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Laparoscopic-Assisted Resection of Metastatic Cutaneous Melanoma to the Small Intestine Is Safe and Effective
Meghan Forster*, Kendall W. Carpenter, Jonathan Salo, Joshua Hill, Terry Sarantou, Richard L. White
Surgical Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC
Introduction: Melanoma metastasizes to the gastrointestinal (GI) tract in only 2-4% of patients, but about 50% of people who die of Stage IV melanoma have GI involvement. The median overall survival of patients with nonpulmonary visceral metastases is only 5-11 months. Multiple randomized prospective trials have shown laparoscopic resection for colon cancer is not inferior to open surgery in either survival or recurrence rates. We undertook a review of our experience with laparoscopic small bowel melanoma metastasectomy, with special attention to morbidity and oncologic outcomes.
Methods: Patients who underwent laparoscopic-assisted resection of small bowel melanoma metastases at our institution from January 1, 2006 to September 30, 2013 were retrospectively reviewed. Collected data included patient and primary tumor characteristics, symptoms, hospital length of stay, post-operative morbidity, progression-free survival (PFS), and overall survival.
Results: Twenty-five patients underwent laparoscopic-assisted resection of small bowel melanoma metastases. The median age was 52 years, median Breslow depth of primary melanomas was 2.38mm, and 7 patients (28%) had regional nodal metastases at the time of diagnosis. The median time from diagnosis to development of small bowel metastasis was 48.4 months. Thirteen patients (52%) had one or more preoperative symptoms, the most common being GI bleeding (9 patients), abdominal pain (5 patients), and obstruction (3 patients). Most were diagnosed with small bowel metastases by PET scan (72%). Of the 25 patients, 6 (24%) underwent curative resection of all metastatic sites, while19 (76%) underwent resection for palliation. Median overall survival in the curative group vs. the palliative group approached significance, and PFS was significantly longer in the curative group (median not yet reached, HR 3.786, p = 0.026). There was one mortality on day 18 after surgery in a patient with small bowel and brain metastases who underwent urgent surgery due to obstruction, developed Acinetobacter pneumonia, sepsis and a cerebellar infarct. One patient developed a wound infection, and one on warfarin had a GI bleed 2 weeks post-operatively, leading to resection of the 2 prior anastomoses. Median post-operative hospital stay was 5 days. Over a median follow up of 14.9 months, no patient developed a trocar site melanoma recurrence. Of those who underwent resection with curative intent, 2(33%) developed a small bowel recurrence, both also had additional sites of disease.
Conclusions: This series of laparoscopic-assisted small bowel resections for metastatic melanoma shows it to be safe, with minimal mortality and morbidity and short post-operative lengths of stay. Oncologic outcomes are acceptable, and curative surgery was associated with durable disease-free intervals, as seen in prior large series.
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