Four considerations for melanoma treatment

As the speakers in Sunday’s “Managing Melanoma” (F105) pointed out, we still don’t necessarily have the best practices in place for patients with the disease. Guidelines in the following areas are fuzzy, outdated, or backed by insufficient research, leading to what Joy H. Kunishige, MD, of the Zitelli & Brodland Surgery Center, calls a “practice gap between what we are doing and what is achievable.”

  1. Reconsider your margins.

Dr. Kunishige highlighted the lack of guidelines for head and neck melanoma margins. She pointed out that reoccurrence rate margins for head and neck melanoma are too high, and that, according to studies, many surgeons are taking less than a centimeter for invasive melanoma half of the time. In addition to face and neck lesions often having photodamage affecting their true borders, physicians not taking the full margin leads to a lower incidence of removing the entire lesion.

Based on the literature available at this time, said Dr. Kunishige, a 1 cm excision margin will remove only 52% to 91% of invasive melanoma on the head and neck.

  1. Consider whether genetic expression profiles (GEP) could help manage melanoma patients.

Pedram Gerami, MD, a professor of dermatology, pathology, and pediatrics at Northwestern University and the director of its melanoma program, asked attendees whether GEP could be used as a consideration in managing patients who have sentinel-node negative melanomas. GEP was developed to assess risk of recurrence independent of traditional clinico-pathologic factors using tumor biology.

Data suggests GEP may help in splitting node-negative groups into Class 1 (with a low risk of recurrence) and Class 2 (with a high risk of recurrence).

  1. Research the new medications for metastatic melanoma.

Emily Y. Chu, MD, PhD, assistant professor of dermatology and pathology and laboratory medicine at the University of Pennsylvania, highlighted new medication options for those with metastatic melanoma, a cancer with a median survival rate of six to nine months. Five years ago, there were no FDA-approved treatments, she said. Now, there are a handful of both targeted kinase inhibitors and immunotherapy agents.

Targeted kinase inhibitors include different BRAF and MEK inhibitors, and immunotherapy agents include ipilimumab, PD-1 inhibitors, and talimogene laherparepvec (T-VEC). Side effects and costs vary. Dermatologists need to be aware of these new approaches to treating patient with advanced melanoma.

  1. Is a sentinel lymph node biopsy really going to help?

John A. Zitelli, MD, also from  Zitelli & Brodland Surgery Center, questioned whether sentinel lymph node biopsies are really beneficial to most patients. Current guidelines call for SLNB discussion in some patients with melanomas less than 1 mm in thickness. When patients choose sentinel lymph node biopsy, he said, the test only identifies one-third of patients who will die from melanoma.

He told attendees that the only time he would consider having a sentinel lymph node biopsy is if he had a stage 2B ulcerated primary melanoma. Otherwise, he said, GEP is a better predictor of mortality than sentinel lymph node biopsy alone.