CO2 Laser Treatment for Regional Cutaneous Malignant Melanoma Metastases Jorien A. van Jarwaarde, MD, Ronnie Wessels, MD, Omgo E. Nieweg, MD, PhD, Michel W. J. M. Wouters, MD, PhD, and Jos A. van der Hage, MD, PhD*
BACKGROUND progression.
Cutaneous in-transit and satellite metastases are distressing presentations of melanoma
OBJECTIVE The purpose of this study was to analyze the efficacy of carbon dioxide (CO2) lasers in patients with melanoma with cutaneous in-transit and satellite metastases. MATERIALS AND METHODS Results of CO2 laser therapy were retrospectively evaluated in 22 patients between January 2004 and January 2008. The number of laser treatments, postoperative morbidity, regional control, and overall survival were analyzed. RESULTS Twenty-two patients received a total of 42 CO2 laser treatments. The number of lesions treated per session varied from 3 to 329. The median duration of regional control in all patients was 14 weeks (range, 3–117). In 9 of 22 patients, only 1 treatment with CO2 laser was performed resulting in a mean regional control of 11 weeks. In 10 patients, an average of 4 laser treatments (range, 1–17) was necessary to achieve regional control. Three of the 22 patients underwent isolated limb perfusion after laser treatment for disease control. CONCLUSION This study shows that (repeated) laser treatment can achieve adequate regional control with little morbidity. CO2 laser is recommended as a first-line treatment to patients with small but numerous cutaneous satellite or in-transit lesions in whom other surgery would induce substantial morbidity. The authors have indicated no significant interest with commercial supporters.
A
associated with substantial morbidity, and making the appropriate choice is challenging.
Multiple treatment options are available, ranging from local treatment to isolated limb perfusion or amputation of an extremity.1 Some of these treatments are
Carbon dioxide (CO2) laser is known to be an elegant option for cutaneous and superficial subcutaneous metastases.3,4 CO2 laser derives its energy from nitrogen molecules. Electric power is used to excite vibrational motion of the nitrogen molecules. Because this is a homonuclear molecule, it cannot lose this energy by photon emission. This energy is released through collisional energy transfer to the CO2 molecules, which leads to the infrared laser light that has the energy to destroy the melanoma lesion. The defect of the evaporated lesions is left open. The remaining
pproximately 3% of all patients with clinically localized melanoma develop satellite or in-transit metastases.1 Such lesions will progress to fungating tumors and may induce fatal distant metastases if left untreated. Early treatment can cure a proportion of these patients. The published 5-year survival rate of patients with melanoma with satellite or in-transit metastases ranged from 18% to 60%.2 In other patients, meaningful palliation can often be established, sometimes for many years.
*All the authors are affiliated with Department of Surgical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands J. A. van Jarwaarde and R. Wessels have contributed equally.
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:78–82 DOI: 10.1097/DSS.0000000000000251
·
·
·
78
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
VAN JARWAARDE ET AL
wound is painless and heals in a few weeks. The number of lesions that can be treated is unlimited, and the treatment can be repeated infinitely. Laser therapy is typically conducted as a 1-day procedure. This study examined the efficacy of laser treatment modality in a series of patients with satellite or in-transit melanoma metastases. The purposes were to determine the number of laser treatments, postoperative morbidity, regional control defined as being able to keep up with the recurrences with laser treatment(s), obviating the need for regional perfusion or amputation, and the overall survival rate.
Materials and Methods Between January 2004 and January 2008, 22 patients (9 males and 13 females) with cutaneous regional metastases of melanoma were treated with CO2 laser at the department of Surgical Oncology of the Antoni van Leeuwenhoek hospital in Amsterdam, the Netherlands. Only skin lesions with a diameter of not more than 5 mm were deemed amenable to CO2 laser. All patients were treated using spinal or local anesthesia. A Sharplan 1030 CO2 laser was used (Laser Industries Lumenis; distributed by Laservision Instruments, Nieuwleusen, the Netherlands) with a wavelength of 10.6 mm, infrared and continuous power in the range of 7 to 10 Watts, depending on the size and depth of the metastasis. To minimize surrounding tissue damage, the superpulse mode to deliver continuous laser power was used. A smoke evacuator ensured clearance of heat and smoke. A margin of 1- to 3-mm normal-appearing skin and subcutaneous tissue was removed with the lesions. The wounds were dressed with Vaseline gauzes for 24 hours. On average, the entire CO2 laser procedure took an operation time of approximately 15 minutes. Figures 1 and 2 show a female with multiple cutaneous deposits before/after treatment with laser ablation. Data were retrospectively retrieved from the patients’ files. The following patient characteristics were recorded: age, sex, primary melanoma characteristics, number of laser treatments, number and location of the satellite or in-transit metastases, morbidity,
Figure 1. A patient with multiple in-transit and satellite melanoma metastases before CO2 laser treatment. Scars of previous laser treatments are evident.
and survival. Calculations were performed using the statistical package SPSS (version 15.0 for Windows).
Results The whole group of 22 patients received a total cumulative number of 42 CO2 laser treatments for their satellite or in-transit metastases. Patient and primary melanoma characteristics are presented in Table 1. The mean age was 71 (range, 47–93) years. The median length of follow-up after the first laser operation was 14 months. CO2 laser was the initial therapy for their satellite or in-transit metastases in 3 patients. The remaining patients had previously undergone 1 or more other regional treatment(s):
Figure 2. A patient with multiple in-transit and satellite melanoma metastases after CO2 laser treatment. Scars of previous laser treatments are evident.
41:1:JANUARY 2015
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
CO2 LASER FOR MELANOMA METASTASES
TABLE 1. Characteristics of All 22 Patients and Their Primary Melanoma
Characteristic
n, Unless Otherwise Noted Characteristic
Gender Female
13
Male
9
Age Mean Location primary melanoma Leg
71 (47–93) years 16
Foot
2
Trunk
2
Arm
2
Hand
0
Breslow thickness Mean Ulceration Absent
3.3 mm 4
Present
5
Unknown
13
IIIC IV Unknown
Initial/previous therapy Excision
19
Isolated limb perfusion
3
Number of laser treatments 1
9 (41%)
2–10
11 (50%)
11–17
2 (9%)
Number of lesions per session (range, 3–329) #10
9 (41%)
11–20
6 (27%)
21–40
3 (14%)
>40
4 (18%)
Complications No complications Wound infection
18 4
8
Regional control
19
2
Isolated limb perfusion
3
11
Amputation
0
1
Overall survival† Median (range) in months
16 patients had undergone 1 or more excisions; 3 patients had previously undergone isolated limb perfusion. Table 2 summarizes the details of satellite or in-transit metastases, laser treatments, survival, and recurrence analysis. A total of 643 lesions were ablated. The mean number of lesions treated at the primary laser ablation session was 51 (median, 20; range, 3–329). The only observed adverse event was a Grade I wound infection that did not require treatment in 4 patients. The median duration of regional control after a laser treatment was 14 weeks (range, 3–117). In 9 of the 22 patients, only 1 treatment with CO2 laser was performed resulting in a mean duration of regional control of 11 weeks. Ten patients needed an average of 4 laser treatments (range, 1–17 treatments) to achieve regional control. In 3 patients, CO2 laser therapy was not able to achieve local control, and
80
n, Unless Otherwise Noted
Regional control*
AJCC stage IIIB
TABLE 2. Details of Satellite or In-Transit Metastases, Laser Treatments, Survival, and Recurrence Analysis
14 (1–41)
*Regional control defined as being able to keep up with the recurrences with laser treatment(s), obviating the need for regional perfusion or amputation. †After the first laser treatment.
therefore these patients underwent isolated limb perfusion, which induced complete locoregional control in these patients. No limbs were amputated. All 22 patients developed distant metastases and died of progressive disease. The median survival after the first laser treatment was 14 (range, 1–41) months. Figure 3 shows the overall survival in patients with initial AJCC Stage III versus IV. Discussion This study shows that CO2 laser is an efficient and elegant treatment modality to obtain regional control without major surgery in patients with satellite or intransit melanoma metastases. In 19 of 22 patients, regional control was achieved. Isolated limb perfusion
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
VAN JARWAARDE ET AL
melanoma with subcutaneous lesions, because the effectiveness of laser therapy for these lesions is limited while leaving a larger defect to heal.9
Figure 3. Overall survival in patients with AJCC Stage III versus IV after the first laser treatment.
was required only in 3 patients and no limbs were amputated. Laser therapy was shown to be associated with minimal morbidity. The only observed adverse events were Grade I wound infections (in 4 of 22 patients, 18%) that required no treatment. Moreover, regional or local anesthesia was used in all patients, and all left the hospital the same day. The CO2 laser was first described for the treatment of cutaneous malignancy by Kaplan and colleagues in 1973 and was demonstrated to be successful in the treatment of multiple cutaneous melanoma deposits.5– 7 Other options have been advocated for numerous regional cutaneous metastases including isolated limb perfusion and amputation.7 Perfusion leads to a complete response in 73% and a partial response in 13% of patients with otherwise intractable melanoma.8 A complete response is durable in half of the patients. Although perfusion is an effective treatment, it requires hospital admission of at least several days, it may be associated with limb malfunction (ankylosis, fibrosis, and/or muscle atrophy), and can cause chronic edema and nerve dysfunction.7,9 Sometimes, amputation is the last treatment option for patients with in-transit metastases. However, there has to be a reasonable duration of palliation to compensate for the morbidity and mutilation from amputation.10 Hence, isolated limb perfusion and limb amputation should be considered in patients with
Electrochemotherapy with high-intensity electric pulses facilitates intracellular delivery of cytotoxic drugs administered by intralesional or intravenous injection. This treatment modality seems to be effective for local ablation of a few large subcutaneous lesions. The response rate is 80% to 90%, and the complete response rate is 55% to 70%.11,12 Electrochemotherapy has been shown to improve the quality of life in patients who have bleeding or painful lesions.12 An additional advantage is that the procedure can be performed under local or general anesthesia, depending on the number of lesions.11,12 For small but numerous cutaneous lesions, laser therapy is better suited because electrochemotherapy is more laborious and its side effects are more severe. With the advent of new targeted therapies and immunotherapy, the treatment armamentarium for patients with advanced melanoma has broadened. These modalities affect the whole body, whereas satellite or in-transit metastases are more efficiently treated with local options. Complete response rates of these drugs are only about 1% and their toxicity is severe compared with CO2 laser.13 Therefore, treatment with these drugs is not suitable as the initial palliative option for satellite or in-transit metastases. Nevertheless, it would be interesting to analyze the effect of isolated limb perfusion with immunotherapy drugs for satellite or in-transit metastases. Patients with extensive satellite or in-transit metastases have a poor prognosis and are likely to develop systemic metastases within 6 to 12 months.2,10 The population of this study was no different as illustrated by the median survival of just 14 months irrespective of the stage of the disease (Figure 3). In 1997, Strobbe and colleagues3 concluded that CO2 laser treatment cannot be considered as a first-line option unless the issue of local recurrences is solved. This was based on the unexpected high incidence of recurrences at the lasered sites. However, the results of this study show that, because of increasing experience
41:1:JANUARY 2015
81
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
CO2 LASER FOR MELANOMA METASTASES
with this treatment modality, the authors now consider CO2 laser therapy indeed as an important role in the first-line treatment of extensive small cutaneous satellite or in-transit lesions. This is underlined by the fact that CO2 laser achieves adequate local regional control (especially applied multiple times). In conclusion, this study shows that CO2 laser provides adequate regional control with minimal morbidity. The results show that CO2 laser can easily treat numerous (up to 329) small lesions in an individual patient and that this treatment modality can be repeated multiple times (up to 17). In 3 of 22 patients, isolated limb perfusion was performed because CO2 laser could not keep up with the progressive disease. Limb amputation was not performed. All patients included in this study died of progressive disease, with a median survival of only 14 months. CO2 laser is thus a simple, well-tolerated procedure and is recommended as a first-line treatment to patients with small but numerous cutaneous satellite or in-transit lesions. It is an attractive, elegant limbsparing alternative for regional isolated perfusion or infusion, especially in the palliative setting.
References 1. Francken AB, Bastiaannet E, Hoekstra HJ. Follow-up in patients with localised primary cutaneous melanoma. Lancet Oncol 2005;6:608–21.
82
2. Hayes AJ, Clark MA, Harries M, Thomas JM. Management of in-transit metastases from cutaneous malignant melanoma. Br J Surg 2004;91:673–82. 3. Strobbe LJ, Nieweg OE, Kroon BBR. Carbon dioxide laser for cutaneous melanoma metastases: indications and limitations. Eur J Surg Oncol 1997;23:435–8. 4. Gibson SC, Byrne DS, McKay AJ. Ten-year experience of carbon dioxide laser ablation as treatment for cutaneous recurrence of malignant melanoma. Br J Surg 2004;91:893–5. 5. Kaplan I, Ger R, Sharon U. The carbon dioxide laser in plastic surgery. Br J Plast Surg 1973;26:359–62. 6. Hill S, Thomas JM. Use of carbon dioxide laser to manage cutaneous metastases from malignant melanoma. Br J Surg 1996;83:509–12. 7. Gimbel MI, Delman KA, Zager JS. Therapy for unresectable recurrent and in-transit extremity melanoma. Cancer Control 2008;15:225–32. 8. Thompson JF, Hunt JA, Shannon KF, Kam PC. Frequency and duration of remission after isolated limb perfusion for melanoma. Arch Surg 1997;132:903–7. 9. Noorda EM, Vrouenraets BC, Nieweg OE, van Geel AN, et al. Safety and efficacy of isolated limb perfusion in elderly melanoma patients. Ann Surg Oncol 2002;9:968–74. 10. Hoekstra HJ. The European approach to in-transit melanoma lesions. Int J Hyperthermia 2008;24:227–37. 11. Testori A, Faries MB, Thompson JF, Pennacchioli E, et al. Local and intralesional therapy of in-transit melanoma metastases. J Surg Oncol 2011;104:391–6. 12. Sasse AD, Sasse EC, Clark LG, Ulloa L, et al. Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma. Cochrane Database Syst Rev 2007:CD005413. 13. Chapman PB, Hauschild A, Robert C, Haanen JB, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med 2011;364:2507–16.
Address correspondence and reprint requests to: J. A. van Jarwaarde, MD, Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands, or e-mail: [email protected]
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
BACKGROUND progression.
Cutaneous in-transit and satellite metastases are distressing presentations of melanoma
OBJECTIVE The purpose of this study was to analyze the efficacy of carbon dioxide (CO2) lasers in patients with melanoma with cutaneous in-transit and satellite metastases. MATERIALS AND METHODS Results of CO2 laser therapy were retrospectively evaluated in 22 patients between January 2004 and January 2008. The number of laser treatments, postoperative morbidity, regional control, and overall survival were analyzed. RESULTS Twenty-two patients received a total of 42 CO2 laser treatments. The number of lesions treated per session varied from 3 to 329. The median duration of regional control in all patients was 14 weeks (range, 3–117). In 9 of 22 patients, only 1 treatment with CO2 laser was performed resulting in a mean regional control of 11 weeks. In 10 patients, an average of 4 laser treatments (range, 1–17) was necessary to achieve regional control. Three of the 22 patients underwent isolated limb perfusion after laser treatment for disease control. CONCLUSION This study shows that (repeated) laser treatment can achieve adequate regional control with little morbidity. CO2 laser is recommended as a first-line treatment to patients with small but numerous cutaneous satellite or in-transit lesions in whom other surgery would induce substantial morbidity. The authors have indicated no significant interest with commercial supporters.
A
associated with substantial morbidity, and making the appropriate choice is challenging.
Multiple treatment options are available, ranging from local treatment to isolated limb perfusion or amputation of an extremity.1 Some of these treatments are
Carbon dioxide (CO2) laser is known to be an elegant option for cutaneous and superficial subcutaneous metastases.3,4 CO2 laser derives its energy from nitrogen molecules. Electric power is used to excite vibrational motion of the nitrogen molecules. Because this is a homonuclear molecule, it cannot lose this energy by photon emission. This energy is released through collisional energy transfer to the CO2 molecules, which leads to the infrared laser light that has the energy to destroy the melanoma lesion. The defect of the evaporated lesions is left open. The remaining
pproximately 3% of all patients with clinically localized melanoma develop satellite or in-transit metastases.1 Such lesions will progress to fungating tumors and may induce fatal distant metastases if left untreated. Early treatment can cure a proportion of these patients. The published 5-year survival rate of patients with melanoma with satellite or in-transit metastases ranged from 18% to 60%.2 In other patients, meaningful palliation can often be established, sometimes for many years.
*All the authors are affiliated with Department of Surgical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands J. A. van Jarwaarde and R. Wessels have contributed equally.
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:78–82 DOI: 10.1097/DSS.0000000000000251
·
·
·
78
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
VAN JARWAARDE ET AL
wound is painless and heals in a few weeks. The number of lesions that can be treated is unlimited, and the treatment can be repeated infinitely. Laser therapy is typically conducted as a 1-day procedure. This study examined the efficacy of laser treatment modality in a series of patients with satellite or in-transit melanoma metastases. The purposes were to determine the number of laser treatments, postoperative morbidity, regional control defined as being able to keep up with the recurrences with laser treatment(s), obviating the need for regional perfusion or amputation, and the overall survival rate.
Materials and Methods Between January 2004 and January 2008, 22 patients (9 males and 13 females) with cutaneous regional metastases of melanoma were treated with CO2 laser at the department of Surgical Oncology of the Antoni van Leeuwenhoek hospital in Amsterdam, the Netherlands. Only skin lesions with a diameter of not more than 5 mm were deemed amenable to CO2 laser. All patients were treated using spinal or local anesthesia. A Sharplan 1030 CO2 laser was used (Laser Industries Lumenis; distributed by Laservision Instruments, Nieuwleusen, the Netherlands) with a wavelength of 10.6 mm, infrared and continuous power in the range of 7 to 10 Watts, depending on the size and depth of the metastasis. To minimize surrounding tissue damage, the superpulse mode to deliver continuous laser power was used. A smoke evacuator ensured clearance of heat and smoke. A margin of 1- to 3-mm normal-appearing skin and subcutaneous tissue was removed with the lesions. The wounds were dressed with Vaseline gauzes for 24 hours. On average, the entire CO2 laser procedure took an operation time of approximately 15 minutes. Figures 1 and 2 show a female with multiple cutaneous deposits before/after treatment with laser ablation. Data were retrospectively retrieved from the patients’ files. The following patient characteristics were recorded: age, sex, primary melanoma characteristics, number of laser treatments, number and location of the satellite or in-transit metastases, morbidity,
Figure 1. A patient with multiple in-transit and satellite melanoma metastases before CO2 laser treatment. Scars of previous laser treatments are evident.
and survival. Calculations were performed using the statistical package SPSS (version 15.0 for Windows).
Results The whole group of 22 patients received a total cumulative number of 42 CO2 laser treatments for their satellite or in-transit metastases. Patient and primary melanoma characteristics are presented in Table 1. The mean age was 71 (range, 47–93) years. The median length of follow-up after the first laser operation was 14 months. CO2 laser was the initial therapy for their satellite or in-transit metastases in 3 patients. The remaining patients had previously undergone 1 or more other regional treatment(s):
Figure 2. A patient with multiple in-transit and satellite melanoma metastases after CO2 laser treatment. Scars of previous laser treatments are evident.
41:1:JANUARY 2015
79
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
CO2 LASER FOR MELANOMA METASTASES
TABLE 1. Characteristics of All 22 Patients and Their Primary Melanoma
Characteristic
n, Unless Otherwise Noted Characteristic
Gender Female
13
Male
9
Age Mean Location primary melanoma Leg
71 (47–93) years 16
Foot
2
Trunk
2
Arm
2
Hand
0
Breslow thickness Mean Ulceration Absent
3.3 mm 4
Present
5
Unknown
13
IIIC IV Unknown
Initial/previous therapy Excision
19
Isolated limb perfusion
3
Number of laser treatments 1
9 (41%)
2–10
11 (50%)
11–17
2 (9%)
Number of lesions per session (range, 3–329) #10
9 (41%)
11–20
6 (27%)
21–40
3 (14%)
>40
4 (18%)
Complications No complications Wound infection
18 4
8
Regional control
19
2
Isolated limb perfusion
3
11
Amputation
0
1
Overall survival† Median (range) in months
16 patients had undergone 1 or more excisions; 3 patients had previously undergone isolated limb perfusion. Table 2 summarizes the details of satellite or in-transit metastases, laser treatments, survival, and recurrence analysis. A total of 643 lesions were ablated. The mean number of lesions treated at the primary laser ablation session was 51 (median, 20; range, 3–329). The only observed adverse event was a Grade I wound infection that did not require treatment in 4 patients. The median duration of regional control after a laser treatment was 14 weeks (range, 3–117). In 9 of the 22 patients, only 1 treatment with CO2 laser was performed resulting in a mean duration of regional control of 11 weeks. Ten patients needed an average of 4 laser treatments (range, 1–17 treatments) to achieve regional control. In 3 patients, CO2 laser therapy was not able to achieve local control, and
80
n, Unless Otherwise Noted
Regional control*
AJCC stage IIIB
TABLE 2. Details of Satellite or In-Transit Metastases, Laser Treatments, Survival, and Recurrence Analysis
14 (1–41)
*Regional control defined as being able to keep up with the recurrences with laser treatment(s), obviating the need for regional perfusion or amputation. †After the first laser treatment.
therefore these patients underwent isolated limb perfusion, which induced complete locoregional control in these patients. No limbs were amputated. All 22 patients developed distant metastases and died of progressive disease. The median survival after the first laser treatment was 14 (range, 1–41) months. Figure 3 shows the overall survival in patients with initial AJCC Stage III versus IV. Discussion This study shows that CO2 laser is an efficient and elegant treatment modality to obtain regional control without major surgery in patients with satellite or intransit melanoma metastases. In 19 of 22 patients, regional control was achieved. Isolated limb perfusion
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
VAN JARWAARDE ET AL
melanoma with subcutaneous lesions, because the effectiveness of laser therapy for these lesions is limited while leaving a larger defect to heal.9
Figure 3. Overall survival in patients with AJCC Stage III versus IV after the first laser treatment.
was required only in 3 patients and no limbs were amputated. Laser therapy was shown to be associated with minimal morbidity. The only observed adverse events were Grade I wound infections (in 4 of 22 patients, 18%) that required no treatment. Moreover, regional or local anesthesia was used in all patients, and all left the hospital the same day. The CO2 laser was first described for the treatment of cutaneous malignancy by Kaplan and colleagues in 1973 and was demonstrated to be successful in the treatment of multiple cutaneous melanoma deposits.5– 7 Other options have been advocated for numerous regional cutaneous metastases including isolated limb perfusion and amputation.7 Perfusion leads to a complete response in 73% and a partial response in 13% of patients with otherwise intractable melanoma.8 A complete response is durable in half of the patients. Although perfusion is an effective treatment, it requires hospital admission of at least several days, it may be associated with limb malfunction (ankylosis, fibrosis, and/or muscle atrophy), and can cause chronic edema and nerve dysfunction.7,9 Sometimes, amputation is the last treatment option for patients with in-transit metastases. However, there has to be a reasonable duration of palliation to compensate for the morbidity and mutilation from amputation.10 Hence, isolated limb perfusion and limb amputation should be considered in patients with
Electrochemotherapy with high-intensity electric pulses facilitates intracellular delivery of cytotoxic drugs administered by intralesional or intravenous injection. This treatment modality seems to be effective for local ablation of a few large subcutaneous lesions. The response rate is 80% to 90%, and the complete response rate is 55% to 70%.11,12 Electrochemotherapy has been shown to improve the quality of life in patients who have bleeding or painful lesions.12 An additional advantage is that the procedure can be performed under local or general anesthesia, depending on the number of lesions.11,12 For small but numerous cutaneous lesions, laser therapy is better suited because electrochemotherapy is more laborious and its side effects are more severe. With the advent of new targeted therapies and immunotherapy, the treatment armamentarium for patients with advanced melanoma has broadened. These modalities affect the whole body, whereas satellite or in-transit metastases are more efficiently treated with local options. Complete response rates of these drugs are only about 1% and their toxicity is severe compared with CO2 laser.13 Therefore, treatment with these drugs is not suitable as the initial palliative option for satellite or in-transit metastases. Nevertheless, it would be interesting to analyze the effect of isolated limb perfusion with immunotherapy drugs for satellite or in-transit metastases. Patients with extensive satellite or in-transit metastases have a poor prognosis and are likely to develop systemic metastases within 6 to 12 months.2,10 The population of this study was no different as illustrated by the median survival of just 14 months irrespective of the stage of the disease (Figure 3). In 1997, Strobbe and colleagues3 concluded that CO2 laser treatment cannot be considered as a first-line option unless the issue of local recurrences is solved. This was based on the unexpected high incidence of recurrences at the lasered sites. However, the results of this study show that, because of increasing experience
41:1:JANUARY 2015
81
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
CO2 LASER FOR MELANOMA METASTASES
with this treatment modality, the authors now consider CO2 laser therapy indeed as an important role in the first-line treatment of extensive small cutaneous satellite or in-transit lesions. This is underlined by the fact that CO2 laser achieves adequate local regional control (especially applied multiple times). In conclusion, this study shows that CO2 laser provides adequate regional control with minimal morbidity. The results show that CO2 laser can easily treat numerous (up to 329) small lesions in an individual patient and that this treatment modality can be repeated multiple times (up to 17). In 3 of 22 patients, isolated limb perfusion was performed because CO2 laser could not keep up with the progressive disease. Limb amputation was not performed. All patients included in this study died of progressive disease, with a median survival of only 14 months. CO2 laser is thus a simple, well-tolerated procedure and is recommended as a first-line treatment to patients with small but numerous cutaneous satellite or in-transit lesions. It is an attractive, elegant limbsparing alternative for regional isolated perfusion or infusion, especially in the palliative setting.
References 1. Francken AB, Bastiaannet E, Hoekstra HJ. Follow-up in patients with localised primary cutaneous melanoma. Lancet Oncol 2005;6:608–21.
82
2. Hayes AJ, Clark MA, Harries M, Thomas JM. Management of in-transit metastases from cutaneous malignant melanoma. Br J Surg 2004;91:673–82. 3. Strobbe LJ, Nieweg OE, Kroon BBR. Carbon dioxide laser for cutaneous melanoma metastases: indications and limitations. Eur J Surg Oncol 1997;23:435–8. 4. Gibson SC, Byrne DS, McKay AJ. Ten-year experience of carbon dioxide laser ablation as treatment for cutaneous recurrence of malignant melanoma. Br J Surg 2004;91:893–5. 5. Kaplan I, Ger R, Sharon U. The carbon dioxide laser in plastic surgery. Br J Plast Surg 1973;26:359–62. 6. Hill S, Thomas JM. Use of carbon dioxide laser to manage cutaneous metastases from malignant melanoma. Br J Surg 1996;83:509–12. 7. Gimbel MI, Delman KA, Zager JS. Therapy for unresectable recurrent and in-transit extremity melanoma. Cancer Control 2008;15:225–32. 8. Thompson JF, Hunt JA, Shannon KF, Kam PC. Frequency and duration of remission after isolated limb perfusion for melanoma. Arch Surg 1997;132:903–7. 9. Noorda EM, Vrouenraets BC, Nieweg OE, van Geel AN, et al. Safety and efficacy of isolated limb perfusion in elderly melanoma patients. Ann Surg Oncol 2002;9:968–74. 10. Hoekstra HJ. The European approach to in-transit melanoma lesions. Int J Hyperthermia 2008;24:227–37. 11. Testori A, Faries MB, Thompson JF, Pennacchioli E, et al. Local and intralesional therapy of in-transit melanoma metastases. J Surg Oncol 2011;104:391–6. 12. Sasse AD, Sasse EC, Clark LG, Ulloa L, et al. Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma. Cochrane Database Syst Rev 2007:CD005413. 13. Chapman PB, Hauschild A, Robert C, Haanen JB, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med 2011;364:2507–16.
Address correspondence and reprint requests to: J. A. van Jarwaarde, MD, Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands, or e-mail: [email protected]
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
