TREATMENTS DIRECTED AT LOCOREGIONAL RECURRENCE AND IN-TRANSIT METASTASES
Locoregional recurrence of a melanoma is defined as recurrence in or around a scar from previous melanoma surgery, or satellite or in-transit metastases. The American Joint Committee on Cancer (AJCC) groups the latter two (satellites and in-transit recurrences) in the most recent edition of the melanoma staging manual (AJCC 7th edition) as a component of nodal (N) staging.1 Satellite metastases, considered intralymphatic extensions of the primary tumor, are defined as occurring within 2 cm of the primary tumor, whereas in-transit metastases are defined as any dermal or subcutaneous metastases 2 cm or more from the primary tumor but not beyond the draining regional node basin.1 Although satellite metastases and local recurrences are often confused in clinical practice, a true local recurrence is a lesion within or very close to the scar from previous definitive surgery, whereas satellite metastases are somewhat removed from the scar but within 2 cm. The bottom line in the management of all locoregional recurrences, however, is that the treatment algorithms are usually the same. Nevertheless, these patients should be discussed in a multidisciplinary tumor board setting whenever possible. Treatment options for locoregionally recurrent melanoma include surgical resection, local intra-tumoral injections, hyperthermic isolated limb perfusion (HILP), isolated limb infusion (ILI), topical therapies, laser ablation, radiation therapy, and systemic therapies.2
The first decision to be made with any type of locoregional recurrence is: Can the entire recurrence/tumor be removed safely, with minimal morbidity, and the patient rendered NED? Complete surgical resection, in the absence of extensive disease, is considered the standard of care.2 Dong et al report a series of 648 patients with primary melanomas and subsequent local recurrence. In this study, 124 patients (19%) had no further recurrences after surgical resection of the local recurrence. One hundred and ninety-six (30%) developed another local recurrence, 178 (27%) developed in-transit disease, and 150 (23%) eventually developed systemic disease. This shows that close to 20% of patients with a local recurrence are likely to benefit from surgical resection alone. Over 50% of the patients in the series were alive at 5 years, many of those who had recurrences beyond the initial local recurrence having been treated with aggressive local, intra-arterial perfusion-based, or systemic therapies.
Intralesional and Topical Therapies
Intralesional therapy for locoregionally metastatic melanoma has been practiced for decades. There have been a few recent advances and phase II and III clinical trials that have explored the use of intralesional and topical therapies for metastatic melanoma.3,4 Bacille Calmette-Guérin (BCG) was the first commonly utilized agent for intralesional injections in the setting of in-transit metastases. In 1974, Morton et al reported their experience with intralesional injections of BCG.5 Regression occurred in 90% of the cutaneous lesions that were injected, and 17% of the patients ...