Nicole Kounalakis

Long-term Follow-up and Survival of Patients Following a Recurrence of Melanoma After a Negative Sentinel Lymph Node Biopsy Result

OBJECTIVE To analyze the predictors and patterns of recurrence of melanoma in patients with a negative sentinel lymph node biopsy result. DESIGN Retrospective chart review of a prospectively created database of patients with cutaneous melanoma. SETTING Tertiary university hospital. PATIENTS A total of 515 patients with melanoma underwent a sentinel lymph node biopsy without evidence of metastatic disease between 1996 and 2008. MAIN OUTCOME MEASURES Time to recurrence and overall survival. RESULTS Of 515 patients, 83 (16%) had a recurrence of melanoma at a median of 23 months during a median follow-up of 61 months (range, 1-154 months). Of these 83 patients, 21 had melanoma that metastasized in the studied nodal basin for an in-basin false-negative rate of 4.0%. Patients with recurrence had deeper primary lesions (mean thickness, 2.7 vs 1.8 mm; P < .01) that were more likely to be ulcerated (32.5% vs 13.5%; P < .001) than those without recurrence. The primary melanoma of patients with recurrence was more likely to be located in the head and neck region compared with all other locations combined (31.8% vs 11.7%; P < .001). Median survival following a recurrence was 21 months (range, 1-106 months). Favorable characteristics associated with lower risk of recurrence included younger age at diagnosis (mean, 49 vs 57 years) and female sex (9% vs 21% for males; P < .001). CONCLUSION Overall, recurrence of melanoma (16%) after a negative sentinel lymph node biopsy result was similar to that in previously reported studies with an in-basin false-negative rate of 4.0%. Lesions of the head and neck, the presence of ulceration, increasing Breslow thickness, older age, and male sex are associated with increased risk of recurrence, despite a negative sentinel lymph node biopsy result.

The RET G691S polymorphism is a germline variant in desmoplastic malignant melanoma

The RET protooncogene was originally identified in 1985. It encodes for a receptor tyrosine kinase. The RET receptor is activated by its ligand glial cell-derived neurotrophic factor. A polymorphism, RETp (G691S), in the intracellular juxtamembrane domain of RET, which enhances signaling by glial cell-derived neurotrophic factor has been described and studied previously in pancreatic cancer, medullary thyroid cancer, the multiple endocrine neoplasia 2 syndromes, and recently in cutaneous malignant melanoma. In particular, it has been shown that desmoplastic melanomas, which have neurotrophic features, have a high frequency of this polymorphism. In previous studies, however, it was not clear whether this was a germline or somatic change. Previous studies on pancreatic cancer indicated that both mechanisms may occur. To clarify this further we examined peripheral blood cell DNA from 30 patients with desmoplastic melanomas and 30 patients with nondesmoplastic melanoma for the RETp. In this study, a germline polymorphism was found in 30% of the patients with desmoplastic melanomas and 21% of the patients with nondesmoplastic melanoma. These findings indicate that the RETp may be a genetic risk factor for the development of desmoplastic melanoma.

A neoadjuvant biochemotherapy approach to stage III melanoma: analysis of surgical outcomes

AIMS Completion lymph node dissection (CLND) and adjuvant therapy are recommended for node-positive melanoma patients. We sought to analyze our institutions experience with neoadjuvant biochemotherapy in stage III patients. METHODS Clinical information was extracted from a retrospective database on stage III melanoma patients. Eligible patients received two cycles of biochemotherapy prior to their CLND. RESULTS There were 153 patients available for analysis. The average tumor depth was 2.5 mm. More than half of all patients presented with sentinel lymph node-positive disease. Surgical complications occurred in 23% of patients. Patients who experienced an adverse event during their neoadjuvant therapy had a worse overall survival when compared with those who did not (p = 0.005). CONCLUSION Our data suggest that aggressive neoadjuvant treatment prior to CLND does not impact surgical complications. Our surgical outcomes are similar to the current literature when adjuvant therapy is used in stage III melanoma. The inability to tolerate neoadjuvant therapy in stage III melanoma is a negative prognostic indicator.

Patterns of Fractionation and Boost Usage in Adjuvant External Beam Radiotherapy for Ductal Carcinoma in Situ in the United States

Micro‐Abstract Among 101,615 American women with ductal carcinoma in situ diagnosed from 2004 through 2014, the use of hypofractionated radiotherapy after surgery increased, while that of boost decreased. However, conventional fractionation with a boost remained the most common strategy used. Both clinical factors, including age and pathologic features, and nonclinical factors, including income, facility type, and facility volume, were associated with these patterns. Background: While the roles of hypofractionated (HFxn) radiotherapy and lumpectomy boost in the adjuvant management of invasive breast cancer are supported by the results of clinical trials, randomized data supporting their use for ductal carcinoma in situ (DCIS) are forthcoming. We sought to evaluate current national trends and identify factors associated with HFxn and boost usage using the National Cancer Database. Patients and Methods: We queried the National Cancer Database for women diagnosed with DCIS from 2004 to 2014 undergoing external beam radiotherapy after breast conservation surgery. Patients were categorized as receiving either conventional fractionation (CFxn) or HFxn and as either receiving or not receiving a boost. Multiple logistic regression was performed to identify demographic, clinical, and treatment factor associations. Results: A total of 101,615 women were identified, with 87,641 (86.2%) receiving CFxn, 13,974 (13.8%) receiving HFxn, and most patients in each group (84.9% and 57.7%, respectively) receiving a boost. Implementation of HFxn increased from 4.3% in 2004 to 33.0% in 2014, and the use of a boost declined from 83.3% to 74.6%. HFxn receipt was independently associated with later year of diagnosis, older age, higher income, greater distance from treatment facility, greater facility volume, academic facility type, Western residence, smaller lesions, and nonreceipt of a boost. Factors associated with boost receipt included earlier year of diagnosis, younger age, higher income, community facility type, adverse pathologic features, and nonreceipt of HFxn. Conclusion: Although CFxn with a boost remains the most common external beam radiotherapy strategy for DCIS, implementation of HFxn without a boost appears to be increasing. Practice patterns at present seem to be driven by guidelines for invasive breast cancer and nonclinical factors.

Implications of Sentinel Lymph Node Drainage to Multiple Basins in Head and Neck Melanoma

BackgroundSentinel lymph node biopsy (SLNB) for head and neck melanoma is challenging due to unpredictable drainage. We sought to determine the frequency of drainage to multiple lymphatic basins and asked if this was associated with prognosis in a large, single-center cohort.MethodsWe queried patients diagnosed with head and neck melanomas who had a SLNB performed from January 1998 to April 2016. Demographic and clinical characteristics were compared using Student’s t test, Pearson chi-square analysis, log-rank test, Wilcoxon-Mann–Whitney test, and Kaplan–Meier curves.ResultsWe identified 269 patients with head and neck melanoma that had SLNBs performed in the following locations: 223 neck, 92 parotid/preauricular, 29 occipital/posterior auricular, 1 axilla. There were 68 (25%) patients who had drainage to multiple basins. These patients were similar to those with single basin drainage in age, gender distribution, Breslow depth, and percent with a positive SLNB (all p > 0.05). Fewer patients with drainage to multiple basins had a completion lymph node dissection (CLND, p = 0.03). A trend toward increased 3-year locoregional recurrence was seen for patients with drainage to multiple basins in univariate analysis (27% vs. 18%, p = 0.10) but was lost in multivariate analysis (p = 0.49), possibly because of higher recurrence rates in patients with positive nodes but no CLND (p = 0.02). No difference was detected for distant recurrence or overall survival based on SLN drainage.ConclusionsHead and neck melanoma SLNB drainage to multiple basins is common. Drainage to multiple basins does not seem to be associated with increased sentinel lymph node positivity, locoregional recurrence, distant recurrence, or survival.

Analysis of melanoma recurrence following a negative sentinel lymph node biopsy

Little attention has been paid to the characteristics and outcomes of patients who experience distant, local or regional recurrence of melanoma following a negative sentinel lymph node biopsy. This article aims to review the published literature on the topic and presents some general summaries regarding this patient population. Patients who experience a disease recurrence following a negative sentinel lymph node biopsy have a worse overall survival compared with patients with a positive sentinel lymph node biopsy. The implications and possible explanations for these findings are discussed in order to both underscore the need for in-depth investigation of local, regional or distant melanoma recurrence among patients following a true negative sentinel lymph node biopsy, as well as increased efforts to minimize the rate of false negative sentinel lymph node biopsies.

Abstract A98: Young women's breast cancer demonstrates increased immune suppression through ciculating regulatory T cells and myeloid-derived supressor cells independent of stage or subtype.

Background: Women age 20-40 have a higher ten year risk for developing breast cancer than the five other leading cancers in this gender and age group combined. Women currently in their 30s have a 1/203 risk for breast cancer in the ensuing ten years. Cancers diagnosed in this age population of breast cancer have a higher risk for death for reasons that are not fully identified. Regulatory T cell (Tregs) and myeloid derived suppressor cells (MDSC) have a role in suppressing anti-tumor immunity. MDSC function through Jak/Stat pathway activation by generation of reactive oxygen species and/or arginase-1, and have been correlated pre-clinically with cancer progression and poorer prognostic features and outcomes. Our Young Womens Breast Cancer Translational Program seeks to identify immunologic differences potentially contributing to the poorer prognosis and potential targets for development of immunomodulatory treatment. Hypothesis: We hypothesized that newly diagnosed, treatment-naive young breast cancer cases would have higher percentage of circulating Tregs and MDSC with T cell suppressive function that similar age women without breast cancer. Methods: We conducted an IRB-approved, prospective translational study of women age 40 and under both affected and unaffected by breast cancer. Exclusion criteria included pregnancy, known autoimmunity or immunosuppressive medications, or other cancers. Tregs and MDSC were isolated from peripheral blood and phenotyped through standard protocols. The ability of MDSC to suppress T cell function were tested in co-culture assays for expression of activation marker CD25, production of gamma-interferon and production of arginase-1 and generation of reactive oxygen species. Results: As expected, Tregs were in higher number in young women with breast cancer than unaffecteds. Contrary to prior publications no difference was detected in number of MDSC identified in breast cancer (n=61) versus unaffected subjects (n=18). However, statistically significant increase in the MDSC ability to suppress T cell activation was identified in the breast cancer cohort with decreased CD25 expression and gamma-interferon production. MDSC from young women with breast cancer also secreted higher arginase-1 but not ROS from their MDSC. Level of MDSC suppression was independent of stage or biologic subtype of the breast cancer and did not correlate with the level of Tregs in the patient. Conclusions: The presence of equal rather than higher numbers of MDSC circulating in young onset breast cancer versus unaffected subjects was unexpected in comparison to prior publications. Our results may differ due to our larger sample size or the alignment by gender and age between the cohorts. Also, these are the first data on Tregs and MDSC to specifically focus on a young female population. Despite the equal numbers, MDSC from the breast cancer cohort demonstrated increased ability to suppress T cell function which was independent of cancer stage, biologic subtype or number of Tregs in the subject. These data suggest a functional difference to MDSC in the young breast cancer-bearing woman that could be exploited in even early stage breast cancer and that is not directly dependent on Tregs numbers. Moreover, the data indicate that unaffected young women have a higher than expected number of MDSC available for cancer to usurp and induce immune suppression. Identification of secretion of arginase-1 as a potential mechanism of immune suppression in young womens breast cancer warrants further investigation. Citation Format: Virginia F. Borges, Oscar Ramirez, Michelle Borakove, Elizabeth Manthey, Christina Finlayson, Anthony Elias, Martin McCarter, Kimberley Jordan, Jennifer Diamond, Nicole Kounalakis. Young womens breast cancer demonstrates increased immune suppression through ciculating regulatory T cells and myeloid-derived supressor cells independent of stage or subtype. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology: Multidisciplinary Science Driving Basic and Clinical Advances; Dec 2-5, 2012; Miami, FL. Philadelphia (PA): AACR; Cancer Res 2013;73(1 Suppl):Abstract nr A98.

Abstract P4-04-06: Young women's breast cancer is characterized by increased immune suppression through circulating myeloid derived supressor cells

Background: Women age 20–40 have a higher ten-year risk for developing breast cancer than the five other leading cancers in this gender and age group combined. Women currently in their 30s have a 1/203 chance of developing breast cancer over the next ten years. Moreover, cancers diagnosed in younger women have a signficantly higher risk of death for reasons that are not fully identified. Myeloid derived suppressor cells (MDSC) have a role in suppressing anti-tumor immunity through Jak/Stat pathway activation by generation of reactive oxygen species (ROS) and arginase-1, and correlate preclinically with cancer progression and in human canceres with poorer prognositic features and outcomes. Our Young Women9s Breast Cancer Translational Program seeks to identify immunologic differences potentially contributing to the poorer prognosis and potential targets for development of immunomodulatory treatment. Hypothesis: We hypothesized that newly diagnosed, treatment-naive young breast cancer cases would have higher percentage of circulating MDSC with T cell suppressive function than similar age women without breast cancer. Methods: We conducted IRB approved, prospective translational studies of women age 40 and under both affected and unaffected by breast cancer. Exclusion criteria included pregnancy, known autoimmunity or immunosuppressive medications, or other cancers. MDSC were isolated from peripheral blood and phenotyped through standard protocols. T cell suppressive abilites were tested in coculture assays for expression of activation markers CD25 and CD69, and production of gamma-interferon. Identification of mechanism of suppression was assayed through secretion of arginase-1and generation of ROS. Results: No difference in percentage of MDSC was identified between young women with breast cancer (n = 61) and unaffected subjects (n = 18). However, a statistically significant increase in the MDSC ability to suppress T cell activation was identified in the breast cancer cohort with diminished CD25 and CD69 expression and diminished production of gamma-interferon. MDSC from young breast cancer subjects secreted significantly more arginase-1 from MDSC. No significant difference in generation of ROS was found between the two cohorts. Conclusions: The presence of equal rather than higher numbers of circulating MDSCs between the young breast cancer versus unaffected subjects was unexpected in comparison to prior publications on MDSC in cancer. Our results may differ due to our larger sample size or the alignment by gender and age the cohorts being more representative. Also, these are the first data on MDSC in a young female population. Despite equal numbers of MDSCs, the functional analyses demonstrate MDSC isolated from breast cancer have enhanced T cell suppression capabilities compared with normal controls. These data provacatively suggest a functional difference inherent to MDSC in the young breast cancer-bearing host. Moreover, they indicate that normal young women have realtively high levels of MDSC that are available for cancer to ursurp and induce immune suppression. Identification of secretion of arginine-1 as a potential mechanism of immune supporession in young women9s breast cancer warrants further investigation. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-04-06.

Abstract C78: A variant of the oncogene RET might be a molecular target in BRAFwt melanoma cells.

Desmoplastic malignant melanomas (DMM) are clinically, pathologically, and molecularly different from other melanomas. Patients with this subset of melanoma are generally older, with tumors exhibiting deeper levels of invasion, a low incidence of nodal involvement, and tend to track along nerves. Previous studies indicate that DMM tumors have a low prevalence of BRAFV600E mutations making them ineligible for targeted therapies with BRAF inhibitors. The oncogene RET is a tyrosine kinase receptor mainly associated with neuroendocrine cancers and is activated by the ligand glial cell-derived neurotrophic factor (GDNF). Numerous studies suggest that given the neurotrophic features of DMM, a variant of RET (G691S, designated RETp) may be a potential molecular target. We examined human melanoma cell lines for RETp and the BRAFV600E mutation and demonstrated that these molecular changes were usually discordant suggesting that RETp might be an attractive molecular target in BRAFwt cells. Further we hypothesized that in tumors with the RETp genotype, certain TKIs may be more effective in inhibiting cell growth in environments rich with GDNF. We screened various melanoma cell lines with and without the RETp genotype and determined their response to clinically available small molecular weight inhibitors. The cell viability effects were accessed in the presence and/or absence of the RET co-receptor, GFRa1, and ligand, GDNF. We show that in cell lines carrying the RETp genotype, GDNF alone increases cell proliferation, and certain small molecular weight inhibitors may be more effective at inhibiting melanoma cell growth in environments rich in GDNF. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C78.

A germ line polymorphism in the RET proto-oncogene predicts risk and recurrence in desmoplastic melanoma.

8558 Background: Desmoplastic malignant melanoma (DMM) has a unique pathological and clinical behavior which distinguishes it from other melanomas. DMM has a low incidence of nodal involvement, a significantly higher local recurrence rate and a predilection for perineural invasion. GDNF, glial cell line-derived neurotrophic factor, is a major ligand for the RET proto-oncogene and acts as a neural growth factor. GDNF has a germline polymorphism at G691S juxtamembrane region (RETp) which is frequently found in cutaneous melanoma. We propose that the presence of RETp in peripheral blood is associated with an increased risk for the development of desmoplastic melanoma and also predicts a greater risk for locoregional recurrence. METHODS Clinical and pathological data were extracted from a retrospective data base of patients with DMM treated from 2005-present. Blood samples were available from 60 patients and were analyzed for RETp using polymerase chain reaction. RESULTS RETp was detected in the peripheral blood samples of 32% of patients with DMM and 23% of patients without DMM. In those patients with DMM and RETp, 43% experienced either a systemic or local recurrence. When DMM occurred without the presence of RETp, the rate of local or distant recurrence was zero. Median follow up was 3.8 years for all 60 patients. CONCLUSIONS These studies suggest that the germline polymorphism RETp may be a predisposing factor to development of DMM and predicts a greater risk for both local and distant recurrence after surgical resection. Future studies are warranted to further understand the role of RETp in DMM.