2019 PHYSICIAN STUDY
Regardless of patient’s risk for positive SLNB, if he or she is medically unfit to act on the information SLNB would provide (lymph node dissection, consideration of adjuvant therapy, pursue surveillance nodal basin ultrasound, or change follow-up schedules), it is reasonable to forego SLNB. Wide excision of primary tumor and a complete therapeutic lymph node dissection is recommended in patients with positive SLNB (Category 1 recommendation). Systemic therapy with Nivolumab or Pembrolizumab or Dabrafenib + Tametinib (in BRAF V600E mutation positive patients) is a Category 1 recommendation. Observation is a Category 2A recommendation. Locoregional RT is a Category 2B recommendation. Study: Seven cases of newly diagnosed cutaneous melanoma from 2018 were reviewed to determine whether sentinel lymph node biopsy was discussed and offered to suspected Stage 3 melanoma patients, and if BRAF testing was performed on Stage 3 and Stage 4 melanomas and if appropriate systemic therapy was offered. The data is listed below:
Every year, in order to maintain the American College of Surgeons’ Commission on Cancer accreditation, Great Plains Health oncologists perform a study to monitor the Callahan Cancer Center’s compliance with evidence-based guidelines. Below is this year’s in-depth analysis to assess and verify that our cancer program patients were evaluated and treated according to National Comprehensive Cancer Network (NCCN) guidelines. Topic: Sentinel lymph node biopsy in suspected Stage 3 cutaneous melanoma, BRAF mutation testing and offering adjuvant systemic therapy in Stage 3 and Stage 4 melanomas Introduction: NCCN guidelines advise discussing and offering sentinel biopsy in suspected Stage 3 cutaneous melanoma. Pathologic features that would qualify for the discussion include: Breslow thickness > 1 mm with or without ulceration Breslow thickness < 0.8 mm with ulceration Breslow thickness < 0.8 mm with or without ulceration with high risk features like high mitotic score (> 2/mm2) or lymphovascular invasion Breslow thickness 0.8 mm – 1 mm with or without ulceration
Patient ICD-O Site
ICD-O Histology
AJCC Stage
BRAF Stage 3- SLNB
Surgical Treatment
Systemic Treatment
Skin, unspecified malignant neoplasm of skin of ear and external auricular canal
Radical ariculectomy & parotidectomy
Ipilimumab + Nivolumab, followed by Nivolumab alone
1
Malignant melanoma, NOS
3A Pos
Dissection
Malignant melanoma, desmoplatic type
2
Skin of scalp and neck
3B Neg SLNB
Wide excision
Nivolumab
3
Skin of trunk
Superficial spreading melanoma
3B Pos
Dissection Wide excision
Nivolumab
Ipilimumab + Nivolumab, followed by Nivolumab alone
4
Skin of trunk
Malignant melanoma, NOS
3B Neg SLNB
Wide excision
5
Skin of trunk
Nodular melanoma
3C Pos
SLNB
Wide excision
Nivolumab
6
Skin of trunk
Superficial spreading melanoma
3C Neg Excision
Wide excision
Nivolumab
Skin of other and unspeci- fied parts of face
7
Nodular melanoma
4 Neg N/A
Wide excision
Pembrolizumab
Conclusions: Sentinel lymph node biopsy should be discussed and offered in clinically suspected Stage 3 cutaneous melanoma. BRAF mutation testing should be performed in all Stage 3 and Stage 4 cutaneous melanomas. Systemic therapy with Nivolumab or Pembrolizumab or Dabrafenib plus Trametinib (in BRAF positive patients) should be offered for all patients with Stage 3 or Stage 4 melanomas. In a review of seven cases of Stage 3 and Stage 4 newly diagnosed melanomas, SLNB and/or dissection was performed in 100% of Stage 3 melanomas. BRAF testing was performed in all the cases. Three out of seven had BRAF mutation positivity. Two patients opted for Nivolumab therapy after discussing the side effect profiles of Dabrafenib plus Trametinib versus nivolumab. Another patient started Ipilimumab plus Nivolumab at UNMC, Omaha, and continued the same treatments at our facility. The management of Stage 3 and Stage 4 melanomas at the Callahan Cancer Center adheres to evidence-based guidelines.
Avinash Pasam, MD Callahan Cancer Center Medical Oncology/Hematology
10
T H E C A L L A H A N C A N C E R C E N T E R C OM PA S S I O N AT E C A N C E R C A R E
Made with FlippingBook - professional solution for displaying marketing and sales documents online