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Case 3: Post-Surgical Recurrent Melanoma

Panelists: Robert H.I. Andtbacka, MD, CM, Huntsman Cancer Institute; Michael A. Davies, MD, PhD, MD Anderson Cancer Center; Antoni Ribas, MD, PhD, University of California Los Angeles; Georgina Long, MD, Melanoma Institute of Australia; Michael Postow, MD, Memorial Sloan Kettering Cancer Center
Published: Thursday, Jan 19, 2017


Transcript:

Robert H.I. Andtbacka, MD, CM:
This is a patient that I would see in my practice, a 60-year-old female who had a 4.6 mm ulcerated primary melanoma on her calf. We did a wide excision of the sentinel node, and the sentinel node was negative. So, this would be stage IIc patient according to the AJCC version 7 staging system. Now, we know these patients have a high risk of recurrence, both local regionally as well as distantly. And we would consider adjuvant therapy for some of these patients, and at least have a discussion about this, which is what we had with this patient. But, she opted not to have any adjuvant therapy. Now, we follow these patients very carefully, and 18 months later, she developed a mass in her right groin, which is on the ipsilateral side of her melanoma. We did a fine-needle aspiration of that and that came back as a metastatic melanoma. A subsequent staging workup then did not show any evidence of any distant disease to other sites. So, the question then becomes, how do we treat this patient? So, Mike, I’m joining you at your multidisciplinary tumor planning conference at Sloan Kettering. I look at the scans and examine the patient, and I say, “Well, this is resectable.” Tell me what the discussion would be at Sloan Kettering for this patient.

Michael A. Postow, MD: It’s a really good question. We have a patient with a high-risk, stage IIc melanoma on her leg who recurs now 1.5 years later on the same leg in the groin. And then, Robert, you said you can resect it, so I could tell you to go ahead and resect it. That’s one option. The question really is, is that the right thing to do? And, unfortunately, we don’t have prospective data to say resect it or not resect it. And so, the questions really that I have in my mind are, is this the first lesion and the only lesion we’re going to be dealing with in this patient or is this just the first of many that are going to be coming? If you were to have the surgery for this patient, resect it, are we then going to be dealing with multiple in-transit lesions on the leg or distant metastases? The standard approach for stage III recurrent melanoma by convention is really surgery, so I would want to explain that to the patient, that surgery is a standard for stage III melanoma, which this patient would have. But, it is of interest to decide whether or not some type of systemic treatment could be considered in this type of a patient in what’s considered a neoadjuvant type of an approach. And we do have clinical trials where we’re testing efficacy of systemic treatment prior to a surgical resection in this type of a patient. Whether or not surgery is the right thing to do in this particular patient…

Robert H.I. Andtbacka, MD, CM: Mike, I thought surgery was always the right thing to do.

Michael A. Postow, MD: That’s right, Robert. By convention, surgery is the right thing to do in this patient with this recurrence. However, it’s an interesting thought to think that maybe this patient would benefit from systemic treatment, now that we have better systemic treatments. We don’t at the moment have any data to say that we should be doing that, and it’s still an area for clinical trials and investigation. It’s been 1.5 years since the recurrence, and it is only one side of recurrence, so that would be a contentious tumor board discussion, I would say.

Robert H.I. Andtbacka, MD, CM: I think the key here is also to really talk about the whole question about resectability. I think that at least for surgeons, it’s one of those things that when you see it, you know it. I think resectability, the way I define this, it’s not necessarily just the ability to surgically remove all of the disease, which is what we want to do with the gross negative resection. I think it’s important for us to recognize that these resections need to be anatomic resections. We need to follow anatomic landmarks. So, specifically in this patient, I would do a superficial inguinal lymph node dissection, a therapeutic node dissection. I would also consider doing a resection of the deep pelvic nodes as well. And we know this from, again, retrospective but fairly robust data saying that the risk of having micrometastases in the deep pelvic node systems is actually 40% or higher for these patients, so we would consider that. There’s actually a clinical trial right now being done asking that specific question: do we need to take those deeper nodes or not? But, I think that in most practices, we would do this. I agree with you, it’s a discussion we would have with the patient. I think if the patient then opted to go for the surgical resection, it’s very reasonable, and that still is the current standard of care.

Michael A. Davies, MD, PhD: Robert, I think one of the other things that we’re thinking about is now that we do have regimens that have such response rates—again, as Dr. Postow said—certainly, one of the issues in thinking about systemic therapies is, what’s the likelihood this patient is going to develop distant metastatic disease? Would a systemic therapy be the most effective approach to reducing that? The other question is, if you have a site where you actually expect, due to the size of the tumor, the location of the tumor, that there’s going to be a lot of morbidity related to the surgery, whether or not neoadjuvant approaches could actually reduce the morbidity of those procedures. And that could potentially be another endpoint that will be important to look at in the clinical trials that are ongoing now and potentially in the future with neoadjuvant approaches.

Georgina Long, MD: Can I just clarify something? Because sitting here listening to you talk, it’s like there’s a big question over this management of this patient. At our institution, this patient would get surgery or…

Antoni Ribas, MD, PhD: Yes, our institution, too. It wouldn’t be discussed.

Georgina Long, MD: No question about it. Or they would be enrolled in a clinical trial, but neoadjuvant would not be done outside of a clinical trial and the patient would get surgery up front if we did not have a trial that they were eligible for. There’s no question, there’s no discussion about it. There’s a discussion, but not a big discussion. That is the standard of care. So, they would be enrolled in a neoadjuvant trial or surgery, then we discuss an adjuvant trial.

Robert H.I. Andtbacka, MD, CM: And I think that that’s absolutely right. I think that, again, the treatment for this patient outside of a clinical trial is absolutely surgical resection; a patient that is surgically resectable. And I think where the nuance comes in is really the tumor burden, the extent of disease, and we’ll come back to that shortly.

Transcript Edited for Clarity
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Transcript:

Robert H.I. Andtbacka, MD, CM:
This is a patient that I would see in my practice, a 60-year-old female who had a 4.6 mm ulcerated primary melanoma on her calf. We did a wide excision of the sentinel node, and the sentinel node was negative. So, this would be stage IIc patient according to the AJCC version 7 staging system. Now, we know these patients have a high risk of recurrence, both local regionally as well as distantly. And we would consider adjuvant therapy for some of these patients, and at least have a discussion about this, which is what we had with this patient. But, she opted not to have any adjuvant therapy. Now, we follow these patients very carefully, and 18 months later, she developed a mass in her right groin, which is on the ipsilateral side of her melanoma. We did a fine-needle aspiration of that and that came back as a metastatic melanoma. A subsequent staging workup then did not show any evidence of any distant disease to other sites. So, the question then becomes, how do we treat this patient? So, Mike, I’m joining you at your multidisciplinary tumor planning conference at Sloan Kettering. I look at the scans and examine the patient, and I say, “Well, this is resectable.” Tell me what the discussion would be at Sloan Kettering for this patient.

Michael A. Postow, MD: It’s a really good question. We have a patient with a high-risk, stage IIc melanoma on her leg who recurs now 1.5 years later on the same leg in the groin. And then, Robert, you said you can resect it, so I could tell you to go ahead and resect it. That’s one option. The question really is, is that the right thing to do? And, unfortunately, we don’t have prospective data to say resect it or not resect it. And so, the questions really that I have in my mind are, is this the first lesion and the only lesion we’re going to be dealing with in this patient or is this just the first of many that are going to be coming? If you were to have the surgery for this patient, resect it, are we then going to be dealing with multiple in-transit lesions on the leg or distant metastases? The standard approach for stage III recurrent melanoma by convention is really surgery, so I would want to explain that to the patient, that surgery is a standard for stage III melanoma, which this patient would have. But, it is of interest to decide whether or not some type of systemic treatment could be considered in this type of a patient in what’s considered a neoadjuvant type of an approach. And we do have clinical trials where we’re testing efficacy of systemic treatment prior to a surgical resection in this type of a patient. Whether or not surgery is the right thing to do in this particular patient…

Robert H.I. Andtbacka, MD, CM: Mike, I thought surgery was always the right thing to do.

Michael A. Postow, MD: That’s right, Robert. By convention, surgery is the right thing to do in this patient with this recurrence. However, it’s an interesting thought to think that maybe this patient would benefit from systemic treatment, now that we have better systemic treatments. We don’t at the moment have any data to say that we should be doing that, and it’s still an area for clinical trials and investigation. It’s been 1.5 years since the recurrence, and it is only one side of recurrence, so that would be a contentious tumor board discussion, I would say.

Robert H.I. Andtbacka, MD, CM: I think the key here is also to really talk about the whole question about resectability. I think that at least for surgeons, it’s one of those things that when you see it, you know it. I think resectability, the way I define this, it’s not necessarily just the ability to surgically remove all of the disease, which is what we want to do with the gross negative resection. I think it’s important for us to recognize that these resections need to be anatomic resections. We need to follow anatomic landmarks. So, specifically in this patient, I would do a superficial inguinal lymph node dissection, a therapeutic node dissection. I would also consider doing a resection of the deep pelvic nodes as well. And we know this from, again, retrospective but fairly robust data saying that the risk of having micrometastases in the deep pelvic node systems is actually 40% or higher for these patients, so we would consider that. There’s actually a clinical trial right now being done asking that specific question: do we need to take those deeper nodes or not? But, I think that in most practices, we would do this. I agree with you, it’s a discussion we would have with the patient. I think if the patient then opted to go for the surgical resection, it’s very reasonable, and that still is the current standard of care.

Michael A. Davies, MD, PhD: Robert, I think one of the other things that we’re thinking about is now that we do have regimens that have such response rates—again, as Dr. Postow said—certainly, one of the issues in thinking about systemic therapies is, what’s the likelihood this patient is going to develop distant metastatic disease? Would a systemic therapy be the most effective approach to reducing that? The other question is, if you have a site where you actually expect, due to the size of the tumor, the location of the tumor, that there’s going to be a lot of morbidity related to the surgery, whether or not neoadjuvant approaches could actually reduce the morbidity of those procedures. And that could potentially be another endpoint that will be important to look at in the clinical trials that are ongoing now and potentially in the future with neoadjuvant approaches.

Georgina Long, MD: Can I just clarify something? Because sitting here listening to you talk, it’s like there’s a big question over this management of this patient. At our institution, this patient would get surgery or…

Antoni Ribas, MD, PhD: Yes, our institution, too. It wouldn’t be discussed.

Georgina Long, MD: No question about it. Or they would be enrolled in a clinical trial, but neoadjuvant would not be done outside of a clinical trial and the patient would get surgery up front if we did not have a trial that they were eligible for. There’s no question, there’s no discussion about it. There’s a discussion, but not a big discussion. That is the standard of care. So, they would be enrolled in a neoadjuvant trial or surgery, then we discuss an adjuvant trial.

Robert H.I. Andtbacka, MD, CM: And I think that that’s absolutely right. I think that, again, the treatment for this patient outside of a clinical trial is absolutely surgical resection; a patient that is surgically resectable. And I think where the nuance comes in is really the tumor burden, the extent of disease, and we’ll come back to that shortly.

Transcript Edited for Clarity
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