James A Pasch, Wendy Liu, Shahrir Kabir, Thomas Pennington
{"title":"Approaches to Surgical Management of Anorectal Melanoma in the Pre- and Post-Immunotherapy Eras.","authors":"James A Pasch, Wendy Liu, Shahrir Kabir, Thomas Pennington","doi":"10.1097/DCR.0000000000003690","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Whilst revolutionary in cutaneous melanoma, immune checkpoint inhibitors have shown reduced efficacy in anorectal melanoma. Nevertheless, their emergence, and the possibility of improved outcomes, may have changed the surgical management paradigm.</p><p><strong>Objective: </strong>To review the surgical management of anorectal melanoma in pre- and post-immunotherapy eras.</p><p><strong>Design: </strong>A retrospective cohort study from the Melanoma Institute Australia Research Database.</p><p><strong>Settings: </strong>A quaternary melanoma referral center.</p><p><strong>Patients: </strong>Patients with anorectal melanoma from 1958 to 2021.</p><p><strong>Interventions: </strong>The use of abdominoperineal resection and wide local excision were compared in pre- and post-immunotherapy eras from first use in 2014.</p><p><strong>Main outcome measures: </strong>Type of surgery performed over time and overall survival.</p><p><strong>Results: </strong>A total of 56 patients were identified with anal (57.1%), anorectal (16.1%) and rectal melanoma (26.8%). Initial management was abdominoperineal resection (37.5%), low anterior resection (3.6%), wide local excision (46.4%) and non-surgical (12.5%) in metastatic or unresectable disease. Immunotherapy and targeted therapies were utilized in 21 patients (37.5%) from 2014 with no difference in mode of surgical management in pre- and post-immunotherapy eras (p = 0.134). Five-year survival was 12.5% for the entire cohort with no significant difference comparing patients receiving wide local excision or abdominoperineal resection (15.4% vs. 14.3%, log rank p = 0.77). Involved margins were significantly associated with wide local excision (15.4% vs. 4.8% p = 0.016) with similar rates of local recurrence (15.4% vs. 14.3% p = 0.58).</p><p><strong>Limitations: </strong>Anorectal melanoma is rare thus we present a small cohort managed across eight decades. Early checkpoint inhibitor trials excluded mucosal melanoma patients, limiting access in this cohort.</p><p><strong>Conclusions: </strong>Despite the introduction of immunotherapy, surgery remains pivotal in the management of anorectal melanoma. Surgical resection may be curative and prevent morbidity due to locoregional progression but can come at a cost of reduced quality of life. Centralized management in experienced centers should be encouraged for optimal multi-disciplinary management. See Video Abstract.</p>","PeriodicalId":11299,"journal":{"name":"Diseases of the Colon & Rectum","volume":" ","pages":""},"PeriodicalIF":3.2000,"publicationDate":"2025-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Diseases of the Colon & Rectum","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/DCR.0000000000003690","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"GASTROENTEROLOGY & HEPATOLOGY","Score":null,"Total":0}
引用次数: 0
Abstract
Background: Whilst revolutionary in cutaneous melanoma, immune checkpoint inhibitors have shown reduced efficacy in anorectal melanoma. Nevertheless, their emergence, and the possibility of improved outcomes, may have changed the surgical management paradigm.
Objective: To review the surgical management of anorectal melanoma in pre- and post-immunotherapy eras.
Design: A retrospective cohort study from the Melanoma Institute Australia Research Database.
Settings: A quaternary melanoma referral center.
Patients: Patients with anorectal melanoma from 1958 to 2021.
Interventions: The use of abdominoperineal resection and wide local excision were compared in pre- and post-immunotherapy eras from first use in 2014.
Main outcome measures: Type of surgery performed over time and overall survival.
Results: A total of 56 patients were identified with anal (57.1%), anorectal (16.1%) and rectal melanoma (26.8%). Initial management was abdominoperineal resection (37.5%), low anterior resection (3.6%), wide local excision (46.4%) and non-surgical (12.5%) in metastatic or unresectable disease. Immunotherapy and targeted therapies were utilized in 21 patients (37.5%) from 2014 with no difference in mode of surgical management in pre- and post-immunotherapy eras (p = 0.134). Five-year survival was 12.5% for the entire cohort with no significant difference comparing patients receiving wide local excision or abdominoperineal resection (15.4% vs. 14.3%, log rank p = 0.77). Involved margins were significantly associated with wide local excision (15.4% vs. 4.8% p = 0.016) with similar rates of local recurrence (15.4% vs. 14.3% p = 0.58).
Limitations: Anorectal melanoma is rare thus we present a small cohort managed across eight decades. Early checkpoint inhibitor trials excluded mucosal melanoma patients, limiting access in this cohort.
Conclusions: Despite the introduction of immunotherapy, surgery remains pivotal in the management of anorectal melanoma. Surgical resection may be curative and prevent morbidity due to locoregional progression but can come at a cost of reduced quality of life. Centralized management in experienced centers should be encouraged for optimal multi-disciplinary management. See Video Abstract.
期刊介绍:
Diseases of the Colon & Rectum (DCR) is the official journal of the American Society of Colon and Rectal Surgeons (ASCRS) dedicated to advancing the knowledge of intestinal disorders by providing a forum for communication amongst their members. The journal features timely editorials, original contributions and technical notes.