 months.4 From the clinical efficacy observed in our
(a)
(b)
(c)
(d)
Figure 1. (a) Positron emission tomography/computed tomography (PET-CT) image. Before carboplatin and paclitaxel (CP) therapy, multiple 18F-fluorodeoxyglucose (FDG) uptake was detected in the whole body including lung, skin, bone and intraperitoneal cavity. (b) PET-CT image. After two cycles of CP therapy, almost all FDG uptake except right cervical lymph node was lost. (c) Magnetic resonance imaging (MR) of the brain showed enhancement at the brain surface. (d) MRI of the spine showed enhancement at the spine surface. patients, CP therapy should be still selected as the second-line therapy for metastatic melanoma.
CONFLICT OF INTEREST:
None.
Junji KATO,1 Arata TSUTSUMIDA,2 Kenjiro NAMIKAWA,2 Ryota TANAKA,2 Naoya YAMAZAKI2 1
Department of Dermatology, Sapporo Medical University, and 2Department of Dermatology and Dermatologic Oncology National Cancer Center Hospital, Tokyo, Japan doi: 10.1111/1346-8138.12535
Correspondence: Junji Kato, M.D., Department of Dermatology, Sapporo Medical University, South 1 West 16, Chuo-ku, Sapporo 060-8556, Japan. Email: [email protected]
654
© 2014 Japanese Dermatological Association
Letters to the Editor
REFERENCES 1 NCCN: Clinical practice guidelines in oncology-melanoma 2014 (http://www.nccn.org). 2 Turunen BJ, Ge H, Oyetunji J et al. Paclitaxel succinate analogs: anionic and amide introduction as a strategy to impart blood-brain barrier permeability. Bioorg Med Chem Lett 2008; 18: 5971–5974.
3 Pentheroudakis G, Pavlidis N. Management of leptomeningeal malignancy. Expert Opin Pharmacother 2005; 6: 1115–1125. 4 Flaherty KT, Lee SJ, Zhao F et al. Phase III trial of carboplatin and paclitaxel with or without sorafenib in metastatic melanoma. J Clin Oncol 2013; 20: 373–379.
Sentinel lymph node mapping of melanoma using technetium-99m phytate by a hybrid single-photon emission computed tomography/computed tomography Dear Editor, Sentinel lymph node (SLN) biopsy has become a widely accepted method of staging regional lymph nodes for patients with melanoma. Recently, a hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) was introduced to enable gamma cameras to capture precise anatomical structures on CT images. Technetium-99m phytate (99mTc-phytate) has been approved for lymph mapping in Japan. However, there have been few reports of its use. The aim of this study was to evaluate a lymphoscintigraphy protocol involving 99mTc-phytate by SPECT/CT. The study population comprised 10 patients. Six patients had a primary lesion on the trunk, two on the head and neck and two on an extremity. The number of SLNs identified per image by the early dynamic, delayed static (3-h late phase) and SPECT/CT techniques was compared by ANOVA, followed by Tukey’s test and Bonferroni correction. Assuming that the number of SLNs biopsied (n = 27) using a combination of blue dye, radioisotope and fluorescence methods was optimum, the SPECT/CT accuracy rate was 96% (28 SLNs). Furthermore, SPECT/CT imaging successfully depicted SLNs very close to the injection sites by masking them to minimize their influence (Fig. 1). Seventeen SLNs were detected on dynamic imaging and two types of TACs were observed. Those of 11 SLNs (one in each regional basin) shared common characteristics: a bi-exponential clearance model of high radioactivity. Those of the other six SLNs remained steady at low level.
(a)
(b)
(c)
Figure 1. Sensitivity of delayed static imaging and singlephoton emission computed tomography/computed tomography (SPECT/CT) for sentinel lymph node (SLN) detection in the cervical region. (a) Delayed static image showing no SLN owing to the high radioactivity at the injection sites. (b) Non-processed SPECT/CT image with only the injections sites identified. (c) SPECT/CT image with masking of the injection sites. A SLN is clearly depicted in the lateral cervix (indicated by an arrow).
Correspondence: Yuzuru Kono, Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. Email: [email protected]
© 2014 Japanese Dermatological Association
655
