RECORD STATUS:

This is a bibliographic record of a published health technology assessment from a member of INAHTA. No evaluation of the quality of this assessment has been made for the HTA database.

CITATION:

Pichon Riviere A, Augustovski F, Garcia Marti S, Glujovsky D, Alcaraz A, Lopez A, Bardach A, Ciapponi A, Rey-Ares L, Caccavo F. Ipilimumab para pacientes con melanoma metastásico. [Ipilimumab for patients with metastatic melanoma] Buenos Aires: Institute for Clinical Effectiveness and Health Policy (IECS). Informe de Respuesta Rápida N° 265. 2012

Mucosal melanomas, far fewer in number than melanomas of the skin, manifest a far more aggressive and more rapid life-consuming biologic course. This behavior attends melanomas at any mucosal site, upper aerodigestive tracts, anorectum, and male and female genital tracts. Prognostic factors for both groups of melanoma are similar, but most mucosal melanomas have reached the dangerous limits, e.g., depth of invasion or thickness of melanoma at the time of diagnosis. In general, the mucosal melanomas are also more refractory to therapeutic modalities. In part, this may be due to anatomic restrictions of site and the large size of tumor when first discovered. This review presents a contemporary assessment of melanomas at all of the major mucosal sites.

Case report of a 69-year-old woman with a melanoma of the urethra. Radical surgery was renounced in regard of the age. We performed local excision with inguinal lymphonodectomy only followed by chemotherapy with dacarbazine. A tumor of this localisation is rare. Approximately 45 cases have been described in the literature at present. The prognosis of the diseases is very poor.

CRD COMMENTARY:

There was evidence of a search, inclusion criteria and quality assessment, but since the review lacked methodological detail it would be difficult to replicate. No attempt was made to identify unpublished literature and it was unclear whether non-English language publications were included; both of these issues raise the possibility of publication bias. In addition, search terms specific to diagnostic accuracy studies were used; these may limit the sensitivity of the searches. There were insufficient details of the study design and size of the primary studies, and tabulated details were not provided for all of the studies referenced in the review.
Given the limitations it is difficult to evaluate the strength of the authors' conclusions, but they appear to follow from the results presented.

Forty-seven cases of mucosal malignant melanomas and the recent literature are reviewed. Twenty patients had head and neck mucosal malignant melanomas; 14 had vulvar and 7 vaginal melanomas. Included are also isolated cases of urethral, anal and esophageal melanoma. Mucosal malignant melanomas are more aggressive and behave differently from cutaneous melanomas. The pathologic description and leveling system known from cutaneous melanomas are not applicable in mucosal melanomas, and other prognostic factors such as depth of invasion seem more important. Extensive surgical procedures is the favored treatment when cure is intended whereas radiation, chemotherapy and immunotherapy currently serve mainly as palliative measures. The prognosis is generally grave. In this review, 5 of the 20 patients with head and neck tumors and 3 of the patients with vulvar tumors had 5 years cures, but later recurrences are not infrequent. Two patients are alive with metastatic disease whereas the rest died from primary or recurrent disease. The main problem in head and neck tumors was gaining control over the local disease process, whereas metastatic disease was less ominous and less frequent. This was different in vulvar melanomas, in which disseminated metastatic disease made the disease difficult to control in the majority of cases. The course of the 47 patients, the poor treatment results and the rarity of the disease show the need for centralized registration and management of mucosal malignant melanomas.

A system for the computerized analysis of images obtained from ELM has been developed to enhance the early recognition of malignant melanoma. As an initial step, the binary mask of the skin lesion is determined by several basic segmentation algorithms together with a fusion strategy. A set of features containing shape and radiometric features as well as local and global parameters is calculated to describe the malignancy of a lesion. Significant features are then selected from this set by application of statistical feature subset selection methods. The final kNN classification delivers a sensitivity of 87% with a specificity of 92%.

OBJECTIVE:

To assess the epidemiologic evidence on melanoma in relation to Parkinson disease (PD) via systematic review and meta-analysis.

METHODS:

Epidemiologic studies on melanoma and PD were searched using PubMed, Web of Science, Scoups, and Embase (1965 through June 2010). Eligible studies were those that reported risk estimates of melanoma among patients with PD or vice versa. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS:

We identified 12 eligible publications on melanoma and PD.: 8 had fewer than 10 cases with both PD and melanoma, and 7 provided gender-specific results. The pooled OR was 2.11 (95% CI 1.26-3.54) overall, 2.04 (1.55-2.69) for men, and 1.52 (0.85-2.75) for women. Analyses by temporal relationship found that melanoma occurrence was significantly higher after the diagnosis of PD (OR 3.61, 95% CI 1.49-8.77), but not before PD diagnosis (OR 1.07, 95% CI 0.62-1.84). Further analyses revealed that the lack of significance in the latter analysis was due to one study, which when excluded resulted in a significant association (OR 1.44, 95% CI 1.06-1.96). We also analyzed nonmelanoma skin cancers in relation to PD and found no significant relationship (OR 1.11, 95% CI 0.94-1.30).

CONCLUSIONS:

Collective epidemiologic evidence supports an association of PD with melanoma. Further research is needed to examine the nature and mechanisms of this relationship.

El melanoma primario maligno del esófago es extremadamente raro y menos de 300 casos han sido publicados hasta el momento. Aunque la resección quirúrgica ha sido considerada como la mejor opción, el pronóstico es muy pobre. Se presenta a un paciente de 70 años a quien se le realizó una esofagogastroscopía por disfagia y epigastralgia de 6 meses de evolución. No había antecedentes de melanoma cutáneo. El examen demostró una masa polipoidea pigmentada de 5 cm de diámetro en el tercio inferior del esófago, que la biopsia informó como melanoma maligno. Se realizó una esofagectomía transhiatal y el estómago fue reemplazado por un tubo gástrico isoperistáltico con una anastomosis esofagogástrica cervical. El estudio de la pieza operatorio demostró un tumor polipoideo de 5,5 cm, con pigmentación negra. El estudio histológico demostró que el tumor correspondía a un melanoma maligno primario del esófago. Los márgenes de resección oral y caudal estaban libres de tumor. No recibió terapia adyuvante complementaria y a los 3 meses de la intervención había signos clínicos e imagenológicos de recurrencia de la enfermedad.

Melanoma metastatic to the liver has a very poor prognosis, and has traditionally been treated using systemic chemotherapy with limited efficacy. Surgery is increasingly being explored as a therapeutic option for melanoma liver metastases, with varying levels of success. A systematic review was undertaken to explore the short-term and long-term outcomes associated with hepatectomy for melanoma metastases, in addition to identifying prognostic factors favouring increased survival. All eligible studies were identified through an electronic search of Medline and Embase (January 1990-March 2013). Each study was independently analysed by two reviewers, with relevant data extracted and tabulated according to predetermined criteria. Thirteen studies were selected that fulfilled the selection criteria, with a total of 551 patients undergoing hepatic resection for melanoma metastases. Metastases to the liver occurred at a median interval of 54 months. The median perioperative morbidity and mortality were 10% (range 0-28.6%) and 0% (range 0-7.1%), respectively. The median overall survival for operative patients was 24 months, with median survival being greater in the R0 resection group (25 months; range 9.5-65.6 months) compared with the R1/2 resection group (16 months; range 11.7-29 months). Overall median 1-, 3- and 5-year survival rates were 70% (range 39-100%), 36% (range 10.2-53%) and 24% (range 3-53%), respectively. Positive prognostic factors may include single hepatic metastases, a longer time to development of hepatic metastases and R0 resection. Hepatic resection for metastatic melanoma might confer a distinct survival benefit in a select group of patients, although disease recurrence is the norm.

BACKGROUND:

Mounting evidence from experimental and animal studies suggests that vitamin A may have a protective effect on melanoma, but the findings on the association of vitamin A intake with risk of melanoma have been inconsistently reported in epidemiologic studies. We attempted to elucidate the association by performing a meta-analysis.

METHODS:

Eligible studies were identified by searching PubMed and EMBASE databases, as well as by reviewing the references of retrieved publications. Summary odds ratios (OR) with corresponding 95% confidence interval (CI) were computed with a random-effects model. Study-specific ORs and 95% CIs for the highest vs. lowest categories of vitamin A intake were pooled.

RESULTS:

A total of 8 case-control studies and 2 prospective studies comprising 3,328 melanoma cases and 233,295 non-case subjects were included. The summary OR for the highest compared with the lowest intake of total vitamin A, retinol and beta-carotene was 0.86 (95% CI = 0.59-1.25), 0.80 (95% CI = 0.69-0.92) and 0.87 (95%CI = 0.62-1.20), respectively. Significant heterogeneity was observed among studies on vitamin A and beta-carotene intake, but not among studies on retinol intake. Subgroup and sensitivity analyses confirmed these findings. There was no indication of publication bias.

CONCLUSION:

Findings from this meta-analysis suggest that intake of retinol, rather than of total vitamin A or beta-carotene, is significantly associated with reduced risk of melanoma.