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Management of Locally Advanced Melanoma

Panelists: Axel Hauschild, MD, University Hospital Schleswig-Holstein; Michael A. Davies, MD, PhD UT MD Anderson Cancer Center; Jason J. Luke, MD, FACP, University of Chicago; Caroline Robert, MD, PhD Gustave-Roussy; Merrick I. Ross, MD UT MD Anderson Cancer Center
Published: Friday, Nov 30, 2018



Transcript: 

Axel Hauschild, MD: Hello, and welcome to this OncLive Peer Exchange® panel discussion, which will explore treatment advances for metastatic melanoma. The tools we have available for treating patients with advanced metastatic melanoma continue to expand, as do the data to help us use novel therapies in more effective ways than ever before.

Today I am joined by an international panel of experts in melanoma clinical research. We will discuss the latest data from studies related to the management of this disease, including ones from the [European Society for Medical Oncology] 2018 annual meeting in Munich, [Germany], and will provide perspective on how you can apply these new data to individualize treatment strategies for your own patients.

My name is Axel Hauschild. I am a professor of dermatology at the University of Kiel in Germany. Joining me on this distinguished panel are global experts in melanoma: Dr Michael Davies, an associate professor and the deputy chairman of the Department of Melanoma Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston, Texas; Dr Jason Luke, an assistant professor of medicine and a medical oncologist at the University of Chicago Medicine in Chicago, Illinois; Dr Caroline Robert, professor and the chairman of the Gustave-Roussy Dermatology Centre in Paris, France; and last but not least, Dr Merrick Ross, the chief of the Melanoma Section and a professor in the Department of Surgical Oncology, Division of Surgery, at The University of Texas MD Anderson Cancer Center in Houston, Texas.
Thank you so much for joining us. Let’s begin our discussion now.

First, we want to discuss perioperative therapy. The question is, how do we manage melanoma in the earlier stages? How are we managing primary tumors? What is the safety margin? Is there an agreement on this? How will we manage a sentinel node biopsy? If the biopsy is positive, what are we doing with a patient? Do we need a completion of lymphadenectomy, yes or no?
So the first question is for Caroline. Do we have any internationally accepted rules for safety margins for primary melanomas?

Caroline Robert, MD, PhD: Yes, I think we are in agreement on this. We know that we don’t need to do these. Years ago, there was a huge margin. It’s very rare that we take more than 2 centimeters of skin. We also know that surgery of the primary is mostly used to decrease the risk of local metastasis. So we also have to integrate that into particular cases of very old people for whom it’s difficult to do a large excision.
Concerning the sentinel node, we have some information now that positive sentinel node burden does not oblige us to do a completion of the lymphadenectomy. We know that doesn’t change the overall survival.

Progressively, the teams are modifying their habits. For example, I can tell you what we do. We still perform a sentinel node biopsy for melanoma cases, which are 1 mm or thicker. And depending on the type of metastasis that we find, we usually do not propose a completion lymph node dissection afterward. But we also take into consideration the fact that the patient is or is not going to be able to have a good follow-up with ultrasound. Imagine a person who lives far away or somebody who is not compliant. Then it might be different. So I think it’s still very important to consider the patients who we take care of on an individual basis.

Axel Hauschild, MD: So can we conclude that there are internationally accepted rules for safety margins of the primary tumor, which are a maximum of 2 cm nowadays? Do we agree?

Merrick I. Ross, MD: Sure. I also think that we’re diagnosing melanoma earlier than we used to. A lot of times we can even use 1 cm margins. For example, for melanomas up to 2 mm in thickness, you would normally recommend 1 cm margins. For melanomas that are thicker than that, we would consider 2 cm margins. But it needs to be understood that in certain anatomic areas, where there’s restriction, like on the face, if the lesion is close to the mouth or the nose or the eye, or in these critical structures, you can adjust your margins appropriately, so we don’t cause undue morbidity to the patient.

Axel Hauschild, MD: Jason, there’s a consensus on doing the sentinel node biopsy, but it’s widely accepted as sort of a staging tool and not as a therapeutic procedure with the attempt to increase a cure rate. Would you agree on this? How is it done in your center?

Jason J. Luke, MD, FACP: Absolutely. I think this has been an area of a lot of transition in melanoma, as well as in breast cancer and other tumor groups. But with the publication of MSLT-II showing a lack of an overall survival benefit in the vast majority of patients, we really no longer prioritize doing completion lymph node dissections. That being said, a sentinel lymph node biopsy is still the standard of care, and I think it’s important to point that out. Even in our area, some dermatologists are even talking about not doing sentinel lymph node biopsies. But for the purposes of our medical oncology therapies after surgery, we absolutely need to have them done because they stratify standard-of-care therapy.

While we may have paradigms with less surgery, I think that’s an open question. Right now, the standard of care is to do a sentinel lymph node biopsy on any patient with thickness of 1 mm. In the United States, we may consider doing it for a slightly less thick melanoma—down to maybe 0.7 mm—with high-risk features.

Axel Hauschild, MD: It’s the same in Germany. We are doing it in patients who have more than 1 mm of thickness, but if there are additional factors like ulceration, which plays a role, we are going down to 0.7 mm.

Transcript Edited for Clarity 

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Transcript: 

Axel Hauschild, MD: Hello, and welcome to this OncLive Peer Exchange® panel discussion, which will explore treatment advances for metastatic melanoma. The tools we have available for treating patients with advanced metastatic melanoma continue to expand, as do the data to help us use novel therapies in more effective ways than ever before.

Today I am joined by an international panel of experts in melanoma clinical research. We will discuss the latest data from studies related to the management of this disease, including ones from the [European Society for Medical Oncology] 2018 annual meeting in Munich, [Germany], and will provide perspective on how you can apply these new data to individualize treatment strategies for your own patients.

My name is Axel Hauschild. I am a professor of dermatology at the University of Kiel in Germany. Joining me on this distinguished panel are global experts in melanoma: Dr Michael Davies, an associate professor and the deputy chairman of the Department of Melanoma Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston, Texas; Dr Jason Luke, an assistant professor of medicine and a medical oncologist at the University of Chicago Medicine in Chicago, Illinois; Dr Caroline Robert, professor and the chairman of the Gustave-Roussy Dermatology Centre in Paris, France; and last but not least, Dr Merrick Ross, the chief of the Melanoma Section and a professor in the Department of Surgical Oncology, Division of Surgery, at The University of Texas MD Anderson Cancer Center in Houston, Texas.
Thank you so much for joining us. Let’s begin our discussion now.

First, we want to discuss perioperative therapy. The question is, how do we manage melanoma in the earlier stages? How are we managing primary tumors? What is the safety margin? Is there an agreement on this? How will we manage a sentinel node biopsy? If the biopsy is positive, what are we doing with a patient? Do we need a completion of lymphadenectomy, yes or no?
So the first question is for Caroline. Do we have any internationally accepted rules for safety margins for primary melanomas?

Caroline Robert, MD, PhD: Yes, I think we are in agreement on this. We know that we don’t need to do these. Years ago, there was a huge margin. It’s very rare that we take more than 2 centimeters of skin. We also know that surgery of the primary is mostly used to decrease the risk of local metastasis. So we also have to integrate that into particular cases of very old people for whom it’s difficult to do a large excision.
Concerning the sentinel node, we have some information now that positive sentinel node burden does not oblige us to do a completion of the lymphadenectomy. We know that doesn’t change the overall survival.

Progressively, the teams are modifying their habits. For example, I can tell you what we do. We still perform a sentinel node biopsy for melanoma cases, which are 1 mm or thicker. And depending on the type of metastasis that we find, we usually do not propose a completion lymph node dissection afterward. But we also take into consideration the fact that the patient is or is not going to be able to have a good follow-up with ultrasound. Imagine a person who lives far away or somebody who is not compliant. Then it might be different. So I think it’s still very important to consider the patients who we take care of on an individual basis.

Axel Hauschild, MD: So can we conclude that there are internationally accepted rules for safety margins of the primary tumor, which are a maximum of 2 cm nowadays? Do we agree?

Merrick I. Ross, MD: Sure. I also think that we’re diagnosing melanoma earlier than we used to. A lot of times we can even use 1 cm margins. For example, for melanomas up to 2 mm in thickness, you would normally recommend 1 cm margins. For melanomas that are thicker than that, we would consider 2 cm margins. But it needs to be understood that in certain anatomic areas, where there’s restriction, like on the face, if the lesion is close to the mouth or the nose or the eye, or in these critical structures, you can adjust your margins appropriately, so we don’t cause undue morbidity to the patient.

Axel Hauschild, MD: Jason, there’s a consensus on doing the sentinel node biopsy, but it’s widely accepted as sort of a staging tool and not as a therapeutic procedure with the attempt to increase a cure rate. Would you agree on this? How is it done in your center?

Jason J. Luke, MD, FACP: Absolutely. I think this has been an area of a lot of transition in melanoma, as well as in breast cancer and other tumor groups. But with the publication of MSLT-II showing a lack of an overall survival benefit in the vast majority of patients, we really no longer prioritize doing completion lymph node dissections. That being said, a sentinel lymph node biopsy is still the standard of care, and I think it’s important to point that out. Even in our area, some dermatologists are even talking about not doing sentinel lymph node biopsies. But for the purposes of our medical oncology therapies after surgery, we absolutely need to have them done because they stratify standard-of-care therapy.

While we may have paradigms with less surgery, I think that’s an open question. Right now, the standard of care is to do a sentinel lymph node biopsy on any patient with thickness of 1 mm. In the United States, we may consider doing it for a slightly less thick melanoma—down to maybe 0.7 mm—with high-risk features.

Axel Hauschild, MD: It’s the same in Germany. We are doing it in patients who have more than 1 mm of thickness, but if there are additional factors like ulceration, which plays a role, we are going down to 0.7 mm.

Transcript Edited for Clarity 
View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Medical Crossfire®: Evolving Roles for Targeted Melanoma Therapies: Assessing Rapid Progress in the Field and Looking Toward Future CombinationsFeb 28, 20191.5
Advances in™ Melanoma: Exploring BRAF/MEK in Adjuvant and Neoadjuvant SettingsSep 28, 20191.5
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