Patterns of Recurrence for Lymph Node Positive Cutaneous Melanoma in the Era of Immunotherapy

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International Journal of Radiation Oncology, Biology, Physics


Purpose/Objective(s): The management of patients with lymph node positive, nonmetastatic cutaneous melanoma has changed significantly with the adoption of anti-PD-1 immunotherapy. We compared clinical outcomes and patterns of recurrence of patients with lymph node positive, nonmetastatic cutaneous melanoma who received adjuvant immunotherapy with those who did not receive immunotherapy. Materials/Methods: Patients with lymph node or in-transit metastasis positive, nonmetastatic cutaneous melanoma diagnosed from 2013-2020 were identified from a prospectively-maintained, single-institution database. Baseline patient demographics and treatment details were recorded. Patients were stratified by receipt of adjuvant immunotherapy. Local and regional recurrence, distant metastasis, first site of recurrence, and overall survival (OS) were recorded, and rates of OS, progression-free survival (PFS), freedom from distant metastasis (ffDM), local recurrence (ffLR), and regional lymph node recurrence (ffRR) were estimated using the Kaplan-Meier method. Wilcoxon rank-sum test, Fisher’s exact test, and chi-square test of independence were used to analyze variables between groups. Results: Ninety-two patients were included with a median age of 67 years and a median follow-up of 2.9 years. Fifty-six (61%) patients received adjuvant immunotherapy for a median duration of 8.5 months. Fifty-three (58%) patients had a sentinel lymph node dissection alone while thirty-two (35%) had a complete regional lymph node dissection. A median of 3 lymph nodes were removed (range 0-83) with a median of 1 positive lymph node (range 1-15). Twenty-four (26%) patients had extranodal extension, thirty-nine (42%) had ulceration of the primary site, and twenty-eight (30%) had LVSI present. Median age of patients receiving immunotherapy versus those who did not was 63 years versus 72 years (p = 0.02). There were no differences in primary site, disease thickness, Clark stage, primary site ulceration, LVSI, extranodal extension, satellite metastasis, AJCC Tand N-stage, and completion lymph node dissection rates between the groups. Patients receiving immunotherapy had significantly improved OS (HR = 0.3, p = 0.001) with no difference in PFS (HR = 0.6, p = 0.08), ffDM (HR = 0.66, p = 0.28), ffLR (HR = 0.18, p = 0.1), and ffRR (HR = 2.5, p = 0.08). The initial site of recurrence was regional lymph nodes in thirteen (23%) patients receiving immunotherapy versus two (6%) patients who did not receive immunotherapy (p = 0.01). On UVA, male gender, number of positive lymph nodes, clinically positive lymph nodes, extranodal extension, in-transit metastasis, LVSI, and tumor thickness were significant predictors of regional lymph node recurrence. Conclusion: Patients with lymph node positive cutaneous melanoma receiving immunotherapy had a higher rate of initial disease progression in the regional lymph nodes compared with patients not receiving immunotherapy




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American Society for Radiation Oncology 65th Annual Meeting ASTRO 2023, October 1-4, 2023, San Diego, CA