At the American Society for Dermatologic Surgery (ASDS) annual meeting, Kimberly Ken, MD, discussed how dermatologists can effectively manage advanced stages of melanoma.1 Ken stressed that it’s crucial to keep an eye on invasive melanoma, as it’s predicted that there will be approximately 100,000 new cases of invasive melanoma in the United States in 2022, and the numbers will continue to rise.
Ken’s presentation focused on 3 main topics: Sentinel Lymph Node Biopsy (SLNB), Imaging and Systemic Therapy. Beginning with SLNBs, biopsies are intended to accurately assess patients through pathological assessments of regional nodal basins and to provide prognostic information. In clinical stage I or II melanomas, SLNBs are one of the most important prognostic factors for patients. Finally, GSNBs may impact future therapies by encouraging dermatologists to consider whether they will offer adjuvant therapy, ultrasound monitoring of the nodal pelvis, or follow-up with surveillance imaging.
The National Comprehensive Cancer Network (NCCN) makes recommendations on when to perform an SLNB based on the likelihood of a patient having a positive SLNB. For stage T1A melanomas without adverse features, the chance of a positive GLS is less than 5%, so a GLS is not recommended by the NCCN. There is a subset of T1A melanomas that have undesirable features. These patients have tumors with a mitotic index greater than 2, especially in younger patients, and consideration of GSNB would be recommended.
Moving on to imagery, Ken then discusses basic imagery. In stages 0 to II, basic imaging is not recommended. At stage 3A for patients with a positive SLNB, it is important to consider cross-sectional imaging such as chest, abdominal, pelvic, and even neck CT scans. At stage 3B-D, cross-sectional imaging with brain MRI would be preferable. And finally, at stage 4, cross-sectional imaging with brain imaging should be done initially. If a patient has had brain metastases, a brain MRI should be done more frequently than someone who does not.
“So I know you’re probably thinking, ‘we don’t do this often’, but we do do it in coordination with our colleagues in medical oncology and our surgical oncologists. When we talk to our patients, when we see them back from their alternate visits with us and other specialties, we really want to be involved in their care and know what’s going on and be able to advocate for them,” Ken said.
At the end of his discussion, Ken discussed the role of adjuvant therapy. The goal of adjuvant therapy is to improve patient survival and reduce the risk of recurrence. When talking about systemic therapy, Ken is mainly talking about immunotherapies like PD-1 inhibitors and targeted therapies. Melanoma treatment has changed dramatically since 2011. Previous chemotherapy agents had no lasting responses or positive survival benefits, let alone adverse effects.
When talking about adjuvant treatment with immunotherapy or targeted therapies, the risk of recurrence and adverse effects must be addressed. Patients can develop life-threatening myocarditis, pneumonitis, or hypothyroidism. Although adjuvant therapy is not without risks, the overall goal is to improve survival.
“With unresectable advanced melanoma, immunotherapy was first approved by the U.S. Food and Drug Administration in 2014. For stage III melanoma, nivolumab was approved in 2017 and pembrolizumab was approved in 2019. More recently, pembrolizumab is now approved for stage 2B or C. melanoma. Last month, the CheckMate -76K trials (NCT04099251) showed that nivolumab met its interim analysis with improved survival to recurrence in patients treated with nivolumab, so I think we’ll see that approval come hopefully it, in the next year or 2,” Ken said.
Ken believes that dermatologists will see more and more melanoma patients in their clinics, and she stressed how important it is to keep up to date with methods and participate in tumor committees.
Reference:
- Update from Ken K. on melanoma. Presented at the 2022 Annual Meeting of the American Society for Dermatologic Surgery, October 7-10, Denver, Colorado.
