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Management of Stage III Melanoma

Panelists: Jeffrey S. Weber, MD, PhD, Laura and Isaac Perlmutter Cancer Center; Jason J. Luke, MD, FACP, UPMC Hillman Cancer Center; Vernon K. Sondak, MD, Moffitt Cancer Center; Ryan J. Sullivan, MD, Massachusetts General Hospital; Hussein A. Tawbi, MD, PhD
Published: Friday, Jun 28, 2019



Transcript:

Jeffrey S. Weber, MD, PhD:
Melanoma is the deadliest form of skin cancer, but unprecedented advances in immunotherapy and targeted agents have led to safer and more effective ways to treat this disease. Today I’m joined by a panel of experts in melanoma to delve into the latest studies, including the most exciting data from the 2019 ASCO [American Society of Clinical Oncology] Annual Meeting. Together, we will provide perspective on how these data can be applied to real-world scenarios and how to individualize treatment strategies for your patients. I’m Dr Jeffrey Weber. I’m the deputy director of the Laura and Isaac Perlmutter Cancer Center and a codirector of the Melanoma Research Program at NYU [Langone Health] in New York City.

Today I’m joined by my colleagues: Dr Jason Luke, the director of the Center for Immunotherapeutics and an associate professor of medicine in hematology-oncology at the University of Pittsburgh Medical Center and the Hillman Cancer Center in Pittsburgh, Pennsylvania; and Dr Vernon Sondak, who’s the chair of the Department of Cutaneous Oncology at the Moffitt Cancer Center in Tampa, Florida, and a professor in the Department of Oncologic Sciences at the University of South Florida in Tampa, Florida. We also have Dr Ryan Sullivan, who’s an assistant professor of medicine at Harvard Medical School and who works as an oncologist at Massachusetts General Hospital in Boston, Massachusetts. And finally, we have Dr Hussein Tawbi, an associate professor in the Department of Melanoma Medical Oncology and [the] director of Melanoma Clinical Research and Early Drug Development at The University of Texas MD Anderson Cancer Center in Houston, Texas.

Thank you, all, and let’s begin. Let’s start by talking about perioperative approaches to melanoma in early-stage and locoregional disease. I think I’ll start out by looking you, Vern, to ask about how the recent results of the MSLT-II study have impacted clinical practice. Because for me, it was certainly a practice-changing publication. How does that publication help you in your outstanding multidisciplinary clinic at Moffitt to handle locoregional melanoma?

Vernon K. Sondak, MD: To review, the MSLT-II trial took patients who had a positive sentinel lymph node biopsy and randomized them to either have a completion lymph node dissection—which for decades has been the standard after a positive sentinel node—or to have observation of the nodal basin, what we refer to now as active surveillance, monitoring the patient as frequently as 2 to 3 times a year with ultrasound. And physical examination. And only doing a node dissection at the time of recurrence.

And Jeff, you’re right. This has been practice changing but not in isolation. Rather, it has been in combination with the changes in systemic management of node-positive disease. And I think that’s very important to emphasize because it stresses that this is a multidisciplinary approach to stage III melanoma. The sentinel node biopsy is the staging procedure. And then, as a team, we talk about what the right thing is to do for this individual patient. Is it systemic adjuvant therapy as the next step? Is it a node dissection as the next step? If the patient recurs, do we continue to treat? Do we operate? These are complicated decisions, and our multidisciplinary tumor board now spends an awful lot of time trying to figure out which therapy we’re going to use and when. We haven’t stopped using any therapy. It’s the sequencing and the treatment, and these are things that are going to come again and again and again today as we discuss ASCO and the modern management.

Jeffrey S. Weber, MD, PhD: So an interesting question is, as I remember in the MSLT-II study, there was surveillance by ultrasound of lymph nodes. But that was kind of in an era when you didn’t have clearly effective adjuvant therapy. So if someone goes on adjuvant therapy, do they also get their lymph nodes surveyed by ultrasound?

Vernon K. Sondak, MD: I think it’s very, very important that they do. We’ve stressed this concept of active surveillance. We work closely with our oncologists. They’re coming and seeing the patient, say monthly, for their treatment. We try to integrate in a nodal evaluation every few months along with an existing visit to the oncologist. If they’re getting treated at home, we still bring them into our institution to see them. The MSLT-II result, that it was safe to forgo a lymph node dissection, was really predicated on the fact that if you follow the patient closely, you diagnosed nodal recurrence at a time you could safely salvage the patient with an operation.

Now we just don’t do elective completion lymph node dissection anymore. It’s an operation that has almost become extinct at our institution. But when patients develop any sign of recurrence in the nodal basin, or if patients present with node-positive disease, surgery is very much a part of the algorithm. And it’s merely a question of how we integrate that in with their systemic treatment.


Transcript Edited for Clarity

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Transcript:

Jeffrey S. Weber, MD, PhD:
Melanoma is the deadliest form of skin cancer, but unprecedented advances in immunotherapy and targeted agents have led to safer and more effective ways to treat this disease. Today I’m joined by a panel of experts in melanoma to delve into the latest studies, including the most exciting data from the 2019 ASCO [American Society of Clinical Oncology] Annual Meeting. Together, we will provide perspective on how these data can be applied to real-world scenarios and how to individualize treatment strategies for your patients. I’m Dr Jeffrey Weber. I’m the deputy director of the Laura and Isaac Perlmutter Cancer Center and a codirector of the Melanoma Research Program at NYU [Langone Health] in New York City.

Today I’m joined by my colleagues: Dr Jason Luke, the director of the Center for Immunotherapeutics and an associate professor of medicine in hematology-oncology at the University of Pittsburgh Medical Center and the Hillman Cancer Center in Pittsburgh, Pennsylvania; and Dr Vernon Sondak, who’s the chair of the Department of Cutaneous Oncology at the Moffitt Cancer Center in Tampa, Florida, and a professor in the Department of Oncologic Sciences at the University of South Florida in Tampa, Florida. We also have Dr Ryan Sullivan, who’s an assistant professor of medicine at Harvard Medical School and who works as an oncologist at Massachusetts General Hospital in Boston, Massachusetts. And finally, we have Dr Hussein Tawbi, an associate professor in the Department of Melanoma Medical Oncology and [the] director of Melanoma Clinical Research and Early Drug Development at The University of Texas MD Anderson Cancer Center in Houston, Texas.

Thank you, all, and let’s begin. Let’s start by talking about perioperative approaches to melanoma in early-stage and locoregional disease. I think I’ll start out by looking you, Vern, to ask about how the recent results of the MSLT-II study have impacted clinical practice. Because for me, it was certainly a practice-changing publication. How does that publication help you in your outstanding multidisciplinary clinic at Moffitt to handle locoregional melanoma?

Vernon K. Sondak, MD: To review, the MSLT-II trial took patients who had a positive sentinel lymph node biopsy and randomized them to either have a completion lymph node dissection—which for decades has been the standard after a positive sentinel node—or to have observation of the nodal basin, what we refer to now as active surveillance, monitoring the patient as frequently as 2 to 3 times a year with ultrasound. And physical examination. And only doing a node dissection at the time of recurrence.

And Jeff, you’re right. This has been practice changing but not in isolation. Rather, it has been in combination with the changes in systemic management of node-positive disease. And I think that’s very important to emphasize because it stresses that this is a multidisciplinary approach to stage III melanoma. The sentinel node biopsy is the staging procedure. And then, as a team, we talk about what the right thing is to do for this individual patient. Is it systemic adjuvant therapy as the next step? Is it a node dissection as the next step? If the patient recurs, do we continue to treat? Do we operate? These are complicated decisions, and our multidisciplinary tumor board now spends an awful lot of time trying to figure out which therapy we’re going to use and when. We haven’t stopped using any therapy. It’s the sequencing and the treatment, and these are things that are going to come again and again and again today as we discuss ASCO and the modern management.

Jeffrey S. Weber, MD, PhD: So an interesting question is, as I remember in the MSLT-II study, there was surveillance by ultrasound of lymph nodes. But that was kind of in an era when you didn’t have clearly effective adjuvant therapy. So if someone goes on adjuvant therapy, do they also get their lymph nodes surveyed by ultrasound?

Vernon K. Sondak, MD: I think it’s very, very important that they do. We’ve stressed this concept of active surveillance. We work closely with our oncologists. They’re coming and seeing the patient, say monthly, for their treatment. We try to integrate in a nodal evaluation every few months along with an existing visit to the oncologist. If they’re getting treated at home, we still bring them into our institution to see them. The MSLT-II result, that it was safe to forgo a lymph node dissection, was really predicated on the fact that if you follow the patient closely, you diagnosed nodal recurrence at a time you could safely salvage the patient with an operation.

Now we just don’t do elective completion lymph node dissection anymore. It’s an operation that has almost become extinct at our institution. But when patients develop any sign of recurrence in the nodal basin, or if patients present with node-positive disease, surgery is very much a part of the algorithm. And it’s merely a question of how we integrate that in with their systemic treatment.


Transcript Edited for Clarity
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