Brazilian Society of Surgical Oncology recommendations on Merkel cell carcinoma surgical treatment.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin cancer with poor 5-year survival rates. Surgery and radiation are the current first-line treatments for local and nodal disease. OBJECTIVES: The Brazilian Society of Surgical Oncology developed this document aiming to guide the surgical oncology role in multimodal MCC management. METHODS: The consensus was established in three rounds of online discussion, achieving consensus on specific topics including diagnosis, staging, treatment, and follow-up. RESULTS: Patients suspected of having MCC should undergo immunohistochemical examination and preferably undergo pathology review by a dermatopathologist. Initial staging should be performed with dermatologic and nodal physical examination, combined with complementary imaging. Whole-body imaging, preferably with positron emission tomography (PET) or computed tomography (CT) scans, are recommended. Due to the need for multidisciplinary approaches, we recommend that all cases should be discussed in tumor boards and referred to other specialties as soon as possible, reducing potential treatment delays. We recommend that all patients with clinical stage I or II may undergo local excision associated with sentinel lymph node biopsy. The decision on margin size should consider time to recovery, patient's comorbidities, and risk factors. Patients with positive sentinel lymph nodes or the presence of risk factors should undergo postoperative radiation therapy at the primary site. Exclusive radiation is a viable option for patients with low performance. Patients with positive sentinel lymph node biopsy should undergo nodal radiation therapy or lymphadenectomy. In patients with nodal clinical disease, in addition to primary tumor treatment, nodal radiation therapy and/or lymphadenectomy are recommended. Patients with advanced disease should preferably be enrolled in clinical trials and discussed in multidisciplinary meetings. The role of surgery and radiation therapy in the metastatic/advanced setting should be discussed individually and always in tumor boards. CONCLUSION: This document aims to standardize a protocol for initial assessment and treatment for Merkel cell carcinoma, optimizing oncologic outcomes in middle-income countries such as Brazil.

Management of In-Transit Metastases.

PURPOSE OF REVIEW: The purpose of this study is to discuss the current knowledge and future perspectives regarding the treatment options for in-transit metastases (ITM), along with the optimal algorithms for patients presenting with this adverse manifestation of melanoma. RECENT FINDINGS: In addition to procedures historically accepted for the management of ITM, encompassing surgery and regional techniques, novel medications in the form of immune checkpoint inhibitors (ICI) and targeted therapies now represent standard options, allowing for the possibility of combined approaches, with an expanding role of systemic therapies. Melanoma in-transit metastases consist of intralymphatic neoplastic implants distributed between the primary site and the regional nodal basin, within the subepidermal and dermal lymphatics. Distinct risk factors may influence the development of ITM, and the clinical presentation can be highly heterogeneous, enhancing the complexity of the management of ITM. Surgical resection, when feasible, continues to represent a standard approach for patients with curative intent. Patients with extensive or unresectable disease may also benefit from regional approaches that include isolated limb perfusion or infusion, electrochemotherapy, and a wide variety of intralesional therapies. Over the past decade, regimens with ICI and BRAF/MEK inhibitors dramatically expanded the benefit of systemic treatments for patients with melanoma, both in the adjuvant setting and for those with advanced disease, and the combination of these modalities with regional treatments, as well as neoadjuvant approaches, may represent the future for the treatment of patients with ITM.

Demographic, Clinical, and Pathologic Features of Patients With Cutaneous Melanoma: Final Analysis of the Brazilian Melanoma Group Database.

PURPOSE: National epidemiologic data on melanoma are scarce in Brazil. The current work presents final demographic, clinical, and pathologic results from the Brazilian Melanoma Group database to detail how patients with melanoma present at diagnosis. METHODS: The online database includes patients diagnosed between 1982 and 2015 and evaluated at their centers of origin between 2001 and 2016. The primary objective was to describe the demographic, clinical, and pathologic characteristics of the patients, and secondary objectives were to investigate the association between clinical and pathologic variables of interest. RESULTS: A total of 1,596 patients were included. Median age was 52 years, 57% were women, and the majority were identified as white. Invasive melanoma was diagnosed in 1,297 patients, mostly localized, whereas 299 (19%) had in situ disease (TisN0M0). Only 165 patients had initial lymph node involvement. Fitzpatrick skin types I or II were slightly more frequent with in situ melanoma (73%) than with invasive disease (67%; P = .054). The median Breslow thickness was 0.95 mm, Clark levels 2 and 3 comprised nearly 70% of cases, and ulceration was present in 18% of patients. The mitotic rate was significantly associated with the presence of ulceration and both vascular and perineural invasion but not with margin positivity, whereas histologic regression was associated with both intratumoral and peritumoral inflammatory infiltrates. CONCLUSION: Despite the limitations of an observational, registry-based study, the current results provide a general profile of patients with cutaneous melanoma in Brazil at the time of diagnosis.

Margens de excisão cirúrgica do melanoma cutâneo primário / Margins of surgical excision of primary cutaneous melanoma

Introdução: O melanoma cutâneo representa 75% das mortes por câncer de pele. O tratamento padrão é a excisão cirúrgica com uma margem de segurança a certa distância das bordas do tumor primário. O objetivo da margem de segurança é remover o tumor primário completo e todas as células do melanoma que podem ter se espalhado na pele ao redor. Margens de excisão são importantes porque poderia haver um conflito entre um melhor resultado cosmético, mas uma pior sobrevida em longo prazo se as margens são muito estreitas. A largura ideal das margens da excisão permanece obscura. Esta incerteza justifica esta revisão sistemática.Objetivos: Avaliar o efeito de diferentes margens de excisão cirúrgica do melanoma cutâneo primário.Estratégia de busca: A busca foi realizada nas seguintes bases: Registro Especializado do Skin Group da Colaboração (Cochrane Skin Group Specialized Register), CENTRAL (Cochrane Central Register of Controlled Trials), Medline, Embase, Lilacs, e outras bases de dados, incluindo registros de estudos em andamento...

Padronizaçäo de técnica cirúrgica para quimioterapia intra-arterial de membros inferiores / Standardization of surgical technic for intra arterial chemotherapy of lower extremities

É apresentado um método para quimioterapia intra-arterial que propicia a oportunidade para a infusäo contínua ou descontínua de drogas antineoplásicas. Os autores descrevem um método cirúrgico no qual é colocado um cateter na artéria ilíaca externa próximo ao início da artéria femural, através da artéria epigástrixca inferior. A dissecçäo desta artéria é feita através de pequena incisäo a meia distância entre a cicatriz umbilical e a sínfise pública, dentro do compartimento do músuclo reto abdominal, sobre a línea semi-circular. O local dessa dissecçäo está fora da regiäo de drenagem dos membro inferiores. O método é seguro, de fácil execuçäo e de baixo custo

BCG oral no tratamento adjuvante do melanoma cutâneo / Oral BCG in the adjuvant treatment of cutaneous melamoma

O tratamento da lesão primária do melanoma cutâneo tornou-se mais racional após as publicações de Clark e Breslow, definindo-se margens maiores ou menores, com base nos índices de profundidade tumoral estabelecidos por estes autores. Além desses índices, outros fatores são reconhecidos por influir de maneira negativa na evolução dos portadores de melanoma cutâneo primário: presença de ulceração, microsatelitose e localização axial. Diferentes formas de terapia adjuvante tem sido pesquisadas, para serem usadas nos pacientes com pior prognóstico. Dentre esses, o Bacilo de Calmette-Guérin (BCG) tem sido um agente imunomodulador dos mais utilizados, particularmente após a publicação de Morton, em 1970. Este sugeriu um estímulo sistêmico ao notar que nódulos cutâneos metastáticos regrediram, após receberem injeção intratumoral de BCG e que, alguns nódulos não diretamente injetados, também apresentaram regressão. No Departamento de Tumores Cutâneos do Hospital A. C. Camargo, foi proposto um estudo prospectivo em portadores de melanoma cutâneo primário, sem doença regional ou sistêmica (estádio clínico I e II do Hospital M. D. Anderson), que foram tratados cirurgicamente e distribuídos em dois grupos para tratamento adjuvante: um grupo recebeu BCG (l.500 mg/semana, via oral, mantidos por dois anos ou interrompidos no caso de aparecimento de recidiva) e outro para servir de grupo controle. No período de outubro de 1983 a janeiro de 1987, 52 pacientes foram incluídos no grupo BCG e 49 no controle. Com o objetivo de analisar a evolução desses 101 pacientes, foram revistos todos seus prontuários, através do preenchimento de fichas específicas. Estas foram preparadas para se obter e estudar os seguintes aspectos: faixa etária, sexo, raça, topografia da lesão primária, estádio clínico, biópsia prévia ou näo, presença ou não de ulceração, tratamento cirúrgico realizado, níveis de Clark e espessura de Breslow. Sexo (p=O,Ol27) e níveis de Clark (p=O,OOO6) foram variáveis estatisticamente significantes na análise univariada de sobrevivência global. Esta sobrevivência global foi de 62,0 por cento a 5 anos e 49,6 por cento a 10 anos para o sexo masculino e 82,3 por cento a 5 e 68,3 por cento a 10 anos para o sexo feminino. Em relação aos níveis de Clark, os percentuais de sobrevivência global a 5 e 10 anos foram 91,7 e 80,2 por cento, respectivamente, para os níveis I-II, 80,3 e 67,5 para o nível 111 e 52,1 e 32,4 por cento para os níveis IV e...(au)