Recurrence patterns in patients with Stage II melanoma: The evolving role of routine imaging for surveillance

Abstract

Background and Objectives: The relatively recent availability of effective systemic therapies for metastatic melanoma necessitates reconsideration of current surveillance patterns. Evidence supporting surveillance guidelines for resected Stage II melanoma is lacking. Prior reports note routine imaging detects only 21% of recurrent disease. This study aims to define recurrence patterns for Stage II melanoma to inform future surveillance guidelines. Methods: This is a retrospective study of patients with Stage II melanoma. We analyzed risk factors for recurrence and methods of recurrence detection. We also assessed survival. Yearly hazards of recurrence were visualized. Results: With a median follow-up of 4.9 years, 158 per 580 patients (27.2%) recurred. Overall, most recurrences were patient-detected (60.7%) or imagingdetected (27.3%). Routine imaging was important in detecting recurrence in patients with distant recurrences (adjusted rate 43.1% vs. 9.4% for local/in-transit; p = .04) and with Stage IIC melanoma (42.5% vs. 18.5% for IIA; p = .01). Male patients also self-detected recurrent disease less than females (52.1% vs. 76.8%; p < .01). Conclusions: Routine imaging surveillance played a larger role in detecting recurrent disease for select groups in this cohort than noted in prior studies. In an era of effective systemic therapy, routine imaging should be considered for detection of asymptomatic relapse for select, high-risk patient groups.

18F‐FDG positron emission tomography–computed tomography has a low positive predictive value for detecting occult recurrence in asymptomatic patients with high‐risk Stages IIB, IIC, and IIIA melanoma

“…Thus, it is likely that the Nx group did not truly have undetected higher-stage primary Five-year survival rates in our cohort paralleled those of prior studies, but recurrence rates were lower than expected. [2][3][4][5][6][7] The present study focuses primarily on routine 18 F-FDG PET/CT for Stages IIB, IIC, and IIIA, while prior studies investigating the role of PET in melanoma surveillance have reported different ranges of A strength of this study is the emphasis on the predictive values of routine 18 F-FDG PET/CT as a marker of the clinician's confidence in the effectiveness to detect asymptomatic recurrence or reassure asymptomatic patients. A high NPV in this cohort provides patient reassurance after negative results, whereas a relatively high FP rate in this particular patient population clouds the clinical decision-making process after positive results.…”

“…A recent study found benefits for CT surveillance in Stage II melanoma, but prospective comparative studies between 18 F-FDG PET/CT and CT are needed to address the question of which modality is superior for this patient population. 3 Increased melanoma survivorship due to increasing incidence and a stable mortality rate has led to a greater need for surveillance. 29 Multidisciplinary care by the dermatologist, surgical oncologist, and medical oncologist is essential for patients with high-risk Stages II and III melanoma.…”

“…33 Those with nodal recurrence detected by the routine As noted in the AJCC 8th edition staging guidelines and recent studies, Stage IIC demonstrates a higher recurrence rate (44%-4%) than those of Stages IIB and IIIA (29%-45% and 30%-46%, respectively) and lower 5-year MSS. [2][3][4][5][6][7]33 Although lymph node involvement is a powerful predictor of recurrence in melanoma, T3b, T4a, and T4b tumors portend a worse prognosis than does micrometastatic nodal disease. 34 35 Neoadjuvant therapy and optimal sequencing of current targeted and immune therapies are also areas of active investigation.…”

“…1 Five-year melanoma-specific survival (MSS) rates for Stages IIB, IIC, and IIIA are 87%, 82%, and 93%, respectively, with high recurrence rates ranging from 29% to 45%, 44% to 74%, and 30% to 46%, respectively. [2][3][4][5][6][7] Primary treatment for Stages II and IIIA melanoma is surgical excision with sentinel lymph node biopsy (SLNB), and close multidisciplinary follow-up is essential to monitor for recurrence. 8,9 Adjuvant immunologic therapies may also be considered in patients at high risk of relapse.…”

“…19 Routine CT has shown clinical benefit for following patients with Stages IIB and IIC melanoma, but it remains unclear whether routine 18 F-FDG PET/CT surveillance for these stages is useful. 3 Previous studies have shown that 18 F-FDG-PET/CT has a high negative predictive value (NPV) of 80%-98%; however, a wider range of uncertainty surrounds its positive predictive value (PPV) of approximately 56%-86%, due to significant heterogeneity between prior study designs and stages included. [21][22][23][24][25][26] In other words, while negative results tend to accurately report the absence of recurrence, errors more often arise in interpreting the clinical course of action for positive results that may not represent true recurrence.…”