Tuesday, August 9, 2022

Surgery After Systemic Treatment for Melanoma

 In this time of neo-adjuvant treatment for melanoma, two concepts are at odds with previous melanoma treatment plans.  

1.  The response to therapy may be better by actually leaving the tumor in place.  

2.  The premise that by waiting on surgery, the treatment may decrease the size of the lesion (and thereby diminish the size/damage from said surgery) or perhaps evaporate the lesion altogether so that surgery is not needed at all.  The impact of these new aspects of melanoma treatments makes decisions about surgery for melanoma even more complicated.  Here are zillions of reports about neoadjuvant treatment:  Neo-Adjuvant treatment for melanoma  That said - there are plenty of good reasons to have surgery to remove your melanoma lesions.  We know that, neo-adjuvant care aside, folks with the lowest tumor burden respond better.  We know that sometimes, one lesion remains persistently present even if all other lesions resolve.  Some patients will become NED after systemic treatment but later develop a lesion.  There are folks who haven't responded well to systemic therapy may need radiation and surgery to tackle their lesions.  The varied reasons for needing surgery are just as mixed as melanoma can be itself.  Still, there is a significant body of evidence indicating the benefit of the adage - "When in doubt, cut it out!" 

There is this from 2019 ~ Cut it out!!! Prolonged overall survival following metastasectomy in Stage IV melanoma

And this from 2020 ~ Surgical removal of melanoma lesions -

That said, there are these reports on varied circumstances that looked at surgery and melanoma patients:

Re-defining the role of surgery in the management of patients with oligometastatic stage IV melanoma in the era of effective systemic therapies.  Ch’ng, Uyulmaz, Carlino,…Long, Menzies.  Eur J Cancer.  Aug  2021.

Although previously the mainstay of treatment, the role of surgery in the management of patients with oligometastatic stage IV melanoma has changed with the advent of effective systemic therapies (most notably immunotherapy). Contemporary treatment options for patients with asymptomatic solitary or oligo-metastases include upfront surgery followed by adjuvant immunotherapy or upfront immunotherapy with salvage surgery as required. For suspected solitary or oligo-metastases, surgery serves both diagnostic and therapeutic purposes. Advances in radiological technology allow metastases to be detected earlier and surgery to be less morbid. Surgical morbidities are generally more tolerable than serious immune-related adverse effects, but surgery may be less effective. Upfront immunotherapy ensures that futile surgery is not offered for rapidly progressive disease. It also provides an opportunity to assess response to treatment, which predicts outcome, and may obviate the need for surgery. However, it is important not to miss a window of opportunity for surgical intervention, whereby if disease progresses on immunotherapy it becomes unresectable. In situations where local therapy is recommended but surgery is not desired, stereotactic radiosurgery may be an effective alternative. The decision-making process regarding upfront surgery versus immunotherapy needs to take place within a specialist melanoma multidisciplinary setting and be customized to individual patient and tumor factors. Ultimately, high-level clinical trial evidence is required to resolve uncertainties in the management of patients with oligometastatic stage IV melanoma but the complexity of the varying presentations may make trial design challenging.

Survival Outcomes of Salvage Metastasectomy After Failure of Modern-Era Systemic Therapy for Melanoma.  Li, Vakharia, Lo, et al.  Ann Surg Oncol.  Aug 2021.

Background: Metastasectomy for selected patients with melanoma was associated with improved survival in the era before effective systemic therapy. Emerging evidence shows that these benefits persist even in this era of BRAF-targeted therapy and immune checkpoint inhibitor immunotherapy. This study aimed to evaluate the outcomes of salvage metastasectomy after failure of systemic therapy.

Methods: Stage 3 or 4 melanoma patients with extracranial disease progression after at least 4 weeks of systemic treatment between 2009 and 2020 were identified and categorized as resected to no evidence of disease (NED), non-progressive residual disease (NPRD), or progressive residual disease (PRD). Systemic therapy was stratified into BRAF-targeted therapy, immune checkpoint inhibitor immunotherapy, or both. The end points of overall survival (OS), progression-free survival (PFS), and locoregional disease control (LRC) were assessed using Kaplan-Meier curves. Uni- and multivariable Cox regression procedures were used to examine factors associated with OS, PFS and LRC.

Results: The study enrolled 190 patients. Among all the patients, the 5-year OS from metastatectomy was 52%, the 3-year PFS was 21%, and the 5-year LRC was 61%. After resection to NED, NPRD, and PRD, the 5-year OS values were 69%, 62% and 8%, respectively. Fewer lines of preoperative therapy, use of preoperative immunotherapy, and resection to NED were predictors of improved OS. After resection to NED, NPRD, and PRD, the 3-year PFS values were 23%, 24% and 10%, and the 5-year LRC values were 61%, 72% and 34%, respectively.

Conclusions: Salvage metastasectomy was associated with durable survival and disease control, particularly after resection to NED, preoperative immunotherapy, and fewer lines of preoperative systemic therapy

The role of local therapy in the treatment of solitary melanoma progression on immune checkpoint inhibition: A multicentre retrospective analysis.  Versluis, Hendriks , Weppler, et al..  Eur J Cancer. 2021 Jul.

Introduction: In patients with metastatic melanoma, progression of a single tumour lesion (solitary progression) after response to immune checkpoint inhibition (ICI) is increasingly treated with local therapy. We evaluated the role of local therapy for solitary progression in melanoma.

Patients and methods: Patients with metastatic melanoma treated with ICI between 2010 and 2019 with solitary progression as first progressive event were included from 17 centres in 9 countries. Follow-up and survival are reported from ICI initiation.

Results: We identified 294 patients with solitary progression after stable disease in 15%, partial response in 55% and complete response in 30%. The median follow-up was 43 months; the median time to solitary progression was 13 months, and the median time to subsequent progression after treatment of solitary progression (TTSP) was 33 months. The estimated 3-year overall survival (OS) was 79%; median OS was not reached. Treatment consisted of systemic therapy (18%), local therapy (36%), both combined (42%) or active surveillance (4%). In 44% of patients treated for solitary progression, no subsequent progression occurred. For solitary progression during ICI (n = 143), the median TTSP was 29 months. Both TTSP and OS were similar for local therapy, ICI continuation and both combined. For solitary progression post ICI (n = 151), the median TTSP was 35 months. TTSP was higher for ICI recommencement plus local therapy than local therapy or ICI recommencement alone, without OS differences.

Conclusion: Almost half of patients with melanoma treated for solitary progression after initial response to ICI had no subsequent progression. This study suggests that local therapy can benefit patients and is associated with favourable long-term outcomes.

For what it's worth!!  Hang tough.  Melanoma is never easy, but there is hope. - c

Sunday, August 7, 2022

Summer time and the living is...

 ...hot...and fun...and worrying (What is happening here in the states, people????) ...and busy...and full of growing babies!!!  As B was leaving the house the other day, he called me to get a peek of these two!

The little one has grown so much, while Momma has a taste for flowers!  She has moved on from the hostas she started with, to buds and blossoms from lilies to roses - yes, the actual flowers!!!  Delish!!!

Despite what we have fed to critters, we did have a pretty good crop of tomatoes this year!  Corn and zucchini are from the market...

A little back to school sewing for my girl!  Are these not the cutest pockets ever?????
Did some serious bits of scrap/stash busting to add a few basics to Teach Moore's wardrobe!  A little sleeveless shift went with the pockets.  Made a sweet little top (already nabbed and taken home!) and this skirt from a remnant of the knit floral from one of her maternity dresses.  Re-vamped a black maternity skirt I had not terribly successfully designed to a rock'n pencil.  Stitched up a simple gathered skirt from the last smidge of a pretty blue dotted challis.  And though it is a bit lost in this vivid floral crepe left over from Roo's maternity/shower dress, I made this cute little gored skirt with a flat front and back elasticated waist.

Speaking of growing babies!  The Jammer certainly couldn't be left out of stash busting plans.  I stitched up these sweet little pants - a free pattern from Purl Soho - 

They are great!  That back gusset is just perfect for little diapered booties getting ready to crawl!

Other preparations have been made for the Jamboree as well.  Closets have been cleaned.  Porch floor sanded and re-stained.  Interior decluttered and baby proofed with space to roam.  Play stations set up.  And as prep for an outdoor Jammer space, B made these benches and table.  I finished the table top with tiles left over from a shower stall project. 

 All sturdy, climbable and indestructible!  Cute, too!  If I say so myself!!!

We are blessed in so many ways.  Ms. Turtle agrees!  Live and grow and love ~ chaotically! - les

Wednesday, August 3, 2022

Sew Chaotically ~ Annie #3 ~ The start to some stash/scrap busting tops

In 2017, I made two Tessuti Annie tops.  The first in a navy linen with sashiko embroidery to the bodice.  The second in a lined gauze with cross stich detail.  

When going through my stash, I found a cream piece of linen I had already cut out for another bodice and just enough of a pale blue linen scrap to finish it up.  So, I did!

This time I used a different sashiko design.  Thanks to Roo for help deciding the color palate!  Of course you need not embellish the front yoke, but I just can't resist!  Either way, Annies are PERFECT for summer!!!  Sew chaotically! - les

Tuesday, August 2, 2022

July Reads - began with lighter fare, after the heavy but important reads of June...

Paris for One - Jojo Moyes.  Short stories.  Okay.  Some better than others. Not close to "Me Before You" - but a nice diversion from recent heavier reading.

Trains and Lovers - Alexander McCall Smith.  Interesting dissertation on love - of various sorts.  McCall Smith - always able to preach without a sermon.

The Beekeeper's Apprentice - Laurie R. King.  Lovely introduction to Holmes in retirement and his young friend Russell.  King is able to keep the tenor of Arthur Conan Doyle's Holmes resonant without being redundant or reductive.  Enjoyed!

A Monstrous Regiment of Women - Laurie R. King.  This sadly felt incredibly pertinent to today's perils for women's rights as each chapter was introduced by incredibly infuriating quotes from all manner of men and the Bible deriding the rights and abilities of women, though they eventually morph into quotes that recognize female ability and what women accomplish daily.  As does Holmes.

The Marriage of Mary Russell - Laurie R. King.  Short story covering the only wedding possible for Holmes and Russell.  Nicely done.

Garment of Shadows - Laurie R. King.  Holmes and Russell - abduction and espionage in Morocco.  

Dreaming Spies - Laurie R. King.  Another Russell and Holmes tale, much of it taking place in Japan.

The Murder of Mary Russell - Laurie R. King.  Mostly the tale of Mrs. Hudson and Billy.  A nice addition to how Mrs. Hudson came to be Holmes' housekeeper!

Riviera Gold - Laurie R. King.  A continuation of Mrs. Hudson's story.  Not quite as good.  But loved getting to travel to Nice and Antibes again!!!

Everything I Never Told You - Celeste Ng.  The story of a Chinese American Family.  Their efforts to fit in, yet retain their culture in America as Americans.  The death of a daughter (no spoiler - it is revealed in the first sentence) unravels at least a portion of the secrets, expectations, and fears they (and we) fail to share with those we are closest to.

Crying in H Mart - Michelle Zauner.  Zauner shares her life growing up with her Korean mom and American dad.  Her difficulty fitting in - simultaneously desiring to be more Korean for her mom and aunts, yet more accepted as a regular American kid among her school mates.  Her teenage pull against her mom's exhortations, knowing all the while they are rooted in her mother's tremendous love for her.  Culminating in her mother's diagnosis, treatment and death from cancer.  Through it all, it was their powerful connection through their mutual love for Korean food that kept them close and in the end, allowed Zauner to cope with the loss of her mom.  Sharing H Mart with my girl made her story real and even more touching for me.

Read chaotically! ~ les

Tuesday, July 12, 2022

Sew Chaotically! ~ Scarlett blouse from

As promised - a delayed post on an exceedingly delayed make - the second "special" long planned top stitched up this spring - The Scarlett Blouse, from Le Laboratoire Familial, made up in Liberty of London cotton voile from B&J fabric acquired on our incredible New York to Paris trip in 2017!

I was drawn to the simple but classic design with it's asymmetrical closure the first time I saw this top!  Having used a variety of French patterns, I have become pretty well versed in French sewing terms, so what with my trusty B as translator when things were confusing and a video tutorial on their site (though the filming is so close to the machine stitching away, hands block lots of the shot and perspective in almost nonexistent) putting the pattern together wasn't that difficult.  The pattern indicates that you simply gather the ruffle, but versions made by other sewists used pleating and I loved the look.  I make a size 40 in most French patterns to accommodate my broad shoulders, though I am less buxom and with a narrower torso than their block seems to call for.  So, I curved and took in the side seams to better fit my shape.  I also lowered the neckline by a couple of centimeters.  I will warn fellow stitchers that the placket is rather narrow.  I might widen it should I make it again.

The only difficulty I encountered was when I put the side seams together and realized that they were most decidedly different lengths.  As I pondered how I could have made such a drastic cutting error, I examined the pattern pieces more closely.  The error wasn't mine!!!!  A you can see from the pic above, the back is a good deal shorter than the front!  Luckily, I was just able to turn up enough of the back after attaching a lace hem edge.  I am surprised other sewists haven't mentioned this in their reviews.  Perhaps, the error is not in the PDF version (I have the printed pattern) or was corrected in later versions.  At any rate, you have been forewarned!!  HA!


I am quite tickled with how it turned out.  It should easily dress up and down while serving as a perfectly combined memento of our NYC/Paris trip!  Thanks, B! 

Sew (and travel - when you can) Chaotically!!! ~ les

Sunday, July 10, 2022

June Reads - Not the lightest of choices...

Hamlet - William Shakespeare.  Surely I read this in the past, though perhaps not as I have no memory of it.  Not exactly the story I thought it would be.

The Friend - Matthew Teague.  Essay in Esquire.   Teague's wife was diagnosed with ovarian cancer at the age of 34, in September of 2012.  She died in September of 2014.  Their mutual friend came to help in her care in December 2013, but ended up staying until the end.  A sad, but accurate picture of love and cancer.  The movie version is also well done.

Between Two Kingdoms:  A Memoir of a Life Interrupted - Suleika Jaouad.  The title pulled from Susan Sontag's essay - Illness as a Metaphor - which argues all of us will move between the kingdoms of health and illness at various points in our lives.  Jaouad was diagnosed with leukemia at age 22.  Her story chronicles her life before diagnosis, through chemo, bone marrow transplant and more chemo over almost 4 years.  Specifically, how that experience colored her world and the people who shared it with her.  She also addresses her path to rejoining the world outside of cancer via a cross country trek in which she visited those who had touched her heart during her time in cancer purgatory. Sadly, ten years later, in November 2021, she relapsed.  Since then, she has endured yet another transplant and faces more chemo, but is still LIVING and sharing hope.

Everything Happens for a Reason, and other lies I've loved - Kate Bowler.  Bowler, an associate professor of American Christianity at Duke, who published - Blessed:  A History of the American Prosperity Gospel.  In it, she covered the tenants of the prosperity gospel as sold via megachurches, in that if you are good enough and love God enough, you win it all - riches, health, prosperity.  However, do not be fooled into thinking that though a devout Christian, she is a follower.  In 2015, at age 35, Bowler was diagnosed with Stage IV colon cancer with mets to her liver.  She endured numerous cancer surgeries, noting in an interview in 2018 that she had had x #'s of belly buttons due to abdominal surgeries and she liked her last one the least!  She battled through chemo, much like mine, and dealt with cold sensitivity and mental fog - to the point that, though you'd think the horrible sensation cold causes the fingers of us in such a state would be enough - her husband put a sign emblazoned with a pic of MC Hammer and the words - Girl!  You can't touch this! - on the fridge.  (Boy, do I understand!!!!)  When that line of therapy failed, it was followed by immunotherapy.  She has been cancer free since.  Due to a small mention, I suspect she is one of the patients with the 'mismatch gene' sequence who benefited so markedly from immunotherapy in the recently published study.  Basically, hers is the story of cancer survival and the long version of "What NOT to say to a cancer patient!"

If you have experienced cancer or wish to come closer to understanding the experience of cancer (though it certainly varies for each person) - I recommend the three titles above.  They are not for the faint of heart.  They are not all encompassing.  However, they all share important points.  Especially, the strangeness of finding a way forward if you are a cancer patient lucky enough to face that challenge. 

In her writing, Jaouad notes these words - 

"I have walked through many lives, some of them my own, and I am not who I was, though some principle of being abides, from which I struggle not to stray."  - The Layers, by Stanley Kunitz

For myself, from ten years ago - July 2012, I wrote these -

"I am not me anymore - or at least I am not the same me that I was." ~ Che Guevara

Never Let Me Go - Kazuo Ishiguro.  An incredibly strange story of love, set in a dystopian world.  Science fiction comparable only, to my mind, to one story line in Cloud Atlas.  With characters whose personalities and issues are so real their setting is secondary.  One accurate characterization being ~ those who embellish their lives cannot endure those who know the truth. Indeed!

The Buried Giant - Kazuo Ishiguro.  Intrigued by the first, I moved on to this. Another discussion of the human condition - love, honor, memory - set in a England just after the time of King Arthur and his knights.  What would be left for us and our relationships if we were without memory?

Nowhere for Very Long, the unexpected road to an unconventional life - Brianna Madia.  A very interesting tale of coming of age and determining who one is through van life and a trek through the desert, reported by Madia as the life she has lived.  Almost too much?  Who am I to say?  However, the writing does highlight both the search for self, the value of seeing the world and our own reflection in it, as well as the problems of using the internet and its dollars to promote and fund that search.  Ergo the reason you have not seen in the 12 years of its existence a single advert on this blog - though tempting offers have been made.  Not entirely sure who made the better choice - but that was mine -  for what it's worth.

Read and live ~ chaotically! - les   And today?  "...some principle of being abides, from which I struggle not to stray." - YES.

Tuesday, June 28, 2022

For heavy hearts ~ Summer on the mountain...

EVERYTHING is just so much right now!  So many are wounded.  Hearts are aching.  In ways varied and heinous.  More will suffer before we can put things right.  I have no wand to make it better today.  Perhaps the words of a poet and the beauty Mother Nature affords me daily will provide a small solace.


Suppose I say summer

write the word "hummingbird,"

put it in an envelope,

take it down the hill

to the box.  When you open

my letter you will recall

those days and how much,

just how much, I love you.

                            ~ Raymond Carter

Wishing a moment of peace, hummingbirds, love and summer for each of you. ~ les