Russell Berman, MD
Practitioners today are having much different conversations than they did in the past regarding the treatment options for patients with melanoma who have non-nodal metastases or regionally advanced disease, according to Russell Berman, MD. Moreover, thanks to refined techniques, select patients who were not deemed eligible for surgery are now able to undergo it.
“It is an incredibly exciting time to be involved in melanoma, which sounds a little odd, but it’s actually true,” explains Berman. “At the large oncology conferences, melanoma was once confined to a small, offshoot room in the corner and wasn’t at the plenary presentations. [Now], we have certainly dominated the plenary presentations and [have had very] exciting developments over the past few years.”
In an interview during the 2017 OncLive®
State of the Science SummitTM
on Melanoma and Immuno-Oncology, Berman, division chief of Surgical Oncology at New York University Langone Medical Center in New York, shared his enthusiasm over ongoing surgical advances in the treatment of melanoma.
OncLive: What did you discuss in your lecture on melanoma?
I spoke about non-nodal regional metastases, which, in melanoma, we refer to as in-transit metastases. I also spoke a little bit about systemic metastasis. Now, what is fascinating is that, with new systemic therapies that are effective for melanoma, such as the checkpoint inhibitors in targeted therapy, people think, “Well, is surgery no longer applicable? Do we ever need it again?” In fact, it may actually be defining a role for surgery that we didn't previously appreciate.
A lot of time when we have these advanced diseases—be it multiple in-transits, unresectable in-transit disease, or systemic metastases—in the past, we would only operate on very select people with it. It was maybe 1 or 2 metastatic lesions that were relatively easy for us to get to without causing a lot of potential harm to the patient.
Now, patients who we never would have considered operating on because of the quantity of metastases, [might] respond to the systemic therapy, and then only have a few persistent lesions—1 or 2 or 3. Then, they all of a sudden become surgical candidates, and they had not been previously before. Rather than thinking of it as, “Well, gee, no longer do we need surgery for melanoma,” it is quite the opposite. We really choose these selected people who would benefit most. It is actually an exciting time.
What advancements have you seen in surgical therapy for melanoma?
We have refined a lot of surgical techniques. We were taking out huge margins 40 years ago that were incredibly debilitating and doing large lymph node dissections with potentially no significant benefit to those patients. We did that routinely, and we thought we were truly doing the right thing. That has evolved over time to the point where our margins have decreased in size based on data and worldwide randomized trials. There is actually science behind it.
The results of the long-awaited MSLT-II trial came out, which continues to have the lymph node dissection story evolve, and that clearly is a game changer in terms of whether or not to complete a lymph dissection—although there are still some variables that we haven't truly examined.
Then, of course, there is advanced disease. Previously, if I could not help patients with regionally advanced disease in any way, shape, or form, there were not many other options. Sure, we had our medical oncology colleagues come in, but they didn’t have really effective therapy.
It has totally changed now with the checkpoint inhibitors and targeted therapy. When I have patients with advanced regional disease or systemic metastasis, the entire conversation has changed, the entire mood has changed, and the outcomes have changed. It has truly never been a more exciting time to be a melanoma surgeon or a melanoma practitioner.
That’s great to hear. You mentioned the MSLT-II trial. What other ongoing trials in this space right now are you excited about?
On a metastatic front, there are things such as brain metastases, which, previously, weren't included in clinical trials. Now, all of a sudden, we have multiple abstracts from the 2017 ASCO Annual Meeting, which is truly encouraging. That’s a space that nobody would ever go to previously. It really has evolved tremendously.
From the surgical side, the MSLT-II trial was long awaited. There had been some small trials—the DeCOG trial out of Europe, for example—but the MSLT-II multinational study was very well designed and executed. We’ve been waiting a long time for the results. The editorial that accompanied that result in the New England Journal of Medicine clearly stated that completion lymph node dissection is not the standard of care.