Surgical Treatment of Sinonasal Mucosal Melanoma in Patients Treated with Systemic Immunotherapy

Abstract

Objectives Surgical resection is widely accepted as a critical component for definitive treatment of sinonasal mucosal melanoma. Systemic immunotherapy, including multiple newer agents, has been used to treat metastatic or unresectable disease. In this study, we examine its efficacy in locoregional control when used in conjunction with surgical resection for primary mucosal lesions. Design Present study is a retrospective review of all patients at a tertiary academic medical center with primary sinonasal mucosal melanoma and distant metastatic disease. Results A total of four patients were identified. In all cases, patients were treated with a combination of surgical resection of the primary tumor and systemic immunotherapy. Three patients were initially treated with surgery at the primary site followed by immunotherapy for distant metastases. Response to immunotherapy at the sites of primary and metastatic disease was seen in two patients. All four patients developed progression or recurrence at the primary site following initiation of immunotherapy for which they underwent surgical resection. One patient remains in follow-up without evidence of disease 20 months after initial treatment; three succumbed to the disease at 135, 37, and 16 months after initial treatment. Conclusion Surgical resection for local control plays a critically important role in the treatment of sinonasal mucosal melanoma regardless of the presence of metastases and whether immunotherapy will be given. This case series suggests that, though immunotherapy may demonstrate efficacy in managing distant disease, surgery should remain the first-line treatment for the primary site.

Sinonasal malignant melanoma

“…The treatment of choice is ablative surgery with free resection margins. However, the complex anatomy of the sinonasal cavities near some vital structures makes it impossible to obtain tumor-free resection margins, with important aesthetic and functional sequelae, unjustified by a distant metastasis rate of more than 40% [12][13][14][15] . The approach used may be endoscopic, external, or combined, depending on the extent of the lesion.…”

“…Irradiation dose information and technique are inconsistent in the current literature. In contrast, stereotactic radiotherapy (1,200 cGy in 2 fractions) is recommended for adrenal metastasis 15 . Systemic therapy does not bring the desired effects in survival 16 .…”

“…Immunotherapeutic agents are usually indicated in metastatic disease and to control local recurrence 16 . Interleukin 2 and interferon alpha-2 adjuvants for systemic chemotherapy have not been shown to be effective 15 . Checkpoint inhibitors (nivolumab, ipilimumab) in combination have been shown to be more effective than single administration 17 .…”

Adjuvant Therapy and Prognosticators of Survival in Head and Neck Mucosal Melanoma

“…In contrast, other studies suggest that immunotherapy may confer an OS benefit, but only for patients with metastatic disease. In a retrospective study of four sinonasal mucosal melanoma patients with distant metastases treated with primary surgery and immunotherapy, Chao and colleagues reported that immunotherapy may improve clinical outcomes for patients with metastatic disease, but concluded that surgery remains the best upfront treatment 34 . Additionally, a recent analysis of the NCDB by Ganti et al found that immunotherapy use was associated with improved OS in patients with metastatic sinonasal mucosal melanoma 17 .…”

“…In a retrospective study of four sinonasal mucosal melanoma patients with distant metastases treated with primary surgery and immunotherapy, Chao and colleagues reported that immunotherapy may improve clinical outcomes for patients with metastatic disease, but concluded that surgery remains the best upfront treatment. 34 Additionally, a recent analysis of the NCDB by Ganti et al found that immunotherapy use was associated with improved OS in patients with metastatic sinonasal mucosal melanoma. 17 Similarly, a multicenter retrospective study of 229 metastatic mucosal melanoma patients observed that those receiving immunotherapy had significantly improved OS compared to those receiving chemotherapy.…”